Importance of connecting the Symptoms with the States of the Organs: Pathology of Fever comprehends the Morbid Changes that take place in the Solids and Fluids of the Body. 1. General Pathology of the Solids, exhibiting a collective View of the Morbid Appearances in the Head, Thorax, and Abdomen. Cases illustrating such Morbid Appearances in each of these Cavities. 2. Pathology of the Fluids.

The preceding history of the symptoms of fever can be of no real use unless it be possible to connect it with the events of which those symptoms are the signs. The events consist of certain morbid changes which take place in the series of organs already enumerated. We arrive at the knowledge of these events first by noting the symptoms which occur during life, and their order of succession: and, secondly, by examining the condition of the organs after death in the fatal cases: a comparison of the symptoms, as previously observed, with the state of the organs as subsequently ascertained, teaches us what the symptoms indicate. By carefully observing the symptoms in a large number of cases, we at length become acquainted with all the important symptoms that arise: by carefully examining the organs after death in a large number of cases, we gradually learn all the important changes in structure which they undergo: and by comparing, in all cases, the morbid symptoms with the altered states, we acquire in the end the power of ascertaining, with a high degree of probability, the presence of an event which we cannot see, by the presence of its sign which we can see.

In proportion as our knowledge becomes perfect, we are thus enabled, during life, and at the bed-side of the patient, to see what is going on within his brain, within his lungs, and within his intestines, with as much distinctness and certainty as we could were the cases in which these organs are enclosed, and the organs themselves transparent. The highly interesting and important fact demonstrated by the examination, in the manner of which we have just spoken, of large numbers of fever patients is, that the changes which take place in the organs are uniform; that the symptoms by which these changes are denoted are likewise uniform, and therefore, that it is possible to arrive at a perfect knowledge of the phenomena of fever.

The present state of our knowledge, it must be confessed, is far from being perfect. To a certain extent, however, it is even already sufficiently perfect to afford the physician an invaluable guide in the conduct of his practice; and the steps that are wanting to complete the knowledge we possess (as far as human knowledge can be complete) future labour and perseverance will assuredly supply.

The pathology of fever comprehends the morbid changes that take place in the solids and the fluids of the body. It is probable that the changes in the fluids are wholly dependent upon those which take place in the solids, although the vitiation of the former must necessarily react upon, and increase the derangement of the latter. If it be true, as is highly probable, that the changes in the solids are beyond all comparison of the greatest importance, as not only antecedents, but invariable antecedents, or causes, it may be considered fortunate that our knowledge of their diseases is so much more advanced than our knowledge of the diseases of the humours. The morbid changes of the solids are ascertained with a great degree of exactness, it may almost be said with a great degree of perfection; while those which occur in the fluids are almost wholly unknown. Until very recently physicians satisfied themselves with framing conjectures about their corruption; and knowing with certainty no one vice that they possess, they attributed to them a thousand. Attention is now awakened to the subject: investigation is going on: and before long we shall probably know, with some degree of precision, whether any changes really take place, and what they are: but the researches which have hitherto been made are so few and so imperfect, that it can hardly be said that a single point is satisfactorily made out and firmly established.

In laying before the reader the pathology of the solids, as far as it is yet ascertained, it is my most anxious wish to enable him constantly to make for himself, as he proceeds, the association between the morbid appearances that are found after death, and the symptoms that were present during life. For this reason every case that is adduced to illustrate any morbid change is preceded by a brief account of the symptoms that were observed, day by day, at the bed-side of the patient. For the sake of brevity however, no less than for that of clearness, none but the essential are noticed. The daily reports, of which all the cases cited, are exceedingly condensed forms, are full, and contain, as they necessarily must contain, many repetitions with which it would be worse than useless to burthen this account of them. Even the statement of the remedies that were adopted (excepting in as far as they obviously influenced the symptoms) is omitted, from the conviction that the mind cannot attend without distraction, at one and the same time, to the pathology and the treatment.

Predominance of affection is the principle according to which the cases are arranged, those in which the brain was most affected being classed together under one section—the cerebral; those in which the lungs were most affected under a second—the thoracic; and those in which the intestines were most affected under a third—the abdominal. In like manner, the individual cases under each section are so placed as to succeed each other, as nearly as possible, in the order of their severity.

Before entering into particular details, it may be useful to exhibit a brief outline of the general pathology of fever, shewing, at one view, the general results which are derived from an examination of the collective cases. In this outline the organs in each cavity are noticed in the order of the frequency and extent in which they are found diseased.

I. Pathology of the Solids in Fever.

1. External Appearances of the Body after Death.

The skin is always of a more dusky colour than natural; it is sometimes studded with petechiÆ, which in bad cases are large and of a deep purple tint, giving to the body a spotted or speckled appearance.

Externally the body always appears emaciated, and on removing the skin, the greater portion of the adipose substance is found to be absorbed; what remains of it is of an unhealthy yellow colour. The muscular fibre is remarkably dark, and this dark colour extends, as we shall see immediately, to the internal viscera.

2. Morbid Appearances in the Head.

Of the membranes of the brain, the arachnoid is the most constantly diseased. It is seldom or never in a healthy condition. It is always either more vascular than natural, or when in this respect unchanged, it is altered in structure, being thickened, opake and milky: when in this latter state, a gelatinous fluid is usually effused beneath it. Not uncommonly, it is united at several points to the membranes above and below it. To the dura mater it very often adheres, particularly at the angles of the hemispheres, or along the course of the longitudinal sinus; and, in these cases, the adhesion is always peculiarly firm at the vertex. The dura mater itself is less constantly changed in appearance, although this membrane also is sometimes more vascular than natural, and frequently it either adheres with preternatural firmness to the skull-cap, or, on the contrary, it is quite detached from it, in consequence of effusion between it and the bones of the cranium. To the pia mater, the arachnoid is also very often adherent at several points: it is seldom that the pia mater is changed in structure, but it is generally preternaturally vascular. In like manner, the theca which encloses the spinal cord is frequently highly vascular, and contains a larger quantity of fluid than natural.

The brain itself is seldom or never in a healthy condition; the morbid changes to be distinguished in it differ greatly in degree in different cases, but still, in almost every case, some morbid change is to be discerned. These changes consist of an altered state of its substance, or of its cavities, or of both. The most usual change apparent in its substance is a higher degree of vascularity than natural. This increased vascularity is sometimes confined to the surface; sometimes it is more manifest deep in its substance; and, while common to both, it may exhibit different degrees of intensity in either. When on the surface, this preternatural vascularity is denoted by a greater fullness of the vessels, and, apparently by an increase in their number; when within the substance, by a greater number of bloody points, which are rendered visible by an incision with the scalpel. And in both situations it may exist in all degrees, from a faint blush to a deep and vivid redness. The substance itself is sometimes softer, sometimes firmer than natural. The softening differs in degree and in extent. Sometimes the entire cerebrum is manifestly and considerably softer than natural; at other times, only particular portions of it are found in this softened state. Now and then, but very rarely, abscess is discovered within its substance. It is remarkable that the cerebellum is always considerably softer than the cerebrum: whence these two portions of the organ are often observed to be in opposite states, the cerebrum being frequently preternaturally firm, and the cerebellum being almost always softer than natural. The pituitary gland also is very constantly softened, and often in a state of suppuration. When the cerebrum is preternaturally firm, the firmness is usually general.

The morbid change observable in the cavities of the brain consists in their containing an excess of secretion. This increase of secreted fluid is usually accumulated in the lateral ventricles: the quantity varies from a drachm to several ounces; when thus great, the lateral ventricles themselves are enlarged, the third and fourth ventricles are likewise distended with fluid, and the passages connecting them are proportionally full.

Common as it is to find a preternatural quantity of fluid in the ventricles, it is still more common to find it in excess between the membranes; often between the dura mater and the arachnoid, almost always between the arachnoid and the pia mater. It has been already stated, that the fluid effused between the arachnoid is of a gelatinous appearance and aspect; every where else it possesses the physical properties of serum, being thin, transparent, and of a straw colour: now and then it is thicker in consistence, opake, and even bloody, and sometimes that beneath the membranes contains flakes of lymph, or is mixed with pus.

It is observable that the two morbid conditions now described, that of excessive vascularity and that of increased secretion, are never co-existent. If the vessels of the brain and its membranes are loaded with blood, there is little or no fluid within the former or between the latter: if, on the contrary, the effusion be great, there is little or no appearance of vascularity. Effusion is the effect and the termination of vascularity; it is the ultimate result of vascular action, and the effect having ensued, the cause ceases to be apparent.

The substance of the spinal cord is seldom changed, either in vascularity or in consistence: the morbid changes which this organ undergoes have hitherto been observed only in the membrane that invests it, which, as has been just stated, is not only highly vascular, but likewise contains a much larger quantity of fluid than natural.

3. Morbid Appearances in the Thorax.

Of all the thoracic viscera, that which is most frequently diseased is the mucous membrane of the bronchi. The disease which takes place in this organ is not only the most constant, whatever be the type or the degree of fever, but it is also the most characteristic of the febrile state. Its disease is specific and uniform. It consists of preternatural redness. The character of this redness distinguishes it from that which is observed in ordinary inflammation. It is uniformly and strikingly darker, the difference in colour being precisely that which subsists between venous and arterial blood. This darkness of colour apparent in the bronchial lining, increases in degree as the tubes of the bronchi diminish in size: while it may be only just discernible in the large trunks, the colour may be nearly black in the minute branches. This change in the natural colour of the membrane is indicative, not only of an increase in its vascularity, but of alteration in its structure. It is almost always attended with a preternatural thickening of its substance, as is demonstrated by cutting through the tube and reflecting the membrane. The tubes themselves contain more or less fluid, which consists of mucus, mixed with pus. Analogous to what has been stated with regard to the vascularity of the brain and to its secretions, when the quantity of secretion contained in the bronchial tubes is great, the degree of vascularity apparent in the membrane is lessened.

In scarlet fever, the morbid changes are somewhat different. The mucous membrane covering the trachea, the larynx with its cartilages, the amygdalÆ and the soft palate is inflamed; the redness is of a brighter and more vivid colour than that which has been stated to be characteristic of continued fever without an eruption: it is similar to the characteristic colour of the scarlatina tongue. But what is very remarkable, and what appears to justify the view we have taken of scarlatina and the division we have suggested of its types, when the cases are severe, the colour of the mucous membrane becomes much darker, the deepness of the tinge increasing with the severity of the affection, until, at length, the colour closely resembles that which is peculiar to ordinary fever.

As in continued fever without an eruption, so in scarlatina, the increased vascularity of the mucous membrane is accompanied with a preternatural thickening of its substance. In scarlet fever, that portion of it which covers the epiglottis, the rima glottidis, and the arytÆnoid cartilages, is especially found in this diseased condition. When this inflammation and thickening passes into the state of ulceration, which it often does, the arytÆnoid cartilages are the special seat of this process, although the ulceration often extends to the amygdalÆ, and sometimes to the root of the tongue.

When in every other respect healthy, the substance of the lungs in fever is so constantly found either engorged with blood or infiltrated with serum, that these changes would seem to form essential parts of the morbid phenomena.

In examining those who die of fever, a great variety and complication of thoracic diseases, in addition to the morbid changes just described, are found. The pleurÆ exhibit every degree of vascularity, from the faintest blush of redness to that which is characteristic of the most intense inflammation, and every extent of adhesion, from that of the smallest point to the complete obliteration of the cavity. The usual products of inflammation, namely, the effusion of serum and lymph, and the formation of pus and of adventitious membrane are likewise found equally varying in degree. The parenchyma of the lungs, besides the engorgement and infiltration just adverted to, presents hepatization and tubercular disease in every variety and degree; ulceration and abscess in every extent, and hÆmorrhagic and calcareous depositions, together with enlargement and melanosis of the bronchial glands. But, since none of these diseases form any part of the changes of structure which are peculiar to the febrile state, it is sufficient in this place merely to advert to them.

4. Morbid Appearances in the Abdomen.

On opening the cavity of the abdomen all the viscera contained in it appear, in general, more vascular than natural, and invariably of a darker colour than in the state of health. Several of the organs are affected in a uniform and peculiar manner, but that which is by far the most constantly diseased is the mucous membrane of the small intestines; and especially that portion of it which lines the ileum and the cÆcum.

The varieties of disease exhibited by this membrane may be comprehended under three, namely, vascularity, thickening and ulceration.

In all cases increased vascularity is the first stage of disease: in a great proportion of cases this increased vascularity is confined to the inferior extremity of the small intestines, which is often distinctly inflamed when not the slightest deviation from healthy structure is traceable in any other part of the canal.

The second stage of disease consists in thickening of the membrane, or in deposition of matter beneath it, or in both. Preternatural thickening of the membrane is often of very considerable extent: deposition of matter beneath it appears to be confined to the situations of the mucous glands. These glands are found in all states and stages of disease from the least to the greatest enlargement, and from the mere abrasion of their surface to the entire ulceration of their substance. Perhaps one of the glandulÆ solitariÆ enlarged and covered with inflamed mucous membrane may constitute the only morbid appearance discernible in the intestine; or this deposition may take place in so many of these glands as to present a most extensive surface of disease.

The third stage is that of ulceration, which may supervene when the membrane is affected in either of the modes just described; but the ulcer will not be the same in both cases: in each it will have a different and a distinctive character. If ulceration take place while the mucous coat is in a state of simple vascularity, the ulcer will in general be extensive but superficial; its surface will present a smooth appearance, and its margin will be regular and defined: if, on the contrary, it occur after thickening of the membrane or enlargement of its glands, its characters will be just the reverse: it will be less extensive, but more deep, because it must penetrate a mass of adventitious matter before it can reach the other coats; and, for the same reason, its margin will be more elevated and its surface more ragged. It is in this form of ulcer that perforation of the intestine generally occurs; in which case the mucous and muscular coats alone are ulcerated: the peritoneal gives way from gangrene.

Whenever the mucous membrane is ulcerated, whatever be the form of the ulcer, the corresponding portion of the peritoneal coat is more vascular than natural; and perforation must be attended with inevitable death, on account of the extensive and intense peritonitis excited by the escape of fÆces into the peritoneal cavity.

Frequent as ulceration of the mucous membrane is in fever, and characteristic as this lesion is of the febrile state, yet it sometimes appears to be present when it does not really exist. From the quantity of adventitious matter deposited beneath the mucous coat, its surface sometimes becomes irregularly elevated, its valvulÆ conniventes obliterated and its aspect smooth and glistening: in this state it may be easily mistaken, on a superficial examination, for ulceration, while more careful observation will shew that the membrane itself remains entire.

Proportioned to the extent and degree of these changes in the intestine are, inflammation, enlargement, induration and suppuration of the mesenteric glands; and invariably those glands which are embedded in that portion of the mesentery attached to the affected intestine, are the most diseased.

It is quite remarkable with what uniformity the spleen is diseased in fever. In almost every case of genuine fever hitherto examined, it has been found altered in appearance and deranged in structure. Its natural purple colour is changed to a deeper and darker tint, and, on the removal of the peritoneum that invests it, its substance, on being slightly touched with the finger, breaks down into an almost fluid mass.

The pancreas, the structure of which is so seldom changed in any other disease, is very constantly deranged in fever. Its morbid condition is invariably the same, and, what is singular, it is exactly the reverse of that produced in the spleen. It is always more firm than natural; often it is exceedingly indurated, and that portion of it which is attached to the duodenum is sometimes nearly cartilaginous.

Each organ having been described in the order of the frequency and extent of the disease it exhibits, we have hitherto said nothing of the mucous membrane of the stomach. This viscus having been regarded in France as the great source and seat of fever, particular attention has been paid to the appearances it exhibits after death. The uniform result of the most careful examination of fatal cases in London is, that the mucous membrane of this organ is less frequently, less severely, and less extensively diseased than any other portion of the same membrane. Occasionally it is more vascular than natural; this vascularity is seldom general; it is almost always confined to its pyloric half; in the few cases in which it has been very great, the membrane has been observed to be thickened and sometimes softened: but no instance has occurred in which it has been the seat of a single ulcer.

Of all the abdominal viscera, the liver is the least frequently deranged in structure, and when it exhibits any morbid change it is both less extensive and less characteristic. The blood contained in it is peculiarly dark and always fluid; its parenchyma is sometimes softer than natural; the gall-bladder contains a large quantity of bile, which is seldom healthy, being almost always in one of two states of disease, either paler and more fluid than natural, or extremely dark and very much inspissated.

The preceding comprehend all the morbid conditions of the abdominal viscera which are peculiar to fever: but the organs of this cavity exhibit other and great varieties of disease, to which, since they form no part of the febrile changes, it is sufficient merely to advert. Such are inflammation of the peritoneum; effusion of lymph upon its surface or of serum into its cavity; agglutination of the intestines; inflammation of the mesentery; false adhesions between the liver, spleen, and mesentery; tubercles in the liver; induration of its substance; tubercles and abscess of the spleen; thickening of the coats of the bladder and inflammation of its mucous membrane: in the female, vascularity and enlargement of the ovaria, to which hydatids are sometimes attached; vascularity of the external surface of the uterus, and inflammation of the os tincÆ and of its internal membrane: it is rare to find any appearance of disease in the kidney in either sex.

Such is the circle of organs which are observed to be specifically diseased in fever, and with the most remarkable constancy. We go on to give individual cases in illustration of these morbid changes and of the symptoms with which they are accompanied.

1. Vascularity of Brain, Spinal Cord and Membranes, with Gelatinous or slight Serous Effusion.

Sarah Agenbar, Æt. 21, married.

After some previous indisposition, attacked, eight days ago, with the ordinary symptoms of fever. At present, unable to give any account of her illness, or to answer any question: delirium came on four days ago, which still continues; mind quite fatuous; extreme restlessness; no sleep: eyes wild and rolling; tongue not to be protruded; pulse 130, weak and indistinct.

9th. No sleep; delirium the same; pulse 126.

10th. Died.

Head. Membranes and substance of the brain highly vascular; no effusion. Thorax. Viscera exhibited only slight indications of disease. Abdomen. Viscera nearly healthy.

Mary Welsh, Æt. 55, admitted on the 15th day of fever. Attack came on with ordinary symptoms. Pain of head now gone; some sleep; tongue loaded, moist; pulse 80; skin cool.

21st. No pain; much prostration; tongue dry; pulse 104.

22d. Stupor; mind incoherent; scarcely any sleep; tongue brown and dry; pulse 108; skin hot.

27th. Coma; erysipelas on face; pulse 110.

28th. Coma increased; tongue deeply crusted; erysipelas extending.

29th. Delirium; tongue black; stools passed in bed; erysipelas extending.

30th. Muscular tremor.

35th. Increasing coma and prostration. Died.

Head. Arachnoid opake; slight serous effusion; substance of brain and spinal cord vascular. Thorax. ^[28][Ten or twelve ounces of serum in bag of pleurÆ; pericardium contained twelve ounces of sero-purulent fluid; that part of it which is reflected over the heart highly inflamed and covered with flakes of coagulable lymph.] Abdomen. Viscera healthy.

Margaret Gibbs, Æt. 63, widow, admitted on the 43rd day of fever. Pain of head still considerable; sleeps badly; pain of chest on right side; much cough, with purulent expectoration; abdomen tender; tongue loaded, dry; pulse 105.

45th. Pain gone; drowsiness, approaching to coma; no delirium; pulse 100.

48th. Insensibility continues; cough, with bloody sputa; pulse 108.

55th. Prostration; pulse 135, extremely weak; skin cold and clammy.

57th. Died.

Head. Arachnoid opake, with gelatinous effusion beneath it; adherent to the dura mater along the longitudinal sinus; substance of brain vascular. Thorax. [PleurÆ adherent; slight effusion in left side; substance of lower lobes partly gorged, partly hepatized; melanotic deposits in the parenchyma. Abdomen. Both ovaria dropsical; partly converted into cartilage; scirrhous tumour in walls of uterus.]

Elizabeth Ralph, Æt. 65, widow, admitted on the 8th day of fever. From commencement, severe pain of head and abdomen; both continue; mind confused; scarcely any sleep; tongue foul and dry; much thirst; bowels purged; pulse 105.

9th. Pain of head diminished; that of abdomen unrelieved; 8 stools; pulse 108.

10th. Pain of head gone; that of abdomen undiminished; 4 stools.

11th. Pain of head not returned; tenderness of abdomen undiminished; 7 stools; pulse 124.

12th. Tenderness of abdomen unabated; now swollen, hard, and rounded at umbilicus; 7 stools; pulse 125.

14th. Tenderness and purging continue. Died.

Head. [Falciform process of dura mater ossified;] substance of brain vascular; more fluid than natural in the ventricles. Thorax. [PleurÆ adherent; serous effusion into parenchyma of lungs. Abdomen. Peritoneal sac contained several ounces of pus and serum; peritoneum covering the liver coated with coagulable lymph; peritoneal coat of the intestines highly inflamed; colon adherent to the omentum all around;] all its coats so softened as to be easily torn; mucous membrane in general healthy.

Elizabeth Gasset, Æt. 32, married, admitted on the 8th day of fever. Attack commenced, in addition to the common symptoms, with violent pain of the bowels. Epigastre still extremely tender; tongue red, clean, moist; no stool for six days; no pain of head or chest; pulse 99.

9th. Tenderness of epigastrium continues; tongue red and dry; no stool; pulse 84; no cerebral nor pectoral symptoms.

10th. Died.

Head. Membranes and substance of the brain highly vascular; no effusion. Thorax. Viscera healthy. Abdomen. [Eight inches of the jejunum intussuscepted within a portion of the same intestine of equal length; the farthest extremity of the intussuscepted part mortified; the mucous membrane of the containing portion highly vascular and in a state of ecchymosis; the intestinal canal, between the constricted portion and the stomach, contracted, and its valvulÆ conniventes enlarged and oedematous; the size of the tube beyond the disease much diminished, and the colon, especially, contracted into a mere cord.]

Joseph Danbury, Æt. 20, stone-cutter. Admitted on the 15th day of fever; pain of head, which has never been great, is now very slight; much vertigo; eyes sallow; no uneasiness in chest; some cough; abdomen tender; tongue brown; teeth sordid; much thirst; pulse 108.

26th. Since last report, pain of head never entirely absent; vertigo constant and distressing; pain in the right side of the head much increased to-day, while the vertigo is now gone; delirium; eyes suffused; tongue dry; pulse 120.

36th. The pain of the head and the giddiness have continued to alternate; both are now quite gone; mind confused and dull; expression of countenance wild; muscular tremor; respiration hurried.

37th. Died.

Head. Pia mater vascular; substance of brain vascular; slight effusion between the membranes and into the ventricles. Thorax. No prominent disease. Abdomen. Peritoneal coat of intestines vascular; other viscera healthy.

Edward Forrester, Æt. 46, cabinet-maker. Admitted on 6th day of fever. Complaint commenced with severe pain of back, loins, and epigastrium, with sense of ardent heat. At present, pain of head slight; that of epigastrium continues; tongue white, moist; no uneasiness of chest; pulse 90.

7th. Pain of head, limbs and epigastrium; tongue white, dry; pulse 96, full and strong. V.S. ad ?xij.

8th. Pain of head gone; that of epigastrium diminished; pulse 110; blood not sizy.

10th. Pain of head returned; that of epigastrium diminished; no sleep; delirium; pulse 126.

12th. Pain of head again gone; delirium continues; pulse 110.

13th. No sleep; mind confused; delirium; subsultus tendinum.

15th. Cerebral symptoms undiminished; tongue dry and quite black; lips and teeth covered with black sordes.

19th. Severity of symptoms had diminished; lips, teeth, and tongue had begun to clean; pulse fallen to 96; but the parotid gland to-day painful, enlarged and indurated.

20th. Tumour of parotid increased; all the symptoms greatly aggravated; tongue not to be protruded.

22d. Insensibility amounting to coma.

27th. Insensibility and prostration gradually increased. Died.

Head. Arachnoid white and opake; firmly adherent along the vertex to the dura mater. Surface and substance of brain highly vascular; gelatinous effusion between the membranes. Thorax. Mucous membrane of bronchi vascular; [pleurÆ adherent; lower lobe of left lung partly hepatized, and partly consisting of a mass of suppurating tubercles.] Abdomen. Small intestines of extremely dark colour; mucous membrane vascular.

Mary Singleton, Æt. 28, married. Admitted on the 8th day of fever: pain of head slight, confined chiefly to the occiput; pain of left side, with inability to lie on it; no cough; tenderness of abdomen; pulse 111.

9th. After venesection to twelve ounces pain in head, side, and abdomen relieved; blood buffy.

11th. Slight pain of occiput; much pain and tenderness of abdomen; pulse 120.

13th. Cerebral and abdominal symptoms unchanged; tongue brown and dry; eyes yellow.

19th. Pain of head never entirely disappeared, but though always present it was always slight; now respiration hurried; tongue extremely brown and dry; pulse 120; eyes yellow.

20th. Died.

Head. Membranes of brain vascular with gelatinous effusion beneath them; and slight serous effusion into ventricles: substance both of cerebrum and cerebellum highly vascular; pituitary gland softened and suppurating. Thorax. Mucous membrane of bronchi vascular; substance of both lungs gorged with blood; [pleurÆ universally adherent.] Abdomen. Mucous membrane of intestines not vascular; but the mesentery highly injected: [liver adherent to diaphragm.]

Mary Ann Lamberth, Æt. 16, servant. Admitted on 22d day of fever. Pain of head, which has been very severe, is now gone; no tenderness of abdomen on fullest pressure; tongue red, smooth, and chapped; lips and teeth sordid; bowels purged; pulse 108.

30th. Cough with slight expectoration; cheek dusky; no tenderness of abdomen; bowels purged; pulse 120.

35th. Mind confused; much restlessness; no sleep; stools passed in bed; pulse 124, weak. A diffused swelling has appeared about the left wrist, attended with great pain.

36th. Mind more confused; countenance sunk; swelling of wrist increased; pulse not to be counted.

37th. Died.

N.B. Probable that the swelling of the wrist arose from the peculiar affection hereafter to be described.^[29]

Head. Some effusion beneath the membranes, and at the base of the skull; substance of brain natural; anterior and middle lobes firmly adherent. Thorax. Healthy. Abdomen. The ilium contained one large and spreading ulcer, the glands around which were darkened and inflamed.

Mary Crouch, Æt. 30. Admitted on the 7th day of fever. At present pain of head gone; some pain of back continues; no sleep; great restlessness; almost constant moaning; no uneasiness of chest; no cough; respiration hurried; pulse 108.

8th. Sleeplessness, hurried respiration, tenderness of abdomen continue; tongue red and glazed.

9th. Delirium; respiration hurried and noisy; lips and teeth sordid.

10th. Subsultus tendinum.

11th. Face livid; dark, bloody-coloured fluid issuing from the mouth; convulsive twitchings of muscles of face and hands. Died.

Head. Arachnoid opake; dura mater vascular; substance of brain vascular; some effusion between membranes and into ventricles. Thorax. Nearly healthy. Abdomen. Mucous membrane of ilium vascular; liver soft.

Mary Goodman, Æt. 50, nurse. Admitted on 4th day of disease: has been in a state of constant intoxication for several days past; has had much pain of head, which is now nearly gone; mind confused; eyes injected; abdomen tender; bowels purged; tongue brown and dry in middle; white at edges; tremulous; pulse 120; skin hot. Died next morning.

Head. Sinuses of dura mater turgid with blood; vessels of pia mater greatly congested; an ounce and a half of serum at the base of the skull. Theca vertebralis highly vascular; great congestion of vertebral veins; some effusion of serum at cauda equina. Thorax. Healthy. Abdomen. Mucous membrane of small intestines vascular; [liver greatly enlarged.]

John Eyles, Æt. 25, servant. Admitted on the 10th day of scarlet fever. Throat sore; deglutition painful; eruption fading; no pain of head, chest, or abdomen; tongue red and glazed; lips and teeth sordid; bowels purged; pulse 129.

11th. Voice hoarse; pulse 120; not the slightest pain of head.

14th. Numerous ash-coloured crusts scattered over the internal fauces; countenance anxious; respiration hurried; pulse 108. Died next morning.

Head. Arachnoid thick, opake, and unusually firm, with slight effusion beneath it; substance both of cerebrum and cerebellum highly vascular; pituitary gland enlarged and beginning to suppurate. Thorax. Larynx inflamed, covered with superficial circular ulcers; tongue aphthous; mouths of ducts on the surface of the amygdalÆ ulcerated. Abdomen. Mucous membrane of ilium and cÆcum highly vascular, not ulcerated; vessels of all the organs exceedingly turgid with blood.

James Moulden, Æt. 17, servant. Admitted on the 5th day of fever; left the hospital three months ago cured of a similar attack. Present relapse came on besides the ordinary symptoms, with severe pain of the head; pain still continues, but it is now only slight; expression of countenance dull and heavy; pulse 92, soft; no thoracic symptoms; no tenderness of abdomen; tongue loaded in middle with yellow fur, red around the edges, moist.

6th. Pain of head continues with sense of weight and intolerance of light; scarcely any sleep; pulse 102.

9th. Pain of head and intolerance of light increased; adnatÆ glistening; pulse 94.

10th. Pain of head quite gone; sense of weight and intolerance of light continue; face flushed; pulse 84.

11th. Pain of head returned; no sleep; delirium; pulse 96; tongue brown and dry.

13th. Pain of head and dullness and heaviness of eyes increased; pulse 84; abdomen tender.

14th. Nearly insensible; pulse 90; abdomen tender, swollen, and hard.

15th. Last evening coma increased; respiration became hurried and laborious; great prostration; expired this morning.

Head. Membranes highly vascular; a large quantity of coagulable lymph effused at base of the brain. Thorax. Mucous membrane of bronchi highly vascular; substance of lungs gorged with blood. Abdomen. On mucous membrane of stomach several patches of a dark red colour; mucous membrane of intestines pretty natural. [Spleen studded with soft tubercles of various sizes, some of which contained a cheesy matter; others a puriform fluid; the liver contained a few tubercles of the same nature but smaller.]

Charlotte Clarke, Æt. 18, servant. Admitted on 3d day of scarlet fever; throat sore; deglutition painful; no pain of chest; some cough; pain of head severe; much pain of limbs; mind distinct; tolerable sleep; no tenderness of abdomen; skin warm, covered with scarlet eruption; tongue characteristic; much thirst; no stool for three days; pulse 126, of good power; V. S. ad ?xvj.

4th. Blood inflamed; throat continues sore; pain of head gone; pulse 130. Hirud. xij. gutt.

5th. Throat unrelieved; deglutition very painful; no pain of head; pulse 110. Rep. Hirud. x.

6th. Throat nearly well; pulse 116.

16th. Had become convalescent; yesterday evening felt scarcely so well; during the night extremely restless, with much noisy delirium; at present quite prostrate; pulse 117, not weak; respiration hurried; abdomen tender; tongue quite dry; four stools of green colour, all passed in bed; erysipelas on right temple.

17th. Lies quite prostrate; insensible; constant delirium with unceasing moaning; muscular tremor; all the stools passed in bed; pulse 126. Died following morning.

Head. Dura mater vascular; some spots of ecchymosis between its laminÆ; arachnoid vascular, with effusion of viscid serum between it and pia mater. Between the arachnoid and the pia mater covering the superior part of the right hemisphere a layer of coagulable lymph of a yellow colour, on the removal of which the pia mater beneath it appeared entire. Shreds of coagulable lymph were also found at the base of the brain where there was more serum than natural as well as in the ventricles. Substance of the brain highly vascular. Viscera of thorax and abdomen healthy.

Isaac Coombes, Æt. 60, weaver. Admitted on 9th day of fever: at present no pain of head; some sleep; face pallid; great prostration; no thoracic or abdominal symptoms.

15th. Convalescent.

21st. Attacked suddenly with shivering, heat, vomiting; no pain of head or of any organ; pulse 96.

22d. Continues quite free from pain, but no sleep; extreme restlessness; great prostration; skin warm and dry; pulse 84. Died following morning.

Head. Between the pia mater and the arachnoid a large quantity of coagulable lymph of a yellow colour, with which indeed the arachnoid appeared to be universally lined, and which in some places was very thick. Substance of the brain highly vascular, being exceedingly full of bloody points, and in some places stained; three or four ounces of serum in the ventricles, at the bottom of each of which lay about a drachm of pus. The spinal sheath contained the same kind of substance, while the cord itself presented a healthy appearance. Thorax. Right lung gorged with blood and partly hepatized. Abdomen. Spleen soft; other viscera healthy.

Susanah Stammers, Æt. 9, destitute. Admitted on the 8th day of fever. Attack commenced with severe pain of the head which continues with almost equal violence; little or no sleep; eyes dull and heavy; face flushed; pulse 126; slight uneasiness of chest on full inspiration; no cough; no tenderness of abdomen; tongue loaded with white fur; red at point; bowels purged.

9th. Pain of head quite gone; less sensible; countenance more dull and heavy; pulse 120; abdomen tender.

11th. Delirium, with much talkativeness; pulse 112.

14th. Coma; bowels continue purged.

15th. Abdomen tender, swollen, rounded at navel.

19th. More sensible; more tranquil sleep; delirium gone; pulse 110.

27th. No coma nor delirium; tranquil sleep; tongue moist, cleaning; pulse 108 feeble.

45th. Appeared upon the whole to be convalescing, but in an exceedingly slow and imperfect manner; there was a remarkable vacancy in her countenance, almost amounting to a fatuous expression; and her mind was peevish and childish. On this day she was seized suddenly with convulsions of extreme violence, and died within twenty-four hours after the attack.

Head. Arachnoid thickened and opake; effusion of gelatinous fluid beneath it; substance of brain highly vascular; in the inferior cornu of left ventricle a pint of purulent matter, somewhat resembling broken down cortical substance; it lay loose within the cavity. Thorax. Superior lobe of right lung gorged and partly hepatized. [PleurÆ of right side adherent;] Abdomen. Mucous membrane of cÆcum and commencement of colon vascular.

Henry Brewer, Æt. 59, labourer. Admitted on the 10th day of fever: states that he has no pain in the head, and that he is quite free from pain every where excepting in the right side, where he has some uneasiness, which is attended with slight cough; tongue brown and dry; bowels natural; pulse 96.

12th. No pain of head; that of chest gone; sleeps well; pulse 108.

16th. About an hour after yesterday’s visit became suddenly insensible; it has been impossible to rouse him from this coma which still continues profound; respiration stertorous. Died in the course of the day.

Head: Dura mater thickened but not vascular; arachnoid thickened and opake; beneath it gelatinous effusion; upon its external surface a large quantity of well-formed pus; a quantity of purulent matter at the base of the brain surrounding the corpora quadrigemina: walls of the fourth ventricle ragged; two ounces of serous fluid in lateral ventricles and at base. Thorax. [PlurÆ adherent; lower and middle lobes of right lung hepatized.] Abdomen. Viscera healthy.

George Blackbeard, Æt. 18, servant. Admitted on the 22nd day of fever: complaint commenced with violent head-ache attended with frequent fits of epistaxis; pain of the head still continues, chiefly confined to the occiput; little sleep; eyes injected and suffused; pulse 102, tongue loaded, dry.

23d. Scarcely any pain in the head.

25th. Pain of the head entirely gone; epistaxis.

26th. Delirium: muscular tremor.

28th. Delirium and muscular tremor increased; pulse 112; tongue more dry; lips and teeth sordid.

31st. Died.

Head. Membranes and substance of brain vascular; ventricles distended with serum; no characteristic disease in thorax or abdomen.

Ann Higgins, Æt. 30, servant. Admitted on the 22d day of fever: pain of head from the commencement very severe; chiefly confined to the right side; still continues, together with severe pain in the limbs; some pain in the right side of chest; cough; abdomen not tender; tongue dry in middle; red and moist around edges and at point; pulse 105, feeble; much prostration; entire surface of the body preternaturally sensible.

23rd. The sensibility which from the commencement has been felt over the whole surface of the body is now particularly acute in the joints; in all of which there is severe pain; pulse 112.

25th. Pain of head gone; mind indistinct; tongue dry: stools passed in bed; pulse 105. Pains in the joints; swelling and redness of left fore-arm.

27th. Mind more and more indistinct; pressure on any part of the body produces extreme pain; joints the same; died next day. At this period attention had not been awakened to the peculiar disease of the joints hereafter to be described; they were not therefore examined; but without doubt the affection was of the same nature.

Head. Dura mater vascular, and adhered with preternatural firmness to the skull; pia mater vascular; substance of brain natural; pituitary gland suppurating; the lateral and the third ventricles full of serous fluid; one ounce at base. Thorax. [Lungs emphysematous; several points of tubercular suppuration in left.] Abdomen. Mucous membrane of small intestines inflamed without ulceration.

James Dennie, Æt. 28, labourer. Admitted on the 8th day of fever, which attacked with usual symptoms: at present pain of head; little sleep; eyes dull and heavy; some cough; respiration hurried; abdomen not tender; tongue white; pulse 112, weak; prostration.

9th. Pain of head increased; delirium; eyes suffused; cough and hurried respiration continue.

10th. Pain of head gone; constant and violent delirium; no sleep; pulse 108.

11th. Delirium gone; profound coma; muscular tremor; respiration hurried; pulse 108.

12th. Coma deeper; extreme restlessness; respiration more hurried; stools and urine passed in bed. Died.

Head. Arachnoid vascular; substance both of cerebrum and cerebellum vascular; all the ventricles full of serum; viscera of thorax and abdomen healthy.

Charlotte Watts, Æt. 9. Previous history of disease unknown: at present scarcely at all sensible; almost constant crying; frequent rolling of the head on the pillow; countenance anxious; pulse not to be counted from her extreme restlessness; respiration hurried; abdomen not tender; lips and teeth sordid. 2d day after admission constant noisy delirium; pulse 120.

17th. Almost imperceptible, but still gradual improvement since last report; more sensible; no delirium; but mind throughout extremely peevish and fretful; stools have constantly been and still are passed in bed; pulse 116.

19th. Large sloughing sores on loins and hips; erysipelas of surrounding integuments; pulse 112, weak.

27th. Sloughs have extended between the shoulders, along the back, and over both hips; great emaciation; extreme prostration; mind continues very fretful; pulse 110, very weak.

37th. Gradually grew weaker and weaker until this day, when she died.

Head. Arachnoid vascular; substance of brain and especially medulla oblongata highly vascular; between the arachnoid and the dura mater much limpid serum; all the ventricles distended with a similar fluid. Thorax. [PleurÆ adherent. Both lungs contained numerous tubercles in a state of suppuration. A large proportion of right lung hepatized.] Abdomen. Viscera healthy.

Mary Sullivan, Æt. 26, married. Admitted on the 14th day of disease; pain of head severe from the beginning; continues unabated and even violent; no sleep; face pallid; expression depressed; pulse 81; abdomen tender; tongue foul and dry. V. S. ad ?xij.

18th. Pain of head gone; delirium; pulse 70, soft; tongue more dry.

24th. Pain of head, which had returned slightly on some of the preceding days, was, from this period, finally lost in insensibility; no longer conscious; prostration; great restlessness; almost constant moaning; occasional retching; pulse 72.

26th. Continues perfectly insensible; all the stools passed in bed; pulse suddenly rose to 120, on the following day fell to 102; eyes half open and injected: no material change till 29th, died.

Head. Membranes and substance of brain appeared pretty healthy; all the ventricles enlarged, and contained about three ounces of limpid serum; a considerable quantity, also, at base; some coagulable lymph effused on that part of the arachnoid which covers the tuber annulare. Thorax. [PleurÆ adherent; substance of lungs full of tubercles, in different stages of disease.] Abdomen. [Liver hard;] other viscera healthy.

Ann Boon, Æt. 14, admitted on 10th day of fever. Attacked in the beginning with severe head-ache, which still continues; abdomen tender; lips and teeth sordid; tongue brown and dry; pulse 120.

11th. Pain of head undiminished; eyes heavy and suffused; delirium; tongue red, dry, and glazed; pulse 108.

13th. Pain of head quite gone; delirium; pulse 118.

19th. Much noise through the night; peevishness during the day; pulse 108.

20th. More insensible; can give no answer to any question; pulse 118.

22d. Constant rolling of the head; pupils dilated; all the stools passed in bed; pulse 108.

29th. Eyes vacant and staring; pupils contracted; head sunk in bed; legs drawn up; stools passed in bed; urine abundant; pulse 117, regular and of good power.

30th. Skin covered in several places with vesicles, which discharge a thin ichor. Died.

Head. Membranes and substance of brain vascular; upwards of three ounces of serum in the ventricles and at base; much similar fluid in theca vertebralis. Thorax. Viscera healthy. Abdomen. Mesenteric glands greatly enlarged; some of them suppurating.

Richard Maciff, Æt. 30, admitted on the 22d day of fever. No account can be obtained of its previous history: at present he lies quite prostrate and perfectly insensible; eyes wild and rolling; pupils dilated and insensible to light; constantly picking at the objects around him; pulse not to be counted, on account of his extreme restlessness, but it feels like a soft cotton cord, and nearly without pulsation.

23d. Profound coma; senseless muttering; constant muscular tremor; squinting; neither stool nor urine has been passed since admission; pulse 96, soft, not intermittent.

24th. Coma undiminished; one stool passed in bed; urine drawn off by the catheter; pulse 100, extremely feeble.

25th. No change.

26th. Died.

Head. Dura mater vascular; arachnoid highly vascular; that portion of it covering the tuber annulare distended into a bag of considerable size, filled with serum; all the ventricles enlarged and distended with serum. Thorax. [Right lung contained tubercles in various stages of disease.] Abdomen. [Liver of unusually deep red colour; in right and left lobes two small sacs, filled with calcareous matter; on surface of spleen a sac, containing matter similar to that in the liver.]

William Tennant, Æt. 18, tailor. Admitted on the 8th day of fever; at present much pain of head back, and extremities; no sleep; face flushed; epigastrium tender: tongue red round margin, coated in middle; much thirst; pulse 99. V.S. ad ?x.

9th. Pain of head continues; scarcely any sleep; pulse 96. C.C. ad ?x. nuchÆ.

10th. Pain of head unrelieved, particularly severe over the forehead; face flushed; tongue brown and dry; pulse 92.

11th. Pain of head quite gone; no longer conscious of any uneasiness in the limbs; much drowsiness; delirium; pulse 104.

12th. Rather more sensible; delirium; tongue unchanged; stools and urine passed in bed; pulse 112.

13th. Delirium increased; eyes glistening; pulse 120.

14th. Mind more distinct this morning; much delirium through the night; respiration hurried; pulse 130. Died next morning.

Head. Membranes and substance healthy; on the under surface of right hemisphere, corresponding with the middle lobe, a remarkably deep and extensive depression, the deepest part corresponding to the centre of the brain; this depression was lined with the arachnoid, which being reflected formed a sac, that contained 12 ounces of serous fluid, and completely filled the cavity. The cerebral substance beneath and around was perfectly sound and entire. Thorax. Viscera healthy. Abdomen. Mucous membrane of ilium and cÆcum extensively and greatly ulcerated.

4. Vascularity &c. with preternatural Firmness of Brain.

Thomas Conolly, Æt. 58, labourer. Admitted on 7th day of fever: severe pain of head early in the attack which has continued without intermission, accompanied with vertigo; scarcely any sleep; face flushed; no uneasiness of chest; abdomen not tender; no stool for four days; tongue loaded and dry; pulse 96, weak.

8th. Less pain of head; no improvement in other symptoms; pulse 92.

9th. Scarcely any pain of head; no sleep; delirium; muscular tremor; tongue brown and dry; pulse 111.

10th. Pain quite gone; more insensible; constant talkative delirium; colour of cheek dusky, almost livid; respiration hurried; stools and urine in bed; pulse 112, feeble.

11th. Died.

Head. Membranes vascular; arachnoid thickened and opake; substance of brain highly vascular and preternaturally firm; some fluid beneath membranes and in ventricles. Thorax. [PleurÆ adherent;] lungs gorged with blood. Abdomen. Liver and spleen exceedingly softened, readily breaking down beneath the finger.

Mary Tiffin, Æt. 25, servant. Perfectly insensible: no account can be obtained of history or duration of disease: abdomen tender; tongue loaded, moist; pulse 99.

2d day after admission scarcely any sleep; delirium; muscular tremor.

3d. Insensibility continues; constant delirium; has passed neither stool nor urine; latter drawn off by catheter; pulse 124, feeble and fluttering. Died next morning.

Head. Dura mater and arachnoid natural; pia mater vascular; substance of brain highly vascular and unusually firm; cerebellum soft; effusion beneath arachnoid and at base. Thorax. [Substance of both lungs filled with miliary tubercles.] Abdomen. [Liver studded with tubercles, similar to those of the lungs; spleen full of the same kind of tubercles, excepting that they were larger, and some of them were suppurating;] pancreas extremely firm.

Mary Poulston, Æt. 50. No account to be obtained of duration of disease: lies quite insensible and prostrate; frequent jactitation of the arms; face flushed; respiration stertorous; cheeks alternately expanding and collapsing during inspiration and expiration; tongue not to be protruded; stools and urine in bed; pulse 138, weak, and easily compressed.

2d. Died.

Head. Dura mater vascular; arachnoid thickened and opake; substance of brain highly vascular and firm. Thorax. All the viscera perfectly healthy. Abdomen. Mucous membrane of intestines vascular, without ulceration; mesentery inflamed; [contained a calcareous deposit of an oval shape included in a cyst.]

William Ashley, Æt. 65, messenger. Admitted on 4th day of fever: slight occasional head-ache; mind distinct; scarcely any sleep; face flushed; no uneasiness of chest or abdomen; slight cough; pulse 81.

5th. Slight head-ache; little sleep; pulse 82.

6th. Pain of head gone; pulse 90.

8th. No pain; mind confused; delirium; stools in bed; pulse 108.

10th. Prostration; pulse 111.

11th. Perfectly insensible; great prostration; deglutition difficult; hiccup; pulse 116, extremely feeble.

12th. Died.

Head. Membranes and substances of brain intensely vascular; perhaps as much so as in pure phrenitis; substance exceedingly firm; viscera of thorax and abdomen healthy.

Francis Hodgkinson, Æt. 15, servant. Admitted on the 8th day of fever: pain of head and vertigo, which ushered in the attack already gone; mind confused; scarcely any sleep; slight pain of chest on full inspiration; slight cough; abdomen not tender; tongue red at margin, centre covered with yellow fur; pulse 117, easily compressed.

9th. No pain; much confusion; much restlessness; respiration oppressed; tongue still moist; lips and teeth sordid; stools in bed; pulse 112.

13th. PetechiÆ; tongue dry; pulse 110.

15th. No material change in symptoms. Died.

Head. Membranes vascular; substance exceedingly vascular and firm; some fluid in ventricles and at base. Thorax. Lower lobe of left lung of dark red colour and inflamed. Abdomen. Mucous membrane of small intestines vascular, and of dark red colour.

William White, Æt. 17, labourer. Admitted on 6th day of fever: pain of head; especially over forehead; mind distinct; some sleep; face flushed; no thoracic or abdominal uneasiness; tongue white and dry; no stool for a week; pulse 126.

7th. Pain of head very severe; pulse 117; V. S. ad ?xij.

8th. Died this morning most suddenly and unexpectedly, after having complained of violent pain of the head.

Head, not examined till three days after death, yet the substance of the brain was exceedingly firm, and seemed to distend and protrude its membranes, so that there seemed something like hypertrophy of its substance; viscera of thorax and abdomen healthy.

John Mullins, Æt. 28, servant. Stated to be a relapse after a fever of three weeks duration: at present, lies perfectly senseless; noisy delirium; extreme restlessness; pulse 70.

2nd day after admission, continues perfectly insensible; respiration slow and stertorous; tongue not to be protruded; stools passed in bed; pulse 60.

6th. Remained nearly in the same state until this morning. Died.

Head. Dura and pia mater highly injected; surface of brain quite dry and hard; substance throughout exceedingly firm, and thickly crowded with bloody points; cerebellum soft; pituitary gland soft; all the ventricles, especially the third, exceedingly enlarged and quite full of limpid serum; communicating passages greatly distended; an ounce of serum at base. Thorax. [Left pleurÆ completely adherent; both lungs full of tubercles, many of which in the left lung were softened and others were in a state of suppuration.] Abdomen. Mucous membrane of small intestines inflamed and thickened; no ulceration. [Sigmoid flexure of colon contracted into the form of a small white cord of very narrow calibre, the superior extremity of which was blocked up by a large scybala; and beyond it there was a great accumulation of fÆces; spleen very small; right kidney weighed only six drachms; left seven ounces and a half; liver extremely small weighing only two pounds, six drachms; it lay across the epigastrium and adhered by a preternatural membrane to the diaphragm on the left side; mesentery wasted.]

Sarah Hampden, Æt. 50. No account to be obtained of history of disease, but it is stated that this is the 22d day of her fever: at present mind quite fatuous; some uneasiness of chest; cough; abdomen not tender; tongue red and dry; pulse 99.

24th. Subsultus; urine in bed; no stool.

26th. Mind rather more distinct and more firm; less subsultus; submaxillary gland enlarged and painful; pulse 108.

28th. Much prostration; no other change.

30th. Increasing prostration; pulse 120, feeble.

32d. Died.

Head. Dura mater vascular and thickened; arachnoid white and opake; substance of brain slightly vascular, but very soft; pituitary gland suppurating; all the ventricles distended with serum. Thorax. [Universal adhesion of the pleurÆ; lungs studded with tubercles.] Abdomen. Mucous membrane of small intestines inflamed; no ulceration; pancreas very hard; liver much softened.

Virgina M’Mahon, Æt. 8, admitted on 14th day of scarlet fever. No account can be obtained of previous history; mind quite confused; extreme restlessness; abdomen tender; tongue very red and sore; tarsi red and irritable.

15th. Delirium; moaning; no sleep; more sensible to-day; abdomen less tender; pulse extremely quick and weak.

18th. Without any material change, died.

Head. Arachnoid opake; effusion between it and the pia mater; substance of brain exceedingly soft; two ounces of serum in the ventricles. Thorax. Mucous membrane of trachea and bronchi vascular; bronchial tubes filled with mucus. Abdomen. Mucous membrane of small intestines vascular; mesenteric glands enlarged.

Dorcas Wingrove, Æt. 23, servant, admitted on the 6th day of fever. Attack commenced with violent pain in the head, preceded by no other symptom that was observed; this pain still continues exceedingly severe, and is confined chiefly to the right eye; mind distinct; no sleep; much restlessness during the night; countenance pallid; no uneasiness of chest; abdomen tender; bowels constipated; tongue pale, clean and moist; pulse 93, weak.

7th. Pain of head undiminished; delirium; three stools in bed; tongue brown and quite dry; pulse 100, firm, strong, and sharp. C.C. ad ?xij. nuchÆ.

8th. Pain of head gone; no sleep; noisy delirium; stools in bed; pulse 120, weak.

9th. Slight, but very transient amendment.

11th. Comatose; lies quite prostrate; stools in bed; pulse 130, feeble.

12th. Died.

Head. Membranes vascular; arachnoid opake; corpus striatum in part highly inflamed, in part softening to suppuration; viscera of thorax and abdomen healthy.

Thomas Proctor, Æt. 45. Date and progress of disease unknown: at present perfectly insensible; extreme restlessness; eyes dull and vacant; tongue dry; pulse scarcely to be distinguished.

2d day after admission. Insensibility the same; almost constant moaning; features sunk; expression of countenance anxious; pulse 118. Next morning died.

Head. [In falciform process of dura mater an ossification, two inches and a half in length and half an inch in breadth, with several similar ossifications along the course of the longitudinal sinus;] the arachnoid and pia mater consolidated into one thick, opake and yellow membrane; substance of brain highly vascular and very soft; cerebellum quite disorganized, being broken down into a yellow, puriform mass of matter, a considerable portion of which lay loose on the floor of the cranium; all the ventricles full of serum, in which floated numerous flakes of lymph; base immersed in similar fluid. Thorax. Viscera healthy. Abdomen. Mucous membrane of jejunum and ilium much inflamed, neither thickened nor ulcerated; [liver greatly enlarged; walls of bladder half an inch thick.]

The following is placed at the end of the cerebral cases, not because it illustrates any new circumstance in the condition of the brain, but because, while the symptoms and the pathology are prominently cerebral, it affords one of the most complete examples of the peculiar affection of the joints already referred to.

George Carter, Æt. 28. Admitted on the 4th day of scarlet fever: throat sore; deglutition painful; cough; no pain of chest or abdomen; nausea; tendency to vomiting; no pain of head; mind distinct; pulse 108, weak.

5th. No pain; eyes suffused; pulse 120, firmer.

6th. Mind confused; eruption partial, interspersed with papulÆ; tongue of strawberry appearance, and rough from prominence of papillÆ; pulse 124.

7th. Delirium, so violent as to require restraint; no sleep; pulse 120.

8th. Eruption changed to copper-colour; tongue dry; pulse 112.

10th. Inflammation of parotid gland.

18th. Tumour of left parotid exceedingly hard and slowly suppurating; slight difficulty in swallowing; pulse 96.

21st. Tumour opened last night and discharged two ounces of bloody pus; pulse 108.

28th. Alternately mended a little and then fell back to his former state until last night, when swelling of right wrist and left knee came on, attended with excruciating pain and great heat without any discoloration: 12 leeches have been applied with considerable relief: mind confused; no sleep; countenance anxious; face flushed; rigors; pulse 135.

24th. Other wrist and knee have begun to swell and are excessively painful; left wrist and knee which had been more easy, again extremely painful; vomiting; respiration hurried; pulse 116, weak. Died.

Head. Much serum both in ventricles and at base. Thorax. Viscera healthy. Abdomen. Mucous membrane of the ilium ulcerated and extremely dark.

All the large joints swollen and red: on opening the knee joints they were found to contain several ounces of serum mixed with pus; the cellular tissue in the neighbourhood was partly inflamed, and partly mortified and sloughing: both wrists were in a similar condition.

James Solden, Æt. 44, plasterer. For symptoms see page 155.

Head. Membranes of brain vascular; substance highly vascular; some effusion beneath the arachnoid. Thorax. Viscera healthy. Abdomen. Mucous membrane of ilium vascular; no ulceration; mesenteric glands enlarged.

John Clark, Æt. 17. For symptoms see page 156.

Head. Corresponding portions of the pericranium and dura mater detached from the occipital bone to the extent of four inches in length by three in width; coagulated blood effused between the dura mater and the cranium; vessels of the membranes turgid with blood; substance of brain vascular; effusion between the membranes; a little at base. Thorax. Viscera healthy. Abdomen. Mucous membrane of ilium greatly inflamed; cÆcum ulcerated.

From the study of these cases we see that the process of disease is as uniform as that of health, or of any other process of nature; that certain phenomena constantly take place; that they follow a determinate order; that the events seldom or never vary; that their relations to each other never change; that in these cerebral cases of fever a preternatural fulness and apparently increase in the number of the blood-vessels of the brain and spinal cord, or of their membranes is always present; or that if a case do now and then occur in which even no preternatural vascularity can be discovered such an event is exceedingly rare; that this fulness and increase of the blood-vessels is either identical with, or passes into the state of inflammation; that the state of inflammation, after a certain period, produces results which are known to be effects of inflammatory action in other parts of the body; that these products of inflammation consist of a given number; that the whole of that number never concurs in any one case, but that two or more are frequently found in combination; that the laws by which any one of these is formed rather than any other are at present wholly unknown; while instances do occasionally occur, although they are extremely rare, in which the state of mere vascularity alone subsists without the formation of any inflammatory product that can be discovered.

From the study of the history of these same cases we further see that the indications of this inflammatory state of the brain and spinal cord or of their membranes are as uniform as the existence of the state itself; that certain symptoms invariably accompany it; that these symptoms not only declare with absolute certainty that this process is going on, but likewise, in general, clearly mark its progress; and that this series of symptoms and the place in which each stands in the series is as follows: namely,

Pain in the head, or giddiness, or some other uneasy sensation in this organ, attended with a loss of sleep and with a derangement in all the sensorial faculties,—these are the signs of the presence of the disease in the brain or its membranes. Pain in the back, loins, or limbs, or diminution of the power of voluntary motion—these are the signs which mark the existence of the disease in the spinal cord or its membranes. These symptoms having been present a certain time, and at length succeeded by—diminution of the pain or uneasiness without a corresponding diminution in the other febrile symptoms, but with an increase in some of them; for instance, with an increase of the sleeplessness and restlessness: at last, total cessation of all pain or uneasiness, together with a diminution of the sensibility—these are the signs which mark the progress of the disease, and which, in general, denote a transition from the state of mere inflammation to the formation of some inflammatory product. Thus far the change of state is certain and the signs which denote it invariable; to the latter other symptoms are added which occur in the great majority of cases, but not in all; namely, delirium, muscular tremor, involuntary and unconscious stools, acceleration, and in general, increased and increasing weakness of the pulse. Other accessory symptoms still frequently occur and with considerable regularity, but as these are more variable the student is referred to the cases themselves, the study of which can alone teach when they may be expected.

Since the diseased states of the brain and spinal cord or of their membranes, which the preceding pathology discloses, exist, as is there shown, in all degrees of intensity, so the signs by which these states are denoted may vary from a prominence which it is impossible to overlook to an unobtrusiveness which it requires careful attention to discover. And from causes which we do not yet understand, the prominence of the sign is not always in accordance with the intensity of the state; but the important truth here maintained is, (and the more the practitioner observes, the more satisfied he will become that it is a truth,) that whenever these states exist in sufficient intensity to produce death, their presence may be discovered during life. It is not affirmed that these states can be distinguished one from another; but it is contended that the existence of some one or more of them may be ascertained with absolute certainty. As we sometimes see death occur, preceded by the ordinary symptoms of cerebral inflammation, when, on examination after death, nothing can be discerned but preternatural vascularity of the membranes or substance of the brain, without the presence of any inflammatory product that can be distinguished; and as, moreover, when some inflammatory product is generated, we are in total ignorance of the laws by which, in one case, the blood-vessels pour out serum, in another secrete pus, in a third soften, and in a fourth indurate the cerebral substance; so the signs which indicate that these events have taken place are to us, at present, uncertain. There can be no question that the laws, according to which each of these events is produced, are fixed and invariable in their operation; and each may possibly be attended with its specific and therefore diagnostic sign; but it is certain that we have not yet discovered the one nor observed the other. And the preceding cases have been detailed under the heads assigned them, rather with the view of making the pathology clear, than in the hope from this arrangement of affording any guide to practice. In the mean time, what we may know, and ought to know, is when inflammation exists: what we may, in general, further know is, when some product of inflammation has been poured out still more to oppress the brain: to the thoughtful and discerning practitioner it would be without doubt a high satisfaction to be able to carry his diagnosis still further, and to ascertain what that product is: the desire to arrive at such precise and perfect knowledge appears to me to be in the highest degree meritorious: the constant and unwearied endeavour to acquire it may not always succeed with reference to the particular object immediately pursued, but it cannot fail to increase his power and to strengthen his habit of observation; and the sure reward of a devotion thus truly honourable and faithful to the duties of his profession, if it should not be, as it may not invariably be, the confidence and the gratitude of his patient, will at least be the proud consciousness that he has deserved both.

Were it possible to ascertain with absolute certainty and with perfect exactness in which of its various modes inflammation of the brain and its membranes terminates, it would be a subject of interest, as far as we can at present perceive, rather to the physiologist and pathologist than to the practical physician. To the latter the great fact which it is of paramount importance that he should know is, that inflammation is going on in the brain of his patient, and that if he cannot put a stop to it in the course of a day or two, it will in that short space of time terminate in some irreparable change of structure, of which death will be the inevitable consequence. This, it is again repeated, it is always in his power to know; and as there is no one fact which can or which ought to have so much influence upon his practice, so there is no diagnosis which it is of so much importance that he should acquire the habit of forming.

II. Cases in illustration of the Morbid Changes which take place within the Chest; or Thoracic Cases.

Angelica Fidgett.

For symptoms see page 125.

Thorax. Mucous membrane of bronchi, in all their ramifications, exceedingly inflamed; bronchial tubes full of mucus; [substance of left lung extremely inflamed; left pleurÆ adherent; right pleurÆ and lung much less severely affected.] Head. Substance of brain vascular. Abdomen. All the viscera healthy except the uterus and its appendages, which were slightly inflamed.

John Potter, Æt. 21.

For symptoms see page 127.

Thorax. Mucous membrane of bronchi, in all their ramifications, of dark red colour; bronchial glands much enlarged; [pleurÆ of right side generally adherent; substance of lungs consolidated; pericardium contained four ounces of serum;] heart natural. Abdominal and cerebral organs healthy.

Alexander Crombie, Æt. 19, seaman.

For symptoms see page 159.

Thorax. Mucous membrane of bronchi, in all their ramifications, highly vascular; bronchial tubes full of mucus, mixed with pus. Head. Dura mater adherent with preternatural firmness to cranium; substance of brain unusually firm; posterior lobes crisp, and cut almost like cartilage; anterior lobes, when cut into, abound with bloody points; cerebellum exceedingly firm. Abdomen. Peritoneal coat of small intestines in general vascular; eight or ten portions of the jejunum and ilium, to the extent of three or four inches each, intussuscepted; mucous membrane of these parts extensively ulcerated, some of the ulcers circular, the greater number oblong, and at least two inches in length; mucous membrane in general highly vascular, but that surrounding the ulcers less so than the other parts; mesenteric glands corresponding to ulcerated portions of intestine enlarged and vascular; crimson spots on convex surface of liver; gall-bladder distended with a yellowish watery fluid; spleen enlarged, and so soft as to be easily broken down under the finger.

Thomas Lewis, Æt. 51, taylor, admitted on the 8th day of fever. Complaint commenced with general pains, nausea and vomiting, together with cough and dyspnoea. At present there is no pain of chest except on coughing, which produces some uneasiness; cough frequent, with copious sputa; pain of epigastrium; tongue exceedingly parched and dry; much thirst; bowels purged; some pain of head, chiefly in forehead; mind distinct; scarcely any sleep; face pallid; pulse 126, weak. Early next morning died.

Thorax. Mucous membrane of bronchi inflamed; [pleurÆ of right lung covered with coagulable lymph; substance of right lung universally consolidated, and infiltrated with tubercular matter;] left lung gorged. Abdomen. [Liver indurated; crisping under the knife; kidneys indurated.] Head. Membranes and substance of brain vascular.

Mary Sullivan, Æt. 40, married, admitted on the 15th day of fever. Some pain of chest; severe cough; much pain of head, with sense of noise; mind dull; scarcely any sleep; face flushed; skin warm; tongue foul and dry; pulse 98.

16th. Frequent short cough, without expectoration; mind confused, yet sensible when spoken to; pulse 90.

17th. Thoracic and cerebral symptoms unchanged; pulse 111, indistinct.

26th. Cough diminished; sensibility increased; she appeared in all respects better until this day, when the cough became more frequent and the expectoration purulent; pulse 60.

27th. Cough frequent; expectoration the same; respiration short and hurried; pulse 60, intermittent.

30th. Respiration became more and more hurried, and the strength rapidly sunk. Died.

Thorax. Mucous membrane of bronchi inflamed; bronchial tubes full of mucus, mixed with pus; [pleurÆ adherent; patches of left lung hepatized.] Abdomen. Liver and spleen extremely softened, breaking down under the fingers into a mass like coagulated blood. Head. Membranes and substance of brain pretty healthy.

Sarah Peach, Æt. 23, married, admitted on the 17th day of fever. Thoracic symptoms came on with the very commencement of the disease: at present there is no pain of the chest, but much cough; respiration short and hurried; colour of the face quite dusky; some pain of head; mind confused; pulse 100; abdomen not tender; tongue of beefsteak character; bowels regular.

18th. Cough and hurried respiration continue; dusky colour of face has become livid; delirium; low muttering talkativeness; pulse 116; teeth sordid; stools in bed.

19th. Severity of bronchial symptoms much increased; respiration panting; colour of skin in general, but especially of face, livid; deglutition difficult; pulse 124, weak. Died following morning.

Thorax. Mucous membrane of bronchi inflamed; bronchial tubes filled with mucus, mixed with pus; mucous membrane of trachea vascular; [both lungs studded with miliary tubercles.] Head. Dura mater and arachnoid highly vascular; theca of spinal cord highly vascular; substance of brain vascular. Abdomen. [Spleen contained a small mass of cheesy tubercles near its surface;] patches of mucous membrane of small intestines inflamed, but without ulceration.

Isabella Lora, Æt. 12. Admitted on the 3rd day of scarlet fever; throat sore; deglutition painful; slight cough; skin covered with copper-coloured eruption; tongue loaded in middle with white fur; red around edges and at tip; some pain of head; pulse 120.

4th. Much improved; less pain of throat and head; pulse 96.

14th. Convalescent and gradually gaining strength up to this day; early this morning seized suddenly with rigors attended with vomiting: abdomen tender; three stools; pulse scarcely to be felt; mind distinct.

15th. Left parotid painful, hard and swollen; throat again inflamed; pulse 124.

16th. Early this morning seized with symptoms of severe laryngitis, for which leeches have been applied with partial relief; tonsils and uvula much swollen; respiration exceedingly laborious; pulse 140, sharp. Died same day.

Thorax. Tonsils much enlarged; mucous follicles full of purulent fluid mixed with blood; some of them exceedingly enlarged, and communicating so as to form cavities; membrane covering the upper part of larynx highly vascular and much thickened, especially that about the epiglottis and the arytÆnoid cartilages; mucous membrane below the rima glottidis healthy; both the parotids, the sublingual, and the maxillary glands enlarged. Abdomen. Peritoneal coat of the intestines inflamed and thickened. Head. Membranes and substance of brain tolerably healthy.

Mary Anne Lawrence, Æt. 22, servant, admitted on the 5th day of scarlet fever. Throat sore; deglutition painful; slight uneasiness and sense of tightness in chest; frequent cough, with copious expectoration; abdomen not tender; tongue characteristic; skin warm, covered with scarlet eruption; slight pain of head; pulse 126, strong. V.S. ad ?xvj.

6th. Felt much relief after venesection; dyspnoea returned in the evening, and she was again bled to the extent of sixteen ounces: blood first drawn with firm buff, that of the second bleeding with coagulum firm but not buffy; at present cough severe, short, dry; dyspnoea; pulse 148.

7th. Tightness of chest continues; cough better; pulse 144, tremulous. Died next day.

Thorax. Uvula and surrounding parts much inflamed, but not ulcerated; mucous membrane of trachea inflamed; bronchial tubes inflamed, and filled with frothy mucus; [pleurÆ of both lungs adherent; lungs contained a few tubercles; thyroid gland enlarged, and so hard as to be cut with difficulty.] Abdominal and cerebral organs tolerably healthy.

Ann Wormington, Æt. 24, servant.

After some previous indisposition, seized, the day before admission, with shivering, attended with pain of bowels, nausea and vomiting; throat sore; deglutition painful; scarlet eruption on skin; no uneasiness of chest; no cough; abdomen tender; tongue covered with yellow fur; bowels purged; mind confused; eyes injected and heavy; pulse not to be counted. Died four hours after admission.

Thorax. Mucous membrane of trachea of dark red colour; epiglottis quite blackened; arytÆnoid cartilages ulcerated; substance of lungs much gorged. Abdomen. Viscera healthy. Head. Membranes vascular; substance of brain preternaturally firm.

Margaret Scandling, Æt. 26, admitted on the 8th day of fever. No uneasiness of chest; no cough; pain in head; severe pain in limbs and bones; scarcely any sleep; threatening erysipelas on face; abdomen tender; tongue white and dry; no stool for seven days; pulse 88, weak.

10th. No uneasiness of chest; pain of head diminished; pulse 72.

16th. Erysipelas of cheek, spreading to scalp, and attended with considerable pain; tongue dry; pulse 96.

19th. Erysipelas extending; this morning attacked with severe dyspnoea, attended with husky noise in inspiration; deglutition extremely difficult. Hirud. x. gutturi. C.C. ad ?xij. nuchÆ. Capiat Hydrar. Submuriat. gr. ij., c. Pulv. Opii, gr. ss. 6ta q. h.

20th. Respiration and deglutition unrelieved; erysipelas of face very painful; mouth sore; mercurial fetor; pulse 120, soft.

21st. Respiration unchanged; deglutition more painful; erysipelas increased, passing into suppuration; delirium; pulse 90.

22d. Difficulty of deglutition undiminished; respiration rather more easy; pulse 98; much pain of head.

23d. No change in the respiration, deglutition, or erysipelas; much discharge from both ears; left elbow attacked with swelling; heat and excessive pain.

25th. Died.

Thorax. Mucous membrane of larynx inflamed; epiglottis much thickened; both arytÆnoid cartilages in a state of suppuration, right nearly destroyed; cellular substance about the right parotid in a state of suppuration; [pleurÆ of right side adherent; substance of both lungs infiltrated.] Head. Membranes and substance of brain vascular; serum in lateral ventricles. Abdomen. [Mucous membrane of small intestines in several points raised in the form of vesicles, containing air;] spleen soft.

N.B. In this case, the erysipelas evidently extended from the external skin to the mucous membrane of the throat and larynx, an event which is not very common in fever, but which does occasionally happen. The affection of the elbow-joint was clearly of the same nature as that described in case 51.

Charles Tyler, Æt. 54, chocolate maker, admitted on the 7th day of fever. No pain of chest; slight cough; abdomen tender; tongue loaded and dry; thirst; bowels loose; no pain of head; much pain of loins; some vertigo; mind distinct; no sleep; pulse 90, full and firm. V.S. ad ?xx.

8th. Pain of head and abdomen gone; pulse 102, full and sharp; blood with very firm buff. Repr. V.S. ad ?xij.

11th. No return of pain in any organ; mind confused; no sleep; great restlessness; delirium; muscular tremor; respiration short and hurried, with mucous rattle; tongue white and dry; pulse too indistinct to be counted.

12th. Delirium became exceedingly violent soon after yesterday’s visit; there was neither pain nor cough, but he passed by the mouth a considerable quantity of fluid blood; respiration became more and more hurried and he died in the evening.

Thorax. Mucous membrane of the trachea and bronchi inflamed; [the substance of the left lung studded with nodules, consisting of coagulated blood, forming the apoplexia pulmonalis of the French writers:] viscera of the head and abdomen healthy.

John Wotton, Æt. 46, plaisterer. Admitted on the 7th day of fever: attack commenced with chilliness, succeeded by cough and severe pain in the region of the heart; has had two similar attacks of pain which he soon recovered; at present he has so much pain in the side that he cannot take a full inspiration; frequent cough exciting pain; respiration short and painful; abdomen not tender; tongue white and moist; pain of head; little sleep; pulse 120, full and hard; skin hot.

8th. Pain of chest diminished; can take full inspiration with less uneasiness; cough less frequent; respiration little changed; pulse 102, intermittent.

9th. Respiration much more easy; cough less frequent, with copious mucous expectoration; pulse 108, intermittent.

10th. Says he is quite free from pain everywhere; cough again increased; respirations 50; pulse 110, not intermittent; delirium.

11th. Respirations 60; no sleep; great restlessness; pulse 108, intermittent.

14th. Perfectly insensible; scarcely to be retained in bed; respiration extremely quick; pulse not to be counted. Died.

Thorax. Mucous membrane of bronchi highly vascular; [left lung adherent to parieties of chest by a layer of coagulable lymph nearly an inch in thickness; substance of lung completely hepatized; pericardium exceedingly thickened throughout, and universally adherent to the heart; heart itself soft and flabby; inner coat of aorta of reddish brown colour.] Head. Vessels of pia mater exceedingly turgid; effusion beneath it and the arachnoid; substance of brain very much softened. Abdomen. Mucous membrane of ilium vascular.

III. Cases in Illustration of the Morbid Changes which take place within the Abdomen; or Abdominal Cases.

Thomas Hindmarsh, Æt. 26. Admitted on the 10th day of fever: too indistinct to give any account of previous symptoms; at present abdomen tender; tongue loaded and dry; bowels purged; mind confused; very deaf; eyes red and suffused; pulse 108, firm.

11th. Abdomen less tender; five stools; insensibility increased; pulse 104.

12th. Abdomen a little tender; tongue quite dry; three stools in bed; noisy delirium; eyes wild and staring; pulse 108.

13th. Tongue no longer to be protruded; no stool; scarcely at all sensible; eye-lids half closed; pulse 96, firm.

21st. Abdominal and cerebral symptoms little changed; sensible of some pain in chest; cough; dyspnoea; pulse 108.

23d. Abdomen still tender, and now become tympanitic; four stools in bed; perfectly insensible; constant muttering delirium; muscular tremor; large slough on sacrum; pulse 116.

25th. Died.

Abdomen. Peritoneal coat of intestines in general vascular; mucous coat of small intestines highly vascular, and indicated approaching ulceration. Head. Not examined. Thorax. [PleurÆ of both sides adherent throughout; substance of both lungs healthy; slight effusion of serum into pericardium.]

Isaac Grey, Æt. 30. Admitted on 22d day of fever; no account to be obtained of the previous symptoms; at present the abdomen in general is exceedingly tender on pressure, but especially the epigastrium; tongue brown, dry in centre, moist at edges; very tremulous; scarcely at all sensible, yet seems very apprehensive, almost constantly muttering and crying; face flushed; eyes wild; skin speckled with petechiÆ; pulse 112.

23d. Abdomen still very tender; says he is without pain; four stools; delirium; muscular tremor; pulse 100, feeble.

24th. In the early part of last evening became violently delirious, and was extremely restless, constantly tossing his arms about, and throwing off the bed-clothes. Died.

Abdomen. All the coats of the stomach appeared much attenuated; mucous membrane of cardiac extremity so soft as to lacerate under examination; that of pyloric end exhibited numerous minute spots of a deep red colour, as if touched with a paint-brush; peritoneal coat of ilium of dark red colour; other viscera healthy. Head. Arachnoid thickened and opake; considerable effusion between it and the dura mater; substance of brain vascular; half an ounce of serum in each ventricle. Thorax. [Right pleural cavity contained one ounce and a half of bloody fluid, left eight ounces; substance of both lungs much condensed, and on their surface an appearance as if blood had exuded and coagulated. Pericardium contained two ounces of serum: heart healthy.]

Hannah Swift, Æt. 20, servant. Admitted on the 8th day of fever: abdomen, especially the epigastric region, tender; tongue clean, red, chapped; lips parched and cracked; some pain of head, back, and limbs; mind rather confused; pulse 120, soft, and feeble.

9th. The abdomen, which continues tender, has become swollen and tense; two stools.

15th. Abdomen still very tender, swollen, and hard; tongue dry; two stools; vomiting of much green coloured fluid; pain of head gone, but sense of weight in it.

17th. Tenderness of abdomen and vomiting continue; delirium; pulse 100, small and feeble.

19th. Tenderness of abdomen increased; no vomiting; tongue the same; pain of head returned; delirium; erysipelas of face; pulse 109, feeble.

21st. Erysipelas extending to arm; tongue brown, dry, and cracked; much delirium.

22d. Cheeks livid; extremities cold and livid; pulse imperceptible. Died.

Abdomen. Mucous membrane of ilium highly inflamed, and ulcers just forming; other viscera healthy. Head. Dura mater vascular; arachnoid opake; substance of brain vascular; some fluid in ventricles. Thorax. Mucous membrane of bronchi inflamed: tubes filled with mucus mixed with pus: [pleurÆ in part adherent; some serous fluid in both cavities; substance of lungs natural.]

Thomas Sexton, Æt. 18, servant. Admitted on 3d day of scarlet fever; complaint came on with nausea, vomiting, and pain of the limbs; at present throat sore; deglutition easy; chest free from pain; no cough; abdomen tender, especially in the region of the epigastrium; tongue white in middle, red around margin; no stool for several days, because, as he supposes, he has vomited all his medicine; pain of head; vertigo; face flushed; frequent attacks of epistaxis during his vomiting, always relieving the head-ache; pulse 102; skin warm; no eruption.

4th. Pain of head gone; vertigo continues; eyes dull and heavy; face flushed; no vomiting; pulse 96.

5th. Sense of vertigo lessened; tongue brown and dry; four stools; pulse 84.

7th. Abdomen tender; tongue brown and dry; six stools; pain of head returned; much pain of back; no sleep; delirium.

11th. Less sensible: drowsy; delirium; three stools.

12th. Insensibility increased; drowsiness approaching to coma; cheeks dusky; tongue with dark brown crust, dry; stools in bed; pulse 102, weak.

16th. Abdomen tender; tongue not to be protruded; three stools all in bed; pulse 130, extremely weak; great prostration.

17th. Countenance sunk; respiration short and hurried; four stools; more prostrate.

18th. No change excepting that the prostration is still greater. Died.

Abdomen. Mucous membrane of ilium and cÆcum extremely vascular, and contained several small ulcers, some of which were merely the abraded points of enlarged mucous glands; other glands in the neighbourhood much enlarged but not ulcerated; mesenteric glands very much enlarged; liver mottled; spleen larger than natural; pancreas indurated. Head. Arachnoid highly vascular; substance of brain natural; gelatinous effusion between the arachnoid and pia mater; half an ounce of serum at base. Thorax. Viscera healthy.

James Gannicott, Æt. 8. Duration and progress of disease unknown; abdomen tender; lips and tongue sordid; bowels purged; comatose; pupils dilated, but sensible to light; expression of eyes dull and vacant; pulse 125.

2d day after admission. Abdomen no longer tender; three stools; insensibility continues; frequent screaming; pulse 116.

3d. Perfectly insensible; all nourishment refused; stools and urine in bed; pulse 120. Died next morning.

Abdomen. Peritoneal coat of ilium vascular; its mucous coat contained numerous ulcers which varied much in size; but all of them were raised above the surface and defined and regular in their margins; mucous glands throughout the entire intestine diseased, and many of them in different stages of disease; some were only enlarged; others enlarged and inflamed; others ulcerated at the apex; others ulcerated throughout; so that the largest ulcers appeared to be diseased glands in the last stage of ulceration; mesenteric glands prodigiously enlarged and hung over the abdominal vessels like a bunch of grapes of the largest size; rest of the intestines healthy excepting that they were much contracted and intussuscepted in several parts. Head. Dura mater adherent with preternatural firmness to the skull; vascular; pia mater highly vascular; substance of brain vascular and firm; slight effusion between the membranes. Thorax. [PlurÆ of right side adherent;] substance of both lungs healthy.

Henry Todd, Æt. 18. Duration and progress of disease unknown; abdomen tender on pressure; tongue coated with dirty yellow crust, red at tip; perfectly insensible; delirium; eyes, glistening; pulse 120, feeble.

2d day after admission. Little change excepting that the coma is more deep; abdomen less tender; two stools; pulse 124.

3d. Coma undiminished; respiration short, hurried, rattling; stools in bed; pulse 132; great prostration.

4th. Died.

Abdomen. Mucous membrane of ilium inflamed throughout; lower part of it ulcerated; other viscera healthy. Head. Membranes and substance of brain vascular. Thorax. Mucous membrane of bronchi inflamed; bronchial tubes filled with mucus mixed with pus.

Frederick Kilham, Æt. 12. Admitted on the 15th day of fever; abdomen tender; tongue not to be seen on account of its being covered with grumous blood from a large ulcer on the right side of the lower jaw; bowels bound; some pain of head; no uneasiness of chest; pulse 114; much emaciation.

16th. Lips and teeth sordid; mind confused; prostration.

20th. Violent delirium; pulse 92.

21st. The ulcer along the lower jaw in the inside of the mouth sloughing and extending; delirium; pulse 96, weak. Died next day.

Abdomen. Mucous membrane of ilium vascular, and contained some ulcers; other viscera healthy. Head. More fluid than natural between the membranes. Thorax. Viscera healthy.

Two ulcers in the substance of the cheeks; that on left cheek extended from the angle of the mouth to the last molares, and contained a large black slough a quarter of an inch thick; this ulcer had extended to both gums, denuding the alveolar processes and loosening the teeth; that on the right cheek precisely similar, but less extensive.

Ann Mount, Æt. 28, servant. Admitted on 15th day of disease; epigastrium tender; tongue brown and dry; bowels purged; slight pain of head; much vertigo; some cough; pulse 111, very intermittent in the right wrist; less so in the left.

16th. Early this morning attacked with severe pain of the chest and dyspnoea, attended with much headache, for which she has been bled with the removal of the symptoms; pain now quite gone; tongue white; four stools; pulse 120, soft; blood buffy and cupped.

17th. Seized last evening with violent delirium which required restraint; occasional sleep with paroxysms of delirium; face flushed; abdomen not tender; pulse 120, firm. V. S. ad ?xvi.

18th. No pain of head; no delirium; slept better; tongue brown and dry; five stools; pulse 132, firm; blood sizy and deeply cupped. V. S. ad ?xij.

19th. Complains of “stupid pain of head;” no vertigo; delirium, but less violent; scarcely any sleep; countenance still heavy, but rather more animated than yesterday; abdomen not tender; three stools in bed; pulse 132, firm but soft. C. C. ad ?xij. nuchÆ.

20th. Pain gone; more insensible; countenance more dull and heavy; scarcely any sleep; almost constant moaning; tenderness of abdomen quite gone; tongue brown and dry; lips and teeth sordid; four stools in bed; pulse 144, weak. Vini Albi, ?ii. Mist. Camph. Fort. 6ta. q. h.

Slept rather better; less moaning; countenance scarcely as collapsed as yesterday; pulse 132, firmer; stools in bed. Augeat. Vinum ad ?vi.

22d. Scarcely any sleep; almost constant moaning; face flushed; skin covered with cold perspiration; tongue scarcely to be protruded; deglutition difficult; subsultus tendinum; pulse 132.

24th. No change except that the prostration continued to increase. Died.

Abdomen. Mucous membrane of jejunum, ilium and cÆcum highly vascular; that of ilium contained three or four large oval ulcers; other viscera healthy. Head. Membranes and substance of brain vascular; more serum than natural in the ventricles. Thorax. Viscera healthy.

Ann Martin, Æt. 37, servant. Admitted on the 8th day of fever; complaint came on with ordinary symptoms, attended with nausea and vomiting; at present abdomen not tender; tongue red, cracked and dry; bowels regular; no uneasiness of chest; slight cough with scanty expectoration; pulse 92, very intermittent, beating thrice regularly, then intermitting for a space equal to that of the three pulsations; pain of head gone; some vertigo remains.

9th. Cough with difficult expectoration; respiration hurried; five stools; pulse 104, more regular.

10th. Tongue more fissured; five stools; respiration less hurried and difficult; pulse 112. Two grains of tartar emetic in solution every two hours.

11th. No material change; pulse 116; has taken ten draughts with the tartar emetic, the last four vomited. The draughts to be continued every three hours.

12th. Bronchial affection very much relieved; last four draughts not vomited. Pt. Haustus 4ta. q. h.

13th. Respiration nearly natural; much less cough; pulse 96; tongue moist; four stools, last tinged with blood; abdomen not tender. Tartar emetic omitted on account of appearance of blood in the stools.

17th. Bronchial affection appears to be quite gone; yet the tongue has again become dry; the pulse has risen to 112; there is scarcely any sleep; and slight muscular tremor is perceptible. Capiat. Vin. Alb. ?iv. Jus. Bov. i lb.

20th. Respiration again short and hurried; face quite dusky; tongue furred, dry and cracked; pulse 110.

23d. Respiration laborious; cough returned with very copious muco-purulent expectoration, amounting to a pint in the twenty-four hours; pulse 116.

26th. No change; a grain of tartar emetic resumed every four hours. Wine and beef tea to be continued.

28th. Neither vomiting nor purging; respiration more easy; cough diminished; tongue more moist; pulse 116.

29th. Respiration much more natural; cough greatly diminished; tongue clean and moist; pulse 112.

36th. From the period of last report she steadily and progressively improved and became convalescent; on the morning of this day while speaking to the nurse in her usual manner she suddenly fell back and expired.

Abdomen. Mucous membrane of intestines in general inflamed, especially that of ilium and cÆcum, which contained some ulcers; peritoneal covering of posterior surface of spleen cartilaginous; other viscera healthy. Thorax. Mucous membrane of bronchi highly inflamed; bronchial tubes full of purulent fluid; substance of lungs healthy. Head. Unfortunately, from some accident, the head was not examined.

Stephen Winter, Æt. 78. Duration and previous symptoms of disease unknown; at present abdomen tender; tongue brown and dry; stools natural; respiration wheezing with some cough; slight pain of head; mind composed; muscular tremor; pulse 100, irregular.

2nd day after admission. Abdominal and thoracic symptoms the same; mind more confused; more muscular tremor; pulse 108.

5th. Respiration laborious; mind quite unconscious; constant incoherent talking; pulse 108.

6th. Respiration hurried and laborious; pulse not to be counted; perfectly insensible. Died next morning.

Abdomen. All the coats of the stomach appeared much attenuated; colon contracted into the form of a white cord; its coats in several places thickened, and its mucous membrane ulcerated; liver soft; [gall bladder much thickened, and its cavity so diminished, that it would scarcely admit the end of the finger, filled with two small gall-stones. About five inches of the recti muscles black and infiltrated with blood.] Head. Arachnoid thickened and opake; considerable effusion between it and the dura mater; substance of brain firm; ventricles distended with serum. Thorax. All the viscera healthy, [excepting that the coronary arteries were ossified.]

Richard Harvey, Æt. 19, butcher. Admitted on the 8th day of disease; no account to be obtained of previous symptoms; at present abdomen tender; bowels purged; tongue brown and dry; lips and teeth sordid; pain of head gone; mind confused; delirium requiring restraint; subsultus; pulse 116, weak.

9th. Tenderness of abdomen continues; stools in bed; no sleep; much delirium; scarcely conscious when spoken to; pulse 108, more firm.

10th. Slept better; rather more sensible this morning; pulse again 116.

14th. All nourishment refused; stools and urine in bed; delirium; muscular tremor; pulse 128, weak; extremities cold.

15th. Passed a better night; more sensible; pulse 116.

17th. Extensive slough on sacrum; slough also on right elbow-joint, with erysipelas of surrounding integuments; pulse 108.

21st. Skin covered with petechiÆ; slough extending; great prostration.

35th. No change, excepting that the sloughs were improved in appearance by the chlorate of lime, but the emaciation increased, the strength diminished, and all nourishment was refused excepting wine. Died following day.

Abdomen. Both small and large intestines vascular throughout; mucous membrane of ilium contained several ulcers of considerable magnitude; gall-bladder contained an ounce and half of serous fluid; spleen indurated; other viscera healthy. Head. Substance of brain vascular; effusion between the membranes; more fluid than natural in the ventricles and at base. Thorax. Bronchi natural; substance of right lung gorged with blood and infiltrated with serum; that of left healthy.

Elizabeth Gore, Æt. 24, servant. Admitted on 22d day of fever: attack commenced with ordinary symptoms, accompanied with sense of nausea and some vomiting. At present abdomen not tender; tongue red, moist; lips and teeth sordid; bowels bound; pain of head gone; that of loins remains; deafness; no uneasiness of chest; much cough; skin dusky; pulse 120, weak and intermittent.

23d. Abdomen tender; four stools, dark; some pain of head; delirium; pulse the same.

26th. Stools in bed; no sleep; delirium; respiration hurried and noisy; cheek dusky; extremities cold.

27th. Deglutition difficult; pulse 128. Died next morning.

Abdomen. Mucous membrane of ilium ulcerated; mesenteric gland excessively enlarged. Head. Membrane and substance of the brain natural; much effusion into the ventricles, and at the base of the skull. Thorax. Viscera of the thorax in other respects perfectly healthy.

Ann Kensit, Æt. 20, servant. Admitted on the 8th day of relapse: perfectly insensible; cannot be roused; no sensation on firmest pressure over the abdomen; pupils natural; tongue brown and dry; bowels loose; pulse 124.

9th. Some uneasiness induced by firm pressure over the abdomen, which has become swollen, tense, and tympanitic; tongue not to be protruded; lips and teeth sordid; stools in bed; respiration slow and laborious; face cadaverous; extremities blue.

11th. No change; has never spoken nor shown any degree of sensibility since admission.

Abdomen. Peritoneal coat of intestines in general vascular, that of small intestines particularly so; numerous patches of the mucous membrane of the ilium raised by matter deposited beneath it, and extensively ulcerated; mesenteric glands much enlarged. Head. Membranes of brain vascular. Thorax. [PleurÆ of both sides adherent; that of right side vascular; right cavity contained some serous fluid mixed with flakes of lymph.]

Sarah Hassell, Æt. 40. Admitted on 8th day of fever; complaint commenced with usual symptoms, accompanied with much nausea. Abdomen not tender; tongue furred at root, red and clean at tip and around edges; bowels purged from the very commencement of the attack; no uneasiness of chest; cough; pain of head gone; that of back remains; vertigo; pulse 108, feeble.

9th. No tenderness of abdomen on firmest pressure; tongue brown and dry; four stools; pulse 108.

12th. Still no tenderness of abdomen; six stools; tongue quite dry; pulse 120.

16th. Abdominal symptoms unchanged, excepting that the tongue has been exceeding dry; nearly insensible; delirium; almost constant moaning; pulse 120, very weak.

25th. Abdominal and cerebral symptoms continue with little change; cough more frequent with muco-purulent expectoration; pulse 130, very weak.

29th. Quite helpless; pulse scarcely to be distinguished; copious expectoration of purulent matter.

31st. Died.

Abdomen. Ilium contained several large ulcers, especially at its termination in cÆcum; liver enlarged and softened; other viscera healthy: Head. Membranes vascular; arachnoid opake and thickened; substance of brain vascular; effusion between the membranes; more fluid than natural in ventricles. Thorax. Lungs gorged; mucous membrane of bronchi vascular; bronchial tubes full of mucus mixed with pus.

Edward Hammond, Æt. 24, servant. Admitted on the 22d day of fever: attack commenced with usual symptoms, accompanied with loss of appetite and sense of nausea; at present no tenderness of abdomen; tongue red, glazed and cracked; bowels purged; no uneasiness in chest; cough with mucous expectoration; pain of head entirely gone; sensation in general diminished; mind composed; little sleep; pulse 110, of good power but easily compressed; much prostration.

23d. No pain acknowledged in any organ; little sensibility; no sleep; much restlessness; delirium; expression of countenance wild; pulse 108, firm.

24th. No pain; less sensible; tongue has become brown and dry; three stools; pulse 124, weak.

25th. More sleep; more tranquil this morning; tongue also is more moist; but the stools have been passed in bed, and the pulse is 124, weak and fluttering.

26th. More sleep; much more tranquil; more sensible; tongue more clean and moist; stools not passed in bed; the pulse notwithstanding is 136, and the pulsations are not distinct, but run into each other.

28th. Mind distinct; more sleep; tongue continues more moist, but no stools and no urine have been passed; the latter has been drawn off by the catheter; pain is now complained of in the right lumbar region; pulse 123. Died next day.

Abdomen. Mucous membrane of ilium ulcerated; pancreas indurated, nearly of the consistence of cartilage, and of paler colour than natural; other viscera healthy. Head. Membranes natural; half an ounce of fluid at the base of the skull; substance of brain much softened. Thorax. Viscera healthy.

Sarah Raven, Æt. 17. For symptoms see page 140.

Abdomen. Mucous membrane of small intestines in general inflamed; lower part of ilium extremely ulcerated. Head. Both dura and pia mater vascular; arachnoid opake; much serum effused between the membranes. Thorax. [PlurÆ of both sides adherent; left lung inflamed;] right lung healthy; other viscera healthy.

Mary M’Gowan, Æt. 18, servant. Admitted on the 8th day of fever; attack commenced with usual symptoms; at present, abdomen tender; tongue thickly coated and dry; lips and teeth sordid; much thirst; bowels purged; stools dark and offensive; pain of head which has been severe from the beginning continues, and is most severe over the fore-part; pulse 116, weak.

9th. Abdomen and tongue the same; pain of head unabated; eyes dull and heavy; right cheek deeply flushed; pulse 110. C. C. ad ?x. temporibus.

10th. Abdominal symptoms unchanged; pain of head relieved, but not gone; pulse 132, weak.

11th. Tongue cleaning; quite moist; three stools; very slight pain of head; delirium; pulse 120, weak.

12th. Pain of head quite gone; but there is no other change.

13th. No sleep; great restlessness; noisy delirium; pulse 126, weak; swelling, redness and pain of left parotid.

15th. Tongue has become brown and dry; and respiration difficult and rattling; face flushed; colour dusky; lies on back quite prostrate; pulse 136, weak; inflammation of left parotid subsided, but it has now attacked the right.

16th. Respiration hurried and noisy; skin in general dusky; cheeks extremely flushed and of deep purple colour; pulse scarcely to be counted; prostration extreme. Died next day.

Abdomen. Peritoneal coat of intestines vascular; several ulcers in ilium and cÆcum; appearance of ulcers peculiar, resembling those of phthisis rather than those of fever; vermiform process externally vascular; internally contained a crop of bodies like tubercles or enlarged glands and so numerous as to form a layer under the mucous membrane. Head. Membranes and substance of brain vascular; more fluid than natural in the ventricles. Thorax. [PleurÆ of left side adherent;] other viscera healthy.

William Waller, Æt. 24, barge builder, admitted on 22d day of fever. No tenderness of abdomen on firmest pressure; tongue loaded and dry; thirst; bowels said to be regular; no uneasiness of chest; some cough; pain of head, which had been severe, entirely gone; mind dull and confused; no sleep; face flushed; prostration; great sense of oppression; pulse 114, tremulous and indistinct.

23d. No change, excepting that the tongue has become brown and dry.

24th. Pulse 120, weaker and more tremulous: other symptoms the same.

27th. Tongue has become extremely dry; thirst urgent; three stools, mixed with blood; abdomen not tender; pulse 100.

28th. After yesterday’s visit, seized suddenly with violent delirium, urgent dyspnoea, and copious discharge of blood from the bowels; these symptoms continued until half past eleven, p. m. when he expired.

Abdomen. Mucous membrane of greater part of small intestines much inflamed; that in lower part of ilium quite black and nearly sphacelated, containing several spreading ulcers; colon throughout of darker colour than natural; mucous membrane of rectum highly vascular; spleen enlarged and softened; [bladder thickened and vascular.] Head. Arachnoid opake and milky, covering a large quantity of gelatinous fluid. Thorax. [PleurÆ of left side generally adherent, of right less extensively adherent;] substance of both lungs healthy.

Margaret Pennifold, Æt. 20, servant. Admitted on the 8th day of fever, which, besides the ordinary symptoms, commenced with pain and tenderness of bowels: at present, abdomen tender, especially the epigastrium; tongue very red, sore, and cracked; lips and teeth sordid; much thirst; some uneasiness of chest on full inspiration; slight cough; some pain of head, especially in occiput; scarcely any sleep; mind much confused during the night, scarcely distinct during the day; pulse 105.

9th. No pain; tongue the same; three stools; slept some; mind more distinct; pulse 100.

11th. No pain; some cough; face flushed; colour of cheek dusky; voice hoarse.

12th. Little change; pulse 108.

15th. Still says she is free from pain; no tenderness of abdomen on firm pressure; tongue very red and dry; four stools, mixed with a large proportion of blood; rather more cough; sleeps well; pulse 116.

16th. Stools mixed with blood; pulse 117.

17th. Three stools, dark and offensive but without blood; pulse 100; other symptoms the same.

19th. Stools in bed; much prostration; pulse 120, very weak; respiration difficult.

20th. Vomiting; pulse 120, weaker.

21st. Vomiting continues; six stools; mind confused: pulse 120.

22d. Vomiting has ceased; deglutition difficult; face collapsed and cadaverous; five stools in bed; great prostration; pulse 117, extremely weak. Died in the night.

Abdomen. Mucous membrane of pyloric end of stomach and of intestines in general vascular; that of jejunum and ilium very nearly black, presenting the appearance of extensive ecchymosis; ilium contained an infinity of elongated ulcers, many of which had penetrated the muscular coat; the cÆcum and the lower part of the colon in a similar condition; there was no deposition of adventitious matter; but the ulcers were formed entirely in the coats of the intestine; other viscera healthy. Thorax. Mucous membrane of both bronchi inflamed; bronchial tubes full of mucus; mucous membrane of larynx perfectly healthy, and without the least thickening in any part; [apex of left lung adherent to costal pleura; adhering part of the substance of the lung contained a mass of tubercles, some of which were passing into the state of suppuration; the remainder of the lung more vascular than natural, and some parts of it hepatized; right lung less consolidated, but still more firm and vascular than natural.] Head. Brain and its membranes tolerably healthy.

Thomas Bryan, Æt. 18, labourer. Admitted on the 8th day of fever: at present pain of abdomen, much increased on pressure; tongue white and moist; much thirst; bowels loose; pain in right side on full inspiration; some cough; pain of head and back, which had been severe, gone; pulse 90.

9th. A few hours after the visit, the pain in the side became exceedingly severe and was attended with frequent cough. On account of these symptoms he was bled to the extent of twenty-four ounces, with immediate and great relief: the pectoral symptoms have not returned; abdomen still tender; five stools, dark; no pain of head, but the skin over the scalp is hot, and there is some intolerance of light; pulse 112. Takes a grain and half of calomel, with two of Dover’s powder, every six hours.

10th. Pain of abdomen continues; vomiting; two stools; pulse 116.

13th. Gums already affected; throat sore; none of the symptoms relieved; tongue has become brown and dry; five stools; less sensible; much moaning; pulse 120.

14th. Abdominal symptoms undiminished; five stools; more insensible; pulse 112.

16th. Insensibility increased to coma; little change in the other symptoms.

20th. Severe pain in the abdomen, particularly in the region of the cÆcum; tongue brown and dry and quite hard; four stools; pulse 118.

23d. Vomits food and medicine; coma continues; delirium; pulse 118.

24th. No change, excepting that the vomiting ceased, after having taken a scruple of calomel at a single dose.

26th. Died.

Abdomen. Ilium and cÆcum much and extensively ulcerated; other viscera healthy. Head. Membrane of brain natural; substance vascular; more serum than natural in the ventricles; some at the base; much fluid in the theca vertebralis. Thorax. Posterior part of left lung tuberculated, and infiltrated with purulent matter; upper part of right lung still more tuberculated and condensed.

Elizabeth Hammond, Æt. 50, married. Admitted on the 28th day of fever, which came on with the ordinary symptoms; at present she is without pain in any organ; face peculiarly pallid; some cough; pulse 120, and weak.

29th. No tenderness of abdomen; no pain; cough; delirium; pulse 110.

32d. Cough; delirium; pain, redness, swelling, and vesication of left leg; pulse 120, weak.

35th. Tongue scarcely to be protruded; very tremulous; three stools; cough; much delirium; pulse 120, very weak; the vena saphena major easily to be traced along its whole course, being hard, tense, and painful.

40th. Delirium; muscular tremor; much convulsive twitching of the face; pulse 130, extremely weak.

40th. Delirium continues; muscular tremor increased; great prostration; leg more swollen, the tumefaction now extending up the thigh; the saphena traced to the middle of the thigh where it ends in a varix, which has for the last two days greatly enlarged; lymphatics along the course of the vein swollen; integuments of a dusky red colour; much thickening and hardening of the cellular tissue over the femoral vessels; says she has no pain in the leg; mind dull and confused, yet answers coherently when spoken to.

43d. Delirium continues; prostration increases; lips and teeth covered with dark-coloured sordes; affected leg darker in colour, and colder to the touch; pulse 120; no tenderness of the abdomen, nor has it been tender through the whole course of the disease.

44th. Died.

Abdomen. Mucous membrane of ilium, cÆcum, and commencement of colon extensively ulcerated; viscera of head and thorax healthy; slight swelling of the whole left extremity; ankle oedematous; the cellular tissue along the entire course of the saphena major and femoral vein exceedingly condensed and hard; on opening the saphena vein there was found a layer of coagulable lymph lining its whole internal surface, which was universally vascular and rough; in many places, especially about the knee, the coats of the vein were very much thickened, so that the calibre of the vessel was diminished at least one-half its size; the lower part of the femoral vein was in a similar state, but its superior portion and the external iliac were little, if at all affected.

Mary Ford, Æt. 30, married. Admitted on the 8th day of fever, which in addition to the ordinary symptoms, was attended at the commencement with pain in the abdomen, which continued for some time, but which is now entirely gone: states that the bowels have been very loose for upwards of a month past; tongue loaded and red; thirst; no uneasiness of chest; some cough; pain of head, which was severe in the commencement, quite gone; pulse 90; great prostration.

9th. No pain in any organ; tongue unchanged; two stools, light and offensive; delirium.

10th. Four stools in bed; delirium; lies on back quite prostrate; pulse 105, weak.

11th. Tongue not to be protruded; perfectly insensible; pulse 125.

Abdomen. Peritoneal coat of small intestines vascular; mucous membrane of ileum and cÆcum contained several large ulcers; in other places the membrane was entire, but irregularly raised by submucous deposit so as to present the appearance of large ulcers. Head. Arachnoid highly vascular; effusion beneath all the membranes; more fluid than natural in the lateral ventricles. Thorax. Viscera healthy.

Eleanor Norris, Æt. 12. Was seized eight days ago with sudden loss of strength, great confusion of mind, and severe pain in the head and limbs; the pain of the head continues, shooting down along the spinal cord to the loins; no tenderness of abdomen; tongue white; bowels purged; pulse 129, of good power.

9th. Tongue has become brown and dry; five stools; scarcely any pain of head; delirium; pulse 120.

14th. Abdomen now tender on pressure; tongue continues brown and dry; four stools; pain of back and loins returned; delirium; pulse 130.

15th. Pain of abdomen continues; tongue still browner and more dry; four stools; delirium; pulse 128.

16th. Deglutition difficult; pulse 120; great prostration.

17th. Stools in bed; delirium and prostration increasing; pulse scarcely to be counted.

18th. Great restlessness; much delirium; countenance wild and anxious; pulse exceedingly quick and weak.

20th. Respiration hurried and laborious; pulse not to be counted; insensible; stools in bed. Died in the night.

Abdomen. Mucous membrane of jejunum and ilium extremely ulcerated; omentum a mere web; all the other viscera healthy. Head. Membranes and substance of brain apparently natural. Thorax. [Costal pleura of left side inflamed and thickened; pulmonary pleura covered with pus; pleural sac contained two ounces and a half of serum mixed with pus; substance of left lung nearly healthy; right side healthy; two ounces of serum in pericardium.]

Maria Moore, Æt. 22, servant. Admitted on the 22nd day of scarlet fever: throat well; deglutition easy; no pain of chest; none of abdomen; tongue of dark red colour; bowels purged; some pain of head, especially at occiput; pulse 98.

23d. Pain of head continues; noisy delirium; pulse 108; abdominal symptoms the same.

30th. Amended the day following last report, and continued to improve until this morning, when she was again attacked with soreness of throat and difficult deglutition; tongue loaded; three stools; pulse 98.

31st. Throat equally painful; deglutition equally difficult; pulse 110.

32nd. After the application of leeches to the throat the pain became easier and the deglutition less difficult; internal fauces very red; uvula much swollen.

33d. Throat again better; deglutition easy; pulse 120.

35th. Throat well, but the voice is hoarse; four stools, mixed with blood; pulse 110.

36th. Respiration hurried; tongue brown, dry, and cracked; lips and teeth sordid; four stools, mixed with lumps of coagulated blood, partly passed in bed. Died in evening.

Abdomen. Mucous membrane of ilium and cÆcum in part highly vascular and much thickened, in part ulcerated; pancreas indurated; other viscera healthy. Thorax. Epiglottis vascular and thickened; mucous membrane of arytÆnoid cartilages ulcerated; mucous membrane of trachea highly vascular; [pleurÆ of both sides adherent; right lung filled with tubercles; bronchial glands enlarged.] Head. Not examined.

Charles Crossley, Æt. 21. Admitted on the 15th day of fever, which came on with the ordinary symptoms: at present, tenderness of the epigastrium, and over the whole abdomen; tongue brown, cracked and tremulous; bowels purged; scarcely any pain of head; mind indistinct; expression of eyes wild; slight cough; pulse 40, soft.

16th. After six leeches had been applied to the epigastrium the tenderness was much diminished: says he has now no pain any where; two stools; expression of countenance the same; pulse 96.

17th. Abdomen has become swollen and hard, not tender on firm pressure; five stools; tongue unchanged; respiration hurried and noisy; no sleep; delirium; face pallid; eyes wild and rolling; pulse 100.

16th. Abdomen hard, especially in hepatic region; slightly tender; vomiting; two stools, mixed with blood; extremities cold.

19th. Abdomen hard, not tender; two copious stools, consisting almost entirely of blood; tongue the same; pulse 96.

20th. One stool without any feculent matter, consisting entirely of blood; delirium; muscular tremor.

23d. No stool for two days; having taken two drachms of castor oil, he had two copious evacuations of very dark colour, mixed with blood; abdomen more soft, not tender; tongue cracked in the centre, more clean and moist at edges; cough; pulse 108, soft.

35th. From the morning of last report the hÆmorrhage disappeared, sleep and sensibility returned, the tongue became more clean and moist, the strength improved, the appetite became keen: he was put upon low diet, and was allowed three ounces of meat daily and four ounces of wine: he appeared to be so much recovered, that it was thought he could bear this liberal allowance; but, immediately on this change of diet, the skin became hot, the cough returned, he had six stools without medicine, the delirium re-appeared at night, and the pulse rose to 100; there was not the slightest pain, either of the head or of the abdomen.

36th. Tongue again brown and dry; three stools; no sleep; much restlessness; delirium; pulse 108, firm; skin extremely hot.

43d. Stools and urine in bed; delirium; muscular tremor; subsultus tendinum; pulse 104.

46th. Sloughs have formed on both hips and an abscess in the right groin.

49th. Abdomen has become swollen, tense, and tympanitic; no stool; tongue the same; vomits every thing; a large black eschar on sacrum; much discharge from the ulcer in the groin; cough frequent; pulse 120, feeble; extreme prostration. Died in the evening.

Abdomen. Lower portion of ilium and commencement of cÆcum contained several ulcers, some of which were of large size; [peritoneal cavity contained two pints of serum, mixed with pus and flakes of lymph; intestines, liver, and abdominal parietes lined throughout with a coat of lymph, easily removeable with the scalpel; intestines adherent to each other and to the parietes of the abdomen.] Head. Arachnoid opake and of milky colour; pia mater highly vascular; much effusion beneath it and the arachnoid; several drachms of serum in the ventricles, and a large quantity at the base of the skull; substance of the brain highly vascular and much softened. Thorax. [In each cavity of pleura about six ounces of fluid; posterior part of lungs condensed; a few recent adhesions between the pleurÆ of the right side;] other viscera healthy.

Mary Baker, Æt, 23, servant. Admitted on the 22d day of fever, which, in addition to the ordinary symptoms, came on with nausea, anorexia and purging; at present complains of a sense of heat in the abdomen without pain; but there is uneasiness when firmly pressed; tongue white in middle, red at edges, moist; thirst; bowels stated to be regular; pulse 104; no pain of chest or head.

23d. Abdominal symptoms the same; no sleep; some pain of head; pulse 120, weak; much sense of weakness.

24th. Tongue has become dry; three stools; pain of head gone; some vertigo; delirium; expression of countenance anxious and sunk; pulse 120.

25th. Tongue more moist; three stools; slept better; expression of countenance more natural; but the pulse has risen to 130 and is extremely weak.

26th. More pain of abdomen on pressure; more prostration; delirium continues; pulse 130, extremely weak. Died next day.

Abdomen. Peritoneal coat of small intestines highly vascular; mucous membrane of lower part of ilium and cÆcum full of ulcers, some of which had penetrated through the muscular to the peritoneal coat; this latter membrane was very dark and approaching to gangrene; peritoneal cavity contained a considerable quantity of bloody serum; omentum dark and inflamed; cardiac extremity of the stomach vascular; other viscera healthy. Head. Dura mater adherent with more firmness than natural to the skull; other membranes healthy; more fluid than natural in the ventricles; substance of brain and cerebellum vascular. Thorax. Mucous membrane of both bronchi highly inflamed; [left thoracic cavity obliterated by old adhesions; left lung completely hepatized; right lung loaded with blood and serum; right cavity contained a considerable quantity of blood and serum; heart flaccid; both auricular valves very dark.]

George English, Æt. 25. For symptoms see page 141.

Abdomen. Numerous ragged ulcers in the cÆcum, which, having destroyed the mucous, had laid the muscular coat quite bare; both the muscular and the peritoneal coats were blackened and in the first stage of sphacelation; an aperture of about the size of a sixpence had been formed in them through which a considerable quantity of fÆces had escaped into the peritoneal cavity; in different portions of the mucous membrane of the other intestines there were slight patches of inflammation; omentum much thickened, adhering anteriorly to the abdominal peritoneum and posteriorly to the intestines; the latter were so agglutinated together, that it was impossible to trace their convolutions; the peritoneal sac contained four pints and a half of serum mixed with pus; the peritoneal coat of the liver adhered to the diaphragm all around, except at one point where a sac was formed which was filled with serum; substance of liver healthy; other viscera healthy. Head. Dura mater vascular; pia mater highly vascular; arachnoid healthy; more fluid than natural between the membranes and in the ventricles; substance of the brain pretty healthy. Thorax. [Right pleura vascular; superior and middle lobes of right lung contained numerous miliary tubercles; lower lobe, one or two in the first stage of suppuration; the under surface of this lobe adhered to the diaphragm with great firmness, shewing that the disease of the abdomen had extended to the thorax; pleurÆ of left side contained two ounces of bloody serum; substance of left lung healthy; pericardium contained three ounces and a half of serum; left ventricle of heart full three-fourths of an inch thick.]

William Baker, Æt. 26. Admitted on 15th day of fever: no account to be obtained of previous symptoms: too insensible to give any statement that can be depended on of his present feelings; points to lower part of chest and epigastrium as the chief seat of pain; abdomen tender on pressure; some cough; voice hoarse, husky, and feeble; no pain of head; pupils contracted; pulse 100, sharp.

16th. Six stools, two passed in bed; hiccup; frequent cough; respiration laborious; pulse 84.

20th. No perceptible change until to-day, when the stools, six in number, became mixed with blood; the expectoration is also tinged with blood; respiration more hurried and difficult; hiccup continues; pulse 120.

23d. Five stools in bed; hiccup gone; no sleep; great restlessness; pulse the same. Died next morning.

Abdomen. Peritoneal coat of intestines vascular; mucous membrane of small intestines, and especially of ilium, inflamed and ulcerated; near the caput coli a large ulcer had perforated the peritoneal coat, and through the opening, which was an inch and a half in diameter, a quantity of fÆculent matter had escaped into the cavity of the peritoneum; spleen very much softened, easily breaking down under the finger. Head. Pia mater highly vascular; substance of brain slightly vascular; a small quantity of bloody serum effused into the lateral ventricles. Thorax. Mucous membrane of bronchi of dark red colour; tubes contained much frothy mucus; substance of both lungs gorged; [pleurÆ of left side contained a pint and half of fluid; pericardium adherent to the pleura costalis; heart flaccid and pale.]

Thomas Kennie, Æt. 30, labourer. Admitted on 10th day of fever: attack commenced, besides the ordinary symptoms, with tenderness of abdomen: at present the abdomen, which is generally tender, is exceedingly so over the right iliac region; bowels stated to be regular; tongue foul, red and dry; thirst; some pain of chest on full inspiration and coughing; cough troublesome; respiration hurried; little sleep; mind confused; face flushed; pulse 120, weak.

11th. Tenderness of abdomen continues; five stools; respiration hurried, with occasional cough and viscid expectoration; slight pain of head; mind distinct; eyes suffused; skin cool, covered with petechiÆ. Died next day.

Abdomen. Mucous membrane of small intestines very vascular, that of ilium intensely so; contained several oval and deep ulcers, one of which had perforated the peritoneum, the aperture of which was sufficiently large to allow the apex of the ring finger to pass through it; the peritoneal cavity contained about a pint of pus; the intestines were all glued together; the surface of the liver was very dark and much inflamed. Head. Membranes of brain vascular; substance rather vascular; more fluid than natural in the ventricles. Thorax. Viscera healthy.

David Piggott, Æt. 19, furrier. Admitted on the 9th day of fever: at present, severe pain in the right hypochondrium, stretching towards the umbilicus, increased on pressure; tongue brown and dry; no stool; slight cough; some pain of head; eyes suffused; pulse 108, firm. V.S. ad ?x.

10th. Pain of right hypochondrium gone; tongue the same; no pain of head; very deaf; slept tolerably; pulse 100, soft.

11th. No pain; tongue unchanged; one copious stool, consisting chiefly of blood; slept well; mind confused; countenance rather improved; pulse 96.

12th. No pain; two stools, with less admixture of blood; mind distinct; pulse 110.

13th. Eight stools, scanty, without blood; tongue dry and furred; slept ill; great prostration; pulse 90. Died next day.

Abdomen. Mucous membrane of small intestines in general vascular, especially that of the ilium and commencement of the colon, in both of which were numerous ulcerations; one in the former had perforated the bowel, forming a hole of the size of a sixpence; about a quart of sero-purulent fluid in the peritoneal cavity; the intestines were glued together, and their peritoneal coat generally inflamed. Head. Membranes of brain vascular; substance natural. Thorax. Viscera healthy.

William Spoull, Æt. 23, baker. Admitted on the 22d day of fever: no pain or tenderness of abdomen; tongue red and dry; bowels loose; no pain of chest; some cough; no pain of head; some of limbs and back; mind distinct; little sleep; very deaf; pulse 102.

25th. Tongue much furred and fissured; four stools; cough the same; pulse 108.

26th. Four stools, mixed with blood; respiration hurried.

27th. Tongue more clean, slightly aphthous; three stools without blood; respiration less hurried; pulse 104.

29th. Severe pain of abdomen, from which he had hitherto been quite free, came on during the night; at present it continues very severe, is much increased on pressure; abdomen swollen and tense; four stools without blood; pulse 112, sharp.

30th. Pain of abdomen not so severe, but still excited by full pressure; vomited a large quantity of bilious fluid; two stools, dark and slimy; respiration hurried; countenance sharp and anxious; pulse 124, small. Died two hours after visit.

Abdomen. The mucous membrane, both of the small and large intestines, in general highly inflamed; the lower third of the ilium, the cÆcum and the colon were full of ulcers, one of which, in the ilium, had perforated through all the coats of the intestine, and formed, near the ileo-cÆcal valve, a large circular opening, of the size of a crown piece, through which the contents of the bowel had escaped into the cavity of the peritoneum; this cavity contained a large quantity of sero-purulent fluid, mixed with feculent matter; the convolutions of the intestines were glued together and their peritoneal coat every where highly inflamed; the spleen, liver, and pancreas were sound. Head. The brain and its membranes were healthy. Thorax. Viscera healthy.

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The attentive student of the important and instructive cases included under this section will have perceived that, in the order in which they stand, they exhibit a complete series of changes in the intestines from the slightest vascularity to the most intense inflammation; and from mere elevation and inequality of the mucous membrane, in consequence of adventitious deposit beneath it, or from the simple and most superficial abrasion of its surface, to the most extensive and deep ulceration, on to the ultimate perforation of all the coats of the bowel.

When a number of cases are thus brought together and placed in juxta position it is impossible not to perceive, and indeed not to be forcibly struck with the uniformity with which a certain series of changes takes place. We do not see the same number of morbid appearances in every case, but we see in every case precisely the same morbid changes as far as they go, the difference being merely a difference in degree; so that the description of such a number of cases as has now been detailed would be tedious on account of its sameness, were it not that the fact they establish is one which it is of paramount importance to the practitioner that he should know; and that there appears to be no other means by which it can be duly impressed upon the mind.

In like manner the uniformity of the symptoms which denote that these morbid changes are going on, is as remarkable as the regularity with which the changes themselves occur. Their great peculiarity, which it is as important to know as it is to understand their indication itself, is their want of prominence. They are always to be discerned, or with extremely rare exceptions; but they seldom or never force themselves upon the notice of the careless or extort the attention of the unobserving: still they are not the less constant in their occurrence because they come without noise, nor is the indication they give of their presence less significant because it is unobtrusive. They do not announce their presence by the excitement of violent paroxysms or by inducing intense pain, because the state of the system in which they take place is incompatible with acute sensation of any kind. The prominent symptoms during life are almost always in the head; the great changes of structure found after death are always in the intestines; and this, which the pathologist learns from observation, the physiologist might have predicted from his knowledge of function. The affection of the intestines in fever is never a simple or single affection: it never occurs alone, but always in combination with an affection of the brain; and the cerebral affection is always antecedent, the intestinal, invariably subsequent; while the certain consequence of the cerebral affection is a diminution, and ultimately an abolition of sensation. It is therefore quite impossible, from the very nature of the derangement that takes place in the animal economy, that the intestinal affection should ever be attended with violent pain. Occasionally, indeed, when the abdominal affection is very much in excess, and the cerebral affection is unusually slight, severe pain may be felt; but that is rare, and the total absence of pain, and even the total absence of tenderness on pressure, is more common. It is not then to the patient’s own complaint of pain in the abdomen that the practitioner must trust for the discovery of abdominal affection in fever.

But though the patient seldom complain of pain in the abdomen, yet in the great majority of cases the abdomen is tender on pressure, and it is so in all, excepting when the cerebral affection is peculiarly severe or is very far advanced. These exceptions render this symptom not absolutely constant, although at the bed-side of the sick the practitioner will find it very rarely absent. The symptom which is still more constant, as the reader must have observed in the perusal of the preceding cases, and which therefore affords a very certain guide to the detection of the disease, is a loose state of the bowels. Whenever both concur there can be no doubt of the diseased process which is going on within the intestine: but as the tenderness may be obscured or lost from the intensity or advancement of the cerebral affection, so it is very remarkable that, in the progress of the intestinal disease, the bowels sometimes become regular and even constipated. The physician who sees the patient for the first time in this stage of the disease, can ascertain the condition of the mucous membrane of the intestines only by obtaining an accurate account of the preceding symptoms. And when it is possible to procure a distinct and complete history of the disease from its commencement, it is commonly found that nausea and vomiting were among the early symptoms, while, as we have seen, the latter is not unusually present in the more advanced stages. The result of the whole is that, excepting when the cerebral affection is most intense and overwhelming, the existence of inflammation and ulceration in the mucous membrane of the intestines in fever are denoted by signs which are quite constant, and in the fidelity of the indication of which we may repose implicit confidence. The importance of the diagnosis may perhaps plead our excuse for repeating them again. They are tenderness of the abdomen on pressure; loose stools; redness of the tongue, especially at the tip and edges, in general preceded by nausea and vomiting, and in the most exquisitely marked cases, and in their advanced stage, followed by a mixture of blood in the stools and a swollen, hard and tympanitic state of the abdomen. All these symptoms by no means always concur in the same case: but the presence of one or two of them will be sufficient to guide the attentive observer to the knowledge of the disease.

We have seen that the appearance of blood in the stools is not very frequent: that the most extensive ulceration may and commonly does exist without it; still when blood does appear it is generally found in combination with an ulceration which is not only extensive, but which has penetrated deep into the coats of the intestine. But although this be the general fact, yet it must be borne in mind that blood may be poured out in large quantities without the existence of a single ulcer. In this case the blood issues from the capillary vessels of the mucous membrane of the intestine, and when examined after death this membrane is found to be of a dark red colour, and presents the appearance of ecchymosis.

IV. Cases in Illustration of the Morbid Changes which take place within the Head, Thorax, and Abdomen, in the same Individual; or Mixed Cases.

Margaret Eades, Æt. 18, dress-maker. Admitted on the 22d day of fever, which attacked with the ordinary symptoms: at present the mind is dull; the sensibility diminished; there is scarcely any sleep; the eyes injected and suffused; the skin hot; the tongue brown and dry; the pulse 120, but there is no pain in any organ.

23d. Insensibility increased to coma; delirium; tongue dry and quite black; gums bleed on the slightest touch; lips and teeth sordid; four stools, dark and offensive; pulse 110.

27th. Coma undiminished; almost constant moaning; scarcely any sleep; three stools of same character; some cough; pulse 124, feeble.

31st. All the symptoms aggravated; extreme prostration; countenance sunk; cough, without expectoration; respiration with mucous rattle; stools in bed: pulse 140, extremely feeble. Died next day.

Head. Dura mater vascular; arachnoid thickened and opake; substance of brain highly vascular, in every point thickly studded with red points; effusion between the membranes and into the ventricles. Thorax. Mucous membrane of bronchi inflamed; substance of lungs partly condensed and partly tuberculated. Abdomen. Mucous membrane of ilium inflamed and ulcerated; other viscera healthy.

William Middleton, Æt. 18, shoemaker. Admitted on the 5th day of scarlet fever, which commenced, in addition to the ordinary symptoms, with exceedingly severe head-ache, which continues undiminished; scarcely any sleep; eyes red and ferrety; tongue white; bowels loose; pulse 120; eruption apparent only on the chest; no soreness of throat nor difficulty of deglutition.

6th. Pain of head nearly gone; more insensible; pulse 126; eruption fading.

8th. Insensibility increased to coma; adnatÆ glistening; tongue brown and dry; lips and teeth sordid; four stools.

10th. Coma deeper; great restlessness; no sleep; stools in bed; pulse 120, weaker.

11th. Increasing restlessness; tongue not to be protruded; deglutition difficult; stools and urine in bed; pulse 150, indistinct.

13th. Died.

Head. Dura and pia mater highly vascular; arachnoid thickened and opake; substance of brain highly vascular; effusion between the membranes, into the ventricles, and at the base. Thorax. Mucous membrane of bronchi vascular; substance of both lungs inflamed. Abdomen. Mucous membrane of ilium ulcerated; other viscera healthy.

Sarah Sharp, Æt. 18. Admitted on the 22d day of fever: the pain of the head, which had been severe from the commencement, continues; complains also of much pain in back and limbs; abdomen tender; tongue fiery red; bowels purged; pulse 100, soft.

23d. No change, excepting that the tongue has become brown and dry in the middle, but still remains exceedingly red at the edges; four stools; pulse 108.

32d. Pain of head quite gone; that of abdomen, which had increased, has now also disappeared; no sleep; great restlessness; delirium; eyes dull and heavy; face flushed; tongue red and dry; four stools; pulse 110.

40th. Cerebral symptoms unchanged; no cough or uneasiness of chest; skin dusky, that of the cheek of a deep purple colour; tongue loaded and dry; lips and teeth sordid; stools in bed; pulse quick and very feeble; great prostration.

48th. Coma; discharge from both ears; vomiting; pulse 120, very weak.

50th. Erysipelas of cheek, extending to scalp; much discharge from ears; tenderness of abdomen again returned; tongue again of fiery red colour; pulse extremely quick and feeble.

70th. During the whole of the period since last report there has been occasional vomiting; the erysipelas gradually disappeared; the sensibility returned; the tongue became clean and moist; the stools improved, and there was even some return of appetite: on the other hand, there came on extensive excoriation, and at last sloughing of back and hips; the emaciation became very great, the prostration extreme, and at length, on the 86th day from the commencement of the fever, she sunk exhausted.

Head. Membranes of brain highly vascular; substance natural; upwards of eight ounces of serum in the different cavities. Thorax. Mucous membrane of trachea slightly reddened; bronchi vascular; lungs dark and much gorged with blood. Abdomen. Mucous membrane of intestines slightly vascular, [but the peritoneal coat highly inflamed, and contained on its surface a coating of coagulable lymph, which glued the convolutions of the intestines to each other and to the omentum.]

Charles England, Æt. 22, servant. Admitted on the 11th day of fever: previous symptoms unknown. At present perfectly insensible; pupils contracted, insensible to light; face and lips of deep purple colour; extremities cold; full pressure induces some uneasiness in abdomen; body of tongue loaded and dry, edges red; deglutition difficult; pulse 100, feeble.

12th. Some sleep through the night; more sensible to-day; no stool since admission; pulse 114.

13th. Still more sensible; complains of giddiness; five stools; tongue beginning to clean.

20th. Had been gradually improving since last report, and the pulse had fallen to 80; during last night he became extremely restless, with much delirium; mind now confused; face of a purple colour; tongue red and glossy; three stools; pulse 120.

21st. Delirium; almost constant moaning; cheeks of purple colour; tongue brown and glossy; pulse 130, but so indistinct that it can scarcely be counted; lies extremely prostrate.

22d. Erysipelas of face, extending down the neck; some cough; abdomen again tender; three copious dark-coloured stools; pulse 130. Died following day.

Head. Scalp loaded with an unusual quantity of blood; the vessels of all the membranes of the brain exceedingly turgid; a large coagulum of blood between the dura mater and the arachnoid; substance of the brain exceedingly soft; an ounce and a half of bloody fluid at the base of the skull. Thorax. Mucous membrane of bronchi extremely vascular; substance of lungs somewhat condensed and very much gorged; [two ounces of serum in each pleural cavity.] Abdomen. Mucous membrane of ilium much thickened, softened, and injected, exhibiting a few points of incipient ulceration; [mucous membrane of bladder thickened and inflamed; peritoneum lining the pelvis vascular;] other viscera healthy.

James Robinson, Æt. 25. Admitted on the 8th day of relapse: at present mind confused; acknowledges no pain in head, chest, or abdomen; tongue not much loaded, moist; thirst; pulse 60, weak.

9th. No pain; some sleep; occasional delirium; two stools; pulse 78.

10th. Mind dull and heavy; returns no answer when spoken to; pulse the same.

17th. Little change until to-day; the entire body is now covered with an efflorescence, consisting of minute papulÆ, of a vivid red colour; mind dull and confused; pulse 120. Died next day.

Head. An old fracture over that part of the coronal suture which joins the parietal bone, seems to have left the brain unaffected; inner surface of skull perfectly smooth; both membranes and substance of the brain highly inflamed; pituitary gland suppurated; cerebellum natural. Thorax. [Left lung contained many tubercles in the stage of suppuration; the apex, which was full of tubercles, adhered to costal pleura; right side healthy; pericardium contained two ounces of bloody serum; serous lining of auricles and ventricles of heart highly vascular and of dark red colour; valves of aorta and of auricles extremely dark;] no account recorded of the state of the mucous membrane of the bronchi. Abdomen. Omentum vascular; intestines throughout of dark red colour; all their coats every where exceedingly softened, the peritoneal peeling off with ease from the muscular; the mucous inflamed, not ulcerated; the mucous membrane of the stomach vascular; a considerable portion of the jejunum intussuscepted; other viscera healthy.

Ann Smith, Æt. 23, married. Admitted on the 15th day of fever; pain of head gone; some vertigo remains; no uneasiness of chest; some cough which excites pain in the abdomen; the latter not very tender even on full pressure; tongue loaded in middle with white fur, red at edges; no stool for the last twenty-four hours; pulse 120, weak.

17th. Eruption has appeared over almost the entire skin, consisting of minute papillÆ of a dusky red colour; two stools; pulse 120.

20th. Erysipelas extending over both shoulders; severe pains in the limbs.

25th. Cough troublesome with copious viscid expectoration; erysipelas extending from the shoulders to the chest; tongue dry: delirium; pulse 110, weak.

26th. Cough diminished; respiration hurried; stools in bed; pulse 120, feeble.

27th. Delirium continues; respiration more hurried; pulse extremely feeble.

28th. Erysipelas still extending; powers sinking; respiration laborious; stools and urine in bed. Died in evening.

Head. Arachnoid vascular; substance of brain vascular; sheath covering the lumbar portion of the spinal cord highly vascular; cord itself natural; effusion into the lateral ventricles; plexus choroides and velum interpositum highly vascular; pituitary gland gritty. Thorax. Mucous membrane of bronchi inflamed; substance of left lung intensely inflamed, being nearly as red as muscle and its lobes adherent; [corresponding side of pericardium highly vascular; right lung slightly inflamed; right pleurÆ not adherent; left adherent throughout.] Abdomen. Patches of vascularity in mucous membrane of intestines and over their peritoneal coat; pyloric end of stomach vascular; spleen soft; other viscera healthy.

Joseph Baird, Æt. 12. Admitted on the 22d day of fever; slight pain of head; severe pain across the loins; no uneasiness in chest; no cough; respirations 44; abdomen tender; tongue red, parched; bowels purged; pulse 134.

33d. Abdomen tender, tumid, tense; four stools; tongue loaded with white fur; mind distinct; scarcely any sleep; extremely fretful.

34th. No delirium; stools in bed; pulse 114. Died next day.

Head. Membranes and substance of the brain vascular; at the surface of the right posterior lobe, an abscess of considerable size, the floor of which was formed by the pia mater; gelatinous effusion between the arachnoid and the pia mater. Thorax. Mucous membrane of bronchi vascular; substance of lungs healthy; [left cavity of pleurÆ contained eight ounces of bloody serum; right six.] Abdomen. Peritoneal and mucous coats of jejunum and ileum vascular; mesenteric glands greatly enlarged; several of them suppurated; [large quantity of serum mixed with pus in the peritoneal cavity; omentum much thickened; adhered to the superior portion of the spleen; to the edge of the left lobe of the liver, and to the portion of the diaphragm immediately above the spleen; in this manner it formed the external boundary of an abscess of considerable size in the substance of the spleen; portions of the sac itself ulcerated; the rest of the spleen nodulated; these nodules when cut into were found to consist chiefly of puriform matter contained in cells; thoracic duct enlarged; receptaculum chyli exceedingly enlarged and ulcerated.]

Catherine French, Æt. 24. Admitted on the 9th day of scarlet fever. Complaint came on with sudden loss of strength, shivering and violent pain of head and chest: at present throat sore; deglutition difficult; some pain of chest; great tenderness of abdomen; nausea and vomiting; tongue dry, brown and cracked; slight pain of head; eyes dull, heavy and suffused; pulse 104, pretty strong; no eruption.

23d. The pain of throat, the difficult deglutition, the tenderness of the abdomen had disappeared; the pulse had fallen to 90, and she appeared to be gradually recovering until this day, when, preceded by a slight return of sore throat, erysipelas appeared on the face; no pain of head; tongue again brown and dry; pulse 96.

24th. No sleep; delirium; erysipelas extending; pulse 108.

38th. Erysipelas has disappeared, but other symptoms are aggravated; extreme restlessness; much delirium; frequent cough, with scanty expectoration; tongue brown, dry and cracked; pulse 86.

39th. Respiration difficult; delirium; vomiting; pulse 120.

41st. Respiration rattling; delirium; inclined to sleep; pulse 120.

42d. Respiration increasingly difficult and painful; pulse 129.

43d. Extremely restless; almost constant moaning; countenance anxious; cough; tongue continues brown and dry; lips and teeth sordid; pulse 122.

44th. Died during the night.

Head. An abscess over the posterior extremity of the sagittal suture, around which for the space of two inches, the pericranium was destroyed, leaving this portion of the bone bare. Dura mater natural; arachnoid and pia mater vascular; substance of brain natural; effusion between dura mater and arachnoid; lateral ventricles full of serum; two ounces at base. Thorax. [PleurÆ of right side covered throughout with pus of very thick consistence, presenting the appearance of the interior of a large abscess, contained two pints of fluid consisting of serum, pus and blood; superior lobe of right lung hepatized and tuberculated; some of the tubercles in a state of suppuration; middle lobe contained a large abscess; lower lobe much wasted, blackened, and in many points softened down to a black fluid; left thoracic cavity contained about one pint of pure serum; pleurÆ very vascular but not adherent; substance of lung perfectly sound;] condition of mucous membrane of bronchi not stated. Abdomen. Mucous membrane of ilium contained several ulcers; other viscera healthy.

John Green, Æt. 10. Period and progress of disease unknown: throat much inflamed and ulcerated; deglutition difficult; respiration painful; much muco-purulent fluid constantly discharged from nostrils; eyes suffused; lips and teeth sordid; tongue cannot be protruded; pulse cannot be counted; noisy delirium; several dark-coloured vesicles on hands, especially in the neighbourhood of the joints. Died the same evening.

Head. Membranes slightly vascular; arachnoid and dura mater adherent at several points; substance of brain slightly vascular; effusion into ventricles. Thorax. Mucous membrane of trachea and bronchi highly vascular; larynx much inflamed; arytÆnoid cartilages ulcerated; epiglottis dark and thickened; [pleurÆ adherent throughout; substance of lungs inflamed.] Abdomen. Mucous membrane of intestines vascular; mesenteric glands enlarged; liver mottled on surface.

Ann Levitt, Æt. 24, married. Admitted on the 16th day of fever, which came on with severe pain of the head and epigastrium; pain of head is now gone, giddiness remains; much pain of limbs; scarcely any sleep; mind confused; eyes dull and heavy; face flushed; no uneasiness of chest; abdomen extremely tender on pressure; tongue red, parched, and cracked; lips and teeth sordid; bowels purged; pulse 123.

17th. After the application of ten leeches to the abdomen the tenderness is much diminished; the pulse fallen to 96; vomiting.

18th. Eight leeches again applied; abdomen now free from pain; vomiting continues; tongue unchanged; pulse 106.

19th. Vomiting undiminished; eight stools; abdomen again tender.

20th. Vomiting; five stools; pulse 108; slight pain of abdomen on full pressure.

22d. Abdomen tender, swollen, and tympanitic; eight stools; pulse 96; great prostration.

24th. Abdomen less tender and tense; still more prostrate.

25th. Stools in bed; pulse scarcely perceptible; features collapsed. Died in the night.

Head. Membranes of brain vascular; substance natural; effusion into the ventricles and at base; pituitary gland suppurated. Thorax. Mucous membrane of bronchi inflamed; tubes full of mucus, mixed with pus; [superior lobe of right lung a mass of tubercular disease; one of the tubercles the size of a pigeon’s egg, in a state of suppuration; effusion of serum into the left pleural cavity.] Abdomen. Mucous membrane of jejunum and ilium much inflamed; caput coli firmly adherent to the abdominal peritoneum; large quantity of serum effused into the hepatic region; substance of liver soft; gall-bladder in a state of suppuration; contained three large biliary calculi; omentum inflamed; [two large hydatids attached to the left ovarium.]

Robert Ebbott, Æt. 28, labourer. Admitted on the 12th day of fever: pain of head, which has been severe, is now only slight; frequent sighing; no pain of chest; frequent dry cough; respiration heavy and suspirious; abdomen tender; tongue dry, black, and cracked, red at apex; lips and teeth sordid; bowels purged; pulse 68.

15th. Mind confused; insensibility increasing; abdomen tender; tongue quite black and extremely dry; teeth sordid; respiration the same; no stool; pulse 72, feeble. Died next day.

Head. Dura mater natural; longitudinal sinus contained a firm cord of fibrin; arachnoid and pia mater vascular; substance of brain natural; pituitary gland softened and suppurating; much effusion into the ventricles; at the base the membranes were elevated into a large bag, distended with fluid. Thorax. Mucous membrane of bronchi vascular; [right lung adherent to pleura, by a single point, at the upper part of the inferior lobe; substance contained numerous tubercles; left pleural cavity obliterated; left lung hepatized throughout, containing tubercles in every stage of disease; apex of heart adherent to pericardium.] Abdomen. Mucous membrane of ilium and cÆcum inflamed and extensively ulcerated; [liver exceedingly enlarged and hard, almost of cartilaginous firmness and texture, weighed seven pounds two ounces; right kidney externally nodulated, internally healthy; left, healthy externally, but, when cut into, found to contain several abscesses; urinary bladder small; walls one third of an inch thick.]

Jane Hallam, Æt. 28, married. Admitted on the 6th day of fever: attacked with overwhelming loss of strength and severe pain of the head; pain of head continues, with distressing vertigo; no pain of chest; no cough; abdomen tender; tongue covered with white fur, but is extremely parched; thirst urgent; thinks she has had thirty stools within the last twenty-four hours; mind tolerably distinct.

7th. Pain of head gone; mind much more dull and heavy; abdomen very tender; tongue has become brown and continues extremely dry; four stools dark and offensive; pulse 104, soft.

8th. Scarcely any sleep; much restlessness; mind confused; insensibility increasing; pulse 90, weak. Died next morning.

Head. Membranes vascular; substance of brain in general much softened, but the floors of the ventricles especially were in an exceedingly softened state. Thorax. [Left pleurÆ adherent at apex; superior lobe of left lung hepatized and stuffed with small tubercles; two adhesions in right pleurÆ, one at apex; right lung stuffed with tubercles;] pericardium and heart healthy; condition of bronchi not stated. Abdomen. Mucous membrane of ilium and cÆcum exceedingly vascular, but not ulcerated; patches of peritoneal coat of stomach vascular; [large lobe of liver scirrhous;] other viscera healthy.

Jonathan Studd, Æt. 27. Admitted on the 28th day of fever; symptoms throughout appear to have been chiefly thoracic; at present frequent cough with viscid expectoration; great emaciation; pulse 102, extremely weak; no pain of head or abdomen; tongue foul; bowels regular; face pallid.

29th. Cough continues; abdomen not tender; tongue brown and dry in middle, red at tip and edges; three stools; pulse 100; mind dull and confused; muscular tremor.

30th. Cough the same; tongue unchanged; lips and teeth sordid; three stools mixed with blood; delirium; muscular tremor increased; pulse 108.

31st. Abdomen has become tympanitic; three stools mixed with blood; delirium and muscular tremor increased; pulse 112, weaker.

47th. On the evening of the day of last report he slept better and waked improved in all respects; this improvement appeared to be steady and progressive; the stools became natural; the pulse diminished in frequency and increased in strength; on this morning the stools continued natural; the pulse was 90, and he still seemed to be gradually though slowly recovering, when, without the return of any unfavourable symptom, he suddenly expired.

Head. Membranes and substance of brain healthy, but more fluid than natural in the ventricles. Thorax. Mucous membrane of bronchi greatly inflamed and thickened; bronchial tubes full of mucus mixed with pus; pleurÆ of left side of chest extensively adherent; substance of left lung healthy excepting some slight patches of hepatization. Abdomen. Mucous membrane of small intestines extremely vascular, in many places presenting the appearance of ecchymosis; at the valve of the colon several small ulcers; other viscera healthy.

John M’Carty, Æt. 22, labourer. Admitted on the 22d day of fever; complaint commenced with symptoms of severe cold; at present, slight pain of chest; cough, inducing pain in the abdomen, which is not tender; pain of head gone; eyes injected and suffused; face flushed; tongue brown and dry; bowels stated to be regular; pulse 99, weak.

23d. Cough very severe; abdomen not tender; tongue dry, brown and cracked; four stools; no pain of head; face flushed; eyes ferrety; pulse 90.

24th. Mind more confused; eyes more injected; delirium.

25th. Insensibility increasing; no sleep; tongue more dry and brown; lips and teeth sordid; four stools; pulse 96.

26th. Constant delirium; stools and urine in bed; pulse 104.

28th. Died.

Head. Membranes and substance of brain vascular; more fluid than natural in ventricles. Thorax. Mucous membrane of bronchi vascular; [pleurÆ of right side slightly adherent.] Abdomen. Mucous membrane of jejunum, cÆcum and ilium very much ulcerated; spleen soft; other viscera healthy.

Sarah Nash, Æt. 14. Admitted on the 22d day of disease; pain of head appears to have been very severe but it has now wholly subsided; lies quite insensible; pupils dilated, but contractile; muscles of extremities quite rigid; hands clenched; arms and legs extended and inflexible; no tenderness of abdomen on fullest pressure; tongue brown and dry; no stool for four days; pulse 110, extremely feeble and indistinct.

23d. Muscles of lower extremities rather less rigid; hands continue clenched; eyes in general closed; when opened appear injected and suffused; much grinding of the teeth; great restlessness; noisy delirium; two stools; pulse 126, stronger.

24th. Great restlessness; scarcely any sleep; almost constant grinding of the teeth; pulse 129, of good power.

26th. So restless that the pulse cannot be counted; exceedingly peevish; began to take two grains of calomel with half a grain of opium every four hours.

27th. Little change excepting that she is now sensible of some pain in the epigastrium on full pressure, and acknowledges some pain in the head; pulse 142.

32d. No amendment in the cerebral symptoms, and the strength is diminished; the mercurial odour is already quite evident, and the mouth is slightly ulcerated; no ptyalism; pulse 126, weak; calomel and opium omitted.

36th. Noise and delirium continue; ulceration of mouth gone; pulse 140, very weak. Calomel and opium were again resumed.

27th. Slight ptyalism; no improvement; pulse 130, extremely weak and indistinct.

38th. Ptyalism continues; sinking. Died.

Head. Membranes vascular; substance of brain much softened; effusion between all the membranes and into the ventricles. Thorax. Bronchi of both lungs vascular, and contained a large quantity of purulent matter; right lung much hepatized; left slightly consolidated. Abdomen. Ilium and cÆcum very much ulcerated; spleen very firm, contained one tubercle; other viscera healthy.

William Gander, Æt. 22, servant. Admitted on 15th day of fever; no account to be obtained of previous symptoms; some pain of head; much giddiness; mind confused; delirium; expression of eyes wild; face flushed; abdomen tender; tongue foul at root, moist, very red at apex; bowels purged; pulse 99, of good power.

16th. No sleep; violent noisy delirium; eyebrows contracted; face flushed; six stools; pulse 100.

19th. Intensity of cerebral symptoms progressively increasing; constant violent delirium; muscular tremor; subsultus; tongue cannot be protruded; pulse 112. Died next day.

Head. Membranes vascular; substance of brain natural; four ounces of serum in the lateral ventricles. Thorax. Mucous membrane of trachea and bronchi highly vascular; other viscera healthy. Abdomen. Glands of the mucous membrane of the intestines in general enlarged, many of them inflamed; some of them in a state of commencing ulceration, others completely ulcerated, so that the ilium and lower part of colon were full of ulcers, which varied in size, from that of a split pea to a crown piece; mesenteric glands much enlarged and dark; spleen very soft; other viscera healthy.

George Bury, Æt. 9. Admitted on the 11th day of fever: complaint commenced with nausea, pain of abdomen and severe head-ache; the latter continues; abdomen, especially epigastrium, tender; tongue red; much thirst; bowels constipated; pulse 116.

14th. Pain of head gone; countenance extremely pallid; no sleep; great restlessness; delirium; abdomen still tender; tongue red and dry; eight stools, dark and offensive; pulse 130. Died next day.

Head. Membranes vascular; substance of brain highly vascular; pituitary gland in a state of suppuration; cerebellum vascular; effusion between dura mater and arachnoid; one ounce of serum in ventricles, two at base; pia mater covering the spinal cord highly vascular; substance of cord natural. Thorax. Mucous membrane of bronchi slightly vascular; tubes contained some mucus, mixed with pus; [left pleurÆ slightly vascular; lower lobe of left lung hepatized; right pleurÆ healthy; lower lobe of right lung also hepatized, and contained several hard tubercles;] other viscera healthy. Abdomen. Mucous membrane of lower end of ilium and entire cÆcum thickly studded with ragged ulcers, raised and very foul, with indurated margins and irregular surfaces; longest diameter of ulcers in direction of longitudinal fibres of muscular coats; mesenteric glands very large, many of them being the size of almonds; other viscera healthy.

John Meredith, Æt. 23, porter. Admitted on the 22nd day of fever, which came on, besides the ordinary symptoms, with pain of chest, cough and hoarseness: states that these symptoms were getting better when, a few days ago, he was attacked with pain of the abdomen, accompanied with loose stools: at present the abdomen is exceedingly tender on pressure; tongue brown and dry in the middle, edges white and moist; bowels purged; distressing hiccup; pain of head, which was severe in the commencement, gone; mind dull and heavy, but answers any question distinctly; countenance anxious; features sunk; pulse 88, feeble; slight degree of hoarseness and some cough remain.

23d. Tenderness of abdomen undiminished; hiccup continues very distressing; vomiting; bowels purged; tongue brown and dry; scarcely any sleep; pectoral symptoms the same; pulse 76.

24th. Tenderness of abdomen, hiccup, vomiting, purging, all increased; eight stools since last report; much restlessness; pulse 84.

25th. Appeared to be more easy yesterday, but relapsed into his former state to-day. Died following morning.

Head. Membranes vascular; arachnoid thickened and opake; substance of brain vascular; more fluid than natural in the ventricle. Thorax. Mucous membrane of bronchi vascular; other viscera healthy. Abdomen. Mucous membranes of small intestines vascular; [peritoneum universally and greatly inflamed; that covering the intestines coated with a layer of coagulable lymph, by which their convolutions were united into one diseased mass; false membranes were formed by this exudation which extended from the under surface of the liver to the right iliac fossa, where they formed a cyst, in which eight ounces of purulent matter were contained; the peritoneum covering the abdominal surface of the diaphragm inflamed; liver enlarged,] but its substance appeared healthy; other viscera natural.

Elizabeth Turner, Æt. 26, servant. Admitted on the 15th day of fever: no account to be obtained of previous symptoms: at present extremely restless; much delirium; almost constant talking or moaning; no sleep; mind quite confused and wandering; when roused to answer a question she seems sensible for a moment, but immediately lapses into low muttering incoherence; if asked whether she has any pain in the head she points to the forehead; says she has no pain in chest or abdomen; no cough; abdomen not tender.

16th. No sleep; constant restlessness; almost unceasing incoherent talking; incapable of answering when spoken to; tongue cannot be protruded; stools in bed; pulse too feeble and indistinct to be counted. Died in the evening.

Head. Dura mater along the course of the longitudinal sinus very adherent to the arachnoid; arachnoid and pia mater white and opake; surface and substance of brain highly vascular; surface of cerebellum vascular; substance healthy; pituitary gland suppurating; more fluid than natural in the ventricles; an ounce at the base. Thorax. Mucous membrane of bronchi highly inflamed; bronchial tubes filled with mucus mixed with pus; [pleura costalis of right side vascular; slight effusion into right pleural cavity, and into parenchyma of right lung; lower lobe much inflamed; pleurÆ of left side adherent; that covering left side of diaphragm much inflamed; substance of left lung partly inflamed, partly consolidated.] Abdomen. Mucous membrane of small intestines inflamed; in that of ilium numerous large, raised ulcers; [liver adherent by several unnatural connexions to diaphragm, spleen and transverse arch of colon, but its substance was healthy; appendix vermiformis likewise adherent to abdominal peritoneum;] head of pancreas enlarged; [internal inguinal glands much enlarged, and some of them impacted with calcareous matter;] other viscera healthy.

Mr. W——, Æt. 50. The progress of this case having been observed with great care from the commencement to the termination of the disease, and affording an excellent illustration of the insidious manner in which the mixed form of fever sometimes attacks, and of the silent but rapid progress it makes without exciting alarm, until, at last, symptoms the most formidable, and which, to those who are not acquainted with the nature of the malady, appear to be most sudden, supervene, it may be useful to give a detailed account of it.

This gentleman had been out of health six months previously to the present attack of fever: he had been observed to be gradually losing flesh, and fading; yet he laboured under no complaint that could be ascertained, excepting that his appetite failed; that he could digest well no kind of food; that he was badly nourished and, therefore, weaker in body and less vigorous in mind than usual.

About three weeks before the fever commenced, his stomach-complaints became worse, and for these he requested the advice of his friend Mr. Chaldecott. During this gentleman’s attendance, his patient was one day attacked with slight chilliness, an unusual degree of lassitude, together with pains in the limbs: but the chilliness never amounted to rigor; the general pains were not severe; there was no pain whatever in the head; yet the sudden debility which affected both mind and body was very striking. Still the mind was perfectly distinct; the sleep was sound; the expression of the countenance was natural; the tongue, however, became loaded with white fur; there was some thirst; the pulse varied from 84 to 96, while the temperature and the softness of the skin remained in a healthy state. In this manner he went on about eight or ten days, and, during the whole of this period, he was daily questioned by his medical attendant and examined with much anxiety relative to the condition of the organs in the head, chest and abdomen; but he was steady in affirming that he was free from all uneasiness in the head, and that he had no pain in the chest; nor could any pain be excited by the fullest pressure, either in the epigastrium or in any part of the abdomen. It was observable, however, that he had some cough without expectoration, and that his respiration was short and hurried. His appearance, too, indicated more disease than his sensations; he was obviously worse than he expressed, or than could be accounted for from the apparent affection of any organ, and this excited alarm both in his family and in his medical attendants; and it is always a truly alarming condition.

On the 11th day a remarkable change took place: for two or three hours he was chilly; to this succeeded heat of skin and flushing of the face; what was very alarming, the colour of the flash was purple, while that of the whole face was dusky; there was no cough, but the respiration was short and hurried; the mind was confused and dull, though a coherent answer might still be obtained to any question that was asked; the pulse now rose to 120, there was little or no sleep, but great restlessness during the night, in the course of which delirium appeared, and the next morning there came on muscular tremor. As the day advanced the flushing and heat disappeared; the mind became quite distinct, and the pulse fell to 96. Towards evening he again became restless, the pulse rose to 104, and about one o’clock, a.m. the increased heat, the flushing of the face, the purple colour of the cheek, the dusky appearance of the skin, the short and hurried respiration, and the convulsive action of the muscles all returned, and in a greater degree, while the pulse again rose to 120. From this state he never recovered in the least degree, but became more and more dull, and at length nearly insensible; his debility rapidly increased until it became extreme; he lay quite prostrate on the back, with his arms extended, as if lifeless; the muscular tremor increased; the respiration became extremely short and hurried; the tongue became dry, red, glazed, and sticky; the bowels torpid; the pulse 130; and with these symptoms he expired on the 13th day of fever.

Head. Dura mater healthy; arachnoid thickened and opake; much gelatinous effusion between it and the pia mater; substance of brain highly vascular and firm; lateral ventricles distended with fluid, much also at the base. Thorax. Mucous membrane of bronchi universally of a dark red colour and lined with a tenacious fluid, which was slightly sticky; bronchial tubes filled with frothy mucus; substance of lungs perfectly healthy. Abdomen. Mucous membrane of small intestines generally inflamed; lower part of ilium and commencement of colon filled with large and raised ulcers, some of which were just forming, while others had penetrated through a thick mass of adventitious deposit to the muscular coat of the intestine.

Before closing these illustrations of the pathology of fever, it may be proper to give an example of the modifications which take place when this disease proves fatal in the state of gestation. If fever attack during pregnancy, there is the greatest possible danger of miscarriage, and the great majority of those who miscarry die. There is no complication which requires a more delicate and cautious management; and the management which experience shews to be the best will be stated in the proper place: in the mean time, the following case is given as an illustration of the morbid appearances which are found (and the appearances are very uniform) when abortion is the precursor of death.

Mary Cutler, Æt. 37, married. Admitted on the 5th day of fever, in the commencement of which, in addition to the ordinary symptoms, there was much nausea; this feeling continues at present, and is now accompanied with vomiting; epigastrium tender; cannot lie without pain in the left side; cough frequent, and exciting uneasiness in the chest; tongue white and dry; bowels bound; some pain of head, especially in the forehead; scarcely any sleep; much pain in the extremities; pain of throat with difficult deglutition; pulse 122; skin warm; six months pregnant.

6th. Much retching and vomiting; tenderness of the epigastrium and abdomen; bowels very loose; tongue white in the middle, red at the edges; severe pain in the chest; great dyspnoea; constant, urgent cough with difficult mucous expectoration; severe pain in the head; no sleep; great restlessness; pulse 150, sharp but compressible. V. S. ad ?xij.

7th. Buff on blood extremely firm; retching and vomiting gone; pain of side entirely removed; less cough; dyspnoea diminished; pain of head better; slept much better; pulse 120.

9th. After a tolerable night, attacked this morning with urgent dyspnoea, soon became perfectly insensible; was delivered of a foetus six months old; at present, nearly insensible; respiration hurried and laborious; tongue brown and dry; one stool; pulse 110; skin moderately warm.

10th. Free lochial discharge; all the symptoms greatly improved; tongue white; moist; pulse 84, soft.

13th. Lochial discharge nearly ceased; no pain in head, abdomen, or any where, except the face which is attacked by erysipelas; tongue continues moist and is nearly clean; pulse 108.

14th. Erysipelas increased and extending; tongue, has again become brown and dry; pulse 110.

16th. Erysipelas extending; severe pain in epigastrium and over abdomen, much increased on pressure; distressing sense of nausea but no vomiting; tongue the same; pulse 96, weak and irregular.

17th. Pain of abdomen increased; stools in bed; no sleep; extreme restlessness; respiration hurried and wheezing; pulse 130, weak. Died in the evening.

Head. Membranes of brain vascular. Thorax. [PleurÆ covering right lung coated with a layer of coagulable lymph; in both pleural cavities a large quantity of serum mixed with flakes of lymph and pus; that part of the pleura of the right side which lines the diaphragm highly inflamed;] substance of both lungs healthy. Abdomen. Peritoneum in general more vascular than natural; patches of it in a state of intense inflammation; peritoneal sac contained much serum mixed with flakes of lymph and pus; pelvis of right kidney inflamed; ovaria and uterus of very dark colour and intensely inflamed; other viscera healthy.

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It would be easy to multiply cases to an indefinite extent, but, since those which have been cited exhibit a complete view of the pathology of fever, as far as it has yet been ascertained, any further details would fatigue the reader without instructing him. And what is this pathology? What are the events, the detail of which has occupied us so long? The account of the pathology of fever is the history of inflammation, and the description of the individual changes that take place in the organs that constitute the febrile circle, is an enumeration of various products of inflammation which are formed within them. There is scarcely a fatal case of fever which does not afford, in one or other of the organs of that circle, some inflammatory product; there is no considerable number of fatal cases which does not furnish a specimen of every inflammatory product. And what are the severest cases of fever, and why are they the severest? With the single exception immediately to be stated, the severest cases are those in which, together with a severe primary affection of the nervous system, this inflammatory action is in the greatest degree of intensity, and is seated in the greatest number of organs; and they are the most severe, not only on account of the severity of the primary affection of the nervous system, but also because it is in them that the inflammation is the most intense, and because that inflammation attacks the system at one and the same time in the greatest number of points. From among the preceding cases, fix upon any one in which the powers of life were, from the commencement, the most completely overwhelmed, and in which they were the most rapidly exhausted, and when the brief struggle for existence is over, examine the changes that have taken place in the internal organs—what is it that is found? traces of inflammation, legible, deep, extensive; while, in almost every case, these traces are thus legible, deep, and extensive, in proportion to the apparent intensity of the fever, and to the rapidity with which it extinguished life. In this point of view, how important, how instructive, how invaluable is the lesson which the mixed cases of fever afford! With few and rare exceptions (and in all diseases some exceptions occasionally occur to what appear to be the best established and the most invariable laws) these are the cases in which the symptoms are the most urgent, and in which they run their course with the greatest rapidity; these are the cases in which the debility is the most striking; in which it comes on the most early, and proceeds to the greatest degree of prostration; these are the cases which are the most purely typhoid, the most truly adynamic; these are the cases which, in general, commence with the most sudden and alarming deprivation of physical and mental power; in which all pain and uneasiness are soonest lost in stupor, in which the stupor most rapidly increases to insensibility; in which delirium comes, perhaps, as early as the third or fourth night, accompanied with its attendant, muscular tremor, and too often with its most formidable ally, erysipelas: in which, at this early period, the respiration is short and hurried, the skin dusky, the colour of the cheek purple, the tongue brown and dry, the lips and teeth sordid, the abdomen tender, and the stools loose; in which, in a day or two more, the abdomen is swollen, tense, and tympanitic, the stools passed in bed, the patient prostrate on his back, completely senseless and powerless, while the pulse is 120 or 130, and so feeble that it can scarcely be distinguished. But what is this debility? in what does this adynamic state consist? It consists of a peculiar affection of the nervous system, followed rapidly by intense inflammation of the brain or of its membranes, or of both: by intense inflammation of the mucous membrane of the bronchi, and by intense inflammation or extensive ulceration of the mucous membrane of the intestines. And why is the patient weak or adynamic? Because he is not only assailed by an affection of the nervous system, which deprives the organs of the stimulus necessary to enable them to perform their functions with due vigour, but, at the same moment, inflammation is set up in three of the great systems, the healthy action of which is most essential, not only to strength but to life: thus the citadel is attacked at one time at three of its capital points. It is not asserted that inflammation alone constitutes the state of fever, nor that the danger of the patient is always in exact proportion to the degree of the inflammation. How it differs from inflammation, and what is superadded to the inflammatory state, will be shewn immediately; but it is a most important fact, that the degree of the debility is most intimately connected with the intensity and the extent of the inflammatory action. Now and then, as has been already stated, the intensity of the nervous affection is so great, and so rapidly destructive of life, that there is no time for an inflammatory process to be set up, much less for an inflammatory product to be formed. The patient is struck dead as if by lightning, or by Prussic acid, or by apoplexy. In this country, he does not actually die as instantaneously as he might be destroyed by the electric fluid or by poison, although there are countries, seasons, and particular spots, in which the concentration of the febrile poison appears to be sufficiently great to extinguish life instantaneously; and even in this country, life is sometimes destroyed by a stroke of fever as rapidly as it is by a stroke of apoplexy, when the latter does not prove fatal in the first few hours.

Now the peculiarity in these cases is, that the internal organs, after death, exhibit no signs of inflammation, unless vascularity be inflammation. The organs which, in ordinary cases, are inflamed, are in these cases turgid with blood. Are the terms debility or adynamia appropriate expressions to designate even this condition of the organs? Just as appropriate as they would be to express the condition of a person who is struck dead by lightning, whose muscles are incapable of contraction, and whose blood will not coagulate. Those who apply these terms even to such forms, and, À fortiori, to any other forms of fever, must be ignorant either of the nature of the disease, or of the constitution of the human mind. If they know the disease, they know that the patient appears to be weak because the primary operation of the disease is upon the nervous system—an operation which, as has just been stated, while it disturbs that due and equal distribution of nervous influence which is necessary to the healthful action of the organs, and, therefore, to the general strength of the system, is not incompatible with, but promotive of an excitement of the vascular system, which terminates in inflammation. Debility is the last, the ultimate result of the disturbance of the functions of a certain series of organs, but part of this very disturbance of function, and a most important part, a part which exerts the greatest influence over the progress of the disease and the life or death of the patient, consists not in the weakened, but in the augmented strength and the increased activity of the vascular system. To designate the ultimate result upon the system by a term which gives an entirely false view of the individual processes in the economy, by which that ultimate result is produced, must, we repeat, arise either from an ignorance of the true nature of those processes, or from not reflecting on the influence which words exert over the manner in which the human mind conceives of things. For the sake of the progress of the science of medicine, for the sake of rendering the language of medicine the correct expression of the knowledge which the science has actually attained, and, above all, for the sake of accomplishing the great object of medicine, the preservation of human life, it is high time that these terms with which physicians have so long allowed their minds to be abused, should be banished from medical nomenclature, or, at any rate, from that part of its nomenclature which appertains to fever.

II. Pathology of the Fluids in Fever.

The pathology of the solids in fever, derived from inspection of the fatal cases after death, has already acquired, as we have seen, a high degree of perfection. The pathology of the fluids is scarcely at all known, and the difficulty of arriving at exact and certain results is great. Why the investigation of the morbid changes that take place in the fluids should be a much more arduous task than that of tracing the changes produced in the structure of the organs, is too obvious to need to be pointed out; but those only who have actually engaged in researches of this nature can form a just conception of the number of repetitions that are requisite of the same analysis, of the care required in conducting each, and consequently, of the labour and time it is necessary to devote to the investigation, before satisfactory results can be obtained. The analysis of the animal fluids in their healthy state is far from being perfect; yet their composition in the state of health must be ascertained, as far as it can be ascertained, as a preliminary step: and, in order to discover the morbid changes that take place in the blood, in the urine, in the products of respiration, and in those of transpiration, and still further to determine the nature and extent of such changes in the different types and stages of fever, it is obviously necessary to examine the respective fluids and gases in a great number of cases, and to vary the experiments in a great variety of modes. Experiments of this kind, on an extensive scale, have been undertaken by my friend Mr. Cooper; and, when this work was commenced, they had already advanced so far that there appeared to be a prospect that, before its completion, they would be sufficiently matured to justify us in laying the results before the reader. And that deviations from the state of health, and some of them of great importance, do take place in these fluids, and especially in the blood and the urine, is ascertained. What they are, with what degree of constancy they occur, how far they are respectively connected with the cerebral, the thoracic, the abdominal, and the mixed affections, with different degrees of intensity in these affections, and with different stages of their progress, we hope, at no distant period, to be able to lay fully before the public.

In the mean time, it is of some importance to bear in mind the true place which the results of such experiments, be those results what they may, and be they established with all the clearness and certainty that can be desired, must always hold. Changes in the fluids can only be second in the series of morbid events; they can never hold the first place in that series; they can never be primary antecedents or first causes, but merely sequents or effects. To assign the reason of what must be so obvious to every one who is acquainted with the elements of physiology, would be entirely out of place here, because it would suppose the reader to be wholly ignorant of the functions of the animal economy. Our knowledge of the pathology of fever can never be complete, until we know the morbid changes that take place in the fluids as perfectly as we are acquainted with the alterations of structure that are produced in the solids, and we ought, therefore, to spare no labour to render our knowledge of the former as exact and certain as it is of the latter. But, as far as we can at present see, when this is accomplished, we shall have acquired little that is of practical utility. There is but slight, if there be any ground to hope that, when the humoral pathology shall have arrived at the greatest possible degree of perfection, it will furnish us with any additional means of preventing, curing, or even mitigating the severity of the disease. With that disorder of the system over which we have some control, with those morbid actions which we possess some means of subduing or changing, we are already well acquainted. In our knowledge of the invariable tendency there is to the production of certain changes in the structure of certain organs; in our knowledge of the vascular action by which those alterations are effected, we may be said, in a practical point of view, to be already in possession of the most important part of knowledge which we can ever hope to acquire, unless, indeed, we may indulge the expectation, of which it would be truly melancholy to be deprived, that we may discover a more sure and effectual mode of preventing these organic changes, or of restoring to a sound state the organs that may become diseased. It is this part of the pathology of fever alone that can afford a clear and steady light to conduct us to the safe and effectual treatment of the malady. Every step we take without this invaluable guide must be taken in the dark, and will be, therefore, not only likely to be false, but very likely to be fatal. When, on the contrary, we undertake the management of fever under the direction of this faithful guide, in every measure we venture to adopt we, at least, know at what we aim: we propose to ourselves a definite object which we endeavour to accomplish by an instrumentality with the powers of which we are in some degree acquainted: we may not succeed, but we fail because we want the means to do what we clearly see requires to be done: if we do not arrest the progress of the disease, at least we do not add to its strength by the adoption of violent and desperate expedients, because we feel called upon to do something, yet know not what to attempt; we do not destroy, if we cannot save. The physician, enlightened by the pathology of the disease, who prescribes for a patient in fever, is like a skilful surgeon, who is guided in the performance of a difficult and delicate operation by a knowledge of anatomy so intimate, that every touch of his scalpel exposes a tissue with which he is acquainted, and discloses the site of a vessel with which he is familiar; the object aimed at by the operation may not be obtained, but, at least, the cause of its failure is not that the operator wounds a structure which he ought to have avoided, or opens an artery, of the situation and distribution of which he is ignorant. On the contrary, the physician who prescribes for a patient in fever, without knowing the pathology of the disease, is like a Charlatan, who plunges his instrument boldly into the chest or the abdomen, without knowing where it goes or caring what it wounds; it may possibly open a tumour and let out the disease, but it is more likely to pierce some vital organ and to let out life.