indicate fever of a primary and idiopathic kind, as well as reactional pyrexia secondary to many sorts of local lesion. We do not go beyond the truth when we say that typhoid fever, catarrhal fever, forms of enteritis, acute tuberculosis, ague, hepatic and portal congestion, &c., are being constantly included under "remittent fever," to say nothing of other affections, in lieu of the diagnosis of which "infantile remittent" is "a refuge for the destitute." But it must be admitted there are some very great difficulties surrounding the differential diagnosis of idiopathic and reactional fever in the child in many cases, and which difficulties those who are best acquainted with disease in childhood experience no less than do those who care little about treating it. We shall here refrain, however, from entering upon this part of the question further than relates to the discrimination between typhoid fever and the reactional febrile erethism attendant upon some diseases of the alimentary apparatus, and we premise in limine, that without meaning to express any decided opinion upon the specific, essential, or fundamental difference between typhoid and typhus, we assume many of their clinical manifestations are so generally distinct as to permit of their separate study, and that our typhoid is the typhoid fever of Jenner. We before remarked that this affection is very frequently included under "remittent fever." The recognition of it as "remittent fever of a low type " is occasionally seen, but the admission of typhoid fever as a disease of childhood is by no means common. In the reports of the Registrar-General fevers are classified as ague, remittent fever, infantile fever, and typhus, the mortality under this head (typhus) including all the forms of common continued fever.* Yet, strange to say, eighty years ago, Hamilton and Underwood differentiated fever in the child, and separated what they called "typhus" from remittent, mesenteric, hectic fever, and marasmus. Underwood writes:

"A fever of much importance, however, is mentioned by Dr. Hamilton, and is a true low fever or typhus. It is very accurately described by him, and particularly as commencing generally rather with marks of languor and fatigue, than with any distinct rigor; the stomach is frequently sick, and pain in the head soon succeeds, with great thirst and restlessness. On the second day there is an evident remission, which is at the first very regular, and continues though in a less degree-till the termination of the fever; and yet, as far as my experience has gone, the little patient recovers, if duly supported."

But, behold the wisdom of modern days! Drs. Merriman and H. Davies, Dr. Underwood's editors, correct the above error, and affirm this distinct and "true low fever" to be infantile remittent. According to Dr. Merriman, "the typhus or low fever next mentioned is a more aggravated form of the remittent with increased debility." So replies Dr. Davies, "we have deemed it advisable to let the title remain, considering it, with Dr. Merriman, as one of the grades of the infantile remittent fever."t

So firm a hold, indeed, has this latter term got of us here, that it is retained even in the work of Dr. West, in which the true nature of the affection so designated is of course known, and as frankly admitted. It is not before 1831 that we find typhoid fever distinctly recorded by this title as occurring in the child; from when up to 1836 several cases are to be found in the Clinique des Hôpitaux,Gazette Médicale,' and 'Lancette Française.' In 1836, M. Hutin published, in the Revue Médicale,' a short notice "On an Epidemic of Typhoid Fever specially attacking Young Children." But it was not until 1840 that the first complete monograph on the disease appeared; in this year M. Rilliet published one as his inaugural dissertation; and about the same time, M. Taupin issued a series of Clinical Researches' upon the same subject. In German literature we do not meet with the recognition of typhoid fever in the child until

Eighteenth Annual Report, p. 181.

Dr. Underwood's Treatise on the Diseases of Children, with Directions for the Management of Infants. Tenth Edition, with Additions, by Henry Davis, M.D., &c. pp. 812-14. London, 1846.

1846, when Löschner treated of it in the Prager Vierteljahrschr.' iii. Jahrg. 1 Band. In addition to the above names we may add those of Rufz, Audiganne, Stöber, Roger, Friedleben, Hennig, &c., as indicating some of those to whom within the last ten years we stand indebted for extending inquiry upon the subject before us.* But until the recent appearance of Dr. Friedrich's monograph, no approach had been made to the able essay upon "typhoid fever" contained in the second volume of MM. Rilliet and Barthez's classic work, Traité Clinique et Pratique des Maladies des Enfants.' The conclusions of the latter are based upon 111 cases, including the results of 12 necroscopies; those of the former are built upon the records of 275 examples, and of 10 post-mortem examinations. As most of our readers who have much to do with sick children are no doubt well acquainted with the labours of the French writers, we shall here make Dr. Friedrich our point de depart, indicating some of the chief conclusions he has arrived at, and comparing them, en passant, with those of MM. Rilliet, Barthez, and others. We shall follow the same sequence adopted by the author in the consideration of his subject-premising that the term "abdominal typhus" is synonymous with our typhoid, whilst the Germans employ "petechial typhus" to signify our typhus fever.

1. It is clearly established that "typhoid fever" is not an unfrequent disease amongst children, occurring sporadically and as an epidemic. Boys are more liable to it than are girls. These conclusions, we may remark, are in consonance with those of MM. Rilliet and Barthez, Taupin, and Löschner, whilst Friedleben's rate of frequency as regards males and females is in the opposite way-viz., 46 boys to 52 girls in 104 cases.

2. The mortality is less in children than in adults, and higher amongst girls than amongst boys. Friedleben's experience agrees with the latter statement, whilst Löschner's is somewhat opposed to it, and Rilliet and Barthez remark, "Girls appear to us less exposed than are boys to the very grave form. In 23 cases of very severe typhoid fever, 19 were boys, 6 girls; the proportion of the whole number of girls to boys in the other forms of the disease being as 27 to 61."

3. It is most frequent between six and eleven years of age, and is rare during the period of lactation. According to Löschner, from five years to nine is the time of greatest liability; to Rilliet and Barthez, from nine to fourteen; to Wunderlich, six; Friedleben, five to eight. Most writers are agreed upon the rarity of its occurrence during the first year of life, some even denying its existence then altogether. But this is going to too great a length, notwithstanding a source of fallacy then surrounding the diagnosis of typhoid fever, and to which we shall presently particularly refer. We may, however, observe that Hennig has recorded it as occurring at the age of three months; Wunderlich between two and three months; Rilliet at seven, ten, and thirteen months; and Dr. Friedrich at six months. We find on reference to our own note-book, a case of "typhoid " recorded in a girl one year and seven months old, and in a boy two years of age. Dr. Friedrich refers to Bednar as having certainly observed it in a child only five days old, and as recording two problematic cases of fifteen and eleven days respectively. Being somewhat curious about these instances, we went direct to Bednar. We found that the mother of the first child died of "metritis," and the child itself exhibited, amongst other signs, enlarged spleen, and perfora tion of the bowel next the ileo-cæcal valve. In the second case, there existed gangrene" of the left axilla, &c., swelling and injection of the Peyerian patches, and splenic enlargement. In the third instance, the infant (a female) showed signs of pyæmia, with commencing destruction by decomposition of Peyer's glands. Bednar remarkst upon these cases:

66

*Some papers by Dr. Lederer on Typhus in Children, in the Mediz-Wochenschr. 1857-Nos. 6, 7, 8, 12, 18-came to our knowledge too late for analysis in the present article. We shall refer to them in a future number, when discussing the merits of the new edition of Dr. Underwood's treatise, and bringing under notice Dr. Tanner's compilation.

+ Die Krankheiten der Neugebornen und Säuglinge, &c., Theil i. p. 114. Wien, 1858.

"The three examples adduced form a gradual transition to a diseased state, having its origin in purulent infection of the blood, and only observed in children within the first fourteen days of life born of mothers who have been attacked by puerperal metritis.”

4. Typhoid and scarlet fevers have an inverse ratio as respects epidemic occurrence. When one prevails, of the other only individual cases are met with. This law was first advanced by Stöber, was acquiesced in by Löschner, and supported by Friedleben, as one easily to be proved. Dr. Friedrich appears to have taken particular trouble in inquiring into this point, and his statistics unquestionably support the doctrine.*

5. We shall here quote the author's own résumé :

"The morbid anatomical changes of abdominal typhus in the child exhibit either the same variations, or the like constant relations, as are seen in the adult in the same malady. In the latter category, splenic enlargement is particularly noteworthy. Still it is extremely rare that the formation of a slough ensues, with the consequent peculiar typhous ulceration following previous infiltration of the Peyerian patches. Mostly only single follicles in the glandular assemblage are infiltrated, and which, either from resorption of the infiltrated material, or more often from rupture of the follicle within the intestinal canal, revert to a normal condition without the formation of any cicatrix. The rupture and evacuation of the follicle within the bowel take place generally only to a limited extent. Ulceration of the mucous membrane of the pharynx, of the oesophagus, of the trachea, &c., is of exceedingly rare occurrence in the child." (p. 100.)

"The spleen was enlarged in all of our cases; once it was of normal consistency and colour, six times dark and firm, and three times soft and mashy." (p. 39.)

The experience of almost all observers since the time of Barrier is in accordance with the statements of the author relative to the aggregated glands. These latter usually present in the child that change known, since the time of Louis, as "plaques molles," and very rarely that implied as "plaques dures." Changes of the sub-mucous tissue and ulceration are rare; still, the "plaques molles" may ulcerate, and in extreme cases even perforation may ensue. MM. Rilliet and Barthez have proposed the question, whether

"This predominance of the plaques molles' is an accidental circumstance? Or, on the contrary, is it due to the special structure of the 'patches' in children, to the physiologic office this secretory apparatus fulfils, or rather to the special mode of irritation which in early life produces tumefaction, and engorgement of the intestinal follicles? This is a point difficult to determine." (p. 666, op. cit.)

With reference to the enlargement of the spleen so constantly met with by Dr. Friedrich, we may observe that his experience is supported by that of Barrier, Löschner, Friedleben, and Bednar, though they all differ somewhat amongst themselves as to the consistence of that organ. MM. Rilliet and Barthez appear to attach but little value to changes in the spleen.

6. Amongst the symptoms of typhoid fever in the child, the following are the chief: splenic enlargement, diarrhoea, meteorism, gurgling; pyrexia, quickened respiration, bronchial catarrh; delirium, somnolency. Shivering, intestinal hæmorrhage, and lesions of motility are rare. According to M. Taupin, out of 121 cases, 109 exhibited considerable, and 10 a moderate, tumefaction of the spleen; whilst MM. Rilliet and Barthez in 61 cases met with it only 18 times; and in 44 other instances observed since their previous publication, it was only 10 times that it projected two inches beyond the ribs.

7. As the cutaneous eruption, a roseola is the common form, more rarely a papular exanthem. By the term roseolous rash, the author evidently implies the "taches rosées" and "rose spots" of other writers. By the "papular" rash, we

Upon some points connected with the relations of these two diseases there are some remarks by Dr. Mayr in the Wochenblatt der Zeitschrift d. k. k. Ges. d. Aerzte in Wien, 1856, p. 47, worth referring to. See also Lehrbuch der Kinderheilkunde, 1857, Heft 2, Analecten, p. 27.

can but assume he refers to the more discoid and elevated of the "taches rosées." At any rate, being in default of a fuller explanation from Dr. Friedrich, we referred to Griesenger, who remarks:

"Whilst herpes labialis occurs so frequently in intermittent but so very rarely in typhus, that its presence in a patient alone renders the diagnosis of 'typhus' in the highest degree improbable, so in a like manner is the roseola exanthem characteristic of the latter. It consists of round rose-coloured spots of a scarcely appreciable elevation, from 1 to 13 line in diameter, which under the finger's pressure at first at any rate entirely disappear, To call it a characteristically papular exanthem is scarcely correct-there are no true pimples."

If we understand the author aright, some amount of "roseolous" rash was always present in his cases; his experience, therefore, would agree with that of Fabre, who says:†

"The lenticular 'taches rosées' and sudamina are nearly constant in children, and what is peculiar is that the former are especially frequent on the back and extremities, so that if the abdomen and chest only are examined, their presence may often not be apparent."

The frequency of occurrence of the "rash," and its degree of profuseness, are points on which there is great diversity of opinion, however; and in connexion with this department of the subject, MM. Rilliet and Barthez give utterance to opinions with which we confess we are at open war. They observe, in reference to the spots:

"They are to be seen principally upon the abdomen, the chest, and the upper parts of the thighs. In the greater number of cases they are but few-from one to six at a time. This result (to which we had arrived in 1840) is the inverse of that obtained by M. Taupin, but conformable to the experience of MM. Rufz and Stöber.... The lenticular taches

rosées' are not constant in the typhoid affection. This we had already affirmed, and the more recent facts collected by us afford not less support to the opinion, though slightly modifying the rate of frequency-viz., in three-fourths instead of two-thirds of the patients. Further, the spots exist in other affections which are not typhoid fevers." (p. 684.).

The italics are our own; the doctrine conveyed by them we abrogate entirely -i.e., that the true taches rosées found in typhoid fever may be met with under other circumstances. Spots that may be negligently or otherwise unwittingly mistaken for them possibly may be, but if there is any meaning in the true ones, it is that they clench the diagnosis of typhoid fever. Yet can MM. Rilliet and Barthez be mistaken? We shall inquire further presently. But are the rosespots not often wanting in children? We certainly diagnose what we consider "typhoid" and yet do not necessarily find them. Drs. West and Jenner are sometimes equally at a loss; and Dr. Campbell remarks:

"According to our observations and those of many physicians with whom we have conferred in relation to the eruption of typhoid fever in those cases which occur in the Southern and Middle States, even where the disease has prevailed as an epidemic, these eruptions are very rarely observable, although looked for with the utmost diligence throughout every stage of the disease. This absence of eruption in cases where every other symptom of typhoid fever was present, has been so uniform that many of our most intelligent practitioners have been disposed to doubt the diagnostic importance of eruptions in typhoid fever, and to look upon them as of accidental occurrence, not having any important connexion with the true pathology of the disease." (p. 13.)

We are as little inclined to believe this latter doctrine as the former one; but in children, certainly, the taches rosées are not so frequently observed as they are in adults.

*Handbuch der Speciellen Pathologie und Therapie, Zweiter Band, Zweiter Abtheilung: Infections-Krankheiten, p. 162. (Red, von Virchow). +Bibliothèque de Médecin-praticien, tom. vi., Maladie des Enfants, p. 516. + Medical Times, vol. xx. pp. 491 et seq. 1849.

8. The disease assumes three forms-viz., a mild, a severe, and a very grave form. As a rule, it appears generally in the mild form. In these statements the author is in accord with the French and other writers.

9. The prognosis is in general favourable, but of course varying with the form the disease has assumed.

10. The disease cannot be cut short, and the best method of treatment is the expectant, with medium doses of calomel between the fifth and eighth day of the disorder. Under all circumstances, the powers of the patient must be preserved, and proper nourishment early enforced. MM. Lombard and Fauconnet have been strong advocates of calomel, whilst MM. Rilliet and Barthez, though not entirely deprecating it as a purgative, quite discountenance what may be called a mercurial plan of treatment. Our author, too, it should be borne in mind, limits the period for its administration to between the fifth and sixth day, when it is chiefly serviceable.

11. The influence of contagion in propagating the disease is very doubtful. MM. Rilliet and Barthez think much in the same way. "Without pretending to deny the influence of this cause, we will rest satisfied with affirming that it is less evident and less frequent than in respect to many other maladies."

12. The influence of particular months of the year in inclining to typhoid fever, or to its greater mortality, cannot at present be indicated. The following remarks of Hennig may not be here out of place. He resides in Leipzig, it should be reme:abered.

Out of

"Abdominal typhus is an extremely uncommon disease in children amongst us. 3,000 sick children whom I have observed, I have only been able to diagnose its existence with surety three times. . . . . Elsewhere it appears more common, particularly at Vienna, where Mauthner once counted 26 cases of it amongst 556 little patients. Several of the former were still at the breast."

Although the idiopathic fever we have been discussing had not been recognised as, and termed, typhoid fever in the child, except by those writers whom we have before pointed out, there cannot be the least doubt its more important morbid manifestations were well known to others, though they regarded them in their totality as constituting quite another disease. Abercrombie in 1820, Billard in 1828, Meisner in 1828, Evanson and Maunsell in 1836, and several others more recently, have more or less accurately described both the symptoms and postmortem lesions of typhoid fever as those of a primary inflammatory infection of the intestinal mucous membrane and its appendages (glands, follicles, &c.) accompanied by a secondary fever of a more or less adynamic type. Numberless instances of ileitis, follicular enteritis, dothinenteritis, &c., have thus been nothing less than typhoid fever. But it behoves us not to be too boastful of our own increase of knowledge. Most of the older writers seem to have had no suspicion of the occurrence of typhoid fever in the child; and even when attention began to be attracted that way, it was thus that M. Chomel, in 1834, spoke upon the question:

"We have not the fear of erring before our eyes, when we say, that below fifteen years of age the number of children attacked by typhoid fever continually diminishes to ten years, after which it appears that children are but very rarely affected by the disorder."

But now practitioners, convinced of its frequent occurrence in early life, well acquainted with its signs and symptoms, and not forgetful of the rocks upon which they may split, are, it is feared, frequently unable to determine whether they have before them primary disease of the intestine, with a reactional pyrexia of a low type-or, on the contrary, typhoid fever. When the course of the malady is short, the child not very young, and a combination of particular causes

* Lehrbuch der Krankheiten des Kindes, &c., p. 91. Leipzig, 1855.