bowels, with a little fever at night, a general loss of appetite and slight weakness. Such cases often from first to last go about their ordinary avocations, seek no medical advice, and must be infective centres, without doubt doing occasionally much damage. The author has seen three of these cases in which one had suffered for at least a fortnight, in the second some nine days, and in the other a long time which could not be definitely fixed, but was probably seventeen or eighteen days. The ordinary typical mild case presents the following symptoms:-The commencement is insidious, it may be marked by diarrhoea or by rigors, fever of a remittent character sets in, the temperature rising the first evening to 100° to go down half a degree or more the following morning. The second evening the temperature will be higher, say 101°, rising as a rule each night up to the fifth or sixth day when it will attain 105° or 106°, keeping for a week or more at or about this evening temperature, and going down each morning a degree or a degree and a half. About the twelfth or thirteenth day comes a change. The temperature, although nearly as high as before in the evening, becomes much less in the morning, going down three or four degrees at the end of the third week, sometimes before; the fever markedly declines and the morning temperature becomes nearly normal, and in the fourth week convalescence sets in. The tongue during this time is mostly red and fissured or becomes dry and brownish. The abdomen is tender, there is gurgling in the iliac fossa upon pressure, the spleen on careful percussion is found to be larger than natural. Between the seventh and fourteenth days there are successive crops of isolated elevated rose-coloured spots, each spot lasts about two or three days. There is nearly always diarrhoea, in a few cases hæmorrhage from the bowels. In many cases bleeding from the nose. Prostration comes on rather late, patients keeping up to the seventh or tenth days. The termination of the disease in mild cases may be as early as the twenty-fourth day, in severe it is protracted to the thirtieth or longer. Sometimes even a mild case is carried off by perforation of the intestine or by profuse hæmorrhage. The prognosis on this account must always be guarded; with typhoid until complete convalescence no one can tell what will happen even when all fever has passed, in a few instances relapses take place. Coma is occasionally present and sometimes active delirium.

(371) Predisposition.

With the exception of a previous attack of typhoid, which to some extent renders a person not liable to contract the same disease a second time, there is only one marked difference in individual susceptibility, and this one depends on age. The disease is almost entirely confined to children and adolescence, a point to be borne in mind in the selection of nurses for typhoid cases. "The mean age of 1,772 cases admitted into the London Fever Hospital during ten years, 1848-57 was 21-25; that for males being 21:45, and for females 21.06. These averages are more than five years under those of the entire population" (Murchison). Persons under thirty are more than four times as liable to enteric fever than persons over thirty. This is remarkably different to typhus. At one time it was thought that owing to anatomical reasons it was not possible for the aged to develop typhoid, but the cases of people over fifty, and even a few over seventy, which have been proved by post-mortem examination to have suffered from fatal typhoid are sufficient in number to disprove this view. All that can be said is that the liability to contract typhoid after thirty years of age, progressively diminishes, and that cases over fifty are

rare.

5

(372) Pathological Appearances after Death.

In the works of Louis,1 Chomel,2 Rokitansky, Jenner, Hoffman, Murchison and W. Budd will be found the most minute details of the anatomical lesions observed in cases of death from typhoid fever. These storehouses of information contain a vast amount of minute details as to the appearances of every organ and tissue. The morbid changes however which are always present in this disease and never present in any other are mainly in the intestines. As Dr. Budd truly remarked in his classical monograph, "Take the diseased intestine away and it becomes impossible, in a common out

Louis, Recherches sur la Fièvre Typhoid. 1841.

2 Chomel, Leçons de Clinique Méd. Tom. I. Paris, 1834.

3 Rokitansky, Path. Anatomie.

4 W. Jenner, Med. Chir. Transact. Vol. xxxiii. Ed. Monthly Journal of Med Science, 1849-50.

5 The Continued Fevers of Great Britain.

Typhoid Fever, by W. Budd, M.D., F. R.S. London, 1873.

ward survey, at least, to distinguish the body of a man dead of typhoid fever from that of a man killed by many another septic poison; take away the body but leave the intestine, by the marks upon it death froin this fever is at once distinguished from death from every other cause." The greatest interest is in those cases which have died at a sufficiently early stage to show the commencement of the process. Death so rarely takes place before the end of the second or third week of the fever that there have been comparatively few opportunities of investigating this stage. An exquisite example is however figured in Dr. Budd's work of the appearance of the intestine probable before the seventh day (see Plate V., Fig. 1, which has been produced from the original drawing); in this the ileum presents its mucous membrane covered with raised roundish bodies so strikingly like an eruption, that Dr. Budd considered it analogous to an internal exanthem. More particularly in the earliest stage which has been witnessed a certain number of Peyer's patches, or of the isolated follicles, as the case may be, acquire a considerable increase of thickness, and stand out in relief on the internal surface of the gut. Chomel says that the intestine feels as if a solid and elastic substance had been inserted between the coats. On cutting through a patch thus affected a cheesy yellow substance exudes. The mucous membrane at this stage may be perfectly healthy, exhibiting no traces of ulceration. In a case in which Meyer had an opportunity of observing the post-mortem appearances on the second day of the illness there was found simply swelling of the solitary follicles and Peyer's patches, without the slightest sign of ulceration; the mesenteric glands were not swollen. In this perfectly recent case a microscopical examination revealed an extraordinary number of Eberth's bacillus in the cells in the submucosa and between the muscular layers or coats of the intestine. The second stage is that of ulceration. This commences in two ways; to the one the French observers have given the name of plaques molles, to the other plaques dures. In the first the mucous membrane becomes softened, and one or more superficial abrasions appear on the surface of the diseased patch, extending and uniting to one large ulcer which proceeds at various depths through the bowel coats and may go on to perforation. In the case of the more common plaques dures the mucous membrane and sub-mucous 1 Mittheilungen aus dem Kaiserlichen Gesundheitsamte.