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Les oiagrammes suivants iliustrent la mAthode. 1 2 3 1 2 3 4 5 6 E^^N^^H^k MICROCOPY RESOIUTION TEST CHART (ANSI end ISO TEST CHART No 2) 1.0 i.l 1.25 ;f Ilia 1.4 III 2.2 II 2.0 I 1.8 1.6 ^ APPLIED IM/1GE I =1 '^3 East Mlurvii at Statiunui-' liitll, l.i.minii. I.tiu'lan-I. ELECTBOTYHtD QV WE8TC0TT A THOMSON PhilADA. PRESS or W B SAUNOENS fc c.:;mp PREFACE. I in: iNcillciiic nf ilic -iric, ,,(' iin»ii<(^rni|)lis i-iu'd imil(>r tlio iMlitor- -ln|ii.t' l'r.,i;-~o|- .N.p||iii;ijj;rl li;i> l)c.ii i( cii.iii/cl l,v all wli.i arc Mitli- ■ iciitlv liiMiiliar uitli (uiimmii {>, read ilii-c unrk-, ami the >cric: has li'iinil a not iiicmi-iilciaiiir |ii(p|H)rtic.ii it[' it., ili-tiiiiiitiou in ijij, and iillici Kii-li-li— iicakinu- iirics. I have -o ottcii lu>art in the lirin^rin>r out of an ilM-li-li cilition. it wa^ .-j..rially ^Tatityiiii.r to tin. I that tin- pi-oiniiK'iit ^|M'iiali-l- who wciv invitcl to ro-o|..ratr \<\ iditinj.- M|iai-;itc voinnic- uciv a- int.'iv-lr.l a- my-rit' in the matter of |.ulilifatioii (,|-aii [■jiMJi-h clition. Th. -(■ chtois have Imimi n(|nc-tcnch addi- tion-^ to tlu; ori-iNal ai'li.-lr^ as -crni iirc-sify to thoni to hrinu. the arll.lc- fully u\< to date and at llir ~:m\v time to adapt them thonniain.' hioj, Mandar.1 ..f ..x....i|(.ii.r that has hccn s.. (■..ii>piciio!i.s ;i (.•alMiv in the (ifiuinal (icrniaii arli.'lc-. In all ca-.'s f he ( Jcnnaii anth.ir has I.|.(mi consiiltod with rrirard '.> tiio |)Ml)licati.)n of thi- ...iiti.in .,f liis w.irk, and has ^dvcn sptrific (•..nscnt. In one case ..iily it was niifbrtnnatcly iit>ccssaiy to siil.-titiite (Wr the tiaiislati.)!! .,f ih.> (Jci-nian aiti.'lc an cntiivly new ..nc hv an American anth.ir, ..n a.<'..iMit ..f a previous arranirenicnt of the ( Jernian a.ithor to i"N.' a tr:in-lati..n of iiis arti.l.' M'parat.'ly from this series. With this e.\.i'|)ti.Hi the .\.ithiiat;cl series will he i)resentcd inta.n. ALFRED STENCiEI^ 7 u»^ ^ . J^^^ I3j£lt4; EDITOR'S PREFACE. Ir\vM~«itli ilic i:iv;it<~i |il(:i-mv iIimI I iiiidcrtook, wiili tin' In'lp ri;;in:il idition is niuMni/cd l,\ all -|>c(ial -tiidcnt^ of ty|(li stndy the di-ra~(s ron^idci-ol in 'lii- II ^'i:i|ili. "Iiirh di-|(lays I'vcfywlicic the tlini' of the ( icrinan nlilioii ; Till' rha|)t<'r on the Il'iiiirinluLry of 'lyphoid Vivrr has l)c<'n tiior- oiiirhly revii'Wid and inw niatirial added, partirniarlv on the distrihn- lioii of the typhoid l.acilli, rspccially in tlic uriiic, in the rose-spot«, and ill the lilooij, III the chaptir on patholoi_ry niaiiy iniimr additions have Im'.mi made, and the i.iipi.rtaiit work of .Mallory has lieen iiieor|Minited. The litera- Iiir,' on the loeaiized lesion- y liaeterioliiMi,. MrthiHl-, |.artieiilarly with refeiviiee to the recent Work on lilood-eiiltiires ami on the detection ,,f th,. haeilli in the urine. Ill the chapter .m Treatment I lininil little to chaiiL'c. The author's i) 10 i:i>ii'ii:s mil \i i:. iiiitliiid- ill till ;i|i|>lic'aliMii ..I Inilri.tln ia|i\ ilitllr -■iriiiwIiMl trnin lli^.-r III 11-1 in tlii- I Miiiiirv , .iml tlh ;niti|i\ iitii' ilriii,'-- mii- nut imirli m ii-c III iv, \\ rii^li! - iiii'tli'i ,,t' I )ivsfiiiiiialiiiii nf llic \ irii> 'rraii,-irii»i,iii I Iiivinl'Ii til,' Air SLiiilii'ari,',' .,f lOarlii in llic MlinlnirN , InfiTlion an. I I )i>^,aninali,pn tlinaii'li II,,iis.-li.,|(| Artirlc- ... Factors I liat Favnr Int'c-linn an, I 1 )i.-,-.aninali,,n ,it' the Disca.sf Faii,,rs IJclaliMLr to tlic Imliv iilual Kxtirnal. not Iinlividiial, Intlni'ncis ('onclii?.ions 17 17 ■M :;2 .•i4 .■:x 40 4» 51 r,4 55 56 70 77 Pathology ricncral Svni|it «« Mfi X7 yo 104 107 110 113 118 122 124 ■^r^^^^^*' **- ■ 12 <'isri:.\rs. Cniirx' nf the I-"rvcr : lv]>(ii:il ( 'omlilion of the liijiiv-'rciii- |itralurr 1:>:! Cliaiii;!- ill tin- (iri-ulalory ( )|-L:Mn.- l"i'_' S|ilrrii :ui(l Tliyrniil (ihiml ITi; t imiiii-lrinMrv i )|-L'aii.- l-^l (ii-ncralivf Oriraiis l!»t Diiri^iivf Oriruiis IDII Ivopiratiiry t >ri;aii> 2:'.S Nervous Syslfin ami < )riraiis of Special Sen>e l!."i'.( Variations in Sviiiploinaloloirv and ('oiir>e 2«7 'i'iie l.aleiil \'ariei' 's .';(l."> Seven' aiiil Mijilerale ( 'a in ('oiirse DepenilinL' upon Constitution. Se.\, aial A-e :;2i» Kernidex'eliees and ijtdapses :!4 . ( 'oI'ValeM'elKM :;titi .'IT-'l ■file I)uration of ( 'onvaloceiire ;'„S(| The d'ofd Duration of thi' Disease :\si) Fatal Terndiiation. l'ro;.'-nosis :\s2 Time ol' Death .'!?«7 <'au.se ot' Di-a'h .'is.s Sudden Death .'ilKI Diagnosis 41 m <'linical Invostiu'ation 4(11 Special DitPprential DiaL'iiosis 410 BacterioloL'ic DiaLTiiopia 41!' Methods of Serum-DinL'uosis 42:'> Prophylaxis of the Disease 4.S1 (ieiieral Measures 4.'!1 Ite^'ulations of the Sewaire-* 'ouilitions 4-11 Water-Suppiv \:',-2 Food a~ a Source of ii.fection 4-'U Prophylaxis w iih Helation to the Individual 4'14 Treatment 44ii OiiMTvaiioiis on Spc'i'ific Treatment 44:i N'lrsini: and Diet 44-! <(i.\TJ-:.\rtivc 'rracl 547 ('li;iii;:i> ill ilic ( Iciiilii-lriiiiirv ( )rLr.'iii.-* 54H Varialiipiir. ill the ( 'niiivf ami Maiiilotalinn,.* ot' iIh' I )i>ca?e . . "(."il Iirlapsis ami Iicoiincmcs 551 X'ariatiniis in the CdurM' 554 lirlaiiniiv 111, ami ( 'nl•\i^lt■m■l■ witii. (Illicr |)iM'ascs .... 562 The KlI'iMi cit' ( 'iiii>litiiliiiii, .\t:c, ami Sex 5((5 DiiraliiHi lit' tlic I)i>*t'a>c ami I'itIihI nf ('iiiivali';^rrn''e . . . 5()9 ViTv Si'Vrn- anil l-'alal ('a.-r>. I'riiL'misis ami Murlaiitv . . 575 I'l-i.-iii'-ir-. Moilalily 5x.'} Diagnosis 594 (iiiin-al ( 'Mii>iilcraliinis 594 nili'iTriiiial IiiaLTiioi- i'.i Iiiiiial .^laLTi' 595 l)iai:mi.--i> ill Stairt' nt' Krii|iiioii 598 Ty|iliiis ami 'l'\ phiiiil Iliwnhr 5!I9 (MluT I)iirrri niial SiLTii- licturcii 'ry|iliu> ami 'r\|ilmiil .... tiOO Prophylaxis ()04 licuulatiiiii nf ( uiu ral am' Lnral 1 ly^'ii'iiii' ♦'mililiiins .... (504 Isiilatimi tiOH 'rraii-liiirlalinii nt' l'aliMit> (>06 Wa.-iiiiii: nf IIn>|,iial Clotliiiii: ti07 Dij^iiit'criiiiL'- ( liitliiiiir. etc HOH I)i>iiiicriiiiii lit' Siik-Kiiiiiiis 609 Disinl'criiiiii III' FiiriiisliiiiLrs ti(l9 ItfL:ulatii)ii> lu\!.'anliii,i.' DiM-liarire of ( 'inivalrM'i'iit.-s 610 Treatment <>12 S|nritlc '{"rcaliiuMit 612 (ii'iicral Prcatiiiciii. Nursiiiir. ami Diet 613 Hyili-otlii'ra)iy 619 Trcaliufiit of S|it'('ial ( 'iimlitioiis ami ( •rLraiiif Ciiaii^re? .... 622 Literature «29 Index ^i'^rt ^i^l^^^^^SifM TYPHOID FEVER. i V^i^sik TYPHOID FEVER. 1. ETIOLOGY. HISTORICAL. Tin: r, coin I it ion ofthf (aiisiiiv,- lii.tor, arid of tlic iiatiiiv uf tvplioid t;v(T \va> ion- iHvvciitcd l,_v the iiialiility cicarlv to M'pai-at,- it iiiialoini- .■allv and .lliiically fVoni otlicr di-ca--..- licarin-c a Mipcrticial ivsctnl.lancf to it. Altlioiii,r|i til,, nam.. t.v|iliiis dates hatk to antitn|.or and olwni-ation of e..nseionsiiess (rO^'.iC, Ineatli, va|H.r). Tvpiiuid (ever i>, without donht, not a di-ease tliat lias develo|M(l or appeared f,r the Hrst time within th< la-t fvw .vntiiries. fei-taiii statements and d.-eriptions made even l)y early wiitei-s_Ms, f,„- instance, Ilippoci-af^—aiv apjilieahle scai-eely to any other di-eaH' than typhoid fver, as Wnnderlieh spe- cially has shown.' With the inereasiiijr impoitaiiee of anatoniie investi- iration, Spi^rclius Willi,, and .Morjrajr„i as ,arly as the sevnteenth and ei-hteenth eeiitinies made reiH.rts of i)ost-mortem examinations that unduiihtedly indieat.d typhoid fever. Clini,.:.! ..l.s.Tvation, however, <'mld not yet he l.rnii^ht into perf-ef aee.,nl with the anatonue eon- ditions at this time: the .linical and th.. patholoeriptiuns often .hd not wholly eoineidc. The diseri.nination of the tvphoid fevers from pla-uc, malaria, an,l a nmnl.er of >cpti,. pn.eesses was' jrpadnallv learned ; l"it imtd within .piite a rccnt period typhoid fever <.ontimi..l to he eon- f-Miul.Hl with typhus f.v.T and relapsinfr fever. Less sitrniHea-K-e shonld lie attaeh.d to relapsinir I'cvcr in this eonncrtion. as it nrs less e.,m- moiily and i> confined to a more eireimiserihed area. Tvphiis fever enn~titnt..l, however, a .erions ol.sta.'l... ..spe-iallv in KiiLdand an.l '■ '■■'ii'v, the eonntrio f-om which, at the r\„M' of tlu- eij.ri,t,H.nth and the lieirnminur „f the ninete,.nth (rntnri.s. th.. most snl.stantial impnises for the development of our kn<.wi(.(liiiii;ic| :i- Will to tlic (li-i'a~i tiial \\v kiiuw tii-dav as tv|ilii)iii fcvci', a- tn all nf ilici-f I'diiditiiiii- kiinwii vai'iiiii-ly as war-typliiis, starvation- ty|iliii-. c :iiii|i-ty|iliu-, ami -iinilar ilcsiirnalinii-, all iit' wliicli wen- even at lliat til oii-iilciiil iniita^'iuu-.. In Kiij,r|anil. mi the ntlicr liand, wliiTi' ly|iliii- \\\r\- hail always liini |irriliiiiiiiiaiit, il i-mild imi for a Imiu liiiii' lif iiiiilri-tc"«l why |)ii~t-iniii'icin cxaiiiiiiatiuri in llic ca^c- i'l (|iii-tiiin only I'Ncrptiunally di-flo-cil tlir lesions dc.-ci'iliiil with siicli driail hy thr l''rcnrh |iliy-iciaiis. In i-'ianiT, I'lo-t ' had a- rally a- 1 SO ( diinon-tr;it<'d tliat the tvpliiiiil frvir- wi'iT I'liii-tantly a—oi-ialrd with drtinitr intestinal lesion-^. His eoiii'lii-ion was lia-ed ii|)on the nnii-iially laiye ainnimt id' aiiatoiiiic material thnii-heil hy •_'(•(» aiilo]i>ie-. Hi- views were niateriallv enlarged ii|>on liy I'elit and Serre<,-' who ealled attention to the faet that undei- the eonditiiiii- in i|iie-tion e-peeially the Inwcr |Mii'tii(iis of the small intestine were iinnKed, and tliat the le-ions slioilld lie eiiii- sidei'ed -|)e it was almost universally liclii'vi'*! that, altiioii^li ty]>liiiid liver wa- invarialily as^ociatcnl with intestinal lesiims, it could, Imwevcr, lie directly contajrious, in the same way a.s small-jnix aud other acute cxantlieinata. At till heirinninfr of the niii(>te<'ntli century, nt a time wlicii tlie I'rench and .ne Kiijrlish were nnalile to reach a clear tinderstaiidinjr, in spite of exact clinical and anatomic oliscrvations, remarkalily definite view-, a|t]iroximatinir tlm-e of the pre-eiit i if I' mirirln i-r ilrs cnrps, etc., I'liri.-. Is04. 'I Tra,i: ,1, h, ti:rr,,;,i;rn.i„,\,;,i;ri'i,i,\ ]'uri>. IM:'.. '■■Ill' l:i cluiiiiiiil.Tiir, ' .!,■,•//. ;i!i,. )ns 'h >]iisti-^>i')itiril*'. fi'f'i'C p"trf-h, ailjiiniiiiUinv, iti.. Paris, 18i;;i. ^ /,,v,,„.v ,/,■,•/;»;,,//.• ,„/,/;,-. Tmni' i Ku'rrr f„nl,,„,l,- I'.iri- 1H:U. r-'-jrrrriiriiTiirwTnrnriWffTririTrT'T^r^^ * i:riiii.i)i;Y. (1. iiii:iiiy. I'ndcr the liiciiri' c f 1 Iilcar-, los cxaci aiiatoinic and ciinical data than iriicili^ciit tinpiiir coni'cinion-; wiiicii ]Miintcd in tho riidit diici'tioii. It \\a> riot nntii the fourth and lil'th drcado of tiic ninctcfntii rcn- tiiry that tiic (hlVcrcniTs of opinion were hai'nioni/(Kl. At tin's tin'.c it ' I'lif po-sii)lf to MTUiT nvncral nt-oj^nition of tiu' nitlividnalitv of tiie two ns pa|>ers from <;ernian, French, and Enirlish source-, a mon<'\\' doi'triiie. The names of .leuncr, .Mnrchi.-on, and < Hnnd- A"./(, in frivinjr expre-sion outside of (iermany to this imix)rtaiit dis- tinction hy pla.'injr sp,,tted fi.ver amonn. tlie"ah,.w,n- the l>M,„.f .,n. h.,w,.,.n I, ,.„,! I)„thi,.n„.rilis,- ..|,„,,.. y„„,. ,,/.\u' of the iii..-t iiitiic-liiii: (■lia|it<'i> ill till' lii-Ioi-v dt' the iiLliclioii-- di-cMM-, :inaiciil i'niin the (li-fn|)tii)iis i- the ■ntliitiirc iiMiltin;: t'l'om cim- llimiiliiiL' I'th'i- ili-ta-f- with t\ |ih(i'(l f.vcr. With the roriiiatiiiii <>t' ;i l)cttcr cliiiical r(inri.|iliiin nt' typhniil ti'Vcr_ iiiiii-c (Irrmilc ctiiilduic \ icws al-.i ai(i-r, anil thr-f iv-ulli|)caiiil nr\t anil la-tiil tor a lun^^ time. At tir-.t, i-athtr I'-cnciiil and n^t -|i<("s wnc had in mind : )iiitiid divii]n|i i-iticn in ti:i> rai-lli and c'l.ntaininalioii ><{' tlu' air. which were hclicvcd tn hr .-|.cciall_v clTcrtivc in >niall dwcllini:-, liidi:intr-hoiiM's, :iiid other | 'Iv vcntilatcileli factors in vaivinir eoinliination etiolo^ie lhe|)rin^ of a period w ho.-e iiiHn- ence was aiiiircciahle iiniil w ithin rc'-ent time-. The putrefactive theorv had di-tin^ui-luil adherents mitil Iteyoml the middle of the nineteenth century. It re<'eiveonal authority and aj>|>arently exact observations exeitisl a protoimd and la^-tinjr intlnence not only upon hi- coimtrvmeii, hut al><) npoii physicians in other countries. Mis view- are repn)duced in the snliMipient air, soil, and water tliem-ies ; and althou^di tliev are replaced to-day hy more accuiiite knowledjre, they led at the time to the adoption in Kutrland of extensive pnictical meas- ure-, which mav lie considered as constituting: the foundation of a lar^re part ot' modern hyirieue. Murchi-ou con>idcr.Hl as esp(K'ially dan^renms tlie deeompisition of orL^anic siil)>tanees, ami ]>articularly that of human fci'al matter. 'I hoe ' S.r lii- U.ll-Uli..w!l w.Tli. .1 Trnifi:,J Urnit lintalii. V*-" Krioi.oay. 21 IIHlc|Kll times the :iil matter, aiu ll^eMM', lie lielieNcil |.j lir ot tlMIII-el\i- i:i|ial)le i.t' ;;i\iie' (>lii;ill, <.f llie |ia'ieii( ami (iiit~iile it' lii- liciily, to ,j)e ( iiatlirallv elieirii( ) |M.i-i,Miiii~ -iili-iaiiee- jieiieiatiii;: typlidiii lever. Ill li!- large work :iimI ill Miaiiy iiidiv iiliial |iiil(lieatiipir-- Miirelii-oii \va< al)le to t'ortit'v liis leieliiiiL;- H itii iiiimerniis iiiii-tratioiis of eiidemies and is( At liiiie-- tile di iiiiviii;:-uater or an artiile of lixid, at utlier 't\' dweiliiiir-niiiiii' ami >iee|>iiig-i eontaiiiinated with jintrid >iili-laiice> le-iilting iVoin tile dee()ni|M)~itiun ot' liniiian feea lliil~ Ijeeaiiie tlie iniiiiediate lailse lor tlie de\ eli>|iiiient of the d lli^ a—oeiate- and >iieee,->ors lollowed the same line o'" tlioiii,dit, witlioiit the addition ot" aiiythiiiir new, so tliat their etioloirii iiive-tiL,Mtioiis and le|ioits Were (|iiite llliiliimi and e\ en ,-eliematie. An advance a|(|H'ared to lie 1 lewilh the e\ |K'iiiiiental inve>tij.nitions of Stieh, and snl>-e- (|iienlly of I'anum, which aroii-ed great inlere-t. 'I"iie>e observers lielieveerfect ditlircntiation of typhus and Ivjihoid tever, a view wholly o|)|)oM'd to the decoinpo>ition-theion, and frc same time' accepted either as predominant or e(|nal in imi>ortanee or as suhordiiiate the sj)ontaii(^)US '• luiM-matie" mode of development. Kach of the-e two theories no doiilit contained some ohjective truth. To Miir. hi.-oii and his disciples hcloiigs the great u.- i'imtraii tiu Lnir. i '>'/■'., .Nor. i., xx. /■) riniiii 1 1:\ 1 1: till- (li-i ;i-c, u ln( li -nlj-((|lli lillv llkc'wi-r jilcixnl ili-lili:il>lc, |il;iiii| llic |>('i'-iilial inllili me I >!' I III' ji.il ii'iil, t 111' \ II u i\\a[ t lie |i<>i-ii|| ciiialiili i| tlurii mil. Ill till' liiii'L;ri'iiiii ■11,11- ill' liail lii'cii -iillii ii'iitlv I Tii, i| li>l' ilinlli.' till' w 111, II a- ri'-iivi'ii till' |i,i iiiiilatiiill d' llir \ iru -, in j^iiiiial corri'il, -ill! In M ;il tllr |ilt'-illt I wrri' a- I'lillciu- las. Ill- rollrl ii-i,,ii-, iiiiiaikaMv aiiili I'ol' III- li r\l,l„,iii liAcr raiiiiiil il('\c|i,|i -|n,|itaiiii,ii-ls ; cm ca-r (,i i:;iiial('- iiiiiin'ijialrlv tioiii -niiir aiilii'filciil ca-c, 'I'lii- i\ i,li,,l>! |M,i-i,ii 1- Villi raliil li\ till' ualiciit Iniii-rll ; il aillnit- i-|i(iiallv ^i llir .-t 1,1,1- w iili \\ llir 1 1 il i- I '\ an la I I'll. It t liii- ilr\ i'l,,|i- imt oiit-iilr, n- M iir- I'lii-i'ii ami III- ili-i'i{,lr- l,i'lir\ III. liiil wiiliin ilir lii,ii\ i,|' tlic tv|ilii,ii| jiatiilil ; anil il i- im>I tlir |,ii,illii t ul' iinlillrirlit ^ciirral iIi-<'iiIII{k ,-itii ,|| nil! -|ii( ilir acti . ilv. itiiiiil ,| 111 al liianrf. I, lit all ;::;rllt i,| -linillr i il Ii'iil ('\ 111 \M III -II lar a- tn run n Irr thr iiiti'-t 111' a- till' iiiiiiiiiiiatc iilacc ,1' I'lijiii I'l' till' i,i,i-i,n. in till' -aiiir wav a- llii' -kin iicrtiirin- a -iinilar liini'tii,ii Willi ii'lalioM'ti, till' |,n-liili' nl \aii ,1a. .\l-i, !l till' tr;!n-nii--iliilil\ ainl tli' lai, iliilitx' nl' i'nilli till' ri,llri'|,tli>ll 111 ■I' "!t'\ rlii|inirllt nl till' I" iiit.'ilnni in lii- ili tiiirtlv ('iKiiH'iatril vii'W that a iiiiiiinial aiiH'Uiit ilii'i'i' ,t' i- -iiriiririit ti,r till' coiixcxaiiir nl' till' ili-ca-c ami ii- I'lirtl n r I'Mrll-li'll. W illi li'i^iial ariiini'li UmM iTarhcd the I'llllilaiiii'lit: (•i,iii'lii-ii,ii tliat II \M,nli| iiinliiiilitrilly 1,1' |)i,--il,U' to |il'i'V('iit the ^|ll^all i,t' till' ili-cM-i' it' 111. iliml- I'liiiM lir i!i'\ i-i'i| i'a|>alilr i,t' rcinlnini; tlic int'crtiuii'^ -tiiiil- iiiiiiii'iinii- ; it iiii^lit cv rii lir Inipi "I tiiat as a I'oiilt i>t' a li'jii] a|i|>lirati',ii ol' siiili iin-a-iiiT- 111 cvrrv iiiiliviiliial (■a>(' till' lii ilil 111' w 111, Ilv iTa lii'ali l>iiilir< i,l,-i'r\a ii< II ti,i' a 11 liinr iiiii-t lie cuii-ldcii'il as masterly. lit- is u iiliiiiliti-illy till' tiiiiiidrr lit' till' ],ri'\ailiii^'' view- ii|h,ii tlic ctiiilniry ot' tyjiliiiiil ti'Vcr. Ncvi'illii'li'", till' patli liy wliiili mir |>r(-('iit (•(iii('(']itiniis liavr liii'ii rc.'icliiil t'lilli wi'd a Imii: ami iiitiiratr cuinvi', in cDiisciiiK'nci' ot' the iiii-lcaiiiiiir ami nli-triictivi' intliiciici' of cariirr tiicoiii's. .Milioiiirli till' iivtlmiri'iiii' tlicfirv of Miirrlii-mi \\a- jriiKlnallv tiis- planii iiy iiiat i,t' tlir -]ii'i'itii'itv nl' tlic ]M,i-iiii, tlic (|iic-tiniis as tu tiic iiKiiic of lii— ciiiinatiiiii ut' tlic latter, tlic (icvclii|)iiiciit of tlic ty|ilu>i(l ft'vcr (iiic-tiiins t'liillicr a- tu tlic iiitluciii III inilivKlual ca -C-, ill cmlcinics ami cjiidcinics, tiic iiii|Mirtaiit it' climate, of season, and of iocalitv illtel|iii-cd jrreat liilliclllts to tile IHiiLTe-- of iliruil It- M.'liL' i.f 1' roi,iii;ati"n. f' ti'.. /''('/., \K'>'.>. "Un l!i-:-'i:,M! K. '*--^ ' i: I I'll. IK,)-. 23 liilil\ of I i>iil;iiiiiiialii>ii i.r Mrli< Ic- .r U<,„\. of <| I Illkini^-WMllT, Mill loll -llli-l.ll|CI'~ U I til tl IC IHll-llll MIIIMliriK I Ilk. w 1-1' iHil mI\\:i\ « ail(<|ii:ilc. Iii-li;icl III iiHUf i:iii I'lilly ;inal\ /.iiii: llii-r rninlitiiiii', tliiy uiic linii/cil 111' wIhi.Is ii^iiuiiHl, iil»vi the nilc, and |h>" iliiy iniii-iicn-aliif, in the ilis-t'iiiinatioii ut' \\ lilmiil t'rVil". Sn|i|iiift tor tlicsc views was lliiiip_'lit tn lie (iinml "ti rctni-iM-ciivt' (ili-nvatiiiii in tlic fmlcinic iihmIc ut' ilis-ciiiinatiuii ut" typliiiid t'tvif, its II i-i~lfiirc III iTi'tain jiiralitics ami (■iicnin-i rilicd ai'cas, ami al-u in tin a|i|iaiiiillv ili-linctivi' uliMTvatiuii that in nt^iuns in wlii: •h the di-(a-(' I' ilcd the lii-t (■a~('s aiiiK I'P •aicHl iil'tcn wlici'c r\t('ii>ivi' cxcavatiuns ut' caith were hcini; made. I'liis luiali/atiiin-theurv has nut liii'ti wliully dulled •veil at the Iile-ell It dav. I II one III' alio ther t urin It sti nialelially mllileliees etiuluirie eiiiiee|)I iutis I'liis tlieurv ut" luealizatiuil allaimd its liiL;lie~t deiri'ee ut" develupineiit ill the tiiiiiuils du< trine of Hiilil and ut" I'etleiikul'er, ut" the ii'latiun lietween the ^ruiind-v.ater and tlie develu|inieiit ut" typhuid t'ever. Hiihl ' elainied to have made tlie ult-ervatiiiii that tiie iiiurtality t'ruin ty|)hoid t".'Ver in Miinieh fe<;iilarly (■xliiliiteil tliiitnatiuns eorresjiundini; with tlie varyiiii; K'vel (it" tlie j^roniid- walir, Ml that when this k'vel was liii;li the muiialitv was feinarkablv 1, uw, aad rlri' rrrsd. I'ettenUuf'er,- n]ion the basis ot" elahorate statistiesd data ami exiiiisive jueal oliservations, tV-ilier develo|)ed the theor^' of IJiiliI, so that at the end id' the sixth and in the seventh de,,■./. }iiul,,,,ir. I!J. • t'lOiir ijio Soliwunkiiii!;i'n iliT TyphusftiTlilicbki'it in Miinchen von IH'jO bis ISi;:.' X,-i/s,-/,r. /. Iii,.l,„,ie, IM. v., 1Ki;H. •Ti-Imt dii' Ai'ti..l..i;ie di'S Typhi '. isa '^•:^'. 2i T) ril'iii, I I I / /; v\;i> iIimiimIii ill;, I ;,| |,,,.| ;,|, iiii ii'M-i' III (III' iiin||:ilil\ \'\i<\\\ tviilioiil li'M-r loiilil III' ill iiii>ii-l i:ili'. A IiImiiil;Ii till' -ii|i|Miiiir- III' till- i;iiiiiiii|-u:itrr lliiiii\ wiii- iiiialili' tn lunil Mll\ ill linili' I'liliri liliiill III tllr IIMllll'l' III' tllr t\|ll|iiil| |Hii>u||, ,'|||i| f\iii ixiiiiillnl iiili ii-l III llii- 111 la|i-i' liiillii T ill till' liai-k'jiiiMiiil llic timri' lliiv iHiiiiir iiiMiKi'il ill till' i;iiiiini|-\\alir iIhihv, iIu'V aiMniiij In lun \ ii u - -lill Miliil al llir |iir-i'iil liav. iiaiiirl\, till' -|«'i'i(ii'it\ 111' the |Hii-iiii ami il- I ijialiililN ul ;^i ii atiniiaiiil liiiilti|ilirati'iii. 'i'l iilli ami crrnr Wrir, Iih^M'S ir, liliscil in llir lllllliri' In lirl' tliat till' [iiii-iili al'li-r |>a--iliLr llil'iiiiL'^li a iini'-siiv " pl'iirf-- ul inalinal ini " in lliiiailli iia-'-i'iiinl umilil lir iii\ ril l>\ tlii- water, ami lIlll- lie lilt nil' I'll. in till' -lliraee 111' llie earth : W 111 le W lull t he level iif the L't'illlKl-Water wa- Inw the (ieletelinll-. Ia\er nf earth Wnlllil he iti ilireel enniiiniiiieatiiiii with the alinii--|ilierie air lliiiiiii.Hi the trrniind-air, ami there wmilil tliii- lie i Ii-triielinn to the inianalinii i>i the |ini-.in. .\|>art 1111111 the I'aet that the thenry nl' I'l lleiiknt'er iiinnreil the iiatiiie 111' the ty|)liiiii| |Hii-iin ami relanliil il- -tiiil\', it wa- rnrthcr atti'iiileil with the lint iiiniii-ii II 'lal lie ili'-aiKaiilMLie that it lirniit:lit >trnni;ly intn the lini 'jiniiml. althnn'^ih a- il m>w a|i|iear- uilliniil -iilli- eieiit Miniiml, the ili— einiiiMtii ill III' the jmi-nii lliriHiirJi the ^'ii 111 mi-ail' mill theme tiii'iiii'^li the alimi-|)hei ie air, ami a- a re-iilt irrcjit ly clieekeil t'nr a time the -tl|i|\' 111' nlhe'- etinliiL'ii' |iu--il li lit ie-. It is i'-|ii'riallv inlere-liiiL' 1" ciilisiiliT the ell'erlive iilijeeliniis nf laelM r- iTici-ler ' ami .'-iiliM'r|uriilK nl' liieinier ' in the I'miiml-waler tlienrv ami ilit^- PfiiiiiiMlinn ihrnUL'h the air, ami In imle tlnir ili^i'riiniiiiiliiiL' sii|i|Kirt of ailnlller liimle i)^ ili--eliiiliMlinii. iiaillelv, that t liiniiL'li H iiler-ilifeetinll. Their views iil.-n LMiiifil iiiiliieriius aillicreiils. 1"lie trrniiml-water tlienrv. however, reiiiaiiieil fur a lime sn linn that in not a few jilaees epiilemiolnL'ie iiive-li- ^ratinll.- were ai|a|jteil In it. insleail. eniiverselv, nf ileihieili;: etinln;;ic views I'rniii llie fail.-. .\- late as the years 1>|ieritlc iiiH I'tion i\\' the water nhlaimil trniii llie river l-]llie. ami ii-iil for ilriiikiiii: ami ilnineslie ]iur|inM's. it was tniiml llial eertaiii eirrles .liil not ennsiilcr il worth while to take this |iij>- sihilitv into eoii^iileralioii. I'lie i:rnunil-waler tlienrv \va.s helieveil to he ' (i,..,„n,.l,- .\hln,,..ll,i„.i,„. ' \'.,ll:mnn„'s S,i,„,„l. U'.i, V.,rlr . IsT:;. N... ."iP,. I i.i -rliiii.'Hiii. " Miiii-ti-rlii- uimI I\!iiii-.|M- uln'rili'ii l' iili'rl.'ilijt\ plui- ill lluiu' I.ll'il.ni. V 25 wlmllv -lllllrlilil I'l I \|iLllll lllr c ijili'lllii' aini In u\ cridliH- till' oliji I'lliili!* r:ii-c(l :i.'.iM].-l till' UMlrr nl' tin- llllit-. A- li.i- liicii -(III, mil- 111' till' iiiH-t Viilinililc :i-|K(|. ul" ilir iluctriiic-i 111' lldlil Mini I'rllciikiili |- i- llir <'lii|illM-i~ |il,iii'<| ll|iiiii IJic \il:ilit\ ;ilii| till' |»i\M r 111' liinlll|iliraliiili ul' I 111' l\ |iliiiji| iMii-iiji, III \\ jiii h I till |< I .11 11 1 lii- |iii|iil- li.nl |iir\ iiiii-ly (liriH'h'd Miiiiiiii.ii. \\|. may ii i ntrni/,. in thj^ tlic lniii iiiiiiri- III' fill' |iii-i'iit view (if i liviii'„' i"iiitai,'iiiiii. A- I'arh an llic vrir I .s ,' I ilil- \ ii'u 111';; 111 III a--iiiiii' iinii'i' i|rtiiiit(i sliajM'. Ilcrcr- < inr mill 111' iiiaili' iiiil\ 111 ihf wuik- (if von Itci'klilijrliaii-i'ii,' \\lii( lallril allciiiiun in ijir t'iii|iii'iii iicciirrciicc III' ('(Kci in the ur^rans ul" ly|iliiiii| |ialiiiil-, i-|ii.i,ill\ in llic kiilnrys. a> well a- In the ji— -iirii'— I'ul an.'iii|iN 111' KIciii Si, kill. .11',' Fi-('li( I,' ami oiliir- i.. (Icinun-Iiaic an i)ii:ani/(Kl l\ {iliuiil ^ i-mi. Il \va- ri'-crvcil liir i'llii'i-ih,' in tjic yrar l.sso, in di-ruvcr llic hacil- lii- al llii' |irc«iiil)aliility. Aliin.-l ii lent iea 1 oii'-ervat inns Uele -nl)-ei|lii'iilly Inailel.y li.ii.erl Ki)eli"aml W'iliielin Mever," who Wnlkeil limler the imeliljve ami ilileelioii of Flieillaiiili'f, while the llliirii-iiliraili-ni-i|e-eiil.(Kl hy Kiel.- \ire not at the |ire-ei)t -ervei- were -non iiidn-trioii>lv emrajred in .-tndyiiii,' the new liaeillns without, however, inateriallv ,i(liliiiir anvthiii},' to the kmiwleili.re of its hiolo^ry. Neither ( 'oze and Felt/ nor Mara^diano 'Sneeeeded in eiiliival ini; and i-olalin.^r the |iiitliou'eiiie ^r,.nii. (Jatfky ' was tli<' tii-t, as the iv-nlt of a l.iilliant inve-tiiration, to lirini: the entile -iihjeet to its |.ie-ent tinn foiiiidalioii. He perfeeted in material point- the nior|ilio|oiry of the haeilliH, and l.v ineaiis „f im- inerons |iaiii-lakiii^r |..i-t-niorteni exainiiiations denion-trated its di-trihn- tion and arian-einent in the oririins and ti-ues, and finallv deserihed the method fir i-olatiiiLT it and ^ri-owini: it in pure culture. Althouirh <.atlky wa- not -uece-sful in cNpiiiincntally prodiicinir typhoid fever in ' WarrM. Zrit.. IsTI, (■.„„, ,;,r,. ,||.,, Kli.Tlh. /„,■ K,;n,/„i.. ,/,,■ l,„lj,ri..l..,i...-hn, MijL^.srn, I.i'ipziL;. IsTJ. ~ /;,;„„■/>, ../ ,/„ M.:/,,-^! om,-,' ,.( Ihr Vr,,:i C.uncU nwl /.",'„/ a.., ■,■,■„„:(•„» /!..,,./ Nn i;. isr,-,. ■■ \y-/>n,rs .Ire/,;,'. iM. jxvi.. ISTr,. ' I'rwirr mnl. Wm-hei'^rltnfl. 1878. ' Vn:-I,..,rs Ar.-hir. U,l. Ixwi. u, \\\\\\\. « M^llh.-ilun.in, fiiis ,/,„, A„i^. (l,s,n„//„itm,„f,: I!d. i. ' I'lrjiifjtiral Dixyrrldti,,,!, liiTliii, lS81. ' Arr/n,-./. erprr. l',iHi.,l. „. I'hnrmak.. Ii,J. .\ii, n. xiii. - ,•■:■::.■,■',:„,„,,„ ,1,,^ ,;,^, ^,iis, i,,-siiii'iiirii^,niit,\ lid, ii. _^.__.aMi> 26 ryi'iinin ii:\i:i:. ;iiiiiii;il- w illi tli<'-c |)iiri' I'lilliirc-, lir wii- :iiili-, I'niiii ilic ccrtiiiiity imil tlic I'M ml lit' hi- I It 111 r iili-i'i'v:iliiiii-, r-|M't;ini'y .if il- iiri'liriTlirr 111 ra-r- iif (\|(lliiiil I'rVrr ami il> aliM'llcc iViilll lirallliy iiiiliviiliial-, 111 fiiniiiilaii' ilir tlcliiiilf ciiiiclii-iun that tlic urg-aiiUiii is the -|i(Tit'ii- raii-r lit' lyiihiiiil Irsrr. 'I'lir -tiulir- lit' (latVkv \m rr liilliiwcil in all cnimtrics hy an cniifninus aniMinit ni' wmk with tln' t\ |ihiiiil-iiaiilli, mi liiat Lii-cncr a t'cw year- a:;iiua- aiiir In inal jirarti-nl liy .Mnnlii- -nii. Klrin, Khli-, I!irrli-llii--rht'rlil, anil nthn--. nni' liy imiriilalinns with |inrr rnltnrr-. ha- -llrrr— a- yrt hrm nhtainnl in drvrlnjiinL'' Inir tyiiliiiiil rrvrr in animal,-. MORPHOLOGY AND BIOLOGY OF THE TYPHOID- BACILLUS. 'I'lir liarilli nf Klirrtli. ill tlirir (ii-iliiiary fnrm, arc cnmitafativcly >hnrt, thirk mil-, \\illi mniiilril rxtrcniitii-, almnl thriic a- Inii^' a- thry arr uiilr, ami in aii-'lntr IniLrth onr-tlilril the in fmii, -\/r. ami arranLirimnt. Tlin- thr |i-ciulo-tilainrnts alrrady inrntinnnl will lie i'niinil in nlij linuillnn-rnltnrr< or tl" -<> ■.c^ ■■ i:Tlni.(j(;v. 27 [icciiliaritii'S, liMWcvcr, wlicii tniii-t'frnil to nilitr iiiilriciit iiicdi:!, in ;i' take plarc iti tilt; liaiilli, and tlic Ijriirlit luxlics tliat liiiliMl tu take the -lain l\ iii" at •'IG. 1, — Typhuiil l-arjlh: imi'D's^ i>rcp:ir;iti''n till' rxtrcinitic- as well as in tlic iniildlr of tlic liacilli wcw tl ojit t'l li(> ,-]iiiri-s. 'riii-c ai'c at tlic iirc-cnt time ciiii-iilcnd a- dciii iciicir-, alti-iliutaiilc I'iilicf to a in'dcc-s of involiiiion in tlic hacilii or a- an artefact dcvclojud in luating antl-ated liy -|iecial inelh(Ml- <.|" I ^j^mtm^m m if r.i '^s. TV rum I) i-i:vi:n. slaiiiiML'. u|i"Ti fill' ]in-ciiri' (pf IhiL^Ha, wliidi ari>c in larir<' iiiiiiihcr-, up |i. l"i and ('Mil -Jd ami iiu'It, fnnii all part^nf the ^ll^t■a(•(■ of the liacilii, and in ,-nitaMr |in|iarariun~ can tVc<|Ucntly l)c tlmnd ■' laclicd and iyinu i'rcf. Sii far :i- i- known, anidnir Ixidic- rc-tinlilintr tin typliciid-hacilln-, spontanciin- innxcmcnt, tn^cthcr with tlaplla (•an>inj:; it. <>ccnr> cnlv in Uaciilns-^dli and I'loscly related t^lin-. A dillerenee ajipear-, licwever, til re.-ide in the taet that the nnnilier •<[' llaiiclla attached I never -nece—t'nl. At time-. e-iiecialK in nld ctiltnre- npini fcehly acid ])iitatii. the liacteiia exhiliit -inmLilv i-etVacii\e |iiilai- limlie-, which stain nmrc readily and mure dceplv than the remainder of the Imdy I't' tiic haeteria (H. Hiieli- ncr ' These al-o ale nnilunlii'dly imt tn he cunsideriKl as -pure-, as i- indicai.d li\- the I'aet that the orji-.nii-nis in which they are cuntained d is imaniinun-ly aijreed hy tiie must ex|>erieiieed iili-er\i r-, the scveril\ uf an attack of typhuid fever is hy im means alwav- pnipiirti'inatc tu the nnmlier uf liacilii- in the ur^^aiis after death and dnrini.- life, and a- a matter uf tiict remarkaiily few liacilii are iicca-iiii;all\- fuimd in -e\ ere ea-e-. it is ".reneiidly easy, with a little >kill, tu ulilain the |ia|liui:enic liacilii frum the spleen, the mesenteric elands, and I'evcr"- patche-, <-pecially at the lieiLdit ><[' inliltratiun and with lici^inniiii: nlccratiiin. That tlicv can lie cnltivated from the liliiud ami the -|ileen dnrin'T life, tlmniih with j^-rcalci' ditlicidty, and alsu fruiii the dcjcctiuii- and tlie cxcretiuns. lias already lieeii mcntiuned. In all "f thi-e cuMiieetiuns it i- important tu know that tlie liacilln- thri\c- lic-t at the tein|ieratnrc i\\' the Imdy, aliont '■\~'^ C, allhuiieh it develops va . 'ly and almndantly al-u at lower temperatures, a^, for in-taiK'c, ::i ordinarv room-teinperatnre. Like the ina|iirily ot pathoirenic micru-iir;raiii^||is, the typhuld-liacillns disi>lay-- facnltative anair.iliiu-i- — that is, it lives and develups either with exelusiun uf owLiin (Lilmriu-) urwith access ut' uxyircn — in the latter event, it is true, with trreatcr enerev and in jrreater ahnndancc. 'I'lie cnltivatiun i>iiiiii>ii ami nil ilk. icnl, witliiiiit iiiKliTtriiiiiir cua^'u lati ACM alter liaviii"- Kmi cxihim'iI liir a (•■iii>ii it' tlic (IcVcl'ilHI 111 i> I'fiulcrcil I if tlic liai ii-tiiictly turhid in i'iiiisc-» A .~liirlit .~ctaiiiiiiii: ^c|>a^atc- nil auntatiiin into iiniloriii iiiinutc ])u. .i- 'i'lial tlic liacilli tliri\c liixiiriantlv, iinilcr favoniliic (liti III articlc- if i; -titutcd dl' till -iil)>taiicc~ naiiicil or nt' rclati -iili-taiicc- need miK' l)e iMciitiniied. We ^liall dwell iiKire I'nlly ii|)(iii the iiii|Mirtance nl' tlii- matter in eiin-ideriiiir the special eti(ilii;;v. When trrnwii in a iiicilia contaiiiiiii: L'lucii>c. lactusi'. ni sacchamsc, tiiere i> lie |inMliiclii>ii ot' ^Ms. Wlifii introduced into the |)eritiiiieal cavity ot' ii'iiiuiiM/.ril i:uiiica-|iii:s. or wlieii introduced, toL'ctlicr with scrum tVom an imniMnc animal, into the |icritonea! cavity of normal L'niiiea-|iiL's. the liacilli i|U''' IV lll^^e their motility and break up into small Ln-anulc.- — the >o-calleil !''■ ''cr's phenomciiou I {'fcitfer and Kolle ' i. It' a honillon culture of the tvphoiil-JKicillus is mixed witli scrum from an iiiimune animal or from a ;)er- sou after an attack of the diseti.se, the liacilli heconie imiiioliile and collect in'.o L'roups or clumps i Durham '■' i. l-'inally, if such a culture is mixed with serum from a patient duriiiLT an attack of the disease, a similar reac-tioii takes place i Widal ' i. The especial hehavior of cultures ot' the hacilliis nl' Elierth n|ioii the solid and liipiid initrieiit media mentioned has liei'ii dcterniiiiiMl most imnntely. Willi reference to tlic detail's, which would he out of |)l!iee in a work of this kind, the special treatises should he consulted. Siiiie statements may he made here with reference to the lieliavior of the bacillus on trelatin and airar. Siah-cultures in irelatin ap|M'ar as delicate, irravish-w hite, sli'_ditly Lrranular lilamcnts, hccomini; more attenuated toward the iMittom ot' the test-tnhe. I poll the surface of the i^elatiii the liacillus exhiliits active frrowth in the form of a thin, hlnish-irrav or <.'reetiisli-<;rav. sliLrhtIv iridescent deposit, |iro(eediiiir from the point of puncture and soon reachini; the liorder of the Ldass. On closer inspection it will U- noted that the outer Iwirder is not reirular, hut slif.'iitly serrated. The hacillus forms n similar thin, iridescent, irrayish-nlule or hluisli-wliite deposit in iil rallicr r^ iu:illv rnmiil nr ulilnu;.' culoiiifs are imt scrrali-d at the |uri|ilurv a,- "ii Lri'laliii. Tlify a|i|itai' ii|iai|iic ami yellDwisli white at llie <(iilc-r. au'l lunre traii.-iui't'iii. uiiili>h. ami mil ii|iale>i-eiit towaril the |)eri)ilnTV. .Micni-c(i|iically tlu'se cultures like«i-e are nmre nr lo.-i ei)ar>ely puiK'tale. uilli rriilnruLral linear t'iiriiiali''ii> similar In llmse iipoii L'elaliii. lv-|Hriallv iiMicxMirlliv i- llir liehavinr i>t' llie ty|ihiiicl-l aiillus ii|inn |Miia|ii. as lir.-t cai'iluily >iiiilie(| liv (iatl'Uy. a i'eatiire thai, acenriliii;: to exi-linir kmiu Km):.'!-, is not e.\hiliiteil liy any "iher ]ialhii!.'eiiie iiiier(i-iir;^aii- i-iii. ir a ili>k 111' hdilr.] |iii|alii nl' fieiijy ai'iil reaetimi is iiaieulated with a l\|ihiM.| ciiltiire. si'ancly any (litlereme in the a|i|iearaiiee of its surface will lie a|i|irei'ialile In the unlraineil rye aller the lapse nt' i'orty-eiLrht Imurs, as cnni|iareil vwlh ihe >url'ace nl'a sterile di.^k iit'|Milalii similarly ex|iiiseil hut lint sn imieulate'l. I )ii nmre eni'eliil sci-utiny, hew ever, the iiit'eeteil ]iotalii will appear Mirmwiial h>s >nii"ilh ami innre nmi.-t t'nr a iirealer (ir lesser ilistance iVnin the pnml nt' inciculalinn. It' a jilatinum limp he stnikecl nver llii- area, a seii^e i.l' imii-a^eil re>i-iance will he felt as cmnpareil with the unii ulaleil piilato, ami at limes ii is pii>.-ilile tii ileta<'h small lihiMieiits or threails \uih the hmp. In a wnril, nni' can cnnviiice himself that, startinjj: I'mni the puiiit iif inorulalinn, an extremely ilelicati', mnist, ^'listeninir, enliir- h s^. transparent cdaliiiL'' has t'lrnuil upnn the piitatn. < )m iniia-n-cnpic exaiii- inatiiin tiiis memhrane will he fnuml tn consist of a pure (ailture of typhnid- hacilli, which, iransfeneil to\arious nutrient ineilia, exliihit their charac- teri.-lic ]n'cailiarities, especiallv the spontaneous movement in houilloii pre- viou.~lv relerred to. .'"ie.ce i( was first ilescriheil hy (iatfk\-. this scarcely visihle deposit has heen recoi;iiizeil liy all ohservers tis an e.-iiecially impor- tant chtiracteristic. This opiinon is naturally not iufliienced hy the ohserva- lion that upon potato ot' neutral or alkalim' reaction or rendered artiticiallv alkaliia- the nienilirane hecomes vi;-ihle as a greenish-white or yellowish- trray or even hluish coatiiiL'. which not rarely is le.ss exteiisivi'. ll' after tlie-e lew refefciii'es to tile inor|ilioliiii;\- iiiid tile ])liy.-iiil(rjry of the I'.liertli hacillus \M' pa-- to a coii-idei-ition of its n'l/e in the ilcvelii|iineiit and (li— eiiiiliatioli of ty]ilini(l fever, and to a (le-ei'i|>ti(ill of till' pro|ierlie- that confer llii- power upon it, the (|ne>tioii ari-e- : ' 'iiii li/j/linlil fcrcr lir c.rjx riiKi'iifn//// iiiilid'id lit ii,iiiiiil/,i hi/ iiidculd'ion iij till' tiii/li(iiil-/ififilhis .' The e-tal>li-hnicnt of tlie etioloiry of typhoid fever lias heiMi in no -mall iiiea-iire re-liained liv the cii'cmn-talice that ;i disease wlxiUy eor- re-poiidiiiL'' to tv]>lioid liver in hiiniaii lieiiiifs iipjiarently does imt oeeiir in any -peeie- of animal. It wa-, thei'efofc, iVoiii the outset iin]H'ol)- alile that till' di-ea-e I'ould lie developed experimentally, and as a matter of t'aet tlii- ha- not \ ci lieeii po— ihle. < iatVky, in his well-known work,' was imalile |)c<'t^, liavc viclilrd im wlmllv cipiicliisivc results ill llii- CMiiiircliiiii. lie iiiVc^liLMtiii's liiiMH''l wcri' al>lc liy iiilruvciiiiu.^ a> well as liv iMlra|KTi- liiiit'iil iiijrciioii (it' larLTi' Minoiini? of [iiirr ciilliiri's nf tv|ili()iil-l)acilli to cause i;i|iiill\' lata! syiii|jlnHis in inii'i-. uilli [nM'iiliar aiiatDiiiic ifsicms : ^uclliiiLr, ( Mil i^iilaU'd ulcii'alioii nf ilic I'olliclfs iit' tiic small ami tlic lar;.'i' inicstiiu-, tM_q.ili(T uitli rciciit iiilillraliuii of tlic incsciiliTic ;:laii(ls. cloinly suelliii;.' of llic- liviT ami llii' kiiliifvs, ami roiisiilcraliic ciilarL'oiiii.'iit of llic s|iifi'ii. .\Ii( rosro|iic cxaiiiiiialioii disclostMl also llic pn-si'iicf of larL'c iiuiiiIhts of ty|]|ioiil-liiicilli ill llic iKail hody and is|K.'cial acriinuilalioii of tlitiii in the -|ili-fii. I'raiiki'l and Siiiiiiionds, liowt'vcr, alllioiiLrli tlicv coiisidcrcil their (■x|H-riiiKnts of 'jvvAl sij;iiiiiraiic(' — t'oriiiiiiir the fomidalioii for siilis('i|iieiit f.\|.frim»'iiis ill immunity and cure — were cautious eiioui.di not to idcntifv iniM|iletcl" the s\-m|iloms induced with Ivphoid fever. It was soon found' iilxi that no miicNiorihy iimlli|ilicatioii of the liacilli introduced into the animals toiik place in the livim: oriranisni. In addition, it was noted that ill" 'ulalioii of small niimliers of typhoiddiacilli did not — as in the case of oilu-r actively |iallioL'ciiic iiiicro-orLranisms, as, for instance, anthrax — L'ive ri^c to noteworthy symplonis. Finally, the circumstance that the miinials ^'eiicrally diccl hefore lhi> end ot' the (irst day and earlier, but warcelv ever hiltr than after three days, aroused suspicion that the condition was rather a liircit intoxication than a true iid'eclioiis disease resultiiij,' from the nuilti- plicalion and continued development of the bacilli. The certainty of the view that the condition is due to the ai i 'in of toxins and not of the bacilli was established by the ex|)<'riments'(if Sirotiiiin,' Hrie^'er, Kitasalo, ami Wassermann.' l?y boilinsible to introduce the toxins alone into the animals, and thereby to obtain the same results as Friiiikel and Siininoiids. 'i he statements of more recent observers,' that by .systematic auirnieiitation (if the virulence of the bacilli they can be rendere.l "actively pathoirenic for animals— that is, their further development in the Vniuiz body with the prfv duction of typical sympioms can be brou<:ht about — yet reipiire eoiiHrina- tion. In siicli an event material advaiita;.'e would be ex pet ed less for the etiolo^ry than for the solution of certain thera|« utic |)roblems. In none of the previously quoted ex|)erii nits do any of the observers claim to have prodiicecl in animals a disea.-e with a course resembliiiL' that seen in human typhoid. A later observer. Heiiilinirer.' found that bv pro- lomred feediii;: of rats and rabbits o.i veiretables soaked in water containing: lyplioid bacilli he was able to induce a continued fever la.stinri. Onlralhlalt i. Pin. Mr./., IHSti. Wolfowicz i' HMui]i;;;irtcn ), hi.iNipirul J)is.^,rfn/ii.,i. Koniirsberi;, 1HS7, t^jnitiiiin, Zri/schr. f. Ilwi.nir. \M i., IHS.;, H,.iiriiornti,l Pripcr, //m/., 15,1. i. u ii. U. f^trvu. V.Jkmann s Siinini!. ktin. \',,rtr.. Nrni- F'iIl'i'. N". 1:!h. ■' !,',<• .-it. ' <;ill"Tl aiul Oinidc, C<,iii/if,~ rr,ici„s lic Ui s ('ll;ll,l,.inrs.,. Ulul Widlll. All,:. ill,, ,!,■ illl^titltt I'nstiiir. KH'J1>, T. ri'lli. /'././., T vi. ; //.„/., T. vlii. ' y.eitschr. f. Jli/ijinif. l!il. mi, s -ii'ti- i/e lilohnii, \m\. No. Id. No. 1 1. Smia- ' Ann. il, 'IiiHt. I'. V. \i. TV fill III I 1 i.vi.n I\M ll'lll llil\. :lll(| ('!H- clic'il nil tliC l«( L'awM |i(i>ili\r aL"-'iiiliiiiiliiiii riiiriinii. Iflli il:iv nf fever. 'I'linc of ihc fmir >LnU((l .■-WrllillLr I'f ilfcll. I\tll| LlUip|iMi':- 111! lln' lu.i l.iihl l:i .1 ll iiicls. ami I'fvci'- |i:ilc iimI iIk'K a f.w ulcfl> ill llic liiHir pari of the Muall Im.uiI. 'I'viilmi.l l.an'li .111. liiii'il fmiii ll Tl ic»i' vcrv .-inkiii.Lr ainl uiiii|Ur nhM rvalinn- lavc mil \ el liirll rdlilirillril ^^^ i:;- ii|i iiiivv Icii' -| I iiclal nllc-l iiiii- a- t" till' (li'Vtlii|iiiiriil iif t\ |ih'iiil cviT III liiiiuaii liciiii:-, I IMC dt' the lii-I ami iiin-l Mii|i"itaiil w i 11 III lliiw ami Ia uliat rmitc leave llii' Imily uf lli latlclll till ill iir-iiiin will naluralK ari-( lU til thf t'lirtlii lirhaviiii' lit' till' liacilli, in airurilaiin' v. illi tin- vai'\ iiii:' (•■imlfimi- iimli \\iiirli tl ii\ all' I'S ariiatril anil ilr|Mi-iti Iill in tlir lir-t ^la[^(M) l (iiic-linn of tlir |ialirlil, a- wt'l T -rrri'iion- ami cxrrciion- 1~ lll~ lilouil liavr naturally n ri'ivnl v-\v alt('lltll:ll. 'i'lic iiliidii i- .-rarcrK' to lir taken into eon-iileratioii as a iiKHJiiiiii of int'eetion. Al.-o tli e\|iinHl air a|i|iear to e -Weal, tile i-\peetoratioii, ami tilt' lie of .-liirlii >ii:'iiiti'"iiirr a- carrier- ot' tlie I'l-iii- of iiitcctioii. Direct C7.ca|ve oi' ilie liacilli with the -weat i- more than (loiilitfiil. lMilati-onic ca-<> o t' |iiiciiiiionia, and. accordiiii;ly, eliniination of hacilll ill tlic ^putilin ami the cxpire of llie inlectioii. llic -talcniciit of Sicard ' a- to the aliiio-t coii-iaiit pre-ciicc of tvplioid- liacilli ill the expired air of tyjihoid patients i- mo-i reiiiarkaMe. and lircs conliriiiatioii l-'ar more iin]M)rtant than all of the .-oiireo hitherto con-idercd are the fecal di-chai-i;!'- and urine. ( Jciicrally the-c are proliaMy tiie exclu- sive media liv which typhoid-hacilli leave the hody. The hi-tory of tvplioi 111 till' niriliilhiiN IN li'tlMll'ill 111 till' lllll-- lilli', in cnll-cilllc'l iiiliiil- 1- I'onlniiiiiii iiv i.r \vlii<>li (ii>|)unuiiity tor ;iiliiii\iinv \v iili mtc -l!ll;il 111. 1 lion. .rl'liM If. ■iv iiii; 1 (,f lAl'nliali'lll :H1 tVdiii tlic .■;irlii'-l -lai. il tlic i>r lllccl-.i- 111 :hI< lilioii t(p llic aliiiiiiliiMcc u f tlic liiiciili ill till' I if inlc-tliic the -c;it ol 1 if llic I.I ttcr anil the ic -|iccllic K .1 1--10I1-, the re itivch lofllollS duration iniinlici- ami coihoii^ik-.- o t tlic tlailv Iccal ( arc taken into con -iileraln llicfc call lie no < «IlMl|- CO ll-Illlltc irolitic -oni'cc ilenoioi;ic exaiinnation ol t\ | iniluiiitalily ami f|-ei|neiilly the [ li>- lollllt tliat tlie for the coiita<;iiliii of typlioiil fc\cr. i^ii-tniii il ilioiil-hai'illi.' f t\ iilii M -looi- lia- al^o (li'in ircMiu'c o f living: typ i; ■nt oli-ei-\er- li: -tal.li.-licd tlii> f-et \Mili certainty ill-tame, { 'liantenic— c,- who in exaniniation |i:iliinl- fiilcd to tind iIk' liacilli only thrice -taiitlv, in accordance wit it' the >tools ot |i; tyj) Il the nature of anatomic Icr 'I'hcv arc found ino>t con- ^ from tin' lic:iiiiiiiii;X "i or fi'ciin the p' the >ceom 1 week to the end of the t hird week and l:it( d of mednllarv intiltration of the lyini.liatii' ^trllctlll•e<, their exfoliation and nlci ■ration, until the ci iiiijilcte eica tri/.ation ot tin; ( )n acc'ciiint el the (litficultv atteiiiliiii; exariiiiiatioii iif the >to<)ls for tv|iliiiiil-liacilli. a >\m\\ Icaiiil reliahh' iiicthoil for their isolation ha.-* loiij; In littiiailties are (le|ieMilcnt es|ieeially iiim)Ii the coiisfa wantinL'. 'I'liat tl ce ot' luiiucroiis other iihcro-orL'aiiisins is ohvious. if these is the ci lit I'he most troiihle Ion Imcillus. which reseinhlesthe ty|ihoid-hacilliis in so many res|ie<'I The cfliirls to isolate the lynhoiil-haci iliis from the stools. iiiire>licciallv to diti'i'rentialc it from the colon hacillns, have resiiltc.l in tlie I lulilicatio n ot several liiiiiilrcil iiapei^ i"() to the time of the introduction hy Eisner ' of the inei mm 111 w ahuosl insiinnouiitalih^ illlllcultler known hy his iiaiiie, the isolation of typlioiii-lpacilli from the stools presented ties. l?v the use of this medium Klsner.* iei> were ahle to isolate the typhoiil-haeilli (luriiii: the fehrile sta'.'e in u larL'e propor- r, the possihility of contai'iiiiaticii aiiahli,' I'iorkowski," Heiiiv,' and L'cr,' liielianlson, ami the \'vr^'<. of typhoid p; oil In 1 icse cultures, lioweVf iv uriiii' \sas not L:uarilei aiiainst. (' iillicrs. Iiv the use o f special media, have also iici n ahlc to ilemoiistrate, with ,1 Sii i.l-. ill til. J- r;illi. -I |illl.lic-Mtinli-. V\\W\VT. I)iUts,-hl- >,>r IssT. N... -J-.'. Cliiir I'tiilt f. /lii/,/i-,-:.J,.,,i No. ;!. MitU.I :ui .1 w i.iui. a 1(1 (iMl.l-chiiii.h. <:nlrU. N. 'i 34 iiiiirc i>r li .-> I 11-. , I ivriiiiiii I i:\'i I: li,. !,a.i!!u- "f H|.li..i.l in ;i l:n-.'r |'i'n|,. nitill nf I -M.U 111-' "Hi, :i n.u nirllm,! h:,,- ,-..h,l,..l tl,r Iv pliniil-lunllu. ti-ti, I u' r,.,-,-',,, IT ,:,-,- nul uf ■.'! .lU.llr.l. TIh^ ,..M1,1V:| nlllv niR-lN l.rtnn llir 1,M .l:u ..r 111.- >''"n.l uirk. Mii.l .lwi|.|.r:nv.l nmiIi iIh' t;ill c,t ll.r liM i . |),„-iii.' ll)r|i:,-; l.-u \(;ii- v;.i-inu> nl,Mr\vi> l,ii\.Ml,inon>lnil..l llM-jniM fn vw■^ uill, ulmh |^|.|H.|.I-I.;,^|||, unur M, llu- nnnr, mnl l.aM- ..ilK-.l ;,„..nll.nl..ll„-nn|.o,l:n,l ,../. ,,| tin- -rrn m.„m„ i1„. -|.rr:„l „I llir .1,-, a-.. In l^'.iit. NiMiiiiaiin .Kinnn-iral.'l lv|.linl.|-I.Mrill, lu I lir nnn.- nl II ..uImI -IS ra,M> .AaihM,..!. Hi- n-iill-u.iv , . ., im .1 u il 1, ^..iia .Ur|.lir,M„. Uv, - ,.,,., ;„„1 ivrnvr.l „n,n„ti,i;,a.in„unlil IM-uhIiL^. in I >:•>. l.ul.h-lir.ll i. n-ui|, of .■uhiin.- ina.li- Uniu llir uniir in -.'l ra,-,>. VMll, i-nlaimi, n| I,. tvnl.nMi- rn.iii :;. i.alrr. l;irl,ar.l...i, ' ,,l,ian».i ll.rl.anlh tr-iii L'.. pul ..t l(il,a,-r,-.xan,iih.i l'^. 1 |..i-.vul. ; ami ll-r -Sniilli ol.lani.Ml ll..n, In.n. 11 .,|' :',') .a-r- _'S |„.r .Till, llir uiiiic n.iiIaiiiiiiL' :il liim- a- iiiaiiv a- .■,(ll)(»i»il.(lll -aiii.-ni- ill .a.-li nil.ir .viilinu li r. I»nriii- tlir pa-l .\rai-. l;illil 1:m(1. iVoiu the uni).' nf ;,.. I\|.i,..i.l l.\i r |iali, nl:- iii ll"' -l-lin^ H;'!'" kiii- lln-i.ilal Ihr tv|.lM.i.M a. llli urn- iH.lalr.l in I'.i rax -. W lnl- lli- l^i; 1 ,,r il„- l,v.|ii.ii.-. ni- ll,r l.a.illi in ll.r uiinr 1,- al UiiM- nt Miiporlan.. n, .lia-nn-i-. il- -u:^u■-^ iin|...rlaiHv ,- innlalmn to llir :■ ival ,lan-.T nl ilir MMva.l anil tran^H.i-M f thr iliM-a-r. Il -l-^u- llm -Miv n,- ran ulii. I, ^hnul.l I..' nliscrvr.l il, M.Tili/alii.ii nfllir urinr. In i:uanl a-aiiiM aiiv clian.r i-niiiainiiialinn nf ilit- walrr-suiipl) "V IixhI. \ THE VITALITY OF THE TYPHOID-BACILLI. W'hal aiv ilin .•.indilioii- nrn.—arv tin' |.r(-nr\ini; tli<' vilaiily of llir tvi.li.ii.l-l.a.-illu- williiii and (Hit-idc llm lininan Ii.hIv, and xvliat ivla!i..n- s'liii. .In iIh-c nondilicMi- K.'a r In inti el imi nf tli, in.lividnal an. I In lli,' p.n.Tal .li".aninalinn nf tiu' .li-.a-.' V Aiv ill.-.' .■nn.lilinn-. an.! tli.' ivlali..!! nf llin tvi,hni,l-l,a.aliii- t.. tlu'in. -nni.-i.Milly u.ll nn.l.r-lnn.l ti.at an .A|.lanalinii nf ili.' iv.'..uni/..."il.l.'-.' Nninnr..us inv,-tiirali..n- in r.-ar.l t.. ih.' vilaiitv nf til.' lv|.l.ni.l-l,a.illn- nn.l.r varinii- .■.m.litinn- liav.' yi,'l.i..l important iv-nli-. In i^.'n.Tui, lli.' m-nli- ..f tl,.-.' inv.-ti-aii.in- hav ma.l.' M |>..-iliv.' im-w.r tn tli.- latt.T .|U.-li.-n pn-ild.'. Kv.ii tli.- alw.n.v ..f -|.niv fnnnalion, wiil.-l. i- >o inii.ortani with ivlati..n to the ivM-lan.v ..f l.a.t.Tia. i- not >nlli.'ic!it t.. llirow .loiil.l ..n th,' iialh..j;.'nir r-i-iiilinan.-.' .if t!i.' t\ iilmi.l-hacilln-. A 'laP.M' vri.- .if ..l.-.Tvatinii- atV.ml ini|M,rtanl cvi.l.'ii.'i' in fiv.,!' ..f til.' |MT-iM.iiiv .if tlw li:i.illi in 'III- livin- hnniaii li.i.ly. Th.' tyiilmi.l- l>a.'illii^ lia- l..'.'n f-.nn.l in intlaininamrv .xn.lat.-. aii.l in |.h.iiil.l th.' ha.'illi hn . 1/,,/ Y,,-'.' v.il IxNNiii.. N" 1'.'. ' /•'"■'"' '■'"'■ ••■•"■''" 1^'"'.^ 1-1 ■' VcntralM. /. link., l^;.^, N" 1 l- ' •'""■ '•■'V" '• ^'"'^ ^..1. iii.; M-.. v„l iv. i I.inart. I'.Kin. \.il i.. i: III It ')<:)'. •tV .'I- a i-c-ult "f -|H.iit:inc(iii- rii|itiii-r Mf li' imi-iiiii 111' -Hell I'liri, ,||,,i,| illllvlinll will ll'il, :l- :l nilr. lie clll-i'il I 111 Tl 1 1\ . NrNCI'lln III lin- i':i- i| (ili-rlll'i- rllol.i^r\ -iii-li a IKi ~-illl|il mil III' III! nut ,r i-,.n-lilir:it rlir ri-i-lailrr of lllr ll.nilli a|i|" lI'- 111 111' ralln !• lilllitnl ill lllr lllllliall il I Ml-. Mllinll-ll Illulli|iliiMliii|l ll I- llri'll ii!i-i l\iil 1" I iIm' I'l.lii- -Iml-llv all' r ill :i tiirtimi - alw i\ - ih I I- iMPl.rl ami >iiiiiiiiiiiil-, 111 111 !■ -1. Illi ■iirrniri' nl iiiiln HI r\i ll- an ni|iiniiii- iiitliii mi 'l"li:il llii- aclimi lamiiit ill prlliji i| IIIMill, II ImwcMi-, ami llial tV iln' iiruiiliv larlir It III' \ il w 1 all llll riill-liirralliill lllll-l ihii-i Ihii-i' iliail if w iiliiiiil li'Vi I-. a|i| n:ir ilrllli'll II' Mivill III till' hiiillr- 111 -li'aliij li\ till' iili-i|-\aliiiii- if Kai'liii-ki ami 111' I'lli-i, ill-' fiiini'i- if w Imlil li mill liv'iiiii' liarilli III lllllliall raila\ia'- a flir lliivi- iiiniilli-, \\liilr llll' lalliT fmnul tln'iii in a i\ 111^ -lair in llll 'II. lirr-i-Ii'lli li.iilii- 111' ilrail iiiiinal- a- lair a- llir -r\ rlllirntll il:i if tl li alliT llii'\ li:lM ll till' litiiiian liiiih 1- lli\ iif fiirlliiT iii\'r-rn;arniii III \al' - iliMi'l -. pliv-iral a- \\f\ Willi ri'^anl in llir inlliirm-r <>\' varinii- :i'iii|i I'aliiri'-. II ha- ali'i'aily tlirr i- lllii-l fivnr- Ihi'Ii iiiililii.lii'il llial llir |ili\ -inliimr \«i'\\ liiilln / iln aliji' 111 uiiiwlli anil ili'\ ili.|iiiirnl : Iml ^il-n nnHliTalr cMrnial Inii- |„l,l|ll|'i- a|i|irar In rVll'l lln illjlivioll- illtl I H lli'l'. 'I'ln' IVjillniii-liai'illi -iijrl'aiilr lli'HTri'- cif I'ulil. I llrV in ('.(II 1". I, ami i'\ I'll rciiralcil ll'r I'Stl'i'lllrK n-l-lalll 111 I'M'H run i--i-l al lrni|H'raliii't'- a- \n\\ a- tni'/iirj' an I lliawiiiir "t ll nil! I'liiilaininL;' iln' iiaiilli iln iml a|i|>('ar In -lni\ llii'in I ( 'lianlmir— 1' am llii. Wiilal, .lamiw-kv '). Tl Mil llir illii-lr.iln 111 Ml llil^ rill linn I- l;i\i'11 Iiv I'l-ncliii 11' nm-t ilp-( r\('(l ('. (.".o.:!" llial i\ |iliiii(l-liai'iHi k('|it ill ii'i' at a lrin|)i'ranin' lictwrrn 1 < '. I j'.iaml 11 ('.(!■_'. - I'".) rrlaiiii'il tlii'ir \italil\ fni- llirii' I tli-. Tlii' lia.'iHi arc fii- iiinrc -m-ilivi' In |ii;^li ti'ni]M'raliiiT-. cnlliin- il\ in^'' in fi'niii llll In lil'tci'ii ininnlr- lit a t<'ni|ii'ratnri' iif lin I!. (i'i~ K.>. llciit i- -ii|i|il(iiiriin'il liy li^rlil in tlic (ii'^lrnrti if iIh' liarilli. wliiili. a- iiiiliiii-r ' \\a- llll' lir-t li I -hnw, a ml llii'ii •): iiinw -k\' " am I (iaillar.!," ilii ilii'ii't -nnliiihl in llir rnnr-riit' a few lionr-, while -iniipli' diU'ii-c iia\- h-lil a|i|iiar- In nilliiinci tlii'in far li'ss imt'ax'iiraMv Till' 1 11' barilli a llll ai'i' rnmiiarativi'lN- ri'-i-taiit In ilrvnn; Mixi'ii willi iiidi liii'iil -uli-laiici's nr ilricil ii])nii inaniinalr ii''ii rt iltrn-ils. inati /,."•. ell. Arr/,h- i. /■;,, /',/'/,. ■/. VInirn, •,!... [ill. \i.\., .-;. 4-JO. r,,iiralhf,iti f. linktri-fh.n"- >i l;,,;,<,/,„/.:,,„l,'. IM ^iii. M,.l;,„l Il.::.,:l. vl, Nwi., 1:^S: r, i,i,-,ilhliitt f. Itiil.l, i-,,,l,.,-,i, I,..,- ,;t. • 1),- r.i.thi.,,,;- ,1, h, h, l:,r.,-<,t.„k.,ul.. li.l. \i., N. ■ /* ,s iilicrij~i'ril'lltts!Hr:<, K\oll, 1 ^?S8. mmmmj^m^^ ■Mi I ) riii'ih 1 1 VI i: (■li'.'--llir\ ri lain in liii-l ainl I II i \ llirli- \il:ihl\ li'i- iiiaiix niMiilli- -aml. a- well a- in carlli. lli.- I.aiilli j" r-i-l t^T -i\,ial Ur.L- (I II. I- ,ii;iini ']. Tlic -ainc lia- l»cn ilmiMii-l ralcl li\ \aiiMii- ,,l,-,i\ . i - t..r llic ^(.il. in winrli ih, lia.illi lia\.- I", n r..nn(| |.. Plain llnir \i!alil\ fur a- Icn- a- lisi' ami a liall' inMnlii-. It i-, li.iu,\cr. 1.. lir . iii|ilia-i/i il (■X|in — Iv tlial II.. .-..nili. ti nt oil-, i\( r lia- ii..liii.l innllipli. ali fllu' i ■•.■:;'; in lli.'-..il.a ra.I llial i-.liiv.llv ..|i|i..-..l lo ill.' -ratiiil.m-a-nini.- ti f til,' a.lli.ivnl- .'I' til.- -i-.,i:n,l-uat,|- tli,..r\ that inatniati (1,\,!, .11111, lit, an.! iv|ii-...in.'ti..ii ..f tli,' t\|ili..i.l \ irn- take |ii:i.T in tin- >n\\, ami lli.i-,l'..|-,' ..II.' wlii.li icikIi r- iint.ii ilii,' an i— cnlial Icaliirf i.l tlii^ doctiin.'. ,\ ^ ill,. .Ii-yihir ,'\|i,'i-iiiii'iii.-. ili.'Sf "f S.'ii/,- rHi'liiiMiiii.' (iatiky,* ail. I ScliilliT ' Ml-,- .'-|H<'iall\ in-lru,-li\.'. Wliil, tlu' la,-l-iiaiii,'.l tv\.. ..I.mI'vi'.I till- l.a.'illi ici nlani lliiir \ ilalilN f..r M'Viral iii.iii'li>. aii.l ,'vcii li.f a \ .ar, on llirca.l- ,if ^ilU. tt.-.. iin.lcr -uilalil'- c.ii.liti.ai:^. llif I..iiiht ..1.mt\.'.I the bacilli In |ifrsi>; tV..iii lu.. t.. tlir..' iik.iiIIi.- drif.l .liri.'tly ii|>..ii .l.illi. ( )t' ,l,'i'i-i\.' inii".rtan.f i- tlic ,|ii,-ti..ti willi nranl t.. lli. |.,'r-i-trn,'(' (.r tv|ili.'i(l-liaiilli ill wati'f. tli,> an-u,i- t.. ulii.li i~ |.li.al,'.l anil dilli.nll. Tlir -iin|.l.'-t |ir..l.l.'in, W i wlii.li iiiaiiy iii\ i-tiL;at..i'- -taftcil ,.nt, i- til.' I.i'liavi.if in .li-tilliil wat, r of in ■ I.tili/.d >|iriiit.r-\\ali r, wrll- wat.T, ..r riv.T-ualrf. I 'mlif tlir-«' ,'..n.ratiir,' ami of otiicf cMraiifoii- tli>Iiirl.iim iiillmii.'i-. it lia- Imcii (IrtiTiiiiii.'il that ill.' I.arilii may pcf-i-t tor as Ioiil' a- tliiv,' iii..nlli>. Tlir iiiLTi'-tiiii: ,'ir.'niii-tam'i' lia- ili-v.lopcil — a- it lia.l |.ivvi,iii-ly Imtii i-tal)- li~lii',l aK,. li.f olIiiT iiiii-fi.-orj;aiiiMii^ — that a ilitVinncf in the vitality ,,|' t|„. |,;i,'illi i- .'xliiliiliil a- till' water in iiiic-tioii i- at n-t or in niov.'imiit. In the latter event the l.aeilli are more i,iii.'kly ile-lr,.ye,l.'' Th,' eomiiti..n- aiv far .iitl'.reiil in un-terili/eil eonneetioii it may he stated at the oiit-.t that the [...-ihilitv ,.f |,r,"-ervii;- the haeilli varies widely in aeeordanee with the ditl'ereiit eheiiiie aii.l lii.,l..L:i.' iieeiiliaritie^ "f the ri-|.eetive waters. l''rom lliis |ioiiit of view it i- I'.in.vivaMe, and it lia> ri'ii.atedly l.eeii ileiuoii-traled prai'tieallv. that in -..me water- the vitality of the l.aeteria i- cM-eedinfily -li-ht, while ill others it may Ix ii-iderahle. Of far ;.n,-,'ater imiior- taiiee than phv-ieal and eheini.- e..iidili.,ii- in tlii> eoiinerti..ii are the jirescnec aii.l a.'tivity of water-liaeteria. N,veithele>-, the l.aeteria iiavt- 1 (■.■ntnilhlalt i. H.,IJ,'r','.h.„u- ,1. I'„rns\t,i,l.,n„l.. IM. XV. ; i,.,r, ,:,_ • /,...-. -'.'. * /-'"-■ ■•'■' S .|, ./„.,/,„ „„v ./,„, l;.-i,-),..li,^', „•//,', /y,n„l. I!,l. V. " Ui .Miittli.il ..1. Sta-i'iltii. .I/,/"'/'"''" l„^i./„tu.r r.iirnr .y>rr!„ir,ifal,- ,/i U.,,,,,. lis; I. E^}^:-i^^^^^^^^hl]!^!mJ^ . :-^^ i:jI"I.<'i, ) II loMlliI |i> I'l IMIII lliiic \ll.ilit\' t''i- nil .III- 1 :l- Itin;^ ;i- i i^lllv cl:i\ - III l.v iici leal (liiiikiii;.'-ual(|- (< liMiiliiii --<■ ;in(i W uiai, Sii:iii-> ai |)iil> iii\ -). !• Sell III ;:rijllv ciiii III-I.IIICI' till' ;HmI l;i"U/ til' I'aiikr III lliiiin, " laiiiiiiali il tlouiii:.' walir, a-, I'nr liiili \\a- cxainiiiiil I>n W nit Ini'rfl ic liarilli WvW tiill III! tn ntaiii llirir \ilalil\ and -till l<> li ijialili' III' iiiiilli|il|i'alii>ii at iii^'li triii|Mraliir'( - ( I '» < '. ami Imi\ I' ). Ill prill- V* 1 I'c ill I i\ I i-iiiii ci|)-cr\icl til ritaii I ami ill till -III I their \ ilalily li>r a- l iiiii'iil rnmi well-. 1 II'' a- llilTc wiv lliat ilir iiiiiililinii-. arc limn- I'axnrali! ■ in tin- ciiiiiiri'tinii in tin ill\ \M'll-iiriit<'it( il i^cnrra! ami liuii-c n I iiinl'iiil'ii il ami c-iMMiallv tn lie iiiptnl 111 iinc-IiL.'-aliiin- iiiln the iiiixic i li--iiiiiiialiiin 111 till' iii-ra-«' w. i-i' r\|irnniinlal i'\ iiirin r in tin- I'lm II I n 1 Miiiilnl al-ip III artitirially |(r lali I-, \\liiili ill tiinr- nt' ('iiidcinii' I iiiiialiK' iniiiicii'ii ' illccia ll.v iiiav 1 .lav : III ini iMirl; mil i- iVmil tile cilll-ct lll> till lo-c Inp |irc- iLTatinn- lia\c .• cailiiiiialcil I r.;/, t' a- prc- lariui ha\"c lArll I'll' Wci 1- -iil)-iilnlcs I'.ir iiidinary drinkiiiii-walcr. 'iyplidid- lircii ruiiiid III retain tlicir vitality in tiiciii t'nr day,-^ iiiiil l<-.' Other ordiiiarv tliiid-, aiiki '). while they die more rapiillv w hen the external tcmperal lire IS low, as well as when tlu' stiMil.s are 111' liiLrhlv ai-iil reaction, or in the ])rescnce of animoniaeal dccoiii|«isi- tiiiii, -iieli a- occms e-|)eciallv when the ^tool> are mixed with nriiie. In the dried -tools the iiacilli retain their vitahty for a f;ir Ioniser ]H'rii«l than under tin iiditiniis iii-t naiiicd and tills nalnrally i^ of e-|K'cial Miilancc with rcL^ard to the dis-emination of the disease. All of the individual >tateiiients hitherto made indicate that the ly|ihoiil-l)ai'ilhi-, in spiti )f the ahscnce of s])ore-formatioii and in spite of a certain >cii,-itivene^s to individual intliicnecs (high degrees of tem|H'ra- ' (l,r:,tt,' l,,l„!. ,1,- ,n;,h;n„- ,i ,-l,;,;iv,p.: ISST, N,,. !». Arehir,^ ,lr ,„;,l,; <,1(,l,\ IM '.I;-/,,;/,. -/-,„ /.„,.-,-li,sii,„l/„'ifs,n,it. !!il, v.. IHHt;. h-ti'lt.T, Ar'„:t,- ,/,■„, i;,'iclis-..r, :,u.l ui.l.r ,-,s„r,l,l,. ,,.n.l,M..n- .^'"''i^' '" ^'"'■'■'' 1'"" .iMHina,,., -Ih. .Irv n„,lia a,v „.„ >.. 1- 1.1 , ..l , ou-i.l.ra. U ...,„„.., 1,., I, >n.,r.l.al ,l„....Mta;:ir.,„ aUa,!.,! ... ,.an i,!,- .,i ,1,,-t .nav ,.,| ,|,._'iv.-. \\r -hall lat.r 1„. ,li-.inhiai..l il,n.ii.Ji iIm' air l- a In.nt. |„v,. ;,u n|,|,.„innnv to nunn f. tli.' v «">h ' ^""1 l-^' tirallv iiiil„.ilanl irrili,.,!- >.[' di-, ininatioii. M t,-^ i-?!-: HOW DO THE TYPHOID-BAQLLI GAIN ACCESS TO THE BODIES OF THE INDIVIDUALS INFECTED? \|,n..-t all ,,l,v-i,lan-a.va...v,.l at llir fn-rnt day ll.al ll,r ,li.j,-tivc ,,.„, ,. i, :,|,|„a,"-.-|-iallv...tnn,i-lMlM. ^,.^la,i^,n.al-ni-i,Mu,■nl.y ,a,■.l„■ M,v,,,a.n..,.s.u .1,. aln,.,-t .a.Im-is ., l^T-al nt , n.rv l.„M. •ll„.,„nvi.u..ni-l.Ua, ,1.,. ,.v-, i,t -lay .hat ,^ pJM.i.l I, v. r ,- ,.., iian- ^i^il,],. in .h. -....■ ,.r .h.' •• .rnr ...n.a.iuu- - .li-, a-,-, a. lor n,-,a„.... „,,,„„ ,;.v.r.^.-a.V.l..s.a,an,l „„ a-l,-. M, n- |„v-, ,„■.■ .n .h.' vi.am.y ,:,. ,1, „i,.,„ i, „„v,r .ulli.l,.,,, ti,r i^h.■.i..^,a-^^i.li.l- la...T. 1 I- 1,,,,..- an,l .h. -Kin. .h,. l.-l-M,- ,...-.al- of .n.ry li..' .h- a. u... ,.x;,n,h,n,a.a. a,v -ran-.K ... !.■■ lak.n in... .■-...-lI r." :: .. m. . > ■■ ^^ .1,1, n|.h..i.lhv,.r. l,:in-|,i.....r.hi-ta..t.ini;...i.... .l..-..n.lMnhala.,..n .,.„„:,,„-,hl,. in.-a,v,-a-,-. i. uiUh.f' 1 "! .h..iv .a.v.nl nn,-.,- ,,^,,i,,,,,|,,M,,r.al-...l,.M"'i-'-l'^'-^^'i''''''''''-^'''"'' ''''■' ■''^'' '''':'':'■''"' ;,,,, In.l.r -u.h ,inn,n-,an.r- ih. infr.ti.... i- .•...'^ ' .v'l >l"-n.J, ,i,„.K .li.i,!,,l llni.i ...n.ainin, l.a.-.rrla o,' i„H..i....- |.a.'i'h- "I 'l-'^'j vvl.i.l, :,l,h..n..h.h,. hav,. .ain, .1 ..m-a.Mv in-, .h.. , ,.h « ulMn-|.,.v.l .,1,, ,,„ ,1„.„ -uall..u..l an.l liav.' .1m,- rn,n,„.n...l th-n' a.-.,..i. m the i,iii-iin.'. ■|'|,c i.i'in.il.al Ilia,,, III- in wlii'-h th.' |...i-..ii ;,ii,- iii.raii.'i' iiit" tlie ,„„,,.,„;, :,, :.,„n,.a,v,lu„l>uhi.-h all ,„h.-,- a.v -■arnly t,. l.y .ak..,, i.,„;..„n-i,l,nm..n. -i-.- i„ -wall...!,,. ,h,. inti ..iv . a.,-,,., .a.h.r „, ,.„„-..,,„.■ .■a.Ti.|,nral,-,"-i>i .a,n,na.i..n ,.. .hr l.u,va ravHy and h. .„.,■, .un.lin.. -.,■„,. n,v-.,.,-.h, ..d, ,1,.. nm-.h-.i.... ..f h-1 =mu1 d.-mk ,„„„i„i„. ,|„, „,,l,„id-l,arill„-. K.-..M, th- .nuulh tho v.n.< pa^es m^^^^ . mrwmnifmmmMi^^mimm^LMsmmm^^^ I It'll III, y .I'.t .i |,rMil._'li llir .•-(i|ili;i'_'i|. mimI -l..in:iili iiiM Hi. iiil.-liiir, iii til.' r.vl.lv alka- |..|, . <! ll \i\ liil'i ll- \\:ill, \^ nil I -|"'i' ll 1,1, li i.iK .' I,ir 111.' h iii|>li:ili.' :i|,|i:ir;ilii-. I I..III llll- I'-'Hl till n,',' llii','n^li ill, I ill, \ iiiii^i.il. III I l-.tr,:iiii I, 111' I'rl.'il..! iMiipliMli.' t;laii.l-, an. I ill.' li--ii,- aii.l crLiiii- lliMl liavf II ll, ,l|, ,|l\ jMlllll I' I ll' a 1 ,1 mil ir,lii'ii-i I 111.' |iiii.<" ,',,|ilaiinii;.' 111.' Iiacilll. ,|' illlrilinll ill. 111-. i\,'-, ,1 .,,1, ,:ill,,ll .,(■ til.' ,A|i.li.ll..- lli:il li''^'' I""" li:l.l "I'll "'li'l I'MtlMi- ,„,,i,. i„.aiii 11.-, iiaili, niails n ■ .iLiiira-liainiii-. tli.' .,i..-li..ii i- iin|i.ii'- i";,„l ;,, I,, |„,u ill.' iv,,l„,i,M..ii.l , iM'liav.' will. l'.'lali.ii. I., til.' ^'ii-lri.' I,ii,,,, I, i, In.iii ill,. ,inl-,l III ll.' .'SlH'-'li'l lliiit ill.' lv|,li,ii.l-l.a'illi, ul,i,|i iliiiN,' .A.'ii M|".M ImIiK a.i.l iiiiln.nt iii.',lia. u ill in,.i,' na.lily |,;,- ilir,,iit:li till' -Mill. I. I iniiir,,! llian iIt .'li,.|il'a-l.a.'illi, wl.i.'h ai'.' ,-l„,ialK -,'ii-iliv,' 1,1 lli.'ailiiin.ifa.i'i-. A- a inalhi' -if fa.l, Imlli |.ni.- ,i,,,| ,.,11,1 ,Ai,,'i-iiu.iilal .ill-. rvMti.iii- -liiA\ lliat ill.' lia.'llli ..!' Kli.rlli ai'.' ,.,.|;„iv,K II -Mint III III.' -.'.'i.tiiin .if llll' -liiii.a.'li. -i t''at tli.'S mav li;,\,. till- si-,ii- uilli tlii'ir vilalily |,ii-. i s , .1. .'-|" .'ially if a.liiiiN.'.l ,,j,|, ,.|,,,ii, aili.'l,- ..f f.iiHl. Til,' IV,', li.Mii-ii.liliin.'a.'i.l li.'.ilal ' l.c i.ik, II iiii,i ,',,ii-i.l.'r,iiii'ii a- .'MiliiiL; a l.riiiM- iiitlii.ii.'.'. I'.|'-iii lia- ,M,| 1,, I,,' ;,l,-i.liil,ls lianiilc— fur lln' I'a.iHi i^iiaii- ami Wiiit/'). \ll,i' Kila-aln' I, ,1.1 ll,' ii-li'al,'.| llir r.'lali\,' l',■^i^lall.•.' nf ill.' Iv|.liiii.l- l.anlli |,,a.'iil-. Siil/ -Imuiil llial in a ililiilinii ,,f liMJPi.liliirii' a.'i.l. •».:! part to IIHIO. til.' iiiiir..-..r-aiii-ni- nlaiiinl i li,ii- vilalil v fm' llii'.-.' ila\-. In a ,1,1, nil. II of ii.'.l |.arl I.I liliiii lli.'V u.'i-i' fmm.l .1. -iniy. il I'V .-^t ran-.'- an, I Willi/ ..,,lv ultiT li.iiii HMi III iliiv.' Iii.ui'-'. aii'l Cliaiil.'iii. '>.-!' an. I Wi.lal' -li.,ur,l ll.al -lijil a.i.lili.'aii.iii uilli livlnii'lilnri.' a.'iil ,liil iml t'lilinly iiihilnl .|,v,.|i.|.iii.'iil .iflli.'.iillur.'-. Sli'i-ii ' anil Haiiil.up.'.'r," wli.. l-i.ik ii|, llic .|ii.'S- li„n!..i,'w. liL.u;-,' i-Hii,' M I'l n.'lu>i.iii Ihal tli.' iinil.'.'li'in atrnnl.'.l l.y tic l,v,lr,„li|..iii' a.i.l I.I l!.. L.':>-ni.' |.nr.' a'j'iii'-: '" • .'iitran.'c nf typlmiil-lia.'illi 1- v>r\ .l.iiililfnl. I iji a.T.mnl nf lli.'.inil,' rapiillv iiii'i'i'asiiiL: iiuinli.r nf .'a,-, s i'.'|Mii'I,'.i as l\|.l„,„l ttilli.iiil i -liiial l,-.-i..ii,-. ill,' i|ii.'-Miin ariM'- uh.lli.'r iiif.'.'liiin ran n.'.'iir tlir,.iiL:li anv mli.-r lian llian lli.' inl.-iinal. nr « lictluT llu- baiilli mav iiiva.l.' llii' Imi.'Iv l.v |ia-ini: llir.ni'j-li lli.' nnrmal int.'stiiic nviiIhhiI laiismi.' aiiv l.'>inii in thai Ira.l. In n'-anl In iIk' tiiM |iii>>il.ilily. th.'iv i- im liimit at'|,r.'S.iil that -ii.h a mml.' nf iiif.'<'li.>M ''an fv.T ."'.'iir. Tlii' <'as.'S witlimil int.'Minal l.-inii- havr lal.'lv li.'.'ii r.'vii'u.'il l.v <)|ii.'. Ilf .'nii.'lii.l.'S llmt 111.' luiiiili.'r nf .'aM'> is inn siiiaM tn jii.-lifv tlu' as.-.'rtioii that ty|.li.iiil-l.a.'illi ' Air/iire.H fir tni'ilfrine r.rix' riini-nl'il' . l'»>''.l. ^ ZiilKchr. f. Ilwiii-lir, H.l. vii. * .\i-rli'irr!< ilr /'/..;m'.. /,"/'' , 1><>*7. i \;.lkmaiiii\i Snininhoni Uin. Wrtr.. Nmi' l''..l'.'i\ Nn. V'**- « /-,'•".,. /);,vv,'W<;^'...i, H^,■^la^. f-'m. iniil.-i' llu .rn,-.'ti..n ..t M.'i'ii. ' /;,///. ./..>,/..■. llni,l.i,is ll<.^/i.. \..|. \ii. » /,...', .it. mi 40 ryriiniii i j-y/a; .•a., ,.v,.,- ,.,wrr llu-o,,..|, Mn mI,.-oI„i,.1v u,,.,-, i„„-ii„al wmII, vw .„■„ i„ f„-,l 1 i THE MOST IMPORTANT CARRIERS AND MODES OF DISSEMINATION OF THE VIRUS. A.).,,,,^- ,|„. ,,,m,..-- ,., ,1,.. V in,-, water i-, M,T,,r,li„.. tu ,l„. ,,,, ,,„ st.ir „t l.,M.wI,.,|n,, l,v (;.„• tl„. n,nM i,„|,„n;,„.. Kv,,, .i,„... ,!„.,, Hi,.-, I:.n.- w.lrr i.n- ,,l,,v,.,| an ii„|,.,n.,nt ,-,;/, i„ ,1„. „,in,l- ,,C |„,,|, ,1,„ |,i,,. "'"'''"■""■''''■■■'' l""''"i"" i'"l"'l'v,|„|,„„.n, .,f,n,,-, i„tiv,i„„-,li-...,-,.: \'"'' '"'• '■' ""■'■ ''^'^'' ''""'i'- '"•" -I'^.N.I .1 ,vn,l,T,.,| .|„ul,.n,l i,. •'^ '-■ '■ '" '■'-''■•' '" '.M'l-i'l tl'V.T. Ka.-!i,.r .Mlhurs ,.-,„.,.i.,llv J)u|..v, l;.„|,|. M,n..|,i-„n. .,.,1 (i.i.-in.,r, ,.,M,,l.,-i„,| ,|,„ i,,,,,,,,,:,,,;,. <•' ".■"'•. Ih'U.v,.,- „i,|, Iv ,l„i,. ,,i,,l,„i,. vi,.u- ,liv,.,„.,l i„ ,„l„.r ,v-|„.,,- Atnr ,l,..,n .1,,. ,li-..ni„.„i„n„|- , |i-„,,, il,,-,,,,,!, „ a.,r u ,,- nrnn- '^"""' '" *■"■''•' l:i"'n,.,v ....I l.i,i„nn,.i-„.,.,-l,v ,|,. \,Ur,- ui,|, •, '•nt.ral ,l.-,.n|„i„n „r-,u:,l| an.l hn.,. ,.|,i,|,.,„i,.-. Thr ta,. ,l,a( ,1,,-,. '■"■'^^ "'■'■' '"''' ■■'' '1'^" 'i'"'- ..-t"itli-l;,..lin^r ,!.. ,|,.ii,.i,,„t kn,,u|„,|„,. "' ''"■'■^'"-" "''I- 'li-'^.-. "ill rv.r rnuain an .xainpl,. of ..i, ,„ ili,. Iiriiilirii. Thr .v-„|,- ,,f Mi.u|..fn l.a.l,Tinl,,^i.. in v,-t l-il hMi, a!.va,lv rullv ,,,„- H.lnv,!, |,,v,. ,„.n„anrMilv ,.-tal,li-l„ ,| ,|„. „;/, „,■ ,,.,„,,: ^„„,- |,.,^.^, 1m-|'1.- |>.nni.t,,ia.l,,|„r in-id,l L.m ,l„. innunirraM,. an,l .M,v„„ Iv ''^"''''''''' '■'""'" - =""i'' "l'i''l' i' M.:,v,-,rv,. a,-,li,.,.a.Ti,.ra,Hl ,li-. ,ui- "■'""• "f '!"■ f.M'l'"i'l vin,-. 1, i- k,,„wn ,l,a, ,|„. watrr of .-,,■„,,„- I..'".l-. ...el -p.-,.,- of ,.„n,lui,-. of U.II-, „(■ ,.i.,, ,,,. ;„„| ,„.„,,,,i,„^ „|. |'<'...l-. tl„. h,l^,-«atrr ,,t-hi|„, „,,x ,..,ntain thr lv|,l„,i,|-l,a,.lll„- in ■, l.v.i.;r-la..., an,! nn.l,r iav,,ral,;,. ..,„„li,i„n> n.MV rym prnni, it- linll.,.,- 'l'V.I„|,nn.,t. That .In- ,l,.v,.I.,,„n,„t i- i,n|...,ill,.,| i„ fl,„vin. „at, r ."M-..~ ^ern, to hnnia.i h.'int:- are in .l.taii -,. ..xt,vn,..| vva, ial.l,. that ''"'•■ "^'""■" ^'" '■"■" '"• ""'.ti'me,! i i- |,'.„.,, |.:v,,.v in.livi.hial ' />;. rr..,./„„,/..,.:„f,.,...„.,„„ t.,,,i„..„. m ■,.,,._ i„.:,„i,, ,^,,-, ■ \,.lk„.n„„\ s„, „„.!„„;. u:,. I-,„7r, N... .-,:!. ' (ii-xiiii,,,,,//, .l/,/,„„,//„,„i,„. S. L'T-O"), J"n<)l,()i;y, 41 .:,-.., ,n.!,niir,.r ri,i,l,,nir, .•aiviullv M,„li,.,l i„ ,l,i, ,.,,„n,.,.ii,,„ ,.x|,i|,i,.. i"<-iili„r.UHl ill |..irt ii,NV (•(,M(iiti..M-, aii.i tlic iiiMM vaiir.l ivlations witli "tli-i- l.iH^^ KnouN. '1-|„. H,u|,l,.-t mimI .vriainly tli.. nio-t iV,.,|nc.it -MviimiK,. ,nnM-i- in intiTii,,,, thi'mmh ■ ""' lH-r|,aiaIr,l iVom (■ ciiviim- .-ta.icc-^ alM, Ili.av i, ,|i,vti,.,i I,,.,...in..s rontaminatcHl I'.v llir ,|,;i,.,.!i,,ns ,,f tv|,l„,i,| |nlirnts natnrallv cxliibits tl„. {,rr,,,t.'>t •liy.THty. It n,ay nr.iv,. ,!„■ :^rnn^ ,|ir,.,,l_v from tlm pati.^nt or from priyy-urlls or ,r.~|,.,ol-. or thron-h artirlrs .i„-,a-ti..,ily .■.,ntaininat<-,l "•vi.l.nlally, or it may In' intlvl,,! in.linvtly l.y invvi.ai.s f-atnrati.ni of ''"■ •"l.P''''iit rartli with Ihii,!-, tainin- the ocrm-. Kveii in the j.n'- harl,aioloj,ri,. ,„.rio,| ninMcr.,n-< .■archil ..h-, rvations bcarin- upon tiiis pniiit urn. ma.lc. amon- whid, a nnnihrr .-ouM \,v ,lin.-t(.l \n iih rnnark- ahlc poHtivrnr-s, in th.. miis.. of lin.i.l an.l of (;i..tl, a-ain.t tl„. >imp!e |"il,vla..!iv,. th.^.ry ..f Mnr.-hi>.m an.l hi. pr<.l.v,->,,rs an.l >n.v..~M,rs in this .■atc-.,ry arc iii.^lii.l, .1, Cr in-tan.-.., tl,,,,,. ca>,.s i,, uhicli w,ll< that f.)r a l.,n- tim.' w.iv .l,ni.,n-trahly .-ontann'Mat..! with tho ..v,all,,u- fr.Mi. .vv-p.,.,!. ..an,,..! n.. ,,r only ovn.ial ha.l ctf.vts np,,n the c.n-nm.T- of the wat.T, an.l ..niv ;,ravc ri-.- t.. th,. .hv, h.pmcnt of lyph.ml f.v.T after tii.. wat.T ha.l b,.,.n -p.vili.-allv inf..i..l with the .l.Jc.'iion- fr.)ni a i-asv .it' lyph.ii.l ti-vcr. In the natur,' ..f things, wli-inf.rtions are .•..nhn.-.l to a f,'«- ea..^. or t.. Mnali.a- .>r Iar.v, h.,n<,M.pi,l.,ni.s. L,..s .•..mm.miv, wh,., ]i.|uid ar...l.-- .,! lo.,.l n^.l .,n a lar;n. -.-ah. ,a<, f.r instarw,, n.ilk, or >aM ""'■''" "' ' '""■'■ '"'■'■'■•-•'' '•> i"..u.s ,,f Nvat.T, will a lar-.r nnmi„.r of '•'^'■^ ^"''^' •'■'■*'>■ *'•'"" "•'"- ^'" -■nviv inilvti .rur. in.iir.vtjv if ' 'iMvtIy n.f.ri...| ....nxw tl»- .li-.,,-.. t., ..iImt lo.-aliti.s wh.r,. n.'W l'"> "t H,l.rti..n .I,-v,.iop. Kn.h.n.i.s .,f ....nsi.l.ral.le ,.xt..,t an.l evn 'I'"''' ..l thr.,,,.-!, the ""'■'■""'(<'iall_v tlic coiKlitiiiii- of till' soil ami tiifir variatidiis iiiiilti' till' iiithu'iicc (if tlio Liriiiind-watcr (ifci>ivc as an cliold^ri,. t'actr.i'? It was oNcriiMikfd that the \^atci-\vays rc-, ini|iei- ti'ctlv or not at all llltcrcd, was olitaineil from larL''"' stri'anis that con- stanllv scrscd ■■ i'<'<'c])tacl few reiiiiiininLT hut jicr-ir-tent o|i]ioncnl- ot the theory of t\|ihoid t'e\i r as I' wat' r-hoi'iii' (li-ea>e. arc in no w i.-e hypothetic'. 'I'lio demonstration ot' 1\ phoid-hacilli in the water ot' well- and stream- has ol'tonrce. l-'.n'.irts wei'c iiiarimar\ foeu- of iid'ccti.-n had ah'cady hccii extinirnishcd. I( ,|,;iv :i|.o lie readiU conceded :it it i- hy no means always po--ilile to demou-tratc the jh'cm m-e of t\ phoid-haeilli <'Ven in water that -till contain- iheii, l-l-]ieeially civally eontmninated water <'on- tains numerous oiher mi that only extremely timc-con-umiuL'' and pain — takiu- inNc-iiuaiiou of lar-e amount- of water will yield approximately tru-tworthv re-ult-. The literal -re .>!' a;i ccinitries from the hcL'iniiiiiir of the nineteoiitli ccn- turv until rc'( iit lime cmilaiiis a lar'-c numher of reports of epiilcnncs. .some -ixeii uitii full detail, iiiducc,! In infectiim of wells. sprinL's. nnci streams. Limitations ot' s| e alone wil not permit extended consideration of tlie>.'. iicv liMv<' heen cnlleelcd iu part li_\ M u pliison. t iiel I. and ( i riesiniTcr ; j-rnoijicv. 43 •ilso Kiflii riiicislcr ' ;uiil IJioniicr ' liiivi' irivi'ii iiuiiicriiiis liil)liiii.'r:i|iliic rcti-r- i-iM >s ill till ir ui.rk-, uliiili .~o !ii-illiant!;.- niiented .similar eharaeters, and the cinise was fiinnd to eonsist in a conimiiiii- cation hetween a lar;.'e eess|)ool and the uell. My opinion that such eoii- tamination ot' the water by the eontenls ot' the eess|)ply is furnished by Liebermeister.^ In the villaire of I.ausen. in which for a loiiir time only isolated ca.sep of tyjilioiil fever imported from liasle had ocrurred, and for seven years no ca.se at all. in the yeai 1x72. anionic M)() inhaliitants. l.'iO, almost 17 |>er cent., were attacked between the months of .Vuirust and ( )ctoher. The epidemic set in so abniptlv that almost 100 cases occurred within the tir>t three weeks. A number of piTsoiis alsi> who were only teni]iorarilv resident in Lau.sen were attacked. Caretul iiivesliiratioii disclosed that all of the houses of the villaL'e that ol)tained their water from puni|)-wells were exempt t'rom the di.sea.se, which invaded onlv those whose water-su))plv wiis obtained from rinmini: sprint;^. With reiiard to these, it was determined that a small brook that constituted their source wa.s contaminated bv the overflow from a ces'^pool and a manure pit allai'lied to a house some distance alxive the viUatre, and in which there had been four cases of tvplioid t'ever duriiifr the months of June. .hilv. and Aii^riisi. ■I,/,,,.. iCit.'.lhv !,i.-li.T!,..i-|.T: Zii. K-.lnv.Tl. /);. Tii/ii Hnllr „. S. ill, J., In;- /\,-/. Iliillr. IsTI. N, liiui-.Mi. r.'..,- A./lnl,,,;-,,- ,/.v Tu,,/,i„ fi''f/fnnina/in, Ziirirlii-r [)i-"rl:tli"n. W'ititfi-iliur, IHT'J i 'l"\-|)tir> in Wiiit'Ttliui- 1. ("■'in- piiP" ;il-M. rcTiiiTliiliLT till' -illni' ipi'liiiiir. \Vi-ililli!Mili. ('<;-f:-;./.:.., 1|. ft I . A KnMniOin, (•;rns/„.,„/,;,:hl./ S,-/,,r. Amle, i^T:;, N", id. Conine-lie, lli,,/., l^T.j, Nu. H. ■' /,i.<-. cif.. S. 04. II TV rill III) I i:\i:i:. All iii^liri'i- ol' till' ilr\cl(i|)iiHiit 1111(1 ciiiilciiiic (li>iriliiiii(iii of tv|i|i(iiil ''■"•■'■I'"" :i i:i;-v .-cai, tV..ni .i iar-r .-Ir.-aiu l^ I'liriii^licii liy liic roiMliiions liiat picvailcl in I lainliiii-L' in llic .iirliiics. In ih,. \,ar> 1X.S5. !««(;. I>,s7, and l»N. i:),MI| |„i--,,ii> u.-iT alla.'kc-.l l,y I\ pliiiij \v\,r. witli 1214 (Icatlis! A> i> l.iKUMi, Ilauiliur-. uiilil tlir i;Trat ciiolrrii-ciii.U'inic (IfiiKin.!. .1 cviii iiHirr uri:<-iill\ than lyiilioiil ih,. ii(i',»ity ot' a cliauiic in it.- ilMiiv-, uaiiT fur ilrinkiii_' ami liiiini.-iic piirpoi-i'.-i I'l ii,> river iillir, uiiici, \\a> r.,iiv(yiii inioili, lioM>ics uiitillciTii and i'i!i| .t-dforall '""""iiii<' iind ( inici-cia! |>ur|i(i.-f> wiilmiit prfvious di>iiit;Mii,iii. A i si the only water liltcrcd was tliiit iiscij for ilriiikiiiL' and culinary |mr|M.,-.rs. I.iit it Ha> dont' wiili M])|iarMtiis tliul. as is now \iionii, \va.-, \ «ni|iloy(d. Ev.n at that time 1 ciintciidcd that the df\ clopincnl of the f|iidfniii' was alli-diutalilc in I'nalfr dcirref to the olivioiisly specitieally inf.Ttt-d \\attT-sii|i|ily than to all other intlueiMcs.' I ha.-ed my o|iiiuon especially upon the !irraii;.'t'ment of the seueraui .-ysteni of 1 laniliiirL'. the ediiteiii.- of which, poiireil into the Kliic. \yere eapahle ot' eaii.-iiiL' intei'tion of the driiiUinp-waler, likewise ohlaiiied from the Elhc, liei'aii:.e the point at wiiich the sewai;e was emptied and that IVoin which the water was ohlaineil were not suflicieiitiv separated. K-lK-cially was it in th.' hi-hcst dcirrcc prohahlc, and even demon>l rated liy llie cxpfrimems of .-iinmoiids, that the relliix wave indnced wilii •I"' '1 1 tide of the Kl'.ie I'arried the inalerial eniiitied tVoin the -ewers np to a:.d heyoiid the ]M)iiit from which the water-supply wa> ohiaiiied. I'roni liic iinit()rm distrilmti f typhoid fe.cr throiiiilioiit the enlire inner city also it was concluded that a iiiiitiirmly distrii)uie(l carrier of the poi-on was opcrali\e. This could .-carcely he aiiythinir else than the waler-supplv. ]-".\eii in ihe eyes of the most fanatic ailhereiits of the locali/ation-theorv the coiiililioiis ot' the .soil and the ;j round-water could not .serioiislv lie takeii into consideration in ti city that for a lonj: time had lieen provided with a model, extensive, intricately raiiiityinir, and excellently workini: s\slein of seweraire. Additional positive evidence was found in the fact that in the iiei<:hl«irin<.' <'ity of Wandsheck, iinmedialely contiiruous to Hamlpiirir, and wIkks,. jnhalii- taiits live under identical extermd conditions, and the same conditions ot' .soil, climate, and weather, there were only a few cases of tvphoid lever diirinj;: the same period. Tln' only point of ditf'erencp helweeii the two cities was in the water-supply, 'Waiidslieck ohtaiiiiiii: its water not from »lie Ham- hur;: supply and not from the Klhe. Still more characteristic was the existence of an almost com|ileteiy iinniiine collection of huildinirs within a portion of the city of Ilamliurj.', in which t\plioid was as .severe .iiid a.s olistiiiate as in the remaiiiiiiLT parts. The Iiitrracks in that section occupied hy the ,S'venty-sixtli Infantry lieirimeut, which contained in its voiiii^-, viirorous memhers material in most marked de<.'ree pre(lis|M)sed to the disease, rcm.iined free from the epidemic, w ith the exception of a few oliviouslv ini|)ortiMl ca.-e>. It was not connected with the ;:eiieral water-supplv. hut received :dl of its driiikiiiL' and other wat.T from a well upon the premises. The .soil and i:roiiiid-waIer theories, however, at that time so thoroutrhly dominated the minds of those in authority that my opinions and recom- mendations' fell upon deaf cars. .'.„/.>,-/,. l',o7./,, /. ,,_//;.„//. i;,s„„.//,,-i/.y,fl,-,,,'. ItJ. xxuii.. 11, .fi :; irrioi.'x.y. V Tlif riiilici- iiil'rifiii 1- lliul uilh cvcrv l! i-liiir liif Water ul' I iic Kliic lii'tuciii till' I "lint 'ii ili-cliai-'jr nt' the >cua-c ami llic .-nnrcr (if >ii|i|il\' fur thr water, anil even lar lieyiiml. runlaineil an im-rea^eil niinilier uf irernis, was nrnnveil Iteyonil linulit liy l)iinliar.' 'I'lieii Iteiiike ileinuii>tr;ile(ll)V lalilt'? the fact, to wliieli ' hail alrcaily ilirerie.l attenlinn, tlial tlio.-i' |)iirtiiiii> iif llie eilv lliat reeeui-ij iluir waler-.-n|i|ily frnrn the ciiininnii suiiree were aliiii)>l iiiiiiiirnilv utiiickeil liy tlie e|ii(leinie. w bile tiie inii.-t |ieri|iiieral ili.-irids i Winleriiiiile, l']|i|ieiii|iirf. ami llnnii. wliii-li al tlial time iliil net >liare f(|iiallv in the lile.-.-inL's of till ninmn .-n|i|ily. exhihiteil riirres|H)ii(liiij.'-|v and >trikiiiL'lv fewer eases. 'I'he elearot riiiilirrnalinn. however, is atlonlfil hv a eonsiilera- tion ii'" the ennililions in llamhiirL' .-iriee the lime < Miiv, 1 •"!:{ :il72 l.-i:«i 11:17 r.in HI'.U 4 (;."i S.(M1 .'iSil L'.oi; l.M Ids loo ;!:!:! 44(i *J7r> 147 IL'S :.'o:; 101; isnl IH'.l-i ■haliu'.' ei l!n- >..iiri'f ..f *il|.l.I\ .-iii.! illlr...lii.ti..ii cf [ill run., n. 4i;2 (i.7ii :;7 . . , ... ■'i!l7 (!.'."; .'.7 (I-J4 (i.:;4 (i.i;'.i (I.! 10 (I. .-,4 (1.41 (l.-'ii o.L"J o..;.'i O, IS 0.00 o.on It is further iiiterestini: and distinetive that more than one-tenth of the ca.ses of tyj)hoid fever in llandinrL' noted in the years l>e in the number of bacteria in the water-suppK'. It was not until the year lf<'X', that the nnt'ortunate circle wa> interrnpleij by chaiiL'itiL' the place for dischar;j;e of liie sewaLTc ami the erection of suitable liltralioii-|ilants. Ill aiiilitinii to water, various liipiid articles ui" DmhI iiavc alreadv iiceii desiirnated a< laiviers of the typhoid contaiiiiiin. ( )f tiies<', liiilk is di s,.|-v iii^r ,,(' ,.vp(.ci.tl |.|insi.v-l,v. ...,.,- |,:,v,. I.Ml , f„„ -h,,u ;„ nnIL liK,. ,|„. 7'" '-"''1''^ ■""'■'■'"' ^" i'~ - ■'■'■ •■'■ - n~ |,„in, „r,.„ll,.,,l ;,v ''"'""-'' "■ 'li-"'il'"n ,.a,| ,„ ui,|,.-|„VM.I Ji-.„Hnati ( ,v,,|„,i;i '"^"' ^""' ^'^" '■'-'■ '■■ -'"^'1' ■■'■ -'■" -■ n,..,.,. ,.x„.„-iv,. ,.,,i,|,:,„l,.- "'■"' '" "'" ""'""■''■'' -"1 i" >l„. '.,i|,,| -,.,„. ,nilk i.an a.!,,,!,-,,!,!,. '"'"~''''""^'' ^""' """■""t ""'li'"" I'"'- ivi.l,..i,l-|,a,.illi, ul.i,.!, ,,.,,.,1,, i„ '"■'■''"'■'' """^■•- i-'l"'- l"ll„.,v|„.,- •MIal,,l,-,.,-valiMn-„n|,.i,n' i;„ '"■"■'■ 'I''" 'I'lrry ,|av-. ai.l. ul,al ,- ,.-|„.,.ialN ,la,„,.r„„v iImv ,i , '"""'■ '■"^'-"'■•" •^""' 'I" '"■• '■i'^'"-- >Ih. milk in ,„|„., .v-i,,.,,, ,„,,, l"'''""'~ ■''-'■v^"i"n-l in a|,|„v,.iaM,. ,k^o,,.,.. I„ ,,|| „ „1U, ,|„„,,, ,„, yl""""'-""^l''"'''"'^"''l"'-'""'ill^>l--an,....,-i,.„f,.v,.n(-.n„„li,i,,,l "" ■'^"'-- '- '■'■I"'"'l^ l"f'">i fll,.. l,nlk ,.r,nilk .u,.,,li,,| l,v,|„. l;;-'"l"'-"M..r,l,Mril,n,i,,n. ,l,v,,n.l, u,.ll-ua.,.r ,.,- -prin^-uafr „, „ |,i,.|, ""'"■'^ '" '"'l"''''l.v. llH.,l,;i,.,-,i„n- Inan ,v|,l,„i,| |,a,i,,„. |,avr ..ain,.,| ';"''^""'- ■^' 'i""- 'I" '•-'- "f >1h' .li-,.a^,. l,av.. I„.,.n tl.nn,! •:, -, '''^'^""■" "■ 'l-'^in". t^M' alu.v. tl„...,,n,-,.„C,|,.. M.|,|.lyin, -prin.-, :iii'l at "llicr tinii- in t|ii. (laii-\ il-.lf. , '■''"■ ^'"■'■'•■'' """'"- "'■ ""'■'■'' !■ "'ill^ a,v varion^: Lilnti,., „i,|, ""■ '"''-"'I "a" '■. 1-V-, I'valiun an.l tran-|.„na.i,,n \r vr-.j. rin-,.,| ui,l, ■'"■'' "^"'■'■' '"■ ''"■"'■' infrriinn tkn.n^l, ,l,r lian.U ,,f niilk.r-. .Irak,-. MTvant-. an.l n,!,,,- ,„.,■-,.,- u I,,, |,avr .■mn,. i niari «i,h lv,,|„,i,| |.:itMni~ an,l ll,,!,- .k/p.-tinn-. an.i uh,,, Ik.vIml' nr^kvtr,! ^niial.k. |„v- ''■■"""■"^- ''■■'^'' ' ^".^'■'1 ""■ ^■' '" a.-nnlan,T ^^i,l, tl„. n,.tli,„l uf .nannliu-tinv, may act in tlii> «a\-. A^ rai-iyas li,.. M■^vuUv. .v|.nrts „f niilk-inHrlkm wore made in En-lnnd t" l""n,.. «l,„.|, an ,.x„„mv,. Ii„.,atnn. .k.v,.|n,„.,|. .\> un instance, a ^.v-t,' |"l''""'"t l.vpk,,,, ,,.v,.r i„ ,i„. year l.s7:;.i„ the ,iis.ri,, of S. ( icor-^eC llanovrr N|aa,-,, Mar.v l.-hou... I |„n. tnav l,e n,enti„ne,L' It s.„.n ,h~vei- Mi,l,.,i,„i„| ,1,. Mu,,v. /'„/,, ,/, / .1,.,,,/, ,/, M.,/ , IKHI. /.'«•. ,■//. lliDLuc y. |"''l lli:it .■..■r\Miils an. I .v-iMrially .•liiMrcr,. «l (lir milk iriiri, a cr-iaiii u ■ll-k I'l were in llii' liaLii iif ,:riiik 'niiin-Mniic]-, uho Has cm iii,-i,mI uiil, || ii'ivMi iiairv, u.i-c allark.il in hir; 47 MID ■(' i]Uiiiliir> MolliHIL' >u.-|ilclol|.s ; ai I'lirllicr Id csl'lilish ll III a >ccon !!■ in\(-iiL'ali(iii lit I ll. uiiii narliiil a lli.iv.i: II, If llarml^■>^ll(■^ • I 1 1 lik Ik I, II- ilairv, tnuinl lie ilii'il -liurllv at I'Miil Ilic |,ciially of I' rcsiill, cmlfaviii iiiiwlf |iarlaki Irruard fnini a t-slalili>limriit ua.s I'losnl aiiij il iliArl. Ilii' ii> i\|i( Timfiii uiili 1,1, lif,.. iria.>miicli ■vir,- alia -k ut' ly)iiioi,| t'.'v.T. Tl,, nliH'h III! i'lnriil «a> i,.,u ,-.|i,,uii |,, I,,' a- 11,1 lis \,s.~c|s I'lilrmir M..,ii .-II I, Ml I, '1 1. Ii.v „ii„l.. (,f airv ijian nns,- '"iili'iit>, romiiiiiiilial.'ij Willi ill,. .„,il iiimamiiiaUMJ I lie ucll .villi ill,, waitr tV 'i"l jii'oiialily also ,liliii,.,| ij,, ii| ^^ liirli ha till- ilairv. Iiri-ii lln-DUii til,. ilijcciiiiMS frill |ari-iit iliiii;.'--li,.a|> II a case of tvplioiij t <-vcr 111 aiiii'i-on ' olis,.r\i-ii numi-i-oiis I- i.f lyphoiil ti-\fr in DiiLlin i,, ,1,. I--- I.I a ^iv,-n I iMrii-t ilial i-,.,-,.iv,.i| ilu-i,- imlk from a ,-,.rIai,i ilairv. uliil llii- lioilsi's that il,.ri\,M! ih,ir milk fXi'lllllt. It 111 mlirr r>l.-iMisliiiicm.s r,-Miaiiii-,J I't. It a|,i„-an-,| that in th,. ,laii-y lir„t m,.|ilioii,.,l inf,.,.! iml result,.,! throii-l .Ml aihl if Iviihoiil t; in of till iiiiiunL.' the ininati's of I mil i-si-rili,',| \- i-vir. All e|ii,leiiiii' ohserveii ii Niiiiilt. Is nil, resting:, havinir oci-iineii iiilleil mil wi. prisons of .^tra.ssliiiri;, ius a result <,f |h,. ns,- „f fi-vir h.-ii K. I Ills was oliianieil ti -iirreil, ami tlie ili.-ea.-e |ilai-e HI wliieli ea.ses of H| n>ni llii> -oiinv was cut olf. The etiol. ileii soon ;i^ ll ,1 11- sll|i|,|y of iililk iiiatenallv sireiiLrll iieil liy til,, tael that ll 111 nil ex|ierim,iit, ,.|it, of]' fi-o,,, ;.r,.|i,.ral eN|>iise,| I,, i,|,.nii,-al. llioroii-l,|v ,-,„ilroll nstanee.s ot' inilk-iiit (; Ho eeiioii ari' r(-(-or< ii-ne inl,.ri.r,-lation oi' ||,is ,.pi,|,.||,i,. |.^ 'le persons iii\o|v,i| were almost, a.s ten-oiii-se with oth,.]--, ami w,.re eoinlitioii.s. Further iiistnielive •reaii et !•' Ii-il mIso I,v Alm.|iiiM,' Roth.' |;,.i,.| Ali Col leii, ami others. Ill ei.iitra--t ^^iti| milk, ivri.-iiii .-irtieh-s ,,f .Ji-inl^ ;|,.,. j tlie laity as ,-a|.al.le ,,f .jimini-liinir the ilano.T nf inf,.,., are 111 repute aiiiiinir i as exerted lui l)aeterieid; lines e\|.ii lali'i' a priiphy lactic. F.aL'-er ia<-illi are freiierallv e-wiiie earliir than ai't.r luilf iiiie to water eaniiot. ll etrci-t lieer anil other lii^ht within a rcaMinahly practi llm-c llial alliinl iIh' ll-c III' milk will rcadiU ipiiiiinr a|i|iai(iil. 'I'lir\ arr, lio\\(\(r. li-- lllidi !■ ((iiilrcl. iMiail-i till- ri.iilaiiiiiiali'pii i- i.ftili ai ridililal anil dilli. nil ul' diinnii-ii-aiinn. and not, a- witli milk, ^\-l(lllalic■ and oil in ir|ii'atcd. and litraii-i'. aiTiifdiiiLiK . I'atliii' i-nlali d ra-i - n\\ niMirr cii'tain riiTiini- ,-tani'i--. widcK di--iiiiinatrcl, -mall and I In itI'oit li-- (■(iii-|iiriii pii- tmi (lr\rl'i|i. it i- ijilitr rliar and li\ iin niraii- -illliriilil U a|i|il'i'i-i.itid llial t\]iliiiid ic\i-f ma\ lie di--i ininatcd tVnm i-lal ili-liiiirni- tl'nin wliirli vi'Licialiirs and t;i'irii-, (~|irriall\, lin\\i\ii-, iViiii, Irttinr, and -iinilar artii'li> i^iiii'falU latcu in an iininiikrd -tab', afr olitainrcl, it tln-c ai'tirlr- 111' rin-rd I'l' -|ii'inklril \\illi intirtrd watrf. Nut li -- ini|'iiiMaiit difiii inl'irtiiin nt' tln-r arliik- nl' li'nd liy t\|iliiiid |i.itiiiit- wlm live in tlir-r r-talili-limriit- iif liy llm-r in altindaiiri' n|Hin llic |i:itiriit>. 'I'liat lifrad and rakr and in.iny uilin- artirli- raliii withuiit lii-iiiL'' :iL;':iiii (■(inked 111' liratrd inav lie a Miiifri' iit' daii:;i'i' ill a -iinilar nianntT dnrs lint i'ii|iiii'i' t'nrtlirr rl.'ilinralinii. It lu'cil niilv hi' imti'il that \ (■ui'talilr-t;nrili-iU'r>, lic1n|-i' LrniiiL' to niarkct, siiriiikli' tlicir uan'> uitli uatrr in nrdiT to Lri|i tin in rif>li ; and rmi-iilcni- tion slidiild lie 'jivrii In till' r>|M'rinl liaiii:! f il tliiM' aif ti'.'iiis|iiii'lcil ill larye nnKiiiiils liv \(>,-rls ii|inii lai'LT >lrr,'iiii>. wliirli. a^ ur have h'CIi, arc mi tri'- (|iiriitlv inti'ili'il. |-'inallv, attciitinii >!iniilil kc ilirntril In tlii' cnliiiitinri.'i thai I'l'i'vail in lIu- dwi'lliiiL''-riiiiins. ihi' .-ah -r(iiiiii>. ami l hi- >liiraL't'-rnnii;- nl' ilrali I's in vr'jrlahli'- ami a rl icIi'S iit' rnnd. .ami the nianmi in uliich tln-r aii' criiuiliil tnL;iiiiii' ill ha-riiuiil.- in larLM' ritirs iiiid rninmiiiiiratr dii'i'i'tly xvilli mil' amalii-r. 'hi arrniinl not alone nt' ty|i|iiiiil. hiit al>o of otiier iiitei'tioii^i ili-i:i,-i<, .-hiiiil'l >anitai'v su|iervi.-ioii and ni: iilal inn of lhe;-e ennditions he more llini'iiiiudi than ha- liilhertn heeii eii-lmaary. Natni'alK'. lv|ninid li-Ner ma\ de\elii|i ill any |iri\:ite dwcUiiiir tllfnlltili dil'ii'l nr indireet int'cctinll nt' artii'le- nl' i'nnii, illld lie cnllVeycil cl-i'W lii'i'e, till' laller niein'riiii.'' e-]«'eiall\' it' the meinlier- nftlie family nr the -erv;ini- take |iarl in nniviiie- the |ialieiit and al-n in dnine-tie wnrk, e-|)eeiallv ennkil'L:. 'I he eiiiiditinli- are Iim-t -erinll- ill till- eiilllieetinli aiiiniiLr the |ioniei' ela— 1-. lull al-nainniiL; tlm-e lieller -ifiiated almn-t ilieredilih' lllilies will he dnlie I'rnlll \WUlt nt' knn\\ ledp' aiul nwillt: tn I I I'll. Ill, y 49 iiu|.r..|Mr .•iiTMii..r..iii,.|,t-. AUm in lio-|.it.iU .li-~,iiiin;iiioii of tv|,lM,i,I i\yr .M-,.|ir-< if tlic lu.-l --rni|„iluiH ,■■.„;■ \,r iiut i;lv,n to il,,. ,■!, Miiliiir^^ "'' ''"• I'lli'iil AUi] lii- \ icinily. ,i, ucll :i, t,, tlic .li-iiii;.,| i,,), (,C 'Ij,. .|i.. '■'"'-'■-■ 'I'l'l il' ill :Hl'liti"ii ill.' atlri„|;iiil.- Iliil I,, ,,l,-,rvc llic ino-l ri-i,| l'iv,.iin|,,n-. M,,-| i|„,|-,,ii::h .li-inrcriioii ,,f il„. |,:i,„|, ;,|„| ..l,,,!,!,,^,^ -111. I |,iv\. iiii..|| .,(■ iiui-.'S rii-ni^r,.,! in i|„. .Miv ,,f |v|,|,.,i,| |,:iti..|it. tV..m ■'''''"- '" •'"• 'IIV, '-|><''-l:ill,v tl,.' i;..liii- .,f „ti„.|.,, ;,,,. ,,-,„,. i:, IK- iiii|'"i'''iiil < -i.l.r.ili.iiis ill ilii- ...nii.vti..n. Kv.'ll illl|..ll- III.' I..ll,|- .hi.-.-,.,. M,,| to >.|„.;,k ,,t' lll..M> los fllVDMlMv Mliinl.'.l. Ill,- |.l,\>i.laii .-aiiiiol lak,- lur -i-aiil,.,| llial llinr,)!!-!. .li.-iiiH.<-|i.iii .,f III'' Ikiii,!.- uill l,r |,nir|iM,| aa.l a|.|in.|.iial.' |,r,-.'aiili.,ii.-i u ill, rc-ar.l l.i lli,. '■'Il''' "' ill'' '■l"lliiiiL' "f ill.' all.-n.laiiN uilj l„. ,,I,.mi-v.-,|. Tlic i\.-s\vM of in-ili.r.- Ml- mn.-.'s, in -nin- iV.mii ih,. h, k-l„.,l i,, tl.c .liuiii--r.n,i„, t|,iiik of '•1.111-111- ili,.;r ,-l,itlnn- ,,r ua-liin- llaai- liaii.ls .-,, tli.,r.)iiL;hlv a.'* I., t-x.-lu.l,. 111.' |in->il,iliiv ..f .•.iiiv.Aiiii: .li-.a.-,--.i'iii.- I,. arli,'l.-s .,f f,',.M[ an. I .Irink. liiMilh.'i.'iil .'ar,' III .li,-i„f,.,ii,in i.-< .•,ii.aii,lv llu- i,i...-I fn.|u,ait m.'aii.'^ I.v "hi.'li I'liVM.'!.-,!,-. ,aii,| run->.-s a..|uii',- lli,. .liM-a.-... Wuh iv-anl Mil.,. lan.M' i liav.' aluay- i„..u .-iiu.'k uilli ili,-la,l lliat .-.-inviallv n.u ■-... ili,.,-,-! t..r.. tli...s,. «!,., ipaii .•anl,'.,-ii,-.- ,,r la.k .if .-kill .1,, ,i,,"t „Ii>,t\,. iI„. n,.-..- sai'v |irfcaiiti,iiis. arc iimn; .■nniiii.iiilv alla.-k,',l lliaii .il.Kr aii-l iHitcr-traiiicl lll|l'>, s. TRANSMISSION THROUGH THE AIR. Rcli'l'i'ii.v ha- ali'.'a.ly l„.,-ii iii.i,!,. t.i tli.' i'.lati..ii „i' tli.. air t.. llic ' •'-'"'" "'■ '.M'li'ii'l 'i'^ir- It v^as ,«,int,'.| „nt that ili-.'ininati.Mi ,.f till' .'"iil.i-iiiiu iliniii-h lli...',ii' ;~ |,.,v-il,l,., w|„.th,.r II... ,.:i,.|.i,.r |„. in a iii"i-t .'..ii.iiti.ii, ..!• ill a .ii'v -lal.' in llic l^irm .,f ,ln-t. 'I'li,. ti,vt ni...!,. "'' iii'';'''i"" n'.|iiir,.- litth i>i.|,i'ali.in. It u.ml.l |„. ,,|KTativ,. aliim-t ('\''lii-iv..|y in (h,'(.v,.ni .,fa -imiy in- ,,f ini;.,.,,.,| (|nM aii.l it.- aci.l.nlal ";""'■""■'■ ill'" til'- I Ii"f:i sii-,M'|,til,|,. iii.livi,Iii;il. r..-.< ,'.,niin,,iiiy, iii.lili;.|'..ni tini.l- in tli.. lin'in .,f -|,ray nii-lit .'.im th.' .'..nta-imn atta.-h('..l '" ''"'" ''"■ ■' i-i'l'Tiil-l.' iMin- ,I..|„,h'i..1 tir-t in th.. „ th aii.rtli.. ii.im.. Kntiaii.... int., th,. ImmK- an,! tli,. I.l..,..l-tr..aiii, li,,u,.v..r, |.i'..l,al,lv takes I'''"' ^y tlir'.ii-li til,. ,liu.,..-tiv,. tra.'t. \Vh,.th..r .ntraii.',. nf tli,.' I,a..illl iii:iy tak.. |,l.i.-,. al-,. thr.inoh th,. n.-pirat-.n a|i|,araln- i- -till a .|,.|.:ital.l(. 'lii,-ti,.ii. It i>..,.|'laiii that ..ntniii,.,. l,y ,hi-. ,..,,,1,. w.„i|,i .-..nMitnt,. th,. .■.\,','lili..ii (iiiR.|nii'.tyi.li„i,i ■.'). .\,.v,.|'tli,.|,.-s. th,. ol.-,'i'vati,.i,- .,f i;n..!i,i,.r, ' ■/'/,.-,. I';ili-, |,S:i(l. no 7) riinin 1 1:\ i:i; wliicli riirni^li cxiMTiin-'Hl:!! ivi.lni.c in r:i,..r..|' ilil- iiichIc .>!' iut'r.liMii. :ur vMirllix dt' ci'ii-'Klrnilinii Mini riinliniiMliiiii. >,-,, ■,. cMii lie -:ii.l iVi'in llii' |iiiMlit |Hpilil nl \ icu VMlli n-ind l" llf ,11-: '.111111:111011 ..r lv|.lini,l l.-v.r ll;rnu-li ill.- iiir. lis ,■../- Iia>. Im'c ■ :i mlmv MiLonliiiMlc nil, ii'i .■nin|,;ui-..ii Willi lliMl ;.--i-iu-.l lu il in .■Mi-|i.T liiiio. ulim c^pfciuliy 111!' iii'|i.-rl.cl :iiiii Isplmi'l tt\.T iiivcrd ti.is view Allli.iuuli il.' pr.vjiU in llii.- <'onn>'ciiuu m the |irrsiiil .Im\. MIKltJKT .ill- 1 1.1- vii'U llll:- ll"l Im-,1I whnllx (I llnl llillr. I 11 1 lill' mill.!- df iniir.-iiril.' iiHJivi.liiMU, uiiiri, lor ;i Ion- limr ■ ..nMiliil.il llir >tn.i.'j.^l -ii|.|.nri for ilu'ilcH irinr..fil,r.li.".'niiniHion of H |plioi.l r>\. r lhron;.'!i tlu' iiir. n:iiiM'ly. lliMI air <-onlaiirni:il.Ml l.v |.utrl.| Mlll^lalM.■s i> ln- lyplioi,! I'tA.r .lirccllv, or al Iim^i of ;nnn.: a> lln- larrii r of llu coniaLjiiini. Al lln' linx'iil ilav'il i-iiolonuir luMllial i.ulri'l Mili>lani-c> of llinn.-clvi >. t-|..' rially llii- il,M'oin|.oMiion-pnK|uri- of t, ■,-,>. (■on>liliil.' tin' cx.alini.' iiL'inl of typlioiil fovcr. an. I ihr opinion of Hial.l llial llir s|fcilic 1\ plmiil ;.'.rin iiniKr I'l,,..,. , liiions liii.l>. al lia>t. il- >-|«i'ial |.al>iiluiii lias al.-o liccn aliaiiiloiuMl. 'lo-.lav u.' n(|iiir.' ll.o 'lii -iralion of oiIh r . lio|o-ii- factor- llian foriiu'i-iy, «l„ii,'\vitli 111.' a|.|..araiMV of typliol.i liv.r. llu' .liMo\,ry llial fonl air from an a.lja.vnt |h,o1 or oilior fo.ii- of |uilritacl'on cnlirf.l lli. il«.lliiio «as .li'.nu'il fiillv ^nllic'ioiii lo i\|,lain llir lausc of the oulWrrak. It uoiiU natiirallv l'" oniiio- too far to jniioiv riitiiv|\ ilio lari:. nuiii- hor ot' <:i-o< r.|.ort.(l liy ivIiaMr early iii\ r-li-ator- in wliioli il ua< l„.ii,A,.,l ijnit llir cuiita'.rimii \va- (li-oiiiinaloil 1>\ <'oMlaiiiiiialr.l air. Soino of ilii-o, it caiinol lie iloiiio.l. aiv -ii-(v|ilililo >>i' -caivoiv any oilier into.-j.rolation. Moiv ivml lii-lori.- of -inillar oliaraclrr uoiiM iialii- rally 1m- jiiil^r,.,! |,y an onliivly ilitVnvnl -tainlanl. Al tin' pn-.nl day it ^\oMlcl lio iio.v-ary to ,1, nion-tnitc that tl.o air in ,;iirMion was lailon with aoliv.' tvphoiil .ontaoiiini, ami thai the . -011.1111011- for its niov.- tnc lit an.l the ,-ntiMin-i- of the ihiI-oii into the ho.ly wiiv .-|M-rially favor- alilc. As an iii-lam-.- of the lack of i.rn-i-ion in c-arll, r nh-crv atloii-, a |MTs..nal .■xix-ii.-n.v ami tli.' lii-tory of tu.i (-i.i.l.-inics iVoiii the well- known work of Mniehi^on will siilliee. \t the he-innin-of th.-sev.-iitles, in a h.iar.lin^'-srhool in Herlin, in wliieli f, vonn- |»-i>o„> ,M-eu|fie.l a lar-e. well-sitiiale.l heilrooni, 1 of these «as atlaekeJ uith s.-vere ivphoi.l fev.-r. an, I was >eiit l.y n.e, on a<-<-oniit ..t his ..onii.ani.Mis, all of wli.ln, reniaine.l w.-ll. to ih.- hospital. Oftieial exaiuina- lion of the ease ,liselo>e.l the preseli.e upon on.- wall ol ill.- ro.Mii ..l a nioi.-l. otn-nsive-sniellini.' sp..t, resiiltin- fn-m a l.-ak in a hrok.-n .h.-.-har-e-pipe in Iht- wall Ni-ith.-r In the li.aise in .pi.-sti.ni n.n- in th.- a.li..iiini'.' Ihhim-. n> I was ahle t.) .■.invin.v nivs.-lf. lia.l there heeii a .-ase of lyiih..i.l fev.r wuhiii a hm" time. N.-verthehVs, the pipe ami the ^|M,t upon lla- wall ha. I L' l.e e,.nsi.l.-r.-.l as the sonr.-e ..f the .lis.-a.s.-. My ..l.j.-.-ti.m that the remainni- :. inmat.-s, .ifalHiiit tin- same a-e aii.l e.pial pr.-.lisp.iMli..n. ha.l reniame.l well, an.l that the ilis.-as.- of tlu- sixth initrht have heen ae.|iilre.l els.-wher.- ironi a (hir.l sour.-,-, ua.- r.-.-.-iv .-.1 .-nlv with a .sympath.-ti.- shni- .ifthe slmnhh-rs. \l.-o. tin- well-kn.i'.Mi and ini, h-.pmt.-.l epi.h-ini.- .if lyph.n.l fever m the K.-ho..l for ho>s altaehe.l to the Coh-hester I'liion in l.umlun' loses most I Scr .Mun hi.-. .11, /'.<•. '■''. H irinl.ni, y 61 "f" il-* '*""'■ Minn' I'lin-fiil scniiiiiy. In ilmt in-^lmicc iimiiv of ihe |>ii|.il- ill a >.|ir>,i|r,,..in iIkiI i-iiiiiiriiiiiiinl, d willi ii m-«it liv iiicaiiM nt' tin; rliin.ii.y «ti-.- :ill:irk«'(| uiili a sfVirc aciilr ili.-.-a.-r. wliirli wii-. ino>| iiiliMiM! iiml a|i|>ran'.| (•arlii->I in ili.w,. M-alr.l inari'sl lli- (i.iriini'V. .Miin'|ii„,ii li.a.l iHi .loiil.t iliai the ,l|.,as.' Has iy|,li,,i,| r.-v.r. ami llial il' n-.-iillcd Inini ll Iialaliun u|' injiinn,!- -aM-" ir.ini tli.' rlniini.y m ,|iir>lii>ii. I'ho iiilialalinii a> llic .aii-c uT ilic (li...'a.M- i.-, Ir,,ni MiircliiMiii's (icrripiioii, iii..>t |ir>il>aMi'. aii.l alriio>i i-i'i-|aiii fmiii tin- nlijiniM. jKiiiit nt' \ i.w ; hm ||,,,v couM Muit|ii„,ii kii.iu. uillioiii M.iih.' am ..t' ili,- |,aliiMil-. ilial lli.' ,li-,'a~,^ was lv|,li()i.l fv.-r/ Onlyrnuii llic fact lli t llic srli,„,l-iii>|Hc|,,r inroiiu.Ml ''I'll 'li^'l 111 llii' "|ii;il"ii nf ill,, alien. Ii'iir |iliv>irian the s\ni|.lniiis .it'ilif. iliscasc n-srii.lilcd I'l.w ,l<>ciil„.,| l.y.l.iniiT as lli.. swn|.|oiii.- d' lv|ili..i,| t'fVir. SnII li-ss rniivinrinu' is lli.- wcll-kiiuwn .■iiidcniic at the sclio.il nf ( lai>- liain, lilM-«i>c ,-iir.| liv .Miir.'hiMiii.i In il,,. Miniiu.r nf ls;i_', nf -ll lin\s in lliat iiisliliiiinn. ■_''• w.tc »i/.r.l within time linui-* w i;li •• il>ni \ |.|ini,|," w itii vniiiitin'.', .liarrliea. ami |ii-n-l ratinn. 'I'hc clisc-a>r wa> all rilnit.-.j in the fart that tlic lio\~ ha I uiln(--c I tlii. re.i|icnin'.' ^>\ a Lirave eln ,■.! t;.r maiiv v,:ii-s. the -really ih ii|>.,-.e I eniii -ils li_'lit nleerilinn i,( one of iIh-m. .striietiires, tn.'.'i her with eiilarL.'eineiit nf the iiie- -ilerie irlanJs. The i|neT.linii at once arises ill ennneetion with this re|K)rt : Is it not unn-iial that voiiiil', previmislv healthy i:iilivi,hials ilie fmni ty|,li,,i j fever williin frnin twentv-three to twenty.fuM! hours? Can the aiiatniiiic cmi li.i.ns fiiin.! , level, ip in a ease i>\' tyiihnhl fever within tli • time iii.ntinnely Is the sii.l leii, aliiinst si, mil. taneniis, illiic-s «oiied hy the intravenous iiije<'lion of putrid suhstanees exhihit intesiinal le,-ions id'eiitieal with those of the I. ovs at Claphain, namely, intense eatarrli i^( the Inwer pnriiniis nf the intestine, especially tlu" ileinii, with acute swidlini: :iiid even exfiliatimi of Teyer'a liatehes and the soliiai'v f illieles. as well as consecutive liv|>erpla.sia of the related in 'senteric ;.'|an Is. SIGNmCANCE OF EARTH IN THE ETIOLOGY. Kai-tli lias played as iniiioi-taiit a roir as air as a can-icr and dis-ciiii- nator of tlie typhoid |)(ii-,.n in ilie views of physicians and in the litei^i- titi-e. It was con-idi ivd as tile e-si'iitial iindiiini \\^r tlie stofitiir np and tlie further development of tlu' imm-oii, wlii( h was helicv,,] to ori;:inato s|Miiitaneonsly in it fn.in putrid .sni)st iiiees, or, acconjinir to the view of Hildd and his disciples, to he deixisite-l as a specific coiitairiiini and tliefo • L,n,.;'t, IKJII, v,.|. xvi. ; M,,l. ,i„:., v.l. iv. ' VlnuH; .l„„„/,„. tH.-,:t 52 I yili'iih I I \ I i: ,,, iiM.l. 1-- innltil.lir:,!!..,,. Il i-,l,:M;„|,il-n.of ,;,rlir.- . |,i.lHni. .|. ..rir si,.„- ,|,.,l ll.i- llp.n-lii. uIm.'I. U.I- .vmI^,,! llMMivtlrill^ Il ,,il.,n, ., ,„,■., I , AIM ,„ nr, -, u.,- ulili/r.l :i- :. -.iin 1,,,-i- lor :ill 111,11. r ■ .■„, lii- "i,„,-. In II,,- u IS ».,v ,s,,l,.n.,| I.miI, ll,. -,,,,,11.-1 .,- «.ll M- ll,. iumM ,a|, „-l\r ,|„.l.i„l.-. If tM'l"'i'l fNT""iinv.| 1,1 ;i lioii-r, .,|-..„ .,„ .,-,:,„•,,.,• i„ ;i I:,,-.,- ,,n ,,, .„,lv ll,. n,i;.tr,l -,ll.-..,l u,,- l:,kr,, ii,l.. .■,„,-l,lrl;,l,..,,, |„-,,\,.1..| ll,:,l . ■■ .,,1 ;, M, i,, 1 1. . 1 a,,' U - n-l <<\'' r.<\\sr. ll ,11 ;„|,|ill,,|, |l,r -U,,„,l.\ ,l,;,,:,.l.,-..f ll,.' ..,fll, ■„■ ll,.' |.l..Nl,,,i'V ..(■ .llM,- !„ .|„ :,,,.! - u. ,■- «.,- . -l:,l.r,-l,-'l, "I il' ill'' 'I'll' li'i'l I'" " -"'■'"" ""'' ,vr,,-..:,„,l i„;.,„,,v:, -l,..il.,"|-:i l"ii'-:'i- lil'i'- l"'' v i. .i,-1n . all .l..„!.l uas ,, ,,i.,\.,|. A- ill. iialm-.' . '■ ill- ...1,1 il^iinii «a- ,,iikn..u ,i, al,(l a- ll,l- ^\a- ,■.„,-;.!.,.. 1 nil,.,' a- l:,—,,- ll,a„ .•..,|.,,-r,,lai , ll vv ,,- |.. -IM. M ,,„iil„ii,. ill,' r..ii-tn,.ll ll,s|...tl„-. - ullli.Hil i,l,„lia„r,. Tl,.' airma- il,,,, ,.-|„.,.ially ...n-Ll. ,.•! a- ll,.' v.lii.L' l"i- ll" |"'i-"ii i" 'I'l'-ll"!'. ^'H'' il \sa~ ImH. \.'.l til ,1 llll- ,-.•:, p.,! Il'..!ll ll„ -..11 1,1 .•,,ll-r,,,lcMc'.' <>( a -OI-1 ufrva|...,-all..„, aii.j ua- tli. ,1 lin'lli. ,' ,11-1 rll.ul.'.l. If it ua- |,..-il.l, H- >l„,u' f,i,'tl„ r ll,at ill.' -.11 ll al I"' 11 liii-ii'''l ii|' ill l'"' ii''iul,l"'il 'I- ^'ii'l lliat -l,.>,ll-- ImI'..,-.' .'X.asail..,,- l,ail Im'.'M l,,a.l.', f.iiialal 1..I,- -in-, "i ,lral„-l.l|.. - lai.l, ll,.' Iia,,-f. I'.,,.'.' of tl„' i„f,'.'t.'.i -r..„i„l-all' t.. ll,.' u..rk- III. '11 a,.. I olli. ,■- -.. i,,..l (1. ,,i.i„-tral.' iiiil-r- t,i,ial,'iv iailii.'iiiial. .a-lh >ali>lu'.l iiiilivi.i„al> .•xplaiiifil ll,'' ."'.'in-i.'ii.'f l„.s„i,.r .l..".l,l l.v ll,,' ta.1 ll.al hir-.' .•^^:lvali..l,^ u.,.1 l,„iMi„L' ..|..'rMli.,„s W.TC il, |,r.,.',a- al...„t 111.' l,a,l...r. That lv|.li..i.l sva.- -hMnlail-.l •'^rv ll,.' citin' .'ilv. uiiili' ll,.' .■v.'avali..„> ii, iii.H »<'n' v„v.Uu>-A U> n ,,arr..w s.-.'ii.,„ :„hI ll.al ll,.' a.r!..i„i,iL' Mr. .is Nvi-iv l.v ,,., i„.'aii. .■>|..'.',all> atl.'.'l.-.l. fnil.'ii ti> all',', t ill.' |.,'.'' 'I'iv.'.l ..|.,,ii..ii. Til,. -,,ll-tli...,'v I'.'.'.is.'.l it- -.'i.„tili.' .l.'\. '1.11,11, '1,1 tlin.ll-li the u.'ll- k,i.,un u..vk- ..f i;,il,l a„.l i'.'tl.'i,k..f'f. ai„l tl,.-.' .l..miiiat.'.l tl,.' tl,.'..i'y of il„',„'loi„ .,f iN|,l,..l.i f.'V.i- until Nv ill, ill ll"' 'ii"-l ''■'■''i" ''""'-• ''"'"' on.ini.l-uat.'i- tli.'i.i'v ..f Unlil ami iMl,'MU..f.'r "a- l,a-.'.l ii|",m tli.' -la- ,i-li,.:,l ,,l,-,rs.'iti..ii tliat tl,.' i I'l'lilv ami ni..i'talily ,,f ty plioi.l f.'V.r in MiHil.'l, 1'.,-.' ul,'ii tl"' -I'liilii.l-ual.r ua- at a l..w l.'V.i. vviiil,' a ruvr,- s,H,n.il„- n'.i,i.'ti..n ,..i-ii,'.i « itii a I'i-.' in tli'' .:i-"iii,.'.-«at.T. I'.ti.'U- k.,i;.|' l,.r..'V.'.l tiiat 1,.' vva- al,l.' t- -iv.' a .l.linit.' .'Xlilanati,.,, tu,' iii.s uh-.rvati.M,-, nani.'lv, tl,at tli,' -|..'.'ili.' Iyi'li"i'l 1 "i-"" 'I'^l"]'- ^li"' ,n„l., - n,aturali.,n in tl,,' .i.'.'!-',- lay..- "f tl'" 'arlli -ati.i'at.'.l wit . snli-tan.'.'- .'ai.al.l.' of uM'l.'iV'iiiiX i.utf.fa.'tion. Wh.n tli" ^^f'-H'l- vvat.r i- at a lii"li l"v.'l tl,i- .lai.Lr.T.HH lay.T of tl,'' -"H i^ ''ov.'.'.'.! l.v ti„' lunii.T. a, 1.1 i- tin,- .'Ht ..tVf, tli.' Mffa.'.' .>f tl,.' .'ai'tli. wl.il.' vvli.'i. ti,.. ..p.nii.l-wat.v o,'.'ni,i.'^ a low l.'V.l tliis . N.'ln-i.,n i- w.mtinu. I ti tl,,' I.,.-' .v.'Mt. Willi tlie ui.l of .^liccial io.'al, M'.iM.nal, an.l iK'fs.mal 1^ iri'il.'ii;) . 63 l1>Ml|itiMM-, til )llt.l'jirim llli^'lll ||<>I lie |ill\ iHImI t'lom i-r:i|)l||;_r tlnMlll'll till' jiiiiiriil-iJir, \\\i,\\ il \\<.iili| 111- |:iImii ii|i irilM tin- Imm|\ Ii\ iMli:ihili"ri, ;ili:irl \\;i- lia-ii| ii| llir .siKi-icinc-. in i.tlu r rilic- will IT lllr ri-r allil lllr Ulli nl' till- Ufi iinil 1 - w :ltl T lliirc II. . fllati..ll |.i vaii:iM..ii- ill till' |.ir\:ili HIT ..|' l\|ili..ii| ti\ ir. aii.j in |iail wa- iliiTrlid .aL'aiii-l llir llii..iTli(al n.inlii-i.ni- ..I' lliat ili-tiii:,'iii-lii'rf- liiii-liT ' ami l!ii iiinr,' uliirli aiTiA.ii |i.-ila\ Iil- i.t' .-i-ilii-al iilili/.a- li"ii I.I all lli;il «a- kii.i'Mial lllr liiiir. 'I'lii-r iiiiiiaii'nl tlir -laliilit'.' Ill I'.iiriiL.irrr'- iliii.rv, \liiili, ill ilic lii^lii III' |in-i.|it kiiuw ImI^i-, lia> no I..IIJI!- till' -iirniliiaiiiT that \\a> attaiiiifl tn it liy it- aiillinr ami lii> |>ii|iil-. \\ illi iT'.rinl III till- -I iti-liral ..li-( rvalii.ii-, tln-f aiT, it i- iriir. appliralili' I., ill.- i-itv III' Miiiiii-li ; lini it Im- li.-i-n ilriiiuii-tiat.il that llii-y aiT ii.it a|>|ili.-alili- l.. a iinmlii-r uf .illi.-f riiii--, ami lli.-x aiT n-r- laiiilx III. I -ii-i-i jiiilili- 1. 1' u,-ii.-ral a|i|ilii-aliiin. \\ illi n-lali.iii III till- li.-lias i.'i- .iC tin- t\ |iliiiiil |Mii-iiii in tin- -uil. aci-nnl- iiii;- I., llic \ii-w III' rctti-nkiifir, tlu' kimu liil^r,. .-.miinniil i-\|K-riinciitall\- lliat till- liarilli lit' Kli.Ttli an- i-a|ialili- uf iTl.iuiiiiLf llii-ir \italil\ in tin- carlli liir a Imii: tinii; — l)i'lt(-r in |Mir.iii~ tliaii in riirk\ ur utlici'w i-c iniiH'r- vioii- -..il — iiiiulit he ciniilia-i/i-il. (m-.m-Iui- ami 1 >(i-liaiii|>- l\ not j.Miatl\ iliiniiii-lii-il Kv i-olil mikI ilrvm-s l-ri' |(. -'l-i). -II that till- |)oi-iin may nnili-r favofaMc i-iiTimi-taiiccs -ni- vivi- ill thr raith l)..th ilii-oii;rli the lold a- will a- the luatcd si-a-on. I I'l' I ditioii- ai-c ililli'iTnt, howi'Vir, with iTirard to the h\ [Kithctic iiiaturalioi, and |)ro|ia^r:,tioii of tin- liai-illi in tin- earth. Tlic fir>{' the hacilli in till' i-arlli or any inrna-c in tluir viruhniT i- wlmllv iimlrinoii»tf;iti'd. In any event, tlie-e tliiiiir- do not i.ceiir, as a rule. /.l-o. detinite local or seji-idiial condition-; cxertintj a favoralilc inrimnci- in thi- connection have not hceii clearly dcinon^tnited. Kveii it' the other ii|iiiiioiis ut' I'etteiikoi'er wen- lietter sn|)|Hirte,r,r,,. l,„it ;„, 11,1,1, ,n,.l(i,; liv fir ln-t ada|ited to take iijt the iia<'illii- from the earth and to elVeet it- further di— eininatioii. 'I"he t;erm may thus find it- way into tlowiii!.'- wat-oil-wat.r into well-, or !«■ wa-lwd out of the niiper layer- of the earth l)v iiun and melted snow. It ^1 INFECTION AND DISSEMINATION THROUGH HOUSE- HOLD ARTICLES. IJcference- to thi^ -iilijecl have already heeii made.' Ill view of the |)ractical imiiorlance thereof, it -eem- de-iralile, houever, to return to it at irreater leni;tli. rndoiilitedly, the typhoid poi-on may remain attachid in an a.'liv -tat.- for a i-ideral.le leii-rtli of time to elothinir. lineii, l.eddin;_', and various lioii-ehold article-. I'nder -iicli .irciim- -taiiee- th<-e article- are irciierally coutamiiiat<'d directly ov iiidir.rlly throuirh tlw dried deiection- from tvphoid patients. Natiirallv. under thi-e Cirenm-tanee- the fiinilv of the i>atieut. the attendants, lamidre-cs. and other i.er-on- w ho-( upatioii re.|uire- that they .■omc in e,iuta<-l with t''e article- in .pic-tiou are mo-t e\|io-ed to danp'i-. Inteetion is. however. frei|uent!v lirou-lit ahont indirectly throuudi healll.y iiiter- m.'diaric-. who r< main well, ar.d who may convey the poi>on atlaelie.i accidentally at the lied-ide to their .■lothinir or their hand- ; and without donht a nniuher of ca-.- of ol.-.aire etioloiry are altrihutai.lc to -neh .i.Murrcnee-. Naturally. ]ihy-ician- -hoiild alway- l.cir in minam(' UMV ;i.-> MHiic I'llici- iiir(cliiiii> ili>c;i>c~, |p\ liiilliic tu iili-ri\c Mili(|ii:iic iH'ic'iiitiiiii-. 'I'licrc is nil ilmilit tiiat int'iiiiuii ni:iy t;ikc> phicc ;it :i (li-I;iiiic liv tiic trMn~nii~-iii ot'iiis cloliiiiiLr ami linen to liis home in IIainliiirler of the patient and a servant had wa-hed the linen, they lieraine ill. the one with a mild, the other with a .severe attack ot' typhoid liver. 'I'hal the lirother had also sntiered from the same disease was nnfortnnately demonstrated liv iintopsy, death occnrrinfr from copious intestinal hemorrhaire in ihe co .r.se of an apparently inihl attack. While the mode of infection jnst mentioned is liy mi means rare for the acute exanthemata, especially variola and typhus fever, and in the acnie infections diseases most cjoselv allied to tiietn, and nuist lie taken into eonsideraliiiii in cases ot' obscure ori;jiii, little or no reference is made to it in the literature or in practice in loniiection with tvphoid t'ever. The samu thitiL' happened with re;.'ard to this as occurred with a nnmlier of other cir- cumstances of etioloiric im|Kirtancr. They were all ncirlecleil or i;:nored for a loiii; time from the cnstotn of looking; at .dl thitiL's from the point of view of the iivlhotrenic or the sulisoil-theorv. FACTORS THAT FAVOR INFECTION AND DISSEMINA- TION OF THE DISEASE. Ha\iiitr tlms t'af ucciipicil iiMrs<'lv('s witii the diiect causes of typhoid fever — that is, witii the pccniiarilies uf it> specific ciinta|>ceially its vital relation-, the variiin> pussjliilities of its imilfi|ilieati(iii, dis- scininat'nii, .iiid iiiva-imi in flic human ImhIv — we shall now take up tlu^ ciintriliiifnrv tiicfur-. namely, flio>c that are of impmlaiice for flic recep- tion of file poison into the liody, tiir its further ilcvelnpineiit therein, mid liir its jiatliiiirctiic activity. Individual liudilv cdiitlifinns and acipiired ccinditions tavorinir the (levelupmcnt of the (li>ea>e arc especiallv to lie taken into ciinsideratioii in fills cdniu'efion. I'erhaps with fnrther advances in kii(iwlesitc per.-' ' 1:1^ ,1- liirtlirr (Icvclopiiicii Miicli tliMt has iMtn said with fVLrin) t.. the tciiacilv of ilic |i(ii-nn is appliraiMc in this ((imici'tiuii. a the wiiolc, <>iir in-fsciit kno\vh'fciall_v cxiKiinuiital, irrdund-. FACTORS RELATING TO THE INDIVIDUAL. Age and Sex. — Tiif \-n-\iv nninlur nl' statistical data with refer- ence to these -uhii'cts, iiowever exact they may apiiear. iiiii-t lie received witli ;rriat cantion. Many are ol>\ ioiisly not at all in acconlaiice with the facts, while others a^n-ee only on jrcneral line-. .Most nii!_dit he e.\|iceted fnini cxtcn-ive olllcial statistical stateinciits, covcriiifr m11 of the inlialiitanls of a country, hotli the well and the sick, rniortnnatcly, the-c -utfcr from variation in the rcliahility of the diaj^nosis and front the deticieiicv in anatonii<' data. In lio-pitals, on tiie other hand, where these conpeci:lllv to he taken into coiisidei-ation t' t chihlreii and married |iersons are for ohvions reasons less commonly sent to ho-pitals than imniarricii hccomcs still {rrcatcr, so that (liiriiijr this |)cri(«l more arc afUctcd tiian hctwcfii the ihirty-tif'th and Corticth vcars. Tlif fiillowiiiir ti^rurcs, liaseil U|)()ii ohservatioiis made in the liospitain of Haiiihur;: ' and i^M|isi(', may st-rvf to illuslratf what lias liet-n said: ( '((«.< ,,/' Ti/jili'^iil Frn I- ill llii- Hiiinlxirij (Irnentl Jloyilln/, JSSd'-S'/. IW*"''. 18*17. !i 10 . . . 11 . . , 12 l:l 14 l-")-'J(l ... L'l -•.':. , . . 2ii-:;(l .... :!l-:!5 . . . :'.i;-4o . . . 41-4.) ... 4<;^')t) ... •"iI-Vj ... rui-tio . . . lii-ii:. . . ' tint I .-pccirifil. I T..t,-.l . . . 4 4 4 ;• .{ 10 111 111 l-J IM IS |K(» 7h ■-'7 21 t! 1 '.i.il b'limlf M ICii 114 • Hi :!4 514 ]:! l:) I'.i 24 2H 17 40S :ii:'.i 24i; 112 .'lO 2il 11 1 l:', 144.-. IVn-i'iil- 0.2 I '. 2 o.i; O.'.l O. .'i O.'.l o.i; 1 :; 1.7 l.'.i 1.2 l.'.i 17.0 7.S Is O.K 0.1 0.2 O.I 0.0 O.'.l HH1.0 " Ki'iiiali-, Tcital. age. 1 • > 4 i; 0.18 0.27 7 1) " (i.:)l :i 2 ') 0.22 II 1) 11 i; 0.27 0.40 :i !» IH O.KO HI 11 1:! 22 2.'> 21 412 41.S 24:1 114 .M l:i 4 4 II 1 I.-. II 21 l!l 11 2H() 2o:> 107 4:; 2ii IS •> 4:i 44 ;>*' i;ii2 1128 .■{r.ii 1.'.7 II II ' I 12 I. Ill 0.M8 I. '.12 i.itrt 1.48 :io,S8 27. W) l.',.s;» 7(11 :i.44 2.4:> 0.117 4!» 0.22 O.IH) 0.13 1437 804 ! 2241 KHI.OO ' II. Srljiitz, ■■ Hiitrau' zur StiUi>tik dcs .Vli(l.iiniiiul-t\ pliii-, .lfi/,rh. ./. Hainhnnift St,i,il^-I\raiil,(ii,iii.tiiilics wen' iriiidi' iiiuliT my din'rlion. Tlu' (li^sprtiitinTi of Hits I'ollow.i tlir w.irk i.f Scliutz with rft'cri'iiif tii the stati-ticiil iiui'sticins ccn.sidiT-il and till' Hrrniii;ciriiMit nC tlii. inalcriul. From the year IHHII the re.-ults are based iipcm iMi'orimiliiin (il.taiiied l> aii>\viMs In a yerie- iil' miestinii.- that I have introduced into the Leipnic hospital- in the suiiie form us UM-d in the Hamburg hospitals. 58 ryi'iio.i) fkvf.h w iiiialv>is i>t' Itl-ll ciisis lit' tviilidid tivcr m tlic .laciilissiiii 11 o- l,i"i|isic hctwcfii l^MI ami l.H'.t:! .lixliwil llic (nlli)\viii;_' ti;riirrs : A.. I, i>-.i i»i is^j, 1-v; i^^i i^^'. i^~' '^"■- ''^^'" ''^'~'' '*'■"' '■"'■" '^'''-' ""'■'■'■ I II 1 ., II II 1 1 1 1 II II o n II II II II II II II 1 1 i II •J II o II II 'J 1 1 1 11 ■_' II i 1 1 ;; 1 II I II 'J o II II i; ;. It ■J :. ■J 'J 1 ■J 1 4 (1 10 14 ',1 ill 7 ;, r, 1 s 1 III ■"• i\ li 4 l."i- I'.i j;, :;-j 11 ■_*"i L'S ;:o ■Jl -'■'• IT :*\ :'.i; ;'.*J IS •'i ■JO -.'4 ■js .Ml 'S-', :;i :;.", ■ VS »ii I'.I L'l *■-'_' :;t "';> -'• •'■ j;, ; ; , J li. 'J'l L'.; ■_':; It "J-I ■J.I ;;ii ■Jlj |.s 1'*-! 4 :;o :;i h ii; s IS 111 > 1-J 7 1.-. l.'l ■JO 7 4 .-, i:; i; M 1 1 ~ 1 1 .'. .'i 11 111 7) '■'• (1 4(» 44 i; ■t ■J 1 1 .'i 1 ■ i •i ■'■ i; '■'• ■ ) 4'. r.i II r, 1 :; 1 - II I 1 4 1 1 •1 II .'.n :,l 1 1) _^ I II ■J *J 1 L .'i.V .'.'.I 1 11 11 1 1 - - 1 1 1 - n II 1 II i;ii-i;'.i II 1 11 (1 II II I L' II - 1 1 - II 7n Ml (1 1 II II II II It - II '■'• II (1 T..U.1. ir; i: I-Jl l:;s l-jo Ijii in:', l'i4 l.!7 ir Arniiiirfil arronliiiir to a^ri'.s. tlicsf t'oiirtfcu \i'iu> >himcil tlif tiillii\viii<; ri'laliiin< : .\i.E. I'aus. I'll icnlUK'- " all iii.M-s o.m Xuy.. 1 f! :!0-:;» . . 'i •» O.l:! :l.i-:l'.i . . , ;! / (144 41144 . . 4 11) III'.:; |."i-4'.i . . . .■V-Ii .... 4i! J. so • iil-.i'.i .... 10-11 , . . 8i; .-.to i;o li'.i . . . 1.-. r.i ... ;).-i!i •J-J. 40 711 si; . . . L'll--JI . , . 4:i4 •J7.IK' T.itil '_'.'p j'.i ■w:, I'.l-.'iO JIM'S. rtTcriiiJu.'f nil Dl'l'S. .f n;: 1(1.40 KM! r>.iil 41 li.'iO '-'!• ISO 20 l.L'.-i 10 (i.i;:i 5 (i.:!-J Ull-'il III view of till' hir-r iiunilxr nf cliililrcii ■ 4.'(1 i tr.'atfil at Ilanilmrir in is.Hi; s7. it niav lir |iriilitalili' to rmisiilcr tlie.-^i- in lalmlar funn ; Nuiill'rr. ii; is i;; r,r.'. MlNL-l- .r .■lliMrni al tai k.'.l. l.i.d 1 s.-, ,; 711 4 -.'o :'. :'.o 10 II 1-J i;; 14 r'Tcrnlnm- ttf Nuliil"T. I'lnliiri'ii al- la.ki'il 44 II. '.HI M) 11 . 1 "1 ■lO ll.:{() r.o lU.liO 71 \:,.:*) (■4 I4.:i0 4:.l « . T, '"I" T.tal . . 'I'lir lahlr >linu>. as lias Ihtii imliratcil, that ty|ilioiil t'fvcr is iml t'rci|iicnt in cliililliniiil nntil alioiit t!ic littli y.-ar. wlirii tlii' triM|mMicy ^'railiially incrfascs until the ninth year, then to rrai'h its li.iirlit after the tfiitli year. A coni- jiarisoTi with the slatriiifiils nt' i-ci-ii^-ni/.i'il aiitlmritifs, as. for instani'c. Muv- chisoii,' Ficiilcr,' anil < Iriissinircr.Mi.-closis ai:rcciiicnt witli tlic li.iriirfS ;.'iven. 1 /),,/.;/. /,,,„/,, I Kranl.l,. it. ,1. (JiTlllllll I.V /.lll/rr. liniu ll-rll « .ii:. ■' .(,-.■/,. f- //..//,, isn-j. » Vc,:-h.,„ . Il„n,lh,„l, .In- spr.-uUni rnllLuluiji,, 1W4, 1' Allll., H(i. ii. KTIOI.OCY. oO Thus. 52 |KT I'ciit. of Miirctiison'-i |.iiticnl- were l)ct\vccii fifteen and tweiitv- (ive years old, |-"iedler' re|)orts lliat '>>*..>*■ |ht ceiil. of his |iatieiits were lielwceii the twentieth iiid liie tiiirtietii year of aw, while 'AA per icnt. were aJHive for:y and only (t.7 ]mt cent, were more than tiflv. The stali.-ties of (iriesiiiirer also. ileMloiir „ith more than .')!() eases Oliservecl in Zurich hetween l< ]K'r cent, from tlie thirtieth to tiie fortielh vear. The" .-tatis- tics of l,iehermcister •' are particularly instructive. a> this oiiscrver carcfullv leavored to avoid the statistical error- allenihnil upon the inclusion of lios|iital-palieuti! : Age. Krnni ID !■■ L'o vc-ir- ■■ I'l ■■ :!o ■■ • :;i ■■ 40 ■■ ■• 41 •■ :.(i ■■ ■' .-,1 •■ i;o ■■ ■• <;| ■■ 70 •■ .\li..vi' 70 M;irs . . Nuinl'iT y'i I'crc-rnlllL'i* o| la-. > Ml ilii' i.iCii iiinii- lyi.li.ij.l r.\, T. .'il'.-! !»H7 274 MM :iO II I i'miiitiiL't' "I' I'n ili-|ii,'.iii.,n iis till- )ii:e in Iht- cuijipjiiril wilh tnlal [.npllla- tllf li\' la;.-.- r.-pff- ti.lll. s.-im-.l l.y 1 :i VI l.ti .s ■j;i 2.0 i; -■» 0.7 >) 111 0.3 •i 10 0.2 O.fi fi 0.1 ().(« 3 0.02 The freipieucy of typhoid fever at various atres iias heen estimated from the rnortality-tahles in a nundier of works characterized liy the larfrene.ss of the tii.Mires. These collections fail to v'ive a representation of the actual .state of affairs, as the mortality is variahle at different )ieriods of life, and .some periods, a.s. fijr ii}.stance, old aw, e.vhiliit unusually hii'li fiL'ures. I.ieli.'r- ineister therefore rei)roiluces the mortality-statistics Of llairenliaeh' with the same ■ 10 ■ 12(!.-, '■ 40 .. 4,-, .. ■■ 1" ■ i-'i ■• in8t; -• 4,-, ■- ,-,(1 .. • '■■' ■■ i;<> ■' LVMil .\l„.v,- .-,(1 viars . . . '■L'O -■:;.', " :j><.|,; '• 2-'i •■ :!0 •■ v;(Wl 771 4 --,7 lti,(l:ii; On comparinfr this with the i)recedinj: tahle. it will be seen that the marked ditl'erences in morhidity are ohiiterated ; thus, for instance, the fiirures for children I.etween the first ami the tenth vear equal those for IKT-sons hetween the tenth and the fifteenth year: and" there is little differ- ence hetween the aws from fifteen to thirty"; while the fiL'ures for old ajre are comparatively hiirli. Sex c;iuses, ai>i)areiitly, little difl'crence with rcirai-d 1m infection with typhuid fe\ cr. On the whole, amoiijr adults men are attacked ' ' ■ '■'' ' /'V/»,s'.s,-)i .s 1 1, III. /III,,-/,. :! .\iill |{,1. ii.. II. -ft 1. S, rj4, ' ./„/,, -h. ,1 huKli r/,,-,ll;.. None Keli.'.-. 1,H7.-,. li.j. i\. ' •• H.-[iartiti..n (1,- la H.'-vn- typli..i(k- i-n KniiK-i-, Ii,; ,1. iiiir. Cumiti .■,.„^„l:. il /iijih, IWPl. m ryriiniit lEvim. i-itliir iiiiirc iVcijiii iitly t!i;ni wniiicii. Wlictlit r tlii> (linriciuc i> due :il),ililc. Of (It'll riniiiiii'^ inlliiciicc in tlic cm-c dl tiicii i- |ir(il);il)lv the jj:rcat(!' i)|i|i()i- liniiiv tirr iiilrctidii, ill tlic |ir(-ciici' of (•(jii.il >ii-cc|)liliilit\ , hv rcnxm "t t:i(':il(i- \ ;iii:iliipiis ill rc-idciicc, in niiti'ition, :iii(l in occnjiiilidn. Tliiit tlic-c ciniiiii^tMncc- (Id iKit iilVcct tlic st;iti>tics in jri-ciilcr device i-^ iindiiiilitcdly diic tn rlic liict tiiMt tlic |ii'('(l')iniii.int influence of WMtci' in tile di-^ciniiKitidii (if tlic di>c:i>c :incct> wdincn in x'mi'ccIv Ios dcyrcc tliMii it di>c~ men. Mention of tlic tiict furtlier >liould not he oinittcil tli;it in lio-|)it:d— t:iti-tic> iiimIcs pfcdoiniiiMte soiiiewliat liecailse tliey enter ho>|iital> more icadiK , and tlicfcfofe with rclativcK' t.'^i'cater tVe(|iiencv. If ill certain ioialilies there i> a iiiarkeil iiiajoritv of caso in males, tins (if ilselt' iiiilicates iMitliiiiir. l)Ut r.itlicr re(|iiires iiivistiiriitiiiii into tlie nature of tile |««|iulaliou. Tlius, for instance, it cuii i)e unilerstooil that, in places that liy reason of lar;re estalilisliiiients or I'actorics attract voung males in es|ici'i;d niimlier, this fact uuulil receive expression in the event of an epi- demic of typhoid fevec in the L'reater lumiher of males allacke(l. Murchison lielii ved the two sexes eipially susceptihle. AiiKini.' 'IV-Vl cases treated in till' London Fever Hospital hctwccii \>^AX and IMil. there were 1211 males and lliL'l females. Also. JJartlctl ' oliserved llTlt males and IKil! females amoiii: '-■W'l ca.scs. Althou;:h Fiedler" oliserved 'u A^ per cent, of males and VIA percent, of t'ciiiales, this may airree with the usual proportions of the two sexes received into the lios|iital. Anionj: 22.'!.') eases of typhnid fever observed in Ilamliurfr. I have found 211.'* males ((15..") per cent.) and 1117 female.- . •''>4.o per cent.'. Iiut teel justitied in stating detinitely that this pre|)()nde ranee of males is not the expression of a iliHereace in predisposi- tion, hut is liic result of local conditions, leading to the admission of fewer women into the hospital. Sinic writer- on pediatrics (West, IJartiiez and Uilliet, Tanpin) helievc that the ditfereiice hetweeii tlie sexes with relation tii predis- position to the di-case extends into ('hildlKKxI. .Ml oliserved tiiat more lioy> than girls were attacked. .Mthongh it is not at all clear liow such ditl'crences can arise prior to the jieriod of sexual (ievelo])ment, the Col- low inir tigiii'cs are striking: IJarthcz and IJilliet, SO hoys, .'il girls; Taiipin, S(i lioy-, ;',.■) girls. I liclicNc, liowcver, that these tigiires are too suiali to exclude acci- dental influences, and that, therefore, they do not sustain the general statements hased ii|ion tlicni. M'ith a niuch larger tlelil for oliserva- tioii-, I have not lieeii ^truck liy the pre) Minder; nice of hoys, .\inoiig \'>\ children siitVcring from typhoid fever, I ohscrved only a few more male- tli.iii females, namelv, 2o(l hoys and 2 lyiKiLoay 61 rutely f..r cacli ymr llif I.")] cmx-.s oliMTv.-d in cliil.lrcii rlnrinj- tlic vcmps ixsii anil |s,s7 i„ Hanilmrtr. It lluii a|i|.ciir(d rliat in lM,s(; i|„.ri."w»Te altacki-il llti ixiys anil M.s L'irls; in Ih.hT, l:U |„,v.> ami 11:! j;irl>. Certain ])liy-.i.p|(.iri (iitiuns in wntncii, as pregnancy, tlic puerperal state, an.l lactation, ai)|..ar t<. (limiMi-ii ihr |,n(ii>- |H.sitiiMi to ly|)lioiil r.vcr. With ivirinl t.. tlic lic-nr .,f iniiiiiiiiitv """'''■'■'■'•'' I'y t'i'-«' -tales t incon-iilcraMc ditVrrcn.H- ,A' opinion exi-t anion^r various aiitliorilie-. ( ;rics.-iiij.r(.r i-on~iiicrs ty|ilioi.l (ever cxcikiI- mi:ly rare iir tiie |iiier](eriinM, ami lie lieiieve- niir-inir iiitlmt- al-o tu l.e |>artienlarly immune. In this res|«H-t he i> in aeeoni with Uokitaiisky. I have aKo oh-erviil ty|ilioi(l infeetioii hut twice in the piier|M riiim, anil Imt rarely .hirin;; hiitation. With reirani to pre<:nanev, in a^ree- •;>ent with Lieiiernieister, I do not i)elieve that the ininninitv i- at ail eonsidei'alile. In Ilaniltari:, anicmi: 1117 women .Js were preirnant — :!.4 |H'r lent. In inv exiK'rienee at jA'ipsie L' |ht eent. were preL;nanl. Kven at tli..-e period;* of life in which tiic predisposition to the disease and the ciiances of prej,'- nancy are diminislie.l, the fii,qires are relatively liijrh, as llie Ibllowimr tahn- lation of the •'!« Hand)iirLr eases will show : Sixteen were l)etween the ai'es of lifteen and twentv vears ; lo lietween twenty-one and twenty-five; 10, tweiitv-six and tliirtv;"4, thirtv-one and tiiirty-tive ; o, thirty-six and fortv. Hrief reference may l>e made here to infe<>tion of tlie fetu- with tlie typhoi.l-l.aciliiis. I.ym'h,' who has rejx.rtiKl 1 case, from the iieart's '■' I. sp.een, and kidney of which the typhoid-hacilhis was isolate.!, and also 1 ca>e with entirely iieir.-itivc tindiiijrs, lias carefnilv reviewesifive findinj.rs. In Lynch's ])ositivc case tlxTc w( re flaind numerous mi(Tosc con- stitution, :ill (ilp-. In tlii- rr-iHrt t\|(liiiiil \\\iv -I iinU ill i-oiitni-t with l\|iliil- ti\iT ;illi| rrliin-iinr t'i'Vrf. \\ liilc ill l:il;ii r|iii|rliiii'- iil' llir tVMi Lllirr ili-f:i-(S till' |iiMiri'|- i'|:i~«i'- in the rMlluiilinilN , 1 -|ii riiills tliu-i' l.iliuiiii^- iiiiili'i' |)1|\ -iriil ili^lrc-^ Mini '^riii'iMlly iiM|i,iii'i I iiiiliili MIT MitMrki'il, I\ plioid ti'Ncr ili'iiiMinl- \\< -iiri'iruT- Mlikt' tmiii jiiMii' :ini| rii li, iVuiii iii.^li miiiI low. ( 'rrlMiii ti'Mii-iliiry iiH'iitMl Mill! |ili\-irMl riiiiiliiiiiii- M|i|ii'ii' III iiH'iT:i~i' llif ]iri'- ili-|iii-ilicin, -iii'li M' |iiiiliiiiiiil I'iMiitiiiiiMl ili-liirliMiicc-, i,nii't'. i'mit, mimI ('\i'i'--i\ 1' |ili\-ir;il Mini iiiiiital :ii'ti\il\. Wlii'tiici- iIicm' iiilliicni'i'- li|H'r:lli' iiy liiUI'I'illL; llll' I'l'-i^tMllrc In lllr ill\M-iuj| ut' tlll' |Hli-llM 111- li\ t;i\ iii'iin;' ilii'i'i'tl\ till' rii('|iliii|| Mini i|r\ ilii|i|lli m ill llic iiI'LlMn- nl' tin- liiiihj i- M- \ rl -liriiinliil in ilmilit. 'I'lic mode of living, whirli ]<\a\- "< ini|iiirl,inl a pMi't willi I'rlMlinii tu till' ili'\ i'|ii|)nnnl ■■I' typliii- ti'\ir, Iim» Ii\ no mh'mii- tin- intlinnci' ii|ii'n ihr i|i'\ i'lii|inn'nl nl' I\|i!iMiil ti'Mi- tliMl \\m~ tii|-iin'i-|v Mtlriluili'il In il. While rrnwiliiiL'' in >iiimII rnniii~, ili'licimrv nt' Mir, li';lil. Mini xrntilatinii im Trn-i' ilii'ri'lly tin' cMpMliililN nl' inlii'tinii Mini ili--i'iiiinMlinn in tlir ra-i' 111' ty|)hii- tr\ rr. I In '-I' iiilliit'in-i'- M|i|itMr tn 111' n|ii'rMti\ I' iiiiK I'liinlitiniiMllv in t\|)liiiiil I'l'M'T. In i-iiiinrclinii uilli tlir hitlir, il i- tn lir imti-d lli;it ili'l'i'iti\ I' linii-i'linlil-iiiinliiinii-. MPc ii-iimIIv m— iiiiMlcil mImi willi iiii|H'rr('it ili'MiiiMLii' ami |ii'nvi-inii- liir i'li'Mii>iinr. iMilnr^ that l'a\iir the .•ic('i 'il' lit'r, i- a iiiMtti T III' daily nloiTvatinii. SimilMr >tatrincnts iiimv lie ni nil' in '^I'lnral \\illi rriTMi'd t('> i- tn lie <'in|iliM-i/i'd. 'rv|lllnii| fcVi-r i- lint riilllilll'd tn jlnViTlV Mllll llli-rr\' Mild till' rnrri'- >|pnndiiiL; |iii\-ii'al rninlilinii-. I ii dni-i'K' |)n[iiilMtrd ritii Mild tlic.-c inn-titiitc till' lii'-t lirld I'lir nli-crvMtinii ill tilis ciimn'ctinii — t\|)liii,- lexer and rila|i-iiii: t'lM r iiuadc tlic liniiii'- lA' tlie [MHir, asyliini> and [Miial in-titntinii-, unrklinii-i'- and jMil-, and a\niil tlir dwi'lliiij^s nf ilir riili ; while ty|ilinii| t'i'M r liiiU tn recnLini/e these liiiiilMtinn-, and neeiir- as riei|Hently. if imt ninre I'l-eiillelltlv, anniiii^- the lielter elas-es ui' siM-ietv lip t'llhe lii;;lie~t eirele-. The " lllisere |)liysii i|n^ii|ne "' all'nnU |)nit<'etinll, in-tead, at;ain-t the di-ea-e. The speeial nlaliniis nt' nei'ii|iatiiiii tn i:niii.in;Y. 63 ty|.!iMiil fever arc ti> !)<■ conxid, n il In^ni tiii- -taiiil|Miint. Aiiinii;: iIjc workinir-clii.— (■> tlir viirnroii-, soimi: iinli\ iiliial- li\ iiij,' iimiir Ixttcr (■i>ii"litinii^ anil (•iit;a>;i(| In nmn- liialtlil'iil |iiir-iiil- arc with |intnn i- ((.nlirnd c.nly \>\ iliu-.c iicciipaticms lliat iiiHc~~italc ilipMt cxiMi-uri' to ilic inva-iim nf tlic isplioid vini>. Ill tlii- cJa-^ licjuni: i-|i'rially iIkim' riii|iliiycil alxiiit aii all wli.. •(■ii|iati(>n hriiiir^ tlieni in cuntait with |.atiinl- ami their (lejection-. naineU , |ihv-i(iaii-, nurses, laiiiiilre>-e-, eeii|)ations ainl ((iiidit icii- de>er\c e-|ie( iai niention that neee»itat(' intimate a-uciatinri of iiidi\ idiial- |ihyMeailv |>rcdi.-|)<)M'd 111 marked dejrree, as, Ci iii>ta , interne- in ho-pitai^, pupil-, in seliiK.l.-, Mihliers in harracks, etc. The (|iie.-tinn ut' hospital-infection, prevlou-iy ret'.rreelioM-ntciisil-,or from articles of tl.od ami drink, |)lay the mo-t important /•.;/,■ i,, this c(.ii- iicction. The fre<|ni ii inceti(,ii is n,,t yet clear, hnt they are not t.i l)e wliojiv ii.'-iiored. I At times a liospilMl-cpi.Jeniic that results from the mistake of a »hMe iiiexpcricMe.Mlnr.'aivh.ss assistant may upset the hest iivirieiiic rc-ulati,.ns. We liave receiiliy ha.l such an nnlortmiate experience' in I^'ipsie in this ci.micction. In Hamluii- where the hv-ienic conditions of the holy throu-h the mtermcliation of some thir.l (x-rson. .Muivhis,.M's experi- en.e in the l.on.|..n Fever H.i.spital was al.-.) .piite favorahl,'. as amoii- lspilals have heen .s,.mewliat less favorahle. In the dacohs- __ ' -.fj - - t-. - 1 r. =^.- J A 64 Tvriinih I i:\i:n. \) f ' s|iil:il (if I.(i|iKi(' '!.'( rnsc^ — L'.l.i |)i r criil. df niisiicniiiiiil Ivplmiil (('ver i]( I urrcil ill ihr riMii>i' lit' tiiurlccii vrars. Ilcic tin- iiiiixs ami lln- ii>,-i>l- aiil.-. aiiiiiiiL' uIh'Iii L'.> ra.-c- mTiirri'il. Wri'f plaiiil iiinli r far iimmc iiii'aMir- alilr cniKliiiiiii.- lliaii iliiix- iiiMlcr llicir care, l.irliciiiM i.-u r liail an iiiiii>i similar i\|irriciirr. oIimtn iiiL' aiinniLr I'.'Hd ca.^o idiinn;: I In- \car.> liinii iMi.i i<> 1>7I' 1) J. I |nr iinl. I'lic f.\|ii'riiiiri> i.T A k xaiicUr al tlir Hrc.-laii I |ii.-|iiiai \\ ll(i|ikiiis llii<|pilal, Hailiiniirc, Jll (■aM> cf Ivplmiil fi ,iT ha\i' nriniiiatnl in llic liii>|>ilal >iiii-f il,« ii|iciiiii:;. cli'Mii \iar- a:.'c). Dmiiij; tlii> lime, 11(10 casis (if |\|>liiiiil fi-viT lia\c liicii tnalc|iilal iirii;iii \.>^\. < M' llioc iiifccicil, > ucrc iiiirM.-*. •'> |iliy:-i(iaii.-. 7 paliiiil-. 1 (irdcrly, and 1 maiil. l-diir (if llic 7 (■a>(> aiiidiiir patient.- (icciirrcil in (inc uani at tin- >amc lime. I lircc cax > of l\|ili(ii(l fever have (i(ciirre(l aiudiii: (liictdi'r- ami ^tlllll■llt^ Wdrkim: in llic pal linldiric lalidraliirv nf llii> Im-pilal. In diie ca-e. thai d|' a -liidciil. a pd.-silile sdiirce of iiifeelidii eiiuld lie li'aeed Id ua-hiiiL;' l(-l-tuli(> ( uniailiiii^r eiilliire> df tvphdid-liacilli wilhdiii pre\idu>l\ -lerili/inir them. ( )|| tile wlidle, my (Npefiellce -IkiU- llial ill well-ciilidlleted ll(i>|iilals i.-iilalidii (if lyplmid patient- i- iidl ii(i(— ai\. ( )iily iiiider -peeial (■(iiiditidii-, partieiilai'ly when llie adniiiii-l lative arraiideiiieiit> are iii-iil)ieieiit, and llie relatidii- lMi\\(('ii ilie adiiiiiii-lnitiv e and ilic niedieal dllieer- i- imeertaiii. wdiiid p( riiiaiieiit, (H' at lea>l teiiipdrary, ^, .Miwdalidii df tvplidid p.'ilieiit- ffiiiii the icinaimlef be re(|iiifed. The aelidii (if cold and the traii-itdi'v Imdily di-tiirlianee- nferaliio t(i il .are fl((|ll(Mtl\ lilelltiiilled a- faeldl- fa\iililli; the (le\ cldplllelll dl" typlidid fever. I"(ir liii- there i-, hdUexcr. im pii-ili\c e\ ideiice. aii(| nut I'VcM Ini-twdrlhv -ii|i|Mirt tia-ed iipdii e\peiieiiee, which, as will lie -ccii, may lie iiiVdked in tiivdr df dtlier cdiili ilnitin;.'- cdiidiiidii-, I helieve that the t:l-d\\tll df the lielief that Cdld la\(irs the de\ clolHliellt (if txphdid fever i- the re-iill (if ediifii-idii with cdiiditidn- llial are theiii- M'lve- a |>ait (il the di-ea-e. I iii.-iy iiieiitidii in ilii- edimeetidii the scM-e (if Cdld and the swcatiiiLT nf the peridil (if ineiilialidii, a- well a- file initial ehillille— . \\ hetlier the illllllenee (if Cdld in thd^e alre.idv iiiti'cted — that i>. ill the pcrind nf ineiilialinn nt' In plidid fever — aeceler- ale- till diitlireak df the di-ea-e, a- appears denidiislnited fur a iininher ^"'l'-'il'nlM«no,|„,-,|,...,i,.,,.„,^ ^„,^ ;!:■'';•,:'''';:'-'''■-'''; '■'•"''■''^='-' '^•"••' '"" ' i-.i.! ';;":" '""■"'■■-—"-.I,.. ,.,;„„,.,„„,., „,.,.. ..,i,,.„;^.;^„ """ T;'""''" "■•• '"'■■I'- ■■"' -Iin.i„,...l„.u,.nn ,1,., ,;,,.,, -I.lp.ol tl„.,-,Mt,.„|..„l ,|iH,,„, ""- ,'" -■'•"••'l-'<-vi.ii 'I- vi,.„ alr,.:,.|v „„,„i„„.,|. ,,.,„,|i,„, ,„ :;:"-7'''^ -■;-•■■•'•- i...li.i,|,.al, an. ■,• ,.,.a.l,.v a,,:.., Z '•■^■'••- '"•<•".- ^I,..r.ly at-,..,- ,.unval,.-,...„..,. f, , :./.•'':"' •"iival,-,.,.|i,.,. tn.n, a.it.v.W,.|ii iMt;...tioi,s .lis V '■"".""■' ""' '"■■"' '"• '"-'" -l-.inllv ni- a,„.i„.. .i„.„|„, •'I'l'-'^ "-'l.v ia,;:r,. s,aii>,i,.s u,„|,! |„. ,,„.,|„^i^.,, „,,/', 'rr '':"," :'T"^' '■'"" '•— — >"n.llv „.„ ,...n-.v,lv- ■inta^i.iiiMii t.itviii,,, t;.v,.,- 'ri,U I,., I , <<'Min J-: /n J ,:J;t ':;;:' 7' ""■'■:'•■'. II '. < .111,(11 ) wild ; (|\ aiir(.'" ' '■"■■■' ,:;;„;:■,;,:;,:'■"-"■'' 1 11 ret* fast'*; rtt'mivitJ ',,.4' .* • I 1 "t tv,,l,„i,| fever tre'ie ''" ' ^^ "if '"- ""^l"!"! a-ioii,. about l|(H)-,.L..s •■'II.V>..,I L>., uiil.,I .■,,:•"'•." •'' '•'•I""-'-' ""<• "f tl.es,. ,.a...s. |,as "">■ '■-«' ;~ -:;;;..i:;i„'^i;l.::;!i-;- !:;;i;- " -™" ' /..■•/.„/.. .1/,,/. ./,„„ .Illlv. |H,-,,-,, '■''■''- "'■/'^n,. „..y. It,,,..,. I V ■■ A'.r. ,/ ,/.. IH.-dl. i I : (Hi I) rimiii I I \ I t: \ ii,_r ill, rlin.in. ml. ,11. .11, ,ii-.:i-. - |i(iliiiuii:ii\ Iiii..ivii„.-i. l,;i- .,(■,,1, l.rrn -|K.k,n ..r 111 lln- .■..iiii.rii..M. iiiImt, iiL.ii- |..iIi.mI- 1- in- ..i. tlir «li..l. l....U,.l ii|M.ii ;i- |.i-..i.vi.-.l. Al-., ;i..,.nlin.r i > ,A|Kririi.v. JM.IiM.liiiil- ill til. liii.l.ll.' :,M.I .-|..vi,-,llv ill ill. a.K:iii...l -la-c ' 'f |'nl ,1 ;i,s i,,1hiviiI..-i, ;iiv .,irn.- iiiivk mIIii.Im^I I.v Ivpli-id lix . f. I ll.i- i, ill,/, ,. ii.,|,.u..lMliy 1m.,mii-,' -lull iKiliilil- -.m.imIIs ivium' i in iIh' li.,-|,il;iK r..r :i l.'ii'-' lini.'. :iii'l I Imi- l-iv aiv willi ivhiliv IV. .|ii, ii.x l,i-.,ii:;l,l int.. .■..iilii.l uilli l\i.li..i.l |.;ili.iit-. ll I- '11,^ iiiilil-.--i'>ii, li..«- ,.\,.r. thai ill lln- .•.,iiii.. li.' -|,..ili.- Im I 'li'' l""'> i" '" |„. |„U,ii iiil.. .•..ti-i.l,Tili..n. I'lil lli:il ll"' .■ni:i.iali..li ..r ll.. l.aii.nt i- ,,„, i,„,„,,,;,nl ra.l..r, I.t pali.iil- -iilV.rin- tr-ni ..lli.'- . lii-..nir all''- ,i..n-.,f \aii..M- Uiii'l-. ll'"!! niali-naiit ii.'..|ila-Mi-. ,lir..in. < -liliiti..iia! ,li-.a-.-, aii.l .-|M-,iallv .lial.,'l.-, aiv -.aiv.lv ,A.r alla.'k..! uiili lsi,li..i.l tiv.r, ill -|.ili- ..r liv.|ii.iil ,A|...-iiiT I" iiili-li-n. In liar ny witli llii- vi,,„ i- il„. la.l tlial u,ll-ii..iiri-lM-l. af.l.ril.- tnl,.'iviil,,ii- pali.iil- ..r in.livi.lilai- uilli lal'iil Inlni. iil.-i- an l.s ii,. ni.ai,- iMiiniiii,' |.. ty|,li..i.| tl'V.T. K\.T\ .vlHl-i-iir,'.! .•liiii.iaii will lia\,' Iri.l -.mir ul n.v 'A]"- ri,.,„,- uitli 'ivr.ivn.v I.. 111.' .|,s,l..l.ni.iil ..f till.. iviil..-i- ..r llir la|.i.i |,i-..oiv- ..f |.i-.Ai..ii-lv iv....^iii/.-.i .iivmii-.Til,..! iiilllirali f llic Inii'- .luHn^r ||„. ,.,,ii,-,. ..r tv|,li..i,l r.v...-. M-. ill.' ■•tli.r .•lir..iiir -li-.a-.- .,f til.' lull-, .iiililiv-nna a.i.l .lin.ni.- I.P.n.liili-. a- u.ll a- l.f..n.lii- • ■.la-is apiH-ir l.. iMliav... uilli ivlari..ii I., tlir lial.ilitv ..l' iMt;'.ti..ii, i„ ;i,v..nlan.r with llf a-.- ami .^.-lunil pliy-ical .nii.lili I lli.' |Kltirllt. (■lii.inic (li-caH- ..f llic n.Tv..ii- ■ \ -t.iii. in -o far a- tli.y ..r.-m- in iiHiivhiiial- williiii tlir |.r.Kli-i"i-..l i«ri...l uf litr, an.l. a- -.. ..ffn iiap- |„.„-. r.,r a Ini.i: ti""' -1" ""t '".i"" ''" "■ii~tiliiti"ii. MtV..fil ii.. iinniiiiiilv t,> tvpli.-i.! t;.v.T. 'I'll.' -tat.in.iil lliat .li.tcti.' .rn.r uitli -.v.,n.larv tra-ir..-iiit.-liiial .-ataiTli -iv.- ri-.' t.. tv,,li..i.l f.v. r i- i... Inii-rr a inatt.T fur .li-.n-im. at tiir pf— nt .lax. Tli.' vi.-.v. .•...i.vival.lr tin.ii „„,.ai-licr..ti..l..i:i.'-iaM.llH.int,i-! -.1 np-.n an iiu'i-rr, . i i,it,.ri.ivtati..n ..I vari.iii- ,,I.MTvati..ii-. Tim-, ii ■- ■ ■ nainly ii..i iin.'"Miiii..ii inr ili.- tir-t ,-vin|.tnn,s ,.f tvi,li..i.i Irv.r i- I"' i-Mt..iin.l.^l xvilli tli..^,' -f ~iin|'l>- ^ra.-tn.-iiit.Miiial' ratarrli. TIh 'ian-vf i- ,-i.r.-ially -ivat '.villi nliivii.T ^, ,„.-.-... f walkiuj: typlioitl liv.f. wl,.,-c tnir natiuv i- ..i>,n ..nly lii-t r.H-.,.^i,i/..l wlirii tli/i.ali.nt i- .•..ini"ll.'v in i.i.livi.liiaU aliva.ly iiif^H'tiKl. SiipiKirt for thi.» view i- an;.r.UHl l.y tiic ,.l,.-.rvati.m that .(• ivl I lint. DC y. i|'-'~ ami iniiii 67 nl.iti ' I. lint ninlv (liiv,il iHiitii' crrni-. I "■ |"<'li»|">-in_' iiitliji'ii if iiiiili- iiikI I." iiruliMli Iv .1 • ■["■iidrnt ii|»>ii III.' all.-ialinii in |n,|r,„.| I'hroMic iliw;t.Tj< nf ||io ni. wliKh ilicy iriM. n.fr\atiiiii'< iiiailc i ilorii- aciil siir,tj(,|i II iillicr rit'ri|ii)iis iliili.-i|iatc.l. .\fllinii:/|i,;i,|ii,., Ik iwnr i-i>i-iaiil iliaii iitlii KMMrir jiiic-,.. ii caiiiiul |,r iloiihh'.l i;;(vi,|,.|-:ili|i- iljiiiiiiiii -ai; ili'Mi III till' frci' lnilriM'liI that tiaiMitiirv or i.rolraclcil alifc liaiHJ. I ■'I'l'-lll''' llllo ill,' i|||,-li||;ll ir ri >n(' arid iiiat.'rialK t; "• M'-IIIIICi I'lirclirallv. it i IiIhiiii'Ii lira iiav, mi till' ,ii iMirs itii-ir till Ml llll'll Itl-O.'l, li'd. llial I'M.li'iiii' III faviir of llii.'. vii'w lia.* mil ri'laiivi olrii' ili-iii'ili-is atlcmlcil \\\\\, iiiirliaril am • •liaiiL'-i'.< ill till •_'a.irii' ■"lit, '111.-. Tlll'V U'lil'M' ||„. .1; rtaiii iili.it'rvalliiii.-i that 11' ill ari'oril witli t|i,> jiiii'c am! Ml II liarai'icr nt il aliiiiii III) |i,.r liilalalimi of tlir -im ai-li :_'fm'rally cxliili alisi'iii'.' or ili'lii'ii'iii •r all t\plioi, li'tiH'iit jii-iili,',| , I.,. (;,.i„| •II. .\.- |ialii'iii- laiM' III t iiiarki'il alliral \ ill fri |iali,'iit..< with cliroiii,' ,1 n- • that i'\ioii.-i\ .»iil|i'rt'i| Iroiii mil- ill ll llalalioii of I If .•loiii- lm'iit.'< 'll ll lyilriicliionc arn lo-l- oIlSiTVlT- iiiav I I'Vl'r, oil ill,. liM-i- of I'Himl ill llli: iiiv own rliiiical ami aiialoini I. -a.-irii' |ii- |iartii'iilarly an i'X|ilaiialioii for ||i|. slalc- liri'iiiii .laiii'c. I (ill I'Diii- > 'li'iiv Hii'.-i' -lati'imiil- ,'iii|ihati('allv. 'l"|ii'>o h ill ll' ililalali if III,' ,-i I'lallv roniiiioM. lio I 'iiiai'li ami ty|ilioi,| f,.v,'r i.- Iiv i (• i)i>-i'rvaii,)n.<, ivf .-liiuMi that the coini'i- "11 iiiialil,' iliriii al.'.,) ilic fiirt 1(1 iiicaii.'* r.«|ic. Ii.inl ami I.,. « Jnnlr,. that tv|ilioi,| f caii.-ii'- ililalation ot' tli,. >iiiniai'l I III iiri'Vioii-Jv hi ■r, on till' othrr liaml. KT .-lalcim'nt of Mot r.ri'lv Repeated Attack ; Immunity W |).,— ,.— II I'liiiuniital iniiiiiiiiitv tu iiifiK'ti hi'tlicr tliciv arc iiiijiviilnal-i .\t all iml Vet llll'll ili'tci'iiiiii, (■veil ll— rrn|ii(.|it tliaii i- k • ■a-i-, |iarticiilarly tlio acute I'.xaiitl 111 Willi the tv pimiil I •'vcnfs, till- i- cxtrciiicl tl V r:irc, Hll-nll lla.-i |icrha|) l^iiiiwii to l)c the ea.-e for other iiireeti.iii... di- lirmlv e-tahli-heil nli-, ■mata. On the otl ler haiiil, It 1- a I-: ■r eimter- relative liruteetinn t ■erv.'iliiin that recovery fhiiii mie .',ti;ick of l,-i,||„i,| iMi elli-oll, .low, I to ( ( Kreti I'liiii -illi:.e(|iient atta, k- of the d l.v nvuvery lioni an attack of tv|.li,)id ( e\('r IS not • '""•'"■"■■' "^ ''='^ '"■<■" -''"^v" '" I'.' the .'ti.-e Cor nio.i/a/„l,,,H ,/,■ fistuiiKic i-t liirrr ti/,,/,,„,l,- e.xperi- w,' , Tli,'M'. V. rU. IHKi;. ! 3 r- I a;-^!^ 68 ryrii"ii> ri:vri:. ,„.„t;,l nl,-..rvMtion-. Ar.-or.ii,.- t-. n.v ou n ..x|Mri.n.v. tvvu atturk- .,f tvplini.l f.v.r in tl.r -Minr ih.-i. ..v l.y >. an- nuv. I lu.v n.v ..;..„ in.livi.l.uU wl.n Imv l.a.l Ilnv ur luur atlark- .luni.j: thrn- liv.-. Surli ail .KMiinvii.v iialurallv i- a rare cNcri.tioii. \,„„n" 1^^> nati.nt. .xaiaiiR-.l will. L-nat car., i., nranl t- this i.niMl durin. ,1,; .i ,vv.a. .y n, ■'•>-, a.^k. \,u.MP' llu'^l :)4 nalicnts lli.rc vvcrr 1- «lio. -Inrn,- iIk' tu>t atta.k .t K l,ia r.v.r. ali haa l.vn nvat.,! in th- (icncrai Ilos,„.ak an, .1,.. i ,:,„..,s ..onl.l 1.. v..nii..a iVo.n .1.. yu..r..,\ ins„„-,.s an,! U.uyruaun^. I'l'ar,.. In th. n.nainin.' :W the stal.Mn.nl «a. a.-Hpna ..niy Nvh.n the eviaeiire \\a> most |.n>ilive. •l\,,h.n.l fever pn-ent- a noteworthy .litV.ren.r from the a.iit.^ exan- themata in the faet that eon.|.kte immunity .k.e> not exiM, as in the hitler, ,h,ring the first ,H.rio,l .Iter the .ri>ease, ana tlial ,.ro.,v->ive .Innmi.tioii ,1,K.- not -Ml.M,|Uentlv tak.. pki.v in i,ro,K,rtion to tlie tune ekip-m- ,,,•„,, ,,„, ,i,.., .M-,rk. On ti... .•ontrary, I have ol.>erv<.l imlivMhials „m,k..l t;.r a s..eoml tin,., hi.fore tlie .n.l .a' th.. lir.t y.ar or Nvi.lm. a i;.\v v.ars aft.r r...i.v.ry from t\ nhoi.l fev.r. 1 l,ave n-liahh. r...-or.ls i.,H.n tliis p.,int in Kl .■as..s in whi.'h a s,...,ii.ll „„a..k ......unva. TlMs.. >h,nv that in :;0 ti... s...-.>n.l atla.k ..t Iyia..M,l tp . r n-..,l U.f,re ,„e h.pse .,f ..n y..a,s. In tW L". ea.s m Ml^U a„a.ks w...... .r.a,..,l in the (u.n..ral ll..spi.al, th.. m> ryais were as loiln. :;;;.. ,„„mi,s l,, 2 ..as..s ; ..ne year in 4 ; ... v..a,s n, 'l : .hive years n, 1 . tour v..i- IS in .'.; tive v.ars in li; thirty-nme years mi. ' ",i, u,e ease mwler ..hs..rva.ion ii. whi..h :'. attiu^ks ...■.■iirr...k the firs i likewise ha.l tWlknvea in .^n\rk i.,n. Th.. pat,..nt was a man, ..r.^- ' .v. v.. ars okk « iio ha.llive,! in HamhnP. fn-n, the y..ar 1^. ., an.l .as ),r.t s..i«..l witii a s..v..re attu.k .-f .ypli..ia fever m_.h.. wm,..r ..t M, ,^ . S an.l was at.a,.k..a tor .he s......,..! time in the year I.H,i.. '^.t'-' ' i-.„- ,l,e mihh.st of the thr.-e atta.'ks o. mrre.l m th.. }-'''• '■^■^- -^.^ ' ' ""^ a, at were .r..a....l in ,i,e (;..n..ral llospi.ak , '"^ .ahiy ,h,s pa i..,,. ha. ....„ ha.l an a.l.li.i.mal a.ta.k .,f .yphoi ' fever m th.. y.ar M,,., ; a. Last W sla..'.l thai i...«as at that time nn.ler ,r..ut,nent m Alt., .a t.,r three week„ for • u'astri.. fev.r." ()l,-,.rva.i..n- "f th-' r..i...at...l .M.,.mT..n.... of tyi.iw.i.i f.ver in the same in.livi.l lal l.av.. h.vii r..]....!..! iV.-.n vari.M.s H.nr....s. Th.. Ii>rnr..s a-.v.. i„ .nn.rMl wi.h .nv own. Thus, (i...!. in Ki.l has ,,.....1 two atta.'ks ... o ,H.r ....nt. ..f hi- ..a-..-. l',.v./ ' in l.S p..r .-.n.., ami K.vumll..l. " ... •-'•- „,,,.,„ A hi;rh p..v..n.air,. i- n..!..! l.y Ki..hh,..-^..' who has pv... ,.-p...iallv ...•..•..fnl ami .xhaii-tiv.. ...n-i.h....ti..n t.. the Mil....... A.m.nt: ,;.;.; ..as^s ,.f .vph,.i.l t;.v..r. 1... tiam.i -S_1.2 p..r ......t.-i,, wln.h tw- a„a,k- ha.l o.-e„n..l. Al-o. lu' ol.-..rv...l ..,>.•> in wl,i.-h th.r.. ha.l l.e.„ ./,,„N.-/,. .1,vA. r. ^'-». .U../, IM, vv. u xv,i ^"-/. H'l- ^^^"i- • \\n-/fnr ^ .li:-liir, li.l. iM. irrm/jK; >-. 69 llircc atul vvvn fl.iir :,tt;..-l>>, a,- al>u (iiiiiirkc ' an.I C.tli' 1 ca-o ...cl, in wlrich llici-c liad Ixvii tlircf atlai'l<>. Will. ,r:s.m\ u, tl... i.ifnsiu- of ||„. ...,.,„hI an,!, in jr,,„,.,„|, „f any M.l.-....|iMiU attack of typhnM (rvrr, tlii> n.v,l nut, a,vnr,|inj; t y .■xiMTi.iMc, I,.. I..» than that nf tl„. H.-st atta. k. ()„ tlu- <-,,nti-.u-v, tluTe li:i\v Iktm aiiiuii- ,„y ,,,s,.s > in w|,i,.li tlir liist attack \va> niil.l, ^^'"''' ''"' -'•" i ":i^ >'> xvnv a> to t.niiinatc fatallv. Tlii- i< iti :' may h,. nioiv -cv. '■■ aiul t.i..iv proti-art.^i tliaii tlic pri- niai-y attack. In this iv-p.-ct al>o thciv is a cciiain contrast witli ilie I'cliavior ,,(■ the acute .■xanthcmala, a- a type of which variola may ajriin he mcntioMe.j. [t i- kn..\vn tliat -econd attacks ol' (hi> ,li>easc arc aiiMo-t invariahly mn.'h le-s severe than the (irst attack. Ail „f the f;.rc^r„i„jr j;„-t^ have hecn Icariu,! from and are ha^.n! upon empiric oh~crvatinn. With inerea-inj; knoul„lp. „C the vital activities of the pathoirei.i( micro-orir:.ni>ms, a I.ett.T iiisijrht into the nature of inminnity ha- I.een gradually ol.taincity of pn.t,M.tin;r experinu.ntal animals. espe,.iallv mi.-c, from the ''"''■"■■' ^ '•"••"•'^ "*■ ^^•l''"-i'l .-Nhnres. It has also Inrn po..il,Ie to ■M.nnnu/e animals t., the a,-tion „f th,. tvphoi.l-l.acillns l,v in,.ans of lilten.l or i.ntiltcrcd typhoid I..M,illon-..,dt,.rcs ; and h has also Inrn l"">.d that tl... l,lo,Kl-s,.,-nm of snch in,n.,n,i/,.l anin.als is in tnrn lapal.lc of immnnizinjr ,,thc,- pi-,Kli>po-.Hl anii.ials. Hy .iieans of an clal.o,-,t,. .eri..^ of expe.i...cnt>. I'lMtfcr and Kolle ' liave l>o .hown that the 1,1 !->e.-,n., of typhoid c.mvalcscents contains Mil.Man.e- winch, wImm. the scrnn, in verv small am...ints, to,r,.t|„,. „ith ^' ;•"'""••■ "*■ the tvph,,id-l.acilhis, i> inj.M.t,,! into tl... al..Iominal ..avity "' a ,-,nn..a-piir. hav.. n.ark,.! I,a..f..>-i,.i.i.- ■ .o|K..-ti..s. Tl...... snlwfan...;s ar.. th,. spc.ific '•anti-hodics," ,.orr... ,din- to thos.. ,|...c.-il«.| l.v I'h'iir.r in immni... ..h,,l...i,-...rn,... ': h-y • lat..r sl.,,w„| that simil.-.'r "'""'-''"'''•'^" '■'' '»■ I'l'-d"'''--! in the >cnim .,f n..rmal m,.., I,v inj.H.t- ' /V.'N,7,. An/,./. Un,. M.J., H,| \\\,, ' Ih.tvh. ,,„;/ H,.,/, . IMIJ, N,,, .17 " Ihiitxrl,. HI,.!. |( ,„•/,., Nov. V>, IHHil, ' l„„ii,, ,),,<.. Kill, i.Hsi; ' Z,,f.f. II,,.,., |!,i v\i. --> . " \\s^ 70 ■yriioin ii vi:i: inu tliciii witli ilrad lv|ili(iiil-liaiilli mI' IiIl;!. vinilciicc. A certain ain.iiiiil .if rcai-linn \\a- .•.iii-cil \>\ lln' injnlii.n, rnlluuiii^- wliidi llir -iriii.i >li(iuc t\ idcmc lliat aiitit.ixii' >iil»tanr. - arc c\.f l.iriinil. In i externa:., not individual, influences. Ivocal Conditions; Geographic— At a lim.' wli.n a -i«>n- taiic.111- li.Ai Idimicnt .it' ty|ilii.iil fi.ir \\a--till In ii.'Vc.l in, ..r. at lca~t. ul„.|i ill,. ii{iiniiin wa- hd.l that tlic |irc-iT\ at imi. niatnralii.n, anil ,li— .■iiiinat' f the -|ii.'ili.' i-niita-iiiin \\ rr.' il. 11.11. l.iit n|i.in llirrarth :mii1 air, .-li unal.r an. I rvni ilici-ivc -iMiiitiram r ua~ attacliiil til ihr liical .■.iiHlili.iii-. At tliat tiin.' it ua- li.li.vi>.l that tli.' |i.ii-i.n ua- .■.iii-IanlK iin-.nt. nn.lrr-uin-' a -nrl "f -InriiiL;- ii|i ami .■.m-tant ri|.iii.liirli.in in .Trlaiii eitii- ami .•ntiiv r.-i.m-. I'r llii- |"iiiit ..I vi.w. Mi-i)iriiiii- Imil-.-. -tr.vt-, l.i.-alili.-. aii.l .itic- uni -p.ik.ii ..f. It \\a- li.'li.N.'.! tliat li.'iv ..i.lv -.lunil iiitln.'m-i- .if Ma-mi. trini«Tatiiri-. waln-lrvil. .-|..vially ,i|' tli.' -r.mn.l-wal. r. .iftm in a — iiaatinn uitli nint.ni|Mii-;imuii~ i\.-a\ alinii- nf lln' -"il :iii.l th.' n m-t rii.'t i.m nf ~.\\ir-, \\.iv n.v.—arv in .ir.l.r h< r.fil.r tli.' --Iiiiv.l-nii |Mii-.iii a|ily i>f a |il i- "t' ntin.i-t iniiHirtame. In tin- iiiaii.T il,.. lel.iii.iii- helue.n ihe -.uli-.iil .ni.l the v, ater--n|i|ily are iiatii- rallv uf imiHirtanee, ami frmn tlii- jHiint .il'vi.w .very |ihy-i.ian >ii.iiil:iT. mm Eni'l.oav. 71 Miakc hiiM-rlf tiiniili.ir- will, tlic .■,,n.liii(,ii- .,f tli.. -,,il ;,n.l ih.. jrn.iin.l- ualrr..f;i placr, r-|„.,l:,lk ii, i|. rclatiuii- |,, tlic w, IN ;,n,l ,,tl„.r>,,„r>v.-. I't' \sal( r---ii|i|)l\-. lli.ic have Imm-11 riiaiU' in tlii., ci.mK.cti.iii iimii.-ioiis valiiahlc iiivc-iti- LMtiori.- iM.aiiuL: i'|k,i, i|„. ,li||;.,-ciir,..- i,, il,,. |„.rMK.al,ilitv (if ilic <.,il and "I"'" '!"• '^'"'i'' =""' til" din.,ii,,M in « I, tlu. .■.|„M-iK<-allv rontuniinalcl -nMiH.I uMl...- I.- r„nv. V..I. Nui |,>, nNrufr(.ii.s.-tii.li,.s rWcr to llif ,Mrurmi,v nt I ir .h>,.aM- ni pla.v.- uli,.|-c tli,. ualcr used f.,r driiikin- and for lion-.- li'.M piii-poscs ua- denvcd n|,rni->. and oiIi.t walcrwaN.-. rndcr Mich comlilions tlic danger oC <'oiitannnaliMM of il,,. wmI.t wiili tvphoid-liacilli durin- IianMiiis-ion is ,.<.«■- ciallv n, I,,. cMisid.Tcd and invsii^.and. Il .-hoiild parlicularlv l,c csiah- lislicl ulirllici- the «atcr-Mi|,|,ly is convcvcd tiu-oiit:l, cndiiils that arc cvci-vuii,Tr .-los,.! and |,ro|,ct(d in L'lvatcr- ,,r I, >.,■!■ dc-ivc a-ain^t the cnti-ancc ot torci-n l.odics. o,- i< d,.i-ivd from open ualcr-conrscs. In ij,,. ';'"''■ "''"' '111' '^■'Hilary ,■ liii f ,lic people dudlnii: in proxiniitv to th.. Mivain. and the .■iiMraeier of their industries, piav a rul,' that can" he accnratcly esliinated. '" :i'l'li'i"ii to th.. local pecnliarities j„,t des.-rili.^.l, a ninnJM.r ':iti,m a lar-,. mirnlH.r ,d' vari,,! nliti,,iis. i„ ,,.,rt well Nnoun, in part Mill Imt iitti,. inv.stioat,..! and with ,!itii,.Mltv esiln.at..i ^"'■"nlin- t,, their iinp,,rta.n.,.. I.ut wiii,.h in all |H.ssild,. I.M'al an.l tein- l""-il '•oMil.iMati.,n- ev.rt a mark,.,! inlhan,,.. .\t th,. pr..-,.|it ,lay th,. •linlouy ,,f typli,,i,! f,A,.r il, ..,.rtain pla,.,.- an,! I,.,.aliti,.s ,.,.|nM,,t !». as •a^ly aii,l -yst,i„ati,.ally lai,| ,lown as ..ippi.^v,! po--ihh. at th,. ii„u ^^'"•'i til,. oi iy th,. u,.n,.ral ,ii-tril.uij,,„ ,,f the ,|i.,.as,. ,,v,.r th,. ,111:..,. w,.rl :i(li\il_v iiiiiMiti-I. W'itli iVLTMiil [" llir -|"ri:il t;fr a Icniir lime tile rlinical ditVcrrli 'iliiHl 111' I lir t W ■ i ili-ra-(-. N lllllrri HI- lr|iiirl- lia\r lircii iiiadr triiin Nnrlli Ann rira. ( 'riitivil Aiiirrii'a and Suiiili Annrira. t'liiin Mt\irii, liia/.ii and I'l in, I'l'inn A-ia. (-|)riially ('ruin India and fVoin tlic larur i-land- ul' .Ia\a. Sninaira, l!"iiii'ii. ctr., a> In lln' mdrinii' uriiiiTriiif and lriii|ii .rariU in.iia-nl |ir(\ alclici' nt' t\ ]iliiiid li'\ cr. It iia- iircii nli-ir\cd al-ii in Atiii'a a- tar a- (•ominimiratinn lia- Ihtii f.-Ialili-iii-d, |iartiriilarl\ ii|Min tlir ra-t and tlir \m-I cua-l, ainiint:- lln' iialiv I- a- Will a-ainiiiiL: l'!iirii|H'iin-. < irii-— iiii^i r Imi'^ aL!'ii |irii\iii. in fl Tiianinr that iiiii-t ti iiAcr -rr\c a- a nindil tii|- -iiniiar iii\ r-tii:aliiin-, tlic cndfinii- (u'lnrriini' nt' t\|iliiiiil liver in l'",i'\|il. Ai)|)ar(iitK , till' uanii and trujiii-al rniintrit- d it dillrr ;:reatly i'vuui ciild ri'ui'iii- uilli nil I rill -I ■ 111 tlir iircnrrciiri' and t'n'i|iii'iiry nl' ly|iljiiid )'r\i r. Miiidfinii- -i t\|iliiiiil ti'Vir iia\c I ii (ili-ri\(d < \ rii ii|hiii liiLih iiiiiiintain-, ill ]>lai-t- nmrr tliaii Idnii niclcr- iiii;li. Tlir ciiidriiiir iiiiiin till' L:rial St. r>iTiiard and in the vallfv- radiatiiii; Irmii it. al-n cited li\- < Iric— intref, i- "ell kniiwii. At that time iinc-tiiird nl' all nl' tlie inoi;L- in tlie inniia-tery at that |ilaee were attaeked. Ajiarl rrmii the ahililv of the ty|ihiiid-liaeiihi- tn lieennu' ludired and dcvelii|) ill aiiv liiealiiv, and it- imt iiicnii-idi'ialile tenacity, tlie uidi^ di-trilintimi "f tli'' di-ca-i' deiieiid- liirthcr n|)iiii the aiii>aienll\ eijiial -ii-ee|ililiilitv uf all race- tu it. In tlii- l'c;:ard al-o typhnid li'Vcr eshiliit- a e(ilitr:i-t with ntllef inl'eiliull- di-ea-e-, -ince to tlie-e there ai'e marked variaticms in racial -n-ce|itiliilit\ . It -hiiiilil he nieiitiiiiicil ;iat |icr-Mii- vvlm have recently rcnuivcd til a -ii-ealled tv|ihiiiil lucality nr hav ■ n-iiled in -iicli a |i!aee Imt fur a -hurt lime arc, a- nnmcrnn- uli-crv atimi- have -huun. attacked with c-|iecial reidiiic— . Such i.Ii-cia aiimi- ha\.' he.ii ni.ide in I'ari- and l.iindiiii l.v Liiiii-. < 'hiiniil, .Iciiiier. .-ind Miirchi-uii. The p iy-)ciaii- nt X'ieiina. and e-|iceiall\ tlm-e ut Miini.h. iia\e had a -imilar e\|iericiiec. .\ii e\|ilaliatii>ii liir tlic-e midniilited liict- i- a- yd walltill^^ I'liniicrly, ' 7/,>r ./ //■, l',it/i. X ,««■•. i:r/ni.< )(,)-, 73 a -..rl „t ••M,',li,n:,fi/ali,„i" «m- oiriui,,! rnii-i,|,.,,.| a- a prnpliv larti,- a-aii.M III.' .li-,,,-,. As iin-.ii|,|H,ri,.,l a- llii- a-inM|,.ioi, |,a~ aluav- '"■'■''; '' '"'- '" ""■ 'lltiivly liMIriial.lr ii, lli,. |ii,|,t ,,|- ,,T,„t | u I,.,!.,.. ^''"■'""-'' ''''""- '"'I-' !"• taken iiit.,c,,M-i,|,Taliuii in tlir rxplaiiatinii. Ill III., lir-t |,lar,., il„. ,„.„. iinii-iial iii.hI,. ,,f |ii;. i;„. ,„,„,. .,.,, ,,f,,,„ .lilHriiiir ;.rivall.v In.Mi ,|„. ,.ivvi.,n- i,„„|,. ,,f IJH, ;,,mI -., iu'v^nu.^ ill,' .h-r-livr ,li-,,|-,.- |,|V.|1~|M.H||M- „, t\|,|loi,j il|t;.rli,,M. i- uf i|,llM,r- '■""''• '" ''"■ '"■^' I'l'"'-'- i' -I !"■ I">nic- ill iiiiiiil that til,, ii.'n- '■•'UUV i~ ill y,,,,,,,- ,1,..,,,,, ,.,,„,„„| „, ,|„. ,|.,„^,.,. ,,,■ ,,^|^j_^^^ ^^^^ ''"■ I'"'-""- I"''"'"-'', niililvr ill,, naliv,-, l„. ha, nnt |„,,i lau-lit l,_v -A|.rri,.,i,-.. aL-ai.iM partakiii- uf .laii^^rrMU- lliin^x |„ tin- ,.,„i,i,.,-t!,,„ llii"l!inkiiin-watrraii.l ailirl,- ,,|- t;.,,,!,,,,,, i,, tl... n,M-,H,k,.| -tatc arc t(. Im' ii„.,iti,MM..|— in -ninlinn ■ ,,uiiiri,.,, i;,r in-ian.v. rau iViiil. o\ -iriv •■I'l.l ,.lii,.r-lirll-li,|,. ■r,„,|i,,l,, ini|„,rtan,,.-liMnl.l n,.i l„ .i.tarli,.! to tlic '■ir-niiiMan.T llial aiimnir ,|„, n,.u,-,,ni.T- tlinv v ill !„■ nianv with a mark,,! |„.|-.on.,l |,rnli-,„,-iti,,ii. With ivi^anl t., tran-imrv rr-Mnicr .,'i- '"'■'■'•■'"■ '" l"r"l'i'i"ii ill a |.la . Ii, illliv, voun- an,! aclnlrMciii (.nvoii-.. ti-.iv,. I Iriv. „i,.rl,ani,-. lalu,,-,.,-.. -,.rvant-. ,.t,.., aiv ,.-|.,..-iallv .•,.ii,.,.ni,.,|." ■■ A,-,'liinati/,ali,m-,li-..a-,.-"an.,,tt,.n-,M,k,.,i,,r, |,ar.i,.,ila'rlv,|iaiTli,.a: l.y «l,i,.li n,.u,.„„„.r- in a ty,.|i,,i,| pja,,. aiv atla,-k,.,l. It i, n,',, in,,,r,,l,- aM.'ilial tli,-,.aiv ,,tl,.|i ,l,.|M.n,|,iil iipm, tvpihii.! iiif;.,.ti,,ii. 'W.,..o;- T.phunl Frr.r r.rrnr.l n,l„ .l,„;,/,<. In IJ ,; I-. ..| ,, ., ., y-'Tl' ■• - I-' ■-. I:: II I ],, I -\|"''i ■'■ ■- •-■ 111 i;. III - In 111 :, 'I |-.-> s 14 .-, .,- Miiv II •lull'. .". In .; s •liilv ,; 17 ,, .J, ^ ':, ',' .! 1 ■' ' ■■•■ '• » :i ■^- ^' '^ "1 i'^ .. "' n !; : ]:: \', i^ :: .■■:;; ■^'1'' -' -'•' I" -" T' 'I 1 1, r, 4 .■ •".!■ ■ , I),. » 1 t 1 1 1 n III I I II in 17 l; .11 Season snd Meteorologic Conditions— Tv,i|i,,i,l iW^v .x- ' '-•"•""■^'•■i"t ami rnri,iany,-,,uiitrii.-aMiiii;,r.iiivlati,,n t.. il„. M.a~,„i- .1"'" ''" '"'"'"' "'■ '■:'■'■"!'-■. i'l Kii^lan,!. aii,l in ,.,a,nlri,.~ |in-..,itin.r -mnlar ...m,l,ti,„„. a-, tiir inMamr, Nmtli Ani.ri.-a ( Ilartl-tt. \V,«mI. '■'"">. lliin ,>,vva,l~. M, i;.,r a^ ,v,„.-n .^„. ivniarkalil.. nnaniinitv in ,l,i< '''■-•■"■''■ '•:v<'>-.vuli,.r.. ,|„. in,T.a-..,| IV ,„.v ,„.,.,„•- .Inrin- 'tli,. latr HUnni,..- an,! aiitiinin ,||.. [„ ,..,„.,.ia||v .,.,,.,-,. an,! « i.l,.,,,r,.a.i ,.,,i- 'l'-"'i<'> it iMi-Msts ,,i in,r,a-.- ,.v,.n Int.. tli,. uim,.,-. niilil \„v,.ii,l,,.,. 74 %yrnnn> ir.vin :ni(l Dr.viulMT. Kn.Mi llil- liin.' lliciv i- ;iliMn-l :i1\v:in> a «lnw ur a mciv ,.,,|,j,l ,l,,,.li,„, Hu. ,„.ri,Ml ,,ri,.a-t |.nAal,nrroflvpli.>i.l Hvrr i- (•v.rv- wliri, iIh -prill;: aii.l ihr iM-inuiiiu nf -miiin.r. r-|Mvially tli.' iii..im1is (,l Manli. Ajiril. ami May. In l,.ii>Hr. a- llir ar,oin|iaiiviiiL' .lia-rainiiiatir ni.nsfiilatioii of llic ,.,.,.- .,1,-,.|v.mI in llir .la.-..l..->|.ilar l.,lur.-ii \W yia,-> l^Ml aii.l l>'.f-' -linu>. ,|„. innnili- in uiiirl, lla- lai-vM hun,l,.r of ,aM - ..r.nnv.l Wfiv uuan- .,1,U \a-uM Sr|,|rnilMr. an,l (l.|,.l„.r. Nnv.ail.rr al>n rNliil.it.,! m, l hr ■ ivrri".' Iii'l. ll-niv-. •nu'lu«,>l |.iv\al.'U.cin 1 .ri|.>ic n,vui> in ll,.' nimitlis or \l.ril Mav, an. I .lunr. In .Inlv llu- iarria.-.-. imurv.r, -.-luTallv l..'L'iiis i,.r:„n an.l il mnlinu.-.- uninw i i-u|.l. .IU l- il> a.anc .lurin- llir auluinn iimnlli- ( Ki" * . A laMr >liouih_' llif nunil.n- cf raM> r.-cav.-d diinn- llif .lilf.r.ul inonlli^ an.l s.ai-i- a.l.lr.l. Tlii- i- .-M ivnuly inl.n Min- tn.m II,,' ■■viua-al unifnrinilv in liir rnn.iiii..n> .liini.L; llif dillcrrnt y,-;u>. AIm> in I»i-.-,U.|i. a.v.n-.linL' m lla' ..!.>, r\ alinns nf ricldrr,' .•xl.'n.lini.' nv.T ,.l.vn v.ar*. tl,r iiP.i.ll,- -f A|.ril and Mav .xliil.it llu- UaM livqiuaicy ,,f ,v|,l,;.i.l Irv.i-, ul,ilr Au-uM : >,-yU^uW-v ,-l.nu il„. In-lu^M wlnlr a .M-.ai'r nnnd..i- ::r,uTalU ..r,nr ,n ll,.«inl.r n:..nl!,> lliai. in .Inn- and lulv V -ii-ikin- ^ilnilariIv h. iIi.m- oI.m i-, aii..ii- i. .■xlnlntcd Ky lli- cyn- .lini.iKin I...i,dunasd.Ma-il.;dl.v Mnnin...ii im- ilu- adnn^-ion> lo lli- L..ii. nn Frvca- ll...-i.iial l.iuwrn iIm- yars 1^4^ an.l 1 >l.-'. I l.av- !;'''l;;'''''\\''^ '',';'; "ram <.n tlif La^i- "I' lii- slaleinent.- ■ 1' ii:. ■ ' "" ~ ' " "" In iI^ dftaiU tin' Lnialdii Hii^^mn 'lOn MM) ■ I - -- - - i - .\f)n ^:v.ii ajo anil J HO . . - ~ - f /. . il J 4 1 iJtSO - ]V l-"tO 'aL'o t - MO 1 mo 1 Kill ; 1 w I 120 1 100 i \ - - 1 i- - ■ no ; V ' ' ! ~^ .lia.M-arn a. .•nmnarr.l uilh llial «\' l.-ip-i'' .■xliii'it.- a r-dnnioii in tr.- MnwHV.luiiin-Mlu. uinirr iu.,nll,- tVon, ihr maviniiMi. of tl,.. an.nnni nmnt i.. airhorrdilla'nnnd.ri-i>-lill.|uilclapj.Mluriirjll,rinonlliot I IcTinlH-r. 1 lii> n.jalion ai.i-ar- 1.. rxiM .-si.iMiallv in llinsr |.la.v>. and alinn>i ..v-ryvv lar.. In tl„,.,. vars, in vNJii.li llu' a.-Tnt nf thr rurv.^ l..-ins >-.,n.« hat lafr and ,|„. niaxin.. : i- ivarlu-l ,-„riv-,..ndindv lal.r .in I.aidon >r\A.u)U^r .,,,,1 (»,.|.,l,..r. a. .■nini.aiv.l uilli Aiil'IiM in l-ripMr.. 1 !,.■ -i.idnnn- ol W^^^-^^^^mmf^^'^'Wrnf^ ^W^W¥^ ETIOI.OCY. 76 ISStJ^MT in Hi iiiliiirL'' IS iiistniclivc in lliis crinMcctinii, \\w t:\\'\i\ I'lu iricrca.-r iii Ilif ilisi'ii.-c iM'ciirriiiL' iliiriiiL' llic intintlis nf S.|iI('Iii1mt ami OriuKcr. and ind .hupiarv r\liiliilinLr aci-iii-(|in:jl\' iIm niiiiitiis dt' N • \ I'nilicr. 1 'iM'cnilicr, Uii' nia.xujiiini prcx aliin j-JL'. •; lll&5 4 5ri.^i| ihM^nm 375 i_; 1 1 ■ ' I'll! ' 1 ,f\ ^ i ] 1 ! rr+-> ~ [335 - U 1 i' — n- .lOO ■;i75 :2r>o 2Tj \ 1 1 / -^ ~| is_ f\ r i JXT FF ' ■ 1 f — 1 -4-!/i JCIO •" 1 \ rn/i 1 1 ' ' \ L 1 JTi \I^ ~ / \ ^ /I 1 ... j / l\ 7 1 I ion 75 N i r ^ i / 1 ... k _.. □N^t/T 1 v\ : : y "^ ; ! \ / ! 1 S/^^^"^ ^y - t) 'I'l If I'au-r- l(i|- III i- riinari^aiilr nniiiinnily in llic ri'lalimw nl' l\ iiiidid (' nnivnsaiitv nf il tr\iT In ~ca~uii arc a- yet wholly nnkiiown. '!"! ivlaiion, it- rcciinvncr in all |MP~-.il>lr, rmintcly -iiuati'il rciriiHK, iiidi that it !■- c|r|icnc|cnl ikiI n|ii>n lucal, lint n|Min urncf -iirli a- ai'i' fi--|iiin-il)lr i'liy ll il I'cinditiiiii^. |i(i«~lldv ■!• "I' iiiiihi|>li('ation and the \ iial ■tivity <,\' the lyplioid urrni it-,lf. Alii -h imirh i~ I kiiipwn witli iv;;afd td the detail- in tl IIS ninncctiiiii. an ni-i -ht ill'., tl If --ohitiiin nf liciicral i|Mcon In inter Inr the ja-c-int t a Lilariiiir dcticiciiiy rather than tn iiriduv it nver witli iiii.-talil tlleiirie' W ith relatiiiii to the iiifliieiiee iif weather anil h d tenilier;lllire in till lert I- iniieli diver-itv nt iipmi iti(ilii!.ry lit" ty|ihiiid fever tli \M'iler>, .111(1 there exists I >ea.-cin. Ill my -ervatidiis in -dine endemi<-, and |ireiiialiire >:eiienili/alidn- have lieeii de. Il I L'^c'iiei-al. It ina\' .1 tl le said tlial in iiin-t Idealities sin imer heat and dryness render |irdiialile an iiierea-e nf ly|iliiiid fever in the aiitiiiiin III,, nth- — an oli-ervatidn that is in aeeonl with the the-irv nt' I'.iihl and I'etleiikdfer and led lip Id the ^Tdiind-water t! vv. M"het! ler iiaiiiji- ne>s aiK 1 cdid weather dpei-ate in an n|)|Ki-ite d irc-tidii IS -till ddiilittii iretiil nioervers. (Ill the (itlier hand, have attein|ite(I to altriiiiite the ■veldjiineiit and the iiierca.-c of the dise;i-e in sdiiie |i|ueos to tl-e?:*! 7« rvfiiDih I i:vi:n. If 'A ! lallir ((.nilitioii-. A- :i in:illii' <>( i.uU it i- nailily c-oiicrivMlpIr lliMt tlic \iru- iHvidciilailv di po-ilcl m|imii llic -iiirarc d' llit- .arlli or in iIk ii|i|Hr la\.r- ><{' ilic -"il may Im carrifil ■•IV li\ I'ain-ualii- nr nirliini;' -n,,\\. and Im ili~-(aniiiati(l i>y linilinu it- "a\ inln wah i-< ondnil- ai-cnl. (-[Hiially tVtim lln' acnic lAanllicmata. |iarlirnlarly tlir inic l„.,lil,,ii,., mall-|"i\, l\ |ilni~ fever, elmlera. ami plai^iie. A- lia- lieeii mentioned, llie-eare Liinei'ally eiinlin.ed to deHniii^ (".rlion-nl' the earth and to certain c.nmlrie- in which, like a tire - nlderiiiL' l.eneath the a-he-, ihev (Mcnr inn-Iantlv. Iin! within iiairow limit-, and then. Ii'oiii lime til time llarinu' np. they (Mend over preal di-tance- and area-, 'rill' pe-lileiice- iucludcil in 1 1 !.■ aciite e\an I heiiiata — v.iri..l.i and typhn- tixcr arc al-i. little ea-iiii of the year nr upon the :,„■,.. 'I'xphnid liver, a- h:i- Keen -ecu. i-, mi the cdnlrary. di-lriliiilol uviiiiially. Ill t'lirtlier ciiiitra-t with the c\anthematiiii- infei'tiiuis di-ea-e-, tvphiiid I'ever ceiierally iMciir- in -|Mif.idie ca-e- nr in ^rnii|i> xi' ca-e>. nirinc- in dwdliiic- a- limi-e-epidemio, m- ncea-iniially ^preadiiitr thrnii-hniit entire -treet-, if the eniiditiuii- fnr ciiiivi villi; the intlvtiiii;- a-eiit arc aceidiiitally thus iinitiirinly di-tril>iilep.vial cniidiliniis. Tin- t.ndeiicy can he readiiv e\plaii!eil ; it i- a ncec-ary n-iilt nf certain characteristic- nt i; tvphniil ccrm. which, a- ha- heeii -ecu. i- imt .a-ily traii>mittcd. lint niilv ••\ccptiniiallv i- carried tlifniitili the air, and then mily im' .1 .. . . ,....l.. I...:.,,,. .....,.' tli.. i,.n:..iit \. ( )iil\ l,\ din-.t • Mincvailc.' of lllr |...i- r coliVcMIIM'.- lllf(.llijll lllr illll'nilcl llii'ii ..iil\ liy uay nf llii' dij^i-livr liact, i- lli.' ili-ra-i- Iraii-iiiilh il. All ol llii-flart~ \\l fever wa- lir>I illelllileil arm. II- tile " e,,iiiai;i(iii» " -ilile. CONCLUSIONS. 'I'lie |1 liLTiiiiiir eeh-ideralioii- lia\e. il i- liMjied. -Iinuri that tlie eli.ilii;;v lit l\|illi.id level' a|>|iear- at the |ire-eiil day in (|iiile ditlerellt lielif fnnii that III uhieli ii \\a- \le\\ed in preliaelerioio^ie time-. Il will lie ii>efiil til -iihiiiiari/e w liMt lia~ tliiH t;ir Imcii rendered eertaiii or |priilialile. ') lie de\elii|)nieiii and tlir maiiile-talinii- ut' t\ |ilinid te\ er are de|ien- deiit ii|iiiii the le-imi- ill the hmiiaii nrt^-tmi-ni n-iiltin'j- tVoin the inva-iun :iiiil the vital aiti\ily <.f the KI)erili-( Jatlky l.aeiilii-. The tv|ihiiii|- liaeillii> i- not ideiilieal with llaeiljiw euli. The relation- that e\i-t lietwii'ii the two iiiiero-orijaiii~iii>. and their lieirree of relalion>hi|i, iiin-t l>e e-tahli-lied liy further iiivc-tiL:;iliiin-. 'I'lie ltovmIi .-iiid the de\elo|i- ineiit of the ty|)hoid-l>aeilhi- take |)laec exehi-ively in the ImmIv ot' the typhoid patient. The nerin- are thrown otV e-peeialK w ith the iiiti-tinal tiiroiii.di the aii-|)a"aee- cannot he whojlv exchideil, l>nt it i- ill ircmral uf -iihordinate iinportaiU'c It i- liir tlii- ri a-on that mere prc-eiice in the vicinity of the patient. Muh a- -nlliec- fi.r intectiini with the acute eNantlieiiiata, i- not adet|nate tor intiction of even tin- most predi-po-ed individual in the ca-c of tvphoid fever. Pvphoid fe\trdi«-- not liclun;;- to the '• <'ontai;ioii- " di-eav mean- of the -ick tlieiiiselves or liy eerm-laden media. The lielief that tlic hacilliis alter leaviiie; the liody re(|iiires further dev<|(ipiiieiit and matnralioii oiit-ide the hody i- imtenalile in the present state of kiiowledire. T) rii'iiii II \ 1 1:. 'M 'I'lic i)|-iiiri|i:il cirri. r :iiicl .li-c iiiiii;i|. .r ..t' ili,. t\ pliMhl -mil i- u;il. r. 1)1— ,iiiiii:ili I' llir l,\ I'liniil -.rill ill ihc .Irv -lull', :ilMiliril I'' | i;i rl i.l( - ..r ilii-l, ihroii-li ill. ;iir i- |i..--ilil.' I. Ill nil. ■..111111. .11. 'I'lic ..|iiiiii.ii lur- , I, ,.,.!, |„|.l ili;i| i\|.li..i.l r..\.r iv-nit- IV.. Ml ill.' -u;ill..\\iM- ..r iiili:il:irh.n «ilii]il\ .if |.iilrl.l l: 1-.- Ii:i- l.r.n uli..||\ :iii:ili.| 'l. I t.|...-ili .1 ill llic ,.iilli, llic l\ pi.. .1.1 .jiiiii 111 i\ r. iiiaiii .:i|.;ililr ..I' .l..\ cl. i|.iii. iil lor :i liiiic, (,, |„ .|,|-,.:i.| rr..iu llii- |H.iiil llir..i|.jli \:iri..ii- ;icii(l(iil:il clih Iil I..11-, Mill. .11- ulii.'li .iilr.Mi.-. liil.. -iil.-.'il-u;il. r, u.ll-u;ilc r. ..r |!..\mii- \\:ilrr ],1:!\- ill. in..-t iiN|...rl ml i.,iil. A l..."il |irr.li-|...-ili. .11 in llic mii-.' ..I ,-,,,i-i ml iiii|.i-. •jiiiili.iii ..r ill.- iiirtli in ;i -i\.ii I...Mlil\ \\iili iIk' |>".i-"ii :i:i,| iii;iiiir;ili..li lli. r. in .11111. 'I I"' :i.i-.|.l.'.l. :iii.l -lill Ir- llir |>illilnili..n c.r ill. |...i-..ii iiil^. ill. ■_!■ i-:iil' :ili.| iiil. .li..!! ..r llic lifi-lil".riiiL; |»'..|.lc |.\ ..siril ili.m- rr..iii lli.- <■ ill n. Til.. -ii-.-.|.lil.ilil\ I'. t\|.li..i.l ll\.i i- .A.r,..lin-I\ \\i.l.-|.n..iii. N.) I;,,,. 1- .A. nil. I nv. -.. till- :i- . \|..Ti.ii..' I.M.Ii.'-. lil;.|.li ill\ 1.— |.iv.li-- .„,„.,| T\|.li.'i.l t'.Ml' li:i- I'"" ..l.-.r\c.l in :ill .ivili/..! c .iiiil lii- ..f ll„. , irlli. in ll.. ni..-l \;iri.-.l .•liniiil.- :in.l :illiliiil. -. ^'..1111- |irl>..ns :iii.| .1,1. ,1, -.•.111- |.riii.i|.:illy ;iir |.iv.li-|".-..l I" lln' ili-.M-.', :iiiil rni.li-t Mii.l u.ll-.l.\.l..p,.l in.li\ i.liril- III -.11. ral 111. iv -.. llriii llif «.:iU :in.l tli..-. .l.'l.ilil I.- I l.\ lii-ii-.'. ('liiMr.n nil. Ill- llir :ior ..f ..nr yv.iv arc :ill;i.!..'.l uilli ,Aliv r:iril.v. All.r lli.' r..i'li.tli v,-:ir..r liH' llir tV.- ..n.n.'V .l.'.'llii.- I'.ii.i.llv. S\ in il-.lf lia- n.. niiirU.il 11 llllclicc. 1'..— i- i.K III, 11. in ,...ii-,'.|ii,'n,',' ,.)■ -..,ial an,l ..llu r lili.'ii- ..f iil-'. aiv iii.'r,' -nallv |.\|..,-nl I.. iIh' pi.-iLiiii \ "f intl'di. .11. an, I lii, r, r..iv aiv in..rc rii..jiiiiilK alta.'U.'.l. i;r,...v.rv t'r..i 11' alla-'k ..I' ili.' lii-ca-r atV..r'l- in lln' inai..iily .,!' ,a-.'- pr..|,.,'ti,.n I'n.rii -iil.-,',|ii,'nl altark- llir,.iii:li..iit lln' ivinaimlfr ,,l' 11,; . A nninl'ir ,.1' in<■.■ 1 tiiiif. 'I'lic ..cnr- ,.,.,,,■,■,. I' ilir, li.iir atla-'lx- in lli'' -aiii,' |.cr-,.n i- iii,.>t ,'\,T|.li,.iKii. Aim. .-I ,.\,'r\wh< '.'. ,'-iM','ially n| lli.' c.nlin.'iit >•*' Kiir,.|..' ami in l-amlan,!, llw liiai..iil\ ,.!' ,':i-<'- n\ tv i,li..i.l tI'Vcr .«','iir in tlir latter |iarl ,,t' ,|„. \rar in lli,' lal,' -nninnT. lli,' aiitnnin, an,! ill,' I'arly winl.r 111..111I1-. in .■..nlia-l wiili lli'' ti'ii'' |"-liliil ll'Vcr lia- a t.n.l.n.'S' t.. ....ntin.' il-.-lf l...'ally. -,. tlial il .•..inin..nly .M-.-nr- in -|H.ra,li.' .a-. - ami -roll]'- "f -n''li ''i-' li,,ii-,'-<'i)in- il m ly Ix' .li-triliiitcd ,.v..r an cnlir,' , ily ,.i' l...'alil\. m^;3m^^i^ :.:^M»^Amm^ /■I I ll'il.ni, r. 79 II. PArHOLOGY. GENERAL SYMPTOMATOLOGY. V> \\ .ii-iilc iiiti-"iiMii- ili-,:i-c~ (sliiliit >ii(li i;ri It \:iriatiMii. ;i~ I\|p|iiiiil H\cr ill tlicir iiianriir |iiiiii(| ;^cin'i-al aiicl |im al iiiaiiite-latinii-, ami in certain ca-e- Inii^ |(l'i)t.acl(K| ecpiivale-ceiice ; ami it', tMoeilii.r with ihi- jiidt lacted t\|>eut' of an iincertain charai'ter are hi'ie to he dealt with, aiiioiii: which |Hi--ihi\ the inten-ity of the infection, certain |ieiiiliaritie- ot' the \ irii-, and the ])feo-itioii of the inlictcd indiv idiial |>la\ an ini|«irtant jiait. Aecord- iiiLdy it is not po— ihle to ^i\c a ^icneral ile-cri|)iion of the coiir-e of typhoid fe\-er. It will, however, he ii-efiil, in conneciion with the tiirthcr di-en--ioii of the -nhject, to -ketch in outline the piclnii of a moderately -evere or sevei'e ea>e of typhoid fe\cr teiniinatiiiir in u \«tv in a |H('\ ioii-ly healthy adult. In I'oiinectioii with this description the pathokiijfie anatomy aiiid m.-mili-tatioii to which it i^ives ri-c, a iiio-t varialile piriixl ot'tiine appears to elapse in u ea-e of typhoid fiver. It is, thcrcl'ore, tiir mure ditUcnlt to deterinine the periiMl of incnhation than in the ease ot' soini' other a<'iite infections disease^, ;is, for instance, the acute exanthemata. Kveii tiic time w hen the eonia;:iuni is received can hut nirely he estahlislied. as this is not eticcted hy mere presence in the neiirhhurli(HHl ot' the ])atieiit or simple contact with him, hut hy pr\ iIm- iM-niiini- ..t iIm' ;iiln:il .li-..i-<'. lli' ili\ hIiiil; lin. I., lu.ni ulii. Ii i- ii-ii,ill\ inili-liii. I. r.Mii llir iM-niiiiii- •■! iIk U\iy. ulmli iii Li'iiifiil j, -iai,,l |, \,r iIk riiM-l ivliiililc -i-ii .4 ill,- Im -iniiiiiL: •>llli' ;i. Iiuil (li-r.i-i . i- -iil,|. ili\( 1\ I'lliii -II linli iiMik'ti iIkiI <\cn illll lll^tlll iLiliiiil- iii;iKi iiniirlaiii -l;ilciiiiiil - in i •.iiiii i 1 i. m 1 Im n w ii li. T lUiliLT ;ill "I' llii- inl' I'll. -I'll i:ili..n, tin dnfal i..ii i.l' lli. \>lilr laliiicv ami a inii- [.riMliniiial -laiic ,|i;il j,. tlir |Mri.«l <.r inililinilr \«M\ (li-niil.ami-. 'I'lii- i- |Hilaiilir ami n-ili— . ll i- l"-t in -av tlial lln p. rinil >,\' iiinilialinn i-. a- a rule, (MviipiMJ wlinllx ..!■ in i>ail l>\ imirliiil il'c-lal imi-, u liil<' a -mailer llilinlHTnl' imlixiiliiaU iiif.vlnl willi lv|.lini.| i:cnn- iiia\ nniaiii cnlinly fnv fniiii -\ni|)lniii- linrim/ llii- iMimd. An .-liinatr nl' IVnin 't tn lO IMP (•.■Ml. I'm- iIk' lallir ,-niu|> will pinKaMy mil Im' Inn lii-li. Ai.iniiir llii' piim-ipal inanirr-ialinii- nl' llir p.rinil of iiii'iilpatinii, lanirimr. a -.ii-e nf appiiiK' i- ir.mnills iiiipaiiiHJ. iian-.a i- pn-ciit. tlic patinit- .•ninplaiii (.1' a -CUM' <>i prcssmv in llir rpiira-triuin. and nt'ltii tlir iiowcl- an- loii- -tipatfd, altli..ii._r|i diarrliia al- ay lir nl.-. r\i- Imi.^ di-,l,i-c nn i.r liiit -liL^lit .Irviatinii- In. Ill lli.' iKiiinal. .v.n in -ikIi lialicnts a^ ahva.lv .xhiliit iii.Tca-cd >iim. pliliility to l.rni>.iatniT- t >i^^^-. ^^xii'^?r^^'''Tmj^JW^ •If J /■ I lllnl III, 1 , 81 v.-irj.itiMii- ;iii>l .iiv i(:i.lil\ c'liill<' .li '|i< II :iir or >J^v\\\\\^r I III' :ii I1..1I I'olMliii'lK'i'iiii lit III' ill,. ,|| ill. |i.iliiiil- lAliil.ll ill.' lir-l iii:iik,,| |,.|,|i| •a-c ilair- iViiiii 1 ii' liiiii w hill "■ -\ iiiiiliiin- iiii'iii'' :ill .if III.' -i;.^- Ill' ill. 1:111111111: ..r ill.- 'li-i-a-i |l|.-. .all III' lic-i iji'lrrninii') till ■liN.'lv. Mlli.iiiirli ' .'lini,.i.i,i- .lal.' ill. lH'Mitiiiiiii.r ri'iiii, tlic "'-•""- '" '"■'' '"• '!"■ :i|'l"'"'' -f'liMrili.a, tlii- i- JM.I.'liiMi,' aii.l I'lii' .liirati r ill. Ml.' I iiiaiiil'.'-lali ."II- III U. Il-l.iMI- lit III. III.' .'Inn. ii-at I- ina.j.- ..-.•m'. il an i ill.' a—.i.'iali'.l anal i.- inanif. Ill- .-an II.- IIIlK ;r|-. t iiii,'-. llii'ir ~\ni|it nii: III VM'i'k-, lia-cl ii|iiiii -tali. Ill-, lull wlii.'li tlu'i','. ail iiiatr l..'.'aii-.' th.' latl.r a|.|i.ar al .iilllrciit ll-i' |il.l.-.'.i th. .|.'\.'l.,|,|||.'nt .if th,' |y|.h.ii.| |,'-i,i||,, xvith |i'||in-. Ill th.' tir-t u.'.'h ; tlh if th.' .li inpl.tiiiii iif iiii,'-i ■ ••Ihcr lllf.-ti.ill- .liva-,-. th.' l.,'j,ri||||i||.r of II |i.-al.'.l .'hillii I'Vci I- iri-iiirally markcl In ^jitrht, oftc III—. I hi- 1- ... iiiii,-h th.' III!,- tj 1111:111- v^itli a -nil .-Ti lal « li.-ii .1 f.'linl,. (Iiscjisfi li V.T I- tll.illMht ,if. It i, k -v.T,. .'Inl! ^iJni.iM Miiy .itli.r .ii-.-a-,' than tvph,,i.| iiiiuii that tl r.'li'i'r, Ah! III.' i:i-M Inal I 11- ali-.ni'.' iif I'j l.'liillllillir ;|||,| ill, lil! i- t< -' ' :" •■<•" |i:i;i.-nt- -till h.il.j .Hit I iill.v I ik.' 1,1 ih.-ir 1,.-,| Mft.'i- th,. lii'M .•liiliii„.>< -l.iw a-.',. Ill ,it' tjic (;.v(T. i-ivt'lv. the iiiajitfitv jrciicr- 'riic i:('ii,'i':il -,'11-,. Ill' til, >|.-.-li\.-ly .l.-iniin-ti-ihl,. w 'lliK-s n.iw iii.TciiN- [.ivity f:i|,i,lly, and also iir.'-|).ini|- with tl if tl K- patiint. T II- iisiia lly wifk may i;i\.. ri,,- |.) ,1 iiM-r .Inriiii: th,. ,.v..|i •'iiiil n-irnlai-. I.iit a.v<'l,'i-it,.,|. | 11' mil,|,. .Ii.n,,^, ,i,i, ,„.,' „| .,-,,^,^. ,,„„,.,,., ^ ,_,. , ti^rn, riiafiii.r in t 'A m tin. car-, with a -en-,, .if iiit,.|i>o |; i(.a(iai'h(., V(.r- iiiiriiDf. and tl M' g2 rvriinrii i i:vi:n. .,,•„,. ym-Mv I > - -.ncrallv |,.VM.nl. Tl.-' l-n-ur. at ti.-l -1,11 .nmM. l,.,,vilv .•oal.Hl. x,.ll..«i-l, uliitr M,- l,rnuM. an.! aU, !!,.■ in,l.o„. ,n.in- l.ra.i.'-f ll,r liii- aiMl tli-' nnntli. .-xliiLit a l.nclmc.v I- .Inn'" l;'^^-"'' ,1,.. ,.n.l of III.' tif>t w.rk. ■I'll.' n..I inMv.|n.nt ...■.•nmn.r ..I' .■piMaxi> at Iln< tini.. i- ..nilr .l'-tin.-,u .-. an.l in -..n.r lutim,- thi- nia.v .,.-., n' .l„,i„^tlu p.n.Hl ..f i„..Ml,ati.... -n.' ta.ial .■x,,n-M..n ..f tl,.. ,.at,.-..t i, tV,.m tli. l-.t a,.atl,..ti.-. ll,.' f.aKMv- nlaM.l, tl». .iM-k- ivM, >...!, ;,„.! Ilw -Uin H'.l- In.t an.l .In. Only -Inrin- tli.' tiiM Hvn .lay- ..1 iIm' t;.v..|'.l...- -lijrlit -u.'alin- -till .■N.-..i,ti..nalK laU.' |.la.'.'. .-1»'.' lly .liinn- " l'.' M-i'n,'. tl... tir-I vv.-'k th.iv an. -..M.rally -li-lil n.anif. -ta.i.m- .m tl,.. „,, ,.r ,i„. ,v-,.irat..ry .M-an-. A .nnnl..r ..f l^ati-nl- will at tln> inn.. ,. xliil.il a .iry. >li..i-t .•on-h. wliil- tlii- i- ^K-. nt in Su>ci'|)tilil.' |>ati.iit>. it i- irn .ithff- at tii-l. ... .-..iM-.lain ii..\\ an.l a^^ain ..f incrca-.'.! .lilH.Miltv in l..vall,in;r. < )l.i.•.■ti^ .■ .Aannnali.n. ..f ill-' Itm^- ,^v i.Taly .r,-,.|.,-..- n.,thit..r t.. a.v.mnt lor tl,i-. alllionpl, luT. an.l tln.>v .l,y ral.- nia\ III' an.lilil"'. , 'lntl.oniai...-itv„r.-a-,-tl,.. ali.l.un.ni-at tir-t ..f n.mnal lonn an.l „„t .ii-t.'...l.-l. Kx.'.rti.'i.ally. - <• nuf..ri-.i. In-'n,.- a,.,ia,vnt t.^wanl ,,„, „„,1 ,;•,!,, tii-t ssrvV. Tlu' .riua-triinn i- n..l .-anly t. .hI.t ..n ,,,,.-nr... uliil.' l.al|iali.m in tlu' fi.lit ilia.- C-a .l.n- tmt . l.-t. any ,„,.,v-i.>n .!.■ ,.ain. In tl,.. marnty ..f ...-.- ,!,.■ l,.,u.l- a.v n,.nnal ..,■ ,.„Miua...l. I n,n..inly.liin. has., li-.n a t.-u 1 -t...,l- ^^1,.V .lia,-,.|,..a al.in.. in H- tlr-t ,i.ri...l a,.,.,a,- n. 1,.. 1.- t,v.,n..nt. Dnnn, ,1„. la-t .lav- of tl,.. fn-t u...U -..„„■ ,.a,i.nl- .-oniplain -,,...,lat,...in.ly .., ,i„an.l h..avin.- i.i -l,.' l-ft -i-L . In "'l-'- i"-''"^'-'' — ^''"''•y '" ,li,,.,.v..rn! ..nly on ,.al,.ati.,n. an.l ,- .l..|i..n.l.„t „,.... h-.-ininnj: .nla,-.- nicnt lit" tlic -|)l<...n. •r„w.,nl til.. ..lo-' "I' '1"' fi'-' "'''^ "'"• 1'^"'"" '"-"" '" ='!'!"■"•■"•'' ,,„. „,„.. „, i;,-,i^rinni of tl... .li-a-... l»n,in^ llw f.llouin^' vv-.k an.l ,„,,„„,. „,, ,.„„li,ion i- .•onM.an..iv..ly -.,•.■. K.o,n ,1,.. anat.i.n,.- -tan-l- ,„:i„t ti„. statr- i- that of .-on.^l.t.-l n,...l„llan -u.llin^ of ['..y.-,- - ,.a...|,..- ,„,1 tl,.. -.ililaiv f.,lli.-i<- an.l tl,.' a-.i..iat..l an.l |.,-.i-.v-,v,. .,...to-,-. ■n,o fVv.f. att.'v a -t..,.-lik.. a-.-.,it .In-i-,^ -I. ti,-t u....k. ,va..l,..- M- l,i,.|,...t iMiint at tl,.. l,..^innin-of tl,. -.■.-on.l xv...k. ..r ,t n-.- to. -.:-1,-,n l.Cri,..,. 1..V..1 n,. to .1,.. mi.1.11- of ,l,i- u..,.k. Tl,....n,iM-,-a.nn-.„i-v.f.r , ■ „,i„.i „,■ , sv....k .If a «...k ami a half im.-.i.- «li.^ - '-■ "' ^' '"""- t,.nt ..onlinn...! fivr,-. tl,.. va,-ia,i..n- li..;vv....n morniiiL' a.i.l ..v.,,,,,^ l.-.,i- ,K.,.m.n. ^.•an..lv ..x.-.....li.,^ tli. no.„,al. It. tnikkr -a-.-, u i- "".•. I'MllDUxiY. 83 il." 'ImiI.v variMti.,,, in.-.y n.-w l„. nw-iv .■.m-i.l.niM,, mul triv ri^.. tu mi, ""•■nn,tt..Mi ..v,,,. ,„• (;.v,.r: ul.il., „„ ,1,.. „tl,..r lu.n.l, i„ ,,,>,.. ..r..,, „..,■,! -vcrii.v. ;,l.,„,nnallv -li^it v.riati.ms ,„.v n-ult fl.r ,|mv< in ;.i, ;,l,M„.t ';'"' """"•■*' '•■^'■'■- ^\'i"' '■'-^"■'1 <" th.. ,l..,r,... of ...,;,|,..n,M,v i.M.lf iIm~ in rn-,- ,,l MHKi..,-,-,,.. M.v.ritv will nuvjv l„. |,..s liui, ::i. C i„ ,|„! tM'.^HM.^ I, Muv n...-l, ((...VM'.at nud-.l.v. mm.I in ,|„. ..v.nin.r it iM.-,x ulrrn n-.. -till i,i.j„.r, ii,> t.. 11- ( '. :m.| cv.n ;,l.uv... Wi.l. inriv.:-,. „r tl,.. l.v.r il niplMinl- of tlw j.Mti.nt -n.limlly '.'■■""'• ."■■ '"" '" ■'" ='!••"'""■'■. -tM|«.nMi> -tat,., a.xl, altlM.u^rj, .„ ,i,.^;^ n. -o far a> lM.oi„niM- iiM|,airni,.Mt of |u,,ri.io ,„.,.niii>, l,.."-|,„r,.i.j,lv .v>|.un.l- t„ ,iu,-;i„„-. it Im,- ..> iiinva-inulv ,litli,.ilt n. .naim-.'in l,i. Mlt-Mt.oM. |.,,rti,Mat,.|.v, !„. MOW ,„t,.rs a .taf of „aivo>i.. S|,oul.l n..vv ;'""H;">i.~ afiM. at llii. tin,.., or -houl,l ,.,-..vio„, ,,ain< iiM-.va^o i» iiilcii-ity. roiri|,|i,:,lioiis >lioiil(| I,,. |,K,k,,i (l.r. DMfi.,,^ ,1,.. ,|.y tl,.. |K„i,.,„s >..l,|o,M .1..,.,, ,i,,.,,lv. (;..n,.,allv tlu-v H' with .,|M.„ or l,alf-.los,..i ..V,.-, in a lla.vi.l ,|o,>al .|....,.l,it„: Tin. !;::"''~:''.-;'"^'"-"'"^-^"i '•"•'■'i">-^"Mn.a,von..,. K...„,,i,..ii,v,i.,ii,i„„, ""• ''"■'^'' ...„v,.rnl with .lark™, ^'";' ''-I'lr l'l<-. Vi. i,|, hrowni-h sin,n,i„ol..,„. „,„,, .,..-i,.,.„.„| „,„,„. ,,„|,„,,,„ „. „,,. ,.,,^,^,^ ^^^^, ,^^^^^^^; ', , '" ,"" ""■■"'"•^""•- 'I ,:> th.. m,.„ „f ''"":".'"■"""•'""'•'-' -I'v -'--k...! in .h.. ,H,M..rior interior portio,,, wh,.. „... v..,.,. ,..,..,„.. 1.. ,„,.tl a.ofhvp..ta,i..oroth:.r,or,.,: "I Mitlaiiiniat.irv ..oii,o|i,|;|,i,,„_ r,.„. th.. hot. .Iry skill th.. w..!l-knowM ro...ok.- .pp.,,. .iurin. tiio 'V''-~ ;'"'"■ ""'"•■'■'^ - rar,.|y ,.v..n a, t .| f ,h.. ,;,., ;•••'<- ;'"l';; '■■nil of ,li,htlv rai...l|ivp..r..,ni...po„ var^in, i„ .i... ""^''"'"' '•""•'-•'^- •"'-'"■" '"-null' of tlK...|,...t...xt..,i.k if pr,.'..„t ip..' 84 rvriioiK I I'y'i^ lit-. II V- R:i' I il,.. tl.i.rl,, wliilc tlic forearms , ,,, , , ,,, ,,,rlv an.l :1.- far. i- n.v.r ,ktuiu..1 1.> th. .n. l- :':::!:;:;:::,::;:,r.l:^::.^"- ■ -■■' • trariiial I'P ,..,,,„.. I'--' ='•'- ;^" '",,,,,,,,,,,,,,,,,,,,.,, .,..rrlK.a ur. «-- :- :"'"'i™i :::;;■'''':;,■:!::::-,.' o. ,.'.«■ ,.va..uation< in tl.c twrnty-foi.r h-ur- 1 r'"'''rn ; .-, an,liuanun,..r>l.-^^^ ;^;r •;;':::;:::::.' ■:;... ■' ^ ■ ■:•■',;"■;;■:;""::: .•'-'-'' rr :":';";::::'■;' 'i".i. -■>•;- ■ ,i,i,„. ,„v.,li.i.nmK. 1M..I I'" "" i.„..r..-iv.- .ni-.lia.- " ;- ' '^';'"';-:':;i.':;:;::.:::;™":^^'-"" turv aif.M'linn i.f tlu' lunt:-. ">"■ ""•> ^""""" " ,. ,,, ,„,,„;,,„i„„ l.ut furtunat.lv not >■• tn- ;;::r:;;:::^::;'::-:i:- -■"^.rr::"::::::::;^ ■»'•- ;■"-" •"; "■■ ;„:,;:,;. ..; .1. ■< ■.-■ tlu' iiaticnt inav l.f .'nilan>r< n .lu.rc -r U'-> nia.k..llN l'.lTllnlji(;y. X." iiii.TMiillfiil. Willi a .Ir.liiiiiii: l.'iul.n, V. Tlii- i- .l.-i-MMl..! tli<. ^tajre -r -I.,.,, ,.,ii-v,.- •I'hr piiUr i- ,i,,w Hnall.r, tli.. Imii.^i. of t\w art.ry iiiun.u,,-, ,|„. .li.roiiMM l,a^ -li-appraiv,!, and tl.r irimv ncarlv tl>,. fin"- I-I-.IIM1V a|,pn,Ni,naf^ thr i„,n,ial. ll... l,.>s l,,.,,,„.,> the rn",|,i,,i,v .,f ill" |.iil-c. iini rarely ;:i\ iiit: way to l.raiK . anlia. Kv.n .liiri.iir the -ta-e of m.m|. .-Mrvs the ~i 1... incist at linu-. Til,. r.>-ia'liMa. Tlir li|,.. and ''"' """•""' nMM,l,-an.. uf th,. i th al>n l„.,',,n,c elcan an.l, t.-jrctluT vvitl, the t,m-Me. In.,. ili,.ir dryn,--. Tl... a|.|Ktif and ili,. M,rs,. .,f tlnr^l r...nr,K and ili,. patirnt- now JM-ir. t,. a.k tl.r to,«l_a ,k.,„ai,.l that «o.,M iMMnnic- !■■ „;■ i.r-.nt and wliirl, ,,(i,.„ ^W,.. H,.,. t„ ann..v- ni- ditr.ivncc- \\--' ;„. ,,|,yH,.ia,i and tlic altcndani.. Uitli tlu' S an.l at the sinic iirri<. uf an appr.viation uf tluir li.lpl,.v-n,..-.- and waknr-., wl.i.l, an. -h„wn aUu ul,j....tiv,ly in ;rr,.at ,.n.a..iatiun and P^'l'"'-- l'-t-tMnai,.iy f.r ,1,.. paii..nt, ^Ir.p n tnrn>, and uitl, a di-ap- I"'^"'""'' "•' ii"Mr-. a.,d dr.an,. tl,.. u,|„.r arniuvin- inaM,lr~iatiu„> likewi-,. Mi^.-id.. j^radnally. Al.uv,. all, tl,.. l.r,.i,..i,itis ''"•' ■"•--""1 ^'i'!' |'>i.innuni.alt...~.ti,nsa>l,av.. .l..v..l,,p,.,I |„.s ; ,1„. ,„i,M. I,......,,,... ,n.,re :''"""'="" ^""' ''■-'""• i' '">•. ^'^-^'i" I'v,. fn.n. all.nn.in. a,.,l at tin,... !' '''■'" '■'" ' '" """-iiall.N lar-.. an,u,n,t. Tl,,. .lian-lna uf,, ., p,,,..;.,, "itn til., alilnil.. iMriud, ih,. ^u«,\- l„,w..\..r .rr„l,,.,llv . • ' ' • iiuH,\,i, jria,ii|;i||^ .K'fiuirin.r a .lark.r cul..,-. " ' • Jt. tayu,.al,l,. ,.a.., ,1„, ,,„i.„, nuw ^,-a.i,.allv I,..,.,,,,... fr,.,. (r.,,,, ^'?'"': , '."^7'-*' ' ••"' "'■ "- "-■<' "'• i" tlu. tunnl. .v,...k tl,.. pr..vi..ns l-iiyMu,,^,.. l,.Kly-,..M,p..,-a„.,V i. .,.„,.„d|y ,.„„„„.,|, „•„, „„, „,„.,^^^^, . nyll,...„.atiun,an.l in all >..v..,-,. ,.a<..s ,1„. „.,„p,.,.atn,v n>nallv falls >-ill n,-,l,..r l...|uw ,1,.. „ur,„al. .„ ,l,ai n.urnin,. ,..,„p,,,.„„vs „f ;i,;= (• •" ,'■"' ".'" "'"- '«>M|KTat,„-,. uf n„.,,|v n,„r,. ,l,an .•ill.V ('.. ,nuv 1>|. til,. !■ nil., tu,- .la.s ur ..\ 'v.'n w..,.k~. Tl„. pnls,., wlii,.l, is - ,,,„.i;,li;- ^.nall. , !,.„ „,.r,.,, ..„t a,„l -luw. i-, lik.. ,|.,. l.,Hlv-„.,„p,.n.,n,-... „ns,a;,k. n...l .va.l,ly va,-ial,i... Sli.|„ ,„„„„, „, ,,,,,,,,, .,i„„,,,,,„.„^ ^;^.^, ,.^,, >" -I.J.I ..I..vat,un uf ,..n,p,.n„„,... an.l ..an-.. ..un>i,|,.„.M,. „-a„si,u,-v ;;;;■--' '-■I'-n-.y .,f puV,.. .„ .tl„.r n.-p....,s al., tl... ..xtr..n,..lv ,:""■' ■ ^^'l'—-'<^ ="•.. r..a.lilv ..v..it..,| wi,l,un, f;...|i„. .,sp,„.i,||, Jij , "'.'~ """•• 1"'"^ "''■■' '"•'■'■ I- ".. .•..,npli,.a,iun .„, ,1„. part .,f ,1,,'. .-M,v,.u,.,a„.,l, .,. „...l,il.i,.,r..a.l,..„„.,.. All .,f his tl,.„.,l,ts ■'■'-' ""'"»on- r,.v,.l... a.,un, ,1,.. i..^-,sti,.,. ni' f,..|, an,l ,1,,. lar-as ••uv.t.ms If' I- !l M) Tvi'imin I i:vi:n. CMS wiili wliicli lie t'l.llciws cvirv innvcini m m|' tlic niirsc or llic ])li\>i- ciaii, I'l'cpin ulidin lie li"iii ~ t'nr t'ulliliiii'iil ol' lii- dc-ii'i-, :in- ili:ir:ict< ri-tii-. It li:i- :ili'(':i(lv iiii n iiKiicatiil tli:il diiiini^ tiic |i('i'ii>i| iil' iii\ diiitiiiii anil that nt' ciiiivalc-i'ciirc- llic |iati(iil i- (xiiuMii tn the daiipr t ]iniiiiniiriia. c^iicciallv ]>lrnii-'.' anil cniiiMiiia, a- well a- i>aiiiiiti~, lyjiliniil iarynL'ili> with iilct nitiiin ami lurni-i- of rai'tilaj:;!-. may lie iiiiiitinntil. ( liaimi- in till' iii\ iicai'iiiiiiu al-ii may at tlii> time a.-siimo an alarminfr /'■/'. Miii- ini.'iti- ami ullicr xMi'r lii-lmiiaiii-rs im tiic ])afl of tiir I'ciilia! nrrMiM~ system arc lintmiati ly Ic— cummim. All of tln-c anil -till nihcr ntl'eriiijj; nay terminate citlicr in recuvcry or in death. Ilii\\ lVei|iient arc \\(H-IrcMnt the uell-knnwii j)ietiire uf the cunlented, fattened typlmid com aic-ceiit. SUMMARY OF THE POST-MORTEM CONDITIONS. The fiilliiw iiiiT sectiiiil will lie ciinijiaralivcly less cDinprcheiisive than SI :ne mhers in this wmk, as a ]iart uf the fict- that miirlit lie eon>iilei'e. 'i'hii~, fiir ciinv ciiicncc in de.-cri])tiim-, detailed slateniciit- as t( llic tv|)liiiid-liacillii» lia\c already liecii niadi' in the sceii.ii on K'iciloiTV and will he made in the M'<'tiiin mi I >iatrnis, while in the scclinn dcviilnl til an aiial\-i- if the individual sym|itiims it wa- im]>ii— sililc in manv ]piace> to avoid a full doerijitiun of the anatomic altera- tions. I lielicve that thi-^ a|i|iarent irrci:iilarity ha- rather cimti ilmliil to coni|«rchc!i-ivciie— . and that it is the licst mean- ol' cliiiiiiiatiii^' otherwise imavoidalile rejietition. EXTERNAL APPEARANCES. Arcnrdin^lv as ilcatli has taken [ilacc dnriiii^ the lir-l .-tajrc ot the (li-easc, whether as a result of the -cvcrity of the infection or of inte.— tinal hemorrhairc, or ol otlie!- -iiddcii aeeidciit or in the -econd staL''e alter iirotractiil -ntl'eriiij,^ or in ciiiise(|nencc :if xveic com|)li(•atillll^. the % '"'&: • -w%^i:.m^f^m 3 l'.\TII(H.ni;y. 87 7"'''"' • •"'•="" "'' ""■ '-'> -"^'v '■<• .li=nM,.,nn.llv „,,,HM„.. T„ ,lu. "'■■"■^'V '^ '- -n,.n,ll, U..1 M,,,!. ,l,i, ,U„ „, ^.„., "r-""'^'";;:"''^""""— 1|'''-|" '• ■•'.v-in-mK ,l„.,...„„i,..,f ' -■':' ;;-^' ';--•'■ i—,.ui,ii,., -la. ,.,■„...... ,i,„,..„r a,., ,..,,, ^'''!";:"'''":. ."'•; -'—"•-''-.-M.i,. .,„i.i.,i n,i. -ivM I rxlnU-:,,|nnH„-l„..lt..„l,,„v,„, ,„h„i„„ ,„.| ,, „,,„,|i„„,,. ,|.„.^ I 1- l->r-VM. an. ,vn..n,llMilNW u hi, ,|.,.k J,,..., ,.,,,,,,,,,,,,;;; ,i^,,,^ :»-.Mr..,„ralK tl,,. -ra, nt ,.,,„-i,l,.raM,. i„,l,il,i,i.,„ „,■ |,|.„„, II- l"..l..~..f,l,„.. ,|..,lalWa ,.n„n...,.l ana..k of ,|,., ,,i.,,,„ "'"■".'"'"'"'•'."•""""-"'"'"•■ "•'•"-.'- 'l'>.'nl...l,..xtn.or.li„arv ;:'""■""■"• "'"' '■ I'^'l'- 'l'-M-.mti"K >kin ,.a.i..nMllv al.s,.....: ""•'.,„■,.. a,Ml ..,.,.,„lan ul.-.r, .,f ...,„si.l,.n,|.N. >i.... X.„" n.n.Iv l„.|- -...v, al~u an. ,,n.~..Mt. A, ,i,n.., .Iut.. is „|,.,„a .hout tl,. ankl,.< " Th,. ."H-.. ..,,.. >n..|, ..as,., an. wast.l. ,.al... a,.,l in.ihn.t.,1 ui,|, sennn.' Th,. \:''-V''''"7 '^''''•'•-'''''''''--'^-itl.a,..n.U..vt.. tlu..;.n„a- """"' i'-'i"";;"';"ii.v-oio.i,.,,..i.,„. i •„,.., ,;„.„.; ,,,,,,1.. ,. ....i. ....,:.. ..n,.l,,.n.n a,.,. ,,.,...,., ,),,. li.s of ,,,,.„,,„,,„,, ,„'„,, ''/'",""■.'' l.i...n,„. ,„ .iy„ ,,.,.,„, ,....,.„.„,„.„, ^, ''':""'V~"' "l-'-'i-'v iit.l,. n.arUI. 'IV t..n.l..„,.v t,> p.rnv. '"■' '"- ""• "'■--■l>--"l--t.MnM,.UIasi„,;,|..„ ' , ,,,, ,i; ,. """ "^ "I "III,. I i;il(.(.- ■ ''•'"-."■■ ",- '■"■ "'■'"""■• ',> <--■-' a.i.l -.„„ll-,.„. |,i„„, ;:;:;: i;:;::: — "'-'^ '- -•' ->- -"■■ '•.".•.■ .i»..'i.; MUSCLES, BONES, AND JOINTS. '';'"■ =;i'i:"=-M,v of ,1,.. muscles In ...,„.n.l |,as'l „ ,,,,;,,„,, ,., i„ ;:;,.i: r\ :i. '"•■ "•;-';• "•• • ">-• t,,. .,.: ,,. ,,,:;: • . .-■- .IM,^ sn,,, ..1 „,.,, a„., p.,.,,,,i,,. , ,,,^ ' '" "" '"'"•"' "-'^ "I tl- -li—. or ..v,.„ la,,.... Th,.s,. ,'"":;: "'- "'••"^'"^; -•■'- =•" -'• • Il-vn,... n„.-t.n,,M..ntlv..vi.l,.n, in rl... lap... ,h.,n.,.i.. mws..|..s ..,..':.:•;:•;':;,. ^•■' '•""■ ^ '"'•• "^'h-- Tl'- 'nn-.l,.,, „|,,, ,„„,j ,.,„;^.,,^, tr,.,,n..n,lv ,.xhil,it n.ptuns ss lyi'iiniii I iM.i: (if |Mi-t-Mln|tilll oli^'ill, lllll ll.ISc (lc\( lii|(.'i'kilaii-kv (ii--l ami N'in-lmu -iil.-i- <|ll('lltl\ CM I 111 I Mllclllioii. (ircuf :iUii ill tile .■oiir-c (ifiillicr :l"Mlc illfcci iull- ili~c:i>i-, :i-. liir iii-lMMiT, l\|iliii~ li\tr, llii\ :i|i|Mai- In !»■ (>|Miiallv (Vr(|llcllt anil rMill-isc ill cl-r- ><[' t\|ilHiiil IcM'l', 'riir mil n.-r,.]!!.- a|iiKaraiii-i' n\' tlic iiiii-rli- atVrrtol in tlif maimrr ilc-ciilMil wa- ^liidinl with .-.|Mcial cnv l>\ /.iikri-. wIk. ili-liiii:ui-lii d, in aildilinii to -iiii|ili' n-ilr^mcralix .• ali-n|ili\ , luo uili.i- vari "I' (liurii'iMti'iii, llii' i:raiiiilar ami t'atl\.ancc..ii(i ami llif tmirtli -Mik tt\' till' ilisca-r. cxliiiiil llic tinn nu'-i-lriicy alrraily iiiciiliiiiictriatr ami |)iimtatf, tlini irniyi-li nd, ami siil)- s(i|ii(iill\ waw ;^rav u, ti-li-inc il-likc ; uliilc llic trnnmlar ami tatty (ic^rcmTatiiin iinonio iiiaiiili-t i)y cliaiiirr in (•(p1ii|-. iiiarkril |(all(if or vrlkiwi-li ili~(ul(iiati(.ii. only alter it ha- cxi-tfil lin' a kmi: ti'iic ami lia> a'taim-il a hi^rh ^railc n- tVoiii tln' fact that till' licMiiirrhairc- jh-ia inii-lv iiicntiiiiiciciatc(l with the (Icircmnitiiiii. Al time- the c\trava-:itiuii- of lilnoil a|i|Mar a- striate ami iiiii-ciali' tiiinrc-. wiiilc at cither time-. a> has lii^cii incntmned, thev t'onil e\teli-i\e lieimirrhairi"' cnlleclioll- with (leslriiction (if till lllll>- (Milar ti— lie. The ili-triliiilii'ii of these 1: raticin> ami lieimirrhaifcs tliiMiiL'hiMit the mii-ciilar sy-teiii i-; <|iiite irreirnlMr. in euntra^t with the i tlm-e -itiiati(iii> that are illViilvnl in the ilee-ellrrative ])r(iee>s ill jxrealot (lej^rec ami earlie>t. .Vceciriliiiirlv, their |)iinei|iai >eat i> the aliddininal re<'tn>, more ot'teii the lower than the njiper hall', the ^rivaler and le^^r peetoral, ami the ilio- psoas. I have ohserved tluin in .1 niiiiilier oi' ill^tam■ s in the liiei ps and trieep- ol'tlie arm. and remarkalily sekknn in the adiliietoi> of the tliii^h, (iiiisiderint: theii lrei|iieiit in\i'l\('iaem in the waw form of deireiieraticlc-lieinato- niata mav imdci^ni -iippnration. Althoiijrli. from existinir haetcrioloMie knowliKlire. tin- po— iliililv cannot he wholly e\elllde ill the coiii-^cot typhoid fever ap]K>;ir to lie rare. I have oli-erved them in a nimilicr of in-tanec> a- jiart maiiifc-taiion of -eeomlarv -cptie pro. -e- Itivcntly. attc- ion ha- lieeli re|>eatidlv ealles.'c<-e- dl- to the pyo^renic nctivitv ot the typhoid-hacilhw. /'I I llnl.iii.y H9 I I.M> ( Ml,n.lM„kv I,.. „l,.-,.rv..,l .li.ri,,.^ lit;. ..„, nU-.ss m. la, .- „„ 1^^:: n, .lu. ^r.:u..r ,K.,.,nn.l n.u.l.. ^hi,!, ,.„„>Mn„.,l „„Iv ivnhoi N ,a 'i ll-..v..,...r.,s,..,Mv,.t ,1,.. I-;i...,.,l, l,M,-ilIn, ,„ ,1... livin:: l,.„lv. T . , M..\u, «„s sui,„...,..,i ,,.,r,, , ,,,.,,,„,„,,. ,,.,_, I,,.,,' :„" ; •'ii'"''^ "I lyi'l I f'v.T ill s.|,irii,i„.|-, i.s'.i:;. •'" Tlir bones ;i,mI ih,. joints .n- inv,,!,,,! ,mu.I, I,.,, ,.„„„„„„|v tl.';M,,l, in a Miun. v:,ri,.,| M.ann.r. AltrMti,,,, |,.,~ I,,.,,, ,linvtn| ,„ .|,...,! I.>...ii~ .-^IK-Mlly ,l,roi,.|, ,|„. „,.,k ui- K,.,.,,.-' I„ |,i, |„„, „,„.,^ ,„, '■"l'""'l 2:!. .-a-,.- „f,.-,i,i. a,„l |«.ri,.Mi,i-. aiHl m,„v tl,..,, ,iMn„.roi.« '""■'■ '■'-'■' ''='^" " '•"I""-'-'- ^' l^"- ='> lM..t..ri,.|,..i,. iMv,.Mi..,li,„„ at I'i''-r, ..,, no, a Hiiall umnUrv n\- ,.,.., ,,r |M.nu-titi> an.l .,MM„„v,.|i,i. '" , ';■ '""'"^' "'■ '.^1''""'' ''■^'■'- ^'■■" 'In- to tl,r l,a,.ill;H „| Kl,„,,|, ,C,„-nil "."' ' '■"' '»• ''"'''^ -iii.n,i-,„ ua- i.,lat..,l in pinv ,.„I,m,v tr,„n J .„„ "t ■• 'MM- n.,„.,-.,.,| l.v I'a,.,,,,-.. |.V,„„ ,|u. (im, ,,,M. S,a,,hvI.„..K...,H |.yo^.M..< ua. i.,|a„..l a. wll a~ I!, ..ill,,. ,,,,|,o„„. Tvpi,,.!,] ,„.,.i,.„iti. ""'.""■ -:""'-^"'> ='^~""i^"-' i-'f'M'i„„a.i f tl„. ,;.„„„. M,,KTti.-ial ';'"■' ~ "' '■'""■ "'"••'"r "'•'•"I- -iNri,,^. ,1,.. |att,T , ,s<. „(• ,1,.. ,li,,,., ,, ''■■■ '-H„.„ .|,„.i„. ,1,„ ,,..,i,„| „,• ,,„„|. „,„.^,,^_ ,„„ ^^._^^,_.^^|,^. ,^__ .^^^^ • 1^^ ""' ''"■";' -'I-—-, Im. „,av ,.....,.,• la.,, in -vaf......,,..,: an.l '-"-"'l-H'>--.ln..-tl,..a„a..k„f,;,v,.,.. I!..„i„ . |,a, ,.,,,..,,,..1 '■'- ••-;•. ,,„,„„ ,,,• . „ , ,, . l-n, ^'mii^ ".to lyriiiill) I iMi: Tlic ili-ra-c (it' the l"'ii'' iiKiy (Mciir ii ■ ••]• in -cvn-al |):irt- •A \\\<- sk.lrtoM at llir -ainc lim-'. O.va-iiinallv, it i- r,.ntiiM.l lu a -mall ana, :i,„l ina\ mm.I.t-o inv-iliili.-ii uitl I injun t.. tli.' I".nc ; w liii.' in niihr inMan.v- |»rio-tilic al.-.v-.- inav .I.a , ln|,. uilli (Alcii-ivr iir.Tu-i- .,f ll„- Lull.-, aii.l .vni ni|,luiv into llw jcint. u illi all ,,r llir ,-,mcninitaiit .laiiun--. 'I'lriniiiallnii in Ilir Innuatinii ..l' ..\,,Mu-,-. uliirli ha- I", n l,„.,iliHii,'.l r-|Hrially l.\ rnn.li .iilii.'iaii-, apixar- to l.r .•\iMt-, uliidi may apprav a- m.-nartinilar ur |M.I\ailici!lar, an.l a- Miiipiiiativ. ..r -imi.lc iiitlamiiiat..ry -niii- |.nM- .»(■.-( K.vii,Sln>mi'Mr. X'.ilUmami), liavc liitli(Tti. n-r. ivcl litllr tliomiiL^li anatomic -tudy. Tlir Mipjiurativ- i,-ioii> ajiprar aiinoM alwa>- to !„• the n-uh of .•oini.licatini;- H|iti.cmia.' I'oiilirk - lia-. liowcv.r, niMii<' a tliun>u;;li ^lll ili-covrn^.l .•oiidition^ -.Mii-v-iinir tli..-r |Mv>.ni in tiir -pl.cn an.l tli.' iympiiati.- ulaial-. Ilc.lc-'-i-ii"- |Mcnliaf lai^v c IK. i tainin>x as many a- 'Jn nil r.;,„Ml-.'oi-|.nMi.- an.l mon, in tlir JM.nr-marn.w of tli..-.' .l.'. 1 at tlif liriirlil of til.' .Ii-.'a-.'. Dnrin- .-..nval.-.-.n.v tli.-.' -tni.-tnn-. iMvvion-ly m.niion.-.l i.v N, nmann an.l I'.i//../. r.>. .'vi.l.ntly nn.l.r-.. -n.li tran- funnation tl'iat ll,.' n,i M l-,,ri.n-..i an' tran-t;.rnw. Wk.'U tk.>.' ,vll>'an- i-n-.'nt in kii-v nnmi..r ik.y imiMi't a l,n.wnisli-n-.l .'..Lt to th,. I„,n.-marn.w, whi.-li l..r-.i.t- tor >on..' tim.' after .•..m|.l.'tc rfc.v.i-v lias tak.n |>la.M-. DIGESTIVE ORGANS. r>, i;.nn.M. t.. tt. .n.liti..n ..f th. t..nL'U.' mikI tl... mn.-..ns m.inl.rano of ti... n...Mtii an.l ,,hai-vnx l,a- alPM.lv K.rn ma.l.^ in tli.' .l.-.Tipti.-n ..f tl,r .rrn. ral -vM,i.t.m,ato|o.v. KnrtlMi- .•.m-i.l.rati.-n ..f tlii-, .-i-.v.ally to tlu. int.n-tin- tv,.l,.,i.l k-i.m- .'f tk.' fan..> an.l th.' i.karynx. i '.nr.l t,, l,v I,..Mi> an.l .I.nn.r. 'viU ■ .' uiv.n .m.l.r th-' -x mi.t..n.at..l.:-y. in ,1„. ;i,.:,.i l,o,lv tk.v an. v,,n-..nt..i l.y nain.lr.l nl.vr- ..f varyin- >ur, „ tin,..- .■..nllnni', ranlv, how.v.r. ..f ;rnat .■xt.nt, l..,t ..N.v...l.n^ly skalk.w, an.l .-..v.n.l I.v a tlnn. .^n,vi-l,-v..llou . n'a.lily .l.ta.'lM.l ,l,.,K.si.. I-oni- .lakn- I., kav.' ol.-,rv..l -in.ilar .-kano-s ,|..wn mt.. ik- It -1 M !,.■ m.nlioM...l a.kliti..nallv tkat. a.v,,nlinir L. (>o|iliaL.^u- not ranl\ inv.ilvcl llofmami. tk.^ nni-.iil ir -trn.-tnn' ..I tk.' t.int;ii<' i- i„ waxv .k..,.,.n..rati..n. Fnrtk.r .l.tail- xvilk n^.r.l to tk.^ salivary glan.ls Null 1m' irivn in .■..nn.rti..n uitk tk.' analy-i- ..f tl... n..l.v..lnal • Kl..TT,w.v.r, l>,.,f~.l.. .I.v/,. r /,/,„. .1/,./. iss'... IM. xliv. : l-;,-./,..,r .V .1/v/,,... 1S7-J, li.l InI- mi^itk^^i^m m^»i}h^sr^::^^iiii- r I riiDi.iK. y. !i| -ytiiin.Mii-. At tlii- |,l;i,v it uill (inly I..- .iicntiotK.I ilm tlicv miv .,li,n tnliml , mIiII-mmI ulicll .li.ltll ll.l- |;lk,.,| |,l;|,v ;it ;||l r.||-|v -t.lL'.' «i' tllr ,|i-- 1.1-. I'li'y til. II ,i|.|HMr liriMcr ili:iii iiunniil, il.irk.r, ,|i ..,],, nd Im-.ium- '-'' >'llnu ,,r .rll(,ui~li i-mI, mikI on iiiiiT,,.,-..|iir .AMiiiiiiMtinn tli.v cxliiliil, ill a.l.ljliuii t,, rvhl, iir(- (if !iy|MivMii,i, ,l,,ii,K- MN.IIiii^r ,,|- ,||,. ;;l.iii(lili.ir evil-. Tlir -loMlMcli ;illi| til.' ll|>|>rr |url ..fill., int. -ill cnii.v ;| >||l,.,|-,i;. IKlt.' |ll.l.v ill ivl:iti.,ll t.. til.' IVMI.-lill.l.T ..(■ til.- -Ill, ill illt.Mill.., til.- l;iro,. ""'-''I"- ■'ii'l 'li'' iv.'liiiii, with ivu-inl to iluir ,iii;il.,iiiic l.-i,,,,-. Kv.ii th.> .•Miii.r ..liMTvcr- iiii.i nil .,f III..-., uji., i;,||.,„,,| ,1,,.,,, iii.iiti.Pii the .Mviinvncc of .lct;iiliiii(iit :iii.l |mii.-t;itr ivilii.— ..f || m-- "'"■ "I'l' ^ m.iiil.r , jui-ti.iil;irly in tlif viciiiiiy ..f tli.' |.yl.,ni-, at times witii iiiiiii..ri.us .Mi|«rli.i.il .i-.-Lm-. or a iii,nk..| iii:iiMiiii!l.it.-,l M|.|.c.ir:iii.v. L.,iiis liMcilt Motliin- .It ."ll >|Kviti.-. n.vniti.in .,1' tli.^ .-..plia-us aii.l -tuina.li ...va- -iniialjy ......iMx Mit,.||,.||i I,;,.. r.|..irt..| mi.Ii a ca-.' aii.l ivvI.u.kI -.v.ral olii.i-s. 1m-,,i„ n.Mi.. .,f tli.-s<. haw ty|ilM.i.|-l.acilli I...11 i^olat.Mi. an.! tlirv • nv i.r.ilial.ly .Iin. to a .-^M-oii.lary i.roccss. Stri.tnro of the ^..^liajrir- rollouiiii: tyi.h,,!.! r,.v..r tank ..ci.,-. S,,.!, ,,,s(.s have L.tii tv|..,ii,..| \>y I'arkanI/ .Mit<.|i.II,' an .•on.liti.m i.. ,in.. to a .i.atri/ati.m .,f th,. >,voii,lary i.i.v,-. The att.Mnpts of C.mil ' an.l (■haMti;ir.| ■ t.. .-tal-li-h a iN.iiliar ty|>h.,i.l air.rti.m ..f tii.. .-t.i.Ma<.h in the ''"■■ii .,f f.M^al ac.Miniiilati.,n ..f ly.n|.hati.. .■I,.ni.nts in tli.' ..iii,..,n. ,„..„,- '"'""■ >■'■' ••'•'I""-'-* ••oitoIm, rati. III. In 1h,. ,1 j.,,mn aU. at tini..s, i„ my .•\|,.Ti.M.v 1..SS .•oniiiionly than in tli.^ .-tomaiOi, -w.llinir an.l i'..l- Tir- .if th.. niii..oiis in.inl.ran,. a.v pn-.m. In .,„,. Jn-tan.v I .,l„.,-v„l .Hip..rli..,al .ro-ions. Sp.vif,.. h.-i.ins .if this ,Hirti.in .if tli.. intotii... have llk.wis.. n..t as yet l.(<.n .lciii..,i-trat.'r.s,.nt. \\ h.n this i- ahscnt, th.. ,li>t,ntion inv.ilv.s pr.ffabiy the |./.7.„, //„y,/.,„, //,,,^, /j.,,„^ ^.,,1 ^.j|. J ^,^.^^ ^^ ^ ^j ^^^ ^^^^^ * '■'"■ l',hl.,„i. ,/,'^ S,;. ,„,,/.. 1K80. It *!:l'._ ■'■•".if 92 ivriioih 1 1 vin. %\] l.ilLir iiilr-liric, ;ill(l l;c III r:ill\ lli< -iii:ill ilili-llln in |i -- iliul'iS'. \\ Ik II llii' ioImii i. 111111-11:111^ lull.: i'liiiii-, ihirk linr:ir -IK'I- r:ill lir -rill i'|i|Mi-i|i' llir ,il lailllili III "I' llir II n -i lllil'N . < )|l |i:il|i:ili.ill llii-i I \liiliil ;i ijili-ir I'l i|i-i-Irllry tli;lll llir liliuillnlir nl' lllr illlr-lill:ll Willi, .inil, :i- will !"■ ili-i |i i-ii| nil ii|>illillL; llir illti-l illi-, llir\ (•iii'l(-|Miiii| 111 llir -|iiiilir I\|iliiiiil iiilr-lili:il li-imi-. 'I'lii- cuinjil lull i- (li'|ii iiiji'iil ii{iiiii :i |H'i'iilial' iiil1;iiiiiii:iliii'\ li\ |ii r|il,'i-ia ul tin l\ iii|iliiiii| .-inirinii-, wliirli, in ari-nrijaiii-r wiili it- -cat in lli.' -mall nr llic iaitri' iiiti-tiiir, miiir- a- li\ |ii r|pla-ia nl l'i\ri- pal' in- nr nl llic -nlitary tnllii'ii'-, liri liiiiiicau «a.- prnlialilv llic tii>l wlm ilirrilfil allciilinii riii|iliiilic;iily ami iiili-llijii;tl\ 111 llir l\|iiiiiiii Ic^inii nf llu- inlisliiic, lie ciiii.-iiliTril it ,-|n'i ilir, allliiiiiL'li lie cuiiiiiarcil it ^^illl llic v:;ri(ili)u.- Ir>iiiii nt' tlic «'Xliiiial iiili'LTiiiiniil. .^-iinihir n|viiiii)iiri liiivc lit-cii i',\|irfs.-cil liv nilur nliM-rv ci- nt llic ^alln• ami it' a later in-rinil. In llic ccli'liratcil Imnk nl' Lmii:^, linwixi r, i-|i-i-iallv ill llir M'cniiil I'lliiioii, tin- iiili-liiial l(■^illll i> cltarly rccii;jiii/ril ami ill lin- main lliiiri)ii;:lily diwrilicil. Ill lllr ilrtailrii > lr-rl'i| it ii ill nf lllr typliniil illtr-tilial ji-inll -rMTai -ta^r- ai'r a|(|ii'n|iriatiiv rrciinni/nl : 1, tlir -tat;r nl' liy|irriiiii.i ; 'J, lliat nf iiiiiliillai-\ iiitillratinii ; .".. tliat nf iiri-rnlir ilc-tnirlinii ami iilrrratinii ; ami I, tli.it nl' riratri/atiiiM, In ;:rnrral tlir-r anatninir -ta^ir- I'un-r- -|lnm| willi rntalll |liirlliill> nl' tilr ilinirai rnlir-r, it -llnlllii, lliiwrvrr, lir linnir ill niimi lliat tllr illtr-tilial Ir-inn (Im- lint (!rviln|) ami rMrmI -iiiiiiltamiiii-lv ami iiniliiriiily, Imt ratlirv in -la:;!-, nllrii ili— triliiitnl nvcr a rnii-iilrralilr |iri'jiiil nf tiinr, ami il likrwi-r uiidrr- irnr- iiiMilniinii ill a cnrrr-ii iiii^ iiiaiimr. ilir Inwrr |((irliiiii nl' tllr ilrlllil ami tlir liriiililinrllnnil nt' tllr ilrncrial \alvc air jrcllrniliy altarkril rarlii-t. < (I'liii tlir im|irr— inn i- rrratnl a> if" tlir |(rnrr-> rxtrmlrii i;niiiuall\- nr ill -ta-r- friilll tlli- |)niiil, I'lllt il' it lir takrll iiitn rnn-iiiri'.itinii tliat rrla|i-(- ,iml n rrmlr-rriirr- nl' ty]itiniil Irvcr arc attriiiiril with rrlirWdl illMiKrliirlil nf lllr illtr-tilial lllllrnll- liirllll irailr, it ran lir limlrr-t 1 tll.ll li\' lin iiirail- llirrly tllr \al'inll- rtaL'rs nl tlir -prrilir Ir-inll, llalllrlv, iiililt rat inli, -Inll^llillLr. Iilrrratinii, ami r\Cll i-nlll|ilrlr rira I ri/at i< ill, ran lir -Imlirll ill tllr -aillr |)nrtinll nl tllr illtr-linr, Tlir lif-i >tai;r, that nl' |i\ pr,-riiiia nl' tlir iiiti-liiial niiirnii- iiinii- lifailr, whirll prnlialiU nrnipir- tllr I iri;iiinill<_ nl' tllr llr-t Wrck. ill /'I I lI'llJK,)- 93 '~"'^""' '":''■' '■"■" ""— i'-.u.-M^, H ,n.|..,.-,.,..| i„,|..,.i| „„ : ;' ':' "-•^'■•■■■'i"^ '--iu ui.l .1, „,,,..,,„„n,v i;„- :,„:n.^„i.. ';"'~"^^"' -'"'"■''■''■ I^.U..H,-U .,.,1 T,„,H-..MM l,i.|„.nl ,1,.,, .., Ilii^ IMH,. l,x|,..,vMM., ..I I',;,.,'- |,.t,l,.-an.| (I,.. -„|i,an tolli,!., ,„,,,,, a- ll,,. I,,nn.,.,„r ,,r ,M...lMll;,rv i„lilin.ii..,i ; Cuniil ^n.l l.-M.ivi.,- ,| , ■I.H.M ,., I,.V,. ,MM,i.. -in„lM.„l,-,.,.vanuM-. In M,-.-,>. „fM.i..i,|.. 1 |,,v,. ..l-rs...| „, .1,.. ,Mi,MI,. nCI,,. li,M u,.,k .I,..m,Im„,.,„ an.l ,uM.-k..,| In,.,,- '"'""' ''"■ '"" - >M-.Ml,nM,.,,f ,|„. ,.,..•„„,,. I,- ..lia.vnt |H,ni,,i.. ,,(■ ''"■ ''" • •""' ''"■ •■•''"■'• "'■'!' -li^l" -".llin. oC tlH.;,.„,i„Ml..:M„l -..li- larv tull,,!,.,. Tl,.. f,v,|Mr„.v. iIm- ,m.„,, .-umI tl„. .I,.|,il, ,,C ,|,,-,. ,i„,,.., I. .•.,K.,.i:,|K l,id. .^VMlr. uC i,„,,„i„ ■■'<■'■ all M"-"""- thai await a>.>NV,..- I,a>,..| n|H,„ ,„.„•.. r.uu-h^- <.\|H'ii,.ni.(.. With tl,.. l,..,i.,.,i„L' ,.)■ tl,.. „,! „,,!,, i„ ,„,. ,,. ,..„,„ ,„,,|,,,,,|^ .,, •I"<>"l"f tl,.. r„M. „,..,l„ll:„-v inliitfati..,, ,,!,,,. ,,,„,. ,,,„|„,,|,, „i,|, .^ ''"'■ - "' ''"■ '""■"■'• l'y|..T..>„ia a.,.1 >w,.||i„.„f ,1,.. i,„..Mi„al ,„„.■.■„. '";■'"''"""■■ '" -'■"'■'•^''- '''•.^'■'■■- i'-'"l"- ■■>\.-,i.l,cs .Ices not a|.|...ar t.. I,.. ('r...|,i,.nt. In th-if (;„•„, a„.l -it„ati,.n. tl,.. ty|.l,.,i,| j,.;,,,,, „at,in,Ilv ...rn- i>..n,i ,„ J,..,,.,,,,! „, ,|,,ir a.,at,.„,i.. -„i,.tn.t,„„. Tl,..v atv ..^al wit). ';»'"■ l.m-,t,„l„.al axi. .„.-n..,K„„|i„^, t.. that ..f ,|,.. i„„..,i,„. ,,,, >m.a.,.i ,,f,„..,,,ally i„ that |H.ni„„ ,.f th. i„t...,i„a| ,..„al .,p,'..„it,. 'I- .„.-..Mt..f,.. ,ma..|,„„.,„, a„.l ^,.,„.„.||y ap,M.ar as .hat-plv ..i.v,.,,,- -nl". At (ir^t ^.vatly n,!,!..,,...!. tl„.y M.I,s..,,,„.„,]v a..,,.if,. a .^^^^,1^ rr.l„r, at tl,.. lM.;,i„„i„. „f ..xC.li,,,-,,,, , ^.ravish-;-..ll..w n,|.„, ' Tho Mirfa.... ,,» tl,.. |.a,..|,..s. wl,i,.|, n-ay pf.,i...t fn.tn .1 in r, .,r ,.v..„ „p ,.. H """• ''I'-v. tlu. i,„...,tit.a] ,„,.....„. „u.n,l„-a,u.. i> at tin...> M„....tl, at •-ti'.r t>„,.., ,ii.i„iv ,,^,„„,,, ,„. „^.,.„ „„„„„,,^„ ,„„,,,,^,^ ,,,,^^,^^_ .^.^;^^___ ;'nt„.s an. .i„„l,tl,.., ,hu. t.. ,1,.. (art that ..,„„. tolIi,.l,.s ..„„.,,•„. int..;!,,, '"""""" "' •'"■ I'.'f'-I' l'='V'. >M.t y..t l,..,..„„ „,pl,...,iv ,.„„fl„..nt ..r at I' .^t, ar.. ,>„t >w„|l,.„ ,., ,i„, i.,v,,| „,• t|„. s.irr..,„Mli,.;r ,iss,„.s. Tl,.. ..'.„- >i~I..n,.y, th,. .|,.jr,v,. „(• ir,tiltn,ti„„, aii.i thr .l,.ptl, t„ wl,i,.h th,.v ..M,.„,| a.v ..v,n.„„.|y varial.l,. i„ ,lin;.r,.„t .-as-.s. Kv..„ at ,l„. pn.<,:„t ti„„. '••■'" not ijuitf cuniin'iiirn^ililc tr irc-rnt iHiuit (il view. 11 ir Muchillaiv -u(lhn<; i- iiv no incan-; aiuii luavs ciinCnicd t" llic limits >f lllc 1 latclii-. At lime- the intilli'atinn cMfnil- IicmmmI llicni to tin an|airnt nMK'im- nicinliranc. I nilcr -iH-li circnni-tancc- >i\rr il inlil- ti-atcil |iatcli(- niav cualc-cf, and, in ccin-i'iincin'c, |i(cnliarly -liajicd liialrd lni'niati(in~ ni tlir dinriiiin .it'llic a\i- dt' the Imwrl nia\' nl'tcu i-iilt. Ill otiicr ca-c-. cm the ntliri- liand. thr pali-iii - arc nnly parlly K\d in inlilli'atiiin. (icmrallv, tl alc-ccncc of the inllllralc(■( in> |)rcl'ci'al)lv and nm-i cxtcn^ix cly in the lo\Mi-inip>t pi tidii- . tile ilcinn just almvc iln' il(MK'f("al valvi' and in llif adjacent 1" liiin~ lit' the crcnni. Tlir intiltraiiiin i.tthc Militai'x' tiiilidc- ciinnnoidv pfcscnt in additi t'. IlIC -\\c lin^ ct'thc jiatclu-. and cxhiliitir.j.'' in ditVcrcnt ca>c- the must d di-trilmli ll ihrnniihiint the 1; tV'jf nitestnie. and at tniic- ex tend- niLT nilo the ~ii:niiiiil lie tiirniation \nre and e\ i n intn the reetum, trivcs n-c ti tiio it' rciundi-h. era\i~h- le in the siiiic l> 111 a-MicialidTi with iilccnit ivc |inicc>,,. ia> hccii iiKJiratcd, lliat tli (■ \ai'iMiis staifc- lit" Miily j.rciici-a||\ cxliiliit var """ ••iii'l iiivuliii Mcrdnliiii: tipilic |.(.i-iioii oCtli,. 1 I"' '"iiipivlifnd.d tliat (.cca-idiially aliii.,-t al! of tl iIi-cimImmI iiiay lie (ilp-ci-\c(l at tl illll- ;rl-;|,l,,^ ,,(• ,.vi,|, Hiwvl in\n|vc(|, ii I'aii H' aiiatoiiilc nine SMS -|"'<'t t.i iiidliratiiiii, witli rcp-ard ic slliic till).' ill the same l.i.wri. .] ll-t the I- ■Ml' - |>atcli('> arc p'licr l-llirlr-. With ,',,( li'aliMii- that iii-a|i|>t'ai' l>\ ah~(irpti til r.'u-r'|..^iv(. altcnitiiiii-, mi hat ill aiKaiii'c of flic Military rrcllCC to the I'C^rl'civ,. ,'l|anjr,.< ill ,l,.t,,i|^ t|„. j„f||'. lli\' MllllCW yellow di-coloi-ati lull, ami then pronic- ri'Mti'l' III ui'iientlly at fir-t |ii'cM'iit a -ri-avish- i\ely ('olla|)M', at iii'si at tiic ami from this point toward the iieripherv. J,, tl 111 iiecroH-. the (ir,t indieatioii of this | K' jiart-: .iiv lived 111'" ai id --wellini;- of the ti~SMe, freolicntl >l''i<'css I sists III a eert; tllliletaelioii of th,. s||n-,,|,|||| |iicntly with rcaetivc ledi nil .|ion;ri- d IMI iile- then ai'i|iiii'( iiiLT inneoiis liK'inhi-aiic. The patches and l-h-\ellow •ayish-vcllow, iic\t a pale-y.'llow or di eoioi', and Mion I'eoiiie from dirt\- hrowiii-l 'ilive jmrii (nun imhihiri if the cont ity o'niy- I s„,.,, icMce of the jrn.;,t hyiMi-plasia of ion the Work of M iNiiry on the hisioh 'lian^c. nitvphoM ,;...„. ,1|„„|,, I... ,„„„,.„„„, „.;„„„„,,„,,„ ,,,^.,_ ,[;,,, f'l till' action of litcration of cndothcli a toxin prodiiciKl l,v the tvplioid-l r lerc IS a pro d the -ucllinL' 'if the iiitc-tinal ph'iid-liacilhis. tl irc phatrocytic in character til their toriiiatioii. 'j' lymphoid ti-sii,. i, ,||„, .,1 most ciitireh Mills am "' ii''''i-oM-, he think-, is d 'I ••ainllarie- li\ til lie to occlii-ioii of tl '''i^viicratioii of |.liai:oc ^'"'•K. He dcMrihes .inland- and the -pl,,.|i. 'i'he procc- ,,)• ,,^t; I'liiiiiis thmmlii which owe t|, ■tic cells licnc-ith tl cir ori;:iii ti M' liniiiLT cndothcliiiiii of th, ■ I similar jmiciiss occnr I'liiLT 111 the iiieM'iiteri lialion IS i-ai'cl nuiiiiiranr ; at uiIiit liino tlicy cNtciid diiwii til tile nni-cnlaf cnat tf(|i in ciinMiiiicncc nf -till-rNi-tinii iiililtintiiin in llir niiu;lil"ii'lii«id ; tlic latlif. ImwcM r. Hinn di-a|i|i('ai>. 'I'hc cduv- aif Hvncfally little, it' at all. drtailicd. 'I'lii' lia.-i' nf the iili-cf ])rc>ciit> a iniiic uf lc-> dafk-fcd a|)|Haranrc -lidi'tly alter cNtiiliatiun lia> lieen ciiiniiletctl, anil it i- nlten -till ruNtfed in \ari(in- ])larr- witli -mall reniain> nt' .-Imijili-. The nldef ]iii|-ti(in- Mum e\liiliit a -laty di-inlina- timi. The inte-iiiial iileiT> M->nnie the tiifin .it'th. |i|-e\ imi- ana- nt' intilti-.itiiiii I'lilv in mi tar a> tlit-e have nut iindei-i;iiiie in\ iihiti.iii hy .-iinple ali-iii'|itiiin. It i- wdfthy nt' inentimi that lai-j;c ednlliieiil nleer- iiiav fiii-ni iti place of the ednthieiit |iatel»>. and that the-<' afe imi-t t"fei|llelillv situated in the nei;;hlMirh(i(id nt' the ileneeeal valve and the InWennnst )Hiftinn nl' the ileUlH. The iileeiN fonltiiiL^ fi-iiin the Militafy fnllieles irenenilly Mttaiii a >m' fl-mn that nf a lentil nr a [lea ii|i In llireeM|Mafteiv nf an inch in diameter. The Iniifritudinal axe- nf the laipr nleer- ate imt i-ai( ly directly tfaii>- veise to the axi- nf the inte-tine. In the fare caM's in which a iinmher (if ulcers lie cln-e tnjrethcr. eveii aniudar ulcer- with -ul)M(|Ucut stennsi> (if the lari:!' intestine ma\- 'ur. I-"in'tlier exten-inu nf the tyjilmid ulcers after extiiliatinn of the >lnnirli- i lielieve. with ntlie.' nli-ervcrs. tn he uueninmnn. On the ntlier hand, tiradnal dceiieiiin;: nt' the idceralinn i- prnltahlv U( t at all nire. mi that nicer- iiay ncca-iniially tiive riM> to perfnr.itinii at a time when e(im|iletiiin nf the |iriice— nf cieatri/atiiiii nii^rlit he exiiectcd. In the majnrity nf caM-. Iinwever. ]iert(iratinu dues lint result friilil -Itch M'cnlidary exten-inu of the ulcer in (le|illl. Iiul frniii the cirenm-tance that the iutlllratinii frnm theniitM't extends dnwu In. even iuvnlve-. the M^rn-a. and that, after exfnliatinii i>^ the -Iniiiih, such a thin, unresistiiiir ineinhnine i- left that it i- imt ahle tn w itli-taud the lire— ure nf the iiite-linal enntcul>. Theiv i- aecnr(linj:ly a ^r'""! ana- tnmie lia-i- fnr the mn-t fiT.|nent nccnrreuce 'A' i)crfnrati\e peritnniti- al a time whcli exfnlialinii nf the -Imiuhs take- iilaee. while the -ccnudary I'M'lliilJxlY. 97 nl..Tition ,n.„ti,„„..l ,.xplain> in pan ,|„. o.vunv,.,.,. .,C p.rf;,,,.,!,,,, nl a iniicli later p. I'iod ,,f tlic .|i-ra-i' In .■;,.. in u|,i,.l, ,|,,,tl, lia- .v-ul„.,l f,,,,,, iM„.-tinal heniorrlia... ,1„. ""'""""-' '- - '"""■^ r„n»ront..l u ith thr i,i,,m .lidinilt an.l ll,,. -i-upl.-t >;'I'"..mI proM,.,,,- M,|,. I,VH,1,.. Tlu. .^..,.-.iv,., npi.llv i;.,.! I.,.' - .•Na,ir.s M,av tal<,. pla.v vitl,,.,- tV.„„ lar^r,, intestinal v,-m.|; „p,,„.,l i„ ,|„. l-'-'"v~, „1 ,.x(„l,ati.,n. an.l wl,,,.. -,nn,p. are ivadilv .|...nMn.tn.U.. .„• MKHMv fr,,n, .-apillarv v,-m.1s, >,. ,|,a, even on p.,>,-n,.,r,en. exanuna.i..n i, ;;;■'> - ''"'"-it ,., ,rate ,|,e .,n,ve of the n,a>Mv,. lH.n,on-|,a..v II.- he,,,,,n,a^,. ,Von, lar.e ve...l> an erve,l espeeiallv whe„ du" -ea le,l ,n,lun,„.,l patehe, are exfoliate,! a> a ul,ol • in la,-.,. n,a„e. ""■ Y - "'^'"^ ''■"•'■ ''■'"" '-'Will^'n.- ..r iVon n,en,u. tninute Ve^M.|. ,. n„, nnviv eneonntere,! in the earlier stap. of „e..,-osis hef-iv '•;'"" ,^':';l'7''- l'"l'— l-i.vu„.,aneesa(e.-,orn.anv, - |.l.-st an. o ,1„ ,n.hs are i;,und to he .pon,v, .Vial.le. irre,nlaH v'll-:s >Ntln-e,l M„h hl,«„|. a„.l hiaeki.h re.1 or ,larl< in ..olor. The-e '■;'"■' ""•, '"'''f ' ""■ '■••■•1"""^ -...nrrenee of eopions intestinal hen,or- rhap. n, the earl,- staj:e> of tvphoi.l ,;.ver ,„,;.,,, „,.. ..,,.^„ .,,. ^,,„ ^,,,.,,,_^, ('i<'atri/ation of the tvphoid nh ••i'- <'<'(npies a> hmir a time, and often ■'l'-^er,in,e. than the preeedin^ .tap. of intestinal altenmon. That I' U-t tnne (or heahn. ,s a n.atter of ...nrse. X., do.l.t, n .der the ;;''•'-•<;■•'..-,. phv.ieal dehilit,. the p.„.ess ,,f h.di;':/^ ......alK- protra..,.. even in the pre.en f le. pn.f.nnd lih.e.^ti. ' : "": ':""-"■•>• ""■ '"'"'"-" •'-•■•i' .V ...rlier writers as atonie nh. • ation 1. ni part to he inehuh.h .VnereieatHxation has taken plaee the artivted ar..s are .till s.,,,,,- 'I I- .1 matti'r ot eiiiMve tli.it »l, i i • i '<|iMs( ttiat the lymphoid strnetiircs at tli.. sit,.< ,.r ;::::: r;."™''; '"'■■-i '•„,. ,,.„„;::;:;': ■ .v ::,■;::; " -it '■"",-': "'' "- "- ™"' •"■■■■■ ,|,„„, ., ' ' ' '"'"" '"■■«"'«>•■ •■l«'"«l , »u.n„. wi,l, I 'JH TYl'lIoll) FEVER. vMiiMtiipii- witli -iirMi'd til tlic iiiiiiilxr, A/.v, dtptli, iind »li>Iril)iiti>iii of tlio 1y|)liiii(l n I- in llic dilVcrciit |)(>rtiiiM- el' tlic iiitotiiio. 'I" in the lattei. and tlii- in the indi- vidual e;ise, st Cdiitinilotisly intil- trateil aii"ot rarely the veriiiiforni appendix, with its follictilar apparatus, is iiicatly involved in the nioriiid procos, and it may occasionally h" the seat of perforation. I have observed as iiianv as ;!l) (iiseascd patches in a sinirle hody, aial I know that other w riters have spoken of a still lar;ier iiumher. A nioderate inmiher of intestinal uh'crs is far more commoii, however, thsni a very larjre nimiher. In a stndv of •">U4 autopsies that I made in llamhurL'' from the tiid of l.sx") to IM.'ST with relation to the mmiher of ulcers, in "JlW cases the specilic intes- tinal lesions wen discrete and in L^reater or less iiiimher. With reference to th'j localization of the ulcers, the notes of 577 autopsies at the Ilamhurf; and Leipsic hos))itals are availahle. There was involved : the cecum in iAQ cases, X.H.;i!( per cent.; the cecum i often toL'etlur with the vermiform appeii- n down into the rectum is jiroliahly least comnion. In the up|)erm77 autopsies I found the frecpiency of intestinal J'.trnoi.ot.y, !»!> porf,.ratini. an. oon«-.-ufivo porilMnitis t., I„. l.', ,„.r ,.,.„t. TIu-^h- fi.Mir,- ..rc almuM „l,.„l,..al «,.l> those ohtain...! I.y .Mur.i„.su„ tn„„ a .olkr.i.:,, .,t' -i.!," .•m.n,,H... n„„ van,,,,.. J..„d.>li a„-l Fr..,,,.]. l„..|,i,al.s .lan^lv, l.i.M ,.er ....,„. Ih. .tanM,rs„. .M„,v|„.<,„,. ,.. ..,11 as ,„y own, an. OM„,.ilV,| Cro,,! a lo, !: M-,M... of v..ars a„,l a,v .l,..n.|,> tre. lro„, a,ri,lw.,H .1,,.. ,,, ,1„. rl.ara.t.T o? ii>,i,v„„al .iHclernKs. llo« „val variations n,ay o.vur in in.livi.Jual ,.,,i,|,.,„. M-s ,s shown h.v ,,,. „l,s..rya.,onsol' lloliina,,,, at I5asl,., who lound ,H.rtoratio„ >- -" "' -•" """'I'-"— >^, l-r .vnt. Th.. ,..at of ,ho ,„.rfo,-a!ion of 1," -u.. ,.o,-n.s|„„„!s w,th n.^..rdto„s fW-.,„..„,.y in jron,.,-al wi.h tliat of ,h,' lo.al,/.al,o„ o( the nleers. Oi 1)4 perforations that I l,ave stn.lie,! in this ;•; ;■'■"""• ""■':'■ ""■^. "'VoIvef tl"';inato,ni,-,,l,>ervatiu„>aiv not -o" sv-ten, -Ur an.| extensive a> wo,,!,! l,e .leMt-al.le (ron, ,l,e ,.!i„i.,,! ,,„i„t „f view <"Me,-ally. reh.tvnee. are f,,,,,,! „„!y ,„ ,!„, ,,,,,,„,„, „,. „.„ „„„,,,,; "''■M.l.ran.. „, the inntn-liate vi,.i„i,v- ..f ,h, I,,,,,,;,,,, i„,i,„,„- ,„ ^„„, MNyra,,,.,. an,! esp.-eially those alterations ar,. n„.„ti„n..,! that are n.ost 'Ntin,ately tvlate.! to tl,ose pr,„.esses. As. i.oweve,-, ,!„. •• |„t„.ti„,l sy.npt.m,." in ,,,se. of typhoi,! fLvr-that is. .liaiTl,,., n„.t, I'te. — mi<|i)lll>tei!lv ,1,1 II, ,t Illation to the iiiterisi at aiiv sta ire ,it th,. ,||, at lea-t III int,'-tinal iiiiieoiis turti ty am! extent of tli,. -peeifi. iTieteorisiu, ase >taii,l in direct |)art, expli,'al>l,. from tl le-io||s, tl lev iillist liieiiiln-ane. l),.iil)tl< ler liivestiir;iti,.ii that ext !<■ ,',>iie,I t« may hesit.ite. with a kn,.wled. > answer fins (iiiesti. 11)11 II -^iieh small iiiiml),T ■am,' wav tliat diphth. :e of 1 eases presentiiijr such lav,' Leeii nienti,.iied. In tt iiH'inl.rane, and aeiit. ria may I.e imatt,.|id,',| with the f tloii, so th,. fl.lh',., nith extr xaiithemata witli,,iit cliaract<'rist iliir ;i|.paratiis ,,f tlu' iiitestii le orm.it ion ,.f i<" eiitaiieoiis enii)- I ver. .\ I'liie rarity, most ev,'i' le mav certainlv, lie iiiv,.lved in minimal <]• tli,.ii}f|i iii^^'tion, in which, aft > cxperiem-ed el iiiieian will r. • ■irrec III ease< of typhoid (■all eases in this er most careful (■"iisKJei-ation of all of tl le circiini- 100 rvrunih I i:\i:i:. >t;mrr-, t\|)lini(l t'tvcr liMil liiTii ili:iL:iiii-(il, lull ii|Min |MP-t-mnrt('m fxnm- iiiali'iii <'iil\ llir uiMrral m|>|":ii';iii<'i- "t' a |irci|nunil inliiiidii- (li-rax' williiiul -|)icilic liM-Mli/Mlimi wcrr tnmnl. I 'iirnrliiiialrl\ , -iiili ca-c- wcrc toriiicrK net i xainiinil liai'tcrinlni^icallv . I'n"'! -till Mtiii- In 1)1- waiiliiii;' llial lv|iliiii(| ti\ii- can uiciir uilli im It^inii wliatrscr ill llic ■ra-lni-iiit('~tinal trail iln.aii: any -la;:r d' lln' ili-ra-c Tliis |Mi— iliililN. liM\\(\(r. iiiii-I alway- In' Ihtiic in iniml, ami -iMTal aulliciilic c'a-(- lia\f ixcii i(|Miri(il wlnrc lr-ion> (MnM imt In' I'umikI at anl(i|>-y. liir changes in the mesenteric glands >ian(l in inn-t imi- nialc rclali'iii to tiup-c cf tlic' intc-linc. 'riicy ari' a- (•(in.-taiiliy iniai'iircl a- llir i\ in|iiialic -irnclnrc- nf tiii' iiil(-tinr, and like tlicrii cNliiiiil llic cliaractrr- >>i' inciliillary intiltratinii. in ;:rni'ral ai-o llic locaii/atinii of tlic |ir(icc-> ill tlic iriaii'i- ciirrc-|Minil~ with that cii^loniary for tiic iiito- tiiial h^ioii, so tiiat the ciaiids in tiic lower paitt of the ileiiin. the eeciini, iiiid the adjaeciit parts of the colon are, on the whole, involved nio-t iic- (liieiillv and in lireatc-t de;:ree ; while iho-e in ihe n|i|>eniiii--t [lart of , the small iiite-tine and the lowcrino-t |iart of the lart:<' inte-tiiie more frccnieiillv remain wholly free or are hiit slijihtly iiivolvid. This (orre- siioiidence will naturally not lie i'oiind eoiiiiilete if larjre nnmliers of ea~e^ are studied, ruder e\ee|iti does not liejrin niiieh later than the infiltration of the lympliatie struetnres of the intotiiie. The ^rlands heeome prominent as early as the e.nnmeiieemint oi' the second week, and attain their jrreatest size at the hei-rht of the di-ease. They are then "■'-' M.i.l iMvvMl.nt ,„„.. N,„ ,,,„K '"'"'■;'■'■• " " I"' ''■'' ''>• '' I'-''- -'»■ -ti,.ni„. i„ ,1,.. .i„„|, ■.,-i;i: --y „. ,,,,-.„, i„ null M„.U. ,„. „.„„i,,„ „,,,, . , ^,^„. „,^ ^^^_.^^ ^^^. '"■-'■""'• ''•;-■"<■'"■■' 'M.., „.,v ,i...„ .„„,„,. .„,,„i.„;,,i,,„,,, '"7 '■"""""".'>■ '^"-" 'i"- ...' th.. .lan.l ,„• ..v,.„ ,1... ,.„,i,.„ ,.|„i,, ;'!"';''""r '"'""'."- ^""' '"-'"'-" ^vm ,i„.„ i,.. „„„.,, ,„„,,. .,;„;„,„ ::,;'':":""^ t"'-"":" ^"'""^'"•- •-■• i>.'H;..,ti..L.„a I''""'' ^'■" ^''■ll.■rMl |>..nt,.iiiti- i.iav r.-iilt ^iver and Biliary Passages.- 1, i, ,.,.n.aH,,,,„i,, ...,...„.. w,,;,...;: , , .'■"-.- .n „s >tn,..,„,v, .lis,.,.nnl.|.. ...... ,„a,.n.,.opi allv Tl,,... :; : ;:'r:;'7.'''';'''''':' '••• ipaiN-, ..,...:„.,.'.,.,.;....,. ' P '" "^ 'V'"'"' -''•-■■yi..^ .ii>.in..,M.ss at ,iin;.p..„t .t..,.. .na,.;:::,: '';;;:■' rr^'rrr ;'';■'■"•■""•■" -•'■,-.....,.- .ii..a.. I :„::, ' ""^^ " "'""'' '^-i'^ i-- -"• ti..... ..r ti.e c III ^riiirra I'l iIk' riiid.ll,. and toward the vu,\ of tl„ i . , y Crom til,, snrti.,-,., ,„,„• a,.|„.ars r::r'' ;;::::";':;'• r; -"■-"■v-™s; 'li-"l-iatio„ with ., V 11 1 ■ '"' ''"' '■^"■"f """•'<"<' ••'■ '-li :r: • :,,:■';;;: ;;;; '- •;^'--> ''.-.■■■ pn....atio,. 102 TV I'll' i> I i:\i:i!. — i •-■■»T» . MiilM-c(.|iic i\ai]iiii:ilii.ii dl' tl,,' li--iir nf tlic li\ir di-ddM-. in <'"'''''-|' llllic «illl lllc IV-llll~ ,,l' liiMilii-i Mjpic lAMIIlill.'ltJoll .lIlllM-l liiii'\ci'|ilii.ii;ill\ in llir fc liiili- -l;ii:r, nidic oi- !,— .nlvanccd allriMl ion- in the liv inio tlrl;;IU-. 'I'lic ili^rnc lali\r |i|-nci— ;^cli(i'allv l)c;.rin- al llic liirililiriv <(t tile li\ ci-lnlinlc, ami ranlv atlain> llir -arnc dc^iiv al llif (inl.irMii ill il- tiutlicr |.iM-iV". Al lir-1 llir -niiiilar anrl mil, id cdU can lie clcarrd iip l.y addili I' acrtic arid ; I'lil -nl.-.i|iirMll\ . il' |)i(,Mr,.— iv ,. fat-intillratioii taki- llic |.laic nt' alliiiniimni- ^'I'Miiiilal ion. tlii-will lie |io--iMc III hilt -li-ht il(-ivc. if at all. In ca-.- of .-|Mviall\ -rvciv iiii-ct and Ion- dniali.Mi tlir par. inliMn itoii- dii;iiicTalioii ami the di-in- l"',i:i':ili I iIk' liMi-li-Mic attain -o marked a dcL'ttc that llic or;:aii i)ccoim> diiiiiiii-li(Kl in -i/, , tlahhv , and pale ^ff.i\ i-h-\ i ll(.\\ in .oloi. and i.- tlin- -ii;;;;i-ti\c of llii' condition oh-.ivol in acute \cllo\\ atro|.li\ of the liver. \\a;:llef' doelihed a> a -|ieeitii' feature of t\|ilioid fever the |ir(>encc of >inall, ^icnerally interaeilioiH, ;;ra\ i>li-« liite mKliile- in the li\cr- ti>.-iie, which he dcMiilied a- accniniilat ion- of l\iii|ihoid cell-, ,ind con-idcred :iiialoM,,n- to the lynijihoid hy |ier|ila-:a <'i' the inle-tinal iollicle- and the -imilarly eon-titnted iiodiili- of the |peritonenin. Iloti'inanri oli-ei\ed llie-e liirrnation- in .".S o|' •_'.",(! ca-i-, lint he lielieved them to lie actually >till more eomnion. Later examiiiatinns, however, lia\c not >howii them to he [leciiliar to ly|ihoid fe\ er. a- thcv have heeii oh-erved in other ilileetioii- di-ea-e- al-o. IJeed.' tVolil a >tiidy ot' tlie-e -o-ealled lyiii|tlioiil nodule-, concluded that the\ are not c(im|)o-ed of lyin|ihoid cell-, lint that in the earlier -ta^c- the ahiindanf tiiielii |ire-eiit ari-e in le— er |iart from the di-iiite^rnili 'I' mili — pace- and ve— el- aroinid till' portal vi-.-el-i, and i- due to the action of the toxin ; tin- oiIk r is due to the ".-M iIm. ..v,.l,„i.|-l,.,.i||u, an.l ,|„... ana. T|,., ,.|,,n„,.,,. .,,• Il"' I.Nr r.,nv-|.,„Ml~ «i,|, ,l„.,A„„Hv. .Iian..., i„ ,|„. |,,,n.,„l,x ,..a ..f ''"' ''''•'■• ^""' ''"- -■'■I'""", in -■ nHli-,i„r,i,,„ |,,„„ ,|,ai in .,tl„r •"•"I.. M,t,,„„„- .1,.,,-.., i, .,.M...allv Ii.|„ i„ ..„|„, „„| |i,„|,i,, 1,^ -|"..li.' .^laMU ,- |„,w,...„ KMO a.Ml luhi. ,. ,.,„„,.an..| will, IV,,,,, '"-'' "' '"•"' '""''■'• "i'li":iO ,..,n,iiti,„„ ||!,„i,a..l,.|). MiMl, |,..s ";"''"";^- ^" '^ ""■ '"'••• ''"• "-'^ ■ i" 'M'iMo nv.r, i, i, vi.Ml ami (lark. <;'■<•" iMNHM lias .v-vntly l„.,.„ a.,,-a.t,.,| „. ,|,., MUatonn- alterations ". Ili.' lar.,. I„liarv ,,a.,:,^,.,. | 1,..,,,^^ an,! ,v..n .li|,l„|,..n,. uy,n-,^.,^ '" "", "^'" "'■ ^^'I'-l'l-M-' -,.| ,1,.. L,,.... Lilian ,.a>.ap., with -.-M.laiv ,l,.Mn,,.,i,,n an,| al,.......- in , I,,, li., ,,,,.,.,,,, ;;,,.,iv,, ,,,,H,,,„i,is, "' '"■'■; '' '"■•" ■''■-""•'' -^ -■'■' unvn,.,.- ,An.lnl. I..ni„ ;''■';";■'■• ■'"•''<. l;<.l.itan,kv, an,| ,„|„.,., AH..,- < .ill-rt an.l ( lin.l.. ' ';■■"' '"■~' ''" ~"-^"'^' 'M'l".i.l-I.a,illi iMti„.;:all-l,la.M,r,(|,iari-.|,„w..,l "':" ""•—•;• I— ^ in rl„. Lilian- ,.a-s,..., w,.,v in p„..,„| ,,,., I-M.,,.k,,,,|,,.. ,.,,,,,,,,.,,,,,,,,., ,,,,,^. ,,,,.. ,,^„,„,,, ,;„.„.,„, 'l-^nll-MnM,.,-. II,. wa. al.l,. .,. ,l,.n,on-„.,„. ,|„. l,a,.i|li in" -.. ,.f •'•> ^'Nt..,.H,.>. Nnnlar„l,..,vati„n~ u,,-.. rna,|,. I,v l;ir.l,-Hir<,.|,(;.!,|.' w|,„ i„ ;'"''■'"""' "'"' ''''i-i ■"■''"''- <'-t .1- ^all-l.la.M.T ,,rol.al.lv ..n^ti- ""'■-="•""" '•""' m,i,.,i-tani > •,.,• f,,,- ivinllvtiun ''' -''li'-'' '-ii-'t -..--..,,(•, I,.. ,,|,.,,,,n,„ ,,,,„..„,.,„,,, ,^,_„^^^ y- '""^'^"^ "' ""■ -'"■'• li"^- l-I-ti.' pa.vn,.|,vn,a, al f ,1;. '"■'■'''^'•■'^''•'"■■^'^'■^'''■'^l''''-''--Mn,l..,-.,,|,,.,. .,|i,i,.„. ,,.„ -P .. .n, ,an.tv,|,|i,i. F,,,- a n,..,... .|..,i| |....,,!ti,.n .:,• I i; ;;': ''''''^ '■'■''•'•'■'';r .'->■'-'•'■-''■'■• •! h-.-m ,.a,t „,' ,i.is w,.,.,. ,. •■- .n-.wn ,.|,n„.al ..,,„,„. - an.l ,1,,.,. „,•„„,.,,.,,,..,, .,^ ^^l Changes in the pancreas a,v n„.n,i„n,.| l.v f,.. writ..,., .,„ '"■'"'•'•"■"■'■ '" ""'"-' ■'■-•^--.nt. an.i .,,,..,vn.ia of tl. .:;: ill y.ri,ri,„.-i,.i,,,.,ti,. .I,,,,/. jAuir.' iM. ii., s. (;n4. /''■ Mi.rh., iininis,,. (idttirifrc!!, 17i;l'. )■,.. ;.">'■ M^- m inl TV I'll' >i II 1 1 \i:i: il,. I,...li,- ..r t!i.r-, A, mI ..!' f. |i!i. i.! u \, 1. Il.irniMnii' w:i< f!ir fir-t to i|i\ir|r iiMilllloli |riit iiiiLilU I'l llii' iMihTci-, Mini lie (il(-(l\ I'd ('li:iiii;c ~ -iiiilLir til lliM-c ill ilii' -;ili\ji\ L^laiiil- n iiiiiiiiir willi i nii-iili r;ilili' refill. iiil\ . Ill iIh lii-l |i( ili'ii liiicrM-i'djiii' I'MiiiiiiiitiMii llirri'will III' iMiiiid i|il:it,iti<>ii ami nv ii lilliiiL'^ 111' till' -iii;iili I' :nii| -lii:illi'-t \i'--rl-, uilli -ii'i.,,- iiitilti';ili I' tin' •.iiljiirciil. -lill-iiitai'l ]iaiiiii li\ iiiii. Ill iIh' l:itir -Ia;:i-- llir |iaiirrca-, wliiili al (ii-t \\a- riiiai'L'i d. Imiihih'- di-ruli hi d and |nt-i'iil-- a L'l'avi-li- \i'lli.« 111' I'Mii L:r:i\ i-li-lii''i\\ II a|i|H'araiii r. Tnuard llir riid nl' llii' allai k ill!' |iaiirri'as au':iiii iM'ri.iiic^ diiiiiiii-liiHl in -i/i'. and iipmi i'iiin|>li'tr rri'iiMTV aiijiiii'i'' il- iiMi'inal ciiii-i-li ini' ami nilm. In the srrund -la^rc the inriia-r in tiir -i/r o|' tlir l'ImihI a|i]M'ar'- In lir dr|irlidint n|Hin iiilari^i'iiiriil. iiiiilli|iliralion, and arli\r ili\ i-imi ot tl'r rrll-, ami llic di-i'ciliu'atiiili ii|MPii allpiliniiinil — t'altv di'^iiin-alii'ii. HEART AND VASCULAR SYSTEM. Lillli' i- UniixMi riiiininiiiLr tlir aiiatuinir I'liiidili'pn nl' tlir invoranliniii in llir i iiial ami llii' tir-l llliiili' -la'.^c mi aciuniil of llic larily dl'dralli at tiii- |H I'iiiii. ( iriH'ialK , llir >i/r. riin-i-lrni'\, and riiioi' 111' tile niMirar- diimi ari' dc-ri'ilird a- nmnial, altlinii'^li. cxiii in rarlv -ta;;!'-, im-rca-rd fVialiilitv. tlaliliiiu'--, dilatalion, (-|Hiialiy "t' tlir i-ij.dil liall' nl' tlii' lic:irt, and di-ciilnniii'in 111' till lirai't-iniiM'lf lin\r "ftcn Imi'Ii niriiiiuiiiil. Tlic-c cnndilidii- aliii">l fnii-tantlv unnr in 'lir Iniulit ot' llic di-ra-e and tlic snii~ri|nrnl ci'iirx' of tlir rrlirilc rtaiir. Tlii- \va- kmiwii alrrady to carlii'i' iili-i'r\ (I-. I-ainmr -' >|ii'ak- ol' '• Mit'trniiii;- " ol' the licaft. with violet iir lirii\Mii-li-vi'llii\\ di-rnlnratiiin. Siili-i'(|iii'nllv. Luni-, Stuko, and ilokitaii-kv iravr di'-i'ri|ilinii- ut' llir iiiacrii-cii|iir cliai!^''!'- in tin' licart-iiiii-cli' at llie Iniirlit nl' tlie attack ut' typliuid t\\v\- that at till' prr-iiit dav ai'r -till ciin-idiTcd iiiudrl-. Nalni'iilK, tlir-c uIimtn rr- wcri' nnalilc In advaiiri' inatrriallv tlw rliniral riiin|)i'rlnii-iiin "t thi'-c mndilinii-. It i- onlv within iTcriit liiiii'- that a rlrai iii-iulit iiitu tlir natiirr "(' tlir t'liiii-tiiiiial di-tiirliain'i-- '4' tlii' Inart in «'!i.«c.- nt" t\'|)hiiid t'i'M r ha- limi nliiaiiii'd a^ tin' rr-nlt ut' a lai'L'''' iiiiinlicr iif valiialih' -tiidic- ut' llii' hi-tuluuif rhatiL'i'- in tlif iiiyurardiiiin. At tirst, nr.diT thi' lradri'-hi|) u|' N'irrhuw," a nniiiliir ut' |iari'nrliyiiialun< cliiiiiircs and cun-iTiitivc rr;:i'ni'rati\ r |)ruri--i'- wi'iv c-talili-lird liy ' f.ur. cit.. (1. I'.il ,/ s,;i. ' Trait,' ill- rn„K.-„l/.it.,,ii hii'./i.it.-. -, iid .'.litio?,. I'-'jr,. ■'Sop thi' tarinni-; jirtifl'' ujion ]i;ir"'iu'ltyiii;it.'U- iii;i:iiiitn:iti"n in Vn-rhnv' -< Ari'lih\ \M iv. — — =,- J.-- « J- *J- --- /• I I ll'iln,, ) 105 ^§ i "■'"'"'■'' ^••"'^"■' ^\^'l'l'--. Il.'lln. .• ll.u.,n,'a,H|„f|„.r<, fowl.;, I, "■'- -"'-'l".M.K a,l,l,.,l a I .I,.,|„.„, „„.r-,„i.,l M,.l,„„M,:„„n ,„■„,- .■---, (,.-! .,Hl„al..l l,N ll;n,.,M. a,„! ,v,.,.,„K i.ui.mmIU .,h,,n,,,| |,s liiillllirri.'^.' •^ "- ''" ['••"■-■ii.liyiMMi.,,,- -ih, r..ti..ns,<...n«i.lii iii.M, ~1„.mM Im .Nvm '-|"-l:llK t., ;,ll,u,„i,„,i,| -nUMllali.m. I...- ,.,, „,.,„„,. , -|.....i;.||v ,„",,„„ "■"■'•'' ""'' '"I"-- ir>li.t,.,N. ,li-...„.,, ;.,, ,;,, in~t.u,.-,,,li|,|„l„.,.,. ,|;,„„. I'.r,,, ta,u. a„.| i„ i-„la,..,l ,„..- |^alin,•, uaxv ,|,..,.,„.nu ,..„ I,av,. I,.,,, •■'-'■'^■■■I. Ina.Mili,,,,. .I,..,v ,- ivinarUaU,. -nlar;;,.,,,, nt ..f ,|,.. ,H,..|..i '" '!"■ '"'"I "' il-nv.ili..u ,,r ,li-i..Mli..ii ali.K.-, .■n,„,a,itK al lr,.| i„ |"lnll>, "ill, almn.lanr ,|,.|„Mti„M „f ,,i.„M.„t in .l„ir vi.ini.v ,Ko,„- 1-^r,. II'".'.,,..!..-.!!,,.,, ,|„,„„.,,,,.„,^..„.,,,,i,,„^, ^,„., ,^,. ^.^^;.^^^l^^^^^^^^ ^""' ^' l"'"l,ar,.|,anu.. in tl„. lo,,,, „f ,„„>„.,•,.„- ,,an-v,.,-.. ,..ar.-„.v.. -.n ,„. ...M,.,„a„v ,|;,.„anl.i-„|,i,.|, 1,„„.,,,„, , „„ |;„,.Ui„.|,,„.,„ /.mLt, an.l ,v,.,.n,K aU, I: l,,.. a,- ,|., ,.| , „,,,..,,., .j |iii«liii't-. '" ■'•I- l'^"'n;l.vmarnu. al,..nHi,,n. Iku. Im.,.m i;,nnJ in l,.arN ,nv-,.nliM.. ' •' ■"l"-l^|i"l'•-l-'^■■.--ll:.-in,l ,l,a, .n„„,l,..ir..x„.n.:i ;'';'";"' ';; ';'■ '•-•— -1 ,. ,„,„ i„,„. ,.,,,,„,;„„.,, "' ''"■ "'.--^"■''""" 'I'MM i„ ,i„. ,ni,l,ll,. lav,.,-. u|,i,.l, |,ow..v,.,- ^;': T^""" -"'-'''-'"'-'i .-.i„„.MK 1,;.,.^, x,„ ,,„, • ";;■'; ""■'"'■'"'■''^'"^" l-n,v. an.l , .li„i,.aUv,„p, , '■"""'• '^' ■■'^'•:^'^'- "'•''■•'-■■"■■'"■ iM..TMi,ial,;,v,„.a,.,li,i..„,,i,., :;:::;^:;;;''f '■':':''■' •-■ i.i^--i-...n,„..i... ,„ .1.11,1,.,.. ■"'""" ■"- ' " '''-■'• 1 I'.v |-n„,.|, „,,„,,,,,. ,„,,,,„ ^,.„.,.,, :;; ;p"" -;[ '■'■' ■'•• ■ ' i;i c.t' the I'dliiliir elements of llie iiitliii.i '<( tin- -mallii- .iil< lit-, wliirli :i- a it -nil -iitVi r eiiii-itltnilile tliifkeiiin^- nt' tliiir wall- aiitl iiarinw Iiil; tif tlieii' liiiiieii. Ivomlierjr lia- Iteeii aMf 111 vfiil's llit-f iili-ti'vatiiiii- imlv in i-njatet! iiislanfe^, anil tlitreti'Te witli ;;iK'! rea-nii f\|ire>-es (iinilit a- tti their tVei|iient\ Miitl i^fiiti'al .-it;nitifaiiit'. S.i lar a- i- kntiwn, the inliamniatdrv iinx't-s lAIiiitl- in -nth a ua\ that litiih the riulil anil llie lel'l -itie- nl' the heai't are iiiMiKtil, the latter uenerallv in niTiiirr ile<;i'ee anil I'rei- efiihlv at the a|ie\ ami the ha-e. Ktmiliert: wi- alile tti ilenmn- strate that the in\ neavtlili- t'iti|iientlv iiii;:iiiatetl iVmii similar intlani- niatiir\ |n'iiee— e- tii' the (\i-eeral| ]ieiieanlinni ami the emlneariliiini. As elinieal i \|ierieme al-ti -liii\\>, the iiitei--lilial niyinai'iliti> aiijiear- in a iiiaiiir''s ut' ea-t- tn nmli I'^rn etunpleie iiixnlntinn, witlmnt lea\ int:' i'lnie- tiitnal til' aiialtiiiiie ili-tiiilianee- in the inyneariliiini. In rare iiislaiiee- (vipii I^evilen. iidinliert; | |>ei-nianent tihrniil ehani;e can jimlialily he (leiiiensti-aleil. Whether al i-ees- i it' the hear' may lie a result has nut lieell ileimili-traleil. In idiilraili-timtioii tVnin ntlier iiiteetiims lii-ea-e-, endocarditis, esiieeiallv that iii\i>l\ in^ the valves ami teriniiialin'; in \al\iilar li-i(in> iif the liearl. i- eMlvniely rare. \'ei;etati\e iir llleentive emhieaiilili- al-11 'oiiii r for which coii-i-t- ill a di ii-e network of -mall vein- and eapillarie- in till- -iiiiatioii. i- pre-ent more freipieiitly in the depth ot the \ i-eeral laver of the pericardium, at the innction lictwccii it ami the -iiperti- eial laver- of the iii\ ocardiiiiii. Tlii- inllamniatory proce— al-o extends iireli'ialilv deepK into the mvocardinm and rarely towanl the -nrtace ot the pericardium. (Iro— form- of pericarditis, with lihii - de|)o-il- or f'lid inllanimatory ctTii-ioii. apfweeialile niaero-co|)i(ally and i,ri\ inir ri-e to clinical matiiti-tation-. i-. TieeordiiiLdy. (jtiite exceptional. In ' Sri' til'- ;i|i|.rM|iriii|i> -■■1 lii'iriii ihr ilini. :il |.urt. PATIIOLOOY. i-.lMt.-d in^tancs. it is trii,., I |,av.. Cm,,.! fihriimus .|,.,,.,si,s upun tl... l'«n.ani„„n, ,„ a.->u..iati„M wi,|, .•,.,M,.ii..atiM^r cT.,u|,nus i..u...tn..nia, ainl iM a tru ,M>tan,r^ |.unil,..,t |„.ri,aniili> as a |.a.t inaniflstation .,f ,■„„,- |ilis,.|s, Mltl..,,.-!. ivs, >il,I,. (I,,.;, ,„„„|„., "t n..t ii.i,„rmn.,n .liuicMl inanif-.^iations. |,av.. as vt n.,t h.m tiior- niiirlily st(Mli..l. Th,. veins aiv in.,iv rrv.|.u.ntly aiUvf.l tl.an tiir art,- n<-. Tv|,l„,i,l ,,!,i,.|,i,i, a|.|M.ars m l». tlic iiM.al ••auM' fur i.hi,.,.iuaH'i ^'11'^' 'l"l„.,y „f ai-tcTitis is ,„ al.ly r,.s,,„n>ii.l,. C,,- sp„Mtan.„us jr...,-,,,,,. „f tl.- ..xfvnuti,-. whirl,, i;.rt„Mat,.|y, is ra.v. Tl.,. aMat,.,„ic ah..n,ti„„s ti.at tak.. |,!a,.,. aiv .-....-i,!,.,.,,! i„ ,|,,,:,ii ii. a lat,.,- >,.,.,i,„.. t.M.,.,lu,. wi,|, tl... .•l...,.al ...a.,iti.stati.msj |„ ,|,.. s.n.,. s.vti,,., will I,,. (;.„„,l a .•..„.- l.l.t,. .l,.-,.,.,|,t.,.„ „f the Stat,, ofth,. i,l,„Hl in «...e.s ol" ty,.h„i,I lever. THE SPLEEN. In its lu.|.avi„r th,. .,,],.,.„ i> ,.„„,,,a,,,I,I,. essi.ntiallv t.. P-.v^r". I-t-he~ a„.i ,h,. i;,liie!,s „f ,1... int,.stiMe = the nu..,.nt..rie ,lan,K -.!«• the... ,t „ ain.o.t always swollen at tl„. ...,„,n„.n,.,.„....,t an,l at the l."|.'l.t of th,. ,li,..a>,.. In any ..v...„, al.,...,... of ..,.la.-K..,n,.nt of the >|.le,.., at tl... ,,e,.io,l i„ v.M.tl.f.,1 a.,,1 ol,|..,. in.livi.lnals „n,h.r the am> of .|.-ty-.,ve yea.s is n.o^t ,.x..,.,,tional. A,.a,t tn,... a (i.w .-a. .s in,.xpli,.a- 'I" '" tins ,.onn,.,.„o„. it a,.,„.a,-s to l„. wa,.tinj, onlv aft,.r ant,r..h.nt ■iMa-e ot ,h,. ..,.,„. ^i,i„j, ,,;,,, j„ ,„„,i.|,„„,,,„ ^,„,, ,^,_.^.^,^,^^j ,hi..k.,„in. '" .t~ ..a,M,l,. or ,in„ hyperplasia of its sfo.na ( Ilofr.nan,.,. an.l th,.,-,.|,v |»n..a,..„,ly .|,.,n,yin^ it> ,li.t,.,.Mhility.^ ,n ,.|.le,.lv ,„„,.,„. .,,,i^ ;;;-|'l.->f th.. .ph.n at tin,,.. p....v,.n,s the oee,.,.,.en,.;.of t.,n...f,..ti,>n. ■ri I , , ' ■ . ..I HIM-,- oi ii.n.eiai.tloi lu. ..n!a,^..n.....t.,t the .pi,.,., i. ,,.o.t n,a,-l<..,l at the l.,.i.htof the i;.|.,-i,e p.;r.', winl,. at the ,.o„,n„.n,...,„..nt of thi. sta<:.. a„.I in in.livi.lnals ,lvin. ; the sta,.. o, .lefl.rves,.,.n.... i,. voh.n.,. i. not n,a.-k..llv in...... a...l: • -l-^.n,..nt o, the sple,.n i" typhoi,! f;.v,.r i. h. ...nen.l not v,.,.v -.1-^l.ie. \\ h,.n the sw..|Ii,,, i- a, its .,.,.a,...,. the ..r^.„ ,,.av 1. :;;■";• ""■"•*• '';"-'>-• a „-..at..r .l,.,. f enla,.,..n„.nt is -;-.,. V .„..., an, ,v..n ..nla.^.......n, to th.i.... ,1,.. .n,al is .li>p... ;'■''''''''■''•■';•''''''•'',-••'-'• "-t an.l a half tin,... or tlvi..e ^n^ .1... n„.a.„,.,.n,...,ts of the spl,..„ i,, ns f,eal ...... of nphoi.l ' ^''|. ill.- iliiii.iil ifi'tii,,!. ';i':'.M,'\h:.'::::;r,;;: x:zi t;;:"', 7"-t"' • -^"--f-i«^.e,„entof ..11 Aiiuly^,, ,,t till. Iiid.vidiiiil Syiii|it.iiiis. I^^^'^ffifl 108 TYfiKiih ii:vi:r. I)| UA1 ION <>i iiii; U,rk. 10 11 l:; 11 ir, •JH 81 Total I'- ll 1." 11 48 1 51 1 1 1 1 1 43 21 14 Tile caiix' lit' the tiihir^ciiu'iit nf tlic --ijlct'ii i> ti> lie atti'iliiitiHl to two main tnctor: (licrpla>ia of tlic tissue. It' o|i|)ortiiiiitv !)(' atf'onlcd to examine tlie spleen from the middle of tlie tir-t to the middle of the -eeond week, the or<_''an a]i])ears smootii and tense, npon -(Htion dark red in color, extremely hloodx , with an indellnite ontlint . Toward the end of the second and in die third week the oriran, \\iiie!i has hecome still laruvr. is softer, at times dark l)rowni~h revith it in considendile amonnt the mnshy. ditHncnt splenic pnlp. ^\'ith the advent of dcferx'e-ceni'c the sjilecii underiioes relatively r.ipid diminu- tion ill size. The previously di-teiideil eajisnle hecomes relaxed and wrinkleil, and the hxperemia >uli-ides, xvhili' the hyperplasia, especially that of the -tronia, |)er~i-ts. The-e chanp's result in a lijihter color, the tran-verse -ection preseiitiiiL^ a \ I'llowi-h-red a|)|)earaiice, at times vell -uch, I)oul)tless, old di>colored and softened infarcts '^m m^t§^>-2 Wf^mmt^^-^^ *l»7=i m ^] '.'^Kb^ii k7«S31 I'ATlloi.ixiY. Mf) liaw l,c..M in.'lii(I.K| hi xhU .l..Mri,,ii„„ Tli, tn,.. al.xvss.s ,.f tlir >|,l,.,.n ■aU' mi>|h.:,iim |,Mi-t t.MVMilt from infiuviiun (.l.nii.r, II..tl:nann, I.,m.Im). Olh.r- Miv M pan iiuiiiCc^tation uf -..ii.n.l Mj.-i-.. H,,,!, indnvt. and al.-.r-(- Miay ni|.Iiiiv i„t.> tlic alMlominal cavils ami -iv.. n>,.(,, uci.Tal, 111 more tavdiiil)!,' ca-,- ciiviiiiiMTil.cl. pcrituiiiii-. S,iiu' ca.-o of •• -|,„ii- taiirun^- n,,,t;iivof i|,r ,.x....-hv,.1.v .IU.-ihI.-I >,,1,,.|i, f,ll,.,l with l,loo,i. at the height ,,f an r\r,.,.,liM-l,v -cvciv attack of tvph.pi,! fcvcr aiv al~o '•'■''•'■'■'■'' '" i" 'li'' litcraliMV (l,ncl,l. I,cii,l,t). AhlioMu-h Mich cax- aiv aiuono. ,|„. ran. ,.v,-c|,tinn~. aii.l cad, i„-taiicc i- t,, I,., ac.vptcd with irrcat rc-,.rvati they certainly cannot l,c entirely iirnore,! in view of the extreme teii-iori, -,,ftn(--, an.l att..imation of the ca|Milc, Mich as (Hcin- in that or^an in severe and i.rotracted ca-cs. The liner altcnitions in the -plccn, which hive l)een alrea.lv ,]cMail„^I hy immeio,,, olwervr-. ,.~pe,ially liillroth ' and Bircl.-Hirsehfcld,-' arc nlat..|, a^ i- known at the prcent day. in,,M intiinatciv to tlic inva^ion "'' 'I l•L^ln i.y the lyphoid-haeilli. which diiriiiir the felirile sta^^e of 0^-. the di-ca-c are (|iiite con-taiitlv |>iv-eiit in tlii- orj:an in ahiiiidanc^ and in piriiliar arraiiL^emeiit. 'I'hev are ,|i-tril)Mted throii-hont the orjraii ^\~u*^\! ill the tlirin of innnnieralde irrc-rn- larly arraiiired jr, |„, ;„ whicli the liacilli lie so cl,„e too-cthcr that in -tamed -cetions th,y ajipcar a> dark, ai|ne spots, at the |)cripliery of which individual hacilli may \ie rcco^-iii/alilc (Fijr. 7). Ill other respects the liist.ilojric alterations are in ^ren. nd scsircciv Fi.i. 7.-si.,.tinn ,.f tt„. si.i.e,,. .h, ,., •liff'Tcnt from those of the acute '•"•""i'^ -f typhni,i.b,„iiii. 1- —larly with ..verdistenti„n of the cavernous veins of 't L pulp ■'-iwuh ,i..thera.Ivai.ee in tlu. tnorhid p,.ce.s, tnost active hJpei; •'';;;'^' ;' ""■ ■"■l'""-- -I--.ts of the splec, and of the stmma, together V ' / \ with til ol* Mtl ill '■ ^'PI'''''n.n..e of th.wc larp. cells (phairocvto, eontainiiiir ,,.1 """ '■•■"^'•''•- "'"'•'' ■•'■'•""fly I'^'V" M...,i.in.l such ..reat tlu'-oretic ''""'"' • ''"'"■ -ij-'"i*i<'=i"'" of inrtaniuiatorv-cha.ifresin the Miidler I V-r,'hnu-'s .\rr},)v. H.I. vNiii. 11(1 TYi'iinii) ri:\i:n. &ii:r-: :irl(|-ics 111' the -|ilc<'n, to wliicli l'"rcii('li iiivotiLiitoi's ojh cially liavc ilirt'ctrd att<'riti(iii (Sirtilcvj, \\\\> not as vet Ikcii .-iilliciciitiv otabli.-lied. ALTERATIONS IN THE URINARY ORGANS. A|>art iVoiii the rari' ra-t> in which (hath take- ]ilacr in th.' carlv stairc" 'it' ty|ihoiil t'r\cr, tlic kiihicv- i^iinrallv cxhiitit nmri' or h-s niarkcfl alterations a|>|ii((ialih' to the naked e\ c, which arc coni|iaralih' to those in otiier [larcnchyniatous or^raiis, es|iccialls- the li\(T. At the Ix'iiiiniin;.'' or the middle ot the second week tiie kidne\> ai'e usnaliv still of noianal -i/e or Iml -iii;htl\ enlarLieiJ, n^iialh L:reall\ rcddeneil n|Min their cMernal a~|iiet, njion -eeijon niarkeli tint, while the |i\rainiiU tor a time retain their dark-red color, with the exception of the papilla', w lii<'li soon aci|nire ;i \'ellowi>h ap|icarance. After a lon^ and >evcre attack of' fe\-er, e^peeiallv in protraetid ease>, the kidnexs »nlisei|nentl\' lie<-ome ^maller. flalihier. and often liiihtcr in cokir, in the same wav as has heen mentioned with rei.''ard to the liver. The diminntion in >i/e ^^cncralK takes jilace at the expense of the cortex, which now a|)pcars smaller, an iireon^ -wcllinir, lieconu' tilled with -mailer and larj^cr t!it-i:lol)nle-. finalK di-intcLTate, and thn-. to^ritlier with iiinnmerahlc h\alini' and Liramilar tnlie-ca-l». oftiii oicliidi' the nrinitirons tuhnles for a con-i'leraMe distance, 'i'lie cells are then pre-ent constantly also in the 'loii'ly tlnid that can at this timi' lie expressed from the apii'cs of the papilla'. Till' parei.chymatoM- dcL''' ■Herat ion almo-I always hei^dns, as can 111' di-tintrni-hi'i| with the nakeil eye. in the cortical strnctnre. and onl\- later, and often not in e(|nal d'nfre''. 1- the mednllary strnelnii' also in\ 'lived. The alteration- ik-crilicd ha\c lucn n Lrni/''il tiir a eonsideralili' time, at least maci'n-copicallv, as part manilt-tation- in cases of tyjihoiil fever of' miiderate and of scvtTe course. (irciror\ ' and iiaycr-have I i:.l,„l, M..I .}..„,■.. IKII. ^ M,l.,.l\fs,l,'» ,:,,,.■<. 1S40. r-T :--.-- -fl Til — TU «i - -»- ^' l'.\rWil.i)i;Y. Ill nr.nv,! to !l,is cniiditio!! in rui,i,rril,,n with ili.rij,. MiiiiiiiiitiMnM, .'m.j ll.-lliiMMii ' :m.i K. \VMj.rii,T,- ii|H..i tli<. I.M>i> „t' , xt.n>ivc -t;iti-ti(>,'hav,. • ii.cii-M.I it ill :in .xliMilstivf maiiii.T. In v.m- .a^rs tlir .liaficrc^" n„.„- tioiM.I ,],, nut |,r..c.v.l Im;,.!,,! tJii, Miif,^ ; l,iit, un i!„. cij,,.,- hand, .■jini- .•ally u, ll-,l,tiiir(l cMiililioiis of a.iitc iicpliiiti- al-., .„viir. 'r|„,,, ,„,,v :i|i|H'ar raHv. in the mi.l.llr .,f tlic >..,-.„m1. ov.h at lli.. iiul ,,t' tlic til-"t \\vv\s, aii.l tli.v may .L.tiiinatc tli.' i-linical pictiiiv to mu-Ii a ilc-nv that Fiviich ..l.-,.rvci-s ,-c|>,rially havr tMl jiistili,.! in a|.|.lyinir ,,, siirh ,,,m..s ''"■'''-'^'"■"' plirotvpli.n,!.' 'riuanatonii, |.i,tiiiv ,,f tv|,|i,,i,| n,.,,h- rili> i- irriMnilly that ,.f acute i.ar<.n,.h_vni il,,ii- hrinon-hai;ir iiitla.iniia- tion. ii~iiaik \Nith -nlM.nlinalc iiivoivrinnit of thr iiit.T-litial li~Mic. Wa-iHi'a.i,! NMi, K,rklini;han>,M -■ liavc .•all...! attention to a iHcnliar variety of iiepiniti^ atteii,|,.,| with niiin.i niiliarv. intei titial, pnfii- lv.it lo,.i.«hieh in raiv ea~e-, a- I have niyMJf ol,..,-ve.| in one in'>ta , may eoale.-.v into al,Mr-es varying in .i/,. f,,„n that of a Lean t that "' '•' "' "■ '^'"" IJ-'Min-haiiHii had alna.lv attfii,nt...l this alVction '" '■'"'"''' "'■"'■'■'• •'■'■• -^t '!"• I'lvx'nt .lav th.r,. i> >eaivelv anv ,|,,nl,t '''^" ''"■ '" ''"" i- ii'M'Tally of M.,,tie ori^rin. liou,.ver. ea~e< of ""''"!'''■ ='''^''<-^'- i" til'' Mdney. ,ln,. ,o the aeti f ,h,. tv,,|„,i,j- I'.naPii-. may oeenr. a- in tii,- ,.a>e ivporte.! I,v Flexiier." in wliiel, there "^i- a .y|,ho„| .e|,tieeinia with toeal ah-ee~~e> in tlie iu.ln..v, from « hieh tile ty|.iioi(l-l,arinn~ was iM,iate.| in pure enitiiiv. I" '"le ease I ha.l th.^ op,«,rti.nily „\- examininjr ,]„. ki.l,,,.,,. f,,,,,, ., "i:iM dead after m niptoni- .,f pure heiii,,ir|,,j,ini,ria. The or-an- were „f nofinal sixe.dark sepia-i.rown in eo|,„.,aiid iinns„allv hanl.' ()„ s,,.,i„n tln_ .■'..•lex nas.lirty hrowni^h i^ray, the pyia.nidal tissi... ,lark l.rnwnisl, >■'■''. .'Mio.t Idaek. The lena! epith,.linm. I.oth in the eorfx an.l in the ""■''Hilary ti~~i,e. was in a Mate of alhiiminoii-taltv elondir,.. an.l ,ii,- iM|"^nited. and the eonvoi,„...| and >trainh, nrinillrons tnUles were IdI'd wirl, masses of l,rounish-r,.|, .lisUtmij: iiemodol.in tnlH.-.,i.ts an.l naki>. A^ in th,. liver, Wajrn.T l,a< ...■.■asi,„ially ,I,.monMral,..l in tl,.. ki.ln..v ■'- >h,. pr.s,,„r of Miiall ,.rav Ivmphonialous „.,dnl,.s. wliLO, .h.v,|.,;, ^'l;"o., ..x..lnMv..lv in th,. ,.or,i,.al tisMi.. in the ininie.liat,. vi.-initv ..f ;;"'";!'■"•"'■'-• "'■tlmannlia~ol,..rv...l tla.n half as Ireipu-ntlv as in till' Jivi'r. ' /....•^ .-it. \ f^'" ■"' """■"■■"■'■ ■'■:■ spr,.;rlln. /'„//,„/,,,;, |i,| j, . ;, \„f ' i.nr. ,;l. |>"rli- .. I)i-iiir-lii tl.. I Th •11 !)).■ IVirt ..r ti,, V.r/,a,„ir ,1 <■( I'nih. "/ /.V,-/.. \> :i"i. V..1, ii -./. (irs,-//..,-/,. ;. n„r:/„ ■//. 1871. m^u 1 1 -J 7 1 riiniii I i:\i:i:. Iniiinl- lit" tiic ki(liii\- iiri' iiliMiMil i:ml\, 1 Intl'iii.iiiii liaviiij,' iMunil tlii'iii III liiiK- ill "JMI :mlii|)-i<'>. 'I'lir ;ill< nilicill- 111 till- irinaiuiirr uf llir iiriii:ii-y IIMi-l MI'i' ixlniiirly tmniiii II :i^ ( i|);nril witli tliii>i' ill llir kiiiiiry-. 1 liavr ill :i iiiiiiilur lit' iii-tMiiccH i.liMrviii iiiiiliniKiii- liriiicirrli:i;^i'> nt' ciiii^iiii-ralilc aiiiuiiiil ill- iiiiiiHTciiH siiialiri- ixtrava-aliuii- of Mnod in tlir iiiiirnu- niiiiiliraiif of liic \h\\U o|' llic kidiicv, a> llirv lia\r lii'i-ii ili-i rilicil liv I.oui- ami liavri-. I'linitcnt [iNclili-, wiiicli ai-o i~ inciitioiinl in tlii' iili ratiirr. 1 have never I necdintered. Tile iniicoii- nienii)raiie of llie ui-et i~ rarely altcnd. here anil lliere -mall 1m niorrliai:!- are oee i-ionally -inn. 'I'lie iirinarv lilailder like\\i-e exliiiiits more or lo- e\teii>ive Ik rrlia^i' into the niiii'ou- niemhrane only in rare easo. At tiini's tljoe are associated with calarrhal state-, or even •■ di]ilitliei'ie " destruction of the mil |s iiicinKraiic. (Jiiile e\ce|itioiially the latter ^dves rise to ]ilii.';;nioiioiis inllaniinatioii of the wall of the liladder, with |)ertonitioii ;ilid jieritoiiitis. Tile urine of ty|iiioid |iatients may contain very larL^c nnmliers of tv]ilioid-iiacilli without t:i\iiiir rise to syni|)toiiis or si^iiis uf an associated cNstitis. ]-'re(|iicntly, -iieli mine contains a lari^fr or smaller niimher of pns-cells, lint it is not iine nioii for typhoid urines not so inlecleil to contain a few piis-cclls. To the condition of ty|ilioid-liacilli in the nriiic without associated cystitis the term •• lii.cllluria " has liecn nivcii. Tiiis occurs in "J'l to '■)'> per cent, of all ca-es of lyphoid fever. It is diltieiilt, however, to dniw a sharp line lietwtcii the cases of liacillnria and those of true cystitis. The presence oi' a cystitis at auto]isy is a llirc occurrenec. It is |>rol)al(le, as llortoii Sniilli' siijiecsts, that a liacillnria olilv jrives rise to a cystitis wlieii tlier -curs inarkinl retention, or if the liladder-walls should lie daina^retl in any way. Vounj.'-' has rc|iurtc»l a most intcrestiiiir ease of chronic cystitis, due to the typlioiil-liaeilliis, persistinjr seven year- after the attack of fever. He has collected from the litei-.itnre two other similar ease-, ha\iiij:, however, a shorter dur-.ition. The po— iliility of infection of the hladder irom without liy intro- dnctioii of the tvphoid-liacillus oii a sound or a catheter has reecutly hcen .su^^cested liv a lillrii.- ,lr|M,-ii- in the Malv.- iiiv "aiv, and aiinw-t aluay- nnly in a-ociatiun with iilu' proccssfs iimu thf .■-oft i.ah.tt- and il ,,-iU. ' I^arynx. — I'lKiii the miKMUs intinliranc .if the laMnx mild '■■"•'ii-lial inaniliMalion-^ aiv ani..n^Mh,> nioM fr, ■.|n,nl or,.,im'nc..s ; K.>s '■""""""'> ''"•> ■">■"■" ■' ' -idrrahlr.l,-,,.,. ,,f xAcitv. Kvcii h.n!i..,,,| "''•'■'•"i"" i" miMrr ora,!,., o.vnr- in a lairly lar-r,". |,rn,H,rti.,n './th,- >v\viv ca-.-. (;ri,, .■,.ll,.,.t,..| an,l ivvirw..! 2l'1 ..as,.. nUtM ''•'"" 'I'" I'l-ratnr.. „,. f, iSi.S. Th.-.. i..si.,n.s ^.n.Tallv an>.. fr-.n, >M,M.rl„.,al ..,„-„m-, whi.h „,ay ra|,i.lly ,„.n..tfate .l..,.|,iv an.l -dv,. '■,'"■ "".;'^""~'^'' "''•'■'■^"i with ,„.ri,. „inti> an.l .l..:tn„.ti.„r ..f ""■ <'an,la,-... ri„. n.nal s..at ,.f ty|,i,.,i.l ni....rs .>f th.. iarvnv is the i-~t..n„r M,t..n,al wall ..f this ..rfran, uh..n..,. ,h..v n.av ...vt.'n.l ,., the l.-t,.r,„r |„„.,i„n „f .|„. v.,..al l.an.ls, p.,„.rally i„ th.. »l,nn „f sn,K.|-li,.ial "'■"; • "" ""■ l"-"'i"'- avails, h.,w..v..r, th.. nh...rati.,„ is ..ft,.,, .1,,,, " "7' ^"""'''•'' "'"' -"" i- -'"-' "f •!''• adia....n. pafts, th,. .........n^ """''";;-"•;'< <1- arvt..n.,i.l ..aftilaj:,.s, an.l th.. in^H.-r of th.. larvnv ;;;l";-"v"';- >■> ot -h. r,.,,.„„l ..artilaj,,. an.l ,h.. ant,.n..i,l .-artiiajres, whi..h .|,.s,r..vs ""• •".■""■■; •l..-ou,h..nt a la.-.,. ,.xt,.nt an,l n.av inv,.lv.. th.. Iatt,.r in -'-MS. u,tl, total ,.xi;.lia,i..,.. Th.. ,.ro..,.ss n.ay ..v..„ ,.x,..n.l h.t.. the - - ,.m,n. I,.a.|,n, ,. ,.n.,.l.ys..n.a an.l i,„il,.,ti.,n .,f th.. n...liastinn,n "itl, ,,ns as o....n,.,v,l n, ...w.-al ..as..s ..i„„| l,,. k,,,.„ . V't M"";'' '<- '•"".".on an e,„tiv.: l,.si.,ns ,.f the ..pi.h.ttis. ip'^lotn- in.livi.lnallv .„. in -n „s \, ,;,„„, i, , "j-"' "t t '., ,,,,i|,„. , 1 \. r . -""'I'^- -^t «"'"•- ""v '■>.t<'>'li"iil iil^iTatidii of tlic 1:1I\11S mill it- -(■(|lltl- the 1:1-1 wnlil li:i- iml \il l.icli -;iiil. To inii-iilcr lliilii :i- •• ilri'llliiliil," III llic -lli'l -ili-r o|' till- Uiil'il, ;i- ( ililiT u lili I'- ll ii I, i- a- litllr iu-lilii il a- llir a--iiiii|iliiiii llial tlic r T i'\ti'ii-i\ r li-imi- Mii iliK' |o Inir ili|iiillii lia. A |i..rliMii ot' nlcrratioii. l-'iinlirr lantiil iniiTo-ro|iir ami liartrriolouii' csaiiiiiiatiolis arc -till llrrili-il to c-taMi-ll llir -|irrilie rlial-artiT of llic-e li-ions. l,ii-eal(llo ' lia- ri|)oilMl tin- iiiltivation of tlir l\ plioiil -liarillii- from the iiillaini.-foniKi- tioii, iiiav ilr\rlo|i imlr|irmlciili\ . w itlioiil anticnliiit nlccratii f llir mucous mcmliranc. Condition- of' tlii- kind would lie comiiariililc witli tlic tvplioid pcrio-tili- of llic lonu lioiic- ,;nd the lili-, and cxaminalioii of the |)n- for l\ |iliiiiil-liaiilli would he i'-|Mciall\ di-irahlc. The trachea and the larirc bronchi arc ranlv the -cat of iirofoniid alteration-. e their nuicon- meiii- l.raiie i- markcdlv reddciied, eoveriil with -canty, vi-cid -ccrelion, and the -c;it here and liicrc of -mall cro-ioii-. < )nly exeeiilionally do tlie-e heeome dispelled into actual nicer-, and IhiI rardy do they L'ive rise to perichondriti-. nccro-i- of carlilat;-e. and |icrihroncliial siipjiiii-atioii. .\ niimher of oh-erver-. parlicnlarly < iric-inLi.T, rejiort the occurrence lit psendomcmhranous diphtheric depo-it-. Tlic-e are in any event exlremelv rare, and tlicv have not yet liecii -nliiieled to thorouirh study l.v modern ni(>lliod-. 'i'lie occurreii f c\ten-ive tilirinoiis traeheo- liroiiehitis (Ki-eniohr) i- noteuortliy. and it i- to he di-liiiirni-hcd eharly l)v it- clinic.il coiirl""-|''--- Tl„ -,„:,ll,.,. .,,,1 ,l„. .,ull,M l„..,„..| "" ^' ' '"•'■""•■'• '''-''■-'^'■•'-K-ii.l„-„.,,|i,„,, „•„„., .„.,,,„,„„, " ;""'"'"•-".. an,| -,.:„„. -,.,.,..,i„„ T,,,,,, i,. W i, I, ,|,., „„|„,i„ „,• '':""' ''•'■'■• ":" ^"•■'■■'■'^—1 I" ■■■■>■ I un,„nia, ul,i.. .„r ■:;"■' ""^•^"; ""i'-"iy-^-iM....iui,i. ,i„. ,v,,i,„i,, i,,.,,,,..,,!,,,,,. :'~" '"■ ,"'\''^'"' '■•^- "" "— '"■'" -H.ii..i..,„iv Mu.ii,..! i,„.,„,i„: ^^"""'- '""'^"■^" I'i" li f,-a-,., ,1 „,li,'i.,„ b„| „ ,:„. ;V""' '7'-'^M'i.>i i- •.-,! a„ .■ ,i„. i,.i:,;„„„„:.v I,ungs.-An..,.,|,.,,M;,ll,,ui,,, ...,,,,, ,„„,...„„,„ ,„„„,,,„. |irrtrr. "]"«' tl„. ,li,tnl,„ti,,ii .,f th,. |,l,„„i_ ,|„, I intcri-it\ iiri. ..,' tl, ]• • . .^.....11 [Mi; iwdidii ,^ _ ' .' ■ .""'' ' .""■ '■'""ImoMs i.ivM.Mt. Tl,.. ,..„„,„|lv sl,„rt ,lMr„i„„ ,. 'M'l I l.'vr,. ,„ ,.|,il,|,v„,an,| tl„. M.url, I,. " '"""■""""" Jt t '7^ '"'"•"■•">• --|"-il'>" <■'-!..•.;,.. that l.v,,.,>,a,i, ''•'''''■' ^: 7''' ''--■'■'"'""" i- tl,.m than in a.lult- -I AniMiiir ,|„. |„|,,, i„Ha„in,at..rv ,„•„,,...,.. ;„ ,i , ' • , '■'•'> i'l ''-'• tn. ,il.nnou> ,nn,n ,'"'"" ' "'" .•as.sat tlic f,J,„ If i ■ ,, "''^ '"■'■'I !'n-cnt 1., t,,,,,.^ i,, si'!t '"'."i;"" ""■ '•^'•;inl<..l-W,.i,.h,s,.lhan,n ,1 l|llllC(li,.,„..,.,,,„ ,.„„„. 77,, .v, |'„ri, ]fjj^,, ._, _ ' /-■. nf. , '"'•" ■'"""''■■ '''-'""/«»,7™, \Vi,.^l„u|,.„, l^-U ^^''■"'-^. '«o.. „v,., „,,,,, ,jj'^;;'; ;;;;:'-,;''-^- •^•". ^^^ ^ana 4. .Ji^ :'--f>lJ}' , ^J_ r^ .^ iV: '-!-".- = - = " <, ^j:3 ,„„„i:.. .i.l. M.v,...K.„.,i.n.l -.:,,,lnl -. TL ^ I--! -.,•.,.., ,,.,,.,...„ -„.l,or,....l,lvMu.l,..l:.ua. ..lU ,1,:,. an, .l.lnn,,. -.;,.,.„,..., ;.„, |„, „„.l,. ..i,l, n^r^ni I.. tl„ir („.,,„■„,•,. N-l nnvK „KMr,,-,-..|,„. ii,.,„.,,i„„ „r ,1„ ,M, -nri:,,-. ..f.h- Inn.uill ..i-,. . ^n-,.n„n .lu.. ... i,„,:,n.v uf tin- ,un,,,lir:,.,a v:,n, .> .n:,v 1"- l^n-.-.H. In ,.nv in-,an,.... -n,. - )-. nn,,..,:..' uln, ,. :.- ..- l"-" ,„.„„i„„...,. ,..,„.ralls .".,.n,- n> lol.nhu- fo.-.n. i- lonn.l n, l^Lar t,.-n,. S.ill 1..-, t,v.,nrnllv -,a|.h,l."."vi. pn.n.nonia ai-l-ai- t -nr a- a nn.nu-inHrlic.n in .-a-.- nC t,|.l,oi.i f. v.r. . . , ,. u,, MiM..l inl-.i....- ■■f -nv|.l ■■■i mimI -ta,.l,vlo..„.v, «m1, l.anlln. ;,,,,„.• ,...-.. .vi.l..'i.l ...■l.a-la..lvl....,......-..l..-.>•. .l........-t.-t'-l. XM.-t --• a .■■- ,„„l-,.v l..l.a.- ,,.,....n.....ia ...■.■...Ti... .l...i..ir tl..- .■....---•I t.v,.l.....l l.v.r „,„ i„. .,,,,..,1 !.v ,1... ,v,.l,.,i.l-l.a.ill..- ..l■ "V.... tl.-..^'l. 'I- p..".'".— -'- ,„,.„P„..l 1.; lV,.sn..l..M()l.-.-va.i..n l\.)a.,.M.v h.aa.-l l.o.-.lo...- Tl... s......,..l n... r..,....-.-.l 1..V Il..ns,...l..-«)l.-..,-va...... lAlX w n,„r .vi..-i..^. 1.... tl.. l.a..,...-i..l..,i.- .•-,-...•. i- i...'.;."l.l.'.^ <"-• 1,,,,, „a.l.. l.v (•|.ant.......>M.. KinUl,.'. I'..-.........," a...i ...l..». ,;„„.,vn.:,.- i....-.i....> ..fl.n,;:.: ..r i\u.r i.. .. Ma... .-I l.y,,.,-.a:... ^,.!....- i.a.i..../...- .v..,. l..l.:.r ,.............!..- -l...' to ,1... ,.........—.>, n-v nn.l....l.....llv 1... i..va,l,.,l l.y ,y,,l,..i.l-l.a..illi. Al.l,....,l., ... -.w ut ..■ .,.,,, va.-i..n- ..f intla.n.nat..rv .......liti....^ wLi.'l. "-av l.- unhm<\ !-> :1.- ;vnl,.,i.l-l,a..ill..-Jt iM-"il'l'' '1-' i' •-> '•''-'^•' ='•'■'''■''''"'■ 7''"^^^ v., ,hi- t;,.-,n ..!• 1....^ inv.,lv...,..-.., if it -•..,• ...-.■...-, -.a.-t «1" - v.tv ,^..„ „„. ,,., ,■ ,v.M. .>,.„. ,„v .lini,., / /'-- i.-ip--. '^■"■' »•:■■ ^'■"; ' Y'A/.s.-. IV.ri-, 1>-'.T. T K'l.A.H.r...Ml H:,rri-. .r^h"s ll'fkn,^ Ih^/.. /i"".. 1>^'-' . -v Kr.,„k,-1 /,,7. /■. klu, Mnl.. Ha. X., S. 4:i',.. I!,{,,r„i.i III'-'/., it'^- N'. 1- 77m,.... I'l.ri-. IX'.'-- = 1. ,.' .ft . , ■ . / ' /^:.>-'T4r.?^"int. All <>t tlic vaiidii" ■'■ I III llllliillla llli'lltlnllMl K'l'Mniii)^ III till' iiiiii- ir, lliiiii).'li raiil\ , tn I a|i: llllr nf irivill'' li-l' I .1 al it till- Iiiiil:-. Mila-tatir al i^i-c — i'^ a,-- III ,1 IS |>l 1 H' ■al iiiaii 'III Mil iiiarv it a riiiii|iliiatiiiir |i\ iiiiia, liavr al~i) liccii iili-ii\ ihI. 1 i|i|iiar~ til iicciir -oiiiculial inure iVi'ijiii'iitU , -uiiicliiiics as tl it' liiliar, i-|iriaallv lilniiinii-, piiciiiiiiiiiia, in -iaitc |inilnirlr(l iiiil ill |ii'i'\ iiiii-l\ ili'liilitatiil iiiil Mil t'cvrr lii|illirllt (■-taliiiii-i ;riii;in'lii IC -llllll III iil-|iiiriil('iit I Miliiili-iii, ami. tin I III' a-|iiratiiiti ti'Mll ■ if I 1: i-l-ll aliif ll run \ ri .1 t'n. III 1 hr t'lii 1 1 iiinil nit, jiiilrii 111' n-p irati irv |(: ii-illit Lfl'l •111 111- 111 •,., - am! 1 III' m of a main Imincli ut' tlu' pulm.Hiarv art.'i'v. The -.nii-ec nf thi> .inlinlii- als.i mav he fniind ill the h.art .ir in th.' ll ll'ir.' |)cri|) peril ilicnil v.iii .if the IiimK I'l.'iiri-y ill the fnrm nf a mnre nr le-s exteit-ivc til .lit inn. Mis (Icjwisit is lint rar.' a- a .'.m.liti.m as-nciated with the various forms .it' pneumonia iiiniplicatinLr typhoid fever, ami iimlcr -iieli circunistani'es, in so tiir as pr.viou- inv.'sti^ratiiiii ha- iliscl.i-cil, i- in l,e allrihiitcil to the iiii.'ro- nrpiiii-m- res|)onsil)lc t'.ir th.' jmlmonary disorder. I-'ihriiioiis and s.ptic |)iiciiinnnia als.) lc;ul at times to empyema. Serous or ser.ilihriiious F HH 7 ) ril'flh I I I / /.'. .; '!' (•_• ■ ''■1 I Alllnll- >'J'.t iM-r- (if l\ |lll"i ran in llir ,-..lll-.' ..r tsplM.l.l f.A.T. I' lnolllM-:,\ (H, III- .Mils . A.r|.ll.lll.lll\. Mini ^:, iirnillv a- III" -..III, I ..I i.iinil. Ill ..r -aii-iviiMii- li,, a! .li-ra-r nl llic lull;;-. ■rii,. ,,;/, ..r r.acillii- ivplm-n- in tin -mm.i- |,I, iin-ii - ainl riii|.\ .iiia^ ,.,„„,,li.alin- Ulili-hl livT li:i- n.Miillv Im.ii .li-m- nl l.> I'' rank. I,' l;,iiiliii-i r,- aii'.l ..111, r-. l-ranU, I ,.l.-. rx,,! I .a-.- ..f .iiii-v. ma ani.nij; .-,1111 ,aM- ..f ivplL.i.l I'v.r. Cnllnr.- Irniii llir piiriil. lit .■•IVii-iiMis -|„,u,.l ill Jia-'.- I'.. I.\lili..-u- ; ill III,' lliinl. -Iiv|.|... n- ; ami in llii' r..iirlli, |.ii,niii.'<-,.,'.'ii-. Ili.lpkin- Ii..-liilal, lull 1 . a-.' ..I ,iiii.\, nia CM-.' .■..nlain.'.l III,- l\|.li..i'l-l'."illn- iii\.r> lai-,- iiiinilMr-. I!, n,lin-iT li.i- i,.i„,rl,,l ■< ,a-. • ..fi ni|v\.nia ami ,.l' pi, nri-y uilli ,tVii-i..n lV,,ni llic .,^i„i.,,,.. Ill 7 ,.| ulii.'li ill.' lvpli,.iil-lia.allii- \va- i-,.lal,,l. II. lia« aU.. ,.,,|l,.,.|,.,i l:i -iniilar .a-.-. Siill -.'Vrral ,.lli. r .-i-.- aiv .■..niaiii. .1 in llii' ljl,.,.;ili,iv. Wliil,' ill.' I,a.-l.ri..l..,-i.- .•saiiiiiiali..|i in -. .III.' ..f llic < arli.T ,,,-.- niav 1,.' ..p.n I., .I..11I1I. tli. iv .an I .|n.-ti..n tlial in a nniiilMT .,f,,i-. - ill,. iypli..i.l-l.a.illn-lia-..,'.iirr..i l,.n., aii.l il- priinarN .■li.il..f:i.' -i-nili.-aii.-.' -..II,- t'ailly u.ll .-lal.li-li. .1. i-|il„ivnl,,-i-i-an iiiip,,rlaiil ,-,.inpli."ii i f I \ jili..!.! I'.v.r .-p..ially tiil,..|v,il,,n- .li-,:i-...f 111, Inn-. It nr- in \aii.,ii- f..ri,i-, nani.'ly. a- part nianir.-tari..ii ..!' a .•..nipli.-atili- ^.n. ral miliaiv till" ivnl..-i- : a- „, ,l,.-.-v. l..l,iilar. rar.lx |.,l,ar. pii.nin. mia ; in lli.- f.irni ..ra.-nt.' a. III. I- ;i .liiv.'l .■\a.Trliali,.ii .111. 1 a.aitc ili-- tnli.'r.'iilDii- |i. iilir..n.-liin- ; "r a- ^,.,„iiiati.,n ..r a pr, -.Ai-iin- api.al liil,.ivn!.,-i-. liilli.rl., piir-niiii: a ,lii^,rj-l, ,.,,rr-,.. Al-.i ill lli.-.illi.f r..iin-, lnlMivul,,ii- alV..'li..n- ..f -.nuc -taii.lin.j.if tl... Inn.-an.l tli.' I.n.n.liial .^laii.l- . .r .iC ni.nv ivin.ilc .-f-an-- inav aluav- I... i;.iiii.l ait.'r .l.Mlli a- ill.' -,miiv.' , .f tli.' iv.-.'iit tiili-iviiln-i-. AU., il„.',„vnrivii,v..f tnl..i-.'iil..-i- a- a niiN.-.l iiir,.ti.,M i- int.iv-liii-, :„i.l lia- 1m, n .•aivfiillv -tnill..! in a f.u ."1-.-. K-p-.'ially in ..;-.- ..f lvpl„.i.l pni'iitiHinia lli.. tnl,. ivl.-l,a.alln- li.i- Im.ii f,.nii.l ivp.al.-.lly t',„^,.tl,..r xvilli 111.. pii,iini."-...vn- .'f Krankrl ami \V.i.li-..i:.ainn, llicii iKiinr.illv in .•..njnm'ti.in uitli .■..rr.-p..n.linL:ly .•.iiiiplii'at.'.l lii-l..l.ii.'i.' .■..ii,liti,.ii-. ALTERATIONS IN THE NERVOUS SYSTEM. Il, ,.,,nt..-t I,, till- ni.irk...l pn .L.tninaii...- "I' .•lini.-il in:iiiif.-ta- li,„i- with ivf.ivm-,' t,, til.' .M.nli-il mTV.,11- -v-t..ni in ca-.- t.f typlmnl f.v.r piir-niiiL' a ~i-v.av <• ■-.■. il"' analnmi.- tin.lin-- aiv .■xtivin.'ly .li-ht. I).Mil.tl.-lv. tin- i- line t.i til., lii.t that tli.. pi-i.timml iwrvi^iis /,..,.. ,-,/. A',.-, ./, M.-i . \:»»>. .N..- !■-■ I-Mllnl.ni.y. llf» ili-'iiilp;inii- arc :illiilmi;il(lr c^iii-cially tu a 'pcrilii- Inluxiralioii ilt|Miiil- riii ii|Hiii llir I\ |)lii'icl-liaiilli, aiiil uhicli i^ciitnillx i;i\i- li-c \,, a Iniii^i- lor\ iriipii --iuri u ImpIIv (li-|)|i,|n,i lion.ilc- lii-|ii|n;;i,all\ lo llii- iiitiii-il\ nf II - -\ III|iImI1I-. Cerebral Meninges.— I'lic dura not raivl\ |.i.-.iii. Ii\|«fvmia illlil I- • |i -- iiiaiknl III! lit ailli(-iMii to l1ir iiiiiir -ilitiicr o| llu' -kiill, wliiili ill tiii'ii i- till II 1:1 ii.iall\ llic - aii'l tlic -iiiii-i - air oricn cli-i.iiili-.l \vitli dark lliii tlic oli-i i\ alion- ot' I'r. Sciml ■iiliiciilar tliiid. ^lu'Wi- iiot( Aortliv /c, u ho iiotcil, on nil tioii of tl cro-co|nc cxamnia liioiv ,,r !!■ ■am and lacninuc. of ca-c- that iliiniiLr life had cxliiliit.d |iroiioiinc id -Mjijitoin- of ni\ tli ucii' caih (le-cril Mil llV I iio- irio-iiiirir. It ■1 e;|.,.- ot (i ■I' ll ^er, who ol>-er\iil them a- earlv a-^ tia- -ceond ueek le (ll-ea-e. I'lirnli'iit een liral and c'crcliio-piiial incninLjiti- are inciitinncd cxccp- llv 'i"i'-ill.\ ii' 'lie earlier literature, hut hax :lv ivccntl l""i"''l "III "II aecimt ot'their clinical -ii.riiili,.ance ( Diichck, ( Uiilil, I,e\d,ii, Krh, ('nr-cliniaim). 'I'Ik -c V iM'cii -iiicia inc~-meer, lllivt ctil|p|ja-i/i i|. c alle.'tioii~ niav, as I hi lira- early a- the tir-t week ol' the .li-,a-c. '|'| lev raiciv Iiriiiinate fatallv. Tl le \ailctie~ that the fehli e iicriod or i\en >1 rtiv afl.r ilcl Iter, toward the cik' ot' er\c-cence, are t'ar niiirc -evciv, and tlie\- more frec|iientl lioii- extensive and iirotliiind e\ id til" firm of lil.riiio|iiirnleiit iiitiltration ,,f \\ • iraclii |ilently ci>iiie ti> anto|i>y. I'llder llle.-e coiidi em e- ot' inllammatiiiii ot'l( le <'erclir en a|i|)ear in d and sjiinal pia- ii'lil. Wlielher the-c proce-.-e-. ale identical .•tiolojri,.;d|y ,„• ;,fc (,( vailed on-,,, j, i„v,,lve I in doiiht. ,i> thoroii-h lii-toki^ric and I l"!:ic -tiidie- ar, .ft lactcrio- yet uantini:-. It i- not impiohalilc that in a porti( 01 tile ca-e- the IkiciIIii- of Kh, ,-t|i i- tl le sole or, at Ica-t, the predonii- Vrrhnv.ll ,1. C, .U../. Wi.v-l.M.I.M. Ii,l. -i';'i iiiui n.ii. ' f'Ttv I'n.iri Tiiv -.•r\ii >■ iii Ilici.l.i \ .. S. 4i;!i aiiil r..n.iwii.i.'. Weill'. Arch. f. khi, M,;/ . Md. '•ilk*' '■ 120 Tvrii'iin I i.vi.ii- ,„„„ ..x.itin,r ...-.t „r M,,.I-m:..io„. 1,. la... v..Mrsatl-.M D^wumu. ,..,«... 1,MV.. I..TM iv,.urt,.a i.. "Inrl, iIm. ty,,h.i,l-l.arillM- ^^a. in.lat.-l ... ,„,„„,„,, Tl,..~.. I:av.. l.,.n r.-ll,,.,,.,! M,. ....Inly. I'.H.M, l.y llnt- „,,„„' \M a.l.li.innal raM. l,a- laflv n.vunv,! i„ .li.. .I<.1m,~ I1o,,U.m. |l,,-,,if,l In oil r ,-a-..-. |.ar.iriilarlv in th.-r ui.h a-n.ia.r,! Iil.nnou. ,„„.n,n,.Mia. .lu.,v i~ ^ 1 ^.-n...l ..-i'l"-' tl- lM-ank..l-\Vri.-li-.ll.an,u ,|i,,l„,.,,,„- .. .1,,. -■an-ativ.. tar.,.,-. Still ...h.r .-a-.- a.r ... !.•■ atfil.- ,„.,., i„ .,11 ,,rol.al.ilitv. ... .!..■ .■N'i'.mir M^vn. ..f .n„. (..|.i.l..u,.) .vvl.r..- M.iual .n.i.in-ili- Al-^»1 tV...n i^.h,...! l.a....ri..l..;ri.- ..1.-. rva....,.-. .!,.• ,;,, ,i,at n...nin-iti,. -vn,i,...,n^ a.v ..n...nn...v,l wi.l. .v.narkal.l.' t.v.|n.».r i„ ,,,-,., .,f ,v,,h.,i.l trv... MMTin^^ In i-la.v- an.l a. ti,n..> xv li.'.v 1....1. .11.,,,. ,.,.ivl.n,~|.inal uH.nii.-ili- an.l tyi.t,..i.l t;.v,.-— i..vva.l ...-vlhci- .. ,U„ in fav,,,- ..r tl.i- vi, w.^ It i- .....l....l.f.l tnK.lly .La. al-.. ~..v|....- ,,„.,.i .„. .,ai.l,vl„.....vi al..n....... in ll.- '■...•in ..f a n,ix...l .nl.rl...n wi.l. .„1,„,. „,i,.n,-.„-a..i-.n-. .nav -iv,. li-.. ... pntnlcnt .n....in,^,t.<. lin- .s ,1,., ,.a-.. .-,..viallv a< a |.a.-t .na..if.-.a.i..n ..f (■...npli.^a...!- m.,.1„ .ania, 1„„ i, ,„nM 1... ...npluM/..! .l.at ...ily a -mail inin..iily ..I all ...-<■> .-t ,v|,l...i.l f..v,.r .■..>n,,li..a...l l.v l.v."'ia .■xl.il-it .lii> l...'ali/.a....n. ■ \„.,.l,..,- i,n|...,-.an. va,.i..v .,f Mr,.,..la.-y l.n.'nl.i.. .n,t.,n..M.,s .. .I.a. ,;,ll„win.r ,.n,-nl,.n. intlanuna.i..n ..f .!..■ -ni.l.H- var. wi.h .n..nn>...- ,,l,l,.l,iti„ H.n,<-.lu-..M,l...-i-. a.i.i .■a.'i.- .-f .li.' j'.tn.u^ l...n... 1. i~ t h' ;„„,,. ,„„.„v,„.tl>v tV..,n ,1... fa... .l,a. tl,.' atr.....i..n ..f .l..' r■^y ,- ..... .■.nly „v...']....U..l .l...-inL^ lilv in tlw l..-..li.nn.lly -.n,.i.l .t .-..ini.l.t.ly .•...na...... '"'" Will, n.^anl ... .!..■ •■..n.liti.... "f tlu' cerebral tissue, i. may l.c. sai.l ,),„ i„ ..aM^, of .v,.l,..i,l nv.r i. l..'.-...< ...> ...n-tan.ly n .n.T.ntr L's-.-ns .,, ,.ha„.,.. i,.tin,at,.lv a-^...aa....l wi.l. it. Hnlil ' .■n.l..av.„v,l ... ..>.al.- \\A^ .vtvLral ...l.ana wi.l, .■....-.•.■n.iv- -..l^'ni..^ ..f va.-yn.ir .l.'^.xr as a., ah<.,.,ti..n j:..n...-allv ,.,•,.-..... 'i'l,..,-.. i- .... ^-nl.. .ha. .I.i-. a.s..,..at...l ,.v..n with ......l.n.t- .lila.a.i..,. ..f .!..■ la..n.l v..n..M.O..-. ,- .l.n...... -I.al.l.. in n,a..v ...-.•<. F...al ...H-.-in.: i <|"it<' v:U': an.l wh... .t .,.,,„.. i- tlu- n.>nlt ..f tlw...nl...H. of th.' .•'■.vh.-al art.-.M..^ .hat l.av- ,,,,1.......... .1... .h.p.n..fa.i.... ,Hvvi..M-ly .ncnti-.n.-l (..Mil.Tat.n^ .....ar....'- iti-) or ..f<'oairi.lati..n in ...... .-r m.'n' .•.•.■. ■l.val MnUM- ...■ \:n-^v vcn.s. M,.vn,..-t ha- -•all...! a.....ti..n .„ a y.■ll..^^ i-h-hn.w,. .h-...!...-a...... ..I ,1, n.h,-al .....-..■x, tl... -n.-fa.v of .h- .■o-,...n. M.^ia.a, .h.' ..|.ti.' thalann. atul th.. .•...T.'.'a .,na.l.-iir.....i..M. whi.h h.' wa^ al.l.. ... .-'a-v .n..T..-...,n- Sr.- ;.i-i \V'>lil' 1 ' '.'n„;)l''''ri'u-.- aL'w. .-..■hai, a.. .i.-i.i.-n- i-i Tm.Ih.s,' /.-/./. -"-"■ ■"-'- 1H58. MumMmmrwi rMii'ii.iji.y. 121 rally til a ililfii--(' ydlowi^lr di-colc. ration ami acciiiniilatiun df lirnwiiisli |(ii:iiiiiil-uniiiiilr- ill the iicrvdii-- cli'iiiciit-, (>|pccialK in tlir L:.iiij.r| ion-ceils. Tllr ..lltjill,-. nfllir ,-,l|~ !«.,•,, Illr uhlitrl-atcll. a- I lotriliallll al>n (ilMTVcd, HI lliat liiially tlic clI-lMMly i~ ~lic,\vii iiiili-tiiK-tlx ami |priiici|(allv fn.in h- |ii;:iii('iit-<'c)iit(iii. I'rriiliar rniiiHl-ci'lJ acriiiiiiilalinl|iear> to he extivnielv fare. I liase oli-erved only l; ea-es ,,f ihe kind. Ali-ee~- of the hraill ocelli-, oera- ~ •'".'■■ ■!- ■•! H'(|iiel of |iiini|(.|it inHaiiiiiialioii of the middle ear. or as a r.-iill of iiieta-ta-i-. In ,,iie iii-taiiei. I have oli-erved -iicli a i^ondition 111 eoiim.etlon with ucm^ral |)y,.|iiia in the -e.|iience of a putrid lie lidK up.,n ipiite a si,„ila,. one of Lei.dct's.' presentin^r svrnptoms "t ■I'litc [.andry's paralysis diirinjr e.mvalesecnce from a miid attack "t lyphoid t;.ver. wlii,.h t..rmi,iated fatally, an,l which upon p.ist- 'n..rieiii examination exl,il,ite.l no material .■lian,ir<.s in the spinal cor.l. In another ,.ase.' also sliowiu- the clinical eonrse of an acute asc,.iidiutj ' riii--rl,,nMnn. (>,•/,«»,//, ,/, C.,,,,,^ f, ,„„. y,,,i ]^^,. TYl'iiniit ii.VKi:. ,,an,lvM>. ..ipillMrv lurnorrlm-.- an.l aivn- of .,,ti.ul.>- vviv tnnn.l it. tl,r iHclulla. T1m> l,a.l.n(.l-.ui<' .•XMii.ii.ali..M in tlii- .m-c iimvc lu-al.v n-iill-. Kiiimncll ' lia- nj"'!-!.-! a riiiiilar caM-. Filially, SliilV^ lia- iv|h.iIc<1 a caM' uitli a vcrv Miiiilar clini-'al n.iiisi', l,ut uiiidi xva- v.Ts a.nic, .l.atli ...■.iimn-: in ci-iiKcn lionis. The .a- aniiiiation uftii.Tnr,! in .In- ..!>.. >linv 1 an a.Mitr i,rin..rrl,aLnr transvcr>c n,v,.liti> at ti,c Irvrl ..r tlir ronitii an.l litth .vni.-il >cL:n,..nl>. Cnltniv. in"tlli^ ca-r xN.iv aKn n.-ativr. All of tlu-c anatcnir . ..n.iiti..n- mn-t |„. ..,,i,-M,T...l a- .•xt.vnu.ly raiv a- •■oinpaiv.l with the \m-v\uy, nut ,„„,,„.n...nlv. c.f niark.''. -,.inal .vinptmn-. In tlii- .•onn.rtion tli. iv ..Nl.tsa -ivat (Irli.icn.y in ili.' >tn.ly ..f typlioi.! I'.^v.t at tlic antop.y- tal.lc. riir peripheral nervous system likrwi-r lia> K.vn lait raivly MiMlir,! in .•a-..-„f tvplini.l i;.v.T. In a-oriatioii «itl. -rrtain .•lini.'al ,„anii;-I ili..n- tl,r anatonii.' Ir-ion- of |.aivi,ri,yinaton- .■.■iiriti- l.avo h,,,v ai.a tli.Tc iMrn tnnii.i. at linu- tln-o,i-lin,it a ^^\^v .li^l^l.ntlon (!'itiT~ and Vaillanl). Alteratic- -■ in the Organs of Special Sense.— I.iitlc l.a< hitlurtu l,r..n l.'arn,.! aiialoinirally with rruanl to the cyrs whirl, .■lini- ,.allv oxhil.it variou- .li-tnrhaiir,-. TLvration of the -•onifa. inti~. an.l i,i,lo,.hon,i,liti-. an.l. in i-olatr.i in-tanr,-. optir nonnti> have Wvxx „l,M.i-vc.l. TIh' .■hanuv- in the .'ais have Imtii nioiv fiv.,nrntly an.l inoiv thoron-hlv >tn.lir.l. Alth..n-h hy no nivan- all, at least n.o-i of tho ,li-tiii!.ainr- of thi- oi^an a.v attril.utahl.' to ..xtriiMon of -■aiarrhal „„,1 nioiv ,,1-ofoniMl ,li-lnrhan,r- from the na-o,,harvnir,,,l ravity, th.' ton- -il-, anil a.lja.'cnt -tructnrr-. Thti-. catarrhal .•oiidilions of the iiuk'oiis ,n,,„|,f;inr of tlir Kn-ta.'hian luho and the tynipanw .'avity atv anion^' thr nioiv ,.o„inioi, roniplicatin,,- At tinw - ,.nnilcnt .■atafrh of th.^ in.d- ,11,. ,,„ ,„-,ai.--, wiih p.rforati.M. ..f the tynipanir nimihi-anc, and. fiirthciv ,„„.ul,.nt atV.vtioii- of adia.M.nt -trnrtnn-. .-|M.,.ially of th.^ -vUs of tlu" ,n:,-toid pro,.,.,-, th.. nlatrd vein-, an.l tlw a.l.ia.vnl MiniM.-. Diphthcn.' atr...ti.m- .d Ih- Ku-ta.'hian tuh.. an.l .>f th.. n.i.l.lh. vm- hav also luvn nhxTv-.i r..p..at.-.lly a- th.^ inniu.liat.' .■M.^n-ion of similar pro.rs^.'s in thf na-opharyiiL.'.'al -tvn.'tMn-. ANALYSIS OF THE INDIVIDUAL SYMPTOMS; COMPLI- CATIONS. Th.. .■lini.^il pi.'tnro of tvph.-i.l f.v.r, s.. ..xtfa.n-.linaiily varial.l.' witii ,T witii iv;:Mnl to tlie m ml t'letoi- a n-iilt of con-tant eiianjieand ^^-adnal evolution of clinical kncnv lc.|o(.__ arc at the prc.-ent day extended and deepened in ail diivction>, tlie Mm, llie i-ilation^ of the typiioid-iiaeillii- to the eoniplcte picture ot' the di- c.i-c and it- individnal -yni|)toiiis, is still in it- incipieney in spite of a lar-e iiMinherof i>olatc jrencral nianifi'statioris. The latter i^ attriUntahle c-scn- tially to the toxins c-enenitiMJ l,y the Nacilliis, the carlie-t kiiowled-e of wliich we owe to I',rieist upon siieh a divi-ion from the m.Ml.rn >tamlp,mit, the,, hjc'tion would at (,m'e aris,. that the present state of I'acierioloui,. invc-ti-.,tion of typhoi.l fev,,- i< l.y no mcan< sn.'h as to .Mi-lity a reparation of the actual syn,pt,,ms of the disca^. from the <""M'li'""i""- In d,.tail much that i> m'w and surpri-iMi.r mav ho l'.-oui:ht forward. A whole seri,s of alten.tions that until re.vutiv were ■■'MKi.len.l as cornplicatini: au.l in.l,.pcndent .,f the tvph,.id ir,,nn are now reeoirui;,,.! as mixc.l infl.ctions of typlioid-|,.i,i!li and other patho- ircmc ini.a-,.H,rj.ani>ms, or even depemi,.ut upon the fyi.hoid-hacillus :'l"ii''. It may MitJic.. in this coinKrtion to n^fcr .mlv to the piindent |>ioccsl<'>'Htic ..Uhsions. a- well as to some manif,.stations on the I'art ot the n.rvous system and the h.art. Fml.T existinur conditions I'-Hvver. It will he better in the followinc- ,lcseripti..n to abstain fron, a n^nd separation of th,. co.upli.-atio.,. from the .-u'ttial symptoms of the -li-nse, and to t.vat of both toj,M.th,.r. In so far as this mav be possible ■MU ,.tfo,t w,ll be maoiiiI a< well a> in llieir Keariiiu ii|kiii tlie (■nurse ami tile tei'iiiiiiatioii of tlie ili.-eaM'. One of the mo-t frei|Ueiit and iiio-t iiii|iortaiit i~ tlie n^eola. 'riii> lia^ iieeii -|ieeilieally desitr- iiated a- the tv]>lioii| ro-eohi, and with what |iro|iriety will he -liowii in the liillowiiiL.'' statements. The roseola (taehe msec lenlieiilaii'e, I,oni-) a|i|)ears ii. the form of small. I'oimilisli, well-eiremii-er'hed nd spots, vaiviiit: in -v/.v from that of the head of a |)in to that of a lentil, and always sliixlitly elevated, whieh fide eoiii|)letely on pressure (liest made with a jrlass pleximeter) at everv staiT"', mid thus are shown to lie purely hyperemie. I'ale red and pnnetate when they tir-t appear, the roMola' rapidly heeome larfrer and darker in color. They are almost always di-erete ; here ■••■ ', there twii, rarelv -everal, coalesce. They ajipear first in the seen .t ol the tir^t Week or in the l>ejxinniiiir i>f the second week ol t. ,■ dl-i se. Cases ill which the exaiithem apjiears later, not hefire the midille or at the end of the second week, arc rare. Kxceiitionally, riseohc appear carlv, from the second to the liiurth day of the disease. I have ohserved this e-ipecially in women and children The roseohc api)car first ili«>n the chest, the alHlomeii, and the hack, rpin the hack they often apjiear twelve, even twcnty-fnin-, hours earlier than upon the ahdomen and the chest, and in the situation first named tlicv are not rarely somewhat lar<;'cr than in the others. From the trunk the roseoloiis ern])tiou n the extremities almost alwavs presiip|xises a rehitively dense involvement of the trunk. It niav he accepted as a rule that this part of the hody is |)referalily and most dciis. the seat of the roseola', and their numher diminishes proirri's-ivelv the fiirth'T from the trunk the alfected jiart of the hody is situated. !u a e.'ise ill which a ro-ieolous cxantliem wa< more dense upon the di~tal portions of the extremities than iijion the proximal |)or- tioti^, and even ui>on the trunk, I would from tin's alone have some .vr.l/y/'/.l/.S' AM) (OMVLKATIOSS. lir-it;iiiiv ill niMkiiiL'' .'i ili:ijriiii-is ot' tv]ilwii cxatitiiciii ot' typlioid fever is not ai)iiiiea:-e> is reailily |M)ssil)l(' Tlins, I have iiou ami then oliserved syjihilitie ro>eola witii erujitivi li\i-r ail' 111 t1 i'iilari:'eiiieiit of tin |ileen to ^i\c ri:-e to iiii|)leasilit eoiifiisii le lar;^e iiia|ont\' of ea>es the e are jprcseiit at one time -iiiirK' or in >i nail iiiiiii i)er, t riiiii "i to 10 or 1(1. I 11 villllir elllMrell tlie\- ale. in iii\ exiierieiiee, ueiierallv still iewcr than in adults. In tli latter the nuiiiher i- ajiaiii diiiiiiiislied in ad vaneeil aire, o ileveloli soliiew Hal more allllll w hal itli reirard to sex. the exaiitlielll a|)|ieal's in irelieral t daiitly in women than in men. .\~ o|)|io--ed to some oh-erveiv, ;(>, fnr iii-taiiee, .MnrchiMiii, I would di-tinetly eiii|iha>i/e thi' tiu't that the ro-eola iiiav he eiitil'eK- waiitiiii;- thr>ii|i.dioiit the entire ee ot' the Thus, iif iL'til easo (phserveil at the lAMpsie crniic-, |>ersistelll aiiseiiee i(iii and the (K pmciit of the exaiithcin vary at dill rent limes and in dillereiil In tl 1 the vear l.S.Hi I ol iserved m larL'er imniher of eases in which the cxaiitl Hi iciii was seaiitv than iii otiier iiiilmrir a rclativelv iiiiieli Ot Itlol eases, which at that time were earefiillv examined from t lis l«)int of view, ini niseohe or hut isolaled niies were found As. to this tlu'i'e we 'PI" re |)erioc|s ni wliu h the rowohe were hut rarelv ahseiit, and ihirli their averaLre |irofusioii was especially strikinir. Perhaps ll le opmioii of Hiiiie ohservers, that the roseola is to he considered as ar iiiilis|ieiisal)le leature of ty|ilioiil fever, may have liei'ii formed duriiiir such |M'rinds 'I'liere is no detiuite relation lietwecn the severity (d' the disease and the den>ity of the ro-eolons erii]itioii, altlioiicrh I think I have ohserved eom|ilete ahseiiee more \'\< iieiitly in milder or aliortive eas<'s than in -evere and loiij,^ protracted eases. The eruption is tliereti>re of diajiiiostie and not of proonosiie siirniticance. 'i'lie diinitioii of the individual io-e->|)(it i< evidently not lon<:, on the averaire from three to five days. I helieve the longest period may he jilaeed at from seven to ten davs. A dunition of tiiiirteeii days, as -tated hy Trousseau, has not occiiitimI in my exp( lieiiee. It is, however, a characteristie ii-atiire of the roseola ot typhoid ti'ver that, while the old spots di.sap])ear, iie\\ oiie> are eon- sfantiy developing;, so that eon-, .|iiently the total duration cd' the eriip- titili is comparatively loiifr. 1 should place the aver:if;e total duration .m^m^wmmmmm^^' i^^^ %•«:':"- rvi-iioiii I i:\i:i! Ill liic cNMii'licni MS l)(t\V(iii 'wrKc Mini tiiiirtccii (lays. I Iimvc rardv iricoiinicrcil a lunger diiraliiiii tliaii llinc wnk-. In iiciicral it may lie >t ilicl that till' niM'ola' lat'cly jicr-i-t licyoiid tlic It lirilc stairc of tlic (li>- iM-r. .\ltliiiuij;|i it ralilHit lir denied tiiat iiuw and attain i^nlated fo-edlu' a|i|>eai' diiriiiii llie al'eid'ile stable, one ~iioiili| lie i xtl'enielv eritieal in I'eu'ai'd to lliini. |)iii'iiiL; rtenidoeeners and iTla|i-e~ the ro-cola' ;^en<'rally fea|i|M'ar, ol'leii ill ei|iial |ii-ot'ii-i(iii ami e\ en in i;ri aler deii-ily llian in llie |ii'iniarv allaek, and tlle\' euntinile -o Inii^' a~ tile ll'Ver |icr~i-!-. I niler >lleli eireiini-tanee- I'osi'iila' IIKIV lie liilllld ill tin tiiiirth and the tittli week ot' the (h~ea~e. and e\-en later. I)ii i-ri-e(i]a' oeeiir al-u i'l th<' e(iill--e i if i itlier disease.- '.' I lielii'VC elll(iri~eellee- like the ty|ihiiid fii-edke (In lull rai'ely. 'llie more -killed and the iilole e\|ielieneed tln' oli-er\er. the le-s coimilonlv will he feport iii-l.iiiees ot' ihi- eharaeler. < )nl\ in a tiw instances ol' aeiitc niiliarv tiiliereiilo-is and ol' eei'elii'ci-|iinal nieniiiLiilis, which were shown on |io-l- inorlcin exaininalion not to lie eoni|i!iealed li\- typhoid l'e\er, have 1 oli-cr\'cd n|iiiii the -kin eni]ilions iiidistiniiiii-hahle Irom tlu^ typhoid rn-enlie. W llile in ea-e- of the aellte eNaiitheiiiata, as, fill- instaiiee, sniall-po\ and typliii- t'ever, the appearance ot' the .-|iecitie eruption i- e'cnerally preceded I'nr a loiieer or slmrt time l>y certain evaiicscent exanlheni-, I lia\e lint rarely ol>-erved tliix' as foreninncrs of tli<' tvplioid ro-e 111' Ijciiiunliaiiic lyplidiii t'cvci-. >iicii m- ii;i\f iiccii (|i-.iil)((l (~|i(cially In Miinlii-oii and Li(lMriiiii~lt r, do ->i.c I)Ii>(mIv >iitlii~iuii nt' utiicr |iirticiri-. cit' tliv -kin ficc t'runi ro-cila-. Friiiii llii~ < ditioii Miii-I \.v -hai-|>ly ditli'ivntiatt'd the insi;r,,i(ic:iiii Ik iiKHTliams int<> the liair-fuljiilcs ot' tlic li^^rs, wiiicli aic not at all rarely (iKxrxtii dm iitj (■(iiivali-cciiri' Iriiin severe attaek- . Kirciilly, altc-nlioii has hern direct. -.j i,, a >lud\ »[' llu' hiooil ohlaiiied Irom the r(ise-s|«its, not alone he<'aa.-e nf the theoretic -iiinitieanee, Imt alx) hecausc (if the possihie iliMirnosiie value. Neuhans ' claims to have tninid ihe Hherlh hacillns in mare than half of the cases exanjined liv hijii, and m1-i Kiniiiiycr - \va- ei|nally sneeessfid in 1 case. In a iar-e nuuiher of (iliscrvatiiins directe.l to this -xiint I have ohtained only ne;.'ative results, as have also other oh.servers, as, tlir instance, Fninkel and Sinunonds, Seitz. .laiiowski, ('hanleincs.se, and Widal. Since the ahove was written, ty|>hoiddiacil|i have heen ohtained I'roni the rosc-s|,ot.s hy Thieinich ■ in :! out of 7 eases examined ; hv Nenfeld,' l;! out ot 14 cases ; ( 'iirsehniann,' 14 out of L'K c'a.ses ; Richardson," o out of (i eases ■ Seiiol/, and Krause,' 14 out of Hi ea.se.s. The method n^<-d in most of these eases consisted in ineisin;: the spot, eolleetii,.' a dro|) of the exuding' hlood, and inocnlatini; thi.s, loirether with .si>me of the ti.ssue-serapinirs, into |li,i,| media. !■; Fninkel.- I.y excisnii: the spot.s, phiein- them in honillon, and so allouni- the haeterni to nndtiply in the tissue, Ikls heen ahle to demonstrate tlic haciena ni sections. From all of this work it seems prohahle that a ^■"ll«''' •' the hacteriii in the hlood of the rose-spots alwavs occurs. The rosn.he .d' typhoid fi'ver are alwdiitely distinct frmn the exaii- them of typhus fev.r. The latter is made npof true niaeiiles, ami not papules. .\t most they may he slij:litly r:ii.s„l fi„- a .short time iiiiine di- ty livid. Ti.ey l<'ave traces, in the Ihrm i>n tli(-i- llian n|M ii lln' iniiik. and il i- a cliararlcri^lic lialniv, lir-idr.-, that llic cxaiilliciii. in markcil culitfa-t tn tlii' ili>triliu- timi nl' till' l\|iliiiid m^cdja'. i- iikclv In lir r-]ic(ially iiiarkc n ay !>(■ incntiniii'd as I'aiilio in tlii' cdnf-c nt' Ivpimid t'cvcr. 1 h.iM- nntcd iiftiraiia mily in cxccptiiinal iii at llanilmru:, and in tt..'! per I'lnt. ot' the ca-i- at l.(i|)-ir. .Iinnir. Ivaynimid. LtMai^'-fc. and utlii r- rciMU't the |ii(-iiiif III' -cariatinitiinn cri'iiti'iii-. and al-n nt' a-ly finptiun-. wliirh anpraird dilfinir till- -criinil and ai-n ;'ii' thiid uirk. ai'ii uri'r liy iin ini-an> i\a- ni-fcnt. .\|iart tVniii tlif iiiiliai \ai'ictii'- '<\' I'a-h |)rrviiiii-ly nn'iitiinud, 1 ha\i' iili-iT\rd niithin;^- nt' thr kind, and am iniTiiird tu thi' virw that at li'a-t a purti it' tiir-r rl'n]itiiiii- air In hr nm-idc red a> dniL;-i'xan- tiuiiis, and this semis tlie nmri' jiruliaiilr. a- I'm- a Iniii:' linii' it \v;i- en.— toiiiarv tn treat tvphnid t'e\er with laijie dn-ir. nf anti|)yietie driii.^s, eanalile nt'teii nf iiiihieinj.r Varied exantiieni-. I'eeiiliur i>liii.-ii, livid splits. varvin;.r in si/.e t'mni that nl' a lentil In a hali'-iiieh in diameter, have been de>erii)eil liy the nlder Freiieli nli-ervei< — a most enMi](lete de-eri|itiiiii has Keen i.n\en, I'm- iii>taiiee, liy Trnn^sean — a> a fre<|iieiit le-inll lit" the -kill. Thev ha\e lieeii de>ii;liateil t;"iehe> lileiiatres or as tvphnid pelinmata. and \Mre eoiisidered l>y .Mnrehi-on and 'rronst spei'itie and i>riiL'iiiisliealIy favoralile -iL^ii- of the disease. The famous tv[)lii lid |ieliiiinala eanie to an iiinoininioiir. end : they were found to lie due tn Jiediellli. The erii])tion de-iiriiated miliaria crystallina i- worthy of nmre e;irefiil eiiiisideratii ill. It oeeiir- iiiiieh nmre t're(|Uently in .'ases nt tvpimid fever than in tlmse nf other infeetinils di-eases. AlthiiiiLdi I eaniint mltco with I-niiis, \vlii> was ineliiu-il to attaeli SfK'eitie siL'iiiliranii' to the erii|itii>ii, I slioiilil not fail to iiieiilioii that of l.")() sneeessive eases of typhoid fever exauiiiieil t'or the preseiiee of siiilaiii- ina. these were found in iiiort or less iiiarkecl de^'ree in i'M. With retrunl .v)l//'/'/.t/s IMi ( n.vri.Kri ln.\s. 129 to the ntliiT iiifiMiiou.i (liMii,-c.i. I iiimv .-t:ii.' ih.-ii I Imvf oliscrvt-.I crvsliilli iiiili.ina |-;ir mihI >r:irl till' M\Cfa; :i\ l.itrr III i-oiir^c m| i\- |ilioji| H'vci- tliaii the i-o.-coln. — fn, 111 il,,. iiii,|,||,. ,„• tli. i| of ill,, -cniiiil to tl ml of the ihinl ,,r the Ix lis. Il a|)|ii'ai- ill the uijl-kiiouii tiiriii ot' loiin.li-li, dj,! rviiii,' in ^i/o from tliat of tlio luail oi' :ilillili;;' of the f mrlli iiicl \c-ii'li a i>iii to that of a lentil, if vvliieli. if t||. •oaii'^ei' to f ii'iii Jal-' anil 'ril|ilio|l lie Well i|e\ elo|le(l, two or •111 iiion- j:eiiei-all\- ll'uer etlliire>ee|iee> of ilTe- lllar ei illtoiir. l'"ille(l with rolileliN ot' water-like el 'I'll oarne->, tlleV euver the -kill like (Ir r iai:iiiali\e 'l'roii--eaii and l.oiii- comiiaivd tlieiii with tear-. On aceoiiiit .if tlie eiilorl ess eoiitellts and the e.\eeedilli;lv tl tlie ve-iele-., tlli'V may readilv I VerlookMl will 111! COVCI'IIIL; of I iiii|H'rfeei illiimiiiati .Not rarely tliey are lii-t a|i|.reei;it(.n the lower portion of the alidi iria ;ipp(-.ir vieiidm^r f,.,,ni tlii, -itualion to the clie-t and the lateral imeii, well as to the tlii.dis. The exaiifl jHirtions ,,f the the f orearnis am I the liMT-. 1 |,.|ve oh-i hands and the dorsa of the iWt, and ■III is usually scanty ii|kii t hut rarely ii|niii tin n der t crved I never U|xin tlif fai'c, irpetie eruption- aro m rare in ea-os of tyj.hoid t^ver that I lis eireiiiii-tanee of diafjrnostie importanee in the ditrereiit latum liom other iiiU'ctious diseas ot the tre(|Ueiit as-oeialioii of this varietv of \-ery expeneiie(.<| physician is aware lalaria, eereliro-iiiiial nieninL''itis, cnip.iion with pueiiinonia, intliien/a, and typliii- fever. Dnrinjr the epid, iiiie of typhus t'evcr at IJiM-lill ill ISTIt I iili-crv.'d nirpe- Ml .. |icr cent, of all cas herpes in ea- liir instance, When present at all, I li.ive foiiiid • ■s -if typhoid fever especi;il|y iiiHiii tile face, and here in the ii-iial situation-. It then appearel 1 1 I IVIR. .53; I'll,' .H.iirn'iKo ..r furuncles, abscesses, phlegmons, iiii llii'lii. 1 iia\r rVill i.li-rr\i'il lit'r llircalrnril iliir.ll\ in ililiililatnl im li \ i. Ilia I-. I lia\r tnrnnnlrrcil (■a-.~ in uhi.-li ri..iii ilii I.. M' lait;ir ..r -malli r I'liniiu'li- ami al.-rr— rs (ii\ii.i|Mil -111 . r--ivcl\ ii|H.ii liir -kin ami had |.. I.r imi^il. Tlir nm-t I'll i|iii'nt -lal ..I' liirimciil..-i- i- ihi- di.r-al a-jH'l "\' tlic trunk. r-|iirially ihr L;liilral iVMi..ii. 'I'll. II llic .lic-t and llir alii|..imii. lln tlii^h-. ami tlir anil- air |iri't'.|-ai>l\ allaik.d. l-'iirnm-iil. .-i- . .f tlii' -kin a|i|«'ar- to ociiii- \'ilh r-|)c.ial l'iii|nrm'\ at linn- wlini ty|ilii.id \\-\vv i- \ i.;l.|■l.ll-l\■ tl•<■al^d u il li tVr.|iiiiillv |V|.i .itrd and lA.ci diliL'-iy (■..Id l.alli-. .'-iillrr I lia\ (■ al)ami..nc.l tlii- 111. tji..!! ..t' Irral nirii! t'lirniiciil.i-i- ha- l.ci'i.ni.' Ir-^ (•(.iiiim.n aiiiiiiiL' ni>- |iatii'nl-. 'I'.i lir -ri.ar.ilcil iVmn llii- c Iili..n arc till' ali-co-t- 1.1' till' -kill that iiavc htiii i.li-t rviil a- a>-i.<'iatcd iiiani- ti-lali.iii- III' a (■i.iniiii.'aliiiLr |>\rnii,i. with -n|i|iiiratiiiii i.l' i..iiit- ami pnrnlcnt incta-ta^i- in intcniai vi-rcra. l'".iriiinati'iy, tiic-c iMTiincnccs ari' raiT. Bed-sores, wliiili l'..rnii riy wrri' ..m ni' tlir nm-t drcailcd .•^('(|iiii< (.f tvnhi.iil t'cvcr, have licci.inr an iiiir..nim..n niaiiit'r-tali..n with the (Irvcl.ijiiHciit of a rational iikhIc ..f ticatim'nt ami nl' iiiir-ino- i.f the iiaticnt. Kvm in -rvcif ca-o nf kiiijr diinitinii they lan generally he aviiidcd 111- alM.rti'd in tlirir early -tajrc-. Apart i'min cNccptiiiiial comli- tiiiiis, the iM-ciirrcncc of a 1>(m1--oic in inivatt prai'tirc. as ^v(•ll a- in the hospital, is a r(]iroa
  • s in l.!t p the o<'cii)ital rcL'ion, arc involved. ,\part from cMccdinyly M>vcrc ca.-cs f>{)nii>licatcd liv septic or other eipially irrave conditions, in which licd- .sores may ai)iM'ar a- carlv a< from the eii;lilli to thi' fourteenth a late inaiiifcstati f the disea.se. It |K'r>ist> from .Sl.i//'/o.)/\ .i.v/. ro.i//7./r.|/7o.V.V. V.il llir bitter |Hirfi<.ii of" tlir f;i)n'|. «i:i i^'<' iiiti> the [iciiiMl (,(■ \' U It olt.ii ,ijr.sj:rav:it.>, .umpli,;,!,-, „imI |.n.lr,„ t- .Mivni.lv. ■ iiiuii-. i;,iiii- .,fl,..|-M,r.- ,:,M Im. .Ii>iin^r|,i,|,„|_., ,;„., ,| .•IU1V:||.>.(.|1(C |>:irclltlitll<;illy iviiiMikcl, j, |„,t MiHiri, m >;it. It niav ii-i'rv.T>. .f III. 'I'l IC -illl|>ll-t ;ll|i| V .•i|i|>r..iiil.-.l l>\ Mill iiM'~l i.iiiiiii.iii i- that iii.liii'cil I II-IImIK- >..il..,| l„„|v II,, nil ill.. I,..,|. I, ,r,.„,.,~,||v |„ >\ |ir.>>iir.' simil r.'^;i.iM :iii.| .>ii ill,. |||,„t K'"- i'l till lit'lii»«' .ill iiiii-..iilMc| r.ili |>rcpiiiiii,.iu jKiiiii. 1,1' th,. Mat l<— , with III- williiiiil ,.,r|| .■\|iiiialiiiii lit' I l.l.nl- iva.hl ic ciiHLrnii^ I1.IIII-. w III .I.^Vli y :iMi| i~ alivadv -.nurwliat ili .•\|(.i-iir.' iif til. t-, Willi "-<•■•. 'I'lii'ii 'riiiiii, uhii'li I"* •' '■•■<' li (■ 'I.MlaiV.llillll, (nlliiur.! \>\ Villi li-i.vMtii.ii of th.. all^tci! |)art. with ih,. luimaii 'I. .M.ain\1iilc tlii liki' -ImiioIi. whiili, aft . i-li ili-rii|iiraiiiiii 111 111 a liariliiiiiiit- • Irl.irlinl in tlir.'ail- -Inllirl .■r M var\ 111^- liinr. i^ lliiiiw n i.tl' or 1- iviiiii\i..| arlili.-ialK. 1- I, wliiili aNii iiiav 111' ii||. -Illirlllai I.HllH |-|1|1|IC(||\|. II--IU i\MI 111 ill.' Illll- i^^-iii'LtIitIi'i ill i-|iriially N(.\-,.i'c aiiil :iil\:iii.i- iiiiir.' an. I iikh mihI.t;;!. n.'.'1'ii-i, aii.l Mil,~.',|ii..|ii|y l„. .xlMiat,..!. aiij I 1 iii-Iann- uIi-.tv.'.! ill.' ~a.-nil canal tu |i.irli.'iil:iily liii v .i.'f|ii\ iii.un III il a- :i w Imlc nr i^ MM willi ill., lii-t .iimI >ni.ar\ , ih.' >kiii an.l I.' may lie cxrulial.'.l. I I'a-.-. ill.' i|.'~iriiiiiiiii '11 II- :iImi iiiav lavc III -f\.'i-a IM' IlIMIll'l Aiiiill i.r vai'i.'ly iif |,„|-.,„.,.. wliiili, | may a[i|M'ai- -imiiltaii.iiii^lv III iniimi'ti.iii with .'.•ilivma ami ill 'il.' irliitcal iin.i .sicml ulrrl'.- Ill' iri'.'triij; ly iva-.iii (it' it- mil.!.' nt' • riLnii, III M'M'i-al. .'Vi'ii in I iiiiiH'i - |>lai'(-, .lev. loll n'iiioii-. ■mai.iii- ami fiinin.'nlon- (.ni|ition> It irivcs i-i^. ii, „||,.||| siijici-ticial ill.' r.'~iill lit' want ot' ii'iiiitlinc, .'onHii.'ntat various ,„,int>, ami it i> ,.-jnriall> A ;l, .•l.'JiiiliiK'v- in the .are of tlie pati. inl vaii.'ty I w.nil.l .iesiirnal.' tl lit. the Mlhenlaileoii- h. Hot alwav- re.iiiiil.ent p.i>tiire, lint it all ill pla.'o that are most Mllli(^•t(K| It .Il t.) proMire in ili. oe.'iirs rather :iiiiy liver ilie low-.Tiiio-t |Mirti if tl 'liptli of tiie aiiai f.l.i. I),.vel iw the <,Hiiteal r.'frion, pref.. le -aeriitn ami the . e-p.vial severity, this varietv .if IknI- opinj- almost ex.'ln-iv.lv •oeeyx, III the ill .a-.'- of itNl— .ire is imlii'.itiN'e ot' '■oii-tinitional .li-Miri.an.'e .,f mitrition. It is that vari.'tv tl iiiiavoiiial.le ev.'ii with the ,noiiii(I lat mav he piofiiiimily stuporous patients, who exhil criipiiloiis .'are. In t| le frener:illv 'II i-ioiialiy a.'.piires e.insi.l.i-ahl,. e.xtent without tl Allien. l.uiN heiii^r attra.'te.! to it, tl lit 11.1 maiiih-tatioii of pain, it le attention of tlie is iH'eiirrintr espc-ially l,(van-e at the :iiiniiii:. in .spite of eonsi.lemhle pr.iL're-sive .l....p-s,...,t,..l ,|,.. loll, ^m exhil, its slisrht or no al P teration. When I hav V, the II pr.)eess niore eloselv, a (1 -triietion, i> lieeii ahle to 'IV.', mlilii'aii.,: ipiH'aretl beneath the imaltere.1 enso, at tini.'s remarkalilv iiis or somewh.'it rclilcmvl 132 7 1 rii<>ii< 1 1 \ I u. i iil.iiialiMi- -kill. 'I'll'- -l.iii i;iiii nillv llirii l.r.-;iiiM t;r;iilii,illy ili-.i.lnnd |,lll|.|l ,-,..| Ml' cAih i:n.lll-ll \rl|..\s IVmMi iliil.ihili r 111 tl|iii;l,.|,i|l. M, iiliuliilc llir lliiliir;ili-.l .in:i 'mm- mihImv;..!!.- -..Hiniii- Ic, tlir iIim|,c 111' ili-lilKllv .1. in..ii-li'.ilili' llii'lii;ilh.ii. .\\A ii"U ili-i Ii.iil;i '•\ (litllnnil, [.iiliiil, iliitv |in- i.ik.- |il;i.c li'.iM ;i iiihiiImi' m|' -mill inv^uhiriy (li-iiilpiilol (.|Minii:i-, mill-- :iii iiiri-iiiii li;i- Imri |.ri \ ii'ii-ly iiiinlc. ll i- 111. .-I rli:iiarlrri-lii' "I llii- variily ut' ln^l— mc tli.il I lie ili~triirrniii j, t;||- IV i\lrli-l\i' liripU lliail "miiil I"' -ll-lxrln I I'li'lii llifiAlrlll i.fllir |ial|ialilr ililllliall v liir I liinniii^ m iii-ii.!niali f llir-kiii. ir i\Irii-i\r iiiii-i"ii- liavc lni'ii iiiacic, nr it iIh' lliiiiiir'i -kin lia- Imiii |Mriiiillc iic..-.-ilil.' in in:uliir li.twc n ill.' -cvcnil viiri.lii- lit' liril--i.r. - .l.-.i ilnil -mli a- lia.- tmn ma.i.' liii |iur|i.i-.- ol ('iiiii|ili'liii. -- ill |ir.'-.iitalinn. ( Ml. 11 till' (litli'Vt'iit varirlii- aii' inri'iiiil inlii nil.' aii.illii r ur a|i|iiai' -imnllaiiMin-ly 'ir sin. r--i\ civ in liii' -aim' iii.liviiliial. ( ir.'iiin-.'iiiitil ;;aii^n'ii.' .•!' tlic -Kin in "tliiT >itiiati.iii- llian till.-.' thi'iatiiiril ii\ linl— iiri-iir at .illicr liini'> .111 iiai't> .it' tlii' -kill that liav.' li.'.'ii Mil.j.i't.'.l l.i ac'i.li'iit.il tnnimati-m m- t.i till' I'trt'i'l- .if ni.'a-niv- rmiiluyitl tm- lln'raiK'Htir |iiir|i.i-i'-. 'I'liii-. I liavc.ili-.Tv.'d in -iliiali.ni- w lirri' [irr\ i.ii.-;y .. ■ i lar.l-ii.i-!' r, :, ilry ■ ii|«. nr-.iint' .itlicr-'i-<'all»'il rc-iiM'italin^^ aL^i'iit liati lifcii a|i|ili.'(l (■ii-.'imiM'nlM'd uaiiLTi'm- .if tlic -kin in an aic:i oi' (•.im-ii.in.liiii; toiiii ami cxtiiil. Al-n, in -iliiatiiiii- 'hat lia.l li-i ii cNiiii-i'.l for an .'Xc— i\ cly Imi^ tun.' In ll,.. ai'tiun.if a i.i.iilti..' .n" an icc-lia^s 1 liavc ••x.c |.liiinally nli-'Tviil the .li'Viliiiimi'iit ..f .'iilan.'.iu- L'^m^rcn. — iiatnrally mil inclmlin.: acute luirn-; iir tV.r/ini:. TIk' ...'.'iirivn.'.' .if true ii.inia as a -.'.|iU'l l;J3 .1(1 liii iiiu alrno-r .v.l„-ix,lx >,,..,„ ,|„^ ,...,||.. I,-, ,n,„Mi,mlv tl,r ImmhI. «r:,,v.ly '•''■'■ "I ''"■ I'"'"- '■'■ i" ''"• ■'^ill^''- T"'. .a--^ n|- ..,„M|,I..|,. Ml,,|,....i:;, h I..-- al.-..lMr,K ,,r .,11 III, l,.,ir.,r tl„. I,.„K. tli.-.l I l,;,v,. ,,|„..|.v„l' r—ival. -,•,.,„•,. r,o,„ ,^|,|„,i,l l,.\, ■,•„.,,. |,,rlL:,„ urii.|u.. ,Mi.| ||,.. l.-i.M, UM- vMivrU nl:,l.-.| t,, l|„. ,.ii:.ri,i,-,| ,|i,,,,-r. 'I'l,,' I,.,, ,,f |,;iir n-,i.,llv l„..J.,~ .Inrin^'ll,.. L.M „,.,,k ..rtln- .11-,:,-., .,,,.1 ,i„„.., 1;,, '"'" '■•"'^•il'' ■ '•v.-.i u|. I,, ||„. tin,.- «1„.|, i|„. |,ali..|ii- 1V-, ''"''■ "■"■'' 'l|'."i"M-. -I'hr lUlirMN ..,., 1,.. :,--,i,-,,| „i,l ,„,,.,n,|iv,. '"■'"■'".^ '''•" il"^ ^ill L'r.Mlu:,IK nrain tlnir |.,ir uiil„,„t Mitili.iMl anl. •nucTillv. tl,.. Ii.iii- l„ „„ „. |„. ,,.|,l;„-,.| i„ ,vrt:,ni |,,-.rl- uliil,. i, i- ,,ill liilliiii: mt in oil„r -iluati..,,-, ri„. ,„u hair i- :;, n.Tally .hicl.T, U;uA.'V. an.l I- lii-l.rlr~~. ||„„, traii-vrr-.. -■.li,.,, ii i-oli.n (mi- -oi,,,. .li-taiir... nnlv ll,rMiiu||,,„t ,|, ,,,,i,,. |,,,.,|,_ ,„„ ,,„„„| |„„ ,.||j|„|,.__,, ,.;,,, „„^ -IMIMV lliat i- |irnl,aMy a-vMial.Hl «ii|, ||,r .iirlin,-- alirn.-I , -taiillv |irc>rlll. Afi.r |.rulra,i,..l ,,.v,..v alta.'k- of iypl,.,i,l f.^,,,. ,|„. nail- aiv ,„,( ninlv tl,i„. lu-t.Tl,-,. an.l Irial.!,.. Onlv in ,,n.. iii-lanrr |,a\ v I ,,I,mtv-,1 ''""' ' ■ '•"•"l''''''l> 'i"-"^Mi ,,tl(V,„„ il„. Iin-.r., and in part aUu ln„„ ''"■ '"-•-••""I llM-...vu,n.,| i, .fill.. .„-...,,(• t,„a| aln,„.,.ia [.ivvion-lv '"""' ■''• '•'"i>l"'-. -lii^lit .'lian::.- in ll„. lin,:, r-naiU, tar |r-- r,,ni- iMMnlv in tl„. tu..-naiU. arr tr,.,,n.„tlv nl,-,.rv...l .-vrn altrr ,.,-.- ,.f tv,,l,„i.l t.v.rof Mi.Ml.Tal.' -cv.rily in y-mM- |.rr>,ms and to u lii.h \ Vo.r,.| ' '■''l''l .illrntiun Mianyy.ar- a;;,,. Tl,,-,. ..„n-i-t in iran-v,,-.'. .^nnT- N- ,i,'|.r,.-M„n. an,! un„,N,.- in th,. lH„|y „f ,|,„ „.,i|. ^i,;,.,, ,„„.„^ in llu. Ma-,. „f n,„-t |,r,,i;„M„l ,|,.|,r,-H„n ,,f ,1„, l,.„iiK. n,,,,.;,;,,,, „f ^|ln.l. .tH,l„. l,K.al ,.v|,r,-M„n. I, i. i„t..r,.-,in.. t,. ,,.;„. that l...|,in,l till- ,i,.|.r,.-ion „r ;;r..,,v,. il,,.,-,. lr,-,|U,.ntlv ,„...„r. a n„,n. .,r !,.-,.ratnn.-,.nrv,., U< „l,s,'.rvati,m '";'"■'■""""""■"''''"• ""'^' ''•"[""•'■■II" int .,f f„rtl„.r ..xt,.nsiv.. inv,.-tifrati..ns .'.n tl... 1'^'" "I In- |)upii- an,| Mi,.,.,.s.„rs. an.l uill nn,!.,nl)ti.l]y ,..nstit.itc the ' /)..<^-,/,, .1,,./,, ,-, /;/;„_ _y,,/_ |j,j^ ^n ^ :.,:[..; ,.„a ,-.,ii ;.,.. 1^4 rvriioin ii:vi:i:. \y.\A~ )',,r -nh-Cfiiicnt stinlio of the triirili- ('(im-c of tyjilioid fever. \\ ithoiil (loiilit. till- leiii|iei-;iture-\ari:iliiiii- in I Ih> roiir-e i>i' l\ pimid f(\cr :nv Im lie eiiii-i.leivil a- llie e\ |iiv--i. HI n|' iiaelerial iiiti i\ idit i. in anil llie n-nltini; i:cneial i-lianL:i- in ilie ImmIv ami llie \ i-eei'a, in eonneeiinii wilh wliieli. nalin-:ill\. imliviilnal ennililion-, and e-|)i'eially the |)li\ -i<'al -tale iif the |ialient hel^ie the allaek-. afe e(i-(i|ierative in the liiUe-t (K'lZree. \\ ilh llle ei .nei |lt iull ( .t' tile fe\ (T a- tile e\|ire— inn of the -|ieeitie ni.'iiiid eoiidilion- takin- [ilao' uithiii the l.od\ . i he oh-ei'\a- tion made h\ Wunderli.'h am! hi- |in|iil--. thai th( \arion- analoinie -ta'^e- of ilie t\|ihoid di-ea-e-|iroei-- are re|ii'odiiei d in a|i)iro\iniatel_v tvpieal iii-e- in the foi-in ol' the eur\c. i~ in aeeord. \\ inideilieh even adni--e. eeHain di-i;neti\e tiaini'e- of llie l\|iieal eni'vo |ia--ed thloii-h the I'elirile eoin--e like a rul line. The -tatellient ol Wiimieilieh. thai i;ii--reaeliinH' diauuo-tie eoiiehi-ioii- ean lie funned from iheeiMve and iVoni certain part- ot' it. i- lia-ed n|ion ihe-e taet.--. ■file seielililie >IUiiv of llie fe\ e|--eiirve Il|ii<'(l a l:ir:;e liuiiiher nf elin- ieiaii.* durinLr ^^unlle^liell'.- ' time ami liir muui\ _veai> aflei-wanl. Amniit: Wllliilerlieh's |i|i|iil> vvlio ilcr-er\e eMieeial ereiiil in t Id- eolilieeliiin, 'I'hier- feliler.- I'lile.' l-'ieiller.' Waeli.-miith. ami ■flioma>' >linui.| he mi'iitiened. .\ii e\eeHeiit Miiiiiiiary. liai?ed upnn |ierMiiial e\|.eri( iiee. has l.een made liv (IriessiiiL'er.' 'I'lie |Uililicali(iiis nf iliiumler.' I ,ie!u rmei>lei-. ' .iiii-Leiiseii,'" /iiMii>.>iMi." ami Imimi-maiin '' eo|l^litut(■ll fiirllier a mine of imiKirlanl nli- .-ervatiiins heariiiL' iijion ihe fe\er ot ty|ihoiil. 'I'he a\'eraue (hiiaiion ol' the I'elirile jieriod in a moderately -exere oi- severe ea-e of t\|ilioiil fe\er i-, a- ha- lieell mentioned, fl'oin three III tlmr week-. ( ienerall\-. the M'hetnalie n |iiv-enlation of the tein|ieratnre- eiirve i- lia-ed n|ioii a duration of toiiv Week-, the eharaeter of theiiirve liein- i-talili-heil for eaeh individual week. It a|i|iear- lietlei- to nie to di\ ide the (li-ea>e into ihiee of t'oilf \K\n>. and ajiineeiate fnnu the ollt.-et 1 Wiin.lirli.li, .1 A 1 iJ.,,.;.>l. Il'ill. H.l ^^i Is.".;. :ni.l l!.l. ^^ii.l^•■.^. yir.-l,. .1 II, :n... \\.\ iii . lse,l /), 77,,--»/(.»,-7/-;rom l^ranknihrtt.. 'M > ,\ . I.iip-ir. ' ,(/■.•/,. I. /,/,„.;. J^ i!,:ii . l!.l \iv. ■■ /'■'■'■ l'"l ^^''i- •,l,w,.',/. //.;//. . li.l iii ' "•'"'• "'!■ i^- « ''"./.. Mil, v.. S. :!:;! u. VJT. ' /•'"■■ ••''• - Ih;,/..,,-/,. A,;-/, t\ l.i:„. Mr.l . li.l iii. •> c.llrrt..! ir..,/.v. ■■Ty|.li..iil Fi'vrr" in 7'V,„ «><■»■« U,n,.ll„„-h. l.iel«ni.ci.'^ttT nil.l llaL'WlKll.ll. n...l,„.-ht„wp;, .n,.l Vrr,,n-I„- „l„-r ,/;,■ .\,.„; ,„/„„,,./. s halt,,, \V„.sn-R fifi th'hrrhnlirn Kfnnkhritm, Riislr. 1808. 1" A7;„, ■-•,■;,«■ .v^<,/,V» uhn- ,r,r li,hn,i.lhi„n 'Ir^ .\/„/..,„: „„li „/./,iii liiit ki:lln, Wussrr. ISsr,. ■■ |)i, l,i,'lu,-ivn Knrni.Ti di'^ 'lypliii-. WJlmnui.' ^ S,niiii,lnhii lilni. V.:i-t,\ " In :i iimiilier ..f -nKill.r p<'i--in;il |iii!.li.-nli"M- iiml -iiiiihir |.ul.lii"in.in- l.y lii-- piij.il^. '■' Zii.ni--..n iinil I inniiriiKinn. I/:.' K„lt,i;issr,h.l„ni,ihn,:,,lr:, Tiiph,,^ aMonunahx, IsTO, SYMl'Tu.\rs AM) ( iiMri.K AIlD.y.S. i;m ti'i-f ti-aiisitdi'v, ill-(ittiiii'(|, miiiI v |irc- wr.w lie >< ■liicw lial loucr in ilic mnniin;^, :inil a \i\\ li'nili- lit' ;i clci^rci- lijiihci' ill the ia fiiiiii:, ih.in uii- nliMTvrd in tlic Kiticiit w lull' 111 a -tatc ot' licaltli. Ill <>tl |ialifiit> a t(iii|icraliirc IS ( (ir ~(iiiifu (■\('iiiiii:. I iihrr -[Hiiiiai liat liitilici- i- iM'ca-idiiaily altaiiicd tuwaiil iiiiddav nv r \\\nvi- tV('(|iii'iiliv attiT |ili\-ical and t t'i'diii (iliitr Iclirilc di-ca-f- \\\\ iiiin-iiai liiictiiatiiiii> lictucni nKiniintr ami cvciuntr ( V i •)■ 'l"lii> in-Ial>ilit_v lA' tlic tcin|icf;itiii('-ciir\ c diirinc- ilic ]iciiiid nt iiicii- )ati(iii i- ijiiitc Ljcnc rally a.->i)riatcarticnlai'ly in the cvmiiii; i> dt'tcii nrirli nmi-c i-apid tlian it i> dniin licaltli. I liclicvc that ^.Tcalcr iiniiortinicc than is cniiiiiionlv L'ivon shoiihl he atlarhcd 1(1 the |inlsf-lrni|ici'atiirc ratio iliiriiii: the |icriiMl ot' iiicilhati( il nh m. ■crvation (it tins ratid at tins tunc iiiav ccca- sinnallv lead the trained oh- server in the rit;ht liireeticn. Invnrialiiv. ami aliimst in a ty|>ical manner, it cei iirs re- |ieateilly that il\v<'liers in a hii.-|iital, tnr instance, .-ervanl.s, laliiirers, mechanics, who ex- hiliit iiiilv ij'enenil sviii|iti)Tns and a|i|iareiit!v are tree t'nim t'ever. are sent In the hiis|iital with an imietinite iliaL'nnsi.s, and snmctimes with a siis|ii- eion dl' sininlatinn. I'nder sni'h circumstances no es|)ecial or^ranic alleratinn will in tact he t'diind, and didv on carct'iil ohservatiiin dt' the aliiiormally marked tlnctiiatinn in the dailv curve and tlie inslahility df the ]iuli5e will atteutiim he awakened td the fact that ini- ]x)rtant proi esses are takiie.'' place in the hddy. The ex|(erieiiced clinician will then. aiiinnL"- dlher thiiiL's. think dt' the iiKaihalidii-staL'e of lyiihoid lever, and recdmnieiid rcr-t in hed uiili a rotricted diet. < >fteii the occnr- reiiec df rejieated chilliness at the licL'iiiniii'j- df the fehrile staire and the sulixijuent characteristic elevatidii of leniiieralure w ill show how justilied wa> the caution oh.-, rveil ( Fiir. !• i. l-"l'. .1. -Tniihir;!! UK ( iir\ • li-.ilii a t a-f - if t\ [.h. ,i.i fi'vcr ill a uaitiT, e.^'-iity ^i\ vrar-^ ii!riiiHlI\ wide (tiiily fliH'tUJUi'iii'* On ttu' Icii'h diiy 111.- fi'lirilr |Mri.'.l ..f a m.nl.Tat.'ly s.^vin- attai-k of typlh-id ft'\' T piir^uiiii; a r- ^'ular r.mr-r si-t in SiWtl'I'oMs AMI CDMriJCATfOXS. 137 Fli the til->t \vc.-k nf fever llie elevation nl' t erii|iei-:iliire a .1 (leliliitive lieiixlit nf the felirile pelicMl lii;;liel'. I'lie Ijiixle (if ascent nf the tenipenituie-emve, in ecuil itaiii- lh( in j.n'iienU, u|- it mav ri- tinini(.nlv the entire lir-t w jiied l>y it. This niodc (if |ir(itiacteelf eCK IS liecll- t' ini|)(irtaiice in ai-aeter- le eiii-\c in detail is chanicteri>i le. Tlu ditfercniial diajrndsis. In additi.m, the reniarhalily iiiiifdrni, el istic e(iiir--e (if this jmrtidn >4' t temperature rises in such a maimer that it i> reirnlarlv from (Kl'^ t. 1.0° ('. I exhiliits n;.dier in the cveiim'r than (in ll le i>receliir|iier d..,ilv var take place either for a few dav> or tl iatidiis than the normal mav irouirhoiit the entire fchrile stre that thecdiir-eof the temperature cldsely ajipnixi, Mates that of le -ell-c. tinned fiver in the tri 111 severe case-. Stated in d This feat lire is oliserved almost al wav^ clail vari.itions onlvof from 0.;!'^ to 0..')°(' "i ir llic (liM'a.-c |iiir-ii' a iiiilil •aniiicc a,~ carlv a- tlic iiiid- lllllT HKII kcl ca-o llic lii'iiimiHii:' 1 if thr t'diirtii - (Icfcncd to llif tliini or . I'k. 'I'Ir' iliiiati f thi- 1 mill in -( vciv ronMiirlircllU'Ilt Ml ol the curve is vanal)l(' ; tioni iliicf to five ila\^, i-irclv lonpr. 1 is i-|)cor- tion I'i tin (iir\<' iliat i- iiio-t i'rc<|iu'ntly -liorti ncd, ill drlincd, or inoditicd. It iiiav (Vfii riiiiaiii wlioily uiidtvclopcd, >o liuit till' .-ta^M' of d(-'cndin;.r curve i'ollow- directly that of contiiHied fever or rciiiil- icnt continuiHl fevei'. T le staiTc o th -eelKlin fehrile curve, liicli. totretlier witli tlu jMX-ecHhiiir, corre-iHiiKls to the anatomic proeo- of eleariiiiX u\> nf the last mtcstiiial ulcers aiu 1 of ju'ojrre.— -ive •leatn/.ation, is freliei-ally ])laee]>ropriately de.-i^niated that of steep eur\-os, the variation^ in teinpeniture are often more iiiaike.1 than in liie previou> sta^re. so that persi-tently or for e of di-eases presenting,- a true intermilt.nt tyi>e of fever. Tempeniture-variations of from 2° to -J..-)' or even ;i°('. are un(h'r nicli cireumManees not SYMrroMS AM) coMI'LllAlt'iys. i:w iiiifMiiiiiiiiii. Tniulii' lias wiili jinipiiciv ]»(iintc|ii'<'ial caM'^ tlic df-ccut of tlic curve takes |ilacc in >ucli a nian- lli !■ lliat the uiornin;:: aiiaine time tlie decline iu tlie nioiHiinj^ t(iu]ieratnre at the liej.nnniu;^ ot' the ~tee|( cur\cs i> <.renerallv V of the fehrile >laire may not rarely lie com|)re->ed into a period of thr« n>iiiu<^ • the fel eelueh a course iua\ he i In- ti'ated by the diauianunalic chart of Wnnderlich i I'ii:. 1 I ). We arc iudelitiil to the c\treniclv eai'etul and paiu-t:ik em— en and Immeiiua tion^ ot' Thomas,' .liirLTenseli,- Zi ~ucli eoniiilete kuowledu'c ot' the conr eour- tcndeiiey of tl ot'tlie afternoon, ireiierallv lietweeii I if tl c ot ine (law that in the late liolir- 1 tive and -cscii o cloc Iciiiiieratiire is likelv to 1 )(■ reached. 1\, the maximum l''rom thi- jioint oii, into the iiitrht d until morning', there is a (rnidiial decline, so that the icni])er;itiiiv lly reaches its lowest poi'it hetweeii six and nine o'clock in the nsua iiiormnix. The temperature-curve often exhihit- a noteworthy deviation in i)er- soiis who hy reason of their oeeu|)ation tr.nisfonn wr\\t into dav. Thus, I have ohserved, es]i(>eially in liakcrs. the heiirht of the tempenitiire to occur in the middle of the nitrlit or eve.i at an earlv hour of nlo^ninL^ and the ({(H'liiie in the curve toward the eveiiiiif^. The ajred and children also occasionally exhihit this inverted type of temperature. It is notowortiiy also that for days and even for weeks mori^ than one elevation of tempei-atnre may take place in the course of tweiity-fonr hours. Xot at all nirelv there are two stieh elevations, one of which ' A,:-/,. ,/. Ilrilk.. 1W4. ■•■ Kin, \i,„i:,.,, „/„■,■ ,/:., lirh.nmUu,,,, ,)rs A>: 'il'^ir. 1S(')(). ■finnltiiplmx mii Imltciii Wnsi' J>ii lirliandlu'ig lies Abiijininalfiipltii.t. Lcip.-ic. tsTO. 1 in T) rilnlh ii.vi.n. "■iiicnillv uciMii- III till' inn liiiur (if till' i-vciiiiii. Idli' of liir (lav . \. ir ii-- (■(! iniiiKiilv at M ialc ^\■ llulill;.^ till' nii:lll. Mnrr lliall tun (■l(\:irHi|l> I'f tciii|i('r:ilun- in llii' IwciiIn -linir hum- a:c li» tVci|iicnt. ( 'iirv<'^ \Nitli twn (ir inure -iicli clrvMlion- in lliv cniir-c of' tlic ilay may -iiiiiftiini'~ pcr-i-t tlirnnnt tlic ciilirr ta-lii:iiiiii. Tiny arc imt .--pccially nirt' in ca-i- in wiiiili tlir ciirvc in trcncrai txliiliit- a IfiiiU'iicy I" maikcil i(ini--iiin- aiiil intcruii— i"ii- I I'iir- I"')- ('uiii'tTiiiiiy tlic caii-c- nl ilic niulli]il<' llnv -f III.' ■! Fio ll.-TempiTntiin'-i'iirvi- from .1 iniM (■.!>.■ (.f t> lilu.i.l fi vcr ol rLBUlar cour.v' ,^ilt.r Wander- llchV 1 )a\ Mt ii • \ ISO T 28 IS 30 31 32 33|il 35 3C 37 38 39 ^o•^^ on- VHll'M'flK'Lr clivatiiiii-; of f('in|M'nitiirc nutliinir i> known, cspiKXilly witli rctrard ti> tliiix' that |Hivi-t rcLTiilarly i'nr a cim^idcniMc tiiiic. As a tran-iinry jjhfiKiinciiiin till' inaiiiti'-latinii i^ imt at all imvly raii-iil liy cMi'nial ili-tiiihaniT-, in part hy iiU'iitai nr phy.-iral fxirtimi, ami in part al-u li\' cniiiplii-.itiiin-. '['\w -ta>ri' iit'runvali-ri'ni'c, likr that of iiirtiliatiun, ha- liy nu mran- hivii -ullliai'iitly -tinlinl with ivjation to llir -lati nf the liiMly-ti'inprni- tnrr. At tlii- tiiiir al-o the nirvr ixhihit- a typiral • har.utcr in I'ar syMrinMS AM> cnMri.K A lloys m iri'ciitfr ili'irn'c tliaii in iIm' m^v of ilic oiliir uciiic iiii'cciiuii~ ili>c;i-(-i. I'lii- i- (liiiil)tl»-~ due to tlic iii'M'c [initrariol .liiraii'iii ni ilic |iiciriliiijr tMii'ilc >taj;f, which naturally niu^t rxcrt a cniiT-iiniiiliu^i iiithiciiic all x'MTc ami iipiiii tlic turni 111' the iiirvi' iii the afcluih' >lai;r anil in [larticiilai'lv Inn;,'-]'!'"'!'"''*'"' '"a^t^ luay cau-c tiic -taiif nt' cnnvah-cciK tn lit' cliai-acti'i'i/cil liy cinacia The tilNt |)eliiMl alter i iloiiTliattKl a^ the -ta^'e ot' -111 |mi'-ues such a coui--e that. (Hi le>s cuniinniilv (in lin' next sui t(i .'1()° ('. (ir V I'dUl ' ' - iii' >n. il.'l ci\e~ eeuce in: >n( iiinai tcnij )ei-a It! ic nil irniu;^- f'ul d'eniiuL; : .lay, e on, , the tin s tini afti av lie iniKt a|i|irii|)natelv tiirc. Ill detail, the eur\ e liiw ini; the la-t t'clnile dav. ■ ImkK -telii|ieiature declino rr a t'eltr'lc -tatrc iif rather ..evcre iir liiii^-|inilracted eniir-e, it remains alxait ;>•)'"('. or emisideralily lieliiw, ciintinuiiiLT at tinie> up to une and a halt' ur even two weeks, and larelv even Ioiiltci-. It' the |)atieiit is kept at re-t |)hysically and iiieii- ion- at tlii- time pMiei-ally reiiiai'i Tliev are then -careelv tallv and in licil, the ilailv tliictiiat unusually sliudit — sli^rhter than tl inoi'e than hall' a deirree. ixcuelldlv teinpei-atiire iisivs little altovi 111' convalescence, the da le liln -loloiric. () that 111 the eveiiniLr the liodv- {(j\ at most to .'Jti..') ('. With tl le nroirre- ilv tluetuatioiis ill the temperati ire lieconie ~ome- wiiat i^reatci, appioxiinatiiiLT the |)hysioloixii', and thi'ii the temperature lieijilis to rise aiTiiin. until, at the heiriniiiiiir or the end ol' the -ecmid week of the at'clirile sta;_'e, iiirely at the heirinniii^r "• the third week, it has re.iclied the le\ el normal to the individual ( FIl'. 1-). Hoth duriii;; the sta^rc of sulmoniial teinpi'iiitiire, as well as durinsj the sueeecHlinir ])eriiMl, the course of the tem|)eratiire in eoiivalescents, how- ever iiuitiirm it appears to lie durinir rest, mav "xhiliit marked iii>taliility. All ]xissilile external and internal iiifluenees — sliLdit mental cxeitenient, visits, news, hojics and disa])])ointments, sli^rjit dietetic errors or transi- tory ■oiistipatniu — now irenerally <;ive rise to sudden, often not ineon- sideralile, elevations of tem]H'r;iture. Even tliou^rh the temperature do nut rise I'roni the suhuurmal iniieh ahove the itoriual. the elevation is rtheless attende It'nt^ a- tiirt'i- wi'i'k> atul t'vrn litii^iT at'trr (li't'i'r\ i'>ot'iu-r. m-^ 142 TYi'iinii) n \i:n. anil -ii<[Hri(in ~lii.iilil (-ixcially uri-c tli;it trie iiMrliid pnM'c.-s lias not fiiiinly -iili-iiliil. A> a rule, ri'iiiKlt-ciiici- ur rcla|i.~<'> tlii'ii M<'ciir. I lioc ari', turtliiTinuic. \<> lie cx- |icili'il it'fiilarLli'iiii'iii 111' tlic .-ipIccii <|. iImc- lint (li-apiifar uiili rcilurlinii ill llic iMMly-lciiijiiratiirc. Ii u ill lie in,-lru<-ti\i' at tlic (•i.iicjii-i (' llii~ MTlinii Id iv|ii-c.(iii(c liair-nt il.-c. that of ll I' Au\ e lielliMl ot llielllia- li"ii aii eoiiiinonlv in ai and then e-|)"- hilts. it lna\' take loiiifer. here also («■■ eiif, however, cases in wliieli tl •riod of ascent IS shorter ; thus the teniperatiire, l'i>iii;r ■h hv stt may reach its hei^dit in torty-eieht hoiii-s, or may e\ eii in still shorter time ris(> at a siiiude jninp to the iMi.MiinillL'' of thele\elof tlieeon- liniied fe\-er. In the la'tef I'Velit the t'elirile period often >ets in wiiii a chill, which is a rare occurrence in ca<-es atlendeil w itli a :-lo\v, step- like ascent. The old rule of' \\'iindeilich, that in a ea-e of typhoid i'ever the teiiipcratiii'c atti r the ccent I'.oes Hot niarn to the iKn-mal e\-en diiriiii.'- the niorniiiir hours. >till ImhU L (1(1 for the overwhelniiiiir majority of all casc~. lint rareU , and sy.\fl-lnM\ .\M) ( iiMi-i,i( \II0SS. 11; ihrii mnstly ill inihl or :ilMiiti\ .• ca^c^, ili,. .-tcp-likc M-cciit of tlic t. |Mr;itiirr i- iiKxIilii'tl l.y :i Iniii-itcprv (Iccliiic to il II' iiiiniia I or Im'I, lie inorrilliir. KMcctliiiirly nipid a-rciil ot' llic initial l«lillM|-;illirr '-^ cliroljii tcrcl far more t'rc.|ii.iitly in cliilihvn than in a alike — a rapid a-c.nt ol' tlic tcin|(cratiirr i- |.c.niiar ratlirr to tlic iniMcr, and llicrcrorr to llic -111. ft l'"ar u'l'cat.T variability witli nlalion to tlic dniatioii and llic Corni of (T or i'\cn alporti\t lir iiirvc i- rxliiliit.d l.y the period of febrile elevation tlian l.v iji inilial -U\irv. \\ Il ir .■!ir\.'- of a feu c:;-!-, niild and ■rww, are 11 .1. -ide, riotl riotlniiLX '.)' a t\|>iial cliai-arter \V(.idd _ la.ed >U^\. If, II' irnularitv \mI lio\vr\rr. iaiur M'i'i.- (.(' cjiai't- aiv -tiidii'd, m.ii 'II'' \>li"li'. 1 l.-iivni. W imdi'rlii'li lia- di>liiii:iiis III >> ., |„ I- ,11,1,: 1. 1 l.iuviiti |u.-iil\ luo :ni.l lliirl_\ lliiir i1m\.- hi HI |„|- rrlll ; nl IIMirc lIlMIl I ll i ll \ I ll I<1' A.W- ill 7.1 | 'I T lllll. ll' ill,. ,,|.|, I- cliil'livii -iri- >(|i;u-Mli.l iV hr \ .p|iiiL.'rr. ll will l,i- >.tii ,,i^tJ,i,lK ll.^il ill.- t"riii.r iiilliri- :i|i|.r.i\niiaU llir l\|.r "f :l.lull^, '1 li<- ihinilii'ii "I iIh' lis v\- u J,- : 1!, I'A. . ij iw. i.i'\-i\v.. ;iimI lliiil\-ilir,-,- ,lii>f Mi.if lli:i[i lliirn-llin ■ 'Im\- lli . hiMr, ll l.t lui , 11 i-U\i-ll ami loiirliin yi'tti> ol,l lui-luHlVf 1,11 11 |„.i- , . hi 1 1 M 111 , liiMnii ii|> I.I llie IlL'C "I I. II M 111- ■I |i. I , , lit. i \\ illi rc^iirii 111 llir [in iiliarilir- in iIh' coiir-r i>\ llic IiAi r, lil ii~ imw , Ju\iV till' -I'vnv and llic -iv.n-l c a-« -. I'.nlli llm--.' of -Imri ilnialii'ii ;,,„! tlm-c iif ri' iimlractnl ciiii-c in ailnll- ii|i In llic lliirtv -til'lli or tlif tlirtii'tli vrai- iif lifr Hviirralls rxliiliil a cnii-iilrrMtilr ili;:n I rlc\aliiin ami n.ii,\M.rth\- rrt:iilarity uf llir lrni|H ralnrr. 'i'lic ilitVcr- cnci' lirlwiin in.iniinL:- ami cviniiiL; t(Mi|M raliirf i> iimi'ially n.il iiioic tliali unr ilr',^|-ir. iit'ttii li--; w liilr tlic aviraur iMurnini; I'Vil i- liuiii ■">!• ,,, ((I C, anil tlic cviiiiiii: Icvtl ii|) til |n.."i < '. ami aiinvr. Of il-rlf it i- lit' i.''r;ixi' iiinrii it uilli a liii^li iMi, i.r th. .h- iiM- ii.|ii|irralnrr lint .-liiilit niiiriiiiiLr rrnii--iiin- taki- plarr, i-|irrially ir tlir triii|icratnrr n main- iiii- intlnrnrcil in -|iili' nl' tlir irii- |ilii\ imnl III" riilil lialli> nr utlitT anti|i\ rrlir IrratnirnI ( l-'ii:. 1 I ). ! I" ihr l(in|i«|-atnrr lir i-|iiiially liiuli, ]iii>-ilili' riini]iliratiiiii- >liiiiilil lie cant'iilly Innkci] liir. S(|itir ciiialiliiin-, |inrniiiiinia, ami M'l'iind.arv niciiiiii;iti.- arc (-|iniallv tu 1)1' l<('|i; in niiiiil. ..•,,.U-T,.,ii,H.r,it.i..-.un. rii.tnaiii-i.rtv- \ ,^^, ^^,^.^,^,^, ^.^^|_,;_^_ pli,,i,l I.Mr in ,,„.m..|ity iM.i >i.ir'' "1.1 111 llviinlly M-Mr.. I'.iiiri^.i uillii.ilt spiiiiil .■.mil'liin ,,,,,1 f;,\.,,,- i, intcri'll|)tf(l l)V 11110 tii.rs. |i,.iitli.in till f.iurtiiiith liiiv .if till. .li>. 11-^1 , i • •'• III' murr iiiaikiil intrnni>^i iliininiitiun in till' .-izc III' till' iml-i'. "illi riiii-iikralili' incna.^r in it- Iniiiiciicy, staniix tlii- oiTiirn-mT as triir .'iillaiiH' ( Fiir. •-'•".)• I---- <'iiinnii.nly, ami then e-ixi-iallv in imliviiinal- hetsveen tlie a-cs rriii'|-all\- onnvirtcd into .11 i ic*" 11« /I rih'ih 1 1 vii: liiiiilti ril Ml- cvrli Mil III |( riiiilli III li \ I I 'V illi 'II tV. n ii'-i - "f IVmiii I .' ( . ;iiitl iniilT iM'lur.n MMTiiiii- :iii'l ' \' nm:: h iii|" i:ilin< - ( I'l-. liM. ■IIIAl 1 1 1. IS Hull !■ ■ 111111111 l"r I il:IiI \ - unci 111. Ill , ( ilhri- « illi li i^iil.ii In III i| ii iiii--iiiii-, III' — iiii'l till- :i|||' ilU h -I \ lie CM -I ila\ - "I l.i;:li iiiiiiii il |i \i r Mllri'iiMlini; « itli hIIh r- il r. inllli ill iMiiliiiiii il II A 1 r. niMiih , 111 ins I \\" lull' 1. Ill i- rli.ilMc'l' ri/i i| li\ 111' 1 IIIIIIII ;I11IIIIIl; 1111- -l;|lli I IhMl III'' lll'jil ;i\i ywj_v t. iiilii iMliin ||\ -llli-illi - W lllli'lll lll'li M-l till r.iiii--li.|i- "I- will I\ i-iihili l-icli TmIiIi- "ImiIx (IllrlllMliiill-. 'I'll -- I'l 'lllMliill TM^i - llnllMclrll .lll'-l 111 lilliilll 111 .1 -I'Srrc .1 lAllillit illi t-|M rial tVi i|iic'iir\ ;i I'iriii "I I' ni- si w illi iiiMiiviil II iiii--i"n- 111 l-allllc -rill' ami iiilrriiii--i'iii-. I \ I n « lull III III! -t ra-i- tl •■ la-Iiuiiini ' \li liiliiliil al llir lii'^iniiinu tin rliaracli ri-- lil- III' M mrmiiiil I. \' r, Ini- 1" ii'"l i -. likiK I" I" niiirli -li'Tti r Miiil III til I"' niilar li li\ M I" ri' ,|' iiiarki il tliirtnali'iii-. I li'-'- mn ik- lilv intiiniitl.nl iiirsi - a ,:ir. wliilr i.l'l' r rliililivn n|i IT inii-t ( iiii-lant in rliilili' n ii| nil III till r|. \i nil III tlu- tiilllll I mil N'MT 111 iiT jr. Mill ntl\' •Xllllllt till' i-.ill'll limi- iili-rfMil III adults. 'I'hr llirm nf the l.in]" ratiiiT-iMirvr i- i( - nlliti' fi'liiMI-kalilr ill ^rvrri c (.,..<,■ i; li aliiivr. a~ it i- i-a>i— 111 .Mi//'/"i/s i\/' |' i|i l\ a ali ii'alnr.', iiimI. r lli.' ciiciiin-lani'.'- iii (|U('-ti.iii niai'k.'.j ll ll.rlin.' ..r liinj iih \ -1 niii.i'aliii'.' iiia\ lal 111 \|i('l'lrnc.'. .ili-ci'vcr- iiiav rcaililv Im' il.ci i\ .1 liy ill.' I.iw I. in|i. i'aliii'.'-|.'\ .1 liiii'in;; llir ciiiir-c anil liy tlii' tall al lli.' ni.i-l -. rimi- |i. ri.Ml, and tiiil» Ix; |.ni|ili'il 111 irivi' a tin iifalili' |>rii;^'iiii iii-i- I V's'Z. I 7 ). ll' iy|ili.iii! li \.i' |iiii'-ui ill. ii' I'.iiir-c "I'llily, in a w.ik ..r .'nl\ a 1. u .Lr.-, an.l a.'c.n'.lin-K uiili a 'ar.'.'ly a|i|)r.'<-ialilr l:i-li;:iiini ; Inn, ..n llir hiIi.t liaml, ilii\ iiia\ lie 'I'll.' niilil ami tli.' niil.|r-i at tiiii.'- -| IIIKJllI V nn iiiiiiLri'ii \\^ -liall lali'i' I'l liirii 1.1 111 -.■paralc I'.iii-i.l. I'ali.ni .it' alHii'li\'i' aii.l till' iiii|i|.'-I at.'liril. 11. : .mlv ill.' Iliil.l la-t in;.'' il|) I.i till'.'.' u. -.■.I t'llIK'. I'llr III k-, an.l ill.' |iriitrai'l.'.i iiiil.l ca-c-, will I..' .Ii-- l.i ca-.'-, la-liiii.' till'.'.' w.'.k-, ni.i-l triiiiiintlv nlili' 111' all ill.' I'.irm> tlic typical. Willi a i'. Iali\'.'lv -Imrl iliii'ali till' in.livi.lnal -taij:.'- mi '(■ cliaracti'iM-licallv iiiark.'.l in llii' cIii'n .' ( l''i I I. p. I-Jtl). Ati.r til.' li.'i-lii .if ill.' t; v.-r lia- lii'.'ii I'.a.'li.'.l williiii lu.i an. I liall', at till' lat.'-t tlnir, .lav -, lli.' .1 iimli.iii lit' ill.' ini.' I'.miiim.'d t'.'v.r i- liki'ly t.i ll.' iV.iiii I'.iiir ..r liv.- .I:i\- t.ia «.'.k. Tli.'ii iIht.' .K'ciir iii.ii'i' niark.'il tlii.'tiiati.ni- nf l.inprratnr.' ..t' l.."i ('., an.l tVcipii'iitlv iiiiicli iii.ii-i', at lir~I -till with ri-i' nf tli.' .'Vi'iiiiiLr t.'ni|>i'ratiir.' t.i tlial .li" ill.' iiiTc'ilin^r .lay, alter wliicli, at tin' i ml ..f tli.' -(('.iii.l ami tli.' lii.jiii- iiiiii.'' lit" till' third week, the di'clin.' K rill- ill till' ti.rni nt' a t rile .-tc.'p Amithcr i'xcc(.di!i;.''!y i-nnini.ni vnri.tv i,f inil.l .'.iiir-. i- that which tV.iiii the l)en;iiiiiiii:; c.xhiliits \ iiiiii>nall\ Ioml: «luniti(Hi, without the a|>iii>ai-:inc(' of aii\ alanuiiii; -yiiiiiioin- ihioii-iioiit the tiitirc i-Miir-,.. |n not a ttw ca-r- witii an intc-rniitlcnt i-iir\ctl' initial -taLic aUo cvhiliil- llii- chai-actii-. and ivc-iMiiJc-crnrr- ami rcla|i-(- aiv al-o likcK to l>r atlcndi'i! with cinally niarkid thictnation- in the ciii-vc. Al-o, cci-tain ca-i- ol' anilinlator\ ty|ihoiil t'cxci' arc. in m; c\]iciiciicc. atlcnih'il uith coii-idcfalilc i-cnii--ion- in the tein|icratni'c- cui'vc, at tinic-e\cii with -ncli inai'ked intenMi.--'on- that in thi' niofn- iiiL or late in the cseninLTor dnriiiLr the niiilit (he tcin|MratMi'e i> -carceU aKo\c ihe normal level, while con-ideralilc eje\ation- lake |ilac(' oiilv (hiriiii: the midday or for a -liort time late in the aflernoon. I I'l.;. 1»- -T.-mf..ratiir'' ' h;irl |V,„ii ii niil.l I'u-.- ..Ilyi.lr ..'1 f.v.r iii a .jirl. . siilil.. n >iiir^ .1.1. Kn.ni tlif no Mli.-tli .Imv ..f th,' .lisriis,' 111.' .■..ur^.' ..f tlir Ntlm-k « u> al'i-l.ril.-. 'I hr <':rv was 111 irki-.llv int.riaitt.iit friii as .-arly iis Ih.' sixth .lay 'I h.- Kv.r wtts alinosl [.urily .1 .iimiiluin liavi' in a iinnilicr I'f in-tance- ol)-ervctwith low 1 veninL;- and higher morain:.' teinjieratnrc, often c.niliine with a Tmmlier ofoihei- irrc^iilarili"- to make .a i|nite rcinarkalilc <-nr\ !■. .\t the siinc S)MI'ri)MS .\.\li < OMI'I.K A llo.WS. 14!) tiliir. liic (•(iiiisc ut" such cM-c- i- dftcti pr.itnictcd, >o tliat tlic f'lhril iMii.d in.iy (■iiiitinilc tnr :i- i]i:iiiy :i- -i\ of cxcii v'v^'.W wci'k-, iiiiil tli if ilif iViiinU and llic iil |iliy-i< DIM iiiav he -urch' ti'i T HI Miiii-li attiiitiMii (•aiiiii I III' jiaid to tl K' intcniiiilc lit and icniit- tcn; I'cliril (• i'iinr>c> di-ciil)cd and li. llic i^rcal irnuiilaiilii'> i ll >IICl <-ll|-V(-. ( )iir w liii i~ iinlaniiliar witli ami iiica|)al)lr ut' iiitcrpi'i'ti IlK'lll is i\ |Mi-id I.I liic lialillily (it ;:rial •rmr in diaL/ini-i-- and |ii'( r-|ii'cLiilv III -iicli ca.-C' Ihal (TN |iIiio(.|i,.||, ><-|itlcciiiia, iiiliar\' liilicri'iil and iitlirr di-ca-c- tiir nmi-c t'carcd than t\|ih li'Vcr arc utlcii incMrrcctl_\ (ha'^nn-cd. It ha- ahvadv liccn imii'd thai nut ninch i- known in j.rciicnii wiili rcL^ai-d lo the caii-c~ of tlic marked tinctnatioiis in tcinpcnitiirc. The condition- are dill'ercnt «ith rcH-.ird to intliience- tlial teiiiiiomrily exert -neii an ctfect. K-jiccialiv in c>- tihal iicnioiTiiaL''c and e\ten-i\e [icritoiiiti- arc to lie nicntioned in thi> • •onnection eisi>tciit (iiarrht a al-o i> often rcspoii-ihh' fiir iiiarkei renii~-ion> ami irreiriiiarities m tl 'rraii-iciit in:'-'kcciiec ot' \ i-it can-cd iiy prntraeicij conversation, excitiiiL' cvations 111 ease- ors, as well as those that arc iic\v>, dietetic error, or trct- tiiii: oiit of lied coiitrarv to instinct inns. .Vatnrallv, all of tl icsc (K'cnr- > are periiii--ilile in explanation of -nddi n oillv when, aft II clexation of tcni])ci-atii er iiio-t thoroinrli exaininarioii. tlii- eainiot lie attrilmtcKl to s,,m,. local complication or to Mi.'.dcii e.xaccriiation of the ..cnci-al m Variations in the Curve in the Stage of Defervescence. Ill the lar; :c majority ot all ca-es of typhoid f,.ver, tl le severe and the denitcly severe, as well also the niild..r. if tiiev liavc in the preccd- iiiiT -taij'o ai) proaehed the tyiiie-a! (linn of tl P le curve, the transition of il leiiipenitnrc to normal i- likely to take place in he fimii of the so-called -li<|i eiir\e, '11 n- period la-t- tiir from tl ll'ce to eli;ht oa\s ill ca-c moderate and not too proi meted coin-e. (^lite irenci-allv, aft er >c\ere lell a- after mild ca-c-. the curve pa-s,.- far liclow the norma! wiili tli. la-t marked decline, <(i that on the niorniiiij c\e,,llli.'- the lemperailtre w i peratlire then varies in ditrereiit lOllOW 111 •S the first afelirih lie lietw cell '■)') ^ ;in I :;tr ('. Tl le tilll- •a-es : it iiiav — as is not iiiiconiii" i:,() rvi'ii'iin ri:vi:i:. ^fSur}^'" and lia- Iktii ili-'Tilin! — i-finain -iil>ii..rm;n wiv! :iim1 Iniipr. tlio ~I:il:i' mI' t iii;ici;ilinii lliii- t'nllnw iii^i' iiiili|.ili:ilr.', Ir.;li'' ca-r-. :itli r ill,. II,, rill ha- lin-u ivarlicu \td. inv-ular lliirliiatioii- ill ill.' cmxi. lliroii^-li u hicli tlir p ildi^ir r\ cniiiL;- Idii- |i, ralinv i- ivaclicil ami |.rnlialil> al-., i- lAnclnl. Afi' r llii- !ia- i - tiinicl fur a fru .lay- ami I lie ili-ra-c icml- tnwarii di . '''im' Icriiiiiia- tiuii. tlir cliaraclci-i-lir •{■.vj.r lit' ciiiaciatiiin lici^iii^. ( )iily in iln' iiiilili -t t'u-,- .an ncuvia ■ and ivliirn cf tin- tcmiicraliirc-ciirvr m tlir |ii.'> •..l,i. A sli-ht nrruil.sivmL. bicm. .■>. tl.,- fnrtv hrst .lay ..r 111., .h-. .!-.■ likclv to 111' I'ciiniililid. i.ii tlic av.T.ip'. in two nr tliivc raivlv imi|. , days Still aiiiitlur \aiiriy i>f dil'rrx (-.■.■mv i- that in whi.li, after niin-nally markcl tliieliialinn- in the eiirvr [MT-i-tin.^- fi.r day-, the diil'eiviiee l.elweeii iminnii- and ivi niii- tein|Hi-atiirr liein;: at times 1 or •> (h-ive-. detliiite ivdiieti.iii 111 teiiiperal life take- jilaee within Irmn IweKe t.i I i-htein liuiir-. neea-ii iiKilly within a -till -Imrier time, ni a -iii-lr -n-..ki'. In ~neh <'a-e- I liaxe ,.li ^1 V f-i>^- 'I tyi.li..i.l l.'\ .'r in ii «..in;iii, ihiilv "rie y.^ir-..l.l- Ii..f.rv,-. . u.... v\itli t«i. iniirki.l y> ar- ..11 l-r..iM ih.- tHriily r..iirtli t.. the ilm liiuti..ns in llii'i'iirv... Willi chills. tw. .ily-liflh .|;iy ..ft ho .li>,. a-,. tluT,- ...•.iirr.-.l r. .'ntii'iil .h . liii... " illi.nit aiit...-...l>'lit n.arkt..l 11.1. tii.ui.'ii Ml Ihi- .iirv... liav of thi' .tis.'ase. a iicciiii.'ir fiiriii of rfiliictioii in tlic curve, ami not an indication ol a coiniiiication ( i'lir. ■_'<>). It i~ |ii-ol);ililv Ica-t frcc|ncnl f^if tlic remittent .■ontiiincil fever of the tii-liLnntn to terniinate siid.leiily. with a critii'al decline, at a single -troke, or (i.r the eri-e- to Im' |ircccded only liy a |ireeritieal elevation on the iireeedinir e\'eiiinir. I have oli-erved ihi- variety of dett'vvc-cence more fi'e(|nently in vounj:- ]iersciiis, and ojiecially in ejiil- di'iii. liiit it occur- al-o now ami then ill a. hilt- (Imu-.-. -Jl and -JlJ). l'"inallv. ill till' le-- common ca-e- ot' tv|ilioid t'evcr that |iiir-nc an irrcLrular ami |irotracted coiir-e or are attemlcil with r.'laiixelv low temperature in the - I . Ill]', riilin.- .-hiin !Y..lii a I..; .! ;.tT;H.k ..f l\ I'll. .1.1 f.\. r in ii man. |>re...|m'. lift, r jiri'iriticul ..|i.\ ali..n. ^lai^'c ill the ciir\e can l>e noted, 'llii- sta^^c then jiur-iii- an irriu^nlar coiir-c, with mor.- ..r le-- marked Ihietualioii-, the inornin^r :iiiil evening' tcmpci-titiire- hecoimn^r irrad- i i 152 rvi'ii'iin I i.vi-.n iialK Iciu.r, iiiiii llic ii.inii.il I. iiii» niturc i- >lii\\!\ rcMrhtil. Xi.w'd ;nialMiiiii'all\, tli(-c :ir.' |Mrlia|i- ca-c- u illi -Inw ly licaliiii:- iili'i i-. "il!i nrnidi-ciic.- an. I -liij:';i-li Ir-ioii-. Tlir-c aiv tlir caM'- al-o in ulii.li loi- a Iniii;- linir iloiil.t (xi-N, and crrtainly Mia_\ lie wanlinir at time - rv.n ailn- thr end of ilic di-.a-c. a- t(i wlial \k\\\- nl' tlw cnrxr ImLmii; Io iIh' aclnal Ivplmid |)niii— and wliat to pu— ililr cutnpliiatiun- and -.iiiul^. TIk' alti'i-atii.n- in the t^nii ol' the cnrvf in n.iini'ctinn with drtiiiitc iniMlc- of ciiiirM of llio t\|>iioii'c- tivc iliaptci's. CHANGES IN THE CIRCULATORY ORGANS. Tlic di-cn«-ion of lin-c will U- taki n n|) In n' on acconnt of tlif intimate fciation of tin- licart and tlir jinl^' to the frvi r, ami « -pccially to the ^tat.■ of liic l>r rca.-oiis tliat wdl later l.e more fnlly detailed, to M'lnii-ate in the de-eription ("1h> witlioiit especial eai-diae di-onlei> and tho^e with >evefe Ik ai't-atVeetioiis. We -hall he-in with a <'oM-i«lel-ation of the ehaiaeter of the pulse in ea-e- pnr>ninir an nnc pji.'ated eonfM'. In all -tairo of sneli ea-es a eloM' e..ir(-i)oiidenee e\i^t^ hetween tiie llirm of the pidM -cnrve and the >tate of the teinpeiainfc. Ill the initial >tajri' it will he ohserved in the majority of l•a^es that the in.-iva>e in tlu' fr..|neney of the pnl.-e take- place in the -ame >te]v- like manner a> the a-<'ent of the tempefatniv-enrve. In .-on>e eaMS the form of the ))nl-e-enrve imitate- exactly that ol' the tempei-atiii-c-eiirve. In other in^tan.'c- the pnl-e-fre(|nen<'y ri-o relatively more ^lowly; while in irritahle in.lividnal>. on the etini: al-o (hiriiiir the tir-t jm riod of the eonlimied liver. I.ikeu i-e. dnrin;^ the peri.nl of fever-h( i-ht, hoth enrve- often exhihit a >trikine- i)aral!eli.-ni. In the amphiUilie -taiie ihe pnl-e-fre<|neney then iieii, rally , -till more -o in the period ..f -tr,p curve-, -o tha.. if the tempc'fatnre ha- airain reaclii d the norma! or ha- fallen IhIou thi-. the pnl-e- lVe(|Uincv will he :ejain a|)pi . iximalcly n.>rmal. al lime- somewhat llcloW, at oIIkI- time- alloM'. In ireneral it mav lie -taled that in the lir-l ilay- of the afehrde l„,,.j,,.l ,1„. ,inml"r of pnl-.-l"ai- more lre(|nenll\ i- relali\.ly hidi than low, the former e-ii.cially if tin hody-tenipei'atnre al thi- period ,l,,i'< iioi I iiir -idMiormal. hilt remain- -leadil\ at ahont -".T < '. or alM.ve. Thi- paralleli-iii l.eiweeii the pnl-e-cnrvc and the lemperatnn' i-. accord- int: to the pP-( iil -tate of knowled'je. Hot reil'rahlc to the aelion of the sy.UI'TitMS AM) lOMl'Lli- moss. latter iipmi tlir licavt :i!iil tlic ciinli'iv.iMiilar s_v>t«iii, a- cai'licr wnic!'- ■lirvcil. I> (I' tiixiii>, which, 111 acciiii >th arc ci-ce|itil)ilit_v ot' tlic individual, reaches a delinite cxpre.-sicni ni each UKln iiliial eas (iiiitc rciiiarUai)l<' and nut eni]>hasi/ed in de-eivey evei I some recent \\ I'ltcrs dli^crvaiih' il is the relaiix'c choree (if inlreijiK'ncy ot' the |piil-e nt'ten ni'iiii: the a.-eent I' I of the tein|)eratiirc-cnr\ (■ and tiiron i-h mt thi' entire -ta^c ol' continued l'e\er. In other words, the unls* in main', even nioi h^ratcU V >ev iUh- not attaii the t'rei|iieiier\i< especiallv III voiiii!!' or In ( '., and even more, the piil-c rantre- aim, it S( I ill the inorninjjr and lictwcen ',i(> a'n' 1(10 in the eveninjr, rarely ri^iiij^ liiiThel lier. 1-: veii ill the jiresenec of -evere maniflstatiuii: marked diar- rhea, meteorisiii, and sliiiht stii|)or — this ciiaraeter of the |nil>e need not !«' ahseiit. Asa matter of fact, well-marked cases ot moderate si verit\' are not rarelv encoiintered in wiiic'li the |)iilse-t"rc(|iienc\' in the inoiniiiir carcelv exceec Is ti lal, and tliroiiirhoiit the entire coinse of tl di-case dcKS not rcai'h \0(\ in the cveninfr- I'lii^ jieciiliar relation hetwceii |)iil-e and fem|ieratiire is re-ponsil»lc tipr the tiimiliar charactel'- istic apiicaniiice (pf the crveil the plieiininennn aliiiost onlv in tliipse helween llie Iciitli and ihc fnurtcenth vear. In vi)Uii;icr children, on the cipiitrary, I have iphserved, ahimsl witlniul exceplinn, rather liii^li i)illse-freinieiic\ . |- >r adi pf tl ills Lid pcniieister,' amimi: rtrrnt w rilers, eiiiplia.- l/r- lliC nitre- piency ol tjie pulse, and lie nientioiis >au\a ii:es, Ilut'elaiid, and lienidt earlier witnesses of the inanlfeslatiiHi. Tlic ex|'l;inali(>n suiriresled li\ l.i •lieriueister, that the typlicpid poison iinhiees dirci'lK, llinpuirh an iri-ilati\i /.v,-/,. ,■/,, Irs ,„„/. ,/,. /■„,/„ T, i,. ruiiv 1> • %\- ■ int TV I'll' III) ii:vi:n. eVsv ^%^i ..tlV.I U|..>u ll... .v!,tral luTVous >>M.-im. .>i..r,:,llv th.' ..|.'(iulla i,i.lon-iUa. ,li,„i,„„i„„ in ,„il..-tiv,|U,n,.v, apiH-m-s I., inr Mot.-wurl liv m>wI |,ru ,aUr. (Mli.T |,o,M„uu..-< Mil.MaM.r., a.s tl.r Lilian a.■i.l^ wlii.'li .'in iilal.. in tlu' l.l..n,l, at tiin'- aiv kn.mn to liavr llu' ^an,.• .■H.vt. Naturallv, iUv ail.T.stmj; ,,u,Mln„ i-. l.v im in.'an- « Imllv -li.-po.-ra ..f hy lli.- l.\ iH,liicM> nicnlinn.-.l. iMirtli.r. |>..~-'iliiv cxp.Tirn.'Mlal, ol.M-rv alinn> aiv ui-mliy n.T.^ary. ll i- nni.uorihv tlial anmn- liic Wfll-kimun .-arluT ol wrvcr.- ul typiioKl iVv.r. (il■ii-^il^Jt■l•,"l.onl^, an. I Munhi.-dii cnnsidcr.Ml intr(M|ni'ncy nf ilic piil.-e unlv a> an cxii'plinnai cnndilion. With n-anl to tlu' (Hialily nf tlic piil-c in |.Tvvic.n-ly licaltliy, ,-,,i.u-t iii.livi.liiai- ill til.' initial Ma-v aii.l at ihv liri-l.t of tlic .li^- ca-r. it apiM-a;-- full ami, partL-iilai'ly in the liivt ],\. iintal)ly tciiM'. If -prcial I'iivmii-tancc- ll" n"t aii.-c dni-ini;- tlic <'nui>f ol' tlic .li>yaMS the pnl.c i- likely I., ivniain cinal an.l ivi.nilar until tlic cii.l of till' f,.l.nl<' pcrh"l. At til.' .11(1 of tlic Mcon.l ami in tlic tliinl w.rk, in severe .aM'^ earlier, tlu piiUc .piitc freiierally is iioie.1 to hccoinc softer without eorr.-poii.lin-- .limiiiuti.iii in its fnliw-. Th.' .-.in>c ..f this inaiii- f,.^,;i,i,,„_th.. iv.hi.ti..n in th.' t.'iiM.ai .if th.' art.ria! wall— is ivspoii- >il.l.. i;,r an.itli.'r.|nit.' ii-nal >iinultaii.'..ii- .'haiiL^c in the pnl:-.' : tli.' pulse |„ ,n..s ,|ier..ti<-. -•v.n tri.'n.tii-, an.l in .■\treniely rare ••as.- polycn.ti.-. .\l-o, this .•hai-a.t.-r ..f th.' jiuIm' a-:;iin is iin.l.aiht.iUy inii.li more fr..in.nt in eas.'s of typli..i.l f.v.'r than in tlios.' .,f m.i-t .itli.T fel.rile (li-.aMS. so that, with many other writ.a-s, 1 atta.h .liaeiiosti.' si^niifi- eaii.v't.. it. If it ii.l iv\i'r is th.nliy ini'icasc.!. Th.' .li.'i-otic pill-.' is ..l)s.'rv.' C'lMri.K A I l').\S. I-").', v:iii;iii(>ris d' llir |>iil-.' in ca-c^ i.f typliuiil t'cvcr niv cuniicirativcly lilMlkril. 'I'll.' (litl'dviir.-. in |)iilM-tVc-.|iiciicy :il tlii' Iimiiiv wlirii llic> tcni|MTaIn;i' i- iiii:iii-t iinti :il tiu-r wIhmi the lcin|)cniliirc i- Imw.-i i- \\Uf\\ to III t'l I H> I" •_''! aii'l rvni ;'.n lirai-. In -viicnil, tlir lii^rli ami ill.' Iiiw nnnilii'i- nf i)iil~i'-lM'al> ami llir liiL:li ami l"\v .l.'irri.'- <<\' t.'in- |)t'i-;ilnn' .if ill.' .laily .nrvf (•..n-.'-|)..ntl in time. If, linwi'V.i-, v fVc.|ii.iil |nil-.'-i.li-ci'vatiiiii- aiv mail.'. .|nii(' markcl .litl'.ivii.'.- .an 1m' mail.' ..III. .-|>.'.iallv ..n .lill.'r.'iit .lay- ami at .litl'.Ti'iil liin.- .'.'t — that i-, in -n far a- tii.y tak.' litll.' n.ili.'.' .if wliat L^.i.'- .Ill ali.iiil lli.'in .i|i.ini-.' |ialii'nl- rc-.'inM.' tli.in. 'I li.-c patients aU.> .'\liiliit .'.nniiarativi'ly >li,irlit .iii the piil-e-fre.|n.'n.'y. In intire a.'.'.inl with this -tale- inent i> the fact that in .'.m-.'i.iiis patient-, at all >tai:.'s nf th.' (li-ea>e, exeileiiieiit of the ni.>-t varied kin.l make- its iiilliien.'.' ap|)areiit in th.' |iiil-e-eiirvi'. Kverv h.i-pital phy-i.'iaii is familiar with tlu' in.Tea-eil l're<|iien.'v .if the pnl-e .in vi-itiiii,' .lay-. Nut rarely the phy-ieiaii, with hi- liiiecr .111 the |)iil-(', is alile t.i anti.'ipate the wi-li that the |)atient is ali'iiit t.i expre-s, -ini-e the fre.|U.'m'y .if the pul-e tli.'ii -ml.lenly liee.iiiies in.'i'eascHl. '''his tendeii.'V t.) tran-it.iry inerea-.' of the pnl-e -hould nlwavs he home in min.l, e-p.'.'ially tVom the pniL'tH'Stie -tandpoint : it is .me .if the iM-enliarities of the typhoi.l .'urM', an.l in the ahseiiee of .'.iin|)lieati.ins is almo-t never .if serious siii^nifii'anee. The eases are t.i 1).' interpret. .1 .piit.' ditlerently anil mor.' seriously in which, from tin' oiit-.'t, the piil-e-fre(|iieney emistantly is .•sp.'.'iiiljy hiirh .ir in wlii.'h th.' piil<.'-<'iirve r.'a.'h.'- a rather hiirh l.'v.'l .'V.-n at the (•.iiiimeiicenn'iit of th.' peri.i.l .if IMirile elevation. Fn.l.'r -ueh eir.'iini- -tan.'es the ilisease mav l«' expected t.i |>nr-ni' a sever.' eoiir-.'. .\|)art fr.iiu this fa.'t, |)irsi-i.'nt a.'celeratioii of ])iil-.'-fr.'.|n.'n.'y i- oft.'ii indi- cative .if e.impliea;i.in- of mo-t diver-e kiml. Tn tlii- .'.mni'ction attention -h.ml.l K.' .lir.'cfe.l e-p.'cially t.i inflammatory atle.tions .it the Innirs and the h.-art, not le-- than t.i th.' p.i— iliility .if c.iinpli.'aliiiL'- |ieriionitis and intestinal heimirrhatre. With r.fei.'n..' t.i the latt.'r tw.i .'.imliti.in-, the iml-e is all the mor.' notew.irthy. since with th.' on ' of p.'ritoniti- th.' t.'mp.'ratnre .'xhiliits a most inc.instant cliara.'ter, parti. 'iilarlv .ifl.n -liowiiiL'' no i>levation what. -v. t. mii.I al < -K.-4 • \ •" «► — • - m !■)(! rvi'ii'iin I III I; « I f < iiili-liiial liciii..rrli:i-.-, it i- i -.iMviiillN l.. lie l.oinr ill mill.! t'lirllicr l|,:ll. ir :ll :lll .mH- illrniMi , lhi\ •J.IVr vl-r lo r;l|li.i lilll ><\' tilr trll,- |M i-atiii-r. 'I'lii- fall nf iriii|>rralinv aii'l lin' imrca-r in |iiil-.-trr.|ii. nry -ivc li-.' In lIlM-r illhr-.'Clinn- ill lllc rlMAC I l''iir. - I. 1>. ---. ' 'l-' -I1m|| ) til mi liar I" tin i \ |i. li. uml .■liiiiriaii a- iini-l iimu-. 'I'lial an ciilinly -iniilai- i-i lali"ii l>. ivwm piil-r ami lfm|ii ralillT iiia\ al-u allriiil >lMlc - nl ,-,,l|a|i-r ..r .plh. I- ni-itriii iir..• UK iitinii.-.l al liii- |ilar.> | l'"ii:. 'j:'.). hi r-|Hciall\ -r\-i'- all il- iliarac- !rii-iic t'caliin- ill iIh' la-t ilay-. and rv. n ti>i- a iniiircr lime )ir<\ ioii~ I" ilralli : t'liim-- ami icii-i'ni iliinini-ii a|>|invial)iy alter llif ilicrdi-m his alri'a(i\' (lisipiMari'd ; llic iVciim ncy liccuim- ((Hi-lanllv liiiiln r, «illi Imv "1 til'' 'li- Kir.. -1 -■l,.,i.i»TuIurr . iKirl frc.ln a -. Mr.' .Msr ..1 im^I.-lI l-wr in a man, tu riiij .. i, ii >.,.r-. uM. wild (■..;hii.>L' Hilliuut ilir. t'tly .li'iiinii>tralili' lau-i- pn.LTc^-ivclv iliniini-liiiii: daily fliictnatiuiis ; tiirdly, tlic ]niW is wlmllv iriTiiiilar. -ratclv |)al|paiilr. and ii.'t to lir cnmitid ( Fi^-. 14). Tlir -taL''!' "I' drti rvc-i-ciii'c and iif alilivili' i-diivalr-ccnri' i- likewise ,],-(. rvillLT 111' e-|iieial eoii-ideralimi witli nrefenee tu tile |illl-e. sliell a- lias lieeil Llivell witli ret'ereliee t.i the emir-e (.1' the telillieratlll-e. Alivadv in the -laL'e 'if ~tee|i curve- the ]iill-e fVet|iieiitly liecomes ^iii:il|,T :,Md harder, with iiidi-rmelne— nr (li-ap|>earaiiee <<\' the diern- ti-iii. Wiih llie marked lliieliiali'ins in temperature, there oeeiir imt rarelv in irritalil individuals e.irre-pnndinLi'l.v wint tliev may l>e eon-|>iei -ly -m.aller than the teni|>eraliire-lliietiiati..iis, >.. that no inofe than the physiolo;,rie ilailv variations appear. .s) l//'/':itir;it- ki|^! ] at re -I III liol Ilic iiiil-c li\ Mil iiii;in- -' (■■•ii-Iaiil Iv a- tlic Iciiiiii ratlin Jiiliil- llic' iviiiilI'Mi and int.'rmitliil type, it i- rliaractrri/( iiiiii-nal anil tar nii'i'r marl il xarialiiliiv witli cvrrv (li\ iati^ni of tli |)ati(iil tfi'iii tlic l\ |i in ''ivatlv niliicrd iia lira! loiir-i' llian in llir carlii r -ta^cs. \'.~\> liciit-, in irntaiih' inrn, in wunicii am I cliildr •\trin-ic and iiitrin-ir inlliinirc-, ilicin-clvi - in<..ii-idi raiilr, iiidiirc i|intc l.li> variation- in lln' |inl-c-cnr\ c. rcmarl^a turn- ■i\ar in li(a ticnt- fniirtrcii day- clap-i' liclnn ih irrvinii- frriini-ni'v a ml miifnrniitv arc apun attainci I. In 11 prntractcd, c-pi ■lallv -cvcrc cii; SI'S tills period may l>c mure cxii iii lei. M ;.; ,11 158 Tyiii"ii> iivi'.ii. (- .. 1 i>- *.v ma I, ,„,.,| -,.;UV,1v1m. mi..,U-l -|"rlall> tllMl. -n tlw ul,(,lr, l-ITNinn-ly ,„,,„„| ,,„U, -r.'.n.lili..n- a,v n-|..,v,| tar m..,v rai-i.llx in \»■.M^)■ V"""^ ,n,n llian „, ini.al.l,, ,,nAinu-ly -„k il.liN i-IumI- "V «■•",. „ a, I c'liiMi'i n. •I'l,,. , liara.i, ,l-lir- ..f ll,.' yn\-v .lr-.ril„ ,1 ,n-rm 1 ■\^ ni.Tr fiv- ,|,„,„U .luring .•..,nal.-r,,„, In.,,, is].!,-!.! r.Awll.ai, .l,„ii,^ tl,a. Ii-n. ,,l|„,-ar„„.i„r.r,i,„,-,li-,a-.-, .-prriallv M„al 1-| .< A , u I ,i.l , i-,,ri.„,al..l. ty|.l,M- f.A',. a„.l ,vla|.-ii,u- I'rx . r, a- u.ll a- i.ii.ni„..i,ia. ll uiH llms l'„. ,.,.„ ll,al, like tl,r -lalr..r il„. I „ „ K -„„, |m i-al Miv. t l,al of ll,v |,iiUo i, al-o "I' ii„|".itai,l (lia-no-iic ami |.io-,iM-ti.- -ii;i,ilic;ii,tc. |.-,,„„ ,|„. .Iia-l,n-li.' |",ii,l ..f view. tl,c relative il,tVei|,,.ney ..f tin- ,,nl-e ii, the felM-il.. -la-e :i„cl tl,.' .lien ,t i-i,i, -. r,e,|,,e„l in im ,,tl,er i„r,.,.lio,i- .11-ea-e, „,a> r,i,ally a^ai,, Ke .„,i,l,a-i/e.l. In a.Mition, tl,i> ,|iaL:„"-ti.. M-lliliea„e,. ..f tl,.' -,I.MeM aeeel.iatinn ..r |„il-.-r.v.|ilel,ey aiteii.li,,^; e,>n.lili..„- -f 'ollai-e ai,.l va,ie.l eni„i.lieati..i,- ii.ay l.e nealle.ir Fi-i,, ;i i.,---„.>-tie p-ii,l ''f vieu it iiiay l.e -aid that ivlative il,tVe,,,.e„.v ,.r the pill-e. with - 1 vnlMl„e a,„l te.l-ioM at the h.'i-ht of tlie .li-ea-,". i- of u,mm1 -i-Ilifieai,ee. uhih' diefnt i-1,1 atl'l p. .lyelot i-lU aio „i,l I -,„.,aal -iu,,illea„.v in pfM.-no-i-. It hecm,.- a matter f.r .■oi,- ,,,,„ if ten-io„ a„,l vn|„„„. ,.f the yy^W fail earlv. AUo, i„:.rls,.l |„il-e- f,v.,,unev at an earlv period i„ ih.. di-ea-e. in the initial Ma-e, or at tli.^ l,euiiinin-of ihe f.-ti-inin. indieat. -, if at all |,e,-.i-tent. a -eveiv e,„ii-e. Thi- i- ,.-|,eeiallv tr,,e in the ea- of men and elderly individnaU. v\hile ,v en and ehililivn in e..|,eral n,a.v exhiWit ,.on-ide,aMe ae.'eleralion of ,,nKe uithont -erion- -i-nitiean.-e. l'-|v,|nei,tlv ,v|M.at.d aeeeleration ,,|- ,|„. |„|1-,. I,, l:;,! ,„■ 1 1(1, a|,;,rt fro,,, ehildreii. i- o,,,ino,i- iiii,hT any ,.i,v„n,-tanee-. Nolat,.l. .|Miekh -nh-idini:. marked and extreme fhiet- iiation- do not indieate mneh, at !ea-t in the teiminal -ta^'e ..r dnrin^' ,.,„ivale-eenee. i;a|.id ,levalion of teM,|.erat,iiv ai,d aeeelerali.Mi of |,nlM" ,n'i-in- -i,n,,ltaneon-ly and n.M ,,nieMy .li-ap|,earin- are of jrravi- .im,if,ea„ee. Intei-Mvtio,, o|' th.' two ,airve- in ,-iieh a manner that the ,„d-e i- ureally aeeelerat.'d vvhiU. the teiniMTal nre .leeline- rapi.lly is evil, ,iloie -el'loii^. Irre-nl:.,ity an,l ine,|,-.ality ..f tlf |mUe nni-l !.■■ eon-idereii Mini ;ilpM"riii;il -l..uii.-, . -.|m . mllv in llii' -t:it;r 1 .-)!> .1 -nii- lioi-|ii:il lriii|iiialiirc . Changes in the Heart-muse le.— It llhr lit' colll-r lllllt the -t;il< illl-r III no -111 rilllrtini|;il acli\ilv 111 ill il.;;nc ntliii- ilii' ("iKiiliiiii anil llii' tlir 111 art — liic part taken l>y tin n niaiinli r nl'llic ciri-nla' t'oi-r )"• alfi :iil\ iiv a|i|iaraln- i- im t vit --iiHiririitlv kiiiiwii — anil it uonlil llnn- 1)1; IT, il-i cliaiaitif i- -I that t'nr tlii- ria-nii al ,1,1,. li, ili-rn-- JH.lh tu^rtlicf. Sparati' i-iiii-iili latliiii lia- Iv liif I xtraiiriiii- ica-iiii-. in tin' tir-t Iv felatcd ti« that of thf t('a-i' ] dii'-iii'^ Its nn li- narv ciuirsc, any ciiMiiifcln'ii-iiiii ni till' rrlatiiiii; Im'Iw It'll till.' JR'art and the pitlsc and the aftcrial -y-ti in i> intifily uantiii With ri'trard to tlw cniidition nl' the lirart in the iiiiiui il slaiic 'if tvphiiid revel- and t •vere ca-e-, a -n l;;hiiiit the eiitift llf-eiieli as will nnel the i'e(|iiii'eineii t- 111' niiHleni inethiid~. have imt a- vet Keen made, mi aeemi int lit the relative I'aniy 1 di >r death at tli period. I'"i'iitll the ciiirK'al and the phy-ieal diaj.'MiiMie pmiit y^teiii are not re-pmi-ilile tor haiii^c- ill the piil-e, lint that under tlie-e coiiditions siieli eliaraeteri-tie < at l('a.-t sliidit tran-itory ti-^siie-ehaiiire- take plaee. eannot he dunhted. or -evere and fatal ea^'s of typhoid fever, however i known that tliey exhiliit profonti.l anatoinie h'Mon- eorres|«.nilinir VMth it lias lonevere -| or eiim])lieatinns. Perhaps their relation- are eoiiii>aral>le t fel-rile aU)iiminiiria to true tyjilioid nephritis. I'ilie loeali/atmns o !hii,-e I I leiinee earl\' I Iv nientione in:iii\ ..l,-,r\ ( r-, :in.l u,iv n,r..,|H,i;ilr.| iiil . III.' I. Mi 1- HI i.lall.in .il-. L. lv|.lini.| I.A.r. I, i- kiinuii al ill.- |.iv-,nl .lav i-..- al-.. A nal..iiiv i I lial llu |.n.l..nn.i l\|,|i,,i,l ,||...r.|. 1- ..r ill.- Ii'arl aiv .l.|..iHl.nl n|...ii |.ar. ii.liv l^al..n- ,|, ,_., n, ral i I ill.' iii\M.ai-.liiiiii a- u.ll a- iip'oi nil. iii\...'ar.liii . 'I'll.' -i-nili.'aii.v ..f iIm-.' .•Iiaii:;.- in il.lail lia- n..l a- mi Im.ii Inlly ,.!,,., I,, I ii|,. i;. i; I..!-; in in- a.lninal.l.' «..rL, lia- |ir. .|..ii\ .all.-d .,,,,nli,,i, ,,, ||„. f;„.| iliiii ilic \arii.n- pan n.li\ inaL.n- all. lal i..|i- in iIm' ii,\,„.;i,-,|ii,iii, ill.' iVi.in.nl all.innii - .1. -.ii.'i-al i..n "\' \'ii.li..u. lli.' l.-> ,,,i,,ni.'n \va\v .l.'j. ;■. I'al i. 'ii. llic - 'jin.nlal n.n "I' iIm 111., r-. lln' .ll\ir-c i,ii,.|,.;,i' , lia.i'j. -. aii.l ill.' liillv .i.'-ini'iali..ii ..t lli.' inv ...'ar.linin .an Ik' r..'.,-ni/(.l "illi ililVaaillv li'..!!! lli. ic .Tini.al inaiiil.'-lal i..n-. ri.Jial.lv ,1,,. |;i.| lu,,.' lili.m- ar.' ni..i'.' Iic'.|ni'iill\ r.-|..in-ili|.' lliaii I li.' ..I In i'- i;,i' rlii.i iiiaiiir.'-lali..ii- ..I.mtn .•.! .InriiiL: li I''. Tli.- .l\.'^^^ll.'llnin-ly |,l■, |,..ii.l.'ranl ,../. i- plav.il iin.|.iMlil.'.ll\ li\ ill.' inl.T-lilial inllaininalciry .,i-,„,.,„.- lir-l .l.'-.iiiM '■ i.x IlaMin;' a liniil.'.-.-nn-in.j' Ml llir ii<'i-iit of tlir Llirilc ,„ |'i,.,|. ir iIh' li.'avl \\a- In allliv \>v\\,vr tli,' ..n-.'l nf tln' ly|ilM.i.l .li-.a-r, |li.'\ .'..n-liliil.' aim. 1-1 .■iilaiii -i-n- ..I' iiiip..rtanl .•lian-r- in llu' .■iiciila- |..rs appavain-. '\'<> tli.' a.ivl. rali.m an.l inv-nlarity .if tlif pnl-c liiciv 1 .|,'/„,7 -., ./. ,"../. Kin,. : /,•.■/.-■. \'"'^-l. I..i|-l''. l-'i- ». I, •,■;,, ,/. jilnj^. i„,rn,. ,i fill, , •[• il , ls.','i: T iii.. l^Tii, :iTln- li:i- li-'ii 'l"-''il'"'l 1''-" I'vl'i'i' I I'li.-li •■l--""- II M.iitii" /.'■'•'■■ ■"'■'■ ls^l ,,„.! ls>--J.. l.:.li.l"ll/,v Mil.! Sir.'l.\ /•"•'.. 1^>--. MlM I-'-T . »liil'- l:"liil"l'U- «ii- -nn.'lv :iM.- 1'. .l.'in"ii-tnil'' il i" -|'il" '•'' n "-' '""•' ''"' in ^ '-n^ali'.ii. M )///"i/> i\/' I iivri.i' 1 1 i"\s. h;i iMc'il M iliiiiiiiiltii'ii ill Vi'liiiiii' ami inliti-ilv ; tlii' ili('l'<>li-iii i-M|«|p':ii- ; till' iml-c Ikihiih- -iiia ll. ->ll. Mii'l liailllv rii|ii|ii( --Mill'. Ill alirr till' a|i|Maraiir.' Ill' tin ihaii;;''- ill iIh' |>iiI- , i '• >a-iiili;ill\ ■Mil at II"' -aiiir tunc, -s iniilnin- it' ililatali ll' llii' liiart Ihi:i 111 ma iki' tliiir a|i|(i'ai-aiiri'. Tlirir ili-v iliijiiiiiiit ami llirir rMiP-iuii \ ; iiiiii'li liiiili' I'll iiinntK llir\ lil'u;:!!-- i;ra(lil- rari'lv taUi' |ilai'r ia|iii iv. 'I'lii' iliialatinii i- like K al lii-l In iiiMilvr t III' ll ll -iili' 111' till iiarl. Far Ir-- i iml lliri, alli|ii-l iiiiiitiK till' riulit -iili' 111 till' ll ni'Ncf III i'iii-i liralil r ilr'^rri', III tiiiii-- -liirlilK iiili'i'lili'il, al iillirr iiiiir^ imli-tiiii'l ami mii-t >f\ I II' ra-i'- Mill al all ilriiiuii-l ralili . 1 1 \ i-ilili |)r('-i'iil ill till tit'tli iiitrr-paiT in llir iiiaiiiiii II \y II al- 1 1 i- .1 lal. • ='l" \- !>.' ll i- lill'ii-. 1 Ill 1 ill I ami al la 111.', lillai'N 1 im mfi 1 - 1 1 1( ■; ti 111 . f 1 iimfi' tliaii tun liiii;! r-liiiailtli- lii'Vuiiil llii-. I lir ili- a|M'\-li('at (•iiric-|Miii(l> uilli an imi-iaM' in llic ana nl' lanliai- iliilni'- In till' li't'l, wliilc till' illlllii'-- rili'U I'Mi'liil- lii'Miinl llii' iii;lit IkiI'iIii- 111' till' -tirnmii. 'I'll till' li't'l 111 till' -lirninii ami ii\rr llir -liriiiini llif ii|i|ii'r linill lit' cai'iliar iliilm Ii -cvi'iT i-a-i'- aii~i -- i- mil raii'K ili-|(lai'i'il il|iuaii!. iillaliiiii ili-i'|ii-('> r\i'niliiii:l\ taint luaii- lllllusl til llli' |>iiilll 111' riilll|ilrli' t;itlicicncy. It is cither a iliicd iv-nlt nt' ililatatinn nt' the Ict't ^iili' nl' the heart ami nt" its aiirieiiliivenlrienlar nrilicc, nr nt' ilii' impainil aeti\ii\ nt' the papillary tnil-ele-, nr nt" hntli. Uiiwcver alarmin:^ these ili-tiirlianec- iiiav at time- .ippcar, thev seem ill fxencra' to he atleiiileil with little daiijrer in caM- nt' lyphnid It'Ver, es|M'ci,illy when eniii|iaret nceasionally t'nr a IniipT time witlmnt scrimis injury, entirely di^- 1^ iy//^^ r*^-, 162 rvriioiii lEVF.H. apiK'nriiifr ('vcntnullv. hi Himc cm-o vvliidi t:iiiic iciiiaili-- "il the Miiatcunic aitfratioii> were -till (Iciiinii-lralilc. Clirniiic in\(icaioii ty]iiiniil fcvrr, with of w itlioiit jM-niiaiiciit (iilalatii'ii, 1 lia\f a- yil never (il)>erve(l witli certainty. I knew, iidwevei-, that i-i>latelill nihei- will lie adileil. l'„.-i,li.- CMC nrrini: at llie heiuhl "I' the (li-<'a-e. revere eanliae -yin])- \eMi< mav al-e make thiir a|i|iearaMee (Inline- the ~ta',^e nt' ediivale-eenee I'relM t\l>lliiiil lever wilhonl ili-lilieti\c -yin|)tatienl kept nio-1 Mrietlv at re-l in IxkI. from ■me lo ihree week- after deli^rve-celice ot the fever there mav appear and per-i-t -erion- di-tlirliaiiee- of the pul-e, which occur oi|.rrwi-e diiriiie convale-cence oiilv after cerlaiii iniurioi,- iiirtiieiice-. aiiil llieii are hut tnn.-ieiit. The markeii accehnition and the iiTcL'iilarilv of the |iul-e Miidir tlic-i ndilioiis ol>tru —far lUiiiv than diirinir th.' tclirih' |»ri."l — di-tre-iiie|y npon the coii- -cioii-ne-- of tli<' patient a- palpitalioii of the hearl. ofl.n a-oeialcl tor a relaiiv.lv Iodl-- lim' — I'l' '" two months ami more. It i-, however. iiiip.irtant and <'onifortini: to know that the eondiiioii is alnio-t iiiva- riahlv att.ndcl with a favoralile pmirno-i-. Kveii in tho-e ea-e- in I l!..;,ili,r:,' iirMpcrh .nipljM-i/.- ilii- r.irilv in cnnipari-nn willi ilie (iccMrniin' ..I' iiivicaniiti- hiriiii: \h>- .uili- >liim- "f ilijilitlu riu. .i^ m SYMIT'iMS AM) coMl'lJCATfiiXs: 1 m wliicli M'\crc jrcncnil ciriiiliitdiy ili~tiirl):mi'('~ dcvcldp,' witli cviiiiu-is aixl tilciiia lit' till' aiiklt',-, at tiiiic- i'('a(Iiiii;r lialt-way ii|> tlic caKo, VI vcTV i- likely tu take place. A tiital tfi'iiiinatidii is ccrlaiiiiy cxcep- lioiial (-(■!• tile laM' III' I jilifi'iiiri~tri',-' ami that ut' /aiili/cr,' wliicli |M)->i- lily ai~ii lieliinjr~ in tlii- ratc^i.ry ). Althunirli ^unirient pii>l-iiiiiilciii ilata licaiiiijr iipiiii tliis iiiNMi'aiilitis of late m riirrciiic arc a^- \ cl wantiii}.', it is nc\ citliclcss uniliiiiiitiil that the cuiiilitiiiii here i~ likewise one of severe pareiiehx iiiatoiis ir iiilei'slitial ehaiiLie in the iiivoeariliiiiii ; and, it' a eonelii-ioii liy analoiry i- periiiitteil, interstitial intlanmiatm-v le-imis will, as ill la-e- ut' diphtheria and mallei levei-, plav the iiio-t eoii-pieii- lill- /v'lA. W'hedier the MI\ocMldilie »\liip|o|lls of Hie period of eon\a- leseeiiee develop oiiK al this tniie. or represent a niaiiife^tation of aiiatniiiie alteration^ in 'lie heail-iniiMle dexclopinu^ in-iilioii>lv at :iu earlier period, eaiiiiot at present I" di'<'ide■ I'lcninL', etc.. were spoken of, llic I'lnnlanicn!;'' work of \"iri'lio\v ' iipun parcnchvina- liins intlani:iiaiiiins tirsi liroULrht cicarnrss into this fielil. Snlis('i|nciitlv. iiolli'hci, Walileycr, and Zenker' I'lin'.iniicd ihc investiLMlions into paren- cliymaliins aitcralions in the licarl in cases of infci'iions disea.se, incJudiiiL' ■u\s iilhers also llie typhoid heart. They dci islraled llie relalive fre- ', icy M.nil occasional intcnsi'v of the parencliytiiMtons alteralimis. and altril.iilcd the LTcater porlion of the c'inical syinptoins to t'ativ dcu'iiiera- lion. .\ new fr 'ul a'.dlation was inanLnratcd hy llayein'" with the denion- stratii f inlerslilial inyocanlilis. Wi.ile I'"reiiih iii\ csliirators .soon veritied and aiiiplilied his stateinent.s. these received the appreciation tliev deserve ai iir ( ieriiians at lirsl only at the hands ot' I/evden." It is to tile credit of Iviiiiilierir in (ierinanyto have eniphasi/ed with especial viiror the matters in ipieslioii in his pnliliciiions from iiiv clinic,'' to have analyzed them critically, and to have snp|ilenieiiteil tliein with anatomic and clinical fact.s. I->pecially he was the first to point nut the peculiarity of the cardiac .'Ureetinn duriiiir cnnvalesceiice, and to atteiii|it to '_'ive a clinical description of it. I'ericari'itis and enducarditis are of far less iiii|K(rtaiiee in eases of lyphoid t'ever. Altlmnirii in the inajority of cases examined anatoiiiicalK liy Ivoiiilierj^" siiialln'ell iiitilti-ation ot" the capillarv walls and id' the I 'I'll.' r:i..',.r:;,.n,Til .■.li'iiia iiiiril i..ni'il l.y .s;innii|" I ' h,-hi„-l,. lid. i. . i- |ir.>l.!il.lv, I'nun Ihr iKtciit. ii> will n- thi' localization, ii.jt alt in.lilc- alon.' to ^lll^i- .lur to rt'rdiai' w.-mkiu'ss. ' . „ssrn\< J'(i'/i,,/,i,iir. :lil cd. ■' limine,-/,, ,,,-lt. l„triri,,f„:M.. 1H70. • >-i.:-h',ir h An-hir. lid. iv. i .<.•!■ tl,,' lit.TMlur' rili'd by {{oliilii'i'u', /••<•. '•.■/. « A."', ril. T /.rit./. IJh, M..I.. lid. iv,. \Sti-l. ^I.ur.c'l. ' Llie. cit. ■M I I. 164 rvriioin ii:vi:n. Miulh-t v.-cN ..<■ tlw (i.'cp-i Imvci- uf il,.. i.,.iir:inliuiM were piVM-.t ill a.l.litioi, t v.M-anliii-. it ni-.y Mill !»■ nuiniiaiiu-.! ilmt tlu-.. pHM-.'^x's raivlv ;itlMin Hirii ;m int.'UMly ;iii.i .Mint a. to >/\sv v\-v f. ll„. .litiiral f.v.u|.l.'in- nf iMii.Mnliti-. Aiiatn.iii.Mliy. it a!-, iiapiun- (Mca~iniKi!iy tiiat ralluT oMcti-iv til.riiK.u- .ic|."-ii- take piarc, at iiuM a ^ii.trlit in.ini.iaiH., .-juvialiv -mn.un.liM- tiu' lar-v v.-mI-. 1 iiavc ol.-cfvc|- -.vciv .Mi.lativr pcii.anlitis, tlii' .•on.iitiun- piTMiit w.iv Muli that, tioni ..ti,.r Mn.ptuni- as xv.ii, tl.cy lia.l tc. !..■ ivf.mHl to inixcl intivtion. In .aM- of lypi.oi.l f.v.r .•.-ni- ],licat..l l.y tnir -pti.- pror,--.-. I iiav in i-,,latnl in^tanrcs ol.-.rviHl fvcn cmiivcina of liic pciicaniiniM. Saiv.K nioiv frcpimt, at l.a-t .•lini.ally .t.inon-tnil.i. . i> cn.l.Har- (iiti-. A.vunlint;- to IJoniluVs anatomic invcMijition-. tlii- is one of tiic 1,.^, .•onnnon a<' "ant:'' "'' the valvrs, it i~ -itnat.il at vari.m- p.>ints of tli.' .n.lo.anlinin, with csptvial fiv- ,,,„.„..v in th.' n.i-hlHirh 1 of th.' .anlia.- ap.x. Th.. i-aiv o.ruiTcn.r of valvnlar Ic-ioiw ..f the heart in the -...pun. f typli..i.l f.v.r appears t,, he .l.p.n.l.Mit np.in th.' niiv anal.miie inv..lv..m.MiI ..f th.' valves. Contra.li.'tofv iv|Hn-ts, e-p,vially .m th.^ part ..f .arlier ol,^el■v.■l■s aiv in part i.r..l.al.iv attrihiitahl.' t.. th.' fa.i that form.rly r.lativ in-ntli- eien.y as a s.'ipwl of myo.ar.liti- wa- n..t known, aii.l it was .•onfus.^l Nvith' mitral en.l.M'ar.liti-. Trn.. valvular ri..l.Mar.liti- I have now an.l th.Mi ..hserv.HJ in the torin of so-.all.Kl nl...|-:itive en.l....ar.litis, with veiTn....sc of ti-kin, ami th.r.i.y |.rov,Hl th.^mM^lv,- I., he part maiiif.-tati.Mis of this syinpt.)m-e..mi.h'N. N..n-..plie ..n.l.Manliti-. t.^rminatin^^ in rh;oi,i.. val- vular .li-.^ase ..f th.. h.ail, o.vurr..i, a- iia- I..M.n ..ssil.l\ -pe.ifi.. tvph..i.l ..n.l.H.ar.litis .l..v..l..p, in my ..xpt'i-i.-ne.-, at th.. li.M.irlit "t ,1„. ,;,i,,ii,. ..tajre— in the see.m.l and at the l)..^rinni..fr „f the tl.ir.l ^^.•.■k. sYMl'l'iMS .\.\l> tciiii' nt' llic >ym|iti>iii-, (>|H'cially the »v>li)lic muniiiir at the a|M'X. and tlii' acccntiialiuii id' the >fii>ii(l piiliiiipiiarv xiiiiid, arc iiidii alive of this (■iii\( 1\ eiiiitiriiiey tlie |M'i>i-teiice (if a \alviilai' lesinii. Ill iiiieeax' 1 lielievcil niv-elf jii-titied in a>-illiiiii^ tlu' a>-i>ciatei\c nivdeaiditis in a ycimij.' man wlin, tdfretlier with elldoeafditis flillowed liy iiiitnil in-uilieieiiey and >teni>-is, exhiliiteil al-o syin|)t(inis resemliliiii: thd-e nf severe an^^ina peeturis, witli [Kiins nidiatinjr t(i the e|)i^'astriillii, tiie iiaek, and tlie left arm. (inite e.\ee|)- tionallv — so liir as I can recall in hut 'J eaM>, in (nie a year and in aimther a year and a half after an attack nf typhdid fever — I have dii-erved the apiiearaiice (if the tir-t di-tinct cliiiieal syni[itdnis (if mitral insiitlieieiicy, which had iki' manife-ted themselves diiriiij: the attack in the tlirin df valvular eiiddcarditis. hut for wIki-c devcldpnieut iki dther (•an>e could he elicited. 1 su-peet that in tlioe cases a rather exteii-ive niunil enddcarditis \v:is present, which devel(i|M'd duriii^f the fehrile peridd of the attack (if tyi)h(ii(l fever, and extended close to hut not upon the valve-. I'hc proi^res-ivc cicatricial eouli-action that j.n-.idiially took place in the iii'ocess of healiujx prohahly then iuv(ilvi,'e, lint -till more fre(|Ueutly toward the end of the fehrile |)ei'i()d and duriiii; the peridd df cdiivalcscence. I hey may occur diice or sevend time- at irretjidar intervals in the same ]iatient, at times without, at other times after, direct external influ- ences. Anionfj; these excitinj; factors helonjr emotional distnrhani^es and ' An-lr .1. lleilk. IWH. ' y,r,-/,.„r' . .\n-/,n: ltd. xxv. t m ■p; Tyrii""> I rvyti- iiiil-ivt ..x,...--iv,. ,.l,vM.'al .ctivilv. -iilii.- iii.-ot.inuv i,. n,-truri„m-, rvp ,„;.,,- a,Hl -innnin^ at -tn„l. ..,■. Tl,.,-.. .a-.- ar. ^r-n-rally ..-,„.,ully ...v..,v in ul.irl,. witliuut clcM.un-tral.lr ...11-. .oUmi.m. ai.prai- .v.... ,,,lv al liMH- .luiinir til.' -•.■uM.I w.vls. au.l i- np-.a!.-! wImI.. ImuIv an.l ,„i„;i a,v k.|.l al.-nlnl..lv at nM. 'riirv r,v,,,wnllv trrtntnaf latally. 'n„, ..|i„„.al -v,u,,tn,u~ nf ...,11a,.-. atv ti,..-.- n-nal .., — .•ail..l a.-.,f ^mlia.' f.iiliiiv : i.ail.ir aii.l h vi.litv. .-iLviallv 1.1' til., la.f aii.l lli«' ..M,v.niti.-. .Irawin- ..f tl... f.atnn-. .■..1.1 -w..at-, .l..,a„-.iH..|iI ..t .■.„,- -.■,.„,-„.-, tinva.lv, -mall. f.v.,n..nt. ifn-nlar fnU.'. 1 l'« anaL.nn.. inv,.-.i.^ili..n- tilt.- thr ma.l.. l.av.. .itluT vaM.-l a ,...^at,x.. ,.-nlt. -v. vvl,..n n...v i,av.. vi..l.l J a.iv .v-.ilt at ail. l.av.. .li-.i.-r.l ,,ann..i,y,na- ,„„- .1 ^n.iati.m ..f th,' l..-aft. lUtly .l.-.n.raii..n. an.l .liiatali..ii. A ,l,„,„„.i, ,,„.ly .,f -M.'h .-a-.- l.y in...i..n. in..tl,...U ( K nl,i-l;..inlM.,-) i> at v. I wantiiiii-. ■| w..nl.l..x|m-lv ..,ni.ha-i/..th.. fa.'t tliat I i.av.- ,viMat..lly ..I.-.TV...1 .l,,a,|, i„ .■..liai.-.. witi..,iit anv .■xpianal..ry alt.Tali..t. in tiic l.."ly alt.r .l,,.tl.. a.i.l i.afti.nlaflv with.,nt .lian.^v in li... ti-nn. An: .-l.T, an.l .•..t,- .i,,o,...v ..f lit.- n.v.,..anlin,n. If -n.l. .-a-.- a,.' tint ii,_'l.tly .l,-.n.-..l ,V..n, .■.,nM.l.Tati,.n, i.nt a,v j:n.n,,..i with ...lav tinva...nin^ tfan-...n-y ,i,,.nlat.,rv .ll.ttlfhan...- xvith..nt .liMi...lly .i.^n MfaLi.' .lian-.- m tli.^ ,,.,,,,,,1,.: .,n..-.i.,n ..atnt-ally afi-r- : At- all ..I' tl,.-. ".■ar.lia.- .It-- ,„,l.an...s tV..,n ti..^ tniM.r an.l fan-i.-fy t.. tli.-v -att-n,^ tatal .•..!- lap-,. n......-afiiv tvlMaLl.. .<• ti... l..afl aL.n.V Tlti- .,,...-t,.,n .-ann.,! 1„ an-^w..n.l n,;,....t.liti..naiiy it, ti... atli.tnativ... Kv.fy tn.ptv,,,. ....l .,l,„.m.r will .v....^..i/.' lu'tv a .LlL-i.^.-y in -^- l^.-«l.'lp'. -I'"^''- ,„,,l„.f. i- appii.'al.i.. t.ot al..n.. t- typi,..i.l f..v..,.. hnt lik..vv.-v t.. -nniiar ,,„„.li,i„„. as-....iat. .1 witl. ..tiuT a..nt.. itttW,!.,,.- .h-'a-.-. A .nmtlK.f -.t ,„„,„,.,.... .nt -,n.li,.- app...r ... ^lH-1 VvM nym thi. -nl.j.vt. atal an...nfr ,1,..,,, ..-iH.iallv tita. .•a,Mi...l ..... a. ...y -iini.. i.y H.....l...r ' ». a--.....a- ti„„ svitl, Hfnitn- a-..! I'a-!-.-. 'H-v l--' ^l-.-v-. tl.at ti.. a-.,,..., o ,.„i„s ..f ,1... ..Nn.i..^ air...... of .1... i.-K-ti....- .li^'a-s ..-,..r,aliy ... tlu. pn..........'...Tns .lM..lipl,tl„.fia-l.a..;il..-. an.l .1,.. I'.a.iHn- py-ryatu,,.. i. ..x.,r...l, ..... ai...... ..l«... ttu' l..'.»'t- ''«'< ^''-" '-l"-i='".^ "l"'" "'<; va-...n....... sv-.,..n. >.. .i.at it. splanati..., ..f .1.- -y.,.,......M-...|.l.'^ "» ..,„...t;.Mn.l ;.a.-.lia,.xv<.ak,u.ss'- i.a...ly.i- ..f .!..• va............ .- "tX" <.. " Tl," .'.■p'....ial .liffi.Mtlti..^ tl.at a.t....l ..xp..r'm...,t< witl. .!..■ l-.i^.n of ,1„. typi...i.l-l.a..ill..^ l.av.. Ititl,.,'... p.vv..nt..l a -,H...ial c.Np.nn..'.,tal ■ x,Ur,.-s l,..|^.n. ,h,. C.n., f N..,,,-:,!,-,, .. I.u! k, .H.^; ,„i,,.....< ..r .Ih' , ,in.. A1-... nrrl.,,. U;„. 1|-.„.A . is:... N..-. M an,l .:! IV.-W ,.,M l.n,„l,..r., y,r/,n„HI ,1. (■'Mr. f- >■»:. Mr.l.. \Vi..-l.:..l..n. W,<; , ,.,W,....-.- l.y 1 h-s-I.t). SYMJ'niMS .l.\l> I nMfl.nw llnss. n; Stlltlv lit' till N( \rril vcrllirli" It i< -caret it' i\|)liiiiil ti'M r M iiiiiii Iv to ii)' iloiiliti'ii tliat ii ■irciilMtors (li-nirl>:uiic- arc in Ir (ii- ill part I" lie allriliiiliil t" \a-r -lal.Hl a l)-(iiiiiil\ . l'"iitiin' ,i,v.-ti-aiiMii iiiii-t .Ict.iniiiir uliat part i- attnlmialilf t.. tlir li-'art it-.lf, an.l wlial tu tlu- vaH,ni..loi>, :iii\\' \»i\\\. ' Changes in the Blood-vessels, and their Clinical Mani- festations.— l/ml'' i- Unowii uilli r.MranI t(. llir art('ii.> iVnni rillici- .,„ ;,nai..ini,- or a .■liiii.'al point of s irw. A prol.al.ly ,-p.vilic .li-.a>.' of ,|„. artcri typlioi,! arl.rili- of Knn.l, iiivr-ti-ator i- .-pc-iaily .{.■s.-rviii-- of ni.iition. Tliis is |H.-il.ly the |.riii(ipa; .aii-c of tiiat ninarkalilc .•on.lition, ti.rtnnatrly ,.I.-.tv.1 l.nt raivly, tlic >o- iranj:ivii.' of lli,' .Ativniiii.- in the roiir-c of tyjilioiil f.'V.T. Til.' t.n.l.Micy at piv-cnt i- t n-iilcr tiic lliroinlio-i- as diic to an inf.M-tiv:' artrriti- ; an.l -rvmil nivi-ti^rator. liav rlainu' are >till nec.lc.l in relation to this iniportaiit point. Tvplioiii >:aii,i;ivne i- oli-erve of tlie mcniher iiiav 1) nie jr;.n;rn'ii : all the toe-, tlie enlire foot np to the kiur, .veil np to the nii-l.l!" of the thidi. I'mlcr -neh eirenm-tance- tlirum- l)osi< will \nss,.;ui. ill iiis leiliires at tli.> fani..us .•liiii.' at tlie IL'ptel Dieii, lias .levote.l a short eiiapter l.> liiis iiiaiiifestati.iii. .\ni.mL' more recent writers I'otni/ Mereier." an.l Le IJeixuiUiet ' iiiav he iiienti.me.l. Keen.' in his a.huiral.le iiion.'.-raph. has .•olleete.l ] 1.') east's of ^'anjrrene in tvph.ii.l fever .hi.' to art. rial tlir.>iiil..isis .ir eiiil«.lisin. The earlies. npiK'arance of the sjanirrene was .ai the f.inrteenth .lay, the latest in the m'Venth we.'k. In tranirrene ..f the hiwer extreinilies it .MTiirre.l xs frt-- .piently .-n ti..- ri-ht as .>ii ih.- I.ft si.l.'. Keen a.lvis..s aiiip.itati..ii m .ran- . .\,;-h. ,,..,. ./,• M,,/.. Ami:., l^o ' '■"'"" "'"'■ ^''l''' '**"'■ ' Ar,-/,. ,,. ■ .A )/■■/.. K.'t. iin.l Mii;>. IHCrv ',l/v/i. (Ii- hii'I. rr/x'r., 1878. ' Cuiim mid., 1878. " /,..,-. ril. 11 SS;] II I '■If ■'^Hmtt ^^ '. HiH TYI'll'ill) I ivi.i:. ah ia ■ •.'rem- nf the <'xt remit iis, ImiI smvs I lint a.< a ^'ciicnil rule it is Ih-mI to \Miit tor a iiiii' lit' (li iiian-alioii ; Iml o|M-ralioii sIkhiI'I not lie (li't'crrc"! \invs al'tiT il> a|p|H'araii<'c. I liavf |i(r>niiallv (iIimtvciI tv|iii(iiil iraiiL'ri'in- nf ilu' jnwcr cxlniTiitv in li iiiMaiico. Ill niic ( asi' LraiiL'rt'iic cit' tlic tl"it ami the lower tliinl (if the thiirii iievelii|iierior tiliial arlerie.- (xcurriiif; in the .-lai.'e nt'llic ani|iliilHilic eurve. In amilher case,' which niciirreii in a voun;; jlirl. and lerminaleil I'atalh, the LraiiL'rcnc resnilcd Imm ihrnmliiisis (if the iliac and femnral arteries, which was as.-ociated with liiriiMiiio|ihleliitis of the ciirres|MindinL' veins, and invuKcil liic fimt and the entire Icl' t(i the hiwcr third of the thiLdi. The ciiin|ilicatiiin a|i)iiars tii he extreniely rare in the li|)|H'r extremities. I have |iersiinaily iili.sirved ;.'ani:rene nf 4 linirers (if une hand and the ciitanedns cnveriiii: (if the hack (if the hand in a |ialient who esca|ied with his life. ( ianL'reiie has heeii nnteij in isnjatcd instances in the distrihiitidii of oilier arteries ; thus, in that of the external carotid, in which ease the auricle, the jiarolid jrland. and the inte<.'ument coverin;.' them mid the adjacent sot'l parts liccame jj:ani.'reiioiis and were exliiliate(i il'atry'). I'os-iihiv certain cases ot' circnniscrihi .1 ccrchrninalacia ocenrrinj: dnr'tig the lerminal stajre of ty|ilioid liver arc to he atlrihiited to inllanimati.ry throinhosis ot' tiie related cerehral arteries. 'I l;ii-. in a woman, thirty-seven Years old. I ohserveil the '_'radiial develo]imeni of riirht heinipjiresis with iijihasia dnrini: convalescence from typlioiil fever without antecedent a|io- lilecliforin attack, 'i'lie case, which came under my ohservatioii in con- sultation at a di>tance. ti rminaled I'atally. The re|iort of the antniL-y hy the atteiidiiiL' plivsician mentioned as the cause of the condition extensive softenii.L' of the niiildle |«irtion nf the left cerehral lieniis|ih(-re iti cdiise- (jiience of adhesive throinhosis of tf.e artery of the fossa of Sylviu.s the walls of which were. Iiesides. consiiivTalily thickened. Welch ' mentions 4 other fatal cases of throinhosis ot" the middle cere- bral arterv or its liranches duriiiL' typhoid fever. In the case reported liy (Xsler. severe Cdiiviilsions suddenly occurred on the ninth day of a mild case of tvphoid fever. Death occurre(l in ten hours after the onset of the cere- hral svmptoms. At autopsv there was tound throinhosis of liranches of the middle cerehral arterv, the adjacent lirain-siilistance liein;: studded with heniorrhaires. hut not much softened. Iti the aorta and the laruc arterial trunk-. I liave re])eate(lly (il)serveis, licre and there even dihitatioti (leciirrinir. In (Hie case, (k i iirriiiir in it man, tliirtv-tive vcars old. p* *'ectly liealtliy lietlife the (itiset of tlie attark of typiioid ti^ver. the arcli ot the aorta, wliicli ])re-ented extetisive retienl.ir tliickeiiiiiix and tiirliidity ot' the itititna. was (lilat(^l to altiiost (loul)le the nortnal. Neither in this ca-e nor in the others iiiidir my (il)servatioti were symptotiis ]ifeseiit ditrinj: life. ' The v.x^o. wtiirli \V!i- iiii.liT my r:in' wlun I wm- ii-i-tant at tlif St. lincluis- >)iitalr in Mainz, lia- l.—n r,ii..rt.(l l.y Ma—nll tl>, „/<./,. .\,;-h. f. I;l,,i. Mr,!., IW. v., S ll'i tl'. ). 1 ill.' ii'ii. !i',\vrv.T. ai,'r(>c with <"nM' •■!' th" i'|.i'ii"n'' "■\pf--i'(l in ttii» piiptT, ^ f.'"' ^it. ■' ■ Thriiinl)i>,si.- aiil F;nili..li.i/i' «'X|ii'c's>lv tiiat ill a i:ir;:c iiiiiiilHr uliMTVatioii, 1 liave alsd ne\ . r eni'in;ile case already nieiiii.nied), either during the ediirx' of an attack of typhoid fever or anioiij^ it~ seipiel-. Kmholi.-iiiof arterie-'if moderate iir >n aller >i/.c, of •.vhich marantic (?) throiiil>o>i- of the left -ide of the heart, e-peeially the anriele, i:. u.-iially tlic source, i- <|iiite rare. Kniholi in the kidiiey> aiiervc o>is of the larjxc v<'ins of the letj, with the finiiliar symptoms of phlcjrmusia all>a dolen-, is not an cs|)ecially nire manifestation in the later stair«'s of typhoiil fever, especially during convalescence. Kvel) at the present day the condition is ottcn eonsid- eiH'd the expression of marantic tliromhosis, and this explanation is pn)l)al)lv correct for a |)ortinn of the cases. On the other hand, the dis- order i- fre(|ncntlv observed tn develop in |)revioiisly healthy, rohnst indi- viduals aftin, must be taken into consideration. Whether such typhoid jihlebitis is s|MHafic and is attributable to tlu' direct activity of the l)a<'illiis of Eberth is not yet certain, but it is not im])robablc from the observations that have l)een made in so many other orjrans. That other micro-orfranisms also, es]H'eial!v py()<;en:c ciK-ci, may |)articipate in this prin-css, that therefore ' See the section on Anutoinio Alterations in the Cir('uluti>ry Organs. =• >- -. - • 170 ryrii"ii> ii.viii. ,,,,„„,,li,,„i„. ,,l,l..l,iti. in .I,. Mri.t MM-, may o...ur, ...n s,.:,r.-.lv 1.- ,l..iil.l..l afl.r the ol,HivMti,.n- nf Dunii..' Lik,. ,v,.l>wi,i .rt.rin-. ,,1,1.-.,..-!;. all.a .Inl.n- ^ n.rally a,.|..M.-- „,„„, ,„„'-i.lr. In nnlv -2 in-tan.r- l,av.. 1 „1.-, n ..1 tl,. -.r,,,,.! tim,' r.|uallv .(l.nialou-, ..hvioii-ly ni <-<.n-. ;,nl'„,v"or .M.nMon of tl,. tli.n.nUoM. f. tl,.. luu.r portion ..f tl.e i„,-,.,i,„. v.na rava. an.l lii-n.-.. t<. li.' otinr iiiar vrn>. ■n,.. v.noM- ol,Mn„iion> in thr .■ -• of t,v,,i,oi,l f, vrr a.v nn.lrr all ,i,,,„n.la..,v~ n,o-, nn,l,-iral.lr ,o,n,.li.-a.ion-. it i- Irur tlia. ,v.-ov...-v nMially follou-. l.nt ti,r .iuratio,, .\- llir .H-a-r i- r,,n~Hl.TaMy pro- ,r,rt..ci • not raiviv tor a- nni.h a- tuo or ti.r.v n.ontl,-, an.l rvm v. 1 l,,v,. no, ol,-..rvr,; .an-rmr .l.vrio,. a- a -r.,n.l, l.u, now a.i.l auain. ,;,,,„„„..ly ranly, .l.taMun.n, of fraj:„u.n,s of tl.. tln-o.nl,..- o.T..rs witli fatal .■Mil.oli-iii. , , • !■ N,„ „, tin ,l,o-i-of ,1„. f.moral v.in. plilrhitis at.-I .hvIumom ot ,h.- -at.lu.non- v,in alonr. or of ,1,.. ,.o,,lit.ai v,in an,l ,1.- .l.vp vrm^ ot ,1„, „„.-l.- of tlw .alf, will, .■•l.-.na of th,. f.-t up I" >!„■ .alt. an.l .-jK- ,i,ll.- with tirtn intiltrali.m an.l ..on-i.l.fal.l.' t..n,l..rn,.-- ..I tl,.. nu»..l..s. ,:.„. ,„ ,„, ,„„ nnv. In i-..iat...l in-tan,v> 1 liav.. ..i.-.rv...l also ,,l,l,,,i,i, ,„.l p, ripl,l..l.i,i- .n ..1.1 vari.-o-.. .lila.ation- of tl,.. v..n,- ..t .!»• ;,.„ i„ ,„„„ ,„.l w.,.n,.n M.tV.rin,^ fn.n, ^^\^^«\>\ f.v.r. in ,ny .Ap-n- ,,;,.,. v...,on- ,hron,l..,M- in tli.' ..onr.. ..f -> pi^.i'l f.-.r l.a- nrn-l ..tl, ,.x...".Kli,..r n.ritv in otl,.- p.-ti..,,- ..f .I..' l-b tl.a.. tl... l..w..r ...xt.vn..- ti„. 1„ on., in-tan.v tl... axilla.-v v.i,, a...l i,. a>,..tl„.r tl„. r.^.t -nl.- ..l.via.. v..in wa- inv,.lv...i. IVm.!-.. lik.' -nany ...1.. r wnfrs. 1 Lav ,„„i,...l ..,«,., in wl.i.l. pl.l.i.iti- :»..l tl..-...„l...M- NV..V p:Hl n.an.i.'sta- ti.,„- .,f, or a..tnally tl.c s-mnr ior, g..,.,",! s..pti....i...a .■.,n.ph..ating tvi)l..>i.l f..v.'i-. . , X- ■ Changes in the Condition of the Blood.-N..,.,.nm> s tato- ntontswith .v^anl t.. tl... .•..n.li.i..n of tl.^ l-l-"! i" -<-;^ 'M''';"! f,.v..r atv ......tain...! in tl... writi-.-s of .a.li.r .1 -.•rv..i>. I L.y ivt..r, l,„„-..v..r, 0..1V t., tl... ..v...,'nal app..a,-an.v- ..f I-I.-hI .•l.tan....l on v.t.o- .,.,.ti..n .>r iV...n tl... -l-'a.l l..Hly ..r that ..-..apinii a.-..,.l..ntally Ih.^o .,h<..rvati...is ,li..l..-.Kl ... littl,. that f.-r a l.-nj: tin,.' tl... M...ly .,t the 1,1 1 was alt..L'...h..v .....l.-t.^l. NVitl> tl..' a.l.M.ti.m ..f .n.,.r..v..l n,..tl..Hls s,...h inv,.-ti^ations hav.. .-.•.■..ntly h.-n n.-.n....! ^v.th .n..ro .„o,...s< Tl... .„..,-pl'"l"irv uf tl... M.H«1 an.l .v.-tai.. ..l....n..'al .•l.a..,tr.. i„ it parti-nlarlv tl,.' l..-havior .,f th. lu..„..,irl..l.i... Lav 1 n stn-h.^l, .,„,! .,„ M ..onsi.h.ration has l„v„ jriv..,, t.. l.a..t..,i..l..ir,.' .nv<.st,jrat,..n Changes in the Formed Elements of the Blood.-W ith rcganl I /),„/>,•;,. .l/v/,./ Uni^ M'.l.. M. \\\i\,. U.'l't.. :; >i. 4. SYMrniMS -l-V" ( OMI'I.II \lloSS. 171 t., tl..- n.l l.l,KKl-.or,,nH.l.s, t!..-s,. Imi n.nly ,xl.il.il nurk,.! rl,.n_-. s i„ r,,n„ «i/.r, an.l .ul-.r, hut tlu ir .num.rai-n I,:,- v,..ia,.l i,..t miuhi.t- ,.-,i„.^ n-ult-. Wl.il. .■Mil-ur vN.-it.i-. .-|H.i:.ll> M^ilM"-/. an.l ll^.v.in, v^.,,v ummI.I.. tu .1... ..^tnu.a .v.lu.non i,. .l.ir >nnMlHr. ,....-. n-,,. writ.T- 1..V.. lumul tlut ii. tlir majority of -a-..- tl,r nuinlMr ot n-l ,o,- ,,„-..l..- nn.l, ru-^ -louK ,.o,.n-iv.. .v.luHiou .iMrin, .!.• Irl-nlr ,,, ,,o.l. Kvl.l.n,... in -u,.,H.n of ,l,i~ -tat.nw nt i~ .■..nUm...l m, tl.r ar.,,!.- o| Zi-l.in' Ti.n.av Hm11:'.'=""1 l.i.l.,. n^urn,' a.pl a- a .vmiIi o| ,,I,-,.>- vation- M.a.l.. in n.v . linir I an. in a.vonl wi.l. tl, ..,,>. -o that .!.■ nnn.l-r >till ,..,"='11<^1 »•"""•""" '"■ -'■""■^^''^" """•'' ^vl.il.. in noMMi. an.l .Khilita...,! i,„livi,lual- a n.ln-tion ... ^;.<><"M";' -• evu, s..n,..wl.at 1.- ...■.nm.l. Tl.ay.r.' fn.in an analy-., ..t all l.l.....l- ,o„„t. -n tv,,l...i.l i-aticnts in tlu. .I..ln>- ll..l.kiM- H-l-'tal -Innn.Ml... ,a-, ..i..v..,; v..a.s .,at.. tl.at th. av.ra,. l..>^ i- al t 1 .M.n.oot. ,... '.,„,n 'riu.'.v,lnrti..n .■..ntinn..- t.. in.Mva-.. nn.il towanl tl... .n, ,.t „„, ,-,|.,il,. p..ri.«l. a.,.l .v.... int.. .1... af-l.-il.' p.-i...!- 1" »•='-'- ""';"^' ,,„,„i„„, how..v..,-. n....n,.n,ti,.n n.ay l..,'in w.U l..r..re ti.e h,.1 ot .l..1.r- v.-.vn.r. Dn.in- .•..nvaU-.v..,'.., n-nally Iron, .w., ... tl.n.c w.rk- atUT ,K.f,.rv.-<..n.v. tl... .nnni..r i< lik.ly ... .■.■.nrn ... .!..■ normal. 1. appears l,„w..v..r,.ha. .!..■ nn.nl...r..f r,.l l,l,-..l-....r,.n-..l... ,.i,y>i..l..poallv n.,nnal to ,1... in.livi.lnal is l.ut >l..wly attain,..!. W.. l.av.. faih.l to t,n.l .1...- „„,,nal ..nn.l..T i.i ,«iti.nts wi... l.a.l lurn In- iV..n. f.v.r t..r ..v.n ...v..n w..ks. Witl. tl... ...Ki't ..»■ r..lai.s..s, .1... .nnnl...r ... r,.l l.l.-..l-.-r- ,,n-..l,.-vvill..f...n l...f..nn.l sn.all..r than .Inrin- th.' h,n,halt lies lilutes im r,esi,H.kn u. knmkm » Koliier. /"""/;. />'«.. T-.'ip.-i>'. W»->. *Juh>,s llupknis Ilu^,,. Rep., vol. viii. U^^Sml^^BM^J/iWf^JmSXi^Stm^^^^M^Ji 172 /I riiniii 1 1:\ i:i: Hi!) H. HI I ,.,„■,„.-, lr-;,ri(r i.n.lM-.. -u.ati..-. Cn.uii/' I.m^ ol,-..|s.-.i tl..^ -]>,nU'- ,r,-:ivils ..f ill,- M I. iui'l ih.rc toiv it- .l.i.-ily, in.-n m^.' iil'tcr cl.l l,;illi^, uuii.-. ;.- Ii'- roriv.llv iHlirx,-, to llir .ir.Tt \Nlii.l. -liini.hnion of tlic v;i-uni.,„„- u, rxcii- ^V-t.Kl -Arrl- u\<' ,,f L.•i.■llt.■ll^ti•^,. In mv .•lini.', av.raK"' ml„.ii,,ii- t,> from SO t,. T:. \»v ,-.nt. liav,' l.r.n oI.mtvcI, n.ivlv i,.wer f,;r„n-. In tlu. af.lnil.' lM>i-l. .-l"viallv .luiintr thr fn>t wr,l<< ,.f tins l„"n,,.l. all ,,l.-.iv,T-, iiHliMlinu; j...i,.l,t.Mi-urn,,.l.>.M-vr,l a lomr prnvnt- a,r,. ,,| li,.in,,irl-l.iii than .iiirini: the f.'l.fih' i«'fio,l, ihi- M;;ain ror- ,v-,,oii,liii- with thr irnau-t .v.iii.-ti,.n in the ninnlMr of .v.! l.lo,,(l- ,.„,.,,u,..h.s wi.i.'h uMially ,..vni~ M thi> -tajr.'. Kaaihr ■ -tafs— aiul m thi- Wf <"m MLMv.. with him ni-on tli.' Imm^ of |„TH>iial rxpvn.iKr— that ,hirin- .•onval.'XTiu'.s vvhil.' the niimlH.|- ,,f iv.l l.loo,l-,.,,ri.n-..l.- i^ ajiain i„ ,,ro.r^s of in.'tvaM', a fmth.T mliicti..!. in th,- p.iv.ntajrr "f hnn,,- irlohin mav tak. I-Kkv. It ,.vol,al.ly n-nallv ha,.,..-> that wluiv ih. ',,„Mnia ha> l»rn a,.i.n-ial.l. th. ivtiirn of ti... hciuvlohi,, to th. norma is, a. in most s.ron.lary unemia,-, n.-.tv KMa.hial than tiuit ot tl... .v.l l)loo(l-i-o|-piisi'h>s III cimiwnson witli what i- known coiUMrninjr the itnkocytos in oth.r iMf....tious .les are funn.l inerea^.I at the l.-.^^ht ot^ th.. attaek, tin- in.Tea-e i. Mantins: with ^reat e,.nMan,.y tn eases ot tvphoi.! h.v..r; a .limini.tion, win,!, may even he very ...uiMaerahle ,s .il^,.n ,.re..nt (llalla-rnina-,- v,.i. F,iml.e..k/ Ki...ler;M in.w.t/ ■ Nae^eh, Tinv. r '■) It eve.. ha,.I.e.,S as Kie.ler show..,I, that, with ...eivase ... the sv.npton,. of the .li^euMS with mark.nl elevation of the te,„,.e,-,tu.-e, ;„.! with tl ..set ..f .•e.T...l..«'enees, the .......her of white 1.1 U'ov- ,,..i,.s nn.ler s still further .-eanetioi,. We have a.T.ve.1 at the same p.. ^ l,,^ ,;t »/,'/.,/■. llrltk.. Bd. x. ' A7.H. VnllfJ. il. Hi.if !,nr. rJt. SYMri'lMS IN/' ' (iMri l< \ ll'iSS. 173 inclii-iiiii-' a S 111 >l. .(•rvers li;lili<i>' iiiilliiixl'i-- it raiilv pivi- li-f tu a tiiitlii r n t' tllr ill-ia-i' II iliU'ti 1,1' 1(1(1(1. ( 'iiillll- aliiivr lo (1(1(1 arc i-art', ami ii-iiaiiv iiuliratf llic miM-t lit' siiiiir iiiiii|ilii'atiiiii has -liiiwii liiat 111 iimiil.1 Till' liiikiiivti- ill till' jM ri|)iifi-al the itVfit lit' Miiiif 1'iin'ii.Mi itli Tl lavcr III lialli' raii-i' an iliiinn li:itc tiaii-itiit inirt-.iM' in llif iilatiiiii ( ii|)licatii>ns wiili mil riilH ill litiiin- lliat nnlinarilv five riM' tl) Iciikiii'vtii^i- ail' altcni In! witli an iinTia-i' in till. nnnihi'T nf white .■..rpi.Mli- tu tln' iiufiiial ami iIhiVc 11 111 wit 111-, III a i"i-i' II 1 till' iIi'M'IkjiIiii r iiiliTi'iirniit iimniminia llji*"' wcii' cinii lit lit' an al)-i'("— ivir till' >ai'i'ii itfil, III 4W0, iw ('iiiii|)art'() i.ri'vinii As tl) the ftVcct lit' lit -ail tl iiTc IS a tcmlciifv her I'l.mplii'atiiins iiixm the U'likocytcs, it may , though ot'ton twi'lvc ilh 1 that iK'im.rrhajro may fX.Tciso Httlc i.r im iiitlm'm< ti.wanl a ItMikocvtnsis nwhin^r its max (imnm to twenty -t'oiir hours at'tcr tlic hfimirrliajrc has occiirrc •latci 1 with a li'iikucvti .1. Th Tiic hchiivior rDiniHisis )f th anil i>lilfl>iti^ afc asMx white coipii-eles in pert'oi-atiun i- uf izn-M impuitaiiee, esi.ei'ially ii> riiaver eoiieliules tVom quite fVei|iielit ar relation to earlv iliafrim^i^ aei'Unite eiuints oil H eases that pert'onitioii oi' the Imi ill iisiiallv lol- OWll 1 l)V an iiierea-e m the nun iiher of leiikoevtes in the |ien| ihenil eir- iilation. 'I'll lis luav he eoiisu in eomparison with previous eo iler.ihle or only sli^'ht, ami appreiialile only Not intreiineiitlv, however, there nuit.- lll aliseiiee ot 1- evtes mav oeeii inerease ; e veil a (liinimition m the num iiher of leiiko- r the latter heiiit: ireneniUv an im lieatiou (jf tile malig- III tv of tlie iufeetion or the prostnitioii of the patient. No ilistiiiet (litfereuee in the ii'duetion m the mini ilxT of tlie white eorpuseles in aeeon lam ith tl le seven at least not in sueli a ceri»iiiL' lli:ii I'll iiIimt\ii' liki- \ iii'liiiH ri-|>.irl- an iiicnM»i- in ilio l<'nl\iH'\ it'» III I\ pliohl li'Nri', ami tin- <|ii('>ti>>n ari-iT- w licllicr lii.-< olix rv aliuii!* air II liralili' hi iIh niilial .ila;.'i-. Kniirli iii\ oli^'alm.-, a.-, liir in-lanrr, liniiiii-,' liaM' riMiml I oii-ii|cralili' iiiiTfa.-i' ■liiriiiL' lln' lir.«l «i-(k, and nnly .-iili-i'ijiK III Iv a rajii'l ii>'( I'raM' in llir iiiiiiiImI' i'I wliili' lili'iiriii;^ I lie I Mil. "I III' ,iiii\ all -( iiici tin I Mini I II r nf li iiImii\ n - a|i|iiar- a'^aiii til iini'ia-i' -InuU ; aiicj in i|i liiJilaltij |iir-iiii-, ariiiiilliiL; '" mM' iiii-i r\ at ii III' , iiiiiir -jiiwh llian in inliii-l iiii|i\ iijiiaU. in wliniii ullin a Irtlini til ill' lliiinial lna\ In llntiil ilnllll'^ (jrlrlV i -i mrr III' ijlirilli; till' tii-t ali iiilli' ila\-. in i-nlaliil in-iain'i -, Kiiliiir -' n lali - lia\ iiiL' "li- ■cfMij iliiiiiiL: iii|i\ all -iilii 1, \ulliiiiit c-|iiriai a|i|iari'lil caii-i , tran-ili'iv iiiiii a-f in till nniniK I' nj' wLiir |i| |-,„|'|,i|.,.|c, ;ili.i\, tin |ili\ -inl.ii; ir, 1 1| I In rj, I 111! I. Ill I. Ill' in-taiiri I \ III n|i til I 7.")l I". I In- nlj-nx at ii m i- -n|i|i'iiti i| ill a fiiiiai kaliic inaniicr li\ a -iinilar hIi-cia al inii nl' Laailir. A- In liir \arialiiiii- wliiili nrnir in llir fi'lalivc iimiiiIhi' uI' llir ilitliiviil \aiiili(- III' liiiNiirx ti -. TliaM-r ■ -a\ - tlnii- aii' llini' inaili clian^ji-. ami ntlnr aiit limit ir- ai;ii-r uitli liiin in llic i^viiiial -taliimnl-. (-11- Nariivli 'l. ij) i'liiii i- a |ifii'^i'i --i\ !■ (liiniiiiitiiiii in tlir |m irciitaLri' "'' jinU- iiiiir|iliiiiiiii'lrai-. ( l! ) riirn- i- a jiniLiir— 1\ i ninca-i in lln |M'iciiita^r nl iniimiiiiiilrar liifin-. till' im rra-i' liriii;.' inaiiiK in tlir lai'i^r nin'inniiclraf varirlii-. (:'il A ciin-taiit l\ -mall [icn i iitaL:'' "I > I'-iimiiliilii' iill- uri-iif*. Nac'Liili tliiiik- llial tlic in-imi|iliili- ii-i all\ iiitiiilv ili-a|i|iiaf ilnriiiLr llii- liii'jlil nl' tlir I'rMT, ami llial tliiii |i(i-i-ii'mi' i- a viiy t-isnralilr |ii-iiMnn~tic -i'jii. Bacteriolo}jy of the BI(kh1. — SimT tin' tiim- nl' ( JalVUv . iintmi'niis nli-il-MT- have (ItAiitcl! tllcln-C'K c- In till' ill\ c-ti-alinll nl' lllr Mnnll |iif inirin-niuaiii-iii-. |iarliriilarly ty|iliimi-liarilli, (Jatl'ky liiin-ilt', ti- i- kiinwii, nlilaimij m;^ati\i' ri-iilt- in lii- ii'.Mi in\ i-lii^atinii- in tlii~ clinc- liiiii. I,alir iii\ c-tiLiatiii- lia\i' ilinitnl tlirir -tiiiric- in pari In ijif lAainiiialinii nl' the lil I nlitaimd I'l-nin -nim inii\ cniiiil jial'l nl' liic Imilv. Mciiifallv llir li|> III' till' liii'^rr. ami in |>art In an iiiv«-lii;:iliiiii nf thai nlilaitiiij t'lnin rrrlaiii parN nl' ilic lindy iIh' xat nf -prcilir Ir-imi-, c-pcriallv lllr fn-cnia'. 'I'lli' fc-illt- air uiiirlv (li\ i ri;rllt. ami ill pari aiT niarknilv ciiiilfailiclnfv. W'liili . liir iti-Iaiicf, Mii--rl ' liniml Ivpliniil-liacilli ill llic liluixi inii-Iaiilly in It ca-r- rxainimii tin- tlii- |iiirpiiM', iillnr-. a-, tin' iii-lamT. Alnii|iii-t " ami Silvc-triiii," lia\i' liriii alilc In (Iniinii-trMlc tlniii ntilv in i-nlalcil iii-Iancc-, ( )li-cr\(i> nf Th..,- .1- J;,r,<. I,s7i;. ' /,...■ ,-it. • (iiiti-liiTLT. iNK.'i. ■' /,.„■ .-.I. ' /. ■-'. » II';, ». I,,,'/. II'm,-/,., issi;, N,„. L'l unil l':!. ' Ji,r. .,,„ .// I'/i/i. I'..,/ . IMi:;. M.)//'/".I/> I V/) < OMI'I l<\ IHiSS 17« • ■-|Mri;il -kill, -ikIi ,1- Kriiiki I ami Sin I-,' ;iN.i Lupil.lio -' and Sit/, lia\i, Imwis.r, jii-i a- ijid (iallkv, in\aiiall> olilainiij mj^alivi' ri'-nii-. Newer wink willi l)elt(r ttietlicKJ-. Iia-, lnn\e\ei-, -Ijunmi that, in-lcjiil iif I\ |iliiiil I, (lies pmlialilv ale |ne-int in e\ c l\ c-.i-e liniin;: -iinie -lai^e 111' tile c|i-ea-e, .111(1 ean lie -|iital. S-Jippttiiinller h,i- lalelv .>|piaiiieetiiiiis iif the iii-e-|>,,ts (sec sc<'tiiiii mi J)i- cii— inn nf the I iiiiividiiai i''eatiircs — I{o.se, attclltiull llll- lltfll «lilr,lc(l mI-c, \„ the Ii1(hmI (if llll' -|.I(CII. I'n-ilivf rt-iilt- cuiilil iiio-i ica-ciiia!ilv l.r r\|icci(il I'loiii tlii-, m~ it i- will kimwii lliat cxaiiiinaliiiii ut' the >|ilinic |>iil|i al'liT clcaili ti^r liacilli aliii wii'c made \<> iilili/c llu-c tindiiii; .did Nri«>cr liiid till- i-]«via!lv in view — \'in'it~ i.i i|Uc-tiiin arc li\ im mean- cuii-taiil, a- llic uli>crvaticiii- ut Stai;iiitta,' tin' cxainiilc, -Imw ; and cxcn if llii- uci'c nut llic ca c, llic daiiiicr (if llic iPidccdiirc wdiild -land In llic way of its ciii]il(iynicnl. One iictKl lint think of llic tcn>cly di-iciidcd >|p1c«'II nftiMi oli-crvcd after dcatli. witli the -iiclchcd and tliinncd-nnl ca|i-nle, and mImi nf the iciidcncv , whitji i- liy i; i lucan- ^li■:hl, Im -|i(intanc(in> ni|iliii-c, and "iic will iidl cM'aiiL' the fear that piinciiirc nf the -plccn dnriiii: life may readilv result in rii|itnrc and danirenin- hcmnrrhap'. 1 have iievt r lieen alile to inaUe np my iiiiiid tn |ierfiiriii the (iiicr-ttioii." ': v't-' „; SPLEEN AND THYROID GLAND. Enlargement of the Spleen. — A1i1iihii:Ii recent enlaivcment (if the >|ilecn, (ili\ii>n-l\ a nianife>tali f the infectidiis |iriiccs-, is (ili>er\cd ill all iiitcdiiiii- di-ea^e-. IK \ ( rtliclo-. a|>art fidiii nialavial li'Vi T- and -c|ilic di-ea-.-. -]ileiiic liiiiicr i- in no di-ca-e (if a- j:reat dia^'- iKi-tic >iLniili(aiicc a- in typhiiid fever. Thi- lint ha- even jrivcii rise to exatrtrcratimi iif iIk' value of the -ym|ii(ini. Smie pli .siciaiis will iKit venture a diaLnm-i- "l' ivplmid fi vcr at al' uithinit the (lcni(iii>traticMi of fnlan/einent of the -iilccn. In addition to the frc(|iieii: duration, and its coii-tant rca|iiicaniiici in rccrudc-cencc- and rclapM'- arc e-|iccially indicative of ty|ilioid fc\ i r. The frci|Uclicv of typhoid clilarp-mcnt of the >plccn in c-eiieral I /,. ' /--/. r /,/■//, .1/.'/., lid. N-\iii « IC/,„. ,„,,/ lil.tlt,-!-, IssCi. N.i- i; iui.l 7 = /,' (" ti.'.l . IS'.IIK « Al.,, N.i-.,.,' (Il:i..lkc. ■Ilii' IliiiL'ii'"'' 'I'- .\l.il-n,i>i;,ll\pliil- illiil \Vi.l:ils Soriiiii.liM-i,..-ii-rli.- \-.Tnil.r.ii ■ /)..-/m/, .„../ ir../. , Is'iT. N.. L' i \\n- r lalv r(.p..rtc(| tli:il :it |,n-nt li. |..rf.inii- |.iii„ luiv of tli.- -i,], ,1, f,.r ,li:,.,Mi.i-li.- |.iir|..-— ,.nlv ill llic nin-t .11-.-. -11;. ■, h.^ Iki.I f..un.| ..11 |.o-t- rlr \Miiiin:ili..ii "f "nc |.;iti.-nl ..„ «||M1,! ;hr M|„.rMll..ll ilii.l l.r.'Il 1 ..M-l'. .rin-.l li lili.' l-iir. 11", rlH. ji.Mi;, ill tlic (■ii|i-iil'- ■•I' iIm -|,1.i-ii. uimI 11X1 L.'niiiis nf II 1 in tln' iil.il.iiiiiiiiil ciivity. mmmm: m^^^mmmMmr ^Wij^mi^w^mmf^ ^^^m$m>&^ KYMI'T'iMS AM) < OM ri.K [ IIOSS. 177 <';iriiini lie otiiiiMicil Villi ccrtiiiiily t'riiiii tile I'oiilts ot' cliiiiciil I'xaiiiiiia- tiiMi. A> will l)c .lire fully iliMii--ctratiiiii at tlic l)|' anatuiiiic ii iiiii.-t In- liiviiktHl. Ill Vdiiiii.'-, rnlm^t iiidiviiluals, wlicii death ncciirs at tht' hcijiht or lowai-d the ( iid of' the di-ca-c, cmii a ~liort time attcf tlu; oii-ct ol' dcti'ivc-cciii'i', iiiorc or it'» rociit ii\ iicrciiiia r 'lurinf; the febrile jhtIimI, this is de|)eiiv in tl..^ .•on.litinn- laM nam.-l may n-i.l.' tluMxplanatinn ..f n,y ,,!,-, nation that vvlui. typlioi-l f.v.r ur.i.i- t;„. ,1„. -,., 1 ni- tlir lliinl time in lli" siiiic patient .nlaipm. tit ot lli. .,,l,...n i- Mli-rni witii ivn.aikaMr Wvunrury . Finally, it -linnl.l l.r „„.„,i.,n..l tliat i.iMluMa.iif lamuiTl.a-c may canx' fapiil .liininnti.m in tl,.. >m- of an .•nlai-cl i>l'- n- l-l—i^iHv wli.i. lli «'-"l'> t^'"" ,,n,tn-. int.-tinal iMtnoifliap' 1- thr -|.lrrn f.mn.l imt faivlv of t.uftnai >!/.•, I>iit ivmarkalily y.il: tlaiihy. an.l w linUi.d. 'I'lic al.-vii... ,,r -plriiii' tnmnr uitlinnt .Ir iMfaKIr i;'M-r i-, .Infitij.: tiw f.liiilc Ma-r of tlir .li-.a-r, an ( Ativmrly laiv anatoiiiic r.Mi.lition. I hav mv-rlf, it i- tt-n.. .x.vptioiially mad.^ tiii- ol.-ivation in yonnfr ,H.,>on>' hnt tii.n iIh^ pan-nrhy n,a of thr -pl.rn Nva- iiMially nt l.Mst i,l,„...-mallv itviHivmi.. -oft, an.l KnlLnn-. tmi-, in m .•otulitioi. of a.-ntf tn.n-iti.m: in J .a--, in la-t, iv.'.nt .•ot.M.l.faM.' .■Nt,avaMiti..ns ot l)lo...l w.i-.' foMiiil in ill.' -|vl<-.n. Anmm: :.77 aut.,,.M.> ■ llatul.m-, L..i|.M,-'. 1 Io.m.I al..,,... ,.f >,.letnc ,„laf...MK.nt ,mt.-.l in 4'... If iVotn tl,... ...... a, v . ..hut.-l .Ih... m «ln. ..,„, of tl... fii<.t..rs nam.Ml • |.l:m,.-.l ih- .•..m.I.im.u. t ,.r.. i-...,.an, hut .•-!.< ^r .•'■nt ..fall <•=..-- in -In^h .■nlMrz.nu.nt ..f ,!,.. .,,l....n uu. «M„l.njr .luriiiL' tl... f.'l.ril.. ^IML'.. «illH...t .1. n,..nslral.l.. .Mu^f. .,•,,, „i,i,„„, ,,„.-.■ of tyi.l.oi.l ..nla.-vn>.nt ..f tl... ^l-l...... Mtt.l tl.o .,„...ial .......lition- f.,r it- ...vniT....... aiv. a- y. t. unkn.,vv,.. Tl... ..ailnT assnn.,.tion that tl..- pv-vxia alon.- Nva- tl„. .•.■-,.o,..il.l,. th.t..r tnnM .■.■.-■ fiinlv l... ,vi...t...l. rn.l..nl.t..lly. thr .hv.h.) ..t ..t th.. typhoi.) ,.nlat-..nu.nt of th.- -ph-n -ImihI- In .n.-t intitnat.. nlati.... with the l,,..ilh.< ..(• KlM.fth an.l it- t..Nin-, In f^v..,- of thi- vi..w, iKihap.. .> llw .,l„,o-t ..on-tant pn-.n... ..f l-a.-iUi in th- -ph-n Mft.r .hath, Mtt.l al- ,!,.. -n,.,...s>fnl .Kiaon-ti-atiot, of th.in l.y pnti-tntv of th,. ^pl-nt 'Innn^: lif,. t.. wlii.h i-..f..i-..n.-.. has altva.ly 1.' ..l-Mfv...! ..v.n .'arly tn ,h,, „,il.l..-t ..a.-..s ..f tvpl„.i.l f,.v..r with a -h..ft ■■.■.nitt..nt ..r n.t,.fm.tt..nt f,.l,ri!. ....Mfs... an.! also in th.' pf.-tt-a.'t.Kl <'as..s with hi-h h.v.v. 1 Inv.. ....n..vallv „l,s..fv...l .■nlafir..n...nl of tl... -phm «v..t. m .-a-.- ..f tvphoia f..v..." aln.oM nna.t.n.l...lwilh f. v.f. With th.. ot.M.t ..t .-.n- SYMI'THMS AMI roMi'l.iCATin.XS. 179 ,1,.^, ..|i(.(. — iliat is, witli rcdiirtiim in the fever-;— invcilntinn of tiie spleiii' tllMi'ir llslliillv l)e<'il!s. At tile e if ti,e t! Hill or (hiniiu' llie I iiiiili ueik it i • then llM Iniiucr, ileiiii.il-tl;it)le in i';im> tli:it |)Ul-lle MM ipnlili:il\ idlirse. 'I'lie ureale-t deirree of -jileiiie enl:il;;(nienl i- exliiiiilol ■felierMllv Ml llie mcih kI lip til tlie lieLrinilill''- iif tlie tllil'il weel e~|)eei;illv |iri itr;icteil e;i-e< i- it likilv lu lie deti'lled |..;i l;iter |)eliiiil. Tlie time fur tlie <•( iniieeiieeliieMt iif (lie s|)leiiie swelling- i-. IriilM iMlMtuMlie ami eliiiii'til kiiuwl'iijre, (Hi the aver:.j.fe tlie iiiiilille ur the >e<-i.iiil half cif ihe fli~l week. Ill tllel;:st ilav-iif the til>t \ve( k it- ilillii a! ileliiiiM- slratiiiii i- (|iiite iVeii'ieluly im— iiilt. I'l-einallire re'illetiiill in the -i/e nf the elllarired -iileeM dlllillj; llie fehrile stajre i> e\ee|iliiiiial. 1 1 eiiiiditiiiii-, as has lucn iiieiill'iiiei 1- tieiierailv iieeiir- 'Hi! ' Miulei' --lieeial I; ill (Miiiieelidli with |inifllse lieirni-- Di Miiw and ilt: al-n alter (-|ieeiall\ |ircitiise diarrliea. lMiniit oecurreil in a wnniaii. tweiitv-tive vears old, wt.o cotiiphiiiieil iine iiiiimiiiir of pain in tlie left side 11 tasteiiiiii: her cliil''' -j which had develoiKMl diirinj: the nifzlil. and a cause for which wax four t splenic tumor, to which theconinieiieenieiit of ce;it sj: mr:^.m- ■^mZgr-T-A WM ii^ 180 TYrii'iiii ii:\i:i:. ii l! If li: >■ ■m ;?: M !' ■ ;;,j:;;;;:u::i:i;:'i:ui:.i':::v ■:;;>. .1.-. i >>...,..„. .u.,,. ,1 ruuuin 'a '^h-M-l^ |.ain in .!,.• l-ll m,I... Cm ..x.MUiK.nnM !,.■ u.> toUMd f::.;;:;,;nn.v.,-. .n.i'ui.i..u, ,.„..„i:,. ...i .nnnw a>.i,.. .,,,. l,„vv..v..r, ;. .li.tinrtiv ,.,li.al.l.'. Irn.l.r .|.l.inr t ;r um.- |.i.'m.iI. In Hu :.,.„r f '.un ,lnv> /•l,illi..~s .,,,,...n.4 l.M- tin. firs. „„,... ^^,th th. .•„„„„.■,„■... ^Z .inlvlo U..- ...s. of Kric.!ri.!> nnnlion.M in I,,.- lM,nnu> In.ns.. n,.ou acute ^plfnic inniur.' 1„ -pit,. ,,f 111.- -.iUMnUUr run-taifV ..f .llliU-rMnilt ..f ll..' -pLrll, its ,l.,„.,„-t.-atio„ .liMi.^aiv. M> 1,M- Imv>, nnntionr-l, .an fn.,uonliv n..t i„. „ntat,stf< ,n ,l,i.o.n>u.ction.MavlM. ..I.tainr.i front tl„. folloxvn.^^ .-litnaf. -na.l. at llM,nl.u>i.l.ni.' tutnor wa- .l.inon-t.-at.d in IS.,!*— S4..5 per ,,,,t • wa- palpal.l.' in :U.-J p.T rruU : ami unrrrtain or waiitui- m :U(, —i:,.': p..r .vnt. Tiii- .pid.Mii.. \va- •■hara.t.ri/.-l. a< tl..' anato,,...' nl,l.ow..l. l.v tl... fr.<,n.'...v of la.-,, -pi,-..!.' t..n.or-. In L,.ipM... a.noMj:- l';'-^''' .".><-. ^l'l-'»i'' tun.or wa. .l.mon-tral.l.. m 1, »,-,l _(;«). 1 p.r .•...It.; wa< iinr..rtaiii or not .LinoiiMralil.. m ..^..-- •in ,; p,.,. ,.,.„t TI...S.. .lata a.v ..l.tain-.l tVo.n Mati-tir- ..ov...-i..,^ a l..n.Hl „,.■„„„,,, ,„a., tl.irt....n v..t..-s an.l .•oll....t...l ly .litT...vnt ol.>...-v...>. 1 1... „„,„,,..,- of .•a.-..s in wlii-.h .■Mlai-..n.nt of tl,. -i,l..'.. wa- nn....-ta.n or not ,K.,no„stral.l.. ap|....i- .vinarkahlv lar^r.' i" .-nipari-t. Nv.tl. tl... -o.-n.- .po,..li..- Ilan.lm.^ f.LMHv.. A....onlin.ir to my ^..ii-i-al .■xp..ii.ii.v. I ^vonl.l l...li..v.. that th.-un-Lont tl... .ntir.. ..on.-., oi' tl... .li^.a... .nlarir.- „„,,„ „f ,1,, -pl....n i- not .l..ii.on-,ral.'.. in f.vni 'JO ,o ■>:, y.v .rut. ot * " \Vm? r,-ar.■ a.v .I... i.. I-avt to tl... si/., of tl.„ orp.n at..l t., .1... ...a.....T i.. wl.i.-l. ,t na-.ts at .litlnvnt ......■<.-. tl... i„,;.,tions pro....^s, ati.l in pa.'t to to,H.un.pl.i.., ntt. n in.l.vi.lual, Lu'tors, .„• to ant,.<....l..i,t or ass.K.iat..l l.-sion^ in a.lia.-....t o.-ai.s. \hov,. all it -l.onl.l 1,.. n.,.ntio,n.,l a...:.;n at this pin,'., that th.. tvphoi.l spioni.. tninor i.. p'"-'^'' "1"<- ""» ='"='"' '''>' •■""^"l<'-^'''''"'"'f-'"''' , YulknidiiHS Snmmliiiiij IJ'ii. \urtr. SYMI'I'lMS .I.V/i ((iMl'I.KM loys. 181 of" size. In tllc tlliilillr "I- |(.\v;il(l I'lr cliil nf tile tirst Week, even at tile l«i;ilillilli; i>\ llic ^icui'il week, it i- ullcii ilrnioii-tnilili' iplilv (ill |ki- <'u~~iiiii III' i~ |iMl|iMlilr liv tli|iii-:i|iiiii )ii-l IkIiiw llir (ii-imI Mii'li, citlii r :i> a di.-tiiiit ridiiiil ur rallicr .-liai|» hnnlci', 111- :i~ a -iii~c nt' iii-|)ii itrnv iiicrcMM' in n-i-taiicc in tlic rtj^inii ill i|iir-ii(iii. Al~", Ml till li('ii;lit III' tile
  • c:i-c, uiili wliicli, a> aiiat4iniiu >Ihhmi, nm^l iiiaikcil cnlMi'iiciiriiil nl' the >|ilf(ii cuin- ciilcs, it is |Mi"ililc in imt a lew caso U< detect unly an increase in the inteiisitv and tlie extent nt' tlie dlllliess witlimit ti'n>t\\iiitli_v tindings mi |ial|iatiiin. In tile minority "l" ea-is, at tlie l)e<;iniiin>; or in tlic middle of tlie second week, at times even Munewliat later, li.e splenic tiimor a|i]«'ar.s distinctly two or tliiee liiiirer-hreadtlis IhIow tlie co-tal areli even dnrinj^ the res|)iratorv miil-|Ki-ition. The anterior inleiior liorder of the spleen rarely extends mncl. t';iitlier downward; then prohahly only \\ hen the tnmor> are ainmrmallv iarj;e or w lii'n the spleen has an im!i>iial shape (<'onsideral)le loiijrjtndinal dianietei — tmijrne-shaped), or, tinally, it' the sjileen is dis|(la can ciin\ ince hin-clt' tiiat in the hcginiiiiig and at the heiirjit oi" the dis,>aM' the s|iiceii i> nf tense cla-tic con-isteiiey, while after the hei d't ot the di^eax has liecn pa->ed it iKcomes di-tinctiv sot"ter, at times to -ncli a degree tiiat it is le^s readilv dci'ion. tfaMc. From tho ditl'erential diagnn-tie point of view it is |ir(il)al>ly true that old malaiial splenic tnmor- or splenic enlargements due to leukemia and p-endo- leiikemia appear tinner and less ela>tic, while enlargements of ti. ,.le<'ii indneeil hy >e|)tic processes fre(piciiily are likely 'o he softer from the heginiiing and thi'ongl t their entire duration. Paljiatl I ot' the eiilaiged >pleen in the cunr-e of tvphoid t"ever is attended with little or no tenderne--. At times, however, on pal])atioii a~ Well as on pirciis,-ion, complaint is made of a certain degree of ])ai!i. Still more rarely jiaticnt- cmiiplaii; s|)(intane(iii-lv, without ])ressnre or movement, of dull pain heiieath the left c. tal arch. More marked tenderness on palpation, or in rotation, on Heximi, and in Invathing, is indicative of special di>ca»e of the spleen or its immetliate vicinity, including first of all peris|)leiiitis, which inav even lie associat<'(igr:ipliie. and individial intlii- eiice~ that may render ditlicnlt and jirevent the demmistraiion of a ^,,l..„i.- tn.>M.r, : i'l.nl.il .nn.lilion- plMV ii.> >iiim11 -•-;/, in tl.i- .•..iin..- ticii. Am. .11- tlic til. I..!- liial iini-t In .|ii(nll> l.c taken iiii«> cihi-kIit- ali.m, in.t...ii-Mi .-|..'.iall.v i- I., l.c ni. iill..nc.l. A> ni.tc.iri-ni in cans of lv|ili..i.l t'.vrr iivn.i-aliv iii\..i\r- lii.' laitir inli-lin.-, an.l (-|.r,ially tl„ nci;;lil".fi I ..f lii.' -nat.r .iiiNalmv :;ih1 liir tl-NUiv- in UMot mark.-.! .i,-iv. . wliiir lii. .li-lmti f lii-' -mall inl.-tinf may !.<■ .-li^^ht or al.-.ni. liic in(iva-r.l .lillirnliv in (Icmoii-Iratiii.: tiir r-plmi.' Iinnor nc'ii l>v n.i mean- aluay- l.c d. |i.ii.li nt ii|m.ii markr llu' j;-i-c.n~ ili-i.nii f tli<' mtc- tinc, alinormai -i/r an.l |'..-ili..ii ..!' a.lja.iiit [...rtion- oflM.ucl, (-|.(rialiy til.' lVr.|n.Mt t'..iiiiali..u ..fa l....|> .'I' .■<>1-la(lc to llir ni-..-nition ..f tlic .nlar-cm;!!! ..f llic -i.l.vn. N"! mnly tlu iv arc a-.K-iat.'.! wilii lli.-.' .•.iinlili..n- tii.' .li-|.iaait.-, a -[.ken uilli M.-callc^l Mipcrnnmrrary -plccns, thn- innrfrrin;: willi palpali..!!. Tlial t.clmical >kiii i- al-o a factor in llu' cxauiinaii. ii in (|ii(-tion may finally !><■ wortlix ol iii„i.iati..n >h,mi.i hr ma.!.' 1iv.|U.i,tlv li,nmf:lio.it a .vrtani |.,-n.„ oi the .li^easr an.l it .-Ih'mM alwavs vkkl •i|.|.n.xiM.aI.ly the sanu- nMih. D.pMul- enoe sIm.i.I.I hv no means he pln.-.-.l U|,..n ih.' reMills ..f a Mii-ie penussion. It i- ,i,>teNvorthv that t.. l! ■ ^l^il^■.l eliiiieiaii, in eases m xvlueli .m aeeomit of MieteoriMi, .'.r ..ih.T l...al e..n.lili .i,s. increase.! limits ol the area ot s,,l..ni.' .lulii.ss .•ami..I he .h^w.nstratcl. s|.e.-ial intensity ol the .hili.ess uiU iii.li..m. that the ..rL-an i> ah,i.,rnially lar.L'e. 'fh.. ^nvatest si-mlHanee. liowever slmnl.l he alla.li.'.l to the results of palpatMUi ot the spleen, uhi.-h is ahvavs I.. U- pra.tise.l himanually with the patient mi the ri^L-ht lateral .leei.hit.is. in su.h a nm.iner that the left han.l Iron, the hnnhar re-'i-.n en.leav..rs t.. push the p..steri"r alHloniinal wall n.i.l the or-an m he palp;.te.l aL-ainst the rijrht han.l, applied anteriorly jnst heh.« the eosta' inarLrin. Little is t.i l.e sai.l elinieally eoneernin .. mi.nl..r ..t' s..hiat.lo t.'.Oii.u-iil ami ili;ii;n..>tii' -iiixi;.'.-tiMns. w^^^:?^mB^^M^m^^^mm^mm^m^m'^ SYMrrnMS .l.V/> ( (J.\ll'l.l.l— tli.' ,.ii>.t nf ill.' jM riiuiiitic symptoms \miv immiiliaiily invc.-.l.-.l l)y -iiddtii X'Vcrr pain \»\n\\ tiic K ft i-nstal airli. Kv.Mi on |....-I-inortciii .xamiiiati.m siK-cial anatomic lesions of the spleiii<- ti.nie are oulle rare. Arnon- .'ul aiitop-ies at llaniliur^' and l-«ipsic I „l,m.rvd infants and lieniorriia-e in I'.'), alwesses ni 4. rnptnre m •-', ami fXten^ve re.ent iHTJsplenit.s in Iti. The last-name.. tii.'nre, jml^rm;: tn.m mv other .•xrK'rien.vs. is rather small. The statisties of ( Jnessm-er heurni- wp,M. anatoiai, rhanps in the spleen 'piile a-re.. svi.l. my own. Amon- 11.H autopsies he noted eonsideralile tli.' eniiditioii ..f the thyfuid ^daii.l .hiriiij: the ..rdiiiary ( se .,f tyidi.ml liver, even le>.- lia,- Ikiii c,I,mtv»-mid in thi- oro:aii, and the-.' mav !«■ nf an intlammatury natiiiv of varyint: inteiiMty, up to termination in Ml.-crs>-formati(.ii. Nevertheless, thev phiy a nioi-e prominent -■.;/. as a « iplicati.m ..f typhoid fever tluiu of the remainiiii; iiilt'ctioii- diseases. W'allher.' who re|>orte.l several ca.ses of ty|)li(>id thyroiditis from my elinie, was al.le to show that anioni: To ca.o in the <"!«• of tli.' thvroid jrlan.l, the morl.id pro.vss is i; .erally ol.servd to terminate either in suppiii-atiun (,r in involution of the inliammatoiy |n-o<'es> without the development of an ahscess. The disorder appears almost always to pursue a favor- able cmrse. as Liehermeist.'r has sliowu, and I have lieen aid.' to ileter- Miiiie from [KTsonal e.xiH'fi.'nce. Alarminjr sympt.mis, atnonfr which dvspn-a from compression and displa.ynunt of the trachea may Ik- mentioned, arc amonj: the rarest exceptions. ( iriessin<:cr, it is true, m.'iitlons a ease of death from siit1i.eation, and Korjru. lost a patient l.v rupture of an ahs.Hs^ of the tiiyroid ■.daiid into the trachea. With pfereiicc to the itiolojry lioid strumitis, it is esi>ociallv to l,e iH-int.-d out that it occurs more fre(pietitly in previously liyiH-rplastic .,rj,niiis, ami it i> therefore more often se<'ii in regions where goiter prevails, for iii.staiiee, Sw itzerland. mi^mmMjs:^^smmm^ f^i'i:- m^-' •mgitifii 184 ryriinih ii:\i:i:. 'riif ri'lalivily t'rfijiii'iil iMciirnur,- ot' tli\ nii.lili- in >^\\il/iTl:iii'l Iim.^ Int-ii ilcmmi>lnil.Ml l.v "llic ,-I;ili>li«> nf ( iin-.-iii-vr ;iii4 I .i.licriiK i.-l. r. 'I In toriii.r olwrvfil lln- ("(iliailioll 4 liliirs ill 1 I •< :illl(i|.>ii >. lln lull. 1- ill 1"' "•' 1^"" |>iili<-iit.s, in ti "illi iil(Sn->.-liiriiiiirKiii. In nlli.r (■..iiiilric- lli\ miililis ir> far li'>s CDniMiiiii in aii-.inlanc-t- « illi tlif LTraUr i:nily (.1' 'j-nili r. Aiiicmj,' :!4!l allIol)^it•.< in llaiiilmrL.' I failed tu hKnivi' a >iiii;l. . a.-. . I'lirlliir, iluriiiL' thf irreal iviilmiil f|iiilciiiir in llialcily 1 hIimtv id tlif rnnililii>ri lull Iwiit- tlurini.' liti'- In l.tii'^ii' aUo il i> a ^'ival raiilx. r.iplrr ' liiif rciMirletl :{ (•a.si> iif aliscc^.- nl' tlic lliMoi.l -laihl aiiinnir '■'-' aiili>|i>ii'> al Miinicli. It i- iiitcii-liiiL'^ tn mill' tlial l/irlilliriiii-'l"a\ii,' •liaii-c liiK, Sliiid- liiark anil \'laclio>,' ami MViral ollni- iia\r ili iiinii-lrati>. Ill (itiiir iii-taiii<~ till' uiiliiiaiy |i\.it;riiii' niirPi-uriniiii-ni-, -tri'|itiM li a, id .■.til|ill\li>r(.ni, lia\r lift n timilil. I'lltlir tlir^f rcllilitiolis tile cnllivc wiL-i ut'tfii III iiv inil'av.inililr, in -o far a- tin' coiiilitiiiii was a |.art niaiii- fcstatiiiii n{' a piKial M'|ili(iiiiia. Willi nrani tu tiu' |iiiin ur.iir-, it a|i|irar> ti|-;ilile tu ile-erilie liuw the eliailjri- ill the state uf llie lirilie, in s(i far a- tliev relate tn tin (■(,n^Iitlltillllal (li>liirlian<'e umlerlyiiij: the attack of tv|ilioiil fever. e~ii.cially to the f, l.rile state, anil to follow tin- wytli a ili-eri|itioii (il' the conilition> that are ittriliiitalile to liireet, more profoiinil, ami nioiv iiiile|ienilent ili ea>e of the uriiiarv a|iiianitii>. During' tlic t'elirilc stai."' the urine ri-.nilile- in many n^i.ect,- that exiretiHl in other acute int'eelion- di-eaM-. Il- amount is e^cniPilly dimini-lied, e-|ieciallv dnrintr the lirst three week> of the di-ca.-i — that is, diiriiiir the ordinarv duration of the fever. In spite of ahiindaiit administnitioii of tliiid. this diminniioM in the amount of urine alinoM •always ueciiiv. natiir.illy with vari'tioii- in accordame with the seventy of the attack, and e-iiecially in accorianee with the intensity and the duration <>f tile fever. In the stap' of -tee|i curves the amount of urine i- treiundly a early as the licixinniny afehrile pcrioil. -Vii iiiinsiial increa-e in the >ccretion of urine 1 ■ Hi,. (■,.n.|,li,aii..n.„ ,1,- .\l..l.iii.ii.:illy|,liu-, .1/ /■ ""■/ l|-...-A . IH'.lli. s i;l„-r ■!:'• .\,i:.,l'.-, Is'.i'J, s,.l|ii,ii,in. ' ■■('.. iitrili. ••i I .111.1. ■ .1.- tliyn.i.lil.- intact.. ' An-/,. ( n.Mi'i.li [Tioss. IH.: • Iiiiiiif^ llic' |iru;jr(-^ i>\ ii.ii\ alc-iriii-r i- 1)\ till irir:iii-> a rail' iiiaiiilc-- I ilicifi, -11 thai llic ariioiiMt iiiav iiacli lii.niMi .■.ciii. ami iiiuit in |\mii|\- liiiir liiiiii-~. The iiiiiif i- till II iriiiaikaliK ii;.'-|,i, a~ ili ar a^ ualir, aiiil nl'r\iiii|in;:l\- |n\\ .-IHTilir ;rt-.|\ ily ijliWII In I < M I J. {{a ri| \ , ., nil thl'll i'-|iiiiaii\- ill ini'\iiii» imThim-. wuiium a> will a- ii III, ilii^ iHilviina iiiav III- a|i|iarriil a- rar Iv a- ll r I itn- iiipriiiiii it' 1 III' ri'lii'jii' |ii'i'|iii|. N\ itii till' I'l'iiiaiiuii ill li,, aiiiiiiint nf iliiiiiii' till- tilii'ilf >t, !>:'■, Ilir I'liiiaiiiiiij,' iiiaiiilc-Iatiiiii- ut' i intratimi arr |iii-.iiit : aliiiuriiialh ilark I'lili.r, triiirfallv larar, nr ui ill a -.I'll iini'^t. wliiili tinn i'iiii>i>t-. |iiiiiri|ially nf iiiali- ami iiiii- ariil. Nut ranly tlir ilark n.lor i|ur- imt iiin'i-|Miiiil iiilinly with ilir -|Hiilir j^niviiv. 'I'lir lulur iiia\ lir iiitin- -iliril liy tlir |in'M'iii'r in tlir urine in rmi-iilri-alili' aiiKHiiit nl' iirinarv |iii.''nii'iil~ iitlirr than tlir nrilinars mii I'-. Ilir-i' will III' ili-i'ii— .III lirii'riv lat.T. 'I'll!' >|iirilii' ^.Miivity i» alnmst aKvay- riPii-iilrraMv iiici "isi'ii — np til |t».;o anil almvi'; rarrly it ilnlini's t.i Kljii. '|'|i,. reartimi nl'tlie iiriiii' fniiii till' lii'^riniiiiiir lit' the ili^ra^' ami at the luiirlil nf the fexir is invarialily -trm.jrlv ariil, iiiili'-.-. i'-|M'i'ial I'lUKliii'iii-- are pri'si'iit. At a later stajre the aeiiiity iliniini-lie-, while ihiriiii,'' eiiii\ali"-ei'iii'e the nriiie frei|iieiitly presents a neutral nr r\rii an alkaline reartinii. Ainiinj,' the xiliil eniistitiieiit- i if the urine, the urea ^hiiiilil lie nii'U- tiiiiieil tirst. The alnin-t iii\arialile ami markeil ineivase in the aiiniiiiit of -.i-ea eliminateil in tweiily-fuur liniirs thniutrhnut the entire felirile periiiil ha- alnaily Keen nli-erM'il liv earlier writer Xeuliauer ami A. V.isrel,- I'rattler.' I'arke-,' .Miuehis, personal iiive-.ti;r:ili"ii-^ ilireetiii t«i this jHiiiit have \ielileil tl I ha\r nut at all rarely iiliser\iil ilniihle the |ihvsiiiliii.rii' avi II. A hirp' luiiiiUr of le same re-iilt. initre aniiiiiiit urea, anil now anil airaiii even nmre than this. The | iriiee.-sis ri'spiin>il)le fur the fever in eases .if typlmiil fever exert ilistinetly the mil t iiu|Mirtant iiillneiiee iipun tin- iiiereascil eliminatimi nf urea. The view that the elevatimi uf temperature almu — that is, the imreased heat uf the lHnly-ti-siie^ i- tu lie liiiikiil ii|)ii!i as the cxeitiii); factor must he rejeeteil at the pri -ent ilay. rniliiul)tellll«} "I Iik-iImt invrMijraliun. ll Ik.- Uti. Malr.i i.s -on,, u , it. I- tlial . v, n at th,. Ini-l.t ..ftl,.. alta.k n. MV.iv -..-.all..! a.Unaini.- .a-.-, -n.l.l.n iv.ln.ti.m in ll,.' ain.mnt ..t ,„va n.avlH,.l.-.rv.'.l,an.l tliat tl.i- manif. Mati.m i- .•al.nlat.-.l t.. nn.l.r tl,.. ,,r.,)in..M> inn.l. ln...v -lav. 1 Lav.' ,,.i-.. nails n.,t a- v.t n,a.l.. >,i.li an 111,-. r\ali..n. I,iU,. .1,.. nna, tl,.' nii.- a.i.i i- a!-.- alin.-l ,n..A.'.|.ti.,nall.v m.ivaMHl i„ ,!,.■ f.l.ril.' Ma.^.', an.! at tin,.'^ .|nit.' .■..nM.l..,-:,I.K . Tl,.. .lirninati.-n ,,|- „,„. a.i.l i-aU...liinini-l,..l a._'ainvvill. lli.' .■..inm.n.vin. nl "t •'"n- V ,l.'^.-.n.., an.l nlnrn- t.. lli.' n..n„al .luring tl,.' I"ii."l ••! iv,'.,v.n. Tl„. .viH.il- l.v Kn li.l,- an.l Sia.ll.i- will: r.-i,nl t.. tl,.' |,r.'-.„.'.' .,1 l,„,i„ ;„,.! ivrn-in an. lainiliar an.l ..li.n .it.'.l ; ( ifi.'-in^.r aU-, .'...,- .-i,l,.|-- tl,..v -nl,-tan.'.- a- aiin.M -tanll\ |.n'-.'nt. Tl,.' .•l,l..ii.l-. a- in n,anv ..ll,.,' a.'„t.' inf.'.'ti.'n- .li-.a>.'-. an' alua.v^ t,,...atlv .ii-„ini-l,.'.l .hiii..'.' tl,.' f.'l.ril.' -ta.'.'. f in- na-.' a-ain ...n-,.!..-- „l,lv ;vitl, ll,.' -nl.-i.l.n.'.' ..r tl..' .li-a-.. H |.i.n'". "< •'"!. \ "P'l. iI.m'i tl,.'.li.„in..ti..n in ,.l,l.„i.l- 'i- .l.'].. ...l.i.t >..l.'l.v niK.i, tl,.- 1.'->.'...^I ,„„.,„„ „f -„.li.n.. .•l.l...-i.l i..i:<-l''l ^^i'l' ''"• ''•'"•■'''• '"'■'■ '- "" '""^"''' ,..„al.l. Tl.i- 1,1,.'.. n,.,, ...'.•ni- n..u a- f.-.-.n-rlv, alll ;J. H hn^ 1„,,,„„, ,.„M..n,a,-v in .a-.'-..!' tv I'l'-i'l I'V.r I.. a.ln.i...-t.'r .■..n.'.i.lrat.'.l ,.„„n.|,n,.'nt .'..ntainin.^ a,, al-nn-la,,.,' ..l' -"Vuuu .'l,l..,',.l m-l.'a.l ..I a ,li,,, ..»■ xsal.'fv -...,,.-. I-I,.' .„..•,' n'.'.'..t l,v|,.,ll..'-.'- uitl. .•-t.nn.'.' f, ,,„. ,,„.i,„,l„„ i„ .'l,l„ri.l-, l,..w.'V.'r. al-.. apiMar vnln.n.l.l.'. >- tl.at. a> a „,„„.,• „f fa.'t. it w.ml.l a,,,,.'a,- u.^'tl. "LiL' t" ni.'l'ftak.' a n.'W >tn.iy of ll,.' .|.i.'-ti..ii. , • 1 ,■ Tl,.' a,,i,.'an,n.v .-I' all.nn.ii, in tl..' nrin.' i" •■:'^'- "< 'M-'"-"' •'■^■'■'" '■ of ...,u'.ial in,,..,.-ta,„.'. Tl..' ...l.-tan.'..> f...n..l '""l-f ^".1. .'Mvnm- .,.,„.•,.- an- kn.Avn I.. I-.' x.nn.-all,....,... an.l >.'n.n,-l..l,..l.n. Lv>s ,,„„n,.,nlv. an.l ..niv ..n.i.-.- ..rtain .l.'tinil.' ......liti....^, l-r"""' ,,,, i,; ,1,„ „,i„.'. a- (i.rl.anlt was tl..' f.t-t t., ,H,int -nt. W .' >l.all fir^t tak.. ,.]. tlu- -•..n-i.l.-.-ati.m ..f tl..' .liuiinali-.n ..f all.n..„n that o,.,.nr>^ witl,....t ,,r..f.,nn.i -li-.-as.- .,f tl,.' ki.in.'vs. a.t.l .< P'.ui-.Hy -l.'s.tr- „at..l a- f.'l.ril.' all..H..in..ria. WV -kail n'tnn, at a -.'parat.' pla..- t., a iM.n-i. iM.l.ril.' all,..i..in.iria i^ <>xm' .'f tl..' n.or.' .-..ininMn luanii.-stati.ms. Ar,-.,nlin<: t., n>v ,'X,...ri..,..'.', it -'an l..' .U.n.mstrat.'.l in Iron, lo U. ''O i^^^U syMlloMS AM) < OMI'I.K AJKiys. 1H7 iior cent, nf caws of ts|iliipitut('rn('Ml of ( Iiiliicr,' tliat allminiiiuria is lonstaiil ilurin;: ly|ilioi(l t'cvtr. is (lilficiilt ot' t\|ilaiiatioii. ( )tlnT olisiTviTs naiiu' lii^rliiT ti:.'iiris than I dn, a.-, for iii^tainf. Miircliisoii.' «lio oliwrvcil allainiiimria in '■>'■'< on a collti'tion of smaller iinliv iiliial ilata I personal ohservation ami that of >ix other w rilers . ami thai >everc eascH is|H-eially were taken iiil nsiileraliiHi. Il i> Inir aUo that Weil ' ami ( iriessiiiL'er irivc hiirh eoniparativ c |Kr(entaL.'e>. Thi' lallir iHlieve? that fi'lirile allmminiiria oeenrreil in one-thini of his eases. Allnimin was present at >onic stai'c of the ilisease in (iUl of .si'll cases (71 |MT cent. I treateil at the .lolnis Hopkins llo.-pital < »sh r ' i. This im-liiiles the castas in which the allininin was con>iileralilc in amoniit. as well as those in which the t'aintest |H)S, wliidi can altnost always he (Iciniiiistratoi iinilcr -iicii ciinditioii-. It cat! lie >tateeverc-t cases exliiliit allinininiifia. Tlic cunditinii is tlicicforc oni' tiiat makes the ]iri>!.niii>is di-tinctiv niorc tjfavc, and the mure so tlu' earlier it apiK'ars, the Imijrcr it pclNi>N, and the ^'rcatiT the anmntit of allinmin eliminate!. Of .'!'.•:> ca«es of fchrile alliuininni ia that 1 have collected, death (icciirred in Hl7 — 27. '2 |mt cent. — a nmrtality fully three times the normal. As the iM'riiMJ for the heiriiinin;^ of allnimitniria I wuiild desjirnate the end of the (list and the entire -ccoiid week, in contnidistilU'tion from other writers (Mnrelii--un and l'in|.'cr). who have never ohservcil il lieforc the sixtiH'nth day, and most frci|ncntl\ lietwciii this timi' ai'd the twenty-fifth day of the disease ; its aihcnt, however, is also (|nite fre(|iiciit to the end of the thin! week, and ii]miii thi~ |Miint I am in ai;reemelit with Weil. Its neciirrenee hccomes less fretpicnt al'ter the third week ; it has, however, come under my ohservation even (piitf! late, np to the fi>rty-<'ijrlith day of the di.-ease. I consitier late apjK'ar- ' /)/,•^ ,/.'v .«,■,. mr,l.. Art. " .Mlnmiii.arii'. " ' /-■"•■ rit.. p. 488. ' /'//■ f'"Oi"/nfjif tonf Thernpif ih.H A/n/'On>H'iffypfins. 1883. * Jii/iii.i ll'f/ikins If"!'/i. /{/■/>., viil. \iii., p, 4'17. 11 w. ^s^' :'^-(Tm'i •'>'i^.^^ %i^^i^Mmmi^^!Mm!ki^amky:^^'^ME ',^iv- ^^riy-y/ ^^"•'■■' ^--'y^-^yi ■ ■-:: MICROCOPY RESOIUTION TEST CHART ANSI and ISO TEST CHART No 2 1.0 I.I 1.25 i- *- illllM |M !r ilia 11^ ^ 12.0 1.8 1-4 IIIIII.6 _A /A PPLIED \tsMGE Inc ^—l -' '■ F.ast Ma.'i i'-ett ~J: ■- ■ "es'pf. New Tofh t»h()y i^;^ •-= 'f^l *e2 - 0300 - Phor« =^ n) 298 - 5989 - Fo« J- i%^-::^:^^-^,!smf^xt^m^i-:'-' ■'^:iUi?^t^^z^^y:,^^s(''' ::^i-<-'^f^^:im/^^o^. IfSH TYI'llnll) Fi:vi:i! Sf>-iv lir a,,,-,, of ;illMin.iiH.m .-|..riMlly M„rav,„-,,l.l.- fmni tli.. j.rujrMc.stic i.oint of view. I liiivr oliHTv.d it t.. lie i;.ll(>\\v.l l.y .IcMth in an unnMuiUy lavj,r,. nunii.r of ,;».-. In i>olatr.l -aM^ 1 iiavf ..hscrvcl ali...niin t.. ai.pcar in tiu' nriiu' .lunn>: the fust \v,rk, to li>li any relation l.ctxw.n it an.l otli.r d.viation. in .•oni-<. and t. nnination. The (•hs.Tvation that tiu ali.uiniuufia is iiics and ncnidcMrii.i- ha- been cnii.iiaM/cd fiv.iiicntly. 'he (hii-ationof frl)nh' alhnniiinn-ia in thr in.livi(hial .as.^ ai.pcai^ to ,.ov, ,...nd aiipfoxiniatciy with it^ intensity. In tinv.-fonrtlis of all ,,,-.- it |,.Tsi-t^ in my exiKficn.e, l.-s than twclv days. A duration „,, to ilinv w.rio, cveptionally al>(. lonpr, i> not at all rare. Of f<2 ea.e-of f in-ile all.nminuria that I have analx /.d. I found the diifation to he from on.' to thiv -lays in •", eases; from four to -ix m .-ases of \n\vr t.l.ril.' alhmniuuria. in a.l.lition t.> erystalline structures, v>\n- eiallv uri.- a.i.i and urates, isolat.^l white hl..o.l-.^.r|uis<.les an.l epith.lial 0.11- from th.. m-inarv passa-.^., and jr.M.erally a f.w hyaline, oth.rwis,. „„el,ant;v.l, tnh.-.'aM-. In tlu' i,r.s..n.v of sli-ht all.uminuria th.-ir nnmlHT i^ p'n.i'allv h. small that th.;- .-an h.' foun.l edi- ,„,.nt ol.taine.1 with" tlw ai.l of the . ..ntrifu-e. OAvv ' Mates that tuhe- ,,,M- wer.' iMVM.nt in iilH .'f th.' S-J!> eaM>— IT j.-r .rnt. ; or, in otluT w.ml-. (i.-! l).'r cent, of th.' .•a.Ms ^h.-win.L' aU.umimu-ia al>o sh.>wed th.' pn-n.'.. ,,f tuhe-.a-t-. Tul.e-.'a.ts of .,ther kind.-, an.l espeeiaily in.'n.ise in the nmnl.er of l<.nk...'yt.s. with evi.h'uees ..f inereast.l .les- ,,uamati.Mi on th.. j.art of tlu' ki.ln.ys, aiv in.li.'ative of m..re ,)rofouiul lesions. Tn raiv .'as.s tl ■ alhutnimiria of typh.)i.l fever may ])ersist ..v.n thnmirhout .■,,nval.s,.,.n.r without havin- h.rn r.l'.rahl.' in the e.mrse..f the .li-.'as.. to n.'i>hrilis. an.l it may ^ive ri-.' t.. a hmji-e.m- tinn.Kl p...'uliar form «\' alhumimiria, at time- nev.T wholly .lisappear- intr. which v.t awaits thon.u^di anatomic inv.-ti^'ati.>n. I l,ave ohsorv.Ml such .•as.'s on sev.Tul ...rasions. hut have hitherto had „o o,,,..rtunitv f.r at.at.nni.' inv,-stiL'ali..n. s„ that I an, w.th..ut knowh..i^'e as t..'„eir nature. Thev are almost always .hara.'ten/,...! hy the presen.'e of a n..rnial antou.U ..f .l/X .l.V/' < oMri.DA rioss. 18!) fxclii.-ivflv of tlie hyaliiK' variety. iicviT any hmI hloixl-cellN ami al iiio.-t a few wliite riiriiu.-cle.^. Canliae iiy|«Tlr(j|iliy ami edfiiia a|i|iarfiilly iln nut occur, ami 1 have likewise tailed to nhi^erve uremic inanifestiition^. In -ome instances I have olwrveil such alhuminuria to i>er!^iril, in a charaiteri>lic nuiuner, for ten or twelve year> after the attack of typhoid fever i treated hy me), apparently without any further injurioi.s elfect upon tlie healthydookiiijr, functionally capable individual, who, on account of the risults of examination of the urine, may hecoine temix)rarily depressed or evi'ti |)ermanently \\\\w- chondriacal — the only manifestation su^'frestive of the existence of dise:u>e. Ill isolated cases 1 have noted complete ilisap|K'araiice of this alhu'uiiiuria, even after the lapse of years, with the persistent peculiarity, it is true, that sliirlit transitorv turbiility of the urine developed on the application of test.s for albumin ai'ler active bodily exercise or after the inirestion of strong alcoholic beverafit -. I have observed a similar form of chronic allmniinuria, the anatomic basis tiir which has not been clearly determi iea, or, conversely, with obstinate consti]iatioii, than in severe cases. It iienl sea reel y be menti(Ui('(l, in view of what is known in geiier.il in this connection, that with the onset of general jieritonitis and also of circumscribed peritonitis, particularly in eoniiection with typhoid ]Mrity|>lilitis, es|)eeially marked elimination of indii-in takes place. I have encountered true iKMiioglobiniiria associatni with hemoglob- ineniia in but 2 eases of typhoid fever. In one of these it occurred ' 7V,,-.sv, V»rU. ISUd. I ¥ $ 190 rvi'iinih I i.vi.n. in tl.r iniddl.' of tlir .-..mmmI, Mini in tlu' otli.T at ilif l.(ri""i"i-' "'" ''"' tliinl, \Mck. r.Mlli <-a-'> t.Tiiiiiiatril fatally with -Mnplui.,. ,,f iiiu-t ,,r,,t;,iin.l intuxi, "111011. KI(Mi|"iTr ' lia> fcTiitly niM.rtr.l a .-a-.' ..f l„.„iool,.lm.uria after n.overy tfcin a m'V.v attack ,,f typhoid f.vct'. |{o<,ur and Weill- unv the lir-l to .'all attention to the i.tv^eiiec of inten-,lv toNie, |,n,l.aMy -|.ecitie Mil.>lanr,- in the urin.' of patients .iilVerinir tV typhoid fevr. L.'pine and ( iiierin have reported most i-eniarkal.le ol.>ervation-of a -iniilar eharaei.r. In the li-ht ofexiMing Unouled-e with re-ard to til., pre-.nee ..f toxin- and antif.xins in tlio ..iivulaiin- Mood in ,-a-,-- of typhoi.l fevei.th.-e oloervalioiis .-lionld stimulate further a<'tive inve-liua ion. h i- tinallv IMMM— ary at thi- pi.iei^ to ref.r to the dia/o-reaetion of Khrli.Oi with the nvine in ,,,-<- of t\ plmid f,.ver. the principle- of w hieli and ihenietho,l,.f elieiliiiL' it may I,,, pre-nmed to he familiar. Doiil.tless, tin- important reaeiioiiean al«a\- U- ol.tain.. may he drawn at a time when otli.r >yniptoms arc not in.licativc of improNcinciit or are im.vrtain in thi- rejrard. It is not<'- \v.,rtl.v. al-o, that in relap-e> from typhoid fev.r the diazo-reactioii, if it ha.l alr.^adv disippeared, ^'cncnilly return-, while it docs not rcai.jx'ar when fever occnr- dnriiii: convale-ccncc from typhoid fever a- the ronlt ,,f or^Miiic .li-tnrhaiice- cs. In all these (M.inurtions a certain .Icirrcc of diai:no-ti<' anliiictly to \w. attachcl to the rca.'tion. althoii-h it is not al.s.,liitc. Thus, rarely, it is true, severe and even al-o anatomically Ii"iMc ca>cs of typhoid fever have Keen ol,-erveil in which the reaction wa- conliiiiioiisly ai.-ent owiiii: to nndclcrminal.lc can-c<. In ad.lition, the ivaction occurs with .>pc.-ial fivipicncy, a!mo-I invarial.ly, in other fchrile dis,.ases, aii-l parti.ailarly -neh a- .itVer dilli.Milty in diiVereiitial diajrno-is, .'spc.ially miliarv tnl)ereiihwi- and llorid form- of pulmonary tiil)crciilo.-i>, tyjihiis fever. 'certain varictie- of prot'ound pneiimonia. malaria, and, finally, acute exanthemata, particularly nn'a-les. The term typhoid hacillnria or liactcrinria ha- hceii applied to the ..on.lition in which ly plioid-l.acilli are f.nnd in the nrine. ■^hi^ oc<.iir- in from "JO to -W per cent, of all ca-e-. The hacilli may he jirc-cnt in -mall mimiicr-, or lhe\ may occur in enorinon- nniiii>er>, -o a- to render ihe urine .li-linctly tnrhid. Horton-Smitli has laid -pccial -tiv-s on the peculiar shimmer uhich i- -(cii when a tc-t-tuhe tilled with such ^,'i,.,r,i; A ,/.«, 20, .1:.!,,-.. i>*:'o. " itrr.. I.M.I. . is;n. .s) l//'/'o,l/.N AM) < OMI'l.KMI'i.SS. 191 niiiic i- liclil ii|) ti> the lijrlit :iinl way tlir ccii- iliiioii c-AW iittcii lie ]c, fdicird witliiiiil ciilluri'- ;iiiil witlimit iiiicriiM'"j)i<' rxMiiiiiialinii. r-ii;illv, tlic hacilli do not a|>|H:ir in tlic iiiiiic iHiiirc tlic tillfciitli day, and tlilc Iciiuili "f liiiir — (•Veil till' iiMiiiili- iir vcar- al'ln iivali-i'i>iii-f c-cvcii year* in tlic ca^c rr|Mifl(d liv 'N'unnL^'). I'lic i-c(ci<:nitii)n of lliis cDnditiuii i~ rvcn nf Miiii'c ini|M>rtancf iVoni the li\ picnic >tand|iciiiit tiian frinn tiif tliat:nii-tic. A patient voidin;,' -iicli mini' is a miuicc of cim-tant daii;2if I" all tlm-i' alxiiit liini. A— ociatt-d with the iiacillnfia i- iViiincntly a niixlcratr m- even an (■\tri iiic iri'adc III' pviiria. It is nut inK.iiniMinn tin- tlic nrinr nf typlmid palicnt>, c>p'>ciall\- it' alhnniiniii'ia lie prc-ciit, t" ("ntain a few pn— cclU. It', liii'Acvi'i', till' |>u> i- cmi^idcralilc in aiiinmit, mic slmuld al\vay« ^ll — pc.t llic pn-ciiic lit' a ty|)liiiidal liacillinia. If, in additimi In the pii-, the patient ciiiiiplain> ul' >li<;lit |iain in jia-^inj: the urine and -liulil t're(pieiie\- ut' inietiiritinii, it is |)riilial>le that a mild ^rade uf eystiti> cxi-ls, wliieli iiiav |)a~> into a nine -evei'e lin-iii ur even U'eume elinmiv-. Thus, nil hard-and-tiist line can he drawn hctweeii liaeteriiiria and ev>titi<. A|)pai'entlv, Imwever, mei-e pre-eiiee ut' the liaetei'ia in the hladder is imt >ntHeient U\ cause cystitis. I lurtnn-Smith i clnde> that " the hacillnria is due to infection of the urine liy a sti'ay ty|)lioid- liaci!l!i~, excreted liy the kidneys from the MoimI, and it> immediate iniiltiplieation in the lilailder-iirinc. If, in addition, the Madder-walls have IxH'ii in anv way damajrc*!, then true Ivplmidal cy-titis tiillows." Nephritis.— Kmiihasis has already heen placed upon tiie fact that fehrile alhiimiiinria cannot he sharply ditferentiated from tlie nephritis not nirclv atti'iidiiiji tvphoid fever, anil, as it a|)pear>, etiolojrically related to this disease. Kaeli may iindoiihtedly |iass over into the other, and thev ai'e attrihiltahle in pait to the same cause, namely, the action of to.xiiis. The nciihritis irencl'ally occurs in the form of acute pareii- elivmatons intlammation, in jiart licmorrhafxi'', in purt non-hemorrhajrie. The nephritis ircnerally o'curs at the iieijrht of the di-ca^e. hctiire the end of the third week ; and it is iiiucli !ess common at a later jicriod. I have, however, ohserved it appear on the thirtieth day, and in one inst:iii<'c even diiriiiix convaleseence. ( 'ases ot' the latter variety are then likely to he prolontred for some time. Of -Vl case>, I noted the a|)pearance of ni'iihritis before the end of the third week in IS. In ■J I'ascs the onset of the complication was placed respi'ctively at the lieiriniiinir :iiiciiliar, although it apjjcars to me ' ./../,»,< Il..pl<,„s }l...p. /{,'/>.. vi.l. viii. l!f. TVI'llntli Fivr.n. tliat 111' •! arc iittackril -uii.rw liat iimrc tVr(|ii(iilly tliaii woincn. ami in till- (■,,, itii.n it i- |)|-iil)alilr tliat the mmlr nt' lil'r. i-|)ccially alcolidl- i-iii. i)la\ - a part. < )t' S I la-c- of iirpliriti- in adult- ( l,(i|i>i'' and liani- Imri.'' -tali>ti«-i, ■>[ ("•ruri-rd in niali-. 'I'lii' |iriiiMii-tinn i- iiiiht -irikiiiir in till' I,ii|i-ir -lali-tir^ ainnc, wIicit it' "i.". caH- nt' iu|>iil ili.-, 11 wtrc in nialo. In cliiliifcn, |iarti no -|i<'iial [indi— |)o-itinii with ivuafI■^■dis|l(l^iti to t\|>iMii«l (ixir i:cn ca-fs (if nc])liritis, ."> \\^■\•^• under -ixtri'ii scat'- of aL'i' ; 11 lictWfin sixtfcn and twenty-five years inclusive; S lictween twenty-six and tliiily-five year- ; 1 lielwecu tliirtv-six and firtv-fuc years ; 1 between forty— ix and tifly-tiv.' years ; 1 atiovc tifty-fi\c years. .Nuiiieron- ;;(iicral statcnieiits liavc Keen made willi rejrard to tlio niaero-eopie anatomy of typlioid nepliritis, hut relatively few with rcLnird to the liner alterations. 15e^ides tindiuL's -imilar to those atteiid- inir aeiite intlammalory le-jons of the kidney-, which arc occasionally ohserved in association with other intec'ious diseases, nninerous ob- servers have reported cases pursuiiiLT an cxtremi'ly pernicious cour>e in which microsei.pic exaniinatioii is said not to ha\c diselo-ed any essen- tial lii-iolot;ic alterations whatever. Tliesi oh-ervatims, it is true, wetv made at an earlier period, and, if repeated with the aid of modern method.-, tliev niijrlit i)erliai>s yield more sat'sfactory results. An atttinpt ha- heen made to separate from the ordinary I'ases of typhoid nephritis certain varieties that arc charactirized by t!ie ajipearance especiallv earlv and in intense dejrree of the renal manifestations, and bv the unusual duration of the same. Tlie.-c may, in i.iet, so thor- oii>;lilv dominate the entire clinical picture that some I'rench writers have devised the special desitrnation ncpliroty|)lioid for -uch eases. Aiiioiiir the tirst of the ea.se.s of this character in the literature are '_' hy Inimerniaiiii,' in wliiili nephritis. (Kriirriiiir at the lieitrlit of the disease anf (iiibler's, who completed the description of his teacher and proiKised the (Icsiirnation ■■ neplirotyphoid."" Aiiiat ' then elaborated the schematic liic.i- tatioiis and descriptioii of this form of disea.se to a relined dej/n-e, nial even believed that it ]ire<.iitcd special anatomic conditions, considerable eiilarfre- > .J„lin-sl,rn,-ht il.-r M,;lirhl. Jhf/irlhn,,,,/'^ ll„ r./n-.-pHnls :ii linsrl. IST'J. » I,..r ,-',l ^ ■■ (ll.siTviit. cialtniininarii' dans In fiiArr t\lili..' Arrh. ;ii'n. ,lr luiil.. IKTO. • " Sur la iii'vrc tjjili. t'li forme renalc,' T/iisr. I'ari-. IbTH. I M'.U/'Vo.U.S' .l.\7» cnMl-l I'ATIny 193 t of tlif kiilncv, wiili cviiliiicfs of iuiiif iiitfr.-tiliiil iiiHiiiiiniaticiii. isiie- ciiillv of llu' iiircii'ul .-Irmiiir ('h;iriicli-ri/.fi IV il> iiitfriM'lv lit' llllMllllill. uitll II>llll('t'liU> tli.'ir ilcir »Micralli)li-|inHii'rts. rciii;irk;il)lv liiirli ti'vcr. «illi till' ii-^ii;il ;il)ili>Miiii;il >\Mi|)tiiii Kus.-iiiuill ' was uiic ut' ti Guliler-Kuliiii ly |H' of cliM'iix', it ils |)ro|i('r dcirrtc of im|M>rlaiirc. t*. Ar, oiililij; t 1} Am Mo( 'ly ■olor am I the IuIk -ca? l>. Ill 1 -(■or|ii 1m y. itioii lilt rv i? rar irofouiii slllp( 1> o t.v |illoiil t'«' VI r. If t l>t wit ill (an li his (MIS iaii\ Imt t ar 111, lliv uriiii' i> iiiv ai'ialily ircsiiHC of liir^'e ainouiits silc-, I'liilliclial I'clls and said lo he from tlu' oiil.-fl r, Imt uitll an alisi'iicc of to (lirrcl atlfiitioii to the y iHiictration altrilmti'il to Tlif o cases iiiion uhicli his iiaiicr was liasfd txhiliitiMl liy no nicaiis <'om)ilft(' ai:rcfiii('iit, and tlicrctorc cannot he uscil in sii|i|Kirt of tlu' doctriiie of a s|ifi'ial t'oiiii of iitplirotyiihoid in the sense of the French cliniciai I' Vrsonally, I am ut the oiiiniun that acute iiafeiichyiiiatuii* iicjilifitis II attack (if a|)|)earin;r earl\' ami inir-iiiiio- a severe ciiiirse (liiniii^r a ty|ili(ii(l fever siinilld lie cmisidtred as a |iaiticiilarly -.eiiuiis (icciirreiice, 'I'll. ■re is, liiiwever, nu reason liir tlic reciiiriiitimi of a distinct varietv (if neiiiiriity|i till I r Inr tlie se;ii ;niticiii of this fmiii utlier, milder fuiii if iie|iliiitis, iif sliurtei' diiiiition, <:cciiiTiii theiirctically lielieNcd. On the c(intr.iry, it' a series of Tl ve cases are ciiiiiiiai cd, a ttnidiial traiisitiuii will he note* le urine cnntaiiis a laiy,. aniduiit of alhiiniiii, with mimerdiis hyaline, irraii- i coii>ideral)l(; aiiKiunt (if hlood, and iilar, ail' id e|>itlielial tiihe-easts and marke(l alidumiiial the di-ease in other respects pursues the typical cuiitve of typlmid, with -ymptdins ; and these facts must he empiiasi/.ed as litiiiii exclusive of both 1 opjKised til the assumptiiiii of a sepanite cuik typhoid and nephritis. Excessive slnjiiir or other uiiusual iierviiu maiiifestatiiiiis are, further, liy lui iiieans always associated with such pnifiiiiiid alteration in the conditiuu of the urine. There is even no constant association of liijrh fever with |iriifouud lu'iiliritis. With reiijard to the fre()nency of true ty]ihoi(i uepliritis, if it 1h> ditfereiitiated as sharply as imssihle froiii feliiiie allinminuria, it will he found, as has been said, to be not at all la h n mv exiierieuce tlic till condition occurs in scarcely 1 ])er cent, of the cases. The pro)j;iiiisis of typhoid nephritis is jTave, and 1 on this iMiint it must be admitted that the r reuch investij.fators 1 irrect, but til not so because the orir-anism is especiallv atfected by the severity of the disease of the kid- neys, but rather because the occurrence of severe, especially heiiiorrhajiic, ne|)hritis is one of the local symptoms of nnnsually profound ifcneral uitoxicatioii. All most half ot' all patients with tvpiioid nephritis die. Ii this respect my experience at H imiiui'ir, where I observeil a mortalitv ' Homlnir!:;pr, lirrlin. Uhi. Itc.r/i., 18H1, No,. !.'(), 21, and li2 i .\littli.'ilurit;eii aus dcr Kiis-iiunirsclu'M Kliiiikj. Ml ■m\ m w ■ m I'.tl Tvniniit I i:\ii:. ,,f :,(i |MT (Till., .litV.r- hiilr imiii ih.ii ill ,,|i,,i,l r,.v,.r ;,i th.' .loliii- Iln|.kiii- llM-|,iial,' llmv l..i|p-ic, wiili I I. I 1" r <■' lit. Iln|.kiii- llM-|,iial,' lliiiv •_'l. ( >r iIk-c J I, 7 ili.d uriv.lrfmilr r\ i. Iciwc- , ,f all ariit,- uciiluii i- in _..;;;; .„.|- ,.,iil. It.aih .M-.iir-. , iilici— an.l llii- i- tli'' iihiit ri.niiiioii — .„„i,l -V in,,|nin, .,f 1,1.-1 |,p.t;.iiu.l unirril iiiloxiralioli, -r uilli ill.' -n|"r- v,,,.i,.n ,.f vaii-n- .■oiiil-lirali...,-. In ■. nf llic 7 .mh - almv.^ inHilioi,,,!, ,l,..|lli „a- .111.' I" |,. rf..i-ali.m. In my , sim li,- ■ a.lnal iin i,,ia .Irs ,|. .|.- I, ,nin..nh. 1 \r.i\>- in l.nl 1 in-tan.-.' . .1 ,-,rv.-.l .l.all. t '.■nr Ir „,,,„•„. Tlii' ua- in a N.mn^ man, in tl,.' lii'-l IkiH' '.I' ll" -' I ^^'"l^ "'' .,„ atta.'U nf ivplini.! f.'v. r, ulm .l.'V.ln,,,-.! rn,iviil-i..n- an.l .'.mia, atur '.v,„,,t -..fl'ir iT!,a-i.- ii.'|.ln-iti- Iki.I NiM..l f..r:i f.'" .la.v- -nlv. In .;,l,li,i,,„„,,l„,, ,,-,.-.,(■ linmrrmann tlial l..!..!!- in tlii- .al.'-.n , n I. nn.'.' l|,„nl.l I..' ina.l,' ... .li.' ^'V.., nf M ni'.'lii~..n. A .'.- .'f i;.'!-'. an.l (ian.-li.T.-' t.nninatin^ in i',r,.v , n . a,.,H'ar- .i..t t.. Ih'I..:,^ ni tin- ^P.n;., ■l-l,,, ,iuraii..ii ..f .-a-.- ..f tvi.lL.i.l n.-pliriii- in uln.-li .'..mi-l.-to ,vr,.v,'rv lakr- |.la.'.' i- vaviaM.'. M.M lV.'.,iU'ntl> il ai^.a.- ... !..■ l.-ni .„„. „,',u„ w.'C'k-. 1 liax.', li..u.'V.r. al-.. ..l-.i'V.'.l ,.n.li-a.-I.'.l .'ii-.'- tliat la-t,.l a- l..n^ a- nil..' w,.'k-. Iii.'..m|,l..n' .-..•..x .vv xMlli lian-t...- ,,,^,,i„„ „,' „,,„, ,,,.,,1,,-ili- in... til.' .'linmi.' vari.'.v a,.|M'a.- ... 1..' a .-a.v ox..,.,,.i..n, in .'..n.ra- wi.l. h.iii.' ...lu'-- ini;'.'.i..iw -li-a-.- in uln.'li .Ins i. w,H kn..wn ... 1..' 11... nn.M,ni.n..n. In a lar-.' ,'Ni..'n.'ii.'.' I liav.' l.-'i-- .„nallv„l.-.'rv,'.l l.n. 1 .'a- tl'a. r..ul.l !..■ in.'ln.l.'-l in .lii- .-a.-'-.n. N.. su,.h .'a-., lia. ...■.Minv.l a. ili.' .I..ln.~ IL.i.kin- Il.-i.i.al, an.l ( M. r ' lias iirvi T -.'til -iii'li a «a-.'. , • 1 ,■ Of otlwr .li-.'a-.- ..f til.' l.vi.ii..Hl l.'VtT, vinnallv n.,.liin^ i^ a^ v,'. kn„wn ..lini.'allv. Tli- ninl.i,.!.' a...l .ho ,lim,.,. hn>,.li..M.a.a ..f WauiU',',' ,li.' .x.-.'.lindy -'a-v i"t;"v,. an.l nu.lt- ,,U. .,1,-;.,.-..- ■ aiv at..'n.l.'.l in -...i.Tal wi.l. .l- >vmp...m-, ..r a. ni.xt 'vi.l. ,1... a,.i.ra.~a.M'.' .'f all.nmi.inna. Kv,.,i ....t..w...'.liy h.ma.nna, .n ,..,„s..,,n.n.v ,.r iiitim'ti...., may !..■ n.nsi.lcv.l as rx.'.r.lin-ly .-aiv. GENERATIVE ORGANS. Male Gemtalia.-l>i-.a>.s ..f .h.' -nal,. ^■.■..italia in tl... .•.M.r>o ..f tv,,l.„i.l f.-v,r a.-.' ..... - tV.'.,n.M.t an.l i...i....-ta..t a> ar.. tli..~.. .,1 tl.c i;,;,,,!,,. As i„ ...il.'.- i..t;'.'ti..ns .liMas..., .'^iM'.ially va.-i..la, ..;tla...- ,,f .11.' t.-ti.'l.' ...-.'ni- in tlic .'.... i-s.' .'1 tyi.l...ul nat.irv atV.'<'ti..n- . Il,«,.i-..i,. ./.7,,.. ll.i.i..,.. II'.-',' /.'•/'■ '"I " ..,,./,. ,/. //.,/.. l!.l. ii.. n,.! ■■Ni.r.M>kru..kl..i...T,.-- r<.n A.n„..sn, . Il.„„ln„./.. '■ ^:t. ,1,.' .'h.-i" .— ..f -n l!.'.'Ui...l.au-.n. V, rl. IL.I.ph^.- '■ '^-"-''- c. IIV/-.:'""'./. 1S71. syyi'ln.us |\7) iiiMl-l KAIIOXK 195 fiNcf. Xiit iiiiicli i;iii lir siiil ill l:i iicial willi I'ciriiril tn tlnir Cn I- tlli'V ll: it ;i- \rl liciii ~c. lli..r .Mi;lil\ :iiii| :i"lliiil"ilil V ilii'il ;i- li:i« llir mrliili- ot' \ ari"!:! I< 'lii:i''i ). 'Is |pIiim(I nr 'liiii- aji ■III- ranh at tlic Im-i i^iiiiiiiii: lit' tlir ili-ra-i', wliili- it i' alini a iiiaiiili-laliiii' nt' llir la^t |iart nt' tlir ti'iiil.- -tai:'' nr llir ti|--t |ial'l hI' <''ai\ali--iTiiri It ;in- u itli rhilrni ir rvi'ii. a - I ll. lii-iivnl •a-r, w itli a 1 'liill. I II aii\ r\ rill, ll i- aliiin-l alua\ - al ll'lnll iiaikc.l rlr\ almii nt lciii|ii ral lire, T ir ti-ll ■Ir ami iiiil llir ciniliilv iiii^ arc, iimlrr -Hell liriMiiii-taiiri-, ul'iin imliiratril ami -unllcii, ami llic -kin it' 1 1 -criiliiin i- nililrmd am ll ■i'a-iii|ial!\' I'llriiiatiiii "111' ti-lirli illv allri-tn! lir-1, aiiJ nt'tfii ah Ir — riiliillinnlv llir rlilillilv nil i- alVivtnl llr-t nr .1' tl almir I I'.-liiirl'l ill-, w liii'li raili; Itr III till' iiiiir-i' lit tlir -|i('riiialir runt in llic aliilniMiiial i'a\it\, aiT i^riir that Ilii'V IrlillM' IITI talil I' iiiiliv iiliiai- >l rr|i ai|i| ri'-t. I rrilllllalinn in ITrii\rr\' l- tllr rillr. III- \\a- rninidi tnl III irnlll till In rniirlci'ii i|:l llitllrrin nc\rr . 'I all tllr •a-i- iinilrr iii\' ll,-' rr\aliiiii. 1 i-c'i'\iil tl riiiiiialinii III -ii|i|iiiratiiiii, u Im-li a|i|M'ai-, nii ill'. In ll' 11' cM'i'i'iliiiLily rai'i'. <^iiiir i'\ri'|itinnallv atrn|ili\ till' ti-tlr I' lIl'M'lnll-. II a I'a-r II mlir ni\ nli-i'i-vatimi -tci'ilitv in tli< iiiali, ili'iH'iiili'iit ii|piiii a/iii"i-|i('riiii.i, \va- with in-nlialiililx attriliiitcd Ik a |iii'\ inii- biiali'i-al ty|)liiiii| nrdiiti^ fmiii w liirli ni'nvirv liail t.ikcii |ilai-r. I liavr |>('r-uiially nhscrvcil tv|iliiiiil iiri'liili- in (1 i'a>r>, ami in all it v\a,^ iinilati'ral. In i iii^laiirrs ilic tc-tii-lc alniii' was iiillaiin- I, ami in 2 IiiL^rlliiT uilli till' ('iiiiliilyiiiis. 'riif atrci'tioii aiiiM'ar.-; mil In (ici-iir in clulilrcn. It ili'Vc|ii|i- i-liii'lly ill yiiuiiL' nicii. Five of my patients were iiinler tliirtv, ami hut one forty-live years nhl. .\n interestiiiL' stmiy ii|miii this siilijeet has Ueeii iiiaile hy Ollivier,' who analy/dl •'! eases of his own ami a eoiisi.l- ( ri.hle iiiiinher from other .sown fs. 'flieri' inav lie iafi:tioiieil, hesiiles, ainoiii,' Kreiich ohservers, Cervelle' ami Sorel,' ami anions.' (ierinaii ojiscrvers es|n'- eially Liehernieister,' w ho ohserveil orchitis in :! cases ainoiii; L'dd of tV|ihoiil t'ever. A late review of the cases of tviihniil orchitis has lieeii made hv Ushiier,'' ulio collectcil 4:! cases from the iiteratiir<', hesiiles reixirtinj: 1 of his own. 1 en of these are iiiciitioiied as liaviiij^ jrone on to sii|i|)iiratioii, ami from the |ius of .') of the.se ca.ses tile typliniil-hacilliis was ciiitivateil. Vnnn a stmiy ot these cases lie conclinles that in most iiif'aiices the comlition is iie|M'n(ieiit upon infection liiroiiirh tlic iilooil with lyphoiil-hacilii, altlioinrh the |)os- sihility of infection hy coiitiiuiity thriui!:li the urethra with tvplioiii-haciili or other Tnicro-orL''aiiisiiis cannot he exclmieil. The nccurreiicc nf eniis-intis with alitinrmal f'fci|iieiicy in cmivalcs- <'ciit- triiin typlioid fever is wnftliy of iiieiitinii, liccaiise at times ot" ' A'.r. ./, M/./., lK,H:i. ' (inz. III,',/. ,/(•>! /l,'ij>.. I,«SO. ' Tf„';~. ruri-. 1S74. « L„r. rif.. I'll oil., p. IPl. ' I'hihi. M,,/. J,.,ir.. vi.l. i. 196 'lYrilnlli I I VI II pivat |.ra.ti.al im|M.iIanrr, lln- «a- . iii|.iia-i/. .i i,y ( iii. — iiiircr, aii.i 1 have lV(i|ii(iillv ..l,-.|-\(il it a- a cli-liirl.iii'.' Ia.l.>r (luriiit; r.Hivalc- .■iiicr. ( haiiL''- ill ill'' |"i>i- :il'l":ii' 'Miviiiilv raiv. ( ..mplilc ..r pai'lial iraii-niir '.!' llic "lyaii, a- lia- Imvii iii(iiliuiiiiil,i lia\r Ihcii i\|i.cl.-,i diiriii^r lirallli. At tiini- il i- likiiy to 1..- a- livr a- ii-iial. aii>l at utlicr tiiiirs iMiuMially ai.imilaiit aii.l im.tfactf.l. In llir laltir cx.nl. .anfiil cxain- iiiatinii n\' \\\r uinitaiia -liuiiM aluav- \»- wm\v, a- aliMi-lioii at liir IxMrinnintr "f t\ |)ii(>iil fcvir may ii.' ivadily r(.mial(il iMJiind tlic iiia>l< dt' alumrmal nu'ii-lrualinii. It' till' normal time ot' mm-tiMiatioii i- not diir until two to tiiivc Wick- alter tl ii-t of the tlvcr, tlic flow iwiially doc- not take place. In trt part of eon\ aie-.^eiice ; at lea-t, tins i-* true of protnieted ea-e- and tiio-e piir-iiinL-- a -( \ tiv cour-e. I lielicve tliat diirinu'' tlie-e period- eoiniilete al)-eiMc of ineiiMrnatioii may he e\l)eete in r;ltlier an irre;riilar manner, even during tlie felirile stap'. After -evere, lonir-pf't farted attacks of typiioid fever, menstniatiou is likclv to I.e ah-ent .'Vcn after .{.■fcrve-ccnee, often not apiM.ariii^r for two or tiircc period-. .Vfter l.s- >evere and mild attack- it oficii recurs dnriiij: convaie-eence. I'rofn-c nteiine licinorrliafrc at tlie licifrlit ui' the disease, witiioiit >pe<'iai local can-c, is rare and of oiniiiotis imixift. It is analojroiis to a ^iinila'' o<'ciirrence in ca>e- of licinorrhajrie small- pox, and occnrs— rarely, it i- true, in conii)arisoii with it- frei|iiency in tiie former disease — in ca-cs of ty|>hoid fever i.resentintr other " licniur- rhairi<'" symptoms. Toward tlic cnil of the di>ca-i or dnriii'r conva- lescence, peri-iiterine hcinatocelc may occiir. a- Trousseau lias ix.inttil out. Still fir li<- common than this is iieiiiatoinetra (Martin-). So-..alled diphtheric and .■roiipoiis atVc-tioiis of the ntcriiie nmcoiis memhrane, whicii, iiiidoul)te\.[ III ill. mi, (Icclll.iliil ii|c,i:iti f till' ^'rc;il( T :iii(l lr~-.r |;il,i;i and at the v:i>:iiiiil nfiliir, |i:iiiit'iil cr.i-ions at the iimiitli ,,|' \\,f iir.ilini, tlic lattc of i~ he cniisideriKl as a fxra\(' syin|)t.iiii, .leciiriiiij; aliu.ist mily in excccdinjrlv severe cases. In tiie rare cases in whi.li it is jMi-^sihle t.i dcni.instrate a l.i.al cause, as in the case just referred to, n very soinctiincs ciisiics, then ^reiicr- aily with extensive cicatricial ilefects extcndinir int.. the vulva, .ir even with vesical iir rectal tistiihe. Inflammation of the breasts in tiu •>.■ ..f ty|)h.ii.l fever, as has been ilescrihcl hy liciidct,' ajipcars In he .|uitc rare. Slight traiisi- t.iry tuinelaeti.iii, li.iw.'ver, is in my <'X|)ericiice s.nnewhat more e«iiim.)ii. 'I iiis may rca.lily he .iverl.i.ikeil, as it iisnallv ncciirs in severe rases at the licif,dit iif the fclirile stajre, with the terminati.in .if which it silhsidcs, s.) that the patient is ii.it really c.insei.ius nf its |)rcscnce, and it is nirelv a s.iiirce nf c.im|)laint. 'Perminati.m in su|)piirati.iii appears, as in the .ase .if the testicle, the thyr.iid jrland, and the ))ar.itid jrlaiid, bv no means t.i be the rule. I'mbably the ba.'illils of Kbertli is the excitinj^ aireiit of the iiiHammati.iii in the majority .if cases. It mav be iiien- lioiied tiiat I have olwerved sli;rlit mastiiis in 2 eases of tvphoid fever in yoniif^ men. The relation between pregnancy and typli.iid f.vcr is deservinn riiiilmv I.iIk.i- (Mriir-, niili i;iv:il iLiii-i r I" llif liH- nf ill. iiiolliir. Ill ins . \|Mri. ii.r llir pinl !•■ |.r. -naiil w 'il MitllriliL' tiMin l\|,li..i,l r.\r|- i- 11. .1 -. Mival, .■.ilainlv ii.'l .■..iii|iaralil.' t.. ill., .laiii:.!- all. ii.liiii; llii- .■..iiiliti..ii in .a-. - ..!' -mall |...\. \. a. l•lll.- l.•— , .^i-asi.iilv i- I" I"- I'.n-iil' ivil a -.ii..ii- .■ .in|.li.ali..n ..I' l\pl I A iMiiiil..r i.r |iali.iil- pa- -al. Iv llin.ii-li lli.' alla.k ..I' t\ |.li..i.l iVvcr uilli..iil iiil.ll-ii|ili"ii ..r |iiv^iiaiic\, uliil In r- n ."S rr, in -|iili' dt' al...ili..n ..r |.r.MialiMv lali.ir, in tlir latli r .miU il liiiM- I'V'H "ill" il lisiiiu' iliilil. Ill 'illiii' I'^i-'-^ 'Icatli ...-.■iir- iiiiiiii-.lial.l\ at'l.r iiil.Tni|i- ti t" ill.' pivLrnaiiiy ..r ..ciiir- a- a iv-ull ..I' -.a.iv .•..iii|ilii'ati.iii-.' 'I'll., .an-.' ..r ^inl.iiii ilcalli, .ill thiris-ix li..iir-, i- u'l'inniHy tlif Taiv.' aiiiniiiii ..f l>l.".'l l"-t. AiiLiiiii- til., .■.iiiipli.ali'.ii-, -ijilii- .■.iiiiiili..ii- with |i-.uii.iili|>iilli. rii- ami '/an- .riTii.iii- iliaiiL^i- ill llif III. riiir tiiii....n~ iii.iiiKraiic -li.nh I l.c in.iili'Hiiil. Miill.r -tall-, li"u. \.T. tlial l\|ili.iiil |iali'iil- aiv ii.'t iii..rr lial.ic ihaii ..ill. r- t" .■..iii|ili.ali..li- "I' laln'i-, -ii.li a- li.iii..rrlia<;i'. In niv .AiMTJ.n.-.' lli.' a^:.' ..I' lli. piv-nanl u.^nian aii.l lli.' ]> iniiilil !'<■ tli.'ii^lit in a.ivaii.-.'. I I..u.\ii'. it may !..■ -ai.l tliat if ill.. inl.rni|,ti ...iir- in tlie lal.r iii..nlli- ..f i.TVMnaii.A , tlii^ pn.-- 11. .-i^ i- .ii-liii.tlv 111. .IV iiiifav..iaM.' than if it tak.- |ila- .■..miii..niy ili.iii in th.. H.c.inil ..r third \V(...k. In pr..tract...l ca-cs ..f typlmi.! ti^v.-ruith a iiiark...lly r.initt.nl ..r int. rmitt.nt t<.mi>.'ratiirt-i'iir\ •■, I li:ivi' ..l.-.rs i-.l tin- .■..lll- l^li..ati..ll n....|ir a- lat.. a- th.' fmrlli week ..f tiie frv.r, aiia>s<..l, tin tJ.H.k In nic> m.iiv fa\..ral.l... On.' -h.ml.l av.ii.l, li..\M'V.r. makinir .l.tinit.- |.n.iiii-.s f.r th.' |..ri...l ..f .M.iivah-t .if ...implieati.iii-. A- an ..vi.l.-n.'i-.>f ill.' r..|iiarkahlc variahility in tli.. -laleiiieiil,- .if writers with re<:ar.| tn tlu urse an. I pr.iL'ii.i>i> nf typliei'l fever in -r:i\ i.l wnnieii, it iiiav~l.e iiieiiti.iiie.l that Mun'liis.ni >tMt..> that the preiliinsis is alwiiyH i_'rnv..'in th.' p,..seiii'e ..f a.lvaiiee.l ltmx i.jilv. lM.|i..viiiL' llmt ii fatiil tenniiiii- ti.in t.i preiiiatiire lilh.ir iiiviiriahlv .le.iirs. Lielieriiieisler ills., e.insi.lers crrnvi.lilv iis ..x.'e.'.liiiLrly .hinL'ereus. Of 1.^ pn'L'iiiiiit w..iiieii. he .ihserve.l I S... ill tlir -.•.•ti..ii i.ii Kii.l.i-x. th.- f..iidili..n- for Ty|ili..iil K.'V.T in the Ki'tii-. vvi//'/'M/v i\/) ( '>\iii I' \ ri'i\s. !ti» nlmrliiiii ill 1.") anil Ar-.xlU in li. liiiim:!;. , in >:iv lli;:! ''t' all. Of ."> |)rfirii:ii:t Will I II 11 iiiiiiiT llic iili.ii'rviitinii i>t'(iricnitiiipT. :i iliuil. jn^ unit lire lalwr li:i\ in;; I., nil ri'.l ill nil. I'r v Liiiwir fliili^lii-n. wliii-li, it i> Irilc. iii< liiilr "iily till- -iiiiill iiuiiiIh r uf I I rM-r". it iipiK'unt lliMl llir _'iii\ iilily «ii.« iiilii iii|ilcii 111 mII lull I. ami cliiilh oiriiiTfil ill .') — :S."».ti jht rini. M\ I hiiiiliiirL' cxi'iri- I'liri'. nil llii' ollnr liainl. I- i|iiii< I'l < nnililt'. timl I \m>iiIi| uIImiIi -niiif iiii|Rir- I a lice III ii. a> II 1- iimri' rMiii.--i\i- mill wii.- iilii,iiiirmt\ alimi in !'*•'<(> ["^xT, .'!■•< :i. 1 |ii-|- ii'iil. VMTi- :'ra\ii|. ' M' iIiim-. l \Miil Id Iriiii ii I VNcrc ilcliMrcil illiniiL' riiiivali-iciirc nt' liviliLT cliililrcii, wliilt- l( I'J. 1 jht rent. wire ilisi'liar^'i'l at'liT iiriivirv I'luiii llir iillaik of ly|ilii)iil liver «illioiit i'ilirrii|i- liiH' lit' till' pri'iriiaiirv. I'i-c;.'iiaiii-v «a-. lliii.«. iml lliriali'iii'ii liv llii' atlark (if lv|iliiilil liver ill cxailly liall nt iii\ |ialiiiil.-. ( »f tin- niluT |iiili(iil.-. in wliniii aliiirlinii nr iirfiiiiitiiri' liilmr Innk |ilai-c. :! ilicil. 'I'lu- iimrlalily iliirinj,' |ircL'iiaiiiv wa* llun liire 7.^ |Hr iiiil I liail, lui-iilcs, a similarly I'avnr- alile i'X|HTiriiri' at llrrllii lufori' llir llainluir;; i'|iiilrliiic. It -linlllil lie IiiiMI- liniit'il, t'lirtlii-r. lliat reMilt.- >iiiiiliir In my nun liave lnfii rcimrtfil fmiii Kill liv (iiilli,' «liii aiiinii.' '.' |ialii'iil.'* hIimtvciI iilMirrmii in 4 ami ili-atli in Iml I. Al-i, Itri/. ■ rr|Mirl- I'riiiii /iriii-M'ii's ilinie al Muni' li llial, of !' pri l;- iiaiil uniiicn. alinrlinii t'aili-il In ni'Mir in >. Saii|iiiii ' riillri'tnii t'l'iiiii \ariiiii« -mircr- tlir -lati-tir- nt' -'■'}'■'• ca-cs lit' |>rc;:iiaiiry liiiriiii: tv|ih'ii'l. AlMiriinii, iiii-rarri.ine. nr |iniiiatiiri' laiiiir iiniiirnl ill lot) ut' tlii-c i'a-('~. I'ratli o ijiiiiiiir iiiiM attack- tlii-r |iai;- ixliiliil -linjit cliaiitr''- "'' allrialiniis that arc nut cliaractcri-tic. in llic -c\crc ami unr-t ca-cs tlicv arc likdv 111 aci|iiirc -I) |iiciiiiar a diaractcr a- In ciin-tllntc an ini|Mirtaiit ii.'iri of tlic general clinical |iiciiirc. Kvcii carK llic niiicniis nicnilirnnc uf the 11 t!i. lip-, aini tiiiiLriic cxliiliit- a tcmlcnc\- to drync-s. At iIk- -amc time the latter i- i -c nr Ic-- cnatcil ami -vMilleii, vvitli «li-liiiet ami iil'tcll ilci |i ilil|ire— iiilis i>t' tile tectll. At llic liciirllt III' tlic (li-casc till! ii|i|icr li|i i- likely in lie rctiiietcd ami llic ii|i|Mr lutli (x|(n-cred diit\ hrowti (ir (•Veil liiaek hy t I I'ld meiheiiie. |)iii'iiiL; iheearlv iieriiid nf the di — ca^e, at tlie ht'i^iiinillL;- and the liiid he >till iiiiii>t hy day, exhiliiliii^- a liideiiex to dr\ii(>.- diih toward e\ciiiiiu; ami lii;^lil. In the >eeond week ot' -evtle ea-e- it can he ke|it inoi>t only with ureal care; it i> tllel- e\tell-, ii' at all, .-Wdllen, and in le->\>ell- eared-tiir ]iatieiit> is hi-own, dry, eiierii>ted and lis-iired, and hieed- readily t'ni'ii the ti— lire-. Tlu' eoatiiii;- of the toiii^ne di,-a|i| tears at a time de|)«'lidini.' ii|iiiii the eharaeter of the indisidiial ea-e, liiit ilsiiallv at the e;,d (if the second or in the liceiiiniuu- ,,t' the third week, iisiiallv di>a|i|H:iriiiji: first at the tip in the form of a t.ia' ^le and at the mar- j;iii-, then lioid fi'Ver. The on-et wa- on the tweiitv-tifth day of normal temperature, and with it occurred a ty|)ical rela])-e lastintr two weeks. IJeeoverv was complete. He has al.-o collected several other ca-es from the liter.itnre. Of peculiar eh.-inu'es in the mucous memlirane re\ioii-ly ill, and in whom the care of" the iiioiith has liceii ileLdectod. Under -iich circiim-tances J have seen the deposits extend di 'vn tlie esojilia^fus to the reLri"n of tlu' cardia, and even to coiistitnfe a serious oh-truction to hreatli'iiLr. 'I'he occurrence of a sevi'iv ca.-e ot' ' ./-,/,,,.. Iln/J.n,s /A, .7,. liu/l.. v.il. i\. syMI'TDMS AM) < OMfl.liMIDSS. 201 llii-ii>li ill :i liii--|iit:il (liM- not ictlcct cnditnMy ii|Min the iiicilic-ii care :iii(! !!;!' II :^^illl.^ 'I'lic .-inictmc^ (pf the tiniccs cxliihit \iiriiMi-> cliaiijrcs in cases of tyidiiiiil t'evcr. L\ iii|i|i(iiil >\\clliiijr df tlic ton-ils and tlie |>alatine aniies — to wliicli reicicnce lia • already liecii made (in tlie cliapter to me to he rarely (lenioii-.trai)lc, at lea.-t elin- ieally. i)iit,r:ict ai. 1 Cliaiitcmes.if liavu oliservetl such iiitiltrations imderijfo disintefrration witli tlie siii)se(|iieiit f'ornuitioii of ulcers, in the floor of which ty|ihoid-l)acilli were demonstrable — a |>rucess, therefiire that is prohahly coiii|)aral)le to the sjiccilic le-ioil in the intestines. In the larjre majority of eases tierc is but slight iuvolvemeut of the pharyngeal structures, namely, inoe-J ryi'iKtifi n.vi.ii. the :iirfcli(m of the lhn.;il exi^l.■(l lo-ilh.r with un almiidaiil |■o^e(lh.u^ eri]|)- timi upon the trunk. ;i (li;iL'ii"-i> of syphilid u;i.- made. 'I'vphoiil an-ina ^\a^ eviy Loui>.".lenner, ami Chonud with refrard to early iuvolvemeut of the pharv iiL'eal Mructnre.- in ea^.e^ of typhoid fever are indi- cative of thi.-. Sulise.pienllv it di. varietv of aiii;ina. which po>M's>e> a certain ileirree of importance a> an early niaiii- festulion of tvphoid fever, has not yd iieen studied bacteri(do,iricall.v. '1 his niijrht prove an intereMin- undertaking that would jKissihly yield iliagnostie results. Actual (lii)litlieric atVc lioiis ..f the ii!iafyii<;ea! stnictiire>, siicli as liavc lieen descrihcd l>y ( iiic»iiij:cr, Oiilnioiid,' and otlief, at tiic iiei.L'lit of the disease, towanl the close of the sec. ml or in the thifd week, are jiroha- bly to 1)0 included aiiKiii.i;- the true conii.licatinii~. In any cvciit, they are e.xtfemelv rare occurrence-, that yd rc(piirc exact hacteriolooic inves- ti'Mtion. I have neix.nally not a- yd eiicountercil a <'a-c of this kind. The exteiisio- pharyntreal space, the Ku>tacl,ian tiil>c<, ami the middle ear will he coiisidci-ed at another place. Thcalterali.iiis in the ].aroti(l gland, and esiiecially the iiitlaiiiinatoiy Ic-ions of thi- ofiran. in ca^s of typhoid fever arc ipiite iiniiortani, (>vcn though tliev are not >o coniiiioii as they arc jreiiefally hclicvcd to he. .\-. i- >o often the ca>e with specially iiainl'iil and conspicuous disorder-, the frec|ii.'iicy <.f paroliti- ha- heeii Lnvatly overc-tiniate.l, 1 have pi'i'-onally (Idennined that during the Ilanihurg e|.ideiiii.'s only 0.;l per cent., aii.l in I.eip-i<' O.o per cent., of the patients exhihitcd inflaiiiniation of ihe parotid gland:-; and in the statistic of IIotTniaiiM relating to the lia-l.^ cpi.leinic, paroliti- wa- noted in Hi of ilidO (.;,>,.s 1 ]» T cent. K.ceiitly ]iafotiti^ apjuars to have l.ecoiiie even less c,,ininon, and this is prohahly due, in jmrt at least, to tiie greater care given ixenerally to the iiioulh of the patients. Parotiti- devcloi>s generally on one -idc ; rarely liotli glands arc involved -ynehroiiou-lv, while disea-e ,d' hoth -llcee-ively i- more cmimoii. I'an.iiti- i- u-iiallv a manife-tatioii at the height of the .li-ea-e. toward the end of the -ecoml or the third ■,veek. altl gh it may conic under ol.-ervation al-o later, .and even diiriii- coiiv ale-cciK'c. It.- Clinic; 1 feature- are -candy ditVe-ent from tlio-c . The alVectioii u-iially o.eiirs in very 1 llrr. ,1, ),.,'./. ri ,•/,//■. ./. /•.//'.■.. .luly, IK.'i.j. ?^V:.?%^^i.3m^^9?f^^' SYMl'TOMS AM) (OMrLIC.l'I'K/ys. 203 III Mini M lri:iilv iniicli riMliiicd in(li\ i(lii:il>, wliicli fact 1 las an in)|>oit:iiii l>r:iriii;j: nil tlu' I'lunsc and ^vlll|)tl .1' cax' ni> lit' till' ruMijiliratioii. In tlic niaj'Tity the ntniiiiaiuliliiilar |)iirtinii tii-t biruiiK- >\viillrii, at'tcr wliidi, with liu ( \((|ili(iii-, the (iitirc ipi'frjiii i> iii\iil\ril. Tlif aU'rctinii i> >i> painful lliat even id'ofomidly xipnrii-f |)ali(nts arc n.iiM'idii- of its (■.\i~l<> of incta.static urijrin, it xt- in with a chill, while a ciirrc>|«iiiiliii;r clcvatimi of tciii|Mratiii-c withont a chill i-i (liix rvcd aliiinst iincxci ptiuiiallv. The atfcctimi niav, as 1 have repeatedly alile teml i-ved, -lili-ide withniit siippiiratinn, even alter enii^idci- eriie— , s\\( iliii'r, and icdiicss ha \e been iire.-cii It. Wh pil nitidii iieciirs, as it dues in must case-, it iiivi lives at till ip- purtion ef the intlained trjaiid, and at ipilur time- the ihe latter event I uive (leea-iiiliallv lieeii alilc to e les l)iit one I tiic itiri iireaii. \tra •t frnii isiiiii Wdimd lar;:e purtioiis ul Ihi imeetive-tis-uc structure nt tin f th. and in the ti'Vin of ncci'oli d-. With rcirard to the mode of origin of typhoid paroiiti-, the view of Vircl low,' that It 1- due to e\ten-lon ■ if infection- processes from the iiioiith throiitiii the diiet of Steiioii to the ulaiid. is certainly correct for Millie cases. Ill several case- I have ol)-er\ed parotitis ncciir ill as-oeia- lion with ulcerative slomatili-, especially in the vicinity ot' the papilla of Stciion. .\l)ove all, it should lie kept in mind that tlii' ;^laiids ill colisciiilelice of tiic action of ire more Ireiiiicnllv direetlv iiiv lived the tvphoid toxin- than are other oriraiis {^I'f -eclioii on Aiuitoiny). .VI II, the tyjihoid-hacilli theniselvcs may in some eases be t! ■ direct excitants of the inflammation. .\t hast I ca-e has heeii rcporliKl (.laniiwski -') in wlii<-li a pure eiiltiirc of the taiiicd from the suppiinitiiit; lilaiid. In a n tvphoid-liacillns has lieeii asscicia t.v| ihoid-liacill nil her ot' otlu rt lis was oi)- r eases the till with the ]tyoueiiie encci (Anton Fiitt ercr '). In a ninnher of instai ces I have lieeii alilc to deinoii- -Irate the pre-ence of sta) ilnlococcl ( xehisivelv ill the ,iiis ohtai pnnetiirc of the jjlaiul diiriii!.'' life. Kxccptionally, I iiavc ohserveil arotitis as one o f the mntoiiis of a eomiilicatinir irenera iympt il septi .Vlthuiiirii earlier writers report the oh-crvation ot' this occnrreiice more fiei|iieiitly, this may !.e due to the fact that tlii' term sept leeiiiia was eiven a wider interpretation than appears justified at the ]>reseiit day. I have also in a nninher of instances seen parotitis as the sole metastatic inanil'estation, without the dcvi .11 ipmeiit of ireiieral pyemia, partH'ula s of tvphoid fever. I can rec; tollowiiiLr -ii])|>iir;itivc I'literitis in eases ot ty| for in-taiice, haviiiir oliserved metastatic aliseess of the iiarotid i- cases tlio atVcrtidii was liilalii-al. Ill L'i'iirral, |iarolitis i- ma' nf ilic -cvirc ami daiiLr" rmis (•iiiii|jlicatiiiiis ut' tviilmiil t'lvcr. Lirl)cniici-trr, anient: 2 10 fatal cax- hctwccii ISii") and ISiiS, iili-i Tv.d jiamtili.- in ti — '_'.>' ["i- ciii. Of tlic H! ca.-rs ut' lianititis r(]>(irttd i>y llolViiiaiiii, U> wliii'ii nft rciuf lias ]>r(\ ioiisly lic and acute ediiiia ot' the hraiii aiv ti> he nieil- timied. A> a foiilt (if direct ( xtcii-ioii (.I'^tlic -iiiipiirati m, |ierii>-titis and neeio-is of the adjacent liuiic--, sii]i|iiiratiiin ct' the niass-ters, hiirrnwiiifj; l>ineiit f\' iiiediastiiiiiis, may take ])lace. Secniidarv ]r.(niia i> a |p(i— ihility iindi r siieh conditions. In 1 instance I (il)-erved iiiriifalph' facial pal-y (>ce al-o ( irie~siiiLni' and Lieliefniei-tcr). Stomach and Esophagus. — Althonuh it i- extfcmely rare that the stomach and the e>o]iliai;ii- cxhiliit s|-ecilic alteration-, and almost never trivc rise to characteristic syniptoins, they do, especially at the iHL'iiiniiiji- of the atuick, ])lay a certain rnf,. it will, at any rate, he well to de\(itc a few Words to the consideration of such pneral and indetinile >yiii|>tonis as the pain in the e|)ii;astriiim, the liati^ca, and the voiiiitinii'. Xerxdiis individuals t'rcijtiently complain of a sense ot dull prc--iire in the e]>ipistrinm from the ]irodroiiial sta^rc into the first week of the di~ea-e. This s.'iisitioii almost iiever attains to the inteii- silv of the doiiiiiiatiiiL'' paiii~. --neli as are cliaraeteristi<- of the tirst days of other infection-, diseases, particularly variola. Severe ]iaiii in the epi<_'-astriiim, therefore, at a ]ieriiid in the coiir-e of a fehrile disea-e when the diairn"~is i- nncertain is ajrainst rather than in favor of tvplioid fever. I'^roiii the ^eeo!ld week on, the eoin))laint> of cpitrastric terical men ; hut nmler such cirenm- stances tliev ajipcar n-cncrally as a transitory t'catnre, and almost never liecome severelv spasmodic or colicky. in some instances the attacks of vomitinji ap]iearcd not to he induce'•'■ SYMI'TOMS .\.\l> < iiMl'I.KWrinS^. 20.') )iiii)li('atiiiii>, such :is intiiiiii;i tis ;iu(l allicil Ihr IHl'lIllUltlS, MIK I, li 'IKUllilIlS, I latent iiitf.-tiiial lirinurrha).'-i icrt'(ii~iti"ii oC Alter ive-eeiiee and (llinil;^ <•<>: invali's<'eiiee, nausea anil voniitin^'' ai'e alnin-l ivs retel-al)le to dietetie en-or. Smie writcfs I'efer to tlie oeeurreiict! lor il>l t uneoiitfollable voniitiii"' duniij^ conNaleseem wliieli no Miate anatomic basis co mid l>e found at ant< j,sy. 1 .1)S<. C.1 tl cs of lis inanile>tation, wliidi I hclic\c to li- pfotfacteil coufsc witli severe eorn|)li<'atioUs. ■xtrcinciv i-ari', oiilv 111 I iliicli from tile oilier ^vmptoms was to he coiisii leivd as one ot iieiii- ric typlioid, I tiiund erosj ■ anatoniii cxiilaiiatioii of tiie vomiting. astritis with numerous ecehvnioses Tl staw. ic a]>|iclite is w I o-t III most cases as earl V as the prodromai d .11 d iiriiiir die first wit'l lallellts aversion, even a distrust, for tin- iiiirestioii ot' iiiod, and complain of a stale e, i)asty, the lieij;lit of the d d or hitter taste, iseas(> tliesi' <1 of a selist' ot I)1I"I1I11L tl iirst. -iihiective manifestations disappi At iiid the patients swallow niechanicallv what i (tt(Teician with the patient and injudiciou I'lat ion to 111 con Hict clati r^ven in th ihvsician th mav be a striitrirle between the sense of dutv and MM-,al.Ml llial ., V,,,,,, ..„„n..rli..„ iMlvs.vn thr t«.> lunM !„■ tlmilL'hl .>! I'.ylliol thr>L. vM-il>.r. hdi.'vr nni ,mlv llial .iila'alinn of tl... Mmuarl, ,„ay 1m. ihr ivMill n ,,,,|,.,„| i;.v..,-, Iml aUu that, r„i,srrM.ly. .xiMiML' .lilalatmn nt lli. HnaKuli ,.,',„- unhni.l inlrrliou. Tl,,- tar. il.al in,' iv i. 1 Mai. alla.lr,! >r\.;ra tniics l,v ivplini.l f,v. I- li-i'MUfiuiv Mi!!.r Imm .lilalalim, nf tli.^ .-l.^inarii i> lliou-IH ,„ |„. .MK-iailv .■onvinci.iL'. S., far a- I kwns. iIhm- Matcinrnl> liavf iHit _s,., I,..,.i, roHli'nur.l ii, llu- (i.ianan lilrraliin'. l'.i>o„allv, tn.in my ..un ",M., riiiK'c. I am unalilr 1" \fr\\\ llnan. l;,.f,.,, ■„.■,• I.a. alna.lv Imtm n.a.l.' t.. tlic Mi|.. liirial .-n.Mnn.- a>al ul.vrs H.MK-.iiM.-s .,vn i„ llu- ;-H.|,l,a^us atu-r d.-alh. TIu-m- ,-an-lv ^.v.- hm- m -va.ptuM,.. In 111.- rax- nf . M,|,l,a-.-ul ..l.-cralion n-|,o,-tnl l,y Mih-lu-ll,- Imu- ,.\..|- for luo .Imn. l.-rni-.- .l.-alh tlu-.v \v;i> Nvrll-inarU.-l .ly^phn-ia. N-v.-ral .-a-r-^nf ,-o|,l,a"'i-inns ,luriM- tvplii.i.l U-v.-r liav.- lu-.-n n-porh-.i. I.lit it is not known wlu-tlu-r .in- has anv analoniic- hasi.. No .-as.-s of luanal.-im-sis as.o- .•ial.-.l Nvitli .-.opha-j.al l.-sions have- h.-.-n r.-|.oi-U-.l. N-vonil rases o| stn.-tn.-e .,f til.- ,->ophai:us tollouinir lypiu.i.i f.-voi- liavc o.-,-\irn-.l Tliis is iisiiiillv a laU-MM|n.-i. I. lit llu- 01IS.-1 of >yinpton.s may l.i- .lurin- c-onvak-sct-n.-f, a.s in the i-aM- rf]ioi-ttMl liy Sumim-rs. I^iver and Biliary Passages.— Thr !iv,-r an-l tlic l.ili.iry pas- sa-os also ,,lav no prominont rnir in tlu- -nli-iaiy ^yinptoinatulo-ry of tviilioii! f.-vor.' K-i.o<-iallv siil.i.-otivo symi-toni- n-t'oi-.M.- to tlKiii arc ,:xt,vi„olv ran-. ( )l.i.-.-tiv.-K , at tl,.- l,.-i,L^ht uftlio .li-.-aso, tlio n-.^ion ot ,1„. livor is ,,,-oaMonallv t.n.l.T on |m-s.iiiv, a-HH-iat..! witli oiilai-.m.'nt „rtiio OP-.U1, n-nallv of iii.Klorat.- -nnl.' an.l |.rol.al.ly .l.u- to l.y|..-.vin.a ami .-ioiMlv ^wi-llii,-. It is f.irtli.r to 1..- noto.l that, in a niajonty of all, ovon H-vo,v. ras,-> of .yplM-i-l thv.T. |.rovi nofn.al si/... So far a- i- Ui.own, tii.' fo.-al n.K.n.sos pivvion-ly n...nti.m...l -ivo ris.. to 11(1 sviii|itoms. I.-t.-ri.-'i-. in th.. oi.inion of ni..st ..xi...ri.-n.-.Kl ..Iwrvcrs, amoiifx Nvho.n Miir.-lii~on, (;ri..ssin,L'.>r, an.l i;i,-l,.-mi.-ist..r may ho m.-ntion.-.l, an ,-l....iallv ran. .naiiif..stati..ii in tlm .'.mrs.' of typh.^i.! f.-vr— s.. rare that s.,.n<., as. for inMan.-o. Fi...ll..r, with n.f.T..n...' t.. W.-ilV .lis,.as.., .-on- si.l.-r-- tliis fa.-t p,.,.i,..rlvof si;rniti..anc..in.lim.r..ntial .lia-n.'sis. I'osMhly this ,nanif..station, wln.-h is .•,mu.i..n in son..' ..tlmr inf.-.'tions
  • .as..s, an.l th.-n i.riii.-ii.allv .lii<- to .liio.h-nal .-atarrli, is s.. raiv in cast-s ..f tvphoi.l fcv.-r l....ans.. in ti.i- .lis.-as.. th.- ^t.mia.h an.l tlu- npiM-r p.-r- , .. „il,„„i„M a- lV.t..n,a,- .-. Ii.-.vn. ,^ |,l,...l.-. ■ .-t.-.. VV,,'.-. I'ari^. l^H.:. ■-• ./„/,». Hu^^kiu. 11..,,. Jirp.. v,.|, viii ■• n.U,. M.I. Junr., O.i. 'JS, 1?W. SYMI'I'iMS IN/' I iiMfl.U A imSS. '_'(I7 Al-n .1' tlir illtr-lilir illT lull little IIIV :illul her- ronditinii tiiMirillL" llic devi li>|) ll: llic lIliiriMll pI'MCOS. II III lit' icicrii* ill >ciiiif iiit(ctiiiii> (liM'asi-, IK1II1- .1 ■K iii:irkce-., aixl lia- -eell It I'll .1 I ."i liiiii- ill S^'ill ea-e-. it- |i-eilllelle\ -eelllT. tii \arv 111 I litleiviil elPlileiiili-, a I- !)a ( usta,' ill IS'.IS, i-e|,orti.l '. ea-e t'l'iiiii the rrnii-\ Uiiiiia ilo-nit: if wlliell lie IkhI -eell W itllill a lliollt ll.-. II. -I la- anaU/.eu •> ■1 i-A-v- fnnii tlie liter :iiir< 11 Ik 'irnhahle the laiimliee i:i tlie-e ( aM'~ Wefe : < :', ; el|(ilee\-t 1-, •'> ; llli-ec -^. ti ; aeiite \ clluw atarrlial. I ; |i\ lc|ililel)iiis, atrn|ili_\ , .") ; |o\ie, -J i illieel'Iaili, i. Aeei.nliiitr In ( )-ler, the i"i-e it' jailliuiee iMMi nriii'j- ill tv|phiiiil text av III' !^riiiipeeiatt il with 'rall-stdiies ami lidlaiiiiili^. Catarrhal Jaundice.— < )-ler think- th;it the -lidit jaiiiKl lee III ea-es of inouel'ate -exei'itv 1-^ till- loriii, ami iiiKler tin- lieaili liiiir II inelmle- l> the S c'ase- re] I-ejMirteii liv llllll. Da Co-ta, i idwever, thinks lliat inii-I of the eax •'i_' ea^es iindei' the ea s are of toxii' onii'iii, a - he ilielmles onlv 4 of till tarrhal. It i> intere-tinjr, in this eoiimetion, that •lav-eolorc ease- feportei "IM'S is the |)l'eseliee of elay- iKlllv of these inililef cases liel I liv Da <'osta, ami in only 1 of Oslef's colored >t()ol- inentiiined. In favor of iiiT of catarrhal, ohstrnetive orijriii is the ■riv;it freiineney witli which the haeilli arc pre-eiit in quite constant occurrence of t\ iihoid-hacilli ii of experimental ini«iilatioii-ty])hoid in ralihits wa in 1S!I the liile. The I the irall-hladder in cases lied 1)V Hlachstcin 1. After (iill)ert and Cimdc' had demonstrated the typlioid- hacilli in the hiiinan ^'all-hhiddcr, C'hiari " showed the almost constant f the haeilhis of KlHTtli in the irall-hhidder — in 'JO of hers. Chiari'- ohMTvations have oceiirri'iicc o I'l autopsic: olteii in cnorniuiis mini liceii lonlirined hy IJirch-Hirsehi'ehP and others. In most c-ases they cause no damafre to the eall-Madder or ducts. That they ])rohahly initiicc more si vere forms of iiitlamination an ' Trnils. ■,/ Ass,..- Am. I'hfis.. Vol. \iv. 3 ./../.».s II,.J'kll,s /In.y,. /{,•/,.. V..1. viii. ' J.,/,„s llupl,i„s ll.'s,,. Hull.. IS'.H. v,.l, ii. 1 mav h'ad to the foriiia- » //-;./., v.il. xiii. '^Se,r. iiufl.. Is'.ili. Nci. ■>><. iinil r,,ti,j,l <• r,;,,,. n.'-.L Wn.-h.. IS'.i:;. N".. -j-j, ' I'iith. Aunt.. Ikl. ii.. -1. .Null., S. H!t4. „/. .le la .M,,-. bwl.. ISIH, N,.. 11. TYI'llnlh I IVF.i:. 1^ li(i|| 111' ciilculi will 111- -|iiik(ii III' l;i((i'. \\ liillur llnv i:ili ihildrf .i mill! riinu ill' lalarrli nl' tin- ilml-, ami -n lead In an nli-tniitivc cataialial jaiiiiiliif, i- iml yil liii\Mi iiiily liy llir |iri-i'iii r ul' a li \\ |)ii— nil- in llir lirilic, a> Well a- In llir liinlc -(Aclr uraili- nl' i\-lili>, it -rilll> iii'iilialilr llial a ^iniilar ciiiidiliiiM can occiii' willi i'('L'';n'il I" llii' liili', anil lliai a -inijilr .alairlial inllaininatimi 'nay he xl u;i tlial iniiiicc- ilioc niililcr i^iailc- nl' jaumlirc. Toxic Jaundice. — In t'a.nriir tlir view tliat many of \\v ca-i'- aiv 111' llii- liirni, Da (n-la inc-i lit- llir-r aii:Mnicnl> : "It- m rniriiici', as a rnlf, a- a laic >\ni|iliini ami in i;i';i\c ca-c- ; tlic cliaraclcr nt' the -tiiiil-, wliicli aiv 1)1. little iiiiiditiiil ; the ecnci-al -iniilarity tu the jaiimlicc miticcd in nther inrcclivc ili-ea>e- and altered lilund -late-, -iieli a> in |>veMiia. The cnnditinn nl' the li\er it-ell' diie> nut ;^i\i' lis niueh int'nnnatinii. Yet where the nri;aii ha- l>e( n careriilly c.xaiiiincd, it has licell rnlind In slinW deu'cneinitinll nl' the li\tr-eells that has lieell likened l)V l'"i'eriehs even tn the state I'liinKl in acute yelhiw atrnpliy." yiieh a ca-e, runnine a eniir-e like aeiile yellow atl'ii|iliy, with, at aiitniisv, a lisev fc-cinliliii!.'' that I'niind in that enmlilinn, has lieeii lately reimrted liv Saiiliniin. Ket'ereiice has al-n Keen made to this cnnditioil hv (iriessineer, |,iel)eniieister, and 1 InlVinaiiii. When this rafe ('"li- ditini: uccni's at all — 1 am imramiliar with it I'lnm |)ersniial nhsefva- tiiii, — it is said tn a]>|iear at the heiirht nl' the ty|ihiiid |irnee— , at times in assiieiatinii with di-timt paiiit'il tiimetiictinn, and then ra|>idly pro- irres-iw a Cn-ta ha- enllected -l-l cases in which the assnciatimi nf ali-ce-s nt' the liver with ty|ihnid fever seeiiUKl k'Vnnd doiiht. Of these, mily 7 had jaundice, lint in I'J it i- not men- tinned at all. I knnw nt' im ease- in which the aliscesses are due tn a hx'ali/aliun of the tyiihnid-hacilli in the liver. Ali-cess nf the liver mav arise in three dilfereiit ways: (I ) .\- niie of the manifestatinns of p'lieral secniidarv se|)ticeniia nr ])yeniia enm|)li<'atiiitr ty|)lini(l fever; ['!) as a result of septic pyletliromhnsi-, in comieetinn with siippiinitive atl'eetinns nf the intestine, e-pecially the cei'iim : linally, (■".) in cnn-e- cpience nf varinii- inllammatnry and ulcerative iirncesses in the larjrc hiliarv jias-atfe- and the jrall-liladdcr. [ have pi/.i' of M liiLrriili'- lo iIkiI (I :i :hi mIm- .,f ilic li \IT. ililll lllll-,- iluf In ;i '1' A -Imihir ("ii'lilinii li:i- hiin i.li-ciAi i'|p|\ Ull'lcl'- ,1 l,\ l,..ui-' riiicr 111 II .1 .-U|i|HI|-.IIIM- I l;ill(|- alicr |irii'lLciiii||-ilis lit' iIh- l;ir\ii\. < >.-lci- liM> l(|>i Wllll'll, III III till' {llll'niiil lilii''-:ili-if>-i Milinii In ilic al'-ii'.-.- "I ill.' h\ri. linn lllllllll.-. Mini Ilic I -Ucll :l r;l.-i', In -ll|l|llll':il|n|l III :l,-inil, :iliH.'>;. 1 I liir .'MMn.lici.alir lyiii|ili-L'-laiiil.-. ami iiiullil'l' ■a>r.- l.iioiiLiiiiir ill llii- Ml I II II I rali-L;iii V. I lit I li lii>l. ill 1"<'^7. ill |iiivali' pru'lir'. In llii- cav an a liM l>.~ lIcVl'llllil ll 111 ill ri'.'lit iliac lii-s,i a- a >ci|iiciicc nf t\ |.lii.iil pi an irrcirnliir. lniLiiiLC uIpmcss. a- lari;c a.- a nlv|ililili.-. nil I it a|i|ilc. in till Icl'l liilic avc n.-c III il Ihc liver, aitciiilcil w illi chills mill rliaracicii>tic ii Icriinllciit tcvir, ami Icnni- natiiiL' liiliilh wise nrii'lna ll tc.l tVll ic sccoii'l case, iimmi ricil Iriiin iiiv clinic li\ Knllll hil:. like- ii|i|iiiralivc |icrily|ilililis. ihhI ;:a vc n.-c Id iiiiiI1I|i o.-cs 111' llic liver III till ilistriliiilion ol' the im tal Vein. Haclelinloiiic iiiiiiialidii ilie.| ilie |ireseii )t" >la|iliy •i (iiilv, anil no l\ | liacilli. III tlic nils. Klel.s' rteil llic liisl inslancc nf ilic IcVcloplllell t nl illisci iias |iriil)al)lv rcpn he liver froiii iijcci-alinii of ihc hiliary |pa.-.-a,L'e- ca-e miller iiiv nhservalnin neeiirreil in a uninai 1. eii;lileeii vears old. «itli an cncaiisiilatci ilisecss at the ^i.le nf, ami lieliiml. I he L'all-lihiiliier. wliieji it' a piLi-cnll's CLIL' ilitn llic sllll- ninicatcil willi ll. eXlcMilniL' in Ilie size 1 I he liver. stance o lA' the l'niirt!i wci lie ciimlilinii hail ilevelnp( ll al tli< iniciiceinent k it( the alt lick >>{ tviiliiiiil U- anil, what niailc the lliaL'llnSIS inn: t ■litfieiilt. it was at the licL'iniiiiii: unattcmleil with |aumlic.'. iiml later was att-mlcij with Imt sliirhl laiimlice. The typhoid inflammatory affections of the gall-bladder and large biliary passaj tliiiripiie-ii ciinsii ilci'ati Sllcil ciccliri'Cllce-- Were melltH illci 1 liv Aiiilial, l,iiiiis. .Iciiiicr. am' I,einict, ami siil)S(M|iientlv were de-crihed, specially liy ItoUitaii-ky, as (li|iliflicric atlcctiiiiis lit' tlif ;,fall-l)la(l»ce-s of tile liver. |ierfiirative |Mi-itoiiiti>, etc. ( 'Imle- fv-iitis ami cliolaiiiritis in ty|i!ioi(l tever have liccii nioie liilly trcaleil of ill tlic p:i-t few years liy Osier,' Mason,''' Da Costa," ( 'aniac,' I{y>ka." ami (illler- Th nitliors liavi tell ami rctiortcd iiiiineroiis i:i-es in lllicli these comlitiolis occurred eitl ^■1 ler as eoiii|)lieatioiis or as ~e(|iicl As to the frc(|iiencv of aciit< ilccvstiti- diiriiin- tlic fehrile attack, m> considerable >tatistics have liecii collected, althoiinlM|nite ininieroiis cases have licen rei>orted hy the ahove-incntioiied writers, \\'ith I'eirard to ' /,.-.-. ,-,/., isjl. .M ,,1., v,.|, i. ' .1'/,,, \V.,„. ,„,,/. /.;/,, isci;. N... :!7. ' /.'.;■///(, l:r,,K ir..7, . IS'.lll. N,,, i| Tlli- Mllirlr r.int;iiii- nil IXtlll-ivc liit.lin<;- Riphy. lit' -illlil;ir r;i-|.-. tlien^ IIIV ritiil lillll .if TuM'.'.l, h'Ini MfHhrll . Illlln luir!:, isiij lSi,:i; iliMl .if .\.,1l II,,-i;„. I.I,„. \y.,.l,. l^S-J, N... .'il : iiiul that et' I'.m kliiis;. iinvi. /);,«.. n.Tiin, isiis, < ll.,„./h.„-/, ,/,,/«'/,. .[„„/. isi;s. ,,. -iMi, ■> /,...■. ,;t. '■ Tr.i,.^. A-^.^r. .\„i. l-hiis.. v-l \ii ' /..„■. ,-it. ' ./..liHS II. ;,/.;„■. lis,,. R,/,.. VmI, \iii. » Mni.-h. n.r.l. ir../,,, lid. hi.. N... L':!. 14 210 7 1 /■//"//. / / 1 / /;. it\ llir ilin|,":\ , it Mi:i\ Im -:iiiI 1 1 1.1 ! Ill :i liiiliiiirr (iT liir ,:i-(- ill w iiii-li ii:ic- t. rinli.i;!!' i\;iliiill:ili..|i- Uiiv lii.iii.', |iini' iilllilii- "'' iIm' I \ pin lii I-I i.i. il In- \\( re nliMiiicil. Hill, :i- iVoiii till' \v..|k ..I ( lii;ili ;i1iil miIk r-, iIk :i1iiiii-| , -i:i:ii |,iv-.iici ..r llic |\ |i|Mii(|-li:i(illi In llii- i:;ill-lil:iilili r li;i- l"i|i i|. ni..n-lr:ili il. llirii iiin-l lir -..mi' -. ( i.ndiiiv linl'T. Ilircnl -linlir-. |.:i\.' nn iloiilii ili.ii :^:ill--l..iii - iviiili r the liili:ii\ ilinl- .111(1 liiill -Miiilili r iii'in- live iiliv !■ |.. inlri'liMn. I'liil wliili -|..n'- li:i\i Imiii IhiiihI in -Mnir (.1' ill!-.' ilclllc r;i-. -, ill llir lli:iiMlil\ tll(\ ll:l\( lie. I ImiII |irr-(nl. ( >!' 7 1 ca-r- ..r l.ili,ir\ inlivli ■..llni,.! I.\ l\((ii, in .".^ in. l:.i!I--Ii"ii - \M IV riiiinil. Ill .'.I ili'ilv.v -mi-. 1 ni|i\ ( ni:i. "I- n!c M liiiii.n «:i- |.ic-(iii \\ill I :j,i1I--|..ii. -, :in.l liMiii II I lie I \ |ili..lil-li;icil In- w :i- i-.il;iliil. It i- |,r,,l.;il,|c- lli.il in in:in\ r:i-, - ili< .|i-iinri|oii i.. ilir tl..^ nf Im!.' i- iliiv I,, niiiiii- ; llic ijinuih (,r ilii l.:Ml(ii.i Imiiil: llin- r.i\'.|vi|. :in iiciilc ill||;ilillii;ili r llii Willi- "i llir -:ill-l'l:i'l'l'l m.i^ I" llicliKv.l, Iciililli: til -ii|i|iin-:iliiin. cli-li nlimi, |Mi--ilil\ nli i i;il i. .ii mihI |ii rti iiiil I"|i. 'I'lir niiiin -\ nilili.in- III' rhnlivv -lili- nil Iniiili/nl |i:iiii :iiiil limlir- III— ;in'l ill' |iri -iiii V ..I' ;i ini '. Tin liinuT i- ii-i,.ill\ li.r:ilril in llir ri-lii li\ |i..ili.ini|iiiini. Km iii:i\ In- hhhIi Imsmi. imii \n\n\\ tin nniliili- ,-[\~. .I.niiiilirr ni:i\- niriii'. Iiiil i- li\ II" 1111:111- ii.ii-l.inl. I'iiiiIhI- :iiii1 nil, IV riiin|i|.li iili-ii\:iliiin- :i- 111 lln- liiliiivinr "!' ill'' linLi"\li- :iiv niiii.il. Siir-ii'il Iniiiti iTiiiv ill llii-i' I'.'i-i- \\ ill '"■ nl'iii'l I" in lin' i-|i;i|il' r nil 'rriiiliiH III. Sii|i|iiir;ili\c rli"liv\ -tili- mill iIh 'lilil lii;i-i- fcllnw iii',: ivplii'id tivir ;irr n.inliiii.n- ivi|niriiiLi -iir'jii-;il livninu iil. :inil rnrtlirr n.n-iili r:itii'ii i.-; Mill ]ii.— ililr lirlT. Till- ivlitii.ii iifiyi.liiiii!-l':ii-illi t'l till' ti.tnrirn.li"t'{?all-StonCS i- an (•xivfill.i'^lv iiiti ri'-liii'^i iilir. Uirliaril-'in ' li:i- -li"\vii tli.il llir liinilli an lVn|iiriillv i!iini|iiil in iIh' I'il''. ami In , < n-liiii'^. ami "llni- lirliiAc ll,;it llir-r i'liini|i- I'l'ini llh' iinrlci fill- -l"ii<-. i'li'in tlir iiitvri'T lit' -ti.iii- tlir I\ |ili"i'l-l>-i'-illi li.iv liivii i-"lal'il ilia nninlirr i.f in-laiicc-, :iii iniMiilalinii nl' I\ plmii!- Ji:ii-i!li intii tlir -all-Maililcr i.r animal- !ia- Ihvii -iinv-riill\ ai-i - |ili-liii| li\ ( iillui't .111(1 l'""nrniir. ' liirliaril-uii.' ( ii-liiiii;. ' and dlirr-. It ||;i- liirii ilcni'iii-tralnl llial ty |ili"iil -liarilli in.ay ivinaiii \ialilc ill tlir -all-l'lai|i|rr t^r \rai--. Ilniiin r' lia- n pnrtnl a r:i-r of -ii|)|iiirali\c rlli,lrr\-titi- iirrliri-ill'.' ri'jiltivll \rar- .'iriir tlic atl.ack el' ty|llli'i(i trvir. tV'iin llir |iii- 111' wliiili tlir l\ pill. iil-liarilln- \'.a- i-ulalni ill pniv niltiirr. Ii'rti 1-1 lire iia- !»( n lliadr in tlir analnlllir -rrlinll tu llir (•i.llditii'll (it » C,m,jd. ,■'„,/. ./,- 1,1 ■•■■■■. '"■-'.. Oit. ;ili. 1>-'.i7. ' / '•'■'. ■> /.'■■■. ■■■'. « ./../,„-• Il.pl.n.s 11' yr /;.///.. vol. V. M '//'/"'/> IN /I ' " 1//7 /( I 7/o\\. 311 ill, 1,||.> ii-,ir. 'I'lii- i- known |.. 1m- lliinn.r, lii:lilir in rMl,,f, :in( |m«i r -|i.(ilii' '.'niN ii\ ( If.. in l'"ln |.. PMil, :i- cniM|i:iivil « iili tin- ii..rni:il, |n_'i; |(> ln:',il, i',i-..ii;iii|i I ). Wilh iv.^;i|-.| \<> ihc inllm n.c ..I' tlii- :illi|-:i- tinii II III III I 111 mil -liiLiI riinliiil- Miiil till' n|-iiii lliiii;^ "I :i ilr'iiiili- iiiiliil'c i« kii.iun. l'..--ililv ill.' -irikiii^: |i;ill.ir f c.iiT.'.l wilh ivuar'l I M lin l''-~ .■■.iiiiii. 'ii "f -iil».riliiiaii' I'.m.lil i. 'ii-. A- I.) ill.' -I'Vi rilv. till- I'M.'iil, iii'l ill.' I. "'a I i/ III' f ill.' ii-iial I\ [iliui.l li-i.in ..r llir iiili'-liiH', liuM'Vi'i', iiM~I --.mmI ..l.-i r\.'i'-, I liili.'Vr, aui-i'.' ihal ill.' -lai:'.'- I.r llii' .li-.'i~.' |)|-..l(al)lv .'i.ri'i'~|M .inl in ;^rii.'ral willi llic .Mi'iiriTii.'.' ami ill.' ili'V.'|i>|ini.'nI ..fill.' I.'~i.>ii, lull llial tlii- i- l.y i aiis Irii.' ill' till' .'liara.'i.r ..!' ill.' in inll'.-Ialii.n-, ill.' ~.'\i rily ami llic ilnrali.'ii ..r ill.' alMl'.iiiinal -ym|il.iin~ in .I'l lil. Kvi'y .'\|i»-i-ii'ii.'i'.l |iliy-ii'iaii " ill I'l'i-all wilkiii',; I'a-.'- ..t' tv|)li.ii.l l'.'\'.'r, witli -li^lil '.'■'iii'ral -yni|il.iiii-, willi.iiil in.'I. .iri-ni, wilh. ml al>.l,iminal |>ain, ami willi.nit .liai'i'li.'.i, thai Li'iiiiiialiil lalalK t'l.un iim'\|i.'i'l.'.l inl.'-tinal h.iiHirrha^.' vni|it.irn- ir.' iml ran' in ill.' carh.'sl stai;.'-, wh.ii llic -|i.'i'iti.' inlc-linal Ic- n lia'^ -.'ari'.'ly li.':j;iin t.i il.'\ i'l.i|>. lOvi'i'v .'ypiTii'ii.-cii |)li\ si.'i.'in will kii'iw ..I ca-c- in'i'-ciilitiix |.r.'|MiniiiaiiI iiil.'-iiiial -ym|iliiin- ihf'.iiiLihiiiil uhi.'harc in niiiaikahic (■iintra-t wilh ih.' A\ii\a anal.nni.' Ic-i.in- liniii.! al aiil.i|)-y. I "hall never I'iii-l:.'! a eas.' sei'ii in .'.iii>iillalieii. A v.iiiir.' w.iiiiaii .lio'l :\I ihe h.'-iiiniiiL'- i.l' ill.' lliinl w.'.-k nf ail atlaek el' I\|.li.iiil t'evcr. Sli.' liii.l mil li.'cii i'.)iu|)ell('.l I.I L'li t;i hi'l niilil five .lavs lict'.ii'.' il.'alh, ami as lale lis a week |in'vi.iiisl v liail <|i.'iit .'iiiisi'li'i-nhle linii' at an cviniiiL' I'liIPrlainiiicnt uillinul sp.'.'i.'il iiii'iiiivcni. n.'c. I)in-iiiLr tli.' llircf weeks |ireee.liii'_' .l.'alli tlu'i'e liii'l lieeii (iiilv variahle. L'l'mTal Iv iliiiiiiii^lie.l, ajipelil.' aii.l im .liarrli.'a, hill rallii'i- i',iiisti|iali..ii. Marke.l t'ehrile niMiiit'.'stiili.nis lia.l he.'ii nul.'.l mily 'liii'iie_' the lasl six .kivs. r.isl-m.irlem ('xainiiialiiiii ili>.'l.is.'il inl.'slinal i\|ili.ii.l lesions ihpiiiL'liiMit an exlenl thai F hav.' rar.'lv -iiM'.- ..hs.Tve.l. In ihi- l.iwi'i- lu.i-lliinls III' til.' ili'iim aliiinst all ..f i'.'Ver's pai'lii-s u. r.' iiifil- irale.i in part ciinthieiil, ami in I lu' ~ta'.'e ..f .'Xt'.iliali.in .)t' the sl.iiiLrlis ; while ' Ti-i.'i', 77,. ~.'. r.'ii'i-. \'*:'0. '^•^ { i V J, 1 21; 71 rii"ii> I n 1 1: i„ ,1,.. .v'i.m of tl„- il.o,-..,.al ^:.K.• nuA ihr r.v.i,,, n-.lt tl.rrr «M. >< .r-vly .. |,v.. ;„v.-, nl , U- MHlnlMM,,.. MH.I ll,.U,.|..r ILimI ■ •! IIm' I.TLfr IhU-H- ,l„, ,|,,i,„K ||,i,.,l l,\ 1, iiliruhir uhii-. in |'i 1 uiiu-iKil „ ,,. i|„. I, -ill- i.r 111! :in|..|.-. nil III. Ullr ot a n 1 H ' ^^ • 1 - M/..'. >lill iiimr -iir|.n-iii. , , , , ■ ,.l,VMi-KMi. »l,M.|,|.nvulU l,:„l,l,...l. in llH...|,i,iiuMulll.rliu.limi.l. mn„iM- :.,i;.M,v..| |..il,.r:ill..,i Ml ai, ul, . r ..I I li — l-MiMrli « iiIimmI pnAinu- ,„.t..«..rll,> .\„i, U-. 1.1 111'- '■'-'• :'l-" I'" l.-i"i-"l '.M''"'"' "■^","' ll'.-' ;'='V'"< .Alnllal t III!' -I'lllJi- '■^ a. 1.1 I., n-rv. a ,l..,-i..ii tliai, |.. |.r.-..'l ii|-ii -li. Mi.ni-' liii. -. , . \\, -hall iMtiiii 111,' .li-.U"i..n ..!■ 111.- imliv i.lnal liil. -llnal iiiamlr- tati..M- uiil. racteorism. Mans, i-ailLiilail^ ..l.l.r, «"rk- .untain ,|,-,ii,,li..ii- ..f th.- rail> ..li-.I,..r iIm- -.a.iH> aii.l ll..' IV..,!!. ii.s . aii.l ,.v.M 111.' .'..ii-iau.'N >.r ilii- -.MM1.I..I11, Mi.li :.- II" l"i';;'i- ■I'-i ' "''•' ,lH.,.s,,.i-,.'ii,'.'..r till' ..l.i..'lix '.l.-.rN.r..ttlM I'n-.nl .laN. < )n tli, ,'..ii- tran. 1 u-uKi a-, it llial .■. .ii-i.l. ral.l. in. I. ■ .n-in . ..'.'niriii- . arlv -.ar.'.iy IhI.'.mi:- alii..n- tin' iiianif.-lali..ii- ..f a u .ll-ii.aiU.'.l alia, k ..f l>l.li..i.l i;.v.r pni-uiiii: a iv.nlar .'..ui-. . ll i-, in U' ii. nl. aparl ri-in liual ;,„.! -iH.'ial .■..i,.liti..n-. ill- 1'- '"I " 'I" '^"'''■'' ''"■ 1'^"""' '"""''* ,„„1.,,. ,,i;-,'rv:i,i,.M an.l tli. .^r.al.r ll..- .ar.' ^iv.'ii lii.n. rml.r fav-.l- ,,,,,. ,„„.|i,i„„- in iirival.' ,,i'a,li.'.'..r ina u.'IIh' In.'l.'.l li..-|i.lal, tli.' niiiil.T an.l ,„...!. rnt.'h ~<^'y -■---. i'' ■•''-iN.'l .arly, aiv l.k. K ,.. I.r „„att.'M.l.'.lui.li in..t....ri-iM. or at ,n..-t 1.. .'Nlnl.i. ,1 in -lijit .k-.n.'. M„n. mark.'.! .n,.t....ri-.n. if it -k'Mk.p- in -|'i'<' '■'' '^ ' •■a''' ;.ii-l n.-tri.-t.'.l .li. t, W a im.-t ..niim.M- ,nai.ir.-tati..n. It ,- nniicativ,. ..I tli.' ...xtivrn.- -.'v.ritv .,f lli.> .-ni-" ..i' tl,.' .ii-.a-.'. an.l i- .k').. n.l. nl tar l.-s .,„ ,lH.i-„..n-itv ..ftlutyph..,.! i..t.-tinal l,'>i..n than M,...n tlu' int. a-ily ofth. ni'iMl inf.'.'.i..ii ulii'li i:iv.- fi-.' t.. |.an.ly-i- ..t tli.' nn.-.nlar lay.T „f ,1,, in,..-,in... an.l tli.'tvl.y ... M-a.,,,,,, ,r,-,..„li.,n. In fufthrr M.,,,H.rt of thi- vii'W. it inav I..' imnti' '1 '1'^" -"V.'iv int.-tinal ,nanil.'Mati..ns ..v.n ruth.T ,i,',-i-t.'nt .liatTh.a. I.> n.. tn.an- alway- ,,n'.'...l.' .t a.'.'...M- ,,.„v til.' ,iH't.'..n-in: an.l al-, .niiv. i-.'ly. ..Ii-tina..' ,'i.nM ,,iati..n .- i.v „„ ",„,an- aluay- a-...'ial.Ml nilli it. It ^.lurally a,.,,.'ar-. ..a tli.' ,',.nti-arv. t.. 1..' a >i^w\ "f th.' m.t. ..ri-m. Til., in.livi.lnal ,„,rti..n< -f tli.- int.'-tin,' ar,' inxiilv,..' in the -a—ns lik.'lv t.. \n- ,li-t..n- iiiii - lliMl l:i\i- iVrrliiiikril ill ll Ci-r 111 ihr nil liiin-lll. Mini iiMlii III, iiia-iiiiK 11 ■ .ii|Mi|-l llial air llli I ■!■ |-i':'i|lly ll a- lir lllll- IH'I 1 r illl- aiiit -iiULii'-l |||ii|-iill-ll IiiimI I AMinillMliiiM. Ill tl 1- rMll';;iil'N liclull^ I -licciaih' rin- -l H HI ilrll, ll I- lllll'. Ill •III- i'ai'il\ , iiiii-l mI-i ll imiijlit if. ll ll Ki- ll in-lMin - I liM\ I' iili-i r\ I'll irki'il nii'ti'iiii-ni mii 1 -\ liililiilll> 111 ilriis 111 illl'irl a-- i.iliiHi uitli lyi>liiiii rily|ililili-. ir. lliri'i'tiii'i', ni.iri ll iint'iiri-iii aiiiMMr- ;:i iiri'Mi M— iirlMlr'l I iIhi'iIa iiiip illrlliilllrll 111 111' utlii-r -rr - I'liii' itiiiii-, ll 1- liv 111! nii'Miis illl lIlMt nil il- "" II Mn'iiiinl il iiiMV nut r\rn ininriiius rllirl-, i-|M'rlM liv liv iliinini-liiiii: iIk' iM|i:ic'ily uf lli.' tlmrax an. Illli'l'lrrill'. with tlif r.'-|>ii'M liiiii. Mlri'M.lv >.. it' Ml m11, "f r-.Mrccly III. If. —in.'. Only in llii' |iiT-.'n.'<' of incl.oi-- il-i'i', even It lallnll ntli'll III' a lint nr tinll .it' illll-IIIH |ir.'t'i ralily tlii' -.'Ml nt' tlic llli'il'MllV'.' prn.'.'— . 11 -nllir .'U'-.- till- tcll.l.'l'll.— I- !■<< n-lMllII\' -.HIH'- wlial liiLlli.'i' liiwanl tin' il\( r. Mil 1 tlii- is I >n--l lilv .111.' til tlu' ('.iniicnital ili-li.i'Mliiill "i' llli' .•rllllll lll>\VMr. I (( 'iii--.'liiiiMiin), will. ll is kiinwn til iir nut ,it mII rar.'K Mi< I'Ml' IIM- I'Mn t'lillv .tn.lii'.l "ii'O ."i-t- . ty|iliiiiil t'l'M'i- Ml till .Inliii-^ Hi.|ikiii- n.i-|iital with n t'l rni.'.' t. aiiil.iiii- iiiai |iain Mini ti nilii'in--. ai'i' frrr t'l'niii pain m' tiinl. Ill' t'nninl lliMl aliniil tu n-tit'lli- nf tlw |iati.'iits rn.'-s, riili. T I." lllMII 111 IH'-lit'.ll llMVl' tl'll III-- 111'-- iillU . I'Min llllf In Sllinc cnll.iilinll ntlnl' lllMIl till' -ji.'.'iti.' li.iu.'l- -inii- \\a- iii-.'-cnt III ali.iiit iii.),-t rnn-laiitl\' p t 14 per .'.'111. nf til.' .'M-i's. It iirri'.l \mi1i M-i'-. it was ilK -II. hi. 'II ill i'Ikil;. nr |i. i-fni'Mlimi in almnt 'i yv .'.n t. .if I'C-CIlt witll lll'I'fnrMllnll, Wll.'ll It WMS 11-111 % mW •211 ryrii'iiii ii:vi:i;. ini'i'. Ill ahiiiit Hi |^HH|ifci( ,,ii-ri, -.vnv in cliani.'lrr. mihI piinAv-niMl m nvrurn twn-tifili- nf all ca-r- \Mtli i)ain iM rniiM. cuuM \ tl,r,|I.MinM :,. t, , ^^ h.I ilrl" t llrlV i- |.ain a-ocialr.l xvi.h :,n i„tlanHa-,r,m--uira.-.'nv,ran i„tlain.-.l I '..v,,- palrl,, lie ,|M.,t,.> ,„ i,„..,vMln- r.-r in uin.h tli. -.a, rr pain, a-.riat,.l will, uiIht -yn,,.- „„„-, lr,l to M ,lia^n<>-i~ nf -nnir a.ai.r alMl.Hninal r,.n,|.h.-at H.n, an,i an ,.x,,l,,r;,ti.m ua- Wnnr nn.lrr l..,.:,! mrain anr-th.Ma. -In-l nn.lrr thr ,„,i,n uImt,. tl>r |K,tirnl IkhI > plain,.,! of u-.vat.-t pain wa^ a lai-v [•.v,v-- i,at,l, uill. ill, -v,,.s, n,n,i> inllan,,.,!. Witii t\n- UmuWuv^ ,>t ,1,;. inl,-lin,. !„■ ina,l,. n„ ,.„n, plaint „f l^ain. I.nt wru a -,.,,,1,. „,n,.h „v,.r Ihi- intlanu.! aiva nia,!,' inn. ,t.v ,,nl. V,t in ..iIht .■a>cs pat,, n,~ ,„„1,. n„ .„,npiaint uh.r, tl,,- ...r„n> M.rfa,-,- ,,v,r tl„. nl.vrs wa> han.ll.-l. It i^ ,,u,Mi,mal.l,. wli,tli,T .. ,.(.,.nnv,„.,. ,.f t:n.--lii.- au,l >i.laf tl,.. ,.,.,.al n^rnn ,„ ra^.- „,. ,vpl,.,i,l t;.v...-— ill.' ,,nnjnu;ilr,n,Hl „f ti,.. \■^•r^^A^. \- t,- tl... .„,,,nvi><... ,.f this plM.n,mu.n,.n. an,l it> Mfikin- fiv.,i...n.>y in ..an.s .,r ,vpl„.i,l f..v..f, thnv ..a,> 1.,. .... .l.ml.t : la.t I wot.l.l ,'all alfnt,,,.. t„ tl... Ih-.t that it sl.,ml,l ..,.t-a. i^ oft..,, th.. ....M,,,,.-!... .•.m-,.l..,-...l a.. i,„p„..,.„t svmpt,,,,. ,.f th,. ,li-aM.. 1.. n.y ..xp..ri,...,.,. tl.,' ph..n,.in....,.i. i. .„ i„..,m>ta,.t that 1 a... ,„,t in th.. l.al.it .,f atta,.l.i.,- ..np..ta.,t .l.a- n.,.ti.. si>miti,.an.... .ith...- 1,. it- al.s..,..-.. „.• it- ,.,vs......... Fn,... th.. tl...„.vt,.. point ,.t- vi..w alM. this i,.,.„n-.a,.,y ,.„nl,l s,.a,v,.ly !„• ..tlarw,-,., !,..• tl... ,|,.v..|<...!!!'.;it a..n.inal ,nn-.l,-. -...'h as la,....-a.i„..-, h,.,nat,,n.ata, ...,.., wl,i..h an. U..,.w.. t,.,.,.,u,. -„ lV..,,n,.ntly, w.th l,.,al intla.nn.at,„y p,'..-- ,.„,.. in ih,. int..rnal al„l,„ni..al „.-ans. ! hav,. ,.hM.,.v,..l th,. ,.,.....nis- si,.ii of -n,-h a.. ,■.•.■,,.■ in a i...inl"'r "f inMan,.-. The Stools. — It i- ,.n-t,,...ai-y I„ -p'^ah ,,f a •• tvph,,i,l -t,,.,!," a...l thi- ,l..-i^nati„n i- ,„.pl-.y.-.l t„ .l,-,..-ih.' a p....n!ia.-, an,l th, ,■, Lav ,1.,,^- n,.>ti..allv in.p,„-ta.,t, ,.|,a,-a,.t..,-i-ti,. ,,f th- i..t.-linal ,l.-,.ha,.n,.-. I n- ,,„„,,„„l!v ,h,.,li-,ha,-.,.- «hi.h a,..: -p,.k,-.. -f a- typh,.i.i -t.-l- l-n-'-t a iH.....lia>- app-an........ Apa,-., h,.w,.v,..., tn.m tl... .k..,.,a.-tfat„,.. -i SYMI-roMS AM) riiMI'l.lrMloXS. 'Ji: liuiil-lKiiilli, iicillicr llirir liliv-icul iKir llicir riicinic cciiililidii |irc.-ciit- 'M' ;iti\ tliiiitr -|"'' 'lati'iii uitli a iiiii tlu' ^(i-r:i lira t itic. Tliiir (iiai:iii-ti<' value roiWts i'si»(ially in tlirir iilii T 111" "tlici- syiiipldiii-. It is well UiKiwii that I sluciis arc til' 1, liuiiitl, "1 \ lllioll oclirc-vi'lliiw ciiiiji- Tlicv cxliihit an alkaline reactinn, and they |m,>m>s at tune-, alt h h hv no means alwav-, a iHcnliar aninii>!h )t' the-e <'li; iraeteristies ai'e at triJMited l)V I'arkes and l.chinann to tl ire-eni'e ot' aninioninni earlionati' am I a ti.Ned alkali. It i- eharaeteri-tie ir llie -lu( a u .1-, when iierinitted to stand, tu M|>arate mxmi nit'i two layei- ri-av, tViahle, ikieenlent, <>i)ai|ne one, and an oscr iwer, vellowi-n- Ivintr. watery t I tiirl id, tiiinslneent one that eontanis i-eniai kalilv littl (onlv al)ont 1 |ier eent.) o alhninin and nnieii-. It f solid matter and is i)artienlarly delieieiit IS evil l.MitIv thi> detieienev of the Hnid in nniens that renders it incapable ot bcinj; cmuU ^(•(l and that tiivors the sepal atioii of the typhoid stools into layers .Micrses of various miero-or^in- So 1 out: aifo ar the vear l.S:W, Sehiinlcin showed that in aildi- ti(tn to all these, ((uantities of triple phosphates are almost constantly present. AlthoU'rh his o])iiii<)ii that these are specific constituents of the ty[)lioid St' ool has not heen con ifirmed, thev are, nevertheUv itl donhtedlv more common in association with ty|)hoiil fever than with d, theret'ore, ar(> not without diaerien 1 miiilit helieve, and that I'licii the disease is accomiianied hv an IV diarrhea, the stools are, in jreiieral, not likely to he exceedinjrly iinincr.nis, particularly not so fre- (|Ueiit as in the majoritv of cases of acute intestinal diseases, dysentery. catarrh, and allied eondit ions F iree to six thin stools in tweiitv- toiir of tv Uoiirs ni.av he eon >i-iiivs, etc. tlif intotlnal .li>cliart;i> >'f lyplioid i>atitiU> aiv alni<..-t always inialKiidiil with jiain ir tciu-nm-. The time 111' the tirst : .raranrc and the (hiraticni ot" tlic diarrhea exiiiliil wi.le variation-. Nm rarely thin >t.".l- (pc-'iir as early a- the IH-odronial Ma-e, liefure the i.n-et »i' the fevei. 'rii.y are ..t'teii ineor- reetlv attributed to riinple int.>tinal catarrh, and ceea-ionally alx) to the e\ee-i'. .■ and protraeted aeti.>n of laxative>. whieli ha.i Keen adnlini^lered i,, overcome exi-tin^r ....nMipation. At thi- time the di>- <-harp"- d > not ,-o readily form layer.-, and al-.. are oftui dark in color, re-.mMini: onlinary diarrheal -tiM,is. therel.y inctva-ini;- the ditlienlty in diauMioM-. This apiKaranee may he due to tiie fact that the alterations in the M.retion of l.iK', parlienlarly the thinnin-: and the lio:hter color ,if the -ecretion, which o<-ciir >o .•.,n>tantly at the heijiht of the di-ea-e, have not vet l.cLnin. Thi. prodromal diarrhea may di-aiiixar with tl.c l.ejri' 'itr of the fever or after the tirst few day> of fev( r, not to re ir thron^diont the entire course of the di.-ea-(> ; or followed for a feu ys l,y con-tipation, le- commonly l.y normal evaenation>, alter which, at \hr end of the tir-t or the he-innin.L^ of tile s nd week, the stool- a-ain heconu' thin, and now proent the characteristic p..a-s,.np-like api)ear- :,„.■<.. In ome ca— stool- of this .•haraeter per-i.-t thronudiont the ■,,,„;,,, ,;,|,,ii,, ,„,,i,„l, rarely l.eyond this, with approximately the same „r varvin- frei|nencv. In other instances diarrhea alternates with .•on- stipatii.n or with normal di-harp-, <.r it .li>appears pern.anently. '1 he ,.ati,-nt- then u-,nei~ally remain more or h'ss .•.,n-lipate.l, or, what is ,„Meh le-s common, the int.-tinal di.-.harjres occur n-nlarly. If an .'xact -tafment is .lesi.v.1 as to tiie fr...pi.ncy with which diar- rh..a ur- in .'Mscs of tvphoi.l fever, it may he said that diarrhea thron.diont the whole or the lar-.T part of the fehrile p..no,i ol the .lis- ,,,., U likelv to occur in narcclv one-third of all the cax'S while m ,,1„„„ ,„ ,,|n:,llv la,-e nnmher diarrhea occnr- hut tran-iently or m alternation with' -olid dl-.ha.-..^. Of o«o- .•^•^-■> tluit I li^ve exam- ined with iv..,rd .o thi- ,>oint, iL'sfi i„.lonL.'.l to the first, and 1 :!..!) ,„ the .-.-•ond ,.ate.orv. whih- II S7 wcv thron.hont frc from diarrhea The-e ca^e. of tvphoid fver "witholit Ivphoid -tool-" .h-.TVC e-pecal con-id,ration from the dia,:no-tic -tandpoinl. The novice i- iar too ivHlilv di-po-ed under Mich condition- to donht the exi-tence .,1 the di-e-,-'e The experien.vd phv-ician. however, may -> still further, an.l ..Kiintain that of this larp. nnmher of .■asc. whhonl thin \s: 217 tlum liair Mctu^illy miIT, r fn.in .■nii-ii|,MtioM, riv.|n.'nllv iliiou^^'iioiit tlie x\l„,K. com-r of the di-ra-v, Ir- niuouly t;.r a -ImiH time. Thr foll..winir fiL'urcs will ilh.sirato tlK■^.• ivlati..iis .norc a.vuratcly ; and i„ ,|,i. ,.„,mu'H;.>u il MK.vl.i' Munlioiifa tliat llu' 1a-ii-»" slalislic.-. «liirl. i„,h„l.. all thu .•as..s ol,s."rvnl at llie' nu.li.'al rlnii.' .lunnL: t,.irt,TM v.ar., m..ro nearly api.n,xi.natc the ireneral prevaU.,. ron.lu.nns that, the llain- hurr statisfirs, whi.'h ecver a .in-le epi.leiuu'. l.:ke M>a„v other ehnu^al nianif.-talicMS -f tvphoi.l fever, the variat'ums ii. the inleM.nal -liM-har-es al...evinhU tint i,M"onsi,leralile loeal aii.l temporal diliereiKv.. Nevertlu- les. a comparison of these titrures .lis.-lo.es on the whole .■onM.lerah e agree- ment Of "'40 eases .Inrinir the Hanihnrf: ephlenne <.t ISH, that were inve(u--2r,.:] i,.'V r^uU : unnua\ stools alternate,! wth eonstipat.on in .V.'--.:i per eent. ; transitory , harrhea nltor,.ate.l with normal stools in 20-.'-!» per eent. ; tranntory .harrhea alternate.1 with constipation in 424-l.\!» per cent. ; .harrhea alternated with constiiialion ami normal stools in :?'.•— l.s l';'"- "ent. Of 1S7,H ca.ses observed at the Lei psic nie< Ileal .■linic hetwecn the vear, ISSO and 1H!I:!. which were investigated from the same point ot view there was found .liarrhoa thron^d.out in 4.S0 -•.':.. (i per cent. ; j.ormal Mools thron-hont in .H'!— 4.4 p«T cent. ; constipation throughout in •'';|-l''-> I"'" eent • normal sto,.ls in alternation with constipation m (.2—0.0 pei; -•eiit. , diarrhea in alternation with normal stcmls in 144-7.7 i)er cent. ; diarrhea in alternatiou with constiiiatiou in oM—-2'.K-> per cent. Bloody Stools.— The hemorrliajrie d!-eliar<,'es \vhi<'h arc lierc cs|HH'iallv referred to are those that take plae.' fnun poninns ,,f intc^stino the seat' of ll'C specific lesions, and therefore -tand in rofi|sc hemorrha-es the 1,1 1 heiuiT di~charir.'.! from the how.l in liter-amounts am! rai.idlv .•auHug .l.^ath l.v lo~s of hl.H.d. In a.rordan.v with the amount ami the -onrce of (he- hlo,«!, an.l ti,.' tim.' that .'lapses l,,.twccu th.' exti, i- siliou an.l the di-.'liar-,- with th.' -tool. ih.. latt.-r will pr.'scnt a varial.le 1 I,iai,a. iJ'S- . I.'i|'-i.'- i^'-''''- h "'■'-• ' ! U M ^Ilii •2lH ll! l^j a Tyrii"ii> Fi:vi:i:. -li-lit at' hlnixl, tlic stmil i-; ;l|i|M'ar.-inci . It' llicn- \>r I'Hl likilv U> l.f vrllMwi-li-rcd HI- KiMwni-li-iv-l in n'hn: 1 1' a ((.iiipaniliv.lv la|.M-,". aiiKHiiU ..r|,l 1 i- uiani dark l.mwn to fcd.li-li Mark in ,.,,l,,r, or even a- an alnio-t \\li,'lly lilack. vi-.id, tar-likr ina-. oficu uilli a -iceiii^li liiiLT. If tiif li(inoiTiia-v tak<- place rapidly iVom on" or -i'\i'Vu\ lai-L'.. vr>-il-. and if the liloo.l i- - i .xprllcd a- a iv-nll ot' acrrln-atcd |Mri-talli.' iiiovenit'iit-, the >to,.i- ar(|iiirc I'alii'T the character of -iniplc loaonlatid Mood, namely, ivddi-h-i)laek or Mood-red, L^encr- allycoaLMilatcd. nia>>e-,or not i-aivly dark ilnni|»of i.loi.d in a rapiid -tool. The n^nal linic for the ocenrrcnee of tlii- dreaded accident i- often .-tatcil to he later than my experience indicates. Altlioiitrli h«'al, tcm- pre I H.H per cent.) were ol)-ervt>:; from the thirteenth to the fifteenth day in 'J:'.. from the .sixteenth to the ei-hteenth dav in :?1, from the nineteenth to the iwc iity-first day m l.,lrom the twentv-se.V,n.l to the t«ci.tv4o.irth day in '.•. from the tNventy-filth to ti.e twentv-..venth .'Sw li.T-, /.".-. nf.. |. 18. ^_J:Cv:*:;v;!vi/;,., -JT • •i.i;' SVMIToM^i .l.V/' cnMI'l.irArinSS. •Jl!» Alter thf «nil of tlic -ccond ;iii(l tlic l). tlic-c all.rati..n>, i.ui to ..xlMiatiuii of tlu' >loii>:lis from tlic alfrrtiKl I'.'Vcr's patcho and s..litaiy folli.lo. DciHiKiiMi: upon tlu> x'at of tlif infiltration au.l the o aU, i. th- peri.Hl ill uhieh heniorrl.i-e is .l.p.ii.l.'nt upon it often .piitc Ion-. Kven at the time when all th.> uhvrs may he thoiijrht to l>o elean, ,,r in jrreatly n^lneed individuals many w.vks after this period, hemorrha^rcs, ^Minetimes .,f fata! de>rre<', inav yet (.(•••ur. These result fiuiu inii)erfeetly thromhosed vessel- ill the floor of uhvrs, often also, ev.n when the intestinal lesions in jreneral appear to he heah^l, from i-..lated shifT^di-h uleers, situate.1 i.oth in the small intestine and also nlatively (|uile frecpienily in th.' larjre inte-tine. This iutfrftinal liemor- ih.iire mav he ol)served to oe<'nr as late as between the thirtieth and the fortieth day of the disease, ami oven still later; I have ohserveil it on the tifty-seeoiid, fifty-tifth, and fifty -ei^dith days, resi)eetively. Hemorrhajrcs appear to he imieh less common diirinj; rela])ses than diirin;:: i)rimary atta<'ks of tlie disease. Of 1 ."):5 cases of hemorrhafz-e that I have analvzed, this eomplieation oceiirrcKl in only 4 durinf? relapses. The nnniher of bloody stools that occur in the individual case is, as a rule, overestimatetl, as it is usually stilted fndn memory. In ireneral, there iiiav Iw from 1 to, at most, t, which tisually are expelled in suc- cession at relatively short int-Tvals. Much more rarely I have observed a larirer luimber of l)looi|)fiir and ITamhurfr that I :. ilv/id, fnini 1 to 4 hl.Midy stools occurred in 22'), and a larirer niiiiilier iiidiilv :>1 : Imt of this latter nund)ei the oases with 1 and 2 stools |>re|«)ii(ierateil. There occurred 1 hliioily stool in 7H cases. 2 Itloody stools ill TiT cases, :> liloody stools ill 4.") ca.-ies. and 4 bloody stools in 4.') <'ases. With roL'ard to ai:r and sex, the mature period of lift' i> di-linetly tliat at \vhi
  • taleiiieiit, a that of Henoch and iJilliet and ilarthez, as apiiu-t o|)po^ite statements by a number of other ob~ervers, I can confirm positively U|«m the ba-is of a larire number of cases. While in ..ervi>«l i I' ^mj_ j.-a^V""^-yi?^^^?^- |HP^ !^J^^:^-:":y^W r •_'-J( > TV rill nil ii:vi:n. Turmtuss^ ii,irMiii;il li.MK.rrliajrc in ms lii-li a. 10 Mii.l .'vni 1 1 jxr .vhl. ul' all IMticM'.^ I have ii.ilc n la.cl tu tlic ii-nally IrsMf fxt.nt :m.l in- t.n-ilv of tlu' tvplioi.l iiililti-atinn ..f tlif inl.-tin.- in .■liiMti 1. I liav.'lHvn nnalilc to not.' any mat. rial .litr.T.n.v l..i\Mvn tli.' t\\.i m'Ms with ivf.Ttn.r to tlio fiv.]!!. n.y of iiciiiofiliajr.'. Willi n.L'anl. Im.u.v.t, to til.' MV.iity aii.l til.' .lanpr..f tlii^ Mniptoin, in.n a|.i..'ar .li-tiiutly ,,, .||-, ..|ii till' t;ravi'r coiulitioii. In ailult.-. ill iiiv e.\|ierifn.e, tlif fn^iufncv of lii'iiiorrliaL'.' is .|niti' liniit.'.l up to ill.' tliirti.tli' v.arof life, aMioii-li frreaUT than in (■liiMr.'ii. Aitfi- ihf ihirli.tli voar tiuT.' is a noteuorthv increase, 'riic nuixin i is r.a.hf. hi'tu.-eii tlK'Vurtv-liflli ami the tiftiilh year. althonL'h later lif.- also is Ml 1 exi«»e.l to ri>k. " I)i:riiiir some e|.i.leniies. it is true, exct'litions to thi> rule appear t.> .x'.'iir. ■flius.'iii Haiuhuri;- in \xx'i voiiiiL' persons suHere.l tr.tni intestinal heniorrha-e with relativ.' fre.iueiiey, as the folloNvmj: ti-nres slum: Fr.im tilteeii t.. twenty v.'ars, 'JT.T per .'eiit. ; twenty-one to t\U'iity- tive years. ■-'•').:! i>er .eiit. ; Iwentv->ix to lliirty years. -Jl.T per ei nt. ; thirty- .aie "to thirtv-tive v.ars. 10.^ Jier eent. : thirty-six to f..rly years, 4..H per eeiit. : tortv-oiie to" tiirtv-tive years, 5,-t per eent. ; forty-six to hfty years, l.-J per .■eiit.; lifty-oiie" to tifty-tive years \:1 per cent.; tifty-six to sixty years. X.'l per cent. ,,.,,■ i- • ■ Oil the ..ther haii.l, the year \> twenty-fiye years. 4 !. per .'.nt, ; twenty-six to thirty years, 4.!l per .cut. ; thirty-one to tliirty- fi'ye years 7 1 i.er ".'.•nt. ; thirty-MX to forty y.ars. 14 per .•eiit. ; torty-one to forly-iiy.' years, 7,7 iK'r cent. : forty-six to fifty y.'ars, •_' (K^r eent. The fn'.iii.'n.'y .'f h.'in..iTha're in r.lation to th.' niinib.'r ..f .'ases is varionslv stat.Kl l.y .iim'f.nt olwryers, Xatui-.iUy, it inak.'S a niatifial dim.rei,.'.. wh.'th.'f'on.' c.n^i.ier. .miy lar-.' ami .'..pLais iu-niorrha-.s ,,r inelii.h's .y.'n tii.' -.li-ht.st a-lniixture of hh"..!. Tiii> .■iivnnistam'e may exjilain s...ne extrem.ly !..^y as w.ll as so.iu' extrem.ly lii-h estimates. Ahove ail, it slionl.l !>.■ .ini.lia-i/e.l that th.' fi'.'<|n.'n'"'' ""' in.ln.l-'.l, aii.l the „„.an of many y.ar^' .xp.ri.n.-.' in .litr.r.nt plai-s is taU.ii, tiie ay.'fage ,-s of |yph..i,l (eyer, olw'ry.'.i l„.„„„-rha-.. in o.:! I'.'r .'.'ut. lloinoile .olheteil the enonn..ns niinil.er of KMHM) ca.-esof typhoi.l f.'yer from yariou- .-oiirces i inclmlm;:'. anioiii: .others, L.)uis. I?arth. i;ai:aine. De ( '. rouyiUe. ( iriessmirer. Li.'hernu'ist.'r. ( .ol.Kiam- nier .iesM'ii. CliyoMck i. aii.l foun c'lMi'iK \ri<)ss. 221 M iirclM>"M li;i.l mtoliiiMl 111 iiiorrlKiL'i' m 1 t').(i |i(r I't'iit. Ill' lasi :-. iinoii ;i iniM'iiiii'i Miiriliisoii |iiT rilil. tlir yran cMsts in the iltsfi-scil 14 iiiniili: nlioii Till' tiuniro ult nl In aml'i ha-i- lii.fi Tlic ti'.'iiri'.- L'iM'ii in llii' ic] s l^.'p.") 1> .11. iiaiiii'lv. ,f ihl' Wii.icii llu^liil^tl I'T kal.U l.iu. (If m;'.i ■111., air rciiiar Ic.liiis Honkiii^ Hn. |.ital. Iniiiorrha,-.' >«;un-< I ill ti IhT Cllll. Amniiu' llir iM-itmii' caii-r llir iiili'-liiial liciiiiin ip', ' Irlclir iri-Mi', n-Ilr--n(-- iiia\ I"' nil HI till' y irl "I liir lalinit, r-|ii'i'i:il iiii: up I ail iiliiiiinl a~ till' iii"-l livi|ii(iii. 'I'lic-f tiictiiiv ai ilaiii llir la'-' 'lial, m inaiiil —I- ii-cll liy iiui'\i>< liatli- ma lit' tvilniiil livi T willi '■ i.riliaL'i' tlial lia- alrcnly urciirrfi 1,1, ■ of dirrcliv rxriliui;- tlir lli'llliin-|l ■\|H riciicf, aiiiliulalun Iy|p|initl trciiuiilly ■In! iiiti-tiiial liciiiniilia^'i-. 'I'lu' trcaliiu'iit lcii>il'v iiitr.-tilial liilii- |_ It i^, liiiuivrr, |)inlialily iiicapa- I ill wli |),l^-ltll\■ HI 1 -till prarll-nl tVri|llillt iili-ri'sr 111 lialliiiii;' It iiiiirrliauc "I'li !;'''■■' |)iilili;; the |)ii'lo(| in wlmll 1 <•,,!. 1 hatliiiitr 1 iiH'<' 1 \:a\v cinpluvcd in-iiii(iit Iv 1,.-, cnM, ami will I nil iff ri'i;an I to till' iiiiii Altlmiiuli l-ii'liiTim i-l'i' hrfolr tllf intniililrti 'II Vlillial ra-r. ci'iit. of i'a~ introduction iii mily 'p.- J" liim. due inainlv to tlir u-i' I- I'Cllt.. t ili-crvi'd iu'intirrliai:!' in •"<. I p^r of livdriitln'1'apy, ami afin- its he rciliii'tiiiii Ixiiit:, arrordiu;^ to ,f livdnithci-apy, I would point out tl lat 111 H iiiiliiirtr, wit h alino-t piiri'ly ('X])('<-tant trcaiin inuiit. at anv rate wit! onlv till' iiifn'i|U('iit iiiiployimnt ol Datli-, Imt ■\.>^ jii'i' I'l'Ut. ot' ra f l)atli-, we oliMTVcd luiuoniiaui' in Wit h iv-ard to till' .'liui.'al manil".->tation, of intcMinal licinorrlia it niav I..' -tal.'d that it-^ on^(•t i< rarely announced in :"!^ance in any special inaiimr. On the c.intfary, the liemonliaire often n.'cnrs—" like a 11 i^h of li-htiiin- ill a .'h'ar ^ky "—at a time wli.n the i.atieiit feels eiilireiv well, and the friend- an- luo-t lioixfiil. Ahduiiiiiial pain rarely precedes the lieinoriha-e. Only now and at;aiii iiave I ol.sevved severe colic and iHTi-taltie unrest of ttie int<'-tin.'s fur from one to several days iH'fore the onset of the hcinorrha^n', Imt I am inclined to .ittrihiite these -yinptoin- ratlier to the ultiliu/e (e'.citinjr) cause of tiie iieiiiorrha^'e than to the latter itseit'. MeCrac.' in his analysis of ."lOO cases of tyjihoM fever with reference to ahdoininal pain, found that pain was present in 14 of the .".(i cases in w hich liciuorrhair<' oe('iirre 1 1 III:. In :i (Idiilitliil i-A-i, Willi I'Miii. till- lildoi!-.A:iiiiin:ili (lay -Ik.w a iii;iik(il i|iM|, ill III -I"liiii ■iml niiiiil" r ><\' ivil (■..i-|iii-c-|i- Inli.r.- any 1,1 1 :i|,|i, ai- r\ti riiallv. Tliayii' lia- I'miinl tlial Ihiih .nliai:c tV lllr Im.wi 1- llia\ lir Inlli'Wiil li\ all illrlrl-r ill lllr IllUnl" I' nt Irllkncy li -. r.arliiiii; it- iiiaxiiiiiiiii iii-iili i.l' iwi iils -tinir lioin-. in -..nn ra-i -. li,.\\,\rr, till- lir niia-r lia- li" .llivl ..n llir iiiiiiiImi .i|' Iciikocylr- in tlir |irri|iliiial i irmlalii'ii. In ra-i- ill \\liirli lllr |ialii III- air in'I alivauy i^rtally ivdiin il in cmii-c- nuili.r i.|" aiitiridr.ii (ii-ca -r i .r i .1' I lir -| icria I -lAriilN ami l^nt: till rat inn nf tlir allark m1' t\ |ili.,ii| li \ .r, -li-lit uriA.n nKnii'i-atciy -i \ rif jirinnnlia-i - ill -niall iiiiiiiImt caii-c im material altifatioii in the -. m ral ciiiiilinnii. l>n.t'i!-c liriiiMiTlia-r. linwrvrr. i- nniici-all r..niliti..n- a MTi..ii- ncnrriiirr, f.. wliicli till |.ali.Mit niav -iiiTiiiali. in tlir coiiv-r nf a 11 w IimIii'-, aiiiiil svir.iit.iin- ..l' inn-i pr. .t', ,iiih1 aciitr aiinnia. l-'..rtnna1( ly. -ncli a iMiiir-c i- .AiTiitiiinal. In ■ .r.lcr ilial tin- |iatiiiil -lionM tinally ilir a- a n lit el' li.inorriiaL;r. it- rr|iratr(l lu'cnnvncr i- ncr.— ary. I lir ra-i- arc <-|Mrially |,allirti,- in whirl, it In,- l,rrii p.—iKlr tM -ii.-tain tlw |iaticiit ill -|,ii,. ,,f , ■,,],!, .11- 1.1— (.r IiI.mmI. lull wll.i llrvrftllrlr-- (lir.- after tile la],-,' nt' a tiw (lav- in r..n-r(|nriirr dl' 1111. Niiertrdly i-eciiriiiiL' and. at time-, net even in-ofn-e lirinnn-liarv. Smli ea-r- arc at the -aiiie time -tl-dlli: evidence of the ureat dcLMVc t(, '.vllicll the re-i-t.ancc cf the tv|ili(ii(l ]i:itieiit i- rctiuctHl in c.>n-e(|iiciicc of imifii.-c h,.-- (il blcdd. ' l,.r. cit. SYMI'I'iMS AMI ( nMri.KW'IKiys. 233 111 l\h.~i i-.l-v- ill wliirh the |M!ir!i! .I'm- !!■ ■! 'li'' ■iMrin;.' lli.' Iir~l ci,].!!.!!- Iirlii>.n-Ii;iui', llir clinical liicliliv In in.- al.iliiiiii':l\ all.!..!. 'III.' -Uill jic.|iiin- a uaw |iall..r, tliciv i- r.la\ali..ii .'l' lli.' I'.aliin-, lli.' |iiiUc lii'c.iiii.- -mall an. I -li.i\\- -ivall\ in.Tca-c.l tiv.|ncn.-\ , li\i'lily an.) .■..1.1- II,-- III' llii- iMniiiili.-. an.! |i..--il.ly -\nc.>]i., a|i|i.ar. Willi ill.' rapiil in.iva-.' ill iiiil-.-rr.i|ncni-y ijuiv i- w.ii.rallv a--ii.ial. .1 a ia|.i.l iv.liii'- li,,ii in liic li..ilv-tiiii|>cratiir.-. 'I'll.' .■nr\. 'iia_\ I..' ..Ii-.tn .-.I 1.. .Ii.'linc t'lMin III ..r II ( '. far ImI..\v the n..rinal — |.. :;."> ('. ami li.L.u — in tlic CI. 111-.' ..r a I'. ^^ li..ni-. 'I'lii- .■liara.lcri-I ic inlcr-ci I i. .ii ..I |inl-c- ami Icin|.. raliiiv-. iiiv. -, ..f whi.-li an illii-tr.ili.ni i^ -iv.'ii, is ,if ^nivo pr. .L;ii..-i- ( I'iu. - I ). jtip.n.Jiic^ u|..iii ill.' .■.,ii-liluti.iiial .•..ii.lili..ii ami tli.' iin|nv--i..ii that til, .|i-,a-, lia- ihva.lv ina.l.' ii|i,,ii llic ,ii-;:ani-iii, i\.n -li-hl li.'in. ,n-|ia;ie iiia\ l,,' all,'n.|.'.l willi iii.nv ,,r I.— mark.'.l .1. |,iv- i.'U ..l' lli.' IukIx -l.iii- l„i-;ilinv. 'ill,' l,in|MTalur,-.Mirv.' .if lli.' iy|.li,,i.l |.at!.nt n-a.l- in a ivinaiK il.lv -iii-itivi' inanmi- !., In iii.,rrliai;v in !'ar ;:ivatcr il.'iiivc lliaii til.' |iiil-.-, ulii.li, in til.' |iiv-.n.v .,r in...l,Tali- int.-linal licini.rrlia-i', liy ii.. 111. an- aluav- li,-,'i,in.- -inall.i' an. I in,,iv riv.|ii,nt. in .•..rn-|".ii.l.ii.-c will, ill,. iv.liii'li..n in l.inp.i'atuiv. I liavc ..I'lii .,l.-irv.'.l tli.' |.nl-i' 1,111 liiil,- inllii.'n.'ci willi ivi; r.'ii.v L. tiiln.--. t.'n-i..n, ami lVc.(n.'ni-y ul,,.n ill,- li.im.rrliai:.' wa- m.t ivimmIcI ..r \\a- l.ut -mall in ani..;mi. (iuilc raivlv 1 have .'viai -.•in ihc |iiil-i-tVci|n.'n.-v tiill parallel with ihc t.'mpcratiiic-.-iirN. a c.n.lili ,n that i-, with. ml ilmiht. In he c ,ii-i.lcrc(l a- a t'av.iralih' |ir.)'^n.i-ti.- -iu'ii. It \< an inlcri-liiii; an. I |iracli.-al t'a.'t that c\cn with the im-chiti'Iico III' |ir,ifii-|. iiit.-linal licni.,i'rha'^c tlu' c\truvasati,,n ami the cvacnati.,!) ,,t' th.' Ii|.„,(l c\tci-iiallN- liy n.. in. mm- alway- taki' pla.-.' in iiiiniciliatc -iic.'i--i.,n. < )ii the .■.iiitrarx", it m.irc ul'tcn lia|)|M n- that ca-.'- arc uli-crvi'.l in which the |iali.'iit lii'.'.mic- pniti.iinilly ain'ini.' ami cina.'iatcl, while ill,' icmperutiirc rapi.lly iledim- ami th.' pnl-e lii.'.unc- -mailer aii^l ni..i-e tVe.|nciu iuii-. ther.'t'.irc, .,f cui-iilcralili- iiilcrnal liciin.r- rha:;.' ai'e pre-ent — ami, niAcrtliel, — . |i.,m- nr I'Vcn .lay- may elapse Im'I'.iiv the ri-nltiiiLi' lil.„iily iiili-tinal .lisi'liai'LT.' take- place. This appears t .air c-peeiall\- when the lilce.liiiii-p.iint i- -itnatcil liii;h iij) in th.'In.wcl ami l' .■ cxtrava-ati.m takes ],lace -h.wly, parll.ailarly when th.' 1,1 1 ..,,/e- tr,,m ^p.iii.^v Fever'- p;itehes whi.'h ari' in a state ..f li.in.,rrha.: ;iilHtrati.,ii. This e,,mliti.,n is al-.> t'avi>r(>n (ilaee. ratieiit- .IviiiL'' tV.nn intestinal licm.'rrlia^rc ipiite yrcmr- ally .1.) m,t (>x|icl the la-t |).irti.iii ..f M.tod extravasated. Under such I 224 (■'n'iMiin-l:iI 71 /■//"//' / ' 1 / /: „. i- f, I .ifin (l.:illi lill''l ..„n,l,n ;,.,,:„■, K.iv,-n-,.. ■.-,-, In. ,.l...a! -:.n. u.n.K , n -Miiaii. I loll III I li,. .l:i-ll.' 1«'M-i..n ,,|- th. alMln.n.n L. tli.' I"''"" "' ''""^^l'^ ..„„-M.,i...:i |..-nli:n' .ivnml.m- -rM-:i,P.n l.-in^ -,.in,.. „:,.- iini-n-l t,, till' |i,il|iatiii;^ han.l. Tlir u.ciinvii.T ..r nil. -tih;il U< M.n..u- .A.m. !'■ '!"■ I'ati.nr- -lr..ii;ll .li,i„„-,av..rMl,l-.l..r.li. ti.-. ii.. nli... . .1..- pl.-i-'" nm pn .■ ...ily ,,|„„,.,n,l ,,,„,n..M. l-nl,nnKi,i,.nTiah I...1 . a-. - .n, ...r,un:„..lv. „,„i,.iilia..;.' i^ aluay- an iini".rlalil aiwl ll, |„. m,,(mI aii'l tilt- ..liifl- '■"l>- lliil r. 'II1III..II. NiM'ltl 1 lia\c in a l iiiinlxi- ..t m-tanrt- -t t ii ,1„.„| nrinl,-~.han-lxl,..u,-an,.r,l„..ir-t i„.ni..n-tia;:,., an.l .u..'.; ...,.„ .lining .iH- li)M 1 •• A l^'-^'l "-nnina.i.... ... .1.. --'• ''' ,, , „, ,l„v,.,lav, i-n... .■a.v.att.r,v,....i.i.... ..f.ii- t..'......Tl.ap. In ,.n..,al..l':.'lu-l'-i. ...•■■...-" ^'11. '^'l-l'l-'" - tli- .■.....- "I '-" nnv,.,..iiv...lav-. iM -...,..■■ a-.- .I..a.l.. ..•.■...- i.. 'I- ' -; "' ^' -■'■ ^ ,„,„„„„..U,,,;,..v,„ -,.v,.^al^^...■^-, nn.r .1,,. li...n...Tha^.. Iia. .■...-,..! 1„ „„.|, ,..-.- .■va.ni....i.... '•!• '1- 1 y ^''''■'- '''■^'"' •"^'^' ^''7 '■'■''"' „„„nn..M.....ial.an.l.li..i.n,..v-..,ni^,ai....l ,lia, ti,. ,.a.i...t. l.av. ..... IV..II1 tlif attciida.it In.-s I'l tl.c ,li,.,l .lirrrtlv tV..ni tli.' Ii.in. ..■.iia-c. la.t .,,,.„utl,, tVo.n xvliu'li .l..-y U...V ....aMv U< .vr„v..r, ... >inW o .,.,„. ,„„,„ii,v ,V„M> i....-.iMal li...n„.-.-hap' .-. ." ^'""'■^'1- 'l'"t.- .)-'l'- ()„ ,l„. av,.,a.;.. iV.„n -.„. :;.. ,..,•-,..... -.Ml,.,.. =;•-<-'„;- ,i,i,.-Mn..r ,.1—1 .li.ti,u.va,:U.2 p.T .vnt.. I....1.-.-....-... at ..S «. t i. tn.... i- ....fav..,aMv inH.....,-.-t 1- tl.o i...l..H,... ..t a .......l..r ..t :lu..:J,w:lS..,....-.-..n...;..-I-I.- 1.. Ha.nl.,..-, 1 ....... .............l ;„Ual.lv l,.v .1,......-. ..:......lv. ... .l.-- ,U„v,.a.•lss7...,.lvll..■. ,,...-...nt. Th..-.. ti,-...-..^...." ...... 'l-''--- L ... aU ,.hv,i,.^n. ,l,a, ..... ....ly .1... '-,.......>■. 1.... =a- ti--^^^^^ ..f i„...^,i..al l. .•-■I.a... ...ay va,-y ..,„.-i.l...-aMy .V.,n. as yet u„k....vn ^^„.,,- a- a ......It ..f t..n.i....-al an.l l....al ...H...'..-...-. _ ' Wh,.tl,..r -..K has anv inll...... m1„. ,.....,....-i- ..f -U^'-".~- ,,,. I,.,.- n„. a,.p..ara^ v., ... l- .l..ti..it..ly drU.uuurA. 1.. .ny ..^l.c.^- .,„;; „. dan.-.- i- ..va,..r in .....n ,l,an i.. won..... F,-...n ,1... .•l.ara.-,.. „r,l... hi Iv M....l-apart. ..a,.U-all.v. in-.u th. al... ....■ an.on.it ..i , ._a,.n:.„..-ti,....i.l....a.. -vlyl Ltai.,..-!. 1 sh....M, L.—r. .s ) Mi'i'iM^ AM< 'r llic illli'-'lnii', |i^il'lirl||:ir|\ llir i'<'|i>li, llnMi uliii'li .1 lii'liiol'iiiaj;!' i- (.ricM lik( 1\ I" Im- t-|HiialK iii:i--ui'. rilr \ iru I.iIm II ii\ :l nilllllirr iil' ( Ij-t illi:lli-ll("l (•lilli (ii;i\c-,' ri'i'ii--c iinr anil ullici-, ||i:il iiilc-l iii.il liciiiiirrli:ii;c i- imt a -crinii-, lull, on iIh (uiiirarv, a rallicr lliN.nalilc ncciiriciicc, i- inn-t rciiiaikaliic W liilc ( ira\ c- lia-cii lii- •.|)iiiiuii ii|i<idc|-- alilc inle-iiiial liciiinnliaL:c uliieii i- ikiI i-e|icalcd. occiii-iini^ in a ruiin-t, fiili-liioiidcd [laticnt willi liiu'li t'c\er, a|i|)cai> at time- tci inliuciicc tin; ^.'cticral comlilinii t:i\-.iialiiy. 'I'lic [(aticiil tlicii Imchiik- bfii^iitcr, the Ieiii|ici:itiirc' decjini-, wliilc tile |iiii-c rciiiaiii- ir'"'il. h!\ ell tllc -plccll 'lliilcitriM'S di-tiilct fcdiicti.iii in -i/.c ( iMclilmr-t, ( iii-ciiinalin ), and it" the occurrence takes |ila<'e in llic tcriiiinal -latrc "i the di-ea-e, cdiivah'S- cinee may at oiicc -et in. A- ii|i|io-ed tn -ndi mrc c\(e|)tiiiii-. is tin- iiM'i'w hcimiii^'- |irc]>. ■nderaiK f niil'a\ •■ralijc ii-nit-, -(, that, e\ cii tVoin the most la\(iral)ie a-|)eet, tl •iineiici' of hcniorrliajre cannot he looked upon as a desii-ahie event. It -li.nild licie atrain !)<• pointed out, and cannot lie too -lidnt:ly empha-ized, that e\eii di-tinuni-hed writers ot'teii base their eonclii-ion- ii|Hin in-ntlieieiit statistics. I have noted periods in which only 2 of ol» successive cases of intestinal hemorrhai^c miller oli-ervatioii teiininated fatallv. Peritonitis is oi f the imto\vard occurrences in the course of typhoid tevef deser\ iiijr of detailed eon-ideration. It may remain cir- cimiscrilied or, as is imfortimatcly more common, it mav lie ;rener:il. In the l.iruc in.ijority of cases hotli varietie- oci'iir a- sequels of the inte-tinal lesion. It is the I'ontaminatioii of the peritoneuni from the int<'stinal ulcers i)y the excitin^r acrcnts of intlaminatioii or the esca|K' ot inte-tinal contents into the alidoiuiiial cavity that, in aceordaiieo with s|M'eial conditions, irjves ri-e at times to circimiscrilu'd fo<'i of intlammatioii, and at other time- to L'-i'iiend ))erifonitis. The iiiHammatioii of the peritoneum is hut rarelv independent of the -pccitic le-ion- of I'cyer's patches and the solitary follicles. Now and a;raiii piiij:rene of the howel from some other cause mav he the nndeilyiiiir tiietor. 'I'liiis, in one instance, I noted such a condition to lie caii-td Ity thronihosis of the artery supplying; that jxinion of the ' Clininil I,fi-ti(ri-s. 1S4S. v,.|. i. '•' Clin. )ih\/., L'cl cil.. irari-l, l.y Kiinztiiiinn. vol. i.. p. 238. I 226 7) iii"ii> 1 1 \i i: i % 1h,\\. 1 :in>l ..f ill.- :ir.-.,iii|iaiiMiiL' \' hi-. I '.■rl'..r:ili. .n ..f ..ill. r ,.|.;:iii- :il-n ,,|;|\ ll( lllr ■Mil-. ..r |.. ril..lllll-, J-, I.T i 1 1 -I :l 11. . ■, II 1 1 ll 1 1 1. ■ . .f I 1 1. ' -|1..M ,,r ..r ill. III. -.111. II.' -I:ili.i- in .■..n-..|il.n.-.- ..f -..I'l. iiiii^ ••>■ :il. -.-.--, lUllllllv ..(■ ill.' -.lll-l.l:i.|.l. I. .'I' ill.' l:lii;.l- l.ili:i|-\ | .:l --:l-i -, "r .||:IM ulwMt"*!" .'I' ill' li""'!' "Ili.'li ll-l- .1. \. I..|.. .1 ill ill' .■..III-.' .•!' ill.- ilUil.'N ..(' I\ |.I|M|.| I. A .1'. I'll, ,, II. -I i.. 11 ,1- I., will ill. r :i I'i. .ill/. .1 |M ril..iiili- iiKiv .M'.-.ir ■.', 11I1..11I |.rl'r..i';ili..ii li:i> I... '11 r:li-..l l.> < u-liiii-,' uli.. lliiiik- llial III ..iiaili CMH- till' .'Mi'li. -I -\ iii|.l..iii- ..I' I" rti.i'iili"ii iii:i> I" .lii.'l"".-i liltl.- I.- il \/,A iiitl:HHiiiali..ii ..f ill'- -i-r.-:i. "iili >■<■ "llli'.ui ill. |.a-a.^'i- ..f iiii.r..- ..r-aiii-iii-, an.) l.a.liii'^ 1" a -li-^jlii a.lli.-i\.' |.. lit. .nil i-.'" Tin- In- -■.,ak-..ra- ill.' |.i. |..rl'..iali\.- -laui' .'I' ill. .rati' 'ii. H' in.-iiti.ni- a .a-.' ..f Miii|.li\'- ■ ill «lii.-li ill. I-.' v\a- |» ril..iiili-. I'Ui il. |"'rf..ral i. .11 t; I; :iii.i al-.. "1 .a-. - ..r ' iainlii. r'-,' in \slii.'li t'alal |>.-ril.iiiili- ...•- i'iii-r.-.l uilli..iil an :il.-..liil.-l> ...iiii.l.l. |m rr..iMli..ii. '!'«.. pli'ii'l nl.'.r-." 'I'll. |„-i'il..iiili- a--...'ial.'.l uilh ill.' -|M.iti.- l.-i.'ii ..f ill.- iiil.-tiiu' i> II. ,t ..iil\ ..11.' ..f til. 111.. -I t'r. .|ii. 111. lint al-.. ..11.- ..l' tli.' 111. .-t .'liai-a.-l.-'-i-li.- .■aii-i- ..r a -n.l.l.'ii .iaiii:. n .11- ami liilal .liaii-.- in llif .■.mr-c ..I' an atta.'k ..r lv|ili..i.l I'.-v.-r. 'I'li.-rr an- v.-rv I'.-w ..lli.i- a.-iitc iiili'i-li..ii- iji-.a-.-- in wlii.'li llii- (•..iii|ili.-ali..i ■m'- at all, ami I'V.ii tluii ..iily a~ a raiitv. At liiii.- |i.-rt'..rati\ .- |i.-rit.iiiiti-, like iiili-tinal lM-in..i';'liai;c, i- till- lir-t .li-lini-li\.' iiiaiiir.-lati..ii in a ca-i' ..t' aiiil>nlal..;-v ly]>li..i.i ti'MT |in-\ i..ii-ly -li.iwinir ii.' -\ iii|it..iii-, nr at Fii'.-t attcii-.airr (li-tiirliaii.v-. 'I'll -.1-..,, ■- 11.. I y ill I'ai-i', -.1 that if iii.livi.lilal- witli |i. rf.iiativi' iM-iit.iiiiti-, L;i\ iiii: an nii.'.-rlain lii-l..iy nr 11 • at all, an- a.iiiiitt.-fi t.> a li.i-|.ital, tlii- |M.-il)ilily -I1..11M .-[..-cially 1»- kcjit in mill. I. I have nhscrv.'.l h tho flr>t r^yiiiiitoiiis of peril. .iiitis (.o.urml ill |Krs.m,^ wh.. Iia.l licai iir.-vi..iislv a|.|ian-iitly h.-altliy in the lonii ..f iiit.-s- liiial .-..lie or suil.lcii ciillapsi' uhilf walking: ahoul or while at wcr... A case iiii.l.'r ..Iwrvatioii was hr..ii..:lil to thf li.i>|.ital a,- on.- ..t v..lviilii.-- : aiioth.T, iin.ler the sii>|.ii-i.)ii of haviiii: attfiuplnl -ui.i.lc with ai'scni.- ; an. I a liiir.l. a- a ca.^i- "f iiicat-iHiismiii..'. Th.-i- <|iiit.- -nrpri-iiiL' :iii'l "It"''" n'""' '-'■ni^"'"' '"i^''- :""'' •■oiii|';ii':il'l'' with ih..-.' in win. -h lli.- -yiii|.t..in- ..f -.■iirral |Mril..iiili- .i(-v.-l..ii mhI- *K,vu, S„n,n-ol '•■'"■/'''■"tin,,. „„■/ S,:,.„l.< „/ T,i,,h„;,t ferrr. IMiila.. 1W.'>^. ]. S.-.X. ' fllnKf!""- M'll- .Iniir.. V..1. xhi.. |. 1 U. • li,,f,.,i M,,/. am/ Sura. .Imi\. .Jlliu- "JH. ..^f ' *{^<^^ lii! ^^\ In 228 IcMirr ; 1" i-ldVatloii li:i 'ivrii'iii, I ivi.i: li:i- lii'cii iiMtiil r\( 11 ill tlic rt'ciinii liy variolic 1\ r hUt w !-<■ i>l>-. r\i writi r-, aiiil ! traii-vd'si' cdlon. lioWiAcr, a|i|ii.ir 'i' !"■ tli :i-iii\(liri'j ami the tlir lavniTil -cal- .f llic It -i Will I lii;anl Id lllllc. Illr iM'clllTrllfl' i if ixTtiiratii II c'liiiiciilo 1-1 .aalh" \\itii thi' |"iii"l ,|' (•\|..lialh'ii dl I \\f -Idiitili-. It- larli i- ,-d trcullrlllK llld i"l- iilli liciiidrri; rr dccill'- rMfcliirh rare, (I rt-iilt- ciiilv iiiuli'i- cxftplidiial rdiiililidii-. 'I'lic |)riiiri|ial liincldi' t' iifrt'dralidii i^t' \\\v liduil i- llincl'drc iIhcihI dl' the tlu' iicciiriciicf 1 (I anil llid tl • k di' tlir ili-ra-r. A iiatdiiiic invi'-tit;al'dii 111'.- that tlir arriilnil dci-iii- i-|Mriall\ wlini tlir iiiiiliillarv iiitillia- ti'ai lidii i- iiid-t I \ti ii-i\r, ami rMiinl- ijdw II Id ihr |M riti ■lirlllii, iir r\rli iii\dlvr- till- al-d. Ill till- way tlir tlddr ..f tlir iilcrr may rdinr td lir fdi-iiiril liv a traii-liirriit iiinnliraiir a- thin a- |ia|irr. that uill hf iinahlr Id with-tanil r\iii ihr -liirlHr-t nirrhanical iiitliitiiri-. In >diiir ra.-r- tlu' i;;tiltratidii ,,ml llir -Idiiuhinj arr -i. ilii|i lliat ill.' iMrildiiriiin alMi i- iii\dl\ri|, ami rii|iliirr iii-nr- ininn'iliali'ly ii|idii thr drriiiTfiicf "t uiiLiliinL:. il dt thf iilrrr-, a L;ria 111 tlir ra-r- jii-I ivfiTVcil t", ill u Imli. altir rlrarint;' n|i llv ihiiinni aiva in tlir iiili-:iiial \\all nniaiiir-, jht- t'di-atidii taki- [ilarr lithi i' thi'dn^h niplmv di' ihrdiiiih innri' or li>s ■ railnal rxtni-idii dt' tlir iii.i ■ralisr |irdci--. 'riir latlrr diTlir- i-lina; hii-h thr iiiTitdiiili- ilrvrld|i- lair — at thr rilii dt' tlir lliild th wrrk. •trr dt' thr ri-nlliiir- d|iriiinr ilr|irmU ]iartly iipdii the ■liiiiiiiarv altcratidii> ami thr iiidilr d|' .lrvrld|iinriit dftlir iird'uraiimi. Ill ra.-r- in w or ill thr t'diii '1" ir rliarai riir iHTtdralidii^ iliir td lai-p' ilinrt SII I'll attain ■nrrallv altrilnitahlr |i it' -triirtnrr, \vlii( Il I iliaiiirtrr dl' fi-di'i a i|iiartrr dt' an iiirli td diir mrh, arr the I'xt'dlialidii dt' lai-iii' |irdt'diiiiil -|dliurli>, Thr Iviiii: rld-r IdMrthrr ill rini-iilrralilr nail rriliritiirin diirninLr-, ;it tinii" iiiiK.hrr, arr dttni rrtrralMr td -ld\\ Iv ])rdij:i'r--ivr 11 Irrratidii. whilr nipt- illlr t nrr- illlr td inrrlia liavr lirril alilr ti lit' the dnrllillr'-. lliral illllllrllri- arr dtli'li ( li-tinL;iii-hril, a- 1 think I i\V, I IV t hr 1. -iliiilinal, -'it-lil |il'rill^| lidii (if ihr inlr-tinr. i'-|M'rially il' it nmlri'iid -mliini iiii;- luriitatinn in a -m due til dtl 'Ir lidrlidii. l'"lirtlirr, thr rdiiilitidll i- vv\ taiiilv dt'ti lllv thd-r r\rrtril liv thr -dliil irr liirrhaiural inlliimrr-, r<|>rria 1 rdlltrllf-. That -till ullirr nirrlKiniral illlllinirr- artilli;- t'l-dlil iiiti-ili'_'- -nrh .v)'i//'/'*.i/^ .i\7' <'iMfiii\nii\.' 229 ••111 MctiMii i-, mil'drtilllalcly, tun (illcii (lciniiii-.t i-atcri-i-tal~i-, all- with (■(|iial |ii'ii|iricty \n \h- lirld ri-piiii-ilplf in rcrtaiii I'a-c-. All tlir-c ]Miiiit- caiiiKil !«■ tdo i-lcai-K- |, in the nvefwhclniiliL;' inajufitv iil' ea.-es the ciinijiliiin- are tiiitnnatcly -iich that, niider the niii>t tiivni'alik' eif- ciiin-tancc-, uitii cafcl'ni nli-civatiun ot' internal ;iiid external prccaii- liiin-, e\cii dce|) iilecration iiiav iniderLTd eicatri/atinn, and c\'en niiiiuto ■rliiratiniis niav reiideri'd harnilc--- liv tinicl y adhe-iiin with aiial period when exf'iiliatii)ii (if the slonuh i- ciirn|)leted, and even at a time when the patient appear- alnm-t ennvaleseent. This nidiirtnnate accident at tnnc- iiccnr- in !• |iat( |-ecl'llile-ccnce t' the speciilc le- nd -iililary t'ullicle- wl th: lleh exlllblt a I'lii- at a tunc <.\ hen ttie inayiri it\ iif th nicer- arc ni prnee-- ot licaliiiL'' nr li tmn. i\c alreadv and I'ririine cicatriza- Illii-c \M In other ea.-e- iinpcitcctly eicatri/ed nleerated areas, especjalK th \'cry thin llooi-, may siili-cipicntly reupcn and iindertro per- tiiralii'ii. l-"inally, the indclinitcly protracted -n-callcd sliiirjri-li nl< may !»■ a -nnn (' c-riat daiiLi'cr. I luixe, l^r instance, ohserved per- t'orativ periinniti- develop all' r the lif'tieth and the sixtieth dav of the disca-c. in mic in-tanci c\en at'ti-r the hundredth dav — a warniiii.'' tor |)alicnts and their friend-, who often charire the physician with pedantic rigidity of supervision diirinn: eonvalcsceiiee. Siii-li late |)»'rfiirati(iiis are cmpliasi/eil also hv oiher writers, iiaiiielv. Louis, Mnrchisiin. ( " siiitrer considers llic shiir^risii uli iricssiiiu'-er, Nieiiieyer, and ollicrs. Aiiiotii: these, (Iric liihty ot perforalion exists llironi:hout (piite a Ioiil' t tiillowiii^' tiirures: is espeeiiiliy (lanireroiis. Tliat possi- iine is siiowM hv the Of I ■) cases o f perforation that I have analvzed, this acciileiit oeciirrei iielw 11-11 the eleventh and the twentieth day in '_'•'!, from the twentv-first lo the tliirtii-lh day in :!1, from the thirty-first to the fortii-th dav in l:!, and after the firtielli liav in »>. rile fi-cipiency of pertiiiation of the howel may, precisely like that ot inte-tinal lieniorrhatrc, he extremely vjiriahh at ditfercnt times. I have oli-ervcd epidei others in which tl nics in which the condition was (inito rare, an .1 le cases were execedmirlv common. I" This fact prohahlv •xi>l;iins the e^ treine divcrsitv in the stat<'ments of \ari(ins writers )n what th s temporal variation in fre(pieii(-\ depends is as yet rvi'iinin II. vi:i: M« I m iinkiK.wn. Tlic .IfLTcc U> wliirh tlic iiiiinlMr ol' ■•as.- of |>rrl'(irati(in may at tiim- iiima-r i.- -Imwii liy an aiialy>i-- liy Murrlii-oii, win. imtcd [M rtliratinii in -JI.J |mi- cml. arnniiLf ln:, Mnti'p-ii- in ca-c- .inrin-' tlir year- fnitn \s\^\ tn isr.i, thi- mnnlicr i- clf. I have pcr.-onally ,,1,,,,,-vcd ;•:! cax-: It). 17 |ifr cinl. — anioni: 'u'\ antop-ics ( lland)ni'tr- Lcip-ic). It will thcrcfoiv not he an f\ai;i!fratioii to a~-nnic that in tVoni !• to \-l |MT 'fnt. of all fatal ra-i- of l_\ [ihoid fiVcr death fr-nlt-; tVoni |ifi-forativf |irrit. Of (i:; dealli-. 'JO (;'.!. 7 per lent.) weiv i\\\v to |ierforatien. Kortunatelv, tln' ali-i'hiti' liv,|nenev of |ieit'oralion. niakini!' allowance \\,r tciniioral and indi\ iihi.il variation-, i- di-tinetly le-- than that ol inte-tinal henionha-e. 1 Im lievi' that nner eent. ot all ea-es ,,t' tvphiM.! lever. In m\ Leip-ie -lati-iie- I Hi'-''; i)atient-) the pi-opor- tion wa- -1:1 jwr einl. in llamhnri: it wa- l.i; I'ei' .: pir eeiii. amoni: lit'O of typhoid f.ver. i- in aLrreiiiient witii my '<-■ . Amonir S-_>!t ea-e- of tvphoid liver in the John- llopkin- llo-pital. there were •_':'. (2.7 per cent.) ea-e- of perforation. Twenty of the-e were fatal, and :'. reeovei'ed follow int;- .iperation. A<:<', -e\. and -oeial eonditioii do not o<-ea>ion -neh marked ditVer- en.v- with r.feivn.e to the dan-er of perforati..n a- - h-erver-. njion the l.a-i-of an in-al1ieient nnml.er of <-a-.-, ^tate. In ^neral the conditions are analom,,!- to tho-e in i-onneetion with inte-tinal lieni- orrliaL^'. 1 helieve that ehildivn, e-peeiallv nn.lei- \\\v a-e of ten years, are le<- .■ominonlv attacked than adult-, and I l.a-e my opinion hoth iiixiii a rathei' larL^e per-on.il e\pcriencc and npon the -talement- ot T.>pin, iJillict and I'.arthe/, Kocher and lleno.h. The prohahl.' rc,a>on fur tin- i- the iicnerally -liirhter inten-ily of the inte-tinal atVection \\\ chihlren, which \\\\> already iieeii mentioned in the consideration ot 1 y.,,! ,/. ii,s,ii.<.-h. .1 .\r,-i, . »■,.■„.. iH,->;i. SYMI'I'dMS A.\I> (nMI'l.lcMI'/y.s: m lirllliiiTllIlLrt'. ;iirc ;iri' ('■■IKM AliiDiii; Miliiit^, tliD^c lictwicii iii.'litcfii Mild forty yc:irs nl' iallv ]ii-((li>iMi-.cil to |>('rtor.ilioii. .\tl<|- tlic loiticlli \ car of life tl ic occiirrt'iK'c IS iflativclv u lati COIIIIIIOM. he coiitiarv oiiiiiion, illv cxprcsxd, tliat later lite is in turn more iiredisposed, i? iKit III aciori I witli iiiv exiieriiii 111 ireiieial, iiicii a|i|Mai- lo lie attacked hy |H'rforation more fre- itiv tiiaii women. 'I'lii- i> liv ii(i mean pendent iipoii ine(|ii: ilit\ the develo|)nielit of the >|>ecific iiitc-tinal icsioii> in tlie two >exes, It prohalilv M|.on tlie fict that, with e(|nal eliamo, men are more itiivorabiv iiiHucni'cd diiriiii,r I'onvaleM'cncc by reason of previous dcrail;r<'mi'iit "t the di<_restive apparati due to oorcr cia-^e>, jirohahiy lu ii-iiiucncc of the less favorahle conditions oi' livini; and of nutrition aiiioiitr these classes, a in' also oil account of the Ic-s etlieieiit iiiiisin)^ ire devoted to them. This is in accord with mv ol)>ervation that the occnnciicc ol |)erioration is more freciiieiit anioiii;- ainhnlatoix- and milder ca-e> in the poorer < rlasso. M urclnsoii aiK 1 (iries>iiii:er proliaMv emphasize iimhilv the jireiloiiiinaiice it perloratinii m tile male sex. 1 have iiotcil | itc(l iieriiMJs in which this ilitl'cr- nis, II. ttw vca r l,H,S(Vl,s,S7 ihicli 1 appreciate, was not present. Tl ilainhiirir, hotli sexes were ati'eeted ahimst iMjiially, and in the yer.r 1M87 leinales evi'ii soniewliat more frecph illy. Symptoms of Perforation. — Tlu' complication often occurs iiuite siidileiilv and unexpectedlv, without nrevioii- iiote\vo'*liv iniiirions .\t times it is iireiH'dcd liv more or le-- ill-|iital, I! have been preceded or aeeonqianied by liiiiiori'hair<'. 'I'hc tinu' when |H'rforation oeciirs is at times ipiite dctinilcly stated by inteiliireiit patients. They complain of stiddea -tabi liilmiiT iiani, or even ot an a( ■tiial if laceration. In the meat majority of cases the |H'rforation is soiniillt;iiu.,ii.-ly wilh llic- "11 -cI of lli^ lin. riT'iiicii ll\ lAili |in rcdiu;.' It, tlicf cicclir ,li-,iif--iu-- ri'tcliiii^ Mini v.'iiuimi:', ii' ' ■ i|iuiicc " t wliicli ihr ^.i.-tiic iiitiiit-. N\ liifli :irc Miiirc or li llic lliu'*'-' 1 1" ^\ii ich til.' ;H-ci(lrUl w \\ chaliuiil. :iMil ot'lcn niiitain ai'i' (A Mriiatol. SiHiii iiiilv -iiiai' am iiiir rcii'liiiijj lllnmil- "I IIIIICOK l>il i(jii> inaltcr ai<' cx] II. .1 with the ili>tiv>s The alidmn. H ll'iw liicoinc- | t.l an CNtlTllI" il.'./V.'. r.ii:r. --i\cl\ innvi' < that tlic (■iilanf..ii- cov.-n li-tcinl. <1, at time- ly; ..I' tlu' :ili(l.iiiicii li anil Ldi>tciiiiitr. 'llic iiiarkolly clcvatcil ])(i>iti..ii nt' the (liaptii-a.jin tli.Tfliv iiiiluccd, in ciMiiiiictioli witii tlir |.(rit..iiitic jjain ajiiirars siiiont illv iiilfrlir.s with hivatiiiiitr. 'I'hc h.iwci- aff 11\ (■iiii>li|)at<'. tlic iiafc>is of the iniisciilar I (let;, If of intcii-ity. 'I'iii' v.Miiitiiii: II"' i-aivlv a..|uiiv- a fc.'al (•tiara.- tlial tlir ciitiiv coiKli- ti.pii ,-iiiruot- the (Ai-tiiKv ol' ilfiis, ami for wiii.-h it may indeed he inistak.il hy tli.. c of limited eNperi.'iiee. Althonf.d, the .-yinptoiiis deM'i'il)ed are ir.iieiaily attrihnte.i t.. tlie iierit..niti- alone, at times, esiM'cially wIk'Ii the |k rit.,niti- pniee- ..riui nates in the vicinity of the ileocecal valve aii.l the |..wivm.>st porti.Mi of the ilenin, and is partieiilMfly ]o<'ali/ce ii.'inted. the extivMiitic- livid and <'.ild, and the face and the h,,dv are ..fteii COVC1V.1 witli c.ild -wcat. The .•..nditioii of the pulse so.in hecines p.M.r. :-.. -oon that at time- it may he the iir-t indieati.Mt of the iritive -iixnitican.e of alxloininal ]iaiii of sudden onset, 'I he puKe licarccly to he counted, and fiv,|U.ntly, at a tinu' when the patient i- still c.,n-<'i..us and the friend- ai.' -till hopeful, is no |.,nirer palpahle at the fa.lial artery. When peff.,rati..u with t;ciicral pcnt..iiiti- is pre-cnt, the hodv-K'mpcitit ,rc ri-e<, .1- a ml.', hut little, ill an invi-ular nianucr, or liot at all. ()n!v toward the cn.l i- rapi.l elevation to an extreme d.'L'i-ee -..nictiuie- ..i.-crv.-d. M..-t flv.|Ueutly a more or le-- rajiid, often ai.rnpt, decline of temperature t.. far hcl.,u the ii.,r!nal occurs, and per- si-t- until death. In -omc ca-c-, c-p,-. ially tho-e with suhsci|Uent elcvafi.m of temperature, I have ..h-ervcd .i .■hill at the .,ut,-et. Flow thi.- is iir"Uirlit ahout in the in.lividu.il ease, ami which kind iil 111 the -cvcrot ca-r-, tllo^f in which thr ilitr-linai cuiilcMlt-, |«ili|-((l ■ f laryi' ii|iciiinii-, ^mm ildtiiic the ciiliic alxluininal raxitv, tlic II, urriir >\iiiiiiiiiiii{i>l\ . >\ iii|itniiis (Ic^ciilpcd, iiitcii>i(ic(l tn ihf iiiaxiMiiii ( '■illa|i-c then a|>|>rar^ to iMi|Mrr([)- lil)lr iliii-iiiLT till' lir-t ti'W hours, ami tlic tcinpcratiiic I'aii^ hriiiw the niiniiai witli ri|iial ra|>iilily. ()tt<'li tlic ahiloiiun duo iiut hi'i'iiiiic ili-lriiilnl, anil till' |> ali>cnt, a i-irninistanri' tiiat ^I'fativ inrna-rs tlic dilliciilty uf dia},Miii.-is even tor tlic cxjx'i-t clinician. The iiia|iirity of llic-c jialiciits, iint'urtunatcly, retain pcrtcct ci>nscii)iisiicss, Minic until iiiuiicdiatcl\ lict'orc ilcatli. wliii tcniiiiiatiiiii lit' the tiist twciitv-t'niir hmii'- niav lake place liet'ol'o the \\ lien ti m>c lit' the |)erit(iuitis i- Icr-^ rapid, the patients may even recnvcr -nmew hat tViini tiie priinai'v shuck, tiie |)nlse niav ram lieciiinc t'uliei- and -liiwer, the tciiiperatui'e may apiin ris(>, thniijrh lairlv, it is true, as has lieen mentiuniil, to anv ciin>id cralilc hi lyht. rnfiirtimatcly, the hope thus amnst'd is almost alwavs cMMS nt" circiiliisiTilicil, iilthnii^rli ;it lim, - ,|iiit,. cMcii-ivr. |MiMl(initi<- ull'ccticiii-, uliiili lio(k mi arrciiilit nf iinlividihil cmii-('>. :Early Diagnosis of Perforation. — ( '(.ii-iclcrinf.' tlic vcrv jirom- i~iiiu n-nll- tliMt li;i\r liiiii iilil:ii;ir(l t'r |Mr:ili\c iiitcri'rri'iicf in ra-c- (if |H rfoi-itidii, ami -inrc i."""! i'<~nll- aiT tiiaiiilv m those (.f llic con-cciitivc |icrilipnili-. Of all carlv -viiiiituiii~. jiaiii i- tlir iiio-t coii-tani ami iin|HirlaiiI. Mi'd-ai' ' ha- iui>-l can tiilly -Iiit'rf.ifatiMii. I'crfdl-atinii (iccnrivd in \'-> of hi- ra-o, and in ail of thiin |>ain was pi-i-i'iit ami -ci'imd -i\(iv. In Id of ihc-c ca-c- tin patient- had liffii pf(vion,-l\- (|iiirt and rointiiftalilf. and were -nddcidy -ci/cil with ,-c\tff aUloiniiial pain, which in -I ca.-c> \\a- -c\(fc cnon-h to make the jiatient <'fv out. In tlie feinainiiifx •'■ i-a-e- the |)ain wa- piv-eiit tof -onii- da\- hefoiv the ]ie1-fol-ation oi-cin-fed. In II ea-e- of -' I I'epofted liv Shatliiek, Waiivii, anaid that a >ndden oii-et of |>ain deinaml- the ino-t eafefid exaiiiinatioii of the patient and eaivt'nl notiiiL^ of I'Vcry -y.nptoin. Altef oii-et the |iain i- n-nallv not (dii-tantly -evdv, Imt i> pafoxy^inal. in -onie ea-c- the pain may lie piv-eiit for -evefal honf- liefofe the oi,-,t ol' tcii- dei-ne-- ami nm-clc-pa-ni. In many ca-c-, howevef, with tl n-it of pain th.'iv i- temlerne-, n-nally locali/ed. most often -itnated in the riirht hvpoi.ra.-trinm. A— ociated with thi- tt ndcrncss thefe i- n-nally soini riLMditv oi- -|ia-ni ot' the ahdoniinal mn-<-lc-. c-|ieeially ot the ri^ht veetn-, ami limitation of' the alxlominal i'i-pirato|-y inovemiiit,-. 'i'lic. c lat.er -iun-. while not nddcn liill of Kody- tcinpciatiire, when pre-eiit. i- a very chafac'teri>tie symptom, hnt it- frcipiciit ali-enec. and tlu' fiet that it occnrs f>-e<|n<'iilly In other condi- tion-, -neh a- liemorrhan-e, make it an nnrclialilc -iirn. Voinitintr i- :in important -vmptom whrn pre-ent. Inerea^inir di-teiition, a^ -.lown hy the u-radnal ri-e of th.' lower line of hepatic dnlne-s, which -honld lie marked out at short intervals in -iispieions case-, is an imi"irtant, thonLdi iisnallv -omcwhal later, siirii. It mn-t :il-'> l"' rcreil that the IIi|)poeratic fai'ics is not only ,i late oeciirreiicc. hnt that the pinched, tlrawii, anxious llu'c may he one of the first siijr^'-estive si^nis to the I /„„.. i-if, ■' li,,st,.„ yi..l. .n„l Sui-.J. ./..„,■ , .luiii- i;s. I'.KMI, .SJM//'/o.l/s I.V/i ((iMi'l.KWllO.SS. 235 (•yiHriiiici'l (ili-crvcr. Miuli attintiiiii Iims Ihtii ^i\in In tlic (|ii III an iMi'K' iiicrc'Mx' in tlic iniiulMT nf 'lie IrnkcM's U- in tli r-lKin iIk r:il rtor.itiiiii. ,\lan\' more oii~\ tlii' IiomI i> n.-nall\ ti'liowccl li\ an inrna-r in llii ia\iT ciinrlnilr*, tVnni a -Inil\ n\' tlii.~ (jnolinn, ti.li, nnniiicr nX ilic irnK nkiicNic- in llic ucriiiliri'a! cii'dilaiidii •lliis niav III' riiii~ii li'i-alil. -iii^lit ami a|i|iri'rialili' unh \' ni cnni- iiansiiii Willi |iri'\iiiii.> rmin 1^ ; llcnrc tllr ^rral ini|MPi'tanrr ul' l'rri|iiiiit ,iliil~ lit' tllr li'llkiirvti'- illllilii;- tli" niiT-c ut' tllr ti'MT. Nut ilit'lv- iiciitl\-, tiilliiwinii; the ri-c ihnr i~ a tiill ; ami in a iiniiilici' nf caM's i'i~c at all, lint tliri'r nia\ r\rn In' a tall tVnin the lull' inav Ih' nil il. ( iimlltliilis .-■llrli IS till -I iri' imiiraliiiii-- nt the iiialii:iiit\' ut the iiiti'iliiiii iir till' |ii'ii-tralii II III till' iiaticnt. Operative Treatment. — Tu Li mIih in (irmiany ami Wil-im in liic till' I'l-iilit 111' tir-l arili'iitlv aiKuratiii Allli'fira air I ca-i'- ut' |n rt'nratix r iicriluiiilis. 'I'lic Aim iir iiiirraliiin ill riraii -ni'iri-iin> ourria IK iiiiik llii' -iiliji'i't. ami have li -t i'anu'.-.t ailviirato ul' tlir utility ut" " Ilk 1 was alilo tlii- |iriiii'iliiri' ( l'"iiim'y,- Keen,' Cii.-liinti' '). I" \^'M, Kiti t Iliri I'luiii till' liii'i'atiirc luS i'a-i"~ ut' ii|ii'niiiun t'ur pcrf'uraiiun in l\|iliiiii| t'l'M'i'. Till' ririi\('r\-rati' in llir riitirr luScasr-- isi>;',.41 per W liiii lliis is I'lintia^lril witli tin' i ■i'i'ii\i'rv-i-al(' in iinujx'r itnl ■a-r- I imt uvrr ."; pcp rent. ), tlu' valiir ut' tin' |iriiii'iliiri' i- I'xiili'iit. < )t' i|n'rati'il ii|iiiii in tlir .luliii-. Hii|ikiiis IIii-|)ilal ilnrin^r tlir |ia-t 1 li ra-r~ \\w VI 'a I'liit. r- li\- l'"inm'V, ( 'iisliiiiL:, anil Miti'hill. ti i'itux crcd- ■I lirr Tliat ujirratiuii, wlirii |irrturini'il early, i's|ieciall\ it'ilmie nmler lueal I'ueain aiie^tliesia, as aiKueateil l)v ('ii-liinu,' i- in it-ilt" imt ut' ^Teat ilaiiiTer III ihe |)atii'iit, i veil tliuiiirli at the time he i- extrenu'K' weak Iriim the etliels ut' the ili~ease. lias liceii sliuwii l)v iinnieruiis cases, ami e-|ieeially li-- several 111! wliiim ex|iluratui'v la|iariitumv was ilune ami nil jiertina m t'uiinil. These results have curruliunittKl the statement ut Mikiilie/, niaile in ISSl : •• It' su^pieimis ut'a pertin-atiun, uiie slmiilil \ imnien, IIIIMI. All III, h ,if S. ./../ill.. nnpi,:,is II, ..p. /, :/.. Uip >]. viii. ur,]i'n/. M-.iVt l'l,;i„. Mill. ,f,,iir^. Miinli :!. I'.iiMI, liuulril 1,\ C'u>liiiii,'. /'"■. <■(^ ml !i!; 236 nlllv 111 (•;!>(•> Ill w ryriimi' i ivi'i: lii(>)i >triiiii: I iMtcclnr :iilhr-|nii^ ;i iriniil ahull I ilic -ill' 111' |Ml|il|aIlMl|, ~t\K nil i'iii'a|i-iil:iti<>M, ilnl llii- tViiiii llic niiiaiiiiii:; iru'cr |M.rli..n ..| llic |K'nl..iii'al ar. Siirli |iirin-o|' rilviiiii-cnlM'd |mii- Iniiili- ina\ al-ii -■I in \i..|,iitly uitli jinit'dilinl niuliiti>laticiM- ot' -lh>ik, anil, (-iirciallv wlnii laiL^r Iri'al alix't— c- aiT |irr-(nt. may lie altfinlnl williiiiM-t .^ravr -yiiiiit.iin-. li(vii\rr\ mas iMlnu umlii- -ndi cdiidi- tii.i'- a> a iiv~nll "f liincly -nruical ii!l«T\ cnlii.n, .t nf -|M.nlaiii'(iii- rn|it- iirc (liiTctK niii\varli(inl(l. Iiii\\(\cr, at Im-1 In- diiliinn-. Maii^ I't' -ndi ca-c- dii'. In a nninluT ofi-a>c- I lia\c nli-crM'd tinc, -itnati <1, Ihiwcv. r. in |:ail- "I' tli. alxloiiiinal cavitv aci'('->il)l(' til ii|MTativf intirvintiMii mily uilli ixiirdiiiL' ditlimlty. If. niidcr ^ll^ll I'lrriiin-Iann -, -|Mintaniiin- iii|i tnif with riimiilftr lAarnatinii dur.' not takr I laliriit i- n Vr iilair, tiii- iii-lii>-ini: cnnditioii may < drair aloiiir until tli 1 ini'inh- of -nllrriim. An inlfiT-tiiiL' pi lir\.-d l>\ iliath due tu ^-luiic t'lirtlicr ('(iiiiiiiicatiipii, ur aiUT -itiim ainiinLr the varimi fiinns of circiiniscrilMHl |i('iitoniti- 1- oriuiiicd li \- till' ca-i" in whirh the ]iroc(': loral- i/i-d to till- riirlil ili;ii- f"-~:i. :i'i'' r-|»'i'iiilly to tlir \icinity ol the ciTiim, ca-i- that ran l"' a|ipio|,riatrl\ d.-ii^nati-d a- tyjihoid p(•^itypllliti^ or pai'aty|>liliti<. 'I'hi-r la-i- oc.-nr mot'i' fivipuiitly than i- tri'iKTaily Ix- licvnl, and mav Im' lookrd upon a- typical proi-.-M-, -incr tlicy oriyrinate from portions of intr-tinr i-pn'ia That 11\- involved ill i-a-i- of typhoid fever. ill ^neh ea-i'- minute opetiintr- I'l | f iiert'oralioii. or even eNtremc ileerativ(> thinnini; i' mav penmt the e-eape o preliensilile in aeeordaiiee with |irevions >t;:tei to note that the >ite the inte-tinal wall without actual perforation, f the intiamiiiatorv irritants, i- readily "oni- llellts It is intcrcstinir if the usual inn.aniniatioii penlyph f the le-ioiis in i|iie-tioii corresponds with that ,f the cecum. In the presence of ty]>lioiil liti~, perforation of the vermiform appendix, which, it i- W( 1 ill the medullary iiitiltratioii, ]ila known, 1- ipiite trt'iii'i'idly involvei an impurtant r^ iiood of tlie valve, as wi T 1 lavc in a iiiiml)cr o A. Al-t~ in llit- iliac t;,— a, iiaiiicU, |(aiiiliil circiini.~ciil.ctl iiililtrati nl' iikkIc- ralc c\tciil, at ..tlicr time- iikhc cMcn-ivc, occa-i.>iially i(nilc iniliirat<'il ; tlii-. it a|(|>car~ to inc, more readily aiicly as in thoc other ca-.-s, the aU'ection may assume the chara.'ter- of l.oth perityplilili- and paratvphlitis, or ot" a comhinatioii of l.oth. In one in-taiicc in private piactici! I (.hservcd the development (.f a retn. peritoneal ah^cc-, which w.is siiceessfiilly evacuated thrnn;,di a lumbar incision. Tvphoid perityphlitis is not ahuic of thei.relic inteie-t, hut it is* al-i> a (M.nditiou of practical imp..rtance. This is true .-peeiaily from the diai^nostic -tandpnint, and here, al.ove all, it is (.f importaiur when the atVection occuiN in association with sli-ht, ill-ch'tined, at tiine.s protracted eases of typhoid fovor, or in tliu course of an att;iek of auil.ulatory typhoid fever. Tlius, I have observed I'ases in which, durin'.' residence in the liospifal fi.llowini,' a |HTiod of ^elle|•al malai.se of tVoiii twelve to titteeii day.-' diirati(.ii or loie^iT. with irreirular fever, unattended with diarrliea anen- typhlitis. which suhseipieiitly wa.s verified either hy the further typical course of the dlsea.se or hv the urrenee of a (^haraeteristie relapse. I have ohserved eases of tvphoid perityphlitis in Herlin and in IfaiiihurL' in private practice as well a.s in hospital practice. rnt'ortunately, no reference is made to this siil.ject ill the statistics of S<'hult/.. Six of my cases from the I>'inii li.i- ;i In-M.U ri ijiMii. |p.ii-|iriil;irl\ lliii-c i\n<- 111 iii|iliiiv ..!' till- -|ili(n .incl llir iin-iiitcrii' :i' c-i-aiic iiiiircl cliniral iiiln |ii i lal ii .11. I'lic ran' ami-. aliiH'-l alw in-laiir( - .r |iii-|'.iraii.iii .,1 il lal-r liili lai'v |ia--a''-i - i|- 111' -(■(■uiiilarv aii-io- I i|' thr li\ir can ^ciicrally mily lie -ii-|ici'li i 1 ' 1 '.^KSi ALTERATIONS IN THE RESPIRATORY ORGANS. 'I'lic-f arr aiiioiiL: tin' t lV(i|iirni ami ihr imi-l \aiiiil ili-nnlrr- in the i'iilir-c 111' Ivhlii'i'l U\rv. '\'\\i\ cciii-i-i ill iiart .il'aclnal ci iliiplica- ilir alli IMlrllt lllHill t li,,ii- ami ~ii|m'-, 111 |iarl nl -Mriaiir aucaai a m- n liac'illu- 111' I'.liri'tli ami il- |iniclml-. A -liarji ililli rent iatimi lutwicii ilir iwii -rl- 111' riiiiililii'ii- i- mil. a- \(l, |io--iiilr ; il i-, ImwiAi r, |irii|i- jiil, lliat till' r\lrii-i\i calarrhal ami iiitaili iiillaiiinialnrx all('ralii'ii> in llir i-i-|>ii-aliir\ iiri^aii- i-|Hi'iall_\ lirlmi^^ iliuli i^ii-ally in llic xthikI (■al('jiir\ . Alterations in the Nose and the Nasopharynx ili. mi-c aiiil llir na-iiiiliar\ n\ iiiiili' ijtnrrailx cxliiliil at tlic lir;:iiiniii'. ami at ihc lui-iit 111' tlir ili-ca-r till' rnmliliiiii 111' -I'-rallnl ilfv catarrli. 'I'lii' iiiiii'i.ii- Mimiliranr nl' tin- iiom' i- liki'ly In lir irililciinl ami -|ionj;y, ami il ri(i|miitl\ I'Nhiliii- a ilark-rcil. M'Uity -wdlinir, r-|M'i-ially nvir tlii' tniliinati'il liiiiic. Tin' M-cntinn 1-. iimlcr -nrli comlitinn-. i|iiit(' inml- ci-ati', :iml tlic iirilii'i' ami antrrinr |>iiiliiiii nl' tlic iia-al ravity arc dftcii ciivcnil witii a fnliciiinn- ilc|iu>it. 1 1' llic naMil easily Kc vci-y narmw nminallv nr in ciin-ccini'nn' ul' roTiL'ciiital ili('iiinl, it inii>t he cin|iha>iz("il ttiat the oi'dinarv <\' typlmid U'vcr. S'vcrc inl'ci'tioii- c.imlition- with a i)rchns fever and inliil- ciiza es|,|.ciallv wimld have to lie ciinharyn\-, which, when expelled in the form of -anL'^niiiolcnt -])nlnni, may irive ri-e to niinccessary alarm, (inite Mi//'/'*i/s- AMI I m1 miirmi- imrii •J.'.O 1^ -u liiall\i- iiciiii- 11 ll~ I- iill-CIVill llV tiir llir iiiiiir ticijuiiills (liiiiii;^ the |ics ■ it i|ii-ta\i- liiiriiiL'^ l\|iliiilil tis rr uciiii' at llii- liim. Nn-i -Miiil i- li-^ iillrli; at till' l)i';.'illllill;_' ut ihf -(iiitlil Ur< k, u liili' it i^ iiiiciiiiuiiiiii at till' u\ii\]t 1)1" till' ili-ca-r, liiTnMiiliu' a^'aili -miirwliat ninri- t'n-i|Mriit ililliiii; the a-I ilay- uf the ti\ri-, in l\,r |m'I iml ut' -trc|i rlirvr-, ami (lmill;_' niiivalc— •iiiii'. lUccdiiii,' t'l'irii liii' iiu-c may lie ii|irati(Vtral tiiiio within I -hurt ]»riiMl, ami it may iK-ca-iuiially !»• -u |ii(itii-c that, in -|iitf >>i' ijiliiin ut' the |>aliiiil at lii-l. it may I a lali' iK'i-iuil in tln' tilifili' ii'riit ariirliuialiun uf tl a|i|> i:ri'atl\' (lr|irc-- l!mi ; ami wlirn it ucciii- at a -tai^i' u|- iliiiin;^ runvalc-i-cm-r, ii mav In- ilircctly a -onrcc ul ihinp ii II a mmiliiT ut ui^laiirt'w I liavi' uliscrvcil jialiciil.- iiinlfr siicli (•omliliciii.s rriliirt'il to an alaniiiiu ua.- cuiiiiicllcii to nsorl to folate of ilchililv. 1 1 !(' rase III jirivalc prai ti.r 1 siil)ciilaiu"oiis iiifii>ioii ot' iilooil, anil in aiiotliif lo il roihicc saline infusion liciicatli the skin, in onliT lo overcome the iniiiemliii;,' ilaiiL'er. laelHTineisler has oliserved '1 fatal anil Mriini|)e II 1. T: |ioiiaile of the ni rarely nccessarv. ■veil from hehiinl s\itli IJell |'s eaniuihi, is not at all It niav lie mentiuniil t'nrllicr that iiu-i-lih id iilav- a nut ii fant n'l/i in tl le oaM's 1 •t' liiinurihao-ie ty|>hiiiil ti\ri-, '.vliirli, tiirtiiiiatrl\ •nr hilt ranlv, and arc atlcndcd with sii ch a ).n'avc jirui^nu-is. Ajiart fruni tiicM' licmuriliai:i<- cases, which nia\' ucciir at ai ly ao^c, vunn^r pcr- Miiis arc pai'tiinlarK likdv tn he altacked with nusc-hlced ; cliililren under tlie aire ut' ten years le.-> eunmiunly, it is true, tiian older ones. Kpistaxis, in my e.\|>erienee, rarely ueeiirs after the furticth ur furtv-fiftli d it till year, ami it then uceiir- alinust s,ii,.|y m persniis prcseiitintr other ttre- ili-|iii»iiiir eundiliiiiis, either local ur ircneral, as, fur instance, elinmic ah'uhuli^m. N\ ith icfxanl tu the frei|iieiicy of epistaxis in iretieral, it may Ix' stateuiiil — a prupurtioii that api)ruxiiiiatis that fuiiiid by FiielH'rnicist<'r (7.") per cent.). Cruiipous and diphtheric aHeetiuns (<{" the nasal inneuus niotnbrane, which are rather trc(|iiently mentioned in ulder writinir-, I have observed with extreme rarity in cases of typlmid fever. When ]irescnt nt all. they iweurred alniust exclusively in n^^sociatiun with similar ])n)ce>ses in the pharynx and n|m!i the tonsils, in which they likewise occur but exeeptionally. Larynx, Trachea, and Bronchi If thise stnicturos ,4' patients with typhoid fever are freijuently exaniiued, some spon^incss J 111 I mi -ff^: / ) rii'iih 1 1 \ /:i; Miiil ii ilri( -- .1 till' I inn I III- iiic mill ,1111 w II .1 III! I.ll-r iimI r:iri'l\ III' liiiiinl in tl I, nii|~ ainl llii' ars I I'l r.ii't ila^'i-, iirip|>alil\ al-ii -li;^lil ili-i'.i|i'laU'iii ,.| llir Inn \i,ral ImimI-, i-|.(rlall\ at llirir iM.iiil- n\ allarliiiiiiil, ami lalliir al tin |"i-li ii.ir liiaii al lln aiili lioi- ii,, 111. 111. 'Ilir lai'v Ml:' al iiiiirnu- iiiiiiilirain al-.i |rii-riii- an a|p|Maranii (iT ilr\ II"--. I lir Mill < "I till' |i:iliiiil niiil. 1- -inli rniiiiii-lani i- i- wiak, iiiici I'tain, .,iiii -iiini u lial li-iai-r M. inniiiiiniriil ralanlial laiv iiiiili- witli I -|ii c lalU iiiaiivi'i -\ iii|>lii|ii- I-, III! till la' I, it I- aliii'i-l a- ran a- niarUiil ri.i'\/a. ■ riliar\ . iinl tV('i|iii'ii! — in "In- nin-l a:jaiu lir i|ilia-i/iil in rontia-I uilli I\|ilin- livn', in tlic iliai.'ii"-i- "t w liii'li il ami ar\ ni;i'ai ralaiiii i- p'lnialK i.l iin|"irlaiii < »| ._;i'ial iniiiiiilaiii .••ii tin- ■.ihrr liainl, in ••■.>- 'I art' nmrr |ii'nliiuiiii all i linii- nl' t iiii-inliranc, ami |iiiirliiimlrili-. I I 'I' i\ iiimiii i; 111' lai \ n\, nil riali'iii "t tin' nnn oil- II 111 null 111 il, tciini. ami ii'iir-f il till -I' n iliilil loll- al I \ jural llial till iiiii'-li..ii ai i-i All' Il III. Ill tl.i' i'liii|iii;i ir -Iaml|i..iiil. a pari nl lln' l\ .ill I'.'M'i' ii-.ir .\llli"iii;li little i- a- vil known in llii- ronni.-'l ion iVoin llir l.arti rio- lo'^ii- -tanil|ioiiil, all allii mat i\ .■ lomln-i. .n willi rri:aril to-..inrot' ihc alli'i'alion- i- iiii.-l |ir..lialiii t'.'ia nnnilni' ol ri'a-.iii-. A- i- Km.wri, 1 1 nil' liaM' I II I II iliinon-iiali il (< oi nil ami Uaiu iii. ami otlirr- ) in ra-rs ot' l\|ilioiil li\i'r, n|i..li llir |io-lrii..|' wall ..T llir lai'NIlX, lirtwcili tlic iioiiil- of attai'lnm 111 of ihr \-. ical lialiil-. in tin \ iiiiiilyof tlif ar\ tilioiil i-artilaui' ami inioii t 111' I'liiL'lotli I-. r-l>('i'iall\ a t it- lia-c, lnrinatioii- ■li an- to III' lo..ki'i| ii|ioii a- ri'iTiilly inlillratiil ly ni|ili-t'olli('li-, paralilr with -iiiiilar li-ioii- in tlir inti-l.m' ami in otlnr ii.irli.iii- nl' lioilv. A- |,r('\ion-l\ m. mi.. m.l i -rr -ntion on l'atlioln;:y ), Si'lniltz has h, I I.l ili'inoii-tratf tin' 'vph' Hl-harllll ill thi-r I'ollirli- ill ill I.iki' thr ti.llii'li- in till- inti-ti '\lillilt .1 liial kill t-mli'iirv to nmii'i-ij-o nccrnlir ilr-tnnli alliirili'il for thi' ilrvrluii Thr I rnaiincr. an (liriilnl. It atVfcti 11, -o lliat tlnrcliy a liirall- is II'-- ilirp ami i'\ti'n-i\'r illi'cl,-. if till lar\ n\ t.iki- |ilari' in thi- I iiMW iiftiii It i- ihli' to olhiT caii-i*-. ran at |iri'-inl Hot li(> ri'inirnrv w i iiictit ot iiiorr or til whii-ii nlri'i'Mti 1- ciTtain, liowi'V r tli't llii iht ilithi'iir a ml |i-rniloili|i|iilit'ru' Iticrtlnn-. wlilrli ittrii wiiT liilil i-i-]ion-ilii liy carliir wiiiir-, have ■tnliiallv Ihtoiiic lr-< fVi'i|n. iitly a ■aii-i' ol till- roinlilioii. ^iiiitlicr inoijr .1' oriirin for nli'rration ipprars ijiii tr fmini'tit. Tl if till' lar\ii\, Il Its fr II' ilitmn thru iv-iilts tnnii -ma at first -liallow. Ii--iiri's am! cro-ions iiivoii the postcro-intcrii ll wall of thr larynv, liitwicn tin l^f tlip vocal liaml-. wliii /ti'iioiii rartihiL'f^ :imi tin' point- of attai-liimiit ■h 1.- loll-, olivilill-lv, lit vclop as II con-i'ijncm'c of the I i\|ii'i'i'iiiia ai il ilrviicss of the inuniii- mciiibr.i brani' and the iiiclvastHl N ) 1//7'/ 1/v I \/, I o 1//7 /< I I /<,\S. 2\\ ri-|iiiMl'pi\ .iili\ il\ ami liiiiiii nl c-.iii:.'li. W ri -ii'li -inall ti--iiii- .iiii illi> li.il 1 \''c.iiali'pii- Iia\i oiiir ill \i loiiiil, llii- iii'uci--, i.uiii_' |i. ill) li iii|i II' ■> I'p I i--iii-
  • r IV iiliiMil ariiiiii|i:iiiii-i itiliri- ii.in|iliialiiiir I'liinliliMU-, attain- a roii-iili laMi i|i |itli. I'll. til till lllii I- rr-llllilli; lliilll tlir Ilcrrii-i- of liillu'lr-. llnl tim-i' clllf til ti--iiir- ami I'fi i-ii>ii-. iiia\ iiiMiUc an I iH-mtiali ll 11 iini 'oil- niciii- liiam- 111 a vars iii'_' iMiiit. W I II 11 ll|i\ lll\iiiiiliiiL: i\ -i \ ■ n . ilaimi imi-. ami, iiinli'f lllr Mlii-t l;l\ 'ilalilr rilrlllll-tallii-, |iliitlaitiil -ii|i|il-. Illa\ I'l-lllt. W'l, tliiT -iiiji ili-i|i iilii-r- i-aii. jiv ri-a-iiii ut' tin ir incnic' n|' nnL'iti. Ik' ilcsiiriiMli'ii .Iciailiiial iii lln' -irul si'U-i- |)illnrli :>!• Iia> lniu ilmic l.v carliiT writer- ilni',- iimI M|i]ii ar !'• Im- ilrtiniti'lv ilitrriiiiiii'il. I lulicvr tlial al the |iri'.-i lit ila\ a inrrirt iipiiii|iiiiiii rauiint In- iMrimii ul' llic iiifcliaiii.-m liv uliiili -ii'li ulrcratimi i.- Iirua.'lil almui. 'I'lir -I'at lit' till- I'lyii^'ral iiln'raliuM i- n ni-taiit. aliiin-t tv[iiral. \- a- liri-ii imiitiiiiiiil. It I- imi-l lrriiiiri:tl\ -itiiati'd uiium t' |MI-tl-fll Wall 111' till- lar\ ii\, lAlrinlia'j- at tiiiir- tn lIn' rmit lui.nii- |iii|-tii i|i- nt' tlr ittailiiiii lit- 111' till' \nial liai I-. in tin- I: ilti r -iiiiatiiiii. It 1- Iriic, alnm^t -iilily ill the rm-iii nt' -liirlit i I'l-inii-. W'itli tlii- -rat nl' |iifililcrtiiin tiir llir iiln ratinii i- a--iiiiali-il tlir l-ii-t tliat -ii-i iinlarv |Mriihiiiiilrili- ami i-i- 111' till- i-ai-lila:;v iiivnlvi- in ll iiajiiritv 111' i-a-r- llic rrirnid ami af\tc inml raftilaurr-. iilliri' -itnaliiiii- in I lir in y|iliiiii| iilrir- a|i|iiar tn lie i|iiilf i-arc at liiinr 111' till- larynx. I liavc in mir in-lain'i' rrvcil. in a--iii'iatiiiii uitli iilcriatiuii ii|iiiii tin- jm-li lim- wall, cfii-iipii III' the ll It Miiti'iiailar liam!, I Icri'ati'iii uiTiir- lint niiii'li Ir-- I'liniinnnlv iipnn tlir ipitrluttis tli; it line- ii|iiiii till' |iii-trriiii' wall, liiil in i:iaii'ral it i- tlii-rc iniuli li-- ijr ami Ir-- r\tfii«. Vii'iirui. I'<'>n. pp L'.-.;i. L'OO. TYI'll'ill) Fl'VFIl ill one iii>t;ilii'<' (Ic^ti'iictimi nt' niic-tiiiiil ot' the ciiiMlnlti- liv ncf'nwl^, .•mil ill MiHitlici- iii>l:iiiii- iiciru^i-; ot' iiinrc tliMii liiilt'. Nixcrtli'^lc--, \\\y.\y\ f'nuii tlicsf cxtcii^ivc loioii-, atVcctinn* of ihc cpiu^lcitlis ;ii'c liv nn iikmiw ihiiiLT" ri>u- ;i> llii)>c nt'ilic inliiicii- nt'llic Imi'siix. '11 irv Ml'c nttcli liiil III' Mllprri-Kltlli hll even Iliitlrril liy tlir ~l ll|ii Hi ills ]iMtirlll. ami iit'till lirrm niil\ lliriiiij.'-li (litliciillv ill >\v:illii\viiii:-. ( liilv in r:i-i- in wliii-ji tliccmi- ^titiitiiiiial I litimi is i_'i':i\r, m' wlirn- \vr\ ixliii-; . dflrrts oxist in tlu' cpiirliittis, dm- aspiratii m- |iiiiiiiiiiiiiia ili\rlii|i. riic iiiiirli iiiiiic l'n'i|iiiiit |)riil'niiiiil lii-liirliancis due to ulceration oC till' intii'iiir ot" tiir larynx air nt' \ari(il kiiiil. IJctorc the nlcci'alivc ]il'iM-(>- rvtrml- ilnyly — nmn- t'iii|iiriit jy , inilinl, it' tlii> i> tile I'a-i' — filriiia lit' till' L^otlis may ilr\ri cnyii'i.Kwrioss. 1A,\ itlv witliuiit antfccdciit iilccrutiim i>t' tlic niiicinis mciTihninc, ;is is l(ch<-vt'(l l>v Ditt i-icli ;iiiii citlicrs, IS :is vt t mMl(i!iuiistr:!!tiex, children appear t» lie ran cxhihit ulceration ot' the larynx far more frcipu^ntlx- than woi third- of the ca-cs under mv oli-ervation oecnrrcil in iiiei ■tioii anleccdciit predi-po~ nvs infliienci Tw In tl prolialilv plav an inip( taut i-M, e-peclall\' clU-oIllc plia r- predomiiiantK' in men. Iari:cly as a iliarvnii'i'al and larvnireal catarrh, -iicli as re-nIt of -niokiiiL^ and ot' It i- douliirul wliether ulceration of the larynx oi'cnrs with especial I'. V,,,,,,//. ./, If, 1 si;; v. /;./-/.. isr.il. .N, 1 //.,-/ No. -JO. «/• ,;,i. .1. 1,1 s„ « ■■ Dh' I.ll r\ n\- iiii'i ■!'i-ii.hi':i-i.' -I iss:; n. ifr .Ir, .\1k1,i l';,ri-. ISiiH. \[\ iiliu- Uhil i)ii Iti'liiui.liun..;.' An-/,./. I.hii. Chn-_. |sst, lid. xxx. &i ■k.,r miu I S3K?^-?^t^ •2A\ ryriiniii ii:vi:i: fivnui'iirv. I„.u..vrr, HK.v !,.• n. , , M.i Mi rrl;nH uuu> mm.I -lunn. -vrunn ,.|.i,U.|,iir;. 11, i~ .> inirn.uplu,: '••AT :.> .Ml M> nf llu' liinn-..il ul. ■.■,■,.- li'm ,,f ivnlm. r.'x.r. whlrh at ■.■•:^•^ r.n^ ,■ M vrry .■,mr.i.icuou> tcMtuiv ..I llu. .i.i.i.'nnc; ^'<^■ i.i-la>i.T. .lu, ac l:i>I .-pi.l.M.n.' .>f tvi.hu> 1,'V.-,- at H,.i-lin, ul„.„ \ p.r .viit. ,.f all ■. i.viilin> |.ali.'Hl,s uii.l.r .mn nl,s.i-vali..n prrM'Ulr.l in..iv or lr>. luavkr,! ii,\..lv,.| lU ..f''if lannx, Tlir tiiiir ..f (-i-.'t and ill.' .ini'alinii (.f lai'VM-val iii.Tratinii in llir .•cuf-- nf tvj.lioi.l Irvcr aiv .Ativinciy .litliriilt •■> .i.KTininr. iiia-iiiii.li a- the iiiiMrr ir-ion-. a^ xwll a- tli.-,. that Hil>M',|U,ntly |.mi>u.' a M'vnv .•..in-.., aiv likrly to W al-im-t Ww tVoiii >\ iniHoin- at tlir oiit- >,.t. 'I'lic .Ir.'iilv -IniM.r..ii- i-ati.-iit- for cxaniinali'.n ,.f the lai-viix. It may \,v -aid in nvif.-ai that ulcTatimi uf the larvnx ,„-,-iir- .■liirtly at th.' !m i-ht nl' lh<' -li-ca-c and in llir ImII.t part nf the fnhi-ilr -tauv! i,rin.i|.ally at a lini.^ wlim cxfnliatinn nf tiic >lnnd,> and ci.atri/atinn nf the nl.vr- in tiir intotinr arc taUin- idanlatcd in>tan(v- I iiavc nl.scrwd, hntli l-y laiynp-cupir .xaininatinn and at an* ,p^v. „lr,.fati..n nf tlf laiynx a- .'ai-ly a- the l,.-innin.L' -f the tliifd wrck : in niif iiiMancc. cvii at tlir l.r^rjnniiii: nf tlic Mv.md wcrk, tlicrc \va- a dfc'i. iiliTf npnii the po-tfrinr wail nf the larynx. Wiicn liic alTrctinii- nf the lafynx triv.' ri>r tn ^ytnIltnnl-, these \vill 1„. nin.t vaiial.le— ln.al pain. ditVienlty in -wallnwin^ as>nciatcymp- tnm- nf aente ..U^ma nf tlie -Intlis may set in .|"it«' sn.ldenly, l..f;.re theiv is anv r.asnn fm thinkiiiLr nf sefiniis disease uf the larynx. Kverv ivi.hnid pati.nt with laryngeal symptnin< slmnhi thei-efn.v he Mll.jeeted tn siH.Mal nlxefvati-n. Thi- ajiplies part ie.ilarly tn th<' thri,at an.l h.rvnx in -evere ea-e- wlter. tlf patients are Mtipnrntis. With ev.Tv inrrea-e in iv-pu-atnry fre.|neney, with tif .lev,l.,pment nf dv-pnea a.'.d evann-i^. inv.ilvem.nt nf the larynx sh.mhl, amnitir nther things alwav-'l.e tl.nnjrht nf as a ran-.'. Mor,. than nne imf..rtnnate ea-e i- knnwn in wltieh -nperf.eial nh-ervefs attrihnte.l -n.Oi SS. 245 I'.illdwiii;.' tlio siiir^cstii'ii oi' l{i)kitaii>l' ill wliicii cxtciiriM' larviijiiai >yiii|ituin> ajipi^ar ijiiito early. I euii>i(lere(l tliis (k^ie-iiaticiii arbitrary aiul scarcely jiisiilieil. Smie reiiiaiks ujHiu paralvr-is of tiie vocal cords will lie iiuule in the slK'ceciliii;^ cliaptt'l'. Trachea and Iv tracheitis and hronchitis arc anioiiji the ccc Anatomy). The-c conditions are nianitcsted clini- cally Ky dry coiifrji, tenderness, and a scll^e ot' soreness hehind the sternum, and tlic-c .-yniptoms are more i'rciitiently com|>laiiK'tl of since tln' tracheitis is likely to ajipear at the end of the tirst and the heijin- ninj: of the second week ; theretiirc, at a time when intelligence is still preserved. On aiiscnltation, coarse, dry n'llcs, sonorous and sihilant, ran l)(> heard. The sii]K'ticial ero^ions of the miieous incmbiiine that are cnconntcreil on p<>~t-iiiortcm exaniinatiou give rise to no .spe\tcnt that tiie ])ossibility of compression of the tnichea or of the large bronchi in con~c(|iience can readily be conceived. In some iii-tances in severe ca-cs of typhoid fever I have, in fact, ob-crvcd rcmarkablv enfeebled, soft breathing upon one side, when no adeidcreil the eaiHc f tills kind, and therctbrc lcri(i~i> diif tci j;!;ui,~ nt' bnnicliial 1\ iiipliatic .;lau(l~ a> tlic |Miiiit nt' tirijriii oi' llie ciiiniiliiaticni. riic catarrh of the medium-sized and smallest ramifi- cations of the bronchial tubes i- a iUhmi ciuiiiniiatidn of tlic calarrlial t'Oiuliliuiis |irc.-int in the iai|;c r air-pa-^airo. By icaMiii df tlio coiistaiicv of ii> occmrciiif, ilii' |H(uliarily of its >yiniitiiiiL> and its comx', 1 l)(lii'\c' tliat it can lie dctinitfiy iooki d ujinn a> a -|H'cilic ty|ili(iid s\ injiioin, and may \w attril>ntcnl)>ei|U(nt writers do not attach to it tliis >it;nilieanee, and altlioutrli tlie former even lielieves tliat he ol'>erve(l hronehiti- far more fre(|Meiitly in ca-e- ot' typlins tiian in liio-e of typlioiil liver, this po-ition i> not wiioliy in accordance with tiie i'aets. I'lie bronchitis altenchii;,^ ly|iinis fever pnrsne- its eonrse witli much more proiiounceil svmptoms, parti<'idarly more marixcd cou^ih and more al)nn(lant secretion ; while in ca-cs of tyjihoid fe\cr, liy rea-on of the slij:ht (ie;;reeof swiilinj,' and si)on;:ine-s of the mneoiis memliraiic and tiie .-mall amonnt of secretion, conLrh i- less frei|iient and le>> se\ ci'e, ae cx|ui'toration is almo.~t always wanting;-. If, howexei', thi' patient- are examined carefully at the heijiht of the fclirilc -tai:v. jihy-ical -iiii.s of bronchitis and hnnichinlili at times, il i- trne. Iml A\c demon-ti'ahle in some dru'i'ee. A- early a- the end of ihr fir-1 or the liiHinniuir ot' the -econd week, and from tliis time on throiio^lmnt the entire t'elirile ])criod. roiiiihcmcl, t're(|Meiitly enfeclilcd. vesicular inspira- tion is audilile, at time- \vith proloULialion of cx|iiration, and sometimes with an aliundanci', and at olhcr lime- with a >careity, oi' dry rale-^ of sonorous and sibilant (|nalily. The -eat of -uch catarrhal condilion- i- c-pecially in the lower lobes. Not rarelv. and especiallv in -even' ca-c-. they . \tcnd throiiLihout the entire hum'. In tho-c -itualions in which cMcusivc bronchiolitis i- jiresont, maririnal emiihy-cnia may develop. Iv'ai'ely. the antcrioi' and upper jvirtioti- of tin- Inn-.:- are in\ol\cd lir-t and nio-t markedly. Such eases -honid be \icwcd with -u-picion, and \w invcsti^'-atiHl lor complications with e-pccial care. It ha- been -lale-tii' ami tVinii a |l^ofr|l(,^li(• >taii oini'ially of >ij.riiiticaii(r lid'aii-c ctlicr iiil'ctT-,iete (leivc, when a|)iKirciit ititistinal catanh, even of >li^ht intensity, i> from tlic outset asscM^iatcd witii e\ten-ive lnoiieliitis. It is to lie iioteil that tile (lejrpec ami the extent of the lironeiiiti- in ca-t's ol" typhoid tever nee. The reverse, it is true, is less common. From a prnirno-tic jMiint of view it is al-o noteworthy that after intense catarriial conditions of early on~et, scveic involvement of the liiiij;- imnicdiiilely adjacent is likely ^ul)M'erved them, and have not(Hl their disap])eannicc without tnices at the termina- tion ot' the attack of typhoid t'cvcr. In iMilatearticularly to the capillary variety. Clinically these con- ditions arc ol'tcii r(KMnrni/al>lc with ilitlicidty it' at all, and this is e-peciallv true of atclccta>is. Bronchopneumonia, which occasionally manifests itself hy increase in the fever, chan^'^e in t'u' chanicter of the ex|KH'tor:ition, i^nd occasionally also hy di-tinctive auscultatory sitrns, ha^ been little invcsti- jratcil t'roin the etiolofxic point of view. In the majority of cases this condition is donhtlcss to he includeil amonir the true complications. In the small nnnilKT of cases thus far investijr.itiMl, principallv the pvopnic liacteria, streptococci, and staphylococci have lieen found. Without dipiilit, lironcliopneumonia in;iy also he of sjH'eilic typhoid chanicter, as i- shown hy the invest ipit ions ol' Polyiicre,' l-'inklcr,- and others, who wii-c uhle to dcnionstnitc the hacilhis of Kherth as the excitiuir caiiscof the inllammation. '\'\ir extremely y:rave c.m-i- of acute edema of the lun^s, which arc fortunately rare, are also dependent u]H)n I'Xtcnsive ' Th'sr, I'iiris, ISH!). ritcd l.y V'iiiklrr. ' l>ir acittrn LungeurnizuniiniKjcn, Wii.'sbadi'ri, 1889. Ill ^1 ■t^^-^t 'fi W^ m i ^■^t i 248 TYrii'iin ii:vi:n. Iiniii(lhi|iii(iiiiiiiiii;i mill cardiac \vcakiic>~ \\\i\\ acute uti-ct, nr with aciiic inicii~ilicatiiiii. i'.niiicliii|iiiciiiiioni:i likc\vi-c ci>n-titiit(- tlic u-iial l)a-i> fur tlio hypostatic congestion of ilic Idwcr IoIh- nf tlic Imi;^^ iliai ..ccurs M) t'i\'i|iicntly III llic latter part nt' tlic t'chrilc .-taL''c ; it- <1c\i|ii]pmiciiI is uIhi tlivoiid, liiiwcNcr, l)v the \\eakiie>s ol' the heart and the iiilliieiici' of tile |K)^tiire nt' the limlv ii|inii the di-tril)iilirin> an iiii|Hirtaiit link in the chain of iiiilavnraMe occurrence- in the eoiii'M' lit' ty|iliiiiil fever. In patients pre-eiitin^ e-|)eeially -e\ ere iiifec- tiiiii and alnadv iiiucli rediiciil, the hvpn-ta-i- dc\clii|)- a- earl\ a- the first hall' of the fehrile slaye nr at its heij;lit, and it i- then nt' espe .with pri)|nn;ied cmirse tiillnw in;,' an aiilecedeiit severe attack. Ill the al)>eiice nf Msteiiiatic c.irefiil exainiiiatinii uf tlii' jiatieiit, fur which there is nt'tcii im s|ic(ial indicatinii, this hypn-tasis niav he rcadilv nverliKiked, as in itselt' it irives ri-c neither tn elevatimi nf tetii|ieralure, pain nil lireatliiiii:, imr tn increa-ed enuirh, and liy im iiieans always to ehaiiifes in the trcipiciicv and the characler <>{' the re-piralimis. On the other hand, physical exaininatinii will at niicc yield the desired iiitltr- niatimi. There will he tiuiiid slijrlitly tyni|)aiiitic nr even niarkedlv impaired re-ntiaiiee, pn^terinrly and iiiferinrly, at tir-t iit'ten cniilined to one side, thniiirli siilp-eipieiitly Usually iiiaiked iipnii linth sides. The vi«'al fremitus is jrenerally iimderatcly increaMil it' the patient can lie indiieed tn siilimit tn invc~titr;itinn nf tlii> pheiiiimcnnii, lint iint rarely it is eiifecl)le-eiit when the liiniichi arc tilled with secre- tion. The respinitnrv niiirmnr i- aecnidinc-ly iiidi-tinct, -nt't, iin Iniijrcr vesieiil.ar, and expiration is prnlnnccd, with a luniicliial character. If the eonifestinii |irn(ri'|.s-e-. fnilher, the rc-piraloiy niiirmiir hecnines markedly hrniicliial and the r.'iles ainphnric. Nut rarely in-piratinii is eoinplctclv nhsciiri^d liv crepitant nr -ulicnpitant rales. With imprnvement in the reniaininir syiii|)tnms t\\' the disea>e sueli ennsnlidation iisiiallv nndci'irnes re-nliitinii. as a re-iilt nf a]i|irii|iriate treatment or witlimit s])ecial intervi ntinn, and is ii-nally fnllnwcd liy no se(|iiels. In some eases, with eiintiiiniil |)rnirre-s of the disease the syiii[>toms of eniisnlidatinii mav increase and extend. ( ntisideralilc clcvatinii nf te:M|>eratiire mav occur assneiated with rc|)eatc(l ehilline-s or even a iii.irkcd chill. I'lidcr such civcnnistances a conditinn nf .\)Mri<>MS .\.\l> I OMI'I.I'W lli>\S. Il'.t hypostatic pneumonia may ■.\\>\< Mvh liukcii cii. Ill .lonh i'|irii(|c'iil li|Mill Ihc > ■ciiiiiilarv iii\ a-i'U lit exciting iifciits il' iiillainiiiMliciii, priuiiiiMlly i1iiimii;1i llir iii-|iii( [)o-tatic ])iii'iiii II una IS u lie lit' tiif must (laiiLicnills (■iiiiililicatiuii,- llt t\()llliHl tcVcl Dfath li nil'-- 111 till' nia|i iiitv iif cas iil.l ivtrv cM-iic, -low (li«aii]>('araiici' i .f the 1)1 ])liv-iial -ijriis ; with a pHH trac'tcelf i> iian ill adults. hie less to the eardiac weakiies.s mv ex|Hrieiiee no ies.s eoiiinioii in children I>t's ot' coii-ideralile duration. Altl ll the oii-et and the conr>e of e'eniliiie ''laiiKHls pnetinionia are usually most eliar;icteristic, the symptoins when it occurs as a com- pliealioii of typhoid fever are exceediiiLrly inconstant. Kveii tlic manner in wliicli it maniti'sts itscit' i- extremely variahle. Generally it sets in with a sinirle or repeatcil cliilliiiess. or a true chill, although these sym]i- toms may he wliuUv waiitinir. 'I'lie ali>ciiee of cliilly symptoms is 260 TV rill nil 1 1 \i:i:. i ^^'•f-/' 1^. T.TWt'^ H iilc |Haioil and llic rc-olntion coin.idi- willi the lii'iiiination of' ilii- |iiii.,d, lliii'f niav (icca>ioiially he a ditiiiilr riiiical diiUni' in lrin|)rialnii'. 1 1', on the otlirr liand. lln' |iniiiiiionia iiiidi r^oi- i-i -oliiii.iii in llic coinx' of the I'a-liLiinni, llie (a'ilical drrlinr i- waiiliiii;, a- a rnlr. and (lcl'cr\i'>cv i\-i-- lakc» IN |iiari'. All cases ol' |in< ninoii'::. even tlio~c tliai do not nivc rise to marked I'levatioii lit' tcmncratiiii . arc attended willi coii-idcralile ini'rea-e in ]inl-e-t'ri'(|ncnc_v ; and in dcliilitalcd |ici-oii^ are eciici'alK a--orialed witli ivdiieiioii in ^i/c and eon-idcralilc louciine oi' ten-ion ot'tlie |inlsc. A e.iire-|)ondiiii:- iiicrea-c in tVeijUeiicv ot' ii-|iiialion and in c\aiiosis are nalnrally (jiiile eoinmon. 'I'liere is tlicrctlire all the more rea-on to look I'or tlic-c -yin|itoni-- in ca-cs ot' ~n-|,ected |incnmonia clnrinc- l\ plioid fe\ir, liecaii-c under tlie-e eirciiin-taii'-i-. -iilpjecliNc coiiijilaint. |iarticii- larly ot |iain in tlie -iile. a- well a- ol' coiii;li and e\|icetoration, i- ot'teii ^\antill'_^ llic ali-eiiec of jiain and tlic -li^lil clianicti'i' ot' tlie iectoration i>|ion the laet that the |ialicnt e\|iel-. tlie>|intmn iiii|ier- lectly and s\\allo\\> it aeain, in jiart ]io--ililv also ii|H>n it- -ecrclioii In relatively small amount. W hen the patii'iil e'leci- the ,-|)ntiiiii, it may lie eliaracteri-tiealK' \ i-i'id. i'ii-l\, or e\en mori> hcinorrhai^ie. I have an ini|ircs-ion that the la-t mentioned |icenliaritv i- more t'rci|ncnt in cases ot' imeiimoiiia iom|ilii-atinir Ivjiiioid fever than in tho,-e of j^cnniiic ]in('iiinonia. \\ ith reL'';ird to ii- >eal and the jili\-ical siLTiis. tihriiioii- jimnmoiiia atteiidiiiL'' typhoid fever diU'er- littli' from that ari-inji- indc]icnilcnllv. As to the coiir-e, the heij^ht of the iiitill ration a])|)cars to me to lie at time- rcaehiKl more -lowly, and resolution al-o is not i-arcl\- com|ile;elowIy than in the inde|ienilcnt form. .\ coiisidcralilc nnmlier of rases do not advance lievund the -vm]itom- of contre-tion. That the\-, nevertheless, are eases of tilirinoiis |)iieiimoiiia. I have re|)eatel FiliriiioiiM |iiii'iitiii>niii is not otic of llir iiiurr <'(iiiirriiiii niiii|.|irMli<>i]:' in t!n' cipiirr-c of l\|ilioiil I'cvir. lis i>(i>iially unl in |«i>si'>siipn i>f larL'c slali.n>|Mirliiin cit' ilif i-axs liiihcrto rc|Mirtcd iiavc not liccn :iindiril with siitficii'nl care IVcim tiic liacliiiidoirii' >laninl, and llic n'sidt.- nt' >tudv of till! rcniaindtr art' inir(lial)li'. F.vtii liii' older unaloniic >Iatt'Mi»nls arc to !>(• a('ct'|ilt'il «ilh rcMrvalinn. as in cases ol' typhoid tiver, in con- >ci|iiencc ot' certain iiisloioLMc coinlilions. the pncnnionia (ie|H'n(h'nt ii|M>n cnca|isnlatcii cocci ina\. n|)oii section, cxhiliit an unusual color ami a >niooili or sliidilly i_'ranuhir surl'a. The nUi- |ila\cd liv the di|)lol>acillus of Kriedl.indcr, as cornjmred to the F'rankcl-Weichsclhautn coccus, in the dcvclopiucnl ot' pneumonia in the course ot'tvphoid fever, is filiscurc. In tlnw cases in which examination luus heen made as to this ]«iint, the diplococcus es|K'cially has Keen found, and oidv in rare instances lh(> hacillus of I'riedhmdcr. which I have perMiiially heen alile to demou>lrale in oidy 1 case. Other Varieties of Lobar Pneumonia. — In addition to hypo- static and true lilirinon- |>neuiiiiiiiia, (.iher varielic- of loliar piiemnonia certainly o<'cnr, 'I'lii^v have, as yet, not lieeii llniron^ldy in\(-tiirated, and a ]>iiilion ot" that which i> -aid to have Kei ii -iirely c|ctuoii»ti-.ited need-- -till fui'tlier inve-tiirition. 'I'lii- i- true, aliovc all, of the ca-es (if loliar pneumonia attrihiitaitlc to ly phoid-liaeilli ( iirnneaii,' < 'haiitc- liie>-e.- I'dlvnere,' i'inklcr'). 'j'hu-, I'cdync'ie fmnd, in adilltion to the loliular pneumonia ali'cadx inentioucil, (Aten-iv'e cou-olidation due to the liaciihis of Khertli. I'.aily occiivreu the excitiiij; atreiit ot' the iiitianiinatory proce->. It is al>o olijected l)v opponents of the view that s|K'citi(' typhoid atlect ions ot' the liin^r- occur, that in tlie ca>e- where pure cultures of the Iv|tlioid-l)ai'iHi have heen t'oiind. the culture- were made >o late that the priniarv invaiKr had died -plrnni-piiliii'iii;iin- ilr lu fir\ r.' 1\ |ili"iilr, " n.-sr. l'iiri>, IK'.t:;. ' A..-, rif. ' /.■:•. nt. ' /,...-. rif. *l '5 »i I \\i, f^i h-- 252 7) /■//"//. 1 1 vii: III i»i 'ill _ V-"-^ inolii.i line III -tl( |ltnciic(i 111- -l:l|i|l\ liM'iil-ci |li:in xvilli Ii;j;imI t'< lluit illlr tu l\ |iliMiil-li:irilli. I iiiloiililolK llic-i- iiiicf(i-i.i" iii-tii- |il:i\ MM ilii|iMr- t;illl / /■/' ill lllr IIIIVcil illlcrlii.il- llial lVli|ll(llli > AVf .■|--iMi;lliiiiiiiiiMiicri iiiiil Niilli ||ii> liacillii- ill' l'!lii rill I l\:nliii-ky ' ). Siri|i|iiii.ccic |>iiriiiiiiinia 111' Iy|iliiii(l li'Xi r i- ilmilillr— In in inn-t lVc(|ii(iilK rnM-iilcrcd a- niii' 111 the nianili-Ialinn- nl' ticiicral -iimidarv -i|ilic inl'cclinn. I'ndcr -iirli ciriiiin-iaiiri- nilii'i- li-inii- due In ilii- nrt;ani-iii can he tiiiiiid in till- lindv allcr dcatli. and nl'tcn rviii diiiiiii.'- lilc. ( )nlv recently \vc Wire alile In deniiiii-lrate in a man t\MnI\-li\c \ear^ nid eiiilMilic ali-ie— e- nt' tile lins ni)elltaileart from mierii-in|iie ami iiaeterinln^iie exaiiiiii.itinii. <'an lie dilfereiiliated frniit tlle ntller Varietie- nllK with \ er\ _''reat dilliellllv. K'eeelllK, niinicrniis a I tempt- have liiin made, u it li I lie aid i if I lie i splnraturv lueille. In olitaiii I v: L.;. I r.,rfs.-l,r. .1 M,./.. Iss'.i, l!,l viii, ' S. 1- al-i till- rniiuiniiii.Mli"!!- ■■r N.in:i;iiin, ISn-lin. l^Vni. ii'ia-li., I88r,, No. ; J-'inkl.r. Wrh.iH.II 7, (■■.,„,. i ',,.•>. Mr. I.. ISSSuiid lS8;i;iind Kurliii.-ky, lui\ rit. ■'• S,., K,.,.li /,!„.,,, /),,, I ,.;,,-i,. Is'iT i .SlU/'/"'/N l.\/' I'lUI'I.K \ll'i.\S. 263 iiLiti ii:il tnuri tlif Inii;-'' ilniiiiir lite tor (Aiimlii:!! i'Mi. I liMVr |iir-oii;illy ;i\:iili'.l in\-f cinlilia-i/iil ;i- "f iiii|Hiil:iii(<- In. in lli.' cliniiiil, :iii.'<-i;iliv IVohi the .li:i;:n.)-lii-, iMiiiil of \icu, that |iiiiiiinoni:i liia\ ..cur cv.ii :it an cai'lv |i( ri."! in ilic i(.ur-c m|' ivphoi.! I'iMi. al linn- -., caily tlial it iiiav at tii'-l !"■ < -itli lol a- an in(lc|..nclrnl rmiilitiun. 'I'liii-, jiiu'iiMiMnic- inlillialioii- have rivi|U(nll\ lucn .ili-iivcd in tin !ii-l wtcU of Ivi.liniil li'MT, lAcii in the tii-I oli(lali(in lliiii lapiilly I'mIIow-; in my ( \|i.i-irn(c. ciltm iniuc ia|iiilly tlian in (lie ra-i' nt' nncxniilicaliHl I'l-ank |)ni iiiiKinia. -Ndl faivly, nndrr vucli lii-i'iini-tanic-., tlicic i- \\>> > viicclcratiori w lialcvcr, or ilic -pnlnin i< lint -I'lmtv anil i- not rlianictcri-lic, (■nn4ainini: no IiI.kmI, (■nca)i-niatcnnif-jnicc-likf in cli inictir. Ctriainot tlif -ulijtctn c rnaiii- t't-tations al-o arc nioic incoii-tant tliaii in ca-c- of p^rniinr pniil- itioiija. Ncvcrtlitic— -. Iiradaclic of nnn-nal -tvcrity and inorr oi- Ic-s marked -t'i|Hir arc -oon noti(t'itna- tion -ooii lieeoiiie- clear, espti'ially if at th( proper time, after tlie diM'ax' is of from -even to nine day-' dnration, eritii'al deferve-eeiiee, or, ill i'aet, aiiv remi--ion in the -yrnptom- doe- not take place, lint tin- pnenmonia in-tead remains -tationary, and a eontinnanee or an incna-e in the oidar^'crnent of the -|ileen, ro-cKihe, ineteori-m, pea— onp-iike st(Mi]-, and Itronciiitis in the previon-ly nninvolviil |Mirtions of the inni.'s make tln'ir ap|H'ai~aiiee, Such ca-e-, in analoiry with tiiose ot' iiephni- tvphoid pre\ ionslv tnii| vil'il- llifiiuirli till' aii-]pa--aL'-i- iiia\ cmiiii-, , ,r tn what lirsj-nc llic |iiiril- iiiMiiia i- |.i !"■ c i.ii-iiji |-i i| a- ijiii- |i> an Mini-iialK rai'K ami faff |ifiiiiaf\ i"cali/.ali"ii •'! t'l' 1 i.iita'.:iiiiii wliiili |ia- ;_'aiiiii| (iitfamr into (lir In i<|\ ll,fiiii;.r|i ill,' . ii-tMiiiafs [iMiial-. Ililwici; -in h , a-i- ami lli'i-r in uliirli till- |iiiriiniMiii, ri.ii-Mlii|alii.n (uciif- at a iat. f |.iii.H| afr llio-r in wliidi, allif an allaik nl aiiiliiilalniy t\|ilii'lii liAii-, a in fnilc-crncc nf a fila|i-i' -(I- ill \\illi -|priilii' |iiii'niiinnii' inrilifati'.ii. N\ '■ -liall in till- rnliifi' |ifiilialp|y liavc to ililU'fi iilialc ffnin |ini'iiiii<>- i>|ili"iil ill till- line iiiiilcii.'-ir >(ii-i- ilii.-c ca-i - in uliiili (.ili.r miifn- ip|.::mi-iii |iii(iiiiiiiriM-i'i, ~lri|)iiici.r(i, ami -Ia|ili\ Inriicri — liki\\i-r i_'i\i' 11-- 1" |iliiiu ii' iiitillfalidii in tlir i litial -lai.'^i ol' t\ |ilioi(l t'r\i'f. Sm li <■ litimi- fi |ifi-iiit ifiir (■iiiii|ilicatiip|i~ diifin;.'- a iicfind in w liirli ci.ni- liiiiatiipii-- i-afrly iif. aiiij in lli<-i' ca-i- llic rjiniral |iirliifc i.t' l\|i|i,.i(| liAcf may lif -ifaiiuri ly altiiid ami at linn- r\iii \\liiill\- nh-ciiriil. 1 lia\i- |ii'f-iiiially ppli-(i'\ iil ca-c- in wliidi |iMi'iiiii<>iiia liiic tu |ini iiimi- ippiii (l(\il.p|Mii iliiiiiiu- till. tl,--( \\,rU lit' an altaik of t\ jilioid t'r\if, wliili' fip-riphr ami -|iliiiir I iilafMciniiil a|i|i(afiil only -iili-fijiiciitiv, anil tlnai III Ipi li I'p dial ii|p tlif -itnalion. Jiiliri^liiiL' diniial r\iilfiiri' in frLranl tiitln>c !ilv|piral t'ppnns nl' |p|itiiiiin- ty|)liiiiil liaH liiiii I'lifiiinlu-ij liy K. WaL'inf.' Iml luitlni- li.' imf lii- pfcdf- I'l-s-iifs were alilf. on !ii iininl nf \\\,- .-latr nf klmw It iIl'i- at llif linir, tii iiiakf ail 1 liol PL'ir iliirifiiilialip.n . t iluir iiim-. 'I'h Ih' .-liaf|>ly ili.-i f iiiiiiialiil fruiii the ^M-^^ tliiis tar iiiiiihniiiil ami tlii> lla^ iiipt al\\a\> Iptrn ilmif. even until "itiiiii a frreiii peri. piI- ale lliiPM- tiiiiii- pit' :.'eiiiiiiie | piieiiianiiia wliieli, in iiPllMP|llenee ipt I'le 111" I i'.'ll il \ . ill I lie ^\ lll| i|c Plual ie .-ellM'. ipf' tile if t\ |illuili-like I'piirse. have lieeil ile- -iniIppI jpiiellliiiity |p|ip pjp 1. or. at time:*. tviilipi|p| jpiiell- iii"iii:i. Tlie eppiiilili. p, |.i-eMiit i.s uiiiliiiilileii,'. iMio nf iiillai atiiiii of tile liniL'-i, uliieli |.iii>iii> a |iartie\ilarly iinl'aviiralile eniirH', in e(iii>e<|iipiiet' nf iii'livipiiial l•i|■el||M^|alM■es. nr Ipip'aiiM' il eiiii.-iili:te> niie of tlie iiiaiiilestatioii^ ot one of I he other >e\ efc iiifepl ipiii- i li-. pfp 111-, a II ion L' " hull .-e|pt ieeiiiia, par- tieiilarly the ervpipijeii.-iip' \:iiip|\. i- lo he ineiiii .1 ahoxeall. In aihli- lippii ipp .-e|ilie |piieinii.iiiia. ih. mixi .| iiileeii..ii- p.l' iiihereu|pp-i- with the |p\oL:enie aLTeiil- that ha\c heeii ri|iealp.ily iiieiitipiiiepl lia\e heeii eoii>iilereil a.- piieii- nippty|p|ioiil iir lyplioiil-piieiniionia. ' Abscess of the lung I- eun-iili n d an e\i, edinudv fare i..iiipliea- li'iii 111' typlmid li\ef. .\li-ee--es are pri.lialiU eiieipiinlei-eil im.,-t fre- ' DeiJ.i,-/!. Ai;-h. f. I.r,„ M. - . IM wxv i,i;,l xlii. » S".' iho »tllt!-t!','- ■•!' K- \\ :i'_'l:'T. N) 1//'/ol/v I \/i / 0I//7 /r I /70.V.V •_'•").". i|iiiiillv a- nicla-tatii' plufiiiiiicna a--iiii:ii(.| wiili cuiiiiilical ini; ^ctii nil DWtiiia ; lliiA al-" i\(i|iiiMiiall\ oriiir a- -ii|iiiU nl' luliar, lilniii'Mi, |iiniiiMiiiiia. Ivmp ra-i- (it tlir lalirr variitx haM- i-umr iimli r riiv |Mr- ~oiial iili-(Tvalii)n. A- llicv ■Kciir, likr tln' |iiiiiiarv cli-ia-i . <~|>i(iallv ill llir latrr -ta;.'!- m|' i\ [ilinid l( vc i-, liny i/wi- li-r iiinli r iln iiin-t laMn-- ;ililc idinliliiMi- In c(iii-i(|iralili- rilanlalinii ut' cciiix ali -c iiicc, it' ilicv dn iml art a- llic laii-c inr a liilal Ic riiiiiialinii nt tin ili-ia-c. \\ it! Mt iliiiil't. tlic laltif i- iiKiic liUrly to occur a- a i-c~iilt ol' ali-cc-- nl' tlic liiii^ (mIIuvv iii;_r i\ plhiid l('\ cr, than it i- alter a I )-•!-- Inllnw iiii; -implc liliriiiiiii> |iiiciiiiii>iila. W lii'tliiT |iii<'iiiiiiiiiia dill' to tin 1\ |>lioii|-l>acili.i~ iiia\ l>i' I'ojluwc'd iiv til.' tiiriiialioii ot' an ali-cc-- lia- not \ct liccii c-ial)li-iii il, iiut it is ciilii:'lv |priil)al)ii', a- the l\ |ilioid-iiacillii- i> will know 11 to lie ail illili'|iciidi lit |iyo;_rciiic aLTiiil. Syiii|itoiii~ oi' pulmonary infarction, wliicli con-i-i, c—cntialiy in tlir dc\ f|o|iiiicMt III' an ariltc alcliialc consolidation, \\illi licinu|it\ -i-, I liavc oi(-ii'V((l rc|iiatcdl\ . It i~ iiio»t rrci|ncntly atti il'ilalilc to tlic di'tai liiiiciit of inaiaiitic tliioinlii in tin' i'ii.dit -idi tlic licait, 1 -|H'ciall\' , in tlic ani'icic and the aiiiiciilar a|>|iendi\. ( >i •a-ionalU , it i~ tiiic, the tlil'oinliiis i-i ijciivcd I'loni the |ieri|ihcial vein-. In -tii|>oioii~ patielit.- ilil'afctiun occur- now and airaiii without noteworthy -iiliiective iiiaiii- f'cstation-; ; tiii- i> innrc likely to he the ea-e -ince -Itch patient- do nut ■ e\|(e<'torate |)i'o|ieil\ . Mo-t rrei|nent|v aeeelcralioii of thi piiUe and of re-])iratorv rrei|iienev are al-o oh-crvcd. While inrarctiiin occurs in -otiic ca-es without a r'hiij and without clcvalioii of teiii|ieratuie, in others it -ct- in with a e'lill, and snh-c- ((ileiitly the tem|)enitili'e-eurve -hows -c|itic charactcri-lics. | have oli-ervcd the latter kind ot" -yiii|)toiiis e-|)eeial!\ iliirin;: cons alcsceiice. riie-c -\ niploiiis arc citlur the tir-t inatiife-tatinn- ot" a |i\eiuie disorder or are due to ciiiholi in tin iir-e ot' -iich a di-ordcr. and tlie-e ea-es aiiiiost always |)iii'sue an utit'avoralilc cour-c. I'liderthe tim-t tiivor- al)l(' conditions tlic-e lesion- arc l'oll,iw''Il:;iii1-III- riinccl'liril, \\c:iknr-- i.r ilii- Ill-all ami L;iiiiial iiiia. iat i^n |il..\ a i !• Ii riiiiiiiiiL;- .•.:/(■ ill il- ili\(|M|iin,iil. In 1 i\\~v I iili-i|-',il piiiiimnnia ili-M-raii- ■•rriir in llir .TiiHinr nt" oiin]iiii':iliiiL' lil'i'iniiu- |.iii iiiiinnia. I'lirtiiiialily mr llir patii iil, 1 In- li-iup rupliinMl iiiln llii |,|(iiral iavil\. aii'l ili^- >r.|Ur.-i nim u:k,- ilischavLicil iiilo ii. A ITMTlidll n|' llir liU- nialillM Mir In wl'llal, llll- coliMillli'llt |iUlrii| ciiiiiy- iiiia. iMLTlhi i- uitli llir :jaiiL'riiiiiii> |.iiriiiiii> nt hiULr. iiii'l m' ti> I'riiiL' alHUit a |itiaiiaiuiil i iin-. 'I'lir 'a-i- I'l' |inliii"iiar\ naiiiri'i'Hc ir-iiiliiiu iVmn llii' a-|i!i-:it!iiii n|' (|ic.iiM|"i-, .1 intirtit.ii- mall rial. Ji ii\crlaiil. !ii llii- rniincciinii a -Uirial '■'■/' i- |ila\ ill. arC'liJillL;' I" ln\ i \|irrii'llrr. Ii\ tllr imilv -ll|irr- tiii.il and ai-" Ia tlir inni'r |iri .I'l mml nlnial i\ r ll.nn nf |inriilinl imi- »iHiti-. and r-|MTiall\ li\ t lir la-i - nf lai-\ nigral nli-cialii m and |m ricliim- .' In d>i|il\ -tii|inr'.n- |ialirnl- -ndi •■■'iidilioii- rrinaiii (•niiccali'd tVi'in llir |ili\-ii-ian -m Iniii; a- llir lr-i'iii- aiv -till -mall, and iircninc di-linrl "uIn- al'lir tlir\ liasc allaim-d a irrlain iMriil. In addilii'ii to tile int'rriii.ii- inatciial- iiHnli"nrd. a-|iiratii 'li nt' paftirli-- ut' liHid i- al-o ocra-iimallv tlir caii-r ol' |ininiiiwiiia \\itli -> ruiidary nani'i'iiir. It >h(iiil(l nut lie t'lU'Lotlin in llii- cnniK rlion lliat a-|iiratii'ii i>t' |iaftirlr- lAcn "f ('. iii-idrralilr -i/v liv |)r .ti.iindl_\ -iii|ii.riin- [lat icnt- iicid nut j;i\ c I'ix' at (iiii-c til -|)ccial -\ in|it'im-. I liavf (iliMivi i liaiiLTi-riH' lit' aliim-i ilir entire Inwcr lnlie nf the rifrht liniL' ill a NniniL' man. lIu' caii.-c I'm- wliirh «as ili>r|(isccl unly ii|Hin ]Mi.--t- ninrtem cxaminatinii l'\- llir ili.-cii\ i-ry nl a (liiii- nt' ilrr(ini|Mi.sf(l meat iinpaiied in a larL'i- liioiirliu>. .\s -nli>e.|iiciilly apiuand. tlie |ialieiit iiad rc-ceivrd inial -nrre|'lili"ii>l\ al the lui-lil i.f the telirilc |M'i-i(iil. w hile lie la\ in a stunmou- -lati . and tin- lime ulieii a purlinii el' ihi.- ua.- a.^pinitt'd •.va> ii'il even iu'leil l.v the iieiLflili'irin.r |lalielll^. I,iel)erimi-ter lia- i'i-er\id ea-i'- ct' i ' leii-ive L''ani:i'<'iii' "•' the iimjr witlmiit anteeedenl inllaininalinn nl' tiie urpin (ir a-|ii'-alioii ut' liireiirn Imdie-, and he ha- atlrilmted the cunditi ii |i the niiil>nal >-e\-el-it\ ot the u;eneral di-tiirhanee nl' nntriliiHi. In \ie\viit'tlie larm' ex|ierieiie{' (it' llli- iili-er\er. the-i' ea-e- . 1 ri ■ e-|ieeia|ly IH ileUi Hi ll\ . I ha\e, tiill!!- Ilali 1\. n.it a- \ el eneolllili red -llell ea-e-. II i- |ieiiiliar ihal MunliiMHi enn-i.lered -anirreiie nftlie hnii: an exlreiiiely rare e.,in|ilieati.'n 111' ivplmid t'e\er. |le-a\\ Inn 1 irr 'J ia^e> « liieh t'niliiwcd I iiMiiiniain the emir-c' nl' l\ plieiil t'ever, ( )ii 1 lie el lier hand, l.ieliermei.-lcr enruUMlen'd L'-aiiL'reiie in i t ameiiLT '-•!" t'al.al ca-e-. il is (|iiile remarkaliio that 1* el' llis ea.-e.- eerlirred in llie rnur-e el' lliree limiilli-, ilurillL'' "liieh the iidsiiital ua- L're.-ilU ii\ erereu.led ami il "a- im|His.-iliie In pnivide -iiila- ,...,. ul-M Cur-rliiuunn. 'Da- I'L. Uli. !■. r. /.„ „. - II.i,„li,„ch ,/, U,i,. Mel., lUl. ii., :;. .\ull. li:; 1 SYMI'I'iMS A.\l> cnMrt KAIIoys. 257 lile livL'ifiiic cnihliliuiis. ( irifssiiijrt'r liasnliMTvcu L;;iii'_'r(iic in 7 cit' llScascM exarniiif'l |"'.-l incrliiii. liiiiiv Loips'u- >lali.-ti(> il i> i-iM-niilid in 1 It inrtaiicf.-' ill ■J"_'>i aiiliiii>ir>. 'I'liat tlic In i|iitiiiy ut' tlic pleurisy i- \aii(iii-i\ -lat< ut' tin- tffiii. It' v\rv\ riiciirii-crilinl |il(iiiiiii' t'liclinii, overy til>riii()U> ',li|>.»^it ii|«m tlir |ili Ilia In lax- nf luliar and Iwimlar i>!itiini(iiiiu or (itlicT t'ocai (li-- iiidcpclidciitly, psjk'- I'iallv tliosc attend (I with tlie de\ e|M|Hiieiit of iiiodenitc or lari;e etfll- >iun>, tlieii llie < litioii is a rar< euiTeiiee. W'lieii it oceiirs at all, it is a liianifestatioii ot' tlie late t'ehriie pi'liod or of eoii\aleseelice. I have exce|(tionallv eiieoiinleied |ileiiri>y dining; tlie first week which was siieh a ])romiiieiit featnre ot' the ease that the (lesiioii, and its primary etinlogic siiriiitieanee in a uuiiilier of these eases seems tliirly well estab- HsIukI (see section on I'atholoj'-v ). J'leiirisy in typhoid, just asunder other (•ireumstaiic<>s, is prohahl^ generally secondary to atf'ections of the lungs or of ot ,er contiguous stnietiires. Cases of empyema csjK'cially ' have heeii able to tm'c to antecedent di-ease of the lung. A number of heiuorrhagic etfiisions that ! have encouutereil proveiderable di-placeincnt of adjacent orgins, whrich, nevertheh'^s, iinderweiit absorption in the course of two weeks.- • Li'i'i'i'i'liT' ami Talaiiioii. K'mli •'"'.. issl. Ciriiiniri SiV. Dif r\r,fa''hrn LmHint- kri'.nktiiitt I,, Ia>, I'^'.il. ' It iiinv 111' cmisiiifTrd ii')tPWiirtli\ lliat in llii:- ra-i' tlic fliiiil nlrtaiiiid with tlic ''\|iliinitory ni'i'iili' ixhiliitcd t\ rharactcri-tir aL'L'liiliiialiiiL: 'Iti' t ii|m'1i lioiiillnn-cultures I'f tTiihi'ici-lmcilli ill tlu; saino Ut'i;rcc m Uif lil", .J-itcruMi cil' tin; imtii'iit. 17 IIL •; 4 i \ \ ■ i ^i 868 TVI'Iloin FKVER. p; The i.ii(i;nosis of sciiiiis cxiidatos in tlic coiir.-i' of typhoid fever is, aceonliiifr to my experienee not |);irticiil:irly imtiivonihie. Tliat it lias been <-on>i(leriHl so ii|hpii tiie autliority of Louis is n<^umouia and tuberculosis in cases of tvphoid fevei', which exhibit iiotliine: di-tinctivc i?MS , SYMI'TOMS AM) VOMl'I.lV.lTIOSS. 2->9 from tlie iiliysic;il- to (Icmoiistnitc tiil)ercU'-l):irilli in iiKxlcrate iiiiiiiIkt in the sputnni, in addition to tlie Friinkt'l-W'ciclisi'lbauni diplooK-ci. Exccptionallv, I liavc ol)si'rv(.'d the tiilxTculoiis priK-i'ss to a|)|>oai' in the t'onn of acute or siil)acnte ])rril)roncliitis. A case of tliis kind under inv ohservation betraii as t'ariy as the third week ; '1 otiier: and this appears to ho the more usual — ihirinj; eoiivaieseenee. As dire<'t examination of the hinirs under such eirenmstanees, particularly at the hefrinninir, vields only uncertain residts, such eases may Ik^ the sdurce tor various errors, es|M^MaIly the asMunption of simjjle riMTudeseenccs or relapses. Such patients also ex|)eetonite hut little, if at all, and the sputum, in niv ex|M'rience, rarely contains hacilli. Of diay:iio>tic im|M)rtance on the one liand arc the in<'rcas(! and persistence of the fever, without onlarpMnetit of the spk'cti or presence of fresh rostnilic, and, on the other liand, I'on- siderahle rapid in< rease and extension of the hronchitie syni|)toms, with pulmonary emphysema, subjective and olijective dyspnea, cyanosis, and sweats. (^uite rare al-o, but imjiortant on account of the daiifjrcr of confu- sion witii other varieties of loi)ar |)neiMnonia oci urriny: in die eoui-se of ty|ihoid fever, is acute tuben ulous infdtraticui of considcnible |)ortiolis of tlie iinijrs, e-|K'eially of the lower lobes. This condition mav set in with a chill, pain in the side, severe couf;h, and blood-tinr hoid fever is, not without «iusc, known |)opnlarly iiss nervous fever. The physician must admit that this desijrnation is appropriate in view of the prominent nervous symptoms of the viii|i- tiiiii- iiri' marl cd. 'I'lioc iiicliidc j^ciicral iiialai-r, niciilal ilcpn- .idii, draiiiriiiu:' -ni-alii'ii^ and iiminLr |'ain- in the I'Micrnilic^ in llic cinir-r nl' tlic larLT luTNi-irunk.-, -acral pain, \frlii;(i, ruaiiiiL; in llii' car-, and licadaclic. Ilcadaclic is jimlialily mic of tlic must cun-lant -\ injituiiis of the initial ipcrind — tar iiinrc (dii-tant lliaii tlic sural pain. Jt i- ai tiint- ri'lcrri'd in the iurilicad ur to tin' ocripnl, Ic-^ cominonK to one -idc .>{' the licad. At oilnr tinii- it fxliiliit- an intriiM' .-taliliini:. liorinjr cliar- artcr. At still otliir tiiiic- — and llii> i- true oi' tlu> inajoritN- o|' -ascs — it i~ di--crilic Worthy of iniiitioii, e-peciallv jiain> in tlie di-trilintioii of tliu .-iijira- orbital, infra-orliital, and oecipilal nerves,' altlioiigli in mv experiellee till V are rpiite rare. ruw.ird tile (lid of tile tlr-t or at tile Ixj^iiinilij^ of tlie >econd week, in ea~es of iiiodi mte or ,-evere eoiir-e, tile eom|ilaiiit of lieadaelie and the I'eiiiainiiiLT >ill)|tH'tive uerxcpii- svni|itolils si-eiH'riillv le— eii. 'ilie patient, now lieeoniint.'' stupid, is no loiiLn'r eapalile of appreeiatintr his londition, and hi- -tateiiieiits eamiot he ri]ie to make new comiilaiiits of hi-.idaehe at tliat time, that attention lie direeti d to foinplieations, e-pel:uMl- Ii'>-;('n ifni'luMlly, tlw intiTr-t of tlw ]>atii'iit in lii> -iiiToiiniliiiir- iliiniiiislio, and the doirc tor I'immI and drink licconics imiirrc-.-iv rl\- Ics-. Tiic patient lies in an apatlu'tic >talc in ii rclaxctl diiisd dci-iihitn-, l)nt still reacts -Injrjiisldy tn lond speakinj,', to <|ne.-- tiiiii-, anil Ik active >ens(iiy impi-e.-.-iuns. His statements are still fairly rational, hnt even siinjlit deniand> n|K)ii mental activity are siMtKlily fullowed l)v faliiTue. Alter niakinj; brief replies, lie relapses into his stU|H(rons condition, in wliicli lie is likely to l)e annoyed by dream-like liailiicinations, wliicli constantly reapjK'ar as s(K)n as the eyes are closed, or even durini;: the half-wakinj.' -late. With the |)rojrrc-s of the disease, jrcnerally at the liej^imiini: or the middle of the second week, in seveie crises or in irritable individuals earlier, the dream-like hallncinations become tninstormed towaril even- in'; and durin f^rown to enormous si/e anil then have become moderate in size. Sime ])atients exhibit a tendeiKy to jr<'t out of bed. I'nder such circumstances tluy rarely injure thei'.iselves or others. Wilil, ilangerous delirium, with threats ajrainst attendants, attempts at flijrht. etc., siu'h as are (|uite commonly observed in eases of typhus t'ever and variola, are very nuich le-^ fre(|uenl in cases ol' ty|)hoid fever. In drinkers the mental disturbance i;enerally reseiiiiiles that seen in alcoholic delirium. True delirium tremens, such as almost always occurs when hard drinkers are attacked with the other severe infectious diseases, as, for in-tance, fibrinous pneumonia and erysipelas, and which sets in with ra|)id eleva- tion of temperature, occurs with relative rarity in ty|)l;oid fever. At the middle or eiiil of the second week tiie delirium, which at Hrst was rtoticcable only toward eveniufj or during' the niirlit, bej^ins to persist also during the day. 'I"he patients can still at this time be awakened at times, and tiuir attention attiacti^l, and tempor;irily even be convinced of tiie n- scioiisne>s more obscure ; and the ])atients enter upon a state in which ii i ;>?^^ ./v^^"'- 262 rvriKiin n:vi:R. h.- .:)■■■. ryr-- ir thcv take ikp iioticc nt' their -tirrimii(liiij.'->, and arc liay and nijrlit in a drcainv >tat(', uncnri.-cinns ut' tlicir cnnditinn. 'I"ln' t'cattins arc rcla.\fisi(inl('>s, even »(inic\vliat drawn ; tlic ( yc> arc wlmlly loiip'r fixed i>n any dctinitc (ilijcct. Tile |)aticnt< innrnnn- and arc (|nieliy rc-tic-.-, l)nt iicccinic niorc ai'tivcly so toward evening' and niiriit. In nnconipliiated ri-cs wliicii ar<' not (it'extrcnic >cveritv tliis cundition pcr-i-ls into tlic tiiird week, and even to tlic end of tliis week, tiien, wit'i tlic Ix^innin;; ni' <'onvalcsccncc, iuidcrjr"in>;' L'radiial iinprnvcincnt. 'Ilic jjatient- now Iwcuinc (piictcr, and ajT'iin at times eoiisiidii^ ; tiiey ln'^dn tii slccj), and wifli a rcduetilccp, t'spcciallv at nitrht, when dream- occur that are t'orpitteii with ditlicully. It can rcadilv he imder-teeoiid week, passes into deei) -o|Mir and into coma. Such patients exhihit the apiwaranee of ino-t profound intoxication, with paralytic i-claxation of the iiitirc hody — an o|M'n month with dependent jaw and dry, cncrustcv a<'tivc interference, he induced to make traii>itory, indistinct statements. Kveii the swallowing rcHcx can he elicited only with ditlicnltv. The urine and the stools are ^rcncrally voided in bed. 'I'his condition niav, in severe ca-c-. continue 'hroujrhout the third week, and it niav jHTsis' even loiiirer, under which circum-tances it is especially to he mcntio., d that the jrraxii,' ot'the jreueral condition i> hy no means coiistantlv attended with corre>|Hi,idinir clevjition of temperature. On the contrarv, remarkahly low fem|><'raturc with a curve oi most irregular course is at times found in assiH'iation with a most serious and most alarmiiifi pncral condition. With the more profound conditions ot' -tupc\ciil\, I'rom thi' simplest tremor to spasimxlic twitciiinjrs and eonviil-ions, arc also (piitc commonly ass(«'iated. This ({(«.- not imply that such motor disturbances do not .-it--'v; syMI'TOMS AM) ((tMPI.WATlOSS. 2(;;5 uIm) (K'ctir ill ca-K's ot' nnxlcnitc and iniltl cuurx'. T1i«n art- iiuicly mure f'riHiiiciit ami nunc iirniKHinccd in tlic sfvcrc ca.-cs, lint ilicy vary with rcpinl to tluir clianuUT, diiratiun, and extent, in aeeurdanee with tlie individual irritaiiiiity. Siiii|)le treiiKir iMcurs in deliilitated, irritai)le iHi-sdii- (|iiite eoinmonly as earlv ;is the initial stajre. 'riii> is the ea.-e also in mure mhiist aleo- hdlic individiiais. More inteii-e motor di>tnri)anees jrcucnilly a|i|)ear as traii>itorv maiiil'e>tatioiis in the later tehrile ,-taL'e in tiie li^diler and moderate ea>e>. 'I'liev cK-eiir early and |ier-i-teiilly aimo.-t solely in the severe ease>, and, as a result, ae(|nire a deji:ree of |)row:ii(i-tii' >i>riiitieanee not to he nndeirated. Anioiii; tlie.-e iiioroeMre di>tnrl)anee> piekinjj; at the eiothinir (Hn.titatioii) i~ tiiM to he mentioned, - it prohahly is the iiiil(le>t and lea>l -i^-nilieaiit t'rom tiie |(ro^r,ic,vtie poini of view. The so]Kirose patient, lyin<: <|uietly, inoviii;: tiie lips miinierniptiMlly, iiinr- miiriii;,' iiieoiiereiitlv, pulls eon-tantly with tremnloiis hands at the elothin^ and hed-coverin^''. In tint, the analo<.ry with the pnlliiif,' of W(M.l, the pinekiiii,^ of ilown, and the like, is ino-t ajipropriate. At times the tremntou-, jerky nioveinent- cxiiiiiit ptive of tile pre\ion> oriiipjition oi' the patient. Ilowver marked the inaiiifesta- tion- inav he in the arms and the hands, there is ot'ten no partieiilar niove- inent in the lower extreiiiities, or at most a certain amount of tremor. M'itli the pro;.rrc--- ot' the di>ease. and in scri eaxs, tlu' tri'iiior and Hoetitation are often sihui as-oeiated with rather violent mii-ciilar twitehiiijr. which is al~o more iiiarkiecially in the forearms and the hands, as a jerkinir ]iroiiiiiieiiee of the mux'les and tendons and the relatees, I'spe- eiallv ill jiatients who are e\ee<'diiiL''ly re-tlcss and liavt' vivid drcanis, more or less niarkol twitehiiijr throujrhont entire iiiiiscle-jrronps may heeonie as>ociateith tloctitation and suhsiiltiis, esjH'<'ially when a piirjxisefnl movement is attempted. Tlii- i- then hifrhly snt' tlii' inii-cli- nl' lln' li:iik ami llic ii:i|i(' lit' llic iicik — i- ((iliic alai'liiiliL;- ami. Iiiiluiialrl\ , not \ri\ riii|iirlil. Siii'li attack- ai'r i ■(• lVii|m iil aini >'\' -lii:iilii' -iuiiil'n'am-i' in ii-rilaiiii' cliiidiTn. In ailiill- iIka air llir (•\|iir--i(iii lilluriil' a imi-t |irc)|liiiii(| t(i\ii' action ii|Hin ilic iriiiral iicrNdii- -\-i(in nr '>\ r-|iiiiaily -(Atrc (•iiniiilicMlinii-, aimin;r wliirli imninuiti-, miliary tnlpiTrnlii-l-, and -ciillc or iininic ('in- aic ('-|ii'i'lallv ti> Ix nnntioiicKJ. In rlillilri'ii I liavc ciiiMi'vvil p'licral I'limiiUinn- witin.iil -cmic' r(iin|illralicin-, ami not larclv tlic ca-c- icrniiiialcij in rccci\(r\. In adult- tiny arc, in any I'vciil, cxticniclv rare. It' liny mciirrcd. I -lidiild iii\aria!ily -n-|icct conililicatiiin-, or rai-c llic i|nc-ti<)n wlicthcr tlic dia;ini)-i> nt tyjiliiiid ti'Vcr i- -till to lie adhered tu. Hccansc lit" the varialiilit\ ami tlic cuinliinatiim- iit' ccichral and spinal di-tiirlianec-, c-|iccialK nt tlic al>mi?-nial imitnr inanit'e-tatinii- aiid tlic ji-vcliic -\in|itiini> nt' de|ir( — idii ur cxiiteincnt, tlic cai'licr |iliy- .•-icians di-tiii^ni-licil a niiinlxr nl dillifcnl v.irictic- ot" typli'iiil t'cvcr, to wliicli, iiatiir.ilU , only su|Krlicial -iLMiilieaiicc can lie attadicd. 'I'lu' liest known ot' tlic-c \arieiic- are tlic I'ollowiiii: : " l'"cliri- ncrvo-a >tu|iida." tliat varietv in wliicli tiic ]iaticnt> lie in a >o])oro-c state — miirinnrintr. trciniilon-, w itli lloctitation ; and " I'cliri- nervosa versatilis," in wliicli. as the name iiii|ilie-, the di-tiiri)ancc of coii-cioii-ncss is associated with es]>ecial restlc--nes-, -nli-iiltiis teiidiiium, cliorcitiirm twitehiiiir, active deliviiim, up to conditions ot' most markcraiii at niimeroii- autop-ii s in \ariou- -tajfcs of typhoid fever. There is |)resent irciierallv -nine -e .lU- inlilti-ition of thi' cercliral tis-ue, rarelv marked iivperemia or anemia. Mrpceiaily is there no eontirm;.- tion for tile statement which one hear- and reads now and then that conditions of evciicuicnt .ire a— ociated with hyperi'iuM, while the " fcliri- nerv( i -iiipidii" is more t'rci|iieiitly dependent ii|ion anemia or scrolls intiltration ot' the -nli-t.in f the liraiii. Marked cercliral eileina, with more or le— marke vvplaillrd llir -cvrrci.'-ciiinil (li~tiirl):ilicf> iiii till' |);il-t uf tlir relit I'M I lltrvniis -v-iciii wliicli liiivr liillnrtu liccii ili- not in-nviil rnlircly -:iti-r:irlurv. It i~ Inic lli:il (jiiitr L^'iiirally llie pnviou-lv iiii|)Minil intilli^rciKc i~ uli-irMil t(iiiii|)n>\c and rcliini in tin' .■.(■(|n(iic(' cit n>|cl l)alli-, anil aU"i iliat 'in tin- other hand, the ehaiai III- and {\\r niaiiire-tations ui' eerehmd di>tiMl)aiiee-, ( -.|ieiiallv tlie vai'vinLT dej^rree of >tnpi)r, do nut eiirre>|H)nd with the heiirht and (lie inten-ilv ut' the te\ ef. On tiie inntiiirv, the most pi'o- tiimid eereln-al (h-tinlianees may .»'.iii' with ipiite low tempenitni-e ; while ea attended with .-yin|>- toms ot' mo-t pi'oiKinnei'd iiei\iiu« depl"i'--ion. Another tiulor, namely, the ateni, is lar mofe important than the tem|M't^ittire. This factor alone, iiowever, diH^s not determine the eiianieter and the severity of the distnrhanees in ipie-tion. 'riie-e iieha\'e and nre modifiey its sta;r«'- With retereiiee to iijre and sex, it can readily he understood that women, children, and the ai;ed rea<'t ditferently than rolmst, ]irevionsly health\ men, if all are ex|>osel. Psychoses. — Althonirh the actual mental di-turUanees ncrurring in the course of typhoid t'ever are often dirnily related to the febrile delirium, and arc ot'ten not shar])ly separable from it, and fre(|nently even ai>pe;ir to arise out of it, neveilheless the character and pe<-uliarity of their onset and course renek, peculiar illusions and delusions aiid associated abnormal acts stand out prominently in some |)atients from amonj; the general symptoms of the ii' 266 rvi'iidin hEvin. ft'l)rili' -iii|Mir, iiiiil arc woriliv ul' >|Mai1 lluv |Hr-i~t iiiili'|iiiie eiieiiin-tanee> arc Verv rarelv -l.ile- of exeileinelll uilli aj:|rre"i\e lelidi lleie-, lint niorc l'r('<|Ueiitly eiin~i>t in aet~ and deln-inn- that exiiiliit the elianieter nl' mental de|ire~-iiin, lit' liar nr an\iel\, with or \\ilhi>nt liallniiiiatinn-. One |iatient may "een|iy him-elt' with f.niinndle-> .-ell-aeen-ation, and lament- a lite which, iVdm a n li;ri"n^ nr nther >tand|MiiMt, lia> lieeii \va>ted ; aniitiier \\\.\\ iiear \ uiei > nr >ee tij^nres thai de|ire— , |H'r-eeilte, or threaten him ; and >lill .iiidther nia\ lii' ri;^idly in Ixil, nut eatin;r ">' di'inkiiiiT I'r leaetinLr at all, iielie\ inij; liim-elf nmlidnle— or even dead. Still dthei'- l»elie\e tli.y ha\e ama—eil j.Meal lurlnne-. which they Tear thev ma\ l(i-i', or Hic\ >earcli liir and lament the lu-- ut' valnalile-. Althun^h, a- has lieeii mentioned, the-e ileln>iori- ul'teii di-a|i|>ear with det'erN t-cence, neverthele— they iVeiiniiitly |« r-i-1 ihciral'ter and hecutne lixed far Inure rreijneiillv than in the -ei|Menic ot mu-t uther iiente inlectioiis di-ea-e-. Ilii' mcMtal de|ire— ion and conl'n-iun, or only certain niorliid conception-, ma\ then |>er-i-t in the |irc,-cnec ol an othcrwi-c apparenllv intact -cnxiriNm into the pcriud ul' eonvalc-i'cnce, or even extend I'ar licyond it. Smie |>atient-. alter they liavi' hcen out ut' lull fur a loiiy time and a|p|ireciatc the natnre of the di-ea-e fiiiin which thev have recovered and the delirium that was a— ociated with it, are still unalile to frei' theniselve- from certain imiici-atixc idea-. In other n'-|(ccts thev make an impre— iun *>{' mental i|nicludc and inielliffcnce, and them-i 1\(- admit that on one point tlioutrht and s|Hecli are morhid, hut thev ai'e con-tantly iiic-i-tiliiy impelled llicrctu. Tliiis. ' (iliscrvid a \i>imL' iniirne\ man lailur w iiu was imalilc to IVce liiiMsell' frorii the helief ilia' a lieiievnleiit wmiian had preseiitcil liiiii with a puud liral of iiiiiniy, and had cuMccaled it fur liiia lieliind a cliiset in the ward. I.iini: after the jialieiit had L'utten nut nf hed this tlimiLdit could only teni|Mirarilv he ilis|K'lleil. liven alter he had iiiipruved reuiarkalily in phvsical conilitiiin, and iiientallv apiieared entirely clear, he was only liidf- ciinvinced with riLrard tn his deliisiun. lie had smiie ilirtiileiice in s])eakinp of it. hut every now and then, in an nnwiitclied nmnieiit, he jrlanced lunir- iiiirlv toward the curner necupicd iiythc proiiiisitiir chest. In aimtlier caw. a wrvant-irirl. eiirhteen years old. durinir the fehrile slaLa- was |M(ss«'ss<'d liy the ilelusion that she jiad heeii visited hy her uncle, who suddenly liecame so LTiatlv disteniled as to hurst. While (Jiiriuir the fehrile staL'c she lamented hitterlv the fate of her uncle, she lauLdied liuriuL' eonvaleseeiu'e at the r ^ -.ii*. .s) .l//'/'>.W.V .l.V/^ tOMri.K ATIO.SS. I'lu ihouKtil "f Ilia |>«'ruliar niflliixl kI' ilyiiiir, liut fVfii utl«T slii- liiul ln'cii tW-e from I'fVfr iiinl mit of Ix-ci lor wcckn slie could not rid litTM'lt' ol llic idea tliut 111' iiiid at lca.»t died. AiioIIht |iati«'iil, a rt wt-fk of the fever ('(jik eniiii;.' Iii.s child, wliich he tlioiij,'lit had lieeii »loleii from him liy liei^dd(or>. and had Ihtii cut U|) and Imrned u|i<>n a -and heap. The hara.s-in;: ihou^'hl tollowed him into convalexence. .\IIiiii|iIj^ were made without avail to relieve him of this delusion liy hrin^'inj,' the child, which wa.« entirely will, lo him. A few hours after the depurture of the child the delusion would return. It) addition lu the fonii er\c sptHMal nniition. 1 have oli»crvc the Ixriotl of defervescenei (inly exceptiuiially in tlie atilirile |Kiio(l. The jiaiient- lie motiuiile*- and cuinpletelv nni'e>|it characteristic form, it will liecome a|ipareiit that sliirhter de^rrees (if hysteric stuinir, with more or less marked catalepsy and plastic tlcxiliility of the mnscles, arc not at all nire in prcose(l individuals. Far less comiinm than the tiirepiinj; di-turliance- arc, in my experience, cases (if actual hystci'ic insanity, in those patients in whom I have (iliserverve(l more or less well- develoiied psychoses at the heii:ht of the fever iir durin;.' cimvaleseence in 42. In 8,") ca-ses the mental dijitiirhaiice iwrurred durintr the febrile stUL'e, in 2 duriui; the |M'riod of irregular teni|ierature, and in ") duriiifr conva- lescence. The.se patients were exclusively adidt.s, and w(inien were more fre- ([uently affected tlian men. I noted 27 of the former and 1") of the latter. In o2 of the eases states of luelaneliulia or (|uiet delirium were present, with I. V * J." 2«H TV I'll' III) 1 1 vin. [p^-^- iir witliiiiil linlliiiiiialiiiii- ; wliilr in llic ri iiiiiiinlir. roiHlilinns i>f iiinrc or Irsg liiMikiil CM ilrrmiil ami i\rii iii.'iiii:ii':il .-lalcT- \\t\v nlixrvi-.l. Willi rcL'iini 111 li\-lrrn|i.v(liic ilirliiiliaino. mikI iT|HcJailv llir ralalfplu' varirty, wliicli 1 liuvc ul>-.. ( )\vili;.' tn till' til 111 lit' III V aitis il\ , llii' mliilil imi- lliat i have iiilliirto liirll alili 111 ill -rlilii' lliilil lil\ |M l-iiii.il iiii-ilAaliiHI Krliillj.' allliii-l lAilll- .-i\il\ 111 llii' |irri riiiii|iaiiil wiili tlin-f liiljiiw iiiLT tlii' utliir iiili rtiuii- di-ia-r-, ami tlicy olltii ixliiliil iiiarkiil -ixii-ilv ami nli-tiiiai y ami |initl-arli'(! liilllilimi. I IliliT lln-i' rirrlllii-tami- llir rnmlitinll i- ll-liall\ mii nt ilr|ili'^-iii|l up iiiilaiirliolia, witli -clt'-aiiu-atiun, trar ami aii.\irt\, -lii|iiir, ami dt'trii lialliiiinatiiiii- ; ilimiL'li mil iiiiirli Ir— luiiiimiii arr i|iiiiii r ii.mliiiinis, wiili |Miiiliar iilia-, r-i«i i.iilv ililii-iuii- nt' jrramlinr ; ami iiinri' ranly, riiiiiimiiilv . rniiiliiinii- nt' r\ritviiiciit n|i tu till' iiiiiiil nf mania or acute (liiiiciitia ( K latl't-Kliinix ' )• Tiic iiniiriiD-is ui' tv|(liiiiil |i>yiliii-cs a|)|M'ar- in genera! tn lie favor- aliic. ( "' llic ca-i's imilir iiiv nli-i rvatinii, prcN imi-ly iiii'iilinncil, wliicli rilc imtIikI ami early in cnnvali-.cinc<', only '1 |Hr^i-t(il licviiiiil .lie piriiHl nt" cniival'x'cncc ; tlio nnc tcrniinatcil in niii\cr\- at'irr >i.\ niontli-, tlic other, at'tiT iii'ic imintli>. The .-everer |„\,|],i.c- al-ii, wliicli nece->itate treatnieiit in hii-|iilai> t'nr the insiiie, a|i|«ar in ireinnil to |iiir--ne a imi iint'avoralile eoi:i>e. AecDnlinir to K ratl't-KliiiiL'. the ]iriiirnii>i-. i- aliim-t al\\ay> t'avoralile in enmlitimis of ijiiict ileliriiim. tiiiict nr even -iii|iiiriin-i inelaiit tnr month-, lint in il"i per cent, of the ea>es it terminates in recovery ; rii'iiverv from eiinilitinii- ot' maniacal e\eitement ami from acute demeiitiu occur- in troin "iH to ti."j [mt cent. n|' ihe caM'>. iSct'ore leaviii).'- thi- -ii'tion it a|i|M'ar- woilliy of niontion that in ('.\e"eilini.''lv rare ea-e> inarkeil |)-ychie ili-tiirliances may he pre-eiit at the \erv oii-et nt' the .ittack nt' ty|ihniii fever, c\ ell a- early as the Hr-t ilav. nr, at least, at the liei.riiininix nr the midillc nt' ihe tiist week, ami thev may then exhiiiit the ehanicteri-tics nf an iiiile|ienileiit di-nnler. Sueli cases are well calculated to irive ri-e at tir-t tn rror in diayno-is. I have nhserviMl '1 ea.-es in which patii nt- nt' thi- kind were at once .sent to a lios|)ital fir the in-ane, where the true nature of the disease first lu'came manifest when, aftir the lapse of eii:ht and twelve days, 1 .1 t S)Mfl'iMS A.\l> f 01//7./' I77"\\ 2«« r, -|,.-, tivrl\, .iil;ii';;.Mi.nl ..I' lli.' -|.l. c n, .lianli.ii, .iinl .li-lim I r.-.nL.- in^l'li' till ir .i|>|i":iliiliri . ■||„, |.„ I iliai iIk' |.ri\ iiiii-l\ iii-aiic, if i\|Hi-r.i |u iIh |M.--iliilil v cf iiildioii, aiv alCi. k.-.l l.\ I\|.1m.i.1 Iim t :ilin..-l :i- Ir. .|11.iiI Is ;i-lH;iltliy ill.|i\iclll;ll-, -linlll.l llk.\M-r Lr r. .llM.l. I- , 1 ill llli- rolllli.l inn. I ll.l.r Mlili .iniiiii-laiir.- ill.' <■ mmiiiI t. riiiiiial i.>ii mI' iIi. -li-.a-i' \ai>,a- ill ,,l|i,r ,a-.-. ill a. nlau..' uilli iIh' .■..ii-l'tiili..ti .if tin- |iali.-m, ili.' MV.rilv n|' til., iiit.rii a' -II. -li . -.11111. li.-ili.ni- a- may I..' pn-.nl. It lia- l.i.ii Mal.-.l llial ilia iiiliil" r ..f -ii.li ca-.- afl. r iv.-..viTy lia.l tak.ii pla.-.- tr..iii Ih.'atta.'k ..f t.|ili.. I Umv H.l.ralil.- iiii|.n.\ .iM.nl, <,r .\.ii.-..iii|.l.i.. iv<..v.r\ rr..iii ili.> p-y. Ii.-i-, ...■< iiriv.l. liiliTtiMiat. iy, thi- i- ill.' .■\rc|ili.iii an. I imt ili' inl.'. Nervous Disturbances with Demonstrable Organic lesions. Alll -Ii lli.' alV..ti"iis ,,f tli.' n.iv..ii- -\-I.iii tliii- tar .l.-.ril..'.| liav.' i...'ii .la-..! s.pai-al.ly tr..iii a ihiiiiImt ..f ..ili.'r- whi.li arc kii.iwii to \i.ni "f tlic iirf^ciit >U\tf .>t our kiiiiwlci^r,.. Witli-.iit .|..iil.t tli. -..-.•allfil fim.ti.iiKil (ii-tiirlianci's will al'.i in tlu -.• .>t' time lic.-.aiic in.. re aii.i iii.irc ac.i--il>li- to anat.iini.' iiivi'-tiiriti.in. Alterations in the Meninges.— Anion..' tlnsf, iiiciiiiijriti>, wlii.li is nsiiallv ii..t contini'.l t.) tlie lirain al.iiif, Iml far more frfi|ii.iitly is oorchrosiiiiial in di^trilmti.in, slioiil.l Ix' incnti.iiii'd tir>t on ai'.-oiint of its iniitortancc. |)iiriii>r cfrtaiii ciiiiltiiiii-s of typlmiil fever ami in eer- tiiiii places iirof.iinul nervous di-tiirliances which can Iw ascrilie.1 only to acute iiitlainniatorv |)r.KVsses involving: the ineniliranes of the hniiii and tile spinal cord, .icciir in the .■.mrsc ..f the disease with varyin^r frciiiieiicy, at times in lar;ri' niimltcrs of c:ise>. At tlie onset an.l .hirinj; the coiiive of tliese ca.-es. the >tnpor, in contrast with the reniainiiii,' symp- toms, is slight, if present at all. Under such circninstances the |>atieiits complain — a- i> iinnsnal at the hci^dit of tlie attack — of ni.ist severe, per- sistent hea'lachc, vertigo, roaring' in the ears, and ))li.)to])liol»ia. At the same time or sIaiiee» i- rare ill the eciiir-e (it' ty|>hc)iil tever (leeurs \s itii I'eniarkahle rre<|Meiuv. 'I'hi^ -y ni|itciMi-eiini|ih'X may oeeur in Ixitli >e\ere anil niihl ea-e-. The inten-ity ot' the attaek, it -hiiMM he e\|)re-«lv iiiiintetl (hii, is nut ])rii]>iirticiiiate to liie >eventv of the ineninjrilie >\ in|itiMii-. A niiid attaek of t, jihoid liver may l)e atten(le!ieiit, at times tran-itory, nn iiintiitie manifestation-. The ihiralion of nienintiiti- liurint: t\ |ihoi(! i- exeeedinjrly variahie. At time- it i- lium li'iir to twelve (la\-; at 'tiier time- it |ier^i>ts thi'onuiiont tile ureater jmrtion of the tihrile perioil. ( )eea-io'!;iily it ev( n a|i|Mar- to jirolMii^r t|i,. letter eon>ii'.eralily. I have ohserveil eases of fi'om tiine to three ami a half week>' dunition. Hendiard ' also pter- t 1 a ea-e of tweiitv dav-' duration. I have never ohserved renewed a|i|>earanee of tiie meniniiitie -ymiitoms diMMnj;: a rela](se of tvjiiioid liver. I have often had o|>]iortunity for ar, atomic inve-tieatioii of ea.-cs of tv|)hoiil liver whieh had -howed -yMi|itoui- of eerehro-pinal meiiin^dtis, Imth tho-e in whieh the -ym|i!iim- referaMc to the <-entnd nervous sv-tem Were sliirht a mpared with tiie -ymptoms to which death was diriM'tlv attrilmtali'e, as well as tho-e in which dcatli unilouhtcdly ri-ii!tei| direetlv Iriim eereliro-pinal miiiintritio. 'i'lie lir>t ^iroup is charaeteri/ed hv the -lii:lil. almo-t nee'ative, anatomic evidence. ( )ne mav lind at nio-t more or le-s marked hyperemia of the - if* inemhranes of the hraiu .mil tin -jiinal eord, witii or witiiout turliidity. \ marked advance in the interp.etatinii of sueii ca-i- i- fnrni-hed liy the interest- iuL'' ol)-ervatii>n hI' I'l'. >ehnlt/e-' that, althoue'i imdcr >\w\\ circum- >t,inee- no co,ir-e anatiiniie li-ion-^ .-iitjicar to lie pre-cnt, nevertheless small-ceil inliltratioii i- deinon-irahle in the nieiiilirane- of the lirain .and -pin:il cord in the eoiir-e i.f the \e— el-, and al-o nderu-copie foci of -imilar cliaraeter in the ti— i f the central nerxcu- -\ -lein. In .-> ea-e- pre-eiitinir inu-nall\ uc ll-marked eerehi-u-jiinal -ympioiii-, which were ilMiiliile— th" direct <'ail-e of death. I wa- ahie ,il aiilo|i-y to denioii-trate the iiimiliar aiiatumie piclin-e of |iuruleiit eerehro-pinal meriinuiti-. In ■". of the-e i-i-e- e-|MMially the pia-arachiioid. p;"'icn- larK ipm the ciiiivexilN- and lalrr.il a-pecl- nf the lir:iiii, w.-i- iiiNolveil, and in h-- deirrei that nf the -pinai crd ; while in the 'J other ca-es tile liieiillir.ini- I'f the iil'ain .'lllil the -pilial cold were eijlially involved. ' j;n-l,;. I.h„. II'-. ■ , |ss,,_\,,. iOO. ' I,.,-. ,-,t. srMrroMs ami comi'I.hatkiss. 271 In these (sises tlic coiKlitioii liud (Icvclopcd IkIwitii tlu sccoikI am', tlio liltli V k ill tlu' course of attacks of tvplmid fever of severe onset, witli ill |>art ^iii uiiii.-.iially inni,r rcl)riie sta<;e, and the disease iiad tcnniiialed tiitallv after a (hiratiuii of fnmi >i.\ to ten days. What relation tiiese e;ise- he:ir to those |irevioii-iy nicntioiitil in which there was no siii)|)iinitioii mll^t remain uncertain until further tiioroujrh liactcrioloj^ie invc-tij^ations lia\c lieeii made. To me it seems ]irol)ahie that ill part at h'ast tiiey ditfer from one anotiier only in def,'ree. In aiiv event, I was ahle in mv i)Mrulent eases tu e.\e[iticeiiiia or luirulent atVeetions in the immediate vicinity of the >kull [t-wr, nose). My cases, wliicli wort oliserveii at tlie hctrimiiiii; of the decade 1>ecially to Siapliylo.»/>. 7/ ,,ir,l^ 11m,-/,.. .Inly !•_'. I'.iOo • I'l.iln. M.;i J..,ir.. .\iii,'ii-l -JH, ls;i7. ' SluliliMi, ■ I'llior t\ pli"-i' ni(>iiin'.;iti-.' /.;• .tun I :!U ii '■>. ^- '15; eh' EL •J72 TYI'IIOID IKVl.n. taimu (ial\ ;i very ttw |ius-ccll>. llic l\ |iliiii(l-liii(illiis wiis (>)>taiiit'ci in |iiiro ciillurf. Al'lcr M-\cral ilavs llic niniiiiL'i'al s\ iii|i|iimis ciiliri'ly ulian-il up. 'I'lial ill 1 1 lu tin II re n.-drl wVA iimrc l'ri-i|iicntly It- liail lo .-^iiiiial |niiicturc, wiiicii i> al-'i iml rari'lv iinlicattil tor ih(ia|iciilic piir|>ii>cs. t'lir the t'liiili);ri<' ix|ilaiialinu nt'llii- im i iii'_'iti<' .-\ mpii'iiis. need diily U.' iiiilicatcd at lliis iilacc. It is ail iiilfi-olinir tad that iiicniii;.'ilic syinplnni.- (icca.-idiialiy occur w it'.. {Treat t'rcc|ucncv in ci riain cpidciiiics ami in ctTtain place.-, ami lliat tlicy iiiav tiicii occur in L'roups nt' iii(li\ iiUial- in tlic >aiiic iioi-c or llic ?anie t'aiiiiiv. 'I'liu.-i, 1 oliMTVtil recently in tlie .lal^oll^^pilal .'i !;ni>es stricken in c|uiek .-ucccvion «itli l\plioiii t'ever. proliaiily in con.-iecpiencc of int'ectioii tiiroiiL'h milk, ami in a!l ilie ca.-cs inenini;ilic >yniploin? preiloniiiialeil I'roin tlie tir>t wci-k lo such a iJcree that in the liisl iieliec'<, (iriessinjjjer, I5iiiil, lavden, Kfl>, and iiivselt'. 1 tniniilitiilly, these eases iii' nieninj^iti- ari>iii;r in the lat( f |Hii(id ui' the disease are tmioiiir tlio tnore severe, and liiev attracted alleiitinn theretiire relatixily early. 'I'iie fact, however, that marked ineniiio-ilie symptoms may ajipear in tlie earliest iwriod nt' tvi>li(iid liver, and may so thonititrlily (ioiniiiati' tlie elinieai picture that the ;ri'cate-t dillieiilty in diaj;iiosi~ may arise, was ])r.ictic;illv nnkiiown lieli>re 1 called attention to it.' I have exetep<'ar on all the stihse- <|iieiit (lavs of the fir-t week as ^ '11 as in the second week. At times their onset was marki'd hv a chill or by it pi; i led ehill>. and the siir- prisiinr development of' facial lier|KS. 1 have ol)-er\cd these ea.ses of earlv oeciirreiiee far more t'reqnetitly than tlio-< that set in diiritifj; the ^ Sitziiti'ixlirrirlif (!. ('..inj. f. iini. Mr,l.. l!.l. v . S. 4i;!i : iind V 'VViiUl' (;!op..rt fmm tiiy lii'imrtiiiciit in tlir IliiiiitnirL' Cincriil ll..-|.itiil . />../'-■// Arrh f him. Mni , I?(l. xllil, Kritz ali'iic ( /;V»./.-.< r/uiii/ms .|»:ii- to l>c iiKirc v;iriviii|)tiiiii' oi' iiieiiiiiLriti- ihiiiii^ ilie ((iiii^e cit .ill attack ul t\ |ihiiii\ely ill vipiiiiix iiidi vidiiais, ill males less eniiiiiKiiilv than in xMMiieii anil eliildreii. I have nii-ervi'il this ediidi- lion iiiilv twice in |iatienls over thirty-live years old. Aiimnix .".S ca>es III vvi.'eh I have mil ■-, 'l'.\ were in wunieii, H' in men, and ■") in children. It", as has alieaih' l)c<'n ineiitiipiied, in eases (i!'ty|ihiiid lever wit! |>ri>- fiilil.d -ttl])<)r. >VMi|itiinis oi' nieniii;_'ili- dc\elii|>, cs|iecial atteiiliun should lie directed to the |M)ssil)ility ul' the syiiiptoni heiii;.'- dne to a jiriinary purulent proce--:. 'I'hiis it is not rare liir c\i~tiiiir old inllainniation of the middle ear to nndcrpi exacerhation dnrine. and [icrhaps in (lonsc- (|iiencc ol', an attack of tv])lioid fever, with siil)>ci|neMt e.\teii-ion of the proc ; to the incninircs. I lia\c personally oliscrvinl this in a ntmihcr .nstances, and in '1 ca>cs was coinpclh d to rcconimcnd imiiiediale trejihininir of tlu' mastoid proce~s. Menini_''itic >ym|itoms have lieen ol)»crve in wliieli sii 'h a condition developed diirini^ convalescence in con~c(|iienee of pyemia, followiiiix extcnsi\c, deep hcd-sore-. in one of these cases pnrnlent -iniis-throinlx. is developed, and in the other an ah^eess of the hniin a- larm' as a j)i^ele, ipiite rarely. It is either eircnmscrilcd or extends over a oon.-iderahle extent, mainly upon the surface of the brain. The eireimiserihni hemorrhairc-', when they jrive rise to .symptoms at all. fill into the cat"ir(irv of fiKal Ic-ions. They ma/ then give rise to liemi- plcfria, es|x>eially wirtical monople^ria with jmiseular twitchintrs upon one side or in circumserilieil areas : at times there is aphasia. I^ess eommonly the latter iK-enrs alone. ]-!\ten~ivc nieniuirea! hemorrhage has hoen ohservcd hut exceptionally. I have personally seen 2 crises in mar'.i lly alcoholic men of middle age who proscnt.alli ...riirrc.l in ii(l, :in«l tl llicr in tin' inid.iic "\' tlif tliinl, wci'k. In IhiiIi llio svtn])tcinw M't in in an :i|>c.plr.litMini tnanncr, and tlicy pcrsi.-tod for two anil three da\>, n-peetivelv, nntii ilealh. Alterations in the Cerebral Tissue and its Vessels.— Tt lia< 1m.1i iiiiiiliMn.Hl in tli.' aiKitnniie MT|i..i, ilial -viiipt.un- depeiidriit ll|..,n eoar-e l,-ioii~ ct' tiie eiiiLllil ti-lleand il- Ve,--el- are not t're.|llent. Will 11 tiiev are jireM'tit. llirv oetaire- <> that they niavwiih (-p.eial propriety l.e .le-iLTtiatcd ,«'(|nel-. We have oh-eiveil hemorriiairi-, e-uholiMn. and throiiilio-i~ of the larire. m.Hlerate-i/ed, and -niall e.rehral ve>-el^, with eireiini-erihed and profuse softeiiinir. and rarely ah-eesse-, a- aiiatoniie i'eatiires. Anions: the <'linieal plieiioineiia to which they -ive ri-e, and whleli often dnrinir life are dillienlt of eorivei int( rpivtation with rcjrartl to the aiiateini.' Iia-is, lieniipleLda, with faeial and hypoirlo-al ].araly-i.-, and riirht— ided jial.-y, oeea-iotially with apha-ia, may Im' ]>oiiiled out. I have perv>nallv .iKs.rved '.' ca^s of tlii> .liaraet.T. In the one. which tcnninate.l lalallv in the course of eiirhleeii Imurs the ceiulilion \\a> depeu- .leiit up..ii icceiil'lieiiHirrhaL'e into the left I. ■Kliciilar iHieleu> and its vicinity ; wlill,. in ilic >. ml c-asc. %\ln<'h lii^euiM- icnniiiatc d talall.v in the c. ciiiholiMn ofilie left Sylvian arlcrv \^a,- present. A <'a.-e proha- l,lv su-ceplihle ol' a >iMiil.ir c.\planal io.i ha.~ h.-, ii ivpnried hy Clanis ' '1 wo otlier eases nf riL'ht-H.lc.l henuple-ia with apiiasia and clioi-eilerin luilchinp parti. •iilarK in the aiin:-. wliicli wee niider in,\ el.s.-rvati..n. t< riiiiiiate(| iii complete re<-i.verv. I am iiiHcrtaiii whether heinurrha-e into the cerdiral lissu.'S or into the ineiiiiiL'es was the imderlyiiiL:- .(mditimi in tiie,-.. cases. Other writers also, especiallv « iricssiiiL'iT.- .lackson.' I'.eiiedikl.' I'.erjrer.- N.iihiia-el." and Slrumpell. ' re|HM-i eases of cerehral he.norrhat'e 'n the C(ii:rse of tvphoid le\cr. ( >>ler ■ has rcpnrle.l the <-a.-e o| a ymni- man wlio during' a mihl attack r.ftvphni.l i;-\cr. on till' ninth day ot' iii:- illne.-s Middenly developed piural hihitei-al clonic <'..nvul>ion<. wlii'ch. tlidMLd. pncral, were more intense on the riLdil >ide. 'flic convulsion^ continued al inter\al> up to his dfuth, ten hours later. At anlop>\ liM-re wa.- founo tliromho>i> of the as. eiidiiifr parietal ami paricloicmp. r;-,l hmi.'ii.-^ ..f the mi.l.llc cerehral art. ry. In a >e.-..nd .•a-c. thai ..f a in.-ci a-e.l f.rlv->i\. in die thir.l week of a m.ul. ratelv severe atta.'k ..f tvph.'id fever, iheri' wa.~ a -rinlual ..nsel o'' paralysi.- ..f the l.'ft ^j,|,,, l),.Mth urre.l lour .!a\- later. 1 at aun-psy an area of thromhotic >..fteninL' in the internal capsule uas f.Hin.l. in Iw.. other ca>es ..f hemi- plegia with >u.l.l.'n ..n.-'l. nuv ..f ili.-m with .■..iivul>i..ns, tliere wa.s rcc(,very 1 /„„,-.;. />.N.-.. Wiir/l.uru'. \s: i. -.vr.^ .!■:/' ■>, / lli..i.l f'.'vcr. T l,J^rtmck. ' J„hns Jl,,j)kins Ji„sp. Jirji., vol. viii. syMl'TnMS AM) coMI'l.IcATInSS. 27i from the t'rvcr .villi i>iilv |iartial rtKivtry from the li(Mii|)li'L.'ia. Wcldi iirlrric- a iiiciilioii^ 4 olluT fatal ra.-H's of tliromhosis of the iiiiili I'hral il.'i IL- iiiadf a mo^t carctiil stmly ol li(Mii|ilcL:ia iii typhoul ami l.as ilK'clt'il 17 cases fioiii tlif litcraliir T if iIk- ca.-rs ilifd, uiiil in liolli of llicsf ihcri' wa.~ a lliroiiil>osis of llir iiii'lilli- ivnliral arliTV. I liavc iili-t iv(tiirl)aiiccs of -pcccli of cortical origin in the coiir-c uf typlioid fcvcr are licscrviiiLT ot' sjH'cial iiiciitioii, since i hc\' form a special eninp iMiil arc characteri/c(l hy the fact that ihcy ucciir alone or at least with onlv circnniserihed par:ilv^is, innj irmei-iilly teriniiiate in recovery with eoinparativ e r;ipiilit\. If they arc altcnilcil at all with inotnp ili-tiir- haiiec- in the irniik or the extreiniiies, thc-e are L'cncrally ot' the char- acter of tremor or ataxia. On aecoimt ot' the rapiil, favorahle course, tli'se casts can liardlv he attrihiitcij to oihei' caii-es ijian to -liirht anatomic alteration not p" rmancnily injiiriiiL'' the -peecii-i'cntcrs. It is peculiar, I'liithcr. that these ca«es occur alnio-t -.i|. ly duriiii; cijiivu- lesct'iice and cspecialh in ehildreii and youiiLT |»r iii-. I l,a\e |iers(inally oliserved llic folliiuiiiL' cases of this character: The first iiccurreil in an irrilahle, s|Miiled ^'irl ten years old. with a neurotic predi.s- position. who. iluriiii: convalesi'eiice t'roi'i a severe anil prolracied attack of tvplioid t'ever. was sinlileiilv sei/.ed on the t'onrth ai'ehrile day with almost coin|)lete los.s of speech after sliirlit disliirhances had heeii noticed on the previous dav. The condition was one of alaxi<' apliasiii. ( 'onseionsneiw and the retiiaiiiliiL' functions of the hodv were pres rv'd ; 1 would note espc- ciallv that no paralvsis of the e.\treiiiilies ilev(do| .At'ter this cuiidition hud persisted unehar.ired for two weeks the disorder of speech hcL'an to improve, and after the lapse of live weeks complete recovery had ensued. The second case occurreil in a merchant's apprentice, tifteen years old, whoso mother had died in a hospital for the insane, ami who prior to the oii.set of a .severe attack of tvplioid fever had eliiriij-'ed in excessive p!iy "al activity ; he likewise \v:i^ .'suddenly seizi'd at the end of ilie third week o'' the disea.se. in the sta;,'e of steep curves, in the daytime, with ataxic aphasia which was accompanied hy considerahle transitory elevsition ol' teiii|>erature. Consciousness remained wholh iiidisturlied from the heL''nnintr ot the dis- order. Iiiipro\ement heiran wiiliiii a week, ami in the course of three ami a half wi'eks almost complete recovers had taken place, except for sliirht ditficulty in formini; words and syllahles. wliii'h ditticulty persisted for months. While still in hed. and alter jre'tin;.' up. ataxic distarhances were (lemoiiMrahle in the lowfr extremities : sensation, however, helnjr uiulis- ' Ahlnitfs Suxti-iii I;/ Mri/,.;iir. \SW. v ' Cltn. Site. Trans., vol. xxvi. iii.. Lmuliin ::iii 111 '-; - >..: Vi- tM.v^t^--!}?^^-:^^' 1% 27,; rvriioin ii:vi:n. ,„rl,-.l ...1 tl„. ,..l..|l.r ,..„.l,„MvtK.x,> „nn,u.l. 'n.. ~. Mt.xic .listurl.uM.vH 1,:„| iil-n .•omi.lrlflv ,h-;ii.|..'Mn.l iii llir .■.mrM t al.uut I. ii vuvk^. l;..f,.n-n.vs in liir lil.rat.uv m .l,i. IH-uliar vanrly m „,, immu -lat.^ I.M.k ,., a .•n„m;.n.liv.lv .-.rlv iHri.-l. Afl.r Kluxinan,,. .a.,. M,h .,,»■. W . im'. .,,,,1 Tn nsM.au • ha.lrdl.Ml ultrM.i.m tn il. (^MM. an,l Isu l.n ' .n-aL'.^l n, a ,„„n. .hornn.l, Mu.lv „f .!..■ m.I,,..-.. A.moh. 'Jh .mm. .■nll..,-.-,l Kv KmIm,, •':, «..n. in .InMtvM, an,l tl.o rrnKiinin- ■■: «-■.■.■ nl.-. m vnni.u' l>.rs..nv Ev.vnt fur tia. pivsr.av uf ataxia n, •.'.as.-.-. Isnin, ^"^ -l r.t.r f anv „,lu.ra.s,..iaI-.,l,uTV,.n>aistnrl.anr... in l,i. <.,>.■.. I ..-all, ...Turn-l n, l.u, 1. ul.il.- .•nnipirf rrcovcry .■n.-,,,.! ni lia- nn,ain,u-r n, li I.r.v K. mn wi'cks, rarely lalrr. OtlHT fonn- ..f.rni.ral n.nnn|,l.-ia inv.lvin- tla' arrn>, tl,r 1.L-, or .,„lv ,.,.rtain -. ,„ of nni-rl,>, havr lik-wi-- Kr.n ,v,Mnl..l .A.v,.l,on- allv in tlu' ill.ratnnv Tluv liav, liuw.vcr. not I.c.m. .•arcfnlly n.v.-ti- p,i..l. an.l Ilw .un.r.tioM, .-iu--ially in tla^ ol.Vr ra-vs rannot !«• .1,-tm- irni-lKi>.iiai ni.nlii.n. TiK..'as...ftins kin.l r.i.orU.,1 l.v Knnnm.ll' is intercstinL', as il pursne.l tl„ ' ,nrs. ,.f an a.a.,.. a.vn.Un. ,,araU>is. ..s .li.l ais.. tl... -as., nt s-.U.nn.g of tlK. l.nll, «i.h .apillarv luna-rrhap-. «ln.i, uas utwier n.y -jl.s.rvat urn ,s..o Ana.oM,v. ,.. I'-'n. 'riu. la.l.r ...•••urr.-.l ,n a u,an tlnr.y y.ars ,.1. . viw, «as l.rnn.'ht t.. .he hospital fn.n, .h. harhnr prnt.,nn,lly .1, n, a . o.n. - ,0M. s,au.. «ith,M,t anv history. Th.-r- ..r. n.-h ..v.-r. n,n.U.ra,.. nuu-"r- is,n, ,al,.al.l- ..,.lnr...nK.nt .,f the spl....,., r,,'..i..y .>t th. n.rk, an.l sutl, .-^ of ,1,1 Jn.ir. v..r,..hral .-..Unnn. hy,H.r.s,lu.sia .>f .h. ^hol. hn-ly .x.^ns e lal.ial n..r,...s. l.nt n.. rns....la.. iK'ath ...•.•urr...! ,.n tl,.; s...,n,l 'lay ..t r.s,- hi , ' in lu. h..s|,ital. Tho ant,.,.sy ..is.-lose.l .:..• hsu.ns ..t an -t.a.k of tv 1 oi. fev.r a. he -n.l of .h.. third week, an.l, in "..hi'--"; the hnll.a i:J|„ns ,nen.ion..,l. n,ark..,l hy.K.r.n.ia of the ,,ia-ara,hn„.,„l the bran, and the soinal o.nl, «illi sliirht tnrl.i.li.y of the .•.•■■el.r..s|ana Ihii.l. The ease. re|..,r,e.l l.v Kis..nlohr » n.ay ais.. I.es. he e.te.l here. e deseril.e,l :! .-asej of ....nsi.i.n.,ns inv..lven,en, ..f .he '"'' ^ ;-|- ■" ^ course .,f tvphoi.l fever, «l,i,h vvre . hara.-.en/e.l e.s,.ee>allv l.y .1, s., thr a Z^^vsi. in the .iis.rihu.i..n ..f .he fa.ial nerve, an.l n, ,.ar, ., .he n,., ...r S .n,i,.n of .he ,ri...,ninal n.-rve Mv..akn...ss or s,.a.^n, n, .he nm.sse.er ;;;.;:;U.s ,. ah :; ,.a,i..n,s ..xhil,i.e.l evi,l..n.-es ,.• pn. .un.l ■;;--<>-;»";' ;^;- at.aek.M ^vith ih- n.rvons svni,.t..ins .Innn- .he tel.rih' Ma-e. In - <.i <« r eos'rv enM,...l «i.h ....,n,iara.iv.. ra,,i,li.y, .hie '1- ,-■"--•;;. - thir.l an.l .!..■ a.,t..,.>v ,li..'l.«..l as .he eans.. t..r .!..■ .n.ul.le n va.M.,n ..f tht : nl lhl..n.a,a l.v ..r.anis.n. r..sen,l.lin. S,aphyl..eo....„s '''---,. y ,K-.niiar l.a.llli. As" in n,y . ase ..f invasion ... .he spn.al .-nl l.y .yph....l- I I'rr,,..^ ,„r./. \:'rr:„sr,;> ,, lS.-,4. N^' l'.^. - . - , , , Rr 4 -• <:.,„pf ,:■„./. .!■■ In S..: .Ir li,..!.. l^.'.O '^ r^.r.,. h.ndrri,.. ISf,.. e nr,„.r,. aU/. kl.,. M.l.. IM^ vvviv Tl.i- ..in- al-. A. ^■..S■^ roU-r.ur. to ,h.. ii,.-,^.ur.. ,.,,;„ yr,.- ,M.ii.ll.r>2 » I)r„tsrh. ,nrd. W"rh.. IS'..:!, .N... •;. '.'.'• ."^ "' V "/^a't/ \ri5'>^*;-r-, SYMrinM.S .\.\l> ( ijMI-I.IC] l,ii.\S Imcilli, s filial cum'. M-iircfly aii\ aitiial iK^inictixn of lissiii' in llu' tiiiMJiilla (ililoiiL'ata was (IciiKiiislraKlc. A ca-c iiiiilir my (iliMTvalidii in llic vi'ar \f<>^\. U> wliii'li my altcntiou was aj MM lallicl only after the a|i|H'aran AA. Milfiiint: from an attack of lyplioiil f( v.r of m(»lirali- Mverily. \l lIu' t'lid of ihr ihinl wc.k (li.-tiirlianccs of >|>».'«-
  • let«' recoverv t'radnally ensued in the course of four and a half week-s. Certain eei-einal iitrve- a|i|Mar to lie involved liiii rarely in tlic course of tvpiioid fever. Facial or iiypoudo-sil pare-i- i- iiieiiti 1 oxce|)tioiiallv. I'os-il)iy tlie l(\v ivp.irtcd <'a>e- of par:ily.-is of aceoin- niiHlation (liiiiii;.' eoiivalescenee ((iiililcr.' Kutel") Kelouir in this jrfoiip.' The oceiirn'tiee of paralysis of the vcxal eord> i-, in |>urt at lea>t, lo he incliidiMl here; while an.ither ]»u oltlie ca>c.- are attrihntaldc (lirectlv tu liHvil disease of the larynx, '-itch a- inilaininatory swelliiifr (if the niiK s ineinlirane ainl the sulmuicon.- tis-iies, and ulceration (see ji. 2V.^ and the siicceedintr |iai:e-). The condition present in the first class is inidoitlitcaralv-is of all the tniiside- su|i|ilicd hy this ncrvi has lint rarely been ohservod ; more freipiciitly, jiaraly-is of certain frmiips of niiiseles, especiallv of the alidnctors of the voeen repi)rtei'C fiirthiT ;it .1 l.it r |.;e,'r the (lis-i'iitiirLT npiniori i.f Kur-t.-r iiikI Kni<'~ '\i. 2h:i\. « (Usiimmelti- Hr!tr,i;i,. IM. ii. '■ Ar.-/,. iihi. ilr Miil.. Dee.. '*;i4. « nnitirh. »i.;l. ll'...-/,.. IS'.!.',, T.'o. '.'«. ' Th.' iiinii,)i.'rii|)li of 1'rzccll.nr.lii | \'..|l(l wliile !lii> v.ilumi wii- in pr<'>v iittCTiipts to show that piiraly.-i* "f tli.'v.M;il ,..nl- in ih.' .■mir-i' ..f lyplioiil f.'viT i- ;i ijiiit'' fr.-(|ucnt .■c-iir- ri-ncc. KurtliPr iili.-orviili..n-i will lie re.|iiin-il te il>'t.Tiiiinf' t.> wlmt extent tliis striking statrmiTil. wliiili i- ciintniry tn tii.' e|iini..n^ liitlnTt.. lirKi. i- oorroet. » hntinfuhrrks Arc/lir. liii. XXX. '■' Hiiifsr/i. Arr>i. t\ l.liii. M'-'l . li'l. Nvili. '" Dnilsi-h. inetl. »'i:-/i.. 1H79, Nci?. Hand L'l. " Virc-liow-IIiis.li, 1870. -^^- "'^/M y^: ^^^: Wn ^M •J7.S rvi'iinii) I III i:. r.i].i\:i. |M r-i-liiiL' int" c"ii\ :iI"-i"Ihc, i- n tciTiil to liv \;iri(pu- nl)-.,r\rr«, ,r nilici- li\ Mnimiiill. I \\A\<' I" (■-•iiially (ili-crvnl m-c nt till- cliMiiKii r. Affections of the Spinal Cord.— Tin-.' mI-m nn (I..mI>iI<>s (|iiilr nil-.', iniirli i;in r tli;iii wa- IpcI'ha cil at a liim- wlnii p. ri|.liiral li.iirili- anil it- iliiiiral iiiaiiiri-lalioii- win; lilll.' kii.>uii aiiv llii- iva-Mi llic larlicr lil.iatmv ' .•aniiiil Im' aircplcil uillmiii .|iialilicali'iii. ( a-c- <>i' mvilili- diliiiilily (Miiiliriuiil l.\ anal ir .■li-.Txalii'ii- have. Iiowi \(f. Iici'ii nli-irvcd in a niinilMr 'it' in-lami -. Sik li a <:i-r wa- irciiilly uli-(r\») m'c nl>" n. 1-1 . ill "li'il' a -IriinL' man. lliiil\ -mi' vi^ais "M. iliiil in llif lii->l li;i.l!' nf till' -iciiHil \Mck 'if an allark ol' l>|ilii.i.l ti\.r. uilli iii"-t iiiai-k.-.j !iyni|.niiiis nf arulr a.-ciiMliiiL.' ' Laiiilrv's >|.i.ial |.ai-aly.M> - nr, il' lliat liTin ]\i- |,n f.rrnl. myrlilii' !irini.->iiii'i . Mi(rnMu|.ii' ami ranliil liacl. lanln^ric I'Xamiiialiiiii nf lln- -|.inal innl ai>c|o>i.| li.^Miml ilniilil iiiva-imi Ky ly|ili(ii.l- liMiilli. wliirli riiiij.l Im' .l.iiiMiislral.Ml Imlli in iraii^MTM' Mclinii.-. ami in <",;lliin'S. A ca.v :.liiiii>l iiliiilii-il willi my nwn liail 1h-,ii iIim i-ili.il liy l.ciiiKl- in ixiil. II i^ iialicnl «a> Mi/.cil. in llif lliiril wnk i.fa mil.! allark ut' typlioi.! fV'Vi'i-. iifhi- -lie- liaij ai'liiaiiy rnlcTfil U|"in (■iiii\ ak^cinri'. willi aciilc >|iinal |iaraly^i>. a.-ri mliiiL' iVnm llic !■•«• • iMrmiilii'S. wliidi itTiniTalcil fatally in tlic ciini-M' nt>. \in ila\.-. uilli >Mii|ili)inti nf aspli\ xia. ami iii wliirli coii- >iciiin>m» «a> pii -cr-, cil ilirini:;liiinl. A Minii-wliat similar cas.-. |irii\iiiL' 'alal at tlic "IhI nf fi-lil'cn limii-s, has li.'cn ri'|iiii-lr.l i>v S.-liiir, 'I'll.- rxaninialinii nf llir inril in llii> raM' -liiiwcd an acailc lii'innrriiaL'ii' iransvcPM' niyclili- at llif level nt' llie In'irili ami tilth cervii-al .-eL'nient>. ( nlliin> in this ea.-c were iieL'alive. I kimu lit' III! I'lhei- Hiiiilar ea.-e. They thus appear tn he (piile rare. ^Vh(■ll1l■r in future iase> liaiilli will he ilemuiistrahli'. as they were in inv ease, in the tissue of the etiitral iiervii;;s .-ysteiii, eanmit he stated in ailvaiiee. ami their presem-i is pii>silily nnly «t' snhnnlinale siirnilieaiiee. It is readih- r -ivalile tliat ;"\ie ell'eets nf .■>pirial severity iiiav -ive risi> to similar svmptnms. It is nntewnrlhy. t'urlher. that i|uite similar severe romlitidiis n|' anite asc cniiiiiL' paralvsi- ha\ e heen ilesia-ih- ' in the rnurse nf \arinla hy < iuhler. IJernhanlt. ami .tliei^, h\ l.amlr) in eases nt' iliphtlieria ami ehnlera. ami Ipv the latter iin i.i-yileu in ra n|' pmunmnia. Still iilher eliiiieal pietiire- iiiKJiiiiliteilly of -iiiiial oriu'in liave heeti i.li-er\eil. 'riiii- We-tiilial,' npnii the ha-i- nf a ea-e teniiitiatiii^: ill reeii\cr\ . has called attention tn a peiailiaf variety nf marked ataxia I'ullnwiiiir tvplmid lever, as.-.xiated with tfeiimr in tin Inuer extremities, xvillmut aetnal itnpainnent n|' •^v<'-~ -Ifem^th nr of -eti-ihility. 1 lit" I >,■■• til.. inMii,.^.r.-,i.li -r N..tliiiie_'. 1 ■ '.'I- »„.'. ./• r ,,f >ik...,1i nf tl,.. l)iill.Mr tyiK^ n-.ml.liii;: tl.n-c :ill.iJi.i- inullipl.' >.I.T..>i-. A -iinilar ..lilim. lias a|,|,ani,llv 1..-. 1,-rrvr.l \>y Kirl.lioiM ainl Slnim|Kll.' Mulii|.lr ii.-ular -rl,r..-i- lia- al-.. l-.n. .,1,-. rvr.l .lii.i.ally, an.l in a nntnlMi- of i„-tan.i- ai.al iralK. in ra-.- -t l^['U'<\A Hv.r. In .•-.„,- |.aii-nii witii it- ...■riimiic'.' in "tii.r a.iit.- iiiLMiidi- .liM:i.-( •^, liii- <"i>- • litioii app. 1- t" !»■ IK'I <\liviiiily raiv in tvplioid. I'ierrf Mari.- ..bscrvc.!. ainoni' 'j:. .asrs of iiiMih.r M-lerosi:' .l<.j).n.loMt UlM... inf.cliaiis ilis.as.s, 11 in w liidi tliif n.tidili.Mi «a.- a m^milI «i lyj.h.M. tVv.T The niilitarv-sanitarv r.'|K.rt ..f tlio Fmi.li .an.puii.'n at 1M,U-.1 likewise nfers U> Minilar cases, KKsteiu ' was ..lie of ll,e tirst lo eall allen- tinti t., this intereMiiii: cotMiilicaliuii. His pal lent exlnlatea hnll.ar distur- Imne.. of siH-eel. an.l ataxia, wiliiont anv other impairment of motor |H.«er or sensation. Analomie .■xaminalioii ili.selose.l insular ^'ray .kreneratmn of tile spinal eoril ami the hulli. Cases ..f -i.iiial panilv-i- of (liilclliy u miintiiT of wiitc r< as of rare ..eeiiiTmce in the coui-.' of or toward llie ei.,-.. of the attack of typhoid fever. Tlu' earli.'r v]Hn1> are not liax^ i,p,,M anatomic examination.' Itecently Kichardicr ' lias piil.li-hei-ar to have mad.' e\lcii-ive ol.-crvatioii-. I have pers-mally made >.,ni<' ol.-ervatioii> at various times and in an irre-ular manner, l.iit wliieh, neverthelc", have yiel.led .rrtain data. I-ike Striimpell. I have found in severe cax- in iialient- who were irrc:itly reduced, toward the end of the I'ever ..r diiriiiL^ convaleMcnce, marked exa^r^'ciation of the patellar tendop-rellexes. Often I was even aMc to elicit sli^rjn or even a mark.Hl .\.liilles lendon-retlcx. In mild and iiKMl.i-ately M'vere cases the jiatellar teiidoii-reth'X is ex-ei'diiiirly varialile at the liei^dit of the di-ea-e. Karelv it is entirely waiitin>r, but in the ^rreat majority of ea>es it remains normal or is s(,mewhat enfeelilcr the piTiml of convalescence, even in mild ciises, 1 have ohserved now and apiin moderate exair^reratioii of the reflexes. ' M.iuii.ri'il i" tlirir li'\l-l k-, '' \',.rlr.',i,ii'iriit-liiIi(M'. HiMH-aikt. I.rhrhu.-h ■/■■,- .\.ri-r,il:ni:,Uii-i/ni. Ml T/ii'.^f. Piiri>, iss.'i, filed I'V .Miiric \vlio u| ■ liiriisill" te liiivo inude no f'.i iniliir obfervulicin. -XL^'jnt- •^^jr^f^m-L.^ 1 t^.r-^ * mi 1 m^ 'SO r)rii"U> 1 1 \i i: III (liil.lnil I li:iM- .il)- lliaii in a. lull-. General Neuroses. — (li.'ica iiiiii..i, i" \vlii.li IMli.t .ui.l r.aiili.-^ !ia\.- i:illi-'\. I-. I'll.- lii>lMr\ r.laliiiL' l.i llii- |i..lnl ua.- I.a.-f.l ii|Kin llir slaliiiiinl .)!' a iii..>l lni>lH.iilliy |ili\^i(iaii. wlm liciili-.l llir wniiiaii .lining: Iht alla.k .if l\|ili..i.l tiv.r. I liavtul"... nliMrvcl .linni.' l■lln.li^Kln^ in •'> .liil.ir.ii in tin' .■niir-c .if l\ [ilmiil I'l-v.-r. Ii ■ . a.-.. « lii.li .lr\ fl.i|ic.l .liiriiiL' .■..nvalfx-.iio Inmi an iiilaik .if uplii'lil li\tr |.ri.|.iiii:i>l >'vcr six wi-iks. ill.' .■iiii'lili.in wa.- prin. i|.allv .me ..I miilal. inl .licrii.' Ih ilcliint:. riM'.iv.rx tr.iiii wlii.li l.-ik |.la. . in llif '■.nir-i' nl >i\ w.. U:-. '1 lie >.-..iiiii oliil.l, in vsli.im llic lii iwil.liini.' M|i|.«Mrc.l iliirini; llic lliinl "> iin.l a liaif ni.mllis after .'..iivalo. .n.c. Witli r.'irar.l t.i tlie tliinl eaw I have im tintli.r n.ite>. In -A iHM' at the .l.ilnis ll..|ikin- II -|iilal of a miiiiil' w.iniaii «liii Im.l ha. I .linmie .li.ir.'a f.>r a \.:ir liefer.' lli. ■n-.i ..f ly|ili..i.l f. ver. lliere was ii ili«a|i|iiaran.'.' nf llu' .Imi-.i.' iii.iv.iiuail- .liiriiiL' llie lieiirlil .it' the f.ver. «itli a ^.'ra.lual r.turii .liiriir.' .■(invali>.-.-n.-e. (H'.itlier Melir.i-i-, ref.felie.' IliaV 1h' llia.l. t.i tlie .icelirretiee of panilv-i- aL'itaii- ( r.«ii«'.likt I. I lia\.' iiei-.mally .ili-.r\ ..I tlii- e.iiii|)ii- iiiti.iii lull i(i fever whi.h he eall.h.ii.i -|iiiie," an.! wlii.li h.' r.uaf.ie.! a- a i)eri-|Hiii.i\ liti^. (>-l.r ha- -in..- r.|>.iite.l a Inr ..f .(iiit.' similar case-, iii.)-t .if whi.h lie nirai-.l- a- e\aiii|i!e- <.f a |iaiiifnl neiimsis, anal, i^ri HIS to tin- iiainfiil .■.ui.liii.Hi in.t with in tin " liy -teiie spine' aiui the •' i-aiiwav s|)iii.'." It ii-nally .•.mies .m .iiiriiii: e.iiivales.-eiiee in lieiimtie indiviiiiial-, ami the -li'_'ht.-t h. iLliiii: m.iveliielits iif the hack inav elicit I'xpressi.in- nf the ni.ist a.iit.' pain. I^esions of the Peripheral Nerves.— Th.' peri|ilieral nerves, csp>ciallv tli.ise (if -piiial .iiiL'in, appear in li.' iiiv.il\.-liic paiiil- v,U ,,f' certain iiiiiselcs, mii-el.-iri'>ni)s, .>r an entire extfetniiy , or even as a jiarapletria, or, in -till wider (li-triliiiti.iii. witli the clinical pietili-e of |>r(iii(iiinec(l |).ily iieiii itis. r..itli the .linical and th.- anat.iniic kiiowledj:.' ..f neuritis itself, and the .iliservation .if it- oeciirreiiee in the c.nir-e of typhoid fever, are ■MH m^w ^€m ■'«iii^.&iiagi£tr»r»i^^ SYMI'loMS .\\1> ( iiMri.lCMIoSS. l!.sl -till .oiMiuniliv.ly nvciil. It i- )>.— il.l.', Ii"«\;- viuii-lv iiilimal.-.l, that a I'.w .a-.- ..f |paial\ -i- -iipi -.1 I" Im' of -plnal .>iit.'iii u.iv ariiially dur lo ii.iirili-. In llii- .•alr^MV 1.. i.,,^' tlir I a-.- ..r atiMplii.- |iaral_v-i- in wlil.li llic mii-.i - ( \liiliii.' ..t' (l.vliic iiiilal.ililv, uitli Icndc iii.— mm |.iv"iiiv. a — Nia!..l Willi •.iilij.rlivf aii.l nl,|nli\ <■ ,li-tmlKni.-,.. nC -.11- siliMii, aii.l ill wlii.h, .A.'M ill a.lvaii.r.1 .a-r-. muN ,iv ..r man rial i,„,,iuv,iii.tit l."ik i-larc. l,.'V(l.ii larly rrf.Tiv.l to ilir |.rol.ai.iiit y n\ tin- Mioiv riv,|iiciil o,viiiivii. r iicriplKTal luurili- in .a-.-- oi' typlioul frv.r in tii- 1.00k on IHs,;im.. ,,( thr Sf.iHul ( 'u-.l. Nriiriiic i.ar.ily-i> ,„-,iir- 1,." fiv,|n(iitly at tlir li. i-lil "I" iIk' «li-.a~.. than toXNani it- <•! aii.l into lair conval.-.M ii.'.'. I liavc ol.-.Tvni iifiintic |.a.-alyM- .,f Ih.iIi lo\\vr .■xtivniiti.- .lev. lop a- lato a-^ tlif fAonly-iiiiitli .lay att.r .1. f. ivcs- rcn..., alnr tlio i.atimt lia.l alivady iroit.Mi .mt of l.f.1. Sndi latr .«vnr- n'li.v i-, it is true, -till iiior.' iiMial alnr ,li|.litli.Tia tliaii after tyjiiioiil f.v.r. I'aralvsis duo to noiiriliri, l,oili wlicii cxttMisivo and iiiou' parliciilarly whoii .iniini-.Tilied, apiH'ars to involv.' tlit- lower cxtri-iiiiti.'M iiiori- fiv- niifiitly than tlie trunk and the np|>er exlremilies when it iK-eurs in ea-t's of tvphoid fever. Ainoiii: inv .•a«>.- are J of panilvsi- m the |KToiieal nirioi,, nnd 1 each of paralysis of ilie uddiietors -f the tliii'h and ol ih.' .pia.lnee|«4. Taralvsis of the latter hits l«en nieiitione.i also hy KratllKhniL',' as well iia hv Notlmairel aii.l Siirnmv.' Of other forms of iieiiritie paralysis, that of the loiii; MUiseles of the I'.a.k, the >errntns 1 Euleiihiirir 1. iis well as that of the iiliiiir and the iiie.lian, li;us U-en reeorded in the literature. Arnoufi the eases ot' para| hv Notlmairel deserve meiitioi 111 an a lillt. I havi- personallv seen neiiri ia of the lower extremities, 4 eases re|iicoiirt ' anlication dnrintr 2. « /,,..-, rit. 1" /,..,-. nf. iiiniiltyphii-." Dr,ifyi-/i. An-/i f. kli V-' f i! ; ^^t-ww^m MICROCOPY RESOIUTION TEST CHART ANSI and ISO IE5T CHART No 2 I.I t~ III il i 2.5 U il 32 111= l" lllll^ 1.8 1-25 III 1.4 mil 1.6 A APPLIED \hMGE Inc ■:6J 482 - 030C - Phofie ■61 288 - 5989 - Fo« 282 ryriKiii' n:vi:n. M 'I': 1 (J3=:g lia> (>('<'iirrc in ^(■\(^:^l iii>tan(('> in my i'.\|H'rifiii'c, iinlriliuliiiii uf certain ncrvi- or in i|nitf i fill- a> I cnsati anestliesia, ~ncli a> arc (iliscvved tliirini^ convaloeencc, c-|)ecially in adiill teiualo. invoUinL^ c.\tcn>ivo ai'ea.~, witliout hein^^ cimlincd t" deliniti' iicrvc-area~, a|i|ieai' In hclniifr to the gnin|> uf livsteric disorders, which are nut rarely encountered in the SI 'Men(f ot tvplioid ti'M'r. \^^j\ t're(|iient than the -iTn|ile deraiiL;'eiiieiit~ of Mii^ation, and especially n'e \('.\atioii>, arc the neiiraliria-. Anioiitr thoe, neuralgic ])ains in tlu' toes and the heel, and al>o in the reniaiiiinir ]iortioiis of the sole ol' the li)ot, have occiii'iid in my e:.|.erii'ncc with |iartieular frc- qnencv. ( 'om|iaratively rare at the height of the disease, they are likclv to a;)i>car c-peeially dnring the ~tage of defcrveseeiiee and the first j>ai't of the period of coin :.ie--i ciice. to the great distre-s of t!ie j)atieiit and also of the phy-ician. to whom the ol)>tinaey of the dis- order soon heci.me- a|ii>arcnt. At times the patient, nnder siieh eircnni- stance-, is nnahle to rest ihc lliot npon the heel, -o that this nuisl he ])lae:ii njion a concave -urfaec ; while at other times the hed-clothing nin>t he >np|iorted liv mcaii> of hoop-, in onler that it may not exert ]ii-c->ure npon the painfid toes. {•"ortnnately, the )iains eventnally dis- a|>j>car, generally withoiii ^|M(ial intervention. Xcverthcless, I iiave e.Nccptionallv oliscrvcd them to per>i^t for a con>ider:ililc ])criod of time, in one instanc< toi- a year and a hall', and in another tor more than two vears. In hoth in-tanecs neuralgia of the heel was present. \enralgia e who jrave ret'erred to it are l)neheck,' Liclici'mci-ter ami Ilagc iiliach.-' .Filrgcn^eIl,' Xotlniagci,* Frit/,' and Krall't-I-'.liing." It i> mentioned also in the Sdiiilint/ Hi/Kirt ';/' (lie (uriiKiii Ariiiiis fi„ IS'iO-H. Sciatica ajipears to he much loss common (llcnedikt, N'otlmagel). I have never cncoimtered it. I have ol)>crv<'d ill a woman, foiI\-one years old, who had a neurotic tendency, Jill extensive, severe neuralgia in the (li>tril)iitioii of the hrai'hial ])le.\iis, in association with persistent lihrillary mn^ciilar contractions in the del- toid and the trieep-, Imt without atrophic paralysis. IJiroveiy ensued in the cour-e ot' three months. I have ol)-er\('d intcrco-tal neuralgia in 'J ca-e-. in I asMicjated with herpes /osier; oeci|iital neuralgia in ■'! ea~e-, the tir-i ilevelopiiig during I z.,,,., ,.,7. • I.,.-. .-.', ■' /.->■ ■■/. ' /....,-. rit. « Kliiil-r/H- Sfii'lirn ,,l,rr ,1, li-'/i'iinil iilhl -/. - Al»i .,„,i,,ilh/jj,lif. SYMPTOMS AM> COMriJC.lTloy'^- 283 the n,.ri.«l oi- irn.j:ulur ,..,n,...ratun., an.l .he o.Iut twu ,h,nM^ ronva- hJnro. lt.r„v..rv onMU.l h, all :! .ax-, in 1 , it i> trne, H.ly at,..,' .ho la„n.i.m -f .he hnnl.ar and .ho .Tural n^ vvs, whieh has heen nu.,.tiun,.i in .he li.era.nre, • have no. .. h.e.ve.l Th.. ^.ate of .he sen-orv .vfhxe. in .he eonrso of typhoMJ ivyrv luui hither,o heen l.n. li..le inves.i^a...!. The li.era.nre eon.ain- hn. sean.y rot;.n.neo .o .he en.lly .nn.h .lin.inisheon.h- at.er .he attaek of .v,>hoid l^ver, espeeially in the lower ,.x.n.n.i.,e>, .he soles of the foot, an.l the ah.lominal wall. In son.e pa.ien.s .he fr.e..on ot .he clothinjx in walking, the wearing of woolen ^..K.kh.^rs and the hke, .ivo rise to a.. an,.ovinfr s,.nse of .ieklin^. In 1 .a-e under iny oh.er- ;ation,oe..nrrin,^inan.an who was hi.d.ly n.rvons hefo.v .ho at.aek of tvphoid fbve,-, the,-e persistcnl sneh a de^r-vo of i:o.,oml .....aneous hvpen-.he-ia of the lower half of the hody. wi.h J.nne.ato an.-.h.Ma ,„.l oxa-.>ra.ion of th,. plan.ar, ere-nasfri.', an.l ah.lomn.al nH.x.-s, that the ption. for a lon^^ .in.o eon.d hv pernn....l .o walk only when a olosoly applio.l in .1... ••onrso of (yphoi.l f.'ver is th.. .'a.-. Am.,n- l-M-J .-..-OS of tvph..i.l f..v,.r analyze,! hy 15e/...l.lr impairm..n. ..t hearn.fr o.^.,.rr..d in 4 p.r eont. in .1... ..onr.o ..f th.. dis..a-e. Other anri-.. als,> emphasize .ho fn..inen..v of .his .....nrr......... Tluw Bin-knor-^ stafs that in 1 S per <.ont. ..f all .■as..s prosontin.ir impairnu.nt of lu.armfr, lio was ahlo t.> .l...ormi.u. tvph..i.l fever as the <.auso .,f th.. .li.or.l..r ; while Zaufal fon,..l a similar ..ti..l..j.ne fa...or in 0.7 ]h-v .vn.., an.l Kranu.r in "2.0 JKT ooiit., of their eases. .See \foo,, S..hwurt«.-s Ilnn,/h„r>, ,/, < ,/,rr„).y,lk.n„/r. 15,1. i. S.lnvMr./^. -Kr- TuuM.ri,. ■ ...r., Arr/../. <>h,-r„h.. WA ami IW.T. .\..at..nn,. r..f.T,-nr..^ ,..„ l.< tou„.l in th.. pui.iT .■!' ('. v.. Hoffiniin, /"••■ <•'' , ■ , , l " 'r,.l„.rai.. Krkr:u,kun.ona..s.i,.),..n,r.u„- l... l!,..,.y,,l,u^. • A,:->. r nl.rmh., :> ..BHtra-e/AirStatistikderOlirkrankli.-iton.- An-I..f. Uhrn.h.. IW. XX. I •>s I ryi'iinii' ii:vi:j;. J 'I'lic ili-Mi-il( i~ lit' iKaiiiiir lliii- liir 111 "-crxtxl arr iiKi-t \ arialilc wiili rrlci-iinr lo ilicir -lal ami iharaclrr. Willi rr^iard in tlir cMci'iKi! car aixl tlir au'lili>r\ canal, tlic i-arc ca-c- nl' caiiurcnc nl' the auricle arc id lie Kdriic ill iiiiiiili|i. \>'iS). I'crio^titi- lit' tlic cMcriial aiiditiiry canal ami |M il'ii-ati.'ii ul' :ili-c<--c- ut' llic |iariiliil ;jlaii(l iiiln llic carlilaL:imiii< iK.rlioii c ' tlic canal arc inure l're(|iieiii. l''iiriiiicuin-i- dt' the cxleriial aiiililcirv canal i- al-n lre(|iieiill\' inenliuiicd. 1 lia\i' Mli-er\cil it in a niiinlier 111' in-Iancc- a- uni- ul' llic 'nianil'olali.iii-- nl' innlti|ile t'liriiiicii- lii-i> ul' tlic -kin ilnriiiiT ciin\alc.-ccnce rrmii ly|>liiiiil lex < i\ Aniiinir the ili-unler- ut' ilie inieinal ear a (li-iiiieiiuii i> jreiierally made lictwccii pnrciv iier\uii> ur t'liiictiupal ili-unlcr- ami tlm^e (Icpciul- cnt niiiiii uriianic eair-c-. 'I'lic |)iirely iinctiunal (li-nrdcrs are liy no mean- rare. A purtiuii ut' tliese make their a|)|iearaiiec a; the lictrinninfj (if the attack, ami while they are |)us>ilily le>- euii-|)iciiuiis at the heiirht of the ili-ca-e, it is unlv lieeaii^e the |)rut'unnilly e (li~turt>aiicc- is tu lie inchiijed especially the cxtrcniclv aniiu\ iiiir. -iil)jceti\-c sensitiuii ut'-unnil as ut" ruariii^'- and riii^'inLT, which is ut'teii pnsent diiriii).'- the first pcriud <>■' the di-ca>e. I'rulialiK' the alniu-t characteristic iiii|iairment of hearing'- at the heiirlit of the disease is al-u in iiianv eases due Milely to ne'-vuii- di-tiirliances. At lea-t, it i- iiftcn inipus>il>le to demun^tl■;ltc any causative Ic-iun with niu-i thuriiuudi inM^tiiratiun. 'I'he priijrnu-i,- ut' the-e di>iirdcr^ is tavur- alile. Thev ilisi|iiiear wiih >nl>-iilcnce lA' the fev< r, ur at any rate with the end of ciiiivale>eciice. While t'urmerly the cause- ii\' these distiir- lianccs were thuiiLdit to cuii-i-t in liy|>ereniia ur anemia i4' the liraiii and its niciiiliraiic-, ur cxeii ni' certain parts ,,{' the middle ear it-elf, at the present dav the actiun of tuxins n|)iin the |iarts in i|iic>tiun is |irii|ierly made re>piin>iMc. The di-iinlers i>\' the middle ear de])endeiit u]iun anatumie le-iuiis arc referalilc ])rineipally to exteii-iun of intlammatury proeesM- from the structures of the na-upliaryn\ thruiiLdi the Ku^taehiaii tiilie tu the middle oar. Nut rarely iiiiicupurulcut int'cctiuiis matter e;aiii> cntnincp meilianicallv to the cavity of the tympanum. The |)ii--iliility ut dis- M'lninatiun uf excitant- of intiammatiun fnun reinut,' m^rans and their luilL'inent ill the ear i- pml lal ily uf -iiliurdiiiatc -iL''nili<-anee. The iniero- urL''aui-ms of ctiulotric .-ii;iiitieauec in all tlie-e intlanimatory ]iriice"es iiave nut vet liecii aile((Uately detcrmiiicd. K-pceially it has imt yet hecii mail<> out to what extent the iiacillus of Elierth itself plays a part in this connection. The coui-e of the aH'cctiuii- of the middle ear varies hetweeii the mildest ea-c- and thii>e which are the mo>t severe and are directly ,S) l//'/V/l/.V AM) ( OMl'I.I'ATIOSS. 2s.: (iMii'.a'niiK or MIC MitcMilnl witli >t tliriniL^linUt tlio ivst lit' liti'. I'lir iii-iaiicr, |i,iriiliiit :-iiiii~-llii(iiiilMi--i-- (ir [Krin-liti- and carirs of till' |H'lnni- Ihihc may aii<(- arc tiir lc-~ ((iriiiiioii in tlic < llic jdiysician examines tiie prot'oimdiv soporo-e jialient lVe(|nenfly anil llioronuiily, and wliieli a.'e ri'coLMii/eil only atiei' they iiavc ^iven rise to sii|(|>nrativc intlanima- tion of the niids' also mention.-. >mall-<'ell iiitiltration of the nieml>ranons lahy- riuth. Disorders of the Byes.- — Thc-e are, on the whole, r.ire in ea.-es of tvphoid t'ever ; at any rate, they are miieli less eonimon than di-eases of the ear. ( iantrrenc of tiie tissnes has cxec|)tionally heeli ol^erved in the imiiic. lUS). True noma eoni]ilieatiiiLr typhoid fever is also ineiitioiud by earlier writers as a caiise for e.xteiisive destruction of the eyelids. I'aralvsi* of the extra-neular muscles occurs most comnioidy duriiiir coiivalcscenct'. Knies liclicxes that certain varieties ot' these c\tra- oenlar paralv^es ;ire tincle.ir in oriiu^in and are to lie attrilintcd to a chronic iiepliriti>. I'nilateral and liilateral ptosis lias lieeii oliserved (Xotlmairel, IIcuocU). Cases occiirrinir diu'injf the hei<.dit of the fever are very rare in the aliscuce of intracranial complications. Ptosis and nliducius palsy have lieeu recorded in the third week of the disease liy Xotlmairel. In a case at the .Folms Hopkins Hos]iital K'lilomoto,- jiaresis of the left eye developed on the eiirhtli dav of the disease. In this case there was |iaralvsis of lioth intra-ocnlar and extra-ocniar ninscles, .nnd the condition was jirolialilv due to a sliirlit local inenin- iritis. In cliildrcu symjitoins of ineniniritis and stralii-mus may occur ' /,...-, rit. tler\in'■•* Kurprrs t(ttri/n>if. Wil'^ll:llll'll. IS'.i*. A Ue. il,- Si-liwrinitz. cliiiptPr "ii ■■ I Iculiir ('■niiiili- <'iitic>n~ in T/ir Sur-ii.-n/ <^,!„pli,-ntin„ii ,niil Seijurls <■/ Ttjp/itiid Fever liy Kei'ii, rhila., ls;i«. I'h^la. M,;/. J..,,,-.. Mari'h ^,. I'.'(K). il TYi'iKni) ri:vi:ii. "^^ f .)-, early, hut it i- (jii(-.li..nal,l,. -vlntlicr tliry aiv a-iM-iattHl witii ;i tnic iiM'iiiiiLical iiitiai nation. I'aral_v.-i> (]f : ,,■ intra-iM'iiJar inii-clt> i> ai.-o -f (■imiiiKin (luring: .•oiivalr-reiHc. l',.r-t,r. will, wiioni K iiic- airivc-. coiiMdcrs tlj,. |,:i,-al- \H~ of :irc,,iiiino(iati(.ii and niydriaM.- a~ (—^cntially part iiianiti-tations <.t' the urnci-al cxlian-tinn ; liir ic-^ fiv.|ncntly tju-y arc due to .■iivuin- .-(•rilird ili^raM' of x\\r anictcd ii(rv(-|iatli:-. Arnonu tlir dnrinjx llic Tel. rile iM-riod, I,ut l.y no means so riv,|ii,.nlly a- lyi.lni- leserand -niall-|.o\, ,,r even tneasle-. lVol,al,!v tlii- eonjun.'tiviti- i~ not ,|,e,.ili,, l,ni i- d,.|,endent upon or llivoivd l,y ''"' '^"■' 'I':" tl"' 'I'lll I'alieni \vinl^- in(re,|nently and elose> |li^ eyes inilidtictly and |M,-HMy ai>o l,y il„. ,iinn'ni-lied seen'li f tears. Dnrin^' <'onvale-eenee. and s,,nietini,- in llie later .Ma<:"- of tlie disea-e, a irne pldyetennlar eonjunetivitis nun- appear. A plilyetennle niav liieakdoun and f.i'in an ulcer, or witliont tliis oriiriii ulcerative keratitis may ariM^. TIicm- ul-vr- arc rarely >o lar-e as to (.dve ri-c to extensive Icid^oma ane thouuhf ,,f ,.,, the cau-e in -uili ea-es. 'J'lie pcr-i-teni firm- of amauro-i>:,i which may lie either unilateral or lulat- cral, generally de|icnd upon atrojihy of tl jitic nerve. The -eat of the di-turhance i- to lie -oiinhi either in the hrain or in the optic tract it-clt. .\moni.f the cau-es of the di-tnrhanecs in (|nc-tion, hcmorrliau'-e and -clcrotic or other variety of f.eal cornsi:. 2S7 an- :d.-i) i>tte!i upcnitivc, :i> Kiiie- ami F()r-tfr, (.-](<'ri:i!!y, !ia\c |)niii!(il nut. optic iifiiriti- duriiiL' tv|.lii]i(l is ii>iiall_v a-,-iiciat(i| with tntiiiniriti'-. Ilowcvi r, ac'ctic ii(iiiiti> may (icciir \vlii
  • ym|itiimatol(iirv, i)f typhoid i'cvcr rcprcM'iit the e\|)ri-~inn of two principal f'aetnrs, namely, the iiumIc nt' actinn nf the haeilhis ot' l^hcrth upon the inxlv, particidarly the dcLrrec ot' its virnlencc ; and the s|)<'ciid conditions of the invaded orjranism itsclt. I'hcsc condition* ai'c, naturally, I'XtrcmcIv varialile. As to the nature of these coiiditioii-, a ])art is alreadv known, at least "mpirically, while a part is -till entirely undeterinined. .\inontr the more important detcriniiiinLT conditions ari', first, the tiictors rclatin;,' to individual, namely, aire, sex, constitution, occupation, and mode ot' lit'e, and the dcjxree ot" sii>ccptii)ility and power of reai'tion. Further, of importance in slia|)injr the cau-e of the disea-c arc special proiidnciicc of ymptoms on the part of individual ortraiis or svstcms, and the not uncommon associated activity of the tvphoid-hiieilhis with other ])athoirenic micro-orirani-ms. In addition to the s|i(.(i;i| eimdi- tions, general conditions also play a rod', an pre-icrvation, devclojimcnt, dissemination, and the dcirree of viridcnce ot' the virus; these arc especially the local conditions, hahitations, state of culti'.ation, ni(«Ies of interciiursc, aixl water-snjiply, and, linallv, the ireoirraphic situation, eliinato, and season. 'I"he varieti<'s of clinical |)icture, cour-e, and termination of typhoid fever resultiiiL'' from all these various inlluenccs ;irc so diverse, oft<'n so eoniplctelv opposed, and, on the other hand, at times so runniiiir tocrether, that anv exhaustive descrip- tion is itnpossihlc. Kvery case, llierefor(>, is different from cvcrv other. and any ilcscrijition can serx'e oidy as a Lrniiie in the tnid^t of this variahility, and determine the most important ])oints of view, A n ■ if '_>H,S TYriinii, I i:\i:i!. ■.-•V:Vj g^ iiih-iiliraMi- hliliilur 111' i.ci I- iij tlii- iiilihfitiiii' liiiSr ;illi;nlv licrli n IriTicI III in llif cliniral -criiuii. ll will lie Im'-I hi ImhIii ilif (|r-iri|i|iiiii willi :i ri ril;il o!' lllr -ilii|il(-l (•(iii(lili(iii- : tlif \ arii'lii- nt' l_\|iliiiiil tr\ir thai n -nil in acccinlancr willi llic -(AtrilN ami llic niililnc-- nl' ihc allack, a- well a- ihn-c vari<'lic- ilr|Hni!inir n|iori tijc iliiraliun ul ihcdi-ra-r in Lrrmi'al. nr nl' it- liillrri'Ml -lai;-)-. It may lir ciniilia-i/ril in aiKaiicc that -(Aifilv anil liiii^r ilnratiiiii nt' tin- ili-ra-i.' dn imt (•ninriilc anv iiinfr than ilu lircvitv anil tnildnr— . Altlniiii:!] ,-nrli r.iinciilrnrc nccnr- trri|iicnilv in the iiulisidnal (■■d-v, tlir M'Vcfily and ihr duratinu of the -vniptntii-- arc, in trcncral, whnlly iiidciirndmi nl' each utlicr. 'i'hc Kc-t cvidciici' ot' this i> atl'iii'y the stiid\ nt' thr varictv in \iv dr~rril)i'd tir-t. The Short, Malignant Variety {Mn/i'/iKini or l-'ulmhintd Tji/ihoiil J'l rrr : Jh/jjii-jii/rilir Wiriili/). — 'riii> variety, which, fiirtiiiiatcly, is rare, riprcscnts, a> its dc-iLniatinns indicate, a furni ot' ty|ilii.id lever dt' iiiii.-t -evere <'iinrse. Sitiie nl' the ca>e~ lietrin after a luiip'r nr slini'ter yieriiid nf iiiculiatioii, which is nut tree t'l'uin syni|)tiiiiis. llic ])atient^ iiiniplaiii fur days in ailvam I' j:reat inalai-e, licadache, vcrliL''", and >lce])lessne-s. and iif'tcn exhiliit iian>ea and vmnitintr. and nut rarelv diarrhea, '{"lie |iiil--c, also, at thi- tiine may he ahiiDrniallv frci|Heiit. and the teiii[ierature tempurarily elevated. Jn anotiier j_'-riin|> of ca-e~ the di-easc set- ill -iiddeiily. wiihoiit pnidnmial iiianif'e-tatinn-, with a -^inLrlc chill nr rc|ieateil severe cliilline--. Almost aKvavs the stairc ot' ascendini.^ lev-cr is eonsiderMhly slmrtened, so tliat witiiin from twciity-foiir to foiiy-eiLrht hours the level of con- stant feent. the patients heeome stupid. They ;irc delirious at nitrht and -ouictiinc - hy day, .'ind lie in ,'t -tate of n^laxatioti, in pas-ive dnr-al dcciiliitn^. with the mouth open, exposini: the drv, li-^sured ton7 r/7".V\ /.V SYMITOMS I.V/; col USE 289 fliMtitatii'ii, and ^n-iiii!iiiLr "f tli. tcrtli, in ynini;.' |n f-niis even cinivii!- -iiiii-, incrca-c tlii' irravitv nf the clinical picture. Nut fanly ritriility dl' the hack witli (i[ii.~tli(iti)nii> ;inil (MIut cciclmi-pinal -vinptoin- arc [irc-cnt lic-iilc.-. 'I'lio >tatc lit' the -jilccii is varialilc. (Icncrallyit i- ili-tiiictly ilctnon- straiilc i|iiile early, even at tiic time ut" ailiiii-^-iuii ut ilic |iaticiit, un tlie x'ciiiiil or the third day nl' the dl-ea-e, and iit'ti ii the ur^ran is cnnverted into a Iar:.'e, ^ul't, and -en-itive tuinnr. 1,(-- cuininnnly cidar;_'crncnt of" the s|ileeii ucciir- later, or i- not denioii-lralilc thronirhunt the entire ciinrx' i)t" the attack". The alulon en I'arly hcconie.- ^Meatly distended, ii,.'. ..]■ 111. |i « 1^^*^?^^ "TT-- .+,-,-f 4.. m • 8 Flo. 'lU. 'li-ini»--:iturr rliiirt fr..Mi a fulimimiit nisr ,if ty|.h(iii| ftvi r in ii woman, tli yi'drs (ltd. tkTniiiiatir.K fnially uii ttn' liKlith day. lliis wiu thi' thinl ca^.e in a h'niscc Thr lUtark lifgan with a chill. Inli.stina: Usinns wiTi' niarkcil, es)i<-rially in the rc^-i.. cuinii an. I the Inw.r tliir.l cf th.^ iNiini IVyer's patrlics were in a statr of ini'iiiillary s in part gruatly Jisinli'L;raiiil ainl m a statu ..f rnni.'i'sti.in. Nu complicatinn was present iriy-tive mietnic. n (if ilie wi'ilinsf. and ill some cases ac(|nires a con^ider:ii)le detrrrc of ten>ioii, wliieh Is an ominous sii^n. 'I"hc -tools are at times diarrheal, at other times eon- stijiated ; tlie urine irciieniliy contains alliiimin diiriiiLr the first few davs, at the stiine time luiiiir scanty, eoiicentrated, anil hiLdi-eolore passed involiintarilv into the lied. The termination is in most eases fatal, followinir proirrcssive lo.as of strciijith, anil at times associated with extremolv hi>rli deirrees of tem- perature {liy])orpyretie form). Only the minority of patients >iirvive. [ii the latter event the severity of the p'lieral symptoms snh-ides toward the end of the second week, the tem[ieratiire-ciirve declines to ;i lower fill i i I : r^' I 2m TYi'iiofi) i-i t:i: i\(l, s\ illi -iiiiiillaiitoii-. iinpniN ciiu'iil in liic |iiii-r ; anil aih r a liin;:tT (ir -liiiilcr |"rin(l tin- |iatirnl liccduu- al'clirili-. ( ■unvali-ii-ncc i- alwavs iiiiu.-iially -i\.ir ami pintrai'tLtl ; llii- .ilicii (n'ciir.- in con-ciiiiciicc of ri(|-inlr-i(ii(c~ anil i'ila|i-t-. The -yni|iic.ni- in lljc |iir~» iicc of wliicli death take- place are llmx" ot iTL >-t |inirunnii inlnxicaiinn. Only e.\ee|)ii,.Mallv i|o earlv intereiir- I'l'ii' iiil' linal lirini.rrliai:!- arcelelale llie lata! lerniinalion. Tcwi- tnoruin cxaininatiiin ili-iln-e-. in areonhinre ujili tlic -ii..rl dnralioii (if tlic attack, liiat tlic lc-i,.ti- in tlic -mail anil ilic lar^c inte.-tine are .-till ill a ■-talc uf nicdull.iry >\MllinL:, and oidy licre and there i> tijere licu'innini:- .-luMuhini:. 'riicir extent and inti n-it\ du imt, \>\ anv inean>, al\\a\- eiirre.-|ii)nil with the severity of the clinical |iictnrc. Althi.iich .-escfc deirreo of i'lte.-linal invulveiiicnt are nmre trei|iieiit, ca-i- aKo occur with leiiiarkalily -liLdit ~|iecilic inli-tinal h -ions. The lafire, soil, dillllielil -jileeii i- oticn the -eat of recent e\lrava-at ion- of 1.1 1. The liver and the kidmy- are in a ,-tate of marked clondv -wellinj^. l'oi-tinialel_\ , a- ha- liecn --t.ated, thi- v.iriely i- t|niie rare. It occnr,'^ princiiially in adidt- n|i to the tortieth year, while children and old |per-ons are attacked much Ic— freijiicnt ly. With n fcreiice to the diinitioii of the |irocc--. the tiilininant tiirtn, \\hich inav terminate lat.ally at the end of the tir-t week, and raivlv per-i-t- until the end of till' -econd, i- to he contra-led with the maci'i.' liirm- of |irotr;i''ed eoiii--e. Severe and Moderately Severe Cases of Protracted Course. — Detailed reference need not aiiaili lie made here to the eiial |>eriod. Tin- applies with esjM'eial frei|Mency to the l:i-lii;ium, which may j>er-i-t for as lonir as four weeks, and e\cii much lon;:er. The fever lia> then le-s ci.minoiilv or only in the first stap' the character of a continued or remittent con- tinued type. \'ery early or even from the outset, the tem|perature is likely to exhihit marked lluctiialions, and mav as-time the character of an iiiterniittenf lyjie or even liecome wholly irnirular. Next in freijuency tli(> stap' of delirvi-eeiice is prolcn;^ed. '{'he characteri>tie steep curve- arc then oh-cured or are entirely ai'-ent, and the iuerea.-^o ill tcinpcratiiic lake- place L'radually. with a more or less [)rotracted, remittent, or wholly irreirular course, in which there are not infreipieiitlv caiisele.ss remissioii? aud exaecrbatioufi. After defervoseenee lia.s fiiialiv taSLtTK u I w./i//'/\v /v .sii//'7'/.i/s i.v/( CD! i:!tl taken placi', ilic ~la;r(' nt' inm uli-ccrni' may lie iiiiu-iiallv Innj.'. Tin' |)aliiiit- iriiuiiii xsiak. and "pIiiii ixliibit niarkcil in-taliilitv cpf |inr-i' ami t«'tn|Kniinri', su iliat iian-iiuiy im ica-r inav lake [iknf wiiluiiii iili\ii,us cansc or npun -li^rlil iii-nViKaiinn. (';l-i'^ air -.A-n I'ncincnt in ',\lii(li (■ i icp iinic^rcMi Ipppmi). riir ini"liiatply >c\ cic anr csiH'cial anxiciv at any tiini- in ;lir ippiir t' llic attack. 'I'lic fever i> ilreii f'nuii the (int-it iiiit Very liii;li, and is (|nit(; irfe^idar nv I'eniilteiit, or so niaikediv inii rniittent tViPin ilie JHtiinnin'^ tliat the tein|iei'atnre-ehart in e|ieaiani-e which seems icniaikaMe t(p the inex|)(ii- eiiccil iph-es ere ca^e~ ^'ciierallv pursue tiicir c|)ears dry and >caly, and the hands and feet are cyanotic and cold. ICinaciation jn-oirres-es iuiiiitcrru])te(lly, althou;:h most careful examination fails to di-i|ipse any --ptcial ori^mie le-ion, and life is ter- minated with the mo-t protoiind marasmus. I'lpst-mortem examination in such eases disilpp~es what elini(al examination had alreadv rendereil pHphaMc, namely, the ahsenee of complications or anv special ortranic ehaiiire. -Murclii-^ppii, who directed especial attention to this form of the disease, -tates that Hokitansky attrihutcfl it to shrinking' (pf the mesenteric jrlands, toc^cthtT with di>ai)pearance of the intestinal villi and lympli-follich's. .\ cliar;i(lerisli<' case (pf this remarkable variety, to which even experi- enceil clinicians make no reference, came under mv oliscrvation in con- sultation, occurriiiir in a trirl twcntv-one years old. wlicj lived amid the iiKPSt ll m •J'.i-j / ) rui'ih 1 1 \ it: t';i\nr:ililr coiKliliiiii.-. Alhr :ni :ill;iik ..|' l\ iilmi.l I'.'Mr ot' ili\ fli Wii ks' iliiialiiiii. wiili irri^iilMr innl I'li llic wlmli' li>» IcMr. llii I'MIiciiI !i|>|>r;iri'>- .-ivi-lv ~liiv,rr. -I llial linalU milv -1^ nr I" In al- ■■uiiM lir cniiiilcil in lln- liiiniiu-. Al llii >anic liim- iIm- |ialiriil u.i.-h'.l in a iViu'lilt'iil riiamicr. ainl ii{ii>ii llir lliin -km >liTlrliiil n\ 1 i- llii' lioih- lii'il -nrm ;.'railualK a|.|'iairi| in ihf iiin-l vaiKil >iliialiiiii- hmt tin- -ai rum. llir Mruliia. al llu- In i I. i-M'ii ii\i> lit' I 111' lit'l ami lirL'iniiiiiL' iiccrii>is nl I lir riL'lil inrina lia\ iiiL' aUn ilivrlii|i(il ill llic la>l I'cu ila\- III' lili-. \l lln- aiiln|i>y iIhti' Ha- im milcudrlln allcra- lii I ihr iiilri'iial \i-iiia, uilli llu- I \ri'|iliiin 111' llu- inli-.-liiii-. w liii-li I'nii- laim-il iiiiimriiiis Mnnnlli. |ii'_Mm in il i-iralnri- in llu- a.-i-i-iiiliiii.' < nlnn. ami ill llu- ili'Uin in llu- Nuiiiiu nt' llu- ili-nri-ial valvi-. in place iit' llie I'cver'tt palelie>. >ii llial i-vi-n llu- pallu'lnirie aiialninv uas iiiialile In an.-^uer llu- i|i;e>iiiiii a.- Ill llie (.'aiise ol ilialii. WcU-charactcrized Cases Pursuing a Moderate and Mild Course. — \\ iiili- ililinili- e\i,-riial m- iiiili\ iiliial inniiil imi- 'H' special iireaiiie ili-ea-e iilli 11 ni\(- ijuii- iiiip|-i--- Id i-;i-(- 111 llii- el-iiiip, llie\ are ill ei-iieial lii-liiej-iii-liei! t'ri'lii imt- aiinllier priiiii|>ally iiy tlieir (liiraliiiM. Ill a iiiimlier i.t' llu- i-a-e- llie iliiralinii i- -Imrn-r lliaii i- tile averaire ill llie Wi-jl-lliaikei! -e\ere ea-(-. W iiile ntluT- plir-lle ei|lially a- ImiLi lull a iiiilii ei.iir-e. .\iiioMLr tln' ea-e- nf tin- tir-t kiiiil, tlm-e an- e-peeialU iliaiaelt li-lie in wliieli llie iiiili\ iiliial >IaL:t's ca>e are n-aiilar ami iiiaiiitaiii tlu-ir iiuriii.-ii priipuriinii-, altliuiifrli tli«'y are >liiirter, Ml llial the leiiipt raliire-eliart, e\ei pi as tu tlif (liiratii m nt' llie \ariiiii- -taL'e-, eiilireU- re-ciiilile- that ut' the typieal variety ( I-"iir. II). ( )th('r caM-- exliiliit a t:i\iiralile (•(iiii>e ill that eertaiii iiidixitliial stai.'-c-; of the (li-ea-e are eun-iileralilv -horteiieil or remain aliiio.st imdevclopetl. Thu-. the initial -taL'f mav he almo.-^t entirely waiitiiiij-, and the lieiirht 111' the f'i'ver iiiav lie reaeheil at a siliirle hound in Iniiii twelve to ciiihteeli iloiir- ; or, a- oeeiil- v.ilh i-peeial t'r(i|neiiey, the -taL'"' "' --tei'l) eiir\ e- i- eoii-iilerahlv shortened or i- not at all marked. In the latter event tile t'ehrile -laire i< ot'teii teniiiiialed hv a eritii-al ileeliiie. C"oii,-ider- ahle -hoileniiii: of the aiiiphihiilie -taue. with complete development of tile initial pirioij and that ot' eonvale-ceiice. i< le-.- common. 'i'he ca-e- of modi-rate and mild de'.'ree. wliirli are iiiial)l)rcviateym|)toms are likely to he exeeedinirly mild, and 'A ■di r I/.7 i77'/\N IS s)i///"i/v i\/i I III i:.^i:. •_".»;'. ill" iiii\iiU' -y tc-m r-|i(i'l:illy I- Inn littlr invi>lvit|. l-'mrn ilic diii;- ihi-tii' point oC \\,\\, tlii-i' ("i-i'-, a|i:irt I'lmn tin- I'lcl tli:ii lli> t'l'Vcr- rurvc trii|iii iiily L'ivi- ii'i :iiln', nr iiialiililv lo ili'iiioti-lrali- lliitri, lliriiiiLfliiiiil llir i lit ire I'liiif-c nl tin- iJi-iM-, , a in! m r i - «iii|ially al-ii liccaii-c nt' llir iii-i'_'iiiricaiil rhafa'trr nl' tlic iti*i'~liiial -vtii|)li)iii-. '^iii li ca-i- arc |p|iilialil\ tlif -aiiif a- llin-c tlial earlier [iliy-ieiaii- cle-i^'iialearateil elii)loi:ieallv iViiiri t\ plmiil tiMf. It i- (ililv a .-te|) rrmii tlie-e Miuiieiate aliil iiiilil ea-e- In lliu-e |iiii-iiiiiL: all cspeeiallv slmrt ami rre<|iieiitlv aKo an e-[ie(iail\' liiiM emir-e. Tlie^e are real]\' -eparaltle (ililv ~nper- tteially, I'lpp tliey are aetiialiy e>pimeete<| l(v all |(i).-il)l" (rati^itimial t'onu-i. Atypical Cases of very Short and Mild Course (Ti/plius Alinrtiriis, '/'iijiliii.'< f,i-ris.sliinis, Ti/jiliniilrttr ( Hiininrili /). — In earlier times tlicso ea-if'S were, ^till le^s tliail tlie preeeiliiie- fiiriii>, eipii-i(lerei(! lever. lie was tiillowed by .liire^ensen,' Bauniier,' and other-, who hel|)ed to jrive «-learness and tiinv to the new doetrine. Ail the ca-es included in this firoiip are eharaeterizwl hy the espin'iai sliortness ot" the eotiive, and fre(pientiy also l)V the marke has heeu mentioned, hv no means always a oharaeteri-tic featiire. On the contrary, the well-developwl ca.-<'s mav 1)0 elassitied, aeeordinj; to the -U}x^e-tion of Liehermeister, into mildv-st ease; (Ty|)hus levissimn>l, ineludini: all ea-es ehararteri/tsl l>y mild- ness and hy hrevity, and into a se<'ond class (Ty])liiis al)ortivus), which includes those eases in which, althoiifih ihe course is short, the character of the disease may at times he <|uitc severe anase is often aiibrcviatetl, but in the ca-e- under consideration this -horteninjr o(\en attains a ino-t extreme ' I'm;!. Virrlri;.. 1 S.IT. Hil Ivi. 'Schmidt. htn'in_ f>iss.. Ziiricli. 1Rr,i>; and t>iffJifi„n!if:ra>\khfitrn. \9.r,i. ' \':,ll,-7tiniiii'x Sniiinilinui ijni. \',,rtr . ]^~'.]. No. ill. « n>,hnii MnL J.,ur.. N.iv.. ISSO: iind Prutxrh. Arrh. f. /Jit,. MH.. Bd. iii. Wi^- • l.'-irc. All tlic ^ta-c- iii:iy lu' cMi-Mcnihly .-licrtciicl in tlicir cuiirso ill- may I,,- -,, al>i idncd a- to Im' umvco^rni/ahlc. .\- in llic ca-c- <.!' in.«l,TaIr severity. >,. aUo in tlir Miil,|,-t. tiii- al.l.icviati.m inav alUrt th,' initial an.l tli^ t.niiinal >Ia.rc^ (-.pccially. -oMiriiriK- in ih,. ti.nn nl' an ahnipt imm. m- a .Titi.'al .Icclinr. .ir l\urr may !,.• a .|nil,. -Tadnaj '■'""""■'"•'""•'I' '"• >ni>-i,irn.T nf ill,. t;.v,.r. It >l:,,ul.l l.c |H,intc,l <.nt that .•..n-i(lci-al)lc -hortrnin- of the initial -laL'c and critical .Icclinc of tl].' fcxvr (iccnr nioiv lVc,|ncntly ir ca^- ,,f al.nnivc typhoid than in tho-c.d'thc mildc-i variety. 'I"h,. i;i>ti-imu ..f the di>..a,-.., which like- wise i- fre,|uently more ,,r I,-- -ivatly -Ih.rt.'iicd. may i^xiiilrt all |"i--il>le varieties nf temperatiire-eiirvc. from that of the ivirnlar reiirt- lent continued c,uir~e. whi.h i~ de,.idedly the leaM cmimon, to that of the |.nre inter aittent or wholly irre-nlar conr-e. with low or m.Klerate telnperalnre. The pnl-,. i- likely to he particularly accelerated and to l,e mistalde only ill irritahle women and ehiklrcn, while in I, - -.ei|.-itive. nioiv rolin-t individuals it exhil.its scaiwly any acceleration tlnvui-lmut the entire course nf the di-eav.. Kveii in the aln.rtive ,aMs with |,it_di luiy -r tl.r ,ii.,:i.,. t<'m|ii'raliirc at the outset, the ^liiiht d(;:ree of , crease in the frei|Uency of the pulsi' is at times cs|ieeially slrikiiiir ( i'"i,Lr. L'lt). IJetore |)assinir to a coii- -ideration of the reinaininir -symptoms of the ahliivviateil ;iiid till' milde-t easf -. a few histories with temperatiire- tracintrs may he luiitlv iriveii to ilhi-trate the \arioiis ii.niis ot' course. 'I he f.iilnw ]uij ciisc ,|i;,v 1„, coii>i(|eri'il as (iiie of ahortive tvplioid iVvcr: A ceinpnsitor, ninel(cn years olij. after several da\ - (if liead;i'-lie. anorexia, and |'l'o-li-;iti()||. \\;is sli.lilciih sei/ed . . wiih a chill. (lii the ,|:iv of ad- riiission c (liiiiiii: the iMirile period raiijred hetweeii 100 and IL'O, and was fid! and of hi_di ten>j -i. Convalesceiiee was uiieniii]iii- eated. and tin- patient was disinis.-ed after thr.-e and nnc-half weel^s nadv to rettirn to w<)ri<. The leniperaliire-elian sh wn in Fi;:. L'7 is from a ea.-ewiih nine davs of fever, on oidy two or three of whiiii the ti'ni|ieratnre was hii'h. hnt which, nevertheless exiiiliited a severe, even ahirinini.'. aspect, '{"he patient was an ohese a.ssessnr, tiiirty-si.x years old. wlio had drnnk a piod deal of In't-r and hail eaten ireiierousiy, thonL:h eiiLML'-ed in lint sli^rht jiliysical a<'tivitv. llu was seizeil with a chill on .; retnrn Jonrncy from Italy. As earlv as theVeeond dav of the disease a larire. palpahle. sensitive, spieiiii- tumor was presi'iit ; on the third day. an aliiindauce of rose(d:e on the trunk, the up|ier arni.<. and the I'av ..r til. .lisi-iis.' thiL-hs. From this .lay on there were stnpor and. towanl eveinuL'- and in the nitrht, active .leliriuni uilh attempts at Hi::lil. From the fourth to the tenth day tliere was mod.'rate aihiiminnria. at first even with >lii;ht admixture of hlood and of hyaline and epithelial casts, and a small nund)er of hlood- ea.sts. As will lie seen from the tem'ieral ure..'hart. the fever siiliside.l ^'ra.l- ually. Complete defervescence was attained lietween the niL'lit of the eri'lith an.l the morriin:r tale of the pul>e W!^^ from the out- set cpiite favoraldc. iMinir intermittent now and a-ain durin- the tirst few ilays. hut never especially ,-niall .ir fre.picnt. Convalescence w.'is nnusn- ally protracted. ~o that the patient, in spite -if the .-hort duration of the a.'tnal fehrile sla-c. u.m.> not .ahl,. to -, i out of h.-d until after four and one-half weeks, and then with a lo>s ot' uei-lit of I'.i pouii.is. J?y the side of thi> cvi~,. may he placed that trom which the Iracinir shown in Fi- L's was olitaiucd. This occurre< inulliply iiniil the .■veriini: .it the llflh ,lay. .-., that a.- many a,- 7:>ii .'..nhl he .■..mileii iip.ni the hark an. 1 the extremities. The ]uil.sc'reinaiiie.| nl:itivelv i:oo,l. even at the h.'i-ht <<[' the fever. heitiLT always i'lill. rcL'tilar. aii.l tense, hut hein}: in..r.' than 1 L'O ,,ii|y .,n die first eveiiini:, an. I thereafler ran-iriL' ah..iil 1(10 anil hel.iw. 'Ihe f..ll.iwiie_' ease exiiihiis a certain contrast to the L' severe .'ases jnst iiiciiliuiifd ; it likeui.-e was attetided with fever of nioderale deirri'i', hut it l>.iv ..f tl Fir;. 28. did not for an hour exhihit any sovere or alariiiitii: svni|)toiiis even at the hei^lit of the disea.-e. It oi'cnrre.l in tin extrenieh rohiist lio.stlcr. Iweiitv years ..hi. The tever histe.l a]loL.'ether for nitie .lays. t!ic markedly remit- tent an.l interiiiitteiit curve risini' <;enerally in the eveiiitijr to from oit^ to ;>!•. I ' ('.. and finally exhihitiiiL'- a jiiiailiar and rare varietv of critical decline in two staL'e.u. lietween the ninth ati.l the lenlh day tlie teni|ieratMre fell from .'J!)° to .')7'' ('.. then fhictiiate.l ti.r two days hetweeii .'IT" and oT.ti- ( '., to decline airain sn.l.ienly helow normal hetweeii the eleventh and twelfth davs. and [lersistinir at this low level .hiring' the first part ..f convales.'cnce ( Fiir. 2".l I. As the temperatiire-eharl shows, the |Hilse in this c'l^e wasfV.mi the oiit.sel iintis. tally slow. alth..U'_di always full an.l tense ; at ii.. tiin.' was the setisoriiim ofth. patient in any deiTee iill'ected. and he e.impljiine.l of hiiiiLrer even hefiire the suhsi.len.'c of the fever : after a lirief, nninterruptcl con- valescence he was restore.! to his full eapa.ily for u..rk with remarkahlu rapi.lity. The followin',' ca.se pursued. ..n the whole, a severe course, with various IWUrATI'JXS l.\ SYMI'IOMS AM) ;enient of the spleen was demonstrahle on the fifth day. with moderate \im li'J.S rvninii, I i:vi:i:. i (llM,MiIi(Mi ot the Mli.lon,..M ;in.| -ll^r),, ,,.,,. |,.l•m■^.■< i,> the ilcocwil n-ioii, iukI ''■""' ''"■ -^•■V'l.ili I" ilu- lliirt.M.iill, .liiv tw„ „r tlirc- tliin. iica->oiii>.like Mnnis «,T.- pa.-.,-,| ,h,ily. Thr ,n r,' nf iho pUlilMll l,M.i ,li,.,| ,-l,„rllv ic-lufc. Ir.iii, :ii, :,ila(k of the ,univ.-l i;..-i. of lv|.l,oi,l tl-\.-i-, uiii, i,it,.MiiiMl licrnori-liML'c-. 'I li'' lollouin- r;,,-,. will „.,-v,' :i> an ,x;nH|.lo ,,f iriir lv|,|ioiJ f.-vfr of tlio iiiiM.st Iy|,c. Il„. |,ali.ni ua.~ a mail. Ion n -.on,, vcaix,!,!. wliolia.l lu'cii m'|,i,al tor monili. fo,- ,:,!„., ,|,,ixili.<, hut ollicrwi^e 1k' ua. rol.uM an.l well iiouri.-lu.l. Thr o,,.-. t of ih,. .lUaM., uhicl, was not prorrdrd hs J .ro. horn. >. u as altrii.lr.l wiih vhilliiios. As carlv as the tim (lay cnhirL'.'inrnl ,,f lhr>pl,.,n «as ,i, inoiistrahh. hv ponn^.-ion'. and on tlu- t.iml (lay as well hv palpaiion. A -niall iMiiiihcr .if w,ll-,l,.v.>l..pr.l niMM.Jii. appcart-a rclativ.ly lai.- h.iu.,,, ll..^ -ixih an.l ihr n.nlh ,lav. Thi-ou-l,. out, tlio cnm-ecoiiix' ..f ilu.h-.a.M. ihoiv was i... .Iiarrhca, hii't, ..n tin. ,■.„,- trary, .■oiislipalion. ( .,nvalc.-c,n,v pro-nsscl rapi.liv, and at its do-t- the l'M> I r II. r ,h~' pntioiit wois-hpii five and a half poun.ls more than a week hcf.irc the hcL'iii- imii: ot'tiic discas.' . V\j. :U . 'Ph,. Icnipcraliirc-cliart of th,. .'asc is, as is so frci|ii('nt ill the mild, si casi's of tvpli.ii.l fovcr. \\h..il\ iini'hara.'I.ristic. The tenipcratiirc. alt.'rnalclv rciiiincnt and inurniilicnl, 'hut .m.'c r.ai'hci .•J!t°('. M itli n-ar.l t.i the .(Hiiv,. ,,f th,. ino,,iii])l(li'ly (Icvci.ipcd, al.hrcviatcd (•as.- ill ijciLpal. it has l„,.n point. .,| ,,iit— an.l ..!' llii.- iIip .asi- last related .ath.rds a li'.i.iil illu-lraiioii — that iiiaiiy. in .•iddilion to the i.revilv, ai-e characterized li.-id.- iiy imii-iial inildiie-s ,,f the sviiiptom,~. .si. that th.y- w.'ll d,-. TV.' the.pialiticati..ii •• iiiil.lc-t." ■jdic-e .'a-.'s set in either im. \pecl.dly with a .hill ..r .a ii'diii- .,f' .hillin.--. or aft, r -li-hi pr,,- dnmies, and then the tn.ixiiniiiii tiinp, ratniv i- r. .1, h. d .itli.r u:radi; dlv or more rapidly. ...•.■a-i,,nally lieliuv the .11. 1 ..f i u .iity-liiur h.uiiv. In all. the u'ciicral c.iii.liti..ii i- l.iit sli;:htly di.-mrlied. The patients are ■ i y.inr.iTioss ix symi'toms ami coiksi:. •2<.)'.) :it iiiiot .-oiiicw liat aiKitirctic, rc-lif-s ami -Iccpl -s at iiiuilit, l)iit aliiiii>l wlidlly witliiiiit ililirimii. Tlic piil-c i-iinaiii- <_'■ I ilinnii^'liuin, and i- oi'teri nniarkaldy -low. ( 'nni|iliiati(iiis and unusual liHalizatioii of tliu typlicid proco- arc cxtivinclv raiv. After ilic fcvc- ha,- la.-trd Ihun m\ to ten day-, (lie |>atitiits rt'cuvir rajiidly and rciui|)lit(l\ . A niliid)er of ca.-LS tli.it should likewise \,v inriudid in the cattjrorv of tile niildot form of typhoid f.vcr (■\hil)it t few davs .xovi'i-c liiit traii-iiory ^rcniral luanitistation.-, with -onu'what higher foviT, hilt till! cniiix; siil)>c((ii('ntl\' a.s,~iiiiic.- a mild cliaracttr, toiniinatiiif; in niU'oniplicatcsidiuir 1. crisis or rapid lysis. 'I'hey occupy a position midway lietweeii the "t\ pints levis" and the •■typhus ahortivns " of Licliermeister, constitutiiiL' :i transition lietween these j.n<>iips, and in their ty|iieal form tliev ilins- frate tiie saying " I'arturiunt moiites, macetnr ridicnlus mus." Siu h cases irciicrally he^'in with aiirujit elevation of temperature foliowinir a chill, and are marked at times hy (piite severe symptoms ol' treneral intoxieatioti at the height of the fever, wlucli at night mav attain a level of llt^ ('. or more ; t'icy also occasionally show es])e.Mal involve- ment of the internal vi-cei-.i, -uch as particularly severe ditluse hron- eliitis and alliuminnria ami ne]ihiitis of earlv onset. The-c cases almost make the impression that all the severe svmiitoms of tv|)hoid fever were Keing <'rowded into a short time; and thcv not iiii-elv give rise to anxiety, which, Iiowever, is soon dissipated, and the loss of weight is at times verv con- siderahle (see the case illustrate(l hv I'"iir. -")• The course of these true ahoi-tive cases -s gcnerallv as loni: as that of the mild and very mild cases. Kvcn more markedly than in the latter, one may note that tin incompleteness in development is at the cxpen-e of tli<' ii]iti:d stage and the ])er'«l of deferves<'ence, so that the duration of the fa-tigium with relatively high lever is ot'ten rather pro- tracted. With regard to the course of the fever during the latter period, the remittent eintinuiil type predominates, hut complete iiiter- mi MO I ) l'Utaili'(-. Tliii- ih,. ra-r illiiMral,.! I.v Fi- _'7 .-licwcl ihal alhiiiiiiiiiiria may l.c piv-ciii a- early a> tlir li.iirtli day of tlic diMa-c, alllioii-h in .-CM IV caM'.- (if til,, (inliiiary t\]if ii i- ii,,i |i|,,.|y to a]i|Mar liclim' tile 1 '> r t l;-c 1-.. 3 4 5 e 7 8 9 10 11 12 13 U 16 16 T. 41 -♦- — ^ :- i -■■- "- \ — 40 -t - r if • ''■- 39 J h ' 38 / / ^ A ' ^ J ■4 ^ 37 "i t f- 1. 1*7 i \f\ /I /^ 1 1 3B "i i ■■-r ,1 t \ i / 35 1 1 • - V . il = I iiikMIc (,f tlir sccoii,! urck. Siill III,,!-,. in-ti-iK-tivc i- a cax' of ahnftivo or mild typhoid fivn- whi.li v\a- iiiidrr my uliMi'vali tlir ,,ii>,.t of uhid «•■-; atlnidrd willi iir|phiiti-, and which piir-iicd it- couf-c amid the rli.iiral iiiaiiil'i-lat inn- ..f the latt.r litioii, and wliirh thcrcfirc may lir ap|)ru|,riat,ly callrd an cvamplr of iir|iliroty|ilioid. A salfsuoiiiaii. lunily yrars old, was ailiiiittcd tiir liriiiorrliiii:ic' iicpliritis nftfi- >hc had liivn ill f,,r i«,, ,|ay>. TJ!.. ai'ioiiiit of ni-jii,- ua;- ciiiLsidinil,! v diiimii-jii-d. and ilic . dark and l.|oi„U ami I'oniaiiicd an iiluiii- daiKv nf all.iiMiiii. iar-(. iniiiilici> of cpii iuiial ci'ls, and hvaliiie and l.lood- (•a>l.-. Tlir UMiipcraturo J-"i^'. WI : which was '■>- { , m\ the cvcninir of -S^iil::: .j:, ■'■,,y:*^- ^i4^:$i,fjcw;.,v^-;^^-'?::^-^' ?/;;:' vf.:-v.^.^.-i^i:^:i'.-.>^i^ v.; "i.^;^ r.i/;/ 1 /vo.v.v /.v MM'/'Voi/s- .i.v/; (nrnsi:. ;j()l till' thiril (l;iy dl' llif ili.-cast', ro.-i' mi the liillciu in;.' tlircc il'\> to Ih'Ihih'H il'*. t :iiiil ^II'.tJ'M'. In :i4'litii)ii to tlii> ilrLTfi' nt' flcv;ili(iii (.r tfMi|H'i-:itiirf, ulilrh «;i.- cniL-iicltTul)!!' lor :i cast' of iiiiil.' Mcjilirit i.-. llic iial|ialilr ciilMrLH'- iiirn' of ilic ^|lll■(■ll [hat was |in>cnt on ailiiii>.-i(iii was .-Irikini;. ( )ri llic liinr a_v ot' tlic iliM'asc ili.-lim-l rovohr inailc- tlicii" a|i|icai-aiici' iijioii tlif chrsl ami alnloiiuii, uiih rallur aljiimlaiit new croi.s up id the tli-vi'iilh (lay. Tlic rialiirr ot' llic attack uas lliii> c^lallli.-ll( d. I Klcrvc-ccicc .-ci i[i licUVccii llic cIcvcMlli aiiil llic luchlli ilav of the ili.-caM-. ( oiivalcsccucL' was thcrcai'tcr iiiiiiitcrni|ilc(l. The alliiiniiii iiail ilisa|i|)cai'ci| from the iiriiic 'i|ioii thi' sixteciilh ilay. >vhilc l.loo.l aii'l .iiiihclial ca.-ls ucrc no loii:.^^ (li'iiioiistralilc atlcr the ciu'lilh 'lav. Willi rcoai'ij \n llic iinlisiiliial .-yiii|itiiiii.- I'liaractcfi^tic of l\|iliuicl I'cvcr. tlic iicciii'rciicc III' ciilai'i^ciiiciit nf tlic .-iilccii i- i|iiilc a.- iVciiUciit ill all aiilifcviatcil inil.i or aliMrii\c ca-c- a- in tlm-c that arc coiniilctclv ciiaractcristic. AccordinL^ to iiiv (ili-ci-vatimi-, llic ciilaro'ciiiciit ot' tlic -|)lccn (icciifs more rrci|iiciillv at a com|iarali\cly early |Krin(l — in ilic lir-t iluys of the t'lAcr or c\cii licfurc it- cornniciiccniciii — in the niilil ami aliortivc ca-c- than in the coiii|)lctcK- cliaracteri-lic (nic-. It ha- iiecii e-|)ecially in these ca«ULtlly bw'ii pjiiitcil out, this ab.st'iioc of diarrhea 'Sli .FjJ¥ r ;502 T) rimii, [ i:\i:ii. ■ •»i«'V ■ i^iluranv Wn,.. „n, |,n,v,. „m,-i, uiili n triviir,. t,, ,|„, ,|,..,vr ,,f .|,.v,.I,,|,- "I'lil nf tl„. -|„vili,. ii,i,-iinal Ir-ioM-. On il,,., trarv, In -.,„nr ,■;,-,.-, "In.li appaivMlls allnr.l ,„, .^mnn.l Inr anxin^.lhr n„,.| niMl,H,-al,l.' Hirpi-i-r, aiv ,A|i,.ia. nr,.,|, ll.r in-lan,v, -n.l,l,n ini,-iinal In niorrliau,. ,„■ |iii'iliiniii<. lii.^T snrh riivum-tanr.- I l.av s., ,. ,.Titoi,itis .„■,„,■ i„ ,\]iVrn~ul I.TMis. In a l,.u .;,>,- n, ulnr!,. .iiirniL' atlark. „f ivpl.ni.l I, w r of ,niM " ■ 'natamrM, .,,„,„. in ,|.. ,i,l„ ,lia. l„-,.a u H 1, ,„ nu phlni,- ,.xa,lal,. ap, ,.r^-!. ih,. ,,,„,>,. ua~ ivIalu.U tavnral.l... (a-.- Ita:al vvrlnrMne |..T.:.„nl,s i,av,- 1 .m nuni ,.„:,.,. ,n ,,;,-.■ L'l't;. Su.l,!,,, inl.-linai F„ n,nn kr^e !>l.' inav r„i,v,Tl rniM, |„.rl,a|.~ aruLulamrv, , .,>,-, n,i., mtI..,,- ,,n,.. | ]rne «rn nisia,,,-,..- „l tins kin,l in u In.l, ,1„. ,„Vu>n„,, „r inuMi„al Ian,.., rl,a..e pivf Hi,. 1,1-M M,L-v.M„,i, that tv|.|,..i.| l,x,r>i Li I,. l,„,k,..| f..,- <>,„.,> '">■ '"",";""■ =' ;."^'" '■"■!> v,.a,> .,1,1. a.^ a.inn,,.,! „„ a,,..,nnl ..f.MHl,i,.n. s.'V,.rr l,l,M„lv .j.ai-rli.a. uiil, a ,lia::n...-,> ..1 .ln,Ml.„al ul.v.-ali.a,. It ua. siMtc.l tiiat i„. I.a.i l,..,.|, ,|uiu. |,.a|,|,v UvU.rv tl,.. n.rnnviic.. ,.f the a,-,i'. .I.ni, ai,.| l,a.l .■..i,i,,,n, .1 al I,,. su,vk witiiniit iiil.riai|.tinM. A Tru ,lav« f.,!- '""■"- l"^;"l'N,,-M.,„, all,.,. ,|„. 1,1 iy .|i.,.l,arLr.s l,a,i l.tn n|,la,v.l 1,; tl.n, i..a->.,U|,-lik.. >t....|-. il„- l,n,|„,al,nv. «l,i.-|, .,n a.ii,ii>..i,,i, l,a,l l.ien -„!,- nonnai n.so u, ti„. .v,,,!,,:.' t.. ::u ( ■. Ti.is ua^ r.,il,,u..,| |,v ivn.i.unt I, vr ot nmd.-ralr >, v. ial> l.,r a |,.Ti,„l ..fci^^ht ,ia\> with .icrlinJ ..f tin. i,.„.| , ,-a- Un-c l.v ixM., 11„. MK-|.„a.,n liial liic ,,,n,iiii,.n «a> nn,. ,,f tv|,i„,i,i l.-vri'ulij, h.;mnrrl,a..'r lV.,in tla. I,.,u..| ua> r,„„|,|, iclv v. rilicl. l„n .,mI v u I,..,,, aft,,- an afclirilf iiitirval i.t (level, ila\>, a sfVcfc rfla|..>.e ..t' till,', ii ,lav.-' (I,i|-atii. "••i,aiiiin- sMn|)t,,ni-. I'm ,i- nioiii,. .•,,tni>li,-ati..iis hav.^ ,K',airrv.| in my e\|,..i-i,.|i,'e with exiivine i-arity m ."i-e- ,,f alM.i-fiv ly|.h.,i.l i;.v,T. C.Mnplii-ali..,,- an,l s,.,,!, 1. l,„.al!/eil ill other ..I'-i, IS at-.. II,, I,.-- ratv in the al.breviate.l li.rin- <,f ivplLu,! <''Ver than in tl nlinars- f..i-in. With ivfeivncv t,, .■.,nvai,-,,n,M^ it lias l,e,ii >iate(l tiiat in e..rre- j^Jxitid.Mi.'e with th.. mil, hi,-- ,,f th,> -.yni|.I.,ni- it i- liv.|,.,Mitly ivin;;rkal.ly slx.rt an,l iin,',.inpl!,- at,.! an,l all,n,l,.,l with .■.,n-i.|,.faM,' i„.,va-e in vv,.i-ht— ,||,.|i l„,y,in,l tlie pivvi,,!,- w.iuhl. '!'!],■ ,-a-, - ..f -.v,!,- ,,n-,l :i>„l ,arly hi-h fevia- are. Ii,,wever. ,,||en i;,ll,,w,.| l,y ,|nit,. a l,.ii- |,eri,„l ' ^'■''- '•''■■ '''■ ''■■ !'• ■'--■ ' An-/,. ,',■„. ./.■ .1/,,A, X,.v., 1^73. ^-^: *.^^^ **,^_r^fc-,ir'a.-^i^"=P^J :_-* ^y*-f:f>^t-^'^ 1M/.7.I //oA.s /.V s) .V/'/'*.l/> .l.\7; (nri:si:. 303 -iC convalc'MviKv Willi ((.ii-iilcnMc .•Miariaii.iii ^ii'l r.illi.r -l<,u ivMnra- tiiiM <.)■ till- |pn\i.pii- I"m|\ -wiiiilii. It I- \M>itli_v lit' ( -|M-.i,il III. riiiu]) tli.il llic riiiM ami aKorliv,- ra-i - aiv lollowcil li_v n lie ..li-mr ■ altii::..||irr' iiiirtT<,-iii/, .1 (liirin- ilic tir«t f.lirilc |icii.Ml. and m.t in lir \ icwni in i|, |iiv.|)fr li-lil iiinil the ucrni-iviii'c ,,|'a niap-c, willi il- rhaiailci i-tir -\ ni|ituiii-, I'd-rdu', I'liiarirniirnt df the -|iiccii. etc. In nut a liw in-laiici- ilic atlack is ii'.t t.a-ininal.,| uiih a >in-l,. ivla|i-c. I have ( J.-.tv,-,! iww an,!, sen tiircf ivla|,M.- an, I iv,TUil,-,Tn,v- 'Ml. .win:: a niilil |)iainarv atta,'k. Witl. n-ai-,1 I,, ill,. i,,ial ,|n|.al. , ,,ftl„. inijuTliMlly ,l,.\ ,.1,,|„.,1 .-aM-, th,. l.ivvity ,,f th,. atn,.k is as wa- ,.in|,lia-i/,.,l at tli(. ,)iitMl, il„. in,.-t '■liara,.|,.|iMi,. t;.aniiv ,,|' ilics,. ,.a.,.s A ,inrati,.n of tlic ti^v.-r i;,i- in,.r,. than t,.n ,,r luvlv,. days i. ..xtivni... ()ri,.|i ,.n,.n!.r!i it i. ,,nlv lV,,ni thiv,. t,. -i\ ,iay-. \Vli,.n ,-,,n val,.-,.,.n,.,. i- rapiil aiiil uiic l,.rniin:ii,. w iihin tin-,,. \v,.,.ks. |,nt ,.vi.n ra-c- ,,t' ,,nlv ''""■''■'•" ''■'>■-■ 'liiiMti..n ,,r -li.^iitly I ., ,.„,.. ()„ ,1,,, ,,,!„.,. |,.,,„|_ .,", til.. iM.-iniiin- ,.f ,.v,.n niil,| ..a-,.- ||„. |„,--il,i]ity ,,f ,i„. ,.,„„•-,. |„.i„^r l"-"lni,.|,.,l ,,!• ,.,,iua!,.-,.,.|„.,. l.cin^r |„.,,|,,n;:,.,l ,,win;,rl,. ri.(.ni(l<.-,.,.n,.,.- aii,l rclap-,- nin-t hu kt.pt in niiii,l in ..\pf(.>siii- an , .pinion as t.. tli,. pr,,l,- al)l(. ,lui'ati,in. Symptoms due to Typhoid Toxins.— Alil.,.,,-!! alni,,-t ail writ,.!-- ul„, |,av,. -tn,li,.,l tl.,. alypi,.al, al,liivviat,.,l i;,nrw ,.r typli,,i,! lever have ..vpr,--,.,! an ,,pini,>n a- i,, th.. , .,,11,1111, ,ns att,.n,!iii- it- ,1,^,1- "l"'"'""- " '"' 'I"' tli,.,,fi(.s l,ith,.|.i,, put t;,nvaf,l app,.a.-s t,> I.,. snUi- cicnt. It i- ,.1-y t,. siy iliai th,- ,.,m,liti,,ns are ,l,.p<.n,l(.nt iip,,n ilio a, ti.in ,,(• atl,.|iMat,.,l hai-illi. ,,r iip,in a ,|iiantitaliv,.ly sli-ht inl^eti,,!) l,"Ti,nh,' n, yrlUr ,1ns.- ,,f th,. Fn.iM'hi. ,.r up,,n -li^dit -n-ccpl ihijit v ,,(' the ,)r-ani.-in, nr, ,iii ih,. ,)ther haii,l, np,.n inark,.n the part „f the l.,Mly. Alth,,n-h th,-,. -tat..in,.nts may e,,ntain inn.'ii tliat is trn,.. M, far a- actual kn,,w|,,|.je i- e,in,.,.ni,.,l. tjieso hvp,,the-es are,.niy fWinnilai,..! pn.hkn,-.. Th,. -,,lnii.,ns mn-t \>v i:ain,.d step l.y stej) hy ni.ans ,,r jiain-takiiiu'- experiin,.mal inve-tiL'-:iti,in. <'"ii-i,l,.rini: th,. ,|n,.Mi,,n Inim thi- p,,iiit ,,|' vi.'w, ,.n,. inav -,, -till further with r, i;.ivn,.,. t,, the pn„ln..|i.,n ,,r c-rtaln ,.i.-,.s, aii,l a,-k— May iK't .all the p,.eiiiiar -ynipt,ini in luiinan l),.i!nrs |„, in,ln,.,.,l hv th,. aeti,,n ,,t' typh,,i,l toxins, jn-t as ,.an 1,,. ..,,nc e\-p,.rini,.ntally in anhiials, as has |,e,.„ d,.ni,,n-trat,.,| with <.,.|tainty hy Frilnkel ami .Smnwiids, \ !{ iilp :iii| /I rii'iih 1 1 \ 1 1:. ^I^'l i\ila-atip and \\ a--iiiiiaiiii. >ii-.r|]iiiii, r.aiini_raiMi ri, ami ..i|i,r-' ( H. 'ImiiI,|ci|I\ al>!lli'laiit |".--iMlil\ ari'l m|,|..,i liiriil v aic allo|-,|r.| |,,|- -ijili iiilM\iiatiMii. It w.piiM |pr iHic--ai\ [" i.iii-iili r ill -iirh ca-c- r-iMciallv ill' a. ■( 1. 1. I Hal iiiL;i -linn ,,1' -ivall\ iiili ri, ,| :i n id, - ,,|' li.. „i in \\ ||i,.|| 1 1„, iipiilainiil liacilli. aln r lia\ iiii: L'ivall\ niiill i|>li(d, liad Ki . n d, -i |-,,\ , ,| i,\- l"i'iii:i. ' I^nrj. I'akiiii', and iIk lik.', and tin ir Iomii- alone rirnaiiii)! aiii\ , . 1 liat tln> liiiniaii oiLrani-ni — |iiv-M|)|m .-iiiu- l:i\(,|-aMc |i(i-»iiiial and external e.,iidiii,,ii read- l.. ilie intiniliii'iinn i.T -mli |M.i-,.ii- d^.e- nut a|'|'ear to nie l.i lie in ilie -lijliie-i d( - ive doi il ,| fu | . ,\- a nialtei-ol' t':i''- I lia\e r. |.eal. illy iili-ii\ed in tin- emii'-e nl' I -e :iiid taniilv I ndi iiiie- diiriiiL' |ieriiiil- w lien ty|iliiiii| l'e\ ■ t- wa- -evefi. in addilinn Id iliaiaeti ri-lie e i-e- lit' \ ar\ iiii;- .-e\ a ril\ . ullier- \\ jm-e e\ planal ii ai \\a~ inn-l reailily tiirni-liid li\ llie a--iiiii|iliiin ><{' llie e\;ilii-i\e aetinii ot' iM\in- ll|Mill llie iir^riiiii^iii TIk -e Were 11 H lie iiT le-- -e\ el'e, al I inie- l|nite -eV ere, ea-e- w liieli M( III ralK iMviinvd in yuiiiiLr iiidi\ idiial-, -la-vanl-, eiHik-, etc., and had a diir ilinn iil' tVnni t w i niy-liiiir In |iir!\ -eii.dii, and iml inure than -I \ I Ills -two. hiiiir-. The |ialienl-. enni|ilained i,|' -e\eie lieadaehe and \eiii;^ii, -hiMiiiii^- jiaiii- in till -aeral reLdmi and in the |i.\Mr extiemiiie-, with IlialLed elllanenll- and nill-elllar ll\[iere-t||e-ia. I'liev Were re-tle-s and -li e|il( --. and Inward tliee\ ■iiiiii.'- and at iiiLihl e\ en -liLrhllv -tn]i(ir- nii-. Aim. 1-1 all the jiaiieiii- e^hiliited frmn the iiiit-et marked nan-ea and \llnlitillL^ In addition In tnlal anmexia nr e\ en di-ifn-i t'nr all tiind. they -iill'ind frnMi liiiniiii;: tliir-t. The tniiirne \va- liea\il\- coaled tlirnU'jhniii. a! lime- tn >iicli ;i (Icirrcc ill tlic ciiur.-e nf a lew hours that il a|i|ii ared a- it' Imiled. At the -aiiie time -e\ere diari'liea oecnrn i| in inaiiv v iihoiit tlic characlcn-'ic pea— oiiji-like color ot' the -tool-. (^iiitc excejiiioiiallv di-tre--iiiL' 'ene-mn- wiih niiienii- and lilnnd\- -ton!- wa- oh-crvcd a nianit'e-tatinii thai recalled |iircilil\- tn niv iiiiiid certain Ic-inn- i\\' the lai-Lie inte-iinc iiicjiiced e\|periiiiciitall\ ill animal- lp\- hhmii- of t\|ihipid I'pxiii-. In the inaiorily ot' ca-es llieri' \\a< sli^rhi iiietiipi'i-in. I lia\c olp-p r\cd enlarL'pinenl of the -|p|eeii in a nninlur of in-tanci-.. Imt ha\(' ne\er -I'lii ro-eofc. At timi-, in the conr-i' (pf from twcixe tip lii^litci'ii ho. if- alter the on-ii of' till' di-i-a-c. there wa- modiratp' allpiiminuria. uhiih in\arialp|y -non -ulp-ii|id. with a -mall nnmlppripf hvaliiie tnlii.- ca-l-. IpiiI without other characteri-tic niipriihip!o!.ric cli'iiieiit^. anil iiar- tieiilarlv wilhipiit lil 1. (iciKTally the ca-c- were atti-ndcil with fever, yettiiiL' in \\\i\\ rp|pp'ati'(l -en-atiipti- ppf ehilline-- or a ilelinite chill, the tem|)i'ratiiro n'achiiiL'- -I'l ( '. in tli(> InlprIlillL^ and at lime< In' ( '. (pr aliovc in the riA7l77',f |.n.i;,nn.l ini<.\i(atii)n. 'I'lir -iili-i.l.ncr of ih,' -vni|pt(itn- ncm- in iIh ioiii>.' of ll-utti tw.iity-tuur In -cvcfily-luu Imur-. at llic lit. -i. and i> alino-t ;'!\vays :i-<(h iatcd wiili rapid d.rlini^ in !lic l.in|M i-;iturc, a.<-.,ni|iarii.d l.y |>rulu-,. -iwcalin-. Kv.n alt.r ih.. disi|,|.(aran,r <,{' ali cillicr inorl.i.'l >.\in|.tnMi- there (, 11,11 i.niaiii inui-nal |iri.-lraliun and larr'.MKir, wlii.li l!' toxin- in animal-. To what extent, if at all, tlio short.-t of the atypical e:i-,.vere hut •inn-ual -ympton,-, so that at the on-et. and not rarelv thnm-diout, its nature may I,,. unreeo-uiz,.i— ncphrotyphoi.l, pucumou phoid, pjeuro- typhoid. typh,,i.i fever MttiiiiT in with m.nii:-iti- or p-vchos.s. Tlicso varieties, howcv.f, will I,,, more appropriately .•on-idcre."l .at >o,ue other place. Tiiosc eases will he eou-i.lercl a-^ l.el.miriuir t,, ,|„. \,^^,.ut v:wieties in th.. >trict sens,, of th,. word that are .•hai-aet, rif..,| hv al,>..nc,. or nul.ln.ss of the fever or -uch sli-htne- of other svmpfom-' that th,. patient is not ivally ,.or,s..i,,ns of tlie exi-tcnec of a -.'rion- di-,.rd.a-. Ambulatory Typhoid Fever.— Th,. ,piaii,u.atio„ amhnlatorv was introduecl l.y ( ;ri,.s.injr,,,., and is -..nerally eniplovcMl ..-p.riaily ' Tm:/,' ,!,■ \Uid . ■.. 77!. ar.i! Sn-.: :..:.'. \.., lie:,-. in :'tC'- ^: ■MW, lyrii'iih 1 1 \ 1 1: (n'tril.inx. In I'l-.iin .■. wImi, il- i \i-|, nc, i- :i.tll.ill\- .Irtliiil li\ -( u rile 1- ( l'.|-oii,iii|( h, ih. i|ii ililii Mii..|i liiinil. ulinli in in\ n|iiMinii i- I,.-, ili-liiirllv, ( l,..ui-. < iLpru. I, iiinl ..(||,r.i. i- riion cmmiiiimhK .iiiiiliiVnl. ■| 111 (jiialilic.iliori .iiiiliiil i|.,|-\ .i|i|ill.- ii:iliil:ill\ |.. ih,' iii,,-| i-.i|i~|iirii,;i-c ;;,liir- iillv ii.-iii- l:I':i'Iii.iII\ . iii-i,li,.ti-l\ . ill tiiii,- wiili ii li.liii^' III' .111111111'", xviiiili iiiiiy Ii,' i,|i,ii|, ,1 ill ill,' liiiili, r , r-|. ,,f tli,' ;itt:ick. 'I'lic |i:iii,iii- <',,iii|>liiiii .,r |ir,.-r, --i\, |\ iiii'ivii _,■ liiiiuii,,!-, ami ;in' |ir,iiill\ |,.«;iid ,\iniii;^. 'I'jii'v lir, iit \\,.rk, iind diiriiiir the _v liiulitt'iij ilrc;iiii>. 'I'lic 111,,. I„i-,,m,- I'lili-; the rii, Ilia! -lal,' i- ili'|ii',»('(i. at linn- irril.-ililc. < n ii,iiill\- llic t,'iiLriir i- >,inii'\\ liiil (■■•ali'il, iiiiil iilni,'-l iiluiix- ihc iiiiiictiti' i- |,i-l iiiiil till' -111-,' ,,t' lliir-I iii,i',':i-,',l. lrr,'L;iilar ii,'lii,ii ,it' llii' li,.\\,'l-, w iili lliitii- Irii,',', iilirriiiiir- w iili ili iniii'ii. ,ir iIh'M' i- |m r-i-nnt i',>ii-ii]iati,iii. .Sunr liiitiriit- ipliiin ,,|' -liirlil aiii;iii,i-i' -\ ni|il,iin-, while otlirr- rxliiliit liniiii'liili,- iniinili-liili,.ii- iiinl iM-licM' lli, in-tls t- tn he siitl'criim t'nini a Ill " ,ir triim inlliiiii/a. 'I"(ni|irnitiin'-nli-i'r\ iitiiiii- arc natiiralU niiiilr iiTi'Lnilarlv, it' at all, in |iri\iiii' |iriiriii'i', in lii ,- nl' :iiiiliiiliiior\ i\|ilii,ii| ll'Vcr; iinil a> llic patii'iit- ari' >rlil,iiii -ml ii, ilir Im-jiiiiil-, ii tliiirniii^!i -tinh- i- as vet waiitiii:^'. Ai'iiinliiiL'' tn in\ oli-ri'vatinii, tlir tciii|n'nitnr('-riinr-i' iii:iv 1)1' of -i'\ cnil \ arii'lii'-. 'I'lni-. tliii-i' niiiv lir -iiiijili' n mittciit i'cvcr at a l(i\v li'Vi'l, -11 lliiit in till' nmniiiiLr tln' Ii'in|>i'ratiiri' ri-c- lilllr aliove the nnrnial. ifat all. (^iiiir i nmnly al-n ii rrirnlar vai'iatii>n> ucciii', with a >ii(|ili'ii cli'Viitiiiii iliiriiiL: llir ninrniiiii m- in tlir niiilillr nl' the dav, as a ri'-nit of cxrilinn'iit. ii\ rri'MTlinn. I'tr., nr witlmut iil>\ii)tis ciiii.-c. Olliii- I'ii.-i'- |iiir-iii' ill! iili'lirili- i'iiiii--i' thriiiiuliiiiil, or ;it Ira-t Tor -rvcril (lays. An inlrnnitlint tilirilr rmir-r i- Icii-t roniinon. in whirli (leva- tioii of till' t,'ni|ii'ratnrr iiKiy tal coi /;>/■ .•;|MMl eases iinex[M'etedlv terminate latally, — as niif irtimately not uneommonly oeeiirs. partieiilarlv trom heinorrha<:e and perforative iK'ritoiiitis, — tliev ofton occasion stir- :'i\ ;50H TYViinii) I i:\i:n. ■■"-ki.* ■■• M^ ■"., ' » jin-c :it ]>()-t-iii(>rt(in cxiiiiiiiKitioii on accduiil of the iimi-iial (K'Vclon- iiiciil and extent i>l'tlie intestinal legion- anil otlier tio visceral <'lKinj::es. Tlie Mronil iri""ii|) (it' eases ini.re ehisely appniximates tlie ediulitioiis ]>i'e~eni in tlie nn(levelii|>e(l, mild cases, and ini<:lit (Minallv well liavo been ieeediii;; ehaptef. I5_v reason ol' their sliiirt dura- tion and the eirennistanee that the slijjlit distlirlianees rarelv restrain the i)atieiits in their aeenstoined oeenpations, they eertaiiilv nften cscaiM> recdi^nitinn, e-peeiallv when they ocenr isolated and without anv dis- timt eoiineetion with well-iK'velo|H'd cas<'s of tV])lioid fever. Not a tew crises of "cold," " anjrina," "acute pistro-intestiiial catarrh." or " iiiHnenza " may heloni,' in this s^ron]). Other cases of the ainhtdatorv <>!)(■ — exactly as \,as mentioney intestinal lieinorrliaue and peri- tonitis, and terniinate t-itally therefrom. With rey::ird to ap' and sex. I lielieve the statement is jtiMific.l that amhulatoiy ty]ihoialienl under my care, a pilot, t'orty-two vears old, had con- tinued ill wrvice uninterruptedly lliroiiirhout the entire journey from New York to HandiurL'. iilthoiiiih he had for a nmiiher of davs suffered from anorexia, diarrhea, occasional headache, and vertiiro ; he ha'' even renif.ined almost constantly at his post duriiiL' the last storinv davs in the KiiLdisli Channel. On the day of his arriv.ll a! Ilaiiiburir the sudden devflopinent of svmptoiHs of rircui.isf-ribed peritonitis conipelled his entrance into ihr liospilal. On admissi at'tt-r :i(liiii.-.-ioii, iliut a iiuirkcii rccriKicsciMuv, lastiii;: t'oiirlffii (l:i\>, «itli lii^'li fever, .■iilar;:eiiieiit of tlie spleen, aii.l ro.-eohe, reiKlcre,! eertaiii niir suspieiuu llial tlie ca.-e iiii^'lit be nm; of uiiihu- latory Ivpliuid. Afebrile Typhoid Fever. — Altlidiigli with iiicrca^iiiir kiiowlfdjje of till' iialiii-e and iaaiiife>tatioii^ ul' lyjdiuid (ever .--oiiie >vinptoiii- n liicji wore earlier eoii-idered patlKP^nKniKniic df this emiditidii were finiiid iidt to l)e -o, it wa- iievertlieh'ss l.elieved — and this was still tiie opinion of (Jrie-sin;,r,.p ;i|„l \V\nies, however, nm-l of iieci^itv have led to tiie belief tliat ty])lioid H'ver also Mii<,r|it l>e whc.lly or ahiio-t wholly unattended with elevation of teiii|)erainre. Just as occurs in other inteetiou.s diseases, as, t"or instance, -carlet fever, niea>les, and variola. Every experience*! physician — the i'aniily physician more fre((Uent)y than the hospital phy-iciaii — will I.e able to recall that durinj,' the endemic prevalence of typlxiid fever tlnre occurred UTider the ,-anie roof, and amid the same Lrenerai conditions, side l)y -ide witli well-char- acterized cases of tile disease, others in wliiiii indivirhiais surtered for a eonsiderabk' time with markeounds in the course of two weeks, however, indicates emphatically that some serious con- • lition must have bec-u present. One cannot relievo himself of the impression that the ])atient, who, in marked conti-ast with the ne^nitive orjranic chan^r(>s, has Ix'on so jrreatly redu.'o.! in weiirht, nuist have been under the intluence of s.une infectious process whose nature, in view of the coinciull of .-stimation. I'roba!>ly it is vaiiabh' .luriiii: dithivnt . pi.lenii.s. Wh.'th.T .a .■.rtaiu ni-'e or sex especially pr.Klisposes to the con.lition is not kn.iwn t.. me from personal experience, an.!, so far as I know, the .lUi'stion lias n.,t ;i(» lyniniii ii:vi:i: hern (■iiii-idtTcil li\ dtlici' Wlilii-. '\'\iv iliUficiiliMtiuii ol" tlic (■;!>( - in (|ii(-tii'ii ti'iiiii ,-ii|)ci'llci:illv similar, nt'clirilc iiioi'lii iKiitirii- larly -iiii|ilc i^a-lre-iiitc-liiial i-alarrli. will, in tlic tiilnrc, \>\ iiicaii~ of tlie ( iriilii r-W idal rcaclimi, In- rcinlcriil iiihtc r liicri |Ki->il>lc ill the |ia.-t. I'l'dlialilv , al>ii, liacl(i-icilii;;ic t xaiiiinalinii ,ii' ijic 1)1m(m|, the urine, ami tlic -todU will 1, ' lu iiicjI'c dftiiiili' rc-iilt-. It wiiiild iiatiirallv lie artilicial Id -ciiaralc llic alilirilc ca-i- ni' ivjilmid ("ever iiitii a rii^idly di-linct uriin|i. Thcv jiradiialU |ia— over iiilo thoM' cax- ill wliicli, duriiiix a Imi;; at'tlii'ilc ihui-m', miK iiKidnatc clcxalidii of t(in|nTatiirc oiwiir- tciii;^i'arily or tin- day,-. A liln-ih' t\ jilmid fcvtT cci-laiidy conn ilinic- il- (■oiiliiiiiriil of ca-o to llic aiiiliiilaloi-\- form. Iran jicr- dlyi;i\c nn >iali>li(al ilala w illi i-rtiri iicr to the afelirile f(jriii of ty|jliiii(l fe\.-r. aitlioUL^li i lia\e Men a ( on.-idei-alile nninlier of >ncli (•a.se.<. Mo>t valiialile e(iiiliilinlio|i>. liuuever, lia\c lieen niaile liv I.ielier- niei.-ter,' uIuj. aLTeeinir with tlie |iraititioiiei> of JSa.-le as to (lia:;iiosis. oliserved many eases of afelirile ty]ilioi(l t'ever. He nfilol in IMiit, in addi- tion to L'Oti ea.-es of more or less uell-(levelo|ieil Ivjilioid teVer. L".* of telirilo anil ]-'l!» of afelii-iU- al"loniinal ealarrli : in l><7<'. '_'(i ea,-es ot' ti'lirile ami 11 eases of afelirile a'-loniinal al^o iiilire.-lim: in this eonneetion. lliat in l)a^le at iha; time individnals who dieil of other (li^ea^e.>J or a.-» u resnlt of aeeideiit freijnently exhiliiled after death the nnex|icelcd eondition of sliidil swcllini: of I'ever'? jiatelus. An inslriieli\e ea>e of afelirile lyphoid fe\ er niider in\(il servalinn in which a |iost-niiirti 'n examination wa.- made may he re|iorted. Jl ocenrred in a laliorer. eiLditeeii yeais old, who liad liccii in the hosjiilal foi- two weeks on acconnt of •■ intestinal <-alarrh," and w lio-e leni|ieraiure. lahen three limes dailv. was fonml to he coni|ilelely normal, with the ex<'e|ilion of one eveii- iiiL'. when. afliT a visit which disinrhnl him eon.-ideralily. it ro>e to :;>.-_' ( '. He exhihiteil al>o no opecial local .-ym|iloms. Iie\\a> only rcinarkahlv lanirnid. entirelv wilhont apjietile. |irestrated. and was nnwilliiiL: to !;■( t out of lied. On the iifteenth day of the disease. (|nile wilhont )irovocalioii, without elevnlion of tcmiieralnre. sym|itonis ot' mental dislnrliance a]i)ieared, with hallucinations and delnsions of I'ear. In an nnirnarded moment the patient spranir from a window, and died instantly in conseipienec of fracture of the liase ot' the skull. The autopsy disclosed a recent enhir^rcment of the spleen of moderate clcL^rcc, h\ peremia. and iirm medullary swellini: may neverthelos he considered as defi- luti !v estalilished. WInli' a nimdier of c-tsps of afelirile tyjihoid fcxcr may, liy reason of their atvjiical .and tnild course, lie included aiuonir tlie tnild and the mildest variety, others, fortunati-ly tlie t^'nai miiioritv, lielonfr to tlie .severe form, even that with a fiit.il termination. The credit is diir ' Li.c. nt.. :i. .Villi., S. 171, 17."i. ^^?7^^^:r^'^^' VAIUATInys I\ SYMl'TOMS AM) ((iriisr.. an psjiociallv to StniKf' and Fnintzol ■ tor liaviiii; diroctiMl particular {'.ttcntioii to tliis .-iihjci't. .My own expLriences ari' ciilirely in accord witli tlioso of tiif observers named. I can confirm tiie statement tiiat severe fjital cases of t\|)lioiil lever in elderly, decre]iit ]>ersons, or in those dehilitated hv overexertion, aicolKilism, or clironi> disease, may l)e entirelv imattemled with fevei', or may even he aeci'd the essential facts with rpjrard to sucii r.ises of tvplioid fever as present deviations from tiie u^umI synip- tomatolotrv of tlic di-case liy i-ea-oTi of peculiarities in their cour-e in {general, or on accoimt of tlie predominant ;■'',/,■ played l>y certain svstems or indixidnal orjxans. 'I'iie literature of ditVerent jK'riods and countries exiiiiiits the irrcatest variation in tiiis coniKH'tion. While in earlier times especial weitrht was attached to tiie variable treneral ])ictnre of tvphoid t'ever, and aeeoidinirly, as is tliouiiiit to-day, the dis- eaM> was liir too >chematically ilivided into a ma>s of ditVerent lortns, modern conce]>tious keep in mintai>li-heaee. It is »eareeiv worth while to re|)eat all the de-it.'-- natious that have ari-en and lia\f been employed in the proi:ress of time. Wc have pr('viou>lv mentioneci tiie so-calleil jxastric and the mucous t'ever (Furntr iiiiiciii:-lioid lever. Not much more can be said of the desiirnations pastric-bilious fever or bilious fever, which were tormeily fre(|uentlv eonsidere epi<.iistriuni, pre- dominafr- ..f jaiiiKlicc in ca^cs i.f ivi)lii,i,i »'cv of Klici-tli, i.nt iVoni tlie ctiol. i( -tandnoint llicy arc father to i.e u-roii|.c-e.- and Weil's disease arc proiialily tiic ino-t inijiortant. Ivcfercni'c i- \ . ly frc(|iicntiy made in earlier writinc-- to vcrsitile ncrvou- fever and to >iii|iio predominate that the name- may Ke retained as short and appropriate. It >hoiild not, however, 1 vcrlooke.l that the ditfcrcnees indicated l.v tlu-e name- are not cs-ential, Imt rather superficial, and in larp' part individual, and tiiat, lie-ide~, \W tr,cat divcrMty of mixed and tran- sitional forms demoiistr:ile> how little impoilance e:m ho attached to any such ^trict systematic ditl'creiitiation. The ilc-iuiiatioii versitile nervon- fever is apjdied to oases in which symptoms of nervous excitement predominate at the heitrht of the disea.-e, at times al-o throiit,diont the entire fchrilc period: (ireat rest- le>siie>s, with marked motor and -eii-ory irritahilit v, delirium ai -lear- liifT early, i).'r>i-.tiiii.' itito the day, with vivid, L'-enerallv friirh hi- sions and halliicitialion<, even cryiiiL: and >hoiititii:, with a ,isia it tendency to ^^ct out ot' lied, and oeca.-ionally attempts at tli^dit. Tremor, fl(i<'titation. and siihsnltn- tcndinimi. even convulsions, in children and irritalile a(hilts complete the clinical picture, wliieli is most alarming to the friend-. In contradis(ln<'tion to this condition, the eases included under the desiu-nation -tiipid ncrvon> fever in>tiiy that name liv reason of the depression whi<'li <'haraeteri/e- their eoinse and svni] toms. I'^rom the ()nts(>t, or at least diirinj^the fa.-titriiii.i, the ])atients aie irrcatlv dojiresscd ])liysieally and mentally, dull, unresponsive to Mimnlation, and without will-pow(>r. Sleepless, with eye- open or lialf-o|>en, they preserve a relaxed dorsal dcciihitiis in lied, with a constant tendenev to slip down- ward. Without lieiiiiT (iilircly nncon and to events L'' idinsE ■.\\:\ viiliials who wi'ic (uM-idi'i'tMl hy llicir iittciKlant- as ciitiiplctclv >tii|MM'- iiii-, and i'\(ii ill wlmm tlu' typhoid li'Vcr was ihoiif,dit to he coniplicatt'd l)y ni('niiij:iti~. The ilirm of stupid iivrvoiis livrr just outlined is ap|)ruxiinat(lv identical with tlie variety of typhoid lever de~crilied 1)\- the l-'reiich and I'ai^Iish as tiie adynatuic form ; while tliey eni|iloy instead of versa- tile nervous tever the e\pres-iou ataxii' or irritativi' typhoid tiver. It iias heen inentioni'atierits >uca-e at the heiirht, or mav eveti occur in the later sta<:es of eases, which at tir-t e\hibite(| an entirely typical I'ourse, or whieli had even pursued a jirotracted conr-i> { Wairner.' ( ierhardt -). This ilanL''er(>us tendency may be (irst maiiit'ested durinj; a relajise. and ' DfutKi-h. Arch, f klhi. Mai., lid xxxii., \w.ii. ' Zrit. f. klhi. Med.. IM. i. '» m .'.l I TYriinii) ii:n:i:. ..-'•r'.n tlii-, Ml iar ;i> I know, was lir-t |)((iiiliil out liy (icrlianlt aii iMiiiiiilii'Mtiiiii. the |ialii'iit iiiailr a i'niii|,lctc rcrnvcrv. riic lii--l licniMi-rliaLTi - a[i])rar In lakr |i!a(T iivncralK' troni the nn-c. Iniincdiatcly tiicnat'tcr. at time- ••iniuitai:r(in--l\-, licinnrrliairo orcur I'mni llic c|i>c(i|(iiT(l, -|iiin;^y j:inn-. 'I'hcii Mclccliia' ,i|>|iti. In <'-|'r<'ially iiiallLniaiit I'a-cs |iriilliiiml i'\ii-a\ a-ation- (if IiIikkI inlii tlir -iiliculaniiiii~ cnnncitivi' ti~-nr. ivcii limcalli tlic -cal]), niav iiccnr I !■'.. Warner). A (•(iii^iilcralilc niiiiilM r < that from the urinai'y tract and the genitalia. I'rei;naut women Mi/ei- aiiiicar- to lie the lea-t cou-tant tiirm ol' licmorrhaLic. and when it occur-, it mav lie attriiiiited ciihi r to iutiirciion or -inijily to lilccdiii:.r t'nmi the liroii- ehial, tracheal, ami laryn^'eal mucous incniliraiic. ]n the further course of the (li-ca>i' uanureiKiu- |irocesscs may lie added to the iiemorrhairc- : [ Iccratixe de-triictioii of the u'lun- and other ]iarts ot" the liuccal mucous memlniiiie, |)ulmoiiary ^aiiLi-rciic, L'^encrally, it is true, in coiijnncliou w ith infarction, and |iseudodi]ihthcric lcsi(in> of the uterine and ve.-ieal mucous incmliniuc. With rcL'^ard to the nature and the mode of oriuiu of this extremely malitruaiit \ariel\, which is fortunately rare, iiolhiiii: i> as vet known. If the modern clinician -neer- at the c\|ires-ioii '•dissolution of the lilood," ein]i|oyc<| l,y hi- ]ireuli-titute. .\t ]irescnt we do not VAniATIn.XS l.\ SYMriOMS AM) ( nllisi:. 316 know whrtlitT ^|H■(■i:ll clianH'tcri-tir,- and in(Hlc uf ailicm nt' tlic t\|)liiiiimI_v or the ctllci- nt' certain cdniiilicatiiin- |ilav tlic riKi-t ini|Kirtant ri'ih in tlii.- (•(iniicclion. Kaiiicr writirs ( I'mn-scau) claiinc*! to have c-taMi-hiMl tliat in tlii' cMM'- in (|ii(-tioii tlici'c occnricd a -|H(iai alteration in tlie li' •kI, ehar- aeteri/ed liv a retnarkalily dark color and di'ticient eoaL^nhi .ility. 1 lia\'e i«'r--onail\, in tlie exaniinatioii of one ca-e durinjr lile, not liceii alile to denion>trate eitliei- tlic~c rnaero-.eo|iie |)ecnliarities or note\\oi-tli\ lii^tolo;jic (•lian;.''es in tlie Mood. In the ca>e aliove inentiiini Ilo|)kin~ llo-])ilal, howesci'. llie eoai;ldation-linie ot' the IiIihhI, dunnu' the period- when lieMiorrha;ie- \\ere occurring, \\a> increased to ten niinntes, Iml dnrinir com ale-cenee it ajraiii Kecanie rednced to t'onr niiinil -. It slionid e-|M-eidl\' he eni|iha>i/t'd, liouivcr, that neither in any ot' my ca>e- nor, -o far a- I can learn, in the li'era- tnrc, has henio;:ioliineiiiia with hcnioMliiliiniiria lircn oh-eived. (aret'id examination of tlu' M l-ve--el-, partieularlv the ca|iillari( -, which ]io--il)ly may -how alteration- of mcire iin]iorlanec than ehani;c- in the lilood it-elt', lias Vet to lie made. With rcixard to the i;'eneral eiio|oL;ic condition- in the cases in ipies- tion, childhood, .is well as vonth and adole-i'ence, a|i|iears to lie more )ire. Anionir S-2!t cases at the Johns Hopkins Hospital, only 1 case, that above nien- tioTied. oicnrred Slijrhtly niarkinl, mild liemorrhairic cases, however, appear to he not nt nil rar.', T1im<, in jiersoiw irreatly exliansti'.l in the .se(pience of protrnctekiii. ill,. Mil„iil:iii,-,,i|, ,-.,iiii,-,-li\,. li-ii,., :iii,| ,A,.|| iiii,, t|„. mil-,. I,.-, ;„ ;, r,.-nlt ,.r til,. -.JiMl,,,.-! traiMii.ili,. iiillmii,., 1„.|, ;,, ,1,,. |„.,.„||,v .,f ,1„. '""'-'■'- ''■""' ill iiiMvin- Iii,n,,.r ,,r ili,. |,i,.-ii,,. ,,|- ,irli,l,.- ,,|- ,.|,,iliiiiir or <."M,.ral tl„. MMMv uni;i\,,ral,l,. Ill,, larli,!- lli,. li,.,ii,,r,.|uo,.- a|,|„.ar':i,i,| ,||,. , .,, .■\I,ii-iv,. tli,.y aiv. All inv C ,•;,-,.-. I, riniiul,.! talally. \\a<:,uv 1,,-| l>ut lu,,-tlnnl-. ,,(• hi- ,,a,i,.,i,-, Tl,, |„.,,^.,„,.i, j,, ,|„.' .li„,|„l_,. ,„arkiKl ca-,.- ,l,.|M.|i,|- ii|>.,ii til,. ,,tli,.,. a— ,M-ial,.,l cnhlitidii-. I 1 ^1- 5ff TYPHOID FEVER IN WHICH SYMPTOMS REFERABLE TO CERTAIN ORGANS OR SYSTEMS PREDOMINATE. '■''"■ "i.U"i-il.v of III,. ,•:,-,.< t,, |„. ,.,,ii-i,l,.r..l ill tin- .-,.,.ti,,n tiave already l,....ii ivtrrn,! t,, in ,.,,iiii,.,.ti,in ujih ,1„. analy-i- ,,r th,. IikII- vi,lual -yni|it,.Mi-. It uil| |„. i,-,.f,|l, li,,w,.v,.f, |,aniciilaily uitii v,.sw\ to tl„. .iiairiio-i-, I,, n.vi.u ill,.,,, clinical- pictiin-. aii.l t.. ".■,iiiii,|,.t,. tlic detail, ,1 ,, tliat at tin- |ilac(. it uill Mitfi,-,. t,. rder ajrain oidy to il„. ,.ascs that -,.t in with -,.v,.i-,. <.,.r,.|if,,-|,inai >ym|itoni,- aiufarc (■V(.n chafa,'t,Ti/,.,l l.y a |ii-(.ym|it,,ni> iv-.inhlinjr :,(.ntc (Landi-y^) a-(vn,linjr |,ai-aly-i< ,.l)M.|ir(. the piitniv of ty|,|i,,i,j fever wli,illy l)ey,)n,l recpj^iiitioii ( Leiidet, ( 'iirseliliiaiin ). ti,. ditli.ulty may attend tho-e eases, whiih ai-e i-are, it i- true, in which the atta.'k of typluml t;.v,.r >et> in with the >ymi.tom> of a psychosis a, id the <-haraet,.ri-ti.' inanii;.-tati,,iis of th.. iin.l..rlyiii^r ,li-,.as<.— the ros(.oke, .•iilarf:..ni.jit .if tlu^ spl,.en, and diarrli.a— .1 i app.ar f.r day- an.l evn f..r a w....k after th.. .in-..t. It i- a niatt.'r ,.f ..xp.Klii.n.^y r.i >p(.city .-n..h ca-^es with th.^ d.-i^rnatiou eer.'hral typhoi.l. Anionir the disorders of the respiratory organs that at times pv,. an miu-ual eliarneter t.i the e.mrse .,f typh.ii.l f..ver, those of the larynx, the hinjrs and the pleuni are the most iiiiiiorfa.it Ar,„.T„T tl„.<„ f I r.i/:/.i //ov.s i.\ M .i//"/'oi/s .i.\/' (nri:si:. :!17 tlioM' (it" tlic larynx arc tlic nin-t ami llic lia-t cMi-piciioii-. < 'a.-f- in wliicli llic entire rlinii-al pii'lnri' i~ durninatcd liy the carl^ (Hi-et aii\' the larvnx ;ire exireniely rare, and the de-ii,'natii)n larvn'^otyiilmid i> artitieial and >ii|Mrtlii(iii,-. ( )t' tar inure >ijrnilieaiiee are tl^' ti^rni- i,i('iiiiiotiijiliiii(l ancl ji/ihi-d- liilili"i'l. Vi'V the jil-litiealion ,,{ the ile-iL^nation |)nenniiity jihuid ( ior- liardt, I'otain, I,e|(iiie, !".. W a^Mier, and recently Kmrert ' have tiirni-he (il)>erv< e ea-e- i>l' typhnid fever in which -yin|itipni- of |inenniiinia a|i|Mar diirini: the tir-t day-. so that the tir-t week is either dominated entirely liy a tyjiical clinical picture of intlanmiatioii of the iunir. ""' the latter i> attende has lieen |Hiinted ont, lie wholly iiiir(roi:ni/ed at tir-t, ami i>e correctly interpreted only toward the end of the lir-t or even in the l)e;;inninir of the -ccund wti'k of the disea>e, when the pnennionic -yniptom^ recede and tho-e eliarael<'ri>lit- of typhoid fever ( le more into the tore^'rciund. I 'ndoul)tec of ^cmiine tihrinou- pneumonia, to hesriu with a chill, with -ul»ei|Uent marked olevatiou of temperature, au(l to he followed liy the rapid development of dense loliar, ireuerally nnilateril, intiltratiou of the lunl.| i- 1 1 kr .i.^N 111 i.,ll nf t.ril |..T- •'l>i'«'- un-.'.l. A".., i:ii,.,| uilli ihi- ih, IT u,.,-,. rnaikr.i ilrvii.-.-. ,,| il,,. '""-'"■• I'alpalilr crilar.riiHiil ..I llii ■.|,|,rii. iiii.l >li_'li| mi. l.nriMn, ImiI iki 'lianlirM ,.|- n.M'.,hr. Ai ihr , n.l ..i' ||„ ||,,nl wc.k ..l i|,r ,li,,-ii.-.'. :ili.r ili,- l'l"'l' 'i'' l-'illHili.lMlioii liM.I rM-l,-.| r.,|- iHo «,iMiTri .|;i\> lain- lliii'c i|.\ .I..!,, ,| ili,- >mii|.I - ,,f n U|,|i,,j,| nlM|.-r, uiili a cliai-ailiriMir lil.rii.- ...ur-.- ..1' llnv,' uc. k-, uiih nii.u,,| fiilarLrciiiriil ..I ill, ,-|,|.rii, i..|,|,M|v ainl rii.|iaiil |.ca >i.U|.-likr -i,,,,!-. alula \\rll..|,\,'|.i|,c.| i-..,-( ..|nu> . \aiilli ,,f llll- lAin iiiiiii .-.. I II.' .■..111--.- ,,|' |.ii.iiiii..|\ |ili..i.| a|i|M ar- |,, 1,.- in ;^, m-ral ih.i -, , -, \,.|v a- u..nM ,< y.,;.„; I,.- ,A|...i..|. (..ihaiiji vav\\ .iiiiilia-i/i.l ihi-. |i. '" I ii'.\ '■■■i-''~ il.aili ...■.nriv.l li'.nn |)iiliii.iiiaiy i^aii-niir. 'I'lii- .a-c "■'■■ II"' i'.\:iiiiiii..l l.ai'i, ri..|..L;i.-all\. In aii..|li. r. .In,' i., ili,. |''rank.'|. W .i.-li-i'lliaiilii ili|il......vu-, .iiipv. ma .1. \ , |..|,..l, l.iit ihr ra-i Ciiallv "I'liiiii'i'''! ill iv.'.iv.rv. .\llli..ii-li ill,' Naii.ty kii..uii a- |.iiiniii,i- 'M'li"''' i-. "II 'li'' ^^li"l.'. raiv, it .I.M'-. II. A.. rill,. 1,.--. al .-..in,' liin,' an, I .liiniii: .filaiii ,pi,|,iiii,-~ a|i|Mar |.. Im' iii..iv riv.|ii..|il I < i.ilianji. |-:. ^^■i-l"l'l- ' I'.i^' |i.T-'iiaMy ..l,vT\.'.l -J ca-.,- ,if |,ii,iiiiH,I\|,li.ii,| at '•"■I'i'i 'iii'l I :i' llaiiiliiii- at liiii.- uImii ir.iiiiiiif lilM-iii.iii,> |iiiciiiii..iii:i |iii\ ail.'.l. Pleurotyphoid.— .Iii-i a- ,lmin- tli.' ...iir-,. ,,r upli.,i,l fi v,t. |il, iiii-_\ ...•.iir- iiiii.'li 1.^- riv.|ii,'iill\ ilian |iiiiaiiiii.ina, -.> aU., ,1,.,- \\h- ,~Mii|,n.iii-,,.iii|,l,A ilial iiia_\ I.,' ,|,-i^r|iat,-,l |.l,iinii_\ |,li. ii,| apjicar l.. he -nil 1," frc,|ii.'iii iliaii iiii,iiiii..t\ |ili,,i.l. N,'\irili,'l, — , lApiTi, mv.l .liiiKiaii-- will lie alii,' I,, r.ralj ca-,- in « lii,-li -viii|.t,.iii- ,,(' |,1, iiri-v il,v.l,,|i,'.|. o..n,. rally a-.uaal,',! with ,liilliii,>, and .Milw,',|iii'nt ,w ,if li'-- mark,',!, riiniiti'iit ciiiliiiiicii W-wv. Tlio,' ,'M-f~ ware tliin at tir-t ciii-iil.Tci a- ..f in.|.|icii(|.'iit, >.i-call<'rii:iii, iiMlil li,.a,laclif, iir,.i;iv.— ivc >tii]Mir, .■nlari:,in,iit ,.(' tin- -|il,.cn, cliarrhia, an. I in.'t.'..ri-in. a- w.ll a- n.-,cla'. .-.tal.ji-lii-,! ih,- ixi-t.'Mc' ..f an atla.-k ,.|' ty|,li,,i,| tivir |ir<-,ntinL'^ it-.ll' in tin- |,f,ailiai' aii.l i-aiv niann.'i'. I liavi- i)(ts,iiim1Iv .iI.m'i-vcI 4 .'asf.-. nf tliis .-liarailcr. In ?, oo|,i.iii3 (■t;ii>i..ii~ ,|,'v.'l..|..',l ra|.i.ll\. Iicini: in l' ,,t' a |,ur.l\ >.n,iis i-liarait,r. while in 1 II ua> MT.Iii'iiK.rrhaL'i". Thi- f.iiirth va>v \\a> unaltcii.lf.l willi ctrii- '■'"II- ■' >li:>ll hi-ictly >k.-I(h thi- la>l .a.v an. I ..ii.- ..1' ih.- i-mm-s with i-ll'iii-i.iii. I saw the ca.-.' with.iiit cti'iisiiiii in thcy.-ar 1 >;'<•;. .Iiiriiii: ilu- l\ |ihi,i,| .-i.i.h-ini.- in HaiiilinrL'. It .icciirrc.l in an a>s,->s..r. thirty-nnc vcai>'.,hl, «li,,. alii-r haviiiL' |ir.-vi.iusly hecii entirely well, wa.> >.i/,.-,l .'liiriiiL: a .-.■-.-iim with i-liilij. Iiesi- aii.l .-.-ver.- |,ain in tlic riL'ht >i,l.-. Tw,, ,lavs lalir tli.- |.a;i,-M -h.jwe.i. Ill a.l.liti..n to the >vniiit..in> .if sli'.'ht .litl'iiM- l.i-.in.-liiti>. e\ii-n>iv.- i.leiiritic f'n.-li.,n ..v.-r tli,. |.,w.-r h.h,- ,,f the ri-lit liiii- In vi.w ,,f th,- iiiiMJerale el.-vati.in .if teiii|i.-ratnr,', th,- .ic-,-urnii,-,- ,if .-.iiiMih-ralili- uinL' '-<-\ciitli iliiy u|' \\iv .|i-c:i-i' ■ .|i-liiir| rn-c,!.! niu'li' llicir aii|n'ar;iiiri- ii|>nri llic mIi iiiiiicii, <-lif^l. iiinl li:i' k. < mh-i.I. nn^' llic Iciii|Mr- alurrciiiir-' mimI tin- iinminiiiL' >\ mi|'I"1ii-. llhrr »ii- iio\v im furllirr dnulil tliMI ll :iM- «:i- Mill' ..f t\ |i|ii,i.| Irv IT u liii-r lir.-l iniirki'l .-Mn|il -ui-rr rc-liT;ililf [i< till' iilufM. Till ur.-i' nf ihf allMi-k u;i- r.i\ muiilr. I'Ih' |iMlii III u;i- ll-ir iVolll IrMT MHiI' llir lil|iM' nl' |nlir Urik^. Mini In- Ti T' .\ i ri' I r;i|iiillv aii'l i''iiii|ilct(l\ . 'llic |ilriirilii' frii'limi |m i-i-inl imiil ilir riL'liili I lav i.r I III' ilivM-r. Si-ii^ i.r Milli.-i'iii I'l' I 111- ;illi''ii 1 1 |Hirlioiis nl' tin- pliMira NMTr iilwlil :il :in t\iitiiiii:ilinii iiiM'Ii- :i li:ilt'-\ t;ir l:ili r. riir nllirr I'iisi iMTTi-'l ill a nun liaiil, Iwnilv -cmm \c':ii> hM. ulm ua.i inlinillcil Im the el i nil' nil llic lil'lli ikiy nf llir ili-iasc, ainl nhitiil I hat inii::h, u illi |iain ill liic side a I 111 a ililliiiiln in lirralliinir, liail ln-cii llic lir.-l -\ iii|)- Imiis ,,l' llic allack. < »ii ailnii--i"ii. a la,_'c riirlil -i'lcil M-riilicninn'lia'j'ic |iliural 1 irii-iiin \\a- ili-c,,\ rrd. I' lie h fl Iuiil' «a.- iiilaci, uiih llic c\cc|iiinii 111' a \\\\ lirnnclniic r.ilo. 'I In -|.|iiii ua> iml cnlar-cil, iih Icri-m wa- iini |irc.-ciil. an. I llicn- ucic im rn-cnkc 'I'lii Iv rcinarkalilc t'taliiri \\<\- a ra^r 111' -ini|ilc M-ri iii> |>li iiri^v « a- llic iiiiii^iial lciii|i. raturc-cniir-c, u liich was thai n|' a coiiliiiiicl liAir n|' iiimlcralc ilcu'i-cc, uilli lull -li^lil ilaily lliict- iialinii-. Nni ijiilil llic ci-lilli .lay ili.l chararlcri-tic |.ca-i.ii|i-Lkc -luiils a|i|icar. At tin- -aiiic time ciilai'L'cinciil i.l'llic .-|ilccn cmlil lie ilcinnn.-lralcil, liiit ru-ci.hc I'ailcl In a|i|icai- cither at ihi- time or >iil)!*ci|iiciil ly iliiriiiL: ih iiifsc nf the ili>caM'. ( 111 I' >ii.-|iiciiiii that llic ca.-e ua> one n\' |ilcuri>- lv|ihiiiil was ciinliriiicil l.v the |.ii-itivc' foiills yiciiicij hy the ( iriilpcr-\\'iilal a;^L'liiliiialii)n-li St. The case Icrniinalcil in reeuvcry at'lcr a iiiosi priitraelcil (■nurse. Till' cirusinii. which had In l.e i-vaciiatcil liy tlinraciH'ciitcsi.s on the luciitv-cii:hlh ilav. did iml rcaceiiiniilatc. M\' uwil ea-es Were. 1 III |i ill I lll.llcly . llnl e\alllillcil I i.li'tcrii ih iLMcailv. It is ccftaiii, hiiwcMf, llial llic t\ |iliniil-liaeillii- ahuie may cait-c jilcii- ri»v.' 'I'lic case- ill wliicli tlii~ lias liccti ilciiinti-tniltfl riillil llic most fiLTiirnii- rcijiiifctiictits tliat cniiiil lie ilciiiatnleil I'lif tlic cstaMislimeiit of |ilciifiiiy|)liiiiil as ail csiiccial variety. 'J'lic so-c4illc(l nephrotyphoid lia- al-n licen |invio!isly considcnNl (|)|i. 1!''J, I'.l.'l). It \va- lliefe meiili ll that its >liar|) ilitrcroiitiatioii liv (iiiMer and IJoliin. ami e-peeially the -elieinatii' cla— ilicalioii ul" .\mat, liail, mi cinder -iiids, priAcd iintctialile. .\c\ ertliclcss, tlic desij^natiuii ti('|iliriii\ plinid m.iv lie aiiiiiieil to ceriaiii ca-cs as dc^iTiliiii^ liricdv and well a |>eciiliar'iv nf llieir cuiir-c. Tliis is |icriiii— ililc — just as lias liceii |)iiiiitcii out with rcirard to |itieiiiiiiily|)lioid and lilciinityphoid — svlicii the comiiKiiecmcnt, a- well as ilic tifst, and even till' second, wci'k of the attack is dotniiialeil liy the clinical pictiiro of ' ('.iiii)iiiro the Kriiirli litiTiiturr i.ii ilii- |i,.iiit. ).. 'J.'iT i -fn iiN" p. lis In ii.l.li. li.'ii. til.- iiajicr^ .if N'.tUT. /.■'(//. ./. /./ N...-. III,'. I. ill- l-nr'n. -Mny 1>'.. ls;iii l,..rii:a -uA I'.Ti.-uli. Uiliirmii infil.. 18:10, Xu. -Jdi;. W.intraiKl. /.'.,■.',.;. Kim. »■■■■>■ . \X'X'.. .N". 1'). Spiri;,'. Mitihril. a. klhi. hisiif. //. Si-lnrrh. 18!l4. 1 It.ilie. Il.t'l ;'. .-^uhli, /An/. In all ill.- 1-.'* ill.- Hpli..i.|-l.a.-illii- L'.o.-ri-.- !■. piiriil.-iil i-H'ii-i.'ii- That il may, li..vv.-viT, iTiM- rUi' aU.i in scTotiliriiiuin i-tl'ii>inMs i-i nIiciwu liy the oast- of Kernel, pre- ■'-■•- -Urlv iiliriiti'-ned. 320 I y nil III > II I / /.■. s.Mr. ;i till' iji'u.'.'CMJ \Ml\r. 'I'llc -iMh IIKIII mI-.i lIlMl ill,' .M-.- ill ,|l|,Mi..ll mIiiIM.I mIumV- I ( • I'll lillilte ImImIK i- Mill I'dlT'-. r'-.'i. mimI I- nn.liil.K i|ii iii-iillii'ii'iii lialM. 1 Jiiiv.- .l.-,rilM,| nil |,M._-,. :;ii(i M ,'MM' ..f U|,l„,i.i \\■^,■v ,,f Ml,..riiv,. .',,iir>^e wImcIi c'xImI.ii,.,! |„.rli.|lv ihr rJinirMl |,i.|i,n. ..f i„|,|,n,U|,|„,i,| o,,lv r.'<'.'llllv I .,I,>,.|'V<'.| M >r,-,,li,| ,.M>r , .f |1„. silu,' . I ,M I'Mrlr I', ' A MlcnllMIlt, tv.iiil\-Mv u.Mi'> o|,|. ill »!„,,,' iMiinly :; «fll-,lfliiic.| ,'iiM> ,,r |v|,li.,i,l Cvrr •'' ' I'l-.iii' H'v.rily liM.I .M'.'urrcd williin m >linri linic |.r.'vinii,«lv, wms scizcl Willi .'-.'ii.siM.Ml-* ot■^||i||i,|,.^s, i;.||,,«,.,| l,y M M,'|,-lik.' .'liMilJoM ■ .f "l.'iii («','Ml lire. All.T ll'c .st'i'iMMJ .lay, I.I ly iirin.' .'..MlMiiiiiiLr larLT Miu.iUhi- ,X ;ill.iiiiiiii, Willi irrcal ihiiiiIhts ..f liyMliiic. .'[.illnliMl. mii.I li|,,o.|-.'ii>l>. um.s vni.l.'.l. 'I'lie niM..iiiit ..(■ iiriiiu was -r.'ally L.-lucn |(CJ'_' ,iii.l jIlL's .\ltii..iiL'h . in iIk' al,>.i„.' ..l' „il„.r ,'.„i,.,,i,„,,iis svin|,t,.iiw, iinllniii: i-N,. iliMM MM M.iilc li.'iii..rrliai.'ir ncplniiis , ',,1,1,1 |„. a.-Mii'iicI I., he I.rc.s,'iil._ii,'v.'rlli.l.>s ll,,- iHTsisK'ncu ..fllic trv.r, lli.' .Irv I, .111:11,., aii.l ..iilartre- in.'iil ,,t III.. >|.|,',.||. ,l.'Mi,,iislralil(' l,v |.al|.ali,.ii on il'i,. (iftli .lav. 1 .iher ^^■"'' •'" <'iirn.ii<',. of 111.. olliiT caM'S in lli,. >an.c I„.um.. raix-.l llic .(ncMJon as I., wli.'tlicr III., c.n.liiioi, riii;:lil not I... .l.'|,app.an.,l fi'..ni the urine on the (.Ifvcntli as yet iiiiknowii. Tnist\v..rtliy l).'i.'teri..i,,L;i.' ex.'Hiiinati.ins .lir<.<'te till' ailii'li 111 llii' -[Miilic rxritinir cailM-^ (il llliisc (lis«'ascs. It lia.-< pre iiiii-l\ Ipcim iiii|p|ia-i/c) that tlir I'xi'-lciii'c 111' l\ |p|iiiiil liver, e-iieeialiy at liie jieriiMJ ipt' its t'elirile iieij,'lit, atl'iinl- |p|i''v eeilaiii |pri)t( .lic.n a^ain-t the inva-iipii ipI' oilier aciito iiireeticiiH ili-> I • -. A- a matter nl' I'ael, the lip||ii\vin>r ^fatemeiits will ^hlp\^ that ihi- i- eiitiiiK tr;ie with re^rarii to j-orne, while with re^^ml to otiier-, even thoiiL'li uitii I'Mreiiii' niritv — ,.r<,iiliiiUniienre in many re^peet-. The older lilenitnre contains far nioro'mimerons |MPsitive statements than the more ns'cnt litenitnre. Manv of the earlier re|Hiils are to lie aeeeptnl with jrreat caution, not alone on aeeoiint of the often mipst iiidelinile description of the exanthe- mata, hilt also on account of the uncertainty in the diagnosis of ty|ihoiil fe\(T itself; for, as has liccn |Hiiiitereseiits the lari^e ninnber of H personal ohscrvations, all on |)atients in the I^indipn Fever Ilosjiitrtl, who were infected witli scarlet fever from other patients in the same ward. The fipllowinir liistnry hy Murrhisini" may serve as an illiistratioii : A iKilice-ottirer, twenty-three years cpjd, was admitteil to the Ixindon • Jour, (/--.s ri.inK mi,!, rhir . 18.30. ' L'entiritr {..Um-u].. ]»ari<. 1H40 (bntli rilvd by Murohisnni. ' hur. cil.. Hii.l 7'™n.«. P(jt/i. S,.r.. 18.-p&. vol. x. • Lehrbui-h. ' Dmfwli. ninl. Il'.^-A., 188.',. N",. 11. and 1880, No. 40. • 'J'i/p>i"itl DL-iriixr.^. p. £ii;i.', trunslated liy /.iiIkit, licrliu, l»ti7. 21 Hi i it Illi 322 TYi'iiniD ii:vk::. FfVtT II(i>|iilal. Nov. !t. 1^57, atUT an illiif>,- of fru'ii twu lu tlircc wcoks' duraliiMi. He exliiliilcii ail tlif sviiiiitdiiis ut' iNpiinicl tfvcr ; a nil. irlazod, anil tissurcil iDnLTiic, tyni|):inili'S, ]irnt'usf watcrv liiarrlica. ami an aliun- lill i)uile nnnieruus ami tlie iliarrhea jier^isteil. Thore now ajipoareil in aildilinn a irenera! .-rarlalina! eniplinn iilentieal willi that i)f scarlet t'evir, tnL'ellier with a straw lierrv-tiin;:iie, with L'reatlv cnlar^.'eil pil|)illa', aiiLrina. ami reiiness ol'the t'aneis. Alter two ilavs the rnseiihe were !ecially instrnciive. In addiiinii to ijie tvphoid fever, which was char- act-'rized sutticienlly hy roseohe ami palpable enlarirenieiit of the spleen, svtnjiloms of scarlet fever appeared at the lietrinninjr of the st'cond week. The well-nnirked and characlcri.- iic cxanlhcm. which persisted for live ila\s. had heen prccedeil inunediately liyanL'ina. w ith ilark-reil di.scoloralion of the mucous inenilirane. The jialient died in cunseinience of scarlatinal nephritis. Kxaminalion of the intesline disclosed, in the neiL'hhorhood ot' the ileocecal valve, the h'sions of a terminated or healed typhoid |iroces.s ot" sliL'ht extent. I have |>i'r~iinally imt a- yet encoiintcrei! the coincidence -d' the two hoi:antlienia-. It i- donlilful whilher nieasle- and t_\phoiil jl'Ver niav occur loi^rlhcr. In ni\ exjierience ' variola and typiioid fever n])iiear almost to I S' . ('ur-i hni:nin. j*i- {'"(k-'T,, ■■■^u /iffti.ssr}t's Jhtnfihur/i, LM '.-d., I87H. Th. Siiii'in. Hrrlin. klin. Unci,.. IsT'J. N.. !l. If' r.iy.7.i77'/\s i.\ sYMi'T'tMs AM) cnrnsi:. \vn cxclnili' vM-\\ otiicr (luring' tlu- trhrilc -t:iirc nf 'k\v\\ disoaM'. I Ijavc rciicatdllv x'tii I'lHivali-icnt- tVorii ty])liiiiiiiall-])().\, liut wlinicvt r iIk' lnirimiiii.t.' "f ll"' attack nf variola \va< (k'tiTiiiiiicd, it (•(iiild lie i-talili>iifil that tlic iiit'cctiiiii liiu>t have taken ])lace in tile ali'lirile |ieri-ilile ]»eriiiii iif iiieiiliatiiin iiir the xarioia. Of () coiivalfM'eiils frniii t_v|ihiji.l tever iiifeeteil with Miuill-lmx whdin oliservei! in the year l'"<7<' 71 in the hi)S|iilal at Mainz, which at that time was i)vercri)Wile.i. the primary :-iai:e heiran in 1 on the ninetetMith, in 2 others on the scventeenlh, ami in 1 each en the sixteenth ami the fnurleenth dav after ihev had exhihited the la>t fehrile elevation ef temperature attrik utahle U the tvphoid fever. A ca>e, apparently of actual coincidence of variola and tvphohl fever, has lieeii reported liy Th. Simon, who in the .same communication .states that it is his iiripression that durinj: the epidemic of smaM-pox that prevailed in UandinrLr at that time, the ca.-es of ly|ihoid fever which ()C durin'i- the felirile sta individual- wli , had. dnriuir the period of incniiation of i\jihoid ll'Ver, a greater or les.s tinii' liefori' the .-ippcarance of it- tir-t -ynipmin-, heeii -ulijected to pro- tec lisc vaccination. 'i'lie-e ca-e- jirove thai at a period in which the oriraiii-in i- aircadv inider the influence of the typhoid int'ectioii, eNcil tiioULrii in !'Ut a latent degree, the activity of the excitants of vaccinia is not alioli-hed. Typhoid Fever and Other Acute Infectious Diseases. — The Septicemic Variety, — Tlii- ^verc l'.>rni of disease, which ha- as yet heen hut little invest igati'd, appears t<> lie tlu' re-idt ot' mixed infec- tion with liacilhi- tvphosus .■ind Stre|)toc(«'cMs pyojrencs, 'Idle eases are -aid to he cliar.icterized hy hiirli tever, nnu-Mally marked disturliaiiee of tiie irenerd condition, con-ideraMe and larly enlarji-ement of tiie spleen, the nie-enterie and the lironchial ^-land-, with, it ha- Keen -tated, often oidv sliirhtlv cars to !>«■ irii.-t \inilriil. Aliiiii-I all the i-iM- liitliiTtii (ili-iTvcil have Icniiiiiatnl tiitally. It i- .■(irrcctK inaliilaiiifii. i-iinially iij llir Ka-ir- nl' cxiicriiiiciital oli-c r\a- tiiiii, that the ciiinliiiicil activity dt' Imtli iiiicni-iirpiiii-ni- is csiifcially (lanircnui far iiicn-c -n tliau that nf citlicr alcnic. I have iici-Minally ii(] ('X|)criciirc with thi> variety of typlmi.! fever. The tir>t and iiio-t iiii|M.rtaiit -tate lit.- relating: U> it eiiiaiiati fn.in Freiieh invotijr.itur: ('haiiteiiie->e and Widal, Vaillard and N'iiieeiit.' and others. They a|i|iro|)riatelv de-iiriiate it as the Funm s, i:lii-niiii ahle to demonstrate the streptoeoeei in the Mood diiriii!.'' life. l'"urllier investiiratioii will have to deterniiiie whether, as is highly ivroliable. a coiisiderahle niiiniierof eases of iy|ilioid fever of inalijjnaiit, fiilniinaiit, heinorrlia;.ne. or h\ |ier|i\retie eoiir-e do not lielont: etioloL'ieally in this eatcLTorv. The ease-, however, in which the ML'niinate and the soliiury tolliefe- of the int<-tine are found entirely free tVoin -iMvilie infiltration, althoilfrh at the sitne time ty]ihoicl-haeilli, toplher with stre|>toeoeei. are said to he jiresent in the other or^raiis, rei|iiire, in my o|miioii. caicfnl reinvest iirat ion, whieh -lioiild lie direeted foens of inllammation. In a ease lately oeenrriii^' in the .lolins Hopkins IIosjMtal the jiatient, during' the end of an .ittack of typhoid fever, siitl'ered from a larjre carhniicle on the lia( k. Cultures taken from the hloixl dnriuLT the height of the att.-iek of tyjihoid -liowed the pre-eiiee of tvphoid-haeilli. Imt cultures taken ten days after the onset of the carhiiiK'le -luiwed a ])ure ^rrowth of StaiihyloiMKcii- aur«'iis. Cultures were repealedlv taken, with -iinilar result-. ImI'oiv ileath. wliicii occiiriUHl after severd week- with symptoms of ircnernl septicemia. Of other conditions allie-u:( L':'4- Viiirml. A>w. ,/,• Ihistitnt. fast,;,,-. IS'.II!, Nu. '2. '' Ch'int.-Anualn,. 1W4, t. .\i\. I; 3 V.[l:lATIo\S l.\ SYMrrnMS AM) ((irnsE. inriitidiicii, i^ not ('\ilii(l((l iiv tlif pit'xiiiH' ot tv|)liiii(l ttvcr. I vjiimid |iatiriit~ at any staL'i' tiiav , on tlic cunt fa ly, lie attackrd liv ei'y-i|>('lar-. lt"lliis is iiiiirc coiniiiiin tnwaiil tlic [' tlic tl lirilr jicriiul anr the |>nicr^s. I have dhscrviil facial crysijM'his ilcvclop (inly witli om-idci-aliic rarity at the hcitrhl nt" the disease. This nirity is <'speeially strikinj,'' in vie>v of the ('rei|Ucncy with which cfi)si(ins occur at the iia-al orilice and tiie li|>-, and the wav in which these are inallrcatcd at the hands of the p.itient hiniself. Whether this nirity is due, in jiart at lui-t, to the fiet that in cases of typhoid f'ever at the heiirht ot' the jiyrexia the erysipelatous infection is soinewhat more severe than in healihv indi\ idual-, tiiay t<>r the present lie considered iiiideea>es ap[iears, on the other hand, to he extremely litre, if it occurs at all. Of the simultaneous existence of dysentery and ty|ihoid fever we have knowlrdiTc oidy throiitrh iiieen- tcry. The loincident occurrence of diphtheria and tyjilioid fever, par- liotllarly duriiiir severe ejiidcmics, is mentioned t're(|iientlv, es[H'ciallv liy older writers. Tloulitless the throat condition is principally one of diphtheria in tli(> older anatomic stnise. Adeipiate recent liaeteriolofric investiiration has, so fir as I know, not yet lieeii made. I have per- sonally not seen diphtheria — in the current etioloixic sense, with rhe deni(}iistr.iti()ii of the haeilhis of Liiffler — Dcciir a,s a eomplication of ' /.(,<•. cit. 1 li •V. ■ ?ie'' Itii It'. i-.'li lYIIInll) I JVIJ;. t_\|>liiii(l fiAri-. 1 would warn (-[Mciallv :iLrain-l (■ont'n.--ii>ii itii tlic >|ii'iilir l\|i|i'iii| aliiiilia |il'(\ i' ■i!-|\ iiiriil ii'iiiil. A iM'i iii~i::nilii'aiii /■:/. i- |ila_\ril in iln n'M|iic-, in Ncpi'il. Aniirica, ( liina, aiicl Japan, anil in nialarinii- ri 2i"n- nn llh ■ ■inciit nl' l-jn'ouc, liv ca-i- lliat Iwivc 111, II :itti-iliiitii| til niixid inll ■ itli tv|p|ii.i(l li-M-r and malaria, and lli.- Iiaxrin Iran.v lucn d' aalcd tv|iliiinialarial U\iy. |-'iMin ihr cM-iin- dr-ci-i|itii.n- ( Ki Udi nnd l\ iimi', S. ii, nliv, and oiliri'- ' I, the ca-c- ri|pfc~. ui an ailniix iiiiv ,.1' i\|ilioid -\ ni|ii 'in- — n-iola', |m:i— Mn|i-liki -ii.i.l-. -iii|iii|-. dilTii-r Lr..|i|.|iiii wiil, il,,. I'lliiilr cMin-c iii.'nii.ir In innrniiniiil liver. .\' .urdini^K a,~ ll.. uni' el' llic iiilici' (it llir twii atl'd'liiin- [ircdnininatc- nv rcci'dc* tctnjMiraiilv nr dnrin;.- thr rntiiv i-niir-r .t' iln di-r:i-r. llif ini.-l \ariid clinii'al |iirl- iiiv. I'l'lcn dilliriih III' inirr].rilaii.in. d(\ i'|..|i-. 'I'lic c'oin>c nt' ilii~ ti.rni of (li-ca-c a|iji('ar- tn l>c i|iiiii' -. mit, . iid ii- |iroi_rnii:-i- i.~ >aid to iii' t'ar iiiorrLiraM' than thai nt' -iinplr l\|iliiiid ti \ i r. I.viin.- wliM ha:- -tndicd ihr t|ni-.ti(iTi nt' iMniliincd 1v|iliiiiil and malarial inlicti'.n and ihi -.i-callid ly|ih(, malarial ti\( r, cdnrliidi - ihat in rri:ii'ii- wIhit lioih ai'r ciimmnn, it i- |ir(ii)aiilc that cnmliiiicd intic- tiolis nut intn(|ncnll\ (iiiiii. li,;t that -neh ca-i:- air crft.ainlv' imt tiic line- that !ia\"i' lice ii di -crilMij in ilir I'nitrd State- under the n.ame '• t\ |ihi'malafial " ll\'ef. It i- ii fiain that .■,!-(- of intei'inilti'iit l'e\-er afe inenffeetly included in ilii- i:f(iii|i. lh.it. withi'iit the intliiciice i in the imdv 111' tile t\ |iliiiiil-liai'illu- in addiliuii In the jih-inndia, are attended with t\|iliiiiil -\ tnjitiiin-. -tujinr. dcliriuni. |iiii-tr: timi. etc.; and. cmi- \er-c|y. -lime |iln-ician- |iract i-ini,' in malarinii.- re;;icii> are in the hahit iif c'liii-idcrinL;' ca-i - ul' t\ phnid with a |)rcdiit!iinant intci :iiitteiit tvpc ot' level' a- inliuencinl li\- malaria, ll -In mid lie cm|ilia-i/ed that licliire -ncli ciiniliincd intectiuti i- ciin-;deri«l a- di mun-trated, the |ila-miiym|itiim-. intci luiitciit -weatiiiLr a— nine- a jironiiiicnt ])osilion. .lacciiiid consider- it, with •j:nui\ rea-on, a.- a |iecnliar varietc ot' tviiho- malari.al Tescr. ( aiiinc live al-n — licvre dc- chieiis — wliicli lias hcon (icscrilied in lin-nia and Ilcr/cc-ii\ iiia liv a nnmlier of oliservcr- (Pick, Karliii-ki ). appear- al-o In liclinii:- in tlii- caictrory. I'rojiaiilv the condi- ^ Mnliitlirt ilrs pniis rhittnU. I'ari-. IS'-!', <r/K, Vnj. \\U. » Cliii. mid. n \'Ai:i \ni)\.s IS sYMrrnMs ami (i,ri:si:. :vn tioii i- uiic ii.-iv, liad rcriivtrrd t'l-Miii inahiria. Karliii-Ui ' lias di mtiIhiI an iiitcrc-tiiiL' ''as"' "^ anthrax (■iniiliiiicd witli tv|ilii>icl livfv. wliicli \va^ ^lllljl•(■Il•ll tn ixiivl'iil liai'ttTiol(ij.rR- fxam- inatioii. ('a-(-iit' (lie (■..incident .Ai-iciicc ..t' rheumatic polyarthritis w iili ty|ili..i.l ti'ViT, wliirii have ex.. |ili.iiially Imcii r(|...rl si)i'citii' cxcitiiii: t;i.t..r; and, ..ii the (itlnr hand, il niil-t always In- Imh-mo in mind that tv|ilii.iil I'cv.r it-dt', and (.tlicr (-(.nditidii- cl.M'ly rc-cniiiliiii,' it -iiii.rri.iallv, iiiav at tiims ]»■ aiiciidcii w itii iiiiiiti|ilc intlainniat.iry atTccti..iH III' ihr i..int-. ,\in..nL' llif lattff (•(iiiditi..n-. certain ea-.- nf erviitoLTcnic -e|iti<'.i|iveniia and int'cli..id fever in dialietic |iatients may lie attended with reinarkaldy low tcm]ierature. I have p. :-oiially oli-cr\itl such an instance in a patient, fortv-tlireo vears es little ehanire diirinir the course of the attack ol tV]ilioid fever, and fjenerally les.seiis only toward tlu' fatal t<'rmination. ' lin-lin. Idin. Woch.. 1888. = (iriessini;iT. Arch. il. llrilk.. 1801', ?-,. .Iiihrff. ^&m\>nii-cli|,,ri,| rv;„.ii,,n d' ( Icilmi'di ;iii|Mars to nii(l.T.ro a .•un>iil(raMf inl.M-iticali.iii uiili llir cMiiiiniiir.HH rjt ..f the I'cvcr ((icrlianlt, |-".li-triii ). Am. iiijr til.' chronic intoxications. ivHrctic.' ii.a\ 1., rii:,(lc t.. iikip- pliini-iii and alcolioli-tn. S, thr a^ I kn..\v, attrniinii ha- Lltlirrl,, not Im'cii callr.l to the l)ciiavior .,f |H.i-(,ns atudic.l cantully 'l cax - of tyi^lioid fever in Mich |Mr-on.-. an|„riaMy will: the l,->ened ))o\ver> of roistanee of sueli indivichial-. i'.oth patient— tlie one a woman, ihiity-two years old, and the otiier a man, tliirty->even vear- old— died a- a re-lllt ..f the di>e:,-e on tile tifteentll Mild tile eijrllteeiltil ■ lay, ropeetively. 'I'iie alisolute -1,.,.|,|,.s-,m-< from il„. i,e;;i,i,iine-. tii<. eon-tant mari^ complica- tions I'xert an elevatiiiir inthience, irfnerally piir.-ues a rather low level. This fact, however, ju-t a.- in the case ot' rinir from typhoid fever at llamlmr-. The lessened jM.wers of resistance in tlioe paticnt> are cspcially appreeialih in the action of the heart. Kvcn from tin hcLnmiinL'- the |.iil-. i- likelv to h\- di-pro]Mirtionat<'ly fn. |iicnt. and oficii lieeome- di-iinctl\ -m.-iller. Ilvhler. and irrcirnlar as early as the middle or close of the lir-t ..r the l.e-inioii!.' of the secoiid Week. Dilatation of the heart al-o develop- ,|uite earlv. M'ilh rei:ard t.. tin- vascular sy-tem, ihe -jxcial teiiclcncv lo hemor- rhaoes is to he considered. Dninkanl- exhibit more frei|Uent!y than otlier patients copious no-e-l)lecd. and arr' otien aliacked llnu^uallv early hy sovorr intestinal lirm<>rrliai:e. the source for which i- eveiituallv found to consist in >poniriiies-, friaiiility, and herni>rrliaL'ic eonecstion of the patches that have not yot imderirone slou <(ii'i:si:. .•{2;» tiuiiiil. The cliiiiial |)i(tiiif nt' ilic ''atiixic ail\ iiaiiiic varirtv " ,i|i|M'ais (■:;rl\ iimlcr tli(>n coiKlitinii-, willi llic • arly ilr\ cldjiniii.t ><{' |iiiilni,;:.| (li-imliaiiic 111' iiiiiMi(iii-iii'>s, jx'i'at roilc-r-nc— , ami -cvctr ililiriuiii. S\ iiiploin- 111" arliial ilcliriiiiii trtiiicn-, luiw'vtr. iHciir — in riha;zir nrphriti.-, ocnirs c-pcciallv carlv and in inarhiil ilitrnc in ilrimkard.-. I'ndcr tin- ddi- ti'i'iiin- intliU'iicc of early cardiur weakness, the latter may reudily j^ive rise to fatal uremia. VARIATIONS IN COURSE DEPENDING UPON CONSTITUTION, SEX, AND AGE, Constitution. — Allhonjrh defmite kiiowledtro is waiitinL' with rejrard to tiie intimate nature of that wliieh is (le~ijriiati'd eonstitntinn, it may nevertheless he staled that tiie eoiiise of an attaek ot' typimid fi\er stands in a most roniarkahle relation to that which in j^enefal is so desijriiated. It has heen seen that yoiinjr vijrorons inilividnals of ltimmI constitution are attacked with especial i'reijiieniy by typhoid fever, althoUiili they recover most readily and uniMJured after a loiijrer or shorter course. Toiiirh — that is, the spare, inuscnlar — indivinlent yoiini; man or a hloomini;, tloiirishinir yoiini; woiimii ]>laceer~ons, when .attacked with tvphoid i'ever, do not hold out. They otten exhihit iimisiially hiirh and iininterrupteil t'evi-r. and they arc early overcome hv sopor, coma, and other severe symptoms r:f'eral)le to the central nervous system. The most unfavonihle ti..;! c is rhe liehavior of the heart, which, often as (-arly as the first week, exhil)its si^-ns of deficient power, so that the course ot' the disease" is almost from the Ixyinniniir dominate . .t' !'.!» per cent, in males and (.1 S..". per I eni. in Tenia Ic- ; w hile ..iir -laii-iie- al I.iip-i.' di-eli.-cd 1 t.7 per cent. t'. .r il,,. i', .nn.i- and I ."..:.' p( i- e. ni. ti.r ilie laliir. Ill certain eiti.- and in certain cla—e- i.T si.ciel\, i.ii the (illier hand, ditrennn- in ni]triii..ii, in iii..de i.l' lite, and in i.eeiipation appear t.v eaii-c appreeialile ditl'ereiici- with rcijiii'd 1.. the characler dt' ihe eeiir-c and the leriniliatii.ll i.t' iheallack ill the lUd -exe-. In ihi- ei.nnecliuii, the ini]i.irlant /■-'/.■ that alci.hi.li--ni |ila\- in men i- ( -.iieciallv 1(. lie ci.ii-idei-ed. Ill wiiineii, naturally — allhoiinh thi-. i.n the \vh..le, iiiakc- iio iiiipres~i.,ii (.11 the siati-tic- — the -exiial liiiictii.n- are ..f lun-ideralile inlhieiice. Ii has already lieeii -ecu ||.,\\ ^r^ally ihrealciied are preirr.iiiit Mild pucr|Mral wi.inen altac hed liy ly|ili..id fever. AIm. diirimr the tir-t period 1. 1' lactation llie jK.wer- of resi-laiHv lia\e appearc(, that children except during'' the earlie-t period of lite oiiMlp\- l.v tiir the lilo>t l'a\or- alile -itiiatioii : while a- early a- the iMrinniiii:- ..r mi ra>v< in li.i-|.i(;il aT)i| i.riv;it.' pruiticc. IM /;/ I /7'*\N /V \)MITnUS [\l> (nfH^i: ;;.;i -ImwIv to iri;ikr it-i'lt' riiiliccal.lc a- (••irly a- lniw.cn ili< t'..iiii|i ami llic lil'di vcar. A I'lirlliri- ( -id' ralili , ami I'n'iii llii- linu- "h |irc.._:iv--.i\ ,•, inrrca-i' in llif ijioilmliiv ijvm-rallv nn-iir- lHt\M( n lli<- niiitli ami ilii' liiilh year. Allciil'hiii -liniil.l !«■ rallcii I'.ilir t'ac-l llial tin' i \|i('rirmc> ni' |.n\atc prariiiT ami llir -lali.-lii al >lal( iiiciil- ntrrriiij I" llif l'iih ral imi'iila i ari' lar mm>it n liaiijr in llii- c.nmTi imh ihaii lln- ilala nliiaiiic'l iV'iHi L'l'iicral lin.-|,iial-. Naliii-ally. iclalivilv im.rc ihiKlnii iliaii ailull.s an' Ircaliii al Iimihc, ami ni' tln.-r aliarkr.l. a iMii.-i'i. I'alile nuiiil)cr in lai'Lir riiirs i-iittT llic iliil'lrcn's liii-.|.ilal-. A<'(or'rniL; I \ . llic li^'urcs t'xliiliiliil liy llu' L'fiiia-al lin-|iiial slali.-lir- aiT Inn luu. Tiir rliara<'tii' i.f ilic (ji-ia-r In rliildnii i-. nn the wiiuK , luililiT than ill adult-. 'I'Iha afi nmii- iv-i-iatit In tlir iiitn\icatinii, and nV( finiiii- its rlVci'I> iiini-r fiadiK ami innf.' cniniili l< ly. With thi- (•nfrr-|>t" fcciivcrir-, ( \'cn ill |ifotrai'tiil, -cvcrc ca-r-. Thr ca-c- ill which tlir \' -linftcr diiratinii iiiaiiili-t tlnan- »clvc- in \arinn- wav-. In a |H.ftinii nt" the i-a,-r-. the -Imrinr diiratinii aii])(^ars to Kc dcpciidi'iit ii|)nii tlic flicl that the iiidividiuil >taL''i's, althniiLdi thrv cxhllut their typical dc\ ( ln|iincnl, piir.-iic a >hnft«r course. A -till lat'i^iT iiiiiiilicr liclnii^- to the val'ictics ot typlmid lover that have licm dcsitriiatcd alxirtisc, mild and mililc-t. which linvc al"(idv l"'cii adc<|Hatcly docrihcd. Cases nt' typical or iireatly prntracteively ajiproachcs that nt" adults. The tendency to a markedly rciniltent eiirxc. which makes itsclt' a](i>an'iit in the ca-cs ot" ahhreviateil emir-e and nt' iiinderale .spveritv, and cspei-iallv in lliosi- (.t" protracted eoiir-e, is iintewnrihy of tvplioid t'cver in chiMren. ( 'ases, however, in which from the lictrinninLT the curve cxhiliits siich marked ami re^'ular lliictiiations as to lie siiL'trt'^- tive of malaria arc di-tinctly le-s conininii in chihlrcn than in adults. The older, ])articiilarlv Knirlisli and I'^rench, clinician- ( Ahercromhie, Wcndt, ('lioinel, and others) early de-ca-ilied .-i- intiintile remittent tcvor a svniptoni-conijilex occiirriiiii, as the name siiLTiTcsts, prcfcraidy during childhood. This was at first considerfMl a special disetisc, hut was siihse- ((iieiitlv reco<;nizcd. tlirouirh the lahors of Taiipin, Rarlhcz and Hillict, W...:;f .1.^.1 Mnf,.t.i^ni» .1.; t^-iiluiiil te\-i.r lii' l^eelTliar eeHlfse. At th-'t tlinC El ■/•) ilinih 1 1 \ i-i: "'""''"' '■'■■'I iialiMv nl' InCniiilr n,. .iMn l(\.ru;i- ii..| iindi r-i I, •""' •''-" 'I"' al"'ni\. ■ind inilW toi-iri- u , iv Kill iiii|m rl'. n K kimun, i_\|ili"i.l Wwv ill cliiMrcii \\:i,- cuii-i,!, iv,| i-.iiv. In ruiiira-i uitli tlir ii-ii:,l I„I,:,n i, ,r ,,r il,,. I,, .,|v -i, mi,, r,,iinv, ll„. |.lll-,-|-:i!.' 1^ rn.in ill,. iH-imiili- •.dili-ly lii-li, ,-|M,i:ilh i,, ,:i||\ '■'''''" '• **iil.^ ill "I'l't- .■liil,lin,, ali.r iIm- tu,iril, \,,i^ ,1,,,,. ||,",. l.nU,-rr.,,iir,|c_v .-.Liaiii ai.|,r,.a,-li that ,,f a, lull-. In -u, |, ,|,i|,|,vii ''''■''•"'-"I i- "i-ii'iialK- ,,l,-,rv,.| in lli, ,,•„. ,,|- il,,, -.,v,,ii,| ,„■ ,|,.. tiiiitiii,'i Is llic irnat.r rv-iMiii!.'- |«,u,.r ,.l' llir '■'"''' '" f'l'' •i'''i"'i "I' 'III' toNiii-. Cardiac Ural:.!,— ,,.vm- iiiii, li |,>s .•cmiiw.lily, \u<\ ,.ii!y in rax- .,|' r>|„.,.i:i||y |,,n- an,! ma.iv c.iiis... Irtv-nlarity ,it' th.^ Inart'- ,i,ti,,n, a- n,ll a- irr,-i,larity ,,C tli,- pul-,. in Iniv,. .111,1 rliytlini. i. ,,|„..|-v,.,l alin,,-t ,,nly in tli,' ,|nii,- .A,v|,ti,iiial ca-c.^ ciniilicatiil liy ,ii,|,M..ir,lit i-, niy,,i'ar,lii i~. ,,r |,cri,':iriliti-. \\ ilh n-ani |., tlic iiiaiiir,-tati,,n> ,,ii tif part ,,f tli,. -lun, .■spciallv tho r,,-, ,,!;,.. tli.v ,\|iil,it little v Mat.-,! a^ n,,tr\\,,i-tliy tliai tli,- r,,-,.,,|,a. Lr(M,iu.nt i'inirK iii.iid nilliir lVii|iic'nl ly :i- a rofii|ilical idii. i -|m ciallv in MiMiiL'' 'liiMii II. uImIc- at llir |iri-cnl day tin' londilidi i- -cair. ly i \ i r rit'i'frnl (m. I'iu'Ii 'li'' li'niliiHV nii iIh' |iait nl' cliiMfcii -ntliiiiiL'' I'n'tn Isplinid li-vi-r Im piik al ihr liii-i aiicl at llic li|i-- i- di|M ndcnl llic tart that cxtcn-ivr lili'i'dintr ti--ni(- and r\( niiali"ii- idMnd \s\\\\ iru-ln tVii|Udiiniiii i- niorc likilx |.i lie di-lriidi-d in cliildnii. Iinl ;.'rn- nlv in i Icrair dcjirr, and ranly m' ;.T<'ally a~ in ailidt-. ( 'liildi-cn i'oin|ilain nioiT |Vi(jnriM l\ lliaii llir laltrr ot' alidnrninal pain. \'iiniilinir :iiid rclrliiiii.'- ,irr not \ i ly rafc nianili^ialion- nt' llic lii-l li\v ilav-iit the taiil than in adult-. Oi-linrt jircnliaritif- <'\i-l, liMwrvei', with fi-ii-ard tn thi' -crinn- intes- tinal inanil'e>Iali(Mi- iTha<.'e and |iei'|ipnilive jierituniti-. lidth are le-s emninon in children, e-pi'iaally in early and niiiMle ehihllnMid, than -dinewlial later in liti' (Taiipin, livelier, IJilliei and IJarlhe/, ileniH'h, • ierlianlt, Hieilerl ). \\ liile arncinL'' :idnll-- ! have at limes ene(innlere i- eom|)ar;itivcly even rarer. This ]>ociiliaritv tinds a -ati-l'actury cx|>lanalion in the anatomic condi- tions in the hdwel. In children the inliltration of the ag-minale and solitary fullielo- i> in irciural far le>s inarkol. Accordin;.l\ , -loiii^hin^ and iilceriitioii will occur under >iieli cireiimstaiiec- iiiori' rarelv, and, if at all, in slighter evteiit and to a loser de|ith ; hut, on the other hand, it imiioiilitcdlv more frei|iiently ha|p|>en> that the niedilllarv <\vellintr nnderirocs involution thronirh ahsorption without di-inteijration. The incscnteric ^rland, an' al-o, in p'lienil, less inarked — that i>, before the bt-LrimiiiiL' or the middle of the sei'ond Week of' the di,s<'ase — is less common in children than in adults, ami that it does ndt fre(|uently exceed niodenite |iroportions. In my <'X|M'ri(Miee, actual |K'rsi>fent alisi'iiee ot' splenic ('iil.Trijenient or of the |K)ssil)ility of it> demonstration has been I'lither l(ss coninioii in ehiiiiren tlifin in adults. AmoiiLT atfections of tlic rcspinitorv dr'"l""i"- "' 'I" .li-.i-.. Il I- :, .i:,i,..| nitlMT liv,|u,,„U- uilli at.l.-.|:,-i- and l..l„ilar |,ii, iiMi,,Mia, ,-|„, ialls i,, ,|, l,ili|alr,| rliilclivii. Sirnpl,. aii'l InllaiiiinalMiN lu |„,-tM-i- nf ||„ Iunl- i-, lh.«,v,r, all ilic iiiMiv ran- a lact lliat -lir.l- a -tn.n^r |i^,|„ |,,„„| ,|„, |;,v,,ial,l,. -lal,. ,,f 111- li.ail-|»,u,i- ill rliiMr, ,1 lliat lia- Im,!, r.|Ha|M||v iK.irilcl .,iit. 'Inir l"l'-l'-. lil'lillMU- |M|. IIMInlila I liaV.. ,,l,,..rv,.l 1,111 . \r,|,|i,„|alK III rjiil- 'liMi. I'l, Ill-ill. an. I .iii|iy(iiia al-.. aiv. an ..njiii- t<> llir -lalciiiciil- uf iii..-t ,.l,Miv,|-, ami niy nun .aih lini,-, , rvlalivdy iiiir.,riiiii,,n. •riir siinc- -lalniMMl i- a|.|.li.aMr al-M |,, ati;.| in,i- ,,1' ihr larynx, l»,ili -iiii|,|.. "'•"'■"' '' '!"■ iiinr,,,,. hiiiliraii,' and |Hri,linndriti-. and iic-n-i- of llir rarlila-.'. A- lia- l.i.n |»mih',,nu\N iiat iiiMiv |'iv.|iu'ii| ai;aiii in I il, r .•liildli,„,d. I'll' -yin|.ioiiH (.11 III, |,arl of tlir n.rvnn- -\-i.ni n-na!lv varv i„ ■'•''"'■''■• ^^'''' yin|il,,iii>, m-vciv li'nda.lir. ri-idiiy ,,(■ tl„. n.cl< and l.;i,-k. ^vncral liyiMn-Mlic-ia, willi -Iil-Vi-Iin.-, dilatation, and rvni in,,|ualily nf tlir |.i,,,il>, and pruf, j .tn|».r i.ro^rn.-in^r i,,!,, dr, ,, .nnia, -Imnld .-|M,.i,,||y |„. iii,.riti.,n..|. N,i\on~ -.•,|ii,l~, -iich a~ >|,inal air.vtion-, nniriti-, and tn~.-intr Jiam- in tlir IkcU and Km- mi trn|ii.nl in adult>--|,a\ .■ |)racti,-allv not "■iif inidrr iii\ ul,-crv.iti..ii in rliildivn. It.-fciviUT may liciv 1„. made a-aiii In llir a- y<'t iiiic\|,laiiird Iraii-ili.ry a|ilia>ia (|i|.. 27."i and L'Td) '•'■ruvvhvj altnn.i ,A.-lii-iv.|y in .■liil,||„„,d, whicli, altlKMi-li nimtii.n.il l.y •■••irli. r ,.li-.rv.i-, lia- ivnntly I..-, a airain {Miintcl .nil, |particiila-|v ],y (iirliardt (Clani- I»i". ) ani T-(iri:ill\ tili-rrs cil no aniitlv. aliim^t mvir aiiMiil in c liiMI 1c, -liorltT than in iulnli-. I 'niloiilit< in later lite. Thr alili'i\ ialinii athct^ all -ta^'e- ot' the di.-ea>e, Imth the t'ehrile jiericMJ and (■•invai. ••■me. Tlie tehrile |H'riiMl ill \vell-i|eve|(i|M'd Oii.'-cs is likelv to lie -hiirleiieil at lime- in all its staire-, while at (ilher times (inlv nlie iir allnlhtr st;|i_rc' i- -lldl-telled, e-]M'eially that nt' aseeiidillLr tem|)eraluie .ir that lit' det'erve-eellC'. It i~ illtele.-till^r that the (iliralii ill (if the fever ill Well-marked ea>e- a;'|iear< In lie -lidrter, mi the wlinle, the Miunirer the child. In ehildicn lielnu the aL'e ('f six years the diiratioi. miieli le-s ediiimiinly e\ee<'(l> tlirei> week- than it >\i*'^ in nlder (•hildreii ; and even in the latter, ditVereiiee- '\-\ relatidii In a^'e are likely td make themselves distinctly manifest in tin inanner indicated. 'l"he fdlldwintr tahle, ha-ed ii|hiii the ca-es iili«erved at Hamlmr^ fnilii 1"f \ \'\ children lietweeii tile aires of two and fdiirlun Ncar-^, the diii-ati(in (if the lever was : ifi * % Vy |.i '.'I iliiN- Iti'tw 1 '-"-' :uiil ■!■! ilu\- M'lrij th!iri :i:i iliiv^ ■_' til ;. vfjirB. r. Ill I'l years. In In 11 ycar^ •XI |»r ri-nl, 71 s ]>,r .cnt, ('■" s per cent. 4 is i; L'.^i 7 •• •1 " 7.7 '■ 11. H '• The -liorter diiratinii of the fever, the irr(>ater resi.-tanee td the actidii of the tdxiiis, and the lesser fie(|iiency and severity ot' i'(ini|ilicatidns are res|i()iisil)le fur tiie fact that cdiivaie-ceiice i> in ;.;( iieral c(im|ileted earlier in children than it is in adnit- This ajiiilie- not diily Id restdratidii (if the -irncliire (if the atl'ecte nndtr till' sinic cucnnislanii ■ J pir cent. Tile ircncnd i'nIc. tliat iclap-o arc likely tn lie the nicirc tVc(|iicnt tile V(]nii;rer the patieTit, i- a|)|iliealilc al-ii to cliildliudd. 'I'lic tend, ncv to rcernde-ccncc- and rela|i~e-- i-, witlinut diiiil)t, inure pninunnced at tliis p.eiiod (if lite iliaii in later vear~. Kxee|)tiiinal cdiitniiiii'tnrv stati'incnl.-- are lia-ed eitlier iipim Uh< -inall >tati~tie~ or upon c.\ce|)tioiial cpidcinie- and cndcinio, wliicli, as a inatler ot' liict, iiiav ocea>ioiiallv C'xiiihit a deviation from the rule. Thus, in lIunihiirL'. in the year 1x^7, altlimiL'li 1 observeil not aefually fewer relap.ses in ehihlreii. tlu' |>er<'entiiLre of relap.ses whs. nevertheles.s (lisproportionately lower than in adnlts ; while the fiuMircs for the year l^WtJ, and those for fourteen years at l.eipsie, aj:ree with those that I lielieve to rcprenent the usual Mate of atiairs. Ihere i 'urreil in IlainhurL' in lc><^(J: Kelapses in adults in l:).4 per cent. : in children in lit..") per cei't. : in Lei))- sic. relapses in adults in 12..'> jmt eenl. : in children in 11'. 1 jier cent. It is interestiiiL' that even in relapses in ciiildren the jireponderant occurrence in the female ,se.v — which almost conslantlv occurs in adults — is at times distinetlv exhihiled. as the followiuL' stalislic.- of Hand)uri(l lever ;i])|ie:irs tii lie ili~liiietl_v le.-~ euinmiiii than in later ehildhuiMl. It i.~ tiiii', as has heeii seen, tiiat iiilra-uteriiie traus- niis-iiiii niav take plaee, ahhuiiL'li tlii>, in ivlaticm tn the nuniher uf t\[(h(iiii iii(ilher>, i- to be eiinsiilere n.'.ili |i,.r .~ick chihiren. lit" with tvphoid t'ever, of the t'ollowinir au'es : 1 r, MmtiKis, r, rj M.inllis. 1-: V.^ar.'!. :-r. Y.'urs Over six vtMir?. L'— ll.:;i l»-r .t. .') (I,77|"r.i, 11 -J. 10 |i, r ri. L'l', :;.'.'.i (..r ct. 41:;— i;:;.S p.r it. Ollivier' had aiiion^- (ill ca^cs of typiioid t'cvcr in children imlv :'. under the a^.' ot two vears .M v own ■> iiatients were nnie an 1 eh months and n ne and tliree-ipiarter years old respectively. Tile clinical statements that have hitherto been made with retrard to typhoid fever in iid'an;- are ba~ed especially npon severe « i ll-dcvcloped ea-is. .\l-o. my •"> ca-es of that character, the onlv certain ones that I havi' -een, piir-iie ln'i'ii curifnUv ci.Ui'clt'ii. ii :vS^n h P\if ;):;.s lyrii'iiit irvi.i:. liiiiKillv ill \iiiiii;: cliildfcii iliii'- the ili-c lie:.)- 1 ■ -ct ill aliniptiv and tlic IcNcr \^l ri-c i':i|iiill\. \\ licii ii li. nciii I -IMi' 1(1 iili-irw tlic iiiilial .-ta:;r, ilic I'lirw Liiin'rallv \\a~ >l •, i • l.cd ,~(iiiu'\\ liat i'a\ ..I [111- .liMil.-i- sliiirtriii'il, a< ill < .,'rliai'dr~ ca-f. Al-n tiic ta-tiLiinin. and wiili it the ciitirr rdiriir |Mriiid. a|>|i( ar- I'l ln' LiriicralK of rclati\"( 1\ -li^rt (liiralimi, alilmuirli cxrciitinnal ca-i - iia\( lircii iiliMT\cd tiiat wrrr |initr:R'tf(l lor |i;iv .'f 11m- ills. 11^ ll, .1 as liiiiLT ;i- t\viiit\'--c\ lii and cmh tliii'l\-'inr da\- lifiorc drrcrvc-c'iicc (MTuiTid ( I'"iiatii\v '). It i- iiiiIcwiiMliy tlial in -cv en ra-c- d' (yi'li'iid ' |-,-;7.-v.,;i.,../ ,/''..;• .1, ■;,/,■ I ,ii,-l.t i,„,^kr„ „ l,!i. ,' . „ i ,„ h , iid. s„l tf r . Tninslatcl into (IrniKiri fr..Mi thr -..niid Kii^.-iuii fiiiti.in, Viriii;a, l^'.iT. *^^ i.« r i/.7.r/7o.\w i\ sy.Mi'TiiMs a\j> <(ifi:si:. ;;:'.9 fcvcr ill infiiiiiv tlii t< ni|Mr;itiirf i- (jiiii. \<\'j,\\ at the i'a-iijriiim, in jr*-'"- cral liitriiir tiiaii (hiriiii.' tin' -iicccfdiiitr ycai-. did liir t('rn|irratiii'<-i'iirv(> i< likriv to rc^cinliic liiat nl' iciiiitti'iit cciiiliiiiicil ti'Vcr. In the |)i'tio(l of (ii'l'(i-\'c-ccnri' the l\|ii- ot' ~t(i'|i ciwvi'S nut rafrly inai\fs it-i'lf niani- li-t al-ii in inl'aiii-. A- an iilii-traliuii. I |irc-vnt tile cnrvc iVoni a <'inl). mid tmo Inun a lilllc patiiiit III' I'ilalnw'- ( l''ij_r. .'Micii^ht incmtli- eld. The |inl-c i-. a- wmdd \iv antici|ialclc in ca-c-i.!' iy|iii(iid li'Vir in intinn-y, wiilmnt llic nniniiif nf |iiil-(-iicat- liciiiL' in il-<'lt' I't' (-|i(iial |ir(i;^ii(i-iir -i^niticancr. I'aiiarj^r- niiiit lit' tile -|i]('ii i- i^cnnallv , allliMnL;li in't <'iin-lanll\', dcni(in-tral)i<' ; lint, (in a-cnt in yimn:; cliildnii tlian in oldrr one-. In one of my ca-i In a I'liild eleven niontli~ old — - wliicli wa- under (Tniiial oli-er\ati.iii from flie. \cry Im Liiiinini.'' nniil its liital terminalion, and \\a- e\;'.iiiir,ed anatomieallv al'ter death, ro-enla' Were at no time deiiion-lralile. Mxeeplionally, liowever, tliev have lieeii foimd in LTi'i'at |irofn,-ioii. a-, fir iii-tan<'e, in ( !<'rliardt'- ea-e. 'i'liin, walerv -tool- appear to lie (piite fre(|nent — more eon-tantiv .--o than ill older children. The daily nnnilier ol' -to not rarely pre-ent from the lieiriimini: of the fe\ er, the cr\iim', :ind tho twitehiiiL:, iiicrea>iih_'- to tin- point of coin iil-ion-, it is well (•alciiiateide, |o l.o n'lplaced liy more or h -- marki il -tnpor and sopor. lironehitis aj.pears in -eneral to he mild in intiint^. while lolmlar piieuinonia is ]iarticii]arly fn (jia nt, .iiid i- one oi' ihe coininoii direci, eaii-e- o|' death. 'I lie dnraiion and inotruo-i- of weli-markid typhoid fever in infants >y^ llil W: !i 1 'r W' ;; 11 1 ryriinii, < i vi:i: ari' ■>"•> |■a^e^ dl' i\]ihel.| lever nli^ervril al Leipsic- ami I lanihiirL'. I leiinil 177 hilweeii I'Miy and lil'lv year- el' aL:<- : 41 lielueeii lilty anil >i.\ly ; II heiueen >i\i\ and >eveiny: and ■> e\ er .-evenly. 'I'liere were 1 ^<^.') lielueell llle au'e- nf lilleea and luenl\-ti\e yiars. iiowiver. The inlhieiiee i.l' later lili' wllh I'erereiiie I.I the eiiiir-e aiul 'ho ])niLriiii-i- 111' llle di-ia-e i- lAiieihiiirly nnl'av nrahle. A- early a- the M'eiilid half 111' ihe liiiirlh deeade ihe di-ea-e in it- ;^cneral eniir>e. ^M'i 1>>>7 \\:i>. in the !ii:e-|ieriiiii rrnni twcntv-oiic til i\\eiii\-tive. 7.7 pel- leiil. : l\M'iil\ -ix In tliiriy, 12.:i jicr cent. ; tliiriN -line to lliiri\-li\e, II. .i per I'eiii. ; thiii\-i\ In inrty. 11.!' jicr cent. ; liirlv-one to I'nrlv-live. l.''..^ per cent. ; l'.irly->i.\ in lil'ly, -It'i. I percent.; fil'ty- onc 111 iil'ly-livi'. -'■'< per nnl. : tiri\->ix In >i.\ty. -'17. -'i per eeiil. The -iati>lic- 111' the clinic at I.eip-ic ( IS'^ll IMt:^. witli, it is true, a hiL'her avcrairc iiinrlalits. di-cln-c .-iiiiilar relatinns. The ninrlalitv was, in llic aL'c-peiiiid t'l'iMM IwcnlN ti t\\ nlx-liiur. \'-\> per ceiil. ; twciitv-llve In tuenlv-niiic, I'J per eenl, : liiirly t(i ihirty-liiur. l."i percent.; tlnrty-tive In ihirtv-nini . ■_'"-. ^1 jur leiil. ; I'nrtv to I'nrtv-l'nur. 2'.'.'-' per cent. ; I'mly-tive III l'nrl\ -nine. .'1 1 ]icr eeiil. ; lii'l\' In liri\-nine. 4U per cent. In the ni.iinril V 111' ca-c- in -cnilc iniiividual- the lici^innin:;- nl" the allael< and the a-ccni nt' i he I'cvei- .ire i.i-radiial. W hen the lieeinniiiLr id' the lilii'ile perinil i- allendcd w iili cliillv -in-atinii-, liie-c are likely to i-on-i>t jreiii iall\- in re]iealcd chilliiie— . only ipiilc rarely eoiilincil to a -inu'lc chill : in the latter case the conr-c is ii-iially aluiornial in other re-|)ecls al-o. The I'lirlher e\-olntinn ill' the entire clinical jiictnre i-; marked l>v the evidences ol' le--cheil |)n\Mr- of re-i-tailce of the -cnilc iiody to the I 'I'rn'ii: ,lr^ ^u(ihulii-s ,/,■ I' r.if.i „,••. Is',i7_ Till- wrk li.ntairis iil-n mniRTuu.s l)il'l''-'j;rapliii' nl'iTciici--. e-|.i-.i:illy {•• n-e.nt Kn mli puMiralinn.-. m\ ri/.7.i/7o\v IS .sr.i//'/o.i/s- i.W) cornsi:. •■vn iiitoNicutioii. Ill iiKirkfil rdiiinist to llic |i(iiiM! ol' \ milli, llii~ lnucifd i't-i-t:mcc i- i'ni|iu litis ixliiUilcil in tlic ^'iiicral ciiinlitidii, ami particii- larlv ill tlic (••iiidilii'ii nf tlic iii'i'vous s_\>ts t'ir((iiciil than tlm-c i>t' (l(|ir(->inii. Tlif ]iaticiits licciiiiic -tn|iiil at an early ]" riuil. Not rarely they are linitiilincllv sni)oru-e or ilee|ii\- edinalci-e at the lieLrinniii^' ot the -eeiilid week. Al the -aiiie I iiiie. or a little later, tri'eat a-lheiiia, aeeiiiii|ianie(l hv tiiiuipr. -iili-iilliis teiiiiiiinm, atul tldetitatioii. sets in. The patients nniler >lleli eirellin-tanee^ are re-lle-s, iitleli whiilly >iee|ile-s, liut jreiK'r- allv without severe ijeliriiiin. Pallid, with relaxed I'eatiire- and hall- (i|iell eves, liilirililirili'_'- t'eehlv to thelil-ehc-, tliev oeeii|iy a I'elaxi'd dorsal deeiiiiitns, the pietiirt' ot' the adyiiaiuie fehiile course of' earlier writer.-. This character ot' relaxation or advnaniia i- exliihited in the cmir.-e ot' tlie t'atal ea-e<, as well .1- in that of the severe cases that ceentiially teriiiiiiate in rc<'ovcrv. 'I'lie latter are i^enerally iiniisiially Ioiil"' in dura- tion, not alone with ret'creiice t > ;lie i'ehrile -taire, lint in coni])arati\ elv still irrcaler deL''ree with ret'creliec to the ^tajre of convalesecliec. 'file fever, under -iieli eirciiiii^taiice-, does not, in the iiiajoritv of ca-es, attain the same heiirht as i.- likely to he attained in -evere ea-cs dnrint as the afilifilc case- of iiio-t -evcre coiM>e, a- was |)revioii-ly inentioncd. princi|ially occur in deliilitated senile individuals. In addition, the lorin ot' the ciir\e is far more t"re(|iiehlly irreu'idar, niarkr'dly remittent, at tiiius interniittcnt, and marked hy .atlai'k- ot'triic or fal-e eolla]>-e than occur- at aiiv other time in lit'e. Ot'teii the -ta^-c- o|' the di-ea-e are im|(erfectl\ if at all, marked In the tcin|)eratiiri'-ciirve. ^o that neither the -te|i-like a-<'ent at the licLi'iiiiiinLr, nor the contiiiiiaiiec ot' a eon-ideralilc a\'eraire ( livation ot teni|ieratiire in the -evere-t periocl ot' the diseas', nor \'ct a marked staire ot' -tee]) curves, is procnt. Not a few ca^'s, on the ci>iitra!'\-, piir-iie -o anomalous a cour-e that the ti^nn ot' tli • ciirxc furnishes II" diaL;iio-lie iiiliirmalion whatever, lint rather mav lead to iiicnrrect coni'lii-ioii-. I lie -low iu;^- of the piil-c, which i- -o t'r.(|iicnt .-iiid eharai'teri-lic in yoiiii^'- vju-iiroii- individual-, is extremely rare in tin aL''<'d, and in niv experience aliiio-t only occurs wIk n the -eiiile character ot' the dl-caso i- al-o li -- mark-'d in other rc-pect-. 'I'lic jiiil-c in eldeilv iiiili\ idiials i-. on the contrary, usually fiv,|ii, nt from the iiit-el — on the a\ cimi.'-c more so than the lu'iLiht of the teiii|ieratiirc warrant-; and, what is indicative especially of a marked toxic etfeet upon the heart ami the 1..-C { till' Hid ili:it the j)iil-c i> <';iily i.t' Inw tcii-ion, irn L'ular, and, when artcrio-rli ro-i~ i- not ]ircMiii, i- - tliat -n early a|i|i(al> in the tlircLMnniid is alxi rc^jxiii-ililc ill <(iii~iiici'alilc dcLM'cc f'nr tlic >tatc nt tlic i(-|)iiat(ir\ nri.Mii-. On accdiiiit (i(' liic iiii|iaircd |ii-n|Md-ivc jMiwcr t t'rc(|iicncy in early lite, xcry eipmiiHinly uccnr- in Iderlv |iers(iii-. i- de|iendiiit ii|i(in tlic -anie i an-e. Tlie atieiits, while jineniiionia due to stre|)tiic(ieei aiiiiears to ine to occur niorc frecjUcntly in the furniei'. The c'reater tendeiirv to Lnmixrene anc' ili-cess in as-oeiation with |ineunioiiia in older ])atients is noteworth\ . That the cliroiiie lironeliial ami [nilnioiiary aifee- tions ot'tcn existin;: in old |ierson> lictiu'c the develo|inient oi' the t\ plioid fever jrivc to this di-ease a Lrnivc a-|icct needs scarcely lie opeeially pointed out. Tlie anatomic and clinical manifestation- on the part of tiie intes- tinal canal exhihit im radical ditl'erence- from tlio-e in other adults. This is ajiplicalilc espeeiallv to the nnmlicr and the character ot" tlic stcMils. Tlie nieteorism, which not rarely is tuarketl, sets in relatively early. In ('onli~adistiiiction to the conditions in childhood, clderlv individuals — and this ajiplics especially to the jieriiHl hctweeii the tliirty-liftli and the fortieth v&ir: exliilut a somewhat irreater teiideni'y to intestinal hemnr- rhant in advanced life, hut rather loss common than duriiiir adole-ci'iicc. TUo increased dillieiilty in the diairiKisis of lyjihoid fcxcr in elderly persons, in < on-ei|iii'nce of the varialiilitv and irrcL'ularily in the fever- eiirve. is still I'lirther aiiirmented liy the -tatc of tip -pleen anil the roseoho. KnlarL'cmcnt of the spleen in eld(>rly persons i-. on the whole, di-tinctl\ lis- common than at other periods of life. In none o| tlie-(> earlier pi nod- have I oli-erved t.ital ali-enee throui.dioiit the entire cour-c of the di-ease neariv so tVeuuenilv as duriiii:: ^'k' 1:''<'1' pei'iods ol r.i/.'M /7".v\ /.v .sr.i//'/o.vv .t-v/( cornsK. 343 life. Kx|i(ri('iicc at tlic :uilip|(-y-tal)lc :it1i>nU :i|)l(iii and it- cait.-iilc, cxtciisivi' or iniilti|)l(; cicati-icc- n-iilliiiir iVniii iiil'arcts, (liU'ii:-!' (■i(iiiit<'tiv<'-li-siic liyj>cr|ila.-ia, ami |irii-|ilriiili • llncl.iiiiiij.f ot' tin- i'a|)--iil(' arc all In l)c iiiciilii>iicc pn Mill llic i.ccuri-riicc III' cMlarirciiu'iit of tin .-plccii in a |)(ir- lidii 111' llic la-i -. lli;- ililHriiilv 111 tin' iliiiiini-tnitimi cif lln' ciilarjiciiiriil, even wiirii il iaI-I-, i- -till t'lirllicr iiirrca-nl liy ili-placciuriil-* ami adlu- >ii)tis, il(|>rmliiit iip.iii di-ra-i' at an larlicr |Mri(id in litr, wliirli naturally arc niiii'c cnniniun in nldrr imlivid"al>. Al~ii, tlic rare cases in wliicli, at the li; itrlil 111' llic dix'isc, I have iili~('r\cil anatniiiically entire inex- Jilicalile ali-enee nf cnlarL'enient nf tlic >|)leeii, i.eelllTcil almiist solely ill elderlv ]ier-iin-. Willie the t\phiiiil ro-iohe do not, in luy experieiiee. oeeiir li'ss eoni- iiioidv ill aiKaneed life, the eriiptioii is, on tiie whole, less jirol'iise, and iii'tcn extends over a shortiT period of time. In addition, the indi- vidual roseiila- arc, in jrciieral, stnallcr, les- hrifrht in color, and of shorter duration — piculiarities that arc apparently associated with the senile alterations in the skin. The same explanation pmhaldy also liolds for the less eoininun apj)eanince of sndamina, and, eonver.-ely, for the t frcipiently, of all the varieties, a lonji-dniwn-out and ]irotr:ieti'd course. Severe eom- plieations are not niimcroiis or diverse, for the simple reason that ajri'ears. Of the s|>e<^ial» varieties of the disca-e |)revionsly nientiiineviiiii^ riM-in-, a- rela|i-e-, if the lir-t iierind nt' the di-casc is -c|)arated I'imiii the renewed clcxatinii i.f tem]ieratiire iiv a ci.mjpletilv at'ehrilc intcr\al. and a- reiaaide-ceiiee-. it' the na-eciil iicciii> diirinj; the pcridd of in\ i iliit inn. licl'.ire the declining: t('m[i('nitiiiv has cniii- jiictclx returned tn the n"rni,il. ('liiiically and anatiiinicall\ , rel.i|i-es and rccriidc-ceiicc- represent rccnrrciicc-. in innre ur le-- eiim|il( le dei.'rcc. nl' the t\|)h(iid innrKid JlfdCCSS. As In the (|llc-tinn whether tlie\- are In lie atlrilillled t(» renewed iiil'ectinii nr In a revisal nl' the [irimaiy |p|-nce--, it may lie -aid that at the |ire-ent lime it lia- liccn detlniti ly -citled that they ari-e in the latter inaimer. I 'iidniil)ied!\', their dcMln|)incnt i- tn lie atti'iliulcd tn the rc-ciitranci' iiitn thi' eiieiilatinii nt li\ iiiir ty|ilinid-iiaeilli which, after llic' |iriiiiar\ allach. were iel't liehind in varinii- nri;aii- ; and a— o- ciateil with till- iimre nr le-- c'nm]i!ete redevclnjimcnt i<\' the Ine.il and freiieral t\|ilinid !e-inn< neciir-. The |iatieiit- tiicn auain exhiliit I'cver, (ifteii in a tnn-i cli;iraelcri-lic manner, with re-cnlarLrcmeiit nt'tlie -|ileen, rn.-en|;c. tiietenri-m. and diarrhea, and. in I'atal <-a-e- in which |in-t- iiinrtem cxainin.atinii- are made, newly d.'\eln|iei| -|iecilii' inie-tinal le-inii-. (-|ieciill\- ree.iii ill fi 1 1 rat inn nf I'lyer"- [latclic-. are fiimd in addilinii In the healed le-inll-. A- litili- nf a detinite n.itiire i- .a- yet knnwn with rcl'erein-c tn the liiaimia' in which the t\|ilini(| \ iru- i- relaiiied and tli 'Liaii- lliat arc (■-]ieciallv In lie tiLcii iiitn cnn-iderat inn in tlii- ennneetinii. as with rctrard tn the nianiK r and the s|iecial eniidilinii- under which the liacilli i:i:( nri)i:s(i:Mi:s \si> i:i i.M'shs. .•Jir> a;.Miii L'':iiri cntraiicr inl" lliv 1)Ii"m1. I'ldlialily llic -|il((ii, lop'llici- willi tlir l\rn|ili-u'laiiil~ .ilid l"ili<-liiaini\\ . aii>l |ici--ilil_v al-o tlic ;_Mll-l)lail(l( r, jilav an iiii|Mpitaiit /■'•/< in ilii- i-(,iiiiifii.iM ( -i r p. 'JnT i. |-"niin tlir cMiir-c, ami i-|H(iall\ l\\i- -.Aciily, 'if ilir |(riniar\ di-ca-c, t , lii-ioii (.111 lir (liawM a- {'> till' |iii.lialiilily I'l' tin- ..ciiii'i-iiicc of a rclap-c. A|p|)arrriily. the |)i((li-|Mi-iiinn to rdap-r i- cvi ii irnatcr in tlic niililcr lliaii in llic -cvirc r c a-c-. In my r\|irri(ncc. unly fmin •_'•'> Id ;;.". |)ii- ccnl. ■■t' rclap-i- nci nr afirr .-cvcic |ii-iniary attark>, wliiir all otiicr- folli.w MiiiiliTatc and mild attack-. It i- c|nit(' cunnnon for alvpical ca-c- >A' tv|iiioid I'cvir — ilic niild<-t. alpiii'ti\<'. or ainliulatory — to lie fo||o\vro-itivr 1)V tlicin (-(■(■ l''iir. o'i). ( >iir lA'i|i.-ii- .-talistirs r-liow tliat ol' ■Jld rfla|iscH, ~'> |kt ctiit. iMcurrfd alUT motlenitf aiit few afelirile dav-, while after the third or the timrth day the onset is oliserved almo-t a> iVe(|iientlv as on the -nli.-eipient days. .Miout h' to I'J per cent, of rel.ip-e^ licLrin afici- the sexcnteeiilh day. anil tho majoritv .it' the-e occur hefore the thirtieth day. I'^vcn after this intiTval, however, relajises may exceptionally occiii-. 'I he lon!_rest time that I have ohxTved to ela|ise lieliire the on-et ot" llic relapse was til'i\ -three davs. 34(j ryi-ii'iii) I i:\i i;. il i ^Mt ( I I'litnii- < >.ii-iil(iin_' till' iliniial -\ mi[iIoiii~ n|' rcl:i|i~i- ;iiin. anil -cs. ril\, llir\ \ar\ alij]"-! a- tn'icli a- (|..c- ilir |ii-inia. >■ atlark. li li.i- Imih -I in llial llir laltir i-. in tjir \av^c nKijciril\ nl' ca-i-, nnalliniitd wiili -li^lii or im inanili-Ialidii- iluiiriL'- iIh- |pi I'idil ..f iiH'iiliatii'ii. Willi till- la' I ii.nr-|iMnil- llic iniiiiiinn \ ii w tliiil llic at' lirili inlii\al up I" llic In i^iiiiiin'j- nl' the in lap-r i- ^nncialU iVcc tVnlil :iii\ -N ni|iliiiii- thai ini'^lil |M.iii' i<> ilic ini]M inline'' ri.nl dia;:!!''-! ic iiii|iiirlalH'i'. Allcnliiiii \\a- callcil -nnic liiiicaL'^ii liv < li ilianll ' lu one tad lliat 1 call c(iiii|ilci( ly \crir\- — ihat i-, tlic inci'in|iiclc ^iil.-iilciicc iil' llu! I'lilaru'^ciiiciii 1. 1' llic ~|ilccii alter tlic |iriinaiy (lct'cr\"c-ciiicc. Si Icniir as the ciilaiLiciiiciit 111' the -plccii lia~ ii"t ili~a|i|M'ar<'ii. the |ili\-iciaii i- not relie\c(l I'l'iiin anxieiv with ii v'ard In a nlajiM'. In the ii\ crwheliniii;; iiiaji'iily 111' -iich ca-e- he w ill. mi the cnntrary, iili-!_'' nnrnial le\ el I'll!' the individual, lull fiir a certain time c\cn lulnw llii-. \\ cll- liiarheil eaM~ in wiiicli. alter deti r\e-eeiicc, the ciiiiise lit' the <'iirve due- Iiiil litiiillie >lll)Miirili:il are Ilnl tn lie cnn-idiled a- enliehided, lillt, on the eiiiitrarx . the ]in~-iliilitv nt' an iiiipendini.' relap-e siiould he .«tliieli cireiiinstance-. in iially marked tlnctnatinii-. If a lai'ee nninlier nt' curves fmni ca.-es of r(la]i>e are aiialy/cd, it will he oh-cncd — as ap|iea;> to nie not to iiave liceii r-iitlieiciilly t'lnplia- >i/ed heretofnn — that in the majority tlii- peculiar preiiiniiitnry char- acter 1)1' the piil-e-ciir\e, which i-^ aiialnirnu< in that nf the ti iiiperatiirc- ciirve, i- pre-eiit in more or Ic-s di-tiiictly marked deLrrcc. I'.veii the ca-es in which, in spite of a -uhnornial I'our-e of the temperature after the priinarv deferve-ceiiee. rela|)-e occur-, the iiii.-et i- fre(|Hently preceded liv the important diai.Mio-tic character of the piil>e mentioned. /.'/.' /; I I'lyi i.M IS I \i> i:i 1. 1 vsr.s. :!I7 •J ..?vXl .1: _ asm 111 If ' n V-t ---i 34a / ) riinih II I / /; r$ .... ^ ■ ? ■ • ■ .. .. . .^ >; ; ; 1 : ,5 ■ • ■ :$ .... s ■ ■ ■ ■ r* 1 CD S ■ < ^. . . . . rs-;;;;- .-5 - ■ • - ^ .... 1 rt - ■ • ■ n ■ - • f, S •••• fj 1 «? .... Tl fl **• .... N r-i ■ < ... ^ : . . < > > •: * > >-. : : ; : I,- — — ■• t ' ' -—-i-f-* — — — .11 - ' ' ' T- ■ :'-ti: M ■ • ■ - .... . ^ - -^. . . - -. H ■ • ■ ■ ! 2 : : : ; — ■-'— =£=: ;;;'«; .'<■ ■ ; . ■ . .^ii . ■ ■;•!■ j fi , ... _.- — -^ > , ■ ': c .... \^ . . . ,-. « ■ ■ ■ • ^> ■ X ... K r;^-' (0 .... - ■ <^ __^ 1 t-; 5: ? > at Q, »5 C*t s s - a w-^ /{/ ' /.T/'/ >' 7 .V /> IN/' l:l I !'">/>'■ ?A9 If tliif^ lie cimpMnil \Mlli lli>' nilliiT liiiv cn-c- in uliirli it ua- |m,— il.lc t.i iiiakr "l.-i ■•> iili'iii- "I' lli«' I'lil-"' :i- ""I'ly •'" ''"■ I" ''''"' "' iii'"l''i'i"". •' (ilrikiiiir .•.liihiilriirf of \\\v i)iiU.-ir;ii iiiL' \»\\nl> ^Micc and the relapse, l«ith the iliiration of its elevation anil the cliaraeter of the curve are extremely varialile, just as in the primarv attack. l>e!ap-e- may occur with fever-period- of from eiirhteeli to tweiitv days, and even loiiircr. They not rarely exhihit ( i'itr. •"'•>) almost exaetlv the same coiir-e as moderately -evere or mild, typical attacks of tvphoid fever.- Kclajises of much shorter duration (Fii;. .">7) ni, V lik<\vi-e exhihit di-tinctly all the usual stajres. In addition to these varieties, relajises purMiini: a mild ooiirsp. of greater or lesser duration, often ijuite coiisidenihly protracted, with 1.. T-. ., .. ._! ,,. ; /' „..-..!.■;., 11 r, lin ;].-,o TYriioiii i-i:\i:i: 'i'-i'l' invLiul.ir. .It liiiH- iiilii'(l\ iiiirliaiai-ici-i-ili-, iniijicratiiri'-i'iirxo. .■ht in L.'1iimI and llir -lioMc-i iTla|i,-f,- liiiallv i''|iri"l \Hlli i( li i( n.r Id .haraclii- ami cmih^c. all the tialun- tliat "!■ Iia\i liic'.nic liiiiiiliar willi a- liclniiijiiiM- \,^ \\\^■ -viniildnialciliiiiA- iif iiiiM. niiM.-l, anil aliiiitivi' ca-r- ,^\' l\|i|ii,ic| I'cvci-. In inaiiv the la-li;jiuni i~ Ihii i.f i.i I. r (Inralinn. an vaii'd i- llic (liaraiti I- uf llu' a-ciiil ami llir di cliiic of th,' cniA.' in llir mild and -hurl r(la|i--r-. ll i- |iarlirnlail\ inlc iv-iiiii.'- that llir cliaractir and tlir |ii(ailiarilic.- iit 'lie riir\r in ilii' | n i In, i r\- a I lack aiT tVi i|iiinl l\ rr|]|'(idiiii(| Imlh in llic K iaiid( -CI iii-i and in lli rcla|)-<. al lime- c\cn in a niiuT cicarlv ddiiicd inaniicr. Tlii- a|i|ilic- c-|ic(aally Id ilic inarkc, :V.K and |ii). I'lidcr th(-e ciivnni-lance- ll n-e| nt' t!ie ivla|i-e vvllli a chill, which i~ dllicr- v\i-i vii'v rare, i- lVei|iienlly dli-irved. ()lher rai'c caM'~ cxhiliit the |iccnliar realnie i^\ niii' nr -evcral marked llnctiiatidn- in the teni|iera- Iille, with cdii-ideralile eveiiiii:;- elevatidii, i)fli)rc tiic .-t;li:c dt' dcliliitc aM-eiit lie;jin- ( |-"i;j:-. .■;.") and HM. In addiiici: td the t'drcLidiiii.'- varieties .if curve-, there dccnr, (-[le- ciallv at ihi' he'_dnniiiL: ut' rela|i-e- |inr-iiiii'/ an irrci^nlar cdur-c, a iminlier dfullier- v\hicli are di-limllv related Id ihc like I'drin- T i'evcr- a.-ccnt in the |iriniarv .iitack. Il mi'd unlv lie meiilidiied further in 'lli- mectidii that ll ii-i I inav he attended with aliiidrnialiv marked remi--idii< in th ■ tein)icratiire-ciirvc. w liieh inav jn-lifV the e\|iectatidii "!' the -an r dl' ,i whdjlv inlerinillent character nf all the -iiccecdiii;; ]idrtidj)-. The cdiir-e df ihe lem|)eratiire at the lieiLilit n\' the i'evcr i- in rciap-cs, a- ha- i>ei n eni|ilia-i/eil, in niaiiv re-]>i'ct- like thai in ihe priinarv attack. When the I'l-li-inni ha- ]ier-i-lcd fur a cun-idcralilc litne, the tciii])cratiire-c|i art- will i ..liKit, jii-l a- in the |iriii)arv attack, the cliar- acter> lit' rcuiittciil (•iiiitimi('i:s( i:.\( ■i:s .wd i: i.i. . i / •si:s. •^:,i tlic almost intcriiiiillML^f cxliiliilccl a -imilar chamrli r nl' ciiivc [V'vs. -ilM- 'I'lir |inl-c' i- i;iiicTall\ iii'H'c tVr(|iii'nl in tlir nla|i~(' llian in llic iiiiinai'N allaik. In women ami ilnhji'cn, ami in men ilcliilitalid liy the antcicilrnt altaik, ilir innnl>rr ol' jiiil-i-liral- i- even likely to lie niin-n illv lii^:!!. A |inl-e ot' TJn in the e\ inini; i- tlnii mit a v.w ■enr- n iiee. ami. il' llie eunilitinu eiiai'.ieleii/ed liy L-rcat \ arialiility. |-;ven Mil A\'j:\\X ]>liv-ii'.il cir mental exertion it may lie lieyoiid enmim- talioii. ami in adiill^ inav ivaeli 1 .".(l or 1 |ti. Tlii- iiiM.al.ilily of the ]iuKe make- itself a|ijil-eeialile. a< ha~ Keen -eell, a- earl^ a- the |ieriotl of ilielilialioii of the l-ela|we. All ill-triietive illll-l rat ioji of the ehaf- aetei- of" the [inl-e ill this |ieiio(l ami iliiriiit: the I'elnile period i- atlinded liy l-'i-. .■'..■|. ])i,-i-,.!i-ni of the piilse i- d'tiiiitelv Tiot so fre(iiieiitly observed diiriiiir the relap-e a- diiiiiii: the jirimary .attaek. It i|uil«' lieiierilly fiil- to appeal' even ii; tlio-e ease- in whieh it was previously eNeeediiiirly well iJ! v'-''^:^--. _v:'': \" "j.'vj:;. ,u.: ii:.- ^..^^'..iiii'i:/;;::, ";>_\,V. .;, ■.;^. r-"--!"?-. /I'Av 7; ? -i)i:s( ■i:.\( ■i:s . i .\7) hei.a rsi:s. ■Ary.i marked. Wlicii the iiiaiiilrstatinri (icciirs at all, it takes jilaee in tlie course III' tlie >evere, protraele*! relapse having an e»|ietially |)ni|(iii^e<| fa.-tii^iiitn. In ~neli eases svMi|)toins nt' eanliae weakne.-s al^i hei'dnie apparent, wliieli (iilier\vi.~e are not eonnnnn. 1 ireL^iilariiy nj" the pulse also is eoniparalively rare. It likewi-e oeeiirs alnio-t exelnsively in tlie most severe relajises. Slow int^ ot' the |iulse, which is so conitnon in roliust viamjf men diirinir the jirimarv attack, I have never observed in relapses, even in such iiidi\iduals. The hehavior ot" the ro-cohe in the relapse is most important, e-pe- liallv iVoni a dia!j;no.~tic standpoint. I'heir appearance may lie actii- allv deci-ive in diai:no>i~, e~peeiall\ when doiiltt e.\i>ts whether the reasceiit ot' the lever may not he attrihntetl to M'Vere complications, lliiv uf th. ci;-,;isi'. Ifl l.t 20 21 2"^ 2n 2h 25 26 27 28 29 30 ;ii 32 nn S'. 3 J 3fi 37 38 3 a W) m i* 'J w 't 4 Temp. j : :" - +- — f— ^- "^ -1- 4- i- -i. ~ -; • ~ 39 ■ ' ^ •- ^ 'V ' r ■^ ^1 f^} „ * 1 rin \ A '■ ■ - 1 T 7l , , ^_ f^ / h I . * ~ i Z- ■^ 37 '-] lA ^ A th.^i^ / -+- — H £_i 1 3(1 -] I / / / / / / / / •f / 1. ■ ■* V ^ i- - ft: " fr ,- 1 -^ - -f---t--4- -+- ■-- -I- - - 35 '; t J - + I - 1- t -1 -i-- ^t- -t- 4^- t -4-- f i' t -i- ^- t 4::::: — -+- -1- .! ^ X .- 1 1 1 1 1 ^ .^- - ^ Fii;. 40. as, for instance, septic states or miliary tulierculosis. In .7 per cent. It is true that, as with reirinl to so many condi- tions in ca-cs ot" typhoid fever, the pc<'uliarities of individual epMcmies must he taken into <'onsider;ition in this conne<'tion also. I have myselt' ohservisl |)eriods in which the roseohe were even more frcipieiit than has ju>t Ihhmi mentioned, and, in addition, we/e al.-o remarkahlv profuse; and others in which they were disiinctlv less cummon and less ai)undant. Their lumiher and <>xtent in the indiviilual case are ireiier- ally xmiewliat smaller than in the primary attack ; hut, on the other hand, 25 wm 14 ?--J K; - i 3M TYrii'iin FEVi'.n. tlic coiHlitiiiii- (ili-irvcil riioii- "f tlir lliii^li-. In accordance uilli llic more i-a|ii|iear Huncwlial cirlier tliaii in the priniai-y attack. Mild and severe ca-c- exhiliit little ditVcrence III thi- rc-ai-d. It i- p"-.-il,ie that ill the -e\civ pi-ntracted ca-c- tl riiptiMii aplpcaf- -oiiicwhal lalef. I have III. -I riv.|U.Mit!\ ul,~er\(d the n.-euhc tu appear diiriii- the rclap-e I.etwci M the thvl and the Hfih day ; -oinewhat le-- c(miiihaily ,,n the M'cciid or tile ~i\th day ; iiiiich le- ennimmily at a later period. In oiiK -1 in-tance- h i\e I oh-erv.'d ro-eoke to :ippear on the tenth ant appearance ,.f ihe re-eohe tVoiu the tir.-l to the ihir.l day »a> iinted in X.7 jicr cent.; fmiii llic tonrth to ihe >i.\tli day in ti"!.-"! per cent. ; en the seventh dav in 14..") per cent. : after the seventh .lav in ."> per I'fiit. The .liirati.Mi .>t'tli.. individual r..-. — i".t u.i-. in L'eiicr,il. not -h..rtcr than iti the primary atl i.k. N.w .riiiition- and rc.-rii.le-iviicc-. ol' the cxantiiem al-.i occiirrc.l in -ever.' and proira.-t.d r.lap-.- Jn-t a- . ■.mi- ni. iiiiv a> in ill.' liriinii'^ atla.-k. Knlarei'iiicnt .d' th.' -pl.-.n. a- ha- lic'ii m.iiti.Mi.'d. .it't.ii doe- not snh-i.l.' i'.itiiiil.'t.'ly att.r th.' i.riniarx -iih-i.i.n.'.' ..f th.' I.'iii|"'ratiir.' in ca-.'^ in whi.'h r.'la|.-e- ....'iir. It may .vi'ii r.niam palpal. h' diiriiiL' the entir.' inl.rval. an. I. in .'..nn.'cti.in with the p.'ciiliai- .'hai^K'tcr ..f the piil-c an.l I. iiii>.'ratmv pr.vi..ii-ly .Ic-irili.'.l, may dctinit.'ly -ii^'^'ost tlic imiM'tidinir niai.-e. r..'f.ir.' l.aMiiL' ...n.-lii-i'm- iil"'ii th.' -tatc .d" the sj.lccn. li..\v.'ver. ..tie niii-t have a-nr.'.i hiin-.lf that pr.'vi..ii- .'idai'-c- ,ii,.,,t of tl ivaii. .1 1.' tl. ..ther .'.iii-e-. ha. I n..t exi-tcd pri.ir I., th.' atta.-k ..f typhoid t'.'\.r. M.,r.. fre.pi.'iit than th.' p. r-i-tcn.'.' »\' -pl.iiic .nlaru'cmi'iit i- it- L'tal di-app<'araii.'.' in th.' int.'rval 1. tw.'.ii th.' i.i'iin.iry atta.'k and the rclap-e. Th.' iii.'iva-.' in -i/e tli. n aLT.'iin '".'onie- d.inon-trald.' diirini: the first da\- ..t'lh.' r.lap-.'. in irciicral s..ine«lial .arli.r than diifili^' the fir-t atta.'k in niv opiiii..n. Ii.lw.'.'n the third an.l tlic -ixtli day. 'Ihe cases ar.' e-pciially n..t.'\v..rtliy. an.l ..f impo.-tanc.' from the .liaL'iio-l i.' .standpuint, in which .'iilafircmeilt ..f the -ph'en had l>"cn entiivl\ uniting' i:s< ■i:s< /> .1 .\ /< i:i:i..\v^i:s. 1 iiirnr witli /iriii-^scii,' \v!iu pn-ci:!- v;ilu:il-l" -!:iti-ti<-- in -ii|>]".rt III" hi- -I;'lcllli'lll, lliat tlir (■IlliirLrrlMi'lIt ut' tlir -|ilf ill the |)riiiiary altarU, ami at iiin-I mily in ilrLrivr. 'I'lii' iiirlrnri-iii rai-civ allaiii- markcil iiitcii-ily. Tin- Imwil- arr varialilr, a- in tln' |iiiiiiar\' altai-k. At tiim- tlirrr i- ilianlira, 'Ailli -mnl- nf i-lia!-:iclfri-lii- ciiliir ami i-mi-i-l'iirr ; ami at ullin- linn-, mi tln' im.l ,ary, cmi-liipalimi ; ,ir one Mia\- allmialc uilli tin' hiIht. Analmiiir cxaiiiiiiatimi — till- ,-lali'imiil i- lia-ni ujvmi llir lomliliiiii- r.iiiiii! in -'11 ra-c- (•xainilici |i,.|v,,,iall\- — (li-cli.-i- witliniil r\rr|ilimi. ill ailililimi U< mmv nr li-,- rcrciit ciraliicr-, m' rlcaii, al ! liralnl iilni-. ri-iillinu' I'l I llic pi-iinarv attack. I'lv-li innliiUafy -wcUinu- nf Iimi'- |(atr!ic- ami tlic -iilitarv Jiillii-li-. in pari in prnci-- n|' -Inii^liiiiir m- liririniiinLr nlrcralinii. N'nt I'arclv. iniilrr >m'li circnmstancc^, in adililimi in cicalri/cil |Kirt;mi- nl' a l\\crV |i;iiili. f'n-li iiifiltfalimi nf pn\ inii-ly iMinpt portimis nt' tlir -ainc jialrli mav he nli-crvni. In aiMiilnii. tlicrc al-n («'ciii's tVi-li -wclliiiLT nt' the iiir-cntcrir trlaml-. Xo ilfliiiiii' I'fl.ilinn cxi-N, iil)\imi-ly. luiwirn tlir rMcnt ami tlu' inlrii-itv nt' tlic fccciit inliltialinn In ilm-r nf the prcv inii- uiic I luivc nliMI'Viil tiir ni'W inlillralimi In lie i|Uitr cMcll-ivf ill tlic prcsi'licc nf i-nJat'Ml liialiiiT- ; ami, (■(iiivcrscly, liavr nli-i rvnl only i-nlatiil t'rc^li -unllcn iiatrlics or fnllirlcs after vrry inarkcil primary iiitc-tinal K-imis. On tlir wlinlc, linwi'ViT, till' iiitc-tiiial Ir-imi- nf ilir rrlajiM' arc ili>tiii('tly lis- iiinncrmi-, ilccji. ami cxtcii-ivc than ilm-c n[' the jiriinary attack. I'niloiilileil relap-c-. a--ncialcil with mily ncent catarrhal liimel'aetimi nf the nuicmis nieniliraiic anil nn alteratimi in the I'nilielcs, e pnr- tinii- nt' the intcsiine prei'eralilv involved in the |>riniarv attack, in the iiiid-t i\[\ ..r. iiinre fVeijiieiitly, Miinewhat remote from, the )>rin;ary ' Wiii-zhiirri. Jnlii-(Jr:iiiil -Srhn/t. 1882. iinil l>nitsi-l,. An-li. f. Idiit. Mo/.. \W. \ \ \ i V . ■* ''J* t^ -^.■r ^. '-■»: ^j.rli''^' I :)ti rvriinii) I i:vi:i;. Ic-iciii-. It line-, iidWevcT, incur iml ;il :ill r;iii iy tii;it ]Miriiiin- - tiiic atViM-iiil |ircvi'iii-K' in -li^rlit dnrinix ilif nlap-c Tliii--, l^r in-iamc, 1 have nl).(rv((l in a i"i-i' ut' •• culdn-l vplinid " i(riinarv allicliuii a|i|pai(iitly inxoKrd alnin-I mdy tlic l.iwir |«irti"n-- lit' till' -mall iiitr-tinr. 'I'lir -liu'litir ili'V('lii|init lit nl' itic anaimnic altcratiniis in jxi'in'ral (■\|ilaih~ al-i) tlic cii-i-imi-tanrc lliat lirniiii-rliai.'t' ami pcitiiratixc |n fitii- nili- air laf It— riiiiiniiin ilnriiiL; rila|i-<- and niTudt-riiiii - tlian diiriiifj tl'r |iiimarv attarls. W'liilr. t'nr iii>tanii-, in IlamlmrL'' wr nli-crvod amiiiiij: a tnlal nl' :liiMi ca-r- nl' ty|ilii'id t'i\rr, 1 "i-'l ra-i l.jti jht cent. — willi iiiti-tinal lirinnrrliaLir, tlii^ iMTi:rrcd in Imii I aim nit: "i-'l rrl.,|l-i I'.Tli |Mr rillt. W itli rctiiTiici' til till' rc>]iil'atiiry a|i|iaraiii-. lill!" i~ i" lie -aid. In MMTr and iirntfactcd nla|i-('- lirmirlnl i- ^riirralK aiiain dcvrlup-. 'I'lii-. it i- tnif, mav lir nl alari'iiii'j -r\( ril\ and cxlriit in nld and diliilitatcd iiidividiial-. and may rvrii Irad tu jiy |iii-tati(' (■iii);x<'>I'"ii- Till' dcxrluiimcnt ul' pncnniniiia and plmii-y i- riniipai'ailvcly rai'o. Tlii.- i- a|>iili<'alilr r-picially ti Irur tiliriiiuii- pmuimiiiia. U illi ri'irafd In tlir ill rvmi- -y-tiiii aUn tlicri' i- littlr nt" -pccial iniiNirlam'f tn ln' miiitiiMicd. In imidiinilc, -Imrt. ami mild rcla|)M'S tlic cases arc in lid- rc-pcd nficii icmaiUalily umninplicatcd. In severe |)riitfaeted relap-c-. i-]ieiially tlinsc tliat, a- appear- tn inc. ueetir alter a mild primary attack, the jiatieni- at time- exliiliit \ inlcnt .delir- ium, nr tliev iiiav mhui tall iiitn a -late n*' -npnr, and even nt' alarmiiifr enma. I'neal le-inii- nt' tile central nerviiiis -ystcin nr clianjr<'- in the iicriplieral nerve-, with enrrc-pnndini:s(i:\( ■/:.■< .\\i> /.•/■/..i/'v/x 3o7 |M(rliiriiiy to i-(cc(V(r iliiiiiij,' tlic alll.ril.! inlcnal ami to t'ortity liim.-cll' airaiii-t the new attack. Also, voii /,ii'iii--fii tin|ilia.>'i/.c.- I he xvcri- coiitm' ot' i-tirinlcs. fiicf.-. He rccordtMl severe syiiiptdiiis in ,')() |„.|- ,.,.||t. (,f recnideseeiiees. and oh.scrveil ;ls iiiaiiy as l.i per cent, teriiiinate tiilally. .M\- nwn slatislics are soine- wliat more luvoralili-. ( »f 1 in rernideM-eiiees. the emir.-e \\a.> severe and alaraiiiii: in 10. while 1 I per c, nl. teriniijaled latallv. Altlioii^rl, ill,, aetiial relap-e- wilii a liitrlily til. rile and protnieled e(.iir~e may aUi) ,\liiliit a -evere clinical pieiiire, tlii- i- far les-, c.rn- liioii, and the mortality is, on the whole, much lower, than in the recru- descence-. Kvcn in the sevefe.-t I'pidemic- tin- niortalitv prohaMv scarcely ever exceed- .". per cent. ; •_'.•'. j.cr cent., or at most i [mv nt., is prohalily the ii-nal mortalitv. In the epidemic at HandiiirL' the mortality during' relapses was relatively high, namely, 4.'.t per cent. i.\mom.' all fatal ca.ses of typhoid |,ver, the proportion of those oceiirrim: dnrinir relapses was (•.? |ht cent, i ( >nr •statistics at Leipsic exhiliit a rtality of not (piite L' jwr cent. ; those of Ziems.seu, 2.H per cent. Steinthal,' it is true, reeord.s f<.,s jK-r cent. As this estimate, however, is hased upon only A't relap.s«.s, accidental iiilluenees are not excluded. The same is true of the nnfavorai)le e.\i)frieiices of Miirchi- .son.' who.se stateinenls were based upon only ](» ca.M's. and who, eertainlv without reas.>n, eoiiaiders that relapses, as a rule, are inon- .severe than the primary attaek.s. Further, the severity of the rela|«-e, and therefore al.-o iti mortality, vary, like so many other features of tyi)hoid fever, undoubt- edly not inconsiderably in accordance with temporal and local intlueiiees. Under all eondition.s, however, the mild cases are far more fre.|ilent than the .severe, wliich, in ireiu'ial, may b.' estimated at from 10 to l,j ])er cent. We observed at Hamburi.', among IIM'. relapses: Mild, ;;t;.")— 7:'..8 |ier cent. ; moderately .severe. 7.H— l.").ti per cent. ; .severe, .'>.>— Kl.tl |)er ( eiit. The duration, the hcis.rht, and the character of the fever, as well as interciirrciit local disorders are e-p(vially of dcterniiiiiiitr iiiHii.'tice witii regard to the chafaeter of the coiir-e and the tertninatioii. A special position with ivgard to prognosis is oc, iipi«l hy the protiticted relapses attciide.1 with irregular, markedly rciiiitteiit fever, as, both in adults and in children, they are at no time likely to give rise to serious concen-. It i- an iinport.int (iiiestion whether the chai~act.T and the severity of the rela]).-e de|.eiid upon those nf the primary attack. I'lidonbtiKlly, as has Ikvii pointed out, it may he oh-erve*! ill inanv cases that the original character . k'.in. Af.'d . i..-.4 P..-i ■.--.■-.-;•.• 2 .■ , - -.; :jr)« ■rvri/nin irvrn. 'C-iJi.'r-^V likrl\ to l)c rt|M';iltil ill till- ivl:i|i-i' m' I" liii'nliir lAcIl Illnrc I'lcurly iiiarkid {-!■<■ I'iu. ■l'^!. I'll' ili.iriiitir nt" ilu' i'i-<- :niil oT the ilcrliiic uf till' I(Mi|Hialiiic al-ii 111 .|Uiii'l\ ic-(iiilil<'- lliat dlp-ciAcd in llir |iiiiii:ii\ allarlv. Tlii- liM- - (-|icci:il!y (•■iii-|)icii(iii- in llic Ic-- tV(i|iii'iiI variilir- ; tin' iii-lainc llic a-r,nl al a ~iiiL;lc -Imki'. nr the niliral ilcrlliK'. < )iil\ rcciMllv I ..li-ii\iil a riinarkalilr c 'iiiciiliiici' lik(\\i~c with rcL;aril l" tlir i-liararic-r .il' ilic rniAc al iIh' Ihil^IiI 'A' tlic l(\rr, in thai a I valc~irhi t'l-mn a li\ |ii|-|iy ret ir atlai-k nl' t\ |ih'iii| liACi' cvliiliitcil al-'p ihiiiiiLr till' ivlaii-c, la~tiiiir hnt a U\\ day-, lAciiin;.' lcin|icratiii'(- <>[ iiii'i'c iliaii II ( . With fcLfaid. hoUiM r. In llif -lAcritN nr {\\,- niildlK— nl' tlic ci'iif-c 111' till' irki|i-r. a- rni:|iairil \\ilh thai i.l' ihr |irliiiar\ altark. il mn-I l>c riiti-idcrcd a- i-tahli-lii'd that thi ii- i- tin ridr. Thn-. in tlic -ri|iii'iii-i' 111' mild allai'k almrtixf, aiiiiniiatiirv . nr alilnilr lyjihnid iivcf — tlic inn-t -rviir pnit fartcil fila|i-i~ may uciiir. 1 ImTuac, in auit'iincnt with a lamr nnmiiif nf wrilci- iZinn— en, I ji liri-mci-tcr, .la<'i'iiU(l, Sicinthal, (liitii. and ntiin-), I may ~lalc llial thi- i- iiiiilc rrn|iifiit. Thi' diii-ali'iii 111' till' at'rlifik' inli' mure than I'mty day-" diira- tinn 1 have iili-er\ed in Imt - in-laiiei-. mie nf tnftv -three and annthcr 111' liill\ -li\ e ila\ -. Von Zieiii.-seii iint(d thai liie diiralinn in Ull reiapM> vvliieli hr (•iiiler|e(l varici hetweeii fi'iir and tliirty-live ilay>. In the nvirw iHlmini: ihajnrily ^ i'tl i it varinl helween live aiiii tweiily-ime da\<. 'I'he tiiiiliii!.'> nf .laccoiiil. « lio noted the nii.st frei|nent iluratinii as frniii eiL'lit In twcii'y-iiiu' days, and mir own . at l.eip>ie . Hitl' . wliere nf L'l(> relap.-es, \s-2 — x{\.(\ p,.,- ,viii. — liistfil frniii ten ti. tweiitv ilavs. are c|iiite siiiiilar. An aiialysi.s nf the .fS-'> case.* nf relapse ol.MTved in' Hanihiirir in ixsi; IssJ iji-elnse:- liial likewise the preat niajnrilv nf rasK, namely, lOL'— Tti.H per cent. — lasted hctwetn live and iwemv days. Itelap-es nf -limter dnraiinii, as. fnr in-tani'e, less than -ix days, are, linwex er. Iiv im means mre. If it he enrreetly a-ii ■I'l (' . i,..im1..?. nC til..,.!, i- Il rlliiT dl^i'ln-eil 1)V /.■/.' 7; I i>i:s( ■i:s( ■i:s .\m> mi. \ rsi.s. ;!.')!> roni'wcd I'lihir^ciiiciil uf tlic -pUHii iiml rf;i|i|it:ii-.in(c ul' ii.-c.,hi , in ;i-.-(i- ciiili'iii willi |«T-i-tiiii clfvaticiii nf iciii|«nitiMc I'm- (nilv :i Hu (Liy~. in otli( r caM-, willi a i(a|i|i(:ir:iii liad liiiifi- 111' Icl'l in ilimlil, need -carcrly lir tMi|(lia-i/(il. 'l"ran-iliir\ cIcAalinn nl' t(in|icraliMc, nul di |icniirnt n|>n ,-liorti>l rela|>.-e.s nr '• alinrtivc rdapx-." m (iiiite rare case-, after the ti\tr had >nl(-iileil and the patient had fnr davs exhihited -nlinnrinal tcni|)cratMre, I have ul).-ervcMieiaIed with headache, malaise, i-c>tle."ne», and even >li«:lit ^tnpor, this ennditinn la^-tin^' fiir I'rnm .-eveiid days tn a wifk. The .-inndtanenn- a|i]>eai-ance nf rusenja', as well as the fin-ther eircnni~tanec that the enlartrcnicnt nf the -|ileen had nut whnlly d Minicwhat diirin;; the |(eriiid nf relative tcMiperatnre-elevatinn, jn>tilicd nie in eunsiderini; these eonditinns aKn as rela|>>e>. It will lie >eeii that the airret'niciit hetween the varimis varietic- nf cnnise (if the jprimary attack and tlmse nf the relap-e is sn cnniplete that one may even speak nt" "afclirile relajwes." Till' fre(|iieiicv nf the ncciirrence nt' relapses a|)]>ears, as ha» heen mentiniied. tn varv cnnsiderahlv in aeenidancc with tcmpimd and Incal influences and in dilTereiit e]iidemi<--. I'rnhahly the ^jreut diversity nf statement amniitr writers in this ennnectinn is dc|KMident aKo niMni ditlcrenees in concept imi. If, as is not dnne in all statistics, the recrndcscciiccs arc separateil from the relapses, it will lie fimnd that the frc<|uency of occurrence of the latter is, on the wlmle, in from G tn Vl per cent, nf all cases. Ill Ix'ipsie. we estimnteil the avera;.'e of fourteen years, wliicli. it is true, varied consiiierahly aiiioii!.' themselves, at 12 jht cent. ; while in HaMihtirjr, in the vear I'^.'^d- IS^T. 14.2 per cent, of rela]ises wereohserved — unilouhtedly n liitrli iiirure, in eoniiiarisDu wiili which the recruih'scences in the strict if .';i;ii TV I n< III) ii.vii:. -i'\\~r l.> |piT ciMl. cvliiliiliil a LTrnl ili-|>ro|Kirlioii. 'I'lic ixircrno iIkiI liiin l>i- iiarliiil liv \:iriiiu> » rili'is in :ii . urclMinc «illi llu- inl(r|inl;iliciii of llii' Icriii i'i'l:i{iM' Mini Ullli h'lii|ni|':il Mini Imnl il jlli riini .~ will In- >Ii(i\mi Iiv till' t'oliciwiiiL' >lalt'iiii'til. wlili'li I li:i\t' iilriailv li:i(l |iri'{':ii'i'i| in jimi'I in llic ilisMTlaliiiii (if Sliul/.. < )t' nl:i|.>r>, lln-n- mc'iiri'i d. aciiuiliii;.' In Liml- wuriii,' ill Miiiiirli. 1.1 |n r iini. ; Miinlii-nn, In l.oiiddii. .'!.(• |icr rciil. ; liicniifr 1 I'liisclii I . :l.:i |i.r i-iiii. ; lliit/. lliinur l>7) 1>77 ,' I." |,i r (•(■III. ; Kii>.|«iii. ' ill l>rc>^i:iii. I.-'I |>( r ccnl.: l!i(liliin>l,' in /iiridi « .-iiinincr nf |.s>l^ ."i.ii |Hr cciil. ; ( liicv~iii:;('i-.' in /niicli. (i.li |.( r (( lit. : ( iciiiardi ~ > ((■!- Icclion li-oiu rc|Kirl,- nl' i'|iiil(iiiif- . *<.■', pir ccnl,; Slcinlliiil. ' in l,(i|-ic 1^77 l>s| ,. ~ ;, |i,.|- cciil. ; I ,iilp( rinci^icr." in I'.ii.-lc . 1 ^ti7 I'"<71', >.(i |ici- ccnl.; 71 1 >.-*"i -. ."».7 \cr ccni. ; Hiilaii,' in I lanilmr'j ilN7.")i. 11,1 |HT ccnl. ; l>iii/." Ill .Nliinicli . I>7>> I'"*'"*:!', 1 '_'."> |ici' cent. ; \ nn /,iiin.».-cii.' in Miiiiicli - 1^7'^ l"'>^l ■, i:!.n |ici- ccnl. ; !>( nmllicli." in I'rcilnirj:, 14. H jut cent.. Weil.' in I Iciilcllnii-L'. I 7. ti per cent. AlT'' .111(1 -ex arc ii(i| uitli'iiit iiitliiciicc ii|>cii tlio occiirniicc of l'('la|i-c-. \\ itii rct'( |-ciicc 1(1 icji . it lii;i\ lie Slid tlial l'cla|>»c- llli(l(iiiiit- c'llv (iceiir iiKifc tVc(|iiciitl\ ill \iiiijic_r |Mr-(in~ tliaii in llic later \cai> ol' lil('. I'lil- i~ cNJiiliitcd with (-|iccial di-liiictnc-- in llie t\|ili(ii(l I'cvcr (it' cIlildlKM"!, .111(1 Ik re. :i- \\v A\;\\\ ~lll'-e(|Uclltl\ -cc, even cMclid-- t(i rc|icatc(l ril.i|i (-. Aiialy.-i.- ot' .):Hi:j ca^. :• al I laniliur.' and i.cin-ic di>cliiM(l 7.'!-> rcla|'tics — 1.')..^ |Kr cent. Aiiimiil: ihc.-c. llicrc ncciirrcd in adulls 4*i.s7 ca.~c.-, with (I.'IO rcla| wi* — 1 -l. I |icr ccnl. ; in eliildrcii, til ."> caMS. w itli id.! relapses — Hi..'* per cent. Tiie (liircrciici .- uiili rcirard In a^'c appear more strikini' in a studv (if tile stali.slics nC !,( ip,~ic aiiiiu. uliicli sIkiu ll'.-i per cent, (if relapses in adults and 1 '.•. 1 |Kr ceiil. in children. 1 lie (lillerencc- arc Ic-s marked uitli icu'^ird to tlie inlliierice (if sex iijxiii the tre(|iienc\ (i| relap-e-. Willi < iric-^iiiecr ami (itlier-, 1 am I .\.,-:ll. l„I.Hi,i,i,:i,l , ls::l. Mii.l K..il..r. //,',./.7 /).v,-. .Miciirli. IsTl " /. ■ .-.I. ' /-"/"-;. /'■--.. Znri. Ii, 1H7:;, * -SiMli-lil. d'T ■rvpliu-l"Ui';;uiiu iiul' il'T iiii'l Kliiiik (Jcs Jlcrrn I'm!', ./i.'iiis- ^.Ti, n.iitsr/i. Ar.h.t. U.i. M,.l . Ii,l v\i , wii . n wiil. 5 I),,- /{,■.■;,/;,;■,/■< T;,.!,,,^. I!n-l.-m. IsCK. « n.iitsrh. A,.-/,./. /,/.„. M,,l.. li.l, \\\i\ . S --".iT. ' /,•.,■. ril.. S. :J1(I. " n.„i^,-h^ .I/-'., ;■, Un, M.J.. |S7:;. |'„l. \ii . S m » /'.'./.. ISSl. l;,|. x\\i\.. S. :;.'.S. /,,.,„,, Diss. •» /,...-. rif.. p. ms. " /.,„•. nt.. p i4i;. " /....■_ .■;/.. p. :;:i7 " /)..,/-,•/,. .I,-./., r /,/,,. Mr./,. I!.l, wlii.. S 1117. " ■ -t:iii-til; .Ir T;, phiiliru,-,,,,;; all!" drr iri.-.l Kliiakd.s Il.rrn l'r..f ZiuIii.,.- //,;,/., 1!,1. \\\\iii,. .-;. :;■_'(! I- ■ r.Lcr (!.■ TvpliUMvci.livc.' l/.n/ . li.l. x\\i\ . S, :'.7il. i« /. .'• r:/.. p. :;j|. n •/.... t>,it. I. -. i 'ri : . .1.. . I ;, ; ... .*..„/ j., .;,, , i ^.u- />7'/.T/'/ >'■/>'/■> !>/' /.// l/'^/>' mi ilii'lill.'Nr, . I km; . ll.'.l I. v.. .\n;il\ -1- "f ill 1 ,1 1 1 '-11 -i;ii i-li''- 1 \ 111 I III- -I II 1 1 1,1 1- n -ull- liir ;i niiriiluT of lIlC \c:ir>. Illll. "11 lIli wiinll, lil-i ji.-.- ho llollUorlliv cllll'i !■( lie. -. ,s ^j^ \i' ,<^ ^ ■ . , . , -^ '^^ ' f » f ♦ i I .T ! '. ! ! !** . . ^ H 5 3! ■ ' ? <'^ 1 J- ><>. \ er. s i^ > ■ ' " -7? "> 1 cr > n . - . ro i^ ^' <: .• • ■ ■ , n : ■-<: ^^^. . 1 ^ ^T^^^* . . . , ■ X :v n < >' C) 1^ • „ S . . . „ ?'i , . i* tr> ..... ri 1 <=> *■ : ■ : ..... » • • • 1 ■ u ' CO , . . . ..... =^ 1;:: >• ' J- t^a-' ■ ■ ■ er ■ • ""^^33 ^ • .... y ' ■ ■ ,J — ■*■■- -L.' *■ • • ■ f-= 3 O r: j « In iiiii-t i';i-c- tlic ...i I. .. I . : .. 1 ,.,. .1 I. ...... 1.,.. .'if^*^:^, ■ m^':/isfyWtt:>^ i:i:i i; i /'/>' / \ ' 7 > \m> mi i / "■ 3fi:J liiipiH'ii t!i:it ill "111- |i;iti.nt niilx r. .timI. -.■. lie- ii|. \,> llinc ...■.•iir, ulul.' Miintli.r i- MlI:i.U..| .,nly h.\ ivl;i|.-.-. Ilh' ,, . irn i,,-. of r.rpi.l.-, ■•■ :hiiI r.l;i|i-"- ii till- -:i |):ili(iil i- ii"l iiiiii.iiiinMii. riiclcr -mil cin uiii- -l:ill(C- iIm- iv.lll.lr-r,li(r ;il -I :iiw:H - orclll- ill lilr .•Mm--.-..f ll..' |iriin:iiv |>< rio.i .,| .1. Ic r\ ( -c n,.- ; mikI tlicii, alhr :iii iilil liii' |..ii."l..l varviii'j Ic'iiL'-tli. <<■ • -''V I'iil nl:i|i-r- .Mviir ( I' in. I-). I, j, ,|iiiir ran , iiiiii t,, iii\ l.ii.iu I '(iLri' iiowlun- iiirin' mc'l, tli:" :' ,v,Tn.i,-.rnc,- IMImu- a prMira.^t, .1 r. Ia|i-r-- .11 -.nr, illv iiM,.l,ral.l\- Mvnv nr ., v.iv^Im r.nv lli. I( i:i|Mraliir( ,. ivnniir.j f. ll.r iionnal I ].•;,, . |:;i, 1 1,,-) -ii,li a |.ui.nt al tlir iiri.;lil i.l -1 di a ivcriiil.-r.>r<>iiii>uiiiiiiL' llir ..rciirr.'nc. c.f ilir.'c r.'hii m>. \ limn" the .")•-':> '•:!>'■> "il'i ri'liipsf that \\c olwrv cd in llic fpidcnii<' at liain- i.nri.' tVniii l>»xti to l-^^7. in 474— !»•.»'. ih.t .■.•nl. — iIht ■■ nind Imt imc icla^iw ; two r.'laiws in 14— .H.4 [)*• r cent. ; and in only •") cii-rs —<).!• |HT(riit. — fiiiKHi^' llii- laiL'c niiiiilHr wi iv three rehip^'s i.li.-erved. I have jvrsonally i.lis 'rved fimr relapses in eaeh <>f •_' cases ; aiiv inv i)revioiis and suKse(|Uent experience. 1 helieve the (Kcur- reiK'e of such "cases to he. on the nverai:' , imich less freipient— 4 jkt cent, would prol.ahly represent the usual conclition.s. With reteieiice to tlic -evcrity of ivpeate' (iiiRltion occur nine days after the termination of the iirst tiiihl relap-e of only eleven day:-' duration ; and also previoii-ly I had repei.tedly enconntere r. J %<^ff-'\-rl:^ ■:ifi^E. ^ir ^■}^'TK-f'-':f^\il^-^'::^r '■■!*■■ '^^■-.^v: /;/-.> 7: 1 ■iii:s( ■i:y< />■ .1 a/' 1:1:1. a /'.s/x ;uir) Von /.iiiM.-.S(ti l.as luailf tlic tolluw iiii' inslniclivi' tiilmlatioii of 1 ca.-vs (if iliiiilili' nla|i.-i' . IhiDil'-ii, .i| till- lir>l rt Ini'M', l»uraui'ii "f Un- v. cuiiti r» lujwr l.-i,..l ,^,„. 'riiiT.- wirk-. Kcuiimi (iuy.-. S,.,,,iiil i;i-- 'llin .■ «,ik,-. Kill! Ill ilic\-. 'I'liinl . a-i' KliMii (l:i\ -, Si-\.iit.-,ii ,1m\ -. l.',,i,illi ,ii-.' l-'oiirti-. ij ,l:i\-. '1 «i-m\-lliiv, iiii_\>. .Iii-I a- ill.' iMciinciicr iii^Mf ivIapM' licars >i.iiif rdatinii to tlir ajrc (if tlir patiiiu, -n a^c al-n a|i|K'ar> t.. play a role in n'|Hliliuii^ i.r nlap-c- and iv,ru" vi.ni;;; [x r- arc (iistinctly nii.ic trc.|nintly altiickc.l. Tim-, at Hainl.iir^', anioiifr 44 ..a-cs of (liiiiiilc i'cla|>sc. \2 oc( iirrcil in cliildnn. if. in coiicliiMon, a few remarks !«■ made ((mccrninj: llic niulionld tir-I !)<• aL'ain Micnticiiicd that at llic jiri-cnt day ili<-f arc (.rciicraiiy ci.nr-idcnii td i.c rcii"tiiinn- of tlic [.liMiary ni(irlii\' a new inva-inn liy tyjilioid- liai-illi. \Uii, no one donlii- any lonircr that .viiain inlliicnec- wliidi were foniicrly enn-idend a- tlie eau-e of rcla|)M- play oidy tlic part of fa.'Iors <'<.ntril)nlor\ to iluir development. This vie- mii-t he adhered to in -iiiic of certain h\ pcreiMtii'il olijcviion-. Knio.ional iliet tie ( rror. Thii-. hut a vear ap'. I oijserved siu'h an iM'curriiice alter the institution of treatment for tapeworm. The patient in :|Mfsti(in. a previo\i-ly healthy lumse-servant forty-three years old, wa.s hroie.dit to the clinic civ.npl liniiiL' of ^'ciieral malaise and iuK-mia, the diairiiosis of ihe faiidaineiilal Irouhle heimr indelinile. He a|i|K'areil to he enlirely free from fever, and exliihited fir 11 time, iiot- >vitli.standiiii: increa.-'ed pnls'-frecpicney, persistent suhnorinal teminTatiire (inoniini:. :>t)° ('. : eveniii}.'. scarcely oti.-")" < '. ). It could not lie ileteriiiined from the hi.story whether fever liadexisled dnriii!: the period prior to admis- sion. .\.s the pallid, considerahly emacialed maa lost over two |M)iinds diiriiij; eiLdileen davs' residence in the lios|iital. in spite of canfiil luirsinL'. the iliscov, rv of a Ta'iiia nuMiiocanellaln was received as a welcome ihera- peiitie indicalion. On the third day. afler siiccc-sful Ircatment for llie t^ajH'Worm. lln' temperalure hetriin to rise, anil there t'ollowed a fehrile Siale if iteveiiteen davs' iluration, hieli, from the characler of the curve, enlarire- tiiinl "f ilic s|il('-ii, ni>.'(i|,r, thill .-icMil.-. mill iliazii-ri'Mctinn. |ir(ivc(l |o lie Ivplmid. I ii(liiiili|('illy, till' |i;ilirnl r:iiiif uiidir iili.--ii-\ Mlinii iluriiii,' iiMi\:i- I'M'ciii-c rr(..ii an allark uf aiiilmhiidrv Iv|iliiii:l iisii-, ami In' .-Dlfrrrcl a rclap-r 111 ilir |iniiiai'_\ "•■■mliliun in cihim .|iuii(t mT l Ik- i rcaiiiiciil iiisliliili.j. A i|iii-liMii I'.ii iiin-iv larin-ily .'iml 1 1 i(|iiini I , ili-cii--i(| \va~ wJicIIki- aiili|i\ iTlir liialiiiiiil III' i\{ilinii| r.Aii-, ,-|ic(iall\ llial uiili <-n|<| lialli-, caii-i'il an incir;i--( in iIk' t'i((|iii m \ .il' irla|i~(-. Manv |ili\ >iriaM-, ex cii the nil 1-1 iiilliii-ia-lir aiK urali-- nf llm-r niilliini-, wcvi- iinw illinu' tn ili — I'l'LTanl tlir |iii---ilii!i!\ 111' an iiiilii\"i-alil rlli rl in llii- niiMi-i! ( I ,ii Imi- nifi-lrr. Ilirinirr. LimIiii. ( iiillilaiiiiinr), wliilc ullinv ( I,ri<-Iiicii-Icrn, \'iil;I ) (AiiiT^-cil a 1 ■.niiaiy i i|ii 1111.11. 1 1' t hr al.iindanl liliTalui'i' U|iiiii tjic anli|i\ I'ltii- iiiriliiiil 111' I iTalniciit lir -imlii i| willi n Lranl to I'li- i|iif-liiiii, it will lie I'liiiiiil llial in iiilain |ilari-anil .11 rirlaiii time-, niiclir iilcn- tirallv llic -aiiir a|i|iliraliiiii uf liatii-lii at iiirnt, the nniiili( r of' iila|i-('- cxliiliil- llir Lrriati-I vai'ialiiin. I lia\i' |icr-iinall\ liki\\i-r iili-rr\"c(| >iiili \arialili' n-nll- al ilitliirnl linn-, wlicn I ciiiiilux nl aiiliiivrft ics anil lialli- nimi' -\ -liiiialii' ill\ llianal |Hr-i'iil, llial I am nnaMc tvin|i- liiiiialiijiiiry ut' ill' ili-i-a-f. ihi- i-liniral |iii-turi- nt' i-mn ali-i-i-nri- i- al-u (-\tn-nirl\ \arialili It i-, lic-iili-, i--|>rriallv intlnt-m-c-d li\ a^'c -fX, ruii-l ilntimi, (•iiiii|ilii-atiiin-. and ri-la|i-c-. !n i^rnrral. it nia\' In- -tati-d tliat I\|iliiiiil ti-\i i- i- um- 111' thii-i- ariili- inli-i-iiun- di-i-a-o that iiin-l t'ri-i|m iitly iiil}i-i- Iri'ininali- I'alalK ur. at tin- innrlii-iun ut' i-iiii\ ali-M-i-nci-. in ciiiniili-li- n-Iiiraliun In hi-allh. Iiualidi-ni. -i-i|nrU. ami |ii'rinaii(-rit drli'ct- afi- (-iini|iai'ali\ i-l\ Ic-- rumninn after it tlian alti-f iiian\ utlu-r inti-i-tiiill- di-i-a-r-. Imln-il. it rallllut 111- dillii-d thai tin- -latrnirnt nil- II inadr li\ the lait\' ihat I'li- Ll'i'iii'l'al i-niidil inn at'trr i'ri-ii\ i-rv ut'li-n liriiinii'- I lli-r and iiinic llniiri-hiii^;' than |iriiir In I In- di-i-a-r. iiarticn- lai'iy in vnnn^r |»-r-iiii-. i- iml uithniit tnnndaliiin. GENERAL COURSE. Willi llir ad i-nl ut riiii\ alr-iTiiri-. tin- lii-'jinnin;.'- ut' wliiili i-aii In- datid tViiin tile tir-l da\ ut |c-r-i-lciil d(-ti-r»«'-rinrr. tin- runditinii ul'llif (■(i.\\.\i.i:s(i:.\<-h: ;5t)7 |>;uii'iit i~ cxtrt'iiiclv variaMi', in accurdaiicc witli tlit> course of tlic antc- (• tlio di>cM-c natm-ally i- in p'licral Itillowcd liv -liL^dilcr (ii-turliancc- tliai arc more rapidly recovered from tlian in older indivliluai- or in those already deliilitated in advance of the attack. I nder ail eirenni-lanee-, lio\vc\er, witli the onset of convalesceiiee from >evcre attack- of typhoid tiver, the i)atients, of whatever a^c and cunstitntion, cxh'hit eon-iilcralile impairment of the treiieral <'oiiicnon,~. The symptoms of the anemia of eoiivale-cciicc, \\ liich often are nio-t profimixl, are toimd on caretid e\a! linalioii to lie d. pendent e^peeially upon alterations in the number and character of the red blood corpuscles and npon vai'iations ii' the pereciitat;e ot' hcinoLrlohin. The red I lood- corpiiscles and I, Minjiiliin, a- in the earlier staires. n^nally ])nrsne a parallel con. , al-o diirinu coiivalc^ccnec, Imt not rarely their curves t persons in general tliaii iti women and deliilitated individuals, will have rcai'hed its niaximnm in the inajoritv ot' ea-cs, acconlinu' to ohservations. mad(> at my clinic,' before the tcrii.ination of the fever, -nl)-e(|nently to ri-e slowly ML'-aiii. Ia'.ss commonly, the ininininm |HTceiitaLre of liemoixloliin remains niK'hanjrc'l for a irrtain time, ilnrinir the first part of the afchrile staps or the hemotrlohin may undefiro -till further reduction. It is intercstintr that |iaticnts who have liecome markedly anemic, on the contrary, frc(pieutlv exhibit iuuiiediately a st<'ady and comparatively rapid increase in the percentage of hemoglobin. I'hus, Kiilncr ob-crvcd In a ))aticnt who had become particularly anemic an ii. crease .f ol jM'r cent, in the hemoi^lobin within six w(H'ks, and in otlicr paiients, not at all larcly, an increase of from 10 to 1") per cent, m the course of a week. Kspccv(ii' and iriild cases, the rcstor;' timi dl" llic ('(itiililiiiti 111' ilic iiliHxl Id liial prc-fiil iHliiri' tlic attack lakc- jilaci' lull ^Iiiuh. l-.vcn al'lcr tlic la|'-c iit' seven wi't'k- wc have l.'iiiid that the li.il'inal liinnhi r nf red hloiMl-eells ami the eiil'l'c-]ii>ndiiiix ]iel'- celltat;ei>t heilliijj;l(iliili have nut hcell elllilely n"jaine-ei|nenll\ with (-|)i'eial caic hy Kohl-chiitlci' ' and Cohin.- i-, in compari-oii with the duration oi' the di-easc and 'vith the amount of wi iijht lo-t in other acute int'ectious dis- ea-es, not so (xreat as wouhl he anii( ipaied. It i- naturally most markwl in llu'ca-csof Ioul;' r llir-ili. ^ CdW \l lycEScK. 369 week l'act<>rv ( \]ihiliati- ( Ic-, in as'ociatiiin th.nw itli. I'lio iM~- in liDily-wtiuiii in tlii' ciiiirsc of t!ic fever appears to take plaic not :ii>riiii|lv, Inii niiiCorniK , as ( 'oliin, l)v llic n-e oi' -nilaliii' apparatus, wciirliiiiLT tin Ivphoiil |ialicnt r<'|M'at(illy for t\V( Ivc days, lias dcnidn-lratcd. Tiic avi-rau^c li»s o*' wciui't a day in a mild, iinconi- pliialtotkin, oliserve*! it to reach iS((ii jrratns and uiiove i[i M'Vere ca-e-. 'llie total Weight wliieli juitieiits liave lost at tlic bcLcinninir of con- valescence is at times ipiiie alarminj.'. 1 iiave noted in an adnlt, after a x'vere, loniT-protiaried attack, wiili various complicaiioii-, a reeen even a- irreat a hi-- as 10 and 11' ])cr-'cnt. H'-pceti\ely. It i- woriliv ot' Mole that in I'liildrcn [ t'oii'td the iiiaxinHiiii lo— of \veit:'lit to he !• pel ceul. The-e hi^ih tiLlui'e- may he contr;i-tens. Thus, in mild ca-e< 1 iiave oh-crved only from 1 to 1.1 |)er cent, lo-,- of hodv-wciu'hl, anil i have e\cn ,-ci ii severe ea>es in which the total lo-~ was not more than from l.o to ;; pei cent. The conditions ih'i'inLr con\ alesceiice in o(iii after detervc-ecnce, and jrrad- iially roVe -ain, reachinij; the prcviotis individnal level oidv after davs or week-. It \\:is -ecn, t'nrlher, that diirin^r this jiiriod of snlinormal tcmperatnrc, a--mniiiir a condition of perfect (piiet on the part of the |)ationt, the daily tliietnation- are >!iirlit, often less marked than in })er- fcctly hi'althy individnals ; Imt that they I'come extrcmelv marked, liowever, in conseciiience of even slight pliy.-ical oi- mental exertion. Tlie^c pciMiliariiic- of the ciirxc arc irenei-ally -o con-tant, and a])pcar in .-io typical a manner after an a'lack of ordinary course, that they con>li- tnte important criteria in the rccojrnitioti oi' convale,-ccnc(>. T have lonjj heeii in the haliit ot" con-iderin;;; con\ alc-cencc alter modems Iv sexcre and severe attacl.-not com]ileteiy c.-taMi-hed imtil they aiipeaicil. D.'ilv 2t ^^^>^3;i^i^fM?y' -^^ ;!7(i 7 1 fll'iiii 1 1 \ 1 1: I--"" ' piV Tf' w (■\|i(ririi<-(' trailii-- tliMt wlicii llicv arc waiiliii;; r !ncii. ( iriiiralK , it i> .-lii;lillv nr nidilnali K lull and It ii-'' : al'lcr iiiiM i'a-f> II 1- ut' nmnial In c|Uciii\ , ami allrr ~c\(ri' allacix- ant-li('at-. llii- iin rra-c utltii raiiiillv »T.-i^triic(' lit' tln' iiii!-r-ciirvi' at ihi^ liiLrli k'vcl I'ur -umc tiim — imt rarfly tin' as luiiU- as twu wci'ks :iim1 nii.rt — is at tin- tiiiir i|iiltc iii-tuniary ; lnit it :-hunlulM'-t'rei|Ueiiev. persi-tin:;' t'ur .-ixleiii ut' eiinvale>eeiier still exhihit a suhnnrnial teiiijiei'al nre, uilh at til>t an imaea.-eil |iIi1m t'rei|neney. With resturaliiin ut' the hmK -tein|ieraiure |u tin' ninanal the nuinher ut' jiulse-lieals then >l Ilk- ^'luiew hat. ami tluetuate.- iiiuri iiiL' ami e\ eiiiiiL.' helween .•>0 anil ■'^u. (leiiinL'" iiji un the furl v--i vent h ilav nt' the liisease is Mi;ain t'ul- hiucil liv exee<-i\e inerea-e in |iiil-e-l'rei|Uene\'. with (•iiiii|ilele irre^Milarity in it- enr\e. riii- eiinilitiiiii |ier-isl> tiir three weeks withnut <'i)rre>|ioiiilMii' elevatiun nt' the hinK -leni|'erature nr ulher ohjeetive ileranfremelit n'' the heart, ami llieii -Inwjv :;ives way tn the t'nrmer iinrmal cnmliiiuiis. 'I'lial -iieli an iiniiMial inerease in |.ulse-l'rei|Ueney i '''• •• ■•^litiite the lieiriimiiiL' n'' a rehi]-e inav he a^'.ain inentimieil. |irinei|iall\ tnr tin' |iur|iose of intriiilm'iiiL' a eiirve ihat esiieeiallv illii.-lrales this nninl < I-'Il'. 4t>j. ;/< « ' i).\y.\i.i:s wA ■ f ■< .^iv/, m 372 ryriiniii 1 1 vin. < o.Vf i/./..sr/..\r/;. M-.i CHANGES IN INDIVIDUAL ORGANS. The heart onlv cMcpti'iUMllv rxliihits altcniliiiiis iluritij.'' conviilp-i- ccnce. Now aix' apiiii, Miidoiihtctllv inuch Ic-s (■oiiunimly than (hiriiij^ tlie rchrilc period, mvoearditis, with dilatation and eorrespoiidinir niaiii- f'-.-tatiiiiis of eai'diac weakness, occurs ; ircnerallv, howevci-. the tcriniiiation is favoralde. Kndocarditis and |)ericar(hti- o. cur >til! more exccption;illy. IttlK-y occur at all, thcv arc almost always rct'crai)le to niixiMl inf'e<'tion, espc<'iallv to a conVplicatinL' septicemia. A rc-ult <>f tin- conjoint intlii- ence of anemia and cardiac weakness, whieli is sDnietinie- inanil'e--ted li-Jif 1 J";r L-iiy l^i2Sf^^^*i^/ ji^mu^m ■Ml rvrnoih ri vri: V; '■ *r'»" '• .'i ^^A ^ , , m (Imiiii: till' lir-t iMirtimi "T llic -Im^'c nl' <(iiiVMl(-ic'iiir, i- cdi ma .iIh.iiI iIii' aiiklc-Miii( \i.>ii-lv ild.ilil.ilr.l |h r-.m-. 'I'lli:. ir |o 1h' lli«lill_'ui>llC'i tV'Hll lllill 11 llilioll \ a r U I \ "I ■llM|,.-l(- 1 FWcUill^' t'f llic Mlliculallroll- <-'<[\ lUl' li-IH. uhicll I- \M.li l\ 1 1 1-1 11 i HI I r,l ov. r lln! rhiiic- 1mmI\, !iii|i»'i ially liKiilii'ii- llii' (ic(airr<'iii(' of llii.- riiinlilicin. ai 1 l.i- lull ranly alliU'l. 'I \Mlliall.ii- iniiiiiria, ami iiiav dcc-iir fnlircly williuiil tlil.- |iIiiimiiiii' t i in -,-ni-< i na^ no (-atiKthi'Kiry cxiilanaliiiii lor llinn. \\r> ill\. 1 liavr not (il>cr\ril liii^ pviiibliiiii- '.M 1 1 iridic, which i^ cxlrciiicly r.iri', ha:- liUc\vi-c hccii prcvioii.-ly considered ( \i. 1 '17 ). Ill the lar-r luajorily of ca-e-. the eondilioii of the digestive organs rapidly returns to the nornial -",,11 after defer\ i -et nee. 'I he liii- and the toiiirne hiiriii to clear even diiriiitr clcfcrvc-cciiee, >o that the tongue is hut -lightly coate are free from fur. After the toiiuiie ha- Idroine fomjiletelv clear, it often for a coiisider.il >le time appear- thin, ^llUlll and rcmiMiih. The appetite, which alino-l always returns with (Icfervc-eencc, often even previou-lv. liecoines tlii- wcll-Uiiowii vnraci,,iis •' aiiiictitc of i-oii- valc>cence," which iiiav he a -oiiree of gnat ilitliciiliy for the friends and the phv-ieian, and nadily of danger tiir a dirohedimt patient, yailnve of the a]>petite to return i- (|iiiie rare, and i:- worthy ol ^])ecial con>id( ration. Kscept in ]ircvinii-ly ill and ivdue.d individual-, this ])licnoincnon i- indicative ol' the latent ]icr-istcne. of earlier alterations or is a siirn <.f impending comi)licaii"ii-. If a-^ociat cd with vomiting and porsi-tence or rccnrrcncc of diarrhea, ^hlggi^h inlc-tinal le-ions iniHt he thoiiLdit of, as >e until ilcath linally occur-. In ca-.s ])iir-ninL' a regular and U'liign coiir-c, the typhoid diarrlna is likely to cea-c Ufore defer vcs- •7l*B *■- V %:^ ^'r^^^fFO^S^^^ "Z^-V. '-.V' ^' ^^ TL*- '*■'' {•iiSV W / <' 7 W /•• 375 ofiiii' i- iiini|ilcic|Kar:iii.i- a- lali' a- lli. |mii..(1 ..f , \ah-- ccnci-. rinv maiiili-l tliciii-i K !■- c-iMriilly li\ Iciiilciiii-- i)\ir llif r.Mjl.m III' till' Ik II- ami llu' gall-bladder, ami alf ill part piiilialiiy iittiiliiilalilr li' iiitlaiiimalmy iniiiiilinii- ilr|Mti(liiil ii|m.ii (he alnin-f ( -tani |in-iiii r nt' t\ iilmi'l-liaciMi in tln' i:all-lilaiiilir ami laiirc tiliiaiv |ia"ai:i- i.fthr paliciil ((Jillxrl ami ( iirmii.' I )u|(r«',- Ciiiari,^ Hinli-Ilir-ilil'clil ') i ■■<■.■ pa-v Jn'ii. Ill till' iiirlil III llii-i' liacli'iiiilinrii- limliii'j-. llic iil(-i i\ alimw rt'cciiliy liiailr i>\- varimi- w riti i-~ nt' the iMTiiiicmc nf liiliai'v culii- iliiiiiiLr cnii- valr-irm-r aii|ii-i- iliiiinii-tniliil liy illii— trativc ra-i'> tliat tlic iiroi'iicc ii'^ tlic lyiilinid-iiarillil- i'l tlii' ;.i-all- liJaiMir mivrlit In- lln' iliinl iiriiiirt. wliu pnsciitiil an aluiinlami' lit' rliiiii'al iviiliiicc, ami al-u liy Miliaii" ami ilamit. I'!\p-ir\i r- (-<■<• ]i. "JJIM. IVnin iiiv iiwii iili-cr\atiiiii- I auMif ali-uliitily with tlic upiiiinii tliat the tiirniatiiiii ut' gall-stones is liy nn tmtms a rare (.iiiirnnic in tin- pcriinl lit' convali-iiiui . in -pile ut" tlir inu^t ficcnt cunti^Klii'liiin liy (.'liantliiril." Natiiiallv, tiic liiniiatinn ut' Lrall-~liiiics iIims nut alway.-t niaki' it-cIf inaniroi a- early a- tlir peiiinl nt' ri.nvalc-ccncc. Tlic lir-t attack ut' cdlic ut'lcii cnuuirli ucciip- mily --uti-c.|iicntly. 'I'liat tlii- may iiccii'- at a vcrv rciimtc imimikI i- -Imuii liy llunm r'-' ca-c, in uliicli llic attack iK'ciirrcil ciiililccii \cai> at'tcr tlic attack nl' lyplmid t'cvcr. Tlic (iiic-tiiin as to wlictlicr cliiilcc\>iitis and ciiolclitliia~is may lie induced liv the actiiiii ut' t\ plmid-liacilli iiidc|Miidently ut' any attack ut" typliuid I'cvcf lia- liccn fai-ed liv ( 'ii~liinu'~ '" ca-c in wliicli, I'lnin the cuntciits ut" tlie LtiU-liladdcr. a imre culture ut' lypliuid-liaeilli wa- nlitaincd, ami yet tlic patient ixa\e nu lii-tury nl' a previnn- attack ut' typliuid li\cr. It i-< mitewiirtliv that, on oliUiinint: a caret'iil history ol' jiatients siitl'eriiiLC t'runi i.i-all--lunc-, the t'aci u|' an anticcdcnt attack of lyplmid l'c\ cr. a shorter or luiiLrer time jircviuiislv, i- cncuiintercd with rcmarkahle frcijiicney. ' r,„„y,r n-wl. iif /■! ,i«,-. ./•■ hi.^r. ls;i() uti.l Is'.i;!, »c;„.-. ,/,s /,.-,/.., i8;ii. /.'■■. '-if ' A,...-. ,-:t_ S lirr ilr M'-l.. \H'M. '• l!"ll. '/'■ hi s...-. ntuit ,h l'„r,^. N.i\ 'Jll. 1,S3C. ' /{;///. mr.l . .luni-'J::. 1800. » /.'- r '/- M.I . IS'.iT » Ia>c. ctt. ioy.,A»i.t Jlojikinn Husji. Hull., vi.l. U. MICROCOPY RESOLUTION TEST CHART ANSI and ISO TEST CHART No 2 1.0 I.I *" illM II 2.5 [1 2.2 2.0 1.8 1.25 III 1.4 mil 1.6 ^ APPLIED IKA^GE Inc ■■^thestef, Ue» f-^" ■••bi,"J ■16) *ei - 0300 - Phone '16) 288 - 5989 - Fq< .•'.7(i TYnioin ii.vi.u. AiuoDir 12 (Mrit's trc;itcil for L';ill-stoiics :il iiiv clinic in recent years. lliere weic I'l. thus ;lO.'.l |ier ci-nt., in which there had lieen ;i |irevi()iis attack of tv|'!!(!!'l fever, an'l ~\ini'!'>ni> I'f chllh■lithia^is liail apinared ileiinitelv onlv snhM'i|nenlK . ( )f the:-e ca.^e.^. li'e foUowiii'^ '1 may he hriellv (U'scrihe(l : A wonian, tliirl v-.-ix \ears "I'l. wa.- received in the clinic on AiiLrnst '1\. l^i'l. on aci'ount ot' an attack of ty|ilioi(l fever. After havitiL'' heen free from t'ever for altno.~t t'onr weeks, ami in a .-lati' ol' |ierleci convaloccncc. she was smlilenly sei/.eil with several attack.- of hiliary colic. sncceedinLT one another at .-^liorl intervals, which niati'rially retarile(l recovery. The second case occurred in a woman, thirty-ei^'hl vears old. who had. in May. IMM). passed throiiL'h an attack of tvphoid fever of five weeks' dnration at the clinic. ]n the i>fi:inninLr of the tiillowinL' year an attack of hiliary colic apjieared for the first time "'d then-after was re|)catcd several times. After she had heen admittei 'he hospital in March. I."v still more .-o. In f^reatlv reiiiieed individual-, with eiit'eeMeineiit anil dilatation of the heart, jitilmonary infarction proliaMy occurs exceptionally. The relation of tiilicrciilo-i- to convalescence i- notewortliv. AVe have seen that old, previoii-ly latent tiilierculoiis processes, or those frivini; ri^e to sli^'lit inanit'otations, may siuldeiily ]iroirress rajiidly diirini:- convalescence: ami also may L:i\e ri-e to new tiici of disease in the form ol' ca-eoiis piieimioiiia or iieneral miliarv tiilierciilo>is. For- tunately, it is rare fur the n-idiia aint s i|Uel- ot' typhoid atl'ect'ons of the larynx to complicate convale-ceiice. cither in the form ol" sini|)h> ulceration of the miicoii- inemlirane or in that of' perichondritic proce-ses !ind iiecro-i- of cartil.aLi'c l*aralv-is of the vocal cord- has lieeti excep- tioiiallv oli-crved. A- ha- heen pointed out. iiio-t o|' the le-ions of the larynx iiientionetrc.-i- tlii'iiiMlviv wilii de-ins witli rci'crcnoc to tiM.il, wliicli may not ho tiiitiiliindnL: llieir worii. Women and (iei)ilitatitl persons remain irloomv, irritahle, and even liypoelmndriacal dtirinir the fir.-t period. Ciiil(h-eii also are likely to he ill-temperecr- sist from the felirile period far mon; fretpiently than they ari>e durinj^ convalescence. Headaelie, which plays no incon-iderahle n',/,- durinir the initial period of tiie attack of typhoiil fever, is (piitc nire durinir convalescence. It the ])ationt is not a person who for a loiii: time preecdinir the attack had siitfercd hahitnally from headache, tlie appeanmee of this symi)tom durin<5 ctmvaleseence >iionld he viewed with distrust. Not rarely com- plications arc conci'alehoid fever there mav also he headache, <'ontinuin>f f >r years, or even ihronirhout life, withont demon-trahlc oriranic lesion. Focal di>ea-e of the brain. juMvistitiij: from the febrile period into convaleseence, and evci beyond it, may. of coiir-e, occur. In thi- con- nection monoplejria and liemiple>ria, a))hasic states, and multiple sclerosis should be borne in mind. Among the sjiinal affections and disorders ()f the peripheral nerves, ataxia and pseudo-ataxia, and the compani- tivclv fnnpient distressin;; nouralirie disturbances, especially in the toes and the lii'cls, slioidd be borne in mind. Anion',' the organs of special sense, the ear almost solely plays any rn/r. Atfections of the middle eiir, with perforation of the tym[)anie nunibi-ane and suppuration, may mal in otlicr v is (•ii!ii]i:ira!i\ fly the iiiu-t t'rcijUi'iil 'H'lilar -yiiip!"!!!. Mdic rni|iitnt tliMii iiti\(>ii> cli~iiiil( r- diiriiii: tlic luriod of con- v;il(-((ii(C arc altcniticiMs in muscles, bones, and joints. In {\\\< ciiniicilidn till' Mit'trninir |)riM'(---c.-, the lacrralinn-, and tlic licinor- rliaLic- into the -uli-lanrc nt' tlic niii-cic- ^irllll!d lie lidrnc in mind. Aitrntidn lia< liicn callrd rcct'iitly in a nnnd)cr ol' ((ininuinicaticins liv .-•ni'iicnn^ 111 till' Iv])liiiidal li-imis ot" tlic Imnr- and |i(rio-tfiiin. I lia\t' r<'|icali'dlv uli-crvi'd |irri()-lili- with .-ci'ondai'v nci rii~i-, a- well a- o.-tcu- invi'liti-, appeal' dnriii!^ convali-ii'iirc, and in'oion^- tliis iindiilv. Such Ic^idii- may eventually rei|nire (ipiTatix c intervention, .-e(|iii'-lrot(iiny, anil the like, and may Lnve ri-e to even |ieriiiaiient im|i,'ili'inent nt" t'lmetiiin of the |iart- invulved. Less eomiiion, lint i'S|iecially wurthy iit'menlii)n nii aeeunnt i it' their eiinse(|iienees, are inflammatury disnrders III' the jiiint^ ari-inir diiriiiLr ennvale-eeiice. Itiiser' had already called attention t(i -ilch involvement ut' the hiji-iiiint. A more c\ti'ii-.'.';- citi-J l>y (.rii;--in;;iT. (■(i\v.\f.i:sci:xrf:. 379 tliat |)rc;.'iianl wimicii, :it'i. r li;i\ iii^'- Micfcssfiilly i);i-s('('iH'('. Mcnsiiiiatii'ii rciiini-. in a iiii>-i % ariaKli' manner. In \iLriiriius, ri)l»u.-t Wdnii'ii, liiii, Mnl'iirtiinairly, xiniciiniis al-o in already liiL'lily aiicrnir one.-, it ()cca>iiinally rctni-ns mmiu al'tir ilct'crvtx'fncc — in -mall amnnni, a- a rule, for the tii-t liw tinic< ; occa-iniially, lidWcvir, mi |>riit'ii^(ly that tlic (lalicnt i- tlicrchy -criiiii-ly injnrcd anil ntanlcil i'l liic |ir(p;.f|'fs-! ti)\var'(l recovery, in utlier ea>e-, on tlie contrary, without >I)ecial can-cs heiii^- disi-ovei'aliie therel'oi', nien-truation lonjr remains al)-ent, even liir nianv month- lieyond convale-eencc. Also, inen-tnial iiiolirnina |)revion-ly ikjI noticealde ai'e con-idereil liy women, at times eorivctlv, as a -ccjuel of the attack of typhoid lever. I'ci i-iiterino hematoceli', de-erihed hv Trous-ean, and homatometra, whicli occurs rarelv, with it- often oli-tinate se<(iiels, hav<' licen referred to (p. liKI). Sometimes the re-i'or some patients they <'onstitiUe dii-cctly a disturbini;; complit'ation at this time. Orchitis and epididymitis are, as is well known, ([iiite rare, and then are iriTierally all'ections of the la-t |)art of the febrile staire. Ainoni,'' (i cases imiU'r my personal observation, 2 developed after deferve-cenee. Till' skin i- i^eiierally dry at the lH't' its trniiiiiatiuM tammt lie t-tal)li>luil. In triinnil it may lie ciiii-iilcrcd a- ciiiicil wWw liir iiiitiiiiuii lias Ikcii mi tin' im|ii-iivcil tiiat till' l>i»l\-\v(ii;lit a|>|ini.\iiii:itr- it- |ir jilaveil in tiii- •■nniie<'ti"n, natni'alK', liv tiii' M'Verilv dl" tlie anle- eedent di-ea,-e, hut a'^e, sex, con.-tiuitiiin, anil eiitu|ilieatiiins are also ol" siicii im|)ortani'e tliat ea-es oi-iirinally df milil cdiii-M' may lie attended, in eonse<[iienee of the intluenee ot' tliise |]i(I(ir>, with extremely ](ro- traeted eonvaleseeiiee. \\'e may recall, in this eomieetidn, the eoiii'st' dt' tvjihdid fe\er ii> the au't'd, and the al'ehrile and slow f'o'Tiis. The jirohalile duration is, naturally, liiyund the r.^itre of e-timation, in the iireseiiee ol' eom|ili(atidns and sei|Uels, as well as in caMS attended with ri'enideseeiiees and rela|i-e-. A]iait, liowpver, from individual condi- tions, extraiicdus eireiim-tanee< -till diHieult of" appreeiation at the piixnt dav mav in the eoiiive of certain epi- the duration ut" c'diivale-cenco detinitely in tiirures, a period ot' t'rom two to three weeks, after \vell-markt>d, nncon)plieated ease-, may lie eon.-idered as short and favorable. Searei'lv le-s eoiiimon, and i|nite u-ual after severe attacks, is a duration of t'roiii four to five week-. In not a t'ew cases convales- cence mav be protraeted even lieyond thi- period, and (X'casionally is of extraordinarv duration, particularly in rclap-ii.j;-, slo\T, or inafantic ca^-c-. Ill l>ci|)sic (HerL')!!! avera.'c (luraticn of convalescence w.is : I'p to tweiitv dav.s iii 5") per cent, of all cases; twenty to forty days, in 89 per cent. ; forty to sixty days am! iVcr. in ."J.H per cent. An anah>is of ■ (I'm; ascs ihiriie.'- the scvi re eiii!'.• cases — 10.3 per cent. ; In'twccn twciity-oii. and forty days in 2447 cases — 711 j)er cent. ; between fortv-onc and sixiv dn\s ii\ I'll cases — ti.'H per cent. ; sixty-one days and over in 1 !'.< caser- — .'!.,s jur cent. THE TOTAL DURATION OF THE DISEASE. It will be ino-t appri|ii-i:it<' .it thi- place to Tiiake some additional remarks concerninLT the total dur:iiioii ot' the di "a-e, which, naturally, i 1. hides both that of the I'cbrih- period ami that of c .iivaleo'cnce. in the lir-t ]ilace, .-ome stateincnts may be aildcd with regard to the TiiF TOTAL DrniTfoy or tiii: it:iLa'. It is iiiccmipaniiily iiKPtv ditlicjilt \n j^ivo an avcm^ro li<,'nrc for tiiis staiji' in tvplioitl than in tlio aciui' inil'ctiotis diseases tliat jyur-iie a far nioif .•yi-lic course, as, for in-lance, iiiirinous jmeiiMioiiia, ivpiiii- fever, relaji^in^' fever, and tiie acute exaiitlieniala. While in the latter liie fever is r;on!ined to siiarply defined titne-iiniit-, the fehrih' ^tal:e of typhoid fever is, as iia.- i.eeii seen, of inhnilely varia- l)le course and ihiratioii, from cases tiiat ixionie afel)rilc in tiie course of a i\\v (lavs, to tiiose lu.-tin^' many \\eel<-. In addition, the propor- tionate fre(|Uencv of the niildu-t cases, the moderately severe, the severe-t, and tho-e of lon;_'e-t dunition, is extremely variable at dilfirent times n dilV.reiit pla later. 'I'he course of the di-ea-e i- es|)ecially prolouired at'tei- the fortieth year and in ■iM a.xe. An examination of our statistics at IIa'i\i)urL' with regard to tlie duration -, ft' '■■ ;;s: TYrii'iin ii:vi:i:. (if the t'cvtr III the varic>u> pcrlixl.- n|' lil'c . (-liiiiiilcil with n'frroMci' lii tlu' iiiirrili \ii-liliil llic rnlli.«iiiL' I■^•.-ull^ • AOB. - I ■ -1 vi ;ir- . . . '.ijii 1 11 '■ I . In ■■ Till is.il 1 1 1 .11- t;n s ■.'.'..7 1.. t p L'O ■ • . . .-..; I :;•-'.."> L'l 1 ■ 'J ' ■ ■ ... . . •'( ■'• :;i.j , ;;ti ■ ■ ... .-. 1 H :!l.o 1 III ■ .... III ;!::,:! 11 t . 1.-, ■• . . 11. U 1 L'll.t! I'liralji 11 nf f. l.ril' I" ri'"I, I J. iM .i ij.iy-. I-' r'tiii jj tn :;.Ti|a\>. :«:ilii\ - jumI "M-r. L' II II. K II..-, '.I.S 1 ■_', I II. '.I L':;.4 l.ii This t:ilii»' nmcluik'.- with the iiinv-tlt'lli \iar, :i< llu' imiulicr nt' cmscs ailiiiillcil at lali r aLT-iH'rimls i> naliirallv .-n .-iiiall iliat llii'V do not aii|icar availalilf tor >iali.-rKal iiur|iii>(s. 'The (litlii'uIlN lit' olitaiiiiiiL'' a u'liirral nuiiMriral iilra a- tn tlir tutal (lui'atiuii 'it' tlic ili-caM' — tliat i-, tVnin tlic licij-iiniiiiL' "I tlic i'cvi r tn the tcnniiialiiiii nl ciiivali'-cciK'c — lucd imt, in \\v\\ nt' tlic fiirc'/iiiiiir. atraiM 'ic ])iiinl(il nut. XcviTllii'li --, a trw ,-uui:<'>t Im' t'lLinri'- may lie ii>ct'iil. l'"iir Wfll-iiiarktil I'a-i.'-: ot' t_v|iliiii(l ii'vcr I -Imiilil cnii-idci' tlir a\ (ra^c liiifalimi iVoiii tlic licii-iniiiiiL'' tn tlic jicriml nt' ili-cliarijrc ami fc^Idralimi lit' the capaliility t'nr wnrk a.- t'nuii five tn ten wccU-. Only tlic al\|ii- cal and tlic milder ca.-c- nm their eniir-c wiiliiii a slun'ici- pciind. Nut a tew cases, linwcxcr. |)ci>i-t till' a cnii>ideralilc time licymid tlic avirau'c pcrind ~tatces in the e|iiiieinie at I Fainhuri.'. 7'J..") |ier iM'iit. Iinil a tntal iluraliiin nt' trniii tliirly-oiie in eii:hty days. Tliu iiverajre iliiratiiMi of all the analy/.cil eases wa.s tifly-tivt' days. FATAL TERMINATION. PROGNOSIS. Witli rcLnird In the prnirnn-i- of the iiiin-t;ilal ca — , aliiiiidant refer- oiices have Keen made at many ])arl- nf tlii~ wnrk, -n that the tiillnwiiiir sc<'linn will enntine il-elf alnin-t exehi-ively 111 the t:il;il tii-minatinn and tile related [irnirllnslie cnli-ii lerat inn-. \\\\\\ rcirard tn the t're(|llcney 111' a ISital tmiiinatinn in n-ciieral. definite lat(il ;it tlic (iiil-rt tli:it >ii(li cxlniiic- arr alliihiilaMc tu (|iiil«' ilctliiilc (•(iiiililinii-. LraviiiLT lln-c jxruiips citCa-c- mit ot (•(iti>ii|(i-:iii(iii, till' irciicral niintality i^ .^tatol liy the earlier ela>-ieal wi'iiei- i

    niil\ir tu inuiliril e\ Jx rieliei , \\k\v- ever, il i- ili-tiiietly lower, namely, iVoiu '.• to 1 _' |iei- cent., ami at iiiu-i, 1 I |iei- ei'iit. IiHiniiy as to tlii' eaii-es llir tl.i~ reiliielioii in luortalilv will -lidw that il i- due in part to inqiroveinenl in -|H(ial inelli(Hl> ol' Ire.ilnieiit and in the ireiieral liyLiienie eonilitioii-, and jio—iMv al.~o to a rednetion in the virnlenee ot' the di-ea-e, in tavor ot' which i- the e\ i- denee which i~ availah'e with rcLrard to the liehavior ot' other inl'eetioiis ili-i'a~i' in this re-|iiet. .V more ini|ioriant intluenee, howc'Ver, than th<'-e (actors ill reihieini.' the j e-ent mortality re~ide- in the pert'cctiou of dia^rni'-i-^, so that a l.irij-e ntnnlier of ca-c-^ |ir( \ion~lv not con-idered a~ typhoid fever, which unexceptionallv tei-iiiinale in recoverv, are now rocotrni/ed as e\ampli'~ of thi- ame tii^ures. lie found amiJiiLr -'•"lO'J cases in the Lomloii Fever Hospital fur the \cars l.s.4.s_ ]^>')'2 a inorlality of \K.') per cent. Thai his and Ciries>iiiL''er's results were the expression of liic ireneral inortalilv-rate in tvplioid fever at that time is indicated liv the result of an inv>>liLration of jS.tirj culleclcd ca.ses i from London, (dasL'ow. Paris, .'^trasshur.', and the I'"rencli provinces 1 of the tit'tli, sixth, and the lieLdiuiinir of the seventh di'caile of the nineteenth centurv, whiidi likewise yielded a mortalily-rate of I'^.oL' percent. The conditions at Vienna wen' remarkaiilv more unt'avondile during'' the same perio — l!.!' per Cent. Of the ;!(!S(1 patients of this LToup treated in the hos]iital, the niortalilv was somewhat hi^'hcr — :'.t)L* !>.S percent.) — undotilitedly on account of the smaller nuniher of mild ca.d with tln'se, the statistics of Thiintrel are int.'rcstinir. whoiiliserved amon^r ,'>(I4 patients in the same hosi)ital. het ween the years IS.lSand iMil. iHi deaths — lit percent. Finallv, 1 woiiM state t'urlher that a study of oCOd cases that I treated pcrsonallv duriiiir the .1 :5«t rvriioin i ivin. t l„ii...l ir-ii, 1-77 \'> !-''7 i!i \\\v\"\i- |>!:i'-r^ I'.rHii!. HiinilnirL:, I..l|isic) cxIiiMl'il ;i i"ial iiini-i:ilil\ III' '.!.:; |iir ithi. Kuril, ^ ill.- Ml \r;ir-.' I>>;i In l^'.''-'. nl >-J'.l ril.-.- I n illnl 111 liir .li.lilis lli.|.Liii- lli.-|.llal. li ; iliiil :i iiiiiil;ilil>-|-aU- uf ~. > |ici r, i,|. Ii |i:i- Im-.ii |iii' -taliimnl- llial age i- nl irreal.-i iiii|inrtamn in thi- .nmi.-.'i i.m. 'i'lm ilanu't'i- tVnm tlic t' imava-i- ra|ii.ll. w ill ailvaniiiiu' year-. A- rai'ly a- al'liT tlir liirlictli, ami |iarlinnlarl\ all. r tlic lifliilh, yrar llir malit;iiam-y nf tlic .•niii>r i> LH-cal. wliiln it i- iiml.iiialily l.-a>l in i-liiMi'.'n li.tw.vn tlic -(rnml ami the tciilh v.ar. In ih.' lal. r year- ..I'ch.il.ll <1, ami in the .-nl>-i'(|iieiit ;,^r,.-i,|.ri.i(l- in a. hill-, np In ih.' nii.l.llc nf ih.' rmnMh .le.-a.le, the .litVcr- ,,,!,■(- in ihe mnrialiiv ami the rajiiility nf ii- in.Tca-c willi a.lvaminu' v.ar- aiv I.— -iii-niiieant. Imt. "ii -imly nf a lame imiiilier nf ea-e-, ih.y aiv. nev. rth. 1.-- , |.rni:iin-i- i- .li-liii.'tly n,.iri' nnfa\nra!'lc than in the |Mvin,l tVnin Iw.lve m twenty-live year-. Til.' li-iirt> ef nie>l vril.rs a-rce willi llin>e ijixcii in the lahl.' jm y. :;>:.. 'I'lm-. I.ieh.-rni.i.-l.r. animi- 174:', i-aM'S, .liirinv' IMi.'i In 1>7(I, f,.ini.l a m..rtaliiv.ir:;tl |,.T.vi,i. tnr lli.' aL'.-|ierin.l- ah.ivc fnrty vcars ; while in th.is.- Ii.l.i'.v il wa.-..nlv ! l.> per .vnl. I'liK'. al I li.' diiii.' ..f Wiimlerlieli, (.Us.rv.Mi -i.alli iH-.-iir in iiimv tii.iii half nf llie cases in pati.nls ah'.ve llie U'j.-nf fnrlv years. < !ri.s>ii:L'.r ulili/es these la. Ms tnr an iiileri'sliir.' explaiiu- ws.- tt- ' FATM. 1 1 i:\ii\Ai iii\ rj:i)i;.\nsis. 386 tinn of I'crfain xlrikiiii' ilitrinncis in tlu- nmrtiililv in ilitl'tTcnt h<>ci>iln!«. \\ liilc lie Id^i 1'^.."< |itT riiit. 1)1' lii.'^ piitivnls ill /iiricli, iiiiiiiiiL.' hIkmii iIkpsc in llic ii^'c |»'rii>«l iilicivi' tiirly vcmis iiiiiiiiifnil I2.li [kt ctnt., Kicdl.r. in I )r i I'Jl ) V / y- ^^^ - — a* /, r — . — - - -- — -A prosonts tlip ]«TceiitaL'('-rflMliiiii of tlic ilcatli.s frmn ty|ilii>i(| fever to the total imiiilier of ra.- 111 14 !• 1.-. is..-, .S L':l.O 3 :!7,.'i Till' (liftoreiiois in projrnnsis (lejx'niiciit ii|«)ii sex are. in contf;!- (ii.stint'tion to tiio.^o duo to ajre, very .-li^dit. Tiie little dirtorciiec that i.s ' S.-parnlnlxIrurk aiis tint lirrii-ht,-,i ,1,-r (l.-yrlhrhaft f. Sutur- iin,l ll,-il kiitnlr zii, Drrs,lr„. 1884. Thi^ valuiiMi' ]iuMic'!iti..i!. u liiih c.ntain.^ a lari;i. amount of carefully stuiiicU statistical data, is much tuo little knuwii. 26 •■>. I 3gf rvrii'iih II VII!. iip|.:nviit ill llii- rniiin'.'li..ii i- line ni iiiiii niliirr i.. .At. iiimI .\\\<\ -"lal .■ciii.litinii- ("<-:ili"ll. in...l.' ..I' lili', Ml.-i.li..li-iii) ; wliil.' in U'lii.ii ill.' -.MM I rim.li..ii- aiv .In. . tlv ..I' iiilliuti.-.'. |.Mrli. iiImiIv ihv^'Iimih-.v. |.iirtii- lili,„i, ,111.1 ill.' |.il.|-|i. riili.i. If :in .-|...i:ill\ i:ir'_"' iiiiliil..r i.f M ..liirll :iiv :i.-.i.|.iil;ilU r.v.i\..l inl" -i li.-|>il:>l in .-.iii-. ( iii.ii.c ..I' cM.niMl ,. |iii.,n-. ill.-.' I:i.|..r- in;i\ I" "t' . ..iih.IcimI.!.' iiilln.'li. .' hih.ii llif iii..rt:ililv if ill.' |.:iri.nt- ;ii.' I;ii'-. 1> nl lli. |M'i'i."l i.f ;i.l..l.-i'.'ii.'«'. 1 li'ltr ,,r,|iiKir\ .HI' -laii.'.- lli.' .lilV.i.'H.'.- ni iM..l'l;ilil \ ImI«..ii iIi.' Iw.i -.■\.- 111'.' -.. -liLilii iImI iIi''.\ ''111 '" :ilni.i-l ciiliivlv ii;n..nKl. Ii i- l,i-|,l\ .'li.ini. 1. ri-ti.' in I lii- . ..iili. ■ l imi lli:il,ili llii' .'..ill'-.' ..f :ill .'pi.l. irii.' ..f l\ plii.i.l li'N.i' ..I' ...ii-i.l. I'liM.' ilnr;ili..ii. ill. i,i..rl:ilil\ ; iitr iiiiii inav ;ll tiiii.- .'X. '.'..! llnl :iin..liv win.'n. :ili.l '■'.'. i.rs,!. 'riiil-, :il I I.'iliiliiiri: ih ill.' \.':ir IssC, ill.' I lalilv :ilii..ii': iiicii ("^.■". |m'|' .'.ill. ) u a- tr>'':i'"'' lliaii am. Ill- \v..ni.n (:'..'"> j.. i' ..nl . I ; wliil"' in 'li'' y>'^'' 1'"*"^" '''■'' aini>n^r «.. ill. 11 I 't. I l"'!' .'.III. ) -liii'ii I V '^''' ■'■'''■'' '''•'' ■""""- ""■" '■'^■■'^ I"'' '■'•"'•I- It i- 11. It W'iilli uliil.' I.I |iri-.nt luri' many -la l.'lii.'iil- ..f ulliui' wi'ilir-. With a li'W .■\.'.'|.li..ii- llii'X nai'li liki' r.'-nli-. Alm.-I rNa.'lly liio sun.' m.irlalilv i- -li..\Mi, lin' in-lan..'. in lli.' f.lli.wiii'.' laliU' li> Miir- I'lii-.pii, in.'ln.rniL^ i^^'Ji' .'a-i-- ..f l\ |ili li'i fi'vrr Inalril in llif LiiihIiim F.'V.'i- lli.-|iital liclwi'i'ii ill.' >i'ar~ l^l>^ ami IS.'iT; Aaini>>l'ilis, I(.'nths, 1'. ri . hti.i;o. Mill.'- '■'"■' "•" '■'''' F.' 1.- '""■ ""■' '-'■'' T...:,l l"*^" •'•■•• '"-■' Tlii- lalil.' nia\ l.r t'l.ll.iw.il liy ..ii.'..f U.'.'l/, trmn iIh' Mnni.li in.ili- <-al .'liiii.', in.'lnilin- lli.- .'a-i'- ..f ly|ili..iil ti'Vi' liilwi'.n tlii' \.'ai-> |S7 1 an. I l'-<7T. ami I'xliiiiiliiii: a niarkiil i.I'.'Im.ii.Iitiii.'.' ..f llic im-rtality in IIIIII. rnilial.h \M' has.' ii.iv an inii-li-ali.in .if llic intliU'm'i' of .•iTtaiii iiijiiriuus li:iliil> i.f lil.' in nn'ii (alnilmlii' "M'r:-^. iiarli.iilarly "f Im'.t). MMrtMlily-l', rc.iitiii;.' ^"■^"•"- liiinr ..-..niuiT;^ t:,„t 1S74 ^^ ^■' '■" 1K7- !-■ ""■' '"'■ ,^-- l:),(i 7..". '.I.'.) AK-i, ilii' social position am! tlic occupation ar.' not of so nin.li siL'iiili.-in.'.' Willi iviiiii-il t.i the |ir.i..'ii.it:iiii'c, lypliu- fi'vcr. I licli.'v.'tliai tvplioiil f.'V.r lia< a- liiil.' I'l'ialinn l.i w.-altli ami |i..v.rly a-< til ^'jvvial .H'ciipaiii.n-. It is not cviii apiiannt tliat an imliir-nt inmlc of life is, in itself, injiirioiis. On the roiitfarv, tin' mixle of lifo of llu F.\ TM. 77 7M//.V.I /7o.V /7.'o/,.\ os/\ 387 lii'h is iilinust riion' rrr(j!iiiii!v lion- |iri' Ih l;ik. >ii-iri ns an i •un- til IN |ili(>i>i t'i'\('i' ii ■tliir tlic irtc'iipaiii.ii- iImi liivor iiilii-tion I'l' IliiiiliKrv) an' to U) mwliat j.'ri itiT ili'i.'n ciiii-iJiiid iiMii-c iiiilavunil il.., I runi tl jiP'^'i -I.IIM r\rii'i|lll''l\ iloll litl'lll. In riTtain -ii|M'rli(i:il r(-|ic^lnrI|l,i|^ II fill. iiiiirU arc pTcivcii c\ccc< llic i>a-c< adinittcd at rtcd wliiili, l)y rca-dii (if iint'avoraMc circiini-tancc- laic, i-i ^cncndiv far more L'i'a\c than that "'■' an carlv -lairc A nut incun-idcralile iiitliicii' cxcrlcd ii|Hin the pn.urnnsi- hy the constitution and the condition of general health pre-ent iicf..rc tlie attack <.', lias ri'L'ard to the eon-titntion, the daiiin r i- t'rotii the nnl-i't lea-t niii-ciilar. -pare iicrsoii-, the -o- illiil toiit.'h individuals ; whih •II iiictitiiiiiiHi, ill- pro^' rnosis mil -t I.. made with irreal caiilioii in the it' olic-e pcr-(Plls, e\cl| yolllli^ iillCS, lilcli d ehl" as \\( linen. Ill adilition, anemic anil clilorotic pei-ons are expo 11 -cd t. ■at d: 'i'hat, Hirer ; tliat in alcohiilii'-. 1" in other oircction s, th, ddirted to n itlook rp ihl tllo-e n 1 IS lintavoraiilc, need xuireelv eiiuihasizci Amonir the evecssc- )liv>ica 1 and mental overexertion arc rt'iel'. to lie included, as well as j)rot'oiind eniutional di-ttirliaiices, irreat Anioiiir chronic diseases, irimt, diahetes, heart orLims, p.irticniarly mil anxietv. respiratorv advanced tphorculosLs, arc to he considered as cspeciallv iiiifav(;rahK'. TIME OF DEATH. The early or late occurrence of death depends in the individual ca-o e-peeially upon the aire and the constitution of the ]>atieiit, upon the -[iccial form of the disease, upon the distriiiutioii of the tvpiioid process in the various orj^ans, as well as upon the niimher and the character of the com|ilications. l?eference will he made later to a niimlicr of espe- cially inijiortant ]Kiints in tlii- connection. It is, however, not without value to oiitain ireiiei-.il fij.rures with rejrard to the time of the fatal ter- mination. The larL'est iiumher of deaths in aveniire epidemics of ordi- iiaty character occurs hetween the <(fin\<\ half of the s|H'(ial cliaractcr ot' .-oiiic ciiidciiilr- i- nianiti>lt (ifdiaili. TIk'^c ('|iid( mil-- arc cliai'actcrizi'd iiy ilic frciincnl occurrcnci' of j)rofonnd intoxication or (-intiaily early inio.-tlnal hen.orrliatre. It is of jii-aetical iinj>oitanee to note tliat death may occur, and liy no means rarelv, Ion;: after tlic termination of the fcWrile sla^'^e. Marasmii-. Hlui:c;i>li j)roce->es, anil >e(|nels play an iinpoilant rnh- in tins coimeetion. I have ol)servesic in the first week of the disease i" t) cases — 2.5 per cent.: second weik, o7 cases — !•">. 1 jM-r cent. ; third we.k. ti.'i cases — 2r>.'J per cent. ; fourth week, .'>! ca.~e.s— L'n.!) per (-iit. , iifth week. l."2 cases — 9 per cent. ; sixth week. 20 c:i.-ies^8.27 j)er cent. ; seventh week, i* cases — 3.7 \>eT cent. ; eifrhth week. 7 casi s — 2.1' per cent. ; ninth week. 5 cases — 2.1 per cent. ; tenth week. 2 cases — 0.^*2 f>er cent. ; eleventh week, 4 cases — 1.0 per cent. Death thus occurred between the second and the fourth week 'n 151 eases — per cent.; eleventh and the fifteenth dav in •')! cases — 14.1 per cent. : sixteenth and tlie twentieth eases — 12.4 jier cent.; twenty-sixth and the thirtieth day in 45 cases^l2.4 per cent.; thirtv-lirst and the fortieth day in ;>5 esises — 11.4 per cent.; fortv- fir.st and the fiftieth day in 21 ca.«es; — 5.8 jier cent. ; after the fiftieth day in o^ ,..,a,,_s — 7,7 per cent. From this it follows that in more than lialf of the eases — I. c. 21') (58 percent.) — tleath occurred between the eleventh and the thirtieth clay. .\ecordiii experience, the pr(>jrno~is of relapses is in ^reneral more liivoraMc than tliat of pritnary attacks and of nHTiidescences. Of the cases of tyjihoid fever with relai).se at Ilandiurp, I ohserve per < ent. CAUSE OF DEATH. The causes of death in detail have ])r"viously been .somewhat di.scussed (sec the chapters on SvmptomatoloL'V and on Course and Termination). With resrard to manv ])oints, therefore, reference must be made to them. Death results, on the whole, in one of thn-e ways. In the first i>lace, in consequence of the severity or the sjMH'ial character of the intoxi<'.i- tion ; m^xt, in coniie<'tioi with unii>nal dev(>loi>ment and -evere course of the peculiar localizations of the disease, especially in the inte-tinf, ::m^Mi£2m:'^M^- r.WM. ti:i:m/\.\tio.\. i-iKxtsusrs. ;{89 fill' rcspinitdry orjr-iii-, lliu iiL'rvi)ii> >y.-tiin, ami tlio kidncvs ; and tinallv, ill consocjiieiur of tlie si-at ami the sovcrity nt' the actiial coinplicatums. Tlio severity ot" the intoxication is prol)ai)ly tiie most inijionaat of the causes of ileatii. From .'K' to oO |)ei' ceni of tlie de^itlis are, in my experience, to lie attrihuted to it. In a larjrer sense the c;ises that jilirsne a I'atal termination with the clinical pietnie of the hemorrhajxic iliathesis ami of hyperpyrexia may also be incliideyiii])toms of actual complicating meningitis. Although, without doiiht, eonstitiition, sex. age, and individual eir- ctiinstauces occa>ion a variahle su>ceptil)ility on the |)art of the central net vims system, it may he stated in general that the prognosis is the more unfavorahlc the more profound are the symptoms referahle to the central nervous system, and the earlier tliev a])i)ear. Liphe-nieister niade an iiileresli.i;: analysis of his patients in the epi- demic at Hasle lietween jst;:) and Is(ix with reference to this point, and fouiiil that of those who exhihited no striking: cerehral svni]iti)ins during the course of the disease. :>..') per cent, died, while the Miortality in those patients in whom only slight conditions of e\-citeiiient. of short duration, or occurring only during the night, had existed, was l!t..S p,.,- cent. Of the cases with marked, furious, or with nuitteriiii: deliriimi. .")4 jter cent, terminated fatallv, while those attended with so|)or and coma exhihited the enormous mortality of 70 per cent. With regard to the ctl'ei'fs of the toxins upon the circulatori- organs, the disturhances that occur in these are also undouhteillv to he onn- sidcrcd the more serious the earlier they occur and the more severe they are. They are usually included under the general designation cir.liac wcaknes-. It is .ertaiii, how(>ver, that in eases of typhoid fever and (d other inftH'tious diseases disorders of the v.isomotors, as has heen pointed out, play just as important a n'/r as disorders in the activity of the myocardium itself. We are at present, it is tnio. not yet in a posi- tion to di-^tingui-h definitely one from the other, or to iMimate the share each takes in their apparently freipient corabinatioiis. ' !? .-^^•^i-'^-- >..Jti- ,4s. ---^„-<^fcs>- ' r?^ -^.- •^r^lfi.^^g^^l^f^^^ rw ^■i. Wtiil t' ■ ''t a;io TYi'iKiih ii.vi.n. Tlic iui)>t iiiijiciriaiil -iiidr to llic ^latc ni' tlic circiilatiTy orjrati- is funii>lu>(l, now a- alwav-, liv a ^iiidy of tlic |iiiIm'. It.- t'i('(|iifii(y alniio mav Ix' nl' I'dii-iilci-alilc iiii|pnrtaiicc — 1( — , it i- true, in tlic ca-i^ of women, cliil of either mx. While in the foinier ^reat fre- qileiiev of ]iiiU<' a|i|iearinLr early is eniiinion, and i- of ii-clt" ot" little siL'iiifieaiiee, it iiiii~t, ill >tidnLr yotiiii; men oreldeily iieivon-, even liy itM'lf admonish the ilinieiaii to exerei-e jrreat caution in ])id!^iio-i-. It liiav even he a matter of coiicer:! if in an a]i|iarcntly ,-troii;^ man the almost typical relative .-lo\viie-< of the |iiiUc ^o p^nerally pre-ent in the first half of the i'ehrilc >taire remains aliM'tit. Dimimitioii in the tension and alteration in the rei;iilarity of the ))iilse are naturally to 1)0 eonsideretiirl(anees are all the more sifijnificant the earlier they appear, the Ioniser they last, and the more po.-itivcly it can 1k' stated that tliev are not deiiendent n|M)n jirohalily transitory complieatioiis. The cxtraordinarv jn-ognostic importance of the state of the eircnla- tion was especially appreciated by earlier ]>hy>ieians. With the iiitro- dnetion of lliermoin"try. and the jiriniary enthusiasm aroused hy this new method, it was undeservedly jnished somewhat Mito the haekj^round. At the present day it has l)een restored to its jiroper position, and there is no iloiiht that for individual ])r(>frn(>sis, on the whole, tlic state of the ])iiKc atfords hetter and safer cratnre. The jirofinost'c interpretation of the course of the tem|)cratiire is dis- tinetlv more ditricult, and i- dc|)endeiit ii|)oii the mo-t variei»licalilc only to rare conditions. Tempera- tures of 40" r. and al>ove, (-.pceially in adults, if fre(|Uently rejicateil, or if a per^i-tentlv Iiigli tem])c: e considered seiioii-. The prois is under some circumstance- reii- derfvl unfavorahle also hy ahnormally low temiK'ratiires. The collai)se anil pseudocoUap^e jireviou-ly mentioue-''t*t- -■■ ^ - - ^^^ ' i" - -' ■ ■ -•■ , ''^l'> • ■.TV-* /•M /'.I /. /■A7M//.V.t 770.V. rilmiSDSIS. \vn Fiirtlicr, pruiriKislic coiiclii^ions Iki-cnI ii|miii tin iriii]icr!iture >li(>iil(l iKit he I'liniuil atUT lno >liMrt a |)cri()(i uf (il)~crvatinii tw witlidut coii-id- , itioii of tlio reiiurmiiij; (•iii'iiiii>taiici~. liuliiil, tlii' rtatc of tlic IkmH- tcii»i>i'ratiiro in ca^os of typlidul fever, as in xiinc otlii-r infections ili-eascs, i> as nineli ilcpciulent upon imlividnal cireunistanee^ a- i> tlial of llie ncrvons >_v-teni and tiie circiilaiiTy orj,'ans. Ev.ry pli_v>ieian, ami e-peeiallv tile family praelilioiu r, lias ineontroverliMe evideiici' of the fact tliat dillereiit individual- exhiliit not only ilitferent felirile reaetioiis to the same inflnenees, hut al>o varying degfees nf resi-tanee to tiiosp inrtueneos. Presnppo-ing all this, it i-, nevertheless, n-efnl, e^jxrially in the first part of the diseasi>, to seek prou'iiostie guidance from the state of the temperature. The licighl and the character of tlie curve are, in this connection, of ccjual imi)ortance. As Wnndorlich and his jtiipils have point(>ions, arc indicative of a severe course. Especiallv the hy|M'rpyrotic and fulminant cases ai-e prone to l)egin with a rapid, nninterniptcd elevation of temperature (Fig. 2o, p. 2H!t). On the other hand, it should not he forgotten that es|)ecially the abor- tive cases pursuing an unexpwtedly rapiil and favorable course at times set in in an almost identical manner. While })ersistent high temperature with slight remissions is in gen- eral to be con>idei'eil unfavorable, evening exacerbations of even con- siderable height p(-rmit of a favoi-able interpretation if they are associated with marked morning remis>ious, or even intermissions. It may be stated in general that the earlier, tlie more marked, and the longer the remissions, the more favorable may the course be exjHH'tee. Naturallv, remissions following a continued fever of considerable (hira- tion inav lie welcomed as an indication of the early advent of the stage of steej* curves. AH these circumstances, however, it may here be repeatparently unfavorable course of the temperature. In the ])resen('e, however, of a snspieious state of the pnlsi', no cour>e of the temperature, not even ap,.xr"ntlv the most favorable, is to be trn-ted. An im|Hirtant aid in the inter|uetation of the pnlse and the tcm]K'rature may Ix' jirovidei! b_\ the state of the lungs. Suspicious changes in the ibrmer must l)e Mil =;:; ,m ■}i ,.yi*: m p ■M2 TV ri loin ii.vi:n. (•iin.~i(i(n(i tlio more serious wlicii cxlciisivi- Ipmiicliill^ :i|i|)r;ii> tailv in jirfvidii-lv iic;iltliv imlividiial-, ina.-iiiiicli as ii> mvci'Iiv, apart tVoiii its (l(]Hiul('iii't' ii|Hiu the iiiltii-ity nt' tlio toxic rtrcct, is related e-peeiaiiy to tlie iinj)airineut of earilia<' aetivity. Still iiiok (li-tiiietive in this comieetioii, ami .vnnetiiiie^ evident even lietiire the pnl-i' ha- ae(jnirer and lower jiarts of tlio luiifCs. The jifoirnosis is naturally ino-t imravoralile with the onset of actual hvpostatic conixer-tion, .-iniple or iiitlaininatory. ( )f the lo<'al tvphoicU"ed, only the nio-t itnp^.rtant will he coiisideied in this place, and then e-peeially in ri^aril to their |)roirno-tie iin]iortanee. ^\ o shall con>ider first the state (.f the intotinal canal. The oeciirrenie if mcteorisni is, from the jiroirnosiii point of view, of in"stiiiialilc signili- aiiiee. Aithoutrh its ap]>eurance i-. in trenei-al, little to ho desired. it3 prcseiu'c in marked dcLrree and it- nip'd development at the heifxht of the disease in jiatients the ri'L''idation ot" whose diet has not Keen noeverity of the diarrhea, or even to the severitv and the extent of the spei'itie typhoid le^ions of th(> intes- tine. Thus, r have ol)>erved the u-ual meteorism of the larLTO intestine well marked in the ahsenee of the sliirhtest intilti-.ition of the llillieles. That the fre(|Uency ot' the sto, and amontr the most fro(pient causes of death, are two other manifestation- on the jiart ot' the intes- tines, viz., peritonitis and intestinal liemorrhaLTc. Peritonitis is, ot' the two, the less common hut liy far the more daiiL'crous condition. In the nature of thing's, it is in the overwhelmin*:Mi per cent. — died, the proportion of these to the remuininc fatal cases was 14 per cent., and if all cases of typhoid fever he taken into coiisiiis v:irie.< in ^ccDrthnce with teniponil siii'l local iiil'lueiK-es, ibe |ir(i|)<)rtioM of fatal lases Iroiii pfritoiiiti.s to the reiiiaiu- iiifr fatal cases of t_v|)lioicl fev Hopkins Hos- pital, 'JO (ol.Tl per cent. I \\ere a.-.-ociateil with perforation ;nil peritonitis. Therefire, of the entire ^21» case.s, L'. U per cent, terniinalml fatally from this accident. Altlioii"-ii a iniicli hirt^er iiiiinher of cases of typlioid fever are seized with intestinal hemorrhage than witli jieriloniii.s — this cniidition i.s likeK to cM'ciir in from .', to ■', uinl even up to 7 per eeiit. of all ca.-es — this ircnnistance i~, iiowever, ( ipcn^uted tiir l>y the fact that e\ eti in the severest epideniics not more than from 20 to ;5() per cent, of such cases terminate fatali\ ; 40 per edit, noiild Im tiie e.\treii;e limit Moreover, it sl„,uld lie enipha-i/.ed that at timo the mortality iVotu intestinal iiemorrhatre is remarkahly low, and, in p'lieral, i^ far hclow 20 jier cent. The varialiility of the condition- in thi- coimeetioii i> shown hy our Hamhnrj^ ,stati-tie- tWr two i-onscciitive years ot vir'nally the same epidemic. While in the year ISSlJ 20.!) per cent, of tlu! c^isc.-, with intestinal iieinorrhasre dieil, ihi! proportion in 1SS7 was oidy 11. t) per cent. In >pite of the nnieh sli;,diter daiiL-'er I'nnn intestinal hemorrhage in the indivitlual case, its mneh i;reater frecpieney jtnts it, nevertheU'ss, in the front rank among the eatisos of death. I should estimate its mortality at about two-thirds of that of peritonitis. .\nioisir the Sl'U ca.ses of ivphoid fever at the .[ohns Hopkins Hospital, heiiiorrha;.'e from the bowels occnrred in 'I't , (i.O:; per I'ent i. Of these ."iO ca.s(s, .') I 10 jxT cent. > died. Or. of all the ca.ses of typhoid fever, O.ti per cent, terminated fatally from this complication. Scaroelv le-s dani;eroas are tlie diseases of the lungS, espoeially the various f.>rms of pneumonia, with tlieir se(|iiels — abscess, jraii of the i;n])erfect development of the etioloi^rie, and espei'ially the bacterioIo!jri(% basis of the various flu'ms of pneumonia, it lias hitherto not bet>n possible to roach definite views with rei^rd to the |)roiriiostlc siixiiificaiico of the individual varieties. In i-cirarti to the time of onset, tlu' forms of pneumonia that deveIo]i late ai)|H'ar to Iw especially unfavorable, liecaus-, under such eircum- .stances, livpostasis. antere(lont cNteiisivo broiioliitis, cardiac enfeeblemcnt, and vasomotor di-lnrbaiicos exert an unfavorable influence ; but al>o those cases that develop at an earlier period. ] irticularly the initial cases proirressjni: under the picture of the so-ealled " i)neunioiyphoid," may beeomo (piite daiiL'-erous. That a tlic cicciirniice of [iiuiiiniiliia i- [Pidlialilv aluay~ a tlilal cumiilicatiuii, llic iiKirlalily I'niiii |iiu'iiiii'iiiia in rhildli 1 i- low. 'I'lir t'avoi'alilf (•iiiiditioii nf ihc luarl ul)viuu.-ly iiK r(a>L-' the puwcr.s ol' roi-itaiue iiiuKt tlic-o circuin- slaiices. Pleurisy, wliicli i- mucli !«■-- (••iniiiiuii, i-, a|ian t'niiii llic |)i-(-(nc(' of i)iinili'Ut anil puliiil cliur-ion-. I>y no nuan- -•• nntiivoralilc a- |inrii- iiionia tVoni the jiroj^no,-.iic staM(l|)oiMt. Small ami even coM-idcraMc ftl'ii.-ions suli-idc williont initoward < nii-riiiicncc-, rvcn willioiit llif nocositv tor jiiin tiiif. Thai jialiint- -iill'ninir IVoni ilironic lirondiiiis, eiiijilivscina, or juiliiionary iniicrculo-j-. iictliro tlio a matter of course. Tlie relation of liiliereulo.-is to tiie eciur-e of tlie attack of typlioid fever lias been fully con>ideri'd jinvioiisly. The condition of tlie kidney is also of j^reat ini))ortance from the prognostic standiMiint. K\cn the cases with -iniple febrile aliiutiiimiria are to In' con>idered cantion~ly. This condition is indicative at least of feelile jxjwers of l•e^i^tanc^■ on the part of the iMKly to tlie action of the toxins, and it is, in piiefal, to he considered the gniver the earlier it appears. The di-covery of tlie excretion of alhnmin may he of especial si'Miifieance in j(i'ogiio>i> if it iH'curs at a time when the temperature is not particularly liigh, and when, also, the pulse exhibits no serious maiiift stations. Nepliritis has a notewoithy inthience ii|ioii the nior- talitv althoujjli it is not so iii)|«ii1ant in this connection as tlie diseases of the intestinis and the liiiif::-. Although with regard to the frei> of so-called nephrotyphoid is gen- erally rwogni/(Hl, but it is by >ome French inve-tigators, however, exaggerated far bevoiid the actual degree. Of tin.") fatal cases in Ham- burir and I.eipsic, -JT — I.") ]>er cent. — were attributable to comjilicatiiig nephriti'. Th.' iinif uTiiity of it- occurrence in both sets of statistics is noteworthy: while of "J b'^. fatal cases at L.'i|)Mc, "hath was due in 11 — ■\.(\ per ce.it — to iiejiliriti<. atnonir the -MVl at Hamburg, nephritis was the immef light in the Ldoomv prosiS. 396 toxin upon the heart and tlic vuMimcit(ir> in irciunil, tlir inr tlic iiiviK-ardiuni, the |>iri('ardiiim, and the endncardiiiiii as can-cs of d'utli arc iiicon^idiralilc The i)ruj;iiu.«i-. uf iy|)linid niycu-ar- ditis lias :• adv liirii |Miiiilcn nf cases of siiild ii deatii. It is not worth whih' to discuss iiidivii0 cases observed at Iland>ur^' and Leipsic : CAtsES OF Death. Sovpritv III' tilt" intVctinn . . Iiitestiriiil iiiTt'i iriit.il in, jiiTitmiilis Iiilr.-limil iicmiirrlmijf I'lii'iiriioiiia Ni'pliritis lli'miirrliiiiiir iliiitlu-sis i*\i'niiji, seiitic'i-niiu Kry.-ipi'l:i8 Di'i'uliitu.^ Miiltipli' iili'icesi'i's Niitnii I'lrerativc liirvriLriti-. iiiM'ri>>ii» of rftrtihi;;!', iiiul ?lm]ui'1.>; I'ulmiiriary oilcinii Sorntibritiiiu- oxuilHtivi- pliMirisy . . Eiiipyema iif the pli'iira I'yiipTii'Uiiiotliiirm .... PiiliMiumry tu'''"rcul(i>i3 ami mili- ary tulllTl'Ulil.-.is PiilTiinnary Ptnliullsm Fatty liPart (niyiicanliti? ?) . . . . Kriliicanlitis Delirium tniiiuins Mi^niiii^eal tii'niiirrhHi;f PuruliTit nieiiiiiL.'iti'i witli ciirii> "f the temporal lione Dipluhoritt Almrtiiin anil premature lalinr . I'yusalpin.x. perforative peritntiitis . Total lltini |U^^•. . 1 I.ii| sic. I'tTii-ntane. NiimlMTof cases. I'orc(-nlai;p IS.; .M 1 S!l 4 J. 4 r<\ 11. 1 4(1 I'.MI Lil il.ii III I'. I) "ii; 1 .-. .-. L'4 11.4 Kl ■1 ;: 11 r).2 ;> 'J. 3 o n..-) 8 3. s 4 1.1 '> o.:i 1 or, 1 (1.3 4 :{ 3 1.1 (I.H (I.H 1 1 0.4 3 n.H 1 (1.3 3 (I.H 3 1.4 1 (1.3 •) (i.'.i •) (I..-) 1 0.4 T (1,3 1 11.4 3 1 (I.H (1.3 1 (1.3 1 (1.3 1 o t 3(17 4 1 :il3 I.'.I (1.4 With rctrard to the manner in which death occurs, it is t^caroely worth s|M'akinj; in detail. From what lias been previously paid, it will apiwar that it is most frcijiiciitly jiri'ceded by sym])toms of the most profound intoxication, with paralysis of the h(art and the nervous system, and these are not much ditfcreiit in cases of typhoid '■ el 'I il .^ m .|^^^* .a ' A- l^!c ;;!Mi TV I'll' II I, I i:vi:i:. fever tli:in ill iitlitr acute iiileetiDiis , (H' lliosi' nt" e(iiii|)liealiori>. Kaeli ol' tli( i'alal local (li.-urilLT.- iiaiiirally iiin>i(-ses with its jiarticiilar >taiiiii tin maimer in wliich (Icatli uceiir-. SUDDEN DEATH. Ill '■Imlinj; this cliajne, , only the cases ot" siiddeii death in the eiiiir-e (iv typhoid I'evcr will he (oii-i(lered miiiu-*" jiat iiiori> in detail. 'J'hesc l.icliido the ca.-es that loniaiii indelihly lixed in the meniorv of the jihysiciaii, in which, quite nnexpectcdly, iliirin^' eonvaleseetiee of apparently >atist'a tory pro^rr,.,., ilu.re occur Mid. As with s any strikiiij; clinical features which arc cspei-ially iinj)re»ed upon the incniory of the ]>hy-ieian. and are theret'ore more friH|iiently ile-crihed and mentioned in ~tati>tie>, >o, with rej^aid to the cases ot'>iiddeii death, an impre>-ioii ha~ nncon-i'ioii^K hceii jruined that they are tiir more frc(pient than they really are. On the coiitrarv, I coii-ider their occurrence as aetiiallv iiifrei|iieiit, and lulieve, in addi- tion, that it eat) often he prevented it' in the later -tajre< ot' the di-case, |>artienlarly the ])eriod of c(invales<'ence, the patients are carefiillv watched, and are kept at list pliy-ieally and nieiitallv, and are not permitted to p't out of IilmI too -ooii. 'riii> -tatemeiit implie~ that the oases of sudden death are lik( ly to occur esp((iallv in the period of deferve-cciice, and even *till 'iiofe t're(|Ueiitly in that of convalcM'eiicp. The nnliu'tunatc occiirrei i~ iiiconijiaraldy le-s common at the heijrlit of the di-ea-e, and it has lieen ol)>ervcd oiilv exceptioiiallv in the fi.^l week. Tt Would \>o a mistake to helieve that easc< of >iiddcii death occur with |ireferenee in persons who already are esjiecially d( liilitatcd hv rea- son of coli^tituton, age, jtrevious disease, severe, protractinl course of the attack, or comi)lioatioii. < )n the contrary, rohiist youthful individuals are attacked quite as often, almo>it still more freqiunlly, even after attacks of the disea-^e of modersitelv reviou-lv well, hut still laiiL'nid /I TM. I'lCnMISWrinS ri!{ tr.in-iciit i)al|)itMtii>ii ni' llif lican, i\liilpiliiiL! a latlicr ~iiiall, iiii-talilc, a. id tic.|ii(iit |iiil-c, Middiiilx , in ur iiiit '<{' Lnl, ;.nii(ially while (■iiL':i<;id ill -iniic jiliy-ical viYxvi itiiii'.' ii|) Id take fund, IT I'oi- (Xaiiiiiialiiiii i.r ddicali '.r iiidiil^iii:: iu -li'Tt \valk> <'cpiitrarv U< lli'' iii-iriii'tinii-. uf tin pliy-iciaii — liiMuiiit- pale and coiiaitsc-, t'alN hack, ami die- wiiliiii a \vw iimmiiIc-. H' tin' ]pli_v.-i(iaii soipii ri'acius the i)atiiiil, lie will ;.'ciicraily ,-lill he ahl.' Ipp imlire -ome- wliat sttTtorous l.realliiiii:, while the jiiil-e i- already iiii|p( ne|p|ihle and the licart-soiiiuU are scareely aiidihli'. The iiii|)res-ioii is jrained that liie patient has >iu aetiial heari-i'ailnr ■, tip whieh cenhral aiiPtnia, as (Piie ipf th • inanife.-tatiipiis ipf ipimIppiiikI Iploipd-ehanp', ha- ei>u- trilniteo(pii afterward, by I^evden*^ and his pui)il, Miller,' in an e-peeially iKPtewcpithy cppmiunuiea- tioii. The question was further elucidated hy the invotiiratiipii.s of Ronil)e'rg' uj)on typhoid myocarditis in my clinic. These more recent pulplicatious have >hown that intlaminalory alteratiipiis (pf tl'c myipcar- diuin plav the iiKpst inipiprtant rn/c in ihi> eoimectiipn, while the earlier investigators a-sumeively from Ciirdiac failure, while Iliichard, Bussaril, and in part als(p Dieidafoy,' consider cerebral anemia as the more important cause. I believe that we have to do here with an unpromising contnpversy, and that both factors are inseparably necessary flir a full explanaticpn lit' his trrm of a \iai'. was ailaikrii iluriiii: tlir la^t |*-iiiMi nf Ins ,-iTvii'i'. Ill- riirniiui il tn ilia_' lum.-iir aluml lor ihf lii>l un k. Iiijl iluriiij; llir liillnuiiiu' "fi'k \\a,> inir-iMl in ilic la/ari-tli), ami .luliM-inicnlh al Immr. Ill iIm- t'uurlli Wfrk 111' ua> I'lri' t'riiiii l'i\rr, liaij a i/uml aji|iflili', aiiil wa> in a riinli'iilcil t'rainr III' miml. .-n lliat tin' |ialunl ami liis tVii-mis coiisiilcrril it |H'iianiii' that 1 t'urliailf lii.- L'lUini,' np aliir luilvr al'i'lirilc ilavs liail |ia.-.-cil. .My |irniiiliiiion ua.s lia.-nl iiimn llic I'ait that tin' jialifiit, in fpilc nl' (.nh- iiiiriiial toin|ifraliirr, siill ninliiiUfil to ixhihit a miI'i, now ami a^'ain itilcr- mitlt'iit. |iulsc iif iiinrc than ><0, ami at the same lime. \\ ith rltar hul taint hfart-siiumls, cxhihiti'il the >i'_'ns ol' slitrht ililalalimi of the niviuanlinm. On the fuiirli'i'iith ilay nf lunvah M'cmf the nnrsi-. rutaintil hy im\ (liiccliori, (in rrtiiniin;,' tn tin- rnoin allrr an aliM-ncr nf scarct-lv ten ininnus. fmiml the |ialiiMii lyin'.: in frmil nf ihc linl, nmniiM'inu- ainl |inl.-(li->s ; anil lirfnrc >ln' ua.- a I lie In siuniniin asM^lanrc the paliftil was ilcail. A]i[iai(iit Iv, tin- patient hail. riinlrai-y In inslrmiinn.-i. i/ni nnl nf In li Inr the purpnx' nf uriualiii^. l'ii>l-tniirlfni I'.vaminalinn \\a.- nni piTiniltfil. Tlic sci'iinii ci'M' is cspcriallv nntiwnrlhy. 1 tcansr I was prrscnt when (Icalh nrciirri'il. Thf paliint was u wmuan. thirlv-diii' viars nlil. who. alicr a iniiiliralt'ly si'Vcrc attack nf lyphniil fiver of iiiur weeks' chiration, wilhont ciiMiplieations, hail lieeii free from fever for five ilavs. The pulse ranL'eil from DO to loo in the iimrninL'. up to 112 in the eveiiinj:, was mnck'ratelv full, tense, ami reLTular, Imt slill (piite varialile in frei|iieney, so that linrin:.' speakin;: or on sliLrhl movements after ealiiif, at limes also without extra- neons cause, the frei|iieiicy wa.s increased from Id to nil heals a minnle. The area of cardiac iiulness was appar(iitly nnrm.'il : the snnmls wen- ilnll and faint: no nnirinnr was aiidilile. 1 had examined the ]ialienl at llie mnrnin'_' visit and had limnd nolhini.' w rnii;:. and al her rii|nest had even onlar'.Teil the diet. After I had L'ot a dislaiice of three heds awav I was rei'alled. 'l i. • patient had sat liji and had reached for a letter w Inch had heen receivid .he evenin;.' hilnre. and which we snli.-ei|neiitly liiiiml to he of an exciliiiL'i'h iracli r. had siiddeidy heconie pale, and had fallen hack npoii the pillow unconsiinn-^. ."^carcelv a minnle elapsed hefnre I saw the patient aL'.'iin. linl her fialiircs were already relaxnl, the pnpils were dilaled and fixed, the pnlsi- was iin IniiL'er perceplihlc. aiid, after a few slerlnrous hrealhs, di'Mlli had taken place willmnt cnnipl.Mini nr snijnd. I'lL-l-mnrliin exandna- linn iliscln>ed nnmcmiis recent cicatrices in the Inwer pnrlinn of the ilcnm ,'ind the adiaccnt pnrlinn (i\' the larL'e inlc.-line. The hrain anil the hint's exhiliifed nn pecniiarilies. The heart was innderalelv dilated and relaxed. The mvocardium was vellowish 'jrnv in cnlnr. t'rialile. and liritlle. Mii rn- scopie exannnalioii disclnsed fall v dcL'cneral inn and scL^nienlatinn nf iherniis- ciilar lilires. with partial niijiteralinn nf the transverse .-Irialinn. The case was nhscr\cd a! a time when thornni:h microscnpic invesliLralinn nf tvphnid mvneardili> was not tnade. Imt I have no donht that the cnndilinn was of this clh'iriicler. [n aililiiii'ii tn niyiicarilitic ])afalv-i~ of llie heart ami cei-elir.il aticmia as a can-e nf sinlileii ilealli, pulnmnarv enilmli-m iiinlniililcilK- alsn phivs i-Mii. riinn\.\ri'i\ ri:n(;\iisrs. .'WO an iiii|M>ttaiil /■:/.. '\'\\< >iiiU.li :uv .l.iiv.-.l i>i [.art In.m llir rrnhial -iiiu-i- ((iiii — iiii.rir) ami tlir |Mriiilirral vrin-. pail i. iilarly llii».> of ilic iMiviiiiti.-, anil partly fn.m llic iii:lil -iiiilil.dl\ i:cii- I'M. tar ill allriKiiliiii; lln' iii;ij"rity ..I' all i-im- ot' ~iid' -ikI.I. ii .l.ath i- .tiilx.liMii .if ill.' ..r. I>ial arl. ri.-. I liavc pivvi..ii-ly iiicii- ti,,ii...i a .a r iiiv i.wii ilia-ilar ari.r. )• 1 1. iii..riliai:i' int." the ^lll>- >taii.c i>{' the Kraiii ami llir iii.'iiiiit^r- i- iii.t iimr.' .11111111.111. It .i.ciir- in .■a-c-i 111" till' li<'iii..rrlia-ii' vari.ly, a- "ill a- n.iu ami lli.ii in al.'..li..li.' palit'iil-. Till' \i.'\v iiiaiiilain-.l liy a (".'U l'"i'iii.'li iiiv.-tiLMl"r-, that .l.alli may rc-iilt ill .•oii~c.|ii.i t' -lid. I. 11 pi'.'iiliar iiil.'ii-ili.'atioii ..t' lli.' lyplioi.l int.-xi.-ati.iii, is f..r tli.' pr. -.iit uitli.nit linn -iipp.Mt. N..tirniL', also, ot a ilcfiiiitf rliaractcr lia~ a^ y.t hi't'ii .lt'im.ii-tral>' iiintTvatfd i'ri.iii til.' incliilla .il>l.Mi;:ata. parti. iilaily 1>\ lli.' pmiim.iirastric iitTvt, cx.'it.'d hv the .lis.asc.l int. -tine, is liaM'.l .'--(iitially M|m.ii the fa.'t that in til.' I'l'Mical .ih-crva'i' •'> ii|)iiii wlii.li tlii- vi.'W i- liaxil l.ical altora- tinii> .if an explanatory i'liara.''.r wife not t'.iiiii.l. The theory has, so far as F kn.iw, r.'inaineil without -iipporter-, an. I has lieen restricted ami altered hy its pr.m dilator in a later .'.ininiiiiii.ati.in.^ • Thist, I'uris, 18C',ii Vinlmw > .AiA/f.v'/ficA/, 18t;;i. lid, ii. * Loc. cit. III. DIAGNOSIS. ;.».^' !ilM l|!l lil;i 'I'm: iilr.ll rnctlH"! "I' i|i:ii.'ll"-i- of |\ |i||i.|(l I'lAi I- U III I 111 lie I llr ililll- iill-l ml ii Ml xsilll liaililii--, l:l|iiilil\ . :ilii| ri rliilllN nl' it - rall-c, I In- li.iiil- lii- 111' llliii'ili. iliiiiiii: iMix iiiriml lit' till ili-i;i-r. I Ml'iirtiiii:itrly, ilii- liicp-l fjatillal iiii'IIiimI i- nn! \i-! a\:iiialili' in a ilr^nr al all a|i|iriiacliittLr |)rrlrcliiiii. (^iii-I iiiii- liavr at linn- i\in linn iai-i'liinn tlii- iifiruiiisMi, hiiNMVir, wliilr rrlalivcK -iin|ilr !■ '■ tlif r\|i(rirniTil liac- t i~ il iiriiliiilili' tliMt llii' liMilrriiiliiLrii' iiirlliuil \niI| cm r Ik tlir • mIii- >ivi' mil' ill tlir iliauii"i~i- nl iiilfii« ili»<-a>i>. 'I'liiTf iirt, liHWi \ I r, rtrt:iiri ra-c-. in wliiili llic irm^l -kilt'iil ami jKiin^taklnu' rliiiiial -liii|\ aluiir laiiiiiil iiiaki- a ri-rlaiii iliairnii-i^, liiit wllilll lliav iiricri lie ill lillili 1\ iliiiilnl li\ liaili liiiliiiri'' Mltlliml-. I'lic riiiiliiir ii-f 111' lalmialiii \ iiuiIh"!- w liiinvcr pn— ililr I'aiiiinl, tlicnrurc, 1)1' tun »tiiiiitrlv iiririfj if ail aci'iirati aihl iiilaiii ilia^iiu-i- i« !■> !><■ liiailr in all rax-. I'liiv ilu imt ami rat t lakr llir |ilaii' nl" lanl'iii iliiiical iili-crvatinii, Imt iiiii.-t l>c nixanliil -iiiijily a> aiil- ami aiiiv-Miry t'aiturs ill arriving; at (liat;iiii«li iii|ii,-ii>ii>. CLINICAL INVESTIGATION. Ill arn mlanco witli (lio flirc^jniiif^ jmiii! .if view we |(liict' clinical iiivi-ti^pitim II ailvaiicf nf tlic liactfriilnf^ic iiictliiMl.s. Altlmujrli vc have III! kiin\vlt'liniil ti'vcr, wliicli is in it.MJf cniicliisivt' I'min the (liaf;iin:^tic staml|Kiiiit, tlitTc arc, mvcr- tlit'ltss, a iiunilxT nf -yniptnnis that, j.'rnu|ifc<|ii(ii<'c, and thi'ir as.sli<' ctTtaiiitv. The diaj^nnsis nf typlmid fcVcr is liy nn m(aii> ditliciilt if a nxse |)iir-iiiiif^ a typical cniir>c I'aii tu'iihscrvcd at tiic outset and fnr a cnnsid- cralilc time ; and if, in ailditimi, mic is iutnrmcd with npird to the remntc and the immciet |)romincnt po>itinii with rc^.^jird tn the rccnjrnitinn of the e — has Inst mnrc and nmrc of it.- dia^'iiostic sijriiitieance, and that at the jiresent day it is reeogniztHl to liavc licci. an oli^tacle to diagnostic progress in the past. At the present day it can mily liesjiid that an indi- vidual presenting the ty]>iinid >tatc liasheeri ti>r some time and in severe degree ex|)nscd to the iiiflncncc (nf the tn\iii») i>f an acute infi-ctinns dise^ise ; whether, hnwivtr, tlii- is typlmid fever nr sniiie acute diM-iis«", as, fnr instance, tyjilius fever, septicemia, meningitis, or miliary tuhcr- culo-iis, is a (juestion for further c-.ireful consideration. i i. Tl. 2« T-'^ M 3:'-', 402 TYi'iinii) 1 i.vr.n. ti) he taken into con.-itl'T.ition in tliis o.nnoction arc tlic char.iotor of til,. t'.liriU nisc, particularly the character ul" tlic tcnipcniinrc- and j)iilse-ciirvc- and tlicir rehitions to eacli otlicr, tlie acute enhirjrenieiit of tlie sjjlecn, tlic appearance of a peculiar ro>eolou> eru])tion, and tlio <'l>ar;icter nf tlie stocils. Next in irnporiaiicc are lironeliitis and pul- monary livpo.-ta.-i~, the .-tate of the IjIoihI, e,-pecially of the leukocyte.-^, and the demonstration of the diazo-reaetioii. With re^^ard to the course of the temperature, the character of it- a-cent, in the well-known -tep-like manner, as a result of which the heiirht of the fever and the lM;:iiinin<; of the fa-tij,'iiun are ri'aclicd in the cour.-e of three nr four, at luo-t live, day-, may he of ^rreat weiirht in t!ie differential diat:no.-is. Scarcely any ..ther infectious di -ea.se to lie taken itit nsiderati"n exhil.it- llii- mnile of (in>et. It is trui' that the contrary condition — iapierature — •Iocs not, a- ha- already lieeii seen, exclude typhoid lever, althoUirh it is fir more freipieiitlv oli-i'rvcd in conneciioii with oilier infection- di-- e;.-e< or with incomplete ah'oreviated ca-e- of tyjilioid fever. If one hears \VunderrK'ir> rule- .Icdartd -chematic l>y m>'iiilier- of the yonntrer .rcncration. ihev -hould he made to undei-laud that he was 1.— familiar with the afehrile and the incomplete varietie- of ilic di>ease, with re.fer- VescelK'c, in the lorin of the cliaracleri-tic steep .iirves, may also lieVe he referred to. In addition, it -I Id he pointed ..nt that when the di-ca-e pur-ue- a mild i'.,ur-i' and at a .ertain a-'c, c-iiecially in cliildh I. \v\-y carlv remi-ion- and intermi-ion- in the temper 'ure-curve -hould arou-e Mi-piciou of ty])lioid i'e-er ; however, tin- i- ti'ie al-o of -evenil other di-ea-.-.wiiich in oihe-- iv-|iect- enter into con-id.>ralion in the ditfeivntial diaj^iio-i-. The >uhiiornial temiieraliire, which alnio-t cin- stantlv and f >r a cou-idcrahle time f.llow- deferve-eenee, i- alMi to he l)orne in mind in llii- conn.rti..n. .Mthou^i i" it-elf it indicai.- only r verv from a e dor- it appear -o constantly and i- -o per intent a- in ca-e< of typhoid fever. That the tempenitiire-curve may he irreirular, vai'iahle. and whollv uncharacteri-tic in tin- various ineomiilctc firm^ of the di-eM>e has likewi-e heen fully poiiiteil out pn viou-ly. ■:r^r •':• .. _._ ■L.''-,v). ■ ,>\f . J'C-' ' ])l.\t:.\()Sfs. 40:] The character of the pulse is nuU'Wortliy on aocoimt of its sl<.w- ncss, L'.s|M.fially in yoiitlifiil, vi^rurous nuilcs. Its r(iiwi-kal)li- sIowir'ss i,] coiiiparison to tlic liciVlit of tlic tciiUHTutiire d(K« "ot (Hvur aiivwliere nearly so often in any otlier .li«case to Ix.' taken int4. consideration from the -tamlpoint of (lill'erenliai diafino.sis. Even tiie slowing of the pnlse atten(h'iiLr hasilar meninwitis is readily to U; distinfrnished from that of typhoid fever by the time and the nuKJe of its appearance. The dicrotism of the pulse is also of diaj,rnostie sijriiiiit-aiiee. It is nnieh more e((inmon in eases of typhoid fever than in ail the other infections diseases taken toir,.t||,.r ; it, dccnrs in typlioid fever especially in ])ersons in the l.loom of youth, in laK'r cliil(llio(«l, and even in oldiT individuals who have not too marked ehanp's in the walls of the arteries. If hoth |)henomena, slowinj; and dicroti-m, are ol)>,.rved top'ther, this fact may materially strenj:theu the .liairuosi>, even in ditferentiation from basilar meninjritis, in which, in a.lditiim to slowing, dicroti^tn is scarcely ever oi)served. 'I'he State of the spleen is of' dia.rno-ti<- value if its acute enlarirement is observed to occur towanl tiie end of the first or at the ix'irinning of the second week, after the sli^p-likc ascent of the tempera- ture-curve has tak.'U place. In no other acute infictious i ially at the time stated, even ajiproxiuiately so fn(pieut ; and in none does this condition persist so l,,ujr_into the third or the fourth week .,f the disease, ami perhaps lonuvr. It is eomparalively rare for the cularj^ement of the spleen to ap|)ear befbrc the becriuuini: of the fever or duriujr tiie very fir-t davs of the di-ease, and this di-.tiui,'uislies typlioid fever from tv'phns fever, and from tlie acute e.xantliemat.i, f,, wiiich lypluis is clo,elv related, if these disea-es should ever be attended with any cnlaru^ement of the S|.l.'en. Tlw state of the spleen diM-iui,' nOap-es i- also notew,,rthv. The per-^istenee or lli(> reappearance ,,f its idargenient after th- primarv '''■'''■''^'•■^'■''' *'*'"• fever is indicative ,f an iiupendiug relap-.., and aids indistinirui-liiuirit, if it d.v.'lop, fn.m tibrile conditions of utli'er oriir;,,. Ahhouirh the typhoid stools possess no ,,uality that is peculiar to them, nevertheless their color, their watery character, with the result- ing tendency to the fbrmatiou of layer-, the yellowi-M, di-intcirrating f*^''!'""'"*- '' ly-tal-. tlu' p.iietratiug odor, togetlwr with the n'lativ ■ infre.|ueucy ,,f the di-charges are offu (|uile di-tiuetive. It is true tliat the diarrhea is Ics, constant than the eularg<.ment of the spleen. It has already Ixm -.■en that scarcely ,.ne-tlnrd of all <'ases exhibit thin stoMJ- f,,r a consid<>ral)le time, while not a few, on the contrary, are even attended with per-i-tem constipation. .WL.-..uA m If^ ■.^.- ^^- -C > wV'^' will' 404 ryriiiiii' ievi-ii I)i;iiit, on the otiier han.l, it is, a- lia- already Ix. ii jxiinte.i out, merely a reMilt ot' tlie inlliieiiee of the toxin upon the inti nal wall. A- it may develop in a similar manner, ahhou>;li le>- eommonly, in tiie eour-e of other aeute infectious disea-es, e>peeially pyemi.' proecsses and jreiieral miliary tuU'reulosis, it ma\ at timo ev.ii iiierea.-e the ditlieulty of diairn"sis. The ino-t siirnifieant. almost speeitie. manifestation i^ the roseoloUS exanthem. Only with extreme rarity and only in a few other dis- eases do eruptions oeeur that ean seareely he distinpiishiHl from the typhoiorte amoii^' the principal l<;iis of tvi)hoid fever, .uost the most fre«iueiit — l)y far more c.mstant than the alter,.! state of the howcls, perha]>s even than of the enlarjre- mcnt of the spleen, and at any rate is in jieneral more readily and more certainly rcrojrnizahle than the latter. If, in addition, the time of the first ai>pi-aranee and t'lat of the disippearauee of the roseola-, thtir apiHiifance in (soj)-, their characteristic distribution uih.ii the Inxly, and the short duration of the individual crtlorescence betaken into consid- erition, thev may be considered! as one of the im)st valuable si^rns of typhoid fever, annt that facial herjies occurs so riircly in typhoid fever, even in the first febrile period, that its ajipcaraiuv in the initial stage of an infections DrAaxo.srs. 405 iliscasc (if (linil)tfiil clianictcr is ajpiinst its hciiiir typhoid. EsjwH'ialiv cortaiii diseases that arc ot'tcii to he most farctnlly considcnHl in the (hfTcrciitial diajriio>is ot' t_v|)hoid ("ever in tlic initial stajrc — viz., jnu'U- nioiiia, (•(•rchrospiiiai iiii'iiinjritis, typhus li'vcr, inahiria, and others — are, liowever, eharaeterized l)y tlie freipieiiey witli which heri)es >eeiirs. The diajiiiostie sigiiitieaiiee ot" typhoid bronchitis is not in<'on- sidenihle, and n]H)n this I place enipliasis, in contradistinction to other writers. AUlioiijrli it ]>resents notliini; characteristic as an indi- vi(hial symptom and attends all other jM)ssihle infections diseases, and some even in special dei;ree, it may he a valnahie sij^n in the not infret^ueiit cases in which, althouj;h the e.xistence of a febrile disease lias been determiiied, other symptoms distinctive either of typhoid fever or of some otlier infections disejise have n( ' yet lieen recognize- toms, indicates the preseiK f a severe infections jirocess ; and under such circumstances the probability that it is tvphoid fever is most likely. Among the .symptoms that have recently been re<'()gnizehoid fever in children, and in adults also in the vast majority of ea.ses, and gener- ally, in addition, early ; and even in relapses, after having j)reviarticiilarlv miliary tuberculosis, pneumonia, certain acute exanthemata, malaria, and ty[)hiis fever, so that it ac(piires decisive significance with relati%'e rarity. More impirtant is the state of the white blood-corpuscles in typhoid fever (see p. 172). S)on after the beginning of the fever, and progressively from this time on, there ooeiirs an often considerable reduction in the number of wliite bhxxl-fcorpuscles ; this does not occur in a number of other diseases im]>ortant in differential diagnosis, but in which, on the contrary, a more or less niarkevniiit(ini- nf ly|iliiiid lisir do nut a|iiMar nr arc indclinilc, careful cuiMjirclirn-ivc invotipitiim iiki\' |irii\idc ilir ha-i- I'ur a mni- parativcly (crtain diaL'nii.~is liy cMlu-inii. Nut ranlv in oases nt' dli-eure i> some suddni m eiirrenee tears awav the veil and n^nders lear the exi-teiiei- uf ty|ihc.id t'ever. AiiMiiii: sueh conditions ..re, e<|>ecially in the initial stajre, to he taken into con-idcnition from the ditfcrcntial diaL'iiosti stand]ioint. it shmdd. however, he home in mind that it is likewise ajre.s, develops with extreme rarity, it is noteworthy, further, that the occurrcnoc of profuse or persistent sweating at the hei<,dit of the fever is stroiifrly opposes clear the history and tlie shorter tlie period of observation. Thus, the tbrtnnately rare, rap- idly fatal, fulminant or hyperpyretii' eases, especially if the history is not silirirestive of tvphoid fever, and if, with exee])tion of I'lilarjremcnt of the sjileen, no strikinir symptom has developed, readily fail of recojinition duriii, iiaincly, a >iniilar ascent ot'tlir icniiHTatiirc at a -inirlc honnd, at tinus at'ler ant(V('lii[iniinl >{' ilic >|il(.'fn. S.inc ot' ilic <'a-c> nf tlii- cliaractcr ai'c <-iin-iilcr(il a- iii-tani'i'- ol' central |ineinniMiia, or even nt' e|ilierneni, nnle~> llie |Mcsalence 'it' an epiiliinie <>t' ty|ilii nl t'e\er nr tlie siiniilta- nniMs (iceuri'en<'e nfdtlier ca-e- uliieli are well-niai'kitl lead- in tlie liLrlu direetidn. 1 lial al-n llie i-eniaininj^ aty|)ic'.d varielie-, the true mild and n\ilile-t ea-e- (it' tv|)li()id lever, may lie a .-eciallv if attended with remittent, intermittent, or irrejrnlar tempcralnre-eiirves. Si'areelv ri L't)i>;al)le at times arc amhulatory and at'chrile eases of tvplioid fever. I'^rror in diairiiosis in a nninher of eases in.ay 1k' dne to tiie fact tiiat thoronirh examination was not made, or that this was not sn^jjested liy reason of extraneons eirenmstanees. Iii some eases roscolre and etdarfrement of the sjileen, which occni' also in afebrile eases, and are scarcely less common in andmlatorv cases than in others, would otherwise have pointed in the riixht direction. I have already mentioniKl tliat in apparently mild cases, in which I'le patients walk to the physi- cian's office or to the hospital, one is occasionally snrprised by such a di.scoverv. In comparison with the varieties mmtioinMl, the well-marked heraor- rliagic cases arc much less to be taken into consideration from the diag- nostic .standiK)int. Fortunately rare in themselves, they p'lierallv exhibit the I'haracteristic symptoms of typhoid fever at the beginning. When, however, the case comes imdcr observatiim shortly before the fatiil termination, with an indefinite historv, it will be wise to do no more than make the diagnosis of an infections disease that has become hemorrhagic, but to refer its explanation to the prevailing tyjH? of epidemic. It should not be forgotten tliat occaslonallv a complication of typhoid fever with ulcerative endocarditis and seeondary mnltiple emboli of the skin may give rise to confusion with the true hemorrhagi form; and, as has occurr«l, that essential Pc]>ticeniic ulcerative endocarditis, if attended with profound toxic effects upon the central nervous system, may be confounded with typlioid fever. It lias already been seen how difficult the iliiiirnosis mav become if certain typhoid disorders of the viscera or actual compli- M 4i)H TV I ■11')/ 1 1 ii:\i:i:. cations liiimiiiiiti llir |>ictiirc(>r liu- (ii-ni-r (rnu\ llic (lutsct, if it sets ill (iiriitl\ wiili ilii' liical iiiaiiirr-inlioii- ulnnc, uliilc the i-ciiuiiniiii; ,s_vin|)Iiiiii» ili-l iiicliv r 'it' lyplidiil t'fvcr lii;ikc 'licir ;i|i|)('iii:iii(c laliT. We may iiu'iiliuri at ilii~ |">iiit the iicplirot vpliciiil, |)ii(iiiii(it\|)iii'i(i, and ])lriii'<>t\ [iliuiil, wliiih lia\r alri-aily licni t'lillv ilc-ci-jlxii. l-"ar tnnrc t'mniciit than tlic-e \ ai'iftic-, ami llicrclinx' (|iiiic nottwuiiliN , is incMinj.'-ii- typlinid, whu'li I wa- the tir-t to ^Iiidy caiil'iilly. \\ lit ii it is present, the dia may lie renilered ail the mni'e clitlienit iiom the fiiet that in larjre cities isolated ia~e- ot' lyplioid lever and (•erel)io~|)iiial nienin- j;itL- almost always i»-,\w >ide hy side. It is -.dso notewortiiv that in house i-ndemies of ty]>hoid t'ever oe('asi()iially nil the eases set iu with meninjritie -ymjitoms. The condition ot" typhoid perityphlitis [ircvionsly mentioned mav aUo ^'ive rise to error in i^ and seriou~ iiijurv to the jiatient, especially when it develops without antecedent characteristic diarrhea, or as occurs at times even after obstinate eon.«ti])ation. The condition l)e<'omes almost beyond the possibility of diaLrno~is when the appendii'itis develops in the conrse of the mildest form or of an ambnlatorv attack of ty|)hoid l'e\er, anyin|itom,~ have in larj^'c ])art subsided and are I'ree from tiver, are ali;:ht, seareelv appre- eial)Ie iiitiuences slmulil he reiiu'iiihereil. Nut less (iitlieuity often atteiinncti.'«-.-E.,f . 4T0 TYfiiniii ii:vi:i:. ■•<■. ■ ttiii|iiTaliir<' willi nlMtivrly ^'ri'ut rriM|U(iiiv ami iii-t:il>ilitv i.t' tlic iml-c is iiiclic alive lit' an ariliicdtni >cvcrr trhrilc (li~ra-c, ami in niiMc nl' all tlicsc is tlii.- symptiitn mi li(i|U(nt uml mi l)«•r^i^ttllI a- in ls|ih.iii-, oincially alter the lerinination of the actnal ili-ease, willi niranl tn the iliet ami |ieriiii.->i(i:i tn pi ued an irrcirnlar eoiir-e nr did not at all innie UiidiT immediate ohservatinn. SPECIAL DIFFERENTIAL DIAGNOSIS. Ilavini; estahlished trnidiiiLr principles with re^rard In individual syniptonis. syinptiini-Lrniiip-, and pneral inndil ion-, wc tnav now eon- tiider some ot' the most important di-ea>es which ina\- he eontonndcd with typhoid fever. I'ew ot" thcM' arc to he taken into consideration from the standpoint of ditltTential diaL'no-is thronj^hont the entire course of the (ii-ieas(\ hut most of them, aeem-dinjr to their character and their manifestations, are to i. eoii-iilcrcd onlv duriiii; certain staL'e-. Acute Miliary Tuberculosis. — < onfu.-ion of typhoid fever with acute miliary tuherculosis i~ especially frei|nenf, and vicf rersa. The Ix'-t diai^nostieians have made uii-itakcs in thi> connection, or have failetl to reach a delinite coiiclu>ioii after week> of ohservatinn, imtil finally the recovery of the patient [imvcd the ea^' to be one of tyjihoid fever, or po-t-mortem examination showed it to he one of niiliarv tnhcr- cnlosis. The ])rincipal dilllenlty in the ditfcrciitial diajrnosis re-iile< in the liict that hoth ili~eases often exi-t for a con-iderahle titne without C'on-|iicuous lot d manifotatioiis, while the distnrhaiici's in the general eomlilioii due to the action of toxins, the typhoid state, mav he e(jUallv developed in hoth. liotli di--eases, after an eipial dunition, are attended ■with sopor, niutterit)'_f delirium, floceitation, siihsultus tendinuni, and finally coma, and are prece is distinctive in each disease. This may he apjjlicahle to typical eases of typhoid lever. In protracted atypical cases, however, the temperature-curve, espeiially the markedly remittent or iiilermitletit type, may jrreatly iiK'rease the difficulty of differentiation from miliary tuberculosis. Profuse j)er- sisterit swcatinjr durinir the febrile statue, es])eeially with an intermittent ^ 1)I.[(,.\()SIS. Ill t»'iii|i(ratiin'-(iirvi', i- in favor ot iiiili;ny tiilx r(iil(i>i- and M^:iiii-t tvplinid I'cvir. Mure impdrtant than ilic .-talr ot ilic i( ni|iiratiirL' mav Im thai of ilii' |iiil-i', ina-ninili as ii~ nlaii\c ^lownt■--, mi fri'cjntiitly oli-crxol in ca-r- ..(' ivplioid fever in yontlit'ul indiviilnal-, does wil oeeiir in ea^es e is also incoiujiarahly K'.~s <'oiiiinoii in eases of miliarv tMliereulo-i--. I'lii' a|i|>earailee of the patient may alone he of -.olne importalleO to the trained oh-erver. In tiie ide-enee of miliary tnliireido-i~ a |Meliliar sjijrht, dilVnse lividity exists at the heiirht of the di~ea-e, which, in eom- hiiiation «illi the !_'eMeral pallor, ^.dvi- ri-i- to a eharaeteri-tie ajiptar- anee, e-peei,dlv ot' the face and th(; e\tremitie-. '!"he state of the spleen al-o i- notewortliv ; it~ enlarL,'ement. lieLriniiiiiLr toward the end of the lir-t Week ot'the dieeond week, is in favor r rotraetion of the alxlomcn is more frei|netit in eases ot' miliarv tuhereidosis, es|)eeially if the eereliral menihranes arc alni iiivolviil ; but, as has .ilready Ikhmi meiitioniKl, typhoid fever also is i|i:ite eomiiionlv tniatteiided with noteworthy meteorism either temponirilv or perma- nently. If it he considered, in addition, that ^evere eases of miliarv tuberculosis may also, precisely like severe cases of typhoid fever, be att(>ii(led with marked distention of the abdomen, the dianno^tie value of this -ymptoin is fnither iliminished. \\'itli reji^ird to the diasrnostic si(i.|ii(".illy wliollv uiiihararicri-lic cxiiiildratinii, ami in wliich, even ill ia-c~ of iiiiliarv tiilit niilo-i^, tiihcnli-lpacilli an rmiinl milv rxctpiiniiallx , and ilun arc ■Iciivcd I'nmi older uli (niti\c foci. ( )n pliy-ical cxaiiiiiiatiori, with a Hernial |h r( ii>.-iiiii-iiotf, drv rale.-, ~iliilaiit and '.inoi-oiK, arc p'ticmlly itrocnt in Loth di-ca-o. if. liowcvrr, an c-lHcially d.n~c, tVi-h an almost natural, r.adily expliealile rt-nit of the direct or indirect <«■< In-ion (it the hroiK hioles hy a imifoiin, dense, and recent ern|ition of tiiiierties. I he dillirential coimt of tiie lenkoeyto inav lie of eon.-idendile value in ditlerciitiatinL' the^e two conditions, in liotli of which there is a decrea>e in the ahsuliite mimhcr. ]5iit, while in typhoid fevtr there i> iisnally a relative increa>e in the larfre inononiielears, in .acute tniliarv tlllierrulo-i- llii~ does not oe<'lir. < )ne examination, finally, -honld never 1 niiltc complie.ated liy miliary tiihenMilo-i-. It is true that this ^^cncrallv occurs diirint,' the later statrcs of the disease, and even diirint: <'onva- le-<'cnce. In the latter event, even careful ohservers, espcciallv at the Ixtriuiiiiiir, will not always he -eeiire a^rainst the possiliilitv of niis- takinir this for a n lapse. Meningitis. — When acute mili.iry tnhcrciilosis i> attended with basilar meningitis, the diairnosi- i- therdiv rendert'd rather easier than nion difficult ; the reasons for this need not he {riven in l.\i;.\()sis. 41.{ It ii(<f liiinl>ar |iim i>l' tin- ).'rtai<'~t viiIik . I'liat simple purulent meningitis, nri^'inatinR Irum (li-«:i-.> <.r the iKisf iir I'l' the mi. Idle ni-{' tlu; tars and ot' the iiasopliarvnx in the ease nf every Hhrile, s(i|K>r>i.se patient, and in a HU.si)iei(iiis ea.-M' linnhar puiutnre -honid lie |h rfiirniei'.^ -'2~ I). Cryptogenic Septicemia. — i'he ditlereiitiatinn ,.f cryptofrenie septicemia ln>in tvphoid lever may under ^(lIne eircnnistaiK'es he (jnitc difficult. The (piite usual development of a typhoid state, the f'ehriUs amrse, whicii, pri-cisely as in a ca.se of typhoid fever, may e.xliihii the curve of a omtinueil or a remittent fever, ami the rarely ah-^iit enlarge- ment of the .si)loi'n, are particularly confusiiif^ in this eoiuuvlion. Ditl'use bronchitis als.., (piito similar to that of typhoid fever, is not rare. Diarrhea is almost a.s inconstant as iu ca.ses of typhoid fever. Frecpiently there is slijjlit, at times even marketicemia. In thes.; <'a.se.s bloo*i-c'ulturua are often of decisive diagnostic value. Other Septic Processes. — An answer to the question whether puerperal septicemia or typhoid fever is present may under some circumstJinces be attendt^l with greater difficulty than would Ix- l)elieveo mistaken for actual typhoid fever; and, on the other hand, it should always be iKirne in mind that pregnant women attacked with typhoid fever quite generally suffer fnim abortion and premature labor. Und r .such circumstances it has re- piitetlly hapj)eneen mentionwl repeatedly, and is to be considere . Ainimly rare a> a cuiniilicaliDn "t l\|ili(iid |r\rr. and that inyiM'anlili- al-o i- li\ no inian* rrci|iii iit ; and lliat liuth iM-nir, il' at all, 'jiin rall\ at tlii' liii;:lil nr toward llir end ■ it -ivcrc ia.-( il a |Mrio(l, tlnritlirc. wlicn it lias jrcniTallv Im ii jmssi- lili' to niakr ilir iliaL'iio-i^ ot' tv|ilioid I'rvi r willi cirtainls. In youtliiiil ]i'r on- infectious osteomyelitis — ii(-i<,Miaicd iiv Fnii'li inv(-.ti;,'aloi- (( 'lia-~aiLrnar) I -pi riallv a^ " Ivpln' i'pi|iliv>airc " — i- not ninly llir caii-i' tor i-rror in dia!.'iio>i,. In ^nl■ll pcrsmis, with an oli^riui' |. lirilr, iy|)hoid ^yinpioni-oulitle-s, intoxiration fmin the inircstion of diToin]io-id orpiiiie >ul>-lanee- ( nie at, tisli, mii-,-e|- i and fluids (water, milk, etr.j contaminated l>y the prodiicls of pnirel'action al-o ^'ives riM' to acute intestinal di-onjers with -'tvphoid" svmptoms. Thi> inhalation of putries present remittent or eoniinued li'vcr. Krror may under such circuiMstaiice- he made in I'ither direc- tion, ina-muih a-, on tin- one hand, malarial proce->es niav lie mi-taken I'lP typhoid ; and, on the other hand, t'lilminant tv|)hoiil fe\er mav he nii-taken for iiernicioii- malaria. That rare lases of amhnlatoiv tvphoid fever with intermittent fever and chills may nndcr certain conditions simulate malaria has already luen mentioned. Ivxamination of the lilooil for malarial para-iie- n-ually c|,>:\r- up the diagnosis without dillicultv in these ea-e-. Influenza. — The confusion of influenza and tvphoid fever is ocea- -iouallv nardonahle. The hiirh fever, the nrostration. and tiie stiiiior of /'/ {i;\t;itiniis, may ron- iriliiiti' III ilii- 1 ml. It is im|Mirtaiit in tlii- •■ liiun tn nlitaiii a liiMiirv 111' tile III ^iiiliill;; 111" llic iliscaM'. In i-a.-ts ul' ilillllclizji lire initial "•iirvza, wiili \\lii

  • lias Imcii luiiiliuiicil, an cviriinciy rirc cunilitinn, ami atVrn-< lit" tl • larviix, as \m11 a- lir.nnliial iai tically never ^'ive ri-e to ilillieuliy in ilie ilill'i reiitiai (liiu'iin.-is at tlie iieij^lit (if tlieir (leveli)|illlelll, lilll iln -' i all llle nmre tVei|Uelitly ill liie i;iitial staj^e, are the aeiite I \anllieinala. Scarlet lever anil variola |iarliciilarly, and also mea-lt> diiiinu' llie |iriiiiaiy Icmi-, may i)e re-|iiinsil)lc I'nr such criiir in miiiiil'' iiciauii- individual-. .Vpart rnun the kiiii\vled;;e of the |irevaleiiee nf the one nr tl tiler of the ili>ea.-es in (plest iiili, the local initial -yniptmns that ,ire mmhi a<"r air-i)a-saL'es, and with re^r-if' to scarlet fever, to the di-tinetive aiii^'ina ; while in cases nf small-jMix, the cliar- acleri-tie sacral pain, a- well as the initial exanthemata, particularly the scarlatiniform, in the trianirlcs of the thitrhs and the upper arms, and the ap|>earaiiec of the variolous etlloreseeiiee ujM)ii the pharynfjeal nuicoiis niemhrane iminediatcly afterward, at limes almost siinultaiic- ouslv, will lead in liie riirht direction. At a later |)eriod varioloid, with a scantv tr'iMtion accident. d'v nliiicil to the trunk, may at most he a .Source of doubt. If it he liorne in mind, liowcvir, that the variolous eruption almn-t ituexce|itionally appears lirst upon the t'ace also in cases of varioloid, that consianiK with its ap]iearance, even in the severest ease:*, decline of tein[)enitiire takes place, one will .seldom he seriously einharrasscd. Typhus Fever. — The ditferential diairnosis may hi' far more i> is of impor- t.Tnee with reiranl to the interests of the comiiuinilv. If a decision bo ^'f m ii*i rvriiDih i-i:vi:i:. m m\ (Ic.-irrd ill tlic fir-t !t\'. i\:w< >A' \\v '\\~v\\-<\ it \\\:\y !"■ iilmo-t jin;"'— ililo if. ill ai|ilili'>ii to till' lilirilc " tv|iliiii(l "' -tat,', tlic ili-tiiirti\ c cutaiicniis niMiiit'otatiiiiis liM\ (■ iiiit yit ilcv iln|>((l. It -IkiuIiI, lu-iilc^, always be ii(,t,.i| — what llic iiu\|M'rii'iii'i'(l I'ladily dVirlonk — tliat even in (luitc M'vcrc caso 111' tv|iliii- t'cvcr ilic cliAildpnurit nt" tin- a-Miriatcd cniiitiitn niav III' cxticiiiiK iiupi rf'i'ci ni- alinii>t (iimiilctcly aliM'nt. In the iirc-c'iicf of a iiiaiki'ij ex iiilliciii in i-iiniici'tiipn witli Imtli tli.-t'a.-cs, tlic (iitl'cfcntialiiiii i- la-x tiir an (■\|i('ii"ni ril iili-( rvi r. The typlmid m,- 'nla is almii-t triMii the iifi;iiiniiii.'' -liirlitly cli'vaicii. |iaiiiilai', ami, tlirdn^'iidiit its riitirc (Inratidii, piii'dy hypcrcinic, (•lantiy liiculur, ami siiai|ily (Iflincil. ( )n the utlirr hand, the >]>i>ts of typliu- t'cvcr arc l('>s sliar|ily limited and arc ill ditliicd : at tif-t jialc, tlir iiiajurity mhiii liccotiif htin- (irrha^'ii-, ~ii that tliry arc then ,-iinplc. imt elevated, s|>(iis nt' IVoni a (hiskv. euppcry ndncs-. only in part disa|ipcarinir 'Hi pressure, tn a ilark livid cnlur. which then distinctly cxhihit their petechial character. The diaLrnii-i- i- t'acililatcd hy the tact that the spots n\' tyiihus fever appear earlier than the typlmid niseula — lictween the second and, at the latest, the lit'th ilay of the disease — and iliey ra]iidly attain their ilctiiiitivc dcvelopnient -iiiLdy and collcctiv. 'y .-it a sinirle stroke, inva- rialilv without recrndocence-, within from forty-ciLdit tu scvciity-two hour.-. The o notcwurthy. A\"liile in cases of tvphus ti'vcr the trunk and the extremities arc (piitc uniformly covered, in cases of t\ phoid lever otdv the |iarts of the extremities adja- cent to the trunk are iiiMilved, and the remaiiiinL'' Jiortioiis ;ire involved in lesser decree the further removed tiiey are t'roni the trunk. In cases of tv])hiis fever, when the exantluii' is devclo|>ed to any cou.-ideralilc dofrroe. espcM'iallvihc forearms and tlu> Icirs are prcferalily iiivoU cd, and als-er this al-o i- likely to remain free from the exanthem. On tl ther hand, the IIh'c in the l.itfer di-ea.-c exhihits a niiinlier of other distinctive t'eature-. Kveii from the licirinnintr it is diffusely red and turLnd, the eoniiinctiva' are vividly inji'ctceioii of the tvphoid patient. Not Ic-s important than oh-crvation of the -kin in the diifercntia- tion ot' the two di.-ea.-c- is the course of the i'cvcr. In ccnitrast with lUAcyosis. 417 the laniiliiir -itp-likc a-i'dit in cm-i'^ m|' tv plii'iil t''/\w r. the tciniicntiiro ill ca-c- I.I' iy|iliii- t'cvcr LTfiirrallv, al't'^r .iiic or ranlv -cvcral cliill,--, ri.-os rajiiilly Id its li(i),'lit wiili -liiilil inii ri-iiptidii, sn tliat witliiii tVniii twoiily-l'diir I.I liiiriy-si\ limii^ a k'\i'l ot" tVoiii In.-")- tn 41° C. is rca<-licil — a tar liii^hrf lr\cl tliaii in ca^c- d' tvjiliuid lever at tliis tinu', iir even In I'a-e- nt' imt unduly exee-,-ive .severity, tlirmii^diont tlie entire l:i>tii;imn. The I'lirtlier eoutve nl' tlie t'evi'r al-ii exhibits ini|Mirtaiit (litlereiiees tiiat <'aiiiint li ln^i(lel•e(l Ihlly at thi- |i(iiiit. Its tutal diira- timi (liie.~ nut exeeeil frmn t'on.'teeii tusesenteen (lavs even in the innst severe eases ut' ty|)lMis t'e\ er. It trcnerally terminates with a eritieal ur a rapid, -tep-like deeline. With the aiiru|)t unset anil the rapid ascent (it the tever tn a e(.n~idei-aliie lieiLrht ci .rre-piinds, in cases of tvphiis fever, alsii the tar earlier appearance (if the severe ^'iieral iiiaiiifesta- tiiitis, with the unii-ual pni-tratinn that edinpels the patient to take to his hed as early as the tir~t or tlie -ecdiid 'law The diher jirnt'onnd dis- Iiirhaiici" referalile to the iierxnii- -v-tem alsn appear much earlier than ill cases ut' typhoid fever. As early as the tirst days thrioiis delirium oftoji (Kriirs ; and t'rotii the hej^imiitig of the siH-oiid week, protliiind coma. 'I'he j)iil~c in all cases of typhus fever, without reference to aire and sex, is exceedingly t're(iucnl tVdm the licLriiminir. in Wdineii and children it may he 1 L'n and more diivinu'' even the tirst da\s ; also, in prcvioiislv heilthy ydinii: men a tVii|Ucncy of pulse is sometimes eneonntored at the l)ei,dnnin!.'. 'iich as i- rarely oli-erved at the heifrht of the disease in cases of ty|)hdid t'evcr. I^ularirement of the spleen is far less constant ill cases of ty])lius than iu tho~e df typlmid iever. When it occurs, it develops eat tier and it subsides more (|uicklv. I have ireneniUv ohserve<'ar duriiiir the middle of the -wond we(>k. and rarelv to persist beyond the |)eridd ut' detcrvcsceiiee. Meteorisrn develops oiilv exce|)tionally in ca-es of typhus fever, while one must ex]iect the occnr- reiK f diarrhea at the heie^ht of the disea.se. and the stools, under the influence of the food administered, may even ;iC(|uire an appearance similar to tlid-e in case-, of tyjihoid fexir. With resranl to the diazo- reaction, there apjH'ar- to be no diU'ercuce between the two diseases. Also, ill caM- dt' typiiu~ fever, which ditVers in this as in niaiiv other conditions tVoiii the ai iite exantliemata, tlie diazo-reaction is (rencrallv (leiiioiistrable at the beirinnine and at the heisrht of t!ii> fever. It inav be mem. lied 'hat the l"ukdcytc-- are usually increa-ed in number in this ecllditjull. Relapsing Fever. — Cuifi'-idn with relapsini: fever is mo,. likely to occur with rcL'iinl to typhu- t'evcr than with rcjrard to tvplioid g^ A\H ryriimi) i r.vi.n. fever. Onl\ tlu' cariv c.i-r^ in ;ui <[ii(i(iiiir, :iiiil (\\v>v milv iluriiijj: tlie tii--I t'rw (Liv--, riiiiM cMiiM' .l(.iil)l. Hciv and tlicrc, it is triie, cunl'iision e((>nc! |i:irin;r lever with :i rela]ise nl' ty|)h oii~i'i witli a ehiih tiie uini- .-nallv iiiifh teniiieratnre — up to 11 < '. and ahovi — reached witiiin a >hort time, the critical decline at the end ot' >even day.-, il.rely later, protect atrainst error. Natural!}-, the denion-tratiou of the spirilla of relap>in!.' fever, if this he thoudit of' in the .'arlie-t eases of an cpideniie, and which, as i- known, can he found durin<: the entire febrile ]>eriod, a ' even for one or two day- heyond ( Bireh-IIirsehfeld ), will remove all .louht. Secondary Syphilis. — The eonfu-ion of the eruptive stajre of :ceondarv svphili- with t\ plioid fevci- is more likely to arise at times than would he helieved. The he-t (ihMTVer> have made mi-takes in this cotmectiou when the exanthem of s.coiidary -yjihili- ha- made its apiiearmce with remittent fever, eidartremeut of the spleen, and. in irri- lahK' individual-, even with jrenerai nervous symptom-. >tupor. ci<'. Trichinosis ma\. in mild ea-e-, with ])redominant L'astro-entcritie svniptoms, (|iiite readily he contounennit of ii .ieei-ion without dillicultv, A< a tinal resort, removal of a pii'ce of muscle for diairno-i- ■ dd he indicated. Anthrax, if unatteudeil with carhunele or edema, in the firm of intestinal mveosis, with the attendant symj»|oms of enteritis, intestinal liemorrhaL''', :>iid the typhoid state, mijrht execptinnally cause dillieiilty in diairno-i<. Acute glanders a!-o is suL't:<'^tive at first :uc, and fuliizinous deposit- uiion ili.' lip- and the <:um-. (Jcuerally, how- ever, the characleri-tie imi>.li,i:inous or ccthvmat.iu- erujuion-. multiple :,l,^,.es-e- of the mu-cle-, or speeitie idcerative le-ion.- of the mueou> mcmhrane- will lead to a corre<-t diairiio-is. The diaLMio-tic relati..u- of pncumonia and pleurisy to t\]ihoid fever have heen >utViciintly di-eu--ed at variotis ])laees. .\t this jioiiit it mav onlv he mctilioued that tlio-e rare ca-e- of central ])neunionia. ■■v ;it lea-t pneumonia 1 -irinniui: ;it the eenler of the lunir, may at times give ri.-e to <'onfusion. and p.irti ('.\|M(tatii)ii generally lield, after tlie diseoverv of tlie tv|i!i(ii(l- bacilliis, lliat llie dia^^n i-i- of the (lisea.~e would lie made Ky tlie dt nioii- stration of llie ortrani-ni in every ease, which many thouj.dit would he a i-olatively simple procedure, has, in tiie orit^inal sense, scareelv iieeii realized. On the i trary, it may he said iliat the dinieidtie> atienditii,' the direct dem iip..n tlie -iil.j,.,.l ,.f th.' .litiVn-ritiiition ,.f tho t\iili..i.l- lacillii-. •■fi?i iliiM 4:20 TYI'IIOHi I i.vi'i: 1-1 ', liiil tilt- lvi.li..i.l-l.!icillii>^ iipnii till- otlKT liMlf ;i|ii>fars i.nlv iis ;in cxtrciiulv .li- ,;lU..'iMni^I, Mlini.sl inins|.:livm .l.-poMt, .-.. lliiii \\^■^\ Ml tlMU> it cMii l.r iMcl up uilli a ncfillr (iiilv in lli- Inriii nf innsi ilclicalu tilaiiHMit.s, if at all It i> iinw known. l.oWfvtT. lliai llic^r ailiercn.vs may lie nuninii/.cil. or oven rntin'ly ilisaj.iH'ar. uiili (vrtain vani'tirr^ of colon-bacill' "a ilial iti.v ,lc|«T,ii lar-cly al-. upon the miction of tlio Jiotalo, so ho tt-st, tlicn- fore. is noi ..f -nal um'. , , ,, , ■ i i S)ine othrr rullural cIkh :i.-trri>lii> arc \niiioiil,tc(ll> -■■ lie < onMiler.Ml a." more irnslwortliv, csp. riallv llir -hamIi in litmii.s milk. Wlnlc the co^.n- liacillus .■ausc> llic milk to l„c.uno r^.pi.llv ami cMivm.ly ucid ami 1o un.l.T'o roagnlalion. tlir tvpho„M,acillns ilocs not .'aus. itrulalion ot tli. milk an.l ivimUt- il onlv vrrv laintiv a.i^l. even if il It kept i" lliP tli. r- mosiat for u.vks. •flir -Im-oM-l.'M i> not less valuaUlc. It ot tuo (IvM, hcnr.clicallv .-calcl i fcrmcntalion-tlask.-< .•oiitainin-: Ln.;,p,..Mii:ar-l.onillon tlu- „„,. is inn,.i,laI.Ml with the typhoi.l-lmciUns aihl the other v\uh the eoloii- haeillus. ami l.oth are exp to a temperature of ■'7 (■ active fermentation, with the evolution ( ♦' -as. will .levelo]) in tiie latter, while this .lo.s not or,-,,,- in I >tlu r flask. The fermentation-test 1„ mes moiv slrikin- if minlc with so|i,l nuirilive me.lia. Of two j.'hieose- a-aror L'luco.-e--elalin tulo. the one inocnlate.l willi the typiioul-l.acillus remains umhamre.i. while the active evolution of -as in.lu.v.l m the other l,v the colon-bacillus elevates t lie -.latin from the l.ottom of the tul.e an.l L-iuscs rents ami ti.-surcs to a|ip<'ar in llic media. In a.hiition to the milk-tcM a.Ml the f.'rnientation-test. the negative rcsiH.nse to the in.l.,l-test. f.rwhi.'h Kitasato ha. descrihed a most useful, simple method, appears to l,e .piite relialde. In -eneral. the colon-liaedlus vields the reaction, while it is wantim: with the typhoid-ha.illus. Hut. since reckham-' has shown that hv particular methods of cultivation the lyphoid- hacilhis niav he made I,, pr.'.dncc indol, and. on the olh.r haml. that unlesi> the .•ohm-hii.'illns he -niwn on an ahsolutely sn-ar-free mednim the develoj.- nieiit ofimiol mav !.(■ prevented, the method must he coi sidered of i|nestion- ahle value, and is useful onlv when taken in cmnection v.ith other filatures. More iinp.n-tant than aiiv of these t.sts in the .liflVrc'tialion of the tvi.hoid-hacillus is its .-peciti,. reaction to the hi l-scrnm of immune ammals and of tvphoid patients. The use of this method i winch will he more fully ,iiscus.sed later in cnshh^rin- its application to dia-uosis ..f the d.sease) as a means ..f hacteriolo-ic dilferenliation w.- owe .specially toi.rnher an.l Durham, wl... api.n.ciat.'.t its full vain.', an.l wlm v.orke.l ..ut fully the .•.■u- ,liti..ns un.l.T whi.'h it mav h.. appli.'.l. While .h.uht has been thrown on its vdue as a m.^ans .Z ditrer..ntiati..n bv s.^veral ..1 servrs. who also (leman.l the u.e..fextn.m.dvi,i-h ,liluti..ns ..f th.. s.ri,m-ev..n 1 : K.d.dDO ami ..ver —it mav b.. s:,i,l il,at v.h.n tli.' s..nnM. .'V.!! in mo.hrate .lilutmns, is c.ii- tr..ll.'.l bv ohs.Tvati..n ..fit- )H'li..n on kn..wn lvph..i.l-ha.alli the test is-piite constant "an.l •■xtivmelv valuable. It nu.M 1- emphasi/.-.l, h..wev.T. that „„ on.. t.'St is sutti.M..nt'f..r the .'..terminali..n .-f the natniv ..t an ..riranism of this .-roup, an.l that ..nlv when all tlu' varh.ns .hara.-teristi.'s an.l results .,f .litl.Tent t.-.sts are taken into CMnisi.l.Tati..n .'an a .lelmile comlusi..n he reach.Ml rnf..rl!mat.dv. nun^ennis .■arlier statements with re-ar.l t.. the presence ..f ih.' lvph..i.l-ba.allus in th,. livin-: bo.ly an.l Us excreta have been ma.l.. witlu.n't cn.i.l.ratM.n ..f this rul... an.l ar,. theivh.re valueless. .Attention sh..ul.l .cjain be .alle.l (., the p..ssibilitv of the oc.urrence ..f WfntralM.f. lUU^ ", rny.tsit.. fil. :irc |ipi1i;iM\ tllCt\ |lll iilii.-, I)ilt l>v DSflv iflutcil i)r;.'iiiii> ins. I In- sii-c;i UU.-tMl iiul liv iiuracouiii illMl or |i:ir:ity| (iwvii.' Ciisliiii^ viiliokl-liiK'illi. Such liiicilli Iki hffii ilcscn hod Widal.' ScliiilIniiilliT.* <»!licr l)iicilli iMtiTiiifdiiilf lutwtrii thi iv|>helv rehiteil, iiioriiUoloLrii allv and eullurallv. to ihe the exael relatioiislilii het ween I lie two (ir<'aiu>iiis tiowever, not hreii coniiiletcly uor ked out. Blood-cultures. — rp li. williln the past year, enltiire- I'mm tlie hxid have lueii lit' little aid in diaLMi'i-is. Iiu> niaile eireiilatint; ti vi.!il-lv -tated ([I. 17-"ii, newer worl ])i)S-il)le tlie denmnstratidii of the ty|ili(iid-iiaeilli in the einiilatintr Mood with Letter nictliu, ill 7n to '*^<' ]>er cent, ot ea^es exannnei 1. (' irki at tlie Johns Hu|ikiiis Ilo-pital, ha- lately i-olated the liaeilli fn.ni \-\ of oH eases exainiiiett III inaiiN- of the ea-i - the eid'iires were obtained i arlv in th. ill-i'a-e. |..ri a |io-ltlVe W'idal te-t had lieeii olitaim d. It certain ea-es liie eiiltllfe alone estal tile (liaiTllo-l- had ])re- vion.-lv lieeti don l.tfii! or even I'teil. Til' I'll le tnetiiod nsei 1 i> Tl.e ,-ki •r the anterior -nrtiiee of the patient's arni at tlie lK>n ftl ani •rtieial veins, is used. I iv ii^ihl: a ~iiiall needle am ent< riiiL^ the ein with one thrust little or no puiti is eaiiseil. Fnmi S to i divided alllonlr^i^^' '"' '^ix Erlonniever d'b od are witlidrawti ant each contaiiiinL'' ')0 e.e, o :>oiiillon 11< V ilaeed in the men ibat( The Hasks are tlien .shaken after tweiitv-fonr lionrs, if eloiidv, atil( <1 not suitable for tryiiifx lairiiosis oi laeillns tv'ihosiis in eael ihl be deeided only by tyjiieal ■.• 1-4. v.il. lii. •1-J TYrii'iiii I i:vi:i:. A ltlliill;:ll tlir Ilictlii.il |irr-rlll,- <■( .Ii-i. Ii r;il .Ic ti ilinic;il (litliriillics, will re llif .finditioii- arr -iidi, a- in a liM-|iiial. lliat it iiias lie ( rnli!ii\ id, il i^of iirnloiilitcil ai'l in diaL'^iio-i-. Cultures from Rose-spots. — A- inwicn-ly lainl (p. 17")), riilltn'r- iiiaili' Irdiii llic ni-t- -put- have -Imun tlic |ir(-riicc nt' ilic I\ |ilii'icl-liai-illii.- ill a liiaj"iii_\ m' tlic ca-i-. Tlir in'crcdiiir i- iiol ic--|Mii.- arc prcMiii. the (liairnn-i- i- ii-iiall\ ainadv clrar. Al-o puncture of the spleen ,inif ca-cs lumbar puncture — \vlii,li i- otun imliiatcd even tli'i'apeiitii'allv — may facilitate the diiLriKi.-i.-- i- cntirelv pmliahlc, and lias liccn vcr'linl liy illn.-trative ease-. Ks|)ecial hope "a- attiichoil fn)ni tlie diitset to examination of stools. It wiLs soon rccofrniwd tliat tiie typhoid-hacilli ( -cc p. '-Vl) us'ially Iia\'e the hi,dy ot' tiie patient ii: the st,„,l^, ami that lliev are tra- ti,,ii was from the ,,ut.et attended with the greatest difiicidty, on a, omit of the ininuiir-e miniher of otlier niicro-ortranisnis at the same time |)res('iit. ami especially tlio-e of tile colon group. El-ner ' has introihieeil the nsi',,f a s|H'<'iai iiiedinm tor this piir|io-e which has given good re-iilts in his h.aiids, and has i)ceii w, irmly ncommeiideil hy I'rieger." Lazartis.^ and otliers ; liut. on the other hand, lias been declare(l liv others ; i'r, net,' Hacdke ') as not entirely rcliahlc. How- ever this may he, the proetHlnre re(|nires the greatest .skill, so that while in the hands of tiie truiiieil ohsf'rver it is applicahle f,, the solution of certain problem-, in its present form ii has no future as a iliuieal niethoil. Eisner's method, lirieflv. is .t? follows : If 1 per rent, of iodin is added to sterilized potati,-i:elatin of lietiiiite aciility. and if jilaies are nuule after a,iiiitioii of the fecal inalter to l,c exaiiiineil. it is possihle. hy the adilition of the iodiii. to exclmie from lievrlopment all other micro-organisms hut ttie eolon-bacillus and the tvfthoiil-hacillus. In addition, the latter develops distinctlv more slowlv ami i;icoiiipletelv. While in the course of tweuty- ^ y.rif. f. Ilv'} II- l'!/-i''"tiyk.. IS'j:,, H,i. x\i ^ Prntsrh v>r,l \V..rh.. IW.J. Ni> .00^ » Bn-lin. klm II'.W, , IS!,", N„ 40 ♦ /'',,. 2. Iil.\i:.\nsis. 4'J3 i;,ur iH.urs iioll.int: of tlic lvi.l.oi.l-l.acillu< can l.c seen wilh the nake. eye •ui,l ^NUl, Imw |«.«ersnf the' iinerosco,*. afler tlu- la|,se of tnrly-eiL'lit Imiir. It will l,e presenl to-elluT vMth ill.' n.l(.n-l.a,illii-. trn.n viihl, il ,. read. I v ,ilsli>,.nii,.l,al,K. uiMiiMhe l^lale. hi a-Mili..,, In il.e lar.'r, n.urh nu.r.- n.ark- ea'lv "nvi.ular, l>r,.wn-roln,-, .1 r,.lunirs ..f il,.' lalter. lli.- nf the tnriuer appea'r ad siaalh liri-hl, irliMeHu,-. exireiu.ly IliKly -ranuhir ikuui.-^, reseiii- hliiiL.' ilrops (if water. Within the l>a-t liw yrai- ..ih.r inedi:, an.l -iie.ial m.tho.l- have 1,,,,,, i,„n„lu,r,l hv IUlU,e|•.>U^ uh-rfSer-. The .H.-t p. UM.,- of th.^e n„.tho,l- ate tlinM. ..f l'i.,rkow-.Ui, K. ..in . and Hi". Kaeh ,,f th.M' nietho,!, \m> uiv,n -00.1 n-iih. in the hand- nf it. author. Ills.. n>in^' hi- n.ethu.l, wa- al.h. n. i-.>hite th.> typhoicl-haeiih.. Inmi IT out ..f 21 ,,.e- in .he f.'hrile -ta-e. It Mill tvtnain- U. I.e >een whether the -.1- eral r-mtine ap|.lit ueek. and -n their i>olation may he of definite dia^mo-tie value. In making' enltnres female. .Imnld he eatheteri/ed under eareful aiiti.eptie preeaiitioii., ami the urine ... ol.taine.1 -houhl 1m. plafd at onee. In males, the anterior iiivthl-.r -hotihl he irri,t,^ited with aiiti.ei^tie .oliitioii.. ami the patient should then void into a sterile tlask. In the .hterminatioii of a haeilhis ohtained in the culture, ^rirat care should he taken airain-t eonfonndin^r ti,,. typlioid- haeillns with the eolon-haeillu-, to whieh ey^itis is .|iiite commonly pe^ininee of the reaction, has not heen found to he of so per aniiii.il- iniiiiiiiii/'il !■> ly|iliiM(| l(\ i r, \\\\<\\ |il;ii-.(| in i|i,. al"liilMiiKil cavily i.t' :\ |irc\ ioii-l\ lualiliy <\|" riimnlal aniinal iLjiiiiic'a- ]M,L'), tii'jfili rniii In lie specitic, it liiadr the iinpnrtaiit aiaMi.-liiiiL'' ilif pr"(i ilnrc. not alone a^ (nic ini])ortani in ils licariiii: oil ilif (|H(,'.-iion ot' iniiniiiiily, liiit al>o as a ino.-t availaMo iiiftliod ot' dillci<'iitiatioii of iiiicni-orL''aiii-iii>, |iaftii nlailv of the typlioid-liacilhi- i'foin flic nii!iili(r'- (•!' tlic coloii-i.rroiip, wliicli liad liitlifrto licin , that the reaction ol' I't'eill'er. at fir-t iielie\-ed to neenr only in the Ixidv ol' tiie liviiij; animal, cimld bi' lililaiiied al>(i under certain condition- in the test-tnlie. The Method of Gruber. — The intiodnction raeti<'e was ed'ected finallv tlironi:h the important latior~ ot' ( irnher and Ids piipiU.' who furnished cxiili'iice that, in the >anic way a> the Mood- sernni of an iminnni/ed animal, that ot a human liciii^, alter recovery from tyjilioid fever, hrou^ht toj_rcthcr with a culture of typlioid-iiaeilli in a tcst-tulie, soon render- the haeilii imiuoliilc and eau-estliem to ayjrre- Lrale in the form of clumps and to he precipiiate entire (picstion. it is of iniportanic that rinilHT at oncf cnipliasized tlie fact that his inethod nf ai:;.dntiiiation e.slah- lished not .ilnne the ditrerpntiiilion nf the typh(iiil-ha<'illiis from sinnlar hacilli. hilt that it was. furthermore. cai>alil(> of furnishiii;.'. directly from the hl.xid-seriini if a liuman licin<:. proof of the previous p.xistence of typhoid fever; thus, of niakincr the diairnosis suhseqiieiitly or of contirniiiif; it if already made I'linicallv. TluTpfore to (iruher. ami with him to his 1 /..t,,\ ;/,..,;. „. l,'/-!:' !:.. IM xxi. • I -ipIV nn.l T^.lIl'.tT I ■,'■•1 71.1 xvii ■' Aiinnlrx ,lr riiistifii' I'asfeur. ISO.'i. ' //.,'./.. IS'.i.'.. ' Wini. Win. ir. .-/i.. 18;»'i, N'c'^. 11 ami I'J. (('•rul'T mid) Durlmm. I'mcrediiips of thr Rnynl S'irirty. .I:inii;iry ". IS'.ii; vol. lii. \fi' l>l.\lic utility ..f -fruiii-fXutiiiMali.iii. AllhoUi:li (Inili.T"- ni.'lliM.l wa- at tii-t only ivtro-i"ctivc, it \va~ ,,l;,l„,r:it,'.l l.y Wi.lal^ in -. far a- li. fm-m-la .1 |.n.,.f that tli.^ mTIIIii r..iM..v.l (■\liilpit.-.l Ihr -am.' aLvlini":"'".!: mUn.'iici', ik.I al.iiic atUr PM-Mv.rv fn.Mi typlioi.l tiv.r, l.ut A-n in tiir 1.. .;imiiiiL' ;iii'i at the li<-if:lit ut' th.' iliMM^c. .\r,'..r,lili-ly, it is [M,.->;i.lr to r-taLli-ll the .xi-t.'ll.-c of ill.' ili^ra-^.'ilirrctly liy mk an- .if -.■riim--r, Dieiilaloy, I.eiuoiiif, Arhanl, Catriii M.Mioti.T, an.l Sin-hA, Wi.lal ami hi> |,ii|.il.- , hi> -talcnuaits led to the iiicTi.tion ot' a nuiiiher of i„v,-li-atiwn- al-o in ( ...rn,an> W iti >liL'hl .iiireren.vs in (h^tail. thes.^ a-iv.-,! «ilh the ivMill.- ol (.niher and W idal and .■onlril.uted materially to :l,r lurlli.r dev , lop.neul an,l Minphtieation of the method. The Widal Serum-diagnosis.— Ilie Wi.lal -enirn-exaniinaii.m as ._r,.iierallv pi-a.^ti-..! at i.rr~.nt, an.i a~ it ha- Imcii -ervicalde al-.> it! ,nv .■lini.' "in a hii-.' iiumluT .d' .m-.-. i- eame.l out in the loll..\vini,' iiiann. r : Blood-abstraction.— I'he 1,1. ....1 i- al>-tia.>t..l either «lil-eetly tVoiii the ni.MJian vein .d' th.' pathut to he e\aiiiine.l, l>y mean- .d' a -tefili/.ed livpodennie -yrin.:.' .t hy the appli.Mtion ot' a euppiiiLr-Lrla-s aft.,rat..ry in a sterile eiiitiire- t,il„. ,,f i>i(hnil.le si/,., are a.le,|nate in iirivat.' praeti.e. Th.' Id 1 olitain.'.! i- inIrodu.v.l int., a iiarr.,\v test-tulte. uhi.'li is tln'ii plaeed ol.li.pielv f,r -e(lim,ntati.,n. If tlii- d.-es n.,t tak.' jilaee e.,mplet(dy, so that the -eniin .iverlvino; the lilood-. hit still e.mtaiu- re.Mil.x.d-cirpus- eh !iis will not inti'idia-e with the i'lirther investitrati.m, as ev«n (lriel . April. ISW. and tlio I.anret, Si>yit. I'.l, IH'.IC. - Setn. in»i. mid., 1806. fnnn Aiiu'ii-t to N.>v(>nil.'>r. ' lireuiT. Prrlin. klin. W..rh.. IS'.i.; No^. 47 an.l 48 St.Tn r,;,trn!hl . f urn. Med.. 1806. No. 40. and 1807. No. 11. Ilii.'dko. Dnia.-h. med. Wnrh.. 18',I7. N". 2. C. Frank.'l. DeuLvh med. W'ueh.. 1807. N..-. 3 and 16. .^>'y.. !»')>». med. Wneh . 1807, N... 3. I'irk. Wien. klin. \Vn,-h.. 1807. No. 4. K.,1Ip. Deut^eh. med. Wi^h.. 1S07, No. 0. (Inili.T. Minieh n,rd. \V..r)i.. 1807. N.v 17. I.pvy and r,i.«*l.T. Munrh. med. H'neh.. 1807. No- oO and .M, I)u M.--iiil d.' Kochi-mont. Munrl,. med. U'oeh.. 1898, No, .-,. E. Krankcl. Ihid r! ■i-2t; TVrilnlli Fi vr.ii I'l I ni.iiii- it- ;i'j-L:liiiiii.iiiii;.' |Mi\Mr -A www lie ctriiilMM i| in ;in Mill r:;iiii \ I W iiLil. Sic-ni iiml ['..r-tir, .I'Jin-inin. Macroscopic Method. Il -.m. ,.r ih, -. ruin llm- ..l.iain,,! i.> IiNin-r.Ti't'il liy tiicaii- "t' a |>l:iliiiiiiii \>"<\< i" -iaiiviI iiiKir cc ni imrh ix lit' l\|i|ioi,l lM.iiill.,n-riil|iir.'. |i|i t'll'.ililv iii'l Ih.ii-i- lliaii Iw.Ui limir- i.|.|, ill a nan i.w I. -i -Inl" . ainl il' lii. inl\lhi.- Iir fA|iM-ii| li. a li in|'i raliiir ■l' -iT ( ., ni till li.nr-. ..l' t'l"tn lliri. n. -.s. n 1 i- llir li .riiial ii iii I't' tlaki- ami liauini iil- lnLriii- li.laki |ilaii in tin |p|'( \ i. ■ii-l\ niiilnrniK liiiliiil lliiiil. ami llir-i' -(«.ii -i-illr lo llic K.illi.ni. Al lln- nul nf luiiilv- t'l'iir Im'Iii-- ihi- -i|iaralh.n "I' llir ti'M'.iili liMin lln tliii.l will he coin- I'li li'l. -" llial tin Iminll'in "\ 1 rh iiiu til' 1 riiinliliiiir \illi'\\i-li -iiliiniiil will lia\c Ikcmiiii- riili|-tl\ rlcar ami lia\i' n LTaiinil it- iii'ii:iiial ri'l"!'. M il li.-rii|iic I'xaiiiiiialiiiii ili.-clu-i- that I lir -I'liinirlll n iii-i-l- -nlcK nf tli(> i!ct;ilirfalf(l illlil (■iijirrrnt liarilli. Knr till' liiiriiiiiir, tlii- tr-i l.iTnnii- oiicrially ili.>liiiriivf if, ln^rillirr uilti llii' il iilalfil lultiiri-. iiiii- i> |iirpairil In wliicli Miaiin lla^< mil liccii aililcd, ami wliirli lluii. ill rnii-i .|iii'iic-c III' till- iiiiili>lurlici| ami |ii'i>i.-liiii: active imitililv ami iinitiirin ili^trilnitinii nf tlic liarilli, i-rlaiii.i ilf* |iiiiiiar\ turliiililv. Microscopic Method. — 'I'lif iiiairi.-(ii|iir |iii.im ilnri' i- n-.t'nl mily an a |)rriitiiiiiar\ ti-t. It i- iiintr ninvfiiiriil ami iniiin nftaiii In |irr- tiiit till' |ii'iil' iit' a t'rW ininiiti-, ran In- \ii\\ri| in iji tail ami iliriTth. W iilal riiiiiiiAcd tliis |iiiiiTiluri', anil in tin' liaml- nt -iili-rijiiriit mIi-ima n- it lia- liirti j^natlv jicfti Ttril. 'Illi' -ilii|ilr-t tniiilr III ]iriircilliri' i-n|i-i.-t- ill aildilli: tlir -rrillil til Ik! tc-tcil til a iMiiiillnii-riiltiirc nt't'inin ten tn lint iiinri' iliaii liLrlitccii Imiirs njil. .iml -IiiiKiiiL'' tlif liatiL'iiiL:' ili'i'l'- It' tlw Mriiiii i.- drrivcd iVniii a t\|ilinid ]iatiiiit. i-|irriall\- ,il tin' In i^lit nf tlir tilii'iir -Iai;f nr a iairr jvi rind, and il a -ntllriiMit ainniiiit — almiil an ii|iial |iart — nt' M-nitn lia.s liiili added, tlir li.irilli \\ill lir -rill i III liiid iatt l\' at'trf the aiilnixturi- tn lirrniiic iininiiliilr and tn inllcit in iliiiii|i- nt' vai'yiiiL'' >izi'. \^ iiili' tlir fiitirr tii'ld nt' \ i-imi rrinain- iinirnnnK nrrii|ii(il li\' tlir -wariiiiiit; liarilli in a riintfnl-iirciiaralinn tn wliirli im -i nun lia- lirrii aildril. llial tn wliirli iininiinr -cniiii lia- linn addrd ivxiiiliit- laru'r area- nt' the \'i-iial til Id tliat arc rlear, with the a^e;iinilialei| elninii- enlleeled niilx in certain place-. ' Natur:ill\. 11- will iii.|i.'Mr fr-iii wliai r.ll-\\>. if .Iri.il til I i- t.. 1 in|.l-M-ii f..r purjiiiii-- rif r\-Av\ lii'tiTiiiiriati .?!. it- :iiii"nnt -IimuM I" iim:i-iii-''iI In I'.iri- it i- lirii'il, iiml hi I'lp' 1.. inu' niiiil-' ii-i' "I' it -h"\ilil 111' ini.Ni.'d witli iin arciiniti-ly (iitiTiniin'il Hiii'iUnt of |)li\ -i-'li'L'i'' .-all si.liitiiiii. M ;>/.!(.■ .Vo.s/.s JJ ]-\.r .liiiirMl piir|M.-.- ill.' iiii(io-(o|,ir |if.H-,-.liir.- Ii;i- .uliivly .li — nl.ic.d llli' lli:irr..-.-,.|,ir. ,>|n.i;llly l„ran-c il .ll"llr i~ iMpalilr ..r I'ul- llllii,- ill,. |v."L'iii/r(l ii..i>-:ii> n,|uin'iri. ril, ii;iinrl\. tlir (l.l.iiinija- li..ii ..!' tlir LM-ralr-l (li'.'iv.' .pf ililiili I' llir -« i-uiu that ill a -ivi'ii .■a^^■ will Irad t.> til ■(■ilfiTli'v .if a-i:liitiiiati..ii. The Earliest Appearance of the Reaction.— In lii- .arlic-t [mMh iti^'il- Wi'lal -lal.-.l lliat llir a--liil iiial liiu a- ni.l c,f lli.^ tii-t wnk ,,t' till' ili~i'i-i'. riir'fliinalrlv , llii- -tail nil lit lia- iml I ii ulii.|l\ c.ii- tii-iii,.,i. Oil the c-Miitrar\, it wa- ImiumI u il Ii L'r'.uiiiL; . \|m ri.iicc lliat llir -.•niiii ar(|iiliv.| tlial iin.|Mriy ..iil\ in tli.' iiiin..rily ..f ca--- l»tuf.' thr l.Tiniiiatinn of tlic lir-t w.vk. -t riv.|ii(nily nd inilil the -.■.•mi.l wr.k (tVoiii ilir -cvnilli In llir I. Ill li < la_\ ), uliili' faivly it u:i> ■Irl-.iycl l.ryniid llial liinr. (Aril to laid- wok- (Stirii, Koll,,- I'.lutiinilliar). Coiiilil.lr ati-cncc of till' ivartioii i- one of tlic ran-I txcijilioii-. Ainoiit: a laix^' iiiinilMr of ca-.-, in only t"o. wliicli wdv -liown 1)V aiito|i-v to he in-tanr.- of typlioiii tl^.r, liavr I failfes--ed the afrjilntinatinu' intliieiiee on the ly|)iioid-l)ae:lln.~, and, if this he not thf ease exehi.-iveiy, wheth.T thi- |.roiM'i-ty iiii^dit not he pos.-ossed exee]itioiially ami in lesser deL'-fie hy sernin from otiior patients -iitVerini,' from other disea-e-. It \va> -oon found that the reaction oiciirs even diiriii;; health (Stern ') and in the iireseiur of a nilinher of di-ea-e-, ajipareiitly es]ieeially in aeiite infections di-iases, >o that for a time the diafrnostie value of the procedure ap|>eared to he dimini-hed hv tlii> fact. On further invotiiratioti, however, it was found that under these conditions the reaction takes place only when eoin|>arativcly lar;;e (iiiantities of the seriwn to he exaiiune. « fA,',/ 1W<.- \., 1.-. * rWj/r«/W. r. :«/i. iVf<\' tic rcai'tiiiii v\illi a ililiitinii ul' mii' in I\\iiil\. r\iii nin in llmiv aiiil mii' tn liiflv, iua\ al ri iir iiml. r ni hi i mlii i. m- ; \\ liilc a i" i-il i\ r iiaiiiuii uiilia ililiil i'lii 111' ilh' -1 riiiii 111 \.. ml mn (,, |iiii\ niciii- allim-l i mIii- -l\ lis ill r:i-. - 111' I \ |il|.i||iirt of llif i|iii^ti(iii ; ami, atiiT lliciii, f?|itiaallv Krcmr. < '. P'rankil, I)ii .Moiiil. ami l-'iii>tcr.' 'I'liat iiIm. mixl- urcs aliiiVf 1 : Jn ii|i to 1 : Id arr nut rcrtaiiily imiiiiitnc nt' lv|ili iil \V\vt lia.i liciM ••liiuMi i>|HM-ialiy liyvan < M-c||. Kiihiiaii." /.irinkc." SlicH'iT. ami ntlllTN. Al riTilillL' In IIIN iHMl niirTr\aliiill>, Hllcll lli.'ll ilillllilill," lit' the .-iTUin air liiit ran ly I'lli'luc in ilic |.ri«i'iii <■ ••( nllirr iiit'ii'li u- ilisfiiM'.--. Stern' hail |ire\ iiiii,-l\ |.iihli:-hei| the i\ai t i-i>ull< nt' exaiiiiiialions in Tn rases nt' nther ilisea.-es. ami ~iil.,-.i-i)iiiiill\ , in inninmlinii u ith .'••kinwer.'" in lull i-a.-i-. AniniiL.' the laller there v^.re. L'n in wliiih a re>|inn>e tn 1 ; 10 wa.- nlilaiiii'i : H' in v\ hirli a n s|inii.-e tn | : _'ll «a- nhianieil , L' in w liii h a re.-|in||-e In I ; .Id um> nhlailleil . I ill « liieli a re-| se In 1 : K) was nhlailleil. Diagnostic Significance of the Quantitative Relations of Scrum and Culture.— iM-nm tin inivnninn- iIm' liiipnriaiit I'mieiii- .sinii ean lie drauii that the i|;aniin-tir utility it' ihe ( inilier-W'iilal reac- tiiiii i- iie|ieiii|eiit, aliiive all thiiii;-. ii|iiin a carel'iil eniisiiicrat inii nt' the i|iianlilalive ivlalii The -mailer the' aiimunt nf seniiii iieee-.strv I'nr till ile\ eln|iinelU nt' the reaetinll, the Mmre eel'taill is tile (jiaj^lKlsis. TIlllS it ha- lieell t'liliml. nil t'lirlhel- stlldv nf the enlKJitinll. that at time- the leaeiinM may lie nlitaimil \\illi alinnst iiiereijilily hiixh dilu- ' Till' imali^iN fur till' I'XHil preimrulinii ami tin' f)uiintitati\ i' ili'tiTniiiiatimi nf the nnxtiiri' nf -•■niin and enlturp iiinnut lie fully (li'>cril.n.'d lierc, tmt they must In- learned pri' III :illy Till' liireiti'ins an- carefully ttati'ii by A. Kraiikil. lifrUn. klin. ICucA., I>^'i7 Nn II, rinil liy Stern, fVntralhl. f. imi. M.,1 . Imh;, N'.i. He The latti'r elitaiiicd i-siieelHlly ill lieate r"'.=iilt«. whiell, li.iwiver, .in- imt iiii-i>-ary fur rlinieal jinrpiisi'- with the nil! of tile I'lijiillarv jiippt of (iiiwrs. It iiui\ In- inriili.ini-il liere that i|uiti' iieru- rule ri-nh-. i|niti' Mitlieifiitlv so fur elinieal piirp'-i.-, ni!i\ 1 limiiied by the u f siniill i:l:i-- I'Mpilbiry pip"!-, iiianufiictureil bv clr;iuin^ nut -ncill pieece ef erdinury !;Im-- tuliiiiLT in till' lliinie One or ninr. ilrnp* ef '.In' -iTiim un- ilmpin-d I'mni lUn- ef the-e pipet- into •( di-le Mild tin'ii fmiu tlu' -iiiin' pipet n sutlii iiiit iiuniher nf drop- nf >|iTiIp water nr -nil -nlulinn ;iri' mldi d tn make a dilulinii ..f nin-iuilf tlio rc'.|Uired ,],...r,.e. If, tlien, with the plnrniuui knp one drn)) ef thi« mixture he aiMi d tn .me • Imp nf ihe linuillnn-eiilnire elilained with the -ami' jil.-ilinuni Innp, a i|niir aeeiirate dilution i- nlitaim-d Tlii- iiieilmd h»< 1 ii iu n-e at the .ln|iii< IlnpUiiii lln^pital and has provi'd inite sali-fmlnry. The nllnr iin'thnd-, a- will a- a emiiplete diMUi<.-inri nf the wle.le pmrednre and i rf-view nf the litirature. Iuim' I ii ^'iveii by ( 'abnt in his been. Th' ,"^i'nim-iiia'_'nn-i.. of Di.-ea-e ' ' r.,- i-ir ■' /.. .- rit. ' /<■'/ f. Hvn. u. inf.u'n.n^i. . xx'.'i. Iiifts, ^ Miinrli. n,'./ If,.-/, lsii7 >;,, ,-, • /iVv/ni. A/ni, H'..<-/i., IxnT. Nn li;. ' /Vl,^v/, ,„r,r \i:,rh , iny7, No. 15, " iu,-hn. hh». ir.i.-/e, i«i7, No. n. yi/.i', Vis7> J -J!) ,i,,„ 1 ;.;(HH( ,„■ .MMin. aii.l 111 M '"i t' NVi.liil'-, -v. I, 1 :JtMH.H. r,,i- .rm'.:il |.Mi|....,> -II. I, ,liliiti..ii> .iir uli..lls miii.'.M.>.-Min. < i.ii.r- ,llv, 1 ,■ ill,. lMV-.ll- !.. .liliiti.Mi- ..!■ rn.,M I -..id tu 1 :l<.n. ;„i.l :,tl".l' Ml.iM..l:uit ,A|„Tir,i,-, 1 U^^ .. n na-..„ ,,. 1.,. sili-ll.-l tlirivunl,. N.A.illirl. — , 1 li:ivr Ir, .|U.iitly -..11 til.' iv;irii •,iir uilli .liliilicli^ ,,|- ,V,,Mi I : Ii"i I.. 1 : 'i'"' :Hi'l ^i'-''^.', .■t'U'H ' •^ ' " "I"" 'I"' '■'•l''""' ,„.,.,„■. uiiliiii a -li-f t.ui.. Til.' time elapsinK before the reac- tion occurs, :i- iii-t iii.iili..ii..i, i- Mil .'.iimIIv iiiil".rlMnl ta.'l.ir in lli.' ,li:,^M...-ti,' .ni,.l..M'ii.Ml ..I' -l,.- nai.i.iM. TIl -li'irl.T ti,.' a.-ti ' tl,,. -.i-iM.i, i.i ..nl.r I., .jlitai.i a r,,in|,l.l, na.-liMii, ll,.' lu-iv .•.rli.iM is llu' ,lia-ii.)-i-^, <-vi'il wIk'Ii 1m\\ .Iliuti..ii- aiv riii|.l..\ . .1. A- a iv-iill ..f ill.- t'-r.p.iiiir, ill.' prill. 'il'l'- li:i- III 'I"' <'"iii'-<' "f la.'.' willi li^'lil- niiifr-liU,. ra|M.lily ..n a.l.lition ..f lliu .inin, a .liairn-.-i- .if tyi.li.>i.l I'cv.i- inav !>.■ ina.l.' uitli iiu-At |>r.il)aliilily wli.'ii .liliiiii.n- .if 1 -.-'.^K oft.ri fv.n xvith .liliili..n- .'f 1 : -", ^r.' .•nii.l..yo.l. Willi n v ,\i..ri.'n.-»'. lai. ly Ix- .•..iniiiittP.l. SI1..11I.I 111.' r.'a.'li.m ii..t ...'.ni' al ..n.'.' with mi.-Ii .liliui..ii-. tl„' ..Iwrvati.m -li.ml.l I"' .'..minn.'.l f..i' a IciiL-.r lini.', ami. with a \ i.'W t.. gri'ai.T .•.Ttainiy, wiili tlio fiinliur a.l.liti.Mi ..f m fum O.-mt .l.'grws (if ililiiti.iii). Ill Ills ii.hniialil.- ]>!^»t u|«mi ili.- ^.mr.'cs i.f error in serum-diagnosis Stern' siwrfesls a .'.intinuatiDn .>! the uiist-rvalioii f'lr a.H IciiiL' its two li.uirs. with |,r...'ressiv.'lv incrcasin- .liluli.ms. Althons-h tins lias yulilnl hini im- portant r.'.-*ulls. -ii.'h a ihtIo.I of oh^Tvation i.s iiccor.linL' to onr fxperi-'nce. 110 lon.'i-r lUM'.-sarv f.ir .■liiii.'al i.nrp.is.s, in vi.-w ..f ihf i.r(wnl nietli.xls an.l the skill iiMiaU'v j « ».-i's-^'. 1 hv tlu- oh^^.Tv.'rs. In my .'linw our ohservn- tions do not. :is a nil.'. .'XtenJ liey.in.l from iift.'tn to thirty minutes, an.l thev are ma.le. as s.'.'ins \<> me quite suffirient. al ro.iin-lemi.eraluri. 1 liat the" proeeihire..! Sn^rn may he .Miiiilov.'.! in ea^s in uhi.'h a .lei'isi.m is ot esiie.'ial importan.'f is a mall.-r .if eoi.rs.'. It s,.,.|ns .|iiit.' imiMii'laiit thai s.mie .IctiiMt.' riih' 1«' made in r.'.j-anl t.. .liluti.iii an.l lini.' limit whi.'h slioiil.i k.'ep in vi w the wi.le-t i>.'-i- l)le apiiiieati.iii "f th.' m.-th ■.! t-i .'lini.'al imri.. -e- ami y.'t eairfnllv jruanl apiin-t .iT.n-s. F.ir several years at th< .I"hii- H.ij'Uins II. .s- pital a staiHlanl ..f .lilmi.m .-f 1 : '>0 an.l a iimNimum tim.' limit ..f .me li.mr have Imvii .•m|il..y.'.l ami have ^Mvrii .'..mplel ^ali-faelion. It w recruni-uiaf.rnn>is, tlic iniiH,rtaiit oIixt- vatinn .-lionld. in conclusi.in, I,.. .M.nsi.Kivd tjiat tli,. ajx^dutiiiatinf,' action ofthr -fiinn may |Mi>i>t ti.r niontii. and cvi'n years af't.T nr.iv- f.-y Inini tlir attack of typiioid i;.vcr (l.icliliicini, C." Ffiiidvcl, Stcfn). A- a iv-ult. it ini-lu hapiicn that in tiic ca-c of a patient not sntl'crint; tVoni tyjihoid llxcr. l,ut cxIiihiiinL^ fever fmin -ome otli.T eaiise, the (Jrnhcr-W i,|:d ivacti eenn-inir in c'>n-ec|n.nce of an anteceih'nt hnt not e\i-tent attack of i^pjioid fever nii-lit lead to error. The po--ihK' • leleiice that tile jii-iory wonM atllifd protection from sueli an error is invalidated l.y tli.. i;„t that mild ca. as well as a diairneslic, importance, inas- nnicli n> Catnn' h.^lievcd that he ohs.-rved a direct n-lalinnship hetween the rapiditv an.! tli,. intensity of the Wi.lal leaclion and the severity nf the individual •■a-c. This statement has already heen c.inlradicted hy Stern, >Mlh whom 1 am dispn-e.l n, a-rce a.- a r.^sult'of per.-^onal experience. ' .V//., „„,(., Is'.m;, N,,. lij. ■ |-^'- H IV. THE PROPHYLAXIS OF THE DISEASE. Tin: iiifa.-iircs t'nr the jncvi'iition of the .Um'um' iii:iy ho divided into tlircf iiiiiiii i:n)U|).- -. 1. (ipiicral, wliirli arc dir.'.'tc cxten>ive collection- of .Iwelliii--, against the di-ease; or. if it has developed, to prevent its di^,-.eminatio^. ■J. Special individual measures, hy means of which the imniediat<- or me-liate tran^mi-.^ion of tyjihoid f.'ver to tho, .■ who come in contact with the patient, or even to reinot.' distances, i> prevented. ;5. I'reventive inoculation, hy ineaii> of which an attcmjit is made to render the person inoculated immune to the di>ea>e. F.,r the priniMpie-. underlyinir iiie foUowinir statemein- reference should he mad.' to tlie chaptrer of the di-endnatiou of the disease hy the -^iek or hv intermciiary aj.'ent>. especially infected art icle— beverages, arti- cles of foot!, liiwn articles of clothing, etc. — cannot wholly be pre- vented. In almost all iilaces of coiisi.hTable size, even in those with the 'le-t sanitary administration, the disease, at h a-t with regard to individual, nndouhtedly in part import.^d. instances, never becomes wholly extinct. In view of the impossibility of preventing thi-, tho prinei|)al effort of iiiiblic sanitation nt and adequate iiie;isures, to the re-trictiou of the preservation and disseniinatioM of the exi'iting agent cmanatitiir from the |)atient. REGULATIONS OF THE SEWAGE-CONDITIONS. Bv far the most important general niea-ure is the approjiriate ne ee— |hi(.1- and dniiir-pils ii' 'lie neiiilil)iirhi>od ci' liiMiian lial)itatiiin>, or i- < i nveved to ailjaeeiit nnii.-eef how little service even the hc^t system of drain- aL'c and -cwaL-'c and the re-nltiiii: ])nrifieatioii of the soil m,;y he. when it i- associated with an nn-iiital>le and directly injiirioiis water-sii| ply, ha- hecn diown l.y the events at Hamhiifi: previoii,-.ly mentioned (l;).. II. lo). An im])ortanl r,,|iiircmeiit of .a ri'ally c-ood watcr-serviee is an imiii- tcrrupicd -iipplv. ill -uch ahnndancc that if i«»sil.le a distinction need not he made Im twecn drinkinL-'-watcr and hss reliahle water for domestic pnrpo-c-. A par from the fact that ahundant op|.ortnnity for infection i- atl'oid.li.'s tlic .luniic \y.\>y for the susi.icion of •ii-irani.' .ontJimiiKitioii, wliilc l)y mcuii^ of tlic lornicr tliu (.n.-ciuc of !.;wi,ria in ^.'runil in tiic wiitir is t-t:il.lir-li(c (linctiy made. Ill „nlrr to i.n.vi.lf an JrrciproacliaM.' Mipj^lv of water for .Irinkiiiu; and • lomoslic |.iu-po>rs it will !»■ iK.-o-arv, in caM^ it ^liall lie ol.laiiUMl from wtlls, that tlic i-vravatioii ^hall l.c MiHicitiitlv .I.mi,. and that the walls, i.articiilarly in llu' upinT portions, shall he r.-ndcn-d inipcrvi.>iis n. the entrance of infccto.l water from tlic upper layers of the adjacent soil hy means of !»nital)le masonry and ivnientiiiL'. , , . , Tlie water derived fn.ni sprie.L'S— of tis de.'l> a sonive as pos.silile— slionit lie c.invcved throu-h iinpcrvious tnhes ilircctly to the l^lace where it is u-cd with all "prai'licahle avoi, lance of contact with the external world. Kspenal care should he directed to the certainty (.f iinpervioi:sness of the coiiduils for spriiiL'-water, from the propln hu tic .-taiidpoii.t, and- luitnrally, also, m coiiuection with epidemiologic investi-ation.s. Water that is primarily the hc-t. if li.il ade(piatcly protecte.l in the course of il> distrilmtion. may lieconie a source of ilan^'er owiiiL' to contaniii.i'tion from its stirroiintlin^'s— pits, infected superti<-ial layers of soil, .lirect commu:\'<'ation with cesspools, admix- ture of rain-water and nielte.l ice and snow, and all other possilile sources of accidental contamination. The history of lyjihoid fever exliihits a larire nuniher of smaller and lar;;er epi.leinics develoi.e wiiich tlie luvvalenee of typlioid fever may be les- seneil l)v proper draitiairc and a suitable water-siipjiiy wa.x sliown first liv the experiences iti I-"nt:laii(l, t.i wliicli were soon adde(l th.ise of France ami (ierinany. In (b-rnian cities tiiat formerly siitl.fed seriously from tvplioid fever — for insUiuce. Municli — the disea.so has at the te :?-■*■ lYi'iinin I i:vi i:. jircMiii iImv Mltiin-t wliolly |iv:in' li.'cii ilciiu .ii>tr:i!fv \\u- f\|ic ritiK-r- u itli ivLMnl Inllit' iiMH-tality tVoin t yiilioiil l"c\cr ill llic army iitMl in llic civil |i..iiiiintinii.' 'V^.r iiio-I I'diiviiiriiig example ill (icrinany i~ tiirni^lu'd aj^'ain liy Hainliuiy (^cc p. \^>). FOOD AS A SOURCE OF INFECTION. That, ill ailililimi I.> tlir wati-r. mn.-l lnyerevi()iis .-tatemeiits. 'I'lie tir-t plaee in llii- cdnnec'tinn i- oeeupieil hy milk, wiiieli, as iniinennH exact in\e-liL;atii>n> liave >lin\\n, may !«■ a -luree (if infection from intentional oi- aceiilental addition of inticled water. Al.-o, the articles of food derivid from it — linlter, clieoe, w liey, etc. — liave properlv reeeiv.d i:rcat attention recently from the |iro|ihy lactic standpoint. 1 low readily -till other article- of food, cspi'cially if eaten in an nneotatc, -iich a- fruit, -alad. elc. may he inllM'led iiy the con- taminated hanil- ot' the di-pen-cr. !iy riii-inir and -prinkliiii.'- with water eontai'iiiiir i:erms, ami hy other manipnlation-. will rei|nire no hirther elalMiratloii. Sanitarv otVueis shonld. far tnoic than they have done in the |iar-t. ilcvotc attention lo the commercial pnr.-nit,- involved in this eonneetion, ^neh as dairi.v-, n-laurants, fruit— tore-, etc. To adopt ])roi>livlaetie measures in tlii- conney the patient and are txtruded es]iecially with the stools anil urine. ■1. Kc-idenee in the immediati' neiglihorlioo'l of the patient, in the same hoii<>', or upon tlie -ame th.or and soil, i-. in il-elf :.h-ohil(ly iuno.aious even f .r preili-po-ed peivon-. if it is po-il.le to protect them from the ingc-tion of ha.alli. w hich taUc-^ yV l>y fir the mo-t fre(|Uentlv in contaminate*! t'ood and hexcraire-. It therefo'-e follows that |)atienl- are to lie so taken care of an ;irr lu he ^M iniitcil ili:it llic\ -liall imi he a snincc nf iiijiifv 111 Mihcr-. 'I'll.' |iatii'iils -liniilil, -d llir a- |ii'acliral)lc, Im' rciiioVfii I'll 111 Cluwilril ilwi'llili:;- :mi| iViiIll >lllTi illllllilHi- lliat ill lint ]irl'lllit iil' slli-l'acliirv i-iilatiiill tVnni lliuse alinllt lliclii. .iliil tllr\- -limilil he ~riit tu ilir liii-|)ital-. Sliiiu!,! Jifv I'ciiiain in ])i'ivair (l«iHiiiL''~, a iiiiiiilirr nf iiica-iirc- that wniilil lir iiiaitcrs nf tnur-c in a liii~|iilal -iioulil lie riuidiv |iiir-iic(l, liut uitli a|i|irii|)iiatc niii. Treatment at Home. — In tivatnunt at limin' «w <>{' the es>cn- lial |iiiiui|)l(- (■iinly in mind the fact tliat tiie |iiii--iiii enntaiiied in the di^eliai'ire- ut' tiie [latieiit inav till' a ciinsideralile time adliefe in an aetive -tate tu all |iii--ilile artiele-, I'fiin wliieli it niav lie tran-niitted l.rielh nr lie eniiveved tnr Lrreat di-- tanee-. It i~ nut le-- ini|iiii-iaiit t'nr tlieiii in kimw that patients witli mild ail'' aiiiliii'atnry attaek-, a^ "cll as healthy |ier-iiii^, may, under certain eireiim-'tanees. aet as the carriers and dis-eminatdi's nt' the \ ifiis. Of the iiiniv inipnrtant tietails, the arrangement of the sick- room may especially Ix' retii-red to. It ^liniild imt he inn small, -Imiild lie sn-ccptilile lit' ventilatinii, and -itiiated -n that a- miieli ipiiet as pnssi- lile can lie secured. I nneeessary articles -hiiiild lie remnved, and this applie-' e~peeiallv to ronj^li woiilleii article-, (diiiiter|iaiies, ear|iets, and iiphnNtered t'iiriiitiir<>. In addition to the -ick-hed proper, a second bed, it' |)iissil)le, slionld Im' in reas ve-sei> ( wiiicii, in the liosjiital, should he reserved tor tiiis jiarticnlar piir|>ose). Heforc lieiiifX thrown into the watei-eln-ei, ihoroiitrh disin- Icetiiin, preteralilv with milk of lime, -hoiild lie practisc\vm\ .>f:i tlii-liiu- -\.-Ii ni. lliciv i- ;i i uriM Mi-iii or pit-MStcni, .li>iiit;rii(Hi uflli.' .•onl.iii^..llli.' |>h i- ;il-n iinv.vsir>-lla' udditioii daily oi' tVt.iu ItMi In I"'" 'jniin- nl' rnilki'l linir r..ri'arli iiidisidual liciiiL' consuKaM: Mitii.'ii'iit. 'I'lial lh..r.,iiL'ii rin^iii- and .Iran-in- <>f ^.'d■|.all^ and L'la.-s V(•^- mI- -Imuld Ik .llrcu-.l r, -ularlN. I"--I uuli a -..lulion '>{' I_vh>I, inay \,v nm- ~idrrrd aluM.M a^ a inall.r ..I .■niii--c. In llii- rnnnirii,,n allcnlinn ^lu)^lld lie -iv.n f>|H-ciallv t.. ill.' .•xurinr ..t' ilu' vr--rl and its lian aJMi aii|ili<"dilf. .m a.'.'.innt nf ilic n lativfly small anitniul .if iiiiicii!- and alliuniui .■nntaiiif.l in llic lypli'iid .Icj.'.ii.ins. Til,' ivlialil.' a.-li.in ..I' milk nf liin- .l.ii.'n.l- ii|m.m it> iimii.r iiroiiara- li,.ii. It >linnl.l li.' . in|.l..yc.| in a- liv^ldy |.|-. (tared a .-tal.' a~ i.u-ili!.' — at anv rat<' imt afi. r it i- .d.l.r lliaii three days. It is li.st l.i iinjiaro til,' n.'.'.'s-arv ai mt .laily, tli.' -lakcl linn- h.iiiL^ mix.-.l whh IV.itii iw.) to r.mi- linn s tlu' :..ii..iiiil td' waUf. U sln^ul.l tli.ii I"' luv-ci-v..! in C'l.i-.'.l \t's-.U. In Fratu'.'.li.-inr.'.'ti.ir uilli <'oii|i.'r suljilial.- is nuicli i'iii|iler eent. of suliilmric a.i.l is a.l.le.l. In ( i.rmany tlie in.tliod lias not. to my kiioul.'.ltre. I'een .nii.luyed upon an exUiisive seal., and 1 liuve no penHMiul ex|H'rien.'e willi il. Disinfection of the Urine.— Tn vi. w of tlie pront fiv.iueney xvitli whi.'h tvj.lioi.l-baeilli are fouml in tlie mine of typli.ii.l patients, often in inunen-.' nMinl..'rs (s.'e p. 31), tlie extreme iniportaiiee of care- ful .li>inf..'ti.in .if all such urine wili he a ]. parent. Cxvyn'has made a canftil .xp-riniinud sin.ly wiili ref.'nn.-o to tlie Ik'-I metliods by xvlii.'h tlii- ean I"' .arri.'.! .mt. lie .'.melu-ies tliat milk of lime liardly ii. Carli.ilie aei.l is of us,, .luly ill larir.' aiimunts an.l str.niL' s..liiti.)ns if a spee.ly r.-iilt i- ui-li.Ml. F..rmalin is an ex.'ellent di-inf.etaut, liiit is t..o expeiisiv,'. r.i.l.l.trid ..f nur-Mirv, ehl.irinate.l lim.', an.l luiui.l .lil.iri.l.s are ..f real vain.', are ni.i.l in tli.'ir a.'ti.m. an.l ar.^ .'Ili.'i.'nl in eotnparatively dilute s,,lntinns. \h lia- fmnd tliat f.r di-inf.'.'ti.m xvitliiii live t.. tiffen niimit.-. one vnlnmo of urine m.iuI.I iv.,uir.' ,,n.-twenlietli t.. .me-tenth of it- voliim.'.d" I :100(» H TL -nliition. Fn vi.'w of 111.' .'X.-.'ll.'nt ivHilt- .il,tain.'.l by tlie u^o of ur.>tr.ipin m eas,'s of tvphoi.l ba.illuria. Ki.'lianl-.m lias a.lvi-.-d llie romin.' admiii- i-trati.in .'.f tlii- .IruL' in the latfr p.'ri.xls of tli.' disea-e a.s a i.revcmive . F.T p.irnMil:,.'- unli n'L'.ra t.. ,li-inf.'<'t:int- ami n,.-tl,...l^ nf (li-i..f.'Ption. r.'frr- .„,.. „.,. L ,„a.l,. n. an urti.l.' I'V K. I'fuhl, Z-iL /. Uv;, u. I,.f.-I.f:..,.k., ii.l. ^i . Ml., ri:iii'iiYi..\.\is. 437 ami [.loplivhiiii.' iiir;i-iiiv. I'n.haMy .")- ;riv.ii ilinv tiiiu's a (lav aiv -utliri.ni \'io-( . it -ImiiM lie nicniioiicd, lu.w. vcr, that -cvci-al ra-t- oj' liriiioo|,,l)iiim-ia tullowini: tiic cimtiliucd ii-c i.f tliis (Inij; lia\i' l»iii I'lpi'itrcj. Till' disinfection of the sputum may \pe well a-< hi> napkins and haiid- kenhiel's. In Di-der toavoiil mnit s.-arv ihrowiiiL' alioni and repeated manipulation, tile articles in .pie.-liou are iiesi kept in not uater-li-hl ) sacks, and tiiesc in tarn in p(n-ce]:.in, eartlu'iiuare. or zinc vessels that can he clused and are partlv tilled with a •> percent, sohiticin of earholie acid. The linen thus nut completely ( !;irtiier), l)ef(jre heinir iriveii to the laundress, and only then suhmitted lo the remaining pr(ice.sscs of ■• ashintr. At the termination of the di-ease the heds arc to he thoroiljilily dis- Itifectcd. W len hed-teads are carefnlly cleansed with a •"> per cent. solution of carbolic acid or lysol, while iron bedsteads are treatc cNenised, particularly in the matter of distant traiispoilation, the ImmIv, without pre\ ioiis washiiiir, should be onvelopel wliiili lli' licil -tuud -ImiiM ln' riililpiil dowti with hnail, or, >liiiiil(l it.-- ciiMi-in;.'- Ii>l(nit( liini.-liiri', it -IkiiiIiI lir tripled with ;i ."i iicr cent, -'iliiiimi (iT carUi.lir acid and S(ia|). I'lirniluic u.~cil li\ the patient, i'-liceiall_v tile lird-li III and cliaif-, and iIk' IIimh-. -Iiould lie disinfected in tile latter manner. It' thi' ttiMir i- nut painted, it will lie Ketter to empliiy niilk uf lime. The cnick~ lietween the Im.ard^ -Imnld receive particular attention. I'hc di.-iiit'ectiun ol" nium^ imt i)ccn|iied hv the patient ami kept t'roin euiitact with hi~ dejectinns i> nimece--arv. In private practice, i.-pcciall\' under ciindition> amid which the inethiid> 111" cleari>iiii.' caniiut he .-iilliciently depended upon, it i~ advisahlc, .'d'tcr emptying the roimi, td undertake, hesides, di>iid'ectinn witii tiie vajxir of fcirinaliii. E.-pccially important aUo in eoniiectiun with piopiiylaxi.- is the maintenance of cleanliness on the part of the patient him- self, of lii.- skill ill f.'eneral, jiartienlarly ahoiit the month and the .■iniis, and his hands. Particular attention .~hoiild lie direi-tdl espeeiallv to the latter. It' this i- not done, the patient may readily coiivev iiifcetious material to various nteiisiU, artieli's of food, etc., and thus hecome a source of daiiL'^ef not oidv for those imniediatelv ahoiit him, hut for others at a irreater distance. The attendants must, for the same reason, connection. The (lisiiifeetioii of liie hands slioiijd he practised ac<-(irdiiii; to the rules ohserve(l hv snrL'eons. namely, thipnuifrh wasliiiii: and hrushiiiL' with snap and water, followed by prolonged iiiinieision in iiiereuric-chlerid solution, giviiiij pro]¥'r attention to the nails and the space heiieath them. In hosfiitals, in this connection, too careful snjiervision of the nurses, ])articu- larlv tho.^e of : iiort experience, cannot he exerci.-ied. Further, physicians and nurses in attendance upon tyjihoiel patients should lie provided with clotliinj,' that can he wa.-hed, aiiii at the end of their service, espeeiallv Ix'fore {roinjj to tiieir meals, tliev should clianjre their clothiiiL'. In hospitals it is advi.sahle, in ea.se typhoid patients are cared for in the same w.ird :is others, to provide hut one nurse for their care, and to keep others, paiticiilarlv those who are concerned in hiin^diiir the food, attendin;^ to the cleansing in p'tieral, and the care of the remaintler, as strictly as possil)l(> apart from the typhoid jiatients. \\'hen ty[)hoid fever occurs in hoarding-sehool.ss, tiarracks, jails, and institutions in jrenenl, espeeiallv tlK)se eontaininp yoiinir persons in considenililc niimher, immediate isolation of the .>.,*;, ...... .„...r..,s.i.i,. ..,..., 1 f....„, »i,.. 1, : ....»,. i> i.. .!.,„*:„ ri:ni'iiyi.A.\is. 439 nwisiires wotil.l, imd.r Midi ••irciimM:iii.v>, Im- ^ll^.■.•l.lilll.■ nl' ;ip|.li.ati(.u olilv uilli (lill'uiilly :iii(l uii>Trl:iiiil\ . Preventive Inoculation. — In MiMiii'm in the |m..|iIi\ luraiii-t lyphoi,!. Tiir mat. rial n-d i. a hoiiilLn-.-nltniv of Harilliis tvpliortus ..f liii^li vinilrn.T, luat.a until all oi..rani-iii- aiv .l.a.l. Tlu' amount iiiociilalcl -lioiil.l ■ !..• -ii.'li a .|naiitiiy uhic-li. if iiij.vt..! aliv.-, would !..■ fatal to a .'..-.d t:m. -nin.a-pifr." Tlw i ulatiou i> follow.-.l hv lo.'al (.■iiiioru.-- aii.l coiij^.'stiou, faiiitm's>, p.^MMy nausva, (Iv.t, and n-tl.•^^n.•app.afi-rori>durc lie r<|M'atf(l iii two weeks. Followini,' tlic injection tlieiv i- an ineiva>e in the baelerieidal pwerof the hlo.Hl, and aUo a very marked iii.reas«' in the af:<:lutiiiating p)\ver, whieh may per-ist for at l.a-t two years, as in eaM> rein.rt.Kl l.y Foulerton. This proettatistic> fi i South Africa are not yet avuilaMe, i>ut out of llK'i per-on> irio<'ulate!( not in.KMilate per cent. Oil the whole, the experience ,-<) far is stronirly in favor of iiKK'ulation. Such a method is naturally mo>t apj.licahlc in the case of |)er-ons goini; into a di-trict where the (lipase |irevail-. or in the case of armies or other lar^e l.odie- of pcisons likely to he attackc-d hy an enidemu! of typhoiil fuver. •i ! ii li \\t' I i rM V. TRI A rWHNT. OBSERVATIONS ON SPECIFIC TREATMENT. A\ r. iifi' yi t I'll' rcnii>\r(l iVciii ;i -[n .ilir iniiiiin iil ni' i\ |,||,,ji| ti \it, /. «■., :i mnl,...! cMii.ililr of (Ir-lr.iviii:: li- lAriiin./ nni-r-, tln' i\ pli. i.l -i.acilliis, ill till' liiiiiiiiij ImmIv ,mhI |irr\ I'liiiiiir i'- 'li--' iiiiii:ii l^n, ir ;iiii niiatiiiu- llir :irii\ii\' i.i' ii~ iM\iii~. nlll jli a imihlur ot nci 111 nli-trv alii'ii- -liiiniLilc (.ii'in-l iii\ (■~ii;.':ilii.ii in I lii- (lii'<(n' .n. Serum-lreatmcnt. If iIm-.> ..t' lo.- . \|., ri, ihv I. Ii,\r.l i|,mi aTirr Hi'liriiiLr'.- iiiL.''. lliiv iia-ipiiil uillmul -ullii iriil I. i;i,.!al i..ii. ( ..ii- olu-ii.ii- l)_v uii!ili',i:y Mial liii|i(> liM-i il ii| till In an- i -| . riall\ lii n | ii\r in the cliiiii"il ami l.acliTiiiJiiL'ir lirM. aial ilu .litiinilly ami llir |:( i iiliai-iu ol'llKcini- diliniis alli-inllnir ty|iliiiiilti\( r I >|i( I iaiiy luiM' rivciilK lnin a;.'iiiii (Itimiii- Mralcil l,y in\(T^li'_'aiiiiii> inin ihr iiIhikiiiiiikhi ,,f aL!;j li;l ii.al imi aial il> n la- linn.- In iiiiimiiiily. \aiual.li- |iri'liiMiiiar\ iii\ i .-li_al iiii;> nii llic .-iilijcri nl' SiTUiii-liaaliiiiiil have Ijrni inaih In ( liaiiliiiu^M' ami W iilal, ami i>]m iailv liy Si lln- ili(i-a|ii iilir arii\ii\ i.iiIk -iiiiiii nf I'diix ah m<-ii1s tVniii ty|iliiiii| t'cviT. a^ "ill a.- l>\ llciinii r ami l'ii|.i-. I\ li iii| i n r ami i.ivv,' with attfiii|ils III tnat ly|ilioiil il \«r ur.li iiij(riiiiii> nl' ihc urimi of iniiiiuii- izeii aiiiiiials i .•aif" or iloi: '. Altiioi|i.'li tiit'sc oli.-crvalioii.s l.avc ili>riiiM'(| a liiniuil inlluincc of ilie imiiuiiH" scniin ii|i(iii cxiK'riniciilal lv|.|ioi(l inloxii-aiioii. a lli(ra|iculic rcMilt Willi n'fiTcncc to tyjilioiil fiver lia.- not as yet lici n inailc out. ami tliis coiilil scarrily lie fX|n'<'t(M| lo I iIutw Im-. in view ot' tlif iiilirf (lill'tTciicc ot' the ex|ieriiiieiital ty]ilioi(l infcriion from typhoid te\(r in hiiiiiaii heiiiLTs. llanllv more than the iniKM iioiism -> of .-mh allciiipl.- ha> Im n iiri:ativ'-. aii.i iln;- to cllin , limiii.iil.'ii •.!' iln' lyplinid \il-U- ll 1 ihr iiil.Mili.. (i.,.l_\ ivlal..l !■■ 'Im-'' U'IV .•.■n.iili innliM,!- mI' irv:iiiiHnt lliiil. --in- m -I. |. riinlni , u.Tf .lire. I. ,| |.,wanl tlriiir:.li/in._'al.n-iiuil |.iilivl':i(!ivr |,r.ict— .- in llic ilitt-lim, w liidi w.Tr ,-.,n-iclc Ti'l :i- iIh' .--.iiii.il f.Miiin. 'I'li.-r i-c|iii>riitc.l til.' lir-t allciniM.- ai intestinal antisepsis. In ilu- cai. _'miv l,rl..n;^, nn(loul.i.-.lK. \\h- tnatnirnt l.y internal administration of chlorin-water, l-i- mcrlv 'nn.'h" pra.ii-r.l, il„' 1 1 :.n-lt..ry .•n,|.|.._vni.nt ol' carboliC acid aii.l benzoates, m.l u.. iodin-potassiura-iodid treatment, w.ii-nilv iv.'.,imn.'n.I..| l.v -v Will.lMiipl.' W'liil' li- - HH'tli'"!- |>".--<--> niily'lii-toia.- ii,t,.iv-i al iIh' |.iv-,nl .l,i>. a inrili...! |..iilih'lly alli.tl t.) lli.ni, nam.lv. ili.' inaiiiHiil uilli calomel, -nil lia- ar.l.nl a.lv..,'alr- ani.mi; th.. niM-l cil-lin-ni-li.'a livin- |.|iy-l.iaii- ( 1 .IrlH-rni. i-lcr, vmm /icni-M'ii ). l,rs-cT.- aipl al'n T hiMi ^.li. 111. ill, ■I'l-aiilir. ami Winiclfrlirli. iiinluulilcilly fsoiiL'liI 1.) nliiaiii Willi llir iTiiir.ly lint -iiii|il> a |uii-alivc ftl'ifl. liiit alM) a s|i.'.'illc. Inrallv ciii-aliNc, |.o->ilil'v ■.\\^<< anliln\ic, arii.m a|«>n tlic inlcMinal imi.'oiH iiHMiil.raiic. Ii wa-i lirlirvi'd iliat lli.-r cH'iiT-i w.-n' iiin.-t nianil'i^l at the (•nmiuriHviiH 111 ..ri'i.' .li-.'as:-. an. I u.-iv .-ai.aMe .if iii.lmaii- an abortive liTininali'Hi. ..r at l.-a-l .niir-i.i.-ralili. iniliirali.m of tlir iiiti'iisily nt'llii' disyasf. Till' mclliiMJ .if 1 iii|)|..viin'nt -till rfv.iniiiii'iiilcil liy tlie advocates ..f till' rninilv iilacr^ ilir lti'i.iIi'-' iMi|Mirtaii.c ii|m«ii its adiniiiistratinn at tlio oarlifst [wis-ihlc |iiri."l nf tlir di-casc, at all events licfivrc tlio end of the iiiiitli (lav. ( )idv a snull iiiiinhiT nf |)liysii'ians lulicvc 'liat the pciikhIv lias iinivid ii~ifiil al-o alter the s<'eoiid week of liie disease. Doses of 0.') isr.uw are administered at intervals of i>ne or two liotirs, ^enerallv three or I'our in llie t wiiitv-t'oiir hours, at the he^innilltr of tlie disease (Liehermeister). liieliernii'ister iielieves that treatment with ealo- niel indiiees a marked miti._'^itioii in the inleii-ity of tlie disease, while von Ziem--eii, ijoini; somewhat fiirlher, attrihiites to the reniofly an infliienee in diinini-hin'_'' the intensity of the whole infi^elioiis condition, and espeeiallv of ihc local intestinal symiitoms. In view of the experi- ence of these two tni-tw.irthy writers 1 am iinwilliiiLr to advise airamst the emplovmeiit of the method in siiiial)le cases, hut would emiihatically stiite, with Baiimler and Weil, that I have heen niiahle t.. convince myself of its ahortive and ahhreviatinsr ctl'eet. What I have ohserved was an incre;isc in the nnmher and a srreenish di-coloration of the st.Hils, oft"!! with tfaii~iloiy depiex~ion of the temperature, which, however, ' rin-//""-'.' .tr.-A/v. I'l.l. \\\iii ' £)i> EntzuihluH:! iinil {'.■•■.i.-hiniriin;! ilrr Schlnmhniit :lrs Diirmkathilr.i. etc., Berlin, 1S30. ; I i [ IIJ rrriinii' 1 1 \ 1 1: ■ |h |H $^n| 'S 1 w i •iM HW I f'lilild Ih- citii-iili Tfd :i- i, n-ull "I iht- cli;illli(:i il-rlt". Mini li"! a^ !l -[Miilir ill'icl i.|' llic illii.;. r lliluulill .il\ , In, Hull I .ilir-hli rilllnu 1|;|,- hfl'll ;.'IVfIL to I lie t'ilcl lIlMl tllO alMirlivi' I'Mun-f ■■!' ca-i > •■{ |v|iIim|.| Wwt in which c'ahnml lui.-' hfiii ailiuiii- ii^tcriMl ill the iuiImI imjhl jii?-! a> wtll he ;illriliiili-cl In the luiliirc nf I lie cmm' a.s 1(1 till' in-aliii'iil fiiii l"\(>l. '\'\\v hir.'i- mmiiiIu r dI' caM* of lv|ihnii| |'r\( r pur-nil];,' a iiiihi ami Axml >i>HT>i\ cmii wIji'ii ihf (in.-ci has hccii severe, as Weil as liie t'aet ihal liiis iiuMiI.er may at liiius lie ;.'realiv iiiereaseil withmit a|i|iareiil cause. .-Ihnijii !'e kept in miinl. and e.-|iecialiv il shniiiii iim he t'ur- (.'Dlleii thai It is ini|M)Ssildc in ilie lirsl ila\> nt' the ih:-ea.se to foresee the eiiaracter ot' ils siili>eiiu nl imioc. iliat. iiiiwe\cr. tlii' calnmei treatment, evi'ii it' inclmieil aim.n;.' disint'eciMul inclliiid-. i>. like all i.th'TS of its chiss, without sutlicient ♦heoretic t'oundal inn, will shortiv he shown. 'llie earlier eiideavnr^ in tin works iit' IJo^sliaeli ' and iJoiiciiard - with rci.Mi(l to -\ -iiiiiatic inle-iinal anti~e|)-i- have lecciitlv lieeii taken up uiiew ill accordance wiiji modern view- and iiicihods. Thev aim at the iiitrodiKtioii into the iriic-iiiie ot' l)actericid:il remedies in amount and form ca|)alile ot' di-iro\ intr tiie t\ piioid-liacilli in thi- situation, or at least ol" inliiliitin^ iiicir de\ eiopmeiit and di-semiiniion, l^ossliacli teeoiiiineiided tiir tlii- |)iirpose especially the employment of liaplithaliti ; while Iloiicliard emjiloycd a -cries ol' remcdie- >iicce--i\ il\- — in addition to naplithalin, ^-najihtliol and ,y-naplithol, iiKJot'orm, -alol, calomel, and (dinliinatioiis ot -evt ral ol the-c leniedies or in comliiiiation with oilici-, as, for instance, iiaphiiio! wiih lii-iniitli salicylate. Tlie iiietliods iiavi' hitherto recei\ed little imitation in ( iermanv, while Hoiicliai'd in I" ranee h,i- inimcroii-. in jiarl ciithii-iastic, disciples. I have persoiiallv made hut I'ev' ol)>ervalioi|. with the method of Kosshacli, whicli lias a frail t'oiitiilalion. I Iia\e not ventured lo follow the more prcnise direc- tions of Iioiichard. His mithod ii(|iiirt's a.s an intioductorv measure tiic admini-tration of I ."i irrain- oi" inan'ne-ium -iilpliate evi'fv third dav, calomel in -mall do-es for irt'ini'iil aiiti-i psis for foiir d.iy^, atid, fiiiallv, daily dose- of t j.T.ims of naplithol w\\\ '1 of hi-mnth salicvlate. It would take us too tar to enter fu v iiiio the scieiititlc iis| .cts of ttio method of trealmeiit in (|iiestion. In this connection I would refer especially to the aclniiralile investiLration of Stern, which leitntfi'X!<'. I'aris, lss7; anil Thernpentiqur r/r.s malrniirn infect. nuftsrp^i..'. Pari-. ISSM ■* Vul^^ninnn' ihn'q klin. \\>rtr.if]r. N. F. No. IHS; and /'■// f. Ilvp. u. Infr/iiium:': . l?'.-'d. irl. i:;. ' JJru:~r-:. rrr::. ]',':rr:.. irS". Ti:yMMi:.\r 4!.l finnllv was ii.flir't."! iii«-ii th.- .luctri f iiil.-tuK.I n..li..<.i>M:' l.v llir rr.-.tn nl.H.Tvatiniis ..'' It. Miillir.' «Ih. .|.-.n..MMr;il.-.l .-uLrlu-ivrly il,- iini.riiiH.'ii l.il'ilv II, |„.i,lil, mimI .li>.:.,-.-.| liunmn liriiiL'-« «illi iM.'a.-urr^ .ivmiImLI.' at pr.-.'nl I'^'Mi tlioUL'!. il u.rr u.-mmiumI llial lli.r.- .xi-lc .1 a i^m, .-.luiv rapa- 1,1,. uf injuriti- til.- |.allio..'.in.- iiii.T..-,.rL'ani-Mi. m -nal.r .|.-ivr aii.l iu..r.- m.rfnai,..Mtlv thai, tlinr l,.-i-. n ""uM l.a\.' Iilll.. valm^ u„ a,'-uu, i M t hr r..lalioi,s nftiM- lv|.l,..i.l-l.acilli,> t- tlir int. . liiiv an.l il> ' t.-nt... piirlinilarlv in .'ases ,.nv|.l.ni,l f..v.r. li i- ki,..wi. that .vn, at a .unr «I»m, th.- a,^ea^J ,|„esimt uemTallv .•oMU- ui.I.t „i,r.,Tvat.,... for ,naliM.-iM. .•%.•„ uttri, u l,H. th.> .•iini.iai. lia-' as v.-t i... kimwlr,!-.' ..f ils .m-i,.,,.-.., .!„• I,a,;,lli have alroa.lv |.a«s.Ml fmm lli.' iiu.Min.s int.. tlir Inlli.lr:.. ih.. mlmmiIitk' L'laiMl-, ftu.l nmr.. .ii-taiit nr.'aiis, .•,, ialiy th.- .^pU-.-n, ^^\n■u■. naturally, t hoy an- nu lonL'MirMr a .h.iii.ttiil attitiulr t..waf.l tlicantiMpii,' iM.'tl.."!, aiiM .•vrn i.nr uf -k.pti.i>ti. will, r.v'aril to tlit> li"!"' tli:it it may in fuimv pfovc niurc ^n(r.•^^t■ui. For the im'sriit, anil i.roi>al.ly for a lon^; tiinr, thr >u.c.»tiii tr.'at- mont of tyi)li..i.l fcvr will liav. to !>,■ pnr-n,.! in -ornr otji.r .iiivtioii. The priiKMpal fi<>t<,r-i in tr.atnn'iil aiv, tli.T. ton' : ( 1 ) Tli.' vtnTal appropriato <"ir.' an.l reKmlatioi, of the condition of th.' paticiK, (-|m- ciaily in a diftclic dirctiori ; I'J) 'i'lic trratiiifiit of a mimlu'r of ini- p.rtatit manif.stations aii.l symptom-tcroups, of .•ompiicatioiis aii, others, however, are attended with such profound manifestation^ and are so frequently followey severe, even repeated, relapses and unusually protraetefl ( ..nvaleseeii.e, that one cannot oseaiM' the impression of the hiirhly injurious inrtuenee of an amhulatir.y course. Patients wluw circumstances offi-r no assurance of aileqtiate care at home should promptly he sent to the hospital. The management of a case in a private house rerpiins strict rcLmlation of eNternal conditions. Provision for the utmost physical and mental reixise on the part of the ]»atient, and onier and discipline in the sif ciiiiilnvi'd ill ihr li-il/l(', -iMiatt'd in a (|iiiot i|uarlti-, and la-ily \ riuilatcd. 'I'lic \tv-{ \\»<\\\ in tnc licu.-c i.- jii-t ^■i"id .■Miin^di. 'I'lir ti'in|i( ralurc ot' llic niciu .-lidiild ix.t he alioxr \-l° "I" II < '• 1 >nriiii; I'avdiaMc inrind- nl'thc year tln' windows slimild lie krjii ..|itn day and ninln. and cxm in winitr a tlidMUtrli airing slunild l)f |ira(ti-cd -cMTal tinii> ilaily. In li..-|iital iiraclici', and w licncvi r |Mi~>ilil( al-|ieei;.l darl^enine- dl' tile siek-roein, arc t(i lie a\"id((l. \ cry iinii-nal article^, dicdralidns, lljinie.-, |iielMres. and tlie like, aliniit whicli the ]>llanta^ie- and the dilirinin df the |iatient readilv ri'V(4\C, .-ildidd he reinnved. The sick-bed — makinL' alldwance .as Car as pd—ihie fdr tlie pre- \idn-. haliil-- df the p.atieiit liMiild in any event iidt lie tdn warm, and shduld lie readily ehaiiLred .aiKl reiideni! clean. 'I'hdx' severely ill -lididd lie promptly jilaced npdii a uater-hed. 'I"he -heets. whieli slioiild lie cliailLreil \\liene\,T -diled ill the -lielite-l deirree, ~lidlild Iliit lie tii" cdarse ill texture, and ne\er wrinkled, dii .■lecdiint df the danj:er of lied- siires. Fdr the same rea>dn ininiediate ennlact nt' waterprodf sheets \\itl' the liddy -hdiild lie a\di(|<'d. While at iIk innieneeinent ;d decnliitiis is the niost iialnral and the ind-t advaiitatrcdiis, at the lieiuhl df the di~ease and toward tlie • ■nd "( (he felirile stiiL'c chanLTf' "f ]>dstiire >li(iiild Ik <'iieduraji('d, and, especially fdi- tin preventiini df |inliiidiiary hyjidstasis, fre(pient alterna- tidii df the ddr~al with tin lateral decnliitiis. l-'vaeiiatinn df liie Ixiwels and the lilad, when the lied \- cJianfriHl, till' patient sliduld iidt sit iiji. Init always remain in the hdrizntitai posture — ])refera!ily in another lied. Many a ease of fiital enliapse could have Iiei n avdidcd liy the iihscrvaiK'c of these ])rccantidns. That in in.iinlainiiiL' -tripeci;il rnir is a matter df <'oiirsr. Xcirleet in this ri-peet. in conjiiiietidii with defective cdiidi- tidiis (if the hed, le.ad- Id the de\(ldpnient df hed -ores, whicli are but rarely depenilent upon t'-e nature of the disease. Imi almost always njvtn in{ ,|„. li|,-, :m.l ihr liv.|iiriil iirollcriiiL' of Miiall (|iiariiilU'.- of lluid, arc ii!,li-pciisal.lr. A \v.H-iiurM:nrmeiit a;^ with n-:u-.l to thr in.livi.lual ca..'. In ^r,,,„.ral. the .Hfli- eiiitiesan.i jHriiliarities in the n..nri~hin,iit ol' tyi.h..i.l j.atlents are t.. he '....,k atteiuhn^' 'he infeetive or the fehrih' Male, an.l in th.ise a-.-.ieiate.l with the local .•haiiges in.htce.1 hy the typlM.i.l i)r..ees- parti.ularly in the inte^line. The maiiif.stations.if the t.>xi.' aeti.>n, parti. 'ularly the f.'hrile e..ntru<'ii.>n ..f the h.Mly-pr.itei.i ].lay> an important /.'./,•. It is the m.>st imp..rtant pr.ihlem in tlieteti.' tr.alment t.. sliiel.l the j> '..ids from this .lestrnctive j.to.rss as far ;. nos.-ihU. l.y th.' a.lmin- i,«, ,ion ..f .•arh..hy.lrates an.l eneriry-.-n>tai!H,,jr t'.«'d. it miiM, fur- th..rni..re, he t:' n into ciisideriti .1. that direct replacement ..f the di^inteJrratin;: |.:.,t..i.ls thr.mgh the f....d is p.,s-ihle oidy in a wholly ina.le.ly nutriti.m is jrreatly di>tnrl>tHl in many other din'cti.ms al-.), esjH'..ially with repir.l to carhohy.lrates an.l fats. It shonl.l he borne in min.l that, in a.l.liti.m t.. the ])r.idiieti.>n ..f hydro- ehl.vric aci.l in the -t.ima.h, tlw fnnetions of the sdivary glan.ls, and pr.iiiahlv th.iM. ..f the ]>an..r..as, are seriously itTipaired, an.l also the se..retion a. .1 th.. con-lituli.in .>f th.' hile are alterens that dcman.l ..an.f.il s(.li...tion an.l |)n.parati.in .'f the f.iod, all the more sine., peristalsis an.l absorption appear t.i he al-o invariably impaireess as a re-\ilt attain an e-^iMH-ially hiirh trnide. Th(.ir anjrm. i\tation i- piv.jjressiv.. with the continnance of the .hsease ; and thi^ naturally increases materially the difiicnlties .)f ireatment. an.l : y 44(i rvi'iiiiiii I i:vi:i: I ^p-^T- ■ 1> ! M "iiii >liMiil(| I, ail ihc |)liy,iiii ilic -|pi(itic iiiic-tii 'rill lal lr-iiiii> |ii(|i(iii(l(rat !■ iivcr all ullici>. |iliy-i(iaii caiiiiiii inaki' it Millicinitlv rlcar l^r liini-cir in tl ifctiiiii that till' iiit -tiiiai i|ilii|ii- cliiiicallv stand in III! ijirci lis Cllll- ■t rcla- i.-o ic li'iii to till' (li-triliiitii.ii and the -cwritv of tiic aiiati.niic li-inn.-, ana-.'. iwn a|i|.aiviitl_v tli,. niildot, may l.c altcn.lul with cMrii-ivi- and |iriil'iiiind inii-iinal iilnratinii. KiiiMiinatrly. It i- i iiliivly |.,i--il,l,^ at the pfonit day to make ].orrwt all"uaii(v lor tiic jinal ci iiidili. m- wltlmiit ivliii-ninu- tu tl- |Mi.-iti(in. ii'iii: aliand.iiiiil. .if a \\at.r-.ii;|, aii.j iiiiiitriT-diiit. < )\vini; to tlie iMH-lit of Miiudi-li iihy-i.iaii-. mid. r ilic oiiiet ; ue -lioiiM tlierehy '•'"''•'^"'' '" njilai-. llie i .teid-, or alletiiiit at lea-t to limit till' de-triieii, 111. I,y mean- of ,.|i, r-y-prodneiiiir Mih-Ianees, earlio- liydrate-, lilt-, -eiaii i- -iil,-tanee-. and, linally, aJM. aieoliol. Ill aee.irilaiiee uiih tlie i;. ii.Tal and Ineal jieeidiarilie- of the di.-e: already mentioned, however, iliroii-liom tiie entire duration of i| telinie -late, and f.ir a eertain jieriod |„.yond this time, all .-irtieles of food -lioiiKI he jriveii .iiily in a llnid, readily dijjestihle, ami casilv ahMirl.ahle form. I'"rom t!ie -ame |M,int of view, eare -hoiild he taken 'liii' ' ■i-hmeiit i- uiveii fn i|iiently. in severe ea-es hv d.-iv ami hv iiiirht. alway- in -mall animint-. at interval- of two or three honrs, ami that al-o -omiioien; |i.alient- -lionld he imhieed hy the attendants t.i take food leLM daily. < >ii the oilier hand. e-|ieeiallv in private piae- li.'e, overieeiliiiL' of the patient -hoiild he eaiitioned aj^aiiist, and it -lioiild 1)(> made ele.ir from tin tset t.. the o\ (.r/ealoii- friends that the l>hysieian eaniioi hope diirinL' the fehrili stajre to make j^oikI t'litireiv tlie loss, hut tliat. hy na-oti of the re-t of the patient in li(.n. DuMitl. 18-18. Tlii- \v..r!, . ■lit. lit,- th.' f.Un.Mi- M.il.-hi.-i.I .fi.'ii .|u.i|.-.l ■ ■■ If y..ii sh.uil.i Lp in iK.iil.t U' I'. Mil ci.ihiiih t.i li.' |i|;i.'...| ii|i.iti iiiv L.'rn.'. i.'il<.- ilii- • H.' f.'ii tVvi'rs ' " • Thr 1\n,l,^.,.l /»,.«■. M,». (;,Tni!iii tnin-lnti.in by v.ui /iiizpr. Horliii, 18r,7, p -^M, Ti:i:ArMi:sT. Ul state, ill a lar;zt'r iuiiiiIht diirinj: tlic .-(((iiiil |>crii«l of tlic disease. 'I lie cxixTiciictKl ]iliv.-ici:iii will (•.niiitciiicl lliof iii(iil)itl iiiaiiit'otatiuii- nut !)v uniiccfssarv >trittin>>, hut \>y appropriatt' individiiul selection ami variation. A tVhrtle Ivplioid patient is not a .-nlijcet (or |>e the widest will vield, and this the pinsieian ~hoiild l)e. Drinks. — Kven more tVeciiiently than deran^^eiufiit of appetite, coinplaint is made dnrini,' the I'ehrile period of thirst, and in somno- lent patients an elforl will he made on the part of the I'riends to (pieneh the i)arehed eondiiion hy atration of fluids. In contr.ist to |)re- vious views, the:-e desires may lie nnconiiitilain of pros.«iire in llie epitrastriuni. a sense of fulness or of ahdominal tension, and of pyro; is .-ind eructation, tmd the stools '; '! 5 'ii: w v-^. tf m 7%^- m li. 448 TV rill nil I i.vr.n. ciin;:iiii >liL'lil!v altimi. cdiirM' rn:iL'ul:i nl' milk in uiiiloirMlilc Miiiomit. Mu.-i t'lr.jiiiiiilv ilif Milininitiinilioii ul' milk i.- ih-cvi'IiUmI Ip\ iIu' liu'l ileal it j.'ivi'.~ riM- In llif I'nrriialion in tlii' >t(im!icli ot' t'clirilc ]iatiiiil> cit' lirm. Iiiiiipv coaL'iila. uliich an- willi ililiiniliv ilip'>llcrini.' only l)()ili'(l milk, lliu cnaLMila d' vnIiIcIi ai-c miI'ht and >n!all(r. Piluiion with ordinary walcr, mineral \\attr. or linii-watiT. also, mav In- u\ .-crs it'r in lliis rdnni'diciii. It i.- |'anii'ulai'l\ ad\ antaL'ci'n> nlicn tci add iiiiicilairi- iKiu-^ ^llilStanl•(■^ ti' till' iiiilL, .-ui'li a> nalmcal. la|>in(a. arrnw-rniii. and .-indlar arti'-lfs, Sniiic |iancnt.> tidcralc tin- addilinn niVail nr cnMiiac !•■ the milk to iMiproVf the ta.-ii'. (lth^■r^ arc ^rratctul I'or | t-i ini.-^inn to lake tlic milk in the tdrm nt' kiplixr. I nder >w\\ ^irl•nm^tall(■^■^. it i.- lru<-. iKf i'i>n>idrralde amonnt lit' carliiin liiiixid j.rr-. nl ^ll■'^ld \ a nx lid )iiir|i(i.-i'. A IiIiimi::Ii il mu^t lie con.-idcml as |. -s \alu:'' If en aci'i.unt nf llir alisi i re ol' )'al, il is casilv ili'ji-iililf ti'r till' n asnii limi in (■iii!>(i|iicii(i- nl' ilir nurhanicid intliicni-cs to uliirii il is suiijnU'd i:i tlit- makiiiir nl l.iiiti r. the lasi in it c-nnlains is in an fs|ii'iaally linr stair nl' .livisinn. I'nr ]ialiriits wlm I. car milk very well, tlio adilition of ircani mav l.c I'crmiticd. 'I'n >..mr laiifnls tlm admiidstratioii ot" milk in a trn/cn slate is n.nsl aijrctal'li . Snili i.t-crcam is iircnarcd liy I'ri'f/.iiiLr, in a sliallnw \i-scl nr liv nuans ni' a mld-mixlnrc. milk wliii'h luis lifcn nondcnscd in a vaciinm. and In wliiili lias Lien addi-i! a small anmiint of siiLrar, and for tliosc wlio {'arc t'nr it. ciniiamon. vanilla, or ihf liko. A lint Ic.-s iinjinrtaiit /oA ;> |ilayi(l li_\ tlic adniiiii~tralinii nf carbo- hydrates in till' ('•iriu nl' iiiiicilMoiiKJii- miii]>, wldcli may he n-jven alniio nr tnixctiicr w iiii nilicr iiutiiciit or stiiiuilatiiiL: articlis, csiR'cially wiili hciiiiljnn nr jiriilrid-. In nrilcr in nndi-r n ' ral.li' I'nr snmc tiii'c llip mucila$r|nouS Soups wliii'li am sn luM't'ssarv. ii,.- |i|ivsii'ian must have a wiile rani:c of fnrninlse. AmniiLT ail till' suUslaiicfS to lie taken inln cniisiiliralion in tliis ■ rnnectioii, oaliiu-al has tlie ;rrfaU'sl nnirilivc valni', nn ancnunt of the ndaiivcly larire ainniiiit of fat and prott-id il I'ontains. I nfortniiatclx . it often earlv exeiles th'- distaste of (liP |iaiienl. I'laler sneli circuinstaiu'es it should lie allprnated with rice, ulicat. irreen corn, inai/.i'. ta|iioca. |ialni sai:o. and the like. I Would further rccominend es]iecialh the addition to sniips >A' alenronat flour, which, as is well known, contains •'^d per cent, of proteids. is solulile'in water and is not coai.'nlateil liv heatiiiL^. and >\liich is admiraldy home hy almost all patients. In the I'a? ■ ot' children anil ynuiiL' adults, success is often had with artificial I'ood . Nesilc"s. Kiifecke's. and others . Snme patients like the adilition of white or red wine, iiisicad of houillon. to the hrolh. In the l.-iler siaires of the diseaM' — as ih. stajc ot' sleep ciirves and that of dei'er- Vescenc( — certain other addilinns mav !),■ made si:cli as h L'ninins or Harteii- stein"s leLrnminose. .\iiniiii; the niilriciit •■ind stimulant .•iitiilcs, meat-broth jirepared .at home is hv tiir the mn-t in he recnninieiidcil, and in prepariiifi this it shiiiili! he noted that the meat nt' fnll-;rni\vn animals (cnw and nx") enntaiiis a lar^'^er aninuiil of extractives, and that nf veal and yuiiiifr fowl a smaller aniniint. In the care of sensitive patients the presence of fat in houillon should he Ti!i:.\rMi:\r -J4!> avoiiii'ii :is I'liliv :is |mismIi1c, aii'l I'li^ ih:i\ Kt- >iitfii'iiiiily illi*rtf'l nV jn-rmit- titiL' il I" >•'>'■{. ;uiil. lifliiri' licaliiiL' it iiiriiin. .-kiiiiiiiiiiL' "li' lln i"'':!!'!!!:!!!'!! laviT lit' tat uii the -iirt'icf. h i< still nmrc iiilvi;'aM>' in >iii-li imm'.- to [ire- iiaro till' iiii-at-!iniili li\ aiMiiij- Imt \\;itir ipr nuicila-.'e Id n ilcliriilc aiiiuiiiil nf •■ liotilo l)(Miill(iii. " 'I'lii' li(-l iiiinlr (it' |irc|)aratioii. isprcially it' tlic itirsciice uf ijflatiii also be desired at tin- sa tirm, ecinsl>t.' in Iniiliii;.' iiver tlie water-liatli. tiir t'r.)iii Uvu to t'oiir lioiir>. e(|ual parts ot' veal or lieet'. willioiil the addition ofuater. 'I'lie jniee. e\|ire>.-e.| ilirouidi a el.nii. wliieii at times is ([uite clear, niav lie u>.'d in tlie manner de.-erilied, as an addition to nnik or laUeii rold in llie I'lrin o|' i'll_\ . A larire ninuiier ot' arlilieiai |iro.hi(i~ have lieen |ilared u| tlie market for tlir |ire|iaialioii and t'o|- ineiea.--;n'j- llu- r I'ntration .>t' lionillon. A niitnlier ot' these are I'ree t'r'ini olijeeiiou: lioue\er. some are iiuile eX|ien>i\ e, and at anv rate tlii-\- oil'er no alvantaL'e over the lionillon |ire|iared at home. Ot' the nio,-i a|i|iroved ot' tiie-e there mav lie mentioned l.iehiL''.^ eM laet ot' tieei', l!r:ind'> .— ■ lee ot" lui't'. and \'!dentine'> mealjuiee. ('lo?e!_\ related t,, ihein are 'lie so-called meat I ie| itone-. which acimilly ]i,.-e.s,- hut little nutritive value and onl\ i he inllueiici' ot' the e-vtracti\ e.-- and the salt.s contained are to he taken nilo consideration. Ill additi-iii In carli.ilivdfate-, the gelatinous substances, uhidl in (lerniaiiv lia\e Im'Ii atraiii re-toi-i d tn t'a\iir liy Seiiatnr. may he liieiitiiiiied a> an adiiiiralile means ". -liiehliiioup he made in the firm of crali-jelly or oyster-jelly. Smie ri'-ivvr ^iimiid he e^ceised in tlie adiiiitiistnilinn uf actual proteid nourishment in ca>e- nf typiiiii-ler"- clinii' at the .Inhns llnpkin- Iln-pital. co'Ll-alliiiinin is verv I'reeK iriven tn typhoid jiatient-. ii-nally in tlie tiirin ni' allmniin- water. In preparinir this the allinrnin i- tlinrni|o-|ily -liaken with Ico and a small ainntnit nf water, tiliii is then >ti'ain(Hl, and (lavnred with leiniin, -lieriy, nr lir:ii;dy. \'on Zienissen espeeiallv reenniniends meat-alhnmin in the form of recenllv exjiressed beef-juice, which has lieen incorpnraled into the German Pharmacopeia. This contains tJ [xt cent, of dry proteid ( Voit and Bauer), Z'J 1 1 i Wl' li:l s 450 TYViioih I i.vr.i:. and niiyiariiitlv is Muilc cii-ily ili^'i-.-iiMf. Il i- "til l«iriH- liy niiiny patifiifs as ;iii ailililii'ii in -uii|i. iiinl \<\ i.ilici> uliiiic in a lii|iiiil ician i-. nf late. iVciniciil ly iin|.nr- tuni'd liv tlic I'ricihl.- nl' tlic |.aliinl. wlm nllcn lia\c l.ii'nnic t'analio nii llif i)iif.-li(m"nt' iiipurisliiiirin. to iiM' -lill nilicr nf tlir inndfrii priilcid prcpara- tion^. NiilriiM'. ^nnlaln^^ . aiid I'lua.-ln arr ilmsc nin>i cnniinnnly nifiiliniicd. Sinialn~c is a n-adilv ^ollllll< mixiurc nf jirnicids iircparcd fnnii infill, and alnmsi irc-i- I'rnin |n|.l>in('. Nulmsi and cucasin arc siiniliir pr.].ar;niniisi made I'r milk. 'I'lusc pnudcnd. nadily sidiildc siilslaiins in:iy. liy rca.-nii ni' tlicir aliimsi inial laslidcssn> — . he hi'.-hly servirrahle « hen aided in aiiinuiiis nl' a U ti.-i t'lil In >nii|,s and he\era-,^. |>:irliciilarly In patients \\\\u have a ir|ini:nane( tn l he use n| i -l's. In spile nl" all llieoretie nhjnciinii-:, alCOhoUc bevcragCS are still indi-prii.-alile in the praetilinia r in ihe tnalmeiit nf lyplmid t'eveii. and l,ielieriiiei-ter have pennain iilly tiisposed id' till- |>reilldiee. AltlinllLdl the tlienreti<' e\ phll'alinll is (liiliellll, ])ra(- lieallv ihe -limiilalintr iiiiliieiic'e id" alenlml iipmi llit eirciilatinii and re-piraiinii i- e-talili-heil lieymid doiilii. In aildiiinii. it is tisel'ii! lor cnn-erxini: waste and L^'nenitiiiir eiierLT}'. I slimild imt he willing: to treat lyplinid patient- at all in eertain >taire> and eniiditioiis \vilh(ii:t aleiihnlies. The einplnvnieiU nf ah^nhnl luitiirallv rei|nin'- strict di^- eriininatinii in everv ea-e. In ehihlnn il is to lie avnided ait-*^'^-f^l Ti:i:.\TMi:.\r. 451 the intestinal altcratinii.-i ; alsn, white IJIiiiie wine;* of some a<:e are usually well liorue. Some |i:ilieiits liear soutlierti wines — slurry, |i(irl. Maileira, and 'I'likav — alsu some Italian and (ireek varieties. They mny lie admmis- tered undiluted nr mixed witli natural .S hers water nr e(dd tea. I ndi- luted, these wines, whieh cdntain t'nim 1 '_' to 17 |ier eent. (if alenhiil, are eniploved in the presence nf iiruirre.-sive weakne.-^s and eondilinns nf euUapse ; ami in their stead, nr allirnatini: "ith them, also cham|)aL'ne, care lieiu;; taken in this cuniieelinn t.i avoid the dislmneslly pre|iared, le.-s valualile varieties so mmmon at tlie present day. While ordinary white and red wines eontain from 7 to >* ])er eent. of alcohol, irood hrands ot' ehanipaL'iie Contain from ID to 10..j per cent. If tiiere lie any reason to em|.loy tlie stromrer alcoholics, eou'nac, rum. and ante may he administered in tea or hlack eoll'ee. A convenient mode of a..miinslerin^' eoL'nae. liy means of which the dose can lie well reirulated, is in the form of the widl-knowu Stokes mixture. 'I'his is especially avaihiMe also for persons who do not tolerate alcohol wtdl ; in addition, the contained eL'L's appear to lie easily dii,'eslil)le. The formula employi'd at my clinic consists of slroiiLT cuirnao 50, volk of egj; 1. svru[) of cinnamon I'd, distilled water, sullicieiit to make loO.' DIET DURING THE PERIOD OF DEFERVESCENCE AND THE STAGE OF CONVALESCENCE. It lias alreadv heeii seen that in many patients the appetite heLriiis to return duriiiu: the -taire nf steep curse-, and alnio-t always and in still greater dcLrree after deler\('Seenee. I'lle de-il'es (if the patient sluillld l)e rcstraiiKMl at this time on aeediitit of the still prccaridus state of the intes- tiatil eaiial. On the other liaii to he taken in eoiisiderahle aiiidiiiit, (ir the earlxihydnite articles of fd(Ml to he eaten, even in the feirm df a thin iiajt. In-t.ad of ejrs-''s, swet^hread or hrain passed tlironjjii a titie sieve may Ik addeil to son|)s. These ai'tieles must sulliee, witii as much variation as possihle, until the end of the first afebrile week. From the sixth or the seventh afebrile day I permit the first solid fddd, iK'trinninir wi^li .some zwiehack or cak';'S, especially pastry ])repar(Ml fruiit alenronat, snake(l in milk', tea. or cocoa. Th^n a soft-boilinl vjrrr may lie permitted, and linely scniped raw tillet or salmon or a mixture of the two. The meat is scrapc'l with a silver spoon upon n porcelain di'*)), and for the first days additionally pa.sscd throUL'li a fine sieve. If all tlie.«e are well ho...., roast yotine; fowl, sipiah, chicken, or i ^v^^^^ -i'- IV. TYPIInlli IIVI.I:. partri'lirc iiiav lie Lrivcn. at lir-i in iIk f'onii i.i' iiun'c addccl tn ^dup ; llu'ii. tiiicK iliviilcil, \villii'UI lal SHUT. At llic siiiic ti ir m",ii at'l\ lnnilicl lean, temli r ]iieee- ul' meat, \tal nr iniiliun entlet. ami tillet nt' lieel'-teaU, vnuii'.' ijaine, liaiv, nr deer. Ill tlie ei.nr-e 111' tlie tliiril week re-nrt inav lie had tn lijlil vcLfeta- lile-, a~|iarairu>-ti|i-, ^iiinaeh, |iiiree nt' trreen |iea-, earrnt-, artiehnkes, and the liki. JMirl.ii: the sccond and third weeks of convales- cence it i' neee~~ar\ til ai!niini--ter timd at least live limes daily ; sniiiu- tliiiiir slmuld lie |iriitl'ered tin patient excn diirinu' the iiiL'hl, it' he is awake, sneh a- milk, eake-, and the like. In addiliuii, all surt- nf trilles ^hl.nld lie ij-ivi II the [latiellt ihirillir thi- Jieriml lielweeii till' |irin- ciiial meal at tir-t, wine i.r meat ji IK ; it' rediieed. eaviar nr ii\-ter<; the I la til I It will lie Lrr;iiet'nl al-n t'nr apple— .iiiee ur i it her tiirni- nf ~le\\ed t'riiit that are nut tun -weet. I 'nennkeil Iriiil-, Imwcver, shmild he withheld t'nr a InliL'' time. The ilietelir reju lalii ni.s previiiii>l_v meiiiliiei'il will iiiitiirally serve (inly as a u'eneral irai'ie ti.r the .-ii|ieiliiu> |ili\^ieian. I'nuii uliirli he uill arranire a (lietarv in aeeiirilame wiili the ]iatient and the rliaraeicr ami the >t;iL'e i if the (liseasi\ While ui' niu-I reipiire strirt nln'ilieiiee iVmii ]iatients ami ii>.-i>laiits with reL'ard In llie diet, their iiistruetinns ^Imulil he L'i\en in a clear and well-detiiied niaiiiier. 1 )uriiiL'' the rritieal iierimU cf the (lisea>e it is wise, ill iinler that im (liti'crence nt' (i|iiniiiii iii.'iy arise hetweeii the patient and the iiiirse and the t'aiiiily, that the ilaily in>trnctiiiiis with reirard In diet he given in ilet.iil in wriiiiiL'. d'lic niiide if treatment de-crilied in the fnrciroiiii:' is nftcn (Icsii^iiated " exi>ctie inii-t 'Z>> even t'lirtlier and say that fur the mild, imiderately severe, ami e\en Inr a mimlier nf - \ere. iinentnpiicated ea.MS, partieid.arly in prc\iiiii-lv healthy indi\ idiiai -. the dietetic treatment and careful sn|>crvi--iiin citherwi-e render -iiperthinii- e\cry other niea-nre. Fur- ther thera])entic intervcntinii will I.e necessary only if the course of the attack Im' -cNcrc or iimi>iial. or in the presence of alarniini'iilirii(l(_vretic liu'tlioy the reccut results of ctiolo^.ric iiivcstii,Mtion i- <|iiilf dillriciit from the fornur one Tlie svinptoin-i-omplcx dcsiirnatcd ftvcr may \»- con^-idcivd in the main as ;iii cxpn-Mon of tlic action of the typlioid toxin n|)oii tin- tis.-ncs and niclaliolism. Tiic sole rational inctlKxl of treatment for fever would, aeeordiii>.rly, consi-t in neutrali/iii'_' the vitid manifestations of the baeilli, and partieuiariy the toxic etVeets to which they trive rise. As is well known, we are still far frotn this poal. Altlioujih for a lonj; time one of the most eonspiciious symptoms of the fever, the elevation of l)ody-teinporaturi> was looked n|)on as the most deleterious, :ind therefore the most worthy of attack, and hy some is still so considerol at the ])resent day, this view is no longer tenahle in the ligiit of current conceptions reirarding the nature and mechanism of the infectious |)rocesses. Our present treatment is directed, on the whole, toward reiiderinir the etlects of the toxins, which, as has heen noted, I'annot he entirely prevented, so tiir a< pos^il>le, innocuous for the patient, and toward sustainiii«r his powers of resistance until the infec- tious process has spontaneously exhausteie iiiterfere - wli^-i- inailviil ilivclnjiriulil aiiil |in>li>ii;rc(l (luralii'ii ma\ lncnrur a .-niirir nf iLmu'ii' I" 'ln' iiaticlil. ai'<' "Hi 11 iinli- ralcil aiiii-.|iiuir an ii:i|>-f ri^iiltiii^ Irniii llii' arlioii <.!' till- t"\iii- ii|H.ii \\{. rriiiral iiii\"ii~ .-_\ ~l( III. am! c'l.n-i-i in tin i'. him'- (jiniil .~lali - I'l' .-M|»i|-, (I ma. cliliriiiiii. ami ]ir(i|iiiiii'l iiivulvciiirrit of tlic liio.-t vital (1 iiliiai itnti 1.-. (-|i»riallv tli".-f I' li -|iiral i"ii aii'l cifcu- latioii. ami uii.iii wliirli ai-.i Kftaiii di-i'idcr- ui the dii^r-tive iTLMtis, of till' miliars- -n iii 1011-, and ul' tlir I'liiiri i' ii- nl' tin- iiiii-rii-. are ilitiinalilv ill piiiili 111. Tliat liy (i.ni ■tin;: tin rniicliniial ili~tnrliam'i'S (•f thr ,-v-lrii!- ami iM'L'aiis in (|m-lii>n tiir ii"ii_\ niav lie niiilcffil iimre rc-i-tant til (Airi-iial niutiiid intliU'iicc. tliat i-, tn the (Icviliipiiiciit nf conqiiifatiini ami tliai at tlic saini' tinir. apart IVmiii tlic iiniiuHliatc indication-. ]irii\ i-imi rii:i\ It madr I'm' llir rmiirt' i- a i'lirtliir olijrct of till' ailliliyi'ilir lIH'llii'd I'f trralniriit. l-'riiin till' iiirt "jiiiii'j- ii I'mIIuw- that tlir limit- nf tlic aiiti|iyrctic ini'lli'id- of trcatnicnl aiT at tin pn -iiit day in many direction- more <'\tciisivc, and in oiIh'I- K .-- .-o : nmrc cMiii-ivc in -n iiir a- wc do not attcmiit to ."ittack a -iiiLdc -symptom. Imt an entire L'l'oiip of .'^cverc con- S(>i|iienec- of the i iiii 'X ieat ioii. and tlii- inetlii'd of treatment i- tliercfore tlioiiijlit to lie indicated imt mdy when the ti'ni]ii'ratiirc rcaelK- a liijrh level, lint al-o when, a- .-o ot'tcii lia;i]icii-. the intoxication is most mani- fe-t with a h'W IhmK -tenipciatnre. or when it i- scarcely clcvatcil at all ; ],.ss eMeii-i\'c in so far as the imlieation f ir amipyreiie treatment is no lonL'i r looked tiir in perfiitict ry manner in every elevation of hody- Icinpei-.itiire atiove a ceilain deirrcc. liiit jirineipallv in profound dis- ttirliances of the central nervous .-y-tem, the circnlation, :!!id the ro-piralioii. in eonsc(|iienee of which tli ' larp'r immlicr of mild and niodcratelv severe ea-es are not siil)j>'ctei(i;ui, .laiiic- Ciirrii ' He USimI \\:ircr. |)|-iii(ip:ilU in llii' I'liiii "T <-'>l'l ilmirli.-. ;il truiii .1 |o ll» ( '., jjiviiiL' ilii-Mi L'lMnTiillv tuici- iliiilv. Ik ■.'iiiiiiii.' al an larly |.irii"| nl' tin- ili.- ciisi'. Mr U.I- SI Mill itiiitali'l IpV iikiii> |iIi\ :-i''iaii.- in all I'nmitrifS. en lliat in till' thinl eililioii uf hi- l""ik lie was ulili- tu n'|inrl luiiiitTipii.s <'iiiitirrii:iliniis lit" 111- >ii( .'I'-s in his iijiiili- nl' iiriH'i'ilurr. T inlniilitcilly, ('iirrii''s stalisiics a|i|ilv tinih 111 lv|ilius ami I" Upliniil ti'Ver, uhii'li at that tiiiif cihiIiI imt Im- llioriiiiLrhlv iiiirrrriiiiali-i|. Kruiii ( 'iirrii-'s i|iiii'hi-s. whii-li. wen- fur !i luni; tiiiic aiilicrt'il to in France as aim i-l llir sulr ini'ihul liv ilir iiiusl ili-tinL'nislicil |ili\ sirians > Ucraniliier, 'IVuiissiMii. ('Iiniinl. anil ( liirniicaii lie Miissy . llicre iIi'VcIi>|>im1 ^rrild- iially ihi' niiMhinl nf ti-iatnimt with riiM liaihs. In I'Dinliinalidn with thr iiiHirhi-s, aiiij also varmuslv inoiiilirl in othi-r rcs|ii'r|>, tliry wen- cni- |>|oVf.| cxirnsivi'lv 11H liTinanv in tlif tirst tv\o lici'ailcs nt' the iiinftemth I'l'iitiirv. anil sunn luTann- so hi/hlv csifiMiicij that out' of tlif iiiosit cntliu- siastir ailvocati's of h\ ilmllifraiiy, 10. Horn.' ilcsiirnalcil it a.s the only tisi-fiil ini'thoil ill ihc iriMtnii-nl ot' ty|ilioiil f.'vt'r. Ncvfrthclcs.s, the pron-liin- «a- not ji'iiiTMlly aiio|itiMl. .\ Uhoiii.'li -till |ira<-tis<.Mi liy some ^von (iictl. Ninni'viT, 'rnnilii-. A nnitaL'c. (Ira\cs . it ^.Tailually U-ciiinf liis- placcil liv ri'rtain nii'iliianal nn-ihoils anti|iyrrlic ami aiiti|iutrffai'tive. In (Ifrnianv it was roviv«'il \<\ !'.. ISrainl.' of Stettin. I'o liini lielontrH the cririiil of liavin,' ilcvi-loiitMl anil .applicij ilic proi'cilurc inctlioilically, aneratiire in t'ever. .Iiirtrensen.' Lielier- ineister ami llaLrenliacli,' /ienisseii ami Inmicrinann " shouhl he nieii- tioneii. In Krame. (ih'nanl I "^T'l 1. of Lyons, introiliieeil the method into practii'c. ami after him espeeially Fereol and Keyiiau ; then Heiiay, Tripier and liouverel." and oiliers. The method soon heeaine |>opiil!ir also in the remaining; eouutries of the continent of Kiiro|>e. and also in England and America. Various Methods of Employment. — i'ln methods nf apply- ilii; water are extreliielv diverse. < )ften sume iiioile- have l)e<>n lii-- fended with j^reat p(> llifh-'thr-riip:i- ilri T'.i'liiix. Sti'ltiii. ISi'.I, /,/;■ }lwlruthfrapie i/rn Typhus, Stettin. ISCi'.'. I)ir llrilniHi (le« Tii/'/i'is. liiTlin. Isi'.s, * Klin. Sf'/'frrn uhrr 'fir Hrhnndhniij ties Ahftits miftcht liry kaltfn W'mtsmi. Li'ip-ic, IStlii ■^ Jirnhiv'htini'i' :nJ Vrr^in'hr uhrr tiir Ainrni'iiiiiq i/rt knltrn WnHsrrx hri fjeher~ hafti-n Ki-'inl.hrilri,. 1,1 ip-ie. IXi'.H " Dir h'fillir'ixsi'riirh'iil'iluii'l i/r.s Ti/jthusnh,l"mninri<. I.eipsie. 187^. ' I,:i fii'-vrr fiiph'.idr tr'iifri- pnr hs h.iiiis //■■■'ilx. Piiris. IS'.KV Tlii- I'lireful nrtiele is ha.seil up'iM ;i liirje nuinlipr nf I'u-is. iirnl ii>ii>;tinili'!; the bp?t description nf the di'vel- opnu'iil inid tin- jiri'-ciit status nf the ipie-tinn in J'rance. 1.^ I f » v\- .-^"'V'j- ..•t*J':*7^^-. ni^' ^^k^%:i^y?^^^ 456 I ) riioih 1 1 lit: llfnlfll' (luiiclir- nf ( 'iirrii , :it llic |iii-(iit iliiv -|".ir_'iri'_'-, tViitii'ri- willi culd \\;ili r. "T, ;i> i-m1iii'i-i iiiii\ ci-.iIK > u-lMHiarv in I 'r;iiii c iiiid in |-,ii;j l.iml, wilil \ llii"jll'-\i;ilcl-, .irc |ir:iill-iil ; lilllljii. \m l |i:ii k- ..t' \al\ iiii; li Iii- |iiT;iliin' nnl i|iil;ili"ii. |Kii'li;il I'rlri'ji r;ii ion |,\ riicMli- ol iiHii-inii^, till- 1 1-1 i.r Wall r-li;ii:~ lllli i| Willi ■ "|i| \\:ilrr. In , ..r i\i n culil iiii\liirr-, liall'-lialli- Willi tViition- ■•!■ iImii.Ih- (a- wi ii iicmmiiik nili il l.\ Uraiid in lii- tir^l piililiralinn i, aiiii, linilK. t'nil Kalli- > '.' inn-t \ai'i' iiim.||\ irii|i|i im il as aii\iliar\ iiiia-iin^ >>v a- jiartial -iih-liliili- wlnii haili^ caniini Im' il-iil nil aiciiiinl ■■!' iiidi\ idiial ■•!■ r\l ram nii- ii a-nn-. \| til>l, ninli r llic jirulcHiiul inlliniicf ..I till- lali'.r- i.| Ilrand and lii- -iiri(~-nr>. and in i-nii- ."(■(juini'i' Ml' u\ tn -liiiialiiiii (•{' ilic -i.jniliiaiicc 111 trill ilr ilcvaliiili of Icin- jxi-alnii', ■■iild lialli- wi ic jint'i laliK t'ivin at Iriii|iiralnn - a- \>>\\ as tVuiii ♦) to In ('., and llic.-f were warmly ad\i.ratid at W iisliadiii ' as late as IMML'. In iiidcr, so tar as [m.-sililr, to avoid tlif -npiio-cdiv
  • occurs in i!:. hitt.r •li-ruM., xv,.mM l.ra -ival rx, ..pti,,,,, an,l <.,>.■> .,f tv|,l,M-. luv ,|iiit,. (W- 'l"'''il in whirl, tl„. |,i„|HM ,H,int i. ,Ta..|„..l at tlic rn.l of tl,inv-Mx, t\v,.|ify-i;,iir. or,.\vn i,, a v.tv \W Ik.uis (,.,,|„|,||.,. j.-jj, .-,7)_ I)|,|.in,_, ,|,„ Hv,.,,,! halt'oC til,. tii-M „,vk til,. ..urv,. i„.|.>i-t~ at tli.. >aii,,. I„.i-l.t, w itii MM.,l..rat,. t,i,,niiiiir i,.t.ii>-i,Mi~ ti,,t ,x,.,.,.,ji.i:r (i..-,^, ,,,. it ,.,,ntiiiii... tu ri-c -l-wly until til,. ,.i^r|„|, ,|;,v, .,, ,|,„ i„ .,,,,,„. ,..,^,.^ ,|„. , |„, ,,„„„„,,, ,,^,^ tins ,,..ri,Mi may vv^/^.wv II „r„v,T. Th,. I.liav i.,r ,,f tl„. ,.„rv,. ,lnfini: til., tiivt \v,.,.l< ,,f til,. ,liMaH. i. M, v..fy |.,.,.,iliar a- to l„. ,,f tl„. Iiiuli,."t aM.-., niu,.l, as tli..y ri-wnl.l.. tvpliiw f;.v,... in u\\m ^VMI'ln 'l.\Jiil.'i', )• .1 '-''■ ""■ -anu. Hm. a,.! nniCnnin ,„' ,i„. n.,n|,..ratur.. „ 1'""' ';'■""■ '' ''■'■" ^"" -•'•^"''"•l.vun\VMn,|.Hi..|,Van,l,„mv nu-H„„. ,|H. ,„.,.a.„„al,„.,.,n-,v„..,.,.ra,.|,a,a,.„.n ln,„ in ,1,.. ,.., : Z7 r'" "'; ''-'■'■ '■'■'-'■I" "l—.l„„ i, .,,.,l.al,le ;■'"'''•"'■'■• ;;;•"•■•'•"--' y i...~,.uai ..1,..,. ,.; sai; Z "■■"l""-aiy lall in the U.,n,u.rat,nv was noli..,..! i„ o.,ly :; ;,,... , Fi,, ,;,,. Dny ..r til,. ,)i„.„„. fi'^. l'.l.-ro,l,|l,.r.i.i^„,„.,.„j,,,r.,,l,|. M,,,!,,- .., .. , |.'iy^cv,.r..ca,..,f,y|,,„„f,,v,., Homis-i,,,, ,.„ m "' ''— ^f^'""" 'l"-^'v.-.,n,.„f,h,s,.v..mh,l„y.,fUu.,ii.,., iri'iilirc, scvrntocn v.-nrs (,|,1 I.TMc'ly scvvr,. ,.,,„„,.. Mnrkt.t pn-rrilical «»o. vnrmii,,,,^ in ,ht curve » eve:";!:;!''';::: T'f '"'"■'' ^^""'' ^-^'''"^ ^ ^'^ "•™- "'='^ ^^•^^.^..^.:^:;.::.;':.a:::;:r;;:;:-7'7''-"-^'''''--^ ;;::'>^--''••■^ ---'-: ;:::^l:t^^^^^^^ In, I, ,. „ a ...n,n,n,.,l .vnutton. typo in sn,.l, c-as-s, „s„allv ,.,„..i.t. , P-|.t.l,Io rcmw.,,.,, .1„,|„,. ,1,, ,„„,„i„^. ,,„„^^^ ^^.,, , ^^ t<'tnp,.n,.nr,. romai,,- ron-ta.ulv l,i..l,. "'^ After tl... .entl, a,„l .Lventl, .lays of tl.o .liseaso, snmcti mos as early 51 1; 7177/r.v I i:vi:n. a- till' niiiili, ;i iiiarkiil cxmiii- niiii--i,.ii l.,;.ri,|, .,, :i|,|„..,|- (r,.iii|iMiv '■ '-^- 1^ :ill'l ''I ). all.l lllr ,l|l\,. iMCnrju- .li-liiinl^ iv irT. -Ill;|l-, ..\u\\ A\i<\\\\vj: inarL.d iiilrMiii--iMn-. In I he -ex iir-i ,-,im-, uhiic rln'iii,,-- iioM- 1.^ viTV liad, lli, •■(Acr rMiiliiiiK- hi-h cvrii iliii'in-' ilic laM ilav.^ nl' til.' (-.cunil) u,vk, and o. ra-i-nally ri-. - :n -ival luiLrlil-. In hicIi (-.i-c> tlic oniiiion- |ilirM..nirn..n ..I' r,,lur munhi.r i.- |.arliciilarl\ mai-kcl. Tlic iM-inninuntM.'IrrvcMvnrc in mwiv and nin.jcral. Iv -( vciv ca-cs oiidiiiu' ill ivruvny i- ni.hd ai llic end ,,1' ilir -,c..nd, .,r, ranlv. dniani: llic (ir-I day- ,,ftl„. tliii.l. u,vk. I nl,-,rv.d il ni.-i rir,|n.nl ly Julurcii llir luclltli and lla 'ilhrniji, and < a;. |i! innallv <.n tlu' -ixtrrnih ,,r the Mvrniiviilli, day (if ihc di-ra-r. Tlic |i(nnanrm -nli-idrii.v cf tjn' trni|M ratniv iliai Inlluw- in tlic -ival niajdrily ul' .aMv- i- (icra-idnailv prrrciird l.y a |icnnd ,,f iVc.ni iw, nl\ -ll.ur- 1.. tiilil_s-ix li..m-- (.-(.nipaiv Fis:. -MM, .Jnrini: ulii.ii iJim. aiv mark,. I variation- in llic cnrvc, with M'vny and viTV aiarniin- di-lnrhan. v- in ihc iiatirnl'-. LTiicral ,■ liiion. Not iiitVcjncntly llniv i- an rMi-cinr v'\-v d' l(in|Hraliiiv, to il,,' Ik i.rlii oC 41 ' or r\.ii l_' . liillou,,! uiiliin tVoni lui I\ i to ,.i-;|itiTn li.uii- l,v a tall liclow tlir t( in|)( ralniv oj' tlir prcv.'din-- inomiii- (,oni|iaiv 1'!^:-. T'^ and (in. \\lirivn|>on iliclinal lall ky .ri-i- of ly-i- n-nailv occni- without any tiii-thcr intririi|,ii,,n. Tlic okl, r aiilhoiv ha\c di>criiicd tills hv tlio <'\|i!'c-->i\i' ti'flll III I till hiltii, rrlfifit {\"'-j:, o| I. A r(.iiti-:ify (|,fccritiral I'all | liiha\ ior ,,{' thr cnrNC i- a di-tini'tlv rarer oci'iirriiico. Ininicdialcly |ii-(ci'-2). The Period of Defervescence. — The tein]ierature-coiir-e,iuri,.; the ^tair(' of ileli'rve-eciii'e -trii.,iiii.dy leeall- what oe, nr- dui'iii;,'- the imtial st.iire. '{'he ahriiplne-^ and ra|iieratiin' at lir-t -inkiiiL^ to ;;,S..")° or .'IS'', and tlien. toward e\enitii:. nioiiiitinir 1' or l."i hefiire its final return lo thi' normal, where it then per-i-t< praeti'^allv without interru|)tio-i, \\ !th almo-t e(|iial fre(|:ieney. in-tiad of this siiiL'Ie interruption, (he fall oi the teiiipenUuie may pre.-eiii a >tep-like curve exlendin" M MIIn)l.\ri)lj,(,y. tV'ini llii-fc (() li;iir i|, ly- (iDiii |i:uf i'i:;. > I ). " llllr Mil l\ gfailiial iMHliiii^r ,.| ih,. riir\r l,\ ,li-linrt K- )17 I'll iriMi-e 1- I- II iiicli i-aivi- ( |''i^. .-, I Km. :,i,-\v Oman, thirtv-tliroo vmrs ol.l v..ri- ^ ,. > u.aL, • Vr • " ""' l'!"-"'''l '■>- with i.T(at ..ir.lim. Tlir (,.,„I..„ry to mark,.,) i„t,.n„i~.i„n .Inrinj, ,1„. p,,,.;,^! „,• ,!,,,•,,,. V.-.M..CS wlu,.|, is aln,„s, .vpi.,.! of ,v,,l,„i,, ,;,,,,. j^ ,.,,,.^. ^j;^,,, ;,_ li:iv ,if til,, .li-.-iivo. 'It h " 'ii)TiT|T;]TaTi4|i5rrferf7n Imy ; f til, .liMi,..,- I''I'. ..-' M;.i,.ll,,rlv.,.„,. y,.ar>n|,| ^.v.r.- ,„-. -f lyyvhus f.v.T. l's.u,l„..ri.,.s ,.„ tl,.. t^.lm, u„y of the liiscase. Fli. "'". -Man, iiiiirtpi'ii v,.|irs ..1.1 M,,,). pnit, ly s,-vrr.- .'ns,. ,.f sli,,rl ,li,niti.,„ Iii^. lill.'t fill liV (Tisi.. "J!i.--,! i.r,.,Ti;;,.ai rise rrvc'il,.! !,y ;, |,t i: -■ ' ii, -zr m \ ■ :, I s / ) rill s I i.vi.i:. |Hii,„| li-iin^r tv,.) or thrrc il:i\-, (Inline; uhidi ilirrc arc .■(.ii-idcfnl,!,. Nan.ilioii, in ilu- rmw, with low nKiriiiii- and vcia liinli evening teni- I ..-. -t Ih. .1;.. ,-. 160 40 HO 33 123 38 100 '37 f. ■ ■ li :±. 8' 3 TO -~r so 3C :;t i-r } ] M 12 ti; ^t rT- ^m n^ Jllf: J !6 ■! :.i -I ; « St!®^' i Fl... .M.-K.,rcn,Kn. iu,!,i>-,,^ht y,ar> ..1,1 , ,„„ t mx.t,.; -ul,M-,|u.'nl ,-„„rse miUl au.l M,„rt. uilh 11 MTV i.r.ir.i.l. .1 |i.Ti...l .if il. r.Ti.M.nri', [iriiitiin--. 'I'lii-: phennineniin ha- received >]ii.cial attention iVoni Kn-eii- .-tcin. \\h(i a|i|Mar-- Id liaxc (il)>cr\ cd it lVei|iienll\-. \'!iy ..1 111.. .l;,.a-.'. 100 V 60 3e CO 135 Tv,. .V..-Winnii;i, t«i-nty s.. -.■ii y. ,irs ..1.1. Si-viTr roiir-.. .lurin- |li.> lir-t w. . k , \.ry sl...rt .lum- ti'.n l!i-._-illiiiti- ..f .l,.f,TV.-r. t!,'|. r.ll til.' nililh .l.iy .f the .Ijv, „,,. Temperature Variations in DifFerent Forms of the Dis- ease. — Fn -cvcre ;ind niudciatcly -everc ea-cs the I'ehriN |»>rii)d, a< lia~ iirevi,.u-iy Ixvn ,-taterl. n-ually ends lietwccii the fiftccnih and tllf .V))//'/v/.l/.l /-o/o^ )■. ''liiiniiiiir uf ,A,.,i i|„. ,n.| ,,| III, toiirili ^u,U III luc'MIiril, ,Im\. S lii,,,-. ihuii^li raivl\ I'l'iil' iiiilil till I,. , /'"-'■^ '''^" '■■-'" •" "■'■"''■>■ i"''"v III- .11.1 ..I 111.- v.,.,,i„| „,,k ':'■'""-'"""' '-i'i"M;,nM-„r,i„..ii-.,,„, Ti„. i,.--,.iiiM.r„,-,i,„,i„,,. ' ■"''■'•'"■'"' "> >l- t;-M-iuiii. .I.inii,. ulii,.|| III,. ,„n|„.rani,v inav 1... 'I'""' '"-''■ *'-••"■'■ anill raiviii u Im.Ii lli.iv ,~ an ,.v,.„; „,„- '":'■■;""•""' ' ■"^"' " <--l"'-i-'n„. „n,il,li,.,.,i,|„C,||,. ,i,„„,vl. "'"' '■' ' '"'"- ""'l"raliiiv ,.f,i,,I iuimI, |,,u,r ,|,ai, |(i , Kj,. :,-,,' O-lin-. .•lUMMi, |„,.-,.,i, niarl.,.,! iviii„-i„„- aii.l ii,.,.nni--l„n- of ,|„. ,,„.v,. «i-iii^>l„.v,.,v,i,-,,hn-, 1,11, ,.v, Mill M„.|i ,.a-,.- ,1„. ,.,„„„. „,„,„,. ^""iv n.- |„ a Im,I„t ,,„in, iliai, ,- ,.,nmionlv „l,.,-v,.,| ,|„rinu^ ,l„. Ii,,t "(vk (p| ivjilioid H\,r. I'Ih' iiiiiial >tai:c -.il-ii i~ I'l .■.lii.'Mtlv al.ri.l-nl in il,,. niil.jrr ,.a>, . i"i> ..r ih.- .1,-1 Kl'., -■.- Wiiil.T, iiL-hli'iTi v.ars ..|.| Mil. I -• »ith r.h.tiv.lv I..W ,, T.,. f;';;''"r^'"';-'»''>''y-'l''-'-y."sol.l. Mil.lcaseof I'lr.-. I'rr.riii.ul ri-i. ' ''""-"■'''■ f"!'"" '"^' ""mr.liat.-ly ui...n nn nttark ■•f r.,urr,„, iVv.T. Al,r„,.t ri«.. of ,l„. „.„„„ nit.ire « nil. .Ml r,.,„i-i..,,. un.i u'ra.lii,,!, sl,.,,.|jk,. .LiVr^,.,. "''":■ ''■ ;'■';''>• '"■'•"^'•- "-■ '■' "- -v,.,... .„,... T1„. f;.v..,- ,nav i"t-n 1.^ Ii,.,,l,t in In,,,, .-.|ity-,;,„r ,„ ,|,i,,y-Mx l...i,rs. ..itlw:- at ,„m. '"";'"' "•■^^■';''='^"'^'"--"l"-n. An ^ tl„. ..a., that liav. n. '""■'• '"■: "l'--va>-" 'Inrinu- tli- (iiM ,lay, I |,av,. n-v..,- .,l,s,.rv,..l a p n, n...,„tl,..,;.v..,.,;,l|„„..,||,vanal„„.,iv, „•... On, ,|„„, ;""'•."";•':••""'■"''•■'' — -•--"- 'V.-. |-..n-ti.ii in ,ui!,! <.a... , V^'~;" -"7- "■"-■ i- "l,i,.l, tl„. n.ur r ,1,.. ,Ii..a.. N„,„ lall.,1 the finpn-atiMV, cnverin- C-nni inv U, ri..|„ .l.,v< ,l,,>.-., ... ,._ o-n V) /7/rs irvrn. '■'■'" '"'"" •'"• ""'•"'^'' >'■'-• ■"'-■ TIh ,I:.IK v:,ri;>tiu,„ ;nv ,,-uallv '••""['•H:.IIVrlv -li^l,,. A t,n,H„;,li..„ ol' l!,. |,.^,., |„ ,,i.i,, |,.,,„„ ,„;, '"■■'■'•''•"' l.-nMu.K.. ,„,.„|„„„„ l,..u,-. :,|,,„ :„-.„„, I,,., „l,..,.|,:.M,|,,u '" "" ""'I'' tl''|IH 111 III iiiiM ||,:i,| in .,.^,.|,, ,..,,,., ^''■'•^ Mnl.|,,r,|,-,ii„i ;,l„,rin,. |,„,n- ..f u |,h,,i,| ,;,,,.r Iimv. moI ms ^" '■"■"^"' ^"» '■"■'"'I -""^- M^ -w, ol,-,.,^:,li„„-. ,.-|,.,,.i;,lK ,„ '■'-■"■'' '■' ''"■ '■'""■-'■ •■'■ '!"■ t - Wcimiiii. thirts'one v., IIS nl.l .\l,..rtiVl' I'lKr i,f ty. I'liu'. fi\i r « iih f, V. f i.iisi-t. I'i'.. V.i l.iil..iri I. I,,rl) lui. y.iirs ol'i. Kxi.'ssiMly Ii1l!1i tiiiti.inilure iiiiliir.liiitely |.i,i,.liMK 'itiith. ninly „l,M.m.,l i„ ty|,l,„. Cvrr. l,„t I wo„l,l ,„,( .ar,. to allinn tl.at tliiv a:-,- 111 ivalitv raivr than in iv|,!hm anil l„,| t lll|i!iratinM-. til,. trMll„.ratlMV-e„m. i. M-nallv .h,,,,,,. than in ,|,, s,.v,.,v ,,nr~ ...ulin^r ,-„ ,,„.,,vrrv. Tlie ,i:ival iiia,|,,nty of mi.-Ii raM-s a,,. ,-liarart..riz,.,l l,v violnil ,„iM.t aii,l '■I'lll ai"l •■". unuMially hid. trn.|,..rai,iiv fV 1,,, v,,v l„ .^innm.. with "lidit niuniin.. r,,ni-M„„.. | ),,„!, n-iiallv .„-,.,i,v l,..tw,.,,i the ninth a-.l th,. tweltVh .lay-ran lya^ la.e a- the Hxie-aith .lav. A p..n...,,til,le I.n.an-.,ni,. n-.. m tl,. t,.in|.,.i-aiiiiv i~ a .■nninmn iili..n.,.n.Mi.in ( Fi- .-,|t). '" "'' '"> •■^'^^■^ '■"■ tl"'nnn,iul.a- ivjriMen.l \1.2- ( '.. and Wunrierlieh ^) 1//7'"1/ I inl.ni, ) >1\ iv|i..r|. a '•■•i-f in uhirh tlir t. iii|.ir.iti V'. . I ■\\>U- 1.1 il. l.rn Mij. a iiiarl "I- (" •|ll('ll!l\ ill y\-- III III. n-.ial I rlii|M laliiiv alliT ill II 522 M i/l' I II \/ \ I nl 1,1, ) vniliLilini, ji, ||„. i,Mn:,.k ,,i \l,.,l.ii u:,. ,.:,rrH-.l „„i uiil, -,,.1, |mi„.- tlkill^r '■•■liv ;i- i- III'. Iv I il.l,. 11,1,1,,,. ,,||„.,. ,.,„„|i,i,,|,. AL TKRA riONS IN IHK CIRCl'LA TORY ORGANS. 'I'lh ,1,;,,,^, , i„ ||„. ,.i,v,|L,|,,IV n.o;,,,,, ,..,„,.i:,||, ,|„. ,,,r,|i,„. ,.|,.„,^,,,^ '" ■"•III- iMll.ii.Mi- .li-, ,-,, |,.,v,. n,, iiiU l...„ -i„.ii,.,|, ,-|„.,,;,|K I,, ,„, Mil.lrni-, K,vl,l, |;,„„l„,.,,. :,nJ l',-l,r, „,i|, -,„.|, ,i^,„,,| ,,,.„|,; ,j,,„ ■, '"■'•"""- •' I'""" 'I' il"' mill"-' iln|.M,-|.„„-,. il,,,i i„ f,„„,, ,,,i,|,„,„, '""■ iii"'-l ;i.-.|iiirrin. Ill- in tlii- ,lii, ,ii,,ii -|„,iil(| !„■ |. .|,,| ]„ ;, ,■;,, ',,1 '■^•i'iiiii'"i"ii "'■ III'- l"li:iM'.r ..r iIm hrail in iv|,|,i|. f.v,.,-. 'x, ,;,i,|i.„- ''''"^"'"" ■"I'l '■' '■' II" iii.ii-l-'l ..It. l;,li..n- in (|„. Ii,.:,rt-iiin-, I.. ..i,.,. i„i,;,|K "'-'■'■^"' '" III'- '-:i'l:i^'f '-..■ iIm' -cli I',lli,,|,.^i,. An., I \ ,. J,, •'!■" ill"''- '"-'-III- <-lini(:illN Hirli ,:n\\ Aiu\ mail.,, I ,.|i;,.|, ,f||„. ,,,^1,,, "" •'"; 'i'-''i-l. ■ili'l pr,,l,alilv ,,n lli,. va- ■ ii..rv ,.-, ,1, ,„.,.„,. j,, ,;,,^ oilier iiil((ii,jii- c|l-«.,i-,-. The PulSL-.--|-"i a |,n.-li,.Mi,' |M,ini ,,(■ \i,.u, tlMivloiv, tli.- ,-.,11- I" IL'O, uiili a n„,rnin;r th\\ u, :mi ,,r |i)ii, js „1,„ . ,.,| .,,^ iMrl\ ,1- ilic ihini ilav, in -I'MT,. ..a-..-. ,.n,lin- in ,vr,,v,.rv ||„. ,,i,U..-rat,. |H.rM>t- at tl„. -am,. Ii'idit ilnriiit: Hi.' tii-t u,,!., „itl, rvm -,„:,;!,.,• ,lailv nani-i,,,,- ,|,.,„ "'■'■'; I"''--'"' ■■'' "'-'• ''~"='lly. ■•II III'- '-ml o|-,|„. (1|.,, ,v,.,.|< an a,|iliti„iial ii-i' in till' Cri.iiniih.v iM.|.|ir-. Kx._T|,t in ,.1-1- Willi a viTv l,..|,| ,,n,^r,„„i,, ,|„. ,,,|nn„. ,,„| „,„. •""" "' ''"■ l"il-' ■•II-'' ii-iially - I cln,.;,,.. ,|„, ,1,.,, „,,,|^ •r,iu.|n| •'"' ''"' "!■ Il" ^^-■'■l^ til" |iul-.. i- likely t„ lM.,.„ni,. -„C, an.l mniv (•<>m[ii-|.--ili|i . ''''"■'"•'■'"■'''■"••'' "'■'''■'■''"'i^iii.-'" iiN-n in ty|,|„,i,M;.v,.r. I (1,„| ,„ !h. Iiy n,, mean- l'n.,,ii,.n,, ami my vsi^wunrr in tlii^ r,-],,,.! a-nvs uiih III.' '>l'-.Tvati,,„..,r,vliaM,. author., (;,.i,..,|„^„,,.,M„,,.|,l^„„_^„„,,,j,^^.^,^^ It wa- ,„v-,.„t in .-,.!. ,,..,• ..,.nt. ,.!' all ,nv ,.,-,-. Fn m..,v tl.an hall' "S'> •V.'l TYriirs I i:\i:n. m k p (if till' (•:!-(■< it MiUK'nrcil •' niiiL; tlic li(ii:lii of ilu' ili-ci-c mihI |Mi--i-ti(l lor -,, till' (ill!,. ; ill till' r'UKlilnIrr it lll-tnl iMiIn linllllW'! Ill lllIT!' (I;l\ -, (irciirriiii; ]i|'iii(i| lally iliirinu;- tlir iicrind cit' (ictirvc^c-ciici'. 1 iln imt itiiU'IiiIm r ('\(r tn li.'ixr .'Ii-itv I tiic liliciioinciiuii ('illur diiriiiL;' llir illitiMi -I:ii;i' 111- ilui'in;.'- tln' ti|--l il;i\> nf tin i',,'~t Wirk. I-iiiNnir the MTiiMil xM'i'k ill -lAi'Ti' (MX'-, cviii ill >iii li a- iiiil in nriiMTy, till' fatr rontiiiiic- IiIltIi ami tlu' |iiiIm' Iiituiih- -iiiallii- anil wrakcr. .- ctiiiic.- inlrrniittint, sn tliat in M.mo ca-r- lipi- ila\-- il ran In' fi'lt and ciiiiiitcd i>nly witii L^'i-at ditlii-iilly. Ali-rni-i' of tin' aprN-licat I'll |ial[ialiiin, incrca-c lif tlir ana of cardiac dnliic~~ to the riirlil and lil'l. and niiitlicd iicart— (iiind-, |M.inl to acute (lilatatimi follow iiitr intcn-c intii'lioii- clianirc- in tlic invocardinin. Marked c\ano-i« of tlic liicc, li; id-. a*nd ii'ct at tlii- time i- a \iry iint'a\oi-al)le .-vin|iloiii. It occurs n-iially in alcoliolie-, in >ntVerei'-; from cln-onic di-ea-e, or in tlio-c wlio lia\e jii-t recovered from -ome ;ieiite alVcction, and alnio-t all tlic patients in whom it i> |ire>eiit die. However. I have known individ- iiaU who Were well iioiiri-lied and \ iiroroiis to recover in -|iit<' of this verv L'raxe s\iii|iloni. \\ lietiii'r the extreme cardiac w !\ ere eases ((iriivsinircr) I liaxc tie\ cr oli-crved. I)nriiii.'' the period ofdefci-- ve-ceiiee, the |iiil-e, wliicli in -c\crc ea-i's ha- lieeii wiak and irrci^nlar, gradually piin- in -IrciiLrtli, and the piil-e-rate lieirin- to diniiiii-h (coin- |iare l-'iL"- fill. If the)-,, ha- Ijciii laarknl cardiac w , .ikiic— w ith dila- t.'itioii. th(> pnl-e. after the normal or -nlinormai tempcraliirc has liccn reached, contimie- liiiweeii SU and !hi in th.' moiiiiin_r and reaches Hid in the rvcniii;;-, and i- c\ceidiiii;l\ iin-lead\ , -o that an\ trisial liodily or ni;'ntal exciicincnt 1- followed liy : ii-ideralile teinporaiy accclii'ation. In other I'ases, marked liy a moderatclv -e\crc or mild course, the piil-e-ivite diinini-lie- i,,,m.. .■nnipiicatin- .•.m,lili,,n. Tli,. pufx-ratr .inrin- tl„. I»ri.«l ,,(■ -•,,nvai...c,.n, .ra.ionali.v t;,lls to l„.|ou- ,1„. normal. aJ low a> of) or ts, ;,n,l inav rrniain at that point for In.in ..iirlit to fonr- tr..n .lay.-. The rause of tiii- l.ra,ly,,.nlia has n..v..r Iuh., ,,rop,,.K •xjilaincd. It also niin,,ns -ijrnili.anee I wa> known to the ol.Ier authors (IJarallier, Kennedy. .Mun^hi-on. (irie- sinirer). The State of the Heart and Blood-vessels.— In tvj.hns as '" ^>l ''' ♦■''^■•■'■> ''"■ "'.v.K.inliti^ in the jrivat niajoritv of cas.s ap|„.ars to under-o eonipL.te inv.,lnti,,n. 1 ,.aiu.ot renieml„T a sintrle case in ^vhieh th.ie n.n. lined any cl.roni.^ insMliiei..nev of the heart-muscle if the inte^nity ,,f the oriran was cstal.iished l.ey.md a douht l.cforc the l"'i:innin^' of the disease. Th.. sune is true of valvular l,.>ion- which neither I nor anyone cl-e has ever .,h>erved as -cpieU of lyphn. fever. We niav aceonl- iiifriy nif.T that acute endocarditis nui-t l,e very rare. The same may I"' said of peri.'arditi-. I never found any inflammatorv dep<,Mt~ or •■xiidates at the autop-ic-, and o,dy once or twice licard'a temuorarv pericarditie friction. Of the eh in-res in the hlood-vcs.els. the arteric-. and v.in-, l,„t li'.l" I- i^nowu. As in all a.MUe infectious di-,.ases, the period of con- valcMvu,-,. from typhu> ieve- is marked l.v th asional .Mrurrcnc,. of so-callcl marantic throml.i in the veins opeciallv in ,l;c veins of the '■iTs. Phey are ,nost fre.iuent h. p.aticnts whose vital p.,wcrs h.v,. '•<■«■" sappe,! I,y want or ehroni<. .lis,,,.,,, a..d in ti.os,. wh., |,av<. snfr.n.l fr.iin a severe fiinu .,f fvphus fev.-r. Changes in tho Blood.-The stat.- .,f the 1.1 1 i„ fvphus fev,.- ;'•': ' " ••'■I'<'^"<"'b ■••■f.MTcil to iu th,. se..ti.,n> on M.,rl,i.l Anaton,v an.l htioloifv. 'I'l'o n.e,,r.ls l.c.|ueathed to us l.v fonn..r ohscrv.a- Im r,..r-,r,l to the.-olor an.! ..oa.irulal.ility of ,h,. Id,..,.! n.. lonirer posses- thc^i^nifi- "•'"«•'• Mttr.:.ut..I to ■.h..n> l.v the ..l.ler authors. Little a- w,. "have '"an...d l,y Mi..ro-.opi,. ...vamination in rcpu-.l t., the spe.ifie ..an-,, of th.' d'^.'a-.'. a few riual.l,. ..l.s..rvations have !,....» ,.l,taiu..,l in r,..ranl to th,. l,h..„l-....ri,us..i,.-. Whil,, th, shap.. an,! app,.aran.... of ,h,.~r,.,! ■"^ "^^ "j ^--^ fill' '^-' 7)77/r.s )-i:vi:ii (1 r,)ii^,l ,. j, iiiKitl'cctcd ill the main, their niinil)cr is diminislu'd in wci' ■ .arknl <■:!-(■- at tlir lici:.'lit "*' t!ic ili~cu()M(liii;_r to the iiliL'''ifvtlirmia \\r liml a riduclinii h, tin- liciihiLrli'liiii ilufiiii: tiic latter (lavs nf tlie (ii>t and diiriiiL'- the sen- I u,-, |<. .\|,\ I'niind llii- rediictidii to he fnun jO tM 1 "i per eillt. ill ll ca-e- that he exaniilled. < hi the other hami, the \v hite lil.""|-ei||~ appear to he in(rea>ed in iiimiher (( (.iiihemalei. Thi-. appear- to he a -peeial feature of the ili-ea-e. and it atliird- a very iniportaiit aid in tlie ditlerential diaL:no~is from typhoid fever, uhieh. a- i-well known, i- marked hv a diminu- tion rallier than iiy an inerea-e in the iiiiiiiher of" the iinkoev te>. In tho-c ea-i- ill which -.eriim tests have lieeii made, it has heen h'lind. as wa- to he expected, that till' -eriim ha- no ai:L;lntin.'ilinir effect on the hacillii- of' {•■.ImiiIi. This tact is of the trnale-t imiiortance in tlilfereiitial diauno>i>. 1^ 4 ;Mi'^^- W^m. THE SPLEEN AND LYMPH-GLANDS. The discrejianeies in the statements ot' varioii- aiitli determined f/iiiira/ii/ much more frei|neiitly than at the aiitops\- tahic in the j:reat niajoriiy of severe ami moderately severe cases and in iiiaiiv milder ones, providin;j: the e.\-ainiiiation can he made earlv eiionidi. 'I"hi- ditferenee lietwceii the clinieiil aP(| anatomic findinjrs p,,ints to the main reason why author- tail to at'ree ; it i- that they made their exain- iii.atitiii- at (liil'ennit -lap- of the di-ease. I have alway- oliserved ciilarLrcment of the sp|(.,.,i very early, distinctly earlier than in tvphoid fcvi'i- — as early a- diiriiiL: the iir-t feiirile days, or even hel'ore the Iteirinniiitr "f the initial stap'. Fi does not, as a rule, persist until the iie^^riimiii^r of doferve-i'encc, and fir that rea-oii ha- ii-ii;illy di-apiieared almost completely in fatal ca-os hel'ore the sulij,.. t come- to the antopsv talil(\ III -evend in-tancps where tlie ntpin \va< at first jHTceiitihlv cnlar.'cd I failed to make it out with certaintv after the heL'inniiii' or >Mi-l-ll.' "f ,1„. H.,.,„„l w.vk. (■;,>... in wl,i,.|, a |,..,v,.,,til,l,. ..nlar....M„nt |Mr-,,~i. l,f.v.>M.l III,. |,..ri.«i ,,r ,|,.|;Tvr-,-,.ii,-,. Miv (liMinrtlv r,-,,v. <><'-aMo,,,lly,,nMl,T,-oii,litiu„-ul„.,v it i. al.-mt tluTMrnt.. inf,.,- n-n- cliMM-,.-, sn..|, a. in i.,.livi,luaU uf a,|va,„T,l au. an.l .l.prav.l l-'lilv .•nn.htiM,,. I liav,. loun.l no ,,..|v..,,til,l,. ..nlai-,.ni..nl ,,f tli.- >,,|„.n •■I'li'i' .-It til.' iM-innin- ,,r .Inrin- thi. ..ntiiv .•,,nt--.. ,,f i)„. ,li„,.,„. |„ .■xaMunin- a typln,- tl-vrr patient fur ..nla,-,.n,..n, of tl„. -|,|,,,,", ,|„. ..nlv nlial.l.. ni.i l,u.|— palpatjon — j, n.n,lr,v,| M„n..wl,ai ,lim,„li l,v ,|,.. •■"■I 'li.il Ilir ..niai-vrnrnt raiviv ,.xr,.r,|- a nio.lrraf .Icur,.,., and tl,<.'ron- H~t..n,v of ,|„. .„..,,>, i-, on tl„. avvrao.., I,... ,|,an in o.Ikt inllvtion^ , of ,!„. nrj,.,n, ulalluT pa-iv,- or ..lirif,! l,v pn--niv, i- coMiparaiivrlv raiv. Aiann- 7(1 palirnts a,hniltr,l a.irin- lii. !!,>, „,...k „f ,1,,. .Ij.,,,,,. wr tail,.,l alt.Tly lo niakc „„. .■nlarir.aMenl „f tl,.. ^pK...„ |,v nalpaiion 'aii.i '"•■"''■ ""t a .l.a.l.Itul ..Mlaru'enuut i,v p.-naissioa in 17, uliil.. ia \uv n.n.ai,,- m;/ ••uses tlu. .•M a,-,.MH.nt ua. a,a,i,. on. n.naily l,...u....n tl,.. tliir.i an.l tl,. <"> 'l-'y. In tlu. ,aM. „f a uat-'lnaan wl,o l.a.i l„...„Ma. inn..,e.l in ,1,,. H..p.ta!. a a,-^.., >,„t, palpal,!.. .p|.,..n was ,„a.l,. ,.nt a. ,i,e ,i,st .xa,„i - -n, n,n„...l,a,..ly att.T the tifst ..hill. I |,av.. n.v.T l,a,l ,1,. „,u„itv '.make an exannnat,,,,, .Inrin,^ tl,.. p,.,-i„.| „f i,„.nl,ati„n. It is pn.hai,!.. tliat a p„s,t,v,. ivsiilt uoiil.l ,,ti,.n !„• ,,i,laii„..l at this tin,... Tlu. ...xt.n.al ly,npl,-jrk,„,ls, lik.. tl... UH-vntww an.l l,fo,u.l,ial ..Jan.K («■<■ Mofi.t.l Anat.in.v), a.v. >o ti.r as I ronl.l ol,s,.,-v,-, almost Tluavs "ortnal in „t...on,pli,.at...i ,.as,... I„ , p,,,, „,• ^i,,, 1,,^,,,,, ,,|,i,,,.,„i, ^;^ t".- mstan,..., tl,..s.. .,f ,|„. (Vi,n,.an war ati.l of tl... Hn-.ia„ ..atnpa.V,,' npnnst tl,.. Tnfks_in(ia,n,„at.,fy sw..|li„. „f tl„. axillafv an.l son„.ti,„,., '.* «1h. t.t.trn.nal lyntph-jriatuls appears t.. hav I,.-..,, ' so,n,.wl,at tnoro '■'.""'I'M', u.i.l .K...asi.,nally t., have eii.le.l in snppnrati.a,. CHANGES IN THE SKIN. Tlie n..n.en..]atnr.. .,f typhns f,.ver (typhn. ,.xantl„.,nati..ns, tvpln.s |.'t<-l"alts. spott...! iWry, IMmms ptat-p.,,, ..pi.ien.i..a, tnorl.ns pnli,.afis M"..;."s pnn..ti..nlaris. fLhris p..ti..„.a,-i~, ..t...,' sh.,ws th,. hnpottan...^ attfthnt,.,! l.y pl,ysi..ians t., tl,.. ,hara..t..risti.. .•itanu-.s of ,!,.. skin fr.„n the- earl„.st t..n,.s wl,..„ typhns was ..onsi,!,.,-...! a snl,vari,.,v ..t" tvphoi.i f<'V..f, to the pres,.nt, when it is r'"''- '.(• its app..aran..,. an.! .h.v..l„p,n,.nt. it. ..hafa..ter a.t.l tioM. 528 ivriirs ii.vr.n ;<(-.:.;- m. -ri i^*^? (ir lil'lli il:i\ ■■t' tile (li-(a-i'. Il iiiiiy a|i|"ai' nil tlic -ixlli i>v MXriiih, or a- (■ai'l\ a- I lie -i ininl <\a\ . I lir liiin' III' a- a|i|irarancc \ al■lr^ in liill'i ri-iit lipi aliiic- ami in ilill'cn-iit (■|ii'liinir>. Ill Uri'liii. in 1>7^. I li'iuiii llial tin- iiii|iii(in a|i|)cart'ii cai-K — nil I 1h- xciiiiil, ihir.i, .i|- |cMii-|li ila\ : « lic|-i:i.-, in ihr ciiidciiiii' 'if ISTH, llic (■ni| linn iifciirrcci iiMiall\ laic i' nn I lu rniirl li. titili. ni :i~ laU> a- llic >cvcnlli ila\. I .-111 |nin a laliic tVnm an ani^lr li\ riiv a»i>laiil. Salniunn. In ;;'.) ri!>, - iluriiiLMlin r|:i(ii iiiir ni' 1^7!'. u I Hi'c • 1 1 II- lime nt' a 1 1| na I'a I icr cnnld liu aiciiratclv imtcd. ii was Innnil In Ik- a- tiillnw- : li:i> ..I III.' .li-rii.s. S.'.' 1 . ■I'liini F-iinli . l-'ilili , Si\ili. . (\1S. - n;i> ,.f III.' .il-, „>,.. i; .^.■wiitli. . 4 Kiirliih , II Niiiili l;. T.iiili . Kl.v.i.tii , 1 1 3!t MiircliiMiii i'i\i> ilir liiinlli clay as llic avcraLTc tiiiu' nt' a|i|n aranro nfihe iTii|itinii. and (•\|rc>,-l\ slalc- llial lie raj-c-K' >au ii appiar later than llie titih clay. ('a>c> in which tin- irii|.|inii i.- ri|«irn d in jiave liccn dclavcd milii the iH'Ldiiiiini: i^i' lii<- ^.i-niicl week, nr cvin until tlii' twelfth nr the rnnrtccnth (lay. iiiii>t 111' acc'c|iu-d with L'nat caniinii. 'rii:it a \itv late a|i]icaraiicc i.s IKissihli' i> ].lci\|..| liy the ca.-i in iiiir taldc'. liiat was distiiiL'iiisiiiMl liv the aiijicaranc 1- '<{ the r.oic la nii ih. i'IimmiiIi day, uitlmiit |iic.-intini: aiiv nthir ]>(M-uliaritv in llir i-niiix- nf llic cli.-cast-. With il- tir-t a|i|icaranrn ilir ifii|ilic.ii ccinu- mit all at (iticr in a -iiinlc I rc,]i. -d that tlin iihiinatn extent i- ii-iiall\ cniniilctc within tiirt\- einlit hniii'-. It is wry rare, in my e\|iei'i( nee, tli.it llie diiratidii nt' tlie efii|iti'cii la-t- Iciii'jer than tlii-. .\ -eeniMl erii|), nr tli(^ ili-:i|i|)cai'aiiec lit' the eai'!ie-t -|ict- and the apjiearaiic'e nt' a iie\v trii[i, i- |)i'aetii'al!\- niikiKiwti, and \m' tiiii- liaxe an iiii|inrlaiit di,ie|iii-tie |iniiit (lillei-eii- tiatiiiir the fn-ei.la id' t\|)iiii- t'niin tliat of ty|iiiiii(l t'e\ir. Ill feuani tci tile to])iiirf:i|iliy ol' the enipticiii, the ilr-t -jint- in ca-e- that I \\;i- ,ilile to iili-er\'e tVniii till' l)ei::ilininn' ilsiiallv a|i|ieal'ed mi the jiiwir .ilHliinieii and almiit the liaek and sluiiiiilers. and alnm-t at the same time, Imt le-- thickly at fir-t, the sputs appeareil mi the clie-l ami iipjier alidmiiinal iVLrimi. \'i r\ -nun lliev appear nn the extreinitie-, wliile llin-e*nii the triinlv c dil iniie tn iiicrea-e in niiiiilx f. Nni ran !\- tile e.\tremitie- ,are cnNcied at the -ame liiiie :i- the tninU. ( )ll tlw fiire- arm- tlie sjint- ii-nally appear lif-t nn the tievm- -iirt'ace-, and iiiiiueili- atel\- ;it'ter\\al'd ciii thednr-al -llfraee-. dnwn tn ill' ll.iek nl' the liallll. < )ii the len- the eni| ti HI appear- .1- far dn^vii a- the d,ir-iini c.f the limi, where it i- nt'tcii \ er\- cmi-picaimi-. In t\pieal ca-e- the eriiptimi is lea-t marked mi tl tlii._;li. e-peei.iliy ..n the .anterit.i' ■•irl'aci.. Tin- di-triliiitimi nl' the eniplinii pre-eiil- a m.arked ditlereiiee (rmii MM//'yo.I/ |yo/.o(, )-. .r2'.> that .r„ in lv|,!,„i.l i;v,.r, ul,..,v ,i,.. ,■„..-,„„, :,„,,„„, |,.,, , ^„„ ''"■ '•"''"■'■ •'"■ I''"'' •"•' I'' V(.| tV,,in Ih.. ininU. K,,M.-|H,t. ,„, ,|„. t-ivani,^ in i_N,,h,,i,l an- -,, raiv a- i,, l„. ;,|,„,m :, rurioMlv. and I |,av,. iKAir Trn llirni a~ liir of u,„n..|', an.l '■l"l'livn or in,llxi,|,,aU uiti, )i,ir, Im.l.i- .Kin. On th,. other l,ah,|. ll„. hi'v i--alrno>i alua.v- tln-li,,!. ,-|„ riallv in the iM-iiniin- an.l i- oft,.,, ili-lin.lly clcnialon-. The a-,.rlion ,),„ ,|„. ,,„|, ,,,■ ,v,,|hi~ .litlir- fro, at of tv,,lioi,| '" -'■'■^'"■'' ahnn,ian,vof ,1„. Ir^on. i- ,ni v in a u.'n.ral -,.,-,■. I' i-.|Mil.' trn,. thai. ,.x,-,.|,i in ..nain ..,-.- in u inri, i|,.. ,.,nption i- ■'^"''""'^"■'>' ^'' '^"" "" 'h" n-unk. ,l„. , HTof , .-,,,0,- intv,,l,oi,| •■■v.'i- .l.i.- no, ,„,,Hv ..,|nal that ol,.,.v..,| in ,nanv ,„-,- ,,f ,V,,Im,. "'"■•■'■ l""h ,h,. tnink an,| iho ,.x,,-,.,ni.i,.. a,-,, m, ,|,i,.klv .-ov,.,-,.,! that th,' "am,, "-po,,,.,! f.v,.,-- a,,,,,.,.. „,!„., ,,„i,,.|, j,„,iii,|,i,, (,„ ,|,eo,lar ''^""'- •'"■'■'■ ^"■'■,„,a f,.u ,a.-of ,y,,|,n. in u In,.), ,|,. ..,n|„io,. i< v.tv '"'"'>■ •''•^■'■l"l"'l an.l .■n, l„. f,nn,l only ali..- a .■a,vti,l -,.a,v|, anil '"■'"■'■'•'"'"-'■ '"" •■N"vn„.u,. „„.,., , , „a-of „,„|:„io„-. I„„|, ,, v' l-'v,,l in a fnlh .i..v,.!o|u.,| ,,,.,.. Tl„' stauvot H,n,,l,. I,y|„.,v,nia ; the- Ma^v ,ln,-in^. w|,i,. n,o,-,-i,a..i,. ,.|,.,n..v. '"■-'"• ''"■ -'^'^""f |M-,„ n,v.i |„.„vl,ial a|,|M.M-an,T. A f.v^l, ,v|,h;,- i;.v,.r -,.0, a|,|-,.nv n. a |,al,-,v,l nia,.,!,.. ,-an,nn.. i„ T' ";"" '''""'■^' i''"-''"^"''""'=""''^'l-Mtil. ran.K la,-^,.,-. whh^ill. ■'<"-l'-'-..-,|'la„. I.. Fi. h. win,.],, a. ,nay l„. I..„ .l,.,..,.,nin.li.v ;"-'--> ■;* th- ^la~, |.l,.xi,„..r,.p, ,lisa,.,„.a,- ,.o„,,,|.,„lv „„ ,,,,,,„,„, ^,„i, .s t K.,.,.t,,,v :„ li,.,t of a pnn.ly l.y,,,.,.,.,,,!,. natn.v. I„v ,j, i,„Iivi.lnal. w.fh „.n.|,.,. -k,n a f..u o,- a n,aJo,-i,y of tl„. n,„,,i,„ ,;,. „ ,i,„ ,,• ,,„,^, """""'■ '■ '"""' "' ""■ ■•"-■-i>'"~ "'■ 'vphoi,! (i.v,.,-. wi,i,.i, „;,. always ,no,.,. ,„• I,... |,a,„,la,-. „,„! ,,.,,!„ ,|,at .•l,afa,.t,.,- a< I ,. ,!m,v :"■"'"■'''■'"' ''"■ ^'■' ^ i"'iltrati,:„ in tvpl.ns li.v,.,-. if p.VM.nt at all .< always n,,,,.], 1,... pn,,,.,,,,,,-..,! ;„„l v,.,-v ,.va„,.s,.,.„t. ''"'"■ '-'a..„la>- „Mt„,.,., ,|„. irn..:nla,-ity an,| in.listin,.tn,.s, of ti,. .„,t- li.i.'s, mul ,!„. pal,. ,.o|o,- of tl.o s[H.ts ,.o„,l.i„.. ,0 ,nak,. it ,..x,.,.c.liM,.lv SI 1 ii. 9' " ^^ ^^i^^S'f' ,>,■■■>, .•' :*: > . 5:J0 7177/rx ii:vi:n. iliffiiiilt til ilrniiin-tititc llii ( iiiptiiiii diiriiig tlic first purely Iivptn'iiiic .-t:i;^i'. N\ liilf a -rarili t'nr iIh' riiM'->|iiit~ »\\ dark »kiiis i- jirarlicaliv liiHK>lc», it i> (lilliciilt ill an any iiim' to i(('ii).'ni/r the cnipliiiii witli certainty witlnnit |irii|(er illiiiiiinatiuii, a eireuni-taiice tliat iaii>e> tlie jrreatest trmilile tn lin-pital re-idents in ailiniltiiiix palieiils (liirinj,^ tlie ni^'lit. ( )eeasii)nall\ , tlie enipii'in >tainl> mit more prniiiiiientiv from its >iir- ronii(linjr> vvlien -een at a -iiii:lit di-tanee tlian at e raiiiie. Ill not a liw ea-e> tlie eruption does not develoji Itevond tlie tirst liy|iereiiiie -tasxe. and, al'ier pei-i-tiiii,'- tor >everal dav~ or lonjjer, dis- appear- e pletely without leavilli; tile -iitrlitest trace on tile liodv of tile cou\ alcMcut, or oil llie cadaver if tlie <'a.-e lias teriiiiiialeap|)ear eoiii|)letel\' mi |ire-sure. Iliev liecoiiic somewliat paler when the plcximcter i- a|iplied, lint the central portion still pre- xiii- a dark-rekin and siilieiitaiienus tissue and evanosis of the tiiee and I 1 DESCRIPTION OF PLATES. Pl.Alh I. 1. H.-.VM. .y|,!,u. lever „,ot» of no, „.„,. ,Iku, ,w...U-,;,u. l,..„v ,,,,,j. ..... .nil „, :■:. l.,,.,v,ai. Htage ; .ak.n f, „„. „>„! ■ . ,.,,„ , ™. ^v.. y..ur.=a age..unn« a„ unu.ualiy ..v.-.v :u,:„ k iV .U\cU 1... ulti- mately re.overe.1. The ra.h a,,,..red ,.,. th,- tounh dav ,.,' ,1. .,i.,ea.. .f.h;Ji::i •''™ '''■''■'■ ^""''' '"''*'•'''■ '^'-""^ '■'■■'-,;,.,; dav Th,- ,•„.....,„.,. ,nv ,.,„• for 11,.^ nH«t ,.,rt of a dark 1m id i,u., a l.w of ti.eiu ratluT ,„„n- .opiKT-olorfHl, „wing to hen-.i-rlm^'it- clmupe. Sm;..red a,,,.,,,,, .he ro.e-.,,..„s are a ^e^^ r.v.n.t petechia., and atone -I'-i .a ilu- i,.^^,•r ti-ht-liaiid poriioti; a more exten. rliMi'v. laupe echia isive cutaneous liemor- Pl \ I'h II. ■•■. Compar.. tai. ui,l, IMal. I. Ko«^ spot, .ak.n In.,,, t!- .(,don,e„ nf a «.,,„an ihTtx..,,,.. v-.rs of a..-, sollenn^; ,Vo„. I,/.!,,,!,! fn-,, Tw, Itti, d.v >!^1 Tl.'vTr i ' "" ' '"'"'"" ''^ ''"'"^ '"''''""■ "'"' """" ■"■ ""■ ''■^' ""^ ^"■'^ '';;■.';'■'■ !';■■!'"■'> -A..,, made l,y tl„. aull„„ at ih,- ivd,id... and l,avt l>wii laulitully R-pro.luL'ed. IS--' i L '■ :^ > 1 f» t fi ■SYVI'InM iliilnii y. r,M ' Miviniti.-. I'litic'iii-. ill whom ilii- |.|i> iionii mmh i- prorni ;i> a rule ITl-illl M I ilsill- -|M-.| K I MI'.'OIIIII ..(■ till' ll.lMl'T||l:i-( - illlo lllc 'olijiiiHliv,.' .111(1 tlic .l:iiK, livid :i|i|Manitlir cil tllf li.~.'--|H.t-. Sll.'li pMliiiii^ lull raicK iciiiv 1 r. ( )c.a--iHiially, .-|.c\ iii^r th.' noi,,ii ct' the hair-CoJlK I.- c,r the haii-tnlli.lfs lii'iii^cKc-. I hi^ |ihi'ii<(' it. It i-i a ucll-kii'iwii tjiil ijiat, in liin,- nf <|.i(|( niir, pMiicnt^ -iitliriiij^ tioiii any (ihii).' cunililidii ami |iiv- lyi.liii- Ctvcr |iatiy |>liy-i(iaM- c)|' li, \,-i\ (AIM i-i(ii «■. A- in (ithir aciitr i\aiitlicMiala, i-|i(viaily variola, l.iit not wilii thr -.aiiic rii'.|iitii,y. thr a|)|Mai-anrc ot' thr ciiiiPtioM in tv|.hii> (<\(r inav Ix' :"'"'ii|''"'''''' "!■ i 'liat.lv |.inrdrd l,y ;, diHu-,. macular, purely hypi'icmic iclii.-.- ot' the -kin, (-p..i.i||y on tin- Lack, chr-t, and nrck. I hi-^ phcnoini'iion i-, how.s r. very rvaiK-.cni. and ii-iim1Iv disippcars l>y the end of the tir-i day .■ the cniptioii. In a \'<\\ ca-i ., (-p,..i.ill\ in [n'r-on- with a -oft, white -kin, I have -ceil the true eruption a inpanied or immidiately pieeclrd l.v th.' ap|>earaiiee of a piviihar laiL'-' maeiil.ir. •• inea-ley " eruption, .H-eiipv-""- eiiietly the t: iieann^ and hack- of the hand-; tlii- .iiiptioii rapi.llv di- appeai-, and euntiniie- t( reeur f.r a -hort time at th<' smie plaee. 'I'he diinition ..f the true typliii- eruption .and the duration uf the iiidivirhial >tai:. - a()pear to vary in the ditreivnl epideini,- and to some eMeiit in dilferent individual-. The avei-,ii,re duration fir severe and moderately -evere eases may he o;iv,.n a- from -<.ven to ten da\ - ; traces ..f the hei TliaLnc eruption, in the f.rm of palc-hrown or t;ri4'iii-li-yellow -pot-, may. however. p,r-i-t l,ey,,nd tiiat time and cotitiniic dnriiiir coiivale-eencc. ■|"lie priin.iry. piir,.|v hypereiiiie ro-e-sp,,t- l.ist a vrv short time. "'■".' ''='i' ' I'lV" lielnonhairie dianire, they n-nally disappear oil the li,-t or -,coiid. or. :,t the late-t, on the third day. If the lienior- rha-ie eiian-e i- ,,nlv p.-rtial, the inacnlcs may u.,t he visil.h. after five "•r -i\ da". -. Like many other phenomena of the di-ea-e, tlie alMiiidance and detrree of (leveiopmeiit .if the eruption depend, ainoiifr other thiiijrs, on tile chara.'ter of the epidemic. In -oine epidemics, aecnrdinir to relialile ailtiiors, they are of slijrht extent ; whereas ,., the other hand, eiiideiilics mm^: ,^=^^V^ o.-j-j rvriirs i i:\i:i:. Iia\i' l)f('n ilfxTilx^l tli;it were ili~tiiiLriii~linl liv tin' miu~ii;il iiliiiiidnticc Miiil |iiciiiiiiirii'Ml rli;if:icl(r I il llic i'IiImiicimi^ clmiip'^. A^cilm'- riol, «(i liir :i~ 1 lia\f ■pIimt\ cil, a|p|Mar In alliil tlir aliiiinlain'c i.t' tlic iiii|ilinii. ( 'iiiitr,ii'\ l(> tlic r\|H riciirr lA' Mun-lii-nii, ( iii(--iiiii( r, I'.li-iiin, I'x-r, and \\ y~-, I liavc -ccii \\u- ci-iiiiiiMii (|iiiir a- |iiii|'ii-.r in dnlilrcn a- in ailult>, anil I'iialMW ' a|>|)rai'- ni li:;\<' uli-trv cd lli^' -anic .IndiriiiL: iVnin invnwn cxiMiii'mi', llirif appiai'^ to Kr no ili-linct rclali'in liclwccn tlir almndani'c lii'n and llir -i\rrilv nl' the di-ca-r. 1 lia\i'-'i'n tin' nm-t >c\tn' tatal ca-i- \\illi liltir ur no crni)- tiim, and. CMnvii'-cU', I lia\c lVci|Uiiillv iili-crvcd tlic sinic cniidiiidii in \(i'v mild ca^i-. I am will auari' that I am i vafiainT in tlii-' \ irw witli that III' M ni-i'lii-iin. ( ifii---iii;:iT. and maiiv i.l' tlir nidcf aiitlinis ( l!a-iiri, I Irndcr-nii. and Stnarl |. In addilinn 1m thr -|iicilir c-liaiiLTi- -" tat' dc-ri'ilicd. tin I'l ai'r man\ ntliif I'litanciMi- |ilntiiiinriia that di'-ri'\c ni'tiii. AniMi'.:.-- ilic ni'Ti' iin|i"nant i- the a|i|icafanrc nf miliaria crystal- lina in till' middir III- at I In- cud ut' tin- -mmd wii k. I'fum unr t.. three da\-- lietiife the liei.'innin_ nt' i|e|er\ <'-eenee. I'lie eni|itiiin i- "I'll II Ver\ aliiindant mi the elie-i and aliduiiien. and i~ mufe ('n ipi' hi \ niineei' than in iildir indi\idnaU, ran l\ neriirrini:' alter the |iM'l\ ..I'th >ear. The euntiilt- lit' the \-e-lele- in all the e:i-e- e\aniilled li\ me \w I'e aeii' .r iieiitial ill iH'aeiiiin, iie\ er alkaline. I iil)-er\-ed mili.ifi.i er\-talliiia in alinndanee in Irum li |Mi-eeiit. tn S lief eeiif. Ill' iii\ ea~e- ill the \ear- i>7~^ :ind 1^7'.'. < M hi r antlnir- ui\e a iiiiieh liiuhef |i( reenta;:e. while ,M nfelii-mi. mi theniher hand, -late- that t III -\ niptmii i- fare. \\ Ili'lleVer lhe\ Were Well deSeli •[ led . the -lldamllia \i ere tiill.iWed li\ di-tiiiet liran, \ ile-i|namat inn "I the -kin. 'I'hi- de-i|namatiiin. Imu- evcr, i> willimil dniilit a \ er\ emnmnii i n > iirreiiee during llie |iiriiid 111' eiinvale-eenee. and t'lillnW- I he -|>eeilie ,v ill-eni | it ic ill a- ,\ell a- miliaria er\ -lallin.a. It alVeel- the entire -kin. inehidinL:' -neli |Mirtiiin- a- were iinl eii\ered li\ the rii-eiilnii- eril|ilimi — a-, till' in-Iallee. (lie iiiee. Ill '1 ea-o diiriiiLr emn ale-eeiiee ! -aw a -hediliiisi' nl the e|iidcriiii- ill JaPire -I'ale-. -neh a- are ii-iiall\ -eeii in -earlel I'lAer. riien i- a marked \;irialimi in the -tateineiit- nf dillireiit antlmr- in reirard til the iieeuri'eiice of herpes facialis. .Iaei|iiiit -aw it iiiiiiK- til'tliiif hi- |>atieiit-. while in (ithcr e|)idemies it wa- allii;.;('tliel' .ili-eiit I ! lertnailll, I'eter-liMfy, I>^7 1-7")). I lielievc the ali-eliee iil lier|)('- fiieiali- til li Aee|itiiiiial • it i- certainly liiirly t'rei|neiit — iiiiicli nini ireijiicnt lliaii in t\|ilii.id t'cvci-. In ix7!l lier|M> liniali- ^\a^ prc-i lit in ' \'.'ili sHii'ji II iilii-i ih--il'- liil<-/.ti<.iisl,riiii/,/iiitr>i nil Knidrsiilli r. Uioii, IS'.lT. sYMrr'iM.iToi.om . '.i |i('r cent. i.C oiir p;ili(Mi«, ^iikI mure Irccjiiciitly diiriiijr tlic Ixtiiniiiii^ III llic cli~c;iT tliaii (llll'iliL; lllr |)(ri(>.i nj' lirt'crvc-i'clicc. Ill .1 nmnlirr of i-m-o, iliiriiiL: llic -rcnid wrck of tin- di-iM^r, I -:i\v ;i niiiilcrMlcly -cvcic icterus, v\illioiil iii;irkci| change in llic I'nlur i,\' ill" -IikpI-. Thr-c r-.-iM- wci-c all \i r\ ;jra\c, ami -I ni' ihcm ( I uiit "f til tiiiiiinalcd t'atally. At llic aiitii|)-ir~ ii, and '"■i"i-i d c'ln-idcralili' annciyaiiii' to tlic |iali(iit dnriiip' I'lnvaif^cciicc, wliic h \\a- |ir(i|on'^cd nn aciMinil nt' tlirir |pr(-cnci'. Bed-sores -nit-iA in a litlli umi- ;; |i|.r ci-iu. n\' ni\- ("I--I-. \)\ — |■^L^•ll•dillL' ca-i^ llial \miv mmli |iiuti-artc and -r<|iicl., the <'iiiiilitiMn mcimiitii] diirint;' llir tnic (•diir-c ot' tlir di-ca-c unlv in \irv -r\crc ca-c-, Irnt in tli.-c tlic -m-o a|i|icarcd -o ra|>idl\- and wcic -o c\tin-ivc a^ tip "iiiiuc-l :i -cvciv ti-n]iliic di-tni-i>aii<-c in additimi ti. 'I -iliiian |.r<--iirc-r.tVcci-. ()c(a-ii)nall\ , tlicy were c(iniliincs>c--(- aiKJ dcc|) nlcirati.>M~ IcrinininL:- the -niiciitaiicdii* (■ciiiilar li^-iic, or cvcii imin> (n- |<~- extensive cxtliliation of nccTutic Ukuc, inviilvinu- the -acnnii ami cnccyx and c\cn the -eapnia'. In vcfv -. (ian-rine may he oh-civdj in tyjihiis i'rv, r in certain portions of the -km lint e\iio-ed to pi'c— lire, hill far rmiox.'d tVoni the center of eircuia- tioii. |",,r ohvion- rea-ons this doe- not occur in the -evere-t C.rins. Thus, I have seen irantrrene of the tip of the iio-e and ear, and verv fre- <|mntly of lli,^ ski serin- the toes. An entire toe may lurro-e and necc-itate cNartlciilatinii. Seli;.,.r oh-erved uan-fciie of the tiiievr-. I my-elf havciicvd- -,.,.ii it, and other authors note it a- ;i em io-itv. • Erysipelas, which in the older wriiino- i- mentioned a- a freipient complication of i\pliii- liver, ha- heroine verv rare, owm- to the favoi- ahle c,.iidiii,,ii~ jircNailin:: in modern ho-pital-. Noma and hospital gangrene, wlii.h are al-o memionnl in the iilcraliire, are of no nioiv than a hi-toric inten-t at the pre-ent da\. Cciti'iii ivliahle oh-,a'ver-iMiirehi-oii, I a'nd. ( Jerhard) proli— to have ii">i'''l ^i pi'iiliar odd- from the -kin of tyjilin- ti \ er patient-, a- in the <'a-e of the other aeiit. iid"e.tioii> di-,.a-es, espeei.aliy tile exanthemata. i -x:i jiA^^^ :.w-' -t-OT; ''-^m^dMmSi^^mM-m^m'm fffifii ■);U ryriiis i i:vr.n. 'I'lii' imIiit is (!(>cril)c(l as mu-ty ur as " iiioiisiv," ami is said t" Ixciiiiic \cry iiiai'kcd when llic |iali(iit~ aii' rIci-cK cniwdcil : llii- i- i|ilitc to lie i'\|pc(Ic(l. Wlii'tiicr it \s:i- (jiic |m ihr taultlrs- vciit ilat inn 1 caiiiiiit -ay, luit I nr\cr iiiiti<'(ii any -|i((i(ic i \lialatioii lV(.iii (.iii' ]>atit'iit> in tlic Miialiit la/aitttd. if'-':*: THE NERVOUS SYSTEM AND ORGANS OF SPEQAL SENSE. Di-lurl aiicc- (if the iicrvnii.-- sy.-tciji aii' \ < ry marked fimn tlic licjriti- iiiiii:, and later ihey t'diin liii' |il'ediiniinant fealiire in llie clinical |iielni'e. 'I'liey ai'e sr and after the jieriod ot' detirveseeiK c, :iiid any e\|Miienced |)raetitioner will recall cases in which the t<'m|icr;iture rcmaiue lal'i^ic, :ili(l, Mitlinil; ('Mil ill "cvcrc cases ; tlii ~tl |iati('iil> an Ii |-(-tl(>-, lie -II] II tluir hacks. spite nt' tlic trivat |irii-tratioii imi-i dl' tlje paliciit- canimt -lei'p day ui- liiirht ; it' tliey do tail a-lecp, tlicy are iiiiiiiediately miixd t'nuii tjieir siiiiiilicr- Ky tenityiiiL: dicaiii-. 'I"lic>e eoiisist >niiictiines in peculiar sonsitiuii- reeiirrin^r again and again, sneli a.s a >eusatii>n as ot' snaring, tlyiiig, or falling. .\t till- peiiiHJ the mental (aeiiltie-, even in tliese verv severe case-, are -till well piv-crvcd. .Mtlioiigli tliey are dull and disinelined to any mental nr hudily activity, tlie paiiciit> -till retain clmseiullsne^^ ut' their siirriiimdings. When -pnkcii t<>, they aii-wcr -hiwlv ami in limken jihra-c-, lint, on the whole, correctly. They evidently, however, experi- ence snine dillienlty in collin'tiiig their thought.-., cannot rcadilv conii e- liend long and complicated ipie'>tioii<, and when they atteni|it to do -o, their attention -(mhi wanders, their thoughts drit't into other channels, or they later complain ot'a marked inerea>e of the pain in the lie-ad and oyes. Toward evening and chiiing tlu' night divmns and hallucinations continue to haunt them. c\en though lliev are awake. A lew are violently delirious, e\('n at this early period. It is evere cases of very short duration, tiiat the |).-y<'hic c ami old :iii<| ,|,viv|)it |i:ili(iil- |iri'-.i:iiiiiii]i; and dnriiiL: llic ciilirc lilililc -la-r. Ill iiin-i ca-i- llic ilrlii'iiiiii i- l)a-id 'III :iiir or iiK.T-c tMiiiiriii- liallil- •■iii:ili"ii- ; ill Mill,!--, iliciv i- a Mi'ilalilc tli-lil i,l' iilia-, ivdii,ii|M ,|ii> I'li'ii'iil '" 'li'' \i r-i' >'f (Aliaii-ti..!!. Til, dclii-ion- aiv ii-iiall\ of a -;id- diiiiiiL;. cl(|ir, — lii^. or a-italiii- nalinv — ilclii-ioii- of death or di-ca-c aHiriiiiM friend-- or r< laii\,-. of |iei-i'ein ion | |ier-onal daiiLier. -onie- tilne- niidei- ill,' iuo~| reinnrkalili eonilil ion-. -i|e|i a- iK iiii: in a liallooii, cr lii'iiiL:- in an o|m i; lioal on llii' lii-|i -ea-. eli'. In otli,r ea-e- ilic lialliieiiialion- aiv , eted willi person- or olijiei- in iIm' |Kilieiil'> iniiiiediat,' \ ieinitv . 'I'lie-e lialliieiiKil ion- max a--iinie the nio-i |-inta-tic Jiiid !iTril\ iiii: form-, or, what -eeiii- to me more fi'e(|iieiit, the\ mav ivler lo tiifiner event- in the )ial ieiil"- lili, to hi- oeenjiatinii, to -nmc tixed haliit, or lo hi- \ iei- and |ki — ion-. In a eoii-idefaMe niimlier of ca-e- the eoiiditioii, a- i- ijiiite lr(i|i, atlv ipfovcil i)\- the lii-tor\, i- a ."iiniile exaeerlialioii ,.i' fehrile aiKJ alcoholic dihi-ioii-. .\ lai'ce ward full of t\|p|iii> fe\<'r |ialiint< otfer- the ureate-t iiiia"-- iliahle conlra^t-, and the confii>ion ari-iiii: fioiii tin- wild nudlev nl' tc\cri-h ^roaii- ind dellri..n- ra\iiin- i- eii,,ii^h to -jiake the iicrvc- of tile -leai'iie-t |)iiy-iciaii ; it lia~ lics I'oiioiisi- l)le attendant- in |iaiiic— Irickeii tliLiht. Aim. 1-1 everv author tell.- of |.e( nliar and often verv reniarkahie hiil- lilciiialion.-. MurcliiMni. HildeiiliraiHJ, I (iiiiKiiii de' .Miis>v ilcMrihcij their nun ver\ iiilerestinL' I'.-yciiic coiiililion,- a> they reeallcf iheiii after recovery. One u|' in\ |.ati(■lll^, a la\\\er. ot a natuially \i\a(ioii> leiii|,era- llicnt. exiiiliiti'il .iin-iirj the lexer -o \ iehnl : litipallix to\\;ird hi.- atleiid- aiit that the Miaii'~ lite \\a- in daiiL'ir. .\liir hi> recoxcrv he reineini ered di>lincily the deiaiU of the teiril'xinu a|i|.arii ion. and do'-ril ed Imx^ ih,. ],iaii ^oiiielime.- a|i|.i ared to lia\eeii,ir >ly |o||m aiiii>aiid Icl'- o|- eUe inlhiled him-elf to iVi-lilful |.ro|„H-iiui;-, or -at > In.- hed uillidiii anv hea.l. Tlie a|i|parilion xva- ,-o IriLjhtfiil at oi,e linie a- lo indue,' hini l,, all.ark the inoii-t,a- with a knite, a> In- liiiii>,'lt' atlerw ai d niniiulMr, ,1. Anelli.r one "f 'ii\ |iati,nt.-, an o|.| -ailoi-. iiiL-iiiiiii'il hi,ii-, If lor ,la\,- t,,^,.|||,.r i,, ;i ,a-,n\'-ii' -I ,li.riiiu a \ ioleiii -lorni. -iirr.Mnnl,,! hy hn-e iilack hiil.-. In '"■'iii.^ |i,aticnt> ih, J dlii,iiial!,.ii> ,ai,' ,\c,','ili!ii: f. i otoiHiii- ami r, | , .it tlieiiis,'lve- il.av aft, r ,i,-i\. W,- had a >ci-,-,,r-- riiidn- in ih,- war,| ulio for day.- a 1 1, 1 ,|a\> uould r,'p, al. ■ II.ix,' \ ,■ aiix ; hiiiLT lo l i ind ',• " and a caelaiiaii who «a.- ,,Milinuall\ iiiLiiii- ,,ii h;- li.ir-,'s an,! |ouii,i -tant ,„-,ii| aliou in |-e|iairiiij hi- I'vi.K'hl ly inn,li dila|.l,lale,l \,hi,'le. .\ |..,i h,,- of in\ lalieiil.-. "ho afnr hi- , ,■, ,,^ .i v l ,ii i;,-.l m !.,■ a ,lerk\\iiii ii\ ,-t,iii- teii,li im-Ji's ■il'duixin t,> onani-iii. iiii.-i'jiii,d liini-. If ,lea,| an,! 1 raii-lale,l t,,lhe lii-hcr ^clii■■ll^. \x hence he , -,1111, 1 hi.ik ,io\\n ,iii his ,|ead hoiiy ami uitlle.■^.- the prcjv ,' I ^"^i« - i*4^a*^ s)MrniM.\'rni. <,'!)■. 637 aralioiis for liis .,hii fiin.Til, f)iiii,!L' lliin linif lie hiv iti :i iimtUriiiff -lilirimn iill.riiMliiii.' uilli cMtiiltiilic ri-i'lilv. Delusion.-" of ilfalli and of hciMi: liurii-.i :ilivc liavi- ;iIhi li.cri (IixtIIkmI I)\ nilu r aiilhur-. 'Ill' -'I ••mil iliirilioii (,(■ iIjc (|(lii-i,,u- Ma'^c. lik. ihc cxinv— Imis lit llic lirliriiiiii it-rir, aiv. i>t' <■ --I', -iilijci't In iiiaiiv \;iriatioM-. In (■iiiii|>aralivrlv rare ca-r-, a- we liavr -n ii, tlic ilcliriiiin ajipear- (liii'liii: tlir lir-l ilay- nt' tin- ili-.'a-r. aii'i in -ui-li i-a-i- llic |ii'ni.'nu-i- i- liail. I l-cim iiilitT line i-:i-c in uln'rli, wirli a ia|>ii| ri-c ..I' iiin|irratuiT, I'Mrii.ii- • li'liriinii iln-laiv.l iiM'lf l.cliMv tlir i ml of t \vriil\ -linn' Ik.iii--; tlii- ra-i' ciiili'il I'itallv uii ijic i'i;;lilli .lav. Milcii nil. IV I'lv.jninllv ilir ililirinni a|p|irar- lair in tin- iniilijlc m- sc.'i.ikI lialf I.!' the -k I w, ■,■],, ,,r ii may in raiv raM-. a- uli-rrvcl iiii.v III- twir,. Iiy invM If. lie ilrlaycil until a .lay c.r wu, lnt'inv the licLriii- iiiiil: i.t' lift; rvc~(TiiiT. .\- a rnlr, the iv-ili— ni- ivarlic- il> liiM'li,-t < yiiiil, ,inlii|). Otiicr patitiit-, auaiii. wlio aiv Mitl'i riiiir t'rnni a very >cvcro form of tho iliMa-c. Io~o their ie-tle-iie>> only to -ink into .le<.j) and 'astinir eoiiia, whieh in the frreat inajofity of ea-e.-; en. Is in deatli after a few da.\> or sorii.tiin.s even aftir t w.iity-f.nir hours, iiut whi.'ii, after |>.m'- si-tinj: several .lays, may .11. 1 in r.v.ivery , as I myself have seen in several eas.'s. Coma. — 'I'll.' f )rm .if -tii|>.)r known as .'..ma-viiril is .if the worst ])..-sil,i,. |,r..M||,,.|ie sii.|iili;.aiie,.. The patient is pal.', evan..ti.', with liai:irar.l lealiiiv- .an. I li.mirinir .jaw, eye- wi.le .ip.u ami starinir iiit.i .'pa.M- usually, h.' is al.-.ijiitely impervi.piis t., .•xt.runl iiiHiienees, •'''' i^l' >"iii.'tiiiie- ih.^ -en-..riuin is ,,idy inodrr.it.'K inv.ilv.-d. 'I'h.. ext.Tnal -kin i- .•,„,| an. I .'.a.-i.'.! with a e.,1.1 p. r-pir:ition, wliil.^ tlu' !■ inp..raliire in tli.' r.vtinii may I,,' -ui.n..rmal ..r .a.ii iMirile. The extivmiti.- are i< y .•.,|.| an. I r\an..ti.', tli.' -kill r,,\,r\ui: the t..es am! lin-.r- ..ft. .11 i- «rinkl...l. anil tii.. linii,- aiv eith.T fl.N.HJ aii.l n,.,tion- l.'.- ..r 111 a .-oii-taiit tivm..r iv-,.M,!)lini: -uli-nltii- leii.liniim with ear- lili..|.i-y. Th.' tivnh.r -.muiim.'s iv.-i.Ji.- -.. int. n-.' a .le-r.v as ainio-t to warrant K.in- .vill..,! a .■..iivni-i ,. \\|„.ili..r the em -iicli very fiiiiit iii:iMilt>tatii«ti> of lite to actual dcatli uftcii dccurs alinor-t im|)(n ('])iili|\ . Sensory Disturbances. — For ol)vioii~ na.-on, l.ut little is known riVanlitiL' tlic taj:r. ~iicli a- |iaiii> in tiio lofs, fitipT.-, and tlii-ii~. radiatinLT i" tlic |)o[ilit(al .-|U(v, wliiili siih.-idc diiriiii: tlic prrioil of ~in|ior and coma, olicn rcajipcar as consciousiicss 1- i-c-c~ial)li-lir(l, ami roniiniu' to annoy many |)atiint- np to tlic time of convalescence. Severe nciiralL'ic Main- in certain ncr\ c-tracts occa.-ioiially a|i|)iar durin- the time ot' defei-vc-ceiicc. 'riie~e nenral;;ic j)ain~ are (|iiitc com- mon, i)nt fortunately -uliside .after a eoni|)aratively short time without any s])ecial treatment. 'i"he nerves of tlie lower exiremitio, espeeiallv those of the I'cct and toe-, are attacked with predilection ; hut I have al-o known the sciatic nerve to he aifceted. The distrihutioii of the hnichial plexus i- more rarely attaeko.\periencc in -Moahit in ls7s and l.sTit. Anesthesia eoiiline(| to ap|)roximate]y the same regions as tlio neti- ralLMa, thouixh more rare, has hceii ohscrved al-o. The attacks of anes- thesia are likely to la-t lonjrer than tho>c of ncuralfria. I have luiown ane.-tlie-ia of .in area on the iliiirh as larjre as the jialm of the hand to persi-t for three months after recovery, and a similar one in the dis- trihutioii of the ulnar nerve to p.-r-i-t two months after reeoverv. Motor Disturbances. — .\mon|)orted ireiieral convulsions and St. Vitus' dance as oee:isional complications of typhus fever. It is worth notiiifr ih.,t any external motion when the patient is conscious or semiconscious, or any <'han>re in the delu-ii,u when the patient is comatose, is followed hy marked jiirjrravatioii of the tremor, jii-t a- in the ca.se of a true Intel iou-tr(>inor. Ill many patients the mu-cular unrest assumes the character ol' sub- SYMI'Tpcarei-tinct catali'ptic condition-^, which for eonvcnieiice are reternyl to at this jxiint, are not fropicnt, although a more or less pronounced tendency to cataleptic rigidity is not at all nire. It has Ix-en ol)serve|l(';||' lliucll W.ir-i' tll.ili il i-, il i- iiii|M,ii:iiil li.r ilic |ii-aitili r |.. !„•<■(. iiii' i li(,niii;;lilv lainiliMr w illi iIk'Iii. I':il-ii~ f, liralilc- III aiiatoiiiii' altiral ii m- aiT y:\vi- — (■•■rtaiiiK iml tiinrc '■"iiiiiiiiii tliaii in i\|.liiiii| I'lVir III- in -iiiall-|i.i\ anil ulliii- arulc ixan- llirniala. Hemiplegia lia- Ikih .li-rrilicd iti varii.n- ciiidcniii- i( ; a iir. ":"ii|"'"i- * 'ii'' <"i-r lit" ilir kiml \\a- i,li~i rvi'il a n;j iKir |.aliini- in 'II'' 'I'l'l'inic III' ls7!i. Tiny a|i|Hai- I.. I.r ili|Mnilrnl. a- ~liii\\n liv ~ ■ "' 'II'' anlii|i-ir-. iin licnii Trliai;!- inln llir nimi - nv intn llic -nl.-lanii' III' till' In-ain, niniT i-arcly uri inilmli- r i linnnlin-i- nt llir l.ir^iT arli'i-ii- nl'ihr rcnlinini. ami llani{ii'ln (Ic-ci-iiinl (iMf ca-i- nf tlinmilii.-i- III' ihr li fi niiijijli' cri-rlual ar|ir\. A— niiatcMl w itii lln-r I liiiiin- wr liml |ial-ii- .if -in:;lr rMi'crnil ics ciiniliniiil iiftcn witli cji-inrjianr.- i,|' -cnsitiun — am-ilir-ia. |pan-ili(-ia. ttr. (/tie ,a-r III' pariial |iai-;il_v-i-. i.t' tlic cniii'c li-hi Ic^- (ilnrin- ilir (■|iiil.nii.' lit' \X~iX), uliii-h at lir-t \va- i iliincil wilh li\ |icn>tlic>ia anil latiTuitli tlinnicati and uliicli diirinir tlic |p(iiiid i.f coMvali-rcncr drv(li.|ird inio a uril-niarkcd niiini.|Mi;:ia, 1 a w incline*! In riirard a- a niiirili-, a- 1 ,lnd. I.y nil iiiicc U\ my nntc-, thai it \va~ later tiil- liiwed liy |.i-(.niiiiiieed inn~enlar ati-ii|(liy. It wmild lie Iputli intefolin^r ami |)riitita!ile In cNaniine hy rnudern niethnd- -ncli ea-e- uf i i(.|ileu'iii in tntiire i'|iidenue-, to >ee uliellicr tlie ina'ioiitv ai'e imi due til iiein'itis. Meningitis. — Intlainiiiatinn of the icrel.ral and -|iinal ineniiiMe< ( Miirc'hiMin, I'eai k. .1. niicr, .Iai|n(pt. IJaial'iei') al)~(ihilely deny the neeiiri'enee ul' ineiiiniriti- in l\ |)hii~ liver. Miieriiii: ' al-n, dm-inL'- the ( 'riineaii e|)ideini •, ua- iinalde to di-eovcr any inllaniinatiMn or .-niiiim-atinn in the nieninire~ nt' 2n<> easo, e\eii thiiiiirh a eai-efnl niiefii-e.,|iii' e\ai linaliuii \\a> made. llaiii|ieln, iii'Vef- thele— , i-e|iiiri- I t-ital ea-e- nl' |iui-nl( nt nieiiiiiMiii- 1,111 (if a mial "if ~rl*\ jialielll- in the epidemie ul' li'iLTa. DISTURBANCES OF THE SPECIAL SENSES. Eye Disturbances.— The eyi -,a- «>■ ha\e -een, aivahimM alwavs iiiMiKeil III a -lijlit dei:rei', tlie!-r bei' -■ ;! marked iiijeeiiiin and an inerea-i-d "■'■I'"'! I' 'III' '■■'njiiiieiiva', Thi-i I ill net i\ a I catarrh, u hieh \ erv iniich r. -eiiiM. - thai which inciir- in niea-ie-. in - ■ in-iaiici- a|i|iear-- dnriiii.' the -taire "I' inciihaliiin, a^-uciated will r\/:i. With the l)C"iiinin«>- of ' (^u-fil l.\ Miir. lii-..ii. sYMrni.M.woi.oi;)- 541 till' f'llirilc imtIikI in ilic i;r<':it iiiMJcirilv of .ax* ilic .Mlurrli l« ><> lii:irl<(c| :i- III lie ..I iij|i-ii|cr.ili|i' cliau^Md-lir iiii|Miilaiii c, -iiici' ilii- -taLTf |ir(~ini-. -d little I 1-1 lliat i- ihaiai icii-tir. In -i\ itc . a-< -, in w liiili llic |(aliiiil~ licwitli iM- ■i|i(ii 111 |iair- wry iiiarli\i', tin' i litimi imt fairl\ Irail- In tlic rnriiialiipii uf -ii|»i- (icial i-iiniial iiliii-. i"ln- (lii|«f laMf- ul'tlii' cortira but fafcK liccniiif (ii^casi'il, altliiiiiL;li I \\:i\f iiiv-ilt' -nn mir ca^r ut' (•xlcii>ivc paii'iuliN - liialiiii- kifatiti-, ami in \ciy -i viir i|iii|(iiiii~ iii-tamt> liavc linn n'lMirtid 111' ncrfiitir kifatiti- uitli ]it ftiiialiuii ul' tlic ruiiua. anil i\cii pami|(litlialiniti-, nm. litimi- that, t'i)i-tnnatrl\ . diil iml miiif in aiiv ul' inyiax'-. I'lit-c lunilitiun- a|i|>|itic nerve atniphy in -pceial tcNt-hiiuk-, Imt in tlie-<'. nnl'iirtnnately, the di-tiiiclion tictwceii ty|)lm< and typhi. id fever i- imt alw.iv< -tiHieieiitlv clear. The nin-ele- ul' the cyel.ill arc nirely invulved. In 2 ca.-e- I saw >Iral)isniii- develop in the coiir-c of the lel.rili' -tap. and disappear .ii'tcr ivcuvery wa- e-tahli-licd. Other anthoiv have iiieiitioned >pa of tlic eye and of the levator palpelinim, fuilowed l)V |)tii-i-. Disturbances of the Hearing. — In contradi-tinetion to what is oliserved in ty|)lioid fever, interference with the sense of licariiii: dno to the toxic clfcet on the auditory center in the lirain or on the auditory nerve appears to lie rare in typhus fever. Mv own exiHrience compels nie to cimtradict Ficlicit's statement that the hearinfr lieeomcs atfectwl toward the end of the first or at the hesrinniiiL' of the se<'oiid week. As a rule, auditory distiirhances do not make their appearance until the jxjriod of convalescence, when they become comjuir.itively fretpient. ■--!r' ",!■: •)»- I ) rill N / / I / /,' riif\ irr ii~ii;ill\ (liic I.. -«> lliiiLT "i' iIk' iiiiirMii- iik'iiiIm'mik' lining' llic |-.ii-t;iilM:iii mil.-. .iu.fi;ir;ili f lli.- i\ iii|.aiiii' ininilii'aii. ..r (■\.ri ill iiitlaiiiiiial.in .|i-.■. :i-i..iiall\ , tin .■..ii- .lili.iii f:i.<- .III .MM I.I |iiinili III iiitillrati.iii .il tlif ina^tuiil crll- v\it|i |iii iii-liti.' all-..--.-, iiiM-,--i;atiiiir -iill;ii-al int.iliriii..'. I'li.M' iii.irl>i nil .iisra.-ts lit' til- car art- liaM.I |)riii.i|iMllv mi tlic 'mwvu- tiLMIi.iii> iiia.li- In llartiMUiiii ' .m ,iiy |iiiliiMl.s in Muaiiit in IST'.t. 'I'lusi' iii\i>li^Mli.iii> a|i|K'!ir I.I lie ihf ni.iiil ii.'.iirali- ami iim-l .■.iiii|ilitc that liavi' api'iari.! on liii'< Milijii'i up t.i tlir pi.M'iit liiiif. AiiimiL' !•'!•' III. 11 «li.iiii III- fxaiiiiin'.i .Iniint: tin- |.rri."l nT .■.nuali'.viMi.'f, Hariinaiiii t'.iiiinl aural .IImiim^ in ij. nr :'.'J.:l prr i-riii. Ili> lalili- i-^ a« t'.ill.lWM An Ullilll.'ili"li III' rrTlllil'-n in ill.' .■ \ l.rill.l 1111. lift! Ill.illU- (i Sw.lliiiL' ■ I' III' ml..- \Mil] . i.i.iiili ..f ih. t\ iiij.uiiir iin in 14 A. I It.- inll:iTniii:iii..ii ..f th. n nipani.- . .-i\ iiy withiiiu p. rt'i.niti- -n •■!■ ili.- ni.-inl.niii.- I A. ut. iTi;l:iniiijiiti.iii witli |..-rr. .riili.m ..I' I In. I wii|Mni. 111. 111 1. ran' ; '. . 11-1- «, r.- uni l:il. r:il, I! I'iiat.-nil ; H '■:i-.- u.-i-.- i-Mni).lirat.'.i wiih prn"-iili- "I' ili.- inii-l"i.l pr ■--. 1 '-a-- u il!i .-Mit'.-rant '.rraniil. - in ih. . xl.-rnal aiMJil'Tv ni.-Mlil- i !. AL,"_'r:i\ ali"li ..f linnilu- ailliilin an. I .liltj. iilt h.-arin- |ii nt I'.-I'.n- tli.- .li .-hm' '■', l!.''-iirn-n t'un '-i'l "t"rili. a . . ] 'rihnilil- aiir-iiin. v\ M ti"UI "l.j.-.-ti \ '■ tin.iini^s ... 1.' IlK.'a-"- ..I' till' lal'\riMli . •> Niiiliiiii.' .I.'iiiiiii- i- kii.iwn iif aiiv ili'i'|iir alterations 'in the nose than lli.' Iy|ii.-ai .-alarilial atlii-ii.ni aln-ailv iiii'nti.iin-ii. Till- ...-.•iiiT.-n.'.' ..t' .-|ii-Ia\i~ .JiirinL: th.- tii--I -taii.- ..f llii- iji-i-a-c, :inil i'\i-ii li.-liir.- ih.' Iii-.j-iiiiiiiii..- Ill' llir t'r\rr. i- \v..rtli n.iliiii;. CHANGES IN THE RESPIRATORY ORGANS. 'I'll.- \ari.iii- pai-N ..f ihi- ri'-|)iral.irv Ira. I all ]i,irli.ijial(- in tin- in.irl.i.l pr.i.-i'" ..I' I\-[ihii- r.-\i'r. Til.- i-atari-li thai all'.-.Is tlir nn-i' ami na-.ipliaryii.\ -jir.-a.l-- iininli-i-- riipt.-illy III til.- JaryiiN. tra.-li.-a. ami In th.- .-i.:ir~i-r, a- wrll .•i> tin- liiii-r, raniili.-aiinii- nt' tin- lir.m.lii. Tlii- .-atairli ..f I he n-pirat.iry livi.-l, .--p.-.-ialh ill.- Iirnnrliiti-. is to 111- n-^rariliil n.it a> a i-Dinplii'ati.in. hut a.» a pci'iiiiar ni;iiiit'c'st;itioii ut' ' Zcitsc/ir. f. <)hrtnk.^ lid. viii . II. :!, SYMITuMA Tdl.na Y > \-\ Jy|>liiis fiviT. It <:iii piuTilly lif ilix niii.l .liiririL' the vcrv lir-t «la\ - ol tlir (li-ra-c, ic.iclir^ it- (.'f.Mtf-t iiitni-ily mikI uiilc-t di-t liliiitiiMi tlin.ii^lii.llt tllc lito||i|ii:il live (lliliii;: til,. Iici;:hl (it' llic IMui'liiil pnic — , ami lir^rji,. In .,|||„ji|,. with ill,, culf.llicliccliii lit n\' (li lrr\ i-cfll.r. Tracheobronchitis.— I'll.' iiilliiiiiriiaiidriul the ini.'liraaii.l bn.n.lij i> arciiiipariicd t'niiii tlir vcrv lM;:iiiiiiii^r li\ l'rii|iiiiit nm^li, w iih lnu >lii;lit (AiM'ctofatiuii. In Ian. |||,> ,;,\,.^\, \. airniiipaiii.il liv \i<\ >li-lii fX|M\' tlif liiadaclii' tlial it cMca>i(iii-. 1 liavc seen siiirlii tm,,- nf lil I in t),,. M-anty, -lairy <\|.evcrc |.ati.xy-Mi-. <<{' ,niijr|iin;r, ;,||| ^r|, ,|,,| a ti^UT III' anv tiilMTcill(»is \va- |>ic>cnt ivcn then ur lat.i. Tin. iucmii.c <.t' a tni.v (il l>lrostration— rarely earlier or later~aii Ui li.nl -r:iivr|\ :iin -,miv l,ii\n;^i:il ilil^ rl iMh-. 1 1„ ir ihiiiiIh r «,i- .ili-nliih U It rrilv ill:; ni I s7!i. Changes in the Larynx. rii.> Linn-'il r\aiiiiii;iii..ii i-. ti.r iili\iiii|- l.':i-Mii-. \rr\ liillii lilt iiinl imi t ii|'|,ii I., i;iniiil mil. \\ Inn il i- |i.."iMr. Ih.ui \( r, ill.' ran-, ..| ili,' Imar., n, ~- ,.l.-, i\,i| iliiiin- ilir lii-l u..k i- I'l.iitiil 1,1 l„ a -iiii|.l. lalairlial r. .mill i..n. niliir- ami liiai 1 laliMii 111' llir M nliinilar l.iii.l-, uilli ili-,i,|. nvn i,.ii ul tlic \ a ,ra I '"i''l- ^iii'l miiiImiI -\m Hill- ,.r ill, mil, -,,11, imiiilii'aii,' ,,.\rrlii:: ilir ai-M, miiil carlila.', -. S|i._'|ii ,i,,-i..n- air al- ■,-a-i,iiiallv |„ iv, |,i il ,1, . I lli-r iliallL.'!- Il-liall\ ili-a|i|i,al , ■ .III | ,|, I il \ , a m I llii- \iii,,- ijlilin.j- f.iiuali -ciii-,.. wliilc wiaL, i- |i.il,,|l\ liar i.r al in. .-I \,a\ -li^rlilK lii.ar-i . Ill ■•! i-iTIaill miliili, 1' I.r r i-i -, nil llir i.llii 1- liami, lli, iiiilial -\:fjr<. ari- |,.li,i\\, ,| l,\ 111.. IV |>i,.|: I ail, lali.ih- in il . Iar\ ii\. \\ lii,li. ,il hi |- in lliiiii-,l\ ,- ,,r ri'iiii llir ,',.ii-ri|iii 111.- lliii l..l|.,u ill ill,' ri'iiiaiiiiiiL'- liiii- li"ii- '.I' llii' iv-|.iial..r\ trail. nia\ In nf tin- -i'a\i'-l -i.jiiiti,-alir,'. III,-,. III..I',' -,'\iiv I'liaii;:!- liiri.iiii' nianiri-l ijiiiiiiL' tin' liii^^lil i.r tiiwanl till- I ml nf llir I'l'lnil.' |M'ri.„l. ami a|i|irai' In lakr llnir nri.^in in crii-inii- Miiil ti--iiri'> nf till |.i.-iri'ii.r lai-\ iil..i.iI wall. 'I'llr-r ilrl'ri'l- a fi ' illlr ,|il',,'li\ |,i ||ir ,|l'\ ia-j-nlU ,.t' ||i,' allraiU lliari - rail I am! |iarliillv ili-iiitiLri'a|r,| nimi.ii- in, ihIumii, . r.ni-,,! |i\ {]„ ,,. -taut im.iilli-liri'.'itliiii;.' nf tin- |ial;,'iil-, win, .ii ilii- -i.i;;,' li,' jn a -niii- lnll-,i.,ll- ,',lll,|iti,in \\illl lllnlltll will,' n|lill. 'I lll'-r ti--lirr- nrriir | H i llii | la I I \ nil llir |.n-ll'lii.r U.'lll. \\llil'll l'lri'« llil- lull I'inr nt' llir lar\n\. ami i|i'\i|n|i im,, i'\i,'ii-i\ ,' nlci'- tliat ~|ii"ai| II-IImIIv In nil,' -i,l,'. ami. a- tllr llln l-.lt i\ i |iini'i -- l„ ,', .111,.- ,1,', iirr. a I lark llir rarlila'.'-r-- I.r llir |ar\ii\. |i.'iniriilarlv ikr .-irv h in i,|. 'I'li,. miirnn- iiii'iiiliranr rn\ ,'rini.r (In laUrr -will- ami li.nii- a -ii ill. I.|iii-li-r,'il. riiiimli-li tiiim.r ,i.\ ,'iv,l liy a wliili-li rMiilaIr, wliirli in ilir Inrin nl' an nirlllll -prrail- In tlir nrii.r|iliiirii|r |,nrtl,.n. ami tllr clltirr (litnilifr II tj.c laryii\, ami may srrinii-ly rm' iiirrr lii,. ii.iiiinr- lil'r li\ a.-|ili\ xia. 'I'lio jiatirnt liriii;: ii-iiallv in a \i"y Inw mmlil imi. (|iiilr iiiiriin>i'ii.ii-. iiir.i|i;i- lilr nf -(.|f-rniltrn|. ami -n -.vrak tii.il llir Iriiiaillini.' tlirkiT nf lit'rraniint n-i-I ('V|.|i tllr -li._r|itr-t (IrLrrrr <-t' i|\-|iiira, tlii- ilai T i- \i'r\ ^.Tcat, ami it is nt' LTn.it iin[inrt:iiirr tn liiar it ii>ii>l;inllv in iihikI. liciirc. in any M'vrrr ra-c tlir larlii-t a|)|)('arani'r nf ryann-i- nr ;mv ntlirr svinjitniiis nf intcrfrrcnri' with ri-[iiralinn mii-t In- cMrcfiilly ioukiMl tor, and traclic- ntmny lir |ii.rli)riia.il withniil iiniliic dclav. M MriiiMAI<'l.iii, Y i 645 Tn tint :i few .■ii^c- |MTiiliciiiilrit'- IcmiI- u> m .f tl ir (•.irtll.iirc, II. ..I i-M>ii,iilv cwii III i nrn|>li ic -.iLiraliiiii ..f llic cartiLi;.'!' I't-i.tii it- jiiii iil- ln\'-l'll' nllc llial II lie- I I'll' ill till ill ■l|ii|-:ill taki- |>l |iu--ia\ it\ , am till' I'a til; I if, a- I IL'i' liia\ 111' '\|.' Ill \\liin till' |iali(Nt iiiii;.'li-. It ilialh i- aviiiilnl in hkIi la-i'- l.v tiniily iiiti rt'iri'Mci', tlir |ii limt i.r ill', rvi'-iiiH'c i- ii-iiall\ I'Stiaiii'iliiiarily pn .|oii;:..,|. .\- a riili-. tlir l-atii'iit- .'111' viii.il,.-.-. I'm- III.' iiiiiaiiiilir of ijnir liv,-; ami s,,im tiim-- "' ~'~ "I ''i' l:ii-.vii\ iviiiaiii-. uliiili n i|iiii',', a Imi;,' ami tiilidii, .uiirM' iif tiiatniiiil 111- fii'i'i-. ill,' |,atii'iil tn u . ir a .aiiiiiila |M'niiaiii'iitl\ . '" "' 'I''" i-' I ['.■■■'viii.^^,|-,,iiri.'i-.'>ir.ni('.| in tl,, MnaMl laA-intlu in !.><,'.» til. 'n'.Mi'iirri'il^i'vi'ri' iarvii.'cal airii'tii.ns. 'flii, ,l,,i's imt iiii'linl,. a Mill irr.atcr iniinl,,.r ,,f |,alicii|.< win. i|i'v,'|i,|«..| ii,.nrM'm'.-vs ami ••..in|.icl,. a|.l'..iiia lit til.' Ii.'itrlit i.f III.' ilisi'MM'. I. lit in wli tl..' v..ii'c was r.'st..rc.l after tli.'v r.'.'..v.'r.'il. In t .asi's lrai'l..'..t..iiiv L.-iainr ii..'.'.«.sarv i.ii R.c.unt ..f iHri- rlmiiilntis I.f ..n.' of tlii' aryt.'m.i.l lartihiL'i'.-* ami ri'siiltinu cil.'inn of tin- larynx. 1 lir.T ..f tli.'s.. r.'.'..v..r.'i|, l.iit lia.l to w.-ar tin- caniiiila «. |,,n;: .u» lli.'v w.Ti' iniil.'r my nl..-,-rvali..n ; in tli.' fourth .•list-, oiifrutive interference Caiiii' Ion late. reii.'li..ii.iriti.- al.M'e>-es are iim|i.iil.t...lly the illrei't caii-H' i.f many .^POTC i.iilim.iiary ami |.l.'iiriti.' ei.ini.ii.'atioii-, piirtiiiiLirly certain foriiH «>f lulmlar ami ii.l.ar |iiieiiini>iiia cmliii;: in t'liiitrreiie i.V piiijrrenuii.s |)leiiri-y. They arc [.rmiiic,.,] I.y aspirati f -eptic mn'-sfs from the al.scov's, u'lich, a.^ Nvc have .-cii, teiiil I., niptiirf into the interior of the laryii.x after a certain time. I Ml. not iiHvm to siy that all <"i..e> of p,„f,r,.ne of the limgs ami «'iiipyema are refenil.ie to purulent amvtii.n< ..f tli, larynx, for then- is III) (loiiht that piitriil inriammations of the piilmi.iiarv ti.een cured. " Diseases of the I,ung Parenchyma and the Pleura.— AmotifT the most frequent pt.lniotmry diseases in tvplms fever in addition to the atelectasi.s and hyi,.,8tatic conire.stion that have .-dn'mlv. ^1 iCJ ■,>, ,-1 .f/ [)Ui TYri/rs I i:\i:i:. I..VM ril'.nvd to, is :i i;,n„ ofliln-iiious |>n(imi...iiu tliat rnnnot hv di.-tin- KNi-lici; iiiicn.M,,|.i..;ilIy \\;nu tlir oniiiwuy (uniis. N,. l>M<'tiriulni:i,< (■XMiiiinaliMn |ia- s.i t'ar Ixcri niadi . It cas.., raivlv ,.aili,i-, and, a- tlic iMticiii-. ..t tlii- lime arc u-iially in a Mu|.on,iis ,ir .•oinatosc coiidi- " ''"'I''' ='!■'■ 1'" 'narkril -mm|,i, .nir-. ( )r,"i>i..Mall_v , an iiirrcar-c in tlir n-|,iralun yaw „v a rin' of tnnjK.ralniv |M,inl> to its o.vnrmirc. KuMv s|mtinn ..r. In fart, cxp,,!,, ration ,,f any kind, is ,,ffn al)s.nt. Only tiv,,ncnt an.l ravfnl cNaniiuations ,,f the patient will tJRMvforo insure the d.t.rtion ..f this r pli, lii,,,,. J ,.,ni inclined to doul.t that the marl. led and aliuo-t whitidi appearance .,f tli.^ inliltrat.d iK.rtioiis of tlie hnifT, pciiued ont l.y Saloni ire dne to any pe.nliar patholo^dc alteration. Th.y are more uatni-ally ex|>lained hy tiie general anemia tliat is usually pre-iiit. Fil.riiious piieuiiionia in typliiis ti'v.T varies, as re-ards tlic frcMuencv of Its ...riirrcnre. ac.-ordini: In lime and place. < In the wlu.le, il appears to l;e dislmetly more t'rccpient than in Ivplioid t'ever, and rnn.s a (leci.le.ilv more severe course. lu I.s7;i uc had to report lihriuous pucmuonia as lli'e immediate .■ausent .leatii m 1 1 cms, s. or l,". per.vnt. of all fatal ea.ses ; hut :{ cases in whii'h this iliaL'Uosis was niaile ended in n verv. Inllamniation of the pleura i- al-o diMim^tly more fre<|uent than in typhoid fever. It is apt ... |ol|,,w loluilar and iol.ar pneunionii. and especially pnruleni pneumonia and lea.i- to purulent and putrid etfii- sioiis, >,, iliat operation- for emp\,i,ia .-iri' indie often reipiired. The pleuritic aU'ec'tioiis, like pneumonia, are (piite likely to he ,,ver- look.d. Tlu- pati.rfs ,,ften do not ••omplain of pain in the nde, and plcuriti.' friction 1~ fivpicnilv al.-cnt, partiv, no doid.t, on acc,,iuii of ''"' l»'<'iili:ii- -"ft ' dslcn,,. ,,f ih,. lil.rinoii> exudate, aixl j.artly also on aec(.iint of the linulid re-piratory movements. •^' '' •'" ^I'lihor^ atrree in mentioninjr piduK.n.ary tid)crculosis or jrt'iicral miliiirv tuli-rculod- a- ; ccasional pliiMtii.n of tvphus fever. It ma\ make it- appearance during the height ,,f the disease, ,,r even diu-iii;: the lat.r -lau'fs of c.,iival,. an al.son.r ..f pain in th.. n-inn of tiir Mnall int.-.in.., and any n.^tcwortliy (lofrroo .,f tympanites IS rarely <,l,~,rve,l. I i„.|iev,- lliat it ...■eiimd in only 1 per rent, ofniv cM-es. I'ain, |.Mali/e int.s- tinal eanai, thi're is a eorresp,,n.linjr al.s,..,<-e of rejrularity or anvtiiinjr espeeia'-y eharaeteristie in the fre r,.semi,l,. th,. ,.hara,tcri^tic ,H.a-sonp stools „f typlioi.l f,.v,.r, r,.t.K,ls mav he vell..wisi,- whi... m lor, iMit th,.y .-ire n..v,.r wat,.ry an.l fr,,. from'nm,..is tli,w is >"• «''id,.n..y to M.paraf. in !ay..rs, an.l the .-oars,. .ninnlar s,Hlin...nt and sharp a.mnonia.-al ..d..r ..haraeteristie ..f typl.oi.l fever ar.. alto-.tluT wantinjr. "" As h...norrhajr..s into the ^r-a^tric an.l inf-tinal mucous moml.nme have ....cas.onally I,,...,, ol,...rv...l at th.. aut..psi..s .,f verv sevro ,-,.,sos tli..re IS, .,1 ..„„rs,., a p„<~ilHli,y „f |,I,„„i ap,H.ari>.jr in the st.H.l (P.an.I- l.er. rw,...h.., |.-r.,.i..hs Mii.l ,„h,.rs). S,„-h cas,.s tnust, howovor he very ,.x..,.pt,onal.an.l th,. r..port< shonl.I he r..c..iv„l with j:r,.at ..aution 1I..1V I. always a pos.ii.ility ,hat th.. 1.1,h„1 is -implv a .-oi .^omit.ant symptom ol a h.inorrha^n,. .|iath..sis, „r a n.cre lo.vd homorrha-ro fro„, th.. nvtum, or hom.u-rhoi.ls. ,.„•. The stat..m..nts of some of the oI.I.t aniliors m n.jranl to the fr..,,„ent ,H-.urreM,.e of int,.stinal hemorrhape I'rohahiy ,|,.p,.„d ,„, an .rror of ,lia;:no-i< l.etw,.,.n tvphus an.l tvphoid (ever, .m,..., as w.. know, the tw . -li-.-as.., w..r.. n..t infro,,uc.Ulv con- l^Tltw.'ll illiMnit,>s llio iumcs- sitv (it L'rc:il cMr.' in JMdL'iir.' I lux- lu'rimrrfiMLTs. A vniiii- Mian. MV.Tiil ,,fw|„,sr iviaiivcs Iki.I ln-fii n-catfd in tlic hi/.a- rcll.i tur lypliiis tVv.T. an,l \, lio was u.lmill.'il »itli tvpical ^vM,|,t,,^l> cC a M-vfi-e attai'k of tlif ilisrasc, l.,i,l a innlusf lifiiiin-rlia-.' on il; . niml, ,|..,v nt Ins illness that fvid.'ntjy canic IVoim sdini' cf lie In-li.r |«>rtii'ns ,,f t),"^ mtrsiin,., At Ihr autopsy, ihr source of llu- lu.n,onl,a-e «as louiui in a duodenal ulcer tliat was evidently of Ion- staii.lin- 'I'liere i- little of iinportaiiec to say re |.atient l)e( les iM.,re and ni,>r. ajutheti.' and hi- mental c..nilition nion' .loiKJed. the tonirno l.ecomes leathery, dry. treniiiloiis, c,,ven-.l with crusts anil niarknl l,y ilxurcs. or smooth an.l iriazed (( )l.erm( ier). The ;:„„,. and li|)> are also .Irv and ••overed with sor,|,s. This dryness cannot l.e av.,ided altofretlier even with the lie-t care during thi> heitrlit ease. .More nirely there i- a -.crhuti.' -otteniuL' of the ^rum< and other portions of tht oral mucous memhraue. with a tendency to heniorrhajres. The soft palate and the ton>il> are at first of a deep-ree<'n ;! ea.es of this kind; li <,f them endifi faUdly, and the third reeoveri'd after a nnieli jirotracted convalescjnoe. CHANGES IN THE riENITO-URINARY ORGANS. The changes in tiic kidneys and their seereti..-,i, so far as i.s known,' is j)nietically tli(> >anie a> in other acute inlW-tious di-eases, fs-.ecialiv in .severe eases oi' the a■ — is hl^di in siKH-ilic trnivity, and stronirly j,(id, with an ahundant sedimen' of u-ie acid and urates. .\s the fever sul)-idc<, and diH'iiiL' the pecicHJ of conv.dcseenee, the urine is liirhter in color, clear, aTiiJ sometimes verv ahundant. (;ric"ini.'cr, who al-o ,|U(ites .Icnrier and Finj.cr us authorities, re|M'ateti.'ii has been dnno l._v Prihruni and Itdii- silick. \Vy<>. ll.-.ii-t'iii. iukI I,:nic ■r.'UU. ^:,-?SMMi^VgII' sYMi'rnMATni.<)ay. 549 of larp. .luamiti.- nf ,.|,,,r, pair iiri,,,.. I ,„y>.lf hav oLmtv,! ihi, >rv..nl till,,- (-iMciallv a >lM.n tiaic hvi\,rr the l.c-inniiii: „f drfrm^- |.lMii.,ii„n,,ii, wl.icli 1 Imvf never ol.MTVed in tv|,h,M,l liver, is ililMeiilt ti, explain. Durin- ti... hci-iit ,,r the ,li-ea.-e tlic excretion „t' nre,, I. often not iiMTea-e.i, sonietinie> it i, ,ven diniinislie,! ( Koseii.-tein, Lan.cn. IX); wlnl<> tlie ex •'■ 'liMi, fi I 11.:, to l'4 -in. of urea ii, tNventv-four hours Uoseii!.teii. touiMl mat tlie .eerelion ,,f „rea «a.s at iir.-t Voiisideral.lv lM'Tea.-lIl(.,|. The cl.ioiids re^r„|:,rly nn.ler-o n.arke.! .liniinntioii, aial .sotnetiines reach a inininiinn di.rin- the fel.iiie p,..-i,Hl. From the iK-innin^r ,{• ,|„, sfVH.nd w.ck it is often iii.|H.ssil)le to demonstrate tlieni. As we shouM expect from tlie fre,p„.„ev of cioiniv sw.ilin.r j,, d,,. kidney .hiring- tin- liei>,dit of the disease, as shown l.v m.moroi.s autop- sies, there is nsuaily a tnodenite fel.ril,. alhi.n.innria in the febrile M-,.re ." severe and mo,leratcly .severe ,.,ses. Tli,. ail.ntninnria , asionallv •imkes Its ap,K.a.-ance .., early as the iiii.ldje of tiie first wek, tnore fiv- qucntly toward the ,.nd of the tir-t or l„.;:i„„injr of ,he .s„eoiid week and .iisapp«,rs with d..t;.rvescene,, or occ:,Mo„allv a (Vw ,lavs I.ef.n' that perio,!. M,eros,.opic examination uf ,,„ ,„.i,„, j,, .„H, ea-Vs si.„ws "' ";':';""" '" '•'">~'^' '■ -^>i'"<->-. only a i;.w epithelial elements tn.iii th.' kKliiey an.! pelvis, and hyaline .asts in moderate mu, ;•... Neveivr ...ad.s of albuminuria, la^liiiir into the [HTio.! of ,.onva- Icseetice an.l acconipaiii..! l.y |,|„,„Iy ,„.i„„ „„, ,„„„,„.„. ,,,ial ..pithelial '•-lis and ..pithelial easts ii, addition „. hvalii a-t~. indicate paivnehv- "•atou- nephnti-. .a cmiplication of imfavomMe prouniustio signiti-Miico "'^" '"'•'"-'-..■!> i. rare. in a ti w. I„i, l,v no mens all, eases i, ends '="''">■ ""'' ^>"'l" - "'• i""nia. i-lve ,,i . i . w hi,.|| we cuiild denio,,- strat,. paivnchyiiiaton. nephri,;, at the ant-.psy had heen dinicallv oiiif. tree Irom nniiiic -yniptoms. I'l .v.umj: in.lividnals. e~peei,|K i„ ,.|,il,|p,„, ,!|„„„i„„Ha with al.iin- ''"'•' ^"'""^'''n-d'l.l 1 in the urine has l.,vn olisorv..! on the f.iirth ..r hlth day ol' the disea-e ^Vei.s.), even hetore the ap,vara.u-e of the ■i-'* ij.jo TVI'lirs //•I/./;. •!.•« .(kX: '"'!" ■ ' '"; '"-"^""^'^ "■ -"■'' •— - " I'i-I'. :.s a rnKs .,v ,,li..„..,, '""'7"""""- ' "■••'- '-l-i.-i,„ila,- lai.M,, ,■„,„„„. „.|„1,, " •!"■ I'a...,,!. Mu-viv,. ,|„. M.phriti-. .Iirv. a.a ml, uvAr ■, ..,„„' I'l"..'nr„v..ryan,.ravarial,l,. p..,-,,,,! „f , : .v..„v,.n i, ,.n,|„„l.,..,llv ';"';• , "':"■"■ ":"l'"": "'^"' ' I''"-i'- ^' -,,a„vi„.-a.,,ina -ia,,,!,., litli(ria, and mmiIci (rv,,-. ' It is worth Motin;: ,ha, .„„.. ,v,...,„ „l,..pv,.,.s, \-i,.,„,,i, an,,,,,.^ ,1,..,,, '"7 :''"^""-'=' l"-'iv,. ,lia/„-,va,.,i„„ wi,h a iUW .l,.^,-,,. „r n^MlaHtJ .n t M..r ..,alw.. ,,r,v,.lH.. nrin..>, .luHN.. a p.in, ,,r,inmari,v U.,;....;, '•'"r '';;'"' • ''"^■^'■-""1— •'"-■<■. 1,.. a..,,,.... ai„l„.,na,a. ' '"• "<-"nvn.v of M.,.ar in ,],. urine. ol....rv..| in ..v.ral ,... l.^ Lu-hanan, l.a.s „,„. .„ ,:,r ,. j ,^,„„^ ,.,^„ ,,,.^,^^^^, ,_^ ■ autliiinty. Bladder disturbances -f any ..vrity ar. „.„ ,.r fr.,.,n,.nt „....nr- r.ru...: an,!, al. h.,n.|, wc n.,H.at,..iIy f„nn.l l,..n,.,rrl,a...s i„,., ,1„. nM„..,„. nxmlM-an,. at n,.. an,„,..y. tl. o..,.,liti„n ha.l „,„ ,...,.,„.,„, ,„,.,.. tonis (Inrinfr lite. • ■ I l{.t..ntion ofnrin,. i> v-ry nnv i„ ,n,.n. Imt ,,ni,.. ,,,„u„.,n in «„„„., -1..VIM ly .Innn.^ tl. .la.ril,. Ma,... Wi,il,. „,. |,,.„, ,„ „, „,„ ,.,„„.„; '•" '"al.s u, only 2 in.tan.v. in tl,:- ..,.i.l..n,i,. „r IsTf., . ,|ailv or at -•a^t an oo,.as,.,nal. n.M.rt t., the eathet.r wa. n.ve.-arv in aln.o.t all the female cases. I., rejranl to ehan,... in th,- p.„it.l ..rjn.ns in tv ,,h„. fever, nnr Kni)ule..,„.. time Pregnant women do ,„„ :,,,|H.ar -„ |,;,v,. .„y -juvial ,„v.li>|K,- MtiuM to, i.ur ,!.«-. |.r.-iianc.v uHonl any |.n.t.rti..M a-ai.i>t, the diMa^o. I'll., rli;,! uf the iiiala.ly on |.r.-i.ancy lias l.,vn uv.Tf.-liinatf.l l.y many author-. Ty|.l„i-, lik,. ,y,,|,oi,]. r.v.r is not i.v anv niran- >o -laii-i'ion. to a |.r.Mrnant uo.nau as i> Nari,.la. A hxyr ikt.v.iUijt,., if not hair. ..r all pn-iiant wonini havi' the .lisra-c without : iitrn'i.ig ahortio 1 or pn-niatiin- l.ii.or. This i- trnr |.artirnlarly i:i cum s in whirh tlu> (lis,.;,M. nialvos its appoaranc,. .Inrinir th,. later niontiis ,,f pregnancv, l.nt even -Inrin- the earlier months ahortion i, i.y no ,nean> a amsUnt oc.(.nrr(.n(.i'. The Knirlish physi.-ians, wlio have pn.hal.Iy enjov,.! the {greatest .■xpcricnee ni this resp,vt. l„.lieve that lyphu, fev.r ha-" a slijrhter ettk.t "" ''" "■-'■ "*■ Pre-naney ti,at. has any other a.iite inlivtioiis disei.se. Waniell -tales that he has never sein an interrnption of pregnancy -Inrinir the conr-e of typinis ■'ever, alll.on^rh it rn.ist I.e admitted that Ins -tatenu.nt wonl.l ,arry gre.ter wei;rht if it were ha.sed ,m a laixaT niiml>cr of cases. Kveii when pregnancy is interriipt.KJ l,y tiie di-.ase, the accident is not alwt.ys fi.lK.w,,! l,y gniv.. con>(^,,„.nees. The gn.atest daii-rer to tl«.' patient is that of severe hemorrhage. .Vftcr stn.ivinir a nnmhcr of these eases one gets the impression, howvcr, that the metrorrhagia is not a resnlt of tlu . njsion of the fetus, l,„t ...ther that the hemorrhage occurs heaiiLso the (list>ase luis assiim..! u " lien.orrhagi,. ..han.cter." VARIATIONS IN THE COURSE AND MANIFESTATIONS OF THE DISEASE. The e.ul of the f,.l,ril.. p,.rio,l in almost evcrv ca.se marks th. end of the (li-ease. RELAPSES AND RECURRENCES. Kolapses and nvi,rren..es, so ..ommon in tvphold, are of the .rpeatost ranty m typhi..,. a..oth,.r among the many points of rcseml.lance he.ween this d.-,.aseand the acute exaMthemat,.|. Althond. some anth.irs, among >'■'■". Man.lliev. ..lain, ,„ |„,„ „|.„,,,„, ,.„,^_|„,^.^ frc<,nentlv. th..v have ail.Hl to pnHJu..,. any po-i,ive proof for tluMr statements, for it i's al.s.^ Intely nccs-ary to ex,.|ii.h. with certainty other complin.tions or s,.,,n,.Is :-s caus..s ot the ntiew,.! fc^■cr, .-ind to -how that the ri-,. in t..m|H.rat wa- immediately foII.,w(,l l.y a s.vomi apparanee of the chara.-teri r.isli. lire -tic ■X' -I 552 Twin's ii:\i:/;. Munl,i>„„ l,i,„M.|rM..v..r .-:,u .„ „u,|„„l,I,-,| rase of n.lnpM. „r r..,.urrtMK.e "•'i ^au 1 ,M>c. Mi|(i (.\,.|| i'.u.'li.-iiriii >,.,. Miircl,iM)i ri'CCIItly, 'rildilMil. (.; ;;'"l''""Min.| ,nnr,. ,|.J,, lrM>,.„r„M,in„l.,..,l,vlM|.>,„,',vronlMn,n„::^.HM, ...-.> M, tl,.. K,.„1,.M I'c-^w Ho>,mal. 1 .nvs.-ir Uny. 1' ol,s..rv,ui.,„. ,„ r.i/;/.i7/o.v.s /.v ri,ri:sE am, ,i/.i.%//7;.sy i v/ow of i>i.si-:.\sk :,:,:>, rrprrl thai. I l„lu-v.-. aiv um,!,,,,!,!.-! ca.-r- ,,f rrlMp-.., l„il I uill also a.M IliMl 1 l„.|i,v.- lUr raso i„ I... aiminalnus. win, I, i> |,r,,vi.| l,y llu^ la,| i1,mI i5 .; l.otl, ,.f tluMu n,.,.unv.l i„ l.sT.s ,„„„„.. a v.tv .„,all niunluT of patients, «h,l. n, l.s,!l „,. taile.1 iooU^-rve ai.vtl '-g in the km resen.hling a nh.i^e or ji iiHurreiice. ij.'f:;- ■>!'-A^y\ 554 7177/r.s I i:\i:n. I..' TM ....SO «Ms tl,Ml ,.| a laLnnT, iwrntv ..six yoar. „r npo. wh.,. al'LT a .•V... , „„•,„„, u-a.,.,l ,a.-.. „r ,v,,l,u.. H.v.T ..tm „■„,- l,v Iv.s.s. ..,„..r,. ' ,": •;"-''-•'•"<• IM-Mv..,,,....,..!, .hu. Mur,\u; ,,.;ri.„l lu- « ' > ■-• tn..n t..vcr. I„> h.>n|H.ra-.ir.. I,..,,,- „H,aiU .m,I r,„al, KLvn. .lav .■l,a,laM,,,l,,.r..|,,la,,,hl,..,,.,,,,,..,-aM.n.n., ra|,i,ll . . -Tl,.. .,,i.,.,„, « 1m,I, i ." Il|' >l„r,l ,lay ,„,!,. .I,.s,.a... ,1,,^, «a.- a ,li.M„„,. ,|,„mi:I, nan v 7 . M>. .M.|,„i,M,^ tl... ,l,„>al >ur.a,.> of,!... 1.,,. ,|,, ^.J-m,.,,. laNT in t |l.r,,.,n, a ,.,... n a 1 ,..,.,; a„..„. < „, ,1,.. .i.U „... ....^^al, i.M^.r . allh.M.I, ,,n, ,ar„.,l. „,,, ,„„ „.„|„ i„„.rr,M„,,|. ",:';:;'; •"■'•"", '•77" ""■ '■";' '"""■ •"•'""'^•^- ""-^ ■""' ""• '- 'i''■'-^' II nciirri'ii "I .itt.Klv ..1 tv|,,„s „,ark,..l i,v .xtninelv hijrh t..n:|.fralur,.. llu tev.-r H.|l ...tarrlMl .,.1, ,,„„ „1 ,1,.. lannx .,.. ur<^ixun- .lis.a.vo ,.f nnv , s,.,m,,„.,. |,a.l i: : ::i:" • ='""'■"■■ ; -7- ':'- *'-"-i i- ••- un,,... -i.un,,,' li,: ,i, ■ '• --'''I -•■ .!..■ th„ , ,lay nm.r ,|,e ...l.i.l..,,... of fev.r U.e •""", ^"' " ''''11 =""' ''"■ I.'Mi|..Talur,:af:aiM l,..,-aM tn'ri,.,.. rearlmi.r ;i!.o(. .... .... ..vemnf: ot ,l,a, ,lav Tl,.- t..n,,K.,atu.-.. ....„,i„„..,l ....lerau.lv l.i.h -r tl,. ,„,,.„ ,lav.. a„.l .1,..,, .^nulually l....a„ „. fall l.v .li.Min,.t Iv.k the lyn, „t ,k.f..rv....,.,.n..,. 1,..,,,.^ ■■n,„,,l..,...l l,y ,l,e „i,„l, .fav. ()„ ,|,, v..,v VARlATIOr ' EN THE COURSE. Tho ro„r.o of ,vplH>s f;.v,.r is siily.-.t to v.ry wi.l,. variations, wl,irh nt ,l.f!,.rrMt t,n„.s a..,i on tl,o st-vnfrth of ol.s.Tvations ol.taii.r.l i„ .litfer- Hit ..|ml(.mi<.~ luvo vvvvWv,\ a -ivat va.-i..tv of ,iiU;.re„t nan.c^ Older Nomenclature.-TJM.s. it was f ,r,m.rlv tl». ,.,isio,„ ,o a,.ply v,..-.o„s nanirs to ihr ,|i„.:,s.., ,i..,„.„.linnr o„ tl.,. [.rnminrn,.,. of sv,„,,to,m n.fcniM.. I,, .Iclinit.. i:.-ni.|.~ of ,,|.j,r:,,js or to sin;:!,, oi-friins. 'I'l.c trnn fill,!,,,.. ,irrr„..„>, or ti/plnis a>a.n,;,.y was appli,.,! lo ..ascs w.il, ...iiiMially s,.v..r,. ,„.,vo„. .nanifo-talions, mi,.1, a« .l.ii.-Jun., roma, siili-iihns tcndiimni, and (.arplioloirv. WUru io-s of -tn.ML'tl, witn .....nliar weak.,...- a.„l ;, t,.nd,.M..v to '•'.11^.|.-.. .......1;- its appranii,..,. ,.arly. ||„. ras,. was ..ali..,I /,//./,„.. „i„j-o. 'nl,nunn,r„s: r„i,hu. .hiscnirnr,,. was .iia-no,ni wl,..„ dia.TJaa -r trn.. isi:.>s/:. r,:,-, Kri;:li-li an.l |,,-li |.l,y.i,.iMii> iKiriimlMrly wrrc likrlv i,, .,„,,k of /:)/./>Hs r„t,n;l,nlis ulirn the timc.ijs rncml.n.iu- of tlir air-|,;,-si;:..s «irlv l).-,.:inu. it.v..lv...| aii.l |.r,-..nt..| ih,. ,„,,st .•.„„pi,.,i.,u-. -vr..|.tom,. Tli.„. iuiii.....t.. vvhi.li a lar;:.. nnn.lur that an..,. i„ a -iniilar maniicr niiulit Im. adcl.Ml, havr littl.' tiiHrc than a lii-t,.ri<. int.n.^t at il... ,,n-.,.„i .lay. Tlir :ip|».araiitilial.l,. n..r usolnl to .lignilV in.li- vidua! forms liy -|w(ia! naino. **" •' "'•■•■ •':"'<•' i' i- "l" 'Mii.'li [.ni.ti.'al litiiitv, not to say of =''''"'""■ ' ''^^''S f'>r:ipr.,|HT nn.lrr.tan.linjr of thr .liM-a.-o t.. lorn, a cavi-M ,.>tin.ato of tlu- .liff.r.Mi.v- in severity an.l .luration, an.l .i~v a nomenclature l)a>c«l on fh,..,. ,|i(riT.'nccs. We will tirst .•onsi.l.r in this ronn.rtion .-ases of mil.l .l..>rr(v, csises ..f >h..rt .luration, an.l ahortiv.. <.a>.s, whi.l, in typhus fever, as in all aente infectious .liseuses, phiy a very ini|K)rtant /•.;/,■. Th.> manifestations an.l the e.Mirse of these forms are Mil.j.vt to reniarkahle variati.ms, an.l the conditions on whi.^h th.^v ,|c|M.n.l are even yt pnieti,.aily unknown. The fr<-.,uenev of their o<<'nrr..n..e vari.-s with the time an.l variety of the ..pide.ni.., an.l also mav varv during .htlen.nt [xTiods of the sam,- ..pLJ-mio. .\.s the epi.lemie spen.l. its fon^e, a r..markal.le inerea.-e in the nun.her ,,f milder ease,s is often ohserved. I think we are justiti...l, in studying the reasons f.r this phenomenon t.. a.ssume a gnulnal ,leer,.ase in th.. str,.ntrth ..f the morl.ifie a.'.>nt as the ..p,d.>n..e progresses: .,r it n>ay he asstun.Kl that afW niost^of the in.l.vi.luals spcially pr<..li>,H,s,Ml to th.. ,lis«ise have I.een attack.Hl those who are less .lispoM.I f. it also b.-eome affe.-ted. We ..annot hot.^ to gam a true nn.lerstan.ling of these e..n.liti,.ns until we U,,rn nion. of the nature ..f the typhus fever poison, an.l until su.'h genend .pustions a.s pnMlisposition an.l immimity hav.^ I.eeu furth.T .du.'i.late.!. If we examine ...ascs .,f short .lunition an.l .-ases of mil.l .le.rree mor.. «.refully, we fin.l tlmt a short atta.'k is l.v no -ueans n.vessaHlv ehara..t..n.e,l l.y a mil.l course. A ,-ase may he „,il,| from h,.,d.u,in.r to eu.l, without heing at all short in .luration; an.l, ..onv..rs,.|v. .,ls,^s^.f short, or ..v..n very .hort, .luration not infn>.|uentlv pres.-nt a ..ruv Hmi.'al picture, not .mly .luring th,. a.^tiv,. course of the .liseasc^ j.ut even until the heginning of deferveseen.'e. Cases of Mild Degree, Well-marked Cases, and Cases of Short Duration.-As cmpan.l with the fre """-"^'1 .•,„„, ,|„,„i ,. ,,..n„aM,nt iiiiurv to ll„. 1„..,1,|, ,,f tl'" in.hv,.l,ul, >„M.-iinu.~. at I,..m, run tl„ir .■,„„•-.■ „i,|, |,i.|, r.-vr a,„l 1 "I r, -|„,,|i|irij,r|\ -r\(.n' i|i-- liiiliaricc- ,,(' tlic :r. ii.nil '■"'i'lili"ii. In an\ ([li- • liriiir, li..u(\ir. ca-i- will l>f ii|,-,.r\c<| in wliicli ill,. 5 ili-ta>c ruii~ it> iniir^r in I llif M-nal tiiiir -('nun Cnp- I III n til MMfiiciri ila\-. of * rviii loDi^vr — witliont once - in:init;-iinir :in nniiMially ; lii;.'li icinpt nitnri'. '^ I llt'^r niiiil ia~i -i irciHT- 5 ,illy ilo not l)ri.rin w itli a V ili-iimt cliill. AftiT a : |iiiio,| duiiiii.' wliiili tlic r p.-itiinl niniphiins of diiHv y liiliiijrs, the liin|)(Tatiii-(" ~' ii-<- (.'railnallv, liv mh'ccs- l -ivc .-.ti|.-, Ml tliat it may S Hot rcaih its iiliimato Uvljn liclorr the I'onnli " - ilay of the ili-ca-c. Ac- loriliiijrly, tlif initial -yinp- toiil lirailarlli', liarKarlic, J voniitini:, I'll'. — arc al-o li-» -I'NiiT, anil in nianv [latiriit- till' ininil fcinain-; i-li-.ir fviu ill till' cMiiini,' ami ilniiii;: the immIii. '|'|„. -nli-ri|ni'nt (■oiir-c ,,t' tlic (c\iT i- ot'i .u.iMi i..>i I nn.w ,,■ // in/. <>(■ llii- MimI, irid thai llic ni-li :il- III a iiiiiiiIm r uf tin II-" I-. a- a rule, li— \\,|| nniUcd. M' ca.-o e as Icpii^r as twentv-two da lys, III wliieli syinjpt(>iii> ol iu'iiuirriiaf^io ncphri.is wen' at first pletoly aftor the end of def very conspieMoiis, and vanislie:! enm- ervoseence. In the case in which the (ever r:*' r-\ •AA.' "1^1 '♦V Vv .■'-r. AiilA MICROCOPY RtSOtUTION TEST CHART ANSI und ISO TEST CHART No 2 1.0 l.i li. IIM 1:3 2 1.25 il.4 m 112.2 [ 2.0 1.8 1.6 ^ .APPLIED IIVMGE Inc ''6) *e2 - 0500 - Phon« tm ryriiis j-j:\j:j;. hi-tol t\V(iiI_v-t\V(i days the ni.-li was so scaiitv and hi-tod mi sIkhI a tiiric that the diaj.'iii»is iiii;,dit lia\f rtiiiaiiu'd doiihti'iil if the cxatiiiiiation had hfcii at all >ii|)crlicial. \\ I' ciiiiic iiixt lc> till' ca.-cs cliaractcri/cd liv short duratinii and a mill! cciiir.-c. The iiiuiliid iihi'iiDMK'iia iti many of thoc casi's arc even iiiildcr than in the lurcj^dinj; jrriiu|). The s|)!cnic cidari^cnicnt and liio cinptiiin art' mily very sparinirly d(V('|i)|)( i], and the di>('a.-(' ends witliin ii'iiin live to ciirht days, 'i'his variety is illustrated in Kijx. 'i"» (coniparc also Fig. (Wi). 'I'liese are the eases in whieli tlio eharaeteri>tie eliiii«d pietnre is often so disf;ui.-einL''cr ami other authors who maintain tiiat tlie rash, or at lea.~t tlie cliaraetciisiic rose()|ou> eruption, is constantly alisent in tlicse ea»es, which, hv the older antiiors, were nsnally desii^Miated t'chrictda. 1 have seen patidits ot' this kind cxliihit a well- inarkeii and clianic- teii>tic eruption wliieii lastitl even lonp'r than the f'ciirile period when tiie latter was very siiort. Abortive Cases. — It will lie well, t'or iiraciieal rca.-ons, to make a di-tinction iictween the ca>es of '• /'. /t de-erihed and tllo^e in which, after a severe onset and clinical course, defervoeciicc make- it> appeai-ance une.\pect(Klly early. The term " abortive tvpliu- " may with pro|iriety he ajiplicd to such cases. In the cases n' tin- clas< it lia|>pens more fr<'(|Uently than in those of " fehri exantliematica Icvis.-inia," althonjrh l)y no means con-tantly, that the liij^licst temperature — after a violent initial chill — is reached within from twenty-four to thirty-six hours or even earlier. After this time the fenipci-atnre usually ])ersists for -evci-al days at ii- inaNimum, ill the tlirm of a continiii'd fever or continued remittent fever-, less t're- (|iientlv it i- (piitc irretriilar. The teniperature. which may lie extremely hitrli. then falls liy ilistinct <'ri-i- { Fiir- 'i*i) la-ting lint a few lionis, and remains normal. The condition of the patient in tlicome case- I have .-ecu a marked enlargement; in otlicr> the organ was not swullen at all. VMUATioys IS (jornsi: jm> MAMi-i.yrATioy.s uf disease. .■f.")'.! Till' ruse-spots ill ahortivi' i'urms are, as •■ rule, few in minilxT and ia>t Imt a slioi-t tini.', altli(.ujr|i sonictinu's a nnnilxr of lluiii unilcii;^ pft.vliial tiMii.t;,niiati(jn nr |KUc!ua' may (lovc!(.|) ind.'i.cn.lcntU ammii: the rose-pots. Tlie ern])tion of larjje inaeiiles tliat has Ween rel'.rrt>.l to ai)|.tar~ to he more eoinmon in abortive eases than in \\ell-Miarive tlieiah- dnrinperominent fwiture of tlie disease. Ill a few ea-es I observed an nnusiialiy .-low pulse uf go.^l volume Fl'.. fi".— TnilMr, ai;ia mncluiii. Almrtive Ciurse Uiw piilso cvi'li iliirint' tlu' IVIirili' inTicd. and tension, sometimes not exeeeis vnuUl lie mad.' will, (vrlaiiily, or at !.aM uitli a fair .L -nv of prohalMlil.v, (-p.ciallv if tiny wcr.' iiiiilcr ol.-i rvaiion ti.r a Mitliciciitly \i>u<: tiiiw. In ..vcrv cpidcniif, liuw. \ (.r, .-in.ially wluii it is at it< lui^rlit and t >\vard till' end. caM'- <.(vur that cannot he diaiinosed witli <'iTt;dnty and in whi.'li til." interpretation will he jrreatly dependent on the ]H)int of view of the ohserver. In these eas..s tlu' fvvvr lasts hut a short time an MAMriisiATioss of disfasi-: :,(J1 tlif clianu'UTistic r:i>li, altlimiirh, at tlir r-aiiic titiic, otIuT «li.-taM.- can Ik.- jxi^itivclv fxchidid, anil tlic lii-t<>r_v ^l|M^v- that tlic individual- liavr liad close rclaticins willi ly|iliiis I'cvtr patient-. Some (if tiie-e ea>e> nii^'lit with ji'Tleet justice he ealleil •'Ji'hrix cxdii- thcmnticd siiir iSdiilhcmnti ," in imitation uf ana!o;_'nus eatie- that (H'ciir in variola and scarli't ll'ver. This form is inentioneo-ed to the intlueuce- of the typhu- liver poi-oii .levelop a condition of ijeneral depre— ion, los- of a|i|ietite, in-omnia, pain in thi' liiad and limlis, iin;;iii^r in the ears, hleedinj: at the no-e, and irrey;ular fehrile di-tnrhaiK'e- lastinj,' for days or even weeU-. without ever exhihiting anv pronoimce jxtlt)' tlaxf" a term that sutlii'iently descrihes his interpretation. Ambulatory Cases. — In this connection the i|uestioii comes up whether walking eases occur in ty|)hns, as in ty])hiiid, fever. Some of mv own observations, 1 believe, point to the oeeurrence of siieh eases, if not with certaint\, at least witii a fair dc^rre<' of probability, and anioiijr other authors I may (|note Becher and Passaner,' in whose writin^r^ similar statements may be fotnid. The IVe([Uency of mild and very mild ea-es ;dso appears to vary with the peripear to be more frequently attacked by this fmn of the disease than do adults ((Uriessinjror, Wyss), and that the milder forms olh'n become more |>revalent amonj; adiilt'^ toward the end of the epidemic, ])artieuiarly amonjr individuals who, owinix to favorable -urroundijij.rs and {food |ihysical condition, may be as-mncd to |Missess a ;rreater resistance to the poi-oii. It is liiffieult at tills time to irive any fijrurcs in rofiard to the froqiieiiey of cases of short liortcsl casi;;, tor till' fini|ili' rca.»on liial tiny ran-ly i-ntt-r llie hos|iital. anil arc mmh practicallv oulv in privalt praiiii'i-. it i- ralliur inlircstinL' tlial .Miirdiison. who lia.- L'ivi-n .-o lari fill a ilrM-npiion nt' \W ili^'a.-r. rail> to say aiiyihin^' alidut tills ola.-s of casfs. iii- statistics in rcL'anl to the dnralion of tiie (liseiise lio not include any ca>c> of |cs< than one week'.- iluiation. Ainoni; .■).■; patients, lie liad o in whom the di.-case ein'ed on the elLrhlii or ninth day. RELATIONS TO. AND COEXISTENCE WITH, OTHER DISEASES. Acute Exanthemata. — 'i'lie iim-t interc-tin^' i-claiioti i- tliat wliicli exist- lietwcen tNpliii- te\'ef and tlie acute exaiitlieiiiala, to which it i- -o tiearlv related. it may lie -tated tliat ty|ihii- i'ever jn-oliaMy (loe> not occ.ir -imiiltaiicoMsly with tiie acute exaiitlicmata, altl,ou>;h i.-nlated in-tance- of such iK'cnrreiice arc ineiitioiicd in tlie literatuiT. '{"lie repoHs are not eon\ iiieiiiL'. however, and the liirciroitiir statein«>nt must hold o-,„.d imtil re po-itive ea^cs are reported. .Murchi-ou, who pcar to have tnet with the eoin- plieatioii under (liMiis-ioii, eivcs i'.arallicr and Hucliaiian as liis auihori- tic- till- the -imultaiK - occurrence of small-po\ and typhus fever. JJai-allicr"- -tatiiuent- caiitiot well l)e invc-liuatcd, atid i')Uch.itiaii's case, the lii>torv of which Murc arc ••;i|)m1i1i' cit' liiiiij^ ((imlpiiicil willi typliii- lever diiriii;.' tlie lieii.'lit "t the I'eliiile -l;ii^e (If tiiwanl tlie eiiil, (ir diirinj; tlie l)eirii"iinv >ti-e|)U)eoeii and >ta|ili_vloeo(ei, i-ptiially er_vsi|)elas. Tlie oeeiirreii.e of fibrinous pneumonia, due to the action of the Fraiiivel-\Veieli.-ell)anm liacilhi-, |)oken of by all authorities. It may develop in any staf^e of tvpinis fescr, but occurs ino-t frei|Uently toward the end of the fel)ril(> ]>erio(l or duriuLT et. The relation between tyi)hiis fevrr and relapsing fever is both interesting^ and important from a projrno^tie standpoint. That the dis- Oitses niav cocxi>t is bevond all dotibt. It is probable that the stajrt' iA' incubation of tv|ihus fever may bcLnii dm-in^ the continuance of an existing rclapsinsin)r fever |)robablv served in Moaliil in \X~\^. nf typhus iiiuiieiHatidy I'ullnw- iiii: an attack of relapsiiii: lever. Similar I'oiiiplicatioiis of typluis and relapsiiiir fever had been repeatedly obi-erved liefore that lime. »Sueli ca.scs are prohalilv not rare when the two diseases are epicasc. S])itz ' reports that in the Mreslau typhus epidemic of 1«7!> several rclap.siuir fever patients, after they had been in the lios[)ital from three to live week> without coiiiiuir in contact with tyjihus fever ca.-cs, were attai'kcd bv the disease, t (ne of these cases closely resendiles ours in the absence of any interval hetweiMi the cml of the relapHini: fever attack and the bc;.'inninir of typhus. Seelii.'er'' also reports 4 instances of typhus infection durinir an attack of rela[)sini; fever, and 1!' ea.«es in which typhus declared itself a short time alt;'r the patient had recovered from relapsing fever. . ;• I ' ii i ;. I I'rtrrxh. me'l. \V,.rl,rns.-l,r. . ISTi',, = Dr„fs,-/i. .ir,-h. f. klin. Mfl.. lid. xxvi. ^ r.n-r,,,. kliru U;.r/irns,-/:r.. 1 8SH, Nos. :,] . ;V_'. ?*ri' 664 TV I'll IS I i.vi.n. Tliai typlius iiiul typhoid fever .-m .xir-t tu;.' of tli.^l^ifincnts on tlii- -ul.j,-.'l arc of little valif. So,,,,. ,,f tl,.„, .laf f,on. a tin,., wl,.'., tl,.' tvs.. .liMa-..> won- i,..t .■arcf.iily .li-lii.-ui-li.'.l. whii.. many ..tl,.i- aiitolaf tl... .li,-.'..v.Ty an.l stij.ly of ll.f KL.Ttl, ba.•illu^. I am .-[iiallv ili.-in.liii..l t.> a.v.|,t tli.' iiiimcr..ii^ -t;it.imnt,~ 111 iviranl to tl.r .•...■Ni-t.'i>..' ..f typlm. liv.r an.l diphtheria. Dipl.tluri.' .•haiiu'.-, ill tl,.. -implf aiKit..mi.. .-.hm., arc, .,f ...iirM., kii.,wn to every ,.x|Kii,ii.'.Hl .>K-.rv.r, Kiit it iviuain> f..r l.a.'l.rioloLM.- investigations in fntur.. .i.i.lcmi.s t.. -l,.>w wl,..tl,er ti,.- .lump^ wer .lepen.! on the L.'.tller ha.iUns an.l .an tlieref..re l.e interpreted as loiri<' >en-<'. The e.,exist.nee .,f dysentery an.l tyi-hns fever I .'.m-Ller very pn.l.al.l.^. I nn>.lf saw l' .'ases in whi.h .Kxnt.ri,' manif.-iati..ns, with mue.,ns an."', i.l ly ^t.H.l- an.l s..paiati..n ..f th.> inf>tinal nni.-.ms memhranc in -hre.1-, f..rm..l pr..minent -ympt.mi^ .>r th.' .li-eas... Miir.'hi^.>n reirar.ls .iyseiit.ry a> a rare .•.,mpli.'ati..n, ..eeiirrin^' with anv .l.'L'ree ..f friipieney only in .•.rtain ei>i.iemi.'s. Thiis, diirin;: the Crinicim war th.^ tw.. diseases ,.xiM...| side i.y -i.le, an.l am..njr the Fren.'li s.il.liers, who livisl ami.! nnfivoral.le hypeni.' .■on.liti.ms, eases w.T.. ..l.-erve.l in whi.-h the same in.Jivi.lual was attaeke.1 hy both di>ea.-.'s. Acute articular rheumatism an.l typhus fever may U- e.>ni- l.in.'.l in the sense that the latter .-an l.e a.-.inin'.l 'Im-injr the exiMen.'e .,f a polvarthritis. An instructive case in th.is re-]).'-'! is ,hat .,f a man. thirty vears of atre, in tlu' ( 'harite II..spital, wh., l..-cam.' infe-'ted .hiring the f.l.rile stage .4" an a.iite arti. iilar rhrrhai:ii' n.'phritis. The Relations between Typhus and Chronic Affections. —The relati..ns Letwcn typhus an.l other .li^<'ases, espc.aally chr..nie eon.liti..ns, have l..'..n r.peatedly r.i'.ii-e/'. I'/vo.v.s ar ihskasi:. .m;.') 'I'll,. ,licilic siil.j.rt:- ; it i- \ iiiiiiuTuiis statistics, tliat the iimrtaliiv i,-. Iowit in \M>inon tiiaii in imii. _ S.nu' "f tlif «arlit>t and tno-t marked nuinifestati..lis of tlie disease in aleulic.lie- are seen in the iierv(in> >\>tein, in the heart, and in the 'idneys. (irave di>tnrl)an't day- : violent, even tiirion-, delirium, often followed hv a transition into eoina. iiartienlarly the ominous form of eoina-vitrij. l'rotraetorly smnll vor>- early in the di-ease, the t.'nsioii .liminishe-, and the rate is j-reatly incrcasixl. There is hut little doiihi that this condition of the puise is due ([uitc as nnich to vasomotor paralysis as to weakness of the hci\rt- muscle. The kidnevs in alcoholic patient- rcjiularly show e-arly and .severe involvement. In some cases the nephritis tnanifests itself merely by marked allminimiria and the presence of simiilc hyaline .'asts in the urine. Other cases present symptoms of the severe-t forms of hem or- rha-rie nephritis, and may terminate faUilly at the enar»icularlv lialile to develo|) hypost:itic conire— tion of the liinj^s follows lofjjically from what has heen said in repird to the action of the heart. Cases with chronic tuberculous d'sease of the lungs also fre(pieiitly occurred amonj; the material uiuh-r my ohservation. It may he said with certaintv that i»eisoiis MitVcrinfr from this condition do not esca])e typhus fever. The development of nr,.neral miliary tul)erculoiiri-li<'ij. ciciiiliiati'il illili\'iilil;il- air |iai linihulx |ii'nii(' m iic atl:i( kiii. ami \M iiia\ aiM llial -iirli iiiiliv iiliial-, a- a nili . -Iinw iliiriiiii-lci i| |Mi\\ci> 'if ri-~i-taiiic. \'iL;ni-. Ill-, ui 11-111 ■iiri-lii'il iiiili\ iiliial- \\\\\\ iioi mal lirart-. arc litlli i alilr {<• n-i-l ihr ilVcri- .it' l_\|iliii~ t'c\ ri, jii-t a- tins lirllir u illi-laii.l all aniii |iiiir(--(-. ( >ii llii-iillur liaiiil. \ I rv ciiriiiilriil |ir|--iiii-, cmh wIkm nut alinlinlic. w illi-laiiil till- (li-ia-r liaill_\ , jll-l a- llic. i|i i l_\ |iliiiiil li\ ii , Tin liiall ami llic va-i /• M , lino- lint a|i|Mir tn liaM' am Inalkcil intliiciicc on tlic (■(illl-c lit' lllc rujrnii.-is. l'"ni' the |ire-< nt I -hall cniilhic iiiv-ilt' tn a tiw remarks nil the inaiiitcslatinii- n|' tin' ili-ea-e in iiitaiicy ami nhl a^c. Typhus Fever in Old Age. — Tlic i licet nt' nl.j ai:e make- it-cll' t'cit as carlv as llic liirtieth vear : after the lit'liith \ear it lieennie- sn iiii|)nrtaiit a f'aetnr that alnin-t halt' nt' -iicli [latieiit^ -neeiimli tn the (!isca-e. 'rvplni- I'evcr ill nlil ai.'c dues iint |ircseiit a tyjiical clinical |picliirc, Slleli as we -ee ill senile t_V|illiiid. A cnli-ideralilc |irn|inrtin|i lit' the \:\\ersnii-, mi the nthcr hand, very liiuh tcm|)eratnrc- arc tint, accnrdiiiir to iiiv exiicricncc, liy aii\ mcaii^ imcnminnn. it nia\ at Ica-t he -aid that nldcr |ier-niis arc Ic— likely In have a hijrli cniitinnnn- nr remittent I'lHitinnnn- t"c\crnt' Iniii: diini- tinn, and present rather an irrcirnlar tcm|ieratnre-eiir\ e uiih marked clcvatiniis and dc|irc-siniis. On the nthcr hand, in nld |icn|ilc the di-casc exerts an early and |irnii(iiiiic<'d influence nil the cireiilatnrv and rcs|)iratnr\' nriraii^. PiiriiiL'' the first week nt' the di-easc, dnriiiir even the tirst days, au'cd individuals [in -(lit svm|itniiis 111' failiiiLT circiilatinn ; the |iul-i i- >tiiall. ra])id. aiic nt" 1 H> are mit ai all nricnnimnii. I A-.iilil'iil 1 Mli-cJiil* lici i>\' till- i-.iriii:!' Ui;iKlii-- :lllil lllr i-i 'll-l:illl .M-rlinincr of -r\r|-c r;il;iirll cX ti 111 I i 11^; inti > I lii' tillir liriiticlliiilc-, ii;.'i-{> IiiIiiiImi' |iiiiniiiiiiii:i anil ~iiii|ili' uc ilitlalii- iiialms li\ |iii-tatir r lilinii- in llir Iiiiil;- vrry larly in llic ili-ia-r. liillainiiialiii'\ ili-ia-r^ nt' llii liiiii;- tinNi a rliai':ii-Ii ri-I ii- ti'aliin- nl' -iiiili' l\|(liii-. 'I'lli' i-rlHral llllAiPll~ -x-lrtll 111 iilil |M r-iill- I'al'lx iMrnlllr- illMi'.Mil 111 a v.TN iiiarkc. Tlir t'lirtn kimwii a- •' ala\ii-ail\ iiaiiiii- " i- |iai'tii'iilarly lialilr I iiir in "lii |» i'mmi-, imm wlicii lliry arc iml alinliiiii'-. A- i-cuani- llir kiiliii'V-, I i-aiimit -ay tliat 1 lia\r iml uiili imnc mirmriiii- m- iiiiiic riiarki'l i-a-i- "f iir|iliiiti> in -ciiilc [.atiint- than in voimi; ami \i;iiirniis mu-. Ontlic iitlicr liaml. iliarrlit'M ami ily-cniiiir atli'diiMi.- of tlic larp' iiit('.--tiiic arc al)lv, tu tiic atiM|(liir ciindiiinn ol' the >kin, tiic typlins fcvtT iii-li xcins to appear simifwliat later in nld peismw anear earlier ami are pnine to lie more extensive. in tlu' matter of aiminiit of ra-h, I do not think there is any frri-at ditVerenee lietweeli old aj;e and other |Kriod> of life. Typhus Fever in Childhood. — .Mthonj;h the disposition to tvphiis fever is not less in <'liildhoiid than in later years, if we disre- i.rard the pniall in |iro])ortiiin to the total niimher of children in the coniniiinity. Of the eoiir-e of t\ jiliiis fever during' ehihlhood little is known. Kven the lielter text-hooks on jiediatrio pre-ent littli' nn re than irenerd accounts clo-ely rescmliliiiLr clicvc that tiicre is aiiv marked ilitVcrence hctwcen tlic course of the di-^ease in children and that oli>erve i;irat. It i- u.iftli\ nC iiuti' that till' M'Niriiy nt' llic lii-ia-r -Imu - niarkcil Viifiiili'iii- ill till' (lilVrrnit a-i'- of iliilill |. 'riu- ^'Vifc-t la-f- ate I'niiml in vi'i-y ynmi;; cliiMi'in up to tlic littli Mar; tlir mil.li'-t, in cliil- ilnii lii'twii'ii till ii'iitli .'Mill tiriciiilli Mat-, wlicna- iliilili'm ImIwciii till' ml;'!'- lit ti\i' ami Irii vrar- ui-rii|iy an iiiiriiiciliati' |(ii-itii.ii in iihmiiI Id till' -I'M rity 111' tile ili'-ia-r. 'rii.'it cliililfiii iVmn Dm' in liliiin Maf- ol'.-iLri' Mil' niiii'li ii— -i'M'ItK' iittai'kiKJ i-i jiaitly iliii' tn llir lait that llir vital lUiran-, i-|icci:illv the rifi'tihilnfy -y-tiiii ami llir iiiiinii nrrxuii- -\-li'in, im-sc-s tri'i'iitrl' |Mi\M'i'- ill fi -i-tancr til till' tii\iti-, Mini |iarll\ on an'omit of tlir roiii- iciiiitivi'ly .|m;| ihifMtioii of ihr lii-ca-c ami tlir irfiatir iiiiitv of com- |ilii';itiiiii-. AiioiliiT fai'tor ill tlu' low ilratii-iati' i- tlir irnal |ii'i'|Kinili'i-aiin' of ca-r- of M'l-y -lioft iliinitioii, or ali-oliltily iilioitivr ra-i'-, in iliililli I. S'Vci'c foriii- of till' iIIh'iisc, -iii'li a> ;iii' oli-irv nl in adult-, i's|H'('i'ill\ tlir Ni-rallcii fuliiiiiiatiiifr tin-ius coml.iiKii with loiiia-vi^il, aii' (li.-tiiirtlv lafi' aiiioiijr cliildfi'ii. Till' lii'iriiiiiiiiir, flio cniirsc, and tlir difrivi-iiiin' of the fever ill well- iii:ii1mena oeeiir mofi. ffei|Mi iitK and .ire inoi'e \ iolint in ehil- di-eii than in adult- who liad lieeii he.ilthv 1m Ci.fi' liiiuir allaekid hy the di-e.-i-e. Cliildfen .ife iiinfi' ffi'i|iii'ntl\ altai 1 ii'i li\- eiinvid>ion.- dilfiiiLT the ri-e Of at ihe helLdit of the ii'\ef. ami the delifinni, restle<>ne-s, ail'l !iniiniiiiiiiiii;i :irc ijiiiti' ;is I'ltiniiinii ;i» in iiiliilt", lull li_\ [xi^ljilif I'liii-nliilaliiin !•< ili-tiiiclly niiiiT larr. rill ,i|)|ic:iniiii>- '.f llir l\|iliii~ irii|i'iMii i- |ir;iitii:ill\ llic> -:iiiic :i- in adllll- of \(iilllili|l and liiidillr :i;;i-. Ill cliilillfli, :l- in M(lnlt-. the aliiinilaiii'i' nl' tin- i:i-li iini|ni -limialily \aii(- widrly in ditliii nl i |ii- dciiii,-. and llii~ i- prnlialiK tin- ri'a-uii tliat cciiain aiillini~ (( Iric^-inj^iT) r to lie soini'vvliat iiKii'i' lVr<|M('iil ill (liiMrcii tliaii in adnlt~. ('aniTinn ori-., wliicli ilainiMl many victim- ainoii;_r llic cliildrcii during ciiidrnin- of t'oinicr liim-, lia- now iiicoini' -o ran' that i' may jiracliiallv he pa— ii'av that tlw foiirte<'nth dav, accordin^r to my experience, mo-t t'nM|iieiitl\' marks the tiid of ilet'cr\ e-ceiicc. Cases in which the fever last- lonj^rcr than the eijrhteeiitli day are e()m])ar;itivelv few in nuinlier, while an imcomplicateil case in whi<'h the end ot' | hall' of nil lln' ca.-i^ cHiviilcscnicc licLrii, c.n ilir ihiiliMiiili i.r till tiiurlcfiilli (lily, ami in iiidrclliaii llircc-tliui-ili< "'' i'll 'ii-'^ lifUMTii ihr iliii-iciiiili mikI -ixicciilli (lays. TIicm> iimiilMi-> u.rc ..Llailinl IVnin an analy-i- i.f ."i:; ui iiiplii-alrd cases. In ihr r|,i(li iiilc "I l^i'.i. ill .Miialiil. \\r >iii-i(.cilc.| ill ilctiTiuiniiii; rln- iliii-aliiiii ol' tin- ilisca.su ill L'!m; ca^cs. an. I ..l.iainr.j iIk' |..l|,,uiii- iiisiinri i\ ,■ laMi' : ('iiii\ alc'scciici- licjaii at'lcr — 7 .1m\- in I III II IJ |:; 1 I .lll\- ill IL'.- s i:. :;:; •• lii > •• 17 •• u; " IS • 14 •' II. •■ '.I •. L'll , ■■ ( iricssiii'jri- .jiMs ihr liiiratinii ,,\' niildci- rases as tVem twelve to fdiirteen ilavs — that nt iju- iiiajoniy ,,{' eases as Irmii sixteen tn twenlv .lay-, .leiiiier lu lieved thai uiii'. ini|ilieatei 1 i'a>es run tlieir emirse in fn.ni I'mirteeii tntueiitv- tu.> (lays at the iiidsl. liarallier ealeuhite.l ihe a\erii>;e .liifation m (1!'.^ eases, ami t'.iiiml it In lie tVniii i, ii l.i lueuiv-lw.i ihns. Ill illi.(iln|ili(ate pound-, till' caii-c ol' which we can at pi'c-ciit mcrel\ siiriiii-e. 1 he .j-rcalesl |o-s in weiii-lil occurs naturally during.' the lieiLdit oC the liis- case. Ill niic of Icisciislein's cases a los- nf 10 pniinds cicciiri-cd hcluccii the seventh ami ih,' lifteenth .lay of the di.-ease. In another the same aimmiit was |..st in the curse of f.mr day.s. I myself have not inf'reipK ntlv seen a loss of from 7' to 12 ponmls in tlie course of from five to seven davs. and ill one I'ase a loss of Iti] poumls lielueen the eighth ami the thirteenth day of the disea-c ill a (ew ea-i -, where the attai'k had lieeii verv severe and pi-otniete llic tliini III' liiurth, ami ii>ii:illy lifl'mc llic tenth e (li.-i'liare'ed and ;^(i haek tn wmk al'tei' three td t'liiir \\eeiv~. This tllVoralile e(im>e ><[' eiiii\aie-eeilee, while jiartlv due to the -hurt (hiratiiiii ut' tlie di~ea-e, violent a^ it i~, is iini|nesiionahiy inthieneed to a lare-e extent iiv tlie tiiet that the oi-irair- ot' dijri...,tion are -n little in\ol\ed in the niorlml [iroee--. I''or tin- reaxm '■omale-cents in tlii- di-ea-e, more tiirtunate than tho,-e reeo\erinij; tVom t\]ihoid lexci'. ean lie permitti'd i'ullv to sili-lV their appetite, wliii'h retni'u,-. heliire or illM'inL;' the period of det'erve-eenee. In -eVere ease^, i \en when the patient- feel quite well, the |iul-e remain- duiMnn' the first or even the seeoud week eoiniiaralivelv >niall, -oft, rapid, and -o extraordinarily -eii-iti\(' to ixternal conditions that the -lii^hte^t proNoeation may iuduee a con-idei-aMe althoii^di trall^itorv li-e in the fr<'i|Uenev. On the other hand, in some ver\' ii'chle patients I have seen a remarkaiile slowiiiir of the pnl-e — iu one -erved iu uaily tldls below the phy-ioloiri"' l<'\el on the first afebrile dav, and remains sui)norinal (hiiinu; tile first, ami often part of the seeond, week of eonvaleseeiiee. It may be extremely low: '\')° or '.W V. in the inornin!.'', with a very >litrlit I'veiiiufj: ri-e, i- not at all un- common. After the second week the teuiperature-eurve istence of the delirium, e>p<'cially duriuir the eveuinfr hours, beyond the time of defervescence i- the most f're(|nent of these persistinjr di — tnrbaiices. J have seen delirium last in this way from three to four (lavs, and even until the end of the fir-t week of <'onvaleseence. In the iTfeat majority of convalescents, however, the rebi.d fimc- i t^- ^fr -A.; ^•:; •"- ryriirs ii:\i:n. Ui<''' "'■ iIk' I'«v( v. Iii.livi.liial- wli,, (oiitiniir f., hav .Icliriiiin in '' '■'■""'.^'- 'li"-i",~' the !iiv, H.\v ,lay„ ii~ualK .xl.il.ii ,l„n„jr tj„. .iavtiiiic a ..s uf mymu'vy for il.rniri- ..vent,-. Tlic |.aticnt'> ivccllc'ti..!. of his illi„>s i> aliiin-t aluay vci-v liiiiitrMly the initial sta^^tliat i>, tlio days .liirinir uliicli the fv.r l.c-in- to rise. Tlicy ivtain a lively rccillcction of the apoiiics of that |)cri(Ml, and convalescent, w lio have ^n.ne thi uli an attack of folapsinir or typhoid ■ v.T affii-ni that the initial symptom- in those .lisoases are not nearly ,,. had as they are in typhns fever. '|-hese initial symjUoms ap|)ear to l,e cniparahl ily to those of >niall-i>ox, Jndfrinjr from what J have learned from typhus convale-cent- who had fi.rmerlv hae. ()i the other hand, the p.riod of hyper|)yre.\ia and of most intense symptoiis leaves a Mank in the minds (,f the majority of convales- cents from a severe atta.'k. A few of them may roinemher one or two panicnlarly impre-Mvc events >n.Oi as haths, the vi>its of the doctor and his ..\-aniinaiions or attempts at tli;rht that they may have made and the mea-nres adopted to prevent their repetition. Others renicial)er only the snlijects of their e;irly delirinni antl halhicinations, and of tluse tJiey retain so lively a recolle.'tion that they contimie to he tronhli^l hy them in their -hvpintr and wakinL-- moiiicnt~, and even when they are fnlly conscious cannot (piite rid theinselves of the idea that there must have Keen some trnth in them. When it i- reinemhered that their hallui. m^ih. its apiHarancc later: in 1 ca.se toward the end of c Ixeii Slid, (|uitc miciiniiiniii diiiiii;: tlic lM)iilc |itriiwl, were ninly met with ill (li-tm'li;iii<',- ciiiiliiiilin^r duriiiu or cncii :it'l(r <'oiivali-rciirc. J~ii|;itcci'1i oIim rvcd in ivcrv ciiidciiiic. No ••a-i- "I' tiu' ioniicr have ever hccii carct'iillv invi^tiuatcd tillitr clinifaily or aiiatoiiiically, and it i- not tvtii known wliicii ot' tiii'iii arc to 111- attrilintrd t'> >|>iiial and whicli to ncnritic di.-- tnriiaiHvs. On the otiicr liaiiiil>.-taiRr or iiicniii|ii-, or on l■nll)oli^nl and tlironilio-i-. I'aralv-i- of individual inn-ilc< or ^'i |>~ of muscles, ur of a -ini;lc t'xtrcinitv, is ipiitc as nnconimon as liciniiilcLda. Of tlic niii.-clc~ in tiic il|i|icr extremity, the deltoid appars to lie mo-t fre(|Uently attaeke.1 : on tic trunk, llie Hiralii- ma-nii- ; and in tlie le.LS the extensor nui-eh- of the tkiudi. Whereas heiiiiple-ia, lieinir due to an orjranie le-ioii, is lisiiallv verv -low to di-apiiear or even reinains ineurahle, ]>al-ie- of individual iiiUMle-, as a rule, disippear iniieli mure <|uiekly, -liowin^' that lliev are |)rolial)ly of a neurilie nalui-e. ^ A inileli more ( niioii event than pandy-is dnriiiM: emivales- eeiiee is neuraliii.., uliieli i~ often very di-tre--inir, |)arfieiilarly the iieiiraltiie pains in the to,- and sole- ot' the feel already referreil to. Thev soinetiino make their appearance duriiiir the latter part of the fehrile |ierio(i. and per-ist for a varialile leii^'th of time dnrinjr convalc— cenee. Althoiiirli I have >ecn them disappear hy the cud of the first week, I have also known them to last two or three weeks. Anionu- the rarer liirms of neiiralixia I may mention indtria of the snpni-orhital nerve, which appears to i)e more ohstinati' than the oiIkt forms that ha\f lieeii mentioned. One of oiir c;iscs was still sntVcrin^- from tiic condition at the time of Lis dischar^rc Mention may alsrv.iv (■..iii|,li,Mli,,ii~ of .■unvalr-ccMcc -lioiil.l !>,■ ii„.|i- li"iM.I ill,- vai-hMi- |.Miul.ni and ii,rr,,|i,- piilinuiian Mti;',-li,.M> ,I,.|m n-lin- "" l'i"'i'l-"' |"ncl ,lriii~. A- lias l».,.ii >iair,l in anntluT |.Lut. i|i, v "'■"■" '•■"I '" I'unilrnl ciru-iMn-, and Mil,jr.-| ilic paiirni tu all tlw ditli- <-iillic- ami .lan^^vr- ,,|' an ini|iv<'nia ii|).i'aliun. The ..r-aii- of di-(-li..n l.rin-- hnt liiilc involvc.l ilnrin- tlir \u\.M '!'■ the (li~ca-r, iIhic i~ hnt -li-lit intrrll'ivM.v uiili cMuah-cn-c ti. !,<• '■^"■•■''■'' ''■'"" '!'■" 'liim-lir. I niy-clf .1 i ivnimilMT anv ca^r ,,f liii- l^ilMl, iail Inmi tli,. iv|.,„-t> ,,|- -.■v.Tal cpMcnii,- it api'...;!!-- ,|,at viui.'nt vcniitiir^. .MvniTini,' attn- the in-otiun ,,f t;,.«l. Iia.~ li.vn oIp-.tn ..I .lurin-- tlu' tir~t w,vk aftrr .Irlirv.. cn.v. I I,,w,.vrr, as a iini,il),.i- of rli.-c ca-cs pivM-nlcl ■■iTiain ~vni|.toni- ivi;.|-al,I,. to llic .vntral iicnon- MMrni, o.a- rannot avoid tli,. tlionuht that tlir pi,,. „.n,,n ina.v have l)ccn ui' i-cntnii oi'i^in. In a \vw in-tanc- patient- \v,t<- -.■,,, tly tf.^nM,,! ,liirii,o ...nvalc- .VM.T by painfni Mia.-cration of tl.,- -nin- a-.i.iatcl will, l„.|i"oiTl,a-.-. IntlaiiiMiation of th,. salivan Ldaiid-, d(.v(.|opin.r ,lnnriy the frl.iil,' pci-iod and (-(.ntinninL; dnrinu .•..nval.-. . :■■■,. ,,r ari-in-r after ti,e rial of the lihiile pei'iod. o,vnr- with variahle tr,|iien the fbnn of imilal.ral parotitis, or, in very rare ean-, of which I have per-onalh >eeii hnt • iiiflainniation of the Hihlin-naj -land-. In n.iv te,l,l,- pati.nl- I have met with -n|ipnrati( f an entire sdivary -land, uiti, ii<<'ro-i> of tile eoii!ii.eti\'e-ti->lle stroma. riiaii-es in th,' -kin are a pariienlarly friiitfnl -onree ,,f di-iurhanee diiriiiLr eonvaje nee. Many patiiiit- continue to miIIIt tiir -onie time atler defervc-cenec iVolil -ail-relle of the eai>, tin-vrs, toes, tip ol' the no-,', and -kin of th,' penis and -crotimi, ari-iii- diirinir the fihrile period. In L' iii-tanee- dnrin- the c|)idemie of IS7!I \\v were dri\cn to pertiirm e\arlicnl.ition of iran-reiion- toe-. Noma and iio-pital ean-rene l,.i\c lii'coiiie -o rai-,' that tlie\- need -eari'cly lie rei'koned with diiriii- eonvalc-i'cnce. I>i i-nl)itn-. OH in- to the rel.iii\-ily -hort dnralioi, ot' the di-ea-e. i- coinp.ai-atively ran', and i- pr.aetic.ally oii.'-;itiiiii, ;i miiiiilar, \ illnui-li-n il uf liliii-li-nd (liMciluraiimi nf till.' -kill, witli Mi'irc "Y Ic— I \i(ii-i\i inc|iir:iiii>n awA iiitiltnitioii lA' iIh- siiliciitaiicoii^ cellular ti--iii', (lc\cl(i|i> ovir tli<' iialc-, in the liiwcr -acral rt'^xii'ii, "I" i\t'n ill the (Icptlis ot tlic tiiM hclWfcii the inillock^. Alter :i tew (lav^ line cir twu small i)|ieiiiiiM- a|i|)ear in the iiiidille ,,' tlie di— eiiliircil area ami ili\ im-i^io'i nr the ili-eaeiis, a snr])ii-inj;ly laii;e (jMantitv uf |ius eontaininLr -lu'eils uf iieemii'- tissue is e\aeiiatev a deeper destrnetive jn'iiecss iioiim mi tn iieem-is ami sei|iiestratiiin of himes, jiartieiilarly in the saeriim and eneeyx, and al-o in the sca|.iilu and tin- triiehanters. ( 'I'l-elv relateil to aeliial deeiihitiis there neeiirs tiirnneuliisi^ i)f the ;;luleal rei^inii and adjniiiiiijr |"irt!iins of the hack. This eiiiii|ilieatiun, whieli is nut verv imeiimmon, ufteli oeeasioiis tcreat su!Verinii' and euii- sideralily |iriitniets the period of eunv.ileseeiu-e. ( )eeasionallv, I have also met with t'nruneles in other rei.'ioiis or ilistrilii;ted over the entire liod\ . ( )liee or twiee I had the saiu,' experieliee 1 hat has l/een mentioned hv other author: of ervsipi las tiillowin^ deeiihitns, tiirnnele, or aliseess, hni, f n'tmialely, I never lost a patient from this eaiise. In the ease ot' a \cry fe\v eonvaleseeiit patients we had a trood deal of troiilile w itii dilViise phley,iiions lie'_;inniiii.r dnriiiLr the tilirile period. I lia\e -eeii tlieiii on the anils ami on the -kin ot' the ahdoiiien, and believe that they Were dne to traumatism, piohahlv self-intlieted injuries duriiii^ delirium. ( )iie of tlie-e patients died of s,.ptieopyemia in the fourth Wnk of lleti'l'Ve-eeliee. VERY SEVERE AND FATAL CASES. PROGNOSIS AND MORTALITY. 1 he eases wiili niodera!el\ severe and -exere sNiiiptoms in tile ordi- nary -en-e haviiit: hein fullv ili-eiissed in the general description of the I'liniial picture, tiir which thev -upplicil the liasi-, will he touched u|k>ii hut liiihtly in connection with |irocii(i»i, ^md inc.rtalitv'. In this scetidu only those casi's will lie particularly mcutii mil that pre-ent unusii.ally severe symptoiiis. and in which the iiroiriio-is i- e\i'eedill;rlx' UlltilX oralilc or alisolutelv fat.il. /. .■l.j;._..,:-i ,. I £i-B iiii •Jl") /■) fill s n:\i:i; '" ""- '•'^"- "'• '"■■'''■ '•'•'•'^lii' '-aM- ,,(• v,i-v -li,,rt .liiratioi,. cili.rs "(■ n-unl l,„^tl,, :„„1 ,.v,,, -,„„.... f ahiiMriiuMy !,„,- .liirati.,,.. all. iiou- 'V, r. cjuiracl-'n/,.] I,v iimiMiallv lii::!, HArr. 'I'Imv aiv il,,. -,,-,, ill,.,| hyperpyretic cases. In „„,-, ,,t' ll„ „,, al'.,r a h„uI,. viol,ni rhill, ''"■ l'"i|"'-aliirr ii~,, ill a -IimH ii„„, , „• at oi„. Im,iii„|, ,,rulil, v.ia' -li-lit iviiii-ion-, I,, ail iinuMial li.i-lil, || uvwrn 11' C. |„in- mIi, 'i, ■'"■''"'■'' ""■'•■:■ -'"'I' ' 'liii-n- a- .Mi-lv a- llir vvnuvs nf tlir"-, ,| '"' ''"■ '''''■'' ''■'>. ■""I 'lii- Irv.l i., ,.,. a nil,, MiaiiilaiiH.i Cir .lav- or nnlil th,. -.v,„i,| urrL, ,.i,|„.r uiij, ,i,:„.L,.,| niuniin- iviiii-.i,,,,- ,,r u ill, I.- Ilian ll,,. |,l,vHnl,,:;i,. ,l,ik varia'iuii-. Siirl, ra-r- ,,,rjv ,Alnl,it mark..! ,nlai-, ,i„ „t uf ili,. .,,1,,,,, ; ,„.,.,,~i„nalK . ,|i,. nroar, nia'v JMrcii,. I'^''l'''''''' ^^'''' '!"■ li''-' a •ll-: V ..(• th,. IIKril.. -v,ii,,t,„nv' Srs,,.. I'i'oiirliiii. i- „-i,allv piVMiii from lli,- li,.i:iii„iii^-. Alun- uilli ll„. UMUM.alk Indi I.in|,..raliMv tli.rc aiv oft, ii an ,.\.v-Hvr iiwiva-r in tli.. l)iil.-r-i-ati' ami an alarniiiiL:- ,' ,.a,-,.- i- ,.\,.,.,.,lin-lv raiv. (a-,- l),.iriniiiii jn-t ,l,.-,Til„.,l. Th(. t,iii]M.raliiir-,.nrv,. fiv,|ni.|it]y i.ivsciits iiiark,.,! variation-^ .jiirinir llu' , •-,■ of -iich ,.a-,-. At (ir-t it i- ,.x,.,.,--iv,.|v lii.i:ii, tlicn it fill- to. ,,r ,.v,.n l„.l,,u, the n,.final. I hav,. -,.,.n ca-.'s ■ "■lonirin- t,. tlii- nr,.,,i|,, (Ki^r. >;<,) in which .h.-ith wa- ,l,.|ay,.,l until the >. ...in- tiniiiHl ,.x,-,.-iv,.ly low f,,r ,lav- ,,r w,.,.k- Im foiv the fatal t,.niiiii.-iti,,ii. ('l,,-,.|y r,.lati.,l to thi- ^-i p i< a v;iri,ty ,.liafa,-li.|i/,.,| hv nmi-nal M'M.fitv an, I alino-t -taiitlv fiial tenniiiati.m, in whi,.|i th,. t<.ni|p,.f- Mtiiiv .•,,ntiiiii<- ,.,,ni|.afativ,.ly low tlif,,n^hoiit th,. durati, f tli,> ili-ca-,.. Subfebrile and Afebrile Cases— rni,> afM.iil,. ,a-, -, -neh as of.'iir 111 lyph.nd, ap|„ar t,i l„. ,.\tnin,.|v raiv in typliiw i;.\,i.. I hav<. not -,.,.!, a -iiiirl,. ,|,.tinii,. ,.a-,. ,,f th,. kiii,l, ii,,r ,1,, | (i,„l „„.iiii,,n ,,f thi'iii liy ih,. ni,,-t ,.xp,.ri,.n,.,Kl aiitli,,f-. ()„ tl tli,.r haml. if ipiitc ' iiiioiilv happrii-- in the ea-,.- that I am ii.iw ,.on-i,l,.rini: thai the tciiip,.ratiif,. .liiriiii: the ,ntiiv p,.rio(pii-. uli(i-c >ti-iin:ili ha- Imcii ndiiccil hv |iu\(.|i\. \\rv, or cliroiiii' (li-ia-c licllirc tlnii- iiil(iiitf:iil (.r a ;.'riifi-iil ilcMri|.lioii uf llii.s variety , uhicli lia.- aevi i Ix-i-ii fully (li'sfrilHMl. ! will ^rivc tlirco teinperaturc-charts with short notos . i'()rr(V|«incliii;f case histories. The first case ( Fii'. 70, wius that of a fcehlo ohl man, sixty-three <)f iiL'e, who for months liefore he was taken ill had lived amid the destitute eiroumstanees. His illness heiran with a series of slijrht chills, which the teni|)eratiire v'radually rose! altho. jrh it 'lid not exceed ;ii excqpt on tw-o days— the fourth" aii'X Tvri/rs //.i/.v.' t" f.ill to Il„. iiort.ial. will, a -|„.1„ I ,.,. .l„,,,|v I,,.,;,,,. ,|,,,„|, ^ |,,,,|,, ^, , l.'.'Mt uus al,>..„| ,l„nn^ ih,. .-ninv ,■„„,>,■ nl 1 1„. ,1,-,;,.... l:,,>,.-,„„, '»:,,; iM> -r II,.' Ml-. tS ■'-it tiit;H+: t t -t- - PAl 'T TTT T ! ' ' #|-T^ff|ti|r Fl.., 7M.-M,i|r, „_;.] vi,fy l!,r,v. Kill Ml t'TiniiKili.,,, Milli ri lMlivil> Imh I, ^, , I»'v>.,,t i„ HiiMll ,„„nl„.,> .,,,1 w.-iv v..rv in,r,>li„ri : l,nl, „„ tl„ ,,- l,,,,,] nuinunn... la'U.cliu... mail,, iliiir appranniiv la,: , aim.,,^' tl,,. r„...i,la lr..inns.' liH.\ cif th.. .liMa>u. Fi... TI.^Miil, , ;,^. ,1 ihiriy, Tviniunitur.. wn= n liiti v.-Iv 1„« from lliv very l..rinnii,n,n,„l ,luri„.. thr lM>t wu, k frll l.cli.w till' linniiai. ° ■» i /7;o(,.Vo,v/s ,|.\7' Mill; iM.liy. ;j7I» .^ '■""■■ '•■''■'•• ■ri:^'"i'y "!' :il!-i:iinn v,a,- Iniiii.! i,, il,,- ,niiic In,!,! ihr li^ini "■'.^ """I 'I"''"'' • "llli' 'l.-V.-ln|H-,l ,M1 III.' MM',.I|,| ,h,v. :l,roril|,Mni.'.| l,v >■.!,- -iiIlN- lfii,|]iiuiu, ,Mi|,lH)l,,irv, and Miullfi-iML' (Ifliiiinn. :ui.l („Miiiiu.-.l' imiil ilr:illl. I'lif liiMiirv i>f tlif .-.■(■(,iul iii.v, ihiil of :i IiiIhm-.t, lliirlv vrjirs i,f m-c is .v.n niniv iTMKirkal.lf i Fi- 71 i, Tlic liiu'lic-t Icin|,..,MliM-(", mtaiii.-.l ",m| v "" liinh-llifciiIiri'C(.iir-.iiflli.M|i,-,.a>c. u:i> :;:•.! ( ■,. and IV.irn llii- .-cvcnlii II. III,. tiMii-trciilli day. uhcu dralh nc.nirr.'d, lli.' tfnij.ci-alni-.- cnnlinurd i,, liill tn S.I niai-krd a (IcLrr.c thai dnrin- tlir la.~l H.nr da^- it rant;.--! l,,.|u..fu ■■'•r and ;;.■, ', and cvmlnaliy dro|,iHd lu ;;:;.;;' and .iL'.l' (''. jnnn.diaulv iK-lor,- 'Icat... In -p'lr iifthi- iinnsnally Inw tcni|. li.-lia-,. dcatli. '''■,"■'•"* ' «■='!< l'> ri^f. iiiid lay in licl in a siaic of ciMisiant rest Icssn^N^i '■i-yini: an. I ycllinL', at la.-l .jnictini: 'i'-uji an.! tallin- into .listinct cunia- vi-.l .Innn-tlic last twi-ly-fi-lit Imni-s pivivdin- .Katii. For tiuvf n.oiitlid l>iiy ..f Ih./ .li-ciisc. Fl.i. 7'2.-MnK-. a^' .1 tliirlv live. FiituI .ii.^u w ith v.ry l.iw iiiii|>.rMtiin'. K.l.ris fTantliomaticus rfiinlis. l(»'ti>r eaten T, his adrniltan.v the pati.'.it had horn with,.iit a home, had srarccly Ml anytliin- and had .Irnnk lar-,. (|nantilics of whisky. (•oinheMiaiu reports l' very similar c.as.-s witli a marked' tiill of tcniiHT- atnrc m the hist days, ni one .-asf to :;;!.7°, in the ,,th.T io .•';l '"^ (' Tids eontrd.uti.m is the oidy one on this sul.jeet found in re.ent literatnre a.u'i even ti.e oldest authors, sneh as HiMeTd)raii,hi,,l UN !h,- .|:!\ ,,(■ !,,.. a,li,,i.- M..M n„- t,„u-,i, ,i;,v „r ,1,.. ,1,-,.... .;,„,„ „, „\.,;.;. i,,,„„,,|,w 2':7]tiur t1 ""'■"; v """■'"!—■ ..i,..::;:r -l.r ,t l„> ,ll„.>.- Il.,> :,n,l .-m„l:,r ra-.-. ul,„l,. , ,„ |„, ,,„„„„,,| '■"••"'■'•-I '"I" I III,- l"nu- ..,,■, HI in.' 11, l\|,|„,i,| iVv,,,-. '■'^""' '""■-"'■ -'"'■••■■'■' '"■^"•1^ -li"i' 'liir:ili..n, „|n,|,;„v,|,.-,TilH,| '"■ ''""I'l"'' ^'ii'l'"i- iiii'It lli.t.nn typhus SideratlS, v.m-n in Ir,- <|ii'ii(\ III ill,. iiiii;.|,.|it i|.hl(iiii,-.. ■IIhn :i|,|„.,,- ,,, .„.,,„• .,|„,i.ilk al tl„. lM..,i,mi„,r .,,,,1 ,|„,i„. ,|„, li'iiilil -I o,|„, •„!>,. „|.,n.|,aiit .■pi.l.'Mii,-. lurticiilarK -.ihli a- ,„.,.|ir -m ;'':|''"'^"''' '" I"' -■ '''"i"^ ^1 -i-^". "I- in I.-IK" .„ana,..,| aim,,. ";''''•"'"•""'■ M'liilii- n,.ii:: tl„ ,.|.l,r ;ni.l„,iv <-n.i"V,..l an aluiiMlant ,N,„a 1,-n.v rr,„ii „|,|,.|, ,,, ,|,,„,,1„. ,|„,„. vaii,li,.. It Nva. ,|iii„. ,,r,.val,.|it .Inii,,^. Na,,..!,., ,„', ,,„„,,,,|.„, ,,„| i,,, |,.. , vina.an "•"■• '■^l""'^'">^" ^ ''"■ '■"'•■•'I'll ami l.'u.-ian., «|„,u,,,. ,i,,I luarlv .M.wll l,„,k.H| aCt.T in lli.nialtrr ,,(• l„,il,|, ai„l piaml .„,i,li,l,,M. •,'. Wen til,' KnL:li-li. 'I'lii' ^-r,,!!,, ii„|,„l,.. ,,,„., ,.n,|i,ij,r ,:|,.,|K. ,,j|i,j„ ., ,;.„ ,|,^^^ .^,.^_, ^^^^_ api-'aranr.. „f ,|i,. li,., .vM,|,tu,ii,_„,,>alK l.,,u,.,,, ,|„. Hiinl mh.I tifih .lav., ,„• rvn .arli.r. .M,,-t ,,f tlu in l„.:,ii, „i,|, a vi,,l,,,( ,.||i|l a,„| a ".•ll-.l.v,.|„|„..| -|,1,.|,1,. ,.|ilarp.,M..nf. Tli,- l,.M,|„.rat„r,. ocnrrallv ihkI,.,- PM.. a rapal and n.iint..m...t,„i ,;.,, ,,„,in^r „|,i,.|, ,|i,. ,,„i,,,t< ."..niplain .iMh.. ni,M M,.!,„t .unptun,.: nnuMiallv m.v.tv lu.a.la,li,. an,! pain in tlu' i.a,k aial ln„l,~. a,,„ni,,a.ii..| not mivk l.v nn,nntr,,llal,l,. v.,n,itin,r ^i-i'l ivl.-Inn/. Tlu. Irni,M.ratinv n-Mall.v r,.a,.|i,.< a u^ival. an,| ..nntin,,". an ..x,...-Mv,, ,„.i.ht. A...arlva> ,1,.. IIpm ,|;,v,|,„ pnU j, „nnM,a!lv >rnall, tiv,,,,,,,., ami niav l„.,.,,ni,. inv-nlar in v.^lnnir a;al rlivllim ...1 tli<. >,.c,,n.l -lay. 'J-|ie pali.ni.. uli,,.,. n„,ilal .-oiMJiti,,,, !„.," ••lnM.|ca,,n til.. ,.v,.ninjrc,ftlH. lir-t ,lay. ciiji,.,. ,|,.v,.|,,|, vi,,i,.nt ,1, la-tinLT until di-atli cr -ink int,i cuna-viuil. Drath i- pr, .,.,., I,., I |,_v MMipl,mi-. ,,f , Mnni,. .aniia,- u.akii,..-. and i.M.ally l,v an ..x,.,...iv,. Irniprraliiiv—i, ,,,-v I suv a hyp, rpvnxia ..I (L'.<; ('. Tl,,. .pciticniption i> n,,t ran |y al>-, in ,„■ imt -paiiimlv '''■'■' '"l"''l: '" II-'' ■■m cxpiv-i,,,, ,,f 111,. ,,|,|,',. pliv-i.ian-, i, •• Mi,"u •iii'l' rnra.li tli,. .kin." .\r,.,,rdindy. tlir dia^nu-i-. V.p^.iaJI, „-l„,„ ,|„, ,-. In till, wav ,,n<. ,.aii iiii,|,r.Iaiid i.,.rtaiM ra.,.. ,|,..,Til„.,l l,\ r, li^Mc aiitli,,r. a. la.tiiii: "iily nur nr t\v,. days .,r a f.w li,iiir.. I',.r^,,nalh . 1 Iwvc ncvvi- iiu.t witli i-.isvs of Midi short diinition. Tl,,. ,Hii,.k...t fatal (■i.ni,.s ii'inni ri:>)ii\n\l\ .i.\/( I/O/./ \i 1 1 y. 581 <-;i-..' I li.v.- l,.„i ,„,,,-i..„ „, ,,i,-,n,. i.niiiinir.l mi iI„' ni-ht Imiu.,,, i|„. \\\\r>\ .'iikI t^Pl'llli iliix > m|' iIic i|i-ra-f. I MiiiM iioi ,,Miit tn iii.iilio,, dial M tii,ii..rily u|' ili,-. .•a>r- miv .lur- a.lrii/,-,1 l,s mark,., I all.iiiMMiuria fn.in il,, ^,^■^ l„.;:i„,iirii.., an,! i|,al 'li|'litl.'ri.' aiii^iiia- air ili-liii.t l_v mimiv ln.|ii. i,i tlia.i in lli,. ..il,,.,- |;,n,i- 111' l\ [iliii- li\ ( r. Ami,...- |I„. i;„„,- ilial al.„.,-l alua.N- ,.,,1 lalalK ...i.-l I,.. iii,|,„l,.,l the s,)-, il|,i| hemorrhagic cases. •^''' -'i 'I''- \:ii'i.l,v always iv.viv ,- raivrMl ,-,,|iH,|,.-ali,,M in ,|,^,|i|,- lioii- (it III,, a, ■I.I,. i.\aiillii.Miala. I.i.t liltl,. atlciifi.ni i, .|,.s,.t,.,| .,, |t ,.\, „ III .,ii„.ulial l,,iii;,.r ..v,.r,. ;"''''i' I'li'Mnii.ri,aa.v„l,M.,-v,.,|. With tl.Hiivt a|.|M.an.i„.,. ,,r t|„. rasl,_ II. the ~,.v,.r.-t ra-i- at tlir .1.,! ,,f til.. H.,,Mi,l ur lM.Hi„„i„jr ..f tlu^ thin! ''^'> "'■' lix'i'-.', ImIhiv li..n. is any M^r„ „(• ;, la-i.—riiMii.T,,... ,„.t,.,.|,ia. mak,- tli.ir ai.|iraiaiM,. and aiv iininr. t,.|y (;,||.,w,.d l,y ...xfiiMvc livni- "iiliaui.s int., ,|„. ,ki„ :i,„l snli,.ntan....ns ,.,.|l,.lar tisM,,. ",,»• th,. trunk and .•Mivii.jti,-. Th.. ninjiiiHiiva. aiv inj,.,.t,.,|, ai.,| h..|ii,,rrhair.- (n.n, tlir lil>s, t.m-i.r. ;:i„n., and ii,.-,. n.akr tli<.ir a|.|M.araii..,.. Tin- i. i;,||,,u,.,l l.y ..,.,.hy,„„M, and ..funin;,- „f th.. |,hary.,jr..al .tn.,.t..r,.s aii.i .li|,htl„.ri.. .•.M.d:,t„.,i ,.r -i,..,.,.,„. „r ,h,. n,n,.,M. ,n,.,nl,raii... S,„n h..n,atiiria „f .vnal .iri^Mii, wiih M,n,. „f -,.v..,v n..pl,r^i-, aii.l aK„ li,.,„al„ria ,!.„. t,. ' ■'''■'-•■ "■'"" •!"■ P'lvi- -f the ki. y and the l,ia.l.|,.r, aiv mi,„.,- a.l.lrd. M^my,,rtli,.,,a,|,.|U,,.a,.|y,.x,„,.,.„,,t,.aM.n.sanir,.i,„.„nss|,..t,.,n. ""■'■.• aiv ,.,„i.„li,la,i.,ii-„f ih.. ,i,iln„.narv ti~Mi..s, s„„„.ti,„„. .,,„1|,„„ i„ jxan^rr,.,,,. „( tlio I, ...... Int..-ti.ial h..|i„.rrl.;i^r,., and. in ,1 as,. ,,r w..iii..n, al.iin.lant nwiroiTliauia ,.,,n.|,|,.t,. th,. li,,nil,l,. ,.|ini,.al ,,i,.„„.,. ,„ "''"•'' ''"■ "'''"'• ^"'"""- "■'■'•<• i" til" h.ihit „r applvi,,.- the t..r,„ " r ai.lti,.|i,.r." In ii.,,-t ea-..-. tl... a|.|M.a.';in,.,. .n.d ,i..v,.|,.i)M„.nt ..f th, h..|n,.iTha-e* iiv a,.,.,.„,,,a,ii,.,l l,y a nipid fall ,,f th.- i,.in|.,.ran,.v, uhi.-h off,.,, sinks t" an ..niiMiallv !,,w l,.v,.| j...t JM.II.r,. ,!„. ,.,,,1. V„y ,lavs |„.|;„.,. ,|,,,„|, It IS .iften im,„,ssi|,i,. t,, t;.,.l the |ii,l.,.. 'IM this ,.xtr,.|.u. pr.istrati.ii. of :,H-2 ryriirs iivi i: Im :lt| I llillli iImi-h -u Ih.IJI-, ' Mi\ I, null ,|. tlir\ • ' " .^ ■iiv liriiil\ iiupiv— ,,| , ri'A.i- ."■.iiiiv. " '".^ "" lllnlv. II, |,|.|l,l,„.-i '"'■"' :^'i''"'"'" ""-I 'I- ..,.. .\,i„i,i. „n,.. ^.a,. „r ;'"■• ",'":' l;'-';— ^' -M-^l ■-!. uln,.|. la,., -I,,.,.:,,,,,. ,;.„i,.,iiv ';;;"""'■'"• '•'^^'•"' 'i"--,:,..!,. ,i •,..„rui,„.i, „.. ,i,„;„i :;:;'''■''-■''■'"'•'''•' ^' '-'--' --i -u...: .,„.... C-.l|l|ll.ir\ ..../ll]^;. , ''''"■'"":' ■";'''"" '■-- '" 'I'i- ^-■-1.-1 ,l.„ ,.,,,1 la.allv ':;/;7''^';'''''r''' '■'''■''' '■ ^-"— i ■.1...,..,,,, ""''^'-"' '" ''"■ ^'i-.v l'--i„im,:.. ,,|- ,|„, i„i,i.,| ,,,,„. , ''.""■;"'• ' 7-^'l-"l„. I„. .,,,.,71.. -.ul,i,.|,,M,-i,.,lv '""'"■'"• '•--'i""'i„.,„.,„ i-. i,a,i,ai,i„„„i, ,.,;,,„„_„;: „. uyu.U;a ,.,.,..,.|„a.. a. w.ll a- ,l„. |„.,.vi„„-lv „„.,„:,„„.,, „,„,„,, "•iitaiicniis lici„,,ri-lia!.^,-.. Tlh- iMIipcl-allllV-rui-s,. i„ thr.c ca-,- i- v,ii,l,l,.- , ,„ I -11, .1.1 \aiiari,i', ^(.tiir ca^cs arc Hiarari.,-,/,.,1 l,v liv,„.,-,,v,vxia ; ,„|,„., ,,,|,i|,j, •■"iii--c. uitli r,iarkc,l iv,,,i^M,, '•'I'"': •'-•""• 'l"'i-'' ■•,,•.■ .■.•IV- i„ Mii,.|, ,|„. 1,1 ,i-,vi;iilar (M, ,.;!,. ',,- "I- 'Aril ii,Ir,.riii.--i,,,i- si|ujr,..tj,,jr ,.,,]. ,.,,, . , .'|".ir:,ii.v ,,r til.. Iiriiicr- -": '~ " '"""■'' ''^- ■■' "-'■!-'' I^'ll in ,l„. ,..|ii,„.,.a,i„..., „.|ii..|, '''-■'--- •''^'V''" '■''^''^''■''■'''"■'' ''•''-'' 'I- -■•••v,.,,,..,|.v ,.,•.,,, .,,,1 '"^"' """'"'"'^ ni.-iTlia,-,..: on,.,. i„,„ „,., |„.,i„„„,,,,„„.,. ,„ „,,, ' r,-/,,,,,,,,,. ./,,„,, ,,„,, 1^^^ ' •'^•'■.,„ - Uuiiill,., >.•,.,, „.l i-cl,||,,,|, vol. i. /7.'/(, \//S/,N I \/, I/,,/. / I/,// ) 5H.-1 -■l".ll-Mu,l.,l:,||„„„mu.i:, i- a ,„„-,. ;•.„„•..., I- ,|„-^:,n,.^ „mI ^''"';:'".",""""'''^'^'-" ■'>,•„,:„.,,.-.,.,.,,„.. „„,„,„.,.,„.;,;„.... '"■ "^'"'""^^ -i.,.ai„.w „ „,,,„„, ^, ,,;,,^_,,^ ^^_,^^^^^_ '","'^ ''''"•""'■• ^'1'' -'' •!'•• '"^'J""i> ,„•.-..,„ ,1,, ,.,.,,,1,,.., .,^„_^,,_ .i.lMiaiMi.- ' |i,rm ,,|' il„. ,|i-,.a-r. .|H.<- PROGNOSUi: MORTALITY. General Consideration of the Mortality-rate.— II,,. ti.M. a, ,„ ,l„. ,Mu,-.:,|i,_v „!• ,v|,Ih,- l;^,.^ i„ i,, |„-„a.|,.-, -.,,-,. j, „o. ,..,-v '" '■"'^'"''- ■'"' '''■•■• ^t^"i^'i'-- ^'1' '^1. .•xhMMvv, a,v „(• „„ val,,;. '"'•H,.. ,v|,l,„„l an.l ivIai.M,,;,^ ti-v,,- uvr.. not .li-,in^,.i-l,n| tr,„„ .vpl,,.^ I'""''""'' """'•'"" '■^-■" -^""I '1- 'i;:M,v, .i.... an. ,l,...v.;;,v „H> Kvrn in lat..,- lin,,-, l,„„..v,.r. u I,,.,, ,|,i. .Ii-,in,.(i..n ua. mun. a.vn- ■■^'"^- -MM,l,.,,lMT..,,a,M-i,.sa,v t„„n,| ,l,a, ..ann,,, l„. attnl.,,.,.! alt .tl,,.,- "';'7'" i" "'-li—. 1 .. ,|,.,,..M.| nal,..,- -T,„., .,,•.. |„.,;„i„„ iiiid dia^iin-i^. Tip. ,rr,„. ,M,ally ...Mil, in an ,.v,.,.-mv,.|v lu^l, ..Min.at. oC ,|,.. ■"■"•'al.ty. ,.,,„„.,allv ulu.n. a, ua~ ,|„. .a,., n, ....-tain .v^^ion. a.ul ..t '';■;■"'" '"■■':"■'- """'''■^'' ""- "'•'■'■ "-' -M.li,.i,.n,iv train,..! „. ,...,..„nn/.. A.,.,|-.|,.v.., ,,„.,! l„nn.an,| .la.n.t;,,-,. I,a....l ,|„.i, .,„i„i,„ .,„.|,„i;,,^. "" -I- uvll-,|..v..|„,,..,| an,! >..v,.r,. ,.a... ,ha, .ann. un,!..,- tl,.!,- .,l...p. vat A^ain. al,|,„n^l, tl,. a.t.n.pt n,id,t I,, ma,!. „. ,.„n-..ot . .,•,•„,- in..i- : 7 '""";"^"'; ''-'■''•"' :.llnnn,h,.,.„r..a...|,v a,-i.,n wit h .Ha..,, nu.nl.,.,. „, .■..,.„■,. ,|..,.iv..,! n„n, vari„n. ,.|,i,|.,n,i,.s '....nn-in.. -.t van,,n~,nn,..„.„.l,..n.nu.,nl.,.,...,ltl.a,tl„.n,ali., v „r tl„. Wi^.'o .-nl.,.,.t t,. tl,,. „...a,..-t variation-. n,„ .,nlv in ,iifK.,v„t I.,..aliti,.. an,l at van,,,,. ,.,.,.„„1„ |,n, ...,,. ,ln,-in,. ,li,r,.,...nt ,,..,-!,„!. „f ,|J ■an,,' <'|)irlMlity ;uv wuA chilH.rate una l.;isr,l om iIm- Imp.'cM miumW.t cf <"isrs. u„ ll„- 1.:,m> oI 4 , > , .■;,>,> nvMl..l i„ th.. l.on,lnn i-.'V.T lln^|,ilMl l,.-t«r»M, IMSaiul iHi'.' ,-,lrMlMtr,l ,1h- ,nnr- t'llilv U -'OM' IMT .ri.t. Anion- !l4s.". r:i>cs inlniitlnl I., llic Intirmary at (■la^M.u iliiiin- a |.cn."l of ..U'Vcn Vfars, la- i-q»"-t.^ a inortalitv ot l,s |,..r tvnl aial -1111011- I:i7t» iiatii-nts ir.alnl in aimtlur (.la,-'_'ow lio>piIal llio ,u,„-.alitv ua. i:;.;, or IT.'-':'. |i.t r.iit. Alnr .•oU.T.iu.^ lliv .■nornions nmnluT of is,.-)'.!!' raM',-. olMi-vf.l l.y liiiiiM-lf ami oiIkt antlioiv, Mni-cln>oii tiiiall) .Ictoniiiiif'l ill.' nioiialilv lo lir l^.TS jicr 'vnt. K,.,,,,, iMV anaUM^ of ilu- liTf, ra^r.^ tlial I obMi-v..! 111 Moalal m llir vrar.* from ls7(i U< \X'i'K aliuoM all of Nvhi.'li ranio from tlio moM ilotitiilc .'la.-M'S of ihr |,oi,nlation. 1 oUlaincl tli.. alarminir litrnro.if :^:;.4 per .rnl. 1 l.f ili-trilanion of llu' casts for tlu' tlir.'o years was a- follow.- : _ _ \(lMiitliMl in l^Ti;, 14S; iloailis, 4ii— '-'7 por (rnt. : m 1>,N .^i ; 'Katlis. o._)__-j,-, :; |„,,. ,.,,,,1. ; in 1.^7'.t. 441 : .Icatlis. ••7— iM.x prr r,hi. A niorialiiy of tVotn lo t,. 1 'J per .vnt. or ovrn lu p, r mit. aial l.-s |,a- li.rn ivporiod in a fou .■pi.l.mir- of minor .vt.nt, ,liara.'t.Ti/c.l l.y uniiMiallv favoraMo .•on.liiion.-. It far moro fro,|nontly liappcn> tliat .lu> „„,rtalilv ri-.- al.ovo -J.i an.l a> hi-h a- :!n l-or r, nt. S.irl, hi-ii ti-nns ,„,, ,,,„.h,,,l i„ ,.pi,!, nii<- « ii.n the HMJal, an.l .■onH..pi.nlly tin- in.liv i.lnal, ,,„„il,i,,n-aiv paiti.-nlaily nnti.vorahl.— a-, for in-tan.'c. wIkmi tli.' ar.ii-na.'' .■al.'ulat.-.l tli.' mortality at :!i;.;i per -•out. ' In lio-iiital- a ni..rtalitv of fr.mi -I'l t.. 'Jo p.T .cnt. i> .piito .•omin.m. It i-.ifton Tivat.T than it is amon- tlu- .ait-i.l.. p.ipnlalion .l.irin- the s.,n,o ..pi.l.ni.i,-, .il.vi.Mi^lv ..svinjr'.itl,.- fa.-t that a ivlativ.4y lai-.' nnmh.T of .■v.-iv ...M- arr a.linitt.Ml. TIh' hiudi mortality of -1.14 p.r .•out. that w ,1.1 ill 1S7I> in Moal.it .■onl.l U- hronjrht .lown t.i IS.S p,r .-.■lit. i th.. .-as.- a.lmitt.Hl in a m.ailHin.l oii.liti.-n an.l tli..-.' that di.'.l h.loro ,,,„ ,.ml „f iortv-,.iuht h..i.rs w.mv ,i,'.!n.-t..l from tii,. total. .Muivhison mUo -tatos that tho m..rtality-rat.. in iii- tTS7 .'aM- wonl.l I- iv.hi.rd were t.i make the -am.' ic.-iiva- tr. >m tio'i. 2(1. Sit to 17.0 piT i'<'iit. it la- Tlw .•..n.litio,,- that .l.'t.rniin.' tli.' .•hanicfr. ani!()(:.\()sis AM) MoirrM.rry. 685 (;»nrr;il external and personal conditions liavinj: an inlliuucc ai'c. rcl,..i\(l\ ^]H•akin;.^ iini<-li licttcr kiinwii. Aiii.iiij: tlic -nicral cxicnia! cinitliiidn- geographic distribution, weather, and time of year were, im dmil)!, foriucily of iiuicli urcati r im])ori.iMC(' tliaii tlicv arc to-day. Certain ol' tlic nldir autlioiv >tatc that tlirv (il)~cnrd a ili^timt iiicii>a~r in tlic virnlrn<-c ..!' typhus t'.'vcr in ci'i-iain coinitric^ and (hii-in^r "■crtain -ca^on- and wciithi r ronditions, l)iit at |irc-cnt we know tliat sm li factor- arc only indiivi ily iniiiortant in so far a- thcv aH'ci-t the -ocial and jicr-oiial coiidilionxif the |Mi|iulati(.n>. Ilcfcrcnci' lia- frcijncntly l>con niailc to the fact tliat LTcat national di-titution, famine, war. and -ici^cs favc. Anionu- individual conilition> age nmlonhtedlv exerts the "greatest intlncncc on the mortality. In childivn and yountr individnal- nnder the ai^c of twenty, Jn,-t as in tv|ihoiil fever, the mortality i> low — not more than from 'l to ■"> per rent. it i- materiallv lii;:hcr hetwcen the a^^c- of twenty and thirty, and in severe ejiidcmies niavlic donhled or more than douhlcd. lictwceii the ajrc- of thirtv and tiirty the mortality is fonr timc< as liijrh as amon^ individnals of nnder twiiity, and after i'orty it n>c> to a stn|icnd<>ns lieitrlit. Thn-, in Moaliit in 1S7H almo-t two-thirds of all the deaths tK'ciirrcd in individual- over forty year< of aj,'e, althonirh of the entire nnmlier of patient- admitted only one-(|narter were of this a^'-c .Vjiprox- imatelv the >anie proportion has l)ccn ol)-erveatisfactory ex|ihniation has so far heen offered. Children inider five years of aire are in jrrcatest lianircr from the disease, whereas the period hetween ten and litteen years exhihits the most favoral le niorlalitv. In the latter jM'tiod the mortality raiiL'es hetween ().•') uiiil 4 per cent., whereas ainonir children under live it varies from ti to 12 Jier cent. The intern'ediate class, 'omprisintr cliildren iietween theaL'esof five and ten. occupies a eorres|)oiidin;r internieiliate position as retranls tlu' mortality i 4 to i percent.). In illustration of this jioinl statistical tahles of Murchison and < Jnitzer are added. The former collect(>d his stati.sticw from the records of .')(i:> children in the London I''ever Hosjiital : I'lulcr "i yriirs Bctwi'i'ii •■> Mini in Vr.'ir- . . 10 ■■ 1.-, ' •• . . (Jr.il/.er ha.sed his cali'ulations on \')>^ ca.'^cs of ciiildren in the Hreslau epi,;;! IS I i."i I'li'lii' 'i yoiviv liilwirll .'i mill 10 \riir- " jo •• l.'> ■ Ailuiiltcil. nicii. IVr .-I lit l.'i 1 li.tii'i 41! • ) t.Tc. 101 1 o.'.i;i -j.Sd TV nil's I IV i: 11. n •'^?^ 'I'd illu-li-Mti' llic iiiorlalily :uii'iir_' ;ill :il;i-> 1 -ivf iwo l:iMi> l;i>iilnM vrrv hirirc I'lLMiir-. mmc !■>, Miir.-lii-.n. I'li-'l nn :',:>()(; imm'- ;hliuiltiii \<> ilic l.ciiuldii I'.Acr llo.-piial iIui-':il: ini ycai>. :u»l a latci' niir li\ (iiill>laiil lia 1 on .'i.i I.") caM.- acliiiilli-il |u |'ni>.-iaii lin-|iiiaU ihiriiii; llu' _\cai> iVnin 'I'lu- Inllnwill- aiT lllr ,-Ulli>lic> (if Muirlli.M.ll ; \--i Sum l.cr (i^Iiiiini .1. iiidi I'rr iciit fiHl.r .". \ f:ll-- . . 17 :', i7,i;'. B.tu.-,. 11 .'. iili.l 111 \.'ar- ^ in ■ I.-. ■ ■• . . IK! ;'.ii;i 14 IS 4. -.I.-) i:, ■■ •!» ■• . :Ai\ •Jli 4.711 •JO ■■ -J."! ■■ . ('.la 47 ;i.o.-> *■ U", ■• :'.n ■■ :ll:l .")•_' l."..I.'l .. ;In ■■ :',.') ;',*';! *>•> 17,112 :;."• •■ in ■■ :;7ii W> mL' 'Hi 111 •■ I'l ■■ . . "J'.c «7 *".( 7'.i 1.-, •■ .Ml ■■ . . -Ji-J :;■.! I.-. K .'id ■■ ."i.'i ■• . . ivi 7H •"iLMMl U ."].'. ■■ r,o ■• . . Khi .-,1 .'iMK) «• i;ii ■■ i;.', ■■ . , HH 4!i .",.',, ii« t> t;.'i ■■ 70 •■ . . A-1 :iH liiiiiii 711 ■■ T'l . . -'t 17 7n.So 7-1 ■ ■ >n . . I'l a h:;.:::! ( P\.M' Nt ■• *) IIKI.IK) , . ."ill 7 la •-'•-'.(M) ;!.'i(iii (iutl.-ladl^ • >lali>li( s arc ; Miilo. I', laillcs. 1'. re. Ill, i'cli .m, 1! in 1111(1 1 '. \cins . •'111 l,."i 1.-, ■■ -jn ■■ . . ■' - 1 .-. "n ■■ ;;(! >. J lll.l :;n ■■ In In ■■ .'.n . . Kill ll.L' . . ai.'.i •.'n,'J ( K. r .'lO • ■ ( ;n (id 1-7 ■■7, 1 4.1, ■-' M\- nwii Iliad rial. (■(in>i>!inj d' 41i>tMiil Salniiinii. llio liillnwiiiLi- lunrlalilv lor tlii.- dili'dcnt a^is ; i'(r((lil. Kr.iiii In 1" -II ) i-di'- . ■jn ■■ ::n ' ■■ " :;(i ■. m •■ '• in ■■ .',11 ■• (ill ■■ 711 711 ■ >n •J.'iO .■,.411 •J(|,(H) 4x. -"li! (•,:>,.(■,:{ Ii-J..'i0 Inn. (HI Tlir iitt-rr|ii'iti'il -tatcinclil tin! lllr rtl'cct iii' aLIc 'HI till' ]ir(ii;ll(i-i- i,< to lie atniliiitnl 111 lllr iliiiiini-liiil |i'i\\cr- dt' n-i-lancr ai;-.iin-t llir niii in- ni-'j.ini-m anil it- lnvin-. jii-t a- in tlm ntlmr aciilr inlnctimi.-^ di-ca.-i--. i- a niiTi- |ilaliliiilr. .\ iiiurli iikii-i' lanuildr rna-nii I'm' llic rajiid v\-v 'd Miiirt.aliu- .at'li r llir :il:i' ('t' tiirl\- i- Ik lie lliiiinl in llir ranliac wcai^iir-s lli:it i- niiirli iiidiv iiridiiini 111 dnrinu llii- |ii ridd (d' lilr ;iiid in lln' |i:ilii((ii;,ir\ (■ iiii|i!i(aliiiii-. c-iHci.illy liy |i(i-tatic iidliiniiiatidn,-, ■lirc'lly (l( pciidiail n|i(iii it. l'n(i<:.\(jsis A.\h MoirrMiTY. ■ >Xi Till' \\\\s\\ iuiirl;ilit\ iliii'iii;: tlic iicriml Imiwciii tliirty ami t'urty. in iirniiiiftiipii III tliat iili-c r\((l in (itl'cr aciiti' inticliiiii> di-ca-c-, i- jnul)- aliK iliii' In llir lar, tliat tvpliiis t'cMi-, \vlii<'li |)i'ci( ralily altaiU- tli<' iHHM'iT (■la--r~, ncncraliv selects lliu-e inili\ idiiaU who liavc -iitl'eiid iiiii-l ill llie striitj;;'!!' tor existence and \\ho~c ■tniii^tli lias liceii .-a|i|Hil li\- U(ii'r\', vice, and ueiieral de-titiitioii. A- i-'^'ranU tile reinarkalile dillei-enee- in the iiiortaliu ol)-er\ed dili'inu' llie tlii'ee |iei-io(U of childhood, we -till lack the lice;-- irv data to otVei' an ex|ilan ilion. it iniuht lie said ot' the [icriod lieiueen the tenth and the tit'leeiith \iar that the clinical niateiial is selcctnl. iiM>- niileli as onlv children ot' <^ooil c pii-iitiiiion and nood powers ot' re i l- ance attain that a".'!' ; and as regard- the lir-t juriod, the death-rritc is [icrceptiMy iiicreast'd hy the tiict that the children are still contendinL: with the ditliciilties of early feedine- and with iiilieritcecnliar inthience on the jiroLTiiosis has lieen aliandoncd in the liifh.t of more recent experi- ence. The <'ll'cct of the-e two factor- can onlv he indirect, and they ari' of inrineiiee onlv in so tjir as they determine hodily and leeiital over- exertion, insiitlicicnt or improper I'ccdin^ and modes of life, and ;; neral har(i-lii|)s. or as they favnr the development of chronic disease, and the ac(|iiirenieiit of passions and \ ices, especiallv alcoholism. The markeil intliieiu'c to he altrihnteil to poverty, disoase. and vice in freiieral is ilhlstraled hv one iif Miirchisnirs tallies, in wliicli the ■>'>iH'i patients iidiiiitted til the London Fever Hospital aredivideil into three cjasso : /■'/;■-/, those ill iriHid eircuMistaiiees ; .■ri-i iiiiidica" liavr liccii kii(p\Mi ;i- ihi- 111(1^1 ilrtailcd tiirm- nf the di-ca^c. Ill ictiaid lij llic constitution, llio~c wlm ai-f naturally (lcli aii\' iiti' ai'c, rvcii uitliuiil fci^ai'il tn aur, tniiver\' Irnni sexcro Ui'iile iiit'eetions di~eaMs, appreeiaMy augment the danger nl' tyjilnis t'eviT niH'd hardiv he ineniinned. That hiMlilvainl mintal iiverexertinti exercises a marked inHneiiee (in tile |iriiiriiii-.i-, even when tiie individual- jidsse-- a strung eciii>titntii)n, are Well till and <>\' a t'avnrahle age. i- -hnwn hv the (act that in all the inure e.\ten-i\e e]iideniie> an Mini-iially large nnmlior of victims were drawn from among |)hy-ieian-, lio~|iiial attendants, ministers, and otlieials in pnhlie institnlions. W hether mental < ion, worry, and <'\eitement without aeeom- panying hodily distnrhanees t< nd to increase the danger from the disease, as ha- liccn iiisi-tcd upon partienlarly hv the older authors, cannot with certainty he determined, hecause it i- rari^K possihie to estimate tliuir intlueiiee apai't from the aliove-nientioned l:i<'loi-s. Not only the surroundings of the patient lietlire he was attacked, hut al-o the conditions nndi'r which he lives during his illnc.-s, have an important hearing on the mortality. i'roper treatment unipicstionahlv lower- the mortality-rate. Among experienced hospital phvsicians it i- generally aeccptcd that any di'lay in removing the jiatieiit from his r.ii-eralile -(jciil eouililion- Into the moiv favurahle surroundings of the hospital -eriou-lv atl'eet- the proirno^i-. 'I"he etV((t (.f sex oil the mortality of ty|)hus fever is purposelv ti'eated attli'did nl'oiir remai'l<-oi, the proguo-is. Iiecanse it apparentlv doe- not I \<'rt aii\ direct inilueiiee upon it. The lower moilalitv oh-erved amoTig wnmeu i- cxjilained hy the eirenm>tancc that the female sex is much lcs< ex|io-e(| to the dcleteiii ill- iuHiiencc- that are uatnrallv ineideiil to ilir jil'c iif mall. In time- — 1 2.-i |ier cent. — wnmen. In 1 •"< 17. ilnrin;: a severe epiileMUL' in w. ■>I.\ |ier eiMit. lit' tile nun ami (inlv "_M(.7 |per cent, ut'tlie women snccnnilieil lo tile di^'ase. Tin- miirtalily aimini: .Miireliis(Jii's :i.">l)(i |iatienl.s, .■ilreaily discusse'l t'nim nther pninls nf ■ iew, amoiiL' wli.im lliere uere almost as manv men a.s wnnuMi. uas 'Jl.l>> |ier cent, t'nr the men and lit. Ill per cent, fur the women. \\ liitliei' certain races |)(is-e~s ;i (liniinislieil [Miue'' (it" rcsi-I.uiec to tlic tic -i^ruitieance. Thev arc just as likely to Usher in a shift of 4'ven au abortive case of the disease as a .>evei-e on . On the other hanil. it may lie said that a mild stai'-o of inva-ion aln\o>t always indicates that the ^nliseinient course of the di— ca>e will also he mild. \'ery nirel\, chietly in tiic senile^ tofnis, it inav hajipen that a com|iafatively .piiet a.nd apparently mild initial siap' leads to a priiti'aeted ilhn'-s with a liital i-esult. I)urin;:the ~uli-eipieiit course lit' the disease certain general Symp- toms and the aition of individual organs and ~vstem- exert a deci-ive inllueui u the pruuno-i^. Anioiie; the-e ti/ature-. the nio-t eiin-iiiruiius niauifot.atiou of the fever, the elevation in lemper.ainrc is uiidouliieillv ut' LTeal proirno>iie importance, althoueh it~ -ionificanee has in many res]ieet~ lieeii exat:- irenited. \'ery hiuh temperature duriuir the initial staL^' or duriue- the lii--t week does not absolutely Ju-lity the expeilalioii of a simiv iliue~~ or even a fatal termination. On the other hand, the pro-peet i- not briuht il a coutinuod or cnutiuued ii initteut fe\er, with a verv high average ' (^lMtf,l l,y .MlirrllHi 11. ."/Ml Tvriii s I i:\i:n. '.* \ m t( iiipc riiliin-, [ici'-i-t- .iIkt the tii'-I \\(rk. Coiivcr-clv. a t'aV(pr;ililo pi-ci^r- Mo~i- l.a-ii| nil ihi' iii.ic Tail ill ilir tiiii|>i'rati]rc alter tlic fii--t wcik i> lint jii-lilialilr. It lia- lucii -liiivvn \\\ -ivcral cxuiiiiilc- ( l''i:j-. (i!i and 71 ) llial filial imilracliil ca-c- may -Imw a iicr-i~tciitly low l"iii|itraImo (lining: tin' la-t tl'U day-, or cviii a «rik. lirt'niT dralli, diiriiii,' wliicli llnir ..iliir (iiiiiiioii- -\ iii]i|i.iii-. (■Miiiiniir willidUt alialctiiciit. Il i- \\i<\ |Hi"ililr Id -tall- uilli rrrlainly wlicllicra I'all nl' tcin|Mra- liiic 111 llic -ivciilli day, wliirli, ac vdicliii;.'' Id W'liridcrlirli, i~ tv|ii<',il ot' a laN'inililc iM-r, may lie ciiii-idrn-d a lasuralilc |iniL:iii>-lii' .-i;.'ii. Wv- sdiially, I lia\c raivly met wiili ilii- iiliciKimciinn. ( )ii ihc hiIk.,- lia.nd, marked irmi— idii< ;iiiil iiitt'rini,--iiin> (icciiiTiiii.^ early nrc mulcitiiitedK (il ta\(iral)le umeii. 1 he aetiiiii 111' tile eireiilalory driraii- is cif I'ar j.M'caler im|(nrtaii<'e ill the |)run|ii,-i-, and alliird^ a reJiaWle mean- nt' jildiiiiii: the coiiisc lit tile di-ea-e. A- lia- iieeii -tatiil el>e\vliere, tile piiNe in t\]illlls lever, lint 'iiilv in wiiiiieii, eliildreii, and nld |>ei'-iin-, Kiit al-n in vi^iir- .111- men, i- urieii ]>rii|iiirtiiiiialely Ncry ra|)id, iiotli earlv in tlie entir.-e lit' the di-ea-e and during'- ilie entire telirile [leriiHl, the plienonicniin iieiiiL;- ill aeenrd \\ itii the \ inleiiee iit the ninde ut iin-et and |ire-pntinjr a certain enntia-t tuwliat i- iii)-er\ cd in typhiiid fever. 'I'lie pulsf-rate il>elt', althniiiih it iiidieate- the early ;md distiiiet invul vcmelit of tlic lii'arl, i< df e\cn le-- impiirtaiiee than nther iiualitics of tiic pnlse, fspo- eialh Vdlunie, teii-iuii, and reixidai'ity. The earliei- the jiiilse iieeumes xift and easily ciiinpre— ilile, or iinei|iial and il're;;iilar, the more nnfa- voi-al)le the ]iroiriio-i-. Karly irreirnlarity of the pulse I believe to lie an e-peeially nsefiil -i;.rii. It iniist, lio\vev<'r, alwavs he renienitx'red that reeiixcrv lia» lieeii known to oeei.r even in ea-es in wliieli the iinlse \\a- liarely |>erce|)til)le for days, and so i-apid tliat it could liardiv i)e ooniited# Next in iiiiportanee to tile ijcliavior of the eireiilatorv svsteiii from :i |M'oi.rnostir point ot' view i- that of the nervous system. It is evident that -evere di-tmliaiiee- of the central nervous system indicate that the elicit of the toxin lia- liicii p.irticiilarly marked or thai the iinlividiiars power df rcsi.-tancc is miicli rcdneeil ; and thus the cai'licr the a]ipcar- aiiee dt' iiervon- svni])toms, the more iinfavoraMe the proirnosis. One -lioiiKl lie p.irticiilarly 1.1-iiardeil in iiiie'< prot'iiosi- when stupor and coma iii;iiiife-l iheiii-elve- carK'. .'^iieli c.-iscs arc n-iiallv graver than ca-e- in which the mind i- le-- m.arkediv .•itl'ccted, e\cii than those in which llieie i- violeiil delirium in the evcnin'j and dnrinj,'' the nii;hl. ( 'iiiii|ilclc iii-omnia iiianife-tiiii.'' it-elf diiriii:.'- the tir-t davs nf the disca-c wa- ju-tly con-idercd a \cry sii-picioii- sxniptom hv the c.ldcr t ;. l'l:(/(,.\(fMS AM) MnUlM.iry. rm ;iiilli..r-. It i- not iiitV(i|ii.'iitl\ ^i |)ivciii-c,r lo \\n- !hi|)(li— nianifi -t:i- liiiii 111 llir ili-ca-c llial li:i- Ih'cii :i]i|1\ i|<--i;^ii:il((l cuiLi-x i^il. .M:ill\ |ili\ -iciiiii- I. lid llir (HciiiTcMcc ol' -|| I i-ii 1| ||- !iii( I iriiini, (•:ir|)linliiL;\ . ami cIimii ii l\\ ilcliiiiu- ami linndi-- a- aiiioiin ilic nin-t (laiiuci-iiii- -i^ii-, ami it i- cirlaiiily true that tliixdcciii |\ in \tiiin- ilu m>t. Iiuvmai'I-, all'cci tlic |ii(ii.ni(i-i- in tlir -ainc lAtriii a-, tlicv dn in t\|ili(n(l trxcr. < )u iiitr t(i tlir -(■If-liinitcil am' |-rlati\(ly -liort dnratinn (if t\ |ilin-- i'cvcr, the |>ali(nt i- alilr tu witii-tami. until the cii'.iin-cnrc of ih.' ni-i-, iiioil,ii| ( ditinn-. that, if they wcrr to contiiiiir loiiLivr. umiiil cri-tainly kill liiin. ficiirral coiivnl-ioii.- arc ot' iiiitavdialilc mm ii. Tlic {.Teat iiiajoritv of adults att u'krd liy < viil-ioii- die ; w licrca- cliildrcii, w ho, a~ i- well known, arc attacked hy coii\nl~ion- in a larjrc niiiniicr ot' iiinch Jos jjjiiivc <-ondition-., arc more likclv to fccovcr. Altiioiitrh \vc ate -till ill the dafk in rc;:ai-d to the causes of many clianirc" in the |in|iil in typhns t'ever, ue know from ilinical ex|)ericnee that a tew of them are ot' iindoiihtcd value in protein »is. In -e\ere eases diiriii^r the heiirht of the disea.-e and, what is even worse, diirin^r the (ir-t week, a very -liii:jpi,|i reaction to li of the wor-t sii.riiitieance. This phenomenon, (lcsi^rnatcr either the future health or the life of the patient. Ti, ■ -iv'iiticance of catarrhal and pulmonary affections varices w iddv and depends chictly on the ap' of the |)atient. Whereas children and youiiir hcaltliy adiilt> under Iwenty-tive years of aire iisiiallv hear an extensive attack of liroiichitis or |)nenmoni:' fairly well, the-c eoinpli- cntions seriously threaten th, life of" ohier persons. It is not too much to siy that at'ter the aj^c of flirtv mo-t nbordiiiite importance, l)oth fi-oni a clinical ami proLHiostic piint of xicw. Diarrhei i- rre, b'lt I have met with it both in mild and in severe ca-es. ('ompli(v- tions with (ly-eiiteiic phenomena, which have rareiv been obserx ed till 692 TV I ■III. -^ II III:. i «j*-v*f.- sV-' 4 iliii-iriLT l!ir in.,-! iv.,ni . |.i,l, ini. -, wviK- iii-ll\ ri-i::ir'lr( I ii- jrraxc :ii ri- iliiil- li\ ihc i.Mi !■ :iiiilii,iv I K.inillicr, I't-i.-i iik, :iii.| ciiIh r^i. .M\ I A|ii III ■ IcaiU IMC |o ir.jani -cxii-c iiirlii.ri-iii. uliidi i- (lirtn- li:ilrl\ a rail iM'ciini HIT ami i- iiiiiloiililcclK llir ri-.iilt ufa -ixiii iiilip\- ii'.ili I' till' iiir\i- -ii|i|il\ ill;; llir iiiii-iMilar wall- of llir int. -lino, ;i> 111' till' v^o|■-l |irnL:iiii-tir -iiillitiralirr. I'll'- I'liidili I' ill.' iiriiii'. liiilli pliN-iial ami rln inii al. alliniU I lie lili\-i.iaii iiiaiiv \aliiaMc liint-. A niarknl .liiiiiiiiiii.,ii in ihr ^m m "I lll'iii.', or loinplilc anuria la-liiin maiiv ila\-. imliiai.- a .l.oi.r III .•aniiai- wrakn.-- lliat .Miiliially |.io\.- I'aial tu niaii\ |iali.'nl ti> ihr iil.l. r nm- al ~i w iilidiu r\.'t.|iiii,ii. A iMi-i fill ilit.Tininali f llic aimmiil III' alliiiniin in tli.' nriii.' i- imi will i it- ini|)iirtaiiri' fm- ih.. |iri'M|ii,-i-. 'I'lir larly a|i|i.Mranri' ut' .nii-iilir ,1,1,. .n nil- n|' allniniin i- .lii-rrviij ii|il\ III -.A-.T.' CM-.-. If. in ail.jitiiiii. tliciv i- licinalniia. witli the iiii,Tii-cii|iic tiiiiliim- cliar.actcii-iic nf iic|iliiiii-, mic lia- tu .leal with a \iv\ ui-a\c .■.ini|ili.-atiiin. .Vimni;; all .'a-c- in |i.r-,in- li.twc.ii tliirtv ami liifty y.^if- ul' ,iu.' vvilli m'|iliriti- tii.' iiiajmitx .ii.' ; aiminj.'- |iati.iit> .if imirc aiKaiic.d -a'jh rccnx.rv i- .ji-tinclly .•.\i-c|(iiiiiial. It -cciii- t.i tu.' i-allicf -i;;nificaiit in tlii- ciiiimctiun tli.it in all iii\ liital .a-.',-, cmm iit- iliL"' a few ill wlii.'li dcalli \>a- .liic in -pccial .ac.a.j.ait-. tlic iiriiic |).r-i,t- cntly -Imwcl a laiyc ainuiint uf .ail-ninin. Mii.'li |irii;;n.i-lic iin|(ii|-taii.'.' ha- lic.n atlriliiit.'.] liv niaii\- aiith.ir- t.) tlic ciiKlitiiin .if the -kin, liy tli.' ul.ler writ. a- partK lui'aii-.' tlii'v w.rt' still nil. let' ilw inriiicn.-.' nf th.' Iiiiin.iral llic.iri.s .if .li-ca-c. I'cr-.inallv I li.'li.vc that tlic iiii|Mirtancc nt' the .•iitaiie.iii- inaiiif.-lati.iii- ha- lieeii f:reatly e\ai:L:.Tate l)eliev.' tli.it the aliiindaili'i' ul' the l.i-e.il.iiis nisli is iir.ip.ifti.i'ia! to the -e\(Mily nt' th.- ivi-e. It eaniint lie lienie.l that a nal.', -.•ai:t\-, |-:i|)i.lly .li-,i|i|)cafiiiir ni^li i- f.nm.l in.irc fre(|iiciitl\ in mild .a-c- ; Imt ill any e|)i.leniic exaiiipl.'s are fiiiind .it' very severe and fatal ca-.- in wliicli tlie typical ni-e.i|.iiis ni-h was -i.iw l l:il:ilK. '" '"iiiicril.,,, uiil, il„. i\|,||,,- \\yvv r:i-l, :i,m| ii- -,,•, „i,|;,rv allcni- ''""-■ lll'llli..ll lllll-l Im' in.'l.lr n|- l|,c (lillll-,. ,\:;|„,-|- ..f ill,' lii,-,. an, I liaiKl- thai, liia-inii.li a- it iii,li,al,- ,ai',lia,' u.akii,— . 1- a |,arli,-ii- '■"•ly l':i'l -iun. I lia\,' raivl^ -, . ii a |iatiiiii-,,| t,, w, i „, ,i| -.iiiif :;i'a\,' ,.>ln|)lii'ati.p|i. ■^ "- ll"' ii'ii'.\ -,\-t,nii,- an, I ,,rt;ani,- ili-,'a-,- -,, (ar ivtlrnHl t,, '''■" '"■'> -li"n,i, ih,. Hi;. ,,f ,1,,, |,ati,,ii, il,,.,-,. ;,,,, „,„„, ,1,.,, ,„.,,. |„, iv-ar,!,.; a- !,.,• a li/alinn- ,.flli,. ,|i.,,iv, uhil,' ,.lli,.|-~ ar,' ,■ |)li,'ali,,n^ in iIk' -tri.l „.n-,. ,,f i|„. u,,r.|. 1, i,. ,,|- ,.,„ir-,, ini,„,--il,|,. |,, ,|,.;,„- ^ -liMq. lin,. ,,f ,|,aii;;ivaliM„ l„.|u,.,ai i),,. ,„,, ^r«ii|,-. It i- ,,,,1 t,K, ,nii,'li I" -nv, li,,„,.v,.r, tliat th,. till,. ,nni|,li,'ati,,ii~ ,A,rt a -[MMaal intliwn,.,. mi til' |)i-,,-ii.,H-, ina-i 'Il a- lli,.y ,-laiiii many vi.tini. att,f tlii' |)rimaiy (Im'!..,' I,a> Im,.,, -ii,M-,.-li,lly ,,v,iv,,in,.. In tlii- ,nnii,vti,M> 1.1 ni",- '■'■'"'I"' '!"• na,I.T,,f il„. ^r,,v,. „.,|„,|. in tl,.. iv^i,,i, ,,f il„. |.liafvnx ■""' ''".'"^' -'I-'-'" "I' '!"■ Inn-. |>iii'iil,.nt aii,| ii,.,T,,4i,- |,l,.Mri.v, "'■I''"'"'-' l'''l'~ " "'■ 'II-' -l^m. aii.l iiiali-iiant lorin- ,,|' .Icaihitn-.' (iiitt-ta.ll^ iv|),.;,f,lly .|ii,,t.',|-tati-ti,- IV,, in tli.' I'ni-.lan li,,~|,ital^ -li,,u tli.-it in ,,n..-~ixth ,.f 7!t(i Ctal ,.,.- ,l..at ,.„m..| aft.T tl... titt,...nl|, -lay -.r III,' ,liM.a-.-. aii,i in half ,,!' tli,.>,. ,|,,,th ,„vunv,l .vrn mIut the tliiiticth day. fn tl... t;,iv-oii.j,r paircs th,. |,r,,>|Kvt ,,f iv,,v.m-v fnmi tvpl.tis fivor Im- lM.,.n >h„w„ t,, I.,, in -...ural ,|iiit,. .i;l,,„inv, aiul tl... n.anv ,h ,ts thfiat.nin- the lifi. ..f th,. patiint in all th,. -ta-..s ,,f th.. .lis.'.as,. lmv,> IH...I. ..niniMfat,.,! ; in ..nn.li.M.Mi, vv .nay a.l.l a s,.nH.what ■,. ..luvritifr "ihscrvati :n. Typhn- r..v..r, lik,. ,.n,.nn„,nia an.l a iW .ith.r a.iit,. inr<.,.ti,,n>. lK.|,.n- t.. th,. ,li...aM.s ..i.ara..t..n/..,l l.v a f..|ativ..|v sh„rt .Inrati.m' "'•■ • ■'•"' l"^"-''^^ "'"'!">-' l-y ''nsis, th,. ..xtf.., iatc ..f whi,.h ..aii ahn,,>t aluay- l„. ,l,.t,.nnii,..l l„.(;.,vhan.l. In th.. vrv w...-st an.l ■•IM'."-''"tly -l.-|..fat.. .a^.'s „n.. may still .tinii,. t,. h,.]),."}',,,- th.' .Tisis an.l nitiinat,. n.,.„v..i-y. an.l th,. latt...- ,.an „((.... 1... ,iir..,.tlv attril.nt..! t.. -an.fnl nin-Mniran.l -kilfi.l han.llin^r „f th,. ,,ati,.nt .lnrinjr",.„ila,,s... Th,' tv-nlar •..•If-liinit...! .•„„,-.. „f tl,.. .Iis..a.,. pai'tlv uWWt. its scvi-ritv and its tlanli\Hciaii 1. 1 aia'i\,. at a (hlliiii,- ,,|.iiii.iii. aniv-,.|ii an\ |iatli..i;n,.ninnir train (,f ~\ ni|.l..' .. I.iii that thr i |,. ,,f oiix'l and >iil,-i,!rii(c of ill,, \arioii- -\ iii|itnniN a- will a- tliiir ,-,ha- i-ti'iici' anil (liiratii.n. ha\i iiii|M, riant |iart- in the |>r(Mliii'ii,in nf tli,. (■iiarai-tcri-tic clinical |iiiiiirc. Kvcii iliiriiitr an c|iiiliiiiic iimi-iial nianitl -tati,,n- ,.f the ,li-ca-c inav t v.afictv (if e\t,.rnal cireiiin-tance- t., -Ii,,« th,. ini|M,rtance ..f niakiii:: :i .•linical dia-n..-i- ;i- - i a- [M.-iM,.. n..t only f.r th,- |,ati,ait hiin-elf, liiil to a inii.Oi -reater dc-ive f..i' th,,-,. -nrroiiiKliiiL: him and for the ciilire |io|inlation ot' th,. t,,\\ ■ ,li-iriei. I'.veii the morliid anatomy, uhkli i,, niaiix iiitliti.iii^ ,11-,.;,-,.- alVord- llie iiicaii- ot' de occurred a> the I'cMilt of -oine acute inli-ctioiis disciwc. ' - (.„• JilM,.\(i.'sl\ -,,- '"" '"""I" '■■ 'I' -I'Mtr a |.Mtli.,-,.„i,. .nirn.H„V':.iiiMi. u 1.1,1, ''"'"''' '"■''''" "•"■ •" 'lia-Mo-,. il,,. ,|i„,,,„ |,.„ .,. ,;,,. ,:,i|,.,| ,,„ , ^^j ^ ,. ih~Min,n,.Mt.,i,l, .litli, ,ilh. -. I'n.ti, ul,;,i l,a- I,,.,, sn.l mI i tl„. |,n ,.„i -I. If ..rthr ,|M<-liMn It Ulll I,,. -,,.„ iImI u,. MIV -till VMrllollt ;i,IN kii-.ul- .■-!-.• .,f thr ||„,.t r-,.|,|l;|l ,|;il I. It I- pn.lMMr tll.H f,.,- -,„,„. "(i,,,,. u,. "''■'" ''^''" '" '''i"'"! liiii''^'! "l-.iv:,th,„ mIoi,,, atiil ll .,,i,,„ IMIIU-I.IK |,iv-. lit- il-i ir «|„lli,f tli.iv aiVMM.N nlialilr.lat; u|,irl, t., Im-i. :i .liauiiM-i- iliiiin- th.- initial -la-r ,,f t.vi.liu- (rvrr. 'ri,,. ,.i,i,.,.ii ,,. M -n|ito,„- al.,11,, „ „|„„i| aiiv IwimuImI-,. of tli- ,Ai-t.n,v ,,f an .■|,'i,|,.„ii,. ""■ '"'"■'• I il"liM.- nC ini;.,.tin,i. iliaMr ■ at h,-t I., Mlakr nlllv a I'luvi-inna! .Ii:,-i„,-i-. ill ,ii,,-| .a^.'- it i- ini|.,,„iM, in -a> iii,,iv ||,ai, that -diiir ariilr iulr.t Imii- di-.a-.- i- ilii|ii>M.iili::. ■I'll'' tn-l iii,|...itaiit ,li-a-, - m tlir .Jitli iviil iai .lia-iiu-i- aiv tli,. a.-iit.. (•\;mtli...iiata, ,-|».,-ialK MMail-|,.,v aiwl -,,irN t f.v.r, .vla|.-iii- tivrr, <-ivl.in-,,iMal iiirniii-iti-, aii.l .n |.tu^niii,. -,.|,ii,.,,|,v ,.,„ia— rii,i,.|i inniv Par, ly typlhiiil tl\ri-. Differential Diajjnosis in Initial Stage. ^-ilir initial -ta-.' of t>|.liii-. r.vrr |,iv-,iit- many |„,int~ nf iv-.niManr,. (., tliat of Small- pox : tin -an,,. -,i,|,i,,, ,,i,-,., „i,|, ,.|,i||,, ., ,.,|,i,||, ..^^j,,^^ |,v,vxia will.. '"" '"• "''•' '-'l^'tivrly -lijit .vnii-M,m., ,.arK, |„-,,t; l" |.>--t,^,ti,m, ^'■"■'''' 1'^''" '" ''"• '"-^"l =""' liml.-, an,| -|,l..:,i,. .„la.-,.ni,.nt. wlii.li iiMially ran !»■ .l.ni,,n-trai.,| at (li.. l..-imiin- ,,r tli,. tir-t vMvk ,,f the (li-,'a-c. 'I'll'' tln-t that pain in tli,- l.a.'k i- a inii.li ni,,n. tV,.,ii,.nt an,| vi,,l,.,.t Min|.t,in. ill th,. initial Ma-,. ..f variola than in that of tvphiis f,.v.T j. „f >lii:lit .lia-l.,.Mi,- -i-nilira,,..,., t;,|- th.. -y,n,,t„iii ii, i,,,.]," |. „„i„,, ,.,„„,,, :incl 1- i„,t raivK al.-,.|,t in th.. niiM.,- timn- .,f Mi,all-|„,x. ()„'ih.. ""'"■I- liMn.i, Ih,. larly ap|M.aran,.,. ,,f an initial -..arlatinal ra-h ' .„. th.. thitrh aii.l npp..r arm i- .,f ..,m.. iinp.iitan,,. aii.l -tron.dv p.,iiit, t- M„all-p,,v. a. it i- parti..||larly lik..ly m ,„.,,„. i„ ,|,„ .,,,,,,,. ,;,^,„^ ,,,■ that ,li-..aM. an,| ,1,,,.- ii,,t ......nr ,.i,|„,, ;„ „.|,,„,, ,;,^,,,. ,,,. -^^ .^_^^. ^ j,^^_^. ^^^. ''"■ ^"■'"•' i"''-'i""- 'li-'^'-'-. < »M tl„. „tli,.r han.i. an initial nira-lv ni.|, '^ "' -'■•"'"'">y irnportan..... Wrv ar an.l rapi.llv -li-api.rarin.r rasli..> „..,.,ir, a> w,. hav,. -,.,.n, -l„,,,|v |„ ,;,,,. „, ,,;„, ,,,, „,,, .,|,|,,,.,,;_ :'"<•'■-! th.. >p....iti.. typhii- f..v..rr.w..-~p,„-: l,„t tho .lia-n,M> i, ..„,„ ■■l.'ar.'.l up l.y th.. app..aran.-.. ,,f th.. latt.r ,.r l.y th.. ..ruptioii .,f tvpi-al Miiali-p,,x l..-i,,ii-.,|„, iiatur.. an.! ,iistril,iiti„i. of w|.i..h a.v ,.|.ai-a,.f ritaL''i'. I'inallv, it may \,r w.ll to |Kiint ..nt h.w lllli|:int 'ill t li. |:i< . . I III li iii|" laliiiv in l»i|li cli-.ii-r- it ill,' . ml ..T ili, iniiial -la^'c iiip.l Ml iIm Im -inning mI' iIi,. iin|,ii..ii .,1 ...nn iiii|m ,11 hm . . \\|ii|, m I_v ||||U- llif lr\ t r i- lil^li iluilli- llii- Mini' allit 111. 1 lai. 1\ (■..iiliniH- In rJM', then' ii alwiiys a maik.d iiH in i. ni|Mi-;ttiii-c in \aii..la ilowii |. aiiij I \iii III li.u till ii.irinal in niiiinarv ra-i -. I 111' ilia-iHi-i- niav In iM ll-ni-li ini|M.-.-il.|i wjun iji, t'c i- a mir-l ion l"l^\'in till liiliiiinaliii- In iiliaL'i'- I'Tiii .il l\|ilin- ti\i|- an«/. |',.,||i lr|i- n-nil a iiilnMnlia;:ir initial -Ia-<- uf llir ili-ca-c ami mil lalalK ImImIi- ill)' ly|iic'al -\ iii|i|i.in-, 1 -|M riallv tlii' la-li, 1m ronii !iil|\ ,|(\ ,|,,|hi|. |\\cii all. 1- an aii|.i|i-\ lia- Im.ii IuIiI iI max m.l l^^ |M.--iM, ),, airi\c al a
  • \ llic |iri \:ilinrc ..r ..m •.]■ llic ..iImi' nf ihr iw,, ih-ra-i - in llic .|i-lri,| ami ill. |H,--il,ilii\ ,,r ill,. |,aii,iii liasin- l...,,iii,. inli.l..l. Similar .lilli- c iillii- ar. . ii.'..iinl, i-i .1 in iIh' .lill'.r. nlial .liaL^n.'-i- rimn -i\.i-i' lii-ni..r- rjiai^i.' f.irrn- ..T ..lli.r aciilc iiitiiiinn- .li-.-a-.-. I 11. ..I r.li i- unh |.. tin- i'iinv-|i.inilini; li.fin- i>\ -caiit \\\iv ami i\ , 11 ..I'lv |ili..i.| t,\ ,r. 'I'lic .lili'.'ivniial ilia-m-i- iVi.ni rclilpsing fevcf ilnrliiL'- tlii^ lir-l, .'I' lAili till' -I r.m.l, alla.k. il'tlir tir-l lia- imt li.-.ii -ntti.i.iilK will ol)tir\ I'.l, i- i\ir.iiirl\ ililliiiilt. i-iiiiaally if. mi' iviii.hilii-r- ilial tli. .li-- ca-i' I't'cn .•iN'\i-l- \\ illi l\ |iliii~ li \ If, a- \\a- llir .-a-.' in Itirliii in 1 >^7!i. Ill n....i-, I'a-.'- tniiv i- m>lliin_ chai-a.'l. li-lir ali.iiit tli.' niml.' .if ..n^j-f '.'i~c, ami iiltiniair Inii^lit ..I lli.' Ic\ii-. Thr a|i|Maraii.'i' ami i^ciuial I'liiiilitiiiii III til. [latiriil :ii'i' iif iniK'li nnH'c iiii|i.ii'taii.'i' in llii' iliaL''ii<>>is 'it' rrla|i-iiii:' f.'vcr. A- a nil.', tlir liciu'I'mI I'.iii.litinn i- ii'inailvalilv j^ikkI 111 i'..in|iaii-..n In lli.' li.iL;lit nl'llii' f.'\.i'. llici-.' i- litil.' iiiv nh I'ln.nl iif ill.' ~('ii-.iriiiiii, ami tli.- .mly -v ni|il.ii,, i'iiiii|ilaiMi- a jR-i'iiiiar, linll, yi.'llo\vi>li-j;i';iy ili>n)liiniiiiin, wliifli may lii'>t lir cnin- /'/ l'..\'/s/> A!»7 I''""' I" ''" '"I I HKnilr IM.IiM.liuU ulh. \,:,\r In, lit.. I -..irir IIIIK- I A| I I., ih. -III1 ^- i'i::iiil- t|.. -|.|..ii. I ,11111.. I ;iM|vr uii|i until.. I- uli.. iDiini lll.ll II |.l.-.lll- Mll\ . Il;ll;l. I. Il-ll, .lllalljrlll.lll ,|l||ili^r i|„. j||i||.,| ,,.|^,. ..r iilli.r (li-.:i-,'. 'I'll.' .Il:ii;l|..-I- ..I' l.|:i|,-iiiir j•,.^,.,•_ 1,, .vM.v.r, .••ill :il>Mi\- !„• , -t:il ill-li. .1 l.y lllr lill.lilli; ,,r -|,i|||l;, ill til,. |,|,.,m|, miiiI ill,-. ..f-;l|ii.|ll- AV, M-ll- :il|\ .|.'lli..||-lr;il.|,' -li..rll_\ ImI,,!,. ,,r mI'I.-.- llirlir-l >iii,| ,.\,\\ .;i.-. •■.■.jin.r Mtl.llk. I>iinii- iliiir -ii!,.,,|ii,iii ,-.,iii-.. 111.' iw.KJi-, 1-,- |in-.iiit -ii.'ii ni;irk.. , .-.lit [iciiliar .iitliciiltic- uli.n a " val.-..'iit IV,, III r.-Jaji-iiiLT liA.r 1. iiiiii„.ii;,i,.l\ attark.-.l l)\ l\|.|iii, (.■\.r. IMir.ii,.' Iia- Im-,ii iiia.l.' l.. tin- .-..iiiiiaiatix . I\ lr,,,ii,ii| |„,„i. Iiility (-,■,■ y\,j:, .-,7,. Ii 11,,,,,] lianllx !„• ,in|,|i;i.i/,.,l ili,,! lli.- ali-. ••.•, ,,t" >|.irilla .liiriii- ili,- lM.:iiiiiiiiLr ..f lli.' lix.r, an. I ili. a|.i..'ai-aii.-c ..f r.i-,- >|H..I- a r.u .la\- lat.r, -iitli..' i,, i,ii|,,w ;ni\ .|,,iil,t- iliat u\:ty <\\~i. If.la)i-iii- |i-\.r lia.l- n- natiifally t.. lli.' ,|i-,ii-j,,n ,,f malarial fever. It «il| f,.a.lil\ :,.■ -..,.|i that lif-t atta.-k- ..f tlii- .li-,.a-.. in '■ '*'■''•- "li'-''' i'- :i- "'11 :i- lyi.liii-. i- .liilciiii,' iiia\ .a-ily I, ail t.) <':-i-.i|-. I>illiinlti.- may .-|,.viall\ )..■ .■ii...iiiil.r,H| in ^v\,-rv li.rm- ..f malaria uilli ,aily in\ ..|\ . iii.iit ,.f i|i,- -.•ii-.,riniii ami tsvi-M |ii-..-lrati..ii, surli a- ......iir in tl,.. ir,,|,i..- :,imI al-., in I l..llaml, 1 liiiiuarv , ami Italy. A- ill icla|i-in^' C'v.r, ili,. ,-\aiiiiiiali f th,. |,| 1 ;||;,| ,1,,. |in.|in._' .if til.' |.la-m.M|iiini uill at .,mc .'l.'ar ii|. tli,' .lia-ii..-i- u iili,,iit tl,,. nrc,'- .-ity ..1' waiting: l'..r tli.' .'Iiarail. ri-lic tall in t('m|..ratnn'. '' '"■'> '"• ''^ "liii^Mv (liUi.'iili, ,-|„.,'iallv uli.'ii a:i ,'|,i.|.'ini.' ,,f ty|.liiis fi'vcr ,'si-t-, t,, ,li-tiii-iii-li i-,,lai.'.l .a-.- ,,i' cryptogenic septicopyemia in it- .'aily -la-..- tV..m th.' initial ..i-.Tiipliv.' -ta-c •■r ty|.|iu- W'vrv. An initial ,'liill an kin. I. A viiimtr man wli.i liii.l rtM'oiitly .'..III,- fn.ni Sil,....iM «a- s.'i/.'.j uiih vi.il.'iit .'liills. licailachc. ni.'liin- an. I Vdiiiinii'.', ami was a.liiiitt.'.l t.. mv .lini.' uitli a l.iirh fever ami marked S|i!enie .'iilar-emeiit, Tli.r,' was 'jri'at ilistiiriiaii.,. ,if e.iiisei.iiisiiess. Tlip tever-eiirve at tir-l |,n'>,iii, ,| llie .'haraeter .if a liiirli c.iiitiim.ius remittent j.'v.'i-. Iiet«,..'n tlie thinl an. I f,,iirtli ,lavs. afl.'r a sli-ht transit. .rv iimrliil- lit.)rm rash .m the arms an. I thi'jlis ha. I ann..M,-,.,l •,>, lll.,l,.i;.,..,] i;,'-;.l - ii i ;J1»,S TV I'll IS I 1:11:1:. •MM.Mlhu- >M>h MKl.l,. .1. ai.|,..;M-MM.V. uhi,'!, >„„„ |„.,,,„u |,W..1,mI in rlKua.l.,- an. |.iv>..„i.mI m >u.|,ir,„„> .li>l-ilMitioi,, I,,!,,, ,,„„■,. :,l,u„.|a„. .n il„. i,,,„|. ^hhI t,■^l..-|„.■>.•,ll^ ||„. I,:,,.k, ,,|-,|„. t.Tl.MiMl ninri, l,.-- ,„,',rk,.,| .,„ , lu I ,„l,k .\- a pncaiil imiMn ,M,a-u,v i!,.|.:,i!,.i,! « a> i>:,lal, ,| lo,-,, i.u ,lav- '''"■^•^""' ■■' >'■" i'"n..n-|,a.,.. -|„„. a|,|„.an,| ,„, , h. .,|,.. „r , 1„. ,,,,, ,|,r pahnar .,n1a,.> ,,t ,u. tM,.,.r.. ,Ih. ,aan,ar M,rla,v, ,,,-, I,,. ,,,.... a,,,| un,|,.,- ,1,,. "'■^•. "V ^'\"' ''- ■■' "". ,lM.a.. ,1,.. .,.,1,1,,, a,,|,..ann„v „,■ a ! 1. li- ,l,M.n,,>,. ua.- ,„„l,n,„.,l a, ,l„. a„t„|,M , u l,i,.l,. h„u, .^,.,■. la, I,.! |„ .vv.al '!"■ 'I'lii'-al 1'1,'tMiv in a ix|,i,.al ra.,. ,,i- cerebrospinal menin- fi^^t'S " 'I -""' •" 'lil''''- Hitli,a..„ilv tV..|„ that ,,!■ M|,Im,^ trvr „, ("■'■'■''"''■■''I 'laiiuvr,,f , ■,■:•,,.•. I,nt ,1 i~ ini,- i^A-.i-th,!,.--, , hat irn-nlar <-a>i'^, in tl„. ihiiial Ma,.^^ ,,| ,1„. ,„,, ,|i„,,-,.., ,,,„,, ,,,,„,„ ,,,„.i,!,,,,i,i,, '''"''■"'"■'-■ '' '■'"•"" •"• 'I'nl..,! that th.av ^,iv , a-,'- , ,f ,.,.|,.|„-,,-|,i„al '"' .^i'i-'l'^" l-^in uitha,.hillan.l. alt,Ta r;,|M,| fi.. „f „,n,,.fal,nv, ■■ ' ''■"' '" 'li~iiiil,: ,.~ ,,f -,.i,,iiMu-- ,„■ ,.v,.i, t,, ,.,,ina. Ifu,. '''■""■'"'"■'• •''-" '!"■ ^i"l<''" li.'.Mla,-h,' tV uhi.'h th,' |,ati,.,it- Mitr..f. th( pain in th,. ha.'K, u hich ,!,„■- ,„,t l.v anv in,.an~ aluav- manih-t JtMlf i'l '!"' t^nn ,.t a,.hai:i.-l..fi-ti,' fi-i,lity ,,|' ih,. nc-k. an,l th. .M-raMonal ai>|>caf;ni,v ,,|' a r,i-,,,i,iM- ra~h ihirin- the via'v lir-t ,lav>— ,a,i, |„.fnr,> thr ri-i.lity ,,f thr iKvk— we liav >ntli, i. i,t , x|,laiiati,,n i;,r ,Kva>i,,nal (•fi'(,r~ in in ivjrani t,, the form, (liMrilmti,,!!, an,l (lcvrl,.],i,i,.iit n\' tlic crni.ti.iM. It -hmiM h,. dis- till, 'tly iviii,.ml„.|v,i tiial ill,. >|„.,.iti,. n ,-,.-- 1 K,t- arc aUvav-, at ,l,.a>t in X\u- liciriiminir. piiivly hv|,..,,.,ni,-. ,,rt,.|i xwy ,,al,. an,| imli-tin,.,. an,l tli.'it , inly a i.,,rti,,ii ,,t' iImiii lat,!- i„.,.,,m<. inniv ,,r 1,.>> iiiark,.,lly h,. r- Hia-ir. TIk.iv i- a «i,|,.-|,iva,l ,.n-,,ii,.,,iw lM.|i,.|; and ,,n,. that lia> I),,!) prrpitnat,.,! in th, vi,.i,,M- nam,. ,,f •• y,< /,,•/,;„/ t./.h^s." that th,. ,.nipti,,n '.f tvphii- t;.v,.r rnini th,. v,.|-v ,,iit-,.| tak,.~ th,. torm ,.f -mal! ;,.„„„- rhai:,.-. On th,. cmtrarv. ii may 1,,. -tat,.,l ,l,.tinit,.lv that anv IMiril,. '"'"'■ '" "'''■■'' ''"■ '■'"•" - rhaii^r,.- a* ,,n,'.. app,.ar in th, liinn ,,f lar-.r ,.r -niallcr h,.m,,rrlia-,.-. with,,iil any pnidiv-inal Man,., i- ii,it typliii- )i.\,|.. Diagnostic Significance of the Eruption.-An.ith.r p„i„t l>/.ll,\liSlS. 599 1,'ciicI'mI iiii|Mii'ian''c iiia\' I ic n]rrilii.nr( I. It i> ll K' iircnl \ari:il>ilii\ lit the rTlintmu a- IV;.ia|-iU it- ilpiiiiilaiK 1' ami iji-iriliiiii i.iiv ra-c- uiii, aiiiiiMiaiit rni|.tioi v.riii- tlir ti-iink aii diiriiiu- tlic siiiir ilill'n-ciit ciiid lii'. that tlic d lii^iiiisis ti-diii (itliir iiil'crtiiiii- ili-ca-c- cliiiractiri/c* iiv liii^h Icvir w itlmul, 111- at lii-t with vcrv -lii;lit, cli iii^ir- ill the -ki lliav lie cNrivdiiiylv dilliciilt. Ditliiplt ic- lit' tlii- kind iirc-ciil thiiii-i>|vc< i'-|ic.'iallv when it is iiciM'--ai'\ to (Ici'ii it\Mvii typhii- a: I ty|ilio whirh, 111 all It- -ta^c- ami in all ll rclatiii itiii'i'-, -tJinds in cld-r-i ii-lii|>ti. it ami which iindniil.tcdly |iiv-ciii,- the uivatcst dill iliaiiiiiislic ill ditl'crciitial dia^rn ICIlItU" I ISIS Typhus and Typhoid Roseolse. -1 cru|itiiiii, which is so ut'tc ll n fcLTiird til the rnsciiliii 11 considered iliai,aiiistic, it iiiav I •e eiiilallV uliiimlaiit ill- eijiially scanty in liutli di-euses. It lillted nut that cases nt" ty|»lius fever, I ';,'imiiiiir, may present milv a t lias ali'caih- ii>we\er -evere t'riini the v( ew n.-eiihe scattere-l exactly as in tv|(iii.i(l fever, and. conversely. ty|ili,iid ('ever may he .•oinliimKJ witli a rash tliat even in ty|ilius fever wmiM have to he re-:ird(KJ as ahnmlant. Sj,,,.,., then, tlu niiinherof the rose-i.ots cannot he depended upon, it is all th" more niipi.rtaiit to make a careful study of their iikhK. of devel- iipment, di>triliiitic.n, and individual clianicteristiis. 1,, repird f.. tlio ilevelopiiieiit.it is to he imt.Hl that the rash of typhus fever appears Mch carli.'r than that of typhoid f;.ver— lielwirn the scvoiid vi'iv ni (1 (ifth (lavs of till lisease — that the 1 unhroken succ on the iWrcarins and Icl^s and mi the hands and ( ;\\ti'eiiieiy rare in Ivplmid ect are ever, wliere; i> iiivoivcinent of the hacks of ^1 l;i <;iiii rv I'll IS Fi:\i:i:. ''"■ ''•""'- ■""' '•'•' i- '^f'viucly mil,,,,. „nt to <;,v Iv,,lr,n, i„ lv|,lii,, Irv.T. ., ,|,:it I ;i|u;.v- -lll.i..,.t llir-r (ilarr- „ , a c.in'tlli .A; „ali,,„ i,i aiiv -ii~|iiii.iii- ca-r. .\ltli,m:.|,tl„. a|,|.r,,vin< Iil,r ta,v in tl„- lu,, ,|i., . j, ,,. ., ,,,,,,,,,,„ .■Mr„l H„,ilai- i„ -,, la,- a- i, „rv, ,■ l„. ., ,|,, -, , , ,,) n.M-|M,i~ in lv|,li,,i,l, a.i.l v.rv rai-ly i„ ,v|,|,i,- i;.v,i-, y, ; ,l„.iv i- a ,iiai-k...l .■.iniraM ""•'"—1 thr IM,rli~, iv -uull.,,. r,..l,|,.li,.,| ti„ir~. will, .l,v|,|v liij,.,,,.,! or .vni li,.,iio,Tl,a^i,. .■u„ji„i..,iva. aiMl uil,| |,„,k ,,f a tv,,liii> CrNvr ,,ali,.„t =""' ''"• l'^'"'''' -"i|""'"ii-. ^"1,1 |,p,Mral,,| a|,|M.aiMii,v in ,x|,|„,M ,;,,,,■. n.- ii.iivi,li,al l,.~i,,„- |,n-,,it v.rv ,.,„,H.|,.,-al,l,.a,i,i.liMi„r, .litHr- on,r~ m ,li,. ,u„ .li.,,,-... Wl,,,,,,,. ,|ir ,■„.,-.,„„. nf ,v|,li„i,l |;.v,t •"■'■ jn,.li,ally l"'''"nic .larkiT aii'l .•vnitually >,„i„.\vliat lirniniTliaiiic ((•o,ii|)ar('"^l'latos 1 '","' -'• "'"'■'■ "I"' 'i-ii-|.a|mlar .■liaivinrr ,,f thr , n,|„i,,ii ,i,„-in)r .,n.l Jitl.Ttlic lici-lit of i,. ,|,A..ln,„iH,i, i- an i„,|Mrlain i,i ty|.|i,,i,| i;.v,.r. OTHER DIFFERENTIAL SIGNS BETWEEN TYPHUS AND TYPHOID. .Sv.,M,|j„ily ii, ini|M,rt,in,-,. t,, ih,. ,.,,n,ii,i,„, ,,(' ,1,,, .|,i„ j, ,|„, ,-,.^.^,^ Ill III,' ,litr,-,-,-nlial ],,\v, M,-p-]ik,. a>,-,-rii ,,r tli,. ,-n,-v,- inl\pli,,i,| t;.v,T. nv,. hav,. >.■<■„ that in tvpliiis i;.v,T. att.T an initial .liill. th,- I.-inp,T;it,i,-,. ,api,liy— witiiin ti-,,n, lw,.,iiy-t;„„-t,, tnrty-, idit li,,„i- an,...„. .piit,. ••"Hiiii"ii .-It tlii- Ma-,-. an,l may p, a-.i-t a,„l ,-v,„ .-..ntini,,. t,, iii,.,-,,,H- with r,-!ativ,-ly -lidit m.M-.iiiii.- n-mi-i.m^ mit:! tli,- ,-n,| ,,ftli,' tii--I ^^^^vk. 'V\\v .-hai-a,-!,-!- ,,f ti„. t,-nip,.i-,-ii,„-,-rin-v,- ,li,,-iiio tl,;. (j,.,, „-,,,,|^ p,,.itiv,.lv .li-tiiiL-iii-lii-. lypliii. Cn^n iypli,,i,| t,.v,a-. A- .■v,-n tli,- ni,,.t -,v,t,- ..as-.s •.ftypim- i;.v,T ,-a,-,-lv laM in.,,-,- ilian tV,,,,, i;„„-„,,,, ,, , .,.v.-ni,-,,,. ,„- at m„M lU'-nty. -lay- i„-t;„-,- ,l,-t;i-v,-,-, ii,-,. 1„ ,rin.. an,! th,- i--v,-i- iiill. |,v ,-,i.i~ ,„■ ■■It l,a~t l,y a Mi,-,-,.-i.,n ,,f lapi,! ,l..,-li,„.., „,. a,-,. n,.t «ill„„it i,„p,,|-iant ,-a-,-tli,- ,!i-tiii-lKiiH-,- ,,r tl,,-' i,ati,-,!t'-. .,,,- '>ral ,-on,iiti,„, an- „„„-li „„„•,■ m-v, ,-,- ami manill-M tli,ii,>,.|v,.s niiicl, .-arli.-r tiian in typln.i,! fcv,-!-. /'/. l'..VO.S7,s-. (;()i ^\' ifi'cas ,1 i\|il ir al \i':\-\ (|. I'aliciii not iiit'iV(|iiHiill_v iTiiiaiii- at \v,.rk 'I'- not MO t,, 1„.,| diiriiiL' tln' tir-t \\,rk ..!' i| jn-o.-lratioii ill is],|iii, j, ..,, j,|.,.;ii Cniiii tli Jtatii'iit-^ ari' foiTtd lu take tn their IkmI- 'I- (li-ia-c. the if,L:iniiiiiir that the I) 111 the lii-t or t IC --fCOIKl il,|\ '■'"'"""■ -ll'l""-. ^111.1 a .Irriarc ihrni-rlv.- (hirili- tllf tir-l Urck ICC I- iiila\((l mil t.vphii-; i'cwr. Iiiit their a|i|icarai or. it' they and in ail is i'<>ni|)arativciy ra|iid from liic ver\ iiejri > I'roni tiiat eliaraeteri-tic -|ieeially ot' tile iiuih tlie |illl~i ■iiin^r ,< not imii-nal even dnriiiu'- th. T fll-l Wrik ami mole in liic in \i;i'oroii» men. IC cliaracle;-i~tie iheroti^m i~er\ed in typhii- t'ever. ill tynjioid iv uiil \ e.\e< juioiiaily K niarureiiieiit ot' th lypiioid tliaii in t\ |)liii~ ti'scr. '| c -|iieeii is a more reMiilar ami la-tinjr | in ilie two lieiioniciioti iilso dilVers it a|i|iears would -111 tevcr. 'c present in t\ plioid Till sln;ii^ '>nini:i! -ymptoiii- are ..f very little im|tortai Ix'twocn the iwo di>ca-cs. j"! lee a> (|iai:ilo>tli iplite eomnioniy deve|o| Ills a moderate (leer,.,, ,,(' iiicicorisiii li:nid, il may lie ahsent diiriii;: tj attack and n-naliy i- .-o diiriiii: the eirlv >ta tiny mean- ^o eon-taiit in ty|ilioid fe\-er as i in typhus thin -tools of a pale ycll-w c.ilor )S 111 ,-cvclv 'M-e- of typhll-. while, on the oti ler IC . iitirc diinition of a tyjihoiM tl'V cr Diarrhea' i- uot hv Sonic of the newer methods of > n-nally -ii])|Ki-ed. wliih iii'c not at all nncomiiioii tl iiimatioii will, ,„, doiilit, p ic jlivalcst value in future ciiMemie- and will help to .leeide the'd iiosi- 111 niaiiv a doiihtfnl Th •li'iiKin-tnilii,!! ,,f iyp||,,i,| |,:i,.i||i i,, ,1„. i,i,„„i_ and h'ce-, and the lu'liavior of enlimv^ ,,f thi- 1 the hlood--i'rnni of tin- indixii method-. 'rheCrnl.cr-Wid.il ; 1 liial linile, rose-spots, ian te-t will eiiahle lis i IC twii di-ea-e-, altlioiiirh. i tllesc II inanv cases to 1 i~ true, oiilv .-It a soMiewlial Wh.ti ler the ah-eii ce o| lellkoi'V to-i- or In 111 typhoid fever will dii.. ,''"'"■ '"^"^"-'■'•^"'i ^ |Hol,;,l,U „„,of;n,v .liauM,„,i,. valMP. S.vrnl """'"!'••"• -'• Virrnnli-hav,. In .,,„.n,ly . ;„„,.! i, „, ho ,,„.;,;,,. j,, t\ [ihii~ t(\cr. . ' Whil.. ,hc. .litfLivntial ,|ia.M,M-~ (V,„n Hnall-|„,x. n- ^^o havo ..,, I'lv-oMN o,,,,t .htlinihi,.., . .,„...iai|v .Inrin. ,l„. initial >,a.. . ,„|„.r umw .■XM„tl„.,„at;,, ,.arti,.Mlarly „„a-l,.„ may. ,lnm,^ ,1„. ,,c.,-i„.| „C .,.„,„i„„ I"--' 'M'^'llr .-MtMMM.. TIh. ,.n,,.,i„n of measles, .......iallv ,I,„W tlir lirM i;.u li,,iir- afli iiijr !y|>liii> tcvri-. ami, ninati.,n of the -v.na.,,, M-ofth,. .kin. It i. t,. h. ,vn„.n,h,.n.| ,l,a, ,]„, f,,„ j, H,.t n.ta.k,.l n, ,,u.a>l,.-, whil.. in typla,. ,;.v,.r it ,..,.,„. ..ntitvlv, or i„ n..v ..as.., ,s ho ..at of a h.w i,olat...l rose->,.o,s whi,.h \u.n are <• Mnmt..n-t„.. In any ..a>.. of ,y,,hn, fW.,,-, ^v,.,. wh..,, tl„. ra-h is ='l;"-' m hoth ,li..a.,.~. an.l ,h.. in,..nsity ami ,list,.il,ntion atv so vnnaM.. that it ,s inipo^-ihl,. to ,lr,,w anv ,|..|init,. .-omhwion It th.. pati.nt- ar,. .vn .Inrin,, ,h,. |„..innin,r of ,h,, <;,,,., |,,,;,,^. „,p '■;■"'"""; ='l'l"="-^- '"• '•' '•-'!=''''" ta,M,.l. th.. ,l,.,.ision lH.,.o,m.s mn,.h ,.asi..r. Th.. rapi.l ri.. .,„,! ""Nsnal h..,;:ht of th.. t..mp,.ratnr,., an.l it. p,.r..is„.n, r ..v,.n m.I.s,. /.\(,.\nsis. 603 '4 -.cnlKlurv illl|H,lt;itlcc ill ill., (litrclviili.il , I i:iir,|, ,-i,. | „ x,.|v r:ir.. c:iM- :i rciiiml pneumonia Iumn 1,,c,,iii,. a ^uiinv ,,t' irnii'. l-.v,ii iiKMV rmvlv, and (Hilv iindrr -|ircial . ,,n(liti.,ii-., an .Tr,,r ini-lii orciir in scarlatina, certain infectious exanthemata, and i,; -rvdv ciiMs ol purpura. Anthrax and |Mi->il,lv glanders mi-ln \>>\- a limc -ivc li-,. u> duiilil, the llirniiT only in tlir r\liviii,.|y raiv ra-i- ol' civlirai or inl.-tinal antlirax uiili,,iit rd.ina or fiinin.Mil.KJ- ; the iatirr, wiim tii.' ciiaracl.T- i-tic inaiiill.-.tati..ii~ in il,,. , .,,i|, ni<.|iiln-anc of tlic ii,,~,., tin, .lira, and '"•oiirlii air I,-, marked :ine ,,f anilii-nx tii,. ,|ii,.>tion xv,,iil,l |„. ,|,.,.i,|,,| ;,'t on,,. I.y th,. l.a<-t.ri,,|,,irie exainiiiation, wliieli in jrhuideiv i> often more ditlieiilt. i-''!*' PROPHYLAXIS. , ■'•■'■'■""■"-'-- --•'^"„wl..,l:„.,„-,|...,M„MVan,In,„.|,.„r '':''"':'^~"'""':''">'--'^'"'""' 'i^i., .n.u,„va,i ,„■ , ,i.,,.,.: •"'•:"""■"■;"':"'"' "■""•■'- '- '■■-l„,„ ..,,.„i„ .|,,ini„. ,„...- '■"'" : "'"'■'' ■'"'■ ''■'■> "'li'-i'-n., if ,,r„,..Hy .,.m,.,l .„,., ....i,,,, ,|„. .nn,M,,.H„M ,„• ,|„. Wi..:,.. ,n„n ...i,.,.. ... ,..,i,..„ ,„,, ;„ ,.„„,.^.| ■-liii'iiil. *" ''"'"■ ■""-' nn|,u,-,:,„t ,.„iM,- in ,1„. ,„vv,.„,i„„ „,■ , ,i.,,^,,„ ,,.,^.„ l>.-^ r,nl„„iu..l iu a i;.„ ..,M,..|UM„„. at .Ik...,.,! „r ,|,., ..l,,,,,,.,. ' „„ REGULATION OF GENERAL AND LOCAL HYGIENIC CONDITIONS .""■ l'-'-"-na.v „„.:,.„•.., I,a..,| „„ ,1„... .,|,.,.a,i„„> n,av 1„. '"'";''■;' """"'"'-'■ ''-•■'•> iM,,.n,vin^ ,l„. ,,.,,..,,,1 an,| l,,,,.! l,v,..i,.ni.. -''■I't-M. ,|,..o-iv,. ,1.. Wi..a.. ur a |,n,|., ,. n,,..lium ti,r i,. ,|..v.i.,;,,,,,, """'""""""■ ^":'''-'"- "-'"■>• ''-"-"1-M''r ~.nr,l„.,,,,.,a.|,V,„n , '["■' !'' ''';■ ' ' ""l""-'^"" l"-'rl- l^"'ti- pnn..i|,l... u,.v liis, lai,| ""';•' ''''-""I"-. -n„n. u , .■ha...x,.n.s..l,|,..,„„„„,, ;"'■';•""' '"""■ "'.■,niv,„.ally ,l,:,n IliM,. ,,,,,1. !!,„ ,,-,.„ I,., lik. '"■' " /'•';" ''■''■"'"^'■'••^^- '"-<■'• '|m..'.l.l...,.,i,ll,i,nM.|r„r,l,„ '''■■^^ 'I-' ll- 'i'-M.. n,i,l„ ari.. >p,„,am.uu>ly. a .h,.,,,.- ,|,a, ,„-,lav I,.,. '>i rii |M I'liiaiii nil\- icliilrd. ' • " '';'"'■;"■''• '" "'>-'- - '■ ^'"fl""- I'av. .l.,n,.,ll,al anvthi,,^ ,l,at .I,,.-. :-';''-'-'lv::ti;..,h,.,l,.v,.|„,.n,..n,a,„U,,n.a.l„C,|„.-,;....i,i... ,,,;,„„ '^: .'"; '"."'-7"""'' """'•' I- '—v,.rl„„l<,l„.n„M important ovM.Tal '"■.""■'l'''.-'"!'"'!""^'"'' <• 'I- .li-n... \V,.k„„u„,a. In„„„.,.an.l "";"■;■'""'""■""' '=""'• "V..,vn,w,|i„.i„|,a.llvv,.n,ila...,l r ,- ,il,|, 7""'';""'""""''^'""""'''' '"I-'-iM;:M,lMaM,....,.a,„M„. i, i,,,.,,.' ,„■„' '"■".''"■'■"""'^■"""■'■'.M'l'"^ f. v..,-. I„i, u.. a,v ,v lullv,l,an ..,■,• ;';"""'7' "''" "''-afK.nl a „.„-, ,;.v,„.al,1 11 il,,- i,. .i;.v,.|„,,n„.„. ':'";:""' "-;';••'-...-• ,v,,l,n-; l,.. ,l„..ii.tin.,lv.„.ial natun.uf •in- .1,-,:,... ul„-l, aua.k- ,1.. ,„.livi.|„al ulu.,K.v.r l.is lu.dti, luw l,...„ ri;'irii ■ i.v/.v. Illli|('i'lllillr -t;itc :ii|(| ll-r i-c ul' it- 'll I- In llll|pni\,' tlic Uill- "■iily ill -en, nil lo .1, |,ii \i' rill •f lllr Ir- Ihvnivil ,|; "iliM ^111(1 -Miiitai \ l''lll(llll(pll.. till IV i- (Liii-cr iif ill,. ,|i. l--(-, l-|lfi-|;lll\ 111 IT^iMii- :iiii| (liiniijr liiiM- vvli, III 1: i';l-c-|l(il-ii|l lirlll^ llll|l(>l't( ir^V I'lllr-, -|"riall\ .lllnili: llllll- nt' .r ll •|ili|rrill", ||||. t,.| I ■'■!■ li"l'iilaliiiii. the I ivr iiiii- mikI .■Ii,m|> 1 irninit- (miiiu II ih lirrliii a- " r |> liiilulllii- l-l-~ I.v tl iiiicii I, all iii-Diiilioii- ii.r ili(„,. xvl 'III II ''"""■^- "'"'l^l -'-• I rlMm-..-,an.l |.ri-un- -Im,iiI,| I Ki llU\r 111 u- aiitlionii, All -iiliiiTtcj t.. a raivl'iil "■ raivliilly iii-|Hct,.(| -|"'.aallv niiiuraiit -liii.-. -JiuiiM :,1„, 1,,. w lll-|)rctl(.!i. ■in-- wa-vd III a coiintrv in wLid, ih,. ,lj. -mualily i'|iii|iiiiic. || 'ii>iiii.'- i.f iii|. In I'a-c i~ |)i(.- Ih L;nat(-t attiiiticii -li,,ii|i| | !<• i^ui'ii to a |iili,,«n .liiWnu; 'lir ( nniraii war, in |S.-,<;, ...,„.,.iall.v .Inrin;^ ,1,,. >i,.u,. ,,f .S.|,a. „|. | till' ilitl'dviit >iiiliiiiin- i.t'tlir Ki'dii'li and Kmrji iiiiiililcr tl, -lii.iildir. \VI IXiMt artnii-, wliirji tl,iii,'lit ii'iii^'- till' Kn<;li-li. will,-,' 1 ii'l-ca- till' iliM'a.-r i-ai-fii'd nil' liut t <'\v virtmis raliiinally (I'd, tin- in'^liTt ,,1' tl.i il-i'lf arnniiir tlir p'tinili l)v a d wliirli riainii'd lygiini' was \\v i"il:rd alter and u 1 111 Were (■ Mni|)l(st li\^icini' I iTiinatiiin nf thci nca-iircs avcii r arinv hv the diM'; I) iii'irr virtiins than nni>l|>ri)acli nf an •■iiidcinii' th freight traffic trmn niiirlil passenger as will wliii'h till' imi- -1,111,1 ..hII "'I'm-' i-iiinitrirs, iiu'lndinir all iililrrts to Cliitl cilli":' 1(1' I'M'Iiii l|llL^ wa-hiiij:, and Mnvthinir that is I'lv, rci|nircs tlir iiii,>t rarcfnl att I'ntmn. dt ■iis|)iri(,us ill this rcs|i(.,.t sliunld lii'liiiT it iltoirftlicr or !).. s,il,j,M.t(tl to a systematic d l>n)tcctioii •illowcil to pass the (Vonti I'asscniicr Iratlic cannot nowaila\ in the d; vi-ion hv to tram] |(risiiiis, r if pos<;i,|,. 1 ly s ot Ian t IC - iiiit: )S am 1 N-a ai niai 1 St: iiit('rru|)tcd,as it could Crincrh " itnic; it can. liow,.v.r, l.c kept under siip,.|- 'i-y piliec. Attention -hi, nil! !«• dir.vted esp.rially i}r;il)oni|> and their l,,di Itions, etc. I- m^rs, to taverns, asvl inns. pos-ii.je, l,e lit once isolated either on the spot very sii.-pieiuns ease ot' diseiise should. iiitahh hospital. Kveii the d pot or in the nearest intected rcLrioii<, the st weIlina-> of hialtl rc<'ts and districts in I; i.v miniijxrants t'rom 111 the hahit of lodirin,,' j,nd il'L'^e citie- where tliev lire • •arryinir on their hn-ii • •"iistant saiiilar\- -n ie>s, ollirht to he lindci |>'TVNion, so that any one att.ickcd l,v the di "I'ly at once l,c -.lit to the nearest hospital, and, if |)ossif,lo, tl le other IJ i 'I Hi III ;'t '-■- i' St; ^^^- TV nils ,i:n:i:. I' i';ii-(t'iil i'.^^::.»in,.. .uJ:t:n:;:i:;:::;;v:::;;;;^ .:i:i''r,,,.';;,=i::';;;,:;i;:;:V v-'- -^h:^.: :;'::.' ;^;r'r i.'./an.„„ In .\|.,al„( ' """"■''''"' ^^ '•'■''rr..,! ,l„.,„ ,„ ,1... ' '-'l.'nk „,,.,„;„„ i„ ,„.,i„^ ,l„. .|,.i,,,|,i,i„ „,•,„, ||_,„,.,„,i„.,, ""■': ^--— '• -,"-!,„. .,,i,i,.,„i., ,;„,„„,,„.,; ; IsolationiUn -pin. ,,nm ,.v,.:H,n,,,.,,., „,...,,.., I,., .li.... ;," '■:"""""^".'"' I— i,.i,„u ,„',i„. i„(;..,..,i ,,.,n.., .,,.1,1,.. '■"'7":'"'"'''"'^", ''■"""'"• ''--'-■-! -■•|-.v,.n,in,n..w ....„„„. :I;:::l;;;:r''''^''^^ -. "■''■•" .--i,... """"■/.■"■";':^"^"' ' '^1''"- '— MMna, x,.l,Mv,.lv ,n„„ ,„ '";""'"";■"■•; - '-'-n ii-„.an.i „.,„„;,,,,.„,.„,, l''-;|'---Kr-|"-i,,nal ,.,,!,,. a ,,„•.,...,..,„,,„„„,„ _ P,t ;:,'"•;, ^' '"■ — 'l.n.,| ,„ „„, transportation of patents. ni,„„v,.,. ,|„. ,,,.,,... i. ,„,„,,.,|.,,„_ ,._ ^'.":"''' '"■^'•'- '"■"-'"•"• "'—P'-ta-i ru,.!!-,!,- .,.„.,... II imlcliniti' ti'vcr. > t''i' Irans- iii ia.-il\ 1),. ,;;;;.l^:;:t:;:r;-\;::::-;:;';;,;;:;J:-;'-i-: -:-■-■ ir ilir iviriilar patmU (l.-ii:,.,.,! (;„• d, 1;m'-c c-itic-. ;i(ini I'f tllr (li-ca-c -I 111- iinr|,(,-c aic iiia(lc,|iiat<. in ";'"•' l"'""'~'^'" ^"■'I'lainl..,! will, ,1,.. ,|„.,.ial ,|an..,.r. ;'"'"''' '"■ '""•"--,..1 wi,|, ,|„. „.aM-,„„-ta.i, r |,a,i,,„. :'"■'""- I'' - '"■ I'f .'. P''li m,.iaU.,„a: a,..!...,. ,. ni, .;. |;;'l;'v,.a,n^,,,h,.,. ,.,,,,v,.van,.,.,aM,| th,.. a- uvll a- ,!„■ ,,.,nain,I.r ,.f ii>lii'(l l.v i|i(. Ii(,>j)ital-., til- tonv. and ,.v,n tlir ua^^.n-, ~|,„nl,| '|„. (■„,., i'i:"i'in / I.Ms, tun ati,| i!i,.s,. m.., -.|„,„l,| ;.|,., |,„|.,. i,, ,|„. |„„,,j,.,| I I , . , .Nuiitai-y -ii|.ii\ i.inii. ■'''"■ ""•'•""! ">■ l'"ii-i.ii; a.hl Mihitint: ,1,,. ,,atir„N, il„. ,.|„,i,,, ,,„| Hrnn,..n„.„iuf„,.,-.l- i„ ,|,.. I„.,,i,.|- „, „f .i,K_, ,„ • , |„.i^^„„ , ^^ ^ a^ u.ll a- thr >,n,at,oM ar„l i„„.n,al aiT.-inw.,,,..,,!- „f l,„-,,„:,l- ui|| 1,,', ''"'•""'■'' '" ""• -'■■■'i ' '!'r,.atM,.„t. ,„„,|„.,. „ith o,)„,.„„,„.,,| ,i„. '■'.''''-' ^'■'■^'•'' i" ""■<■.•"■.■ of, ,atirn,-. I„ ll„. s,„„. ,,|a.-,.„i|| |,„ (•iv,.,, a Iru iM.,v-.arv pivaiitio,,. „|,i,.l, ,|„,„|,| |„, ,,|,„,,,,,, |,^. ,,,,,__, j^_ nnm,.,|,a„. an,.,„lan,.,. „„ ,|„. |.a,i..Mt~_|,|,v,i,.iaM.. l,„-,,i,al a,„.,„la,„. ami Dtlicial- ((iiiiirctcd uilh tli<- in-iilnlioii. ' lMn,H,lial,.|v ail.r a,l,„il,aM,v ,„ ,i„. |„„|.i„| ,|„. ,,a,i,.„,s .l,„ul,I .■-.•iv.'al.atl,aM.II,..,.a,vtnlly,.|,.an-,.,l; th.ir ,l,„|,i„;, a,,,! nn.l.nv.ar ■■' '' ''*■ l"'"l"''''> 'li-i"li-'-l Mn,| k,.,„ in I,,-.,, u.i:-v,.nlila.,.,l r,,,,,,,- at ~o,„.. .iMan.T ln,n, thr wanl- „„,i| ,|„, ,,„i,,„ ], ,|i,,|,„,.,„i -,•,„. '';"",";: ~ .'I'l I- 'l—'l in .■io.hin,. ,.n,vi,|,W l,v ,|,.. I,.:,,i,,l, ,,„| > -,,1,1 I,,. Mn,.,lv|,n,|,il,h,.,|fV,,,nn-in,anv,,, I,.,. ,,,,,,,.,,,. .V„v,,.,n "'-'-;1';.Im.^. .,-,., I,..,. .,,;„,, l,..|,.„.i„„ ,„ ,„.. pa,;,.,,,, ,|,a, ..„„;„, i„. ':'"'• '''-""'•'•"•■' ••'• "'■•'! i~ wur ,. ,„,,, „, „,• „„ ,^ ,_ ^,„„,,,, ,,^ .l'Mn,y,.,||,y,in.. Iti~U>,.„-,ly,„|.av,l„.,,a,i,,.,,,.„„,|i,„,„,„„i,^. t"|--Mcll,|,.-.tni,-tl,,M,.f,l,,t||i„ir,|„„ ,,,,„„ ,|„, ,.j,|^ ,, • li^ti'irl l,y th,' 'iMv-anl ,.f il,i> |„-,va,iti..„. it lllfivtillir :|n Clltilf I-;v..n i,,s„,all..r,„w„s, u|,..,v ,,„ ,i,„.. |,, ,„,.„ ^i,.^,„ j;,^ ;;;':::l;:;^:!r;^;":;,:';:,-,slt-;:;:,:;;.,^'""" . ' '%"'"-' ••?'■•■'■"' 'li'-'-'i""- -I I.I !.,■ ,riv..n i„ ,vu,.nl f., tl„. wash- ing of hospital clothing, ,,am.. .iv .1,..,, ,,ati..„ts witl. utluT '' ' ■ '■ '"'iifi. \vi 1 a Ml lit ,111 (if Iv-iol ..i.,l r- , ■ 1 <.uii,i,i, n|.'t.n. ,.„u..r ,.f,l,.. a„n,.,,,„.,i, 'ai. a,i,l lu.liev.Mllar;,' a ':;:;; k..pt tr,i„, .vmla.l uitl. .1,.. air aiv ,|„„|,|v ,lan-,.r,n,< ',".'- '"■ .■•^i>"^^"r,. t„ >,ip..,-iH,,l,Ml >|,,,„, |„.(;„,. 1 wasluiiir. I'f lifLriiiiiiiiL'- the priicess nt' III iinler t,i pivvciit t ic cIijtliiMir fniii, lifciiiiiiiir spottfil hv the l„,ili *j.i''i ' ;') J (inn /■) I'll Is 1 1 \ in. i.^ wc.ll to urn; II w,.,,k .«nl„li„„ ..| .,,,|. u.|- u„|, „ |i„|,. „„|,, ,, «w..H.r,. Ti,i. ,.r..,.a.Mi,.„.i.:.„..;:,.:;;,M ■';;.; ;:::':;;';"r';"' '■'"■'""" villi I 1.1 1 .■ . . '•• "" i'"\ >,,||,.| =;;ir;;::;:!::,;;:;rJ;:r:-::~^^^ '' ''" iiili.iliiiaiii- ;,||,1 i|„. iiiiili,,. ilii- cm |,r IM l-llMlr.l I,, ,|,, ||„ i,. '"'■'■ :'"'""-"^'">-'- I 'M,. ,„,„m.,. ,,„i,i„. n,-„„„i„„-t;„-,i„.,ii- '"!""'■'";' '•'■•"'---"I i-i-i- ■-- .1,,. L„M„i,i,-„ii,„-,,i„i „- "''"■;"^ •'",-""" '"""'■"■•■'■'-- -ualN ,,.,..,,.,1 ,„ |,nv:,„.|,„„.. '■■'II I"' ll-"l t^T llll- |.III|,.,M'. _,^ ■'!''"." ' "' ^isinf^'ctinff washinK, bed-linen. :„„l outer clothm«-,.„.M. ,„ ,|„. „-,. „n,. „ „,,„„ ;„ „„ „,„_, ^^ „ ;''''"'■",'" "; I— null. IV. I,„. :,„.l l.all,,.,. ,:„■„„.,„-,.: , !;:, ""'■'""' ' '■ !"• ■"• - ""- -I- ■'-I'l'-N .1.-.,- 1 1, i, "';"'""-', ■^"■''''"^ >iv:,„.,|.|,l, ,i,.r ,.,.,„. ,.:,H,„l„.„i,, ..lun,,,. =""' 'M'"-"'! '" 'li- .li'- l-r .-i iininlMT ,,| ,|..,\,. ,.'; ""• ',"■ i""-^"ii^ ..M.„„. ,!,:„, Inri,,. r:v .-v |„.n.,i,.,. |„ M,„|,i, "'"'■''; ''^"'- ""■ '■""■'■'1'"" '•-"•.llll M,.nli/;„i .V K,„.|, „; 7'''"'''" 1''"''^ 'IMiillvni,^,.|,.||,in. ;,i,.| nn,|,.ru,.:,rlu .x |,,. ''""' ''"■ '■'■'■'" ■""■ '■""" li-m- I.. :. nn,|„.n,l,nv „f ||m' ,„ ||..' < ■ ■" ■■' ~l"''i^ill.v .-ii-ln„.,,.| ;,|,,,:M;,tn-. Tl,. rl,„|,in, u,-,- ,„„ ,i',| ":r"""'' ,'" ' "'■-■'"" '"'"^ lln,|.,r, ,■,.,„„.,„ ui,|, liv,. -,..-l,l, , ""• '''-""■'••■'! fl-.l-. liL,. ,lia,,„-,h,. 1„„K li,„.„. ,| ,1 |,„,1„„., ''■''"■/"■'""■ l!l^iiil-l-. Iiillou-, ..nMl n,:mr f anv U,„| niav I,.. i'Ni"-.l witl,„ul Mitlinn^ a„v ,1: .,, |.;,,.„ |,,,„ |,;„|.„.,.|^ ^i,,,,,, >liiiiil(i .■ilua\- 1m' of ih,. i;,|,| "- ^'lll-'.^ ill •I'Mrlni,' lln-|,il;||,. I, lav l„- •"'"'-'■';" '"■' ^"'^"" ^\' 1'" l""l^"-'l~ -l-nM 1„. ,ak,.n a,,ar,'an,l '■^l'""''' '" ill'' •■III- \'' ,t 1,„|, valii... ih,.v ina.v U- ,|.s,n,v,.,i l,v (iiv ; Mank,.|< ,.„v,.r mtrs a,„l „,1„.,- ,iM,..nal> inav 1,.. ,li.intl...,n| l,v l.„ili„^ ; l,lai,k,.,' Van ,: .l.sii,f,.,.„.,| l,v „„,r,|y ,.x|„Mi„^ tl„.,„ l„ tl,.. ..„n lor a Iru ,lavs. n,,. ,,„v „!■ other articles used by patients i, 1,-. i„i,.,.rtaMt '" '.v|,l,ii. (,.v,r than in many .,tl„ ,■ a.aii,. int;.-ti,.,i> .lis,,a--L-. l'lat,> ri:nrin / ia/v. liOli n(|iiiiv ,,i,lv siii-hj,,:: j„ |„ •t u.ii.r, a- till ill till- tic,., a- llial (if the uiImt '• '" ""■ l""~"" "I '.M'Ini- t.A.r i, iM,|,.,(i.,.rlv kI.iv-cs, ~|k»,ih, ;i,„| i;,rl^, l-l-,.an-. .,„.,.„„..„ .la.-..-..,„l u„. ,..,.1„..,,, .| ,,, „,.„,„„.^„ ,,,,^.,^_.^; (Hllv "'■'''''- '"-I''-'-''- '-■-.. i,:iv,.,ii,.,,. s|>"iii;i-. ' ""'■'■"""" ^ "'•• l-l--n-. ..,. TUv disinfection of wards ,> 1 private sick-rooms aCt.i ih,. . '"""■'nst,,Ia-..,|i,.,,H.„.,,l„„.|,i ,.,„ 1„, k.,,„ ..,,_, ,;,;,^.,„_,„ . .......PS ,laM,..,., a.ul ,„|„.,. v,.n,-li„l,.,. I,, .h,. ....,,.„ '„„ ^...•n.;v,.^.v..iH,u„i,.|,„,, „,,.,,.„, , ,,_;■ "" Dsxnftton of Furnishings.- A,-,.. v,.„nla,i„„ ... , .,. ' ' '"' ""•'"'"-••M-tun.s a,,,! „tl„.,. ,„.,.„,„.,.. „„ ,1,.. .,.„. .,,. f.iii,iv.",|. aii,l t „. wall- a^ u,.|| ..^ ,1, i- ,- , " . , a> u, I a> III.. ,.,.,l,„j;. ,„1,|,.,.„.,1 ,„ a ,,,n.ti,l ,iis- ' ;• "■'''-"'■<•'-'. .,r,l„ ilin^ i- „„„.|, ,„.„■,. „......a.-v in - .•v.. ,l.a,,,n HKH.. ,,r ,1,,, ,,,,,.,,, .,,,^ ' 7'"^ 7"' ;"''"'^^ •■"••■ l'='l'-'- tl..,v .I,,,,,,,, ,„, ,,„,,„„, ,,„„„ ^^,„, :;;''-;■ ':-'';'^ -•-''-<-..■•■ ...vtunv ,.„„,.,.„.,„„ ,„..,, ■ I I' * .1 till) / 1 fill ■> I lA i.i: i m \ :,..;., -ra,..,i.,ii:,i,.,„t;.„.,i„„i, ,.|,i„,i,i„r ii„„,,,„i „■,.;,„, i,„ . ,v,.-i, ,„„ "I ullll, W.i-li. ''';'■ "'""■ '- -'■'■"'''•"' ■-'""ll> "'tl, -,.n -„:,,, .,,,,1 ,:„l„.|„. „,.| -|"-> :M„nn„„ l„ .,,. |,:„.| ,„, In .,„„„,; ,M- :,n.ruar.| n.l.l„.,| „,)■ „„| »:i\' 'I "I |iaiiilii|. '"'■,""":'' """""" ■""' l""nMnv|,.n,„,|„„h ,.,l -l,..„l,l l„ „,,.|„,,| "itii J :i to -I III I r, ni. „, ""■•" ■■' ■■ai-l".lh M,„|. \-;,nH.|„,| ;,,„! .-l-l,.M-.-a,vl.,.„,.|,„„.,|,„|, |„v:„l. TI„.s,M„.,„., I,-,,„,,|„',.,, "'"'^^"-'"■''''"•""■'-""'■•■•"-.■■'li-'nnM.-. :,M.l ,|„i, Ir ' , ", ""■ ;"'■'";"'■•■ ;- "rl-l--,|. ,|,„ ,.„„,i,„ , ,1.1 ,„. ,,„,„„^,„| '";;'""■;' ■' '-''-'t,.,.,..,i I. i,oiii,„,„„i„„„„,„„ ,„„^,. ,„^,,,._ ■■'■;'""";'. """''''•, ■'"■"^—-i-:iji„. „,• ,i„. ,„,i,„i-„.., .„,, 7"- "'';•" "':"■" ''■'- '■"■ In..,., ,,„||„n„n. . ,„„.,.K i„:„l,.,,„a,.. „. «l<'.-lr.y llio |K,i-(.n m|' |\|,|mi- |i \ , r. .\-i. U,.n,.,.m1u„K ,|im,.Ml, —linni;..., „,.,!,.„ ,„„„,,al-;„„|„,,|,„,. Mm. „l,„...,,^.,,„,,|,,,„ ,-a,iv,-al,l..,„,,.n,„v,.alll„„,l„.,„„-, , ,,.,.,.,- '" •';'■ 'I'-mti-ti,,,, ..r -hi,,-, railrna.l ,..„.-. a,„l srU\r\,.. ,1,,, U-.y', I.. ■-.. M-,.| |,vu|,|,n- ,;..,.,. ,.a,i,n,-.,l„. ,n,.,|„„l- ,,,,.-,.nl.,..| .;,r,K...lli„„.. =""' liiriiin,,.,. „ill -Mlli,.,. ui,l, |„.,,|„.r „„„li(i,.ati,,M-. , '•'-'"'■'■'■'i n„.-,,i,,l „,.„.,U |„ .;,nnal,|..U,|. ul,i,.l, I,a. „„,,,„1, '"'"" '■"■■""M„.,„l,.,|, l,a- n,.v,.rl,....n,rinl in ,v ,,1,,,- ,;,,..,. ,.■,,„„ „,,.;, w.'know,,, 'I- na,nn.„C,|,„,,„|,„„i, .,.,„,. |„,,,,.,|,|„ „,.,,, i^.^^^^^^l^^^^l "•;;;'' '"■;''<;-. I- l- nn.,.l, ,„ 1,„ l,,,,,,.,, „.„ -ar-tMl ,..,.. n,,,,.,,,, will I..' hkhI,. ,lnn,„. ,1,.. ...M ,.,.i,I..,„i,., -i,,,-,.. i| ,1,,... ,,,„v,. .Urrr-.M 'l-|"--Ht ntl,..r,.,„n|,li,.,„,|„„.a-ur,.-uil|l„. i,„M„:„-,.lv>i,„,,ii(i,.|. Tlu. ,ii.ini;.,.,i„„ nf |„.i,a„. I,„u....,., , l„.,.a,.n,.,l „„, M.r,., --tnl Iv l,v ,';':.;;:':: i""/""'^'";; '■^'■■' '''■•■''-- -'''-ii-n.ion,,,.,.':!..,!, ,'"„'";" N"-:; Iv -ran,,.,! ar. ,„a,.,i..ally alu,.s .;.,m„I ,o |„. 1. fh.uk u ,„-, -..rv,..,.> ,.a„ I,.. „l„aiM,.,l l.v a,,|,li..ali„M ,„ ||,.. |!„.„.,1 „,• i,;,,,,;'.;;:'"""-^ '■' '"■'"■^"■',,■,..,1 |,n,,,..rlv M,„i .InHnl i,, ,1,.. ........ssu-v Rcgrulations Regarding the Discharge of Convalescents -IVlor,. all„u „„• ,.„„val..-,.,.„,, „, ,„„„,, ,„ ,|,„i,. ,:„„i|i,., „„| ,„ j,,.;^.^,,,, ''*'■ " -'"'"''' ■"■ '•.■nu.-„l.,.,v.| ,!,a, ,|„ V ,,, ,,,,,, I, ,. ,,.,,,,.i,„, ,,,,, I"";''" '' ''"■ ' -n-v p,v..an,i„n- l,av,. 1,,.,.,, n,.irl..,.„.,l. j,,-, a- ntl,,.,- ..•;,ltl,v |„.r-„„- n,av,|„ if ,|„ v hav „„. in ronta,., ^w,h pan,.,,,- or l,a\-,. li,.|.|i in an int,.c,,.<| \va,-il. '■"'"■ -"'■'■'•'' '^■■'>'^ '"■*'"■'■ '!"•>• ^"v .iiiiiiii/..ii -.i:i|, Mild •ill >,nvcM (., tl r ■ (.■:ili-iii: !• ■""' "^IKT, .■arrlMl utfrllti.,,1 l„ "tlltT IkuI > p'TiiMii, ,,r ill,. i„ at , ,1 l-l.'lllic I ""' •li«inl-.tini, ,,(• ,i„. I,.,,.. |,.,„,| '■ 'I'l"' !:.-! I,ath -.|„,„|,| I,.. ,,,1^ li'MI III ••N. it '■'""■'"""■"■•'I I'.V |.MlPrMl- ,,r ll tlii> filial linili, til,. ,.,„|\;,|,,„ '■ iHPMlll.ll |„ I |iia<'.. tliai fia» lint Kir liclMML'mj.'^. \t"tir t| M '■'"'liiiiR if" Itii.. |m>; I ■nt- AT<- t(i i\ r*' -i in 111 M i|(,i| ■rila.I Willi III,. j,„i,,.,„ ,,,• ji,,. ^j "■••n carfliiilv .li-ini;,,, ,| .,,„| iiv liavf takni li'iL'. IT in ilirir |il(-ri\|.,| ti i.-caH'. >iii li llv ^^mm c'^(< treata;ent. SPECIFIC TREATMENT. I':- to the |.n-...ni liin.'tluT,' Imvo Iuhm mo M..lcwr;naiMv .,f the .li-casf in Fran^ iiMt appear tc liavc I.-.I t,, any ra.vfiil alimipt- in tliis .linvti,,,,, altlum^rh a niirnl.tT ..f Fivn.'li pliy-ician- vv, iv at the time u,ll tniiiu'.l ai:.l r.,m- pftont ti' ;iai,. new and more .■Hieient methods of treatment than those at present in u^v. Even the maiiilest .iilHeulti..s eiieountered in the studv nf the nature an,l hfednsiury of ih,. cause nf typhus fever and the ahsence',.f nnv definite knowledge ,u re-ard to it simuhl nut det.- ns in future epide.nirs from niaknit,' experiments m immunization and seiotheiajiv. We nu-ht f) feel .■n.'oura,ire,l hy the resuhs of vaccination in preventhiL' small-pox and hv the famous acnevementH of Pasteur in the (.valn.ent an.l prevention of rahips. W helher experiments in connection N\ith Ivphiis fever will nls,» he crowne.1 l.y success and ,.f what nature the r.^snlts o'f iLcse experiments will !«■ cannot, of .ourse, he predicted to-day. I have alrea.lv. in the .haoler on the treatment of typhoid fever, ha.l o.easion to point out • iie thllaev o<- reason- niL' by analoiry. and I feel impelled to repeal the warninj: in this' place. .\~ opinions in re-ard to th.. nature of tvpdnrs fever ehan^re,!, niimer- 'Ml- attempts were mad., to diort.'M or alM.rt th.. .iisease hv l.h..,,.t as many mor,. sm-h .h.eirines ami svstems of thcrai.eulics as Ih.re n i ! he hotdiea.ls ami visionari..s in our art. J5ut if on the c,,;.- trarv, w,. (,,| ,,w ll„. ,,a,h of ,.l,v.rva!ion an,l sn.'.vssful experi.n,-,. ,n ih.'se '.ises^ni .,tli,.r w,ir,ls. il„. pail, ,,f ,.„,pirieism -ui.le,! l.v r..ason— our fre.. an,l un.ra,nn,..I..,| in,L.m,..„ will l,,,.l us on to new an,| h..tter view, than ean l,e h,,p..,l t,,r fr,,,,, a l,rain that is rnhMl hv hyp,,thes..s." ' /.-..-.' , 1. I7>i. AI2 Ti!i:.iT.\f/:\T. 613 ;:::r: -'•;:-'"•—"■ ...•.., rt..,.,!,;., . lyMln.. n^:,,.., ,..,,,,,,.,,, , ..I.n.i... .,,,1 ,„„...„...„,„..,„ ,.,: GENERAL TREATMENT, NURSING, AND DIET. ti caM'-i liMlicnts to l)(d ■ Ix'^niining that lii'ir DWii accord. n- .hat absolute rest in bed ,l„rin,r ,i„. '>win,,o.l,cin,cM-i,v,,r,|,,.i,i,i,, ,,.,,,,,,,.,, _,.^.,,,, ""•"""" ""''I- i' - nuvlv necessary „, onlcr ,|,c It p... u.thou, s,.,.n.- ,l,at absolute rest in bed ,l„rin,. .l. 7"- ""• " '-■^' "'♦'■•■- l..:.st a wccl"•"'■•'--"..■ '.^a-pa,. a„., "11"' ii"tlle ti.Mii the vcrv heuiiiiiiiiir. ''; ""■ -•'•'";'• -"t :>fthc l..r,he .;,r,ner hal.its ..f ,)„ „a.i,.nt may he .nn-ulle,! to a c<.rtai.i cv-enf I, l n , |>.ili.iit> .,,,,1 ,,.„,.,. I , . '■""• 'f ^' I'' I"' iii<..lenitclv ,.,M,1 , ; : '^'V'"; "'■•, "- ^'" '•-'•>— nd hed should he ' - '-.I ow the ,,at,e„t to Chan... If, pn.lon,.| and ' Xk;;or 'V;:'"';''""'^ —•.,.., n'o,nth:o..tset a.';. l' t..^T, T ^'~ '->^' -' --y - |.<-il.l-. It should .ri..,!.;;,:?: ■::::' ■' ^ --"•--I.patientandal the ''"'"■ l"'"''i'-" "f .larkeiiiMir th.. room Cnnerlv ,-, i . ■ Inrmfiil ., i , ■ .,, . . '"•'"""" '.^ "■'•"Muneiidcd, is jis 'i.iiinliil a> I. e\ce-Mvc iMiiiniiial (HI It |, ,„,i,. „ , rz::::::z;:., > t:;:::::z: :-■;;: '"'"■ ''"^'''"' """"^";'- ~ '■'■ "• I"-i'-l<'. !>'■ individual, who have ■ '•■/'" :"'^"''^ •■'■' i>.'M>-; although Mich hrell rcliih^rcd i llllillllMe li\ -.:-.'i;;;:J;. ;;■;;:: '- -- >.i->- I>i'nii:;a h,r::e,.|,i,lei,ucaM,li„ ,>l•„.es^>|„.^. thcllr, ' . ■ ■I SS-:i«ife 614 rvi'iirs Fi:\i_,;, It,- <■(lllr^»■ I (■\ct»i\.' 111'". :lll(l. .-I ,■ ;| '•■• .h..wIkU rn,„i,.-.„.,| |,v |,r„„.,.,„,. tlK.MtU..„l:,„t>tVo,„ jrem-nil |H,|„il:ilin„. ni.v.n, ,,||,,«,.,| „, „nii-K'v,ili ih,. ll ilie ,.'""■;":"': "'''■' 'f "' <■ ""■ i--- 1- i,,,, ii,,„, ,,;. ; ,... xmII Im. .Iivii-,.,! in ,|,.t,-,il Ciiril,,.,-.,,, ' .-ulMt ..Tan,,..,,.,,,. .,v ,„...,.s,n ,;„• In- „w I,:,,.,,,,, , ,,,, " 7'-'lv"l-. Mn.lh,..ns,l,l..,;„. tl a,v ,„•„„.„,' i.,„/ " '"•;■ '''^'"'- '■;•'"'■'■•' '"• """-- 'i'--"y p- -in..,,, „,.•„„.,• ; :"•""--;-';-■ .■.-,.■,.,!. Tl,i- ,„v,.an,ion i. M,.,n. ,K.,...,arv i.v,,, t — " .y,.l:..,l f.v..,.. Any pl,v-i,.i.n„f ,..,..„.!..,„... knows h„;vH„.h "l'.l'-ts ...,l tl... ,.nau.i„;„i„„ „,■ ,1,,. .h.liri,,,,- p.-m,.,,,, .,,,1 ,„ wlut •„. <'x.>nt , ,..v ..,,„.,• in,,, hi. l,:,llu..i„ati„M.. ...n,v.„. l,i. .l„liH,„n ,„ ,|,.. •""'" "' '"^""^'- ■""' 'l"i- ;:iv,. ,-,•>,. ,„ i„..al,.„lMl,l,. l,,,nn ..,.;:i;::''M:''i:,:i:;:;:::rt:::-;;;;\.r:;:-^^^ All w„„l.„ ,,|,j„.,,, 1,1,,,,^,,,., „.,„,„,^. „,,,.,^^. ,^_ ^.__^^^ „,.l,.,l.,.,n.,l ♦".'■"""-■ -"' """-• "l>.i<-'> ..' wl,i,.l, ,1,.. ,.„i.„, a. w.. know. ..|in.s witlMlu. ^n.at.Mol,-,ina,.y.>l, 1 l.„ ,„ v,..l a. on.v tV ,!„. ,.,„.;' 1 ;-..vunwtan,... ,,..nnit.tlH. .a,-,,..,- .1 1.| ,„. ,„,,,,.,„, |,, ,inol,.n,n' wliicli I- .■asily (hansel and di-inllricl. Tl„... |,r....aniio„s, ..ft.,, .•am,,] ,.„ „i,h .|i„i.,,|tv i„ p.-ivaf nr-u-- '"■'■• ^..■;; P.-1-.l.v 0I-.TV...I in all u,.li-r..rMla.,.,| ho.pilals, l,nt thcT,. .„v ""'^' ''"■'■""";- '" '' -•-' i" '•'■.^^"•'f "• '1... ,,la..in.. of ,1... ,,ati..„t- Removal to Hospitals.-\VI„.,„.v,.,. i, i. at all po-.ihi,.! ,v,.i,„s <.'vrr patnnt- -l,onl,ln,„ I,.. a.ln,i,t..| to o.,,.,,.al ho-pi.al-, l,nt if ,|,is "■'"'"."; '"■ ^'^""''^'- '' "'"~f ^" >'■-' '"■ n.,n,.,nl„.-..| ,|,a, n,..>v isolation in ;l"-,al wanl. n..ar tl,.,.. o....npi...| l,v o,!,,.,- p„i,.nt- .io..s „,„ .„.li..,. ''"; '"'"•="■'• '''■'-^'•' '■ '■^"'"•i".' <•>-. Ix' "I'lain.Hl „nlv l,v phuin.r ,i„' I>|'t.<;-.ts n, a -p,vial nan! at son,,, .lis.an... (Von, all th. o.h.r.-if p..,i. '.l'^ .t -i.onl.i 1... at tl,,. ,op of ,1,,. l,,,i|,|i,,. ,,,,1 ,,,,,,.. I,,,, ^^ .,,, ^^ ^^ ' _.._ (Miti'ani'.', i])arat(.' It is ahvay- n.n.l, l,..,t..,- „, l,av,. -p,...ial ..pi.I.,,,!., |,„.,,|„,, ,„. j^,,,^,,,,,, l>iiiMiiii:~ cMrmci'trd uiih tl ri:i:.\rMi:sT. "■ ,i:'ii''i-;il liM-|,it.i|, ,,,!,. I (iir, I :i- ;irc in iiM ill ;||| III ih ••"ii-tnicii,,ii ,,|' I, nil, I r<' kiii.l. I'"' =""' '>l'''"> 'ivrr |Kair,it>, the harnicl. "ij;nc(l tlir tl le I"' |nvt,.nv,|. \i ,„, |„ii,ia,i,iit 'ii-triKiid oil il |>c>t-l l<— >v,-t(iii i- i"ii>f i- axailalil ii~ ^y~iriii ca-ilx and !■, \\ari|~ cai iiM>|>iial- I -day — I iiivil i'i|" ,,f tlirir allind on, su nrcosarv Cr liotli tl Mi!aiit~. piiticnts and T !<• \M -llrjllll '"I'ws >lioiild l„. „,„,, l.v dav and nj.d mil '«■ '■'-rrc>|.,,]idiii;,|v ini'iva-rd '!'•'■ >|'.-i>"M-. ,,f i|„. year I nial. Iiralilli;' (iicil It ; HI winter tlicrc i'ii-. Dnriii.r tl,,, I.' ill '■ iijx'ii air. 111 !«■ M jinn-iici' ot' Open-air Treatment l'i"|M.rly prot.ct.Ml ai,raiii,f <„ii and n •■•I'liiir niy patients "'7-:"'' '?■'"""•"'• •\>" ^1' tlie l,.,pe I .,,„,„i„..,, i re I ever liv (Ills 111 '""i""t siy tu(, iiiiieli ill (;,v.,r of liie II the l><'j,'iiiiiiii<,'-(,f i:'vea veiy tavoniM,. .tlivt on tl ■I '"'IIS w a- never ivaiized, tin |iroeediire pruxcd <'vlai:e — ti "' P'"i''iits Ixvanie cpiiet, and "'■IV more (iivoral.ly iiiHiiene,.] 1,^- t| II' violent iieadaelie and insomnia — "tlier mean-. 'J"|i melit;il eoiiditioii of vii '■ intensity of the d IV aiiv Mioroiis and very favoraiily in(lne patients ,,ftei, s.niled to I., Th as a direetlv '|«'n-air meth.Ml is of vaiiu. not oiil y as a s\ni to tl d 'iirative, treatment, ptoniatie. lint al> !'■ '■'■iitral iiervoii- -v.-tem I •^mce we known that the .■hief d: 'It'pres- K's III exce.-siV( i'\<'itatioii or e\ iiiji-er eessivt' Aside from the henefil to th, "|"'''-:i"i' treatment al?;,rd til'' spread of the di>ea-e. patient, thoroiiid\ vent ""■ ""'>t etre<.tiial mean- of m,ard ilafioii and tin iiij: at It slllirle 111 is to the strict use of tlie,«e iiie; who coiitrMei I'I'ysieiaii was iiifeeled, aii.l thai t ires that I at! nliiitetlie fael that i the (II: iroiii l,s7(i ,,, i.Hjs, "<'re adiiiiitcl to M ease was ( K' pereenlaire of hospiial att "lien all tl le ea :'.'".l"ritv of Ihe hospital inf "•'iliil ami treated hv tl ''>ll-'pleiioiis|y low ihiriii- the ll ses of ty|)liii.s fever lot a eiidants iree veans iirriiiir in Berlin P' Iiviiliiids had if tl mlers thai t teetioMs that did "' "peii-air method. Tl not neirlecled occur iiiiLdit have 1 le irreat X'eii a\-oi(led !'■ Mece.s.sarv hatl war!s, iii.^tc.ad o|' in tl IS Were to "V""'.''"' '■ ' '""' ''^•^""■'l -irict >«' LTiveii exclusively in the I if lli t' alteiidants "' "■•"■'■""■ "I I riy ventilated I)atl who ciiiiiract repeatedly lu-lecti-d to ul I lie di.sease h lev tins or mi, inerelv out of I rye ■rooms. Most laziiie.ss. m '/■ m£ SI 616 rvi-nrs r/.v/,/;. F limy rcrimrk tli.it I ; "■'"."""' ^^'"' '•""'• '•--!■ -.i.-. I ..„ ,,1,.,.,..,! , ,.. „ "'"' " :n::::;;::;:-^:::-,:;;;- -.■;:>n.i.-....;;::;r:;::;;:,:::;:';::'''- "--■--<•<• Diet iV.,iH in,,, ,,,,,, ,;,,.,. "•<''-i...itlK.san,..,,.i,...i- "";' "'." "" "'"><■ tii=i> oi„,.,i„ i„ ,i„. „,,,(„„ lit "1 ty,,l„,i,| (i.v,.r.ill.| th.. ^.^^^ — .„, .1,.. van„„s .„.n,,.,ns an.l Mu...|KM,i>n,. „r .iig..- "'"^"■- •'"■ •'"■• -'""'I' M>ist ,.x..|,Mv,.iv „r li,,„i,|. OCall (;H,.l..,„ilki> ,1,.. „„,. ,1,„ •„„,., „..rly fuDill. ,|,„ ,,,,„i,„. ...■ii.>ii. tlu.num..,,fsn,.plvin..ll.„nnM.,.H,,,l,,,l,.:,,....,,.| ,|,! „„, II i~ t.i Im' ivtrrctt.^l tliat a la?.r. til.' tM.ril,. |),.ri.H|, aiv iinal.l.. t.i tak V imi.mImt „|- ,,a,i,,,„, ,.s,„,.iallv ,l„riii,r '■ ". ii' liii-I ill iiiiiri.K|i(i„| f,,,. I- I"';.-'- ^'-.M ,„„. l,„„..v..,, ,„„u l,i,„..,f t., 1,.. t.H. ,.a.ii; 'i-'''"'"" "t -trMa.. ,„• „(•..,„„.,„„, salt ,„ay l„. f;,„„.| t.. anMUT A v.rv ^""' '•'"". --'-"'■ 'Hi^i^fr tl,.. milk wi,l, ..,„iM„i,| -ul.,;,„,,: .,„.,, ':.",-'",''";"" ''"■'"^'•^"■'•""-' •• Ki'"i"nn..|,LaM.i ,l„. iik... l„.,.a,M. i, =."-l^.l,..l.,., m..an- „r ,„..v,.„,in. ,1,.. fi.n„:„i.,„. i„ ,„.. .„„„„.„ ..f '-- .^1.11. ,l,a, ln,..,.f;.,.,. ., „„„.|, wi,l, .ii.,„n„„. An ,.,,,'.llv '■""■""• ''■•'■^''^'!'- '• • --' -■-- H-.. ii „..nnilk. |.i..l, ;;'-M---'-l,.:il.tal,l,.. A.ain.,l,..,,a,i..„r.„,.j..,.n,„...... ':•■ '■"■'7;"' ;"■"' ':""^ iiii.iiUkfo,-„i,vi,„. ,. „..„.„,,,•.: ;;!;';;; "'•''■ ""vpi,us .i.,, i, ....naiiy ,„.,.,.-,.. ,.. ,„,,,,„., Ill-Ill.'..... M,av,., ,,..... ,il,,.,|,., ,1,1 ,,,,,.,,;,, ,^.|,,.^_^,,,,, ^^._^^.^, ^^^.^^^^ ( tlif r(s|iimt(iry |iassif:L's 1- li-nn In- uli,.,, il„.,.,. wa- intcn... ..atani \r|l ■|-:il il:i If til.- hiilk i- «,.|| 1 l rliK """ "i'l' 'li'' tivatiii,.,,! ,,f tv|,|i,,i,| palatiilil \ai lip-- A- ll;|~ ltd i,\ ail rale-, o-n,.,, I'liMiil tc\cr,' <■ tMi-anv l,.|i;.t|i ,,)■ ,i|,„. ,1,,. ,„|,,, '"■III -ai.l III I'oiii 111 order to ivikI 'i' -ii'li a dii t |'' ii~e(| niiiM ( iriiia. -a' Mat t\< ""• 'ilM.v \,iii IIV "f the li.|iii,| ,h'el. I-: '•"■Iter, >(,ii|,< |,iv|.are,| uiih II I'- '■oiitaiiiiiiij evapuraii.l (Viiil- .„• irteli-telli .-. le.riimiii, t i> uell III alli -e, liiav he or we may ailij I,,.|ilie-K ■Male llie iliii-k •■liii'kcii, or iiiir i'litiiar; 'i|» Willi el, -Ml- |,n,t| |«riiiitte<|. • ; Ihi.-' mav he ,1,11 liieal-siiliiii, 111. >\M'et-lireai|s. le iliiniiL' an I eulltailim^r j.j,j_rj, lalve.s-lii-iiiii.M It -hnlllil I a;:e of ty)iluis tt-ver. '<• 'll>tilly patient- -iiirerinir "Tile, as a •■lllier s|i,|v,| ii, with tl '• »■. prepareil with K| s<-ioi,> soiiietimes take to it quite kiiidl 11 a private 1 se. [>; and .served in a rreeii irhl.ss to V i( It is Itlelils vvl em s meat ]ire.« a> are fiiHv I' .'iiise the hidod im.xeij with wine or h,niilli V color. llleilts ill lll.l\- lie ^■'""1 mental cunditioii who are aid. allou...! -iili.l i;„„| j,| ^1^1 to .•h.'u an. I - any -ia-.> ,if the .1 mav I iv|iai-ati.ins .Im lieiirllt .if the tl'Ver. T -prill;.- .Iiickeii, Tl '|i'''l', ;inli.i|i|M..I II leal. K' treiienil rill. iioiirs, a ihelll t litt '■ ■" ■•' "111.., ami to .■ml.av.-r I. pati.'iits ivui-iilarlv (."mI t\ o .-at when tl tl ly all iMissi everv t\\,i to thr... d lev are stn jHiniiis. I'ati..iit [Hissilile iiiejiiis t.i in. hi "" '"• tlinv tim,.> .Inri.ij: tli,. ni.rht— i ee r.'.'.ive s.iiii. or .■\ample, milk, l "iinlloii |i. li'i: il ■ u. a. (ils Tvntis ii:\i:i; -Wfl! y.i^-, ;";'"""""'''"■'"-• ''--ii"-'ii-.i„.n,.,n„.iini,. ,.,..,....1 „, '■'";;" ""■''' — " ■ ""-:i'llv n, ,...-, ,„| ,1,,-,.,. ,„, ,,,„ i. '"-I- -„„.„.. 'Ih |u,„.n,--l,„„|,|,,„,i,„,|,„|^,^„,.„^.„|^_,, ._^^^^,_ ,n,u.. C.l.l,. ,,!,,: ■""■"''";• "'- l"■-i^-l"i.l,..o.MM,.,„■ >; „,..„„„„..,i. All ,i,.i„ks \ iili pi(>|„r ,-,.,,-,.. ,|„. „„,iill,',i„,| .-.■„,„,i,',„.-iv '1,:;,; ""' '"■'"""• '''■>• ^'■"'- '" <•""-. "-y >l,„„l,l I,.. I.,,,,, li.i.-^ Im.,.,, ;,|„„„t ni,iv,.,-...|ilv :il,ai„lo„,.,i. ". „..„„„i,,,„i,i ,,,.„,„,, „„„ ,v „.,,,•„,„,,,„,, ,,,,.,„,^^.„ ^:;'; ••;""'";"" ;"■'■" ^'-•■•"•--•"^-.-.•■•-...i ...■....„:.,.. t li«... iiM. i„a.\ Im. tli<. inraii> ,.v..„ ,,r -aviiitr lifi'. It i- -.■a,v,.lv „,..,...,,y ,„ „„.„n,„. ,i:,al,..vv.l,.i„|..,..„ ,„,,., '':":"•■'"""■"-•"' """--^Hia,- ,.>,..„•:.,„ n„..an, „. ,,■.„!,.;, N a.ln,,M,.rn,„„„ „,n.n I,,, ,,,„,. ^ I '«';.,, ni„.„ ,1„. ,,„i.,„, ;, ,„.,: --Hi ..a,„,„r ,,„,,(,,. i, ,|„„.,i„„l,.aual n,„ i„nv,,u.„„v ""'"'■^ ";;'""', ''"'"■ —i '"iHT .v..,.,. -,,„,„,„„.. Ti,.... ,a,i,.„;. ;;: •: ;: f- '^t ' "' • ^' "'• '■'■ '-■■ -"-'---'> '"" "I :i K""'! .|imlily, (.>|„.,.iallv I'lN,,..,- r.,allvwi,l, ,!„. l...,i„„i„^„r,|,,i,,.,„ „...., anli.,ri (ill "■I'' ""i-lv and tlhir C iriiirr ti>«;n klll'illi: tlic -|i,.|-ia| „ •'I I'oinliariii^r t|||. i;.|, iiIIjimI- ,,|' tlvaliiKiii, tl called antipyretic methods 'Hlr Ihrt liial |||,.-,. mhiIlmK | liili'iMii and it~ "•.iiMii: oil iv|.|iii- j;.v,.|- i. iikI tlic Ilia i\Mlli, >" tliar lie Iia~ ly ilciMaiid- on ill,. ,|| ■rl||,v til i:i\<' not licrii j)i'ol>;il i"~i' Unit a i'on~,-,|i||.||,.| ii lilK'tcl I' so- |"Ttnnity n,,r i|„, ,i„„, , !<-• -Teat jirc.^ uorl ''■ii~i\i' iiiid or car '""'■vrr, |||,„t •(111 |llll(|||lCS, ol)>crv;i- inctliod-.. I I <-|" riallv on ||\,| roi !'''•' -"•'•'"- |.l;i.vinn,lMvlianr,.,,i,||,,„ i:i\c a In liinipy and tl l(>C renewed ~||"Ken of tlir inidolll.tcd c n-i' of ant i|>yretir drii e|iideniiis tl '"' '" ""iiI'Mlini: llie (i'V,.!-. It i- ,,, I !<■ i'|icii-air tnainieiii '"'■ "' 'Ve-h, (iv,|ii,,niK '"■ 'i"|'<' to iMiiiiiir til,, nij, ion. j'lovidinii' tlieiii, <(( e|) tile patients in the ••"iirse, with th. Ai • ii">t iii(ii> ""-';r >Ik. vMrioM. „.,,. „,• hydrotherapy tl '-i"n-;'l,!e methods are I le ll>e of tin I "ater inattn . til.' Mni|i!i'-.t and the •athin;:, |,„,,| a|.,,li,ati,,ii,,|-,.„|,i, ;„„, II S'ver e (■ax- patient on a water-l.ed tn I- lias IxH.n stated eUeul I'lil the l(e.ri,| "■|'<', It IS l„.st '" '••'H|.erainre may l„. .till thrtl -'■veral Ihnes a day, a |.r.«-,dnre tli ''"•nn- the patient's po.iti.m. Tl 'i'l to put the ler I iiereased |,v ,\ iiKehanieal niliiet lailuliijr th " ean easily 1 IS X' carried out ion e watt even ie(K| w 111 all s- I'ess the patient. "•■r, ;is has 1 K' use of water of a 'een reeommeii(l(il, and it evere leases an •irinniiicr and dnrin.r tl "•'-'•••W >l'-'iild he pia,v.| u„ th.. head f, "■'itahle. the ii>e tiirhaiiee of chan le entire M \y len ther '" Inciters tnhes :iii,t: .111(1 relillinir tl 'file periiMl. If tl •"111 tl]( II' patient is ven- di-ease, eap and tl <' IS severe laelh leadaelK ' -inall pi||,,„- filial „.i,|, j,.^^, »_ I'lvieral.Ie, for they avoid the di le iee-eap. 'speeiallv ill th(! 1) rn'miiiifr ,,f ,1,, "liieh is often V ":"■'"■'• """"■•■>^^i>-«Telialde means! ^vater is valnaide. l{,,t|| ,| 'fy t roil 1)1 esonie. "f '■"iiiliatiii),rtlieii|., le lee- iiiinia, III lee-l )a.,. applied to tl p !•(•(■(, I'd ia I '■ijiid and irre |ulicni- a ( I i.f Inkcuann uc'i-|iark a|>|iliid to tlir irnnk ainlliivM !■ (All! niilir- (liirinL; llic lir-l half nl' llic ni;:lii i- -m 11 — 111! in allaviiiL: ii'-llr-~iii— and indiicin;^- -lc<|i. .\- a rnlr. i.nr -Imnld ;:Mafd auain-l iIh' Iimi t'rc|ni'nl n-c nl' vcrv cnid |ia(k-. a- llicy liavr an inidr-ifalilc lA.'itiiiM- cll'ivt mi nianv |)ali(tits. Treatment by Baths — Aliliun-li .ipiniiin- nia\ .iitlcr a- to tlic niiinliii- iil'iiiiil of Inkcwaim lialli- llial il i~ di-ii-aliic to ('iniiiov , ami a- lo thr way in wliidi tiny a-i\\ in ly|ilin- t'cscr. I liavc Ioiil;- Ihid llii' ii|pinion. wliidi | lind a^r^'c- with that of the majoiily of |ihy-iciati- at thr |ii(-cni time, that tiic |ii-in(i|ial olijcct aiincil al and thr \aliii' of' the liath liratnicni lie not -o niiiili in the i-cdiictjon of tlic lcin|irfaliir(' a- in the faxoralilc cll'cct pfodnrrd on tiic cntifc -ym|ptoin-c'om|)!(\ of thr fivci-. |iaftiriilai'ly on ccilain \ilai ccntcf- that aiv (-jicrially im|ili(atcd — namely, the fc- pi fa lory ami ciivnlatofN cfntcis. 'I'lic tfiilh of tin- a|>|icai'- more tiifciiily in typhn- I'evrf than in anv olhrf t'elnili' di-ea-e. W'hcfea- I frci|m'nll\ (ili-ef\cd an excfedin^^K- -li'^lit and vciy li'm|>onify inllnencc mi the lein|ief;itiife, the etlcH't of tiic liath- on till' (M'feliral finietimi- and on the fi'-|iifatof\ and rifcniatofv ofMan- \\a- al\\a\- -o mafkcd ami |icisi-i(iit that i do not IicIIcnc lv|iiiiis le\ii-ean |io--ilily lie tfi'atc. The iiieiliod to lie |inf-ne(| in the lialh Iffalinriii niii>t lie >tficll\' fi'^iilaliil areofdiiiM- to the indi\ idiial cii-e. I have alfcaiK' dealt with tlii- niithod at -onie jeliLllll in the -eetii 11 'r\|il|oi(l j'l \ ef.' to whii'li I viWr the feadei' tof t'l ifl lii'f d( la il-. I \\ill onl\- -ay that in tviilin-, a- in ty|ilioid fe\if. I iie\ef n-c cold lialli- e\ic|il nndrf -|ieei!il eiiN'tim- >laiicr-, ami n-nally pfcfef /iiin— en'- method of i;fadiiall\' I'edilciiij;- the tein|)e|-aliife of the hath. I Jilaee tile patient in a hatii of L' I to 2i) , and ■ifadiially cool the water to lin or IS", rarelv lower. A ■■old. damp eloih or an iee-eap i- applied to tiie patient - head (hiriiii!' tiie liatli. KxeepI in ea-e- of eMreiile deliilil\iir uitli -mile local contfallldi- caiiiiiT aH'cctimi it i- a L:ood praetiee, in -tiipormi- and comatose patient-, 1 -;.■.• T.l/J,.;,/ I--,',;,-. |K 4-'l';. iSSi- tui.mmi.m: •;•_'! Ill ^'■i\(' ;i cold (Iciiiclic (i\ci- the lirad mikI trunk, lilln r:it iiilci'N ;il~ iliiiiii" llic li.itli i>r al llic cimI III' the lialli. ALiaiii, Imwivi \\ \ n-c c.lil wale r or (•\rti ircil wall!' uiily in -[(ccial c~, (■iiniintiiii: rii\ -eh' u itii wali-f at a lcrii|>iratiirc <>\' IS , L;ia>liially ri'iliiccci i,, |ii . alll ^'li utlici--, ..n < 'nri'irV i-ccciiinii('iiilaliiiii, lia\"( ail\ i-rd llir ii.-c nl' Icc-u airr a> a iMiiliuc jiractiic'. 'I'lii' rn'i|niiM-y ni' lln' liatli- -limild ili|iriiil imt alnr rrvcii iliiclK- (HI till' lMiilv-li'ni|)iiMtiirr, a- I iiiii-I airaih iiii|ilia-i/c, Imt un tlic Lr<'tii'i'al (■'iinlitiiiii, ami |iartiiiilarl\ nii tlic cuiiiliti'Mi >i\' tlic cciilfal imia mi- -\ -icin, tile |p||Kf, ami till' fi'-|iil'atici|i. A- tli(-c -\ lll|itiiiii~ ai^' liUiK' to lie xp tiiMili iiKirr ip|)~liiialc ami -rvnc in l\|iliii-, a '^fiatir iiiinil)»r (if lialii> will, a> a fiilr, lir ncc(~-ai\' than in t\|iliiiicl tivrr. When llic t;icilitic~ arc liinitiil, a- in |ii'i\atc |n-aiticc, wluri' it i- ni>t alway-; |Ki»il)l(' in j^ivc a full Latli, it niav lie atu|idr, (ir deea-innallv in marked catalc]ilie cdiiditidiis, pruvidiii^r they are imt edm|ilicated liv a siihiidriiial tem|)er,itiirc. My experience is stniiiirlv UL'ilinst the ad\ isa- liility (if em|)ldyiiij; it in cdiiditiuns (if marked excitement. In place df cdld liatlis llerniann, lui the strene-tji df hi- ex|)ericnces dnrinir the Pcterslmrir epidemic df iSTIaiid 1 ST'i, advdcatc- the use df pnitraeted lukewarm liaias. Ilis ultimate results — he had a mor- tality (if le<'iallv as rcLnirds the sedative etfeet, from baths df this kind cdiiiliined with cdld ('(impresses or an iec-liai^ tn the head. I should advise tliat the nietli(Ml he tested carefully in future epidemics, opeeially as certain niddern authors in (Jermany (iJiess, I'liverridit. and Kichli(irst) have warmly recdmnieiided it in the treatment df tvphdid lever. lu a irdance with the then aeeeptc(l principles df therapeutics I made a very extensive n-e (if antipyretic remedies dnriiiLr the years fi-din 1S7(! to IHTS, without, however, any marked result. Now that dpinidiis dii the treatment df fever have niideryone so marked a chanire, and, as has heeii repeatediv stated, the ad\antaL''e o<" reduciiiir the temperaturi' alone is accoiiiited of luucli less importance I t;:JJ / 1 rill ^ II ill:. liP* than I M'liiriK. I ,iin liK'liiici, talirnt~ -.wr niiicli ni'MT lialih In lie ailarkiij liv -ntliliii licarl-liiiliin' lliari an' paliiiit^ -iilli I'inL' Irnni l\ {>li'>ii| I'.a rv. 'I'Im- u-f 111' -alir\ lir ac ill. -Milinni -alii\ laic, kairin, lliallin, ami anti- t'cliliii -hnuM I" alianiloni'l all"L:il lie; nn aminnl nl' ihiir niaikrd cll'ii't on llic licai'l. (.^iiinin, anli|i\i-in, iilnnaiclin. nnl lacl'i|i|ii niii riiav 111' ii-id in icrlain i-a-c-. accniilini: In llic |ii'iii(i|ilr- laid dnuii tor the Ircatini'Ul nt' I\ plioiil li\ . i.' <>t'all iIk-i- ii nirdii -. Iart..|>|i('nin i~ llir,.ni' I ar -t iin-lincil In ri'iiirnnhnd, and I liaxc i-iriinK had cnn-ii Nralih' i\|ii rii ncr w il li ii. it i~ |irariically wiilmnt any injiii'ion' ctl'vcl mi tlic luarl and n -|iiralion. and, ill adililioii i.> i;- ni.irUcil .•iiilipyiTtic aclinn. it i~ c-iici'ialK iix't'iil tiir allayiiiLT lAciliiiicliI , ilcliiinin, and iii-nnini,!. Oilier rnni'dii- li.ardK innic into roii-idi ration in an ordinar\' ca-c of ty|iliii- I'cMr, In |iri\ati- |>racticc and liir lio-|iiial |i;iti(iit~ w lio arr t'oiKl ot' t.ikin^; in. (liciiii, t lie ii-iial liydrorliloric acid ini\liiiv or ;i dccociioii ori|niniii with li\ ilrocliloric acid iii,i\ lie |irc-crilicil. m TREATMENT OF SPEQAL CONDITIONS AND ORGANIC CHANGES. In ^pcakiii;^ of' llic (Vent- and condiiion- tlial inav call (or cspocial till ra|icin ir intervention in the coiir-e ot" t\|(liii~ tc\ er 1 iiiav inciitioii jiarticiilaily weakness of the circulation, cardiac and vaso- motor palsy, and collapse in general. In a ili-ea~i^ wliicli i> relatively -o >liort in duration and ><> severe in it- -yiii|itoin-. where the cri-i- may li e\|)ectcd at a dctiiiite jieriiHi, the |)atiinr- lite may de]Mnd on liceiiiniiiH- a rational ircatineiit to cuiiiliat iiii|Miidini: eiilla|i-e at the |iro]per iiioineiit, aiiiiiir it- tiirce. MvirvthiiiL' nia\' dejicnd on kce|iin!.'' the patient alive nntil the tit'l(inth or -ivcnteciith d.iy, when the cri-i- ami a -|Mintaiieoiis cli.an;/'e till' the liett.r mav Kc e\|icetcd. .\llhoii;_rh -timiiLiliiiir rciiiedie- -hoiild he liiiiiil:inl- ;iiv iii|iiirri|, |„.ii. |i,:iv\ 1 1 ii mmi i:iii wit,,-, -li.iiv, ..I- , |,;,i,i|Mi:iic. I':iliriil- ..fill,. I vr .1,1-,- hi.iy !„■ -i\,.|i l(r;iii.l\, I illiir «illi ,.r «illi..iil ual, r. 1 1' .■\aii..-i- i- in. -, ni. :iii,| ili,. (■\l|-iiiiili,- :iri. I',. I, I and llic l(iii|M'iai iir,. i~ -iil.h..i'iiial • , tin- |iall,iit U in .■.•lla|.-.., ::i-,,:.', immII,,! uiii.^. ,,r ,.,-nac in -lr.,ii^r |,h„.|, ^,,|i;,,, ,,,. ,,..j i,,.,^. lie ii-,',| H ilh a.l\ anlai,'.-. I |.arli,-iil:irlv iv,-,,i ,„,| ||„. „-.• ..f al...l...| in ih,. Inriii ..|' ll„. u.ll- kiLiuii S| ikes' iiiixlur,.. ..n a,v..iiiil ..I'lli,. .-a.-c wiiii «lii.li ilu' .!..-,■ nia\ l„- rci."-.I'ilc.|. ;ui.| lM■.■Mll^,■, ii.iiiL' ill ill.' r.irni ..f a iiic.li.'nii'. il piiiu lie L''iv,ii ^illi'Ml III,, paliciil'.- kii.iwjiML'c. Til,, loriiiiita in n-,. in niv '.•lini.- i> a.-, t'.illnus : K. Spiril \ in i-.ii;nac, • lOn : N.. I : Svr. I iiiiiiiiii.iiii,. J.-, ,, , A.|U. .1.-1 . i;,,,,, •M >i-' ">i r iw.. i;il.l...|„.,,ii|'ii|. .v.ri tvv.. Ih.iir- < )i'ra-i.i|ially I ailil tiiicl. vajii'. alliir., .l.n t.i ."i.n, a- : rvc L.tij... IT ih,. |p,iliriil ,.aiin(it ••\\all..u ..r ali-oliii,.|y nln-,-. t., take .■•l,...|i..|, it iiia\ I.,. ailinini-lcivd in a iiiitriliv,. cncina ..(' lli<. f,ili,,\vinir t'..riniila : B- ."^I'liit, \ ill. c ..-nil.-, .(,11, . Tiii.t. val..r iilh.T., .-, ,( . Vi|..ll ..X . N... I : Mile. ;.niiii iiriil... 2n.t(iv(l .■xrlnsivciy in tli.. r,,rin of" liy|.iMl.iini,- inj,..ll,in~, catfcin in the fliiin (iCatllin. iiatr. siliivl., ,,ii accimnt .if tlic ^ivaicr MilnJ.iJitv in tlii> ti>i'in. I iicvir u-.. iiy|),i,l,.rnii,- iiii,.,.ti,ii,. ,,f' (tlicr, a- llicy aiv ncitluT >,i <|iii(k ii.ir >,, la-lintr in tin ir ctrrct- a- .•ainiilinr. ami aiv. l)(-i,l,.s, very |)anilnl and th..|ii,.|itly pnninr,. al)>c,.~~,'s and ikcimh^ ,,1' tli,. fattv li— iic^. For 111,. liy|Ki,l,.rniic inic, i ,i, nf ,.aiM|,h,.r a frolilv iir,.|ian.,l .-..ilnlii.n IS I., lie i.n.ffj-n.l l,i th,. ,,ffi,.ial caniiiJM.r nil f..uii.l in ih,. >i„ivs. I ii.>,. a .«tr.Mi_' an. I a weak s.ilnli.in, a.' •ilin.; to llic t'.inniila- : R. ('iiiii|ili..r. irit.. .Kill Mlljlll.. I II. .iliv. pari-s.. < >r a.- .~.iliiii.i ..ainplinri tiirlin? : IJ. ('Mliipli. trit., HI. ,.liv. piil-I»>., 1 O: -.0 , K.n. l.O; ■'i.O. w '~1.U' i;j J / 1 /■///> / / 177.' V— - f [?T-i- 't ;■ ■ ! ' ♦• - - i ll llif ii-f mI' i':iiii|ilii>r lin.-i l)ri ii ilft'itltil upnii. ii -li.MiM lif L'ivcii in ;.'iii. (■riMi« .I..-I -. (Ill, ,,!• m.i -\ niiL'i I'mI- nf tin- uiMkir -•ilulinn iii:i\ !„■ -imh i\tr\ oiii In ihrif li'iiii>. :iii.|. iiiiilcr • i-rlaiii finiiimtiiiH t «. tin- -.iiiic :iiiiiHinl "I" ilii- -iicin'ri- iii:i\ I.. -iriiil:irl_v uiliiiiiii-lricil. Nn ili.-a;.'ri'iMlili- ii-ull> v.\\\ i.i- I \|..|iii'| imh .,| .mI |:i|,-.. in 1\ |i|iiis ti\i'i. M- ll ilm- ill nilur inliciiiiii> i||.r:i.-i-. iMllciii. '■» 111:: |M ll- >|,i(ial arhnii nil llii- \a-iini'p|nr -v-iim, i. ut'iiii I'muihI i\i n-nu-U u-i lul. W ll. 11 lln- pill-.' i- \c \\ i:i|pii|, inv^^iil ir, aiiil \^^\\ in liii-i.iii, illL'ilali* i- imlirih ll ;iimI in,i\ |iim\c' ii-i liil. IT, Ihiwcm r, ||i,' .-.iHaii-c- rMiiiinnr-, il i- III II, I |.. -nl.-iiiiiti r.illl in. I lli-r 1 11 Ml I ■(In IT- -llMllM. Ill' ri.nl-n, I ii ■ i unil li IK 1 1 W il ll ol IllT, f-]iciia II V |ili_\ -il al, iiiitliiMl- i,r In .tl III, III, lilliii r,„.liiM_' a|i|ilii'a(iiiii a-, liir i\aill|ilr, llir iiv-liii" Im iIii lirail i.p llir | ir.i •• Hi li.i , ailil lllf ll-t' 111" the walir inalllT--, \xiili ..r uitlmni rliaiii.'iiii.' llir « alir, anil iikiI -|ii.iit.'in).'' — iir llif a|i|ili('aliiiii nl' waiinlli. In iiii|iiiiiliiii: liiirl-tailiiri' mlil circvcll liiki'Uarin li.iili- mii-i In- n-nl «iili laniioii. None Inii a lii;.'iiic(| I'anatii' nil till- -iilijiri i.r IimIi-iiiIic ra|i_v uill (lrn\ ilial iIhn IcimI In liriiiLT "" fiilla|i-c. N\ Inn the [piil-r i- llir. ails , llic triii|iiTaIiii'r i- -iilninniial, ami tln' lari' aiiil rMi'iiniiic- ail' i\ aiintir, ininli ijni.il iiia\ lie ai-i'iini|i|i-lic(l liv tilliiiL' tlir water iiialln-- uitli w.iriii \\atrr, lis a|i|(l\iii;x Imt-watiT linllli-, li\ \s i-a|i|iiii;r llir cxtniiiilir- in flannel-, ami li\ the a|)|ilieatiiiii III I,(i!er"- a)i|iai'alii ii-in^'' warm water — In tlie prrenrilia. Nervous Symptoms. — Ainnii;: ntlier m Mi|itnin- .ami < iplieatiiiiis rn|llirinir ,-|ieeial treat till lit tlm-e alVceiiiiir the iiervnii- >v-teni oeeiipv tile lir^t plaee. rill Mitnleralili headache, whieli t'rei|llellll\ ileelare~ jtMir at till' lieiiinniiiLr 111' till- di-^ -■■, rti|iiiri - eiieri:etie t reatnieiit, A water pillnw ainl an iee-eaji >liiinlil lir-t lie nnlered, rnjlnwed in iiianv eax's hv enlil ilniicliv- til the lieiil. The-e may lie irivcii aliiiii-t without ehan^'-iiiir the patient", pn-iiinii, nierelv li\- Imjilin^r lii.. ||,ail n\ er the f(l;_'i' 'it' the IhhI ami plaeiiiif ;i ve— el miller it. Manv patient- lliiil emnpre— e- nt'enlil water, til which i~ added a little \iiie;.'-ar, alenlml. nr call de enlii;.''iie, i^ratefiil. Warm euinpre,-se.-< are -ninel iine- -iinthillL', e-peeiallv ill iilil, anemic, nr Verv i'celile |ierMill>. In yiiiithl'nl, pletlmric imli\idnal> iin he-itatinii ~liiiiilil lie felt in ajiplyitiL' arlitieial Iceehe- liehiml each ear nr In the tempunil reirimi. Il the-e mea-iire- Tail In relieve the headache, .aiitipvrin, pheiiacctin, and l.i'-tnpheiiin may lie le-nried tn. I'Aeii npiale-, e-p(eiill\- hspii- dia'inie iiijeetiun- nt' niiirphin (i).(H to (LOlo irni, p insomnia. It ihi- ...niimu- iiiiiiii,.ini|,...,ll\ \\,y Mv.nd Aas~ ir i.i;u MMval, M rl„ |,ah. ,„■- 111, , an.l i„ aiiv Ma-,. „|- ,|„. .||.,,.,, ,, ,,',;,J,„. ••'''!'■ ^""""iil •.!■ .iuimmI -l,.,|..A,.n-a n,ark,..| ,.,„, ,|,, ..,,,,,„.,, ■vnl-r-. «|,i,.|, a,v ,,t„„ -,, |„-,,|;„„„IK n.s,,K,,|, ,,„l, ,l„-,,n,,l, ,1,.., „ llic rntirc ,',,iir-,. ,,(' il,,. ,li,,..|>,, ^'"'"' "l»" ^"i- nnl l,;,,|i ., ■..,., n,, II j, .■Miv„,..K valiial.lr aihl ,,rt..|, ^iilli,-,- 1,1 ,iv,. aliiiu,.,! t,. nini,. ii,.,.|i' tl 1" "11,. I,ut th,,-,. uli,.-,. pi.,.<,.ii,.,. i. al.s,,lni,.lv r,.,|iii,-„| '<■ intunt. H,. -li.iiM not l.c spiiLn WK ill HI (i2t; T) riirs 1 1 VF.i:. m :■■ e^ ^ii m %, w^ I"i iiimc<'i>-;iril_v. iiiid I'circc ~liiiiili| m-xcr ln' ii-cil csccji! in cxti'iiit' r;i»c?^. I'"iniiii(-~ .iinl ;i ciiiitiilciit >ii ihr jmii ot' lii~ allrnil:iiil> fii\f l!u' ;rnaK-t aniniint nt' < n.-iiiiiM^ciiuiit Im ilir |i,iiiiiil. If ilcc|> CO.aa Mini stupor (ltv(l(i|i. -tiniiilani- ni:i\ lie r(i|iiiiv(l. I'liilcr -iicli niiiililiiiii- ci.lil (|iiiirlir> ill a liikruariii lialli nr in an ciiiiiu lialli-tiili may nc ii^cliil. The iiii|Hi|-Iuiii't' nt' cantiil alliiilinn to tlic uriiiai'v -rcrtliun, ami llir tVi'c ii-c nl' tlir callictcr. il' nccc-sarv tn ciiiiihat i-ciiiiii:'. and ii\ irliiliiiL'^ ufllif lihnldcr, caiiiKit lie tnu .-lriin>'lv iii.-i.-li'd U|(ciii, [lartiiiilarly in tlif ca^c nf a -tii|MiroiL-. |iati(nt. 'I'lic vomiting lliat otVcn airuiupanic- llic li(aila: w-v of aipia amy-dala' amara'. T" relieve the t loiihlex iine hyperesthesia < if tile -Kill and liliix'les and the iil)-tinate pain- in the linger-, tm-, and xile- nf tin feet, whieli an |iartieiilarly eniniiKiii diiriii;; tiie initial -t.ii;e and ai^ain dnriiiir the jieriiid dt' defei-ve-eeliee il n|- |iike\variii I'l-ei— nit/ liaiidaucs -liiillld lie tlie al'e fe-nfted \><, . lih.rufdfiii liniiiieiit or meiitliol -lioiild lie prelert'ed, the latter either in a -olmion of iili\i> oil e ■y\\i\\ I U'licve to lie even lietler, ill tilt; liinii ol' a jia-te : .\lll\l. n.'i ■_'.(!; \';i-i'liii. pari--.. .",ii (I, M. Si;.' — Spii'Mil Ihirkly i'li !\ pii'rc el" liiit ,ui(l ii|ipl\ Tlie respiraiory organs may rii|nire ii-eatment in varimis wtivs. 'I'lle !rieile-| attention -hoilld lie jiaid to the eiinditioil of the lliisc, the na-o|)liaryii\. and he larynx. Attendant- -lioiild he in-trneied to |iay speeial attention tu the ("ire of the uo-e and mouth. I rrij-aiioii of the iio-e with ';ak -alt -oliitioii or some (li-int'eetin^- -ointioii niav oeea-ioiialK lie iieei— ar\. I'"or the milder alfeetion- of the throat and larynx the ii-nal Liirules are (|iiite a|i|iropriate. I i' the \..iee he^in- to ehaiiue and hoar-eiios develo|i-, tlie irfeate-t \ i^iilaiiee i- iieee--ar\. TIk er,.:,! liahilitv to se\cre and ripidly iiroLnv— in^- ehaniie- in the lar\nx in t\ jihii- fe\(r and the -llddeii de\ elopmellt ot' edema of the ulotti-. often leadinjr to asphyxia, niii-t alw.iy- lie lioriie in mind. I 'inler -iieli eireiim-tanees the |iatient, e-peeially it' he i- lllieoii-eioii-, -lioiild lie watched (lav and niylil liy a re-poii-ilile Mersoii to ascertain the projier moment fin- traciie- oieilV. p rnEMMHST. (327 ='"vat.n,.Mt. It i- III., K „, |„. (;,||„„,..l l.v hv,,.,- Mallr .-onirc-tlo,, oftlu. luM-., W|,i,.|, ,.v,,„ „„v U.VM~i,,MMllv'|„. pn- v,.ni.^ l,v st.vn.r.lK.ni.,jr ,1,,. lu,.,-, an.l f,v,,,„..,tly ..hanj:!,,. ,i;,, ...jf- ,„ ot tllr IIMtiint. Tl„. digestive organs .1., ,„.,. a- a n.l,, n.,,,;,-,. „,.,.„„.„,. \hnm, tlu. l„..,l„ of ,l„. .Ii-,.a-.. a,„l .Inri,,,: ,.„„val..s..,.M.-,. ol.-tinat,. .•..n-.t,,..t„.,- .„„,,iM„.s ,.....,„.- ai.,1 M.ay 1... t.vat,,! I.v ....ans .,f ,.,.,.,natu -'"''" alM|,„n,Mal M,as~a,r,.. ami, in rnntfa.liMin.ti,,,, t., tv,.h,.i,l IIavp, 1,J Ilic adiiiiiii^ti-atidii nt' catliai-tio. ' " I>iMnl„.a an,l ,n,.t..,riM>, raivlv ,v.|„ir. tlMrap.uti,. it.t.Tvvntiu,, •' '"■""■^"' '- "^"^'"> =' •""-' '" > >.vii.i.t..,M, a.MJ, wl„.„ it i. p,.e,,,,t :i"l I'll Ill's ai'c \aliirlc~s. Tho changes in the skin that fn.pu.ntlv .„..■,„■ ,l,„-i„,r tl... poHu,! ■t .•onval.-,vi„-,. aiv t.. 1.,. tnaf.l .xa.tK as in lvpl„,i,| C.v,-,-. As ,vj:anls i|„. .I..v,.!.,p,n, .,t .,f l„.,l-..„v^. tl„'. jr.vat.M uat.hfnhH..s 1 iu...,.s>arv. fur ,|,.. patimts a.v n>M.,||y pn.tnnn.llv pn,.tn.t...l an.l :"'"""'""r '■' ""■ ''•■^'""!-'^- '-'-' "•a.v is .u.,.;..>a,-v not onlv to l^-l. .I,r l.,W,ln,, ,.|,.an an.l s.nooth, JMit al.o to M>l,i,.,.t th/l.o.lv to ,.ar,.- '"' ''^'.'l>- '- i"^"i""- It I.MS l„.,.n >|,ou„ hou- ,,,M..klv i|,„ mos, """";'"'■/' "'="'"""^ lM-i->on.. wln,.|, at (i.-s, arr not' noti-.-al-k. inuv lU'vi'lop. ' Hi.' treatment during convalescence, if „o ,o„,p!ic,,tio ,s «lcv,.|op, I. >inipl,T than in anv uthcr acute intiviions .lisoan. After the en.lof the felnile period tl,,. pati..nt>, a< a rnh. .-(vovf '■'7 ';''"'">•' ■' •'"■ l'l'v n.or,. often ealh.l ,„ „, rostral "'"' Mill ish than to em n^.. '■;'"' ••'I'lxlit-'. when if returns, may he .ratili,.! m itho„t anv sp.H.i..l 'T'"'"'' ^' ■■'^ ''^'- ^'''■"•"'>- '"-" ^1"'W"- I refer the trailer to t'he liiree- tlolis previously i:iven as to ili.t. -n,,. nervon> >y.ten, ami ti,e hear, eall fl.r niure earefi.i attention Mt tni. tnne than ilo the ili.eMive or.ran. I„ ,„anv eonvale-een, there 's M |H.r>Me,„ nervoM- irritahility or a eo.ulition of depression, with "'"■':'■'' ''""■'• "'"" "*■ 'I'" '■'"•■H'-t .•.ml n.emorv. Sneh -omlitioiis '■;;'""'"■ ••'"" "■ ••"-• -'"^ •'•'-' '-•on, exertii,,,; Too „arlv mental <'t'"t or ev,,„.n,ei,t, whether plea>nral.Ie or the reverse, are" likelv to retaril r<.eo\,.rv. A prolonged period of rest I. neeessaty. espeeiallv if after delerve.- """:"' "';■ '''''7 ' '"""- -'-^ =""< --'k- r,„ler'.neh iditions the '"""'" ''"'"''' '"■ '^'1" i ' '""il tlH- symptoms have improv,.!. after er lin rif: i - 'ffl I ()-J.S Tvr'iirs lEVF.n. wliicli lie ii;:iv l)c iillowcil In u'ct up fur :in lioiir ;il :i time. Auy lU'irlcct inav lead te cmituf;iniiilms t-t iiiorhis contaRiosis. Vcnot.. Ijoo. Mussii, I)e ffl.r. jK-stil. ciiin petc.liiis. Vciict., ir.-iti. HuU.t's Uibl. uwd. pract. I. Andr. Cinitiuli, Ciniiinfiitar. lir I'csti-. W'lict., l.J.Vi. I.i'liciiwald, Cliroiiili iilliT diiikwiirdii;iri Tolfn. Nui-iiIkti;, 1»;I5. Huxliaiii, Ol)sor\ . dc iii-rc ct iii(irl>is epidi'iiiiii-. l.7. Ha,-«Tii>lirl. Ilistor. rnrdi.'. iiiurlii r|,id..Miii-i .■!.■, \'iiKli't'., llr,H. Sli-;ii-k, (llwrv. iiii'd. d.' rricirlio ,uii, iKtrrliii-, ( ■uri-nilii'. ITW;. K.Mirirl.atiin. llistnr. iii..rl.. vnuUm. amii 17!i:i,-t 17!i4:i Kniiin.irallis raptivis Ciilm- liacitiiii dilati. Krlaiiticri. 17'.t';. Sclinf.T, rcl,,.rda> in iirid iiiii l!,.:;,.i,-l,iK-^r ] 7(i:i l„.ns,li..|,d.> Ncrvnilirl-cr. Krlanuen I7IM-,, -^ ' Cum,-, .M.-,li,-„l Itcports on tin- KtlV.-t. ,,|' \V„|,.r a- a U.-nu.K in Frvvr l.ondoi- 17!>7. .1. Hartnumn. Dct anstcckMndc Typliii>. M,.,! .lii-ui--. /.,iiMiii;. Nr, 4:,. 1H)7. A I'r. 11,'ckiT. I"c-1..T dii- NiTvciiti.O iiT. Willi., in liiT-lin 1«(I7 InrT-.litcn. Krfti V. llil,l..nlpian,l. fclM.r den arisfckondw, T-plm . ni'l.^t .initr.'n Winki-n ziir H,- wlirankunj; .kJ.t iranzlirlirn Til-iniL' d(>r Krii-MH^sl und nnliriT,.raiul.T.T M,.n- >rh..nspu<-„..,i. Wioii, IHIO. (A 1 k In,- it> ii,„,. rcnmrkahly ,.l)j,.(.tiv,., an.l oven t()-11 wiirtli rcadiiii;.) Wi'dcnii'ver, ]),■ IVl.r. pct.uliial. (i..ttiin,r,.n. ]H\->. llartinann. Tl rir (I,h anstivkciuim Tvplni~ Wion. 1812. Ua.-..ri, Stni-ia il.'lla tVl.r. pctivli. di- (i.Miova 1 7!i'.>-18(K). Milan... IHIH. llul'i'laiid, (■.•l..r.li.. Krici;-p..»t. li.Tlin. 1H14 A.k.Trnann, V,.n d.T Natiir.ios an.stockcn,!i-n Tvpliu^.. ll..i,l,.ll„.|y. ihH. II. .rn. KrfahninijL-ii iil.or dii. anstcok.Midnn N.Tvcn- i.n.l La/,arvtliti.'l...r •' .\„tl Bpr lin, IH14. \V..lrt-, |{,.Mu.rkMni;..n uL-r dio Kr.iMkl,..it..M, w.l.lio ini .lalm. IKIH in Wars.liau iM-rrsclifn. l.,.s„nd,.rs iil.,.r .l.-i an>t,..'k.'n,l.Mi Tvpliu>. H,if,.l. .|.,„ni 1814 K.Mianl. H.'.trai:.. /.ur(J..>.l,i,l,|,. ,1,.,. IIirn..nI/.„r,di.n!: und dos an.«t..<.k,.n.l..n' Tvi.hus Hiif.l. .I..iini., 181.V . I • KoM^>, l,l..n.ilal d.-s Kl.vktl..l...rs .nit d.'f ..rirnlal. IVt. Niinil.or!:, 18ir, Annstn.nt;, A I'm.-t. Ill,i-tr. ..f Typhn- V.v,;-. I,.,n,l,,". 1819. K. .Iai'ks„.i, A Sk.'t.'h ,.)• tl„. Hist,,ry ..f (■,.ntai:i..iis Klvt l..,nd..n 1810 llark-rand Cl.oyn.r An .\,r,aint ,.f ((„■ hVv.T Lal.'ly Kpid-niind in Irolan.l. I,..nd..n. Mar-li. (.l,.,.rv. .,n .1,,. ()rii;in an.l l,al.-nt I'.tI .,f r,-y,.r^. I)„l,|i„ H,,,,, «..„ lM-.'7. V..1. 4. II-' (•■■rri-an. On tlio Kpidcnii,- K.-v.-r ..f In-lai. 1. I,an,-,-t, 182H and 1830 (i.-Hilti.T ,1,. (Uaiil.n. I),, ri.lentit,-- . I'f.uflV'r, Uiitranu /.ur (iwhiiliic- dcs I'etecliialtyphus. Bamberg, 1831. f.2» !* •13 4. 630 i.iTEiiMrni:. V,-\vy l..tt.-r -n T^pliU- F.'vir. Diil.lin .l.iiini. ..f M. .1. S. , . iK:iii. t;,.rl!iii.| ;.i..| I'.iiTh.k (III th.' T\pliu> Ki'v.r whicli ..r.iiiiv.l :it I'liilu.l. Shin in WM\. Ain.i. .l.iiHii ..r \I.il. Srli'iK'c. \m|. I '.1 Mini -jo, is:;: 'I'l -on. A St:iti-lli ;il In^inirs into Fcv>r. l-Minh. .Ii.nrn , \dl. .Ml. \K\h Ijniv.-. l>n tlw StMt.' ••( ill.' l"u|.il in 'I'viilin- :incl llii. l-.-..!' rHlhnlonini in Certuiii Cii-c.^ .il' r.v.r DnI.I, ,|on,-n . l>;s Vull>'i.\. l)u •■■r,\iiliu- IrMT .•tell' hi lirvrv I \ | .lioiilr U An(;li'tcrre. Arch. i;i'n. di- nn'^il., IN'.'.I, Kdillu'll, Tri-iili-. T>|.lni.- K.v.t I.Mnd..,,, \KV.I. AniliTsou, Ol.-irv. Mil T,v|.liii-. (Wa-^'.iW. IS4li. Cliri-li-c.n. An. ( '■ 'iilinucil K.mi- in Twi'ilii-. S\>l. ot' I'rurt. Miil . Vol. 1 , l.omlon. IMU. l,iini|oii/,v, Siir I .ipiili'inii' ili- I\|ilni> riin-rnil i|iii » rcmiv » l!(iiii.« en 183'J— lh4l>. .\nli. iiiMi. ill' null . 1S4'J. Krnii.il\. till tlh Conncv Ki-twri-n Kuininr and KrMT In Iri'liiinl I'tr. Diililiii. l>-47. Stokr,- mid Cii-iik. On tlio .Mortulii;. of .Mid l'riiititioTn''-> in In-lnnd. Diildin, .('ilM-n. of Mill Si-., Ih47, Ir-ls. UiiiiTod, Clin. Oli-iTv. ..1! Coiitiiiiicd Ki'ViT iit St. Itiirtljoloniiw - Ilo^,. London. \M><. Griivis, Clin. I.i-ct. on tin- rnutiii' of Mcdirini'. II. Kd Uiildin, 1H4^. Viri-liow, >littliiiluiiL,'in iil.ir dii- in OIhtm lilf>i 'ii liiTrM-lii'iidi' T\ pluiMjiiiifriiie. \'irili. u. Ui'iiili, Arilii\, lid. II. 1K41I. Stiili. Zur piitlioloi.'. Aiuitoniii- di- ol.i-r-i lilc.-. 'ryplm-. Kl'iMidii. S. :!•_':!. V. B.-ircn-iiniin;. I'idiiT din 'I'v |di\i> in OIpitmIiIi -ifii. llai- '■ - .\rili. X. 4, 1840. Vindiow. Kriii-ilii- uliiT din oliiTvlili'^. Tviilui>. Viivli. .^nli . lid 111. 1H4'.». Siiclianck, Mittlit-il. iilicr ilir T\ pliu-t'iiidi'inii' iin Ti-Mlicncr Kni.-i'. I'rairiT A'iertid- jalirsclir., Bd. L'l, 1H4!1. Scliilt/.. r.diiT Tvpliii- i-sanllicnatiiii-, iK-iiliartitct in den WintiTiiionati'n di'S .lalircs 1847. 184H. — Kl>i'nda, Hd. ■.'•-'. tH4lt. FinuiT. Dii' walm-nd il(.,- .lulirc 1841',— 1848 im I'r«i;er ullu;. Krunkeiiliause btobaih- ti'ti-n Kpidiniii-n, l84i;— 1848. _ Kliriida, Hd. -J;!. 1841'. JenriiT, Tviitm> and Tviilioid. Kdinli. Monthly .Imirn. of MmI. Siii-nre. Vol.*. IX and X, 18411— 18r)(l. Chri>tioMiii, On tlic I)i-trilnui..n of Kt'ViT l*atii>iil.» in a Hosjiital Mnntlily .Med. .loiirn., 18.V>. Flint, Cliiiii'al Ki'port- nn Conliinu-d Kcv.rs Hau'd on an Anuly^i.- of li;4 Ca.-cs. Hiitlalo. 18.V.'. I.indwunn. Dim- Typliii> in Irland. Ix-oliai-liti-l iin Soniint-r Is.'ili. Krlani;i'n, 1853. FiinrPi. Prpuvi'> iliniinirs di- la non-idiMitili' dii typliu.' it di- la liiA n- typlnndf. Ga/,. nii'd. do i'aris. 18iV4. Vin-liow. Iiii- N'otli ill! S|ii'!->»rt, Wurzl'iirt'i-r Vi-rliandl.. Bd. Til, S. WTt. — nil' lliiiiiifnpidi'Tni.' in rntPifraiikiMi iti-. Klii-nda. S. l(il. ( Boili artitlo.i alco in (Ji'S. Alniundl. iiu- d Gch. d. oH'i'ntl. Mi-d. n Si-in-hrnli.liri. ) Biirlli 't, TliP Fi ■••r. of till- I'nitcd Stati-s, 4lli Kil. I'liiliidi-lpiiia, IS-'ifi. .laqiiol, Dii typliiin di' I aniip<" d'Oriiiit. I'aris, \X'*\. Pi'ai-iK-k. On till- Varii-tii-- of Continin-il Fi-vit and tlnir |)i-iriininiition. Med. Timep, 18;V.. Coili-liiT, I'l'^iinir' d line nii'iiioiri' stir I" typliu>. oli-orM'- pn \'al-.lc-(irare etr. (iaz di-s hop., .lull, 1«.'>'1. MavfT Dii- Typhu-i-XHiillii'iii i-ti-. Wichi-nhlutt di-r \Vii-n(r AiTzto. 18.W. Mi-nnti.-. I'vii h. elin. ft anatoin. -^urquelnni's iniintiide 1 hist, du typhus. Thi-se. I'ariH, ls.-,7. ii I.I ri:n.\ ii m-: (i.tl Muri 1)1 lIi>torv ..f till/ Di.-liii , Kiii;ImmiI himI Kt rkaul'. Typli rxu 'f 'rvpliii- iind 'I'v |ili,,iil Kevi-r. Miil, 'I'i I Iff, itln'rijut. in tintli re Sfliiislii|Kil, ..ir. l,,.ii l\ |>lii,|iir. ,t (ir I ;i|>|iaritioii dn Ividi. e\ttiitlii'liiat. en Ki.'ypti'. I'll, in.-d.. 0, I , 18(;i. ('uzaliis. K\i inii'ii tlii'..rii|ii<' .1 |iriitii|iii' dc 111 ijiK-linii rclati\f li la diictrinc di' 1 idi'ii- lit.' .Ml ,lr I Kniilc. Diri'inMitiill.' Diai Niitiirl'orscli.-Vi I iiiin-idi'iititt' dn typliiis dc la lirvri' typhoid^. I'n inrd., IKi;i. iici-i' d \aiitliciii. voiii Alidi'iiiiiialtypli us. liir. d. 3ti. lHi;i. <;rirBini;,T. I'dnT KlccktUd.cr itc Arrli. d. Iliilkniidi', Hd, II. 18i;l. AiMiiM IntVctiunskrHiiklii Tlicnip., 2. Autl.. 18114. i-n : .\li.-cliii. KliTklicliiT. \'irili. lliindli. d. spec. I'atliid, ir HiMirtliiil. diT tyidiiis. Kraiikiii iiiit lliH'c der Wiiriiii ■pi lliilk.. ih; Wundcrliili, Hcitrai; Mini;. Arcli. t'l Duncan, On tin; Intmiliicti.in of Kcvcr iiitii \. Gdurricr, It.iat d unc cpidiMii. dii typliu.s (iIimtvc a Toul.ni 1804. These 3I( IHtli;. .MurcliiM.ii. Pi.- t\ ver|)i<(d, etc. Med. Tiine.^ ISCiL'. ntpellier, pliiiidcn Krankliritcn. Tehers. v.m Znl/.cr. ii.-rliii, 1807. 1 V lllplel.. eidleitiiili ,,r the litenitll .rk-, ) ( \ ery specially of tl Ider Kni^lish und French Rosenstein. Mitth iluni;en uher diis Kh'cklielier. \'ircli. Anh.. lid. 4.?, 18«i8. V. Tresknw. Vorl. .Mitlheil. uher York. d. Typli. exanthein. etc. Kerl. klin.AViichtnPchr Xr. 7 11. 8, 18(18. ' Naunyn, Bericht uher den exHnthem. Typhus in (Miireussen. Berl. klin. Weehenschr. Ni 18(18. Seliicf. (•decker, A'erhuiidl. der Berl. nied. (i Becher, Mittheiliini;en aii-derTviil •s. Berl. klin. Wochcnschr., Nr. 'J--, 18()8. Nr. 4!i. M u. .'.I, ls(;8. liliiis.pideiiiie ill Ostpreu.ssen. Berl. klin. Woclienschr Miwler, KrfahrnnircMi uher di.' Behandluni: dPs Typh. exanthiinat. etc. Greifswald l8liN. Varrentnipp, Die Kleeklie'.en'|ii Reg.-Bez. Gunii.innen wahrend des 11. 18(1!). ■xiinlhiM'iat. in Bn'- 11 i. d. .lahren 18(18 i. d. .Ill des KiickfalKietHTs iind d^, Klecktyphus in Brcslau ahren IKilK imd |8(m. Deut'oh. Areh f. klin. Med.. H. .s! 4 u. ;'., Bd VII. 1, Statist Bericht iil»'r dus Allerheilicjenhospital Breslau. 1870. (S. 105f") cxanthemat. Typhus in klin. und "-aniuitspiiliz. Be/.iehung. Nacli I'assaiiiT. Teller d «:12 J.I I in \ rri.i. 3-"^ ll«g 1^^ mm.. ■ H tMB II Hi'.il.ii, liiini;.'.ri w.iliriii.l il. r ...-t|iriii>-. 'I'v |.lin-i-|iii]iiMii' i .1 .liiliri'ii IstiHu lhi;'.l Krliiip^rri, |S7(I J'rrrirr, Kllri- il.' lit irii-civ ii i\|,liu- ilim- In |ir..MMii' il AIlj.t. It.'c-. dcs iiifiii, do I I. luilit , l^Tii W'uriilfiliili, I'i-Lli .ih- Iliai,'Ti..v ,|r- Kl.c k!_^|.lili^ \'..|kiu. SiitiumI. kliii. Viirlmgc, Nr. l!l, InTI Murilu-'Mi, On tli'- I'lrio.i ,,f In.ul.at. ..i T\]iliiis. Iti-lup.-iiii,' Ki'ViT, eU-. St 'riinina» U..-,,. U,),., \-,,l. Ill, INTI ()l)oriii.'i' r. I)i.- i'i>uii Kail.- .lir li.iliri.r KK ■ kt\ |,lni>r|.i.iriiii,. von 1873. Bcrl. kliii. \\^.l■ll(■ll^.■llr., Nr. :l(l u. :il, l^T:;. — Zur ('i.iiluiii'iri di'^ wicdrrki-liroiid. m und d. s Kli'rktypliiis. < '(■irlmll)l. f. d. ined. Wi.-M'M.-d].. Nr. ;!i;. Ih;:;. Zulzcr, Ziir Actiiiliii;ic d.- l-'lrrkt\ pliii-. Nmli l!<'ol,ai'litiiii(;eTi iius drr liiTliinT Kpi- diiniij Mill 1^7:1. X'in-trljalir-ilir. I'. i;irii lill. Med., Jan., S. 18,'i, und Zrit-clir. t'. prakt. M.'d , Nr. 1. I.s7l Ilidi-iv lii'..!.arlitiin^'in uKirTspli. ixantliiMimt. und l-'il.r icnla. l>.ir|iiil ini'ii. Z<-it.M'lir . lid. w i>-ri. IlritliT. H.Ti.l.t iiKiT di.' ini .lalir.' Is7."i aiif d.T Klinik iiiid Al.tli. d.- I'r.d'. I.nhcl 1 !>a Ill-ten K.ill.' v..n l-"lrckty|Om.<. Wi.'nir rn.'d. Jalirb., 187.'i. I,.'l..Tt. Kl.'rkt\|.lni- V Zi.-ni".!! -^ llandl.. d. ^|.lc. I'ntli. ii. Tlienip. l'. Aiill., Hd. II. Is7i;. Wy-, Kl.,kti.l.,T (liiliarl ~ llaiidK. d.T Kin.l.rkranUli., lid. II. 1876. F. lIiTnnann. Pi.- KI.-.kty|iliiisi'piiliMrii.- v.'fi ls74iind 187'). I'rtorsli. ni.'il. Wixdipn- -.lir . Nr. \i:. 1S7(;. Martin. Ktiid.' Mir li'iuloinii it.' ilii ly).liii< daii> !.• d.'part. ilu KiiiistiTc. 'I'll. :-c, I'liri.-. lH7i;. Kai'/."r.>w-ki. I'i'Ii.t ilio K|iid.'ini.' il.- 'I'v pliii- .■Mintli.iiiat. ini Spital d.r lianiilii'rz. Sidiw.'strrn in I'.i-.Mi. I).'1U-.1m- nif.l. \Vo.li.;n-.lir.. 1877. -- l)i.' kalto Liift al< .\ntipyn-liciiin. Ktifiida. 187'.i. <).-iT. r.l..Tcli'n Tyiiliu> .x.nitli.'iiuit. in Wii'ii. Med. .lalirl... II. 4. 1S77 Daiiiry d.'- I) rt-. I!.-lati..n- .l.' I.'pi.|.'-ni. di' ty|ili. ii.'ti''(liial .!■■ I il.- M..|.n.'. Arcli. de nii'.l. naval.*. 1H77 V. .S'li.'V.Ti. I'cti.M- .lie L'l-e'.Mi .1.1! cxanlliini.it. Typliu- in der A rni.'.' zn .'ninifi'iid. n .-anitat>p.di7.. Ma.~^^■l;l In. Vi. rliljalir-rlir. f. irorii'litl. Mi.l., 1K77. .Mit.«-li. .\i-.li. f Miii. M d.. 1880. i 'Ph.' arti.-l.- ..f li.iiarv. Hartnuinn. an.l .SaloMi..n nl.r t" lli.' niat.rial i.Iisitm.I 1.\ m.' at tin' H.tI. -t.ill. liara.keiilazanlle at M.'al.it i I'i-I..r. Die Kl.'.klv pliii>.-pid.'nii.- j,, ()!,.. r-.lile-i.n ln7i;— 1877. A'ii-rtiljalii--il-,r. f. !;.•- riehtl. M.-.I., H.l. 'J'.i. 1. 18NI. (i.iltdainneT. I'l'ln-rili.' Ki'>l- iiml l."eiiliaii-.i- I'ur .lie arineren V.ilkM'lu.-seii. Vi.'rt.l- jalir.viii„ .Nivv V,,rk. Hu.-t. .M..,|. OutL-tudl, Klrrk- iiikI ltucklalllicl...r ill l'r.u.«,.,.li. .'r. L'ti, IHM. (in.l.iti^'irtcr K.-idir im KlmltviOim iiid Sill-;;. J. urn., 1(SM. koiiii;!. pn-ii.-.-. ^tati.-t. Hii I'.' rliii, IHHL'. 11 Kr^uii/.-II.-li zur Zt'iL-chr. d. Mi.lia,li>, Dor CMiMlh.MMat. Txpliu- in ivt nis>i>,hrn Aniiof nul d.r llMlkaiilmlliiMs.^I 1H77 7H. (ti»-tcTr. iiiililai-arztl. /I'it-cli., 1MM2. Aluttaiid Hli.ns Micr(..„rguni,nis in T\idius F(v,i liiit, Mrd. Juuin.. I),-,- , \m:i. Wfichscll.Hi-Mi. r..l,or .-ini^i. sult.'iic f..niplia.li..n.-n dl■^ Tyidi. .•x.mth.Mnat in una- tmn. u. iii'tii.loir. Beziiduin;,'. Aiii;i-in. Wifmr nii-d. Zrit., Nr. L'l!— L':!. l«H;j. CurMliniann, Kl.cktl.l.ir. /,i.rn>Mn - llundl,.. Hd. 1.', 3. AuH,. Ihni; MuntzW. VvUt dii. Vorl)n'itiini; d.s Klirktyiihus iji l'rru»..|i (Lis lhH5). l)i,,. Her. iifi 1HM7. I TntiT (iutl-tadf- I.cituni,' I'l'iirl.. ii.'i. , jHn.,w.,ky, r^LiT da- Kvanth.ii, dc- Kli-cktypliu- Intornat. klin. l!und-,l»,i,, 1M88. Sei'liircr, I)!,. Kl.'cktv |)liu-c-|,idrrnic in d.-r -t.idt. K ninkmanstalt zu Kc.ni-.1«TL' I8«0 Lis 18HJ. Ii,.rl. klin. \Vo,-1i.m,-. hr.. Nr .".I u. .VJ, IHHH. R.'icl..,i;,..M,ndl„.it.ai„t, \ .TortV.nlll.hu.i^'.-n d.-. f.-lMr ..in,- Flrrktvnhu.M.pidHni,- in Mundi-lpui-i,', 1H88. Chn.^tir. A (■«.■*,• ..fTyphiH Kt.^..r(■ ,11,-. with II,Mnat,.,nc>i,. (ilaM'.-w M,.,| .),,urn l)w.. IKHH. M.,n.„u,.t(-,K.h..z.('ontril,,.t.ar,-.tnd..dutypl,...XHnth..mat. Gaz. In-l,,!., Nr. L'8 1888 HIawa, KUHl...Mir!.. typh. ,.xanlli,Mnm. Arcli. H.dir.ni... dcMnrd III 1 IHH'I Th.„n„t. I,., typh. ,.xanth.-nnit. d,- lil,. T.idy. Ann. d. hy«. p„l.|. ct do nu'd. l.Valo, I H!( I . M..y, Zur K,.nntni,s d,.,. llan,n,.|„l,in...halt,.s d.-s m,„..s I.ein, Tvpl,. -xanthonrnt. Dis, Dorpal, 18111. Thainot ,.l Culnn.^t,., N„t,. ,.,.r ,|n..l,|„... oxanM-ns d- nung dan.s lo tvph. oxanthenrnt. Ann. di-rin-titut I'astciir, iH'.i-J. Thoinol, Art. KIc'ktictKT. Traito ,!,■ mod , 1802. L..wa.s,lu.w. r,-l,,.rdi,. Mikr.H,ri:aniMn..ndrH Fiooktyphus. DPUt> >'■ *'■ '■'^'•'•i - Chantoino.sso. S-K-ieto n.M. dos hopit , 18!l.-i. -_ li„l„of ot iinilil. Somaino mod., 18i.H. (Tlioso w.irks ti-oat ..f an o,.i. .lomw wlnoh l.roko ..m |„ Mil,, i„ ih;.8, and sproad fnim thoro to tl.o prisons of I'uris and oriviron-. 1 proniiors nmi- ¥": W M M '■ t;;ii i.iii.nMi ni:. K.1-. Ii. 'I'niil. .|. - iriiihi.ll'- r|.li|. Iiil.|ll. - I'lili-, \>:>i. |)iil>i<:' nicl> Miial -|l il Inii lirii >l<'i,- ilii i\|.li .mui- ih. ,,,,,1. An h. .!.■ ii„-.l . \|Hr., Nr :;. IVil ( .iiiili.iii;il.-. l.,M\|.li . \!iiilli. inril, iIm/. li- M. illiinl- liull :;.ii ,lr tli. rii|i . inm. |1. - I .ili,|ilii allMi- |iullli"li i;ni\i - (ImIi- !■• t.^ I'll <\llli ill. mill ij'ilnlu, IMI'I. l),ii-.|i-iiii. . I.r n |,liii- ,l:,ii- I 1 1|.. , I, i^;i.; (ill/,, liii,,!., Nr .;'.i - 4:;. 1n:i.".. Iti.lit.r, r.l.rr I- I.-. kls|ilni- I >. iit,-. In- mid. \S ... l;i'ii-i lir. . N r :;|. Ihii:,. .M..-I.T. Kl.-.kty|.li\i-. Kiii.nl..m- Km \ k|..|.,i.lii-, :; Ami.. Ih'.i.. Siulliiiiiiui. ('•.ntnl.iil. a 1 l.i-t..ii-.' ilii l\|.li i-MiiillirTiiiit. i;.\ . i|.' iii...| , N r H, mO.'). ru'tni-kv. I'.l..r ilii- Aiiriri't'ii il.- |-'|. . kli.l.'T- in Srlil.-i.ii iih.l .li.' /ii .l..>.-i-ii \'ir- liiiluiii; L'''iL'ii. 1. 11 Mii--i-. i;' 111 \ I. rt. Ij:ilii-i In- I ..|I. nil (i.-ini.lli. il-|.|l. . Ih'.i'i. I..', .iiliiii'.il. IcKir .111- \ .irk..iiiiii.ri \.iii H'l. rkti. I..r iin.l II. . urn n- in Kn-liiii. /..iw lir. lur ll\;:i.n.' un.l liir..i -K niiikli.. li.l. l'*. Iv,; I-'iliil'.vv , \'.ir|.-iiiii;. n nil. r ii. iit>' I iilV, n.in-kriinkli. il.ii liii K iml.-iill. r .\' i|. in Itn-i-.li.'Ti. Wi.n. IS'iT. N.tl.T, r'l.-i kl\|iliii-. 'I'liiil.' .1.- in.'..l |.iir Hr..iiMcl' I. l^-;iH. Mil.- \Vo..n..y, N,.t.-..n tli. Kti..l..t:\ ..rTvpliii- K.-mt Mril M..I .I..urii . Apr. Iv.ih. l!iilf..in- nil. I I'Mrt.-r. A l!.-.-iin-li ii.l.. lln- l!ii.!.-ri..l.L'.\ ..f T.i plm- K.-\.-r. I'riliniiri. N..ti.-.-. K.linli M..I .|..uni.. Nr L'. lH!i!i. I'.l.-. A'.-rl.ri-ilinit: '1'- Kl.. kn pliii- in H..liiii.n TriiL' m.-.l W ... h.-n-. hr., N r. IH. IS! 10. I.ittli-j.ilin iin.l K.-r. An ()iill.r.'»k ..f T.vi.liii- I-'.-mt K.linl.. Mi-d. .I..ui-n.. IH'Mi. Til.' nil.. VI. t.ilili.iirmptiv i- ii'.t inti-ncli-il t" l.i- (•nrll|ln•lll■n^iv('. It iiiclmlrs the ni..n. ini|i.irt:iiil |.ul.|iiiili..ii- .l.-iiliiitr uilli tin- i-|.iili-iiii..l..u'.v. imil » miinli.T nf ottiiTs wllic ll .-..lltllill -..|ll|. >|ii'rillll\ Mlllllll.lo (lillll. K..I- til.- ..1.li-r liti-nitiin-. .-|»-i-iiilly tin- Kni:li-li und Kn-mli up |.. IKC.-,. tin' niulir i.- ri-fi-rn-il t.. tin- rln--i.-:il wurk ..f Miiri-lii-.m. Tlio phiih' wrk iinil llirsilis HHndlnicli dir tii-lnr -i:.'..^'riipli riilh..l.it,'ii. i'..ntHiii ii ili-taili'd Hccuuiit of the histiirj- and giii- i;nipliii- ilislriliiitiiin ..f typhus fi-viT. MHiiii yi^, r IP*' ' i ■ i "^^^M^mi ^**>i INDEX. Aiili'iMKN. T.ulpiiti..ii ..r in l\|>l,..hl. L'l I ill tv|i[i.iiil fi'vif, S4 .\li-ci'>», (•iitHiii'iiii-, ill i\|iliii.. :,:;:; Ai rliiiiiiti/alioii. ili.i'ii-i'-. 7:; Ali-lii-i!.' ca-rs Mt' t>|>liii-, .'.Ti; A-.-, iiilliii'tiri' ..I'. .Ml ty|.li..iil iiil'i-iiii.ii, -'ii; Air ill tnui-iiii--ii.ii ..I'tv |ili..i.|, l'l Alliiiiiiiniiria in |.r..i;ii,i-i- ,,(' tv |,||,,i,| ;;:ii in ty|ilii.iil. IHi; in lyiiliii*. .'.Ill Al. -nil. .lie lirvrra^'.- ,1- H|.ln.i,| |,r.i|ill \ liic- lii-, 47 Aii-iiholi.iii. Iy|.lioi.| „imI, :;■_'.'* ty|ilin< mill, n'l:iii..ii l.ftwr.Mi, .">(i4 Ai..|».(iii in ty|ili.,i,|. I:l-J Ainaiiro-i- in tynlLiiil, 'JHC, \inliiiliit..rv tviilnii.l iVvit -'.tir, ■ ■ ■ ■'' Ani'iniii 111 (•..iiva|..-,.nr.' IV.. in U|,li..i,| :ii;7 An;;ina in ly|.li..iil. -JKl Aiiinml ln..i'iilali..n willi lvpli..i.l, :!0 Anihnix, ty|)li..iil an. I. .liir.TciiliHl ilia^'- n.i..i-, JIs typliu> an. I, .lilf.T.niial ilia;;ii..-i-. i;ii:! Willi typli.ii.l, :!-_'7 Anti-li..iii..< ..(■ typli..i.l, H'.i Antipyri'ii.' dni.,'- in Ivpli.iid, 41)0 irii-tli.Mls in lyph .ii|,'4.'i:! ill typliu-, i;l'i Antipyrin in typli..i.l. li;-_' A.irla in typli..ii|, Ir.s Apha-iii in typli..iil. ^71, •-'7.'> App.-liti' in i\ pli..i.l. L'll.'i Ari.Titi-, ..l.litcmtin^'. in lvpli..iil, 1(J9 in lypli..i.i, 107 lypli.iiil. Iii7 A-iatic .•li..|.Tfi witli typli.iij, 325 Alavia in typli.iirl, 27M Haiim.uria, IIJ Hiu-illus of typhis, olin, i.-al nature, 482 disseiiiiiiatii.n, 484 entniiii'c int.. Imdv. JX7 iiiicnipiirH-itic naiiiri' ..f, 48.3 iii.mI.; .if ai.ti..n, 4S1.' i>f tmiisnii^vi.ni. 4H(I nutiirc, 4H2 rpuctiiiii t.) clii'iniial-, 488 typhosus, acids and, :>'.• au'ar piiltun-<, 211 animal iniMiiIati.nis, :!i) bttoilliH c.li an.l. dirt'crpiitiati.iii, 4l;i binl.isry. 20 carriers .if, 40 channels ..f iMitrani'i' int.. liody, ,38 (if I'xit fr.iin biidv. 32 Ha. illn- lyph.iMiv r\iltivttti..n. 28 .In ini; an.l. '.W, ••il.'.a .if LTH-tii.' jni.'i' 1. 11. :;:) i;iill--|..ii.- an.l. L'lo U. latin iiiltiir. -. 2'." Iii-t.ir\. 2."i in III. 1.1,1, 171 IV.iiii nis.'..|;i 127 in li.ini-iiiarr.iH . h!i, 'JO in liiitt.T, 4i; in .-adavcrs. oo in t'.'.-,-. :!2 \ ilalily. 37 in ritn-.'ill in milk. 4.'i in r.is.-.il.,-, 17.-, Ill -pIciTl, 10".» in urine, 32 vitality, 37 In water, 40 vitality, 3r. isiilati..n'.if, I'r feee-. 33 ini'iiiii^'iti. an.l, 271 .ii..rpli.i|.ii.'\ . 2ii in.iveinent.-, 27 pii.imi(iiiia and, 2'il 11.. tat. 1 ciiltiiri'. 30 -p.ire-t'.irinati.in. 27 slainini;, 2W vitality. 34 in ,«.iil, .'iS Haeteriiiria, IIIO Hatlis in typhus. r,20 lii-d-nres in typh.iid. 1.30 in 'yphiLs, ,^33 «uli<.utaneiius. 131 Heer as tvphiii.l iimpln laiti.'. 47 Mile in typhi. ill. 211 Miliary pa»sai;es in e.invaleseenec fiiim typlh.id. 37--> in typhnid, 20ii, 20!l p.'-t-iii..rtein appeanini'.', 103 Mlailil.T iliani."'- in tvphus, .'..Vl 1 in typhdid. p.isl-nnirt.Mii apiwarancc. 112 HI I elian:;e- in typliu.s, 525 fr.ini r..seiilip, 127 in typhi. i.l. 170 hiiiterii.l.iiry, 174 heninirl.iliin in, 172 I{liiiid-i;,.il,.,, ji, |N|,|„,i,l, I'll'; I'""'-""""' iil.|..i.niiii-, 114 |liM/...i,:„li,.;, i„ ,li„i.'ii...|- ..I iv|,li,,j,| -lllilliir, ciilarrli ..I. ji, ivplmiil. L'4i; (d.", ' Hn.n.liili- ill .ili'.rtn.- |\ |ili..i.| ::i>-J m. 1\ |,li,.i,l IIMI ill ilii.u'ri.-i- .,r H|.l,.i,| 1(1.-, |i„, ,„ u|,|„,j,l. J).-, in l.vpliHiil, L'l'. .I.uiii- .,.,n,,|.-,,,H.. 4:,| Hn.iic li..|inriiiii..iiiii 111 i\|ili.i.| -JIT III i\|i|iii-, i.li, ''"•'I-'' rvMiiv,,! I -s; l)i:;..nM. ,,r-„n- in lin-n.-i- ..f n 1.1,1,. liiitl, I- a- :, . iirii, r ..t' ml,, l|.,ii ill i\ |,1 | .-,;i| ' ''■ IM l\|,|i,.l,|. I'.i'.i, )i,| |...-l-ll,,,ltrlli llli|„ liruh.'i'. 'HI < u,,Mi,i III int. -III. ill .11,11-. ji-i-. in II, u i.liii-. i;l'T ('aiiiii.- fiv.r, :;-.'i, ,r,„ ,. Vlm ,„_,■,-, h, in tv|,lHi-, .-,47 t iitan-li. -ii--tr,.-ii,l,-liiml, H|,li,,i,i |. ,,,, | i,|,|ii |„.,.j,| „ii,| u i.liii-,' i-,.|„ti,.ii l„.i»,.,.„ ( iilarrlial l\ pliii-. .'i.'iy .-.1,4 (.'iTi'lmi! aiiiMiiia, -iiil.l, II iliiiili ir,,iii, :i;iH m iili i\ i.li,,i,| :',-j.', '"■'■"■\i" I.M'l"'i'l -■" Ililhl>ln;;.»at.l „-'a ralli. 1 ,,f imV, li, ,1, in II--"" I" t.M''"'"' l"-I- !■"■ :.).|..:..- I\l.h..i,l. 41 •""'■• I-'" llrink- ii,U|,li,ii,|. 447 ,,'-M''""''- ,■''!' •""•' '" t^|■,ll,.i.l. |...-t- 11.11, i,|,|„„n,,M... (. iM-c'l,r,,lMiilai in. , ir, nil,-, ill..,| in u |,li.ii,l. | l;i ',''" lK-,i,i,r\ Mil, I tvj.iiii- 1. iali.iii l.,iw(...|, < . r.-l.|-,>-|.ll,:,l l.v, 1, H|,l„,i,l ..,,,,1 ,|llV.'|v|i- .-,1,1 li.'ii"" '-'•'' uiili l^|,lh,i,|. :::;.■, iii.-iiiiii.'iii- ill i\ |.li,,i,| 27i) t\l.li.iii| and. ilittiiviiii.Mii..n 41.; K,M( all..ti..ii- in ,iiai:ii..-i- ..I' u |,li,,i,| 11 |.iiii- ami. .JitV.M'cntial iliaui,,,-!-. .ViM 4111, Clii.oi,!- m ui-iii,.. I,, 111, ti,, 11 ,,i; in Ivpln.i,!. ,liaiiL"- in. in U1.I111-, .',41 I""' ,li-,a-.- in t\|.li'..hl. L'.-:; < li..l..\-lili- in , \al,-,,n,, li,,n, n- in , , ,in ai, -,', ii,v iV,.ii, i \ pli, ,i,|, ,(77 |'li"i'l. -M-'i ill H|,l;,.i,i. 1L>-J, 4i;'.i ill l\|.li,ii.|. -.'O'l, 41I7 Kai-tliiii .•li,il,.i:\ ,,f i\i,li,,i,l .-,1 t'li.,;, Iitliia-i, r..ll,.»iii- tvj.li.ii.l. L'Ki Kh.rlh- La, illu-, I'l.' .S... al-.. lUinllus ill ...iivali. 111.- rr,.iii i\|ili,,i,l, .!7.', !',//,/,,,,-,(«. «li..|..ra. .\-iali.'. willi t\ I'.li.ii.i. ;'.L'.". Kl, lii, li - ■,lia/.,.-i-,a, li,,ii in t\|.li.iitl. I!KI <'li,.na ii,ii„.r in t>|,li,,i,l. L'l;;',. L'WI KI-iiiT- 111, tli,,,! i.C 1 \niiiiii»ii,.ii ,,f .(,...1- t lir.iiii,' all'.', ti.in- ami lv|iliii-. iiliiti.,11 1.,- 4L"J tu,-, II. .-.i;! Kini--i in I\ ),l:i.i,l. 111.', <'ii-,iilal,TV i.rLran- .liain^i- in, in tvplm-. Kmi,„iiii|in- in H|.|i,,i,|, Id.'i •'-'■'. iil,.iaii\. U|.li..i,l ami. ilitl'. ri-iitiHlii.ii. .Ii-iv,l.r- .,t'. ill iy|.lh.i,l. Ii,:: 41:! in t\|,li.,i,|. I.VJ . K|.i-l,.lii- ill I\|.li..i,l. li;i. L'41 pln.iil. I :!(l' ■>l in \\ pliii-. .'.:;.; <'li,|liiiiif III .li--. i,iinati,.ii ,,f' l\|,li.ii,l .",| wild Hpl,,.l,|. ::■.'! <'..tf',-,- a- n pin, ill pr,,pliyla. tir, 17 K-i.p!,aL'n- in Upli.'i.l. L'04. "JOt; <'..M. .'tt'.,i ,,r. ,111 i\pli,,iil inl',-, ii,,n. i;4 p. -i-n,, n 1, n, appiaiami', !il <''.iiiiimli\ili- in ,|ia.jii,.-i- ,•!' typli.i.l im; Kii-la, l,ian till,,' in t,pli,.i,l. \-Sl in tvpln.i.l. i;hi; K\aiiili.ii,iita. i\pli,',i,l ami. .lilt.T.Mitin- ('■.ii-litiili..ii, .■IV.-il ,i!'. .,11 t\pli,.i.l iht',,'- ti,,i,. 41.'i li'.ii. I'.-J t\pliii- iin.l, (iitl'i-nnliiil '!iHirm'>i^, r.(i:i in typhii-. ,ll',.,t .if. ."ii;.". Kyi' < haiiiri- i" iM'lm-. '".I'' <'..ii!a.ji,,n lli.,.i-\ ,.|' |\pli,,i,l. •_'! ill ,-,,nMil,-,, ■!!,,' tV lyplini,! :;77 <', nival, -,■,■11,, in tv|.li,.i,|. 471 in ],r,.:.'n' -i- ..f lypliii-. .Mil in lypliii-, i;-J7 KmIi.iII in lyplmi,!. ■-'Mi p.i-i,..! ..I'. , .,miiti,.n ..t',,i-._riin- .liiriiiL'. "di K\,-. ,|i-i:i-,- ..I', in I\pli,,i,|, ■js.'i in lypliii-. ."iii'.i in typlii.i.l. p,r-i-ni.,it, ppi-anuicc. 12'J <'iir\/ii ill ilia'_'ii..-i- .,t' txpln i'l. Im; <'ninial h.tv,- in l\pli.,i,l. L'77 K \ r 1 kikhk.h. .'.•'^1 Cn p|,.Lr.ni,' -, pii, ,.jn ,iiiia ,litV. n.niial K,l.ii- .■a-tnn-i- pii,',liiali- ,.f Ivpliu? .lia'j-'i'.-i- t'l',,111 l\pllll-. .■||i7 .'..'^7 ('ilta.j.'i.u- al.-< .-- in lypliii-. .'jli.'! ,xnii! li.niali.a ^iIll■ .■xalltllclliato, .Wl <'\-titi- in tyi.li..i.l. lli.' ,if typhus, 5'jy ^ ^ » ► fM>i:x. 637 KfhrU mititicu r.f tv|iliii. .'.sa vr«iitili-, 'Ji.t Ki'ci'.. K,i, illii, li |,|i,„i|. III. ;i-j \ il:ilit\ . .!7 Hcirt^n-Siiiitli liMll,.„i .,r iirin.- .Niiliilini- tii.ii. 4L'o IImu-. Ii.,|,| arlirli. in lii--. iiiii,:iii,,n ,,|- lv|.li..iil. .VI , ll>.|n.lh.n,|,v in l\i,li..i.|. 1,1 l-iliml.- J.lillall:!, .\l.lli;il. III H|,|i,,i.|, ih IV plm-. i.l'i '''■ , llv|..i|.M,li,. ,1,.,.. ,,f ni.liii-, .-,:,; clmn^. - in, in |\ pliii- .Viii ^, '" tM'l'-"l. !■". " I. iKi-.i > ill iv|,li,|. .-..;,; [.'■""'™' '[■'" ,'" '.M'l'""l !'■■' iM.li.i.n u, m-Mi.. in Iv,,l,..i,|, \K> i-<-(n<. ty|.li..i,| i,i|.,||,,„ .,|-. 1,1 Ihf.iilil.. r.,i,ii|,.nl f.'.Mi- ;!:1| H ilMnn.u- pn-iiiiinnii, „i,.| |, ,,|ii,. ,..|:,ii,,r, lut\n.-n,,,. Is ,,|,..i,l „i„|. ,iiir..n.ntMli..n. 4M ,. I"tw..ii, .1,.: Iii..,iil;iii I iiniiiml- vwili Ui.li.i.l .;ii ■.'""''■''"''"'■""■■■-'• Iii«aiiilv, tvi.ln.i.l mill L'll.s '•"""" '',-"".M'l'"i'l. 1-" |I.il.--lnial„nli...|.-i-, ,.|,1,,„mI ,n III '" '.M''"i- ■•■- ' ill tM.l...i.|, 111 i"'""i'"iii','". L'l: s..- III-.. ,s/,,„/, |ili..i.l. :;;.-, in ,lia:;,i,;.is ..ItviiliMi,!, 4011 ,.',';',''"'"'■■-'' , . '"I"---' i^uft\,l,.,i,l, :!,.:! (.aM-t..n,.. 1,1 ,.,, rival,. ,,■,•11,. ■ liMiu iy|ili..hl, in H|.li..i,l. HT, -i,,:, , , .■'",' n- , , l..ir..r,ili..ii in U|.|i,,i,|, 4,,.; ,.'>!'' I'"'"ll'-";l ,-'!:' Ini.-liiH.. ,„.a,ii,;„i„„,,r. in ,v,.li,.i,l ;,7 '•""-'■•"', ""^ '''""■'.' ';•' '"'.M i.l. |".-.-.n..r|..|ii„,i,...'„:iii... .,1 -|-iitaii...,i-. ,,l til., .vtr.. I.... in inv .,|„|i,.,i ,.f ,n,.,liil|,„-v -«. Hi, li,, . , . 'M'l I. I'M Iw i,| ..,1 ■■< -kin.n,v|.|„,i,|, |;-J n,.,.r,,.i:,,r, in ,v,,l„.i,|. I,:, ""■;-"."""•: "Mr,n|,li.,i.| -.'U • ,ii,..r.„r, i„,v,,i;,.i.|, ;m; .,m :"■"■"■,:'""■'■• ' 'II"- '.M'l':';" I. ■' In. .-tin... ill ,.r.Jn...i-.,r,^,,l„,i,| :;;i2 '■■■nit.l h„i,.u„,i- in ,.,,iiM,|,..,„i„,. ,v,„„ lnn,xi,„,i,,i,-. ,v|,l„,i,|i,n,l ;;-'^ ,, ., 'M I. -« .lill-.n.„ti,i.i„n, 411 l>.nil..-iinii:irv .n-ixiin-, . Iian:;.- in, m t\- ■ '''"',"■:'/'', , •'aiM'I. t in ,iia..'n,,.i. ,.rn|,li,,„l, II,.; f.liin,!-,-. „i„| ix,,l„,i,|. ,lii|-.ivnii„| .Im^,. ,„t,.nl,:il -o: li'-i-. HH ,,„i,. ._,,,:, Mini lv|,l,i,.. ,|iir..,vi„i.,| ,li..,^,„,„i,. ,,„:; .r,.int- in , m,|,.-,.,.„,.,. ,>..,n tvpli,.,! :;7K ::::::':;;::;,!:;;:;■;;:-'•:;;:;::,■ ::;i,:!^'4.; ^;::-^;,:-ri'^;"-'"- '^ '■""■■'■ ■^■" II , . , . Kniinv-, ili.ii.M-,-^ in ill uiilm, .",i(i ll.iiiiliiirL,' H|,li,,i,| u-\,r I |ii,|. mi,., 41 ' lliiii,! .|i-iiif..,ti,,,i in U|,|i,,i,| 4;i H.-..,lii,li,.jn (■.,iiM,l.-,...n,,. IV t.v|.li..i.l, I.\.Tvii,,N, i,'"'-^',''"'''' -"" , -,- L„.t..|,ln.',',i„ i„tv,.l,„i,l, 1,;:; " lii,|.-,. ,ntv,,l,„i,l. 1,;,-. r.„rVnu'...v,,liM,l -I.-, ' in, ■,.ny,il,.-,. .,,,... l,-..,i, iv,,|„,i,|. :;:;; |,„nnN. .Imnu'.- in, in tvplin- :,1 1 '"'■^';'"'"V"'-"'""^""'I ■■■■"' '"■ :il.--.... IV ,!,,l,„i,l ;:.; iiiii-.-l.' in lvpli.,i.l, l.-,:i , ,■ ' ,. ', ,,., ■:'iv-i-„n'.i„,,,,.,i ,,,.ii„i ;„,,,,,,„;,, n,r;:!i'';;i-'i::',:;;nr ■:;;>''■' l{:::;;:^;.Ti;,';;;^/.'!:;r!n;;;.,i„i,,.,:. '---u,,, ..,,...!,,,.,, ,,^,,,05 in ...nval,.,,.,.,,..,, fn.n, ,v,,li,,i,|. :;,;: |.i . i,,' ,v,,|,:.i,|;"i.,,i II.M,„.n-l,:,:,i,. .■a=,.s ..t ..,|,1,„-. r.si |„ ,.„,|,„i..„.,. ,|.,;,, ui.l ..i,| :;7.-, |.l|.'n,.nn.nau, pn.L'r„,-,>.,rtypli,|.. .-,;rj i„tv|.l„,i,| -oi; ■' in'u l"'- 1'; '""/'I:'"- •■''- 1''-'- ■■t..,ii a|,,...a,-an,.,., I„l |...-t-Mi..|-|,-Mi a|,|..iiraii. .■. 11(1 I'M'.-.'I .rl'ty |.|i,,i,| inl', , h,.ii ..II, I f ■-■^.i ^ i;;;m .11,! , ^:-?'^'' Luiiif. ul»<-.-.. .,(•, in U|.li..i,| -,i ifiiiiirniH- ..(•, ill l>|i|i,,i|»»luii..„iii;...ii,,„,,,- i„ ,.,,i„.:, ...^ I" l"""'.'ii'»i- Ml H|,l,..i,|, :i:n i:;i:;'r:wr,;r;»;^!:;r -■ .;;£;!;;'.■..-„.. Lv.M,,i.-«iumi., ,.1.1.,,,., i„, i„ ,.,.,,„.. -.,. ^;^;;:;;'^!^;'"- '^ i' liinili |- ,.|,„., 1,,^ I'l I, ml. ,;,; Mu \i(u ,,i„i iv|,|i,,i,| f,.,,.r, li.-, t,\(ili..i,l i.ikI. iliM'i ,-. ,iii„t|..|, ji J Willi l\ Jill. .1,1. :!ji| M..l»rl„ri..,,.p „,„| ,,,,1,,,,. ,1„|, r. nl,;,| ,||. iii;i,ini>, iViT Mul.; u'-Mil,.li«, ,.|,„„^„,. ,„ i„ ,!,,,_ ..^1, 111 l>|,li..i-Ml. i„ tvpli.li.l, ,..„i.„„.,-- ti'ii, iippi'iin,, I |., ill tvpli.iiil. •.',;;( Mriiiiifitl,, ,..T.I,r,.,.pi„„|. i„ ,v^ ••pi,li.,i,l|. (■|.n.l,r..-piiii,|. H|,|'„,|,| ",,'„'| pli"i''- lH'. 'J>''' ,,i!iiiili-t.ili..ii of. I'T^' tiil.i.rcii|,„iv i,, uplii.iii -j;;; t,vpl,..i,| Miul, .Iiin.n.|,ii,„i,„i 112 .M>.,,,i,^.mH p||,.i,| ,;|,, ■^''•"-"•"■'ll"li i H„l typli..i.| :;:ii in t\ pli.iiil. I'li; JI- - llt.'li,- -l:,,i.|- 1,1 Ivph. i.l IIHI •M.I. .ris,,, in ,,|.,,.|„„i; ,,!■,,. ,1,11, .v,- 111 tipl|..i,|. 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M,n..|..„,. .-,h| .-,.„; '■""■■■'/".""■I I >•> "I U|.lh.i,|. -JO 'lun.l l..w.r, l„.„„,rrl,«u'i,- ;l|;i '■■■' n, li|,l„,|,|. |;,| i;''ti.r,k.,r.T. 111..,,,. ,.,• „|,i,„„| .,, -,. ,';,'"";"■ '; "• '.M'l- -.1 •Vl- (""■■'"•" in lw,l,..,.|. '..; .,-, " .-r„,.,|,.. liial,.„i.i,o; fiolii "' ■•• - I ■ •' (\ |p|i..i.| ,;i,7 ill I\|>li..i,|, |7i) i:.-ll.\..., .,.„„, rv. in H|,li,,i,), ;!h:; '"■'■'] Ill l\|ili..i.|. 171 '''■'"■• '•l.»-'i.-iii'-<>ili"n..f ,,„,„,., ,,,,„ 41.M I't.'irt'iT ~ j.lii-M,,ii„ri,i. 1"! 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'.m ...r.,.,,,,. „n M|,li„i,|in,-„,, „' ■ "■ ^■•H;"V"i-,.|niiiu,,|,„i,|, ,7,, in iM.li,,-, .-,.-,1 "■ '' >'.iHalina ami ,^,,|,„., ,|i,i; |.,.n,i:,| ,||.,„ l'n.-n,,.i> ,,(■ tv|,liii. :,s:\ ^ .'"-'-■ '■"- [•'•••|.li>la\i,„i' tvphii-, iliit ■ '■■■"■'"' '';;■;■ l.^l'li-nl an,i. ,litlrivniiaii,,„ I -lll|..|||aill,,|lt., ,,|- 1,;„.|||,|, iv, ,)„„,, .,,. . ^'" l\v.-li...... ill , villi, ,1,1 ■.,' , 'M"''-'!- Ji, ,^,,1, ,,|,,,„,,| ...,^ lir.i.'li,,~i>' "UN >'iill.a III l\|,|i,,j,| jsj '■"■■'■'■"•';:;"' '■""""■ .m Min.;.,.ti.,i,. s.!':!:;:":,;'::;';'!. "; 'p'^r:\ -• nl n,.n,,i ,,,,,, „n,,|„,„| „„.,,,, 11,^ .jj^^ ' "'""■"■■"■.V .■inl...|i-in in u,,|i.,i,l „„|.1.|, <'"'■'"■'■"'■■" Ol'in'i'l in|-i-.-li..ii. '7:! 'I'.'.thlV,,,,, .;:is ■' ■ '"'*' " "'I""' I"-'"- - Mini Upliu-. r,.lati„ii I,,.. iraiiLrri'iii' ill tv|,li,.i,| ■!■,-, . twi'Mi, .'.i;:; in/anti,,ii i„ i^ |,li, ,i,|, 'Li-- >'rli.-nii,i in |v,,li,.i,l, , ..|vl,r,,.,,ii„| m,.,,- tiil.i,|-,Mil,,,i^ in nt,|„,i,| -KM , , ."lu-ili- Willi. L'7.i I'lil-i' .■liaii-c... ill i\|,|,,|, -."i ^ -^ I ■■■ii'i. iliri'.ivniiaii,,„ .ji.-. ili'-i'-li.v ill tv|.li;,i,| l.-,4 " NTiini-tn.atni..nt ,.f H|,|i,,i,| 441, in l^j.ln.i.l, l.VJ ■^".'' '■"•■;■' "I. "ii t^|,li,,id ii.f,.rti.,i, ,-,.( •Ii.i'.i,-lir Mil,,,.. |.-,M '" 'M'!-"i-. I'"i in ..,iiM,l,.v,.,.„,.,. 1.-7 N, k-l....l III H|,| 1. IK in .|,f.,|-v., ,.,.||| .,;,^,,. |.-^, jSick.r„„i„.^_,„.,-aii^,.n„.nt ..f. in tvpli,.i,i, p^fe^ t-T -'t^ «|H>: 640 iMit:x. Sirk-i ■li-iiil'.'cti..n "f. in ivplii.id, 4.T7 Skin, aiic>llH-i:i la'. III U|ilii'ic|, i;sl rliiui:;.-- III. in t\|iliii-. .M;7. HIIT i;;ci;^rii I', in \\ |ilh>|i|. |;i:.' in ri.MMilr.. I'liii' Ir.iui typliniil, ;i79 in |ir..';h'-i- •■<' l\ |.liii-. .'.'.i^ in l\|iii.'ii|. ■■<:;. IL'I. li.'i in l_\ pliii-. . ! il;i'- in. -"'-T, i;:;7 Siiciiil riilnilli.'n- ill I^ jilr.l-. I'.Hi -iiii.'. ■If. .1 ..l'. on lv|.li.ii(l iiil'.-.ii.in, I'.'J S.mI III i:tlMl.'i;_v ..t' t\|',li..hl. .1 S|n-rial !*»'n^i'>. ciiun::'*-- in. in ivpliiis. .'ill! S[iiniil I'.iril ill ty|iliniil. L'7h |io>i-iiiMrIi-in ii|.|"':iriirH c. IJI (•iiriily>i- ill l\ |ilioic|. ■;7'.i |iiin<'tiiri' in imninniti- in !\|.lii'iil. i;71 Spii-i-n. Imcillii- t>|ilin.ii,- ill. lo'.i rliiiiiiXt'S in i\ |itiii-. .'t'Jtj cnliiririTiiiMil 111. 17ii iil-.^ni I'. 17V . I-I1I1-I-. !7x ilinnni-InitiMn .if. IHO eiirl\, 17;i tiirt i-iii ill, 1"^:; pnl|ialiii|i ill, I'-l [»-riii'-i'iit in, ls"j limtni.-li-.l. 17:i ri'ilufiiiiii III', 1 7't -iil.-i.l.i f, :;4i' :'..'i4 lirnnirrlniL'i' in, in l\|iliiiii|, I8L' in iliiiu'iiii-i- 'if ty|iliiiiil, 4111) inliinl- 111', ill l\|ili.ii.i IM'J in t>|iliiiii|. 17n ('\;iiniii:iliii'i, Isn jH.^!-iii..ri. Ill ii|.|i.';(r,inr.-, |(I7 jinn, lull- i.r. in i\ |ili.iiil, ASJ S|.iililn., .Ii-iiil'r.ii,.ii .il', in I\ |iliiii.l. -i:' ^l iii'li, ilil.'ilaliiili .if, in l\|ilh.i.l. .in; .li-.i;i-i-. n |.li..i.l inf. . liiiii nil. I i,i; ill ty|ihii, I, 2(M iiii-l-lniirlilii ii|i|ii:ii:.ni .■ ^'l Sti"i|». M.i.i.K. in U|i!i..i.l -.'17 .111--' •-'!>• L'l',i, 'JL'l fr.i|lli-ji. \ , L'Lli iniiiiif.-liiti.in- i.f. -J-J] Mi.irtiililv, L'-J( |iriiL'n..-i-, "Jl'l t.ini.iTnliir.-. Ill ( .- in, L'23 i.i l>pli.ii.|, '.'It |ist-iii.irt<'in iippesr- 1111 , '.HI 'I'liii-il- in Ivpliniil, L.'nl 'I'.ixin-lvph.ii.i I'.iMT, lid;') 'I'lllilli'll III l\ pli.iiil, L'|.') p..-t-iii irlriii app.aniniic, 1 14 'I'l-i. li..il.iMn. Iiili- ill lypliii', ^4.1 'I'll. Iiiii.i.-i-, I\ pli.iiil, ililf.i-.nlial iliiiL'iiiisif 4is ' 'rri-iiiii- III 1;. pli.ii.f L'i'.4 'I'llf. r. Ili.i-i-. anili iiiiliar\, lyplmiil llii.l, ilitf.i-.lilialiiiii, llll piiliii..iiar\, in 1\ |-li..iil, 1 Is l.\pli.ii.l iinif ii'. 'riili.iviil.iii, ill-, a-.- ..f tiiiiu- Mild typlnis, nliili.iii |i. l\\i . !!, .'ii;." Typli' . |iipliy-iiii-.i. 4 I 1 Typlii-ali.iii a p.lilr .In-.. :,i)\ Tvpli.'i.l fa. illiiiia, I:mi 'fi-v.r, 17 iili.|.iiii.-n in, 84 llll.liilllilial plllplltinll ill, 'J14 alinrliM', 'J',!:; Iir.iii.-liili- in, :;iiL' i'.iii\al.-i.iii-.i. :;il2 r. niisii .if. L'!!;! (Iiin:ii.i-iv 4U7 iinplii-ili- in, :'.00 p'Tiliinili- ill, :i(i"J ri'lap-i-- in, :',(i.; syiiipl.iiii,-. :;ii| tiMiipiT!iliir.-.iir\ in, 2li4 nli-.i -^.■- ill, |:;(i ai'cliitiali/Hti.iii aiut. 7'i aiiil.i cixaiilli.iiiutii anil, ll'Jl inf.i'li.iii- .|i-i'ii-cs witli, ;;•_':! aih nanii.', •'>]'■'> ufffrii. , :'iii;i iliiii;iii.-i-, |ii7 utfiilinii- I.f Kiilin \- in, 17(1 iifli r-fi'ViT III', ;:.'.'.i ' iiir ill lran-nii--ii 11 .if. 4;t ulliuniiniiria in. I st; ul.'.ilinli-ni an. I. :'.-J,s llllialir.-i- in. 'J^n 14llilitllalii|'\ . :ill". llillLMiii-i-. Ill7 iU. 1 an;lira\. .litf.-i-.nlial .li:l"n.l^i-, 41S mill iilli.-r .|i-.a>.-. r. lali.m- Ii.'|\m.ii. ii.'i a II -ilia III, 'Jul aliin .1 ili'ii illalii ! : llla\i.-ailv naliii.-. .'IH Ittypi.al \^illl -li.,rl. iirl.l . .air^r. '"Xi isi>j:x. (54F Tviilinid f''V.T Imcillus. 'JO. 1 V|)rii'i cUlii.i /y/i/iij,si(.i. l„.il-4i.ri-s ill. !■!!> bill' in. lill b-.liiirv i.;i>>aL;i's ill. liOtl. lld'J iio^t-iiiiirtorri iippiuniiicc. 10-i bilinii-. :M1 blml.liT in, |,..»t-in.irt.iii iipix-urancc, 1 r.' I M,M.(1 111, 170. St nUi' lilo,,,!. I lil.Hiil-vi-M'ls ill. ii'T l>iKlv-ti'iii|«'nitiiri> ill. ]M tioii'i'- ill. ii..>t-iiHirtiMii iipii'iiniiice, 89 j liriiin uIp-ii — iii. -•■> bruiiilii ill. -1") |i..-t-iiicprti-iii iippeiinui"'. 11-4 lirmu'liitis ill. L'1'1 _ | bruiicliupiiriiiiiniiiii ill. -IT (•iit:ilili^v iti. Jii? I'litiirrli '..f -iiiulItT linin.liml tulies iii, •-Mi; ciTi'linil. -Ui'i iiiii:;'- ill. po-t-iii'irteiii sppfiir- :iiir." ll'i in'rvr> ill. 'J77 ti.<»ue ill, ~H post-iiiiirti'iii pi'aniiii'e, lliO V('>»cl- ill. -71 ccn'liiMiiiiilui'iii ill. l''"^ coreliro-piiiii; I'.-v.t ami. .lillVreiitia- ti..ii. •-"■.'.I clil.irids ..f mill'' in. l"-'' ch.iliTv^f.li- in. -Jil'.i. Ii;7 rli.ili'litliia-i- r..ll..win-. I'lO clioi-i'ii minor in. -li-t. 'J^" rlii.inir ili-i'H-i'- willi. :i-7 ric'atri/.ati-.ii .it'iiiti -tin.- in, '.)7 circ -hit'iry or^an- in. I'l- cli'anlitii-'> "I' l""l.v in. H* of piitii'iit in. !:'.x of pliv-iiiaiis ami iiiir-r~ in. 4;>8 I'liiiical 'inM'.tii;ntioii. 4iM clotliiiiir in i|i"i-iiiiiiulioiinf. .i-l coUap-i- in. iMart ami. lti''> .•oiiipli.alion-, r.'L' <-oiiiiim-ti\ili- in. -^'i .•oiilat;ioii tlii'orv of. 'Jl .-oiila'iioii-m-" of 77 I'oii.al.'M'.n.r from. .'.lii'. 471 am'iiiia in. o''7 appititr in. o7 t t.iliarv pa:-ai;i-~ in. •!7.j t.oiirs in, I'm-i clioliTV-liti- ill. •'■7."i rlioli'litliiii-i- in. ::7.'> I'oUP-t'. ^'''O ,|i._;,.-ti\.' ..i-L'an- ill, :i74 (Uiratioii. :isil I'lir in, ■177 ('VI' in. ■!77 i.r„ll-Mailil.T in, 37'> ^'all-tom^^ in. ;!7.") jrcnilal fiiiirtion- in. 378 hc'iidai'lii' in. ^(77 houii in. :'.7:'' lii'ino^'loliiii 111. ■!'>" 41 Si'.' ul.-o Hit- Typlioiil fcv.T. convali'^'enci.' Hid ill, .17S larynx in. -''711 li'u'kocyli- in. 174 Inrr in. 'M'l liiiii;s in. :'.7ii lm■ll^trualioll in. ."iTO inii-ili's in, .'>7k m'rvoii> .-y.-li'in in, 376 piilM- in, -"'I r.'il I'orpii-rl''^ in. M'l' pkin in. '■'>''■> ti'inpci-amrc in. 14(1, lili'J urinary oix'aii- in, ■!7>< vi'iious tliroinlio-i- ill, 374 coiivali'Mi'iit period. .'^4 course of, .-tleet of a^'O on, :5:!0 ett'eet of eoii-titution on, 329 ell'eel of -lA on 3'.''.' \ariation^ in. -H7 ( raiiial nerve- in. "^77 eiitam'ous am-llie>ia in, 281 ev-titi- in. 1 1- d'.a.l Ko'li.- in. 4;;7 d'-atli in. can-'' "f. 388 niarnei' of 3'.i.'> Midilen. ■Ml' lime of, ;JK7 d''. ' nipo-itioii tlieory of, 20 .{.■lip-'iin in. -lil d.-lii-i -n- ill. -'■'.'» dial"-!.- iiMllilu- with. 327 ,r,:,^,,„,-i>, 4(10 a::'' in. i">* lipiiieliin- in. 4ii.'i ( liroiiii- ili-i'a-i- and. 40'.( eonjnnetiviti- in. 41") eoii'-titiuioiial il'iioriiialitii^ in, iO'J eory/.a in. 40i; erv'-talliii'- niiliaiia in. 41(4 di;i/.o-reaetion in. 4ll."i ditVer.ntial. 4111 liaeti'i-ioloirie. 41!t ear atteetion- in. 4 epi-ta\i> in. 41"; lii-rpi'lie ' riiption- in. 404 ill -la-'- of d. terVM-'llee, 40t» . iiile-tiiial li.inorrliaL'i' in. 40(1 jaiimli''' in. '"i; 'lellko'M'- ill, 40.-1 ineteori-in in, 404 niiv-d iiifeetion- in. 408 ') perioil of oliM'rMitioii in. 409 piritoiii!i< ill. 40i; pid-e ill, 403 relap-e> ill. 410 r.i-eol 11- e\aiitlii'iii ill. 404 -pleeli in. lo:'. slooN ill. 403 swealiiiir in. 40ii |"iiip''ratiir'' in. 402 vi9 » I I I'.i. I, ,^ i' -_\;£- -.^ ~ 3^ -5y. ■ : '.^ ' : .. l»;- f-i".: ^' tojite^ t !■-; 1 /.V/'AA'. Tyjihoid fovrr, di;;rs|ivc MrL;»n~ in, |„..,. T iiicirlcMi a|i|ii-iiriini'i', ',)() (liplitlirriii Willi, :i2,-, (]i.-.cii.-M-.. ..f rv,|,in,tiiry .irpiiii, In, •l(i^ di.-iiilV, iiMii in, 4ii (.t'r,„„l in, 4.'>: lit' lini'ii in, .):{7 , ul' >ii-l<-n.oiii in. 4:!7 i lit' -iHiiiMii in, MT ' lit' wiitiT in, MT diiMMiliM.- of rirrui;iiurv iirtriiii.s in, 4i-\i i>( ilini'stivr iiri,'iin> in, ih-i of IllTVlllH M.-l.'lll in, ili'J dissi-ininiili(.ii ,'.f, 4ii I'nrlor- t'i\.i|'ini;, "i.'i drink> ill, 447 (liini in, pip>i-Mi.irHMn ii|i|i(noiiicc 11 dur;iii..n ,(", ;;mi d,v.-i'ntiTv wilh, :i-J.") Par ili.scii'sc- in, -JKI I'ar in, 4til< oars in, |i..-t-in..rtiiii apiioarancc, V22 farlh in i-ti..|(.^'v uf, T)! ciiniciatiiin in, .'.(IM ••inli.iJiMii in, li;!l i'ini.s.-iiins ill, l!i.', on (if. To ondu(„,"i|iiis anil, ilitl'i'n'ntiation. 413 oniliicariliti- in, lo:,, liii;, lti4 fpiilnnii's ni' 7i; <'|iii;l.>tti^ in. Ii:;. -Jll •'pi^la.vi.- ill. L'::',! fnipti.iii of, IL14 t,vplioiil rv hi u,,,i, 127 orv.'^ipi'la.-. in, |:io orj.^ipihi.-. witli, ;!'J4 ci>opliiiL,'Us in, '.'(11, oOti posl-nioii. Ill iippi'iiranop, 91 t-spi'ciiil varii'tiis of, 470 etiol.iL'.v. 17 |'o^^lnsion^^, 77 lii-lorii' i-oii.i(|(.ralioii.<, 19 cxiiininatioii of stnols in, 402 pxanlliiiiiata anil, liitl'iTrntiation, 414 oxtiTiml iippi'iiniiiii'-, po~t-inortfin. Mi inli'LTiinii'iit in, lL'4 »'vi' (Ii-. inlri-^ in, 'J'.i'i •'.viliall in, :.'m; ev 1 in, piKt-inrirti'in appranini'i', 122 fiisliijiiiiii of, h2 fatal tiTiiiination in. :!82 fi'lirili' coursr. l;!:! ■stjii;.., Kl iliiration, 141! fi'iniil.. L'lnilali.-i in, 190 lloiiitiiiion in. -Ji;.; fooil infi'ctioii in. 4:54 fliliMiiiant. 2KH iliiH,'iN.~i-. 4(h; funinrl,., in. |:;0 Call-Miiililir ill, 209 panirn'm- in, 1(,7 of IM. Iv in, 212 of -kin in, l:!2 jipiTitain'oii-, lii7 gari;oiiii:,.|;i,.nt in, 214 ,\pli..iil I'rviT, ca-tric, .'ll 1 Uu-tro-iiitr-tiiial ralarrli and, ti6 iTi'iirralivi' or;;iiii- ill, 194 i;. nilo-urinan oriran- in, |H4 k1iiiiiI.iv, ililli ivntial iliai;noHii 4I8 ^'r..iiiHl-«,.,i,.|- ami, 2:; tlii-on. .'C hair ill,' I. '12 )ii'adar'ii' in. 2i'iO jii-ait in. po>i.,„.„.t,.„i ,i|,j sranoe, KM lii.ait-niiiM li- in. l.v.i lii'iiiiplci;ia in. 274 lii'iii.ii,'|..l,iniiria in, 1H9 lii.iii.irrliai;i|.. .'A:', iiiiii:iio>i-. 407 liirpi'ti. .■iiipii..n, in, 129 lii-t..r\. 17 lioini- trratini'iit. luirscs and R«.sislanU III, 4:i') liospital iiifi'iiion. (;.'! lioii-i-lio|,l anil !i., ill disReiiiinution of .".4 li.vilr.itliiTapv in. 4"i4 li.vpiTi'iiiia of iiiti.>iiiii. in, 92 livp.ipyn lie. 2KH, .■!l:i ili.ii;iio>i.. 401; Ii.vpoMiilii' i.oiii,'|.sti.in of luiifja in. 24H iniiiiiinitv. (i7 in ni;i.il. ':{40 in rliililliood. :!:!() aliiloiii4.|i i.i, .i.'in tii'il-Mirrs in, :i.!:i duration, :i:i|, :f:{,', fflirili. >_Miipt..iii,s ,131 lii'iirt ill. '■'•'.V2 inti'stini - in. 333 kidiii'v ill. 3.{4 iiiorlaliiv, 3311 nrrvous .-; -liiii in, 334 l"-riloiiiti.s ill. 333 piil-i'-niti- in. 3.',2 I'l-lapM- ill, :!:',!, ri^piratoi-v atli.cti.ins in. :i33 skin ill, .,;12 spiiial siiisi' iiri;an.s in, 334 spli.cii in, 333 in infants, 3311 pi-..:;iio-is, 339 piil.-|. in, 339 skin in. 339 spli'i'ii ill, 339 stools ill. 339 tiiii|Mratiiri- in. 339 voiiiitii.i; ,0. 339 in latiM- lit; 340 iIiai;no>is. 342 fi'NiT in. 3-» lii'urt 111. 342 •nti'-tinrs in. 342 kidnivs in. 343 prolan. .-is. 343 puN.. in. " ;i iTlip.-os in. ;;|:i n-piratorv atl'iTtions in, 842 skin in, 313 spl.'i'n in, ■42 I -^^ iM>i:.\. 'AA nU of. !4H 'l'\ |ilicii.l ('•■vr. iMi'iil.Mli"ri |M-ri..,|, ,;) iiiil . .iii III urine 111. Ihii iiilr. Mmii, ,<]■<:[ ,,( ai;,. ,,ii, :,(; i<( c.lil ..II, Cl "if .■•i|l-lilUlii.|l ..II, lij of |..l'llti II. i\\ of iiii.(l|. i.f liviii.; i.n, ill.' of ..( rii|intic.ii 1.11, i',-J of pn'i;niHi( V ..II. t'.l of |.iiiT|.iTiiiin ..ii. 1,1 of -.A ,.,|. .Vi I.f -...■i.il -iiil.' ..II. CL' "f -t..iii,-i.li .li-.-;,.,-v ..II. CO cxIiTiial iiillii. I ~ 7(1 fiii't..r> fiivi.iiiii;. .',,1 (;i-'.'.,'rii|iliii' iiilliLMici-. 711. 72 iiiiliv iiliiiil iiillii.'iii'i'.. .~>i; l.nul illlllli-llri..-, 711 iiii.li'iir.ili.uic iiiiluiii,-,.. 7;! iii-rv..ii. (|i-..a>i's luiii. i;il M'ii-..M and. 7.'i ti'iii|iiraliin' inlliii'iirc. 7.") \M'atlii-i' .■iml, 7") iiillaiiiinati f lirfii>t,s in, 11)7 iiillaiiinial..rv, :!IM inociilati'.n in. '.'M iii>aiiity ami. L'»IH iiiti->tiiial liiriiiiiTlmi.'c in. '.t7, 217, 4i;5 pain in, 'JI4 | piTf.irati.iii in, 4i;(i intistiiii':- in, 21 1 po l-in.irti'Mi appi'iininci., !i| iiitoxicaii..M.> anil, .'>2,H (lirti'n.ntiiiti.iii, 41-i irritativM. :11:! jaiuiiliiv ill, 20«;, S,-.. aU.. ,/„>im/icf. joint- in. po in, 172 lip- ill, \'M livi r in, 20(1 po-t-iii..i-t..|ii appcaniniM'. 101 localizati..!! tlii'orv ..f 2:< lo>s I.f wi.ii;lil in, iii'iH liiiii; aliMCs- in, 2.'>4 Iiinirs in, p.ist-iii.irtiMii appciimiice 11-. nialiiria anil, Ii.'), ;i2ll (litliiintiation, 414 liiali' i.'1'iiilalia in l'<4 inalii;naiil. 2MH nianiMiiiis in, 2! iiml, ilitfiTi'iiliatioii, 41') Jiicilulla i.l.|oni.'atii in, 27(: p..-t-iii..rti-ni appcanincc. 121 liii-nin.ji.al lii'ni..irliat:i. in, 27:! iiii'niiii:i.< in, I Hi. -Jtlii. .See al.oi Mr,,. iin.nini,'iti-, ill, .;i)!) 'I'vplK.iil fi'viT, iiirii-truuti..ii in, 1% iiii'M'titiric lilanil- in, 1(N) iiictcori-iii in, 212, 4il.-i mild, liiiiprraliiri. in, 147 tniliaria ii\ -tallinii in, 12H milk and, 4,'i inilral iii-iil!ii i.nrv in. 1115 111 I .-.^'iu in, 27ii iii..rpliiiii-ni and, :(2K niLilalilv . :;k1 Hi;.- and, :!h4 I'liinalc- an. I. :!K4 ,i;i'..!,'rapliii- ditlVrcnco, 384 I'ai'ial inlliii'iiri' on, :!M ."I'a^. .11 an. I. :iK4 iMi.|..r iiiiimfi-tiiti.iii- ill, 2il2 nioiitli in, lli'.i niiir..ii-, ;il I iiiii-ili- in. p..-1-iii..rtciii iippearaiire, iiin-.iil,ir al.-i-n-- in. 88 ni\..|ili~ in, 27S iii\.irar.liti- in. 10.') Iii-t..n, lil:i -,\ niptoiii-. lliO nails ill, 1:12 na-al cavit.v in, 113 niiMipliiirynx in, 2.'!8 miUM.ii in. 204 ii('(To>i,- ..f iiiiotiii., in, ;t5 ..f laryi. ^ in, 24 : ii'l'liriti- ill. 111, r,il. See also .\.j,/,,-;t:s. iiiTv.m^ .-y-ti'iii in, 2.'i0 l)ost-iiiortc 111 HppcHrance, 118 niiinili.'ia in, 282 ni'uriti- in, 2K0 opti< , 2H7 nciin.si.- in, 280 iionia in, I:12 nose in, 2:i8 iiuivliiir in, 443 ol.litcnitin;; iirti'iitis in, 1C9 of fciiis, (11 on liili- in, 1!I4 o^tl'olll^ .liti, and, H" ditffi-.-nliation, 414 ostiti- Mild, 8',i otliiT disi'HM's with, ,3;>1 paniTcio in, pi..-t-iiiorlciii appparanci', t(i:t pii|iiilar cxanttioni." in, 128 paraly is in, 277, .s;.... I'arnhjxiH. pan-is in, faiial, 277 pan.tid irliiiid in, 202 pan.titi- in, 202 paili..|..i;v. 7',l piTi.anlitis in, KXl. 1(13 piricliondrilii' al.sci.-s in '"2 poi-iili.. II. Iritis in, 1 1 .. 24.< pori..s|iii. an ,, H!l pi'riplii.ml mrvi's in, 280 ii.'iM.iis >ysii'ni in. pi.st.nidrtPm, iip|"iininci', 122 )«Titi.iiitis in. 22.".. S.M. Perituniih. jHTforativc in, Wl. 08 644 i.\ni:.\. Typl. i,l iVvnr, poritvphliti- „„J, .litlVrc,,. tiiitiori, 4(i,s !"Tily|iliIiii- ill. •_':;,; l''Vi- - liiU.lir- HI, ',):;, KH |>lmr\ 11- ill, :;iMi pli'-Miii-.-iin in. ii/j pliN'l.ili- in. In;, li;;» |ilil<':;riiii.-iii „il,n i],,],.,,,^ i,, |,;., |ilili';;rii..ii- in. I.'KI liiii-unirl,i„,i,| i„ |„,.i.„„,,,,„, ,,,,,„.,ir. Ill I i:i ' ' I'l"unsy. ilitli'iviitial ,liii:;ii,,-i, 4|H pliMiri-v in, I IT. L'.'iT |'ni-iini..nia. .litV.Tcniiiil ,|i:,^r, „,,.;, 4|,^ >i !■ uImi l'iini)>n,nia. pn. inn,, til,, nix in, SyX p'-t-iii.,i-l.Mn c-.,n(liti,,n-. m; pri'i;niinry ami, rcliiti,,n ,,|-. p.i; pr'v,-nti\r iiiiTuliiti,,n in i;') |>r,ri;n,.-i,. :>:> iiiliiiiiiiiiuriii in, :;ii4 (■iniil;it,„.v .,r-iin- :in,|, :;im) i''in.-titiiti,',ii „n,|, :;,s7 lii'iilili 1111(1. ;is7 inli~tiin,| ln-iij..ir|i]i.r|. ;„ ;j,i,'; int. -tin,- ;,i„l. ;;:iL' "" ' kiilni\ in. :;'.il Inn:;-: in. ■.\\i\ :;;i:; iii'plirili- 111. :;:■( '"■i-np;iii,,n Mini, .i.si; p'Til'^iiili- 1111,1. ;::,■_' pirllli-y ill. ;;'.i.| pniiini,.nia in. ;;;i,i ^''■^ mill. :;,s.". '•■'li-il p,,-iii,,ii .,11, 1. ;j,i<,i ti-nip,Tiitiii'M and. .■;!)0 pn,|,)nliirtir. ,,f liiitv. 47 IiV"pli.\hi\iv iii,livi,!,|.,l. 4.'!4 ni.ii-iiivs I,,,-. 4:i| pr,.ir:i, |,.,1. •_".«) p,-uli..^,-- in. -ji;.-, piilni,,iiury irunirnwic in. 1'.",.-) inlanli,.!! in, L'.',.', tiili.riii!,,.i, anil. i,(',. Us pill- in. HI. l.vj, .s,.,. „i„ /-„/,„ piil-i-t.iiipi.nitiii-.' ,,!'. l;;i; pyiii-iii in, 1!(| pM' in. niTV,,ii!, sy.^tiiii ri'miili'-ci'iiii' in. ■iir-c. H'i, ;!44, .350, n-lap.,. with, ;!i;;l t''rniiiiiiti..ii-. ;;,",(; ri-( rii,|cM-,.n|. i".i| r.'il c.irpiiM-l..^ in. 170 rclfi'\r> in. •>~u, :.'k:! r^'lap^.■ in, :!44 nlinrtivc, .'i")9 iit'rlirili', .-{.'■i!) »'S>- :iinI, .iilO .nil-,, :',(;■, < lianiitiT of, A't' ■ ,.iii-.(.. :!.-,(; iliamio-i^ and, 410 'liira'.i.,ii, .'!,-,7, \\r,H l'n'.|iicnry nf, :i.-,!i inti-titmi .-vriint.irii.s, .35,5 iii'Ttiilitv. i?.',7 'rypli.,i.| 1. .iT. niap.. ill. .'I.'iii pn.i;no>B.. :{k« piilsf in. .■!.",!' iv,rii(l..vi!i.,. Willi, I!,;,-) ri'pcatiil, .■;•,:! n>pinit..ry artV,.|i,.ii- in, a56 ri..»c.,|ii. in, :j.-,;i ■-'■\ ami, ."lid i-plci'ii in. .{41;, ■;;,4 ti'iii|MTiiliir.. in. :!4i;, .S4y t'Tiniiiati.iiis, :!.",i; tinii-of, ;i4.''. rcliip.-c, in. Hti. 471 rrliip-in- (-..viT. ilirtVr..|,tinl diau'm.H- 4 I * ri'p in. JS7 rli.iiiiialic pi,l\artlinii.s with ;j27 ri'-i'"lii in, al,.-i-ni'c ,,l', 1^',-, "T. I'll ,1,(1 (V.iiii. 1^17 lifi' I.I', iL'.'i lypliii.- i-nipii,,n iind 127 ■■" '•'■'■iiltiuv.-, iiiil in dia^rnosi.. 4i;:> ri'M'i.hi-,,f, Ki, IL'I rotlirlji -.vith, :!■_'!' ^aliviiry ::l:.nd.., p..M-ni,,rt..,ii ,1, „|.. s.aiM f,-v,M' 1,11,1, ,liiV,.,v„tiatii,n, 4l.j -riul. t I,. NIT H iih. ;i;_>| ■-'■iaticu ill. -^S-J, fidiTo-i- in, L'7i| " '"'■■"> r^pliili^. .1 ll'iTcnlial diiii'- n.,-i,. 41h I'cpticciiiia and, dittVrcnliiitinn 41:i .''■p'l'V'I'i" ill. '■'■n■l.^,^plnal inonlii- iritis with. 27o Sijiliri'lnir. .'!l'.". si'ViTi', 2W of atypical ,.,„;,„. „,„| .vniptoinn- tiil.iiry :!1 1 ■ ' >i'"iii.'i' ciinilini.iis in, 4,'',l i-lii'i'l 'n.iliiriiaiit, L's.vi Ml k-hi'd in. 444 sirk-r,,i,iii di-inrrctinii in, 437 i-kin in. K\, PJ4. 4(;<( .•■li'i-pini,..^ in. L'dO .-iiiall-pi,\ and. C"). ■.\2'Z ditli'n'iitiiiti.in, 41 r, soil in .■ti,,l,,;.r\ ,,f, ,-,) spinal , .,i-d in', 278 pi'-t-iii,,rt<'iii app..aranco, 121 ■'liM'fii ill. 171I pii>t-iii.,rlriii appearance, 107 puiirtiiie 1. 1', (22 -p'.riidir ,11-,.... 71; >tiiiiiii, h ill, 2(14 pii>t-iii.,rleni appeaninre, HI •-ti")'.~. di-inlee|i,,,i ,,f 4:;,r-, stiHd* in, 214. S,.e nh.i..SA,„/.,. .-iihMillii., ii.iiHiniiiii in, 2tW siidaiiiina in, ;i(l| ■«yiiiptMiiiiii,,|,,irv, 79 variati,,!!^ in. 2«7 i.\in:x. 645 I T.\i>liipiii li'ViT, iVTiipi. .ni>, H;i. \'22 ill iriciiliiiliipii piTiiKl. ho t«'iii|)cmlnn', iiMiMitoi' 137, Hj (li'M-.-iit oi; l:JH liii;li. 114 (liiriiii; .LiiMili'Mfiit'i'. 86 iiiiiltijili' . l-\!iti'>ii>, 140 pwiiliarilii- ..!'. 144 v.iii,iti..h- ill. I:l7 teiii|iiTuiiin'-rin-vc, umitiI uf. ]4'2 ill IlliM rii-i-., 1 17 ill .-tUlir lit' (IrliTM-. .■111!', 14',< ti'iiiliiii-jcrkiiii; in, L'l.:; t.t.-iiiu--liki' I'.iiHlitiMii I ,. •.'(i4 tliinl Icliriji' |MTi.iil. I;i7 tlii'iiiiil..isis ill, li;7 tli,vi.iiil -laiiil ill. 18;i tli,vriii(liii< 111, 1h4 t'liiLriii' ill, I'.i'.i ; -l-iihirti'iM ii|i|>i'iiriiiii't'. IK) ti>ii-il- in. L'lll tii\ir ill li. Ill nil iinnoii, -v-tcni in. 20^, -,v!ii|i|oMi-. :!(i:{ tnirhiM ill, \H'i l"'-t-iii'ii-l ii|i|ir!(niiiio. 1 14 •ri'iitiiiciii, .■iiiti|ivn'tii' iiirtlmd^ in, 4->'J, 4i;i) liiilli-. 4-">.'; li,vili-..tli,i-i(|n , !.-,( iiili-liii:il ■•iiiii-cii-i- in. 441 siTiiiii. 4 HI spi'citli-. 4411 tn-iimr in. I'd:! trii'lii.iM-i- unil. iliiV. ri'iitinl iliiii'ii.iai>. IIS Irisimi- in. ■_"14 luli.TrllJ.isi, Mini. ililll'lTlitiiiniHi 41(1 l,viilHHnn(l ilitl'i'n-iiti.ui.in. 4l.i. lilMI ii'liilinii I,i1wm..ii. oi'il "■' I:i' in .'i'.!!! iilii r- .if inti-liii.i in. '.ii;, :i.8 J iiivii ill, IS.", I ii'ii- :iriil in. ISr, iiriiiiiry njipimilii- in. 1S4 "i\'iin« in. |Mi-t-iiioitiMii iippeiininoc. 11(1 iii-ini' ill. S4 ili-"liiliiillri.-i in. |H!I iirlic-iiriii ill. IL'H uti'Miii' iimciiu^ iiiiMiilimiir 111, I'.h; viiM'iiliir .•ivstPiii ill, piKl-inortcni up. pi .iiiiico, 104 I vciii.s ill, I'il) viiinitin!; in. L'04 wiilrr-ii|,p|y in, (:',•_' Wiilal n:irti,iii in, i!;i Wifll.illt illtr.-tilllll !.'..iin|i-. .".ii, w Willi, lilt ivph.iiil -toiiU, •Jli; Tvplinjcl -pin,-, -Jso -til.. Is. L'U t'liiii-. syiiipl - ,|u,. til, .30.'! ■|'\ pli.iiiliil -tilt... -JCO i'\ pli..i.ii.tti-. L".i:i 'r,vpli..iimliiriiil fcvrr, .320 'r.vpliii- iili.irlivii-. 2!IS !lt,'l\iilH. ,'|,',4 'l',\pliii~ .■uu.\..-ud_\ imiiiicus, u.',4 liiitli- in, (j3> llllTiTliln. .'iSS mliirrlmli-, :,:,:, llv-i'llLTll U.- ,').')4 t xuiitli'iii. .VJ7 Typliii- I'l'MT, 47') iil.iirliv ,u.-i>. .Vi8 iiliiiii..ii.iii iiiij. rclmiiiii tiotwi'on, .jii4 iiinl.iilatitrv ca^i'.-. .V;! unll.ia\ ami. liilliToiitial in, o\i'> (■U(la\ CIS .i,|. m. .'iliO in rirriilat'irv Mri;aii>. .JJIi in diu'i-tivr trart. •■|4" in LriMiiiM-iirinaiy nn;u'i>. .j48 ill inari, .'iL'."! in ni-rMMi- -y-li-m. ",;!4 ill piil-f. .'iL'M in n-pinitiiT'v orijiin-. •■)42 ill -kill. i;J, chn.iiir iirtiTiiiiii- .iiid. ndation lie- 1 »' nil. .'1114 ''"'I'li'i f "ii.'aii- diiriiii; con , iilos- n-llri', .■)7(l I'l'ii-tiliiiiiiii. I'rt'iTt ..f. ,",i;.'i .■iill'al. -.■.■; Hl'7 (•iiiniil.-ri'iit-. di-rliar^'M nf, i;|() ''"'"' •' lariiilinn- in iiiaiiif.-iation- "I'll. .-,.-,1 • i-.vpl.i^'.Miic -.•piiropy.-iiiia and, dif- f' I'l'lirial iliiii;nii-i-. .■|!i7 dia-n.i-i-. .Vi4 ill -!iii;i' 'if rlilptl.iii. .'illS dia^'ii.-lii. vi^r,|i|i|.,,| ,■ pruptiiin .",!IS ' dii't. I'lji; iliHi'i-riil Inini' of, ti'uipiTaiiiii> vHrin- lion- in. .-,|H di^r.-tiv,- ur^'aii-. i;l'7 di-iiif.Tii,,n of lii'd-liiini, t;08 of fiirni/,.v. iS5--«; Txptms f.'vcr, iiiiiiiuiiit\ , 4h!t ii' iliiMliooiJ, .'ii;: iiH iilmlii.ii -tat;.'. :Ak) i-c'luli.ri ill |.r..|.lnla.\i>. iKM', I lvrii|p|i-i;lariii c liaiii;i-. .)L'i; tiiiilarial ('•■v.-r ami,' (Jillrnntial iliai;!!,.. .'•i>. ."i;i7 iiiai.ili>tHli..ii-, variation- in. .V.I t... 4;i7 ' ^ iiiil.l la-i-, ."..■>.'. in.>rl.iil aiiat..riiv, ftO" ni..rtalit_\ , .'i;.), ':,Ho ai;.' in. .>.". I'Xlirnal iiinditicii.- in, iJHo ;,'<'.i!;ra|.liii' (li>lril.iiti,,n in, &85 in..i|.- ..I' lilV. ox- cici Mi|iati..n in, .j^7 piM-- .ual .■.inditi..n.- in, uHo tiin.' i.f M'ar in, 6>H."i wiath.T ui, ."iS") iii.T\..ii- -_\ rnpLini^, tj24 >.\-l.in," r.ij n.iina in, .'.:::. luir-in;;. (il:! I.e. ii|ia,i..n prpdisp..sin!: t<>, 40ti "III a;;.', .■tl.'ct ,,|', ,-,i;i; ly|itm.- I'l'HT, >; |.(.|. I'lian;;.'.- in, OiJi; MiMi'pliliilii\, 4MH ?«ralini.', .jL'I >_\ iJipti.Tn-, .'il.i U-n.p.ratur.' iji. ,")|;i II: I'.^innliiL: >Uii;c.<, ,".14 III lal.r >tat;i'.-, i')14 tran^nii...-i,„. ,,r, |,v ,|,.,„i |„„ji^,j ^^^ "■'"i-r'Tt"!! 'f liali.'nt, lUMi Ircatiii.'nl, l.atli,-, (13) liMlri.lli.Tapi, (il',1 I'l' i.ruani.- 4 sidiTan.-, ".Hd I'liKA in typliiii.l, 1H& l]ri.' a.'id i'n typli.iid, \Hr, rrinan hji|iai-alii- in lyplinid, 184 .ii-L'aii- 111 .•.■nMil.'.-i.'nci' IV.. Ill tvphdid ;i7x • ' I'p'ii-aii- tn'atiii.nt. til.'i pen. ..I ,.f (..innloccnic, 'if.!! ..i;,l..tVrv..-,-,.,i,.,., fnip,.mtu|vin,Mr, i,, t.vpli..i.i, p..-t-n„.rt. ni apiH'arance ..( ,i;n-al.>t danircn.t Hil\cti..n, 4Hi; no i iitaiani-e, pn('iin,..nia and. .lim-rcntlai diagn..,.-!.-, Iii,,. |,„,.i||,|, n,,l„„,i- i,,, :',2. 34 » ii.ilii\ . :;'t .|i-ii.li-.-li..n ,,r. in t\|,||.,id. 4.i6 ill t\plii.id. ll-J, 184 ri-..l.ilinuria ii tvplici.l, 18!i rrtii'iiria in l\pli,.id, 128 I tiriiH' niiiiM.ii., iiH.iiil.mn.. in tvphnid li»; ■ ' r,(p:! pr.iL'ii.'-i-, ■)7'>. ".K.'. a;;.' in, 58'i disj'Stivi' (iruiin- in, 501 I'st.Tnal ('..ndili..!!.- in, aSS cv.' in. "lOl Ki'n.Tiil syiiipt..ni?. .18!! h.'ni..rr.iin,'ic' plivnoniona. f)!t2 inilividual ..r.;ans in, o8!» iiiPtiM.ri*iii in. ."i!t'2 miKJp lit' life, in, AST "f "ii-i't in, 58!l nfTVi.ii- sy-tciii in, .VtO •loriipati'.n in, 'i>*7 p<'r-..nal I'.mditii.n^ in. .')8.5 respirat.iry iin;an.-i in. .'i!ll spvi'rity of syinptonis in. .589 s'rciii in, r)!)2 tinip ..!' y..ar in. fiS') w.'iitli. r in. .'iH.'i pr. .) liyla\i>. i;04 rpiiirrcnci^ in, rifil rrlap-.- ill, .''i.'il rclap-inixlVvpran.l.ditfprential.Jiau'n.)- Wi.lal r..|i,ti..'ii, L'!), 4 Variola, t\pli..id anil, dirt'.rpntiation, 41.-. ' typliii^ an. I. dirtcrpiitial diaj;iio.-i< ',<)(, \ with typli.ii.l. 322 'Vascular -y^tciii m typhoid, i«itl-iiii,rtpm app.-iiriiiii-... i((4 A . '11. .11,- tlir.iiiil....i- in coiivalescpiu'e from typh..i.l, .■!74 \'.'r-.atil.' niTM.u> I'.-vpr, 312 \'.>niitini; in typhoid. 204 Wai KR. hiKillii- typli..piis in, vitality, ISO .li-infpcti. f, i'l t\ph..id. 4.'i7 rolp of. ill typh..id,'40 W.ll-watpr, typlioi.l fpvcr from. 41. 4,'? . .MO rp>^pinitory ..mans in, 620 roseola in' iVM scarliitina and, ditfi'i-.'ntial diajriiosis spasoii, 4il7 spx in, 4!HI ptfiTt ..f. r.oo skin clianir.'s in. .V27 xx'iul c.inditioii.s in, 4% .■arlii'-t ap)ipaniii( f. 427 ill typhoid, 423 niacr..sco|ii|. nicthi.d in, 420 niiriiisci.pir in.'thod in, 420 ..(•(Mirr.'ni f. limp plaii-inn l.pfopp 42!i !.ro;,'n..stic siirnilicaiipc ,.f, 430 r. Inli..ii of -.-riini and ciiltiiri- in. 428 spiTilicity of, 42" Widals method of ai,'j,'lutinatii.n, 425 *f -'^/^—i *■ '*;!f ££?U^ •■¥> r-.JSt^.' ^^^.■v>Pi^,?;-^^P^i Catalogue SL Medical Publications W. B. SAUNDERS Cf COMPANY PHILADELPHIA ». * * * w 925 Walnut Street w » * W * LONDON. W. C. 161 Strand Arranged Alphabetically and Classified under Subjects See page 20 for a Lilt of ContenU clasiified according to lubiecti 111 lif uli- it»licatif)n nt li.)i>ks Tiil. \n,..l-. idwrtiseil in this CataloRui- .l^ 1. iri'j u'/J ty iuhcri;/i,v arr usually iiiU'.l Iri.ni tr.ivfilini; s,.lii iiors. hut iluv will In- s«-nt ilin, i Iruni th.- ..fliri-..t pi (ih iri;. s of sluiuu.-ut pp-paiil) up'in ini-ipl of \h>' prlc.-, i;iv.'n. All llu .,it .i.lv.ru^.'.l .111- inuini..ulv for s il.' Iiv lioi.ksi-ll.rs m .ill put- ..I tl.r rnilnl St.ili-. , li will I"' ■.i-iit -..1 .my aililn-ss. (.iiriiRi' prt-puil. on n-cnpi ut tin- piihli-!ii-il price. M.uun nmv In- si-nt .at the risk of tin pulili-lur in eiilii-r ol the lollowinK w.ivs iiiMii. A ..nlrr, an expre-- inoniA oriler. u ti.mk i-hick. ami m .1 reKistm-d lettir. Miiii. v ~, iit ■M :nv o'li.-r M n i~ It ll" n-k ol the senilcr, SPECIAL To pli\si, 1 ins .,1 .ippriiveil iredil 1 k- will l..> - tit, p..-t-p,,iil. on ih. foil,, wing OFFER terms S5.n0 i. ish upon ililiviTv of books, .iiul ni,,nlliK p.nnu-rit- o' #5 01, there- after uiit I lull amount is paid. .\ny one or two volumes will be sent on thirty days time to ilioM' w!i., ,lo not caie t,» in, ike .1 lirf;e [lurch.ise. I An American Text-Book of Applied Therapeutics. i'.tiiud liv I\Mi-- ( Wii-'iN, M. I>., I'lolcsor ot I'iMiliif ol' Mt'diiine and of (liniial Moiln liic, IflTfrson .M(.'(li(:il ( 'o11cl;o. l'hila(ti-l],liia. Haiiil-omi' iniporial 01 la\i) \oliiiii(' of 1 ^d iiaf.jc--. llliistrati'd. (loth, S7.00 net : Slu'cp or Half .Morotio, 5.S.00 net. S,'/./ Av S:i/>si'ri/'fu'n. An American Text-Book qf the Diseases of Children. Secor^d Edition, Revised. Kditfd liy l.oi'i'- Si akk, M. 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ADDITIONAL VOLUMES IN PREPARATION. 17 NOTHNAGELS ENCYCLOPEDIA ■''if OF PRACTICAL MEDICINE Edited by ALFRED STENGEL. M. D. Professor . I l lin;. .1: Mcli.^ins in :hi- Tniv tT-i:v . ' I Vi:i:s\ Kama . Visjunj rhysLiian lu the I'ennsylvania Hospital 11 !■< uiii\Lrs.illv .ickiiuwlitl-Lil thai tlu- ( iirni.iii-. It. id tin uurKl in Intc-rn.il .\K(li( in.' ; an. I . .t .;11 tlK- ('.1.1111,111 wi.rlo im tlii^ suIml-. 1. Niithiia,i;frs ■■ i;ii,\- cl..inili,i ol >ii.. i.il ratlic>l..,;\ aii.l 'lln rapt uti. s " i-, ...nmUcl '■> si lit.lar^ In liL- uitlioul (|iu-^ti..n tlu- best Syitem of Medicine in existence. So nicts^ary is this book in tlu- -imh' ui Int. rnal M. iluiiu- that it . ..m, ^ larL:i ly to this oonntry in tlie original ( 'lurni.in. In \i.\\ ..l ihr^t lad--. Mi-^--r-. W li S.uimK ix \ ('..in- pany have arran,u;i--(l ^^ith thi- piiLli^hi 1-. t. . i-r-ii. at oiicl an authorized edition ol' thi-- iirtal <.-m'><'li>iii- ha . .t iiRih.ni.' in llii-hsh I'..r the pn-i lit a --ft of smm ti-ii or tv.xKi.- \.)hinK-^, n.|irisLntin.i,' thr 111. st practical part of this enrvrlop.dia. and selerted with especial thoufrht of the needs of the practical physician, will be published Tin- volumes \vill contain the rt-al (..s-.-nif ..f lh>- .-ntir.- ni.rk, and the pnr.'ha--. r nil! then fore obtain at less than halt the .list the cream of the ori.uinal. I. .iter the special and more st'-'ctly scientific volumes will be oflered from time to time. 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NOTHNAGEL^S ENCYCLOPEDIA VOLUMES JUST ISSUED AND IN PRESS VOLUME I VOLUME VTI Editor, William Osier, M. D.. F.R.C.P. Pfijeiwr i>/ Mcii.i-i' inM'"!' //.'/><"■•• t'ni' > rsity CONTENTS Typhoid Fever. 1^ I'^" <- k-o.masn c.i l,t.-ii>~ic. Typhus re ■.'( .[ lA-u-ic. Typhus Fever. l''y '"-^ "■ Hati'iMime ■■' Editor, John H. Musser, M. D. , r/ew .'/ Oini^al M.autK. . I 'ii:tr.ity ,/ CONTENTS Diseases of the Bronchi. I'.. "^ , '• ^'^ J' ' ' ' M \NN. .1 1., ii.-;c. Diseases of the Pleura. l.v PK. R"-i Ni A' ii,>'l l;<;rlin. Pneumonia. \i^ I'K. 1'. Av I V:l ' HI, uf Ma-' Iti'in i;. VOLUME II Editor. Sir J. W. Moore. B. A., M.D., F. R. C. P. L. of Dublin /■r.y.J.-."- .!/" /•'••»'-"■'' "/ -W.'/"""-. '^■'V"' ^••■• "J^^"; '^'". MiiMiK "I Uii'in-LMi. Whooomg Cough and Hay Fever. ''X "^ ''./'" ^'ir, .., ..-.en Varicella. IM'^. In n"NJ','^ ,iNMN of rubint;.-!!. Variola including Vaccination. lyl'K.U Mm.knusn.'T l;a~le. Haiid'ome ..uav.i volume .if ..%<.t 700 i-ag". /!i VMK, oi Kul. VOLUME m Editor, William P. Northrup, M.D. /v,/.-, CONTENTS M,a,les. r.v 1)k. Til. v..s JCruKSMN, .ii lu!:^,.,:. Scarlet Fever. 1'- -l';- --» .uith.T. Rotheln. l-.v llH. -uiie nuilu.r. VOLUME VI Editor, Alfred Stengel, M.D. .'',■'11 n'riiKht CONTENTS Anemia. I'V T'R- ^ ''■"'^' ' "• *"' r'^nUfort- '^ "uT-Main, .na Lk, A. La/aki>.m I li.r- lotttnburg. Chlorosis, '''y.!'^, "^ ^'.'^ N..ciK')i.'N, nf Kinnklo,t- ''-fR. ,l Vi^nii.i. Diseases of the Suprarenals. r.v 1>K. K. Nki -sr.K, ul \ iciin.a. VOLUMES rV, V, and XI Editors announced later V.,1. IV. -Influenza and Dengue, ''y ,"'~- ^■ 1 I K nil N^TtuN, I'll "li'UiH MalanalUu- eases. I'V I'^.J- M vnn m.i R'- ' ' Vicm.,. v. ', \ - Tuberculosis and Acute General MiUary Tuberculosis, l-- 1 'k. i.. < .km i, \' .1 \1 Diseases of the Intestines and Peritoneum. l''y !"<• "■ -N'-""^agh„ pf \ icniia. 19 -: rr..t.t-^J 'IS .11' CLASSIFIED LIST OF THE MEDICAL PUBLICATIONS or W. B. SAUNDERS O COMPANY ^. i'i m\ ANATOMY. EMBRYOLOGY, HL^^TOLOGY. Bohm, Davldoff, and Huber A Um- book of Hl>t 'h i;v 4 ClarkBOP— A Tixt lio >knf Iliiiology. . . 5 HayDes — A Manual of Ai.;iloinv 7 HeUler^ATcxt-r.oi.k c.f Kinbrv'ul'-iK'y. ■ • 7 Leroy -Ks,emial> of lli~t..lui:y' '. i; Nancrede - l^ssontialsul Aiiatumv 15 Nancrede— 1;->' niials ol Anat.iinv ^md Manual of l*rac:ic.il I Ji>M-til>iii, 10 BACTERIOLOGY. Ball — 1 ss.nlialbOf li it'trioloj;)- 15 Frothlnghara — I.alior.iiory(iuicle 6 Oorham 1. iM'Mt.ay ''"urs.' in Bacieri- Lebmann and Neumann— Ail is cf Rictc- fiol.'ijy Levy and Klemperer s flinica! V,j i r - ..1 ;;v Mallory and Wright- I' [tl,uluL;Kal !<■ :, nique McFarland— I'aiho^-fiiic Iia '■ r.a CHARTS, DIET-LISTS. ETC. GrlfBth— liifmi bW, -:.t C!, it, . Hart— Iiui in Mcknc, ami in litiUii. Keen -I >peratiMn H ank Lalne — IcnifieraTurr i iia:I Meigs — iVedini; in Early Infancy Starr -1) iis f..r Infants and Children. . . Thomas — liKi Li- ts CHEMISTRY AND PHYSICS. Brockway- K5-i-nti ilsnf Medical I'hvsics, Wolff— l■;^senti lis of Medical Chcmistrv, . CHILDREN. An American Text-Book 6 Oleason — l'..~eliti.ils of Diseasesolthe F.a; . 15 Oleason -I-ss. of Dis. of No>e and Throai 15 Gradle -I'.ai No ■•. and Tin. ..it 22 Grilnwald and Grayson- .\tl is of Di^ e.is '5 "t t:.-' I. ir\ n\ 16 Haab and De Schwelnltz -.Atla-^ of I'xter- n '1 Di-e.i-e- . 1 tie l.\e if, Haab and De Schwelnltz At a= of 1 'ph t . ilmos^ , ,:.\-, 17 Jackson — \I.inu.il o' D s. a^i s of tin- l-.v ■, s Jackson— li,^entl.lI.S of Diseases of lye, it; Kyle —Diseases of the Nos,- .-md 'Ihroat, . 9 GENITOURINARY. An American Text-Book of Genito-fri- n.iry and Skii. Di> a^e^ Hyde and Montgomery -Syphilis and the \'enereal I)iseases Martin — !>sentiil.i of Mm.-r Surgery, li.iiulai.' 111; ind Venereil Diseases. . , . Mracek and Bangs— .\tlas of Syphilis .md tiie \'enere,il Dlse.ises Saundby — Renal and Crmarv D seases. . . Senn ilenito-Crinarv Tuberculo-is, . . . VecU — Se.\iial Imp itence GYNECOLOGY. American Text-Book nf Gynecolog)-, . . 3 CrajCln- l^baelltl.rLiof i;vneCiilof;v 15 OarrlgUeS— l.)|sea-e, oj \\'..men 6 Long — >yliabus of GynecoloLiv 9 Penrose — Diseasi s of Women . ..... 10 Pryor— I'eb- c Ir.tlunm ili.-ins 11 Schaeffer & Norrls -.Vtl.i- o! Gynecology, 17 HYGIENE. Abbott — Hx'giene o! ri,,nsnii~ Bergey— Principles of llvpiei Pyle-lVr~ mil ll\ .,'1. nc ' ' . ■il'le Di-enses 3 e 22 II Corwln — I'hvsiial Diaunobis Vlerordt— .\ie.li,al Dri-nosis DICTIONARIES. The American Illustrated .M. las! Du- tionnr\' The American Pocket Medical Di ti narv, Morten —Nurses' Dictionar\- MATERIA MEDICA. PHARMACOL- OGY, AND THERAPEUTICS. American Text-Book c nnd Hyde and Montgomery— ^>l>l'.l:. a" J il"-' roxi..il'»;v, ., ■/,, ^ \,'v'.n\ 111M.1-.S ,' " ' Ooleblewskl and Bailey -Atli- of Pi,- igartln- I>sentiaU of Minor Surgity ra^^rs ( ausi cll.v A. iilinl^. t i '^ Hand is^iiii;, ' nl V.-n.-rrrill H-.n >■>, . 15 Hoftnann and Peterson Atl.is ■ f !.• uril jjraceltand jtelwagon— Vthi^ot Ui»ea e:, Mc.ll.in. ■ ■ ■ NERVOUS AND MENTAL DISEASES, ETC. Brower— Minunl of Insnnit ■ 2 = Chapln-i-'-'inpfti'l'"'" of '■ '""^•, ■ ? Church and Peterson Nervuu^ a .1 M^ n- _ Jakoh&Visher - Ath.ofNi m- >^-' 'em, 17 Bliaw—l;sseniial5 of Nervous Ui-ea-t ir lllbarnly. ■ NURSING. DavlB-nhsttlrican'Hivnrcui.igicNur-in Orlfflth-TlK' Can of ihi- li ibv . . . Hart— Uit-l in ^itkncss and 111 Healih, Melgs-KiTdiiig in l.irly Infancy. . . . Morten - Nurses' l)xliunaiy, Btoney — Mitcria Miilica for Nir -c,. Btoney I'mctica; I'oinii in Nursinc;, ■ • Stoney- Surgical 'Ii-ilinic fcjr Nurses, Watson— Handbook foi Nurses, OBSTETRICS, An American Text-Book of ( n.sietr cs, Ashton-1'.ssem..ils t)l t-ibsieirus, . . . BolsUnlAre— Libsieinc Aceiii-nis, . . . Borland -Mo.ieni Ob:tptric5 Hirst ~le\t-Uook of Obsietrus, . . Norrls -Svllal.us of t^bsletrics Stelwagon- -1;,, Mil 1, of lJi = eaes of tlie 16 SURGERY, ami Schaeffer and Edgar-Atlas of Obstetn- cal Ui.ignus.s anil Ire. itment i/ An American Text-Book 'f Siireerv. An American Year-Bookoi M. .i,vi.uai,(l >-iiii;'rv, Beck— l-iic Hires 15 Beck-M.uiua; .it Surgieai Asepsis . . DaCosta— Manual of Surgery, . International Text-Book ol Surgm 6 Keen - < ip'rauou 141, uik 7 Keen— lie Surgical Compl.cat.un 7 ^L.,|uel- o' Tvphoii! Fev.r. . . _ ■ 10 Macdonald— Surgical Ui .gnosi-an.lTrc.t- 10 nient ■ I', Martin - Hsstnii lis o: Mm^ r Mirg.ry. 13 Hand.ging, aiuiVcTu re.il DiseaMs, . . 13 Martin- Ess,nti.ds of Surgery 14 Moore — < ii'bopedie Surgery Nancrede-rriu.iples of suigerv. . . pye— li.indaging and Surgical Dn-s-in^. 2 Scudder 1 le.itni. m of Irauuies. . . I-, senn- leniu.-Uru.iry Tub-rculosis, . . 4 Senn- rractical Surgery t, Senn-Svllabiis.4 >urgery. _ 7 Senn— I'athology and Suig.c d Treatn,. nt (,1 lumors, , Warren— Surgical Tathologv and Ih.ra- 5 3 ■) 15 >S 10 10 II 13 12 13 tl'.n, I J Wolff— Essentials 12 L'line Zuckerkandl and Da Costa-Adas ol PATHOLOGY. eiper.nive Mirgerv. . . ■ ■ " SSi^S'SeJ^^A^.lsdf'l'dl^^og.c ; URINE AND URINARY DISEASES. Hi-tology. ■■,■■•;; !J oeden-'bnic.alExan.mau.mof the Urine. 10 Kalteyer-F.-senlalsof P.uliol-c'x _ . I:, °83by-Renal and Urm.iry U.eases. 11 MalloryandWnght-KdhcogicUTec. ^ ^^'^^^Handbook of Urine-Ex.nmina- ^^ Benn—i'atholosy and Surgical ■Ireaiui.nt „'J;;^'' V...,'nf',nl= ' nf ' Exaniiuiti'm of of Tumors • ■ ■ • Btengel-Text-Book of I-athoIogy._ . ■ i^ Warren- Surgical I'athology and Th-T..- ^ peuli'S 'PHYSIOLOGY, Bastln- I.aborai..M l-.xercs.s in Botanv. . 4 .nAmerlca^^f^-ology, 3 0<.eh.ws. - BaU,. .Vtias of O.s- Budgett -Essentials of P'-V'o'.oS). ■ ■ -^ F.aymond-rext.l!o..k of I'liyMologv. . . Stewart- Minual of rhvsuilnL-v. ■ ■ PRACTICE OF MEDICINE. An American Year-Book m Me.bcne and ^ ^ g^;^ie„.-Mr,lical Hand-Atla-e~ . . 16,17 II I.t.ls f Exainin iti'in MISCELLANEOUS. '3 17 Oould and Pyle— .\nonialies and Curiosi- ties of Medicine ^ Orafstrom— Massage, ... •••■•■ ^ Keating— How >o Examine for Life Insur- ance, ■J 1 Saunders' Medical HandAlla-e- 1 I Saunders' Pocket Medical Koimuiary. Anders-Practice of ^'i'',i«;_'nf_;^_ • ■ " ; ^ | gaunderb' Quest.nn-rompends Elchhorst-Practice of Medicine, . ■ ■ Lockwood -Manual of tl.e Practice of ! Stewart and Lawrence— Esentials of ,, , Medical I-.lectri itv, . Medicine • ■ ■ ■ ■ ,- I Thornton- Dosc-Hook and M.inual ct Morris-Ess, of I'laciice of Med.c.ne, ,_,, Thornton ^ ^^. ^^ Salinger and Kalteyer-Modem Medi- ^ j .yj;^^'.^;jlaii and Kisbet-Diseases of the ^ 8t^'y'ens-M-.nualofI'racticc of Medicine, .3' S-omadi '3 .' . J 'J < THE LATEST BOOKS. Bergey's Principles of Hygiene. Ihc I'unciplc-i of lIy:,rK.nc: .\ Practical M.uui.il U,r Students. I'liyMciiii,.,in.l M.altli ortlccrs. \W D. |i lli-ki.ia , A. M, .M 1 )., Fir-t AsM.tant, Laboratory ..f I ly.^icnr. L-nivcrsity of IVnnsyl- vania. Haiulsomc octavo vohuii • of al.out 500 pa^es illustrated. Brewer's Manual of Insanity. A Practical .Manual of Insanity. By Daniki. R. Hk,,\vi;k, .M. 1).. Professor of Xervous an^l Mental Disease^, Rush Medical (;olle<,'e. Chicago. i:;nio volume of 425 jiages, illu.strated. Gorham's Bacteriology. A Laboratory C.urse in Hacteriojo-y. hy p. p. Gokii.\.m, .M. .\., Assistant Professor in Hiolo-y, Hro..vn University. 12,1,0 volume of about 160 pa-es, handsomely illustrated. Gradle on the Nose. Throat, and Ear. Diseases of the Xose, Throat, and liar. Ry Hexrv Gk.ai.i.e. ^^.n,, Profess,,r of Uphthalmol.;,-y and (nolo:^^y. Northwestern University Medical .School, Chicago. ILand.some octavo volume of Soo pages, profuselv illustrated. SoUmann's Pharmacology. A Te.vct-Hook n\ Pharmacology. Ry Tok.\,.„ Soll.m.xnn, .\L D.. Lecturer on Pharmacologv. Western Reserve University, Cleve- land, Ohio. Ro>Td octavo \-olume .,f about 700 pages. Wolfs Examination of Urine. A Handbook of i'hysioh.gic Chemi.stry and Urine Examination. Hy CiiAs. (-,. L.WorF. M.I)., Instructor m Physiologic Chemistry, Cornell University Medical College. i3mo volume of about 160 pages. f r r '■\:
  • atient- with rei:ard to their -n-ceptihilily to lixdro- therapeiitic tiiea-nri -. they are fir-; placed in a full liatli at a teinjicratiire of from .".I to .;l ( '. l*erhap~ tin fir-1. hut (.nlierally the second, hath max lie cooled to L'T or '!')' ( '. li\- the LTadiia! addition of cold water. The ii-e of wat'r .it a tempcraliirc lulow '2- ( . i- rarely iiidicate iialli. Till' |ialifiil slii.iiM iii'MT ;.'i'I into iit nl' llu' lialli una.-sist('il, evi'Ti it' till' tiili lie |iiaii-il at till' siilc (it' ill. Mil. lie riUMt aiv\u_v« lie lit'lcii ami rarrii'l liv ll.' :i|lciiiiaijt.«. llu lialli-v, atiT sIidiiIiI cover the clu'st, aliiiusi li> llic iitrk. anil llir wi'll-sn|i|)iirtt i| patirnt shoiilil rt'inain ((iiii'l. ( >ii till' 111 llir hanil. he is l'iiiiIv riiMifil |itr>isli'iill\ ami llic y,a.Wt ip ('.)Mstuiiilv k('|it in 111. vi'Miftit. Diliilitalcil i'uliviihials may lake tniull iiuantitirs ut' alcnlml — ir i with cii'.'iiar. port w iiu', or, with aih iiilau'c, Stokt'8'?« niixtiiri' liit'ort' ami iluriii;.' the I'linrsc nt' tl'p hath. .M'ttr tiic hath all paticiil.s shmil'i ri'i'cive sin'h stiiiiiilaTits. .\t the I'om'liisioii of the liatli the patient slimilil he ilricil, always in the rciunilH'iit posture, n|Hin iin alternate heil. anil ilelirale patients slionhl he itrinl lieinath a woollen hlanket. They should then hi' kept in lieil, snitahlv hut not too heavily covered, and the utmost quiet alimit them should he maintained. It is aL'reeuhle ami advaii- ta;;eiinn Id .some patients, as von Zieiii.s,sen especially ailvi.st'd. not to he dried at once, hut to he permilted to lie i|uietly and to sleeji, and to have their clolhini; cliaiii,'ed oiilv suli.-cipiently on awakiiiL'. In private practice the tuli is kept in tin room coiisianfly, at the side of the hed of the patient, while in the hospital it is j;enerally |iorIahIe, or often the patient in hed is moved into the liath-room. The |iracliie of {)er- mittiiii; the water to stand for day-i in the tuh, and of iisiii^ it for se.eral (lavs in succession after warminir it hy the addition of aiiiount.s of hot water, is a practice that sliould he stron;;ly condemned. This wool' make it impossiliie to secure the iieci'.s.-arv cleanlines.s on the part of the patient, and would certainlv j.'ive ri.se imt rarely to infections dise.ises of the .'^kin — furunculosis and jiiileLrmon. In adiiilinn. the daiii:er to the attendants from such infi'Cied water is hy no means to lie u^ denslimated. Indications and Counterindications. — The repetition of the hath is governed less hy the ranL''e of the liiidy-teni()enitiire than hv the symptoms i-efcialile to the ceiitnil iiervnus system, the jiiilse, and the respiration. Mo~t |ilivsiciaiis at the prc-ent dav endeavor to avoid extreme reductions in tenipcnitiire liy means of the liatli. From the use of the kiinl desi'rilied, the sim|ile lukewarm liaths. or the Zienissen flKlihiallv cooled liatli, the reilllclinn ireiierallv diH'T^ not exceed one fir two dcirrc'S. In trenef.d this may lie considered as ipiite siitlicient. PjVen ill severe cases and at the heiirlit of the disease, front two to at most four haths in the course of tweiity-li'iit' hours will >renenilly he sufjicient. The lukewarm hath (iVom '!'>" to .'50" (". ). of lon<'iu. -as wjll as ri/i •,■ ' 4.>S TvriioiK ii:vi:u. in m l)V I'livcrriihl. luccntly, ilicy liavc \»fu lii;:lily ])^:li^»■e may nnt iei|iiire the liath-treat- inenl ; diet, re-t. and the .-\>teinalie rei^Milatinn I'l' tiie ;•< niaininu' (MJiidi- timi- are here L''ililv \\\'<. I I or tepid .-|MiiiL'int:-, which are refi'e>hinLr and exert a f,.4-.irahle inlh'etiee npnii the IK r\iiii- sy-tein. in in'>derale and ,-e\ere ea-is an iec-liajr is kejn eMii-taiitly ai)|ilied tiMin head thr(iii;.'li"nt the fclirile |ieric"l. \\'heii the |inl-e-lr. (|neiiey i- hiirh, it i- \seli al-u to ajiply an iee-hai: hmt the heart. .Marked intestinal -ymptimis, es|ic- eiailv inetenrisin, demand die apiilie.itidii .itey filline; the water-cii-iiioiis with < .ild water, ice, or even cdd mixtures. Whereas caution has lieen sevend times advi-ed in the emiiloynier.t of vii;orous hathinLr-proeedures, especially \<'ry iJi,^ TRE ATM E.ST. 459 reocnt mvoranlitis, idocanlitis, or pericarditis. Also, jwrsoiis with artiTiiisilcrosis or iiicoiiqilcti'lv foiii|)tii>altd vaKiilur k-iioiis of wiiue staiKiiiiLT an- to hv ixviiuli d t'roia tiiu batli-triMtnicnt. I'liiiritic ftl'ii- sions oi' (diisiileral)ii' ainoiiiit likewise eoii>titiite a rii:i(l eoiitra-indieatioii, wliile ill tlie case of drv jiicuri-y and |iiiciliiioiiia this luetliod is contra- iiidiciitcd (iidv if tliey are a.-.>ociateil with wcaUiuss of tiie heart. I'hlehitis al-o coii-tiliiIc> a coiitra-iiidicatioii to tiic liath-trealnieiit. I)itl'ii-e hmn- ehitis lira teiidcncv t i liv[>ostasis of ilic iuiiu'> i- coiisidcriHl in myelinic as a special indication for the bath-trcatinent. In <'ases iirc>entiiig severe hirviiL^eal legions it is lie-t to omit the halh-treatment. Snp- jMirativc intlamination of the middle ear, with jicit'oration of the tympani' inemlirane, drmamls L'rcat care to ]irc\eut the entrance of hatli-water. Much camion -hould he exerci-cil in hatiiinir pei-sons who have prcvilv been ill, e-|>ecij|ly tho-c havinir tiibereulosis or broli- chicetasis with a tcialcnc} to hcmorrhatrcs or in the presence of inarkeons. They commonly bear hydriatie treatment jtoorly. Hven in youthful persons of this character, particularly in " bloonung, thriving " young wom(>n, unfortunate exjierieuces are not rarely encountered. Such individuals exhibit a tendency to weakness of the heart, which b(>com - ! t wm reiulors tlic l):it!is (laiiiri'i'niis al^y lor altdlidlios. That there are also pnviiiii-iy .i|i|iar(iitly litalthv imtmiiis \v1ii>. wIvm attaikcd witli tvphoiil liver, <\i< iiipt lirar thf ha'lis well and lifiiiiiu' markedly hmtrtiid and fxliau-Icd in ciin-ciiiifiicf, is a notiwui i iiy (■nl. ( )!' the .-cvcral varieties ol'tyiiiioid I'lVrr. only llic nirc h( in(irrl;:ii:if \ari>ty rcallx dcinaiid.s care with regard tn liydriaiic incasuris. ANTIPYRETIC MEDICAMENTS. The Value and Action of Antipyretic Drugs Antipyretic dnij^s, wiiiili, cvcti at the hcifrht of the hatli-trcatnicnt, were contmlfred hy tile niajiirity ut" jihysicians as less inipnrtaiit tlian the hiltiT, tii-ulse, and tiic re<]iiralion, whicli is coiisidcred as an especially impor- tant result of tiie liath-trealmcnt, is scarcely demonstrai)le foUowiuj: the tl-e of the antipyretic drutr-, with a few e.\ce]>tions. The majority, on the contrary, in full do.-e- j-ive rise to nuirkedly depressing or directly injurious secondary eti'ects. To the sim])le reiluction in temperature, which all these agents usually liriuLT aimut in marked dcL'rec, die earliei- siguitican"e is hy no means attached at tic pre-( ut day, a> has lieen seen. The custom, still far loo common, of administering .inlipyietics in a routine manner wiienevcr tile temperature rcache- a certain level, .and thus, of course, freipieutly, i- to he condemned. The extreme ell'orts to maintain the tcmpcraturi' :it a low h vel for a considcnihle time, or constantly " al'clirile." a- it i- de-iLrnated, iiv the administration of salicylic acid, kairin. tiiallin. and tiic like, are actually dangeroi •, and, tiM'tunately, have licen almo-t entirei\ aiiandoned. I'ersoually, I make imomparaiilv t'ar le~s use of antipyretic diiigs than of li.illi-. I'roni \ear to year 1 have tri'adnally given up the former inoi-e ant;itcmenl vvitli a cjcnr conscience, a- mv c\|iericnce- durin^j the last ten ycar~, compared with tho-c ihirint: the period in uhich I prescriocd ' <''iMi|>;iro I 111' ili>. u-.ion uiKTi :ii;'ii|'\ n>'s. Cmv!. f mn. Mtil.. IHS,', ; .ii^il hitrrnat. ruE.infF.yT. 461 tlic.-c rcmidics more trwly, art' not any loss favorable tlran tlic latter. U at the prcM'iit tiiiic I ,-till occasioiiallv ailiii' li^tcr an antiiivrctio (irnjr, tliis is (Ioik jircloraiily in tlic so-callcl liyi.crjiyrotic ca.-o, ami then e^iieeiallv wlieii the liatlis cannot, lor extraneou- or individual reasons, he einplov-d. I re^triel niysell', iiowever, in tlii^ eonne<'tioil to a I'ew reniedle>, ot" niiieli I know tiiat witii very sliiriit or no injiM-iou.s seeond-irv etfeets, tliev exert. In addition to the rediietion in tenijierature, also sdii',. intluen-e n|)on thi' ty|ihoiil state. I do not use salii vile aeid or sodiura .sahcylate. Altli< utrh they reduce the hodv-teinperatiire luarkedly and ceriaiidy. thy have neillier an alilire- viatin^ nor anv olher iavorahle intlueiii'e upon tlie course uf the disi'a«'. They inav, in fact, not rarely he actually daii.'en us, in so far a.s ill y may cause coliapse in |)ersoiis pr-'.-eiitiuL' not entir.ly n'>rtnal cardiac ■oiulitions. lutiermanv, aceon. ','ly, the use of the preparati. ns 'f sali ylie acid haa appareullv heen :•' .;.ioned hy most physicians: whih' in France, under the inlluence'of (Jueimeau de Mussy, Jaccoud, and Vnlpian, these |ireparations are -liU employ (>d. Kairiu al.*) ha.s proi>erly lieeii almost ahandnned. Its administration is likewise almost unexceiitionally followed hy marked de]ire.ssion of the hody- teinperature, hut irenerally with mo-l uii]ilea,-ant. often actrally alarndii';, S( ndarv manifestations: cyanosis with cold sweats, c.irdiac weakness, and occasionally [)rof iriid disturliance of hreathinir. The action of thallin apjiears to resemhle that of !:air.:i. hut is attended with less serious set lary mani- festations. In the opinion of com|K'leiil authority, however, the entire etlect is less marked and loss persistent. I would admoiush also airainst the use of aT'lifehrin. Althoujrh it is markedly antipyretic < th^-ee or four times more so thai, antipyrin s its adndu- islralion mav he followed hy quite iniantici|iated and danperous seci>ndary manifestations, eyeii wluii it is triven oidy in stoall ifises. 1 ndouhtedly, even death m;iy he attrihutahle to its adnninstration. The secondary inaid- festalions in (piestion consist in chilliness, cyanosis, and csp •citdly ir'-eL'U- larity and feehleness of the action of the heart. crtam nld, r renudies, paiticidarly veratriu and diijitalis. play no rule whatever .is :.ntip_\ retics "t the prL'sent day. ToLTether nith most i»hysici;ins,' I employ almost ady quinin, anti- pvriii, and ])hi:tacetin. < 'ontr:iry to :i niimlier of titers, of these I .still prefer quinin.^ With a ]>ro[)er adininistr:iti' n — this must naturally he letirned — it h;is :ilinost as certain an ellVct :is the other two, and jxeiierallv a more [MTnianeiit eifect : while such secotidari- r, '■ Crl.cr :h'< .intipyri'tisolii' AVirkiinir 'li'^ Cliinin." Pnifxrh. Arch. f. /Jin. Mr,l . lSt',7. I'. I. iii. ■ .•\nti]1yrl■ti^('he HoihuctlKKlpn. ' Zi'm.^.Hnt'n Jl'Uiii. ./. Tlirrnp., lid i. ■ fyptius iilniiimitKilU. " Ziems^rn' is Hand. d. irprr. I'afh. u. Tlirrnp., liil. I. Thp " .■Il-kiinwri invi -ti^ntions of I.icliornici^ti'r nn' still at thi prp.^ont (lay 'Utficicrit ' ■ ■:' ution for the Ptnploymont of the fnii'ily. Kvi n ]>rr\ ioiisly, Brocii (1S40) ill I .1 inii W. Vc>!:t il«V.i'» and ■\\'ach'^tiinth flHf,:!) liiid made invpstipitions coiu'i'a., , .j' itiiti, without, howcvpr, haviiii: cli'and up tlu' situation. A mi:.-''^^''^'- hf ♦ m I M 4i;2 TYfllnlli ll.Vin. tiirliiiicc.-i as UKiv !)r |iriMiit ari' tar Ic.-.- t frrc lii'Mi (laiiLTtT. I lir i'iii:_'ini: in llif (ar.-. .- mean.- mi Ir iiiirnt as il i- otlcn .siiil ti> lir, aiiil, what i- nlM^t iniiniriant, tlio rrincd^' i- llic Ira.-t ilanirtf- iiiis I'r in 1 t" l.."i j:rains. llanlv. I u'ivi' as inacli as - L'rain.-. and .-carci-lv f\tr ninrt'. Ilic adniinit-lrali' n slmnlil take iilaiT, as Lii-lifraK'i.-:U-r rii i nnni'nu.-, not al lln- luiirlil (if tlir t jnj|ii_Tatnri'-ck'vati()ii, but si»nu' tiinu lurliir, in •nirr tn cdunii rart this s' 1't as |ii)s.-iliii'. As the action 1)1' i)uiniu Lriiu'rallv luM'i.ints distimlly a|>|iai\'nt 'n\\\ in the ('(jiirsi' cf two or thrcf liour.-. tin- \\ ih avvra,i.'f. iVmn ciglil to twelvf hniirs at'u-r ihe iiiL'isiii'ii i.|' ilic iiuinin. It' tin- t( iii]i(rature tiii'ii lu'L'ins 111 ri-i' aL'ain. il dms iioi. in manv cases, reach the previous level, even in the cnin-, nt' an addiiional iwentv-tniir honrs. It i>nnteu(irthy that the renieilv shniild ln' aihninistered at i'i:ce in full dose, or in ;'. few smaller doses at intervals ot' not loiij.'-cr than t'roni one-<|narler to one-half an hour, Isnialler fre((nently, and, what is most set ion-, lieart-weakiu'ss not rarely occni's, unless trri'at care i- oli.-erveil in its adniini.-tration. I'drst jirepared hy Knorr and introdiieed into thcra|iiiitics hy Filelmc it i> at tiie ]ircseiit time jiroha- hlv the nil st coinnioiilv cin]iloy(t snL'L;('~'ed for (|iiiiiin, and tiien also reeoinrneiideil for antijivrin, diiriiiir the af< hrile jieriod, in order tlia its fleets may he utili/cd in [irevciitiiiLr the daily exae rhatioii. Like iniimii, it.s use is f llowed, m t 'iilv iiv a reduction in the hody tcmiieratwc, hut not rarelv al-o hv iiniiro\-cini'nt in the no ntal stati' and hy ;i eerttiin feeliii}^ of wcll-lioini.'. The d sc i- iVotn '1 to o (rnim-. Wli.'ii first aiiminist reil. it is advisah!.' not to jrive the entire ch se at once, hnt in tuo ^ c|u.d [ar's, with an interval of an In lir hetwi en them. In patk>nts in wliom tiu r ■ is any mispiviiirr as to the ci nditioii f llie lieart, it is w '11 to administer ai fir~t only from 1 to l.o irrams. and thereafter hoiirlv a ilosc of fr.,m d.To to 1 L'ram. The r' incily. if badly home liy the >iomach, mav h administi n d hy enema, and. hy r< asoii of its ready soliihililv. (>ven snhctitancouslv. Phenacetin, wiiich dniilar efVect to antijiyrin, and is eni|.lovelinul(l rrccivf cari'l'iil attriitinii. With lactophenin ((Ihm', iV.-m o..") to 1 crnim), wiiicti iias bwn m im.iiil«>n. How successfully these are counter- acted 1)V tiie hath-ircatitient and how 'ittle of a favorable icharacicr is, on tile other hand, to he expected from antii)yretic dru^v, whii h, on the coiitrary, may often he a source of injury, has likewise I .en snlli^ielltly empha>izcil, Shoiilil proirres-ive enrcchlcmeiit of the <-ircnlation make ii.-elf manifest, in spite of inteliijrcnily employed hathiuj;- tfcatnient, fiinher systematic intervention may he of fxreat, and, under some eircum- stances, of life-rtion to the increase of the collapse. It may in this eonneetioll he kept in mind that febrile jiaticnts bear distinctly lar and champajjjne, also eofjnae in strotii;: coireo or tea or in the form ot .'^!okes"> mixture, are es|)eciall\- ellicient. Patients who swallow hadlv or exhibit a di-!astc for ah"! 1 may take eosrnae, under some condition- with ethereal tincture of valerian, in the form of an enema (coirnae, 'JH; etluTeal tincture of valerian, ■") : yolk of efrjr, 1 ; mueilaf^e of jrum arabic, "JO ; water, sufiieitnt to niake lot' ; to be ^iveu in two or three parts by enen-aV Amoni; .-timulatiiiL; drufrs I employ j^refc rably eaffein nternally ' Vrag. inrd. II'.cA , is',14, \,,, 11. ■ Leiirhuch. liuw idition. 'vm ^fi^i'm vV^'. "-•- '•<■ '^i. . -Y*-: ■■•p-r.;;. ■-■'S :^;- l^^^v^: f!?-- V*'- 464 ivriinni iivin. Mm 'y limniiaf ^filWPf' and suhcutaiRHUisly), ati llie iKitifiit ami i~ u.-clc~s. I linM lore nniilov tin- rciiHilv a!iiii>,-t .-nKly .sulicutaiicou.-lv. Tlic cplliiial i !•» \»v (■.■nt. i caiiiiilMiratiyriii^nlul- -. .-ertaiu atid ].er,-i-tent than tiiat of eaii.|iiior. In adiition, the injeetions are cinite paiidul, and not rarely ^dve ri-<' to iieeror-is at till point of piinetiire. Mii>k has larj^ely ;;one (;ut ot use, ane decrepit individual-, warmth to the preeordium, |ireferahly applieil hy mean- ot' I.eiter's tiilie-, may lie of -erviee. Should tiie extremities lieeoine eojd, the a|. plication of handap- and hot l.ottle- -hould not he Iletrleeted. Digestive Orgaus. — Tlie care of the mouth and the na-opliar- VHL'eal eavitv lias already t"in coii-idered. .\ inimher of infeetioii.s di-ordci-s of the larvnx, tlie iiroiiehi, and the Iuiil's may in this way he aveni.l. Tiiat artitlcial teeth -lionld lie ri'iuovod throuirhout the entire febrile period, e-peeially in the ease of deeply slu|.orous jiatidits, is a matter of eour-e. The developnient of thrush should be attacked vii^oroii^lv on its lirst appearance. In the ])resenee of jiarotiti-, which f|-.<|Ucutlv Mili-ide- without the oeelirrenee ol' -llp])Urati(.n. cold elolh.S or an lee-baL' mav be aiijilieil. Should suppuration prove inevitai)le, hot poultice- -hould be applied, and then free inei-ions be made as carlv a.s jios.-ible. The intestinal symptoms are L'end with peri-ta!ti<' unrest, eoKhky pain, and tenesmus — the last oceiirriu'_' more commonly in e.ises of c,,loiyphoid. In -onie ea-es it is ' Til.- :iions or aa ice-bag -hould be applieti to the ..bdoiiien. Should tiiese iiiea-ures afford no relief, not much de])end- ence eaii be placed upon others. I have observed scarcelv anv giKnl from the use of oil ol' uirpentinc, externally or internaliv. in s|)itc of its fre(pient reconuiieiidation by early ])raetitioners. The lii confined ])riiicipallv to tlie large intes- tine. When especially the small intesti.ie is greatly distcndtnl, not much will be accomplisheil with the tube. Direct puncture of the intestine with a fine needle, v.hich has received nvonmiendation from various sources, is dangerous on account of the li;d)iliiv of peritonitis. At any rite, by reason of the marked jiarcsis of the intestinal tulK", almost always jiresent, and the con-idenibl(> loss of elisticitv in the overdis- tcndeil :il>domlnal wall, no gas will escjipe thniugh the neeille, for . obvious ]>hysieal reasons. In the ])re,-ence of intestinal hemorrhage, and even nivm the slightest indication thereof, absolute rest in the dorsid |>«Minriil (1iim'.> may l)c ^ivcii. Il' tlic luniiinliiiL'"' i^ liirlit, nr on the cositioii <>[' more copious litiiKir- rlia^'r. a -pnoiilul of imiM milk, or a corn-iioiMliiii: amount of niiiciiaf:!- iioii- sou|>. mav !«• i,'iv(ii cvirv two or tlircc lioiir^. Control »ristal-is >lioiil(l i>c proviiitd for l>y means of o|iiiim, in fri'(HH'nt, c'vtii litroic, llos(•^. l(v til"' nioiilli or tlic nciiim. In llic jirt'stncc of frcnt'i-al restl('ssn< S7-, one slionitl not lioitatc to ae not to resort to the use of stron;: stimulants too early. Moderate collap^^e, if iiitelli<.n ntly controlled, may he fav irahle to tlironihosis of the hletHJinp v<'sscl. In the pre-eiice of considerahle cardiac weakness following; protu-^e hcniorrha>:e, these considerations may naturally \.i iimori-*!. I'tider such circumstances the treatment already described for eollai)se will he indicate.!. In some esiieciaily alarminfr cases I have ol)serv(Hl piod results follow the suhentaneous ■ intravenous infusion of wniium <'hlorid, and even from transfusion of hlooil. The u-c of c:dcium chlorid in iar>:e doM- (•_' frra-u- every three or four hours), and tiie suhcMtaneous injection of a 2 ])er cent, solution of irehitin in order to incrca-e tlu' a^'nlaliility of tlie hliK.d and so favor thronilHi-is in the hlecdin^r xe-sel, liave liecn lately tried at the Johns Hopkins no>i)ital. in -omt> ca-es apparently with eii the ahdominal cavity, to search for the site of perforation dire<>tlv, and to dose it, and thin t , make a thorough toilet of the peritoneum, are due to Mikuli.v,' and J.ii y,.lkmnnn'.t SnmmliiJirj Uin. V'rtraar. No '.'R'-V ' Pculxrh^ Text. J. Chvr.. Is^ST. Hd xjv,: and V.rhandl. ,\. dndsrhrn GFS^flUrhnft n„r.. 1880 A complete MMioixraphy Lciriiii: upon tlio j.n n-durc in .|unsii..r is vpn l>v r.psr-lpwitz.'^.h and W,inna.k. MMhed. au.i,Un Grcmgf bitten d. M'd.u. Chir., Bd. ii., H. 1 u -2. S. .TJ. rl .if/ Ti:i:.[rMi:.\r. 467 Tlic ilotiiil- ;iii>(■ l!if lAciH.iit it-iilt-. ohlaiih'il liy llu' ii-.' a-t r<\\ \>:ii-~, ami -incc llic cliaini- i\(i-,i- tiiMi arc tar u'lcalrr tlic carlitT it i^ iiiidcitakcn, it i- of the iitino-t iiiiiiniiaiKi' tiiiit lli«' n.iiil: '.ill lie niof^iii/cil caily ; and wiiii iiirn-aMS ot" skill ill carlv diajrim-i^ will li.uhtiMlly come an a|i|iri'(ial>li' reduc- tion ill the iiiMi-Ialitv frniii thi^ accident. The alteiidiii^^ |iliy.-iciuil sinmld liavc tlie |n(— iUility of |iertoi-atiiiii constantly in mind, and with the onset of the tir-t -ii-i)i<'ioii^ -ym|)toms a nio-l careful examination should be made. All feeding,' should lie .-lo|i|.ed at once, all forms of liiith-trt-.itment should lie diseonlinueil, alisolule n -t ^hould Ik> niaiii- taiiii'd. and the patient shuiihl Ix watch d with the jricalest can> until all iHi-sihilitv of till' exi-tence of a perf n-atioii has passcil. (in rejrard to eailv diajiiio^i-, ~ee p. '2-'>\) 'I'lie u>e of opium in these ca-es is ju-tifial)le onlv after the diai^iio-is has heeii made and operation d( cided iiiioii. As soon a'- perforation is helieveil to lia\( urrcd, immediate surgical intervention is demanded. The results of this procedure (p. '2:]'i) fiillv warrant it- application wherever conditions are such a- to render laparotomv for aiiv other conditii>n Jii-tilialile. 'llie introduc- tion of the use of local cocaiii-anesthe-ia in thei' cases liy ('usliinji has Imh'II a di-tinct advance, in that it has maile the operation [Missihle in manv (;ases in which the administration of a jrencral anestlieti<' would ot' iiself lie a source of coii~idcral)le danL'<'r- Kven in cases in which the pertiiratioii has not lieen reiderees recover without such intert'erencc. However, this is not true of a majority 'A' the cases. Of II cases of typhoidal infection of the jja I l-l (ladder aeeoiii|(anyin'.r or following'- ty|thoid fever, collected l>y Keen,' .">() resulte recovered; while of the reniainin); i*) not ojvr!it»>d iij)on, al! dieil. There ("an therefiire U- little (juestion as to the advisa- liililv of operation as xMin as perforation is diaf^nose*]. .Vs to op'ration, in cases ot' cholecystitis with marked distention, Itefore perforation, the opinion of Keen- may l)e (pioted : " I am decidedly of the opinion that ' /,.«• cit. ' ( iinmc ,/ ./ffi.i Iliipkins Ho.ip. Hep., vol. viii. [ u ■\r,H TYfll'ill' t ivi.n p. Iiii:^' '^-■ in .li-t.tili..li .it' ill. -ill-lil:i.|.l.r l.r..ini.l Mir-i.Ml int. rt'.ivn.r i- tin- l«'-t. It i- WiV Intlrr 1.. |nv\.iit |»rl'..r:iti..ii tlwiii l.> r.iii.'tK it aft. r it lias iic.iirr.'.l. < »|.( niti..ii ill Ml.-.' .a-.-, al-.. uimI. r l."'al .■...aiii-aii.-tli.-ia, lia- I.-ni iJMii.- !i\ < 'ii-liiiiiT ami l.\ Mii.li. H. Siij.].iirativ.' .■Ii..l..v-tili- an.l .li..!. litliiaM- •..ll..u in- l\ |''"'''' '''■^"' f;li.iiil(i, ..I' .■..nr--r, ri-.fi\.' -uriii'-al 1 r. atintnt. Iho diseases of the respiratory organs may n-piiiv tli.n- pcuti.' intcrvcnli.in. Marlv.! .l.-iv- ..f li..-.-t.l. have n suited IV tli.' .iiviini- staii.f that til.' patioiit-, stiliH,r..ii. ..r sL-imm^: ]ir..tniiii.ll\ , . -i... ially if til.' nasal orilicf lias Ih.mi taiiii".ii.il. Iiav.' l..sl an iniiiuiiM' am. .mil .'f 1,1 1 int.. th.' na-..|.liaryiiui>al .'av ilv an.l liav -wall'.u.'.l it, in.'..n-.- .lu.tirc ..f wlii<-li iIm' li.'m..nliair.' 'Ii..'s n..t i.n.iiiptly . ^^v t.. th.' kii..ul- clir,. .,f til.' atl.ii.lanl--. I liav.' ma.l.' it ;i nil.' in -.•vciv. ..l.-linate ca-i's ..f f|)i-la\i- t" applv tamiM.ii- ii..t al..n.' iV.nii tin' fnnit, l.ul al-o fiMiii iii'iiin.l. Tlic tivatm.'iit .if tlic l\iili..i.l l.-i..ii- "f lli'' lar\n\ lia- aliva.ly ■rivfii rise t.i an .'Ni.'iwivi' lll.a-atmv.' Ii tival.- .-ixrially ..f lli'' in'li- .•ati.,ns f..faii.l tli- [HTli.rinan. .• ..f Ira. li. ..I. .my, witli \\lii.-!i, in -cvire ca-cs. tli.T.' -li..ul.l !»• ti...l.la\. 'I'll.- ..|..Tati..ii, Im.wcv.t, ha- aU" its (lark si.h', .-ii.'.'ially in <-as.s ..f ty|.h..i.l f.-v.T, inaMim.'h a- in tlu-iii, fi- m.ir.i than in ih..-.' I'lv fn.m f. \. r. it fa\..rs ih.' ,l.-vc!..pmciit .if pn.iim.iiiia, Imth hy a-|iiiati..n an.l l.y r.M.'iiti.iii ..f s.'cr.ti.m. On,, nni.-t ahvay- h. ]iiv|ian'.l f.-r ih-' .l.'vi.l..iim.'iit ..f ali-<'c:-s ..f the thvn.i.l trlan.l, "M ac.,,imt ..f it- irravity, l.iit. ('..rtmiauly, it i- ii"t fn- ,|iiCnt. It S...1I1 L'iv.- ri-.. t.. attack- .if snn'.icati..n, ami it sh.ml.l thiT.'f.irc he iiii'i-f'l as early as jxi— ihlc, Mv far the hc-t treatniciii i'lr typlinid linmchitis i- that with bath~, cohl fri.'tion. an.l nmi-t a|>|.li.aii.iii>. I scanvly c^.t iis.^ the so-caUe-l i.xjurt.iranis— iixM^acuaiiha. HiicL'a. .I.'. WIk'Ii imi".rtan.c is attached ti, tlu," use ..f drill's, tlu' ailmini-trali..n .«f li.|. anini.m. ani-. is least iniuriDUs. Sh.iul.l ^ymi.t.ims ..f .•ardiac vvakness U- a.ld.-.l t.. lluise ..f lin.n.'hitis, measures ,liret..l e-|iecially t.> the jirovcnti.m .-f imlin.mary hy|..istasis are in.li.atc.l. Tnder such circuni-taiices fre.iuent chancre .if jv.Mti.m sh.iuh! he hr(iu._'ht alx.ut, and an endeavor sh..ul S... Ihp r..f..n.:u-s <.n (.«-.• l-':!'' im.l tl..- fMllowi..;; \nvz<-* -f H'i- wrl<. (-l..ri>illy tlip exhaustive work uf Luniiij: iIilt.- iju'iithhi'd ^i. i;4;!;. ^:frsv« ,f^/ •3i:i inilMMI-.W Jtjy The trcatmtMit of disorders of the nervous system i-, as has ulri'iiilv Ix'cn |Miii)t(;il use- of liydrt)- tlicrapy. A muiiiIxt <<{' .IriiL'^ :il-" (i|Miiiiii, aiilipyriii, plicnacftin, and lactoplifiiiii) appear to rr valiiaMf -irvui' in tlii:- connwtioii. In atldition to the i^'cticral aiitipyr tie tnatmciit, >p.ci:il nnasMrf> and modi- fication:* of liydrotlu'ni|M'ntic inftlior with eataleptie symptoms — often recjuire sjn-oial trciitment. The depressive conditions, when they atUiin a eonsiderahle de^rret; of severity, should he controlleil hy means of cold douches in the tepid hath, and, in particularly rohust persons and when the attiick pursues a iiyperpyretic course, even hy means of (piite cold full l)ath-. A useful adjunct under such conditions con- sists at tim»'s in the cnemata of valerian and eojriiac previously men- tioned. In the presence of niarki^l irritative states —rc when he conies under observation, or if such a condition catmot be [ircxcntcd, in stiite of the utmost ciiro, it should be treated in accordance with the rules of anti- sepsis. Tiie application of plasters, formerly practi.scd, is to be rejected, on acciiunt of the dani,'er of retention of the .secretions of tlic wound. Dressinfjs with borated or other antiseptic ointments arc most suitable. The fortunately extremely rare ca.se.s of very extensive, multiple, and progressive h-d-soros, attended with general nutritional disturbances, can at times be favorably influenced by treatment in a permanent water-hath. The treatment of erysipelas, furuncles, and phlegmons should be oarriiKl out in accordance with general rules. With reference to typhoid affections of the kidneys, it need oidy be remarked that they do not contmindicate mild bath-treatment, while under such circumstances certain antipyretic erinu> pnifrnosis of true reerude-eeiiee.-. Tlieir treatment U ttie same as tliac iif tlie severe tvpliiiid statt' in L^enei-al, witli especial ei>n>ide-atioii for the eireum- i-tanee tliat tlie patient.-, already ^neatly redne( d in eonse<|iienee of tiio antecedent period of disease, are preposed to cardiac weakness, piil- tnonarv liv|(ostasi>, and -tates ot profound nervou> cxiiaustion. Only the milde-t liv>, and the like are entirely to he avoided. The most important eon>i(leration under these cireunistances is suitahle nourish- ment and ahundant administnition of stimulants, especially alcohol. The relapses, which, on the contrary, are of favorai)le pro(rii.i-i-, reipiire treatment oiilv when they are ahnormally ])rotraeted or when a severe, lonji-enntimied relapse, following: :i mild, at times amliulatory, primary attack, con-tilnte-. actually the |.rincipal part of the entire disease'. I'lider such circumstances, naturally, the lules already laid do,vn for the |)riniary attack are applie;il>le. Whether relajjses can he prevented when their imminence is to he fearinl on account of the persistence of enlarirement of the spleen and of the diazo-reaction into the afebrile jycriod, as well as the relation hetween the ])ulse and the tem](erature p?-eviously mentioned, is douhte -lioiild not he [mt- iiiiltcareel\ lie reaelied iM't'orc the la|»e ot" four week-. C'omi)lifatioiis ot'teii re(|iiire roi in lied lor even iniieli loiii.'er periods. The patient and the friends should l,o clearly instrneteil that the course of eonvalescenee is not Ic-s de|ieiident ii|>oii strict ohedienee than is that ot" the previous >la;re>. In lied the convalescent- should remain a> (piiet as ]io»il)|e and avoid sitting: up too lonj;, particniarly iti the first jiaiT of the alelirile ptate, they -hoiild, so loiifT as possihlc, lie kept away from severe, particniarly t(Mhnical, lead- liifT, while lijrht, indilVerent literature may he read to them. Visits also shonld lie restricted dnrin^r convalescence, and onlv snch |)ersons •'dmitted as deratnre-enrves of convalescents on the otlieial visitin;:- days. It is a iisefnl and a welcome snhstitnte for iniidi that is forliiddcn to hrinj; the coinalescint in lied into the open air, if the weather is f:ivleted. the usual activi- ties may he resnmed cainiot he determined in general, hut tnnst he decided accordinjr to the individnal ease. The nature of the attart. Cunsiilcralilc altitndcs (ahove ]()()() meters) or riu^oroiis sea- baths, particularly in the ( Jerman S(>a. are in p'lieral to he interdicted. In winter a residence in the South, in Southern Tii'ol, at the upper Italian lakes, or the Kivicr;i is .ippropriate. The Isle of Wi^ht is also, imder certain circmnstance-, a snitahlc resort for recn|ieration. Those of moderate means should, at lc;;-t after severe attaeks of tyjihoid fever, spen liiilicrto undis- povcml cause of wliii'li repnMliices itMlf oxclii~ivily in tlii' Ixxly «'f tlic individual atrcctud. Tlu' disease oriy the peculiar character of tlie temperature-curve, and by the fact tiiat the characteristic eruption appears at once instead of in successive crop.s. HISTORIC The plan of this work docs not include a detailed description of the history and geographic distribution of typhus fever. These subjects have been c;»refully treated by a number of authors, esjiecially Murchi- son and August Hirsch, and tiieir description is so complete that later writers have done little more than cpiotc from their works without add- ing anything of their own. Tviihus fever is one of the diseases that were probably known to antiiiuitv. It is possii)le that even Hip])ocrates ' encountered the 'The syiuinyms f..r typhus fiv.T arc: SpotteJ typhus, pxunthcniatic typluis, typhus contasjiu.sus, foliris pi-tili'ii-. tVUri- putridii, febris petoohiiilis, morbus pulioaris, typhus cari'iTuiu (jail fever i. f.'l.ri- hi'llka, fehris oastrensis (oamp fever', febris Tiautica iship fever), sliip tyjihus, liuiiL'er typhus, and feliris Iluncrarioa ' Huiit^.irian fever i. ' The term tvphus, as well as other names by which it is knuwn, sueh as spotted typhus, exantheriiatie typliu>. petechial typhus, etc.. came iiito vo^ue at a time wher. the disease was imperfectly understood, and should therefore be discarded, * De morb. popul., lib. ii., iii. 4r» f '."KS 476 TYl-llls I EVI.Ii. m (li^t•;l^l■, MTnl -unic iM\-('-tiir:it'ir- riaiiii tn have f'niinil passajjos tlint s<'<'m to I'rtcr ti] it ill llic \\iitiriif- 111' Actiii-, l{|ia/(-, ami A\iccnna. 'I'lic' cai-lic-t iimiii-lakalilr ri|i(irl- date I'ruiii tlic ijiidillc a;:c.-, aiul air liy iiiaiiy aiillini- a-riiliiil [>> .laiulm- ilc I'arlilm- ( 1 ItJ.'!) and the (icascs, csix^- cially llic jilaiiUr. 'I'liii-, tlic •• |ilairii'' " ( |it-l i wliicli (iriL'iMalcil in C'v|iriis in tlic years 1 .")( i:,--_'H and nivairt'd alnid-t ili<- wln.lc .it' Ital' was iiiidniilitcdly ty|)lius t'cvcr ; liii> i- |)iiil)alil\ tnic al-n nt' the dist';..-~e called iniirhiis J luni/diii-ns, wiiirli I'aired in the arinv iil' f'liarles the Fitlli diiriiii; tlie -iei^e (if .Met/, in the yi'ar I J •"»•_'. I'he a|i|ieaianet' of the disease in Italy at that time I'miiid a hi-toiiaii in I'laseatoriiis, to whom i- line the credit tor the first liieid de-eri|ition ol' tvphiis, ixi.-i- tively di-tiiij^nii-hiiii,' it I'roni other di.-eases, e>jieeiallv the plaixne. He calletl it iiinrhu.i /rnlicu/dri.i. Hildeiihranil lielieves that a nnnilier ot' other dixa^es de-ittnated as the |ila<;iie (|.esli in the sixteenth and seventt'eiitli eentiirie> were lind(;iil)tedly epideinies ot' typhus t'ever — as, for instance, the plaf.Mie in iliiiiixary in lo"))! — t'l'hris 1 Iiini;arica or paiiiKHiiea ; the phifrne in Mei--eii in loTl ; the plai^iie in l)eninarl; ( I ti I .'!— "I'J) ; and the pla<;iic in U o|' later times — as, for iii>tanee. tlie " Funljii'hrr," rep"rtar ISO"), it hecame e|>idemic throuf^hout (iailicia, Himirary, and tlie .\ustrian crown-lands. The writinjrs of Rennehanni, Schiifer, Ilecker, h'asori, Larrcy, Ilnfeland, Horn, and especially the famous monoi:ra|)h of Ilildenhrand, which to-day stands as a pattern of epidemiolojry, ref(>r to the ahove-mentioned e|)ideraics of the end of the eiirhteenth and tlie heLdniiinjr of the nineteenth centlirv. After IS.'JO the disease ahatcil ^n the Kuropean eontineiit. iiotahlv in < iermany, while in Irelan dcatlis wire r cDrdcil. TliP vcars I Slid and 1S-_'S ay:ain witncsxHl severe cpidcniiis in hotli countries. In tlie iliirlies Ireland -utVered nio-t, and in the h.^inninf,' (if tlie t'(illii\vin<.' decade Scdllaixl iliielly wa- attacked. In iSlC, tlie vear of famine, an nnii-ually -ever" e|iidemie limke out in Ireland, ami this was carried to iCnirland, where it reached il~ hif:he-t ](oint in IS 17, and continued until the end of the tMlowiiii: year. It is a tliet thai seems incredilile that outhreak ot' the di-ea-c. To Vir( liow we owe a cla--ic de-<-ri|ilion to that time -up|)o-ed that they vu're -eeine I'roni the disea.-e. The Italian campaiiin of I SCI and the Tnrko-Kii — iaii warof 1S"S eontrihnted a mmilii'i- of \ictim-. .Imluin'.;' fi'om Micliaeli'- de-eription, the sanitarv condition- in the Ku^-ian army mn-t ha\c liccai appallinir, any tvi>hns ie'\er, and half of those attaekeil -uccnmiie rvr,i,i ,i|,|.,;iran.r :i-,i,i ,|.Mru\,,| ||„. il|,i-i..n i|,;,t ImvimIi -,,il ua- ii..t ti.vonil.l.' i.Mi, ,|r\v|.,|,„„.„,. In |.s;»,;;,„ ,.|,i.|,Mii,' l,r.,k,. ciii in i.ill,.. The- .li-.a-( ua~ r:mu;\ l,, ||„. |,ri-..i,. ,,r Pari-, «|i, ,i,-c il -|„va.l In il,,. < ily and -iii'i'.iiiiii|ii|._.-. \tl.r III,' ,|.i.|,nii.- ,,f 1SI7 aii.l |s|s, t\ pliii- Wsrv .■,,iil iii,„.,l (,, liii-.r III rcitaiii n-iun- of ( I, ii,ian\ until t|ii> iM-iiiniiii. ,,f tli,. ci-litic-.. •'^""■'' '''•" 'il'"' i' li:i- Ihvoimc .11, 1,11,1. • ill l'|.|> i- fi.,| " -'sillily tr,.Mi ill.' II, i;;|,l,.,riiiM r,,|i,|, |,r.,\iii,.,., ,,f lin-Ha. ami at iiiliT\al- il iii\a,l,- (i, iiiiaii\, li-av,llii|M i,, a ,|iiv,ti,,ii Cn.iii i'n>\ to u.-l, an.! -iiiva.liii- ,,v,r ih.^ , miiv .■..imii^ . |i i- t., !„' ,.I,-.,tvc.|, ''""'■^'■''- '!'■" '!"■ iiiliii-ils an. I .li-iril,iiii,,n nf lli.. .ii-.'a ..iiMaiitlv «liiiiini~li in ill,' -.■ .liiv.'ti an, I il i- ,,iil\ in lli.. .a~I,'iii |M,rlion- .,f (i.Tiiianv, |,aiti.'iiiarly in ili,. lV.>iiii, i- ,li-iii.N, thai lai-,. ,n,lr.ni.' ,.r «|,i.|.nii.- ..iiilavak- ,,rrnf. \\|„.|i, i,, d,,. year- jsiiT and lS(;s, ti,,. di-.av ua> .arii.'.! int.. KaM.rii an.l W.-i.tii I'm-ia i.y va;;alM,ii,i-, it .Mv.ll,,l t., ,.n.,nn.,ii- •■i.i.l.ini,-. Tliii., in ih,. .ji-tii.-t .,f ( Jiiinl.iiin.ii al.,11,. |(l(i(»,,i„.^ XV,. ,v n.|„,rl,.,| ((iiiti-ta,lt). Ki.iin- lli,. |„.ri,„| in.ni |S7.", t,, lSS:i th.' ,'a-t,Tii |.invin,',- and pari- nt'C.ntral (nrinaiiv ui'iv vi-il,-,l liy a -rvrv iJMvak of l\ pliii- f,.v,r ; mii,! dnriii;: tli,. (iv,. y,.ars from I.S77 t,, I.s,s2 (iiitt-ta.lt iviH.itcd I (i.iKKl t-a.^'s admittc<| f. tlie l'ni--i,in li,i>|)iial-. '" ■'" ''"■ ' •" ••\t,n-ivc (■|iid..nii<'s, iJcriin ami tlic larger .'jtio ,.<' Noitli.a-tcrn an,l S.,ntii,aM,rn ( i.rinany, -iicli a- K;ini--l.(.rjr, Stcitin, I).lll/iL^ I'.n-laii, ,l,., u,r,. iiiva,l,Ml t.i a irivat.r .,r los (..Merit. In • ■wrv .'a-.. tli(. a|.|,r.,a.-li .,f tli,. .li-ca-f \va> fr,.ni lli,. i-a>t, and, t:,rtii- iiat.ly, it ii..v,T sn,v,.,.,|,.t cvi'iv v.ar, '■'""i"?-' ii-nally fr Ka-I,rn .aii.l \V,-tcrn !'rn^>ia and I',,nM.rania. the fii-t -t,i|i|iinii-|ila.v ..f til,. (•|ii,l|.nii<' .m it- in.iivli fnun t t.i w<.>t. It ^1"''""' ■' "ir 'li'' ''l:!" "f iiili.aliit.aiit- I.y \vii,.ni it i- ii^naliy i-arri.nl lli.at i-, va-al...ii,|-. an.l |.,iv,,„< ,,iit ,,f „.,rk an.l without , known :i- -[..n-'" (I'.iim.n). u,.r.. the .•liief t!..'! ,,f the di-ea>e. The heller I'.nt of tlw [...|.nlati..n. ih.,-,. who ]..,-.-,■<- a pennaneiit d<.niieil... weir ;ittai-ki>t illway- he trai'i.l t,. dir.'.-t eontact with tv|(liii> |.ati.'nts. Diii-iiiir the |..'ri,,.l fn. Ill l.s7ti t.. I.s7;i I w:i- Mi|.eriiiteml.nt ..f th,. I5.Th'ii |.,.-i-lioii>,'. th,. la/ari'ti.. in M. .al.it, and then. eiij,.y...| ahundant <'|.|.,,rtiinity for stii.lyiiiir the .lisease. I haw the rejM.rts of (177 ens...- Ills I < line I7'.» iliitili" U<>\\\ til it lliiii'. I,:itcr I -aw :i tin -jioruilii- i:i-'- iTi 1 IiiiilnirL' ami lii'lpsic, l.iotiL'lit !>> '•nii;:niiii- Irmri I'i.ImihI iiikI llii— i:i. Tlir ImI- luuiiiL' (l(-iTi|.tiiiii ol' ihr ili-c:i«c i- Km-iiI mi .1 -tiiily ul' tlii«c ('iiiilrriiics ainl 111 a tiiiinlxr nl" -|Mii-;iilic (ii-c-. ..<■( inrintr rliii ll\ III my |iri\alc iinctin', tli:it wire 111' i-|«i'taiiil|xiiiit of ditliT- ciitial . i L A'^ :- S'f^.' E T I O L () G Y. ¥^ ;:ii, ^i^ ORIGIN AND MODE OF TRANSMISSION OF THE CONTAGIUM. 'I'M'III - I i;\ i:i: i- ■ ..| {\u- MmM . ,,MIa-ioii- ,|i-,.;,-.c< klinwil tMlllcdi- • ■iiir. Il ,,ii-iii:ilc- ;iii.| -|,iVM.|- tn |,n,li-|„,-,.,| iii,|iv i,|ii:il, „,|,.U |,v ,1,,, .lir.Ml ..;• M.lilV.I l|:|I|-.|lii"iMt| ,,r ||„. -|„, ilir ,,,|||,l^inill, .1, \, |,,|,1||M ill 'i" '"■•',■• ■•' 'II'' I'^iliiii'. I'll'' uii'i\f ,.|' li',in-iiii"i..n .111.1 , iilr;iii.-.- ,.(' thr cnlil^i.jiillll ll'ln ill,' l...,|\ . :,||||,,l|._.|| n,,t .-I- \,.| .irrlllal, K 1,111. \MI. i^ ::ii.|..iil.|..|l\ ih all ,--,iiiial- -iinilar |.. tlial wlii.-li ..[.lain- in iIm a<-iil<' rxaiilliirjiata — -inall-|...\. -i-arlcr tlsir, in.a-l.-. . !.■. Til.. |,.,--il,llii\ ,,| il nia-iiiMi ..I' l^ |,l,ii- t. \. !■ .,ii-ii,atin- ..nl-iilr and iii.|.|., n.l. nll\ ..t ili.. 1,.m|v ,,f ij,, |,aii,ni i- n.. tii..ir .■,.n.i...|ii.-ti..ii ..T i\ |,|i,,j,| ti\|.|'. ''""-■■'-"■ 'Il 'I 'ii'i'- "lull :i -|..iali.' ..li-ih ..1 i\|i|iii- fiMi- \\a- .'..11- hi.lcnMJ |,.,.-il.l. aihl iwii usual, llir . ..ula-i..uMi. -> ..I lli.' .li-.a-e in ilio lii.i.l,a-ii >,u-.' wa- U|.li.'|.| l.v a f. u |.|,\ -i.-iaii-. u..nil.lv \<\ I'lU.M. uli.. ua.- i;ir ill a.jvaii.i' ..l lii> liiii.-. Hi- h :i.liin->. Ii..\\.\ ,i . w, i, 'm.,i al.K- l.i .li-|.,l I'lilii-cly llio lIuM.rv ,,f mi.a.-iual i.' ..iiLjin. u liidi .-iivv i\ c .' imlil a\.i-\ mu.li Int. T .late. .MuivliiMii, liJMi.-.lt. uhi. a.kii..uli.l-..| ilial I la- . ->, ul i,a I [...ini^ in llir .li-,a-.' aiv llic -|.,. ili. iiv ..f tl,,. |„,i> ni.l i> r, |.r...lii,ii,,ii in llic l)ii.ly ..f ih,' |.ali.iil. .l.\..|,- >..i,,c >yAvv I.. il„. |,(,>Ml,iiiu ,,| an iii.li-|..n.lciil. Fix.nlaii.'.,ii.- ..ri.'in. a lli...n llial i\,ai ( ,,'i.>>iiiLj.T, uilii'all lii> a.'iinicn, .l...s net .|uitc viMiliin- I., .Ji-.'ar.l. lie l„li:.. ,.^ lli.al in miv .ii.ms. i>|„cia!l\ hIuii llic .lisi.a,-.- !.n-ak- ..iit in i-..|al,-.l |.|a<'.-, a.- ..n ^lli|.|.nai•.|. In |i|-i>..ris. 'clc. in the iilisciicc of l\ |iliii> paliiait.-. •• i-c-.mr.-r iiin^l I .■ Iia.1,1.. llic hI.h iirc nalin.'* of llu' niia.-ina." LniiL^ after ( ;ri.'>.-ini:sil.K' iin.l ..ciairrcl ii..t infrc.|iuaiiK . Ill .jiiit.' i-fCfiit tiin.,- K,I>.|| aL:ain'>li..vu.l a IcaniiiL' I..\\ar.l tlic same flic.ry. liclifviiiL' tlial .Ti-iain inn. ..u.. lis i.'.ian> in thi' I.m.K mav, iin.ItT Miil- aliii' rxli-rnal (■..n.lili..n-. assume a ltiiiI -|m. iti.- \ iriili'ii.c. Ouiiiir 1. 1 liir I'Mivnic facility with uliicli llii' .li-ca-c i- .•arric.l fr.iiii iiidiNiilual t.i iii.livi.lual, >|i..railic .■a-.c- ..f t\ |iliii- lc\.r arc \ crv rare, 'llic ili-casc is aliii..-! alway- cii.lcniic ..r ili-tiiic||v c]ii(|cinic, ami under iimi-m.lly fav..ralilc .■..iiditi.ni-, c-|ii'cially uli.ai lai'tre iiiiiiilicr- ol' men nrc massed t.iL'ctlier in -..cial ..r milit.ary d.-titiiti..ii, llic nmiil.cf i.f individuals attacked i> rarely eiiiialled .r exceeded hv aliv of the Mtlicr ' ',•./.-. //.v. 1K7,-; .,,1,1 /■„/,,/. hit.. \S". 4sn t'TtOLOOr. Ml itilfctiiiii- ilis(;i-f-. riic iiii.-t I \lin-i\i I |iii|(iiiir- arc uli-i i\i d \\ licii tlir y llir lii-t |i|ar(iliiiiiiiiant t'cirni ul' •• 1\ |iliciii| " di-ca-c. 'I'lic di-(a,--o i- (Mca-iniially .arricd t'lniii llic -h.iii- ol' Inland and l',ni.'l:ind t'> iicii^liiMiriMLT iMuntrii'~, |iarti(nlariy in inunfic- witli whicli l-liiu'land maintain- an arli\i' iiiinincr that liixor it- l)ceii.dnm. Ilnilaml, Norlli Aineiiea, and, tn -nine e\teiit, l'"raiie( , wliitlicr. duriiii: llii- e. When an niilid-cak nccnr-, it i- alnin-t alxvay- dciixcd fmni the e:i-lc;ii c(jim- tries, c-|)eeially l{ii — ia, in many pari- nf which, |>artienlarl\ in tlio Haltic .nid i'nii-li |in>vince-, iintnrtunatelv 'iir ( iermair. , the di-i'as<' is t'lidcmii'. In liiiiiirary, 'i'nrki y, and the adjninini.' Oriental cnnntrics the (li>ea-c ap|iareiilly never iMM'umes.c|iiite extinct. N'ariniis parts ..f Italy have liecii visited r<'iMat('laiids the disea-e seem- never tn disap|M'ar entirelv. Spain and i'ortii^ral, nwinn^ tn their u^c(iir|-;,|,hic pnsitinii, are rela- tively free frnm the disea-e, althniiirii mild niithreaks have oconrrod, the last niie in I'nrtmral in ISSO. In Atrica the diseaso ha- Iwen observed ehiofly in the maritime por- tions that carry nn an active trade with Kiiro|«-. In .Mtriers, where it ap])earcd fnr the tir-t time in the early si.\ties of the last eentur)-, it seems to have lu'comc endemic. Persia and ( 'liina are never free from its unwelcome jiresonee, tlip m f3'^i- «*>=«*-> 482 Tvriirs ri:\-i:i;. .ni-.Tv uii.l M,iiM!..r of tlir inlial.ikint- furni-liin,- al-niulatii ..pixirtmiiiy I'nV tllC iiccliri'lllcc i.t ilic di-ia-l'. In.lia aiipcar- L. U- !vlat i vl_\ fivr. Munlii-.M, c.iiM imt .Ifti-rmino to ln^f tvphus frvcr is at th,. ,,r..-..„t tin,.. in,on.stin. f^.r hi-.^ri.. r..a.,n- ,,„lv. ^y--^' ';:';;^ ;, ^^ sw,,|.,.rl..r, of the th-ory ..f a .-a.,.ous, nMnn.ana,.al natnro of th. tM.hu> i:iini.()(,y. 483 CMiiiaL'iiiiii " ' l.ifliiL' ami (illicr> miiil'IiI llicii' >troii;.'c>i Mnrmiiciit in llic |ic|iri'a'l "\' tin- ili.-riiM'. Mm-li iiiftTrf^t attailns In a i-lia|ilcr in • ii'ir.-siiii'fr s clas.-!'' uork, wliicii >lamls a- an i'.\ani|ilc lA im-i>ivr M'ifnlitic rcasoiiin-^, in wliidi. al'lcr a carct'iil anal\>i.-; nl' all ihc flinldi'-ic larli>rs, \\v i-ctulcs tlir llinn-y nt' lln- L'a.-iMPUs natnrc of llic cdnta- t^iuni aii'l 'li'<-larc.< il--tlir conlajiuni — Id lie i 'ii.siiilar ami (lu>t-likf in i-haraclir. Ill I'l'jar'l to tin- variiiiis llii'iii-irs ailvamci. « Id the niiiTiipara>ilir natiir<'Ml' ihc l\ pliii- roiiiaLium. uc >liall |la^iilaU'il fX|i' . iimnts III' llic lirsl iii\ i'.-li:;alnr.- ami nslriri iiiii>rlvi> In llic ninrc iiMportaiil nt llu- newer roni riliiilions. \\ liirh t'\ en llie aiillinrs llieiiiselves ilo mil alua\ s <■' n- ^iiler i|llile eoii\ iiieiliiT. Ill l.ss.S Mnreaii aiMl ('."•lie/ ' lieserilieil a liai'illiKs resciulilini.' ihc Hlicrth liai'illiis. wliieli iliev isiilaleil Irniii llie IpIimp 1 ami urine of palieiil.- ami which ihev reLTarilc'l as ihe prolialile cause ot' ly|iliu- te\er. A vear lalcr lllava's- work on llie poison of lyphus fever, liaseil on inalerial olitaiiieil from llie I'raL'ue epiileinic of I sss, aroiiseil L'real interc:-!, anion;: ineilical men. Illava exaniiiieil 4-i caila\ers ami olilained from alioiil Iwo-lhirils of' ihem a peculiar slrepIoliaeiHus, which he was alili lo fiml in ihe livinir siihjecl also. althoiiLrh. il is Iriie, nol wiih the same con- slancv. Ihe niicri)-ori.'aiiisn! was foiiml milv in ilu' lilooil ami cnuhl not he isolaleil from the orirans. Illava liini>elf is verv .'uanleil in his slateinents as lo the speciiicilv of his inicro-orLMiiisiii. ami ,-oon aflerwanl il was ilis- piilecl hv other invcstiiraiors i Cornil, ilalies. ami others i. Ill \X'^'2 an important paper was puMishetl liy Ix-waschew," who foiiml iniiiiite, very rclVaciive. ■cus-like corpuscles in the lilood of typhus palients. cspeeiaiK in that ileriveij from the spleen. I'liese were toiniii in fewer nuinhers in other portions of the cinailation — t'or inslanci'. in hlood lake, from the lip of the liiiL^cr. Some ot these corpuscles were proviiieii with llaLiella that couhl lie siaiiicd hy l/illlerV nielhod. like the t!a!.'ella of t.ie Elierlh liacillu>. He also liiiiml free llaL'elia without aiiv a|ip;ireiit ediiiicc- lion with cocci. The.se rfpiroeheta' exaiitheinatiea. as he called them. Lewas- cliew rcL'arded as various forms heloii'/inir to the same drL'niii.sm and iiidi- c.alini,' dill'erent staires ot' th"ir lit'e-liistdry and develupment. and he was stroiiL'ly inclined id accept them as iIk cause of tvphus lever. .Soon aflerwanl Thoinoi and Calmette' ileelared that lllava's niioro- iiriranism was onlv a secondarv phciiomenon without aiiv etioloirjc sicrnifi- (•anee. and lirouirhl ferward a new cause of the disease. This tiiev desorihed as a tlau'cliate. and in .some case> amelioid. orLrani-m. which tliev claim to havi' loiiml in the sphaiic hlood o|' ."i liviiiL.' suliject.s and in 1 ease from the pulmonarv hlood alter death. Diiliicf and liriilil ' descriUed a sni.ali diplococcus provided with a ca|>- sule. which tliey elaiincd to have found in the hlood, hut especiallv in the ' ■■ ('..iitrlliUl ;i I .'lu.l.' liil typh, c\;inlli ." <-,r:. /,,/,./, ],!SS. y,, L'S ■' ■■ Ktii.lc -ur 1^' t\|ili. exiiiitli . ■ A)\-/,. IS.J,;,i.r ,/,- »„■,/,. lss;i, T. iii.. 1. an.l ('.•iltruH:' f. li.tl.l.. IS'.lll, '■■r.-l"T.li. \likiv.-orL';i,.l-iiM'ii .1.- Kl.-.'ktyplni-.' I).;,i.,-I, mnl. \y,,rh.. ISlrJ. N'l. |:l. ■■ r.'liT Ji.. MikM|.iini-il.'n .1.- Kl.-ktyphu-. ' ' /'-V . \,. :M. « ■■ N'..l.- -ur >|UrI(|u - .Aiiiihii. .li' -;in;.'il;iii- !'• lyph, .■\:nith,. ■■ .\ iiim/r-! ,//■ / h.^titilt l''i^''-nr. IS'.I-J. ;,n,| Trnitr ,1,- ,„. ,1 . \.^ ( h.-.r.. ,t. I! Ii:inl . t l!ri^~iiii\. T. ii . p, 0. ■• I '.'iilrii.iui :ii .', r.!ii,lr .■di.i!.^;;;-^ palhMl,,^i,|in; cl baktOriohigi.jiiL- Ju typh. exuntll. ' .l;v/i. drin,,t. Exp, rin, . Is:i4. ii5i« - ^«^:- ..►i"._ » 484 TVi'iirs ri:vt:ii. air-passa^cs. in pulnH.„arv lo.i. an,l in the .,m.m, These llu.y .aui - c^ I el'i l,e ree.en zea « hen Maine.l with nu-thvlene-hluc. he nnero-r^^an- l; -vvere .mwn on vanon. nn.ri.ive n.e.lia, a. a.ar, an.l y.ehle.l orunf:e- ^^lov eultures. The au.hor> al.. helieve ttu.t they were ah le by ex,«.n- ;:n,ul il'oeuiation of .nin.al. to pn.Uue a eon.lit.on re.en.hhng typiu.s *''7-inaliv. it mav he achh,! that M,>if ! nj: ai:o .le..rihe,l a variety of „„„1 spiVUa reswnhllM, Le.uH.luwV nr,an,.n,s n, the hU..ul of yph f..ver pa ien,.. an,l, lurlher, that '- heeM ,nan .lawns to have -hseovere.i Mnall u,-,o.iU. ha,.illi Nvi.i> rounae.l eMre.ui.u.s. oeeurr.n,' ejther u. ,,a,rs or ,n ir el '.in< «hieh he savs he uas ahle to euhivate on hloo.l-sern,n hut n.;l ^^.h ; amUhieh he-.al-ea .he Haeillu. san.nin>s .vplu exantheuwU.n (•; have a v.-'itahle .an-ple-ear.! of ha.-.eri.,lope tMul.n,.s. an,l U «.ll 1,. I for the present to reserve ju.lpnen.. t»ui.e re,en.ly. u, tae. n,en M ' Vxnev , have' eo.ne forward .leelarin,. that tiie hloo.i ot typhus tever ^ '■ ; tree iVom speeitie n,iero-or.aniMns. Kelseh's theory, .hat t - --e ovph.I- lever is a Iniero-or.'anisn, .ha. i> usually in..oeuo„s an. he.'on.es patho^^..>ie only ..n.ler sp.rial .on.li.ions. has alrea.ly he.-., r.t.rr..l to. Nature, Persistence, and Mode of Dissemination of the Contagium.-lt foH.AV.- h.^Moally, r.nn. „nr i-noran.-e of the |M-e.■ pa.i, nts-.h.' .■xi.itv.l a..-, the .■xhala.ions fnm, th,- ski.,. .■t..-an.l that i. a.ta-'he. ..s.-lt .o.h,. ,l,„t .•ontai..e.l i.. ti,.. M..To..n.r,...L^ a..,.o-ph.T... Mthou.^h ,h,- -.■.■o,,.! „,rt of this hv,,o,h.-.i> .alli.'s ui.h th.. .-.■...Its of our . NiuT......r. the Ih., ,,ro,.oM.i,^, sho..l,l i;,r,h.pr.s..nthea,.epte.lwi.h ^.vat ............ The r.->-n. tinai... of Kh.T.h ha.alli i.. the ros.-spols of '> T|;;'';' ;'-^;;; ,N..,n-i.n. N.-.ifehl. ( •n.-s.'h.uunn ^ s.n.ntrly snL'i:esl< the a. v.sah.h.N. tn £ . iien,i,-s. of .naki... si.nilar exa.ninnti.M.s of the typhus lev.r ,ash lil our' i.pr,.v..l ha..t.Tiolo.i.- n,..,ho,i... That .he ..on.a.nmn ,s ..xer. ..l "; ,i;^ tVees'a.M nrh.e. as i.. other intV-.ious ,iis..ases, se.Mns douhtL.l ... the ca.se of typhus f.'vr ; eertah.ly it has nev.-r h.e.i p.ove.l. I, i. ,„-„hal.lo that tor s,,,,,,-.!.,,.- h.nMV a...i atUT. as wl! as .h,.-i..^. the iVhrile pe.-io.l of tvph... tiv, r the ..onta^i..... ......ti.,ues ,o r.rro.h,,.- i„..lf in the i,nnt...liato surroun.iin-.^- of ,h,. pati.nt. Dnnn;^^ th.- ..n.e it „na,n,l,.e.llv at.a.'h.-s its..lf to the .1..-. in the at,no-,>he.-. an.l .- vers onsilv tntnsf.iTe.! to inanin.at.. obj.-fs ha.,..le.i hy, -r '" '1- ....n....i,at.. ^:i,.hb.>rh.,o.l oC the pati,.n,. .>n whi.-h, „ lor lUv,.rahle ..ir..,.-nsta..e..s. it ;ai..tnins i,s vi.-,.len.v f,r son,., ti...... An.on. the-e ,.l.,.vt- ar.. cl.,thi.,g, ..n.l..rw...r, l,e.i-.-lo,he-, .'urtai-.s. .arne.-. uphol-f.-...! h.r...- ' Bra. M'd. J>.ur., Uw., 1H^3. I irri'ii. ')(,)■. 485 tiiri', unci, ill t":i(t, :ill ulijccts svitli a rmitrli, wiM.lly -iirfacf. Tliu fact tliat wasiirrwoiiicli, ixdrixmi alt('iiilaiil>, ami iIidm' wlm aif iliai'pil with tlif (iiitv lit' (li>iiit'(ucii oltjeets are protected atrain>t eoiiiact with air, particularly air in motion, the contairimn clinixinjr to them may maintain its vitality till' manv months, or even lonp'r under e-pecialiy favorable cireiiin- «taiice~, ami the disease mav thus he carrie, and other public conveyances. It should be reincnilicred that hcaitiiy ]icrsons may, without becomintr infi.tcd themselves, carry tile poison in their clothes or in their hair, and in that wav transmit it to individuals wiio arc not immune. In the iiitere-t of the c(>miiiiinity tiiis fict should be borne in mind by |)hysipians, attendants, cii ij.rvmen, friends of ]iatients, and, in fact, by all persons who come in contact with tiiem diiriuif times of e|)idemic. riieri' i> a rciiiarkal)le reseinhlance in all these coiulitioiis to lliose obser'-oil in tile acute exantheiiiala — measles, M'arlet fever, and siiiall-|K>x. Owiiij^ to tlie i;reat dt'velopiiieiit of railroad and iiiaritiiiie traiis|M)rlatioii. sp()tte.'-I-,- '' 486 rvriirs i i:\i:n. ^ii-^i^'V" i) llic ]>iii-u!i ill i\\o <-.\A:WiT \- at all |in>lKiliii', ami I Iwlicvi' tliat llii' iiitl'ctitin take- |ilarr in mv\ iniu-li llic -aiiic way ,i- in tlir ra~c nt' inaniiiiatr iiiiii'.i- (in which llu ntaL'iMni Ma~ licin (lf|i i>it(i|. In ihi- cunnc'ctiiiM it -nni- to nir -ii;'nilirant that the (lanLi'tf "I' int'<'cli>'n i~ di-- tiiirtlv mnrc marled in itimiiI i-:i(1;i\ i r-. 'rim-, while wc nr\ci' ha!' inrectiun e;rcat(--t '.' I 'tidcuilitedlv , iit the Keirilininir and at the liei:;ht uf the I'ehiile -taife. l>nrilii: tin: statr«' time ueeuis mily liy the tran^tni.— imi t lit' the |iiii-iin that has liecii |ifiidileeil diifint: the active |iciMiid uf the di-ca-e and hecii dc|>i»ited mi -iii-fnmiditiL^ uliiects. It i> tlMic that I'c|-r\- and ecftain ntheiv- i-idef the daiiir*''' <'t cun- ta^rion ir|-cate,-l dnfiiiir the |ieiiiid ut' cunvale-ceiice ; lint I think thi- It- at) crriir that i- ilnc |irul)alilv tu a mi>take in c-timalinir the |h riutl ut' inenliatimi. I'm- m\ ]iai't. I cuii-ider ti'aiisniissiun |)ii-silile diiiinir the |ieriud nt" iiieiiliatiun, and ali-ulnlei\ eeitaiii diiiiny the initial ^tai:e. 'I h(> tact that dnfiiiir thi' lattei' |ierind patii nt- are alilc tu on alimit ur travel in car- ma\' e\|ilain inan\' ca-e- in whiili the |)atient- deiiv ha\ iiitr eumc in cniitact with individual- atVected with the di-ea-e. In this eiimiecTinii I renieiulier a very iiisliuclive vam- that I saw when a ^tuilelil. 'This iii'ciirreil in une nf lny felliiw->lnilelit>. u Im heeaiiie iiit'ecleil while atteiidin;.'- aclinic on a i\|ihu> livci- |iaiienl. He \\a> nne nt' thni' stmleiits t'riini another i|e|iai-|riieiit. ulin liad spent an limir in a t\|ihii> t'ever iiatient's riiniii al a lime when the |iatii'nt hail iis \ el im t'evcr. and enin- plaineil (iiilv lit' ^liL.'ht L'eiieral malaise, depressiiin. and pain in the laad and hack ; hut mine nt' the ;-tuilents had lieeii in the rnnin after that time. ( )n the evoiiinLT fnllnwinir their visit the patient was seized with a chill, this heinL' t'iilln"-e.l liv the n>iial initial rise in lemperalnrc lliLdit days later nne of the liiree -indent.- was taken with typhus t'ever. It uas s\ih:-eiplelill\- a-rerlaiiied hevninl a dnulil that he had nut relunieii In the hmise atier that lir-I visil and had imt enme in cnnlaci wiili any nilier patient : in fact, there had lint heeii aii\- nther ca.-e 'A' spniieil t'ever in the town, all the others haviiiLT lieen ciiret'nllv isniale.l in the hn-pital. The <|ne-tinn whether ur nut the d.antrer uf intectiuii xaries in indi- irrrni.ncv. Is7 vidiial ]i:iti(Mits nr in ccrlMin ll>itii- cl' ilic di-ca-c i< very dilliciili in (K'cidc. Mv own cNiMricnc-c IraiU nir to lidicvr that it dm- not. Altlioniiii < ii-ic— in^Ti- (•(,n-itlii-- a >c\( re ca^i' rncHT daii^ci'dn- lliait a tnildcr line, we uv.w xcntni'c l<> remind cvcm tiii- e\|ierieneed aiillidr tiiat it is MeNcr [Ml— ii)ie tti e-tiiiiate willi -ntlieiiiit aeenraey tiie inlliK nee to l)e attriiinte llie |Mr-onal e lition- ol' the individual altael«-- the coiitaLiiMin tind entranee to the l)odv? 1 ai^ree with the inajoritv of ol>-erveis in helievinj;- that in liy far tile iii-eatest niiniher of ea>es the |ioi-on that eliii;:-. to infected oi)|eets in the iiinnediate \ icinity of tlic patient is carriet prominent rn/r in the etiolojry of' tyjilioid fever, api)ears to lie of verv sei'ondaiy importance for the entranee ot the tv|)hiis fever coiitajriiitn. A very few anthnrs ( \cttor) still maintain that direct contact with the patient is necessary for the transmission uf the di-ease. The niiestion that has often Keen raised as to the length of time necessary to l>e ~pent in the neii:hl)oi-h(M>d of the |)atieiit or the iliiration ol'the contact with inanimate carriers necosary to |irudnce the infection has a pi n'elv theoretic interest. (Ii\-eiitlie necessary coneeii- tiation ot' the |ioison and a fair debtee of predis|Misition on the |)art of the iiidi\idiial, it ajipear- certain that a very short time — -I'Ven a liw nioni' nt^ mav suniec to infect him, altliou;_di it will lie fiiiind ditliciilt to procure relialilc evidence on tlii- point, <--|)ecially diirinj; an ciiiih iiiic. 1 saw uii iiistriictive ease of this kind, oeciirrin;: in ii furniture iiianiifac- turer. who was (iiiite certain that he had not eoiiie in contact witli any fever patients nor with an\- suspicious oiiji'cts, and MiiiouLr whose employes there hail iiiit heeii any case of spotted fever, lie had, however, interviewed a Wdrkiiian, who appiared to him to he ailiiiL'. promisiiiir him einployinent after he shoiilci have recovered his health, 'flic interview diil not iasl more than five minutes, and was held in his ]irivate otiice, which was very small and hadlv vcntilaled, the windows lieiiiL' cIommI. Twd davs afterward the work- man was sci/eil with tv|)hus fever and admitted to the la/aretto at Moahit, where he had a typical, tlioiiL'li mild, attack ot'tlie clisease: while the maiiu- faeturei'. whom I >aw while actini' as a eon>ullaiit duriiiL' his illness, con- tracted a verv x'vere foria < ' the disease on the seventh ilay after his inter- view with the workman. m ^g^^^ 488 TV I'll IS I i:\i:n. Mii-i [latiriitr^ irivi' :i !ii-l!ir\ n!' hiiviiii: lii'cii 1 mi-ciI ti> ini'irtinn rciK'nIrilK (ir (■iiiitinuoii~U tiira Imi.j- linic I'lir |)rri'i-c iiioniriit wlirii till' |piii-ii|| rll'icl- an clltlMIlii' inl'i (lie limlv i- 111! (liilllil llr|Mll(l(lll nil aci'iclcntal iiidi^ iiliial "V rMcnial I'Miiditiuii-. In ;:'('ii(i':il it riia\ \»- ~;ii(l lliut tlii' ilaliLicr nt iiilirii.pn iiicria-o with the tV<(|iicii(S' ami iliifalinii lA' cxiiii^iirc aiul willi tlii' loiiccuti'alidii nf the poiMin. '\\\v lallcr >Iaiiil-- in ilirccl ratio to the hiiiiiIhi' ot' patii'iit-^, and ill indirect I'atin In tlic >\/.v and cxciilinif ol' tlic vcntiialiiiir tiicilitii'S of tlif ward-. Reaction of the Poison to Chemical ind Physical Agents. — Tlic |Hii~oii a|)|«ais to I ii-taiitly rcju-iMliiccd in the IhhIv of tlie putii'Mt dnrinjr tlic I'clirilc |)iiiiid, and it iiiii|ni-tiiinalpiy maintains its liiixlit'^t dcj^fcc not a|i|iear to Ik? ea.«v to destrov the ]ioi-on liv <'hemical mean.-. ilic -implcr methods of di-infeetioii t'ornierly ii-cd, -ueh as -prayinjr the room with carliolic acitl or chlorin water, are pidhalily of very little v.ihie. 'I'lie newer dis- infectants that iiavc leeciiily 1m en recommended, snch a- formalin, have not as vet hecn tlioroiiiihlv ti>-tcd. The di-iiifii'tioii ot' l)c other hand, .aiipear to he far more dc-trnctivc to the |Kii-oii than anv chcmi, of course, well known that epidemics arc hotli more freoi-oii wa- wafted across a iiai'i'ow -treet a.nd carried to the inmate-^ of a liou-e on liic o])])o-itc -idc, I have ne\'er -ecu iiifeetion carried in this wav in Moahit, where we had ol'tcii to till one harrack- with tyi)hil.s jiamm,:.Xii : 1 .1!: / 7,' I.IUSI 'o.s/.w ,■ ( 'OM) inn SS. -l.s'J l>:iti< Ills, am! tlic aiijniiiiiijr uiii with |i;iti(iil- litli ri'i/ t'roni -iirj^qiul injiiiic-. It i-^ (i\viii;r to lliis (|iialitv nf tlu iiiiLriiiiii — that 'if not hcmLT <'a>il\' <'arri<ital l>y iiii-takc or want of JikI^'^- intiit, the (' liocs not >|>rcail li<'vonor^, |iro\ iiliiijr tlit wanls arc lartro and airv. The rpidiriiic hiHoiiK^ jr''"t'i~ii oidy when the nunilxr of typlins patient.^ in tiie wards increases. N'entilation has a marked ii.tlucnce on the contairii'in, tlie ])rophv- lactic iin|)ortaiice of which cannot l)e too nineh <'inpliasi/ed. In large, wcli-ventilated wards that arc not too crowded the virulence is nuicli diininishcd, especially it' the patients are kept in the ojx'ii air, or if the doors and windows arc hit oiieii. I made some very instructive iihscrvatinii> in this respect in the la/aretto at Moahit. Duriiiir the siminicr i ihs 1 kept mir patients aliiio>t all dav in the o|)eii air, wiiich incidentally had a very ^.'ood thera|)eutic etlect, ami in winter the windows were kept constiintly o|H'n, the wanls ix'iiij.' ke|it well heated, however. Not a siiifrle physician ami very tew of the utteiidunt.s were infected ; of the latter, oidy those were iii'ected who, contrarv to iiiv orderfi, liad liathecl the ])atieiits in the small, ill-ventilated hatli-rooms, instead of in the spaiioiis, well-veiitilateil ward. S) inncli ii>r tlu> reneral conditions that t'a\or tiie origin and spread of the disease. 'Ihe |M)ison has always Keen tinind most virnleiit when large nnnd)er; of |)ersons have l)e<'n irowded toge*^lier in imprope.lv Ventilat(Hl and ill-kept localities under had hxgienic conditions. I'risons, badly planniHl Itarnicks, iinis, and liMlging-housc.- of the lowe>t kind, work-lioiises, ships, and defectively liuilt hospitals are the chief foci of the disease. Ileuce it is that w<' have the varion- synonyms, la/;iretto fever, ship lever, prison fever, camp fever, etc. PREDISPOSING CONDITIONS. PERSONAL CONDITIONS. Tli(> ])r(>,'vere epidt-mies. I think this i- very douhtlid, and none of I 490 TV I'll Is I i:vi:i:. tlir iiioic ircciii aiillnir-. aiiiiiiiL; \\ li"iii I \i.ii,li| cninit ii,y-(ll, :i|i|i(ai-^ til lia\r hail ai!\ l'a\ iralili- r\|M'riiiirc in ilii- ri-|icrl. ( )ii the I. till I- liai'd, I'lic allaik I'f the di-ia-c (diil'ns all aci|niiv(l iiiiiiiniiil\ "11 llir L'lval iiiajmilv nl' |i(i-iiii-, la-liiiir a Iciiiij liiiii — n-iially I'lir llir rchiaiiitli"- "!' lli" iiiili\iiliiar- liti\ In llii~ ri-|H(l. al-n. t\|iliiis I'cvi'l- n-rnililr- llicanili- lAanllicniala. r-|iiiiall\ -rallit li\fr, rma-lr-. anil varii.la. Whitlnr ihr iIilTci' "f i lunily atlrr an allaik nf l\ iihii- I'lM r i- a- i:i'i:il :i- i' i~ in lln -i' ullni' di-ca-t- i- a c|nr-tiiin n\\ \\\\\,-\\ iliriv i- a illlViivncc lit' ii]iini.pn ainnnLr lli<' val-inn- aiillini'-. ( ;ii( — inL;ii' ami Muivlii-nn i-r|"irt ca-i- nl' llir siinc ine(|iienee of sueii a lieiiet", it lias Imi'.' Iiecii the eiistimi rvuryvliere ill the hri:iimimr ufan e|iideiiiie 111 emiiliiy alleiiilaiits ulm liiive already had llie ili-eaM'. The wiMli.iii nf this |ii-iieeiliire i> pi-nvid l>y M lirrhisiili's ex|ieri- eiire ill the Lemliiii I'lx cr lliis|iital. lie si\ s that he never saw an atteiid- aiil allai'kid iiiore than miee. Age and sex a|)|ieai- \'> evert ;, very -iiliiirdii'ate iiiHiieiiee nil the -u-rt iiti'i.ilitv to ty|ihu- lever, a- i- -Imun whenever the eiit're ]Hi|inla- tinii 111' a liie.ilitv i- iA|iii-ed til the -.line ehanm 1- id' inreetinli niider identical cxti nial ennilitinli-. Nut inenn-idel-.ilile ditVerelice- lia\e. lit ciinr-c, lieeii iili-crwd. -nine i.r which are ea.-i!\ e\|)iaiiie.l, while tnr (ithiT- the c\|ilanatiiin ha- imt .i> \v\ \-. and in the cniirM' nt tiiiii' eiadiialK' extend- tn the n-ideiit |)nrtii f the eianiniinity, tlie-i dilli'i'- ciicc- liiadiialh- di-a|i|iear. In cniilitrii- where the di-ea-e i- endemic and i- Imt lirnii;.dil in Kv ihc ilnatin<: |iii|iiilatinn. it ii.-ually aU'ect- l.intli .-exe- ciinallv t'rniii the licLiiiiiiiiiir- ri:i:iiisi">sis(, < h.mii rinxs. I'.il 'I'lir l.ol prnnlV ..r ilii> Wf liiiil in Kiiirlaiiil ;'ii'l Irrhiinl, llic diL-^n' limnrs • >( ty|iliu> I'lM'f. Ill till- l,, :!7.>ii iiicii :iii'l -'iT'.'J "niiicii uiri' ailiiiilli'il. hiiriiiL' lln' Irisli c-|iiilciiiic n| 1H|7 I'.Mlic- iiiiiulii'i- i>l' uiinicii «a> rvcri LTtMlcr lliiiii ilia I nf ijic imii. .IL'.I II IumI. - Mini :; I. .■;'.'> liiiiali-,- hriliL' allaikcii li_V llir ili.»a.-r. It' ur ciiiui'Mi-c ihi- uilli llic Malisiirs nlitaiiinl in (liill.-lal in rni.-^ia. wliiTc ly|iliiis I'lMT i~ riMlimir 'inl\ in a iiniilcil -cii-c, aii'l i> ii-ijall\ lii'iini;lil in IV n('iu'lil>"rin_' cMiinii-ir.-, uc tiinl llial. .Iuiiii_' tiic ycai> tVoiii l^>l lu Ix^.'), aniniiL'- ii tula! of :;'.tL'."< indiviihials alun k. \\wn- wivv L".in.p malrs ami jlij:! t'cinalo. Till' slalislics llial I iililain.MJ in Mualiil ^ll•il.inL'ly illn^'tratc x\ iial lia|.|i.n.s wlifii ilic ilisiMx' is not ilistinclly cnilcniii- ami ulicii -tfinL't'iit liyiritiiic |in- caulions arj.- laki'n to |in'vcnt the lloalinL' |io|iiilation from iiifcctinL' the InTMiancnl i-.'-iilnit.-. Diirinir iIh' year- I ■-T'* ami |s7!l«f trcatid l.y far tlic LrrraliT nuinlitr nt' all ra>r.- of i\ plius i\\rv that occiirrfil in iHrlin. a total of .■)■_' (I ; ol'tlicsi-. t'HH \\,\f inalo ami only :;•_' ffiiiali'S. Unthcntlur liaml. we have an intcrolinL' oinniniiiicatioii from l'a>saufr, wliirli |irovcs that wlicii tlif sexes arc (M|iially cximisciI to infection, llii'y are ei|iiallv Mi>ce|itilplc. !Ie tells of a wc.Min.' |.arlv tliat foiiml a lyiilms |iatient in llie lioii>e wlierc tlii' wciMiiiL' was licM. and that folloueil him to the L'rave a few days later. Of the niemUers of the party, lit were attacked — ."< of them women. I ni\>clf have oliserved similar cases. I renieniliiT. dlirinL' the Herlin epidemic, in one of the meaner lodidiiL'dionseS the proprietor, his wife, two hiirinaics, and a |«)rlcr wtTf attacked at the very out.set of the epidemic. As to the (pic-tioli uf the iliHllellce of agC, We liillst licit place Iilllcll feliaiK-e uii iiieic iiumliei's. liut iiiii-t take into coii-idei-atioii not only the variations in physical ciinditinii iiieideiit to aire itxlf, Imt alxi llic (lin'erellces ill social condition, liindc ot' life, occiipatiiHi, etc.. peculiar to the ditliTeiit period- of life. If we examine the reports lia-ed on lar^ro ntinilicr- not marly .so iiiiicii conliiuil to a certain |)eriiid of life a- arc the other acute inicc- tioii- di>ca-c>, c-iiccially typhoid fever. I-"\cr\ ]icriod <,\' lit!' will lie found re|irescnted anionic tlic adults, iiicliidin^ individuals over tifty years ol' a^c, in whom, as is well known, the predi-pn~itioii to typlioi in any lartrc epideinjc of coiisideraMc duration -1; iw that the |)ercent,iL'-c i-f imiividuals attacke irnat, or even ereat.r. than tlie jureciitajjc of all patients anions: the inhaliitants. Childnii arc ipiitc as lialile to the di-e:i-c as per^m-^ of advanced ajjre, altliouuh ohlcr children ajipear to lie iiioiv siisce|itililc than youiiLTer oiie<. Infants at the lireast are the least ,!ispo-ed. Aiiioiil^ children, tho-e lietweeii the aliill |>i>|iiilatii>ii, a l:'(""I inaii\ cif w lioiii air iiinnniii'. I iidrr -inli rii-iiiin-tain c- ilic niolliiilily aiimnj^ cliililicti, wliicli ii-iiall\ raiiL;(~ licluciii 1 '_' ainl |ti pir rciil., Mia\ iiicrra-c «t pnidnrtivr I'l riiid luini-li ii!in-nall\ lari;c nnnilirr- nt' ca-c- i- i-cadilv (Aiilaiiicil liy i\ti rnal i-nndiiiMn-. It i- dnrin;^ tlii- |ii rind liiat a man i- iimi-I artivc in llif -truu'-dc \'<li(ius the ili>trilnitiiMi a.'* \<> atrf nf llii- 44(1 luitii-nt.- ailiiiilli-cl ti) till- la/.aritl(p in .Mualiil in llic year l^T!*: \.j, t'atlctit'i iiilliiilli-.|. UimIit In , :; In 1,. ■_'(! 40 •jn i.i ;:o IKL' .■■,(1 t- |n l'''> In t,, .'.n <>H :,{> I,, i;n riS i:ii I., Tn 8 7n t" ^n 1 44(> If \vf ('(iiniiiiri' tliis talilc witli tliiit nf an ciinnl niiinlior nf tyiiiioid fever ca.-e- siniilari\ arraniri'd aeeordinL' tn Hire, we >ee at niiee that in ty|ilnis llie latter [icriiids nt' iil'e are inure >tr(iiiLdy rc|ireseiite(l : almost oiie-tliird nf the patient.- were nvcr I'nrtv years ni' aL'e. and 41 nf 440 patients were lietwecii tiftv anil >c\enty. A similar residt is shown in the fnllnwin;.' table from the (inttstat statistics : \;;c. Tatiiiit^ nilniittod, fn.l.r i;, K'. 1". to »n ;!0ii4 In 1,. i;n i.W (Iv. r i.n . . «!' N.it a-.rrl:,i.ir,l 72 Miirehisnn's statistics of I! t')() cases treated in the I^/ondnn Fever Ilnspital pns>e>s an eipially stnmir interest and are particularly instructive liecaiise thev deal with a cuiintrv where tvplius fever is endemic'. I'IHI'Isi'osi.m; cnMniinss. VX\ Ailc I..MI II HI. I- r iillu. kk .Mi; !■■. T'l •M to *2'i I'l. 1 1 ■■'■■d •ih u :iii .11.; '.1 '.I'J no 1. , . .>-■• u.;t» :t."i (• I'l . . :.'7t» 7.81 40 t. 1 . •_".|'J H 11 4r> t. :,ii ■.' 1 -J If. i'> 6()t. .'i.'i I.MI 1 u 55 t. i.ii IIHI L' '^'.l till !• 1 'i . . . •^'^ 1' .".I Il't t' '■1 ... •!-' 1 Jl Til t. Jl II ii'.l T'l 1' HII i; U. 17 U VIM' Ml o o.cw ;4.m; Till' prn|.iirtiim of rliiMri'ii uttackfil i.- 'lii-lnil.Ml 1>\ llir rollmviiiLr res i-oliiTl(.| liv ( Ir.i/.iT iiM.I IaOhtI ilurini: ihf r.rf.~l:iii r|.i.|iiiiir nf \s[\'.\. Of :i Ii.imI lit" l"*?:; tvpliii- fiMi- pill Ml-. 271. oi- 14..>, |..r iviil., uirc chiliiri'ii. iliviiifil iiccunliii^' lo ;igi' m.-* Inliow.-! : flirii HI.. I 1 1- .'. .-, t.. Ill 111 tn I.') NuinlK-r. O l.V.l i;7i The tiiMp «li(i\vs ii iiiarki'il rise in the |irii|n>rtiiin witli ■iiicrcii.^iiiL' iiire. and a iiiilaritv in llif prii|iiirtioii sliuwn liy llio variniis airoiit' rliilillii""i In thai ill ivpliiiiil It'M'i- — a -iiiiiiarily tliat ili.-^appt'ars in the case ut' ailnll.-^. Atrain. siirkliiii: iiit'anl> >linu a viTv siii'lit ili.-|Kisiliiin. a.- ilu also I'liilijrcn iiniliT tivf vcai> lit' a^'i'. I'rnin tliis pfrioil the lialiilily inrrtaM> willi facli yi-ar of lit'i'. ('tilain jiliv-iiiliio-ir (•iiiiiiitiiin-- animio' wuiii'ii. -inli a« pregrnancy, tlic puerperium, ami lactation, ilo not appear tu have any |)arti(ii- lar inthifiici' mi tlic lialiilily to ty|iliii- fcvri-. imr iln tiny rnntiT any iniiiuiiiitN a^'aiii-t tlir lli^-(•as('. 'I'liis i- an int( ri'-tin;.'' puint in tlir ilit- fcnntial iliaLnm-i- t'nmi tvplioid f'cNcr. airaiii-^t wliicli tlic-c conilitiuns appear tu atl'nnl a reiiain iinitcitinn. 'i'lic intliicncc "f tlic ili.-ra>i' nn till' fetus lia- 111)1 a- vet liceli deterinineil. General Conditions. — I'lie general bodily health ami tlio individual ami social conditions of life on wliieh it ilppeml- jilay an important rn/<- in the etinlofxy. Opinions on this [Miint have not lieen moililicl to anv exient hy tlie eN|ierienee- ot' later years. It is a matter oi general exjierienee that tiie liahility to typhus fevor, J, , I'M / 1 /•/// V / / 1 7 /: ' v'i- .-..J' r '^. iti ii-. ir -.1 \M II 111. III.' 'I iimI v\ i'I' --|h. mI. I- nil rni-cl |.\ anMliiiiL' lliat (•\li:ni-l- ill. iiiiliv hlii.il ili'l 1m\m|-- 111- Im..|||\ .iikI III. III. iI I. .111. \\:illl .111.1 |»'\.ii\, Ihiiil;. i- iiii.l \\..n\. .iiiil "llhi .i. pr. --1IIU' . in uru-l.iiiccs ll;i\>' :iU\.i\- I" '11 ill.- iii"-l |>..v\.'l lul illii- "I ill' .li-. ;i-.-. Siicli . ..ii.lili'iii-, "I ."111-., in. 111. I. iiiili\ L'l. iii'' li\iiiL:- aii.l .■!'.-.■ (■I'lW.liii'j- ill lillliv all. I ill-\ ' lilil.il. .1 li'.il-.-, -ul'j. ' I- llial lia\. ali-.a.jv I" . II -iillii iciilh .Ii-' 11--1 .1. \\ . Ii,i\ ' -. . 11 u lial an iiii|K.iiaiii pari liny |il,i\ ill iiiiiiil.iiiiinj- an. I aiiL'Hi. ill iiii: lli.' \ inil.ii.'.- ..I' lli.' . "iil.i'jimii. >ii' li iiiij'i\ ..raM' . "ii'lili.'ii- ir. iialiiialK iii'.-l niailv.r' --' ' I 1 1" .•|.iiii"ii llial ill.' 'li-.'a-i- wa- ii"l .'n' -.. inii.'li t.' lli.' in. nlil ami |ili\ -i'-.il .■\ haii-i I '11 iii'lii''.'! !.\ |..i\'il\ an. I ;:.'n. ral iiii-. r\ a- I" I li.' in. \ ilal.l.' liia--iiiL;' !"'j'lliii' ..I l.ir'j. iininli. r- in -mall. li.a.lN \.iililal..l li.'ii-c-. ami ill'' .■.111-. .|n. Ill in.ii .i-. .1 .laii'j. r "I'lin.-I inl'ili"!!. \ i^laii.'' at till' .'.in. Iiii. .11- ..l' lli.' L.tt. r 'la--.- will. Ii'.u.-s.r, -iilli.'.' t" 1' riin- ilii- "|.iiii.'ii. Alih'.ii'jli ilii \ li\.'aini.l l..ilrr -iiri"iiii.limj- aii'l in in..r.' .iriliilU \iiiiilal..l li'.n-. -, il i- jiiiiml lliat a; irllii'in '.\'.iv\' rli"ii ami . \li.in-li"ii :i.l a- .li-liii.l pn .|i-|..i-iiii; fa.-l"!-. I'liy- -ii'i.in-. atli'ii'lant-, "lli.ial-. ami .■l''r'_'-\ in.-ii ar.' partinilarly likely t.. a.'.|iiiiv ill.' .ii'.a-i' l.\ .■"iil.i.-l uitli pali. Ill- w li.ii lli.'y an w.ak.n..! \<\ l'.ii'j-.'"nliiiii. .1 la I. Ml-- .liirlni'- lli.' li. i^ilil "I" .in .pi'liini''. llni r \ ilal l'"rcc-. Ik ilii; .'\liall-l' 'I li\ .\.'--i\i U'.lk. w.riA. :in.l I. .--.it' -li'i p. ('.I-'- tlial I'lirni-li a -IrikiiiL,'' pri."!' "f l hi.- ,-lal. iiu'iil can li. 'r.iiiii.l in aliii"-l all ill.' .'pi'l'iiii''-, I n'''all ilif . a-c "fa y.iiML' plix.M'iMii, in lu.^ ihirU ->.''''iii'l \iar. "T p'.^Mrliil l.iiil'l aii'l in pi'ini'' .'.ni'lili'iii. w li.. umki-'l lliniiiL'li a -.'V.i'.' .'pi'l.iiii.' "t' iNpliii- li'Mr la^liiiL' liir.'.- iii"iilli>. iluriii:: uhii'li liiii.' li.- >p.iil aliii.'sl all .la\ ami a l"""I p:irl "I' lli.- iii'jlil in ill-\i'h- lilali'.l wanl^ lillcl willi lyplni- pali.ail- : l.iil. ih'MTiIi. 1. ^-. li.' .li'i i.'.I ..in- Ir.'i'l ih.' .li-.a.-.'. S.'iiir tiiii.' ial.r. atl.r li.' Iia.l l'.'''.ni' inmli utakiiu''! I,\ '. I'laiii ili'pi'.'—iii'.' .'\p.'ri.ii''.'>. l"-> "I' -l.i'p. Mii'l ii.'i'\"ii- .l\>p.p>ia. Ii.- Ii'''al'''l "iilv a Uw pali'iil.- in u.-ll-k. pi li'iii-'- in a lari'i' ''il\. i''.iilr.'i''U''l ili.' .li-.a-c uiliiin I"" «.' k-. aii'l ua- lirmij-lil l" iIm- mi'j.' "T iIi.' L'rav.'. ( '.'1-.'- "t' llii- kill'! ilhi-tral.' I.'inp'.rar\ \ariati"ii- in llii' lial'ilily nt' llio «aiii.' iii'livi'lual. an. I iii.'l n. -Imu iliat ilic lial.ilily m lli.' .lis.'a'-.' may .-u.l- 'l.'iiK iii'.'iiiii.- vrv 'jnal ini.l.r ''crlaiii .'"ii'lil i"n.<. ' )ii til.' "tli.r liaii'l. -' t'a.'t- can I"' .iti'il t.. -Ii..\v that tlm -ii-coj)- tiliilitv til tlu' ili-i'a-c i- (iiiuiiii~lii'.l wlicii tlii' iiMJiviilual i^ in pcrtirt /•/.7 /i/n/'"s/\<, / o\/.//V'/\ V Hi.", (•i>rii|iii.iii, iililiuiijli ii'il ill ilii' Niiiif ilcirrir a- it i- iiicir i-mI Ia i|.|i|(-^- iiii: ImmIiIv (■■iiicliiiMii-, III II:iMiluirL' I Iki\ 1- t'ni|iiiiitlv -ii-ii |iMticiits wliM Ii.pI ri.iilr:i(l<'(| lln' ■ li-<:iM- ..iilfiiui- llic cii\ , ail. I wild, luliiri' rMihiiiL' tn llii- Iim-|iiI:i1, hail .s|iciit. Iii>iir» ami cmii -iiu.ili'l in iiaii-.tw -iri'tl-. \Mlli. I'Ik' hiiU i \{ilaiiMliiiii fur llii^ lliai I I an -/iv i- llial cmh ilir | -i r |iiii|ilr in IhiiHlMirL' c :irii i'uiii|iarali\rl\ j i u:i. -.anil an-, ar ilin.-lv. lairlv uill lii|, -■■ llial lliiir liiiiiii- ari' ■.'rnrrall\ in ■juimI I'ntiilil hhi. jl III III lianlK 1" -:iiil tlial CXhaUStttlJf diSCUSt'S lia\c llir -: • itl'iit a- \\lial tlir Kniiili rail /'' iiii<:rr i,/,ii.^i"/":/i'jii' . Aliinlii: ciiiiva- li-.-iiit- |! 'hi iitlifi' ai'iiti' int'i'iliiiii- ili-ia-r- llicrc' i- iiMi|Ui-liiiiial)lv a Lrnati-r .|i-|'M-iii..n tu contrail lln ili-ia-r ain! ri'|iriHliii( lln innlrrin tllnrlii. Ill l|ii-|iilll- ullilT till l\|illll- [laliilll- a IT lint -lltlirirlll l\ i-nlatnl, |iatirlil- riiii\ ali-riti'j- IVmim ntlnr ili-ra-c- a f t'lunul In !"■ |iartiiMilarlv lialili in ilii> ili-ri-r. Chronic or Acute Diseases. - In ilir -amc way. a -till r\i-tiii;r cliriiiiii' 111' -iiliariilr I ililimi tlial lia- liil In a inaikiii ili-tiiiliaiirc nl' llir niilriliiiii will iiii ria-i' ilir lialiilit\ in iln .li-n-r. I tnlixiiliial- -iil- tiTiiiir Irniii rlimnir nr -iilianitf ^la-lfn-iiitr-l iiial calarrli ainl iirr\'(iii-. (I\ -|ii|)-ia a|i|ii'ar In lir pari iiiilarly -ii-i' |iiililr. I'a |ii riiiinil |ili\ -iriaii^ tell II- Iin\\ . illiriM;^ Lr''''al C'| lii Irlll ic-, i I H li \ ii ll la I- \\ lin lljltn thai time apiirarril tn III- cnniiiarativrK ininiiiin'. niav lir altai'knl it' thrv licininc rcihiri'il li\- ili^ri-ti\i' ili-tiirlpaiii-r~ ami arr then f\|in-ci| In tlir iiilirlinn. I'alirtit- -iitVcriiiir tVotii rlirnnjc mr\nii- di-ra-i-, i -|Mriallv \\ Inn thcv arc amiiiir or cinaciatcil. al-n aiipcai' In he \rrv ra-ilv ititritcil. < )t' the iiilliirtiiT nt' I'i •riilatiifv ami riiial ili-ia-r-, iinthinii' a|>j>('ar-; In III' kiinun, iinr lia\r 1 aiiv riTiahlr nli-rf\ alinii- In utli f in tlii~ r(-|MrI. The fi'latinii lit" t\'|iliii- tiAir In rhfiiiiii- |inlinnnar\ ili-ca-c. r<|>rriallv III tlllirfrllln-i-, ha- LI'lM'tl ri-l- In -nnir ililVrlTin r- 'A' n|)inin|l. 1 caiimil iiinlir-taini Imw ^niiir nt' ihr [irniiiimnl nlil.r |ili\-iiian-. -iich a- ilililriilirainl. ran -prak nt' the rrlativc imi.iiinitv nt' -urii |iali('nN. ami I iiiu-t aLTi'rr with Miirrlii-nii in taking'- the n|i|in-iti' -taml. Ainntiu iiiv paliniN I had a lai'L^r niiinlirr wlm-r apin- wrrr imt rlltinK' -miml • ■■iii'l it' it i- ailmitlril that liilirrrnln-i^ nnt int'rcipicnth minpliraK- or ti.llnw- typhii- t'rvrr, it ranimt wrii lir ilriiiril tliat at Ira-t a lar;:!' pni- pnrtinii ,,f thr-r patiriit- liail a latmi tnlnfriiln-i- at the tiiiif^ tiicy were int^i'ti'd with tvphn-. ♦ 'lirmiii' iiitii\icatic)n~, -itch a- Irad-pni-onitiL'', ami paitimlarlv the al)ii-c nt" alroliiil, act a- di-tiiict ]in'Mtl'criii"- from v.m 71/7/r.v ii:vi:i:. (itliiT acute iiit'rciiiiii- ili-ca-c, c-iMciallv diiriiii.' lln' trlirilc ~ta<^c, lia^ not a> \ rt liccii ea>(-.at l.a-t chiriiii;- the fclirilc -tairc. and that thi- iiiiinnnilv onlv diinini-hc- with the Kcu'inniiiLr of dcfcr- \('-cinrc and d(ji> imi di-aiijicar until the fever has eiitiielv siihsiih'd. r.iit We know iiotliiiii.'- ot' tile liehaxior ot' t\]ihii- fexcr in tlii- roiieet. except in coiMK-elioii with I'ceiiiTciit fever. Patient- >iitf( riiiL'' from the latter di^ea-e are, aieordiiiM- tn my nli-ervation, a- well a- a<'cordiiii'- to other aiiihor-, \( ry -ii-ceiuilile even duriiii; the fluile .-tauc m I >aw an iiiMnietive ca>e i.f tlii> kind ciiiriiiL'- I lie e|.iileiiiic of ISTHin the lazarello at Mnaliit. It «a- ihal nt'a voiiiil:- inali. Iwciitv -three vcars of a_c, ill \Wio.~e lilipo.j ihe >|iirilla liiei lieeii Inuiid en ihe la.-l dav of lii<' lliird rela|iM'. ( )ii iIh' full. luiiiLT (lav iLr palieiil had a severe I'liill and lii> teia- |)eraliire hei^an \ti ri>e : the tevei linued liiLrh. and on ihe t'oiirth dav a charaeiei'i le\ir ra-li made il> a|i|iearance. 'Ihe allaek wa.- mild and ver\ -linri. ihe fever haviiiL' eiilirelv di.-a|i])eare(i "i\ the eleventh da\- (>ee V'vi. 57'. cat^ ~^' Wk Needle-- \i> -av, cx|ierieiice- -Hell a- the-e do not iii-lif'\' -iinilar arLinnieiit- in rcLial'd to oiher iiil'eeiioii- di-ea-r-. Occupation and social conditions i-m iiillnence the liahililv to typliii- lexer only in -o far a- they deierndne the [.liw-ieal |iredi^|io-iiii.' factor- that iiaxe lieeii referred t(j. or a- lhe\ iiivoKe an iimi-ii il (■\|)o-iire to the infeeii(.n. I'miIi llie-e eiinditi(iii- are pre-ent in the ])oorer ela— (■-. .Viihoii;' the hitter ela--e- I he (|lle-tion id' ('\|io-iire i>, of eoiir.-e. more inijMirlant than eoii-lilnlional condition-, which are iinfavoralile onlv a- the le-iill ot' aeeideiil or iiceii]iation. Some l-"aiiili-li anlh ir- claim tiir -pecial oci ii|ialiMii- a certain de|_rrce of ]>rotection as.'^iin-i ty|(liii-. They nicniien in tin- re-|i('ct tanners. Workers in fat. candleinakcrs. and liiitcher-. In ;itti-ilintiiiir their rela- tive iminnnity to the tact that they are more or Ic-s eonstantiv li.uidlini.f putrid material. ( irie—ine-er niiconscioii-ly incline- tnward liic mia-matic theorv of tvphn- lever, which he has himself el-ew hi re refilled. I'or mv jiart I have -ecu a- ni.aiiv cases of the di-easc .■mionix linteher- a- ann.n;.'' ntlier workmen. It i- true that diiriiii.'' oiir epidemic the individuals lieloiii.riinr lo this trade were nio-t of them vairaiionds. I»iit even if it slioii' 1 lie found that liiilchers .ire le-s lialile than other workincn, a fact which, as I liav(> -aid, I do not eon-ider proved, the ino-t natural exjilanation is that tliev are iiiKpiestionalilv lietter llollri-l,ed. y7:/-7'/.v/'o.s7.\v, < oMUTInXS. 4 'J 7 SEASON AND T'^TEOROLOGIC CONDITIONS. Aiiinii;.'- ir<'iifnil i'ti"!"j;i<' tliclnrs the m.';im)m :ii!i1 nift(tirolo;.'ic coiidi- tioiis arc to l)c iiiciitioiicil. 'I'luy ixcrt very little intluciicf uii ivjiliu-. t't'Vcr, wliicli, tlicrct'ori', dillvrs in tlii- ic.~|)(. In litct, it wdiild a|)|)car that tlic ilfV(l(i|piiiiiit and invasion ot' tlic inciting cauM' arc in no wi-r niiiditit'n('li external eunditicins. It lia> iieen nii-erved, liciw f\cr, tliat the di>ea>e i» more jprcvalent during the culder reason, nm-t ni' the e|iideiiiie> havinir roaehid their heiirht in the early r th- ><{' the ; ar, — tliat i^, in the latter halt' of the winter or the early -prine', — ami .-uh^ided ai;ain durinir the >innnier. JJiit thi> can lie explained in anothei- wav. Ihuinir the cold >eason all till' tiu'tors inthieiieiiiir individual di<|)o^iiinM and tran.-nii~>ion ot' the ])oi-on, -Hell as want ot' i in|i|oy nienl. |)o\<'i1\, and o\ci-ero\\dinj: in liadly \'entilate(l Imu-e-, are iriiieh nioie active. With the eoinin;^- ot' sinniner the poorer |iortion of the population naturally leuiU to seattei-, Work hecouie- more pl( iiiilul, and the eunditions ot' life are aec(>rdiii<;lv inipiov cd. Il has alway> heen (jhserved in ilu' iar^'cr cities, uctahK iu HcrliM. tliat ih,' disease rapidly disappi-ars ainohu'' llie waiiderinLr. liMuselrss portiou ot' tlu' inliahilaiils a> >oun as they licjin to >leep iii tlu' upiMi air in>lead el' secUiuLT the sheller of "pens" and as\ luins. GENERAL MANIFESTATIONS OF THE DISEASE. Sporadic Cases.— Endemics and Epidemics. — lh(> etioloL-^v of typhu- liver i- iu many n-pecls pcvuliai-, ami this alone lends to the di-ca-e a di-tinci character of its own, e-ptvially as rcjirds its ontlm ak and the manner of its s|«read. A lunulwr of features that di-tinirui>h it -harply from typhoid fver and irive to it a niarkeon is carried throne;h the air; its virulence and ix'rsist- en.'e whenever ventdation is det'eetive; ami. tinally, tlio tiiet that tho di-easc i- constantly pre-ent in lint few countries of th( earth and is only occasionally carricil to other-. I his explains why in countries wIkm-c typhus fever is eiidemic. and the population is pnietieally saturated with the poi-on of the disease, it IS only relatively endemic or sporadic. liecondiiL'- di-tinctlv epidendc only when a larjre numher of predisposed individuals have liad time to ] 'U' im.l] TYPiirs }Evi:n. I'lillci't. It luvcc fails to ;i"iniu' ulaniiiiiir |)r(p|Kirtiiiiis when it is carried til a ic^'icui wlici-c it i~ imt i iKlcinir and win re the cntiiv |M>piihitinu i- acc(inlinM;|y |iivdi-|Hi-cd ti. it ; nv wliiii, on tlic iitlui- liand, laijrc iiiiinlpcr- iif |ircdi-|i(i-cil individual.- nmir into c Uric- wlicro tlic |>c>i-ciM is (•(Mi>tantl\ picscij, a> i.ccnr- in time nf war or in i^rcat liMLiiiitiirv niovt iiK ills. Tliat tlie pn-t'iici' of tla^ poison i- an aii-oliitcly essential factor niider siicli circuin-tance- \va- -liowii i)\ tire l'"ninco-|'riis-ian war. Aitiioiiirji tile world has nevci' -ccn tlic nioliiii/ation of t:reatcr nia.-ses "f' "I'll than iirrcil at that time, typhn- f,ver did not develop, while typhoid tever and dy-ciitcry, which have an entirely different etiolojxv, (•lainnKJ innnniei-;il)le victims. 'I'lie wide disii ilmtion of tvphoid tever is one of its chief points of di-tinetion from typhus tcxcr. 'I'liiis, while typhoid fever oc-iir- sjioradically, or, at lea-t, anion^^ a r.lalivelv small niimher of patient,-, and li ■cine- epidemic only when the amoniit of the infective material is as-i ntal'y increased in river- and watcr-svstems, typhus fever is scarcely ever confined to -in^de cases or hoii-c e]ii(Ieniies, ani;s epidemic whenever the coiitacinm invades a [xipii- lation that is not protecteptinir intiincy, and both -exes are eipiallv attacked. The eoiidilion of the individual, es]iecially a depraved state of nutri- tion and loss of vital enerjrx due to the ert'ect- of poverty, hiuijrer, and disease, exi'rt- an enormous iutlucrice mi the di-position. Tvphus fever Is the disease of povertv--strickeu and -iifl'crinir iiumanitv, and it always follow- in the wake of war and mi-er\-. The i;rcat majoriiy of iiidividiial- aci|uirc immunitv liv one attack of the di-ease. The way in wiiich the irerms leave the bodv of the individual in wiiom they arc produced, anil the |Kirt of entry by which tliev gain aeces- to the body, are not known ; it is probable that the respiratory i'i:i:iiisi'i)si\t; ( os/ii j/tixs. 499 oryaiK ,in uf tlio cli-cuso aiv inn>t |,l.ntitiil in tlic imnic.liatc uvu^U- i)ui-|i,.(iil ,,!' llic pMticnt. iinil they ;irc r;irric\ (|ii>t. Tii.'v iillac'ii tlicMi-cKr- witli irivai tcnacilv in tlic \arion- ul)jcct> that (•onic into diivrt .■..niact uith tlic patient (,r tiiat liaw Imvii r\{>,,^vd '"''"'-'"■'■ 'i"J-' ■lii-- 111 llii- «a.v tJK' .li-.a-r niav ivinaiii .Idfiiianl tor a Inn;: ["Ti.MJ ,,f linir and may lie cairicj to .ii-tant |ilac.- cnlii-flv tivc fidni thr .li-ca-f, t ofall hv water; n,,r .!,, they appear to iv-ide in tl„- -oil or to have ativ ,-peeial relations with it. as ua- ti.rnierly ,.rron,.,usly h.liev.W oftvph.iid -erni-. The -nni total ..f eiioloirj,. (;„.,,,,. ,, ,.;],. ,.^[,|.,i„, d,,, ^"......j ,,.J, ^^.j,,^ uhieh th.. di-ea>e spread- an.l it- p.culiar trn,|,,wy to' appear in epi- atii'nt- are entirely free frmu -yni|ituin~ ilurini: tlii- iierii"!. < )nl_v i.eea^innally do tliey eonijilain nf iniletiliite :-viiiiitiini-, -neli a- lieadaelie, vertiL'". I'ain in tlie liaek. loss (,l'a].|ietile. faliLnK. nr depn-H.m. In a !'<■« in-taiiee- e(,ry/a and emi- innelival catarrli lia\e lieen imtieed. In llie ea-e ..f two individuals who i>- 111' infected in tlie liii-|iital, nnder my jiei'-nnal di-ervatinii, tliri 'A ei-v -liu'ht fever, witli |.raetieally imrinal daily vafialimi-. Tlie len-th (if the |ieri..ii ,.f iiieiiKatiMn -.afie-. (.uinir tn -miie eaii-es n.it a- vet verv well kn"\Mi. I a^Mv.' with iim-t ;nilliMi'- in i -iderini: till' n-nal dnratinn to lie tVimi ei-iit t" IweK'-. al nm-t 'f.nrteeii. day> ; liiit a dni-atii.n nf tVniii fniiv t" -even day- lia- niM ;itedly liei n i.li-erved. On the iitlier h.and, an inenl.ati.m ^taL'e i-f three unk-" diiratimi -hmild alwavs lie retra riled with -ii,-|iieiiin. A few eases have heen reporled in the liteniliire hy reliahle aulliers 1 Mureliisoii, (ierhanl', in uhieli the iiiruhaliini \\a>siiil to have la>teil only a duv or hilt a few hour- The ^llol■to^l |iirio,l ie my .■N|ierieiiee wa> loiir days. This wa> in a mail, fortv \ears of n^'e, romin;.. Inaii a loealily alMi- liiteiy uhove siis|iieioii. who had taken part in ifrtaiii feMivilies :. a |iiililii' hou^ where he had heen a >traiiL:arallier and Clieyne. 15aiikroft - in reirard to ea-es in wtii.'h the ineuhalioii peiiod lasteil from one and a liaH' to six monih- are due iiiii|iieslioiiahly to errors of ohservatiou or diairiiosis. THE SUBSEQUENT COURSE OF THE DISEASE. The siilisc(|ii( nt eoiir-p (if tlie di-ease may lic-t he de.-cniied liy irivini: the hi-ti.rv of a -evere, \vell-develo|>e a narkalile uiiifurinity in its chief iiianifestalioiis, in its &00 I'Mllnl.ncY 501 iliiniiioii, and ill tlic lom-c ami iikmIc ..f ii- iiTiniiiaiidii. In all laivc (■|iiil(iiiii-- iiol inaikcdiy inuililicd liv rMiiiiai c lition-, c-iicciallv -ucial ■•. 'Ik' rliaracirii-tir |ii.'tinv i> the -aiiic in ii, main fcatiiro. A i - liai-i-uii of tli<. ili~,a>c a- we know it to-day witli the d(MTi|)tioii- ot' older aiillior-. >|io\vs that it lia> not cliangid in any i'»cntial particiilar ill iIki coillSf ot' tiiiic. 1 III' on-ci ot tlic di-ca-c i> almost always al>rn|it. The fl'vcr is ii>licrc(l in liy one or two di-tiiict cliill--, or, i ■.■ rarciv, liv <'liillv M'lisilions la^liiit: tor ~f\cral lioiir- or an ciitirf da\ . Tlii- in ino>t ca.-cs ciid^ ill,, true initial >tai:r ot' llir di-cax. In roii>c,|iicncc of tlie -nddi'ii, violent on~et and tiie ra|>id ri>e ot' teniperatiire with eliill>, the patient- are viiy nmeh pro-tralcd \'\ i the (piit>et. .Mo-t ot' them are <|uit.. miaide to uoik, and take to their lied,-. t dav ; while even tho-i' who po-es> a jri-eat lV~i>taiiee 11,-lially ^rive up nil the .-ei'oiid or thiril day ; I'oii-eipieiitly, me >oiij:lil iiiuc'h earlier than i- ii~iially the iM-e in typhoid t'ever. Jheehill i~ either aeeompaiiied or llillowed iiiimediateiv hv naii-ea, voniiiiii-, a -eii-e ot' piexiire ill the epiua>iriiiiii, aiio~itioii. Tlie t'aee is tiveri-li and r..lv. The miieoiis memlira f tiie nose and palate in many eases hoeonies l">;;j:y and reddened as early as tlu^ eveiiiiie; r,f' the rir>t day, and the I'-'t'*'"'-^ '' l'l:iiii "f a fee! ill!.- of dryness and >erat<'hiiiir in the throat, or even of marked dys|ihagia. While the mind i> iiMiallv clear except for a >lijr|it de|)rev>ioii and ajiathy diiriiiir the (hiylime, marked distiirh- aiices of the s-n-oriiim l.eoin to >iiow tliein>el\c. toward eveiiiiij: or • inriinr the iiiu'lit. The patients l.e^ri,, f. lo^. interest in their surroinid- iiitrs, ea>ily drop the thread of a conversation, and, if left alone, have ini,r ilreams and talk in their slee|). After the ejiills and the nausea and vomiting- have siihsidiKl the lever rapidly ri-^es. and a dull, tlirohhinjr, sometime violent and stal.hinjr headache, vertii:.., Miid tiniiitiK aiiriiim he.'.mie pr incut syiuptoiii-. Some individna'- siitVer from violent pain in the sicral reui,,n and cannot rest ca>ily in aiiti. especially in til.' le;.rs or of hvperc-thcMa in the filljrer-tips, toe>, and >ole- of" the feet. I'aiii in the joints is rarelv present. The tonirn. i> treiiiuloii> ami drv, aii>{' \\\>- pl!:ir\ n\ :!n(l ti.ii>i!,- iiicrc;i>(>, ami llir |i:iliciit- ('Miii|ilain Ijitlrrly of a lai^iiiu- tliiisi. 'I'lic a|)|Mlilc i« allM.^vilicr |,,.i. 'I'll,. alMloinni i^ ii.iilicr -u,,llrii imr paiiil'iil. <\r( i.iiiiu III llii' (■|iii;a-lii<' ivuii.ii, wliicli in maiiv |)aticiil- i~ V( TV -cii-iiiw I,, till' tniicli. Ill the 1 »■;; imi ill" :iiii| iliM-iiijr the ciilirc tir~t unk ill.' JMiwi'U ai-i' il-iiall_v roii>li|iati'il ; rai'rlv tli, re i- (iiall'lir-i. 'I'lic .-|llrcll ri; I, 1,1 lli'is /„,in,l. ]-. W | l,y |„.r,.||,,i, ,ri allll |)a 1 1 111 I loll t(. Ill' (li~tiiii'lly ,iilai'-i'i|, a I'ratinv llial i- rliaractcri-fir of tlu' ili-iaH' ami foriM- :i n-i'inl iliai;iio-tii' |i..iiil in tlii' ilill'civntiation IVoiii lv|)lioi(l \',\tv. Till' |iro-lrali.iii liHTia-r- -o rapiilly llial iiio-t [latii'iil- ari' lianlv al.lr to HI ii|i iliiriiiM til,. tii-H ,|;iv. ,,f ill,, lir-t wi'ck ; Inn. iiotwitli.-tamrnii: flii'ir la-Hliiili'. till \ I..- alMiiit i',',tl.'"ly in Im'iI alilr liay or iiijrln to olilain I'rin -liiiit^ -li'i'|i. rill' l'i'Vi'i--i-iii'\ 1' ilillir- (Voni that of ty|iliiiiil frviT in tliat it ri-c,< nijiiilly on tlir lii--t fru ,lay-, rrarhinu a ronMilrraMi" livinjit and i'\liiliiliiiU' -liiilil ilaily Nariatioii-, uliirli ilo not, a- a niir, ex.-, nl lialf a deafer. ll [lartaki'-. of tlir rliarartiT of a lonliiiiicil frvi r, of, inofc rarvly. of a rontiiiiiiii rnnittint t'l'Vrr, ami rarly attain^ an I'Vcninir ti'iii|ii.ratiiiv of 1(1 C, altlioiii.|i in m'Viiv ia-.i'~ ami iiritai.lr iiiili- viiliial> it may rravli frmn Id..", to 11'. 'I'l,,. tiniiiiTatiirc rafclv iiill.« lii'low ;'.!• ill till' iiiofniiiix. W illi till' rapiii ri-r of tiiii|ii ratiin. tini-c i~ a rofi-c>|iomlinir rapid, imintmiiiiti'il ri-r in tin t'ri'i|iiiniy of the |.iiIm.. K\,n in vipiroiis nun the |>nl-c n-ually icailn- liiOon the fonnoon ot' tlir mi-oihI dav, and in tlir ivinini: 1 r- it ri-r- to 110 or TJO, wliilc women and rliildnn show an cv. n ;:r(ati'r I'Xiitaliility in tliis ri'spcit. I liavc ni'vcr .HTP, in till' lii'irinnin- of ty|iliii> fi'vif, tlir ili-|iro|.oition hi'twii n the |)iil-r-i-atc ami tlir tiioid li'vcr, and that is .m. freinieiitiy olj.servwl in yoiinf: men witii typhoid. Tile arteries in tlie lieLMniiiiifr are .soft and tiie pnl.-e i- iiornai in voliinie and ten-ion. Tiie dierotisni, eiiaraeteri-tie of t\|.hoid fever, is ali-eiit diiriiiti- ilie tir-t days, and .soiiietiines later, in iiv far tlie n-reater niiiiiliir of ea-i's. \\ hiie the fever and otiier ^reneral distlirhanei s are nmleriroinjr a rapid and iiniiiternijited rise, tliere appears, I.etweeii the third and the tilth day, or oeea-ioiially lieti.re that time, a phenonienon tiiat is iiio-t iharaeteri-tie of tlie di-ia-e and oiteii deteriiiiiies tlie diagnosis. Tliis IS the ro-eoloii- eruption. It appear- at !ir-t in liie form of pale- hmI, hvpeii'inie |iatelii-. varying- in -ize fmm that of a jiin-liead to that of a lentil, eiriular or ol,|,in;r in -liaj.e. and haviiiLT iil-deliii(.il iKlgcs. Sir r.triioi.iK.y. m\ Wlii'Il till' I■;l^ll (ll'\(]ii|>- lllliliii l;.l\ , llic |i;lt(ll(> ;i|i|Har lil>l oil tllf ll)\\(l' kIuMIiII IlMll nil lllc cllc-t llllll ~||( illldcl'-. I'IlcIIi'I' tlltV -jirfMcl at (line lAcr till' liack ami cxtiriiiilio iluuir to llic dnr-al -iirlacts lit' tlie liaiuls ami liit willi >ii<'li ra|ii>lity tliat the ultimate iiiiiiilx'r (if till' |)atcli('> i> ii-iially icaclicil within t'lotii tiiit\ -(■i;.'lit In H'vciiiy-twu lioiir--. Ilii' paliii- \ far in tiic L:r<':it(i' nuiiil)ri- nt' ca-c^ tlic lace a- well, the ia>l licin^ -iinplv vciv hhkIi i<'ddcmi| and -woUcm, and (ittcn a»ntiiini^ an ah-olutcl\ niicannv ('\|(i-(~-iiin nn acnunit ul'tlii' iHldcnini: and iicin- (iri'liaj^ic injciticm u|' tlic cnnjunctiva'. Siniidtancnn^ly with the riu|itiiin nf the i-oscula, or, in irritahlc indi- viilnais, l)ct'i)!o it, a incaslc-likr i-a-h niakis its appearance, atlietinj; with prediieition the extenxpi- -inliicis nC tiie tiii-eariMs, tiie lejr>, i'he>t, and alxloinen. This liide> liel'oie the disap|M'afance ol" the typical iTiiption anil leaves n<> trace. Dnrinji this |)criiid ually thin and pointt'd, and its sur- face shines as if it were lac(|Uered. Meanwhile tlu' catarrhal symptoiu.'* ill the pharyuf^eal structures and in the larynx have increasiKl. There is hoarseness or even aphonia ; the presence of a short, dry cough sh()W.s that the bronchi are also Involved. This is confirmed by ausciiltiitioii, which reveals crepitant and subcrepitaiit rales over the entire e.\t<'nt of the lunjrs. The complete developn.;'nt of tlu- err.ption usually marks the zenith of the disease. The fever by this time has readied its heij^dit and remains stationary for a varyin no rest by iiiirht or by dav. Sime talk, work, or yesticnlate in their dreams, either reviewiiifx fi)rnier [htIckIs of their lives or iniitaliiig their usual occupations. ()tlier> become viulentiv excited by visual or auiid hallucinations. Thev iinajrine tliev are bcinfj j)ursued ami threatemHl witii personal violence; they cry out aiiij defend !■ s^; • Ui: i w^ mi T) fill s II ill!. tliiiM-.l\i- ; i|ii\ iiiiii| I oi' ImiI and iry u> (-iii|ic rinrn tlicir tiii-iiirc~ |,v tli^lil kv Ii\ .iii.irkiiiM- their altc ndaiu-. Tn |iliii- tc\ii- |iali(iil~ in tlii-, ftap' ni tlh ,li-,a-.' air ii |iaral>l\ iiio|-c clilli<'ii|| i,, mina:;!' ihan aiiv (il'icr-, ami tlu' ucik in a uill-lillc<| wanl i- alxnit a- cNcilin;: ,.,,1,1 fxliaii-tiii'; an i a|)i li, nrc a- dui i,,r~ c,r niir-.- ale likil_\ t.i nint with in tlic cxciri-c lit' ihrn' |ii'ii|r--i(in. Dnrinir llii- tirni' — u-nallv nn the m'C(iim1 di- third da\ alter it-; iippcaraniv — the fn-cila (rM|itii.n, which wa- al lir-t a |iiiiv h\ iMivinia, Miidci-5.rii(- a |icculiai- t ran-tlninal i^n. A ccitain |ir"•■•• |iini need. Thcv Kfc. ■ ((iiiiiir-nil.ircd, w ith ii\ id icntci-, m- the ciiliiv -|Mil may a — nnic a dirty. Miii-h-i-nl a|i|Maraiiir. In the MAcn-l ty|M' (if thi' di-ca-i- imi-t <•{' the h-inn- iindiTi.'-ii thi- Iran-liirnia- ti(in : and when, in aiMitiim. cntam ~ cii' rxtcn-is c -nlicnlaiiccin- hini- orrhairi- makf their a|>|icai-an(i-. the -kin may a — nine a man\ -cokircd «lil-ky a|.|i(arancc that i- |)ii-ili\ i|\ i(rril'\ iiii.'. l>iirinir the lir • half (if the -(cmd wc.k- — .imdimc- a little earlier, sometime- a little later — the elinieal |iietniv, a- a whole, ha- n,-nallv reached it- hiirhe-t developmcTil. The |ialiein- are .at ihi- time extreniclv weak ami |ii'o-t rated, ah-oliitely a|iathetic, and cut oil' from the external world. 'I'he heariiiLr i- ]iraclically li.-t. the -peech i- mmnlilinii and uiiintelliLdhie, and the eye- are ^tarin'.f ; with month wide open and liaiijrinj;-, trcniulon- j.iw. the patient lie- in Id jiickinj; at the Ix'd- <'iotlie-, with -nli-nlln- teiidimnn and cariiholoirv . 'I"he wild H-e-ture- and the -houtinir, to>>ind. -iiperlicial. and laliored. In era\e ca-e- an I'xamination of the ehe-t at thi- time will -how- either a -imple h\ po.-tatic condition, a lohular pneimionia. or ,in exien-ive inllammatory hypostatic ci'iisolidatioii of one or liolh iowcr lohe-. Taken all toiiither, the clinica! picture i- woir-e than anvthitii; that I'M llnl.ocy. 603 i-.\\\ l.c iiMM^rmcl ill .i.iitc iiitirti,,!!^ (Ii-r;i><-. |{iit rccnvcrv is [H.^ihl,., rvrn when the .li-,M-,. ha- ivar|,r.l tlii- .xtiviii,. .t:i-.'. KuViimat.lv tor tlic |.ati.nl-. it i- a -liar|.ly -, IC-limit.d .■:tH..ti..M ihat niii- a .('i-tjijii a;icl licm wliich nvnvirv i~ |M."il,l.. ivcn in the >,.\ .r.-l ,a>(- lir..viiliiii; the |.li- -.l.iaii .'aii nianaL'-.' to -n-laiii lii- pali.nt Amuv^ (I,,; tin day. that riiii-t v\a\^-c lMt\\,-.n tl,,. time of hv.iv-i iiitosi.ation and the r|-i-i-. Ill iiio.l,i-ai,.|v Mvnv .a-,-. an. With ih.- tall ,,f trii,|„.ratiiiv m..'~t of tlic oth.T -yni|.t.,in- l«.iri„ i,, -nl.-idr. Th.- triu(H ialiiiv-,-niv.. up t„ ''"- '' inaiiitaiii- tiic charari,.|- ,,f a ( tiiiii(etor,- the. vvW\~, a -o-eallee- th.> fever fill-. |,y Iv-i-, with a step- like eiirve, rather than hy eri~i-, « ith a rapid, eontiniioii- def.rve-.e..|iee. In oth..rea>e-, however, th.. fall i. >,, al.nipt that th,. n..rinal t..mp,.i-a- imv is r..a..|i.Hl within li.rty-.iuht h,,:irs. ,,r at ino-t after three .lay-. A .l..ferv..-,.eii.... lastiiiir fiv,. .lay> .ind ov.r, \\itli mark.d iiit<.rnii-.si,,n .,r irrejrularity in the .nrv... i- ..ompainitiv.ly nir.., an.l should sii^rjre^t a wirefnl (■xaniinatioii for po-^ihle ..oinpli..ations. The li..^dnniiiir ef ,|eft.rvese..n..,. is mark..! I.y an improvein..nt in the pills... .\t lirioIojrie pjite. The return to th.- normal fre.nieney is jmidiial. As late as the fonrteenth day, ..r evn laf.r in very s..v..r.. ..a-e^. th..r.. mav l,e n.ark.^' variations in th.. pul>..-rate after the sli:,ht.. 1 1 \ I ir Ml^';;i-l- the |iii-cnrr ,<\' r.,|il|i|ic.il ii .11- ..r ..t' ;i -|.l(Mic limi..|- line to NllllC |-:lll-c lAi-lillj- ImI'mI-c iIic -.1 III' l\|lllll~ |1 \ I I'. I'll'- r||;ir:[. 1, I , (ii' -kill-li-iiiii-. -uli-|i|.- .ll'lrl- till i|i-i:i-r li:i- nacll.ll il- ln;:llr-l |ii. ill, .lllcl, «illl llli' i\r.|illi.l| III' ih.i-r |i:i|i||i', lli.ll ||;|\c IUll|(Ii;iilli> |Ml>i|li;|| i|i;||l:.'r, (111 hill |l('l-i-l lllllil llir IiI'I'IihI iif ililcl'Sc . Ct'IM*. Till' |Hi., lli.ll li-lmi- ii-ll;ill\ lllllil f^ii lir;ilili\ . fiiivK -li|V,|,|\, U(al ill'.:. \\ itli llii -iili-iiiiiiii- 111' ili( rdiiili- -\ iii|iiiini- till' Iniiiriic' i-i!.'-aiii> its liiiii-liii-r. ilir I led |ialclii> ileal- ii|i. aiiil llif t xciirialiciii- ami li»iircs Ileal. 'I'lic \..ii I- Main- in -trciiLrtli ami ir-diianrc, and lln' Ihiar-fncss, ulicn due -ini|i|\ In ralarili m- ii-ii-inn-. in tlic lai vii\, di-a|)|)car> ; trnt iiit'n(|iirnti\ , liiiwiMT, the laryn;x(al iiiaiiitr-talioii- aii- (piilc xvcri' and ]i( r-i-t (111- Miini' til r may lActi he incni-alilc I lir ili-liirlianri- in tin- iiii:i'-li\ c a|i|iaratn-, |(articnla?-|\- tlic (iianlica, wiiicli i- i|iiilc rn'(|iiiiitly |in-(iit liiii-iiii: tin' -rrond vMii^. di-a|i|i(ar wilii tile -nii-idinrc III' tl t'lviv. Ml. -I |i,iii(iii- \ry\- mhui >ii(iw a jr ijiiitc satl' U> jxratitV witii a ciiniiiarallN (In lilirral dirt. It', as ii>iially iia|i|icn- in nm(im|iliratiil ri-c-, i \cii lictiirr tlic li \cr has cntiply di-a|)|M arcd. llir 1 \inin!.'- ri-c nf tiiii|irraliirc Ikcchiii- ic-s liiarlri-inj:ly lirief lime recover t'l-nin a di-ea-e that -iioi-li\ licfnre iiad i)ccn tile can-c of llic criate-t anxiety, imt ti> sa^v tlic dopair, nii liie part iif lii< attcndaiit> IJarriiiif c(iniplieati(in> and x'ljiicl-. tlic iliiration uf wiiidi e.iiiiKit he fiire.-ccii. the end ot' det'cr\i'M'cncc i^ reaciicii in tlic ■.''I'cat iii;ijiirit\' (- within I'rnni twcKc In seventeen day-, .and the patient enters iipim tlic pcrii.(l (it' ciiinale-ceiiee. In nut a li'u modcnitciv severe, mild, and iii)orti\c tiirin- ot' the di-ea~e the felirilc period i- ended nincli earlier. Cases tiiat at the onset wcri- ijiiite se\ire may reach the sta;re nt" defer- vescence in froTu -ix to ten day- ; while the milder and aixirtivc eases may tcrininate t'a\oralily as early a- the thirii or the lil'th dav. When dcatli i- ian>ed -itiiply Ky the sevcrilv of the disease — that is to say, liy the to\ic ctl'ect on the vital uriran-^ — -it occurs iisnallv in the middle or second half of the -1 nd week. .\ filal termination lietiire the ninth day, or as early a- the lifth or sixth ilav, oicnrs onlv in the Mi)i:i;iii .lA.i jiiM) .V)7 niii-t -rv.r.' furni- ct' tlu' .li-. ;i-f or in iiitii|>li.'iil<'n- aixl -.iin, U nuv |>r..|.,nL,' tlic niurl)i(l piufc— iti(lititiii( l\ , .mkI i\rnlii:ill\ Nad i.i a !< tliai lirmijia- tioii. MORBID ANATOMY. THE EXTERNAL FINDINGS. \\ illi till' cxcciiliMii dl' ||i< not \(r\ iiiiini i > i'a>r< in « ImcIi th,. >.kin of llic cadaver -Imw- pnn iieeil tiaci- ><\' the eliarac teii-iie eniii- tidii. little that i< peeiiliar i- tunnel at the aMtii|i-\. Th.' ehrd limlin-s an- ~neh a- are always idi-erved in aeiite inh'eliciii~ ili-ea-e~, and a dia"-- lio-i> at the antii|)-y-lalile can at lie-t i>u\\ he made hv exehi^inn. Ouiti^' 1,( till' hrief dnratinn .if thc' di>ea-(. t\|iliii- fever eadaveiN exhibit very little einaeiation. Kijrnr i -ti^ i- uf n >li;.dit, anfn-i(in, and, MS in tnaiiy other int'eetiuns disea-e^ (~eptii- |iri.ee>si's, tvplmid fever), deeiini|Ki-iti((n hetrins early, even in eoul weather. It death incurred while llii' erujitidM wa- pie~ent, ;,'ri'eiiish-vellow |)er-ed with |.etc(hia> and larj.rer lieinorrha;ri<' areas, may still he sc<'n. Branny di Mpiamatioii of the epi.lcrmis m.iy also l>o ohserved, j)artieiilarly when, as freipiently hap- pens, stidamiiia were pre-ent. Bed-sons arc usually alisent, heinjr found only when the patient has (lieations anil sei'nie time. In a fiw cases lih!e;,anoiioiis processes or eirciiniMrilied areas of cntatieoiis f,r;inirrone arc jire.-eiit on the tiiifjers, toe-, cars, and tij) of the nose. Tiie imiseles, which, like the fat, are not dimini-lu^] in volumr, appear red and dry, and on section often have a dull sluvn. f 'crt.iin iniix'les, e-p.vially the rin-ti and the imi-ch's of the tliijrh, oceasionallv present ulcerations that, from the |)rcsen.v of fresh liemorrhaircs, are seen to have l.een produced during' life. I'nder tile mierr.scope the museles present the chanjros .leMTihe.l l,y Zenker in typhoid fev. r : simple atrophy of the fasciculi, with irnunilar ai> '. fitty dejrcneration ; more nircly, waxy dejreneration occurs, vhi- '., when present, is hss extensive than in typhoid, thus jx.ssil.Iy af.e.-dini: an oxplan.ition why tlio jiwuliar linear or macular cIi.iul'c jirnducinjr the " tish-Hesh " appearance so frpfpiently found in typlioi.' fever cadavers are almost ••onstantly ahsent in typhu ; fever. The hones and joints do not appear to hav(> heen carefullv invest!- •;• 6(M 1) rill N / / I / /;. I ■lf- i "■ lihli li 'i ;^:il"l III l\|'liii- li \ ( r. Mild 1 ni_\-(lr li.nr im |ii'i-(iii.il nli-irx nlinn- tu '■111 I on till- |p..iril. THE CHANGKS IN THE RESPIKATOKY ORGANS. I lie |i -|>ii:ili'iA .ir;::ili- l'ii(|iii lit l\ , IT iml iv^'ulillU, |.l> -ciil ili:i'lifc» «it' vaiimi- Liiiil-. Ill' 'I ;;' - ill til' ii|i|M I- .lii |,;i— aiT'-, vvlii.'li aiv -.. lVi.|iifnt !m(l N\lii'li ill iii.iiiv 1 |iic|i rilic- 1 \i. ml In the ,|,i|„r |i..iii,,ii~, |i;i\ c alrciiilv lie III ivtiriiij I Ir-.iil.nii; il"' l;' II' I'al iliiiiial |ii'liirc. Swilliii-, mail rail. Ill, ;mi| n .ii-i -i j, ,n ,,|' il,,. miin.ii- iminlnaiir nf til'- II"-' , |'liai_Mi\, ami lai\ii\ an' an u tin' I\|iiral tlmliiiL'-. In aililitimi Im llir-i , Ml- lilh II liiiil -ii|ii i-lii'ial t r..-i..!i- i.t' ilir niiiinii- im in- lii:iiii' ami i Iiialr mil: iialiii\ i iilai-i im in i.f llir imi-iN. (hillii' • illn ' liainl. ili|ililliii ir iliaiitii- iii llir |iliar\ iinral -liiirtiiii-, w hji thr |iiiiilih linn nf ilir|i iiliii-, ;iir ili-liiiril\ iiiniT rare. Ill a i'cw ra-i- 1 lla\ !■ -rrll all 1 Mrli-is r i j i | ilil | ii I'ir Mil 111 I llallf ill tllr lalV ll\. r\tlllllillir a^ tar a- llir l|-ariiia ami llir laiv i iMomlii. Ill ii|ii.it-. Ill' many i|iii|i inii- \m liml inrntinii ut' i\liii-i\i' -ii|i- |iiii-alii.ii 111' till' |iliar\ii\ ami nf -iaiti lar\ ii-ial atli rlinii-, i niiilitiiiiis |n:niiially ali-nil in nilur r|iii|iinii - i ( i |-ir--iiiMr|-, M iirilii-iin i, Ms' |iii-iiiial iiii-ii\atiiiii- wii-i' lit' a \ rr\ nnl'is m-alilr iliaractcr. In alinn-t t p' !■ lint. Ill' till- ra-i- II. mini; In aiiIn|i-\- I limiiil intrii~r lar\ iiiri a! tii-ia-r, inli-i-tllii: ill liia|-k.i| liililriiilii: ami -wrilim; nf tlir lillli-niw niiiiiiiiaiii'. willi .ill Ilia ami iin-inn- m- H.-mi-. l|,i' !a ; iiarticiilaiU' (III llir |iii-liTiiir wall, nil ihr r|ii;;|ii||i-. ami nil I iir m ill i ir.ll.il lialliU. .\--iiriatiil uilll llli-r ilialli;!- 1 iili-i'l\l'(| rr|icalrill\ till' |iic-r||i-r nf ]iii'irliniiiiiili-. wliirli ill i\ir\ in-tami- wa- I'liiiliiird ('\rlii-i\i l\ in tin- mylriiniil iMilila;,''''. I ln' ••iniilitiiiii a|i]>far> tu lir ^'cinralK iiiiilatrral, ami it alimi-t aluay- liaii- In mi rii~i- nl' tlic alVcclcd carlilairc, uliidi, liriiiu'- in iinimiliati riiiit.irt with llir ilri-|ii r lavii'-, i~ i-iiii~laiill\ liallii'd liy till' ]iiis niiitaiiird ill tile [HiiNrt tiirimd li\ till' iiimnii- iiiciiilii'ani'. \\ I'irliM'lliaiim ri'|Kirt- -imilar timliii:;- in inniii rtinn witli tin' |iiiriilcrit cliaiii:!"- Ill' till' |ili.'iryii\ and lafviiv. ( nmiiaiiii!.' tlir«r rliaii;^i'- willi tlin-r nli-i r\Til in till- -.inir part- in lv|ilinii| lr\ rr, niir i- -lriir|< li\ an cxlranrdinary n'-ciiiiil.ii'ri', |H)iiitiiii^ tu -iiiiilar caii^'^ in llic two pi'oc- (■»-(■-. wliii'li iiii(|iii'-ai;('s till' iiin-t riin-taiit rindiiiL.'- rnii-i-i in .'i ratai'i'lial I'liiiiliiinii nt' ilir trailira and lii'iimlii, iii\ nlviTi;.Misiially tlii'ir linc-t raniitiratinii-. a ciinditiun tliat sliniild III' ri'tfafdrd a~ jiart nt' tlic di-ca-i' it-clt' ratlin- than a- a (iiiii|ili- oatinii. Ihr miiriiii-; imniliram' i- iiitrn-rl\' ri'il. .iiid I'livrri'd with a niniliratr aiiiniiiit nf ti'iiariiiiH M'crrtiiiii ; iH'ca-inii.'ilK- it i-- tlu' M'al if Miii:i;iii I \ I i'i\ty 'it)'.) Ii.iii.iril:iv'<-, rnnly l;ii^:r Iti . \f, lit. CM. tirniit' |>.irlii'iilarlv in .•;i-.r> wli. n hiiiiil.ir < li:iiii;<- ;iiv Iniiii.l in .ithtr Mill. mi- .1,1,1 ..i-,,!,. iii.iiiliniiK -. In I ,'M liniiiiliili- I- . |..-,l\ I. laiiil tu (lie at. i.vta-i i |..i.ii- laf |iiii'iiiiiwiii:i wliii'li aiv ijiiit,' liv.|iiiiitl\ toi;,|,|. 1 1 > |Mi-tal i,- .nn.r,.,. •'"11 '•' till' Imuit lull.'- ua- I'oiiii.i III aliiKi-t all ;li.' liiKJi.- .Aaiiiiii,,!. Or.'a-iidialiv til, |-,- w.i-f lliiii, j inliirrt-. I li,' lrii|ii,'iir\ III l.iliai- |in, iiMioiiia \alii-. in tii,' ,|itlir,iit .i.iil.inii-s iin.l in .Htli'iviii |...aliii,-. Wliil,. M iii,lii-..,ii aii.l li,. ,.l(l,r lai-li.ji \viit.T~ n-irani it a- a ran- ...■iiinvnr, . aii.l -miir .,\' ili>' |,r,iiiiini'nt yminjiT l'"n'ti.|i ^ili\ -Irian- i i'lhiiiiiM. N.ilii) ij,, nut ,'\,.|i il.-iTil>c it, "■'• i" iHiliii tiMiii,] l.iliar |.ii,'iiinM:iia ..|' ,,n,' ,i|- -,\.ral I, .In- a- liic iinni.'.lial.' .an-.' ..t' ,|..:illi in I", ,„.r ,-,.||t. ,,•' all ..m- is|,|,ii- li.y.r cadaver-. 'I'h,. inliltnitinn \\a- .a. .■,-,|i,i^r|\ ,|, .,,-,., aii.l ili. r,,l,,r ,,|| .-.•.•|i,,ii ua- a L'l-ayi-li y.ll,,u ,,i- ;,ii iiiiii-nalK l,ii-|it \,I|mu ,Io-,.|v ri-.'nil«lin'_' tl,,' a|i|M.aran(v -.nirilli -.-.■ii in lil,rin..i:. |in.'iiniMni.i. It r.'ni.ain- Cn- lal.r l,a<'t.Ti,,|.,-i,- lin r-tiiralioii- tn -li.,u uIliIlt tlir -inii- '■"".^ '" ill'' .i|i|"Mi-:iii,v- .l,'|H.|i.l- on a -iniil.irit\ ut' .■an-,', in wliirji •'•'-'■ '"l"!' I'li.'niNini.i nin-l [>,■ .■..n-i.hav.i a- ;i tvuv , i|,li,-atioii. \\i niav ni.nli.,n in iia-iiiL-- lli.it |.iicnni,,nia- .vi.lrnilv -imilar in (•liar:i.'t,r have l„rn in vr r, nt tinn- .il-,. ,,l,-,.rv.-.| in oIIi.t i,.,';! lilies ( Knikcnli.TL'' anil lli-ann-.liu.iw-, Ii,ani|Ml.'ii aii.l JliLTi). A Ifw .iiitli,,r- n-I.' ill.' trin-ili,,n ,,f |>n.'iirn.>iii;i into ^ranirivni- ..Ctlio lilii-shnt I liav.' n.v.T -...n -a.li a n-,ilt iMh.w tho tl.nii ..f |hi. iiin,,ni:i Jii-t .l.-(i-il.,,|. Miinlii-oii. (Ili,— ii,;r,.|-. ;.||,| ,„li,.r- <|,. n.,t a|.i..ar to liavc soon iii.in\ ,■,-,- ,,f iran-ivn,.. It i- tin,, tjiat I liav.^ -oon :. .'a-.s <.f -an^rivno, l,ut tli.y woiv all ,iiio n, |.,.ri,li,,n.liiti- ,,f tli.' larvnx, wliicli ua- .•\r,...,|inL,rly |)iv\al..nt in tli,' o|iiilonii<' ..f |.«7!l, ui,,| was I"''-''"' i" •■^■'■>T "II'- "I' ill'' '■a-.-s m.'nti.,n,-,l. In ..a.'ji insfan,'.' tlio ii'-Ti.tic oailila;,r,. was iriiiii,Tso.l in a [....•k,.| .if i;.ti,i |,n- that lia.l por- ('..i-ato.| into til,' int.TJor ..f tlio larvnx, -., tliat a-|iirati..n of tlio putri.l materials niii-t lias,- li.'i'ii ini'vitalile. Kxeept tor till' liiiriiions pleiirisy rcirnlarly |ire-ont in pnciinioni.i. liw cluiiitros wore oli-erve.l in t!i.' ploiini : tli,' most (V.'.inent w.tc ic-iiv- ni..-.s and small eireiim-.Tii.ed pat. 'lie- .,|" lil.rinoiis exudate. Stoils exiiilates aro viTy rar.'. wiiil.' empyonia .an.! f.li.l efliisions in eoniioctiou witli imiriij cliaiiires in the Iniij;- are -oniewliat more t're(|i!ent. J J oKi rvriirs j i:\-/:j:. fcH' i THE CIRCULATORY ORGANS. 'I'luTf i- ahiK.M ;il\v,n- iinilalcral ililatation nt' tlio licart. In cases uliiif (Icatli iKciii- iilali\(|\ cuilv, liic iiiii^cic i- tlaiii)V, Inalilc, dull, an. I <tiiinalily liav<> to deal witli tlir tiii-ni o|' inHriiiiii- niviicanlili- that ha- ivccnilv Imvii stu.licd l,v the aid "f niiKlcfn niicr liv common <'on.-ent iVirafdcd a- ainoiiLT the LTeate-t cnrio-ilic- in t\|)liii- I'evcr. rcric^ardilis a|)|icar.- to he c(|nallv rare. 1 have n:'Vcr -ecu it. Mie condition of the va>cnlar -v.-teni in tvpliii- tevcr has not l)ecn tlie -ulijcet ot' much inve-tiixiitiiiii. In the aorta and lart'e arterial trunk- ! have l^und iM.lat(crilicd cutaiiCH)u^ ^ranicrene descrilied in a ii inner parac-rapli is due to vascular chaiitres ; and it' it is the character ot' tlie-e chaiiires is unknown. 'I'he lilood in a ty|)hn.- t'evcr cadaver i- ilarker and more Huid tliaii normal. ( 'oairnlatioii is distinctly le-s inaikcf> ; III (illirr I il caiial I- aliiin-t alua_v> normal. Iiililtrati <>|)i it~ till' IliU on 1)1- (Ir^iiKTatioii of ii'lr< i- iic\cr tliiiiid, anil I II- inc.— I'i'vor'.- |iatclic.- anil I lie -olitarv IMI '■~ ^ ■•■., (lint nn II u->- n\nn of th,. -mall inr.-iin,.. Tlir ^lalunimi- in tlir oMrr liicratiiiv in n-anl to the o.timt.mi.v of ini,>tiiial ulirr-, i-|».riallv in ih,. .,|,al| iiiir-tiii.., hrtray an rrror in .lia-noMs. Tl a>r- uvrr iin.lonl.tclK "ilrotyplm-" (tyi.hoi.l frvm, u lii.-ii, a> «,• know in pranir,.. ua- init jwoporly iliMin-ni-i„..| from typhn. fcvur until I,,,,- after th,. ,lilV,.ivii.-,. I'<'t\v,.,.ii the ixv,, ,li-,.a-,.s jiaij Imtii frnily ,-talili~h,.,l ,,n th vli.. ^r. mil. Is. W hen i.rr.hym.M- arc |,r,.-cnt in th,. -a-tric ami iiiti'Miiiai .,„,- nu.n.l.raiic. tli,.y arc UMially al>o t;„in,l ,,n th,. |,crit,.nciini. whi.h in all other rc.-|ie,ts is tini'liaiiiriMJ. Th,. Iiv,'r ,!,„■> n,,t, a- a rnl,., ,,r,.~,.nt any variati,.n- ,.tli,.r than tli,,>,. <'l.serv,.l in ai'iite infiitioiK ,lis,.a>es jr,.iicrai|y, nain,.|v. mark.W ,.|ilari:v- iiieiit, inerea-,,! <.onMstcn,.y, liyfiereniia, ,,r ,li-tiii,.t >i^r,,- ,,f ,.|,,„dv .''wellinjr. A fatty liver, whii'li is >ai,l t,, o,.,.nr fr,.,|iienlly ( Kn.ken'- Ijorg), IS ii,,t, in my I'xperieiife, a ,.,iinmoii ,.<.eiirr(.|iec. THE SPLEEN. Tlie splenic clianj^ps are not >„ ,.,,nstant as th,.v are in tvpl„,i,l f,.ver \\hen ,l,.ath o,..-iiiv later in th,. ,liM.as.. than iiMial. the enlar>:,.mcnt of the e,.ti,in in such .-a-.'s pn.>cnt> a ,liill wiiie-r,.,l, or ,K.,.asionally ,larl<-iv,l. ,.,,|„r: the markin-- aiv ..ompl.K.lv l.lMm.,1 ami the pulp i- .oft, -oinctin,,.. ,.v,.n -,.,ni(liii.l or almost tliii,! Occasionally «c (iml intar.t-, ulii,.|i in ,.Ntrem-' , ■,.,.„., ,„;,v h.a.l to rupture (Ja<|iiot). Hoth the ol,ler an,| th,. inor, r.-.-eiit authors a-rce ,„ai ll ,. o.viirr,.,,, f p cm,. ..„lar,^.,i„.nt ,s ,i„„.!, h.., .V,.,,,,,,,, „„| ,|,.. ,|,„,,,„. „f ,.niar.r..|,u-i,t is "Hii.h les> ,1, typhus thay ni lypl,„i,l t;.vcr. On,, of ,|„. ,no>t ra.ii,.al -late- m|'Mts,„i this point is that of liarallier lepiilenii,. in ,hc prison of Toulon,, Mm foiin,lspl,.ni,. ,.|,lar^'eiiu.i,t in only one-thini of a total of )(U; ..a^cs ("M-I.anl f,.iii„l tlu;c,ilarv'...ii..nt pivs^-iit also in onlv oiie-thir.l. while Miir- Hn.soii rcp..rls hmlniL' it in two-iliinls of his autopsi,.s. \ nivsi.lf i„v...sti- fs-H i ;^l''.7'".' '-,^"""l"'i''--"" tvplHis f,.v..r pati..|its iluriii.r ,he v,.ars rH,,Saml IM,!.. lak,nirl.'.-.(. ,.ra„is as tli,. ..xtreiiie for a m.rrnal spl,.,.ii 'llciilyi, I ohtain,..! the fol|o« iiii: r,..,ilis : Not ,.nhi,-,.,l in l.'l> .'ascs "-.il lo.lOO u-rains in I o ; ;!IM( to 40U ,rr;„„s i„ ],; . 400 ,„ .-,o(> .r,.,,,,/;,', f ,, . ■JOO to m) grams in 2 ; (iOU to TOO jrra.u. in .'J ; ahove 700 grains in I rx-e' m r,i2 TV I'll IS ji \i:u. ".•i.-llic nil,., Tl,,. r,.|.,ii,,„ ,,t ,1, . I I'"-"" ■" •'■!■ :' 'Nn,i,.nil.. ,1,-rrn .1- t;.ii.ui " ; , ; * :'"^'':r' r '■■•■■':'' '"I'-v,,,,.!,. „ „ ii,,,,,,,,,,, ,„ '■ "'Mnu,,,:.' !:,|,l,. ,,!' C:; ,,(• i|„. i;,^,,,,,,, ,.. ^Mldrmii ISCS, CMllipij,,! liy ,||y :i>,-i>i;iiit. I'l r-.ATIOS ,,K nil |.|~KA^K. Win. II 1 .11 Till MM. KIN, LT„n,> ^.nnn>. ^.-nun- ,.ni,„. ,.r,„uv Jrams III II IL' !■; 1 1 ()M r I 1 I I 1 I ! 1 1 \2 THE GENITaURINARY ORGANS. .''"'"■'"''";■■ ^='~ ^' '-"I'- ^"■" ■ I"i-='t.'ly .■nl.r^,.,'|. hv,„.,vM,l,. .,,,,1 ''"";■.""*" '" ""■ '•'""""•"" "''I"' M.,.,1 ..i,„„iv -u.-. ^.,„„ a.-M imiijiaralivilv lr,.,|,i,.ni ,• |,li,,,ii,,„. 1.. .Mualiit, u, 1S7N .,,,1 l,s7l. „, ro„n,l. ,.n„nn.^ Nl ,..„l.,v..r~ ", ,..i r liortioii ot ill,. iii-,.i,i>. i"iM>. .111(1 III 111,. ,,|,|,i,,. X"tlii,„ ,.K,. ,„...„li.,. „. ,v,.l„, ,;.,,., „,, ,,.,.„ ■, ,,„, ,„„■,•„,. '""■' v' ''"' ^"•>""-"n"^"v ,„„■, ami in ,|„. p.nii.lia. (),.,.;,-i,„ ^ (■li;iiii:i'~ ill till. ,.ni|,iin,.t|.i ■:i-iiiiial '■"""• ~".^P>'Hi- ),ivii,,t,iiv lal„,r ,„. Ml„„.,i,,„ H-M to >l„,u-,|,at typliii. ,;.v..,.. Iik„,„„., „„„,, i„n.,,j„„, .,i^^,^^^^^ .^ NCTV JikcK- to iiitcrni|(t |iiv^;iiaii,.\ . THE NERVOUS SYSTEM. 'i;i,. niTvoii. ,.-„.,„ in ,v,,||,|. ,l,v,.,. |,a. ,..„...iv..,| iittl,. at„.„tio„, '"'-"l-.-„l,n. tl„. ,„.„„ii,i,.,„ ,,ar, i, ,,lav, in tin- .Mn,,„onia,olo,n- Hv,M.n.|n,a„t ,li,. .„r,a,.,. of ,|,„ ,,,ain, ,..|,.,na,o,K hilihratio,, .:;i,l iipacitv of ill, . |,ia niat,.r, ami an i iii'iva-,. Ill III,. v,.|itri,-iilai- tliii,|. «|ii,.|, ■1^ M nil,. ..|,.ai-, may o,...aMo„allv l.,...,,,,.. li.inoHia.i,.. aiv ,1,.. „„m ;"'':"''"""''^"'^"-'""i I"i'l-n,v,...^iila,.i,v. Tn,..„„.,iin,i,i. ,,,„,,,, '" '"■ -7 '■^"■"- -"^ a. l,.aM , .,.,1,. „nh in ,.,.,,aiii ,.,,i,i,.nii,... |.„,. .-nallv. I iiav,. not m-t n i.li a -im. of i, a, ,l„. a,ito,.M-,al,|,.. Ham- l"U,,,nH,..o,l,,Hian,i.,ii,,|i,i,,n.,..a.,.,,,f,,n,.n|..|,Mn.. ,i,i, i„ .„e o|ii,ii.ini<. >iii,ii,.,| 1,\ inni. M,.|,i„j,,.al li,.,i,on.|,a.,.. ar. ,li<,i,„.,|v „,„,,. (V,, ,,„,„,. ,.:,..,,,, ,„„, f 'I m .S)'.1//'7V>V,l7V>/,or,}-. ''T'r' """'"■ ' '-''I --""■- -i'l .v,.:,llaf;.n-,. ,■,,,,„„„ • 'iitirf lirnii>|(liric. ol;! to (■i.vci- ati . *" ""■"""■'■ l'-'"l.l-n..nl,a„- in,., ,|„. l.-ain-nl,-,.,,,-,. •„■,. ,li "'"' •'"' ""■'■'■■■'- '" '!"• •'■•"•'■I,i an l„,.|i,.,, an. n„.n.|v -i.-n. , f „1 II-,. '* '' >'UMs (it clirDiiu* al.-ol.ol,Mn. .„ ln.,|n,.Mt in ,v,.ln,. f;.v,.r patimt- A>.o,i„. |,i„a|,.„,,|.,,;„,,„j|„„., I,av,. n„.n,i„n..,l in.n.a.. in ,|„> ;:r7"';'- ;'"'-''• '■■■■•-'•'' ^• ••l.an...s in tluM.n;iu li..t\..us sv~t..ni. nut ini.r , l.,„,>,-,, ' ^ " ii"tliin:,r j, 1,11, ,„■! SYMI>TOMATOLOGY. Whereas tj,,. anatoniir ..han^v- i„ fnlm^ tLv..,- .„■ v ■ ■ • ■ .--i -tni nni. n , J, ' ' , r'i ! ^ ^ '' ^- *•'"— ••^'----■:..a,n „ ..et.;n;;:::;::'::;: :7";'"'-'-v"'"'" '-''•''-■'''ivia,.a,a,ta..,., ;::::z ='^*'"'t ""'■i.i^li ill iinportan..,. .,nv ,,(• In- r, • , "'•'"^" IHH'nliafities. In.le,.,! tl, ... etV , '' ~ ■•""~"""-'al -r -■.,uin. <-ase in many oiUw infctiuii. ,|;.,., „■ ■ n ■ ^'" * ,1 • ■ ■ ' '" '•'^*^-- '^ "■••lallv ni tv|,„,i,l (;,v,,r It,', to tins nu,.n,-orjrani.H, that «e att,.il.Mt,. the n.onl.n-'n I ^ :::::::::;::!;:':;;!;;;;!';;'■' ---:-".■:-.:',«':,:;; i'>'l'"rtan..e in the .11,,,,. ' 1 "''''' '' "^ ^'"■'' ^'t-'' ^''i-i'-n..:.;;:;ir;:i::''z:x:' '"'»■ • -' THE TEMPERATURE. Its ' .'irr/f /■ pl{i'S!(./ Iff// li i ■ 33 •".1 1 /■) rills I i:\i:i: The Temperature ., the Beginninj- and I,ater Stages ''■'"■'- "-'"'■'■'' '" '■> ■•'"■ l — il.lv - .rn.l. .lull-, M,n,v r;„vh ■' '•'•-'" -' ■'-^"' '■ ' "■". "hI Ih, I,„,|„.ratuiT ri..> r:,|,i,|K J,, tiMl M- r:i,lv .-,- il„. ,.^,.,H„o. ,,r ,|„. I,,-, ,lav it n,MV ,Ar,.,.,| ;;;, ,,„| ,„,, ''^"■'■'> '•"^"■'"- '" • •^'•'■■■^" I.n,„. ,v,ni-i,.n ;,!• ,„„ , v ,lu„ I .If "''■-'■'■•■ "" ''"■ ''■ll""i',,- „„„■„„„, ,l„. ..,,,, „.n„n,v ,.„nnMU,- ,„ ,,,.• ^"^"'''■•^""' '" ''"■ "^'"in^Mrtl,,. .V , ,h„ ,.,„„ |„,,„„| ,|„, |„,i,„ '■'■^"""' "" ''"■ l'i-''"ln,u (lav, iv^i-trnM,: |ii.:, ainl mv,,- \r„,. ^Hio.l,,.,- la|,~..,,r,„,,„^-r,„n- I,,,,,,-. ui,|, a v.n -lid.t n„,n,l,„. ivini- •^""'' " '''■"'■'"'- " •""! '^'" I'il-'lHi-. |„ „„,-, ,,,.- a.iutlH.r ,i-. i- """''"" ll"-'^'M,n^ nf ,|„. ,;,„,,|, ,1,,, |,,„„|,,,,. |.-i„ ,>,,^ .|.|^|_ _.^^^.^| n.-r m tluT,„vr,|i-,iM^lli~lK.~ ,^,,|„„ t,.,„„ ,,,,|„,i,| I,,,,,,. ^ ,,,,,,,,^^^^1 iMv ..r ih,. .li- -i.>i I - ' - < t ■ J - ' ■ I Fi... I 1 ^ -.'V. rr fiisn of typhll.-i. Typical fi 'vor riirvc in | art i|iiiv:Miiiiiniic ri-.. i„ ilip fMiponitmr t., ii- lii:.l„..t [.nint. >u