his condition was as follows: Temperature 104, pulse 140, respiration 24. Patient was more or less stupid, tongue was furred, dry and brown; breath fetid; chest normal; bowels had moved that day and stools were liquid and of foul odor. There was no abdominal tenderness, no tympanites, no gurgling. Diagnosis was withheld, and he was put on liquid peptonoids, and a prescription containing calomel, salol, and guaiacol carbonate.

March 21. Temperature 102, pulse 130, respiration normal (as they were throughout). His condition had not changed. He had passed two bloody stools, without any straining, and contained no mucus. His nose had bled during the night. In the evening of the same day the temperature was 103.5, the tongue was black and dry; there were sordes on the teeth. There was still no tenderness, nor any tympany. The provisional diagnosis of typhoid fever was confirmed. March 22. No change in his condition. Turpentine in emulsion was ordered to be given every four hours, five drops at a dose. March 23. Patient had been very delirious since the last visit. Bowels had moved several times, but stools are of the same character. Temperature by axilla was 101.5 Pulse weak. Ice helmet applied, and whiskey ordered. P. M. Condition the same, except that the delirium was not quite so marked. March 24th. Temperature 99.5, Pulse 128, better volume. There were hemorrhage spots all over the body and limbs; the gums were bleeding, the nose had bled several times in small quantities; there had been several tarry stools. The urine was highly colored, but an examination on the 25th showed no albumin, no casts, no sugar, sp. gr. 1008. In the evening the temperature was 100.5 by axilla, pulse 128. There was a conjunctival hemorrhage involving all of the inner canthus of

the right eye, and two small ones in that of the left eye. March 25. Temperature 98, pulse 128. Petechiae were fading; two small tarry stools. Ecchymoses everywhere that the patient was handled in turning him over, also on the parts of his body that were pressed upon by the bed. The stupor had disappeared, as had also the delirium. There was great languor. Evening temperature 100, pulse 128. There was decided hematurian. March 26. From this time. until the 31st there were several tarry stools daily, a great deal of blood in the urine, a good deal of gas with the stools. The turpentine was discontinued and adrenalin (1-1000) was given in doses of five drops every three hours by mouth. In two days this was increased to ten drops every three hours. The temperature continued normal in the morning and from 99 to 99.5 in the afternoon. The pulse varied between 128 and 136. The tongue began to get moist and to clear off on the 26th. On 27th patient complained of hunger. On 28th broths were added to the dietary. On the 29th the urine was very scanty, but increased to normal after the administration of lithia water freely. On the 30th there was no blood in the stools, and they were well formed. On the 31st the urine had cleared up, and the adrenalin was discontinued. The ecchymotic spots and the conjunctival hemorrhages were gradually absorbed, and the patient made an uneventful recovery.

There are a number of things about the case that deserve to be emphasized, and a number of others that are quite characteristic of the type of typhoid that occurs in children. Let us look at these first. They are the rapid rise of temperature instead of the gradual rise as in adults, the absence of prodromes, the shorter duration, and the increased manifestation of the nervous symptoms. All of these are shown in this case.

But the particular characteristic of the present case was the occurrence of hemorrhages in all parts of the body.

Here on the fifth day of the disease there occurred two hemorrhages from the intestinal mucous membrane, which continued every day thereafter until the fourteenth day, being quite profuse most of the time. Epistaxis occurred on the fifth and on the eighth days. Hemorrhages from the mucous membranes of the mouth and into the skin began on the eighth day and continued until the fourteenth day. The conjunctival hemorrhages occurred on the eighth day, and the hematuria was first seen on the ninth day, continuing until the fifteenth.

The temperature was peculiar. Ranging from 102 to 104 until the eighth day, it then fell to 99.5 and varied from that to normal during the second week, the fall being simultaneous with the occurrence of the hemorrhages into the skin and mucous membranes. The pulse was good, although at times it was weaker than at others.

An examination of the blood was made on the 10th day for the plasmodium, but was found to be negative. No count of the corpuscles was made, I regret to say. The corpuscles were crenated; otherwise there were no abnormalities in their microscopical appearances. The Widal test

was not made.

In looking over the literature of the subject, there are very few references made to this variety of the disease at all. In fact none of the recent text-books on pediatrics that I have consulted refer to this affection at all. All of them mention, of course, that intestinal hemorrhage occurs in the typhoid of children, but only in a very small proportion of these cases (3 per cent. according to Holt). This variety, however, is quite rare. In the epidemic at Basle there were noted only three cases in 1900; only one has occurred at the Johns Hopkins in a series of 829 cases. Curschmann has seen but six cases. Various other observers have reported cases of renal hemorrhage in typhoid (see bibliography below); Gillette a case of hematemesis;

Powell a case of hemoptysis; Blyumenau a case of hemorrhage into the larynx; Koenig a case of profuse hemorrhage into the mucous surfaces, and Barlow a case of purpura, occurring in the course of typhoid. But the case of Koenig's seems to be the only one that could be classed with this variety. This is the only case that the writer has ever

seen.

There is a good deal of doubt as to the cause of this affection. It has been assigned to overcrowding, to deficient nourishment, to scorbutic states, to alcoholism, and to the predisposition of youth and adolescence. The latter could have been the only etiologic factor in the present case. Trousseau thought that it was due to an altered state of the blood in which the coagulability was deficient. Osler found that in the case at the Johns Hopkins above referred to the coagulation-time of the blood was increased from four to ten minutes during the time when the hemorrhages were occurring. The subject needs further study.

The results have been very unsatisfactory in treating the condition heretofore. All of Curschmann's cases died; the case that is reported from the Johns Hopkins recovered; Wagner's mortality was 66 per cent. All hemorrhages in the typhoid of children are very dangerous, the mortality varying from 20 per cent. to 50 per cent. according to different observers. We would naturally expect that this variety would be much more dangerous to these little patients therefore. From the happy result obtained in the present case, we are led to hope that in the new hemostatic, adrenalin, we may have found a remedy that will contro! the tendency to hemorrhage, and thus conserve the strength of the patients until they can overcome the attacks of the

enemy.

BIBLIOGRAPHY.

Taylor and Wells. Diseases of Children.
Holt. Diseases of Infancy and Childhood.
Osler. Practice of Medicine.

Curschmann. Typhoid and Typhus Fevers.

Barlow. Purpura in Typhoid Fever. London Lancet, 1884. Gillette. Hematemesis in Typhoid. N. Y. Med. Rec., 1889. Green and Galloway. Two cases of Hematemesis. London Lancet.

Koenig. Profuse Hemorrhages from all the Mucous Surfaces in a case of Typhoid. Chicago Med. Recorder, 1893.

Powell. Hemoptysis in Typhoid. Westminister Hosp. Reports, 1890.

Blyumenau.

Hemorrhage into the Larynx in a Case of Typhoid. Vranch, 1899.

Buisseret. Renal Hemorrhage in Typhoid. J. de Med. Chir. et Phar., 1889.

Duckworth. Hematuria in Typhoid. St. Barth, Hos. Rep., 1885. Fishe. Hematuria in Typhoid. Med. News, 1884.