The Diagnosis of Pachymeningitis Interna Hemorrhagica

so much so that no differential diagnosis was made.No doubt, careful examination of the heart would have called attention away from the other symptoms, at least temporarily ; yet even if the signs of valvular disease and enlargement had been discovered, they might not have been brought into connection with the fever, for at that time the symptoms of sepsis in gen- eral and of septic endocarditis in particular were even less known than they are at present.In both of the last two cases the intermittent fever had a duration of many months, but as the temperature was not re- corded it is impossible to know the details.The cause of the peculiar temperature curve in this disease is not known.It will be remembered that Cohnheim accurately explained the cause of intermit- tence iu malaria as being due to the nature of the infectiug agent, as we now know to be the case.Cohnheim thought that the intermittence of pyemic and septic fever was due rather to an intermittent in- toxication from a continuous source : " the fever is not continuous, because such focci do not produce fever per se, but only because their constituents enter the circulation.This is not necessarily continuous, but may be influenced by various circumstances."3In cases such as those here reported this explanation does not seem tenable.It is difficult to imagine that the poisons elaborated in the vegetations enter the circulation intermittently as supposed by Cohnheim, but more reasonable to believe, as was suggested by Murchison in his classical article on the subject 8 and expressed by Musser in his valuable contribution,4 that the " phenomenon of intermittency is due to rhythmical responses of the nervous system to a con- stantly-acting poisoned blood."While the examination of the blood in such cases is the most certain element in the exclusion of malaria, other diagnostic differences are illustrated by the his- tories given above.One of the most striking symp- toms iu the cases seen by me was a marked weakness, a constant fatigue.In Case I the patient felt as well as she could wish during the apyrexia, but she was too weak to do anything.This is in marked constrast to malaria where, even if the temperature goes one or two degrees higher than it did in this case for many days, the patient not only feels well in the interval, but is actually able to do a considerable amount of manual or mental labor until advanced anemia pre- vents him.As regards the characteristics of the fever itself, the temperature is not so high as is common iu malaria, and I do not think the other symptoms of the attack are usually as marked as they are in malarial fever with a similar temperature.Hospital Advertisements.-TheLondon Times of July 23, 1895, contains the following: Anybody in London having spare time on Monday, 22d, or Tuesday, 23d, July, is invited to visit the Poplar Hospital for Accidents between 2 and 7 o'clock.Newly built.Newly fitted.No debt.No horrors.No in- fection.Best Way.-Drive or bicycle, forty-five