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up to the age of 15 years, but 21 per cent had symptoms calling for urgent treatment. In those the temperature ran very high; stupor, delirium, tympanites and sordes were all present. The history of one of these may be of interest.

Child B, male, age 712 years, was taken sick on the 24th of November, 1900. Came home from school, complaining of headache, but played some. Had diarrhoea for the first week; afterwards constipated. On the 6th day of the fever the mental condition changed from apathy to marked stupor, which endured until convalenscence was well on way. From the beginning of the stupor he never articulated until the end of the fifth week of his sickness. Emaciation was extreme; cutaneous hyperesthesia was well marked and general all over the body; the muscles of the back and neck were painful, and on moving the arms and limbs the child would cry out with pain. As the disease progressed the stupor became more extreme. It required great effort on the part of the attendant to arouse him sufficiently to take food; the tongue early became dry and covered with a brown crust; the abdomen was distended; the legs flexed on the abdomen, and the face presented a pitiable picture of distress; the pulse was extremely rapid and weak, and required constant stimulation. It was almost impossible to keep the child off its back, and as a consequence hypostasis had to be fought continually. He had as complications and sequela deafness, suppurative otitis media, falling of the hair, marked slowness of speech, mental weakness and poor memory.

The epidemic presented examples of almost every type of the disease known, the afebrile and ambulatory forms excepted. There was the "mild," the "grave," the "cerebro-spinal and hemorrhagic,” the “gastric or bilious,” the “adynamic,” the “sudoral," the "abdominal" and "thoracic," the "typho malarial," and lastly, the "intensly malignant or fulminant” form. From year to year, for the last ten years of my practice in this locality, it has not been unusual to have cases of ambulatory or walking typhoid fever. In this epidemic, however, such cases were noted for their absence, except in a few children under 10 years of age,

, who, however, were not allowed to walk about. In other years patients have walked about and recovered without any complications or sequela, save emanciation and general weakness, but in this epidemic no trifling escaped its punishment. It seemed utterly impossible to deviate from the simplest rules governing the treatment of typhoid fever cases without aggravating the disease


and thereby prolonging its course. Another feature was pecially noticeable; out of a mild type of the disease any of the . forms mentioned might, in the midst of the most hopeful prognosis, suddenly develop and cause it to prove exasperatingly intractable.

Typhoid fever is now, and always has been, a treacherous disease, full of many pitfalls in the way of complications and sequelæ ; but this epidemic was unusually so. The hemorrhagic type of the severer forms was very prevalent. In this class I include those cases who had hemorrhages from the bowels, as well as from the ears, nose, mouth and mucous membranes in general. Fifteen per cent of my cases had hemorrhages from the bowels; of these 5 per cent were children under 15 years of age.

One case I saw in consultation and another went to her home in Denver and died of violent hemorrhages at the end of the second week. The one I saw in consultation was a child of 512 years of age. She had a violent type of the disease, marked hy active and continuous maniacal delirium, abdominal pain and tympanites, dry tongue, high temperature and rapid pulse. At the end of the fourth week of her sickness a violent hemorrhage came on. Five minutes after the hemorrhage began she died. The whole contents of the vascular system poured out of her body in one heap, completedly exsanguinating her. The balance survived the hemorrhages, and all but one recovered. This one subsequently died of unilateral lobar pneumonia. The hemorrhages were characterized by profuseness and early occurrence. They were accompanied by a pronounced fall of temperature, which seldom arose to any considerable height until convalescence or death ended the scene.

Thirty-three per cent had delirium. The character of it differed from a more or less mild type to a wild maniacal type. The low muttering type was present in 15 per cent of cases in children; 10 per cent had severe tremors, accompanied with great restlessness, and 10 per cent had the wild type of delirium. In adults the "low muttering" form predominated. It came on usually about the end of the second week and lasted until convalescence. It was not unusual, however, to find it present as early as the end of the first week of the disease. Intestinal flatulence was the rule, and marked abdominal gaseous distention occurred in 18 per cent of all my cases. It was one of the most troublesome symptoms. It occurred in the constipated form as well as in the diarrheic form. It was extremely troublesome to one patient,

In one

who had organic heart disease, and caused an increase in the rapidity of the pulse and respirations in mostly all cases. child the heart always became irregular under excessive distention. Colonic flushing, with or without turpentine, or the introduction of the rectal tube, invariably relieved this symptom. A gut distended with gas favors hemorrhages, deep ulceration and a freer absorption of decomposed products and toxines from the intestinal canal. Enteralgias from direct pressure of the distended gut, on the greater and lesser splanchnic nerves, were common, and in this abnormal condition, we have a satisfactory explanation of the vaso-motor disturbances that accompany this disease.

Constipation was the rule all through the disease. A small percentage of cases began with a characteristic diarrhoea, whichi continued for the first week. This was followed by constipation. One adult patient had a troublesome diarrhea, consisting of watery discharges all through his sickness. The initial manifestations began in the larynx and pharynx. The temperature did not run high, but the throat difficulties continued without interruption. Thick tenacious secretions, which were exceedingly hard to remove, formed therein. Those in the naso-pliarynx underwent decomposition and imparted to the breath the most sickening odor. At the end of the second week the bowels became enormously distended with gas; the intestinal discharges were exceedingly offensive. It was absolutely impossible to change their character, and even with frequent colonic flushing, antiseptics, etc., the odor, watery stools and tympanites continued until his death, the sixth week of the disease.

In these cases, the shortest duration of temperature was 14 days, the longest 49 days. The curve, as a rule, was not characteristic of typhoid fever, except in a few cases. One of these was Mrs. A. W., whose temperature chart I exhibit. It shows two recurrences of the fever, one on the 22nd day of the disease and one on the 33rd. Her case presented an uncomplicated one up to the 35th day, when phlebitis of the femoral vein set in. Possibly the rise in temperature on the 35th day was due to the advent of the phlebitis and not to a recurrence; at any rate it marked the beginning of the end. Stupor, which day by day gradually deepened into coma and coma vigil, accompanied this last thermometric curve, and she died of exhaustion ten days later.

Hyperpyrexia was not the rule. The highest temperature in any of my cases was 105.6°, the lowest 96.2o. A sudden fall in temperature was rare except in the case of hemorrhages. The pulse was rapid as a rule. In the case of Mrs. A. W., already referred to, it was found on only two occasions below 100. The last ten days of her sickness it ranged from 120 to 160.

In the case of a boy of 15 years, who had a recurrence of the disease, the heart during the whole period of the recurrent attack had to be vigorously supported. On the day of the recurrence the pulse went rapidly up to 124. Except for the absence of an endocardial murmur, a diagnosis of malignant endocarditis might easily be made. On the 12th day following, a pulse of 160 was reached. It ranged between 136 and 160 for the following nine days, when it suddenly dropped to 78 after a sponge bath. The highest temperature recorded during this time was 102.8°, the lowest 98°.

In five children and two female adults, cutaneous hyperesthesia was marked. The slightest touch would create great suffering This condition was usually accompanied by clonic spasms of different groups of muscles. In one case great rigidity of the arms, limbs and spine was present. The upper arms were forcibly drawn to the sides and the forearms and hands across the chest. They could not be removed without the exercise of great force, and any attempt at doing so would elicit the most pitiful cries of suffering. There was a fixed ecstatic expression of the face and a rigid condition of the muscles of the neck. The tendon reflexes were normal; the pupils responded to light and opisthotonus was absent. Bronchial cough was present in the early stages in nearly all cases. Fully 25 per cent. had marked catarrh and hypostatic congestion of the lungs, 5 per cent. had lobar pneumonia, and 3 1-3 per cent. had fecal impaction low down in the rectum. One case had peritonitis, one a gluteal abscess and one necrosis of the nasal septum followed by perforation.

As a result of the epidemic, 37 deaths were recorded. Of these, nine were children under the age of 15 years, five males and four females. Two were below the


5 years; 28 were adults, 14 males and 14 females. Of these, five males and five females were above the age of 25 and below 50 years.

To Prevent Chordee. — Ricord prescribes pills of camphor (272 grains) and opium (72 grain), of which two or three are to be taken every night.





Denver, Colorado,
Alienist and Neurologist to St. Luke's Hospital; Consulting Alienist and

Neurologist to Arapahoe County Hospital.

The statements made in this paper in regard to the value of the study of temperature, pulse and respiration as aids in the diagnosis and prognosis of certain diseases of the brain, are based upon the records and observations of 374 cases, grouped as follows: Meningitis (tubercular), 80; meningitis (from suppuration of the ears), 20; apoplexy (from hemorrhage, thrombi and emboli), 60; acute alcoholism, 40; acute fatal cases of insanity, 12; tumor of the brain, 60; abscess of the brain, 14; cases of traumatism of the brain, in which were observed two or more of the following conditions : shock, hemorrhages, depressed bone, contusion or laceration of the brain and its membranes, 88. On more than one-half of the above autopsies were made.

It is not enough to have recorded the temperature of the body, the frequency of the pulse and respiration per minute. The temperature, as manifested in different portions of the body, and in certain cases at corresponding portions of the two sides of the body, the variations in the frequency and character of the pulse, and the respiration, with its numerous variations from the normal should be noted at regular intervals. In all acute brain cases, these observations should be repeated every two or three hours during the day and night. In cases in which an early diagnosis is of the first importance, as a guide in the treatment, the physician should not rest satisfied with the records of the trained surse, but he should personally repeat the observations for himself. The more experience one has in making such observations, the more keenly he appreciates the necessity for absolute accuracy, and the sooner he becomes impressed with the fact that much care and patience are needed for the work. One of the essential qualifications for all such clinical details is a fondness for scientific investigation, both for the physician and nurse. If

* Read before the Colorado State Medical Society, Denver, Colo., June, 1901.

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