nation, but Sengree investigated the transmission of infection by flies, by placing them in Petri dishes in which there were cultures of various microorganisms, and then allowing them to wander over sterile agar. The growth of various microorganisms on the agar demonstrated the danger of transmission of disease by flies. Joly 2 has also demonstrated the danger of infection through flies by having these insects walk over gelatin plates and obtaining cultures from these plates. He notes a number of diseases which are undoubtedly spread through insects, sometimes through mere contact, sometimes through the insects carrying the organisms in their internal organs, examples of the latter being seen in plague and malaria. W. M. L. Coplin3 has investigated the same subject with a similar result. [We recall the account given by Agnew of a case of transmission of anthrax by flies.]

4

H. A. Haubold describes the conditions that existed at Chickamauga while the army was in camp there, and attributes the illness to the bad hygienic conditions. He states that the subsoil is very thin and that a stratum of rock lies very near the surface, so that the watersupply became readily infected, and the soldiers could not be prevented from drinking it. The typhoid-fever epidemic was extremely virulent; the temperature was often high and the delirium very violent, and it was difficult to carry out proper treatment, as ice could scarcely be obtained and the milk-supply was entirely insufficient. The nurses were few and ill-trained. [In camps the difficulty of preventing soldiers from drinking water not intended for that purpose is one of the most important elements to be considered in the spread of the disease. Strict discipline is invariably repaid by decreased illness.]

5

Pathology.-J. H. Bryant describes a case of typhoid fever without lesion of the intestine which occurred in a child of 1 year and 9 months. The Widal reaction had been positive during life and the symptoms were fairly typical. The postmortem showed enlargement of the spleen and mesenteric glands, and bronchopneumonia; the typhoid bacillus was present in the mesenteric glands. There had been severe diarrhea, a proof that this symptom is toxemic and not due to local disease of the bowel, since the intestine was found entirely normal. [It does not follow that the diarrhea of typhoid fever is wholly toxic. Many facts show that it is in part of this nature.] A. J. Lartigau describes 2 cases of typhoid septicemia, in 1 of which there were no intestinal lesions. In the first case cultures from the spleen, liver, mesenteric glands, bone-marrow, heart's blood, and kidney showed the typhoid bacillus. The patient had been ill about 10 days. The second case was ill about 3 weeks and showed no intestinal lesions; but typhoid bacilli were obtained by culture from the heart's blood, lungs, liver, gallbladder, and spleen.

A. Deléarde records a case of typhoid fever in a boy of 15, in whose blood typhoid bacilli were found twice upon culture. He was admitted on the twentieth day of the disease, and had a profuse purpuric eruption, due, it was believed, to the bacillemia.

1 Med. Rec., No. 3, 1899.

3 Phila. Med. Jour., vol. iii., p. 1303.

5 Brit. Med. Jour., April 1, 1899.

Gaz. hebdom. de Méd.

2 Gaz. des Hôpitaux, Nov., 1898.

Med. Rec., Oct. 22, 1898.

6 Johns Hopkins Hosp. Bull., Apr., 1899. et de Chir., May, 1899.

Schulz' describes an interesting postmortem finding in a case of typhoid fever. The intestinal lesions were characteristic; and further than this there were a number of swollen red areas on the under surface of the epiglottis, which microscopically were seen to consist of lymphcells, and in the connective tissue beneath them there were large numbers of staphylococci and bacteria which presented the characteristics of the typhoid bacilli. [Lesions of the pharynx, esophagus, and upper airpassages are no doubt much more frequent than is usually believed.]

W. Fordyce reports a case of intrauterine typhoid fever. The mother died of typhoid fever in the fifth month of pregnancy. Externally the fetus seemed entirely normal, and the organs appeared healthy to the naked eye. Cultures of typhoid bacilli were, however, obtained from the kidney, the spleen, and the intestinal contents, though the blood seemed sterile. Fordyce believes that typhoid fever may be communicated to the fetus with several possible results: the first being premature expulsion; the second, that the fetus may be born alive and suffer from typhoid fever; and the third, that it may be born alive and healthy.

Symptomatology.-E. Jauchen has observed an epidemic of typhoid fever in which the incubation-period could be accurately determined. The subjects affected were 36 soldiers who had, on one day during a homeward march, drunk freely of water in a village infected with typhoid. The incubation-period was as follows: In 3 cases, 2 days; in 7, 3 days; in 6, 4 days; in 4, 5 days; in 4, 6 days; and in 5, 7 days. Only 7 cases showed an incubation of longer than 1 week, and this short period is thought to be explained on the ground that the soldiers were exhausted at the time they drank the infected water. Apert reports an observation upon his own person to show that the incubation-period of typhoid fever may be very protracted. He was studying the serum-diagnosis of the disease, and thinks that he unquestionably infected himself in this work. For a month and a half he had headache, pains in the back, occasional epistaxis, and moderate emaciation. After this time the disease appeared in typical form. The serumreaction was positive on the second day. The fever lasted for a short time only. It is quite possible that the disease was in full course before it was recognized as such, and that therefore the incubation was not so long as described.]

J. Tyson, in discussing observations made upon the soldiers admitted to the University Hospital, states that 112 cases of typhoid fever were treated there with but 5 deaths, the mortality being 4.5%. Nearly two-thirds of these cases showed diarrhea, the remainder having been constipated through practically the whole of the attack. Rose-spots were observed in 53.5%, and seemed to have been absent in the others. Hemorrhage occurred in 9 cases, or 8%; and perforation terminated 1 case. Of the patients with hemorrhage, 2 died and 7 recovered. The Widal reaction was present in 77%, in 2.1% it was doubtful, and in 20.7% it failed. These results, however, are considered somewhat untrustworthy. In 7% of the cases thrombosis occurred. The notes record but 3 instances of the presence of albuminuria. The malarial organism was 2 Scottish M. and S. Jour., July, 1898. 4 Bull. méd., p. 1013, 1898. Phila. Med. Jour., Feb. 25, 1899.

Berlin. klin. Woch., Aug. 22, 1898. 3 Wien. klin. Woch., July 7, 1898.

found during convalescence in 2 cases, and in 1 other case it was found when the patient was admitted to the hospital, but not subsequently. Orchitis was seen in 1 case. Relapses occurred in 12 cases, a percentage of 10.7. So far as determined, the average duration of the disease in the whole series of cases was 414 days.

J. C. Wilson,' in reporting observations at the German Hospital, records 147 cases, among which there was a mortality of 3.4%. He notes, however, that in connection with this low mortality one must remember that the average age of the patients was but 23.5 years, and that all were picked men who but a few months before had been known to be in excellent physical condition. Of these cases, 64.6% were from Camp Meade, and over 25% from Camp Thomas, Chickamauga. The temperature became normal on an average of 22.4 days from the beginning of the attack; the average duration of the stay in the hospital was 31.2 days. Hemorrhage occurred in 5.4% of the cases. In 1 fatal case 2600 cc, of blood were lost in 6 discharges from the bowel. Relapse occurred in 14.2%. Multiple relapses occurred in 3 instances. The Widal test was carried out at the hospital and at the city laboratory in all cases. 5 instances the records from both places were negative, and 4 of these cases were unquestionably typhoid, while the fifth was doubtful. Venous thrombosis occurred in 5 cases, in every instance in the left leg only. The malarial parasite was found in 35 cases, usually nonpigmented intracorpuscular bodies; but also free hyaline bodies, and free pigment in the blood. In several cases, chills controlled by quinin, developed during convalescence.

2

In

A. V. Meigs states that 214 cases of typhoid fever were treated at the Pennsylvania Hospital, with a mortality of 8.88%. A number of these patients, however, were convalescent upon admission. Meigs treated 48 cases himself; 2 of these were fatal. He condemns the Widal reaction as applied to health-board work, since he has often had positive reports when the patients had not typhoid fever; and, on the other hand, it had often been negative when the patients undoubtedly had typhoid fever. He mentions a case in which were all the symptoms of typhoid fever, even to rose-colored spots on the abdomen and repeated hemorrhage from the bowel, the Widal reaction being positive. The man had been sick 3 weeks before he entered the hospital, but soon grew better. Nine days later he grew worse again, and passed through a rapid course of acute tuberculosis. The mesenteric glands were not found enlarged; there was no alteration of Peyer's patches, though there were irregular ulcers in the lower part of the ileum and the colon, and a general eruption of miliary tubercles was found. This case is believed to be strong evidence against the value of the Widal reaction. [Testimony of this kind is positive only when complete bacteriologic investigations have shown the absence of the typhoid bacillus; and at the late period of this man's death it is possible that even bacteriologic examination might have been negative, and yet that the man had passed through typhoid fever.] The mortality under the bath-treatment is compared with the mortality of the patients who were sponged. For the former it was 11.58%; for the latter, 6.72%. Meigs believes that this speaks strongly against the use of the bath. He admits that the records of such

1 Phila. Med. Jour., Feb. 25, 1899.

2 Ibid.

a small number of cases cannot be considered of great importance in deciding such a question.

B. F. Stahl observed, at St. Agnes's Hospital, 144 cases of typhoid fever. He notes the occurrence of a temperature of 107° F. in 1 case, of more than 106° F. repeatedly in 3 cases, and in many others the temperature was frequently very high. The blood in all cases was examined at the city laboratory, and in 10 instances the report was negative. He notes that diarrhea was decidedly infrequent in these cases, most of them being markedly constipated. The general mortality was 2.8%. Six cases of phlegmasia occurred, 4 of hemorrhage, 2 of orchitis, and in 4 cases scorbutic conditions of the gums. Gangrenous dermatitis was seen in 10 cases, the trunk being most commonly affected, after which the face, neck, gluteal regions, genitals, and legs were the most common seats of the gangrene. These cases did not come from the same camp, nor did the gangrene occur in one ward or floor of the hospital, nor in those cases under the care of one set of nurses. Therefore it did not seem to be due to any local cause of infection. The gangrene occurred chiefly in those who had marked circulatory disturbance, such as very weak heart, arterial change, or phlebitis. The rapidity of its development was most striking, and in favorable cases was succeeded by quite as rapid healing of the necrotic areas without any resulting scar. Three of the cases were

fatal.

R. G. Curtin, of 200 cases that had been treated at the Presbyterian Hospital, noted that most of them were mild, of short duration, and followed by few sequels.

J. M. Anders 3 saw many serious cases among the 266 cases treated at the Medico-Chirurgical Hospital. There were 26 cases of hyperpyrexia ; circulatory failure was frequently present; severe hemorrhage occurred repeatedly; in 2 cases insanity occurred, and in 2 hemiplegia ; in the same number purpura was observed; 13 of the cases were fatal. Combined typhoid fever and malaria was never found, though carefully looked for.

H. M. Vinke1 studied the epidemic of typhoid fever which occurred at St. Charles, Mo., during which 200 cases developed in a town having 7000 inhabitants. The mortality reached 8.7%. In the fatal cases intestinal hemorrhage was observed 5 times, perforation 4 times, erysipelas once, and meningitis is stated to have occurred once, but there is no postmortem reported. Orchitis is noted as a complication in one instance. True relapse occurred but once. Three cases were treated by the Woodbridge method, and there was certainly no abortive effect, one case lasting 41 days, one 28 days, and one 24 days. The cause of the epidemic was contamination of the water-supply by sewage which contained dejecta from a case of typhoid fever.

G. A. Muehleck reports the results of his examination of the blood of 90 soldiers, chiefly dealing with the morphologic elements. The red cells were reduced in practically all cases, the most marked reduction being found in the fourth week, when the number frequently fell below 3,500,000. The hemoglobin was likewise reduced, and the reduetion persisted into the fifth week, when there was some increase. He notes hypoleukocytosis in 79.1% of the cases, but an increase of leuko

Phila. Med. Jour., Feb. 25, 1899. 4 Med. News, July 30, 1898.

2 Ibid.

3 Ibid. 5 Phila. Med. Jour., May 20, 1899.

cytes in 20.9%. A very considerable number of these cases, however, had evident complications that would explain the increase. In 7 of the entire series of cases extracorpuscular and intracorpuscular bodies that sometimes contained pigment, and that in 2 instances showed ameboid motion, were observed. It is considered probable that the ameboid bodies at least were plasmodia; but in none of these cases were there any clinical indications of malaria. [Undoubtedly malarial manifestations are frequently absent during the course of typhoid fever, though malarial infection is present. These cases are prone to exhibit malarial symptoms during convalescence from the typhoid fever.]

Alezais and François have made a study of the arterial tension in typhoid fever, with a view to determining its value in prognosis. They reached the conclusion that while ordinarily the tension is lowered in proportion to the severity of the disease, no dependence can be placed upon this sign, since in some cases of but moderate severity there is great lessening of the tension, and in some of the gravest cases, owing to pulmonary or other complications, the tension is fairly good and sometimes normal or excessive. The study of the tension, therefore, has some value, but it is of much less value than determining the rapidity of the pulse, the latter being one of the most important of all signs in establishing a prognosis. [The authors could with entire propriety have gone a step further and asserted that the most valuable of all indications are the rhythm and character of the sounds heard in auscultation of the heart.] Contrary to this assertion, however, Rosenthal 2 found in 7 of 57 cases of typhoid fever that the first sound of the heart was everywhere inaudible, and in 5 other cases it was practically inaudible at the base. This symptom seemed to bear no definite relation to the severity of the disease, and did not necessarily indicate any serious complication. The author thinks that it is due to some functional difficulty with the cardiac nerves, and not to inflammation of the myocardium, since its occurrence is very irregular, and when the sign is noted the condition of the circulation may be very variable. [This report is at variance with accepted belief and with our own experience. Weakening of the first heart-sound is regarded by nearly all clinicians as a sign of evil omen, and we believe that this view is well founded.]

C. E. Woodruff 3 directs attention to the fact that cases of fever, particularly typhoid fever, run a more favorable course and have lower temperature in dry climates, as a result, he thinks, of the readier evaporation of the moisture and consequent greater dissipation of heat. He states that in the Philippines the continuous bath is frequently used with strikingly good results; the patient being immersed in water at about 90° F., and the temperature subsequently reduced by ice to 70° or 75° F.

4

G. Dock records the case of a soldier who had been in Porto Rico and who had an attack of typhoid fever which began with severe chills on each of 3 successive days. He had had no fever before this time. There were no malarial organisms in his blood. The temperature rose rapidly after the chills and went through the course usual in typhoid fever.

1 Rev. de Méd., Feb. 10, 1899.

3 Phila. Med. Jour., May 27, 1899.

2 Klin. Therap.-woch., Sept. 18, 1899. Physician and Surgeon, Apr., 1899.