day following passed stools which were typhoid in appearance. Collapse again occurred, and on the twelfth day symptoms of meningitis developed. Finally, a rose rash appeared, and the spleen and liver were found to be enlarged, and the case proved itself to be one of unmistakable typhoid fever. The age of the child, the sudden onset, with flushed face, the high fever, the collapse, and, finally, the meningeal symptoms, are of interest.

In some instances in which this high temperature is noted, when the physician first sees the patient, it is not in reality the earliest perversion of normal temperature, in that a mild and unnoticed fever has, perhaps, been present for some days, even though the patient has felt perfectly well. High initial temperatures indicate that the physician must be on his guard, because they mean severe infection or some grave complication which he must search for and discover, and particularly is this the case if the initial temperature is ushered in or is followed by a chill or rigor. Not very rarely careful study of the history of the patient will reveal an exposure to malarial infection, and an examination of the blood may reveal the presence of the malarial parasite.

The more sudden the appearance of the disease, and the more rapid the rise of temperature in the beginning of the first week, so much the more should one expect in general a short and even abortive attack, and, conversely, the more rapidly the temperature falls as the end of the first week is approached the better the prognosis, particularly if the daily fluctuations are marked.

Very sudden development of true hyperpyrexia, unless due to some essential complication, is very rare.

In some instances, not commonly met with, typhoid fever is ushered in by a severe chill. As already pointed out, these are most apt to appear in children, and in the majority of cases indicate the development of some coincident infection. Chills may, however, be due to the typhoid onset itself. They are met with more frequently at the onset of relapse than at the primary onset. Thus, in a case recently under the writer's care, a man of thirty-five years, after several days of malaise, was seized with a violent rigor. and became so ill at once that he was forced to go to bed, where he passed through a severe attack of the disease.

Under the name of "Sudoral typhoid fever," Jaccoud records in La Semaine Medicale for March 12, 1897, his belief in this special type. The onset of the malady is sudden and is accompanied by severe headache in the retroorbital and occipital regions, with shivering, fever, and sweats, so that the patient resembles in this condition one suffering from an intermittent attack. These attacks are often quotidian, and the febrile movement is hyperpyretic. These peculiar symptoms cease by the fifth day, and are followed by the usual course of typhoid fever. Quinine does no good in these cases, and they are not due to malarial infection. A second form is characterized by the primary appearance of headache and fever and then sweating, which is profuse and asserts itself much later than in the form just described. The febrile movement is distinctly intermittent in type, but not so markedly so as in that form named. In other cases, in place of a marked rigor, the patient has a subjective sensation of coldness in some part of the body, which can also be perceived by the physician if he touches the spot. In these forms these irregular manifestations may last three weeks and then gradually cease in the fourth week. Sometimes these cases are, however, very prolonged, and Borelli has reported instances lasting seventy or ninety days. Indeed, Jaccoud regards the length of the attack as characteristic. There are practically no complications. Albuminuria is extremely rare, but intestinal hemorrhage of mild degree is not uncommon. Peritonitis from perforation, Jaccoud asserts, is quite unknown in these forms, and he regards "sudoral typhoid fever" as a mild type of the disease. Notwithstanding the close resemblance of these types to double infection by the malarial organism, and the typhoid bacillus, both Jaccoud and Borelli believe them to be pure typhoid fever, because they occur in persons who have never been exposed to malarial infection, and because quinine is useless.

The differential diagnosis is necessarily difficult in the early stages of the disease, although in general Jaccoud would have us believe that it is easy. It must depend largely upon the absence of any history of malarial exposure, upon complete development of most of the characteristic signs of typhoid fever, and, finally, upon the absence of any signs of the malarial organism in the blood and the presence of the Widal reaction.

In the well developed stage of the disease, variations. from the usual temperature course are very frequently met with.

Of the cases in which the temperature is of low degree and mild we find much to say. In the first place, in very rare instances cases occur in which there is not only no fever, but actually a condition of subnormal temperature from the beginning to the end of the attack. Thus in several cases under my care, some years since, there was a characteristic temperature curve in form but not in degree, the morning. temperature being distinctly subnormal, and the temperature normal, and in which the return to health consisted in a "lysis," in which the temperature gradually rose to normal instead of falling. Again, almost equally rarely there is no temperature movement whatever in the sense that the temperature is either above or blow normal. Cases of this type have been recognized for many years by close students of the disease, but are not commonly recognized by the general practitioner, who is taught in the medical schools to regard fever as a necessary symptom of the malady. Many years ago the elder Miescher recognized these cases, and Liebermeister recorded, in 1869, 139 cases of "afebrile abdominal catarrh," which he thinks were in large part due to typhoid infection, and, in 1870, 111 cases of the same character. Many of these cases showed evident enlargement of the spleen, and in some instances a roseola. Strabe (Berliner klin. Wochmachige, 1871, No. 30) has described 14 cases in which no fever was present, although at times the temperature was subnormal, and in which, nevertheless, the other characteristic symptoms of enteric fever were present to so marked a degree that they could not be taken for any other disease. The mortality in these cases was no less than 14.1 per cent. So, too, Fraentzel (Zeitschrift fur klinische Medicin, 1881, p. 226) has recorded 41 cases treated in a field hospital during the Franco-Prussian war, in three of which the fever did not exceed 99.1 deg., and in the rest did not rise above 102.2 deg., and yet in which the mortality was 39 per cent. for the 41 patients. Guitéras (Transactions of the Association of American Physicians, 1887) records a case in which he diagnosed the condition as intestinal obstruction, in which the patient died of peritonitis, and at the autopsy the lesion of typhoid fever was found, although no fever had been present. Vallin (Archives generale de Med., November, 1873; see also Liebermeister and Hagenbach, Aus der med. klin. zu Basil, 1869, p. 9) records a case of death due to perforation in an afebrile typhoid fever patient and another of intestinal hemorrhage in a similar case, and I have seen several cases of this character in one epidemic. In still another epidemic another instance was met with, which has been recorded in the Memphis Lancet for July, 1898.

In La Province Medicale, November 26, 1897, Weill and Piery report a case of apyretic typhoid fever, which they considered in other ways entirely typical.

Two cases of apyretic typhoid fever have also been recorded by Wendland (Deutsche Medizinal Zeitung, August 29, 1893). These cases were confirmed by autopsies and illustrate, at least to the satisfaction of Wendland, that temperature is not a true index of the severity of the dis

case.

So, too, in that condition known as "abortive typhoid fever" the severe onset and high fever may so soon be followed by moderations and signs of convalescence, with a falling temperature, that the course of the temperature may be more aberrant and the chart misleading.

Here again, however, as in all the various forms of temperature just described, the physician must not be readily led into a diagnosis of an aberrant form of typhoid fever by the knowledge that such aberrant forms occur, for these forms are so infrequent as to be curiosities, and are so rare that the probabilities in an obscure case are against their presence. Only the clear and undoubted development of a sufficient number of pathognomonic symptoms, coupled, if possible, with a positive reaction with the Widal test and with a history of recent possible typhoid infection, should cause the physician to reach a diagnosis of these types of enteric fever.

In aged persons enteric fever is usually mild in its temperature curves, and the characteristic febrile movement is so irregular and distorted as to be devoid of much diagnostic value.

In other cases the fever is peculiar in that it fails to follow the so-called normal rise in the evening and slightly