3.7. Ord. Ol. Terebinth. gtt. x; Acid. Muriat. dil. gtt. v every two hours, with Quinine gr. viij daily, and restricted diet.

3.8. Tongue not so dry; is better. Whiskey f3ij.

3.9. Temperature elevated. Ord. to be sponged.

3.10. Has had four stools in the last twenty-four hours. Some sonorous rales over chest posteriorly. Sponging to be repeated when temperature rises.

3.11. There is some subsultus. There are more numerous râles heard over chest posteriorly.

Ord. whiskey f3v daily; turpentine stupes to chest. His diarrhoea is better, considerable hebetude.

3.12. Tongue is not so dry, and is cleaner. The spots over his body are beginning to assume more the appearance of petechiæ. They are found everywhere on his body. Has had but one stool within the last twenty-four hours.

3.13. He is brighter; skin feels better; tongue cleaner; pulse but 80. Fewer râles heard in chest. No change in his treatment.

3.14. Spots disappearing. Two stools in last twenty-four hours, not so loose in character. Pulse dicrotic.

3.15. There is no tympany. Had one natural stool yesterday. Sudaminæ over abdomen.

3.16. Doing well. Pulse very slow.

3.17. Tongue moist and clean; no diarrhoea.

3.18. No diarrhoea; spots are still to be seen, but are fading every day.

3.20. Takes a little lemon-juice, as the gums are disposed to be a little spongy.

Stop turpentine and muriatic acid.

3.25. Bowels somewhat constipated.

Ord, enema of castor oil.

3.26. Stop quinine; give whiskey f3iij only. Allowed chicken and two eggs daily.

Ord. Tr. Cinch. Co. fzij s. t. d.

4.4. Slight chill, headache, and pain in side. Temp. 101°.

4.5. Temp. normal again; as well as before.

4.8. Has been up for a week, and steadily gaining in strength, except the slight attack on the 4th, when to-day, without his having taken any indigestible food, or indeed any reason to which it could be assigned, he was seized with a relapse, his temperature rising to 105°, but being reduced a half degree by sponging.

4.9. Spots have again appeared in great numbers, and they are very large. Last evening his temperature reached 104°, and was reduced to 101° by sponging.

4.10. Doing very well; spots are still making their appearance.

4.12. Diarrhoea not at all excessive.

4.15. Spots are very numerous.

4.20. Temperature nearly normal.

4.25. Doing perfectly well; up and about.

4.30. Left in ward, upon completion of my term of service.

ABORTIVE ATTACK, FOLLOWED BY TYPICAL ATTACK.- -Thomas Rogers, October 15, born in Philadelphia, assistant nurse. Admitted

VOL. I.-20

24 20 20 20 20 24 24 24 24 24 24 24 28 26 20 20 20 20 20 20 20 20 20 18 18 18 18 18 18 18 20 20 20 20 20 20 20 20 20 18 18 Chart of Typhoid Fever with relapse.-Original attack.

FIG. 17.

306

Chart of Typhoid Fever with relapse.-Relapse.

January 25, 1883; discharged March 26, 1883, cured. Father died of hemorrhage from the lungs; mother living and healthy. Two years ago he sustained a compound fracture of the left leg from a bale of cotton falling on him; otherwise he has always enjoyed good health. For the past three months he has been assisting the nurse in the receiving ward of this hospital. Four days before admission, without unusual exposure, he had a slight chill, and felt cold for several hours. This was followed by fever and a feeling of weakness. He also had slight headache and the bowels were constipated; no epistaxis.

Upon admission patient has a good deal of hebetude, face flushed, temperature 102°, pulse 106, tongue slightly coated, moist. Has slight pain in right lumbar region, but no distension of abdomen. Urine negative. Ord. quinine gr. viij. daily; liq. ammon, acet. f'zij. q.q.h.

Jan. 29th. More hebetude; tongue more coated with brownish fur, red at tip; bowels continue costive; opened by an enema.

31st. Is brighter and better. One doubtful rose-colored spot seen on abdomen.

Feb. 4th. The morning temperatures for the past two days have been subnormal and the evening rise is very slight. All the symptoms also indicate the approach of convalescence.

6th. More fever; pulse weaker; functional murmur heard over heart ; sudamina out over abdemen. Ord. whiskey f 3ij.

8th. Some fulness of abdomen; had three loose yellowish-colored stools in the last twelve hours.

9th. A few doubtful rose spots out over abdomen and back; sudamina still abundant.

10th. More tympany; numerous rose-colored spots out over abdomen and back; slight epistaxis and bronchitis.

11th. Pulse more feeble; still slight diarrhoea. Increase whiskey to fjiv.

15th. Has a good deal of hebetude, but no headache; fewer spots; pulse weaker; temperature lower. Increase whiskey to f3vj.

17th. Temperature high again; most of the spots have disappeared; slight epistaxis and subsultus; no delirium; bowels not open for two days.

20th. Temperature falling; spots disappearing; still fulness of abdo

men.

25th. Temperature has been subnormal for several days, and he is doing well; tongue cleaning. Has emaciated a good deal, and is weak. March 1st. Is convalescent; tongue has lost its redness.

8th. Continues to improve; allowed semi-solid food.

17th. Is now quite well; has gained a good deal in flesh, and is stronger.

The examination of the bodies of those who have died during a relapse reveals the presence of two sets of lesions in the cicatrizing ulcers of the primary attack and the recent ulcerations of the relapse. The latter are usually less extensive, and are found to be situated at a greater distance from the lower end of the small intestine, than the former, for the reason that the Peyer's patches most remote from the ileo-cæcal valve are least apt to be affected in the primary attack.

No satisfactory explanation of these relapses has as yet been discovered.

FIG. 18.

They occur in patients of both sexes and of all ages with about the same frequency. They have been attributed to errors of diet, mental and bodily fatigue, and the like, but, while we know that causes of this character often provoke recrudescences of fever, and can understand that they may act as exciting causes of a relapse in cases in which the predisposition exists, it does not seem possible that they should by themselves be able to bring back all the characteristic symptoms of a specific disease. It has been maintained by some authors that a relapse indicates that a new infection has taken place; but this hypothesis, even if we admit that it accounts for those cases in which the patient is allowed to remain in the place in which he has acquired the disease, does not explain those in which he is removed during the first attack to a hospital where all the sanitary arrangements are presumably perfect. Griesinger has endeavored to explain relapses occurring in hospitals by suggesting that they may possibly be due to a fresh contagion from other patients with typhoid fever in the same ward; but this explanation is rendered improbable by the fact that relapses have occurred when cases have been thoroughly isolated. As I have already said, during a long connection with the Pennsylvania Hospital I have only known a single case of typhoid fever to originate within its walls, although relapses probably occur in its wards with the same frequency as in other hospitals. To adopt Griesinger's explanation, it would therefore be necessary to assume that a patient just recovered from an attack of the disease is more susceptible to the action of its contagion than patients suffering from other disease; which seems improbable, to say the least. It has also been maintained that relapses are due to the inoculation of the previously healthy Peyer's patches by the typhoid poison which is thrown off with the sloughs from those first affected. Maclagan alleges that relapses are more frequently met with in cases in which constipation is present in the primary attack, a condition which he regards as favorable to absorption; but this is opposed to the experience of almost every one who has paid any attention to the subject. In the cases which have come under my own observation it certainly was not the case, diarrhoea having been present in all of them. It is more likely, as suggested by Liebermeister, that part of the poison remains latent somewhere in the body, not developed, destroyed, nor expelled during the first attack, but brought later into activity by some exciting cause. Da Costa adopts this view, and says that relapses of typhoid fever are not unlike the outbreaks of malarial fever which occur after worry or fatigue and when there has been no chance for a fresh infection. Different plans of treatment have at various times been charged with increasing the predisposition to relapses. This is especially true of the cold-water treatment, and the records at the hospital at Basle show that the proportion of relapses and the number of deaths from them are both increased under the use of cold water. Liebermeister thinks, however, that this does not necessarily prove that this treatment favors the occurrence of relapses, since before the introduction of this plan of treatment many more typhoid fever patients died in the first attack of the disease. Employing those cases only for statistical purposes in which the patients have survived the first attack, he finds that the difference at once disappears, there being 9 per cent. of relapses before the use of cold water, and 10 per cent. after its

use.