lution taking place at a certain time, and consequently the patient is getting well. At that time those who advocate the eliminative treatment say that they are able to cure the disease inside of eight or ten days, but I think those are the cases that get well practically without any treatment. They reach the point in ten or twelve days in which ulceration or necrosis and ulceration would not take place, and consequently we have early recovery. If they did take place, they would do so in Peyer's patches to a small degree. I believe all of these cases, if they are not malarial, in which recovery takes place, in which we have a subsidence of the acute febrile condition, even at the end of ten, twelve or fourteen days, are mild cases of typhoid fever in which intestinal ulceration does not take place, or if it take place it does so to a limited degree. I believe and have always believed, from the pathology of the disease and from the general symptoms, that typhoid fever, like acute lobar pneumonia, if not taken within the first twenty-four or forty-eight hours of its incipiency, can not be cut short a single day by any kind of treatment.

Dr. C. M. Curtis, of College Park: I have enjoyed this discussion on typhoid and malarial fevers very much, and I want to endorse every word that has been said in regard to those diseases, with the possible exception that I may have misunderstood Dr. Kendrick when he said. that there are many different varieties of typhoid fever.

Dr. Kendrick: I think I said there is a great deal of difference in the grade of fever in these cases.

Dr. E. C. Thrash, of Atlanta: After hearing Dr. Sommerfield's paper, it reminded me of a case I saw in consultation not long ago. The patient was a child, ten years of age, whose elder brother had a long attack of typhoid fever, who was stricken down and had apparently a simple form of fever for some three or four weeks, when a

general periostitis set up. We first made an incision over the clavicle and let out quite a quantity of pus, then there were two incisions made along the radius and a good deal of pus was let out from there, and later on three incisions around the knee were made and two or three incisions up and down the tibia. I suppose there was a quart of pus removed from various parts of the body as the result of a general suppurative periostitis. Acute osteomyelitis was set up in the forearm and the bone was dead for about four inches, which finally sloughed out. We could not do a radical operation at this time on account of the lowered vitality of the child. A complete solution of continuity of the tibia took place three or four inches below the knee from this acute osteomyelitis. We made an incision around the knee of all tissue that was not already necrosed, and depended upon these incisions to let out the pus. Clamps were applied and the wounds were dressed very rapidly under gas anesthesia. The child was left in this condition until it could recuperate, so that an amputation could be made. The necrosis around this joint continued. We treated the case week after week, and finally the child got into a condition so that the necrosed bone could be removed from the arm. and later on we amputated the leg at the lower third, and apparently got along fairly well, but there was some infection of the bone higher up than we had amputated, and later we made a resection of the bone above the site of amputation. We removed something like four or five inches of bone of the forearm, and amputated the leg a third time. The child has now made a complete recovery, is perfectly strong, and has gained twenty or thirty pounds in the last twelve months.

Dr. Louis H. Jones, of Atlanta: If I did not misun

derstand Dr. Kendrick, he considered typhoid fever like acute lobar pneumonia, as not capable of being aborted unless it was nipped in the bud in the first twenty-four hours. How will you abort it at all?

Dr. Kendrick I had reference to pneumonia. Not to typhoid fever.

Dr. J. W. Duncan, of Atlanta: I enjoyed this paper very much. It is a fine paper. It is timely. For several years there has been quite a difference of opinion about typhoid fever. Six years ago this month I attended the State Medical Association of Tennessee, when this question came up there and Dr. Cowan, whom many of you know, a very excellent man in Tennessee, asserted on the floor that he had not seen a case of typhoid fever for twenty-six years, when every member in the Association had been treating more or less typhoid fever. Cases of typhoid fever in the mountains of Western North Carolina and East Tennessee are different from what they are in South Georgia. There is a difference in type, a difference in severity. A large majority of them will be delirious up there a part of the time during the course of typhoid fever, whereas farther south the disease runs a milder course, as a rule. You may have some intestinal lesions, hemorrhage, but the severity of the attack and the amount of delirium are not present as much as they are in the mountainous country. It may be in consequence of a different condition of the blood, as many of them succumb to the disease who have been delirious for two or three weeks.

As regards aborting the disease by eliminative and antiseptic treatment, we do not know whether that can be done or not. Many of us doubt it.

As regards lobar pneumonia, I believe there is an abortive form of that affection which under careful manage

ment will subside in three or four days. We know that. We have seen these cases. We have seen them with all the typical signs of pneumonia, with the brickdust sputum, and the temperature drops to normal on the fourth or fifth day. Our text-books, however, do not claim from the history of these cases that they can be aborted by treatment. Typhoid fever may be better in ten days, in two weeks, sometimes three weeks, but it is typhoid fever all the same, and I agree with the author of the paper in that respect.

A Member: I would like to ask Dr. Kendrick to describe his method of aborting pneumonia in twenty-four

hours.

Dr. Kendrick: It is claimed by the givers of veratrum that pneumonia can be aborted in twenty-four hours by this drug, and by venesection. Personally, I have not given three doses of veratrum in my professional life. I do not believe pneumonia can be aborted under any circumstances. When I have a case of pneumonia that I can not abort, I never institute any treatment along that line. I simply mentioned this in discussing the subject, that I do not believe, as a rule, there is any abortive treatment of pneumonia, except that free venesection may possibly in the first stage of pneumonia approach the idea of aborting it, but I have had no experience along that line, and I institute no treatment whatever with a view to attempting to abort pneumonia.

Dr. T. J. McArthur, of Cordele: I have been much interested in this discussion, and I agree in great part with the author of the paper and what has been said by the discussers, yet I believe some of the remarks in both When the paper and the discussion have been extreme. I practiced medicine in Southwest Georgia for a few years I occupied the position of saying that we had very

little typhoid fever there. I began to realize that we had fevers there which were not recognized always as typhoid fever. I repeat that I believe that the remarks that all continued fevers there or anywhere else are either typhoid or malarial is an extreme position. I believe that we have malarial fever in the beginning, and especially in chronic malaria that clogs up the system, so to speak. We have full metabolism going on, but the functions of all the organs are interfered with or made sluggish, and as a consequence effete material is retained within the system after the malarial organism has been destroyed, and that the retention of this effete material in the system frequently produces an irritation that causes a fever which is termed by the laity in that section of the country a slow fever. I believe frequently we have fevers that are typhoid that are termed a slow fever by the laity. It is an extreme position to say that all continued fevers there are typhoid or malarial fever. If you say that the trouble originated as typhoid or malarial fever, I might agree with you, but I believe we frequently have malarial fever, and especially chronic malarial fever, where the material elements in the system are disturbed, supposedly by the malarial infection which remains producing a low grade of fever.

We have mild cases of typhoid fever in South Georgia, and I may say in malarial districts. As to why we have it, I do not know. I am inclined to think that in the last two or three years probably nearly all of our people who live in malarial districts have had at some time their systems charged with malaria. Nature in her efforts to fortify the system against the infection of the poison forms toxins to combat that poison, and in doing so probably the typhoid germs in the system are made less virulent. It holds them down to some extent. It is either