phoid often presents a decidedly remittent character at the outset of the attack. The non-recognition of this fact leads to frequent mistakes in diagnosis, and that many cases of simple typhoid, and especially its mild cases, are imperfectly classified under the headings, malarial, typhomalarial and remittent fever. In these cases we usually make our diagnosis at an early period in the progress of the disease, before the distinctive characters of typhoid fever have been developed, and at a time when the fever is very often remittent in its character.

We find in the first medical volume of the Medical and Surgical History of the War of Rebellion that continued fever was changed to typho-malarial, and later the Board of Medical Officers recommended change in nomenclature from typho-malarial to typhoid.

Professor Osler, in one of his New York addresses, in speaking of the third fever, where in New York they called it malarial to keep from speaking of it as typhoid fever, he called it New York malarial, which is one of his synonyms of typhoid.

Dr. Wood, in his "Practice of Medicine" (ninth edition), says: "In some instances typhoid fever presents no other symptoms than those of moderate fever. The tongue remains soft, moist and whitish throughout; there is no vomiting, no considerable nervous disorder, no great prostration; in fine, none of these peculiar symptoms commonly dominated typhoid. The disease runs its course in two or three weeks, sometimes in even less time, and then subsides spontaneously, leaving no unpleasant effects."

This fever occurs mostly in autumn and winter months, and can be traced usually to unsanitary conditions. All the fatal cases of this class, where post-mortems were held, were found to be typhoid fever. Where remittent and

intermittent fevers are prevalent you don't find much of this type of fever, hence this all goes to prove there is no third fever.

In handling these cases of continued fever, we should be very careful to make a correct diagnosis. Before we entertain the idea of a new fever, we must use all means and methods at our disposal to exclude malarial and typhoid, and especially typhoid. To exclude malarial, first cinchonize our patient; second, make microscopical examinations of the blood in search of the malarial plasmodium, and, if results negative, you may feel safe in excluding malarial, unless it might be the autumnal malarial, and you may further exclude by trying the typhoid test, which, if affirmed, certainly excludes malarial. As soon as we have excluded malarial, and doubt typhoid fever, we should at once send Dr. Harris, of Atlanta, a specimen of blood, requesting him to wire us the results. The best means of examining the blood at home is with an apparatus gotten out by Parke-Davis & Co. called agglutometer. I consider it a very safe and reliable test, and recommend it to all those who have not tried it. There is full directions with it, which is too lengthy to mention here.

I think that is one of the wisest movements of the State Health Board, when they suggested a laboratory stationed in Southwest Georgia to investigate this continued fever. It is the duty of the doctors of the State to urge its establishment at once. I believe it will help to settle this question of a third fever, and cause more of us to make a correct diagnosis of typhoid fever.

In short, I say when quinine will have no effect on this fever and you can't find any malarial "bugs" in the blood, it should be treated as a case of typhoid fever, and we should continue to do this until those who maintain the

existence of a distinct form of continued fever discover its cause, define its character and give to it a specific name.

If, as some may claim, there is a form of continued fever widely prevalent, which is influenced by the same predisposing causes, but is distinct from typhoid or malarial fever, the burden of proof is upon them, and we should never accept it until proven.

DISCUSSION ON DRS. SOMMERFIELD'S AND PALMER'S

PAPERS.

Dr. H. McHatton, of Macon: The question of a socalled simple continued fever has been up before this Association in various disguises since I became a member twenty-three years ago. I want to agree absolutely with the paper that has been read. I have spent much time in trying to find a simple continued fever. When we have a patient who is not malarial, where we do not have any tubercular condition that would cause it, where it is not caused by syphilis, you may make up your mind that in this country it is typhoid fever. I talked over this question with Dr. Welch twenty years ago, because the older practitioners claimed that there was a simple continued fever which was neither malarial nor typhoid. Dr. Welch asked me for some pathological specimens in order to make an investigation. I was never able to get such specimens. When the patients began to get worse the symptoms were those of typhoid. Patients with this simple continued fever rarely or never die. Let us take a group of cases I had some ten or twelve years ago. One case lasted ten days, one lasted fourteen or fifteen days, one lasted about three months, while another one died at about the eighth week. Either one of three or four of these cases would have been taken for a simple continued fever. We have a practitioner in Macon who recognized

a case as one of simple continued fever last summer and treated the case as such for four weeks, after which the case was turned over to me. The patient had two distinct relapses with hemorrhage before he got through. If we go on with these cases of simple continued fever, the first thing we have is a hemorrhage or something that is absolutely pathognomonic of a typhoid condition. So far as we are able to discover any proof, I think we can safely say that we have no such thing as a simple continued fever. The sooner we recognize this, and the sooner we treat the patient as a typhoid fever patient, the more will we lessen the mortality from typhoid fever in this State.

Dr. J. D. Herrman, of Eastman: I treated a young German two years ago for a supposed case of continued fever. It was an uncomplicated case. He recovered in about three weeks. Four months afterwards he developed an abscess on the outer aspect of the thigh. He was operated on by myself, and I found on making an incision that he had necrosed bone. I did the usual operation. He recovered in time, and in six months thereafter developed the same affection. He was then sent to Atlanta, where he was operated on by Dr. Nicolson. His recovery was prompt. Six months afterwards a similar abscess appeared, and he became very much discouraged. He went to Europe, and while there consulted two or three physicians, one of whom lived in Vienna. He was carried to one of the hospitals in Vienna and operated on. His brother wrote me a letter, asking whether he had ever had typhoid fever. I told him that he had a fever which lasted three or four weeks; that I could not pronounce it typhoid fever at that time. They were unable to find the typhoid bacillus in the cancellated tissue of the bone. He

recovered from the operation and is now well, so far as I know.

Dr. W. S. Kendrick, of Atlanta: With the experience I have had as a teacher of this disease and clinically at the bedside, I agree with the author of the paper and with the remarks made by Dr. McHatton. I do not believe, outside of thermic fevers, that there are but two great divisions of fevers, and those divisions are the ones that have been mentioned, malarial fever and typhoid. The typhoid can be determined by the diagnostic symptoms ✪. enlargment of the spleen, the rose-colored spots, the gradations of fever, its ascent and descent, as a rule. Of course, there are many exceptions. Whatever course they pursue, I believe these so-called continued fevers are practically all of them typhoid. We have to differentiate between malarial fever and typhoid fever, and, as a rule, the diagnosis can be made in these cases without very great difficulty. One of the greatest difficulties in arriving at a correct diagnosis in regard to typhoid fever as compared with any other disease is to differentiate it, for instance, from acute miliary tuberculosis, as they run parallel with each other. Miliary tuberculosis, however, is almost universally fatal. The symptoms, the clinical evidence, the appearance of the patient, in a large measure are exactly the same as in typhoid fever, and there is no question in my mind but that many of us have lost cases from acute miliary tuberculosis which were diagnosed by us as cases of typhoid fever. We have intestinal hemorrhage and other symptoms which are similar to those seen in some cases of typhoid. As has been expressed by the author of the paper and by Dr. McHatton, there are many grades of typhoid fever. Some cases terminate in ten or twelve days in resolution. Instead of having intestinal ulceration and sloughing, we have reso