fever with its concomitant symptoms is due to a catarrhal inflammation of the gastro-intestinal tract produced by the parasites in their first invasion previous to the administration of quinin. The height of the temperature often reached in the course of the fever may be caused by the ptomains of gastro-intestinal fermentation going on in this impaired digestive tract. Typhoid fever, with its mortality of 8 to 20 per cent., is, I believe, a disease very much less frequently met by members of this society than is the remittent fever of malaria, and yet we hear of it in numbers in every part of the city and adjacent country, but rarely know of a death. I know of no differential diagnosis which taxes the capacity of the physician more than that of typho-malarial fever.

The variability in the invasion of malarial remittent, and the steadiness of typhoid after the fastigium is reached, forms a marked difference, and when we are confronted with such cases as Lewis and Jackson saw, and as were so graphically pictured by Wood, Watson and Flint, our task is easy, but when with cases described by Osler, Anders and others, and investigated by Burk, of Texas, then we must not expect the clinical picture with a stepladder temperature. The tongue. the eruption, the facies and apathy, the dierotic pulse, the muscular tremor, the diarrhea, bowel hemorrhages and sloughing of parotid glands, with the stupor and delirium, but must rely solely upon the Widal reaction, which I believe Dr. Krauss stated was reliable in 97 per cent. of cases, and which the New York Board of Health concludes gives the reaction from the fourth to the seventh day in 70 per cent., and from the eighth to the fourteenth day in 80 per cent., and in the third and fourth week 90 per cent., and absent throughout in from 5 to 10 per cent.

Table of Symptoms.

REMITTENT FEVER.

Onset generally intermittent. Irregular remissions.

The temperature may arrive at 40 (104) within 24 hours.

Headache rare in the beginning; of a neuralgic character, pulsating, variable in its position and intensity. Sclera subicteric from the onset.

TYPHOID FEVER.

Onset gradual and progressive; regular, though very slight morning remissions with evening exacerbations of temperature.

The temperature does not reach 40 (104) before the third or fourth day. Headache from the beginning, permanent, severe frontal. Sclera white.

REMITTENT FEVER.

The apathetic expression of the face, the dryness of the tongue, sordes upon the teeth, are not very marked.

Breath foul.

The delirium may come on in the early days; it is recurrent, but changes with the exacerbations of temperature and other symptoms, and may give way to grave symptoms related to other organs.

If there be pulmonary congestion, the cough and other symptoms come on suddenly; the areas affected change from one to the other lobe or lung and may disappear and reappear again with varying intensity; dyspnea is very pronounced; circulatory disturbances are marked, even syncope.

There are usually restlessness and anxiety (jactitatio corporis).

Peculiar grayish color of skin; sometimes a slight jaundice. Herpes common.

Anemia more or less marked early in the course.

No characteristic exanthem; urticaria not uncommon.

At times there may be transient tympanites or ileo-cecal gurgling; they are but slightly pronounced and paroxysmal; diarrhea is slight or absent, and has not the characters of that in typhoid fever.

No distinct course.

Urine high colored; may show a trace of bile; Ehrlich's diazo-reaction rarely present.

Blood shows no leacocytosis; eosinophiles not notably diminished; serum does not cause agglomeration of typhoid bacilli (Pfeiffer, Durham and Widal); malarial parasites and pigmented leucocytes present.

Fever disappears under quinin.

Is an endemic disease, occuring particularly in rural districts; rarely epidemic.

Treatment. To bed should be the first order of the doctor, and as a prophylactic to others, all dejecta from the patient should be received in a vessel containing a sufficient quantity of disinfectant fluid before being emptied into the common receptacle. All soiled clothes and bedding should be well disinfected before washing, and persons living in that locality should be very careful about drinking the water and milk of

the place. The patient should at once be kept on fluid diet, and just here, it is useless for me to suggest anything until the regulation course of calomel, quinin and some antipyretic has been given to the satisfaction of the attending physician. And then the quicker we realize that we have no specific treatment for typhoid fever, and have no bowel antiseptics with which we can reach the microorganism, but must treat the patient for typhoid fever, the better will be the result. In the first week it may be necessary to give some hypnotic or anodyne to relieve the headache, restlessness or pain in the bowels. A few grains of calomel with regulated diet relieves the nausea and vomiting. If constipation attends after the calomel has acted give a cold water enema as needed. If diarrhea is troublesome, opium may be needed, but cold bathing usually stops loose bowels. The mouth and tongue should be cleansed daily with some disinfectant. Temperature should be kept down with cold bathing, tubbing or packing from the first day of the disease. Antipyretic drugs should be used sparingly, yet there is no objection to an occasional dose of some antipyretic, when by its use the fever can be reduced, pain and restlessness relieved, and sleep induced.

It is not in every case that cold bathing can be intelligently had, and in such cases I find thermol in 5-grain doses would serve a better purpose than any other antipyretic of its kind. It seems to hold the temperature down when repeated every four hours with less vacillation and prostration than any other of the antipyretic drugs.

For the disease itself, the most efficient treatment is the application of cold water begun early. Delafield says "the temperature as such does not add to the danger of the disease nor require treatment. The systematic use of cold baths of a temperature of 65°F. lowers the mortality of the disease, but not because it lowers the temperature."

It is generally conceded that cold bathing lessens the mortality. For a failing heart in the second week, digitalis, strychnia and alcohol serve the best; alcohol is not only a stimulant to the heart's action, but being so diffusible and combustible furnishes food for the fever, thereby lessening the oxidation of tissue. When there is too much distension of the bowels,

cold applications-the ice bag-or in some cases hot fomentations to the abdomen, and the internal use of small doses of castor oil or turpentine, seems to meet the indication better than any other.

If much subsultus and tremor, give opium or compound spirits of ether.

For hemorrhage from a sloughing gland in the intestine, or even as a preventive, I think I have gotten better results from nitroglycerin than from any other treatment; its effect is in dilating the vessels throughout the body, lessening the blood pressure in the gland.

Opium and astringents are the old remedy from which I have never gotten any results other than checking the peristalsis of the bowel, which at that time is usually at a standstill from gaseous distension.

In convalescence, the principal point is to make the transition from fluid to solid food, and this must be done very cautiously, but it may be done on the fourth or fifth day after subsidence of temperature, beginning with scraped beef or mutton. When the fever continues much beyond the usual duration, I find it well to begin feeding with some solid food, even before the fever subsides. The strictest attention should be given to the room of the patient; the surroundings should be cheerful, yet quiet, and cleanliness and light should be in the room. Water should be given throughout liberally.

DIAGNOSIS AND TREATMENT OF DIPHTHERIA.*

BY JOHN PELHAM BATES, M.D.

ST. BETHLEHEM, TENN.

Symptoms. The incubation period is very variable, so much so that little diagnostic value can be placed upon it.

Invasion. The child may complain of chilliness, slight indisposition, aches and pains in head, back or limbs, with a rise of temperature, not usually high, 101-102°F. Pulse rapid and compressible. The pulse is usually rapid out of proportion to the rise in temperature. There may be, when first seen, a * Read before the Montgomery County Medical Society, December 13, 1901.

considerable degree of prostration. The tongue is coated with a whitish or brownish fur, edges red, and later becomes dry. The patient may complain of some soreness of the throat or, perhaps, no reference will be made to the throat. On examination of the throat (a procedure that should be a routine practice on the first visit to all children) it will be found red and swollen, patches of false membrane will be found on the tonsils, sometimes giving the appearance of small ulcers, but on close examination the ulcer-like appearance will be found on and not in the structures. These patches spread and coalesce, spreading up the half-arches to the uvula, to the posterior nares and pharynx. The pseudo-membrane is at first whitish or ashy gray, but with continuance of the disease may become yellowish or brown or even reddish brown from the admixture of red blood corpuscles. The membrane is removed with difficulty and leaves a raw, bleeding surface. It rapidly reforms and is often shed and reformed during the course of the dis

ease.

The glands at the angle of the jaw and side of the neck are enlarged and painful. The inflammation in these glands sometimes goes on to suppuration. In severe forms of diphtheria the whole side of the neck may become tense and brawny. There is an ichorous discharge from the nostrils, especially when the posterior nares are involved, that excoriates the corners of the nostrils and the upper lip. When secondary infection takes place, which it does early, the breath has a foul or fetid odor. The urine has the usual febrile characteristics and contains albumin by the second or third day. According to Anders, albuminuria is such a constant concomitant that it may be classed as a symptom of the disease rather than sequel. These symptoms are such as are found in cases of medium virulency, but this disease ranges in symptomatology all the way from slight indisposition to sloughing and gangrenous condition of the throat, or to death in the first day or so from the overwhelming of the system by toxins, leaving scarcely any local signs of the onset.

Laryngeal Diphtheria. The onset of diphtheria in the larnyx does not usually cause much systemic disturbance, because of the different histological structure of the laryngeal and