These conclusions were seemingly accepted by the leaders of opinion, but among the rank and file of the profession there was much muttering and shaking of heads. The general practitioner was loath to let go of his convictions, founded upon clinical evidence, against the dogma of immunity. There are those among the older members of the profession who recall the many battles over the diagnosis of enteric fever in our efforts to make our American typhoid conform in its symptom-complex to the typical typhoid of the German writers. The makeshifts adopted to avoid the direct issue, from which arose such terms as typho-malaria, typhoidal conditions, typhoid pneumonia, etc., only revealed the perplexity of the practitioner concerning this subject. The writer has a vivid recollection of a stormy debate in the N. Y. Academy of Medicine (1883) over the question of diagnosis, in which such leaders as the elder Loomis, Austin Flint, Fordyce Barker, Delafield, Janeway and others seriously discussed the question of admitting, as typhoid, cases in which constipation was a feature, in which the classic twenty-one days febrile arc was not present aud in which there was absence of rose spots and right iliac gurgling.

Out of all discussions arises the fact that typhoid, even in adults, varies its manifestations in different epidemics, in different stages of the same epidemic and in different individuals. Any one of the symptoms formerly accepted as pathognomonic may be absent. Ambulatory cases are known to us all. Diarrhoea may be absent; anorexia wanting; cephalalgia and other cerebral symptoms and epistaxis not in evidence; splenic and hepatic enlargement not demonstrable; roseola may not appear; pyrexia may run from ten to forty days or even be totally wanting.

While accepting these vagaries in adults, many were loath to admit the possibility of typhoid in young infants, in the absence of the complete symptom-complex, because of the rarity of post-mortem demonstration of the typical ulcers in the bowels. It remained for the bacteriologist to clear up the

question of diagnosis and furnish proof conclusive that no age is exempt from the invasion of the typhoid bacillus.

In

The work that has been done in the search for the bacillus of Eberth in the blood and urine shows its presence in from 21 to 57 per cent. in blood and in 20 to 62 per cent. in urine of cases studied, but no investigator has isolated it with sufficient regularity to be valuable or practical as a diagnostic procedure in general practice. In other words, the failure to find the Eberth bacillus should never be accepted as a negation of the diagnosis. Moreover, the laboratory facilities and technical training necessary for the demonstration of this bacillus in the blood and urine, far beyond the reach of the great majority of practitioners, make it questionable whether such measures will soon be employed in the ordinary diagnosis of this disease. This is less deplorable as we have in the Widal test a simple and easily applied method that has been sufficiently tried to prove its reliability within reasonable limits. With ordinary care the positive reaction may be accepted as evidence of the presence of typhoid fever. applying the Widal test the possibility of error is estimated by different observers to be from 2 to 5 per cent. For instance, Zupink has obtained a positive reaction in four out of six cases of Weil's disease, in six of cholithiasis, in one of cholangitis and in one of carcinoma of the liver. However, by means of the serum reaction and with very little aid from symptomatology, the diagnosis of to-day is accepted or rejected, and by its means we have been compelled to recognize typhoid in children as common, and in infancy by no means extremely rare. That the infrequent post-mortems fail to show the intestinal lesions of the adult no longer disturbs us. It is now understood that in infancy and early childhood the severity of the ulcerative lesion of the intestine generally shows a ratio inverse to age. The physiology of the intestinal tube may explain why Peyer's patches and the solitary follicles show only infiltration and exudate instead of the extensive necrosis and loss of tissue seen in adult cases. Be that as it may, the

fact is sufficient for present purposes that this stumblingblock to diagnosis has been removed and the arbitrary postmortem requirement has yielded to a recognition of the demonstrable fact, namely, that infants rarely exhibit the destructive intestinal lesions.

The late epidemic in Chicago has served to demonstrate further the frequency of the occurrence of unsuspected typhoid in children. In many instances cases coming to our clinics, presenting symptoms of the ordinary summer gastro-enteric disturbances or of malaise with slight rise of temperature, responded to the Widal test. Subsequent careful observation frequently demonstrated the undoubted typhoid infection. Some of these cases were placed in hospitals, many were observed at their homes, but a surprisingly large number of typhoids was found, which would have escaped detection under diagnostic methods formerly employed. Jaques, of the Health Department, found, out of 127 suspects between the ages of three months and four years, 23 positive and 10 incomplete Widal reactions. Churchill reports 7 positive and 2 incompiete out of 75 cases between the ages three months and four years, in children brought to the Lincoln Park Sanitarium for summer diarrhoea. Koplik states that out of 199 febrile cases in children in which Widal tests were made, 84 were typhoids, 81 of which gave positive reactions.

An experimental test in 100 sick children, made by Thursfield, gave 42 positive results. On the other hand Nachod found by the application of the serum test that the number of typhoid cases in his hospital children dropped to 13, while in three previous years, when the diagnosis had been based solely upon symptoms, they had numbered 35, 40 and 37 respectively.

Morse, one of the first to make extensive application of the test to children in this country, reported only one positive reaction among infants with intestinal infections. It is fair to state that Morse's observations were made at a time (1898) when typhoid was not prevalent in Boston.

Kasel and Mann report a number of cases from tests. upon children in families where typhoid prevailed which from clinical symptoms alone would have escaped diagnosis. Evidence is abundant of the value of the test in differentiation from other gastro-intestinal disturbances.

Without further burdening this paper with statistics on this point, the conclusion may be fairly made that careful application of the Widal test will reveal many cases of unsuspected typhoid in infants and children. This is especially true during typhoid epidemics.

We must accept the conclusion that typhoid fever in children presents many peculiarities when compared with the same disease in the adult. In fact, the variations from the accepted adult type of symptoms are so wide and so numerous that we may be justified in discussing it as an "infantile type" of the disease. The exceptions to this are sufficiently numerous to emphasize the rule. As in discussing typhoid we make use of the terms, "abortive type," "ambulatory type," etc., so we may now profitably add to the nomenclature "infantile type." That occasionally very young children present a picture of the adult type is, perhaps, of no more frequent occurrence than the infantile type as seen in atypical adult

cases.

What are some of the more marked peculiarities of the infantile type, as seen from an analytical study of a large number of cases in regard to invasion, onset, duration, severity, temperature, pulse, anorexia and other symptoms, lesions, accidents, relapses, complications and mortality?

As a rule, the symptoms of invasion are so obscure or the period so brief as to give the appearance of a sudden onset, not infrequently accompanied by vomiting, with high temperature, rapid pulse and symptoms of acute intestinal disturbance. The characteristic prodromal malaise of the adult type is generally not in evidence. The duration of the fever, as a rule, shows a ratio inverse to age. Many cases show a pyrexia

of from 14 to 21 days' duration, while a temperature lasting only from 7 to 10 days in young children is not uncommon.

In spite of the sudden onset, with symptoms indicative of the severest acute intoxication, the degree of toxæmia reached during the height of the attack is not nearly as profound as is usual in older patients. We have the stupor, and occasionally the comatose condition, also the dry, heavilycoated tongue, foul breath and restlessness, but less frequently than in the adult, less intense and usually for a much shorter period. Carphologia is rarely seen in very young children unless the constant picking at the nose and lips be a phase of that symptom. Subsultus is seldom seen; and meteorism is exceptional. The general ataxia, so familiar in the adult as to have led to the universal employment of the term "typhoidal condition," is not so common a feature of the infantile type. As before mentioned, post-mortem examination of the intestine shows infrequency of extensive ulcerative lesions in very early life. The fact that asthenia is less marked in infantile cases may be explained in part by the shorter duration of the attack.

The temperature in very young children rarely shows the typical typhoid arc, but sudden exacerbations occur from slight and often undiscoverable causes. Defervescence may be somewhat abrupt and convalescence may be prolonged by repeated attacks of pyrexia. The amplitude of diurnal variation is sometimes extreme. The pulse is rapid as a rule, seldom dichrotic but in severe cases remarkably arrhythmic. Anorexia is not nearly as marked as in adults. The majority of the children in the typhoid ward clamored for food during the first week as well as during convalescence.

Accidents and complications are decidedly less frequent in the young, with, perhaps, the single exception of skin lesions, as eruptions, furuncles and abscesses. Hæmorrhages occur less frequently and are rarely fatal. The initial epistaxis is infrequent. Relapses are not so common as in adults. Persistence of splenic enlargement during convalescence is