to bed from weakness within a few hours. It may be so severe and sudden that the patient will fall in the street without previous warning.

Nausea and vomiting are commonly present, and may be distressing. The tongue is heavily coated in the first week, later having a tendency to become dry and brown, with sordes on the teeth and gums. The bowels are usually constipated, although there may be diarrhoea.

The pulse is rapid and full, being between 100 and 120; it becomes more rapid and feeble during the second week. Marked slowness of the pulse may be observed at any time of the disease and may continue into convalescence. A drop in the pulse without improvement in other symptoms is not a good sign. The urine usually shows the presence of albumin and casts in moderate amounts from an acute degeneration of the kidney. More rarely there are present the urinary changes of acute exudative nephritis.

Early in the disease there is a look about the patient which is often of diagnostic value. The face assumes a dusky flush, the conjunctivæ are injected, and the expres sion is dull and vacant, the whole appearance suggesting marked intoxication. The pupils are contracted.

The characteristic eruption appears from the third to the fifth day, although it may be seen as early as the second and as late as the seventh day. It consists of small, irregularly rounded spots, of a dirty-pink color, appearing first on the abdomen and chest, and becoming more general, although rarely seen on the face. It appears in one crop, and is all out in from two to five days, lasting from seven to ten days and then slowly fading. It is usually abundant, though in some cases it may be scanty. At first the spots are slightly elevated and disappear on pressure, but after several days they become petechial and more permanent, remaining after pressure. They have no well-defined

margin. In children the eruption resembles that of measles, and from the mottled appearance given by it to the skin the eruption has been termed the mulberry rash. In some cases there is added a diffused, deep mottling of the skin with large purplish blotches; in others there are hemorrhagic spots or a general erythema. These manifestations are not characteristic and are inconstant.

Cerebral symptoms are marked and appear early. The headache, so marked at the onset, usually becomes masked by other nervous symptoms by the end of the first week. Delirium is a fairly constant symptom. In very severe cases it may come on in the first twenty-four hours of the disease in the form of an acute mania. In less severe cases it is not seen until the end of the first week. It may then be only a mild delirium at night, or it may be more decided, persisting throughout the day. This latter form is often associated with delusions which at any time may render the patient violent. In severe cases, during the second week there may be observed alternately with the delirium a form of deep stupor known as "coma vigil," in which the eyes are wide open but the patient is unconscious.

Deafness may appear in the second week without assignable cause, but from it the patient usually recovers.

If the case is to end fatally, the temperature rises, often to 106° or 108° F. before death, the delirium and stupor become more decided, there may be retention of urine and incontinence of feces, the pulse becomes more rapid and feeble, and death occurs from exhaustion from the toxæmia. Should the patient survive until the third week, death usually results from a complicating pneumonia.

If the case is to recover, on about the fourteenth day there is a decided fall in the temperature, the patient frequently falling into a refreshing sleep from which he awakes weak but convalescent. In some cases this crisis occurs as early

as the seventh day, or at this time there may be a decided remission in the temperature, practically an abortive crisis, which is to be considered a favorable omen. In other cases the crisis may be deferred as late as the twenty-first day.

In some epidemics light cases are seen, running a mild course, with a temperature usually under 102° F., with but moderate cerebral symptoms. The crisis usually occurs between the seventh and the twelfth day. Occasionally there are observed in severe epidemics malignant cases in which the patient is overwhelmed by the virulence of the disease. There are rapidly developed a sudden temperature, usually high, progressive heart failure, stupor, and coma, and death may result in from twelve to twenty-four hours or within two or three days. In these cases no regular eruption is seen, but ecchymoses and hemorrhagic spots are irregularly developed.

Complications.-There may be broncho-pneumonia, which in rare cases is complicated by gangrene of the lung. Gangrene of the extremities or cancrum oris in children has been observed. Meningitis is rare and is always fatal. Abscesses in the skin and the joints may occur, and suppurative parotitis is not uncommon. There may be hemorrhages into the skin or from any of the mucous membranes accompanying serious cases. Thrombosis of large veins or of cerebral sinuses may occur.

Convalescence is usually rapid at first, although it is months before it is complete. There are no relapses. The patient may be left dull and feeble-minded, from which condition the recovery is gradual. A few patients develop acute mania in convalescence, but the ultimate prognosis is generally good. Paralysis from post-febrile neuritis is not

uncommon.

Prognosis. The mortality is from 10 to 20 per cent., varying with the nature of the epidemic, the previous con

dition, and the age of the patient. The disease is rarely fatal in young subjects, but is very serious in those past adult life. Complicating inflammations alter the prognosis according to their nature.

Treatment. The patient should be isolated thoroughly from the start. To lessen the danger of contagion to nurse and to physician, the windows must be opened freely to admit fresh air. If possible, the patient should occupy two rooms, one by day and one by night, the freest ventilation. thus being afforded. In epidemics the cases are best treated in tents, the patients being protected in winter by extra bedding. This fresh-air treatment is not only a prophylactic measure, but seems also to lessen the actual mortality. Windows should be protected by bars in case mania develops.

There is no specific treatment for the disease. Formerly mineral acids were so considered, but they are given now only because they afford a pleasant acidulated drink and do no harm.

The treatment, then, is entirely symptomatic. The temperature is best treated by hydrotherapy, as in typhoid fever, the bath being given as soon as the temperature reaches 103° F. Internal antipyretics should be avoided if possible, because of their depressing effect. Alcohol in some form is demanded in almost all cases, and it may be given in large doses until a good effect is observed on the heart's action: 10 to 20 ounces of whiskey may be required in the twenty-four hours. The delirium and headache should be treated by sedatives combined with hydrotherapy. Other symptoms should be treated on general principles.

RELAPSING FEVER.

Definition and Synonyms.-Relapsing fever is an acute infectious, contagious disease due to a spirillum, and cha

racterized by a febrile paroxysm of about six days' duration, followed usually by one or more similar recurrences at regular intervals. Synonyms: Famine fever; Spirillum fever; Relapsing typhus.

Etiology. The disease is a rare one, occurring in epidemics which last but a short time and then die out, leaving, except in very rare exceptions, no endemic cases. Epidemics were seen in Philadelphia in 1844, and in New York and Philadelphia in 1847 and 1869. The last epidemic of any importance was in Russia in 1886.

Epidemics have frequently been associated with those of typhus fever, the spread of both diseases being favored by filth, by famine, and by overcrowding of people. Neither age, sex, nor climate exerts any influence upon the epidemics.

The disease is actively contagious, not only by personal contact, but also through clothes and bedding and through the medium of a third person. One attack does not secure immunity from subsequent attacks.

The exciting cause is infection by a spirillum or spirochate, first described in 1873 by Obermeier. The spirillum is a slender spiral filament endowed with motion, its length being three to six times as long as the diameter of a red blood-cell. It is present in the blood, but only during the febrile paroxysm. Before the crisis and in the intervals. between the paroxysms only round glistening bodies are seen, which bodies are supposed to be the spores. Inoculations of the spirillum into man and monkeys have repro

duced the disease.

Pathology. There are no lesions characteristic of the disease. The spleen is large and soft and may rupture. There are parenchymatous changes in the liver, the kidneys, and the heart-muscle. There may be internal hemorrhages. The tissues may be jaundiced.