it occurred in only 13 of 58 cases noted by myself. As to children, Rilliet and Barthez speak of epistaxis as occurring in one-fifth of their 107 cases, and Taupin observed it in only 3 of 121 cases."

The hemorrhage may take place at any period of the fever, and may recur repeatedly. The quantity of blood lost may vary from a few drops to several pounds. All observers agree in stating that the bleeding is never followed by any relief to the symptoms; while, on the other hand, it may be so profuse as to be the immediate cause of death. Several examples of death from epistaxis have come under my notice.

CASE LIV. Enteric Fever. Death on 10th day from Epistaxis. Autopsy: Enlargement of Spleen and Mesenteric Glands. Commencing Ulceration of Peyer's Patches.

Mary F―, aged 20, a servant in a gentleman's family, adm. into L. F. Hosp. on July 29th, 1857. Was taken ill on 22nd at Ramsgate, where she had been on a visit for three weeks. Her symptoms before admission had been cold shivers, headache, pains in limbs, urgent diarrhoea, and prostration. July 30th (8th day). Pulse 120. Slept well; is free from pain, and intelligence clear. Skin hot and dry; circumscribed flush on both cheeks; one or two lenticular spots; tongue furred and red at edges; abdomen tympanitic; gurgling, but no tenderness, in right iliac fossa; three watery stools. Was ordered beef-tea and milk, a starch and opium enema, and a mixture containing acetate of lead (gr. iij.) and liq. morph. acet. (m.v.) after each motion. Aug. 1st (10th day). No worse until 9 p.m., when she began to bleed from nose very profusely. When seen about an hour after, pulse was almost imperceptible, skin cold, and features pinched. Four stools, but no blood in any of them. Cold was applied to forehead, and 10 grains of gallic acid, with 20 minims of sulphuric acid, were ordered every hour. Bleeding, however, continued, and patient died at 11'40 p.m., before plugging could be resorted to.

Autopsy, 31 hours after death.-Cadaveric rigidity well-marked. All internal organs very pale and anæmic; old adhesions over left lung. Liver 34 ounces, very pale. A little pale, thin bile in gallbladder. Spleen 9 ounces; very soft. Mesenteric glands much enlarged, one or two almost as large as walnuts; surface on section much injected. Stomach and upper part of small intestines contained several ounces of partly coagulated dark blood, but mucous membrane of this portion of digestive canal was healthy. No blood in lower portion of bowel. About a yard above cæcum, Peyer's patches began to be diseased. The number and extent of diseased patches increased

▾ BARTHEZ and RILLIET, 1853, ii. 685.

• TAUPIN, 1839.

towards cæcum; many of patches were elevated fully one-eighth of an inch above surface, and contained a cheesy, yellow deposit; mucous membrane over most of them was intact, but on one or two, close to ileo-colic valve, there was slight ulceration; membrane between patches was intensely injected. Solitary glands in cæcum, ascending colon, and lower part of ileum likewise elevated, and contained a cheesy deposit.

i. Emaciation.

In cases of enteric fever protracted to three or four weeks there is usually great, and often extreme, emaciation. The difference from typhus in this respect is very remarkable. (See p. 248.)

SECTION VII.-STAGES AND DURATION.-RELAPSES.

a. Stages.

Although any sub-division of enteric fever into distinct stages must be artificial, it may be well to consider the disease under the following stages: 1, the stage of incubation; 2, the stage of invasion; 3, the stage of glandular enlargement; 4, the stage of ulceration or sloughing; 5, the stage of lysis; and 6, convalescence.

1. The stage of Incubation is considered at page 467.

2. The stage of Invasion lasts for one or more days, and extends from the first feeling of illness until the development of decided febrile symptoms. The invasion is often so gradual, that neither the patient nor his friends can state the precise day on which the illness commenced. This has been the case with more than one-half of the patients under my care. Jenner could only ascertain the day of commencement in 7 of 15 fatal cases.a Louis and Chomel speak of the invasion as being in most cases sudden: but the experience of Forget, as well as of Bartlett and other American writers, confirms that of Jenner and myself. At all events, the contrast which enteric fever presents in this respect to typhus and relapsing fever is remarkable. (See pp. 179 and 375.)

Of 63 cases, where I noted the mode of commencement some years ago, pains in the head and limbs, commonly aching, but sometimes neuralgic, were among the earliest symptoms in 56, and most of these patients also suffered from irregular chills, languor and giddiness; in only 3 cases did the disease

A

JENNER, 1849 (2).

LOUIS, 1841, i. 419; CHOMEL, 1834

commence with anything approaching to rigors, but in several instances not included in this analysis I have observed decided rigors, and in fact all the phenomena of ague, during the first few days. In 12 cases there was great nausea and vomiting; in 5, considerable pain in the abdomen; and in 26, or 41 per cent., diarrhoea. In several of these last cases, the patients had been suffering for a week or two from ordinary autumnal diarrhoea, before any symptom of fever appeared. Very often the patient is at first thought to be suffering merely from an ordinary bilious attack. Boils and abscesses have been sometimes noted among the earliest symptoms. But the one symptom which is never absent from the first is an elevation of temperature.

3. The Stage of Glandular Enlargement extends from the commencement of fever until about the twelfth or fourteenth day. Some of the intestinal glands probably continue to enlarge after ulceration has commenced in others. Strictly speaking, this stage includes the stage of invasion. It is characterized by a fever of a remittent type (the evening exacerbation reaching its acme about the fourth or sixth day), vertigo, headache and general pains, disturbed sleep, daily increasing prostration, copious excretion of urea, furred tongue with red edges and tip, diarrhoea, occasional vomiting and epistaxis, and the appearance of the eruption. Sometimes there are no abdominal symptoms, and in rare cases there may be acute delirium, or bronchitis with great pulmonary engorgement, which may terminate fatally. Death, however, rarely occurs during this stage, and very often the patient continues to go about.

4. The Stage of Ulceration or Sloughing extends from about the twelfth or fourteenth day to some time between the twentyfirst and twenty-eighth day. This stage is characterized by a persistence of fever with less decided remissions; successive crops of eruption; tongue more or less dry and often red, glazed, and fissured; distended abdomen; diarrhoea, often with membranous flakes or blood in the stools; retention of urea; delirium, and other phenomena of the typhoid state. The duration of this stage is variable. It may be protracted by pulmonary, abdominal, and other complications; but independently of any such cause it may be carried on to the end of the fourth, or even into the fifth, week, and for a time there may be what Wunderlich has designated the amphibolic stage-a period of uncertainty, or of changing fortunes. After decided

N N

remissions or even a condition approaching to collapse, there may be one or more recrudescences of fever lasting for several days. These must be distinguished from true relapses which supervene after a decided intermission of pyrexia and apparent convalescence; at all events, when death occurs after recrudescences we do not as a rule find evidence of recent disease in the intestinal glands, as in fatal cases of relapse.

5. Stage of Lysis. The termination of enteric fever, like its commencement, is gradual, and is not marked by any critical evacuation. Resolution takes place by lysis, and not by crisis. At first the morning remissions become more decided, and then the evening remissions less severe. Simultaneously with these changes, the tongue becomes cleaner and moister; the cerebral symptoms abate; and fresh lenticular spots cease to appear. When the intestinal lesion does not go on to ulceration, the stage of lysis may commence as early as the end of the second week of the disease; and then during the third week the pyrexia may be essentially of an intermittent type, the pulse and temperature being normal in the morning, but the latter rising two or more degrees towards evening. More commonly lysis does not begin until some time during the fourth week, and then it may last from two or three days to a week, and is liable to be interrupted by complications.

6. Convalescence can only be said to be fairly established when the temperature is normal on two successive evenings. It is also liable to be interrupted by relapses, peritonitis, the development of tubercle, and other dangerous sequelæ; and irrespectively of such mishaps, it is always slow in cases which have run the ordinary course of three or four weeks, and where consequently there has been considerable emaciation. Although the temperature keeps low, the pulse may be quicker than during the fever, and the patient is slow in regaining his appetite and strength. In all these respects enteric fever contrasts strongly with typhus.

b. Duration.

The ordinary duration of enteric fever is from three to four weeks. Of 200 cases which recovered, and in which I was able to fix the commencement with tolerable certainty, the duration was: 10 to 14 days in 7 cases; 15 to 21 days in 49; 22 to 28 days in III; and 29 to 35 days in 33. Thus, in all but 7 cases the duration exceeded two weeks; in nearly three-fourths of the total number it exceeded three weeks; and

in one-sixth it was more than four weeks. The mean duration of the 200 cases was 24'3 days; and the mean duration of 112 other cases, which were fatal, was 27.67 days. The mean stay in hospital of 500 cases which recovered was 31.24 days, and of 100 fatal cases, 16.52 days; while the average duration of illness before admission of the 600 cases was 10.78 days. Of Hoffmann's 250 fatal cases I have ascertained the mean duration of 215 cases to be 28.9 days. It is obvious that enteric fever, apart from complications and the chances of a relapse, is a much more protracted disease than typhus. (See p. 185.) My observations lend no support to the doctrine of critical days, as applied to enteric fever, although I have often noticed that it terminated about the 21st or 28th day.

When the fever is protracted beyond the middle of the fourth week, it is in most instances kept up by some complication or by non-cicatrization of the ulcers in the bowel. Under these circumstances the fever is often marked by extreme prostration and emaciation and a tendency to bed-sores. Sir W. Jenner has expressed the opinion that, except in cases of relapse, fresh spots never appear after the thirtieth day, and that febrile symptoms after that date are always due to some incidental complication. I have met, however, with several instances in which fresh spots appeared daily as late as the thirty-fifth day; and in one remarkable case, where the general symptoms were mild, fresh spots were noted almost daily from the fourteenth to the sixtieth day (Case LV.). Griesinger has also observed that in uncomplicated cases the fever does not invariably terminate at the end of the fourth week.

On the other hand, enteric fever may terminate in death or in recovery at a comparatively early date. Most of the febrile attacks known in this country as 'simple continued fever,' or febricula,' are abortive attacks of enteric fever, terminating between the tenth and twentieth days (Cases LVI. and LVII.). In these cases the inflammatory products deposited in the intestinal glands are probably absorbed, and ulceration never takes place. (See Varieties of Enteric Fever.) Again, although death in enteric fever rarely occurs before the fourteenth day

Cases are not included in this calculation, in which there was a relapse, or in which the fever was prolonged by complications, after spots had ceased to appear on skin. In most instances the cessation of fever was determined by the thermometer. 4 HOFFMANN, 1869. In some of the cases the precise duration was not determined, and I have excluded others where death was due to pulmonary phthisis following enteric fever.

• GRIESINGER, 1864, p. 244.