diff options
Diffstat (limited to 'old/60419-0.txt')
| -rw-r--r-- | old/60419-0.txt | 11853 |
1 files changed, 0 insertions, 11853 deletions
diff --git a/old/60419-0.txt b/old/60419-0.txt deleted file mode 100644 index 9f44cc5..0000000 --- a/old/60419-0.txt +++ /dev/null @@ -1,11853 +0,0 @@ -The Project Gutenberg EBook of A Treatise on Fever, by Thomas Southwood-Smith - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll -have to check the laws of the country where you are located before using -this ebook. - - - -Title: A Treatise on Fever - -Author: Thomas Southwood-Smith - -Release Date: October 4, 2019 [EBook #60419] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK A TREATISE ON FEVER *** - - - - -Produced by Richard Tonsing, Chris Curnow, and the Online -Distributed Proofreading Team at http://www.pgdp.net - - - - - - - - - - A - TREATISE ON FEVER. - - - BY - - SOUTHWOOD SMITH, M.D. - - PHYSICIAN TO THE LONDON FEVER HOSPITAL. - - - LONDON: - - LONGMAN, REES, ORME, BROWN, AND GREEN, - PATER-NOSTER ROW. - - 1830. - - - - - PRINTED BY G. HAYDEN, - Little College Street, Westminster. - - - - - TO - - HIS GRACE - THE DUKE OF SOMERSET, - PRESIDENT; - - TO - THE VICE-PRESIDENTS, - - TO - THE TREASURERS, - - AND TO THE - OTHER GENTLEMEN CONSTITUTING THE COMMITTEE, - - Of the London Fever Hospital; - - IN TESTIMONY - - OF HIS ADMIRATION OF THE DILIGENCE - WITH WHICH - THEY LABOUR TO PROMOTE THE PROSPERITY, - AND THE - CARE WITH WHICH THEY WATCH OVER THE INTERESTS OF THIS INSTITUTION; - - WHICH, - IN THE MAGNITUDE OF THE BENEFITS IT CONFERS, - NO LESS THAN - IN THE INEXPENSIVENESS OF THE MEANS - BY WHICH, - THROUGH THEIR ECONOMY, IT IS ENABLED TO SECURE THEM, - - IS EQUALLED BY FEW ESTABLISHMENTS, - - AND - SURPASSED BY NONE; - - THIS WORK IS INSCRIBED - - BY - - THE AUTHOR. - ------------------------------------------------------------------------- - - - - - PREFACE. - - -The following Work is wholly of a practical nature: its object is to -ascertain the real phenomena of Fever, and the most safe and effectual -treatment of the disease. It was found impossible to include in this -volume some researches of a statistical nature which it was at first -intended to incorporate in the work. - -On looking over the account which has been given of the phenomena, I -find that, by an oversight, I have omitted to make any mention of the -peculiar odour which belongs to a fever-patient. It is so characteristic -that a person, familiar with the disease, might in many cases be able to -pronounce, merely from the odour of the effluvia that arises from the -body, whether the disease were fever. - -I cannot allow this work to go forth to the world, without expressing my -obligation to Dr. DILL, for the great assistance he has afforded me in -the collection and arrangement of the cases which illustrate the -symptoms and the pathology, and in the construction of the tables. And I -am happy to avail myself of this occasion to bear my testimony to the -excellent history which is drawn up of every case admitted into the -house; to the completeness of the record which is kept of the morbid -appearances on inspection; to the care which is taken of the sick, in -the absence of the physicians; and to the able and zealous manner in -which, as the resident medical officer of the Fever Hospital, he -performs the arduous duties of his office. - - _S. S._ - - _36, New Broad Street - Dec. 1829._ - - - - - CONTENTS. - - - Page. - DEDICATION i. - - PREFACE iii. - - - CHAPTER I. - - Further Investigation of Fever necessary 1 - - Facilities afforded by the Fever Hospital for prosecuting the - Study 5 - - Antient Doctrines relative to the Nature and Seat of Fever 7 - - Hippocrates, Galen, Sydenham 8 - - Modern Doctrines relative to the Nature and Seat of Fever 13 - - Cullen, Brown, Stoker, Burne, Clanny, Clutterbuck, Broussais 14 - - Errors common to all these Theorists 30 - - Questions to be solved before Fever can be understood 33 - - Precise Object of Investigation 34 - - Proper Mode of conducting it 36 - - - CHAPTER II. - - Varieties of Fever 41 - - Common Phenomena 42 - - Importance of analyzing the Assemblage of the Symptoms, in order - to ascertain the Common Phenomena 43 - - Results of the Analysis 45 - - Organs always diseased in Fever 48 - - Functions always deranged in Fever 49 - - Fever not Inflammation 50 - - Distinction between Fever and Inflammation 52 - - Common Phenomena of Fever exemplified in Plague 53 - in Yellow Fever, 54 - in the Varieties of Fever of Great Britain 54 - - Different Varieties produced by different Intensities 58 - - Received Classification and Nomenclature defective 60 - - What is really meant by Genera and Species of Fever 70 - - True Principle of Arrangement 71 - - - CHAPTER III. - - Of Synochus 77 - - Division into Synochus Mitior and Gravior 77 - - Succession of Phenomena in Synochus Mitior 78 - - Indications afforded of Disease in the Nervous, Circulating, - Secreting, and Excreting Systems 81 - - Progress of Disease consists in progressive Increase in the - Derangement of these Functions 85 - - Phenomena of Recovery 91 - - On what the Transition of Synochus Mitior into Synochus Gravior - depends 93 - - Classification according to the different Organs in which the - several Affections have their Seat 95 - - Synochus Gravior with Cerebral Affection 96 - Subacute Cerebral Affection 96 - Acute Cerebral Affection 107 - - Cases illustrating Synochus Mitior 112 - - Cases illustrating Synochus Gravior with Subacute Cerebral - Affection 114 - - Cases illustrating Synochus Gravior with Acute Cerebral Affection 116 - - Synochus Gravior with Thoracic Affection 120 - - Cases illustrating Thoracic Affection 123 - - Synochus Gravior with Abdominal Affection 128 - - Cases illustrating Abdominal Affection 137 - - Synochus Gravior with Mixed Affection 142 - - - CHAPTER IV. - - Of Typhus 148 - - Division into Typhus Mitior and Gravior 149 - - Typhus Mitior, with Subacute Cerebral Affection 149 - - Cases illustrating Subacute Cerebral Affection 155 - - Typhus Mitior, with Thoracic Affection 157 - - Typhus Mitior, Cases illustrating Affection 159 - With Abdominal Affection 161 - With Mixed Affection 162 - - Typhus Gravior 162 - In what it really consists 162 - - Dangerous nature of the Error that it consists in Debility 164 - - - CHAPTER V. - - Of Scarlatina 168 - - Characters by which it is distinguished from Continued Fever - without an Eruption 168 - - Division into Scarlatina Synochodes 171 - Typhodes 172 - - Events which occasionally occur in Fever, but which form no - essential part of it 173 - - Preternatural Sensibility over the external Surface of the Body; - Excoration and Sloughing; Erysipelas; Inflammation, &c. of the - Glands; peculiar Affection of the Joints 173 - - - CHAPTER VI. - - Of the Pathology of Fever 176 - - Importance of connecting the Symptoms with the States of the - Organs 176 - - Pathology of Fever comprehends the Morbid Changes that take place - in the Solids and Fluids of the Body 178 - - I. GENERAL PATHOLOGY OF THE SOLIDS 179 - - External Appearances of the Body after Death 180 - - Morbid Appearances in the Head 181 - in the Thorax 184 - in the Abdomen 187 - - I. Cases illustrating the Morbid Changes which take place within - the Head, or Cerebral Cases 193 - - 1. Vascularity of Brain, Spinal Cord, and - Membranes, with Gelatinous or slight - Serous Effusion 193 - - 2. Vascularity of Brain, Membranes, &c. - with Effusion of Coagulable Lymph and - Formation of Pus 204 - - 3. Vascularity of Brain, Membranes, &c. - with copious Serous Effusion 210 - - 4. Vascularity, &c. with Preternatural - Firmness of Brain 218 - - 5. Vascularity, &c. with softening of Brain 224 - - General Results established by preceding - Cases 230 - - II. Cases illustrating the Morbid Changes which take place within - the Chest, or Thoracic Cases 235 - - III. Cases illustrating the Morbid Changes which take place - within the Abdomen; or Abdominal Cases 246 - - General Results established by preceding Cases 287 - - IV. Cases illustrating the Morbid Changes which take place within - the Head, Thorax, and Abdomen, in the same individual, or Mixed - Cases 291 - - General Conclusion 322 - - II. PATHOLOGY OF THE FLUIDS IN FEVER 328 - - - CHAPTER VII. - - Of the Relation between the Phenomena of Fever; or the Theory of - the Disease 333 - - - CHAPTER VIII. - - Of the Causes of Fever 348 - - 1. Of the Immediate, or Exciting Cause of - Fever 348 - - 2. Of the Remote or Predisposing Causes of - Fever 369 - - - CHAPTER IX. - - Of the Treatment of Fever 375 - - Modification of Treatment required in prominent Cerebral - Affection 398 - - Thoracic Affection 403 - - Abdominal Affection 405 - - Treatment of Scarlet Fever 408 - - Treatment during Convalescence 418 - - Appendix 425 - - - - - FEVER, &c. - - - - - CHAPTER I. - - _Further Investigation of Fever necessary: Facilities afforded by the - Fever Hospital for prosecuting the Study. Ancient Doctrines relative - to the Nature and Seat of Fever. Hippocrates, Galen, Sydenham. - Modern Doctrines. Cullen, Brown, Stoker, Burne, Clanny, Clutterbuck, - Broussais. Errors common to all these Theorists. Questions to be - solved before Fever can be understood. Precise Object of - Investigation: proper mode of conducting it._ - - -On my appointment to the office of Physician to the London Fever -Hospital, it was stated to me by the treasurer that, among the objects -contemplated by the establishment of this institution, two things were -conceived to be of paramount importance: first, the accumulation of -facts by which the true nature of fever might be more certainly -ascertained, and secondly the cautious trial of remedies by which a more -sure and successful mode of treating this fatal disease might be -discovered. During my connexion with this hospital I have faithfully -endeavoured to the utmost of my ability to keep these objects in view, -and I now venture to lay before the public the result of my -observations, in the hope that they may contribute something, however -little, to the stock of knowledge already accumulated. - -When we consider how many circumstances connected with the origin and -the propagation of fever are wholly unknown, which if known might have a -most important influence in preventing its occurrence, in arresting its -progress or in lessening its mortality; when we consider in what -profound obscurity the very nature of the agents that produce it is -still involved; when we consider how easy it is to swell the long -catalogue of its symptoms, but how difficult it is to discriminate -which, even among the most prominent of the train, are the essential and -which the adventitious, and how still more difficult it is to ascertain -which are the invariable antecedents and which the invariable sequents, -or which the causes and which the effects; when we consider how few -comparatively of the external appearances have been ascertained to be -the sure and certain signs of any known condition of the internal -organs, and how often the existence of several known conditions of the -organs remains altogether unsuspected until the demonstration of it is -afforded by inspection after death, and when finally on all these -accounts we consider how vague the objects must be that are aimed at in -the treatment, and consequently how uncertain, how indiscriminate, how -fruitlessly inert, how perniciously active, how unsuccessful, how fatal -that treatment often is, it must be admitted that fever still presents -to us a vast field, in the culture of which the difficulties to be -overcome are not slight, and the most diligent labour that can be -bestowed upon it may by no means be attended with a sure reward. - -Of many branches of science it is truly observed that much time and -labour are necessary to establish a single important fact; of some parts -of medical science this is eminently the case, but perhaps of none is -the observation so just as of that which relates to febrile diseases. It -is remarkable how entirely the most distinguished physicians of all ages -who have treated of this subject coincide in the feeling, that with -regard to this important class of disease it is impossible in the short -life allotted to the most aged to do any thing more than add a little -knowledge to the common stock. If there be any foundation for this -feeling it can only be by every man faithfully endeavouring to -contribute what he may be able, be the amount ever so small, that that -stock can speedily become large or ever become complete. - -In bringing to this common stock my humble mite, that the offering may -not be wholly worthless, I have confined myself as much as possible to -the detail of the facts that have been observed, and the statement of -the results that have been obtained from experience. By giving a -connected view of the phenomena I have hoped that I might possibly -assist the actual practitioner to form a more adequate conception of the -disease and guide him to that particular remedy which experience shews -to be best adapted to each of the more important affections he is likely -to encounter. Out of the means furnished for the accomplishment of these -objects by the receptacle of fever for this great metropolis I have -endeavoured to select such specimens of the disease as will place before -him a vivid and faithful picture of the most interesting aspects it -assumes, and such a detail of treatment as will shew what particular -remedies afford the best chance of success in each type and stage, and -in the most common and therefore the most important modifications they -present. If I have at all succeeded in my aim he will find himself -placed in a good measure in the same situation with myself; his -attention will be directed to the same phenomena in the order in which -they occur in the series, and hence he will have the like means of -judging of the relations which these phenomena bear to each other, as -well as of the accuracy of the analysis that has been attempted of the -more complicated, and the soundness of the inductions that have been -made from a comparison of the whole. - -The London Fever Hospital is capable of receiving sixty-two patients: in -most seasons of the year its wards are full: often there are numerous -applications for admission which cannot be received for want of room: -there pass through the wards from six to seven hundred patients -annually. Two physicians are attached to the institution under whose -care the patients are placed alternately in the order in which they are -admitted: there is one assistant physician whose duty it is to perform -the office of the ordinary physicians when either of these may be -incapable of attending, and there is besides a medical officer resident -in the house. A history of each case, containing an account of the age, -occupation and residence of the patient, together with as full a -statement of the symptoms of the disease and of the order of their -succession as can be obtained is entered in the journal by the resident -medical officer. Each of the ordinary physicians attends daily and -enters in his journal a daily report of each of his own cases. The -resident medical officer goes round the wards twice a day, namely, early -in the morning and late in the evening, to observe if any change -requiring attention may have taken place in any patient; and if any such -change be observed by the nurses during the interval between these -visits they are reported to him by the head nurse without delay; all -such events with the modification of treatment they may have required -are entered in the journals. Every case that terminates fatally is -examined after death, and an account of the morbid appearances is -entered in a book kept for the purpose. In this manner, in the progress -of years a mass of facts accumulates relating to the statistics, the -types, the symptoms, the causes, the diagnosis, the pathology and the -treatment of the disease, whether successful or unsuccessful, which both -on account of the fullness and accuracy of the record and of the extent -of the period it embraces, cannot but be of great value. - -I am encouraged in the attempt to make this record, as far as it has yet -gone, useful to the public by observing the feeling that prevails among -those physicians who have studied fever with the greatest diligence, and -who have contributed most to our knowledge of it, that it is a disease -which is still little understood and the treatment of which remains -extremely vague and uncertain. Perhaps there is no disease so little -understood as the ordinary fever of this country and none by the -mismanagement of which so much life is lost. Dr. Clutterbuck appears to -me therefore to describe the situation of the physician to such an -establishment as the Fever Hospital, not more candidly than truly when -he says—“It becomes a duty incumbent on those particularly who have been -placed in situations favourable for observing the disease, to give the -result of their experience to the public, should it tend, in any degree, -either to prevention or cure. The enquiry is by no means exhausted, -considered either in a theoretical or practical point of view. There is -still a want of uniformity of opinion among physicians regarding the -nature of the present epidemic, as well as of fever in general: while, I -am sorry to add, in practice we are not much better agreed;” and when he -further adds;—“To ascertain these modifications” (that is the -modifications which require a modification of treatment) “is the great -desideratum, which nothing but the most cautious observation, aided by -much time, and the joint efforts of numerous individuals, can fully -supply.”[1] - -The slightest glance at the history of the doctrines which have been -taught relative to the nature and the seat of fever from remote -antiquity, and more especially a consideration of the variety and even -the contrariety of the received opinions respecting both, in the present -day, but too clearly shew that if the ancients were in error, there -cannot be many points with regard to which the moderns are right, since -there is scarcely one in which they are agreed. Further observation and -investigation are therefore not yet superseded. There is as yet no -uniformity of opinion among physicians even whether the primary seat of -the disease be in the fluid or the solid parts of which the body is -composed. Scarcely is the most ancient doctrine respecting it of which -we have any record, that it consists in a morbid derangement of the -fluids, and that the excitement which attends it is the result of an -effort of Nature to expel the poison received into or generated within -the system, obliterated from the imaginations or banished from the -reasonings of physicians. When indeed we see a patient in the latter -stage of some of the forms of fever with his dark or leaden skin, -pouring forth its peculiar and fetid exhalation; with his foul tongue, -his offensive breath, his vitiated and almost putrid secretions and -excretions, we can understand why this doctrine should have taken a firm -hold of the human mind and should have been able to maintain its ground -through many centuries. Yet when the phenomena came to be observed with -the accuracy with which we know that they were observed and recorded, -and examined with the acuteness with which we have abundant evidence -that some of the most powerful minds reasoned upon them, we may justly -wonder that the order of the events, together with their great variety -and opposite nature did not sooner suggest doubts of the accuracy of the -theory and give to the inquiries of these celebrated men a new -direction. But so far was this from being the case that when -Hippocrates, considering the increased heat as the essence of fever, -founded his division of the varieties of the disease upon this -principle, whence his _causus_ or burning fever, his _leipyria_, or -fever with the parts externally cold and internally hot, and his -_epialus_, or mild fever, with a simultaneous feeling of heat and cold; -when he ascribed these different forms of fever to the superabundance of -one or other of the four humours, blood, phlegm, yellow and black bile, -and considered the disease as the result of a contest on the part of -Nature to expel the morbid humour, or to render it inert or harmless by -the process of concoction, the mind of Galen so many centuries -afterwards, was so well satisfied with this hypothesis, that his -powerful genius contented itself with the mere amplification of the -conjecture and the addition of similar conjectures of his own. Whence -assigning the different sources by which a morbid heat, which he also -considers as the essence of fever, may be excited in the body, he states -“that the fevers thus produced are modified by the prevalence or -putrefaction of one or other of the four humours of Hippocrates; that of -the three kinds of intermittent the quotidian arises from the corruption -of phlegm, the tertian from that of the yellow and the quartan from that -of the black bile; that in whatever part of the body the heat begins it -ultimately extends to the heart; that as soon as this happens the -general commotion of the vessels commences, and that in this manner -Nature is employed in exerting her powers, endeavouring to assimilate -the good humours to the parts which are to be nourished and to expel the -bad, but that if at any time Nature is unable to expel all the morbid -humour either from its thickness, its abundance or its tenacity, or from -some obstruction of the passages, or from her own want of power, it will -necessarily undergo putrefaction, if it remain long in the body, and -produce the most fatal effects unless it be expelled by the process of -concoction.” And so many centuries after Galen wrote, Sydenham who -brought to the study of medicine one of the most acute, upright and -independent minds that ever adorned it, commences a work on fever, which -for fidelity of observation, for graphic description, for accurate -discrimination, for bold and yet cautious treatment, has been justly -considered an almost perfect model, with the following extraordinary -assumptions:— - -“That reason dictates that a disease is nothing else than Nature’s -endeavour to thrust forth with all her might the morbific matter for the -health of the patient; that seeing it has pleased God, the Governour of -all things, so to constitute human nature that it may be fitted to -receive the various impressions that come from abroad, it must -necessarily be subject to many diseases; that these diseases proceed -partly from particles of air ill agreeing with the body, which having -once insinuated themselves into it, are mixed with the blood, and affect -the whole with a morbific contagion; and partly from various ferments or -putrefaction of humours which are detained in the body beyond due time, -either because it was not able to digest them, on account of the -incongruity of their quality, or to evacuate them on account of their -bulk; that these circumstances being so nearly joined to the human -essence that no man can clearly free himself from them, Nature provided -for herself such a method and concatenation of symptoms as that she -might thereby expel the peccant matter, which would otherwise ruin the -whole fabric; that the plague, for instance, is nothing but a -complication of symptoms by which Nature casts out the malignant -particles, by imposthumes in the emunctories, or by some other -eruptions, that were drawn in by the air; that the gout is nothing but -Nature’s contrivance to purify the blood of old men, and to purge the -deep parts of the body; that when Nature requires the help of a fever, -whereby she may be able to separate the vitiated particles from the -blood, or otherwise expel them, either by a sweat, a looseness, or some -kind of eruption, she accomplishes this object in the whole mass of -blood, and that by a violent motion of the parts; that when this object -is accomplished suddenly, either by the health or death of the patient, -the disease is acute; when, on the contrary, the matter of the disease -is of such a nature that it cannot have the assistance of a fever for -the separation of it; or when this kind of matter is fixed to any -particular part, which is unable to exclude it, or when the blood is -vitiated by the continual flow of new matter into it, in these cases, -the matter being very slowly or not at all concocted, the diseases which -proceed from such unconcocted matter are called chronic: that acute -diseases proceed from a secret and inexplicable alteration of the air -infecting men’s bodies; that these diseases do not at all depend on a -peculiar crasis of the blood and humours any otherwise than the occult -influence of the air has imprinted the same upon them; that they -continue as long as this secret constitution of the air and no longer; -that they do not come at any other time; and that these constitute -epidemic fevers; that, on the other hand, acute diseases arise from this -or that particular irregularity of particular bodies, which, because -they are not produced by a general cause, do not therefore invade many -at once; that this species comes every year, and at any time of the -year; and that these may be called intercurrent or sporadic, because -they happen at any time during the prevalence of epidemics.[2]” - -That conjectures so gratuitous, and so utterly incompatible with the -structure and functions of the animal frame, should at such distant -periods of the world, under such different conditions of society, and in -such different states of science so entirely possess and satisfy the -minds of three of the most extraordinary men that ever illustrated or -extended any department of science, will appear the less wonderful when -we consider that the doctrines relative to fever which displaced and -succeeded these, originated in precisely the same error, and vary in -their aspect only in conformity to the progressive advancement of -general science. When the structure of the animal body became more -generally studied; when the functions performed by its different organs -became better understood; when the morbid actions constituting or -resulting from the derangement of these functions became more closely -investigated, the influence of the nervous system and the effects of -vascular action, began to form the subjects of investigation, and from -this period the attention of physicians was fixed less upon the fluid -than the solid parts of the frame. The properties and motions of the -fluids were now clearly seen to be dependent upon the action of the -containing solids, and the action of the solids to be under the -influence and control of certain laws peculiar to life. Disease, studied -under this juster view of the animal economy, immediately assumed a new -aspect, and theories arose so much more consonant to the known -operations of the living body, so much more explicit in their language -and intelligible in their nature, that the ancient doctrines were at -once exploded, and the very terms in which they were expressed became -suddenly, though, as it now appears, only for a short time obsolete. - -Cullen, building upon the foundation laid by Hoffman, rivalling in the -number of his pupils, and exceeding in the brilliancy of his success, if -not in the perpetuity of his fame, any name of antiquity, achieved with -unexampled ease and suddenness this great revolution; and in opposition -to the ancient theories taught, that the first change induced in the -animal system, by the operation of the exciting causes of fever, is a -diminution of the energy of the brain; that all the powers of the body -and all the faculties of the mind, that the functions of sensation and -motion, the processes of respiration, circulation, and secretion, all -fail or are diminished in the general debility; that after a certain -time a morbid increase of some of these functions, especially of the -circulation, takes place with an augmentation of the heat; that these -three states, that of debility, of cold, and of heat, bear to each other -the relation of cause and effect; that the first state is the result of -the sedative or debilitating influence of contagion, marsh miasmata, -cold or any other exciting cause, and the subsequent states the result -of the first; that the debility produces all the phenomena of the cold -stage, and especially a spasmodic constriction of the extreme arterial -vessels; that this spasm or atony of the extreme vessels exists not only -on the first attack of the cold stage, but remains during the whole -subsequent course of fever; that the spasm of the extreme vessels throws -a load of blood on the central parts of the circulating system, which -proves a source of irritation to the heart and arteries, and excites -them to a greater action; that this increased action, the source of the -heat and the other phenomena which constitute the second or hot stage -continues till the spasm is relaxed or overcome; and that this -excitement of spasm for the purpose of producing the subsequent reaction -is a part of the operation of the _vis medicatrix naturæ_, the innate -preserving power of the constitution. “Upon the whole,” says this -celebrated theorist, “our doctrine of fever is explicitly this. The -remote causes are certain sedative powers applied to the nervous system, -which, diminishing the energy of the brain, thereby produce a debility -in the whole of the functions, and particularly in the action of the -extreme vessels. Such, however, is at the same time the nature of the -animal economy, that this debility proves an indirect stimulus to the -sanguiferous system; whence, by the intervention of the cold stage, and -spasm connected with it, the action of the heart and large arteries is -increased, and continues so till it has had the effect of restoring the -energy of the brain, of extending this energy to the extreme vessels, of -restoring therefore their action, and thereby especially removing the -spasm affecting them: upon the removing of which, the excretion of -sweat, and other marks of the relaxation of excretories take place.”[3] - -Whatever may be thought of the superior power of the theory of Brown, -the pupil and rival of Cullen, to explain the general phenomena of the -living body, whether in a state of health or of disease, the doctrine of -the pupil relative to fever, differs in no essential respect from that -of the master. Like his predecessor, Brown attributes all fevers to -debility; and affirms that the distinctions which physicians have made -about the differences of fever are without foundation; that they are all -the same, differing only in degree; that the debility during the cold -stage is the greatest; that of the hot less; that of the sweating stage -which ends in health for the time, is the least of all: hence in a mild -degree of the disease, as cold is the most hurtful power, its effect is -gradually taken off by the agreeable heat of the bed or of the sun, and -the strength thereby gradually drawn forth; that the heart and arteries -gradually excited by the heat acquire vigour, and at last having their -perspiratory terminations excited by the same stimulus, the most hurtful -symptom is thereby removed, the hot fit produced, and afterwards the -same process carried on to the breaking out of sweat; that the cause of -all these diseases, from the simplest and mildest intermittent to the -gaol fever and the plague is the same with that of diseases not febrile, -to wit debility; differing only in this, that it is the greatest -debility compatible with life, and not long compatible with it. - -This very year, from Dublin, from the largest hospital for the reception -of fever in the British Empire, precisely the same doctrine has been put -forth. “Common epidemic fever,” says Dr. Stoker,[4] “especially when -contagious, as I have frequently asserted when speaking of its pathology -and treatment, has not appeared to me at any time to be essentially -inflammatory. Adynamic fever, a denomination for typhus fever, which I -shall employ, as I have hitherto done to express the putrid or malignant -fever of Sydenham; the slow nervous fever of Huxham; the nervous fever -of common language; the synochus, typhus mitior, and gravior of Cullen; -the gaol and hospital fever; the _fièvres essentielles_ of the French; -the epidemic of the Irish writers; the contagious of Bateman; the typhus -of Dr. Armstrong; and the proper idiopathic, or essential fever of Dr. -Clutterbuck: whether it exists separately or independently; or is -combined with any of the other forms of febrile disease, sporadic or -symptomatic.”[5] “Typhoid or adynamic fever I consider to be generally -symptomatic of morbid changes in the physical characters of the blood, -and have, as on former occasions, stated what those morbid changes -are—but I have arranged inflammation under the head of symptomatic -fever, merely because it is more usually connected with some change in -the structure of parts, discoverable after death: on the other hand, -typhus fever is connected with morbid changes, that _primarily_ take -place in the fluids, and produce morbid actions, and sometimes permanent -changes of structure in the said parts. These changes too in the -condition of the blood are distinguishable from those which we have -stated to occur in inflammation; and the morbid actions excited -relatively by those changes in the blood are also distinct. In -inflammatory fever on the one hand, increased action, in typhoid fevers -on the other, debility, is almost the immediate consequence. On account -of this debility being an essential character of typhoid fevers, I -denominated them adynamic.”[6] - -At the close of the last season, in a work,[7] the materials of which -have been drawn professedly from the London General Hospitals, doctrines -so similar have been laid down, that Dr. Stoker says of it—“the views -taken, both of the nature and treatment of fever, by Dr. Burne, entirely -accord with those which may be found stated in my Medical Reports from -the Fever Hospital, as well as in my separate Essays on that subject. -And as (when speaking of his denomination of fever) I have already -remarked, this leaves, I think, no reasonable doubt of the epidemic -fevers of London, having lately become more typhoid or adynamic, than -they had formerly been. It is further satisfactory to me to find, that -the treatment which I had long since adopted and recommended in our -typhoid fevers has been found suitable to the prevention and cure of -those in London; and that too in proportion as they have acquired more -of that form, with which I was best acquainted.”[8] And Dr. Burne -himself states, “that the adynamic fever has no local seat; that its -nature is _a morbid condition of the blood_, produced by the operation -of the primary cause, the respiration of a contaminated or poisoned -atmosphere: that this morbid blood, acting on the brain and nervous -system, is of itself sufficient in very many instances to bring about -the very great derangement and imperfect performance of all the -functions of the organic and of the animal life; which great derangement -and imperfect performance of all the functions constitute the phenomena -of adynamic fever.”[9] - -Instead of regarding with these authors a vitiated state of the blood as -the essence of fever, Dr. Clanny, on the contrary, believes its -proximate cause to be a want of power in the system to form blood. “The -proximate cause of typhus fever,” he says, “is a cessation of -chylification, and consequently of sanguification, during which time the -lymphatics of the whole system act with increased vigour, and in this -manner the lymph taken up by them from the system supplies, for the time -being, the place of the chyle in the blood, and as long as this state -continues the patient labours under an acute disease, heretofore called -typhus fever. When the chylopoietic viscera resume their functions the -disease gradually recedes, and health is ultimately restored.”[10] -“Chylification, like secretion, is a function of the brain, which under -peculiar circumstances, or states of the atmosphere, is impaired, and in -severe cases is suspended altogether: hence typhus fever.”[11] - -Such are the leading opinions of those who maintain that the seat of -fever is in the fluids, in which opinions we perceive a return to the -old doctrines, although in the modern version, it is true they are -somewhat modified and presented in a somewhat more definite shape. - -But in direct opposition to all such views of fever, it is zealously and -ably maintained by a large and increasing sect, that this malady is -strictly a local disease; that it has its primary and essential seat in -one organ, and that it consists of inflammation of that organ. Thus Dr. -Clutterbuck, who may be regarded as one of the most distinguished -advocates of this opinion, in one of the best works which has ever -appeared on the subject, contends that fever of every denomination and -every degree is the result of inflammation; that the appearances which -have led to the conclusion that it is a general disease primarily -affecting every function of the body are fallacious, and that, when -strictly examined, it will be found that all general or extensive -derangements of the system, are referrible to local disease in one -organ. “Fever, in regard to its effects on the system,” he says, “is the -most general of all diseases, and gives rise during its progress to the -greatest variety of symptoms. These, contemplated in the mass, present -nothing but confusion. Like all complicated phenomena, they require to -be subjected to strict analysis; that their order may be traced, and -their relation to each other and to the exciting cause shewn. To the -neglect of this may be ascribed the error, as I conceive it to be, which -has been so generally fallen into, of considering fever as an universal -disease, or one that affects for the first time the whole system; no one -part being supposed to suffer necessarily before the rest. Whereas, when -the disease is minutely scrutinized, and its first appearance accurately -noticed (which indeed from the slightness and consequent neglect of the -first symptoms is rarely done) it will be found to be strictly a -_topical_ affection, the general disorder of the system being merely -_secondary_, or symptomatic of this.”[12] In another work it is further -stated, that all the varieties of idiopathic fever, which differ but in -degree, as well as those which arise from specific contagion, as -malignant sore throat, scarlet fever, small-pox, and so on, arise from -one and the same affection of one and the same organ, and that that -affection consists essentially in inflammation. - -A similar doctrine has for some time been taught in France by a man -whose disciples have already spread over every country in Europe, and -are fast diffusing themselves over the new world, and whose devotion to -their master and his system, reminds us of days long past, when the -attachment of the pupil to the sage was as reverential and as -enthusiastic as that ever paid by true knight to lady-fair in the -brightest days of chivalry. “Penetrated by the sublime views of Bichat -as to the sympathies,” say M. M. Coutançeau et Rayer, two of the most -ardent disciples of this school;[13] “rich in numerous facts observed -with a rare sagacity, M. Broussais came to overturn, from the very -foundation, the antique edifice of fevers. In his works as well as in -his lectures, he has applied himself, for many years, to demonstrate, -that the fevers which had been called essential, were nothing more than -local diseases, inflammations, nay even gastro-enterites.” - -These writers go on to state that, according to Broussais, all fevers -are of the same nature, those termed malignant differing from other -fevers only by the violence and danger of their congestions; that all -the causes of fever act locally; that, considered in a general and -abstract manner, fever is invariably the result of a _primitive or -sympathetic irritation of the heart_ through the effect of which its -contractions are quickened, and that every irritation sufficiently -intense to produce fever is an inflammation.[14] - -There is thus a perfect accordance in the doctrine of these two -celebrated and rival theorists, Clutterbuck and Broussais, respecting -the nature of fever: both are agreed that it is an affection of the -solids of the body and that its essence consists in inflammation: both -are agreed that that inflammation is strictly local, being seated in one -organ: but in determining what that organ is, there is an entire -discrepancy in their opinion. According to Dr. Clutterbuck the organ -universally affected in every variety of idiopathic fever is the brain. -“Out of fifty cases,” he says, “of which I noted down the symptoms with -the greatest minuteness at the bed-side of the sick, generally once and -often twice in the twenty-four hours, throughout the disease, I find -that no two of them correspond in the minute points though they all -agree in the essential one, that is, in a manifest affection of the -brain and its functions; various in degree and probably in extent, with -numerous but accidental complications, from the affection of other -organs.”[15] This affection of the brain, consisting of inflammation, it -necessarily follows, as this author elsewhere states, that fever is -nothing else than a species of phrenitis, or topical inflammation of the -brain; that it might, therefore, be arranged in the order of phlegmasiæ -with pleurisy, enteritis, and other symptomatic fevers, but that since -the term phrenitis has been generally applied to a particular form of -inflammation of the brain and implies delirium, which does not always -occur in fever, although it is a frequent symptom, that of encephalitis -would form a proper denomination for this entire class of diseases, and -might be substituted for the term fever. - -Broussais, on the contrary, contends that the primary and essential seat -of inflammation in fever is the mucous membrane of the stomach, or of -the intestines, or both, but especially the former, and that, therefore, -the proper designation of it is _gastro-enteritis_. While it had long -been conceived that inflammation of the digestive organs is the cause of -certain symptomatic fevers, Broussais maintains that the most important -discovery (most important because so intimately connected with the -treatment of the disease) that this affection is the cause of all -fevers, idiopathic as well as symptomatic, and that there are in fact no -essential fevers, is peculiarly and exclusively his own. Thus, according -to this theorist, all the fevers of authors are connected with -gastro-enteritis, simple or complicated. “The simultaneous or successive -inflammation of the stomach and small intestines, designated by this -term,” says M. Rayer, “is of all the phlegmasiæ the most frequent, and -at the same time that which has been oftenest overlooked or mistaken. It -is not designated in any nosological table. Not long ago gastritis -itself was generally looked upon as a very rare disease: of twenty-eight -thousand two hundred and ninety-nine sick admitted into the civil -hospitals of Paris in 1807, six only were designated in the returns as -labouring under inflammation of the stomach, whilst six thousand one -hundred and forty-three were treated for continued or remittent fevers.” - -The prevailing doctrines relative to the nature and seat of fever at -present then are two, the direct reverse of each other; one, that it is -a general disease affecting the entire system; that this affection of -the system consists of debility which is manifested first in a loss of -energy of the brain, but which rapidly extends to every organ and every -function, and that consequently _the absence of any primary local -disease_, ought still to form, as it has so long formed, an essential -part of the definition: the other, that it is in the strictest sense a -local disease; that its primary seat is invariably fixed in some one -organ; that the affection itself consists of inflammation; and that that -inflammation is seated, according to one opinion in the brain; according -to the other in the stomach. - -As must necessarily be the case, these different and opposite theories -are found to have the most important influence on the practice -recommended by their respective authors in the treatment of the disease. -The advocates of the first deprecate all active interference: the grand -evil to be contended with is debility: the physician can easily weaken, -but he cannot easily strengthen: he can depress to any extent he -desires, but he cannot communicate power as he wishes. In a malady -therefore of which the very essence consists in loss of energy the main -duty of the physician is to husband the strength of the patient with the -most anxious care, this being the chief means, as Cullen expressively -termed it, of obviating the tendency to death. The important inference -is, that every kind and every degree of depletion that can add to the -primary cause of the malady, must be abstained from with the utmost -caution. By the clearest and shortest deduction this will necessarily be -the result to which every mind must come that really believes that -debility is the essence of fever, while he who admits its inflammatory -nature must think it criminal to stand idle by and allow the most -extensive derangements in the structure of vital organs to proceed, -without even an attempt to check them, as long as it is in his power to -use the lancet or to procure leeches. The very order in which the -believers in debility enumerate the remedies they recommend affords a -striking illustration of the extent to which their theory influences -their practice;[16] while the advocates of inflammation state explicitly -that the remedy of the disease is one, and in point of importance one -only, namely, the remedy which all admit to be the only efficient agent -in the treatment of inflammation. “Fever to be treated successfully,” -says Dr. Clutterbuck, “must be treated upon the general principles of -inflammation; but at the same time with the modifications arising out of -the peculiar nature of the organ affected, and in some degree also the -nature of the exciting cause. Blood-letting, which but a few years ago -was looked upon with abhorrence in the cure of contagious fever, and the -utility of which is still far from being generally appreciated, is -proved by ample testimony to be not only the most powerful, but the -safest of remedies.” And in every variety of fever, and in all its -stages, leeches are to be applied to the stomach, according to -Broussais, and scarcely any thing else is to be done except enjoining -rigid starvation. Emetics, purgatives, bark, wine, are all denounced; -nothing but leeches and “diete absolue:” a costive state of the bowels -persisting during five or even ten days is a good symptom and not to be -interfered with. - -That men who exhibit such talent for observation and such acute and -active powers of the understanding as many of these authors exemplify in -these very works, should, while writing with so much earnestness against -each other, fall into one and the same error, and that an error so -palpable, is no flattering exhibition of the state of the art of -reasoning among the members of the medical profession. The degree in -which the science of mind is neglected in our age and country, may it -not be justly added? especially in our profession—that science upon the -knowledge of which the conduct of every individual mind is so dependent, -is truly deplorable. Medicine is an inductive science, the cultivator of -which is peculiarly exposed to the danger of making hasty assumptions -and of resting in partial views, yet it is not deemed necessary that he -should be at all disciplined in the art of induction, or should be -cautioned against any sources of fallacy in the practice of making -inferences. All the partial and imperfect views of fever which have now -been brought before the eye of the reader, originate in one or other of -the following errors, obvious as they all are: either that of assuming -as a fact what is merely a conjecture; or that of assigning to the genus -what belongs only to the species; or that of characterising the disease -by what appertains only to a stage; or that of mistaking the effect for -the cause. On careful examination it will appear that one or other of -these errors, which are as serious as they are palpable, has vitiated in -a greater or less degree every generalization of fever that has hitherto -been attempted. - -Thus the believers in debility derive their notion of the whole disease -from the phenomena which occur in the first and the last stages only: in -these, it is true, they may find abundant evidence of debility: but then -they overlook the intermediate stage in which there are generally the -most unequivocal indications of increased sensibility in the nervous and -increased action in the vascular systems: in this manner they -characterise the disease by what appertains only to certain stages of -it. Again, when they contend that debility is not only the essence of -fever in general, but is really characteristic of every type of it, they -affirm what is indisputable of fevers in particular seasons, in -particular climates or in particular constitutions; but beyond this -their generalization cannot be extended: in this manner they assign to -the genus what belongs only to the species. And when Cullen goes on to -affirm that the proximate cause of all the morbid phenomena is a “spasm -of the extreme vessels,” he commits the additional and more palpable, -but not less common error, of assigning as an undoubted fact, as a real -and ascertained occurrence, what is only a conjecture, and for which -there is not, and for which he does not even attempt to adduce the -shadow of evidence. - -Precisely similar to this is the error of those who for the most part -belong to the same school, and who attribute the essence of fever to a -morbid condition of the blood. The blood may be diseased in fever, but -if it be so, these writers do not _know_ it, or at least they do not -adduce any evidence that they are in possession of such knowledge: they -do not appear so much as to have questioned chemistry; at all events, it -is certain that they have hitherto received no satisfactory answer. -There is no evidence on record that the alleged determination of the -blood takes place in every type and every degree of fever: and if there -were it would still be but one event among many, and one that occurs -late in the series, and therefore could possibly be nothing more than an -effect. - -In like manner those who maintain that inflammation of the brain is the -sole cause of fever, assume as an established and admitted fact the -universal and invariable existence of inflammation of the brain in this -disease. Inflammation of the brain, without doubt, is demonstrable of -many individual cases, and of some whole types: but beyond this there is -no proof that the generalization can be carried: the evidence indeed in -regard to many cases is entirely against the assumption, and is as -complete as negative evidence can well be: consequently it must be -admitted that even this hypothesis, in the present state of our -knowledge, is founded on the error of assigning to the whole genus what -belongs only to particular species: and it would be trifling with the -reader to attempt to prove, that this is still more certainly and -strikingly true with regard to inflammation of the mucous membrane of -the stomach and intestines—an affection which in innumerable cases in -which its existence is certain, clearly appears on the slightest -examination of the succession of events, to be an effect and not a -cause. - -No comprehensive view can be taken of fever, no just conclusion can be -arrived at relative to its nature and seat until it be studied with a -consciousness of the liability to such errors and a vigilant endeavour -to avoid them. The present investigation has been undertaken with a deep -consciousness of the danger and a watchful and unremitting care to avoid -it. Even if the effort prove to be without success, the example can -scarcely remain without use. - -The frequent and formidable disease on the investigation of which we are -entering, cannot be understood until clear and exact answers are -obtained to the following inquiries. 1. What is the series of phenomena -which constitutes fever? 2. What are the particular phenomena which are -common to all its varieties and combinations? 3. What is the order in -which these phenomena occur in the series? 4. What are the organs, and -what are their states, upon which these phenomena depend? 5. What are -the external signs of these internal states, or what are the indications -by which their existence may be known? 6. What is the external noxious -agent or agents, or the exciting cause or causes of the disease? 7. What -is the particular remedy, or the particular combination of remedies -which is best adapted to each state of each organ? When these questions -can be clearly and perfectly answered, and not till then, we shall know -the disease and its treatment. In order to make any real progress in -this knowledge we must therefore prosecute these inquiries. It appears -to me that we are already in possession of ascertained facts, adequate -to answer with a high degree of certainty, though perhaps not with -absolute certainty, several of these questions. In keeping these -inquiries steadily before our view in our investigation there will be -this great advantage, that it will enable us clearly to perceive what we -really know and what still remains to be ascertained. - -The phenomena which constitute fever, like those which belong to all the -processes of nature, consist of a certain number of events. The events -which take place in this disease are before our eyes: they are -abundantly familiar to us all: no one man indeed has seen all the forms -of fever which exist, nor observed all the symptoms of those species -which he has witnessed, but accurate records are to be obtained of them -all: records upon which we have this assurance that we may rely, that -all the important events in this disease are so obvious and striking, -and indeed force themselves so powerfully and constantly upon the -notice, that there can be little danger that any one of consequence -should be overlooked. Accordingly medical writings abound with the most -minute, and, as far as can be judged, accurate histories of the symptoms -which accompany all sorts of fevers, whether epidemic or sporadic. It is -not in the observation of symptoms that the danger of error lies, -because these are matters of sense, but the danger arises from a -different source. Supposing, for example, that all the important events -which accompany all the important varieties of fever have been -ascertained, and that thus our first inquiry relative to the series of -phenomena which constitutes the disease, is answered, still as many of -these events are observed to be often absent, while it cannot be doubted -that fever is nevertheless present, we must necessarily enquire in the -next place, what is that particular combination of events which is -_essential_ to the constitution of the disease, an enquiry which -embraces the second question proposed for consideration, namely, what -are the particular phenomena which are common to all the varieties of -fever? Now in singling out this particular series of events from the -great mass, we are liable to several sources of error. In the first -place, we may stop too soon in our enumeration; in the second place, we -may mistake the adventitious for the essential and the essential for the -adventitious, and in the third place, we may overlook the real place -which some particular event holds in the series, and so may suppose that -to be antecedent which was truly sequent, and consequently assign that -as a cause which is only an effect. - -The first thing to be done then is to ascertain the concourse of -symptoms, and the second, to determine the order in which they occur: -when these two points have been made out, what is essential and what -adventitious, as well as what is the cause and what the effect, become -at once clear and certain. But the difficulty lies in discerning amidst -the infinite diversity and contrariety of symptoms which the different -modifications of fever present, when we may safely assure ourselves that -we are in possession of all the essential phenomena. Our guide is -_invariableness_ of concurrence. If we can ascertain that a certain -number of events _invariably_ take place in every form and every degree -of fever, these events will give us the particular phenomena which are -common to all the varieties of the disease. If we can further ascertain -that these events _invariably_ concur in a certain order, we shall have -discovered what events bear to each other the relation of cause and -effect. And the establishment of this relation of events, this constant -connexion with each other, this uniform antecedence and sequence appears -to me to be the only theory after which it is consistent with the -principles of sound philosophy to search. If I have endeavoured to -establish this connexion, and have thus ventured, as I conceive, in a -strictly philosophical sense to propose a theory, in doing so, I have -carefully restricted myself to the attempt to deduce a legitimate -conclusion from facts previously ascertained. It does appear to me that -these three points, namely, the common phenomena, the invariableness of -their concurrence, and their mutual relation are satisfactorily -established. Whether I shall be able to communicate this conviction to -the reader I do not know: but I hope he will at least coincide with me -in opinion that this mode of investigating the disease affords us the -best chance of arriving at satisfactory results. - -Whatever be the phenomena of fever they depend upon certain states of -the organs. Whatever be the noxious agents or the exciting causes of the -disease, and however they operate, they can induce the disease only by -bringing about a certain condition in a certain number of organs, the -individual events constituting the disease being nothing but certain -changes in these organs. It is therefore of paramount importance to -ascertain what the organs are which are implicated; what the conditions -are which are induced in them; what organ sustains the first assault and -what organs are attacked in succession. The pathology about to be laid -before the reader will demonstrate the first two points: the -establishment of the last two will be attempted by an examination of the -history of the cases. - -Without doubt the life or death of the patient depends upon these -conditions of the organs. In a practical point of view therefore, this -is the kind of knowledge with which it is of the greatest importance -that the practitioner should be familiar. Some of these conditions are -indicated by certain signs during life: some of these indications are -obscure, and may be easily overlooked or mistaken by those who have not -acquired an accurate and extensive acquaintance with the disease. On the -other hand, there are external appearances which are extremely apt to -suggest a false notion of the state of the internal organs. These -fallacious appearances are sure to lead those whom they deceive into a -mistaken, often into a mortal practice. Certain conditions of vital -organs, if allowed to remain long, will terminate in fatal changes of -structure. Certain remedies, if applied in due season and with due -vigour, are capable of removing those conditions. Life therefore must -sometimes depend upon the power of making this diagnosis with accuracy. -Of some of these conditions, the diagnostic marks are clear and certain; -those which indicate other conditions, in the present state of our -knowledge, are obscure and uncertain. I have thought no labour too great -to put the reader in possession of all that I have been able to -ascertain with regard to this most important part of the subject. In the -attempt to communicate this information, I am conscious that I may incur -the charge of tediousness, on account of the number of repetitions which -occur, and which I have allowed to remain because I could see no means -of removing them without sacrificing clearness to brevity. Elegance and -conciseness, in a work of this nature, ought not for a moment to be -considered if they endanger its practical usefulness. A knowledge of the -condition of the internal organs, in fever, can alone guide us to a -rational and successful treatment of this most dangerous disease. It is -only by examining the body after death that we can acquire this -information: it is only by observing the symptoms during life and -comparing them with the morbid appearances after death, that we can -discover the signs which indicate the existence of these states. For -these reasons I have not hesitated to give numerous cases and to detail -many dissections. If after the study of these cases and dissections the -practitioner be enabled at the bed-side of the fever patient to discover -with greater precision and certainty than heretofore the condition of -the brain—the condition of the lungs—the condition of the intestines, he -will not think the time he has devoted to the investigation ill spent, -nor shall I think myself without reward for the labour it has cost me to -draw up the record. It is only when from external appearances we are -able to see what is going on within each of the great cavities of the -body, as clearly as we should do if their walls were transparent, that -our interference can be sure of doing good, or secure from doing -mischief: it is this kind and degree of knowledge alone which can teach -us both when to act and what to do; and what is of almost equal -importance, when to stop and to attempt nothing; and if the perusal of -this work should contribute in any measure to the attainment of this -knowledge, I shall not have laboured wholly in vain, “to add something -to the treasury of physic.” - - - - - CHAPTER II. - - _Varieties of Fever. Common Phenomena. Importance of this Analysis. - Results of the Analysis. Organs always diseased in Fever: Functions - always deranged in Fever. Fever not Inflammation: Distinction - between these two States of Disease. Common Phenomena of Fever - exemplified in Plague, in Yellow Fever, in the Varieties of the - Fever of our own Country. Different Varieties produced by different - Intensities of the same Affections. Received Classification and - Nomenclature defective. What is really meant by Genera and Species - of Fever. True Principle of Arrangement._ - - -Fever is a genus consisting of several species, and each species -presents many varieties. The external characters of these varieties and -the internal states upon which they depend, are so opposite, that no two -diseases in any two parts of the catalogue of nosology present a more -diversified appearance, or require a more varied treatment, than may be -the case with two different types of fever. The fever of one country is -not the same as the fever of any other country; in the same country, the -fever of one season is not the same as the fever of any other season; -and even the fever of the same season is not the same in any two -individuals. Many of the circumstances which constitute these varieties -in the fevers of different seasons and of individual persons, are slight -and trivial; but some of them are of the greatest possible importance, -and those diversities, especially, which distinguish the fevers of -different climates, are intimately connected with the causes, whatever -they be, which render the disease mild or severe, and, consequently, -comparatively innoxious or fearfully mortal. - -Something there is, however, which, amidst this astonishing diversity, -preserves the identity of the disease so completely and so obviously, -that there never has existed any dispute about that identity, under any -aspect which it has hitherto been observed to assume; so that all -physicians, without exception, unhesitatingly accord the name of fever -to the mildest form of the common fever of this country, to the yellow -fever of the West Indies, and to the plague of Constantinople and of -Egypt. Bring three persons, each exhibiting an exquisite specimen of one -of these several forms of the disease into the same ward of an hospital, -the external aspect presented by each would be so different, that an -unprofessional observer would probably be able to discover in these -modifications of the same malady no common property: yet there is no -physician who would not, in each case, instantly pronounce the disease -to be fever. There must, therefore, be something that establishes the -identity of the disease under this diversity of aspect. What is that -something? Whatever it be, it must be common to all the varieties of -fever. Thus we are led at once to the second inquiry which we proposed -to keep before us in this investigation, namely, what are the particular -phenomena which are common to all the varieties and combinations of the -disease? - -The importance of making this analysis has been felt by every person who -has directed his attention to this subject from the remotest antiquity -down to the present time. That it is not as easy to be made as the -necessity of it is plainly to be perceived is abundantly attested by the -want of success which has hitherto attended the efforts to perform it of -the acutest minds, and the acutest minds, the pride and boast of our -science have applied themselves to the task. Notwithstanding their -labours however, the analysis made by Hippocrates has been received -through succeeding ages with little variation, and continues to be -received even in modern times with only slight modification. And yet -that reflecting men of every age have not been satisfied with resolving -all the essential phenomena of fever into heat, although they have all -consented to designate the disease by some term expressive of that -property,[17] is attested by proofs no less striking than instructive. -We are informed by Van Swieten, that Boerhaave collected with much -labour from a great variety of authors all the symptoms which they had -observed in different fevers: that from these he threw out such as did -not appear in all fevers, and that finding himself obliged to exclude -one after another, he was at length greatly surprised to find the -catalogue so short; it being ultimately reduced to three; namely -shivering, frequent pulse, heat. - -This is a sufficient and an interesting proof that this illustrious -physician saw the importance of making the analysis in question; it -shews also, that his ingenuity suggested probably the best mode of -conducting it which a philosopher sitting in his study could devise; and -the only proper mode of conducting it the circumstances of his age and -country did not place within his reach. Accordingly his success did not -equal his labour: for out of the three phenomena which he fixes upon as -those that are common to all the varieties of the disease there is not -one which is invariably found in any type of it; while in innumerable -cases the combination of the three is not found. Shivering does not -occur in some of the worst forms of the malady; and where it does, it is -confined to the commencement of the attack, or to that of its -exacerbations. The pulse, instead of being always more frequent than -natural, in some of the most formidable aspects assumed by the disease, -has been observed to be as low as forty or even thirty in the minute, -and, from the beginning to the termination of the attack, the heat in -some cases is below the natural standard, as it generally is in the -commencement of the cold stage. - -To the catalogue of Boerhaave, Cullen makes the following -additions:—“languor, lassitude and other signs of debility, together -with derangement of the functions, particularly a want of vigor in the -limbs without any primary local affection.” This extension of the -catalogue adds in no respect to the excellence of the generalization. It -has all the vices which a definition can possess. The characters are not -present in all cases; the very opposite are strikingly prominent in -many, while the last, “without any primary local affection,” has so -direct a tendency to mislead the mind, and positively to prevent it from -observing the real phenomena of the disease, that it may well be -questioned, whether the introduction of this single phrase into the -definition of fever, has not been the occasion of far more practical -mischief than has been compensated by any good that has been -accomplished, or ever can be accomplished by all the rest of the -nosology. - -In the last attempt to improve the definition of fever with which I am -acquainted, Dr. Wilson Philip says, “If we lay aside Dr. Cullen’s term -pyrexia, (which it must be borne in mind is precisely Boerhaave’s brief -catalogue) we shall considerably lessen the difficulty of giving such a -definition of idiopathic fevers as shall apply to all cases. They may be -defined as follows. Languor, lassitude, and other signs of debility, -followed by a frequent pulse, and increased heat, without any primary -local affection.”[18] Inasmuch as this definition contains fewer words -than that proposed by Cullen, it may be liable to fewer objections, but -it is less faulty only because it is shorter. - -This total failure of men, all of them of unquestionable acuteness, and -some of them of splendid genius, in their attempts to discover the -common phenomena of fever, affords a strong presumption that they have -not pursued their object in the right path. Without doubt, before it is -possible to succeed in any scientific investigation, it is necessary to -form a distinct conception of the object of inquiry. Fever is not an -entity, not a being possessing a peculiar nature; and the object of -investigating it, is not to discover in what such nature consists, or -what it is that constitutes its essence: but fever is a series of -events, and the object of inquiry is to discover what the events are; -what the events are that invariably concur in the series; and in what -order they constantly succeed each other. When we have discovered this, -we have ascertained all that we can ever know of what is termed the -nature of fever, as it is this, and only this, that we can ever know of -any object or process. Every natural object consists either of one -single substance, or of several substances united; and our knowledge of -that object is complete when we have ascertained what that single -substance is; or what all the separate substances are that combine to -form it. Every natural process consists of a number of events, and our -knowledge of that process is complete when we have ascertained the -events themselves, the order of their succession, and the events to -which they give occasion. We can make no real progress in knowledge -unless we keep steadily in view the kind of information which it is -possible to acquire, and which it is to our purpose to seek; and -dispossess our minds of the phantoms which have so long enthralled and -abused them. - -In relation to our present subject then, the first object of enquiry is, -what are the events which invariably concur in fever? - -Where shall we look for the events? Not in the symptoms. Symptoms are -not events: they are only indications of events: symptoms depend upon -states of organs: they are the external and visible signs of internal, -and, for the most part, as long as life continues, invisible conditions. -It is then to the state of the organs that we must look for the events -of which we are in search. - -Are there any states of any organs that always exist in fever? Are the -states constant? Are the organs affected constant; and can both be -ascertained? If this can be truly answered in the affirmative; if it can -be proved that there are certain conditions of certain organs which -invariably exist in fever, in every type, in every degree, in every -stage of it, we shall have arrived at a satisfactory conclusion relative -to the first part of our inquiry. - -The evidence is as complete as observation during life and inspection -after death can make it, that a morbid change does take place in a -certain number of organs in every case of fever, from the most trivial -intermittent to the most alarming continued fever, from the mildest -plague to the most malignant typhus: that at the two extremes of this -scale, and at all the intermediate gradations of it, there are certain -organs which are always affected, and that the affection in all is -similar. - -The identity of the organs is inferred from the indications they give of -disordered function during life: the identity of the affection is -inferred from the similarity of morbid appearances which they exhibit on -examination after death. - -The organs affected are those which constitute the nervous system; those -which constitute the circulating system, and those which constitute the -systems of secretion and excretion. The spinal cord and the brain; the -heart and the arteries, especially their capillary extremities; the -secreting and the excreting organs, which in fact are composed, -essentially, of the capillary extremities of the arteries; the secreting -and the excreting extremities of these arteries, especially as they -terminate in the external skin, and in the mucous membranes, which form -the internal skin, this is the chain of diseased organs: derangement in -the nervous and sensorial functions: derangement in the circulating -function: derangement in the secretory and excretory functions, this is -the circle of morbid actions. - -There never was a case of fever in which all these organs and affections -were not more or less in a morbid state: there never was a concurrence -of this morbid state, in this complete circle of organs, without fever. -The events which _invariably_ concur in fever, then, are a certain -deviation from the healthy state in the nervous and the sensorial -functions; a certain deviation from the healthy state in the circulating -function; a certain deviation from the healthy state in the functions of -secretion and excretion. A deviation from the healthy state in one -circle of actions will not present the phenomena of fever; a deviation -from the healthy state in two circles of action will not present the -phenomena of fever: there must be a deviation in the three circles -before fever can exist. Such then are the common phenomena of fever. - -For obvious reasons the detail of the proof that these several events -really and invariably take place, must be postponed until the phenomena -themselves have been stated, or what is termed the history of the -disease has been given. - -But it is not the invariable concurrence of a particular number of -events that is alone sufficient to constitute fever: to this must be -added invariableness of concurrence in a particular order. As will be -shewn in the proper place, there is complete and irresistible evidence -that these events do occur in one invariable order. Derangement in the -functions of secretion and excretion never comes first in the series: -derangement in the nervous and sensorial functions never comes last in -the series: derangement in the function of the circulation never comes -either the first or the last in the series, but is always the second in -succession. - -The order of events then is first, derangement in the nervous and -sensorial functions; this is the invariable antecedent: secondly, -derangement in the circulating function; this is the invariable sequent: -and thirdly, derangement in the secreting and excreting functions; this -is the last result in the succession of morbid changes. - -Supposing the matter of fact to be as is here stated, and the proof that -it is so will be adduced hereafter, it is clear that we are in -possession of the true characters of fever. We know the events: we know -the order in which they occur: we know therefore what it is that -constitutes the disease, and we know consequently what it is by which it -is distinguished from every other malady. No other disease exhibits the -same train of phenomena in the same order of succession. In inflammation -some of the phenomena are the same: but the order in which they concur -is not the same; and this affords a clear and universally applicable -mark of distinction between fever and inflammation. In inflammation -there is similar derangement in the secreting and excreting functions: -there is also sometimes similar derangement in the circulating function: -but the derangement in the nervous and sensorial functions is seldom if -ever similar: the derangement that does take place in these latter -functions, while it is apparently different in kind, is certainly and -invariably different in the order of its occurrence. In pneumonia, in -enteritis, in hepatitis, the spinal cord and the brain are _never_ the -organs in which the _first_ indications of disease appear: the earliest -indications of disease that can be discovered have their seat in the -affected organ itself: it is only after the disease has made some -progress that other organs and functions are involved; and apparently, -the last to be involved, and certainly the least to suffer, is the -nervous system. - -We can now then answer the questions so often asked—are fever and -inflammation the same? and if not the same in what do they differ? Fever -and inflammation are not the same, because the term fever is -appropriated to the designation of a certain number of events which -occur in a certain series: the term inflammation, on the other hand, -expresses another series of events, each event composing this train, -succeeding each other in a different order: and the difference between -the two series of events is precisely this difference in their -individual phenomena and in their order of succession. What the physical -and the physiological condition of the organs is, as contrasted with -their condition in the state of health, has not yet been made out with -regard either to fever or to inflammation: in the present state of our -knowledge, therefore, we can neither affirm nor deny any thing -respecting either the identity or the difference of that physical and -physiological condition of the organs in these two classes of disease. -What inflammation is beyond the series of events we are able to observe -we do not know: what fever is beyond the series of events we are able to -observe we do not know: we compare the events and we see that they -differ: and since the use of names is to mark and to express -differences, it is right to distinguish these different events by -different terms. But though in the present state of our knowledge we are -not justified in considering fever and inflammation to be the same, yet -the close, perhaps the constant connexion between them, is a fact of the -utmost importance to be known, and requires to be incessantly before the -view of the practitioner. And of this we shall have but too abundant -evidence in the sequel. - -Supposing the proofs hereafter to be adduced to be conclusive, that the -events in fever and their order really are what has now been stated, how -clearly and beautifully does this view of the disease enable us to -recognize one and the same malady through all the modifications it -undergoes, and therefore through the countless aspects it assumes. Out -of the system of organs that are always affected in fever some may be -more and some may be less diseased; and it is easy to see how, from this -diversity alone, the utmost variety may arise in the external characters -of the disease. Thus, at one time, the spinal cord and the brain may be -intensely affected: consequently the patient may be seized with violent -pains in the limbs; with ferocious head-ache; with early delirium, which -may rapidly increase to such a degree of violence as to require -restraint: or, on the contrary, all the muscles of voluntary motion may -be seized instantaneously with such a loss of energy that they may truly -be said to be paralyzed: at the same time the sensorial faculties may be -overwhelmed almost as completely as they are in apoplexy: thus may be -formed one type of fever: and such a concourse of symptoms is actually -found to exist: it ushers in the plague when it first stalks into a -devoted city to sweep away its thousands and its tens of thousands. - -At another time the disease may seize with peculiar violence upon the -organs of secretion, and especially upon those which belong to the -digestive apparatus: hence the liver may suddenly pour forth an immense -flow of bile, so vitiated in quality as to irritate and inflame whatever -it touches, and so abundant in quantity as rapidly to diffuse itself -over every part of the body, and to tinge almost every tissue and every -fluid: at the same time the stomach and intestines may be involved in -such acute disease that the powers of life may be exhausted in a few -hours by incessant vomiting and unconquerable purging: thus may be -formed another type of fever, and such a concourse of symptoms actually -occurs in the yellow fever of the West Indies. - -Now we may witness a severe though a less violent affection of the -spinal cord and the brain than occurs in plague. There may be present -great pain in the back and limbs; intense head-ache; early and violent -delirium; a burning skin; a quick and strong pulse; urgent thirst, and -constipated bowels: or, on the contrary, there may be not pain of the -head, but giddiness; not delirium, but stupor; not a burning hot, but a -moderately warm or a cool skin; not a frequent and strong, but a -frequent and feeble pulse. In either case we have a fair specimen of the -common fever of our own country, the first forming the variety which may -be termed acute, the second subacute cerebral. - -Now again we may witness a concurrence of symptoms very similar to the -latter in the commencement of the attack, only that there is from the -beginning greater prostration of strength; and a rapid increase in the -derangement of the nervous and sensorial functions: together with a -brown and dry tongue; a tender abdomen, and dark and offensive stools: -thus may be formed another type of fever to which is commonly assigned -the name of typhus. - -In each of these cases the most urgent symptoms have their seat only in -one set of the organs that compose the circle which we have said to be -involved; but in every case all the other organs included in that circle -are as really, though not as intensely diseased. When the spinal cord -and the brain are so violently affected that the patient appears to be -struck with paralysis or apoplexy, the attention is not strongly drawn -to the state of the mucous membrane of the digestive apparatus; to the -nature of the secretions and excretions of which it is the source; to -the temperature of the system, or to the condition of the circulation: -because the affection of the nervous system being overwhelming, and all -the other affections being comparatively trifling, it is natural that -the former should, in a manner, absorb the mind of the observer; yet, if -the skin, the pulse, the tongue, the evacuations are examined, all will -be found to be in a morbid state, and that morbid state will bear a -certain proportion to the affection of the nervous system. - -In like manner when the organs of the digestive apparatus form the -strong hold of the disease, the morbid condition of the spinal cord and -brain, and the altered action of the heart and arteries, may attract -less notice; but that morbid condition will be not the less real, and -will contribute its portion of disease to the general derangement of the -system, not the less certainly because the indications of its existence -may be less obtrusive. - -And in the milder forms which the fever of our own country presents, in -the most intense cerebral affection with which we ever meet, there will -always be present unequivocal indications of deranged function both in -the heart and arteries, and in the organs of secretion and excretion: -while in cases in which the brain may be tolerably clear; in which there -may be little or no headache; little or no pain in the limbs; no -delirium; in which the disease may be chiefly seated in the mucous -membrane of the stomach and intestines, and the prominent symptoms be, -pain of the epigastrium, tenderness on pressure over the whole abdomen, -a red tongue, and frequent stools, still if we examine the state of the -pulse, if we look at the quality and the distribution of the nervous -influence, if we observe the operations of the sensorial faculties, we -shall find these functions to be as truly, though not as intensely -deranged as if the full force of the disease were spent upon the organs -in which these functions have their seat. - -Thus, although all these organs are invariably affected in every case of -fever, yet in no two cases are all these organs affected in the same -degree. Sometimes one system is more affected than another; sometimes -one organ of one system, and these different degrees of affection, in -these different systems, are variously combined and modified. How great -then must necessarily be the diversity of symptoms presented by the -different forms of fever! How incalculable are the varieties that result -from difference of intensity alone. One degree of affection of the -brain, for example, will occasion violent headache, constant -watchfulness, great restlessness, a peculiar expression of the eye, and -intolerance of light; in another there will be no headache, or none of -which the patient will complain; there will be sleep though it be -disturbed and unrefreshing; there will be no peculiar expression of the -eye, and no intolerance of light. By one degree of affection the -sensibility will be rendered preternaturally intense; by another it will -be totally obliterated: one will produce violent delirium, another, only -slight wandering, or unrefreshing slumber: one, violence requiring -restraint; another, profound coma. In the circulating system the -symptoms will alike vary. One degree will produce a quick, strong and -hard pulse; another, a quick, small and feeble pulse; another, a slow -and intermittent pulse. A similar diversity will be found in the -temperature of the body: in one, the heat will be little changed; in -another, it will be below the natural standard; in a third, it will be -intense, and the organs of secretion and excretion will equally vary in -the extent of their morbid changes. - -Thus, from one and the same affection of one and the same organ, not -only different but opposite symptoms will be produced in all the organs -involved in what we may call the febrile circle. When to this variety -are added diversities occasioned by various stages of the diseased -processes that are going on in the system; by the previous state of the -organs affected; by the reaction of the affected organs one upon -another, producing innumerable and ever varying combinations of -different intensities of affection, in different sets of organs; and by -the treatment to which the whole have been subjected, we cannot wonder -if the symptoms of fever appear to be countless. - -That no two cases of fever can ever be precisely the same, and that it -must be vain to seek for the common phenomena of the disease in the -external symptoms, must now be obvious: and why success can never attend -the search after these common phenomena in such symptoms as “shivering, -frequent pulse, heat,” must be equally manifest. These as well as all -other symptoms depend upon the state of the organs. But we have seen -that in one degree of the same affection of the same series of organs -there may be shivering; excited pulse; burning heat; while in another -degree there may be no shivering, a slow pulse and a cold skin: so that -from one and the same affection, differing only in the degree of its -intensity, the symptoms may not only vary but be directly opposite. The -proper object of pursuit in all these enquiries, therefore, is the real -nature of the affection, and the symptoms are of consequence only as -they are indications of the existence of that affection. Symptoms are -not _the_ thing in which observation should terminate, but signs of the -thing without the knowledge of which, in every individual case that may -come under his care, the practitioner ought never to be at rest, and to -the discovery of which they serve as guides. - -It is then in the organs alone that we can find a perfect uniformity: -but their condition is as fixed and invariable as the return of day and -night. All the operations of nature are uniform. When, in any case, we -have succeeded in discovering what the operation is, we see that it -never varies. The same causes, under the same circumstances, always -produce the same effects. The causes of fever, whatever they be, under -the same circumstances, always produce the same conditions of the -organs. In proportion as we ascertain with clearness and precision what -these conditions are, we observe that they recur in all cases with the -most undeviating regularity, and when our knowledge of them shall have -become complete, it is probable that we shall find that they are as -constant in their return as that of the sun after its setting, and that -they no more change in their nature or progress than the sun deviates -from its path. - -The all important thing for the practitioner to know, then, it can never -be too often repeated, is what these conditions are. It is greatly to be -regretted that we do not know with precision the condition of the most -important organs in the intense fevers of other climates. The condition -of the most important organs in the various types of fever as they occur -in our own country, we do now know with precision, and the main object -of the present work is to give an account of these conditions, and of -the signs which denote them. - -It is found that particular conditions of particular sets of organs give -rise to certain groups of symptoms: these groups of symptoms have been -supposed to form different genera and species, and have received -specific names. Were the nomenclature of these genera and species of -fever perfect, the name would in each case be expressive of the -condition of the organs upon which the assemblage of symptoms it denotes -depends, and perhaps in some greatly advanced state of our science, when -these conditions have been perfectly ascertained and have become -perfectly familiar, an approximation to this desirable classification -and naming may be attempted with success. The state of our knowledge, -however, enables no one to undertake the task at present, and in the -mean time the slightest glance at the divisions which have been -attempted of this class of diseases, is but too sufficient to shew the -total absence of that kind of information, which, if there be any truth -in the preceding observations, it is alone of value to possess. - -Thus febrile diseases are commonly divided into idiopathic and -symptomatic—a division which is liable to the fundamental objection that -the diseases included under the second section are not fevers but -inflammations. There are no fevers but idiopathic fevers. It has been -shewn that fever differs from inflammation both in the individual -phenomena forming the train that constitutes the disease, and in the -order in which the several phenomena succeed each other. There are, it -is true, individual phenomena common to both; but since the series as -well as the order in which the several phenomena stand in the series are -different, to call both by the same name can only produce confusion and -misconception. - -Of true or idiopathic fevers two great divisions are made; one -comprehending intermittent and the other continued fevers: a division -founded on the occurrence of the trains of the phenomena in an -interrupted or in an uninterrupted series. Intermittent fever is further -divided into intermittent and remittent, the interruption in the series -being said to be complete in the one and incomplete in the other. In -continued fever, on the other hand, the trains of phenomena are supposed -to proceed in a perfectly uninterrupted series, whence the name -continued. The single fact suggested to the mind of the practitioner by -this classification is in the highest degree trivial. - -Of the particular groups of symptoms which have been brought together -under the great class, continued fever, it is impossible to discover any -kind of principle which has led to the formation of the distinct -assemblages that have been made, or to their nomenclature when thus -collected. Synocha, typhus, synochus, are the three genera which modern -nosology, in the power and pride of its strength, has put forth as at -once distinctive and exhaustive of this class of disease. The aggregate -phenomena constituting synocha, form just that particular series which -is common to some forms of fever and to all acute inflammations: namely, -“Calor plurimum auctus, pulsus frequens, validus, et durus, urina rubra, -sensorii functiones parum turbatæ.” The train of symptoms thus brought -together do not alone form any variety of fever. The second group of -symptoms forming typhus—“morbus contagiosus, calor parum auctus, pulsus -parvus, debilis, plerumque frequens, urina parum mutata, sensorii -functiones plurimum turbatæ, vires multum imminutæ:” and the third, -forming synochus,—“morbus contagiosus, febris ex synocha et typho -composita; initio synocha, progressu, et versus finem, typhus,” -independently of their being brought together and named according to no -known or even assigned principle, are liable to the further and the -fatal objection, that they do not even occur in nature. - -Even Dr. Wilson Philip, who labours to reconcile to nature and to -improve in accuracy and comprehensiveness these classifications and -definitions, expressly admits that a simple synocha or typhus is a fever -which we rarely, if ever meet with: for that however high the -inflammatory symptoms at an early period may be, those of typhus always, -at least in this country, sooner or later supervene; and that however -well marked the symptoms of typhus may be in the progress of fever, in -almost every case, the first symptoms are more or less inflammatory; -that the fevers mentioned by authors, under the names synochus and -typhus, are in fact no other than varieties of the synochus; that when -the symptoms of debility predominate, the fever has been termed typhus; -that when, on the contrary, the inflammatory symptoms are most -remarkable, and present through the greater part of the disease, it has -been called synocha.[19] - -Again, while according to this received arrangement a train of symptoms, -every one of which is found in acute inflammation, is made a distinct -genus of fever, numerous diseases, each forming an exquisite specimen of -fever, are totally excluded from the order, and placed at a considerable -distance in the nosology. Because scarlatina is a fever attended with a -peculiar eruption on the skin; because rubeola is a fever attended with -an eruption on the skin also peculiar; because variola is a fever -attended with another peculiar eruption, and urticaria with another, -these diseases are not made varieties of fever, but, designated by the -term exanthemata, are formed into a separate order: while, on the other -hand, fevers attended with petechiæ, with papulæ, with aphthæ, with -vesicles, are accounted fevers, and accordingly are termed petechial, -miliary, aphthous, erysipelatous, vesicular fevers; whence synochus -petechialis, synochus miliaris, synochus aphthosus, &c. - -Without doubt is right that these varieties of disease should be -discriminated and named; but this mode of classifying them has a -necessary tendency to divert the mind from dwelling on those essential -circumstances which make all of them mere varieties of one great -disease; and to fix it upon those comparatively unimportant though -obvious circumstances which simply modify the malady without in the -least affecting its identity. - -It has already been stated that the grouping of the symptoms, or, in -other words, the formation of the species of fever cannot be -scientifically or usefully accomplished until we have arrived at a -perfect knowledge of the condition of the organs upon which the trains -depend; and that our knowledge of these conditions is so imperfect, -especially with regard to many of the species, that this classification -cannot possibly be made at present. It is not even known whether the -condition of the organs in intermittent be the same as it is in -continued fever. The mere periodicity in the recurrence of the febrile -paroxysms by which this class of disease is at present characterised, is -an exceedingly unsatisfactory principle of distinction, unless we at the -same time knew the state of the system upon which that periodicity -depends. The alternate transition of intermittent into remittent and -continued, and of continued and remittent into intermittent fever, of -which the history of epidemics affords so many striking examples, and of -which Sydenham, Pringle, and all the older writers have recorded so many -interesting accounts, as events which they themselves daily witnessed, -seems to shew that there can be nothing amounting to a generic -difference between these several diseases. The type, as far as we have -the means of judging, appears to be determined entirely by the intensity -of the disease. An intermittent increasing in violence and malignity -changes into a remittent or a continued fever, and a continued or -remittent, diminishing in violence and malignity, often assumes the form -of intermittent. Speaking of the epidemic constitution of the years from -1661 to 1664, Sydenham states that, in the year 1661, the autumnal -intermittents which had prevailed for some years broke forth afresh, -especially obstinate tertians; that increasing daily until August, at -which time they raged fiercely and became extremely mortal, in many -places seizing whole families, and destroying great numbers, decreased -by degrees until October; and, disappearing at the approach of Winter, -were succeeded by a continued fever, which differed from the Autumnal -intermittent only in being continued, while the former returned in -paroxysms: that both invaded almost alike; that those who violently -laboured of either vomited; that in both the skin was dry; the tongue -black, the thirst urgent, and that, at their declination, the morbific -matter in both was readily exterminated by sweats. “It was manifest,” he -adds, “that this fever belonged to the family of intermittents, because -it rarely appeared in the Spring: it was a sort of compendium of the -intermittents; and, on the contrary, every fit of the intermittent -seemed to be a compendium of this fever; so that the difference chiefly -consists in this, namely, that the continued fever once begun, perfects -its effervescence with the same degree of heat; but the intermittents -perform their business by parts, and at several times.”[20] - -In like manner, Pringle, among many other examples of the fact, which, -indeed, he states to be of constant occurrence, gives an account of an -epidemic that prevailed in the army of the Netherlands, and which in its -worst form assumed the appearance of an ardent fever. He states that the -men were suddenly seized with violent head-ache, and frequently with -delirium: that, if sensible, they complained also of grievous pain in -the back and loins; intense thirst; burning heat; great sickness and -oppression at the stomach, sometimes with vomiting of bile, sometimes -with evacuation of bile by stool, accompanied with tenesmus and pains in -the back: that this fever generally remitted from the beginning upon -bleeding and purging: that if these precautions were omitted, the fever -went on in almost a continued form, and that its tendency to -putrefaction was so great, that while many had spots and blotches, some -had mortifications, which were almost always fatal: that this fever -continued to rage throughout August; that it began to abate with the -heat in the middle of September; that from this period its violence -diminished, and the number attacked gradually decreased; and that now -“the remissions became more free, so that insensibly, with the coolness -of the weather, this raging fever dwindled into a regular intermittent, -and entirely ceased upon the approach of Winter.”[21] - -What that condition of the system is, which, in forms of fever that are -thus mutually convertible, causes one to persist in an uninterrupted -series, another to remit, and another, after disappearing for a time, to -recur in distinct and regular paroxysms, is wholly unknown. Sydenham, -indeed, cuts the knot and removes the difficulty at once. Speaking of -the return of the fits in intermittent, he replies to the inquirer into -their cause,—“I would fain know why a horse comes to his growth in seven -years and a man at twenty-one; or why some plants flower in May and some -in June. I am persuaded that the progress of nature is as certain and -regular in this case as in any other, and that the matter of a quartan -and tertian ague is subject to Nature’s laws and governed by them, as -well as any other bodies whatever.” The regularity of nature in the -production of disease, no less than in the maintenance of health, cannot -be doubted: but the point in question is not clearly one of those -ultimate facts, into the reason of which it is wholly vain for the human -mind to inquire. - -Hitherto, however, no one appears to have hazarded even a conjecture as -to the cause of this striking difference between these two forms of -disease; and pathology, as has just been observed, has afforded no clear -light to enable us to determine whether the febrile circle of organs is -similarly affected in both. Examinations of fatal cases have been made; -but none on that large scale and with that accuracy which alone can -render them of any value. I have endeavoured to ascertain the morbid -appearances in the spinal cord and the brain, and in the mucous membrane -of the respiratory and digestive apparatus, from those who have been -long engaged in extensive practice in districts in which ague prevails: -but I have been able to obtain no satisfactory answer, excepting that -intermittent does not kill! Greatly as the severity of intermittent is -without doubt diminished, in the present age, yet we cannot receive such -an account without blessing the bark of the seventeenth and the skill of -the nineteenth century! - -A similar want of knowledge exists relative to the condition of the -organs in most of the Exanthemata. To supply that want in regard to the -various forms of fever that prevail in this metropolis, which, there is -good reason to believe, differ but little from the types that appear in -other parts of the country, is one of the chief objects for which this -work is undertaken. - -It is not the object of the present volume to treat of intermittent or -of remittent fever, but only of that class which, in ordinary medical -language, is termed continued. Of the apparently endless varieties of -disease comprehended under the term continued fever, it is found that -certain forms occur in this country with great constancy. Each -particular assemblage of symptoms occurring in these different forms is -said, in ordinary language, to constitute a type or species. Each type -or species depends on a particular condition of the circle of organs -that has been described. The causes that concur to produce this -particular condition of this series of organs, will be treated of in -their proper place. But these assemblages of symptoms never occur -without being accompanied by these particular conditions of the organs; -and these conditions of the organs are never found without having been -connected with these assemblages of symptoms. In all the forms of fever -hitherto observed this condition of the organs is found to be absolutely -the same: it never differs in any thing but intensity; of this the -evidence is complete and irresistible: the direct and legitimate -inference is, that all these different forms of fever differ in nothing -excepting in the intensity of the affection. Were the terms genera, -species, variety, merely used as short expressions to denote this fact; -to point out and to name different degrees of the same malady, degrees -which it is important to discriminate, because they require material -modifications of treatment, a clear and precise meaning would be affixed -to these words: in nature there would be foundation for the distinction -they imply: in practice there might be convenience in their use. But the -nosological distinctions at present inseparably associated with these -terms, appear to me to be either so vague and unmeaning, or when they -cease to be indistinct, to excite notions so false and pernicious, that -I think it right to abandon the use of them altogether. The more we -investigate the subject, the more satisfied we shall become that -continued fever is one disease and only one, however varied, or even -opposite, the aspect it may present; but that it differs in intensity in -every different case, and that this and this alone is the cause of the -different forms it assumes. Many of these diversities it would be -frivolous to distinguish: some of them, on the other hand, it is of the -highest importance to discriminate. For all useful and practical -purposes, it is necessary only to arrange the different assemblages of -symptoms into two great classes, the one comprehending the mild and the -other the severe forms of the disease. All the forms that continued -fever can assume, and all the individual cases that can occur under -either, must be mild or severe, and, therefore, must readily find its -place under one or other of these divisions. The only real difference in -the disease being a difference in degree, it is proper that the -principle of the division, by which the varieties it presents are -classified, should be founded on this, the only true distinction of -which it admits. - -It is difficult to frame, and still more difficult to bring into use, -new terms; and there is nearly equal inconvenience in using old terms in -a new sense: but if the new meaning affixed to an old term be clearly -intimated and rigidly adhered to, it is, perhaps, upon the whole, -productive of less evil to adopt the old, thus determining and limiting -the signification, than to propose a nomenclature entirely novel. For -this reason, and only for this reason, I propose to adopt two words, -borrowed from the nosology of Cullen, and in common use. These words are -here employed merely to express differences of degree relative to one -and the same disease. The mild degree may be denoted by the term -synochus: throughout this work, this term will be used to express the -milder form of fever; that is, its ordinary or common form, or that -which it is found most frequently to present in this metropolis, and, I -may add, in this country. The severer form, on the other hand, may be -designated by the term typhus. Each will be found to present a distinct -assemblage of symptoms; each will be found to depend upon a particular -condition of certain organs; each will be found to require a peculiar -treatment. - -For the purpose of distinguishing further important differences, that -is, differences which bear an important relation to practice, it will be -convenient to divide each of these two great classes into two minor -sections. Thus, synochus may be divided into synochus mitior and -synochus gravior; and typhus into typhus mitior and typhus gravior. This -will afford convenient and ample means of throwing into distinct groups -all the varieties of fever that occur in this country, which it can be -of any practical importance to distinguish. - -This mode of viewing fever as one great and extensive malady never -differing in nature, but in every two cases differing in intensity, and -giving rise by these differences in intensity to various forms of -disease, thus affords a principle of arrangement applicable to all those -various forms, which, while it is at once simple and comprehensive, is -at the same time in the highest degree practical. It directly leads the -mind to the observation of the real, the important differences that -exist or that may arise; those differences which must influence and -guide the treatment, if it be not altogether blind, and in the worst -sense of the term empirical. This principle might easily be extended, -and I think with advantage, so as to comprehend the exanthemata, and all -the forms of fever which have hitherto been known to exist, or which can -arise. Scarlet fever, for example, is continued fever attended with a -peculiar eruption upon the skin: at one time it occurs in a mild, at -another in an exceedingly severe form: the assemblage of symptoms in the -first are precisely those which it is intended to comprehend under the -term synochus: the assemblage of symptoms in the second are those which -are designated by the term typhus: thus scarlet fever exhibits at one -time the synochoid, and at another the typhoid type; the first being -what is commonly termed scarlatina benigna, the second scarlatina -maligna; and each type is capable of existing in two degrees of -severity, one of which may be conveniently distinguished by the term -mitior, and the other by that of gravior. - -In like manner small-pox is a fever attended with a peculiar eruption -upon the skin, which eruption modifies the disease in a very remarkable -manner, and gives it a history and progress peculiarly its own; but it -is as much a genuine fever as typhus, and ought no more to be taken out -of this class on account of the eruption upon the skin, than scarlatina, -which likewise modifies, in a very considerable degree, the whole train -of febrile symptoms, and is attended with a peculiar condition of some -exceedingly important internal organs. Small-pox, like all the diseases -of this class, occurs in two widely different forms; the one mild, the -other intensely severe: in the first the concourse of symptoms are -precisely those of the synochoid, in the second of the typhoid type.[22] -And the same I am satisfied is true of the plague, of the yellow fever, -and of all the different forms which this great disease, of many aspects -and names, but of one uniform and unchanging nature, presents. - -These distinctions and names then, though it were easy to raise -objections against them, may serve for all useful and practical -purposes. They tend to impress upon the mind the great fact that all the -modifications of the disease are still only modifications, and do not -affect the identity of its nature; and they afford convenient sections -under which to detail the symptoms that attend and discriminate the -important diversities in degree as they present themselves in practice; -to exhibit the condition of the organs upon which those diversities -depend, and to explain the treatment which experience teaches to be -appropriate to these several states. - -The present work will be restricted to the consideration of the -modifications of fever which we have proposed to designate by the terms -synochus, typhus, and scarlatina. - - - - - CHAPTER III. - - _Of Synochus: Division into Synochus Mitior and Gravior. Succession of - Phenomena in Synochus Mitior. Indications afforded of Disease in the - Nervous, Circulating, and Excreting Systems. Progress of Disease - consisting in progressive Increase in the Derangement of these - Functions. Phenomena of Recovery. On what the Transition of Synochus - Mitior into Synochus Gravior depends. Classification according to - the different Organs in which the several Affections have their - Seat. Hence Synochus Gravior with Cerebral Affection—Subacute—Acute: - with Thoracic Affection: with Abdominal Affection: with Mixed - Affection._ - - -It has been stated that, for the purpose of forming into distinct groups -certain assemblages of symptoms which it is important to distinguish, -because they bear an important relation to practice, it will be -convenient to divide the synochus, the term by which we propose to -designate the common fever of this country, as it presents itself in its -mild aspect, into two sections, namely, synochus mitior and synochus -gravior. For reasons already assigned, it will likewise be important, in -treating of these different modifications of fever, to notice in each -both the phenomena which form the assemblage, and the order in which -they succeed each other. - -On careful examination it will be found that the first symptom which -denotes the commencement of the ordinary fever of this country, in its -mildest form (synochus mitior), is a loss of mental energy. This is by -no means the first symptom which attracts attention: it is commonly -overlooked for some time, and excites little notice until it has become -distressing. Patients in general are incapable of analyzing their -sensations or of determining the order of their succession; but if -medical men, who are but too subject to be attacked with this disease, -will take the trouble to reflect on the order of events as they occurred -to themselves, they will probably be satisfied, after the most attentive -consideration, that the first indication of disease they felt was a want -of power to conduct their ordinary mental operations with ease and -vigour. Such at least, perhaps I may be permitted to mention, was the -fact in my own case; for, having suffered a severe attack of fever, I -have a distinct and vivid recollection of the dulness, confusion, and -want of mental energy which I experienced for a considerable time before -I was conscious of any corporeal debility. - -This affection of the mind consists particularly in indistinctness and -consequent confusion in the trains of ideas; in inability to attend to -their relations; and, as a necessary result, in the loss of power to -think clearly. The individual feels that he is not in a state to form a -sound judgment on any subject upon which he may be called to decide. - -Closely connected with this mental weakness is the loss of energy in the -muscles of voluntary motion. Lassitude is the result. The patient cannot -move with his usual vigour, nor even sit without the feeling of -weariness. The debility thus seizing upon both body and mind, sometimes -occurs in each so nearly simultaneously that, it must be owned, it is -difficult to determine in which it appears first. - -The next symptom in the order of succession is still more -characteristic: it consists in an uneasy sensation which is quite -peculiar to this state of the system. No description can convey any idea -of it to one who has not felt it; and to him who has felt it the word -fever recalls this uneasy feeling so instantaneously and vividly that I -apprehend most unprofessional persons conceive it is this very feeling -that constitutes the essence of the disease. It is much more distressing -than pain: the mere restlessness which accompanies and which forms so -large a part of it, any one would gladly exchange for intense pain. In -all diseases it is this which makes the sufferer on his midnight pillow -exclaim, “oh! that it were morning!” and in the day, “would that it were -night!” Though it is so frequent in its occurrence, and so peculiar in -its nature, yet I am not aware that it has received any distinct name: -it may be called, until a better is suggested, febrile uneasiness. - -It is seldom that these symptoms exist long before positive pain is -felt. With very few exceptions pain is first felt in the back or loins -and then in the limbs. It is rare that this symptom is absent in the -commencement of this form of fever, and it often occasions more -uneasiness to the patient than any thing else during the first stage of -the disease. - -Already a remarkable change is commonly visible in the countenance. Its -expression is that of dejection: it is often strikingly similar to that -of a very weak person suffering from fatigue. The colour of the face is -pallid, and the features are somewhat shrunk; but its general aspect is -so peculiar and characteristic that an experienced eye can distinguish -the disease even at this early period, and without asking a single -question. - -The skin partakes in a remarkable degree of the debility which so early -shows itself in the muscles of locomotion. This is indicated in a -striking manner by its increased sensitiveness to the physical agents by -which it is surrounded, and by its inability to resist their influence. -Ordinary degrees of temperature produce a sensation of cold which is -sometimes intolerable: chilliness is felt even in a heated room, or in a -warm bed: hence the sensation of cold, sometimes increasing to -shivering, which has been considered one of the most constant signs of -fever. But this feeling of chilliness by no means depends on external -temperature: it is increased by cold, but it exists in spite of an -elevated temperature: it arises from an internal cause, and is not to be -counteracted by external heat. - -While the patient experiences the sensation of cold, there is no -diminution of the quantity of caloric in the system. The thermometer -applied to any part of the body commonly rises as high as in the state -of health, and the skin, touched by the hand of another person, -communicates not the feeling of cold, but often, on the contrary, that -of preternatural heat. There is no positive abstraction of caloric from -the body nor any failure in the process, whatever it be, by which animal -heat is generated; there is only altered sensation, in consequence of -derangement in the function of the skin. In this form of fever, the -chilliness in many cases never amounts to shivering; in others, there is -an attack of well-marked rigor, and in others, again, there is either no -feeling of cold, or it is so slight that it escapes observation. - -The symptoms now enumerated are all clearly referrible to derangement of -the function of the spinal cord and brain. There is as yet no affection -of any other organ obviously or, at least, much developed. The -circulating system, it is true, is just beginning to be affected. The -pulse is no longer perfectly natural. It is more languid than in the -state of health; sometimes it is also quicker: at other times it is -slower; now and then it is scarcely changed in frequency, but its action -is invariably weaker than in its sound state. - -At the same time the respiration is affected in a corresponding degree: -it is shorter and quicker than natural; the chest does not expand so -freely, and compensation seems to be sought in an additional number of -respirations. Oftentimes neither the pulse nor the respiration appears -to be much altered, if the patient remain perfectly still; but if he -rise and walk across the room, the pulse instantly becomes rapid, and -the respiration is quickened almost to panting. - -The transition from the affection of the nervous and sensorial to that -of the circulating and the respiratory systems is thus clear and -striking. Physiology teaches us how closely these systems are connected, -and how mutually they are dependent one upon the other, the closest -observers and the ablest experimentalists candidly confessing that they -are scarcely able to determine which is the least dependent, or the -action of which is the least necessary to the others performance of its -functions. The nervous system being first deranged, it is thus consonant -to what we know of the healthy function of the animal economy, that the -circulating and the respiratory systems should be the next to suffer. - -How long the nervous system may continue thus deranged, before any other -organs are involved, excepting the circulating and the respiratory, to -the extent just stated, is uncertain. There can be no doubt that in this -mild form of fever, the range of the duration of this isolated state of -disorder, if we may so express it, is from a few hours to several days. -The rapidity or the slowness with which other systems of organs become -involved seems to depend very much upon the acuteness of the attack. In -general, the more acute the fever, the more rapidly the individual -phenomena succeed each other, and the entire series becomes complete. -But this is not, and it is important to bear in mind that it is not -invariably the case: for experience teaches us that the severity and -danger of the disease are not diminished by the slowness of its -approach; and that cases occur, which are slow in forming, and which do -not for awhile excite alarm, that ultimately become truly formidable. - -It has been stated that the circulation languishes with the diminished -energy in the sensorial faculties, and the loss of power in the muscles -of locomotion. After awhile, the pulse which was feebler than natural -becomes more full, more strong, and generally more quick than in a sound -state; and now the skin, which was cold, becomes preternaturally hot. -The previous cold consisted, for the most part, of altered sensation, -there being little or no loss of caloric: but the feeling of heat, on -the contrary, is the result of an actual increase of temperature; for -the heat in the interior of the body, as well as on the surface, rises -in some cases several degrees, as is ascertained by the thermometer; the -range of increase being from the natural standard 98° to 105°, beyond -which it is seldom found to augment in this form of fever. The heat is -at first not uniform over the entire surface of the body: it often -happens that some parts are cold while others are burning hot. The heat -is oftentimes particularly intense over the forehead, or over the back -part of the head, or over the whole scalp, while the cheeks are commonly -flushed. All these symptoms denote a morbid condition in the action of -the heart and arteries. Since the generation of animal heat is so -intimately connected with the circulating and the respiratory functions, -it is probable that the increase of temperature is the result of some -morbid action of the capillary vessels belonging to these systems. What -the disordered action of these vessels is, which produces increase of -temperature, we do not know, because we do not know what their natural -action is which produces the temperature of health: but the object of -scientific observation is in some degree accomplished, when it is -ascertained that one condition of these functions is invariably -connected with a morbidly-diminished temperature; another with a -morbidly-augmented temperature; and another with the temperature of -health. - -Immediately the circulation is thus excited, the functions of secretion -and excretion become deranged. The mouth is now dry and parched; the -tongue begins to be covered with fur; thirst comes on; the secretion of -the liver, probably also of the pancreas, and certainly of the mucous -membrane lining the whole alimentary canal, is vitiated, as is proved by -the unnatural quantity, colour, and fetor of the evacuations; the urine -likewise is altered in appearance, and the skin is not more remarkable -for the sense of heat, than for that of dryness and harshness which it -communicates to the touch. With the excitement of the pulse and the -increase of the heat, the pain in the back and limbs and the general -febrile uneasiness are much augmented. - -At this period, then, the fever is fully formed; the series of morbid -phenomena is complete: any thing more that happens is referrible to -degree and to duration, and must be the result of one or other of these -circumstances, or of their combined operation. And we now see that the -organs affected, constitute precisely that system of organs which has -been described as forming the febrile circle: that the symptoms which -denote the fever are just the symptoms which indicate a derangement in -the several functions performed by these organs; and that the order in -which they become successively involved is exactly that which has been -assigned. - -As soon as the preternatural heat comes on, pain begins to be felt in -the head. Dr. Clutterbuck, in describing the general character of the -ordinary fever of London states[23] that “the _first_ symptom almost -invariably complained of is more or less of uneasiness of the head.” If -by uneasiness he meant pain, there is, if there be any truth in the -preceding observations, a long train of symptoms to intervene before -this symptom occurs. That it does ultimately occur is certain: but -commonly its place in the series is much later than is here assigned: it -is disordered function of the brain, indicated by loss of mental energy, -that appears to form the first symptom in this morbid train. - -The pain, when it does come, is sometimes slight at first, and -occasionally it remains slight throughout the disease; at other times it -is pretty severe. Cases sometimes occur, in which, instead of pain, -there is only a sense of giddiness, and now and then the uneasy feeling -is described as that of lightness: or, on the contrary, as that of -heaviness or weight. But whether the feeling be pain, and that pain be -slight or severe, or whether it be giddiness, or lightness, or -heaviness, it indicates a similar condition of the organ, and requires a -similar treatment. - -With the accession of pain of the head there is a manifest increase in -the disturbance of the sensorial functions. The inability to think, to -compare, to reason, to judge, great as it was at the commencement, is -now much greater. Instead of being more dull, there are certain states -of the mind which now become more acute and vigilant even than in -health. Sensation itself, at this period, is invariably acuter than -natural, as is indicated in all the organs of sense. The eye cannot well -bear the light: there are few cases in which the full glare of day does -not excite uneasiness, while in many the ordinary light of a room cannot -be borne: in these cases the opening between the eye-lids is frequently -observed to be contracted, as if from an involuntary effort to exclude a -portion of that stimulus which in health excites no inconvenience, and -this state of the eye-lids assists in giving to the eye its dull and -heavy expression, so characteristic of fever. The increase of -sensibility in the organ of hearing is equally striking. Sounds which -were not noticed during health become acutely and even distressingly -sensible, while accustomed noises, such as that of a crowded street, are -always painful and often intolerable. The skin, considered as an organ -of touch, is in a like morbid state. An impression barely sufficient in -the state of health to produce sensation excites the feeling of -tenderness, and alternations of temperature, which in ordinary states -are scarcely perceptible, are painful. The senses of taste and smell, on -the contrary, are nearly obliterated, owing to the altered condition of -the membranes upon which the sensitive nerves are distributed. - -From the earliest attack of the disease the sleep is disturbed and -unrefreshing; now scarcely any is obtained; the febrile uneasiness will -not allow of repose; the patient cannot remain in any position long, -incessantly shifting his place, never eluding his pain. At this stage -the sense of uneasiness in the limbs, oftentimes the severity of the -pain over the whole body, is peculiarly distressing. - -With this progressive increase in the affection of the spinal cord and -the brain, the derangement in the circulating system is proportionally -augmented. The pulse is invariably altered, both in frequency and -character. Generally it rises to 90, sometimes to 100; but in this form -of fever it seldom exceeds this number; and occasionally it never rises -above 80. The stroke of the pulse is usually stronger and fuller than -natural, though it commonly retains its softness, and does not impress -the finger with that sensation of sharpness which is characteristic of -ordinary inflammation. Occasionally, however, a degree of sharpness may -be perceived in it, and it is not easily compressed. - -The thin white fur which already had begun to appear on the tongue -progressively increases in extent and thickness. The colour of the fur -usually changes, as the disease advances, from a dirty-white to an -ash-colour; but in this form of the disease the tongue always remains -moist, and never becomes brown. This state of the tongue is almost -always accompanied with thirst, but it is never urgent. There is always -a loss of appetite. The bowels are generally constipated, and the -secretions of the whole alimentary canal are vitiated. - -Thus we perceive that the progress of the disease consists in increasing -mental and corporeal weakness; increasing pain in the back, loins, and -limbs; increasing heat of skin, acceleration of pulse, and general -febrile uneasiness, together with the occurrence of pain in the head, -and progressive derangement in the functions of secretion and excretion. - -The fever in this mild form is now at its height. It remains stationary, -or at least with very little change for an indefinite period, generally -for some days. The cerebral affection does not increase beyond what has -been described: there are no greater indications of disease in the -respiratory organs, and the mucous membrane of the stomach and -intestines does not denote any progressive advancement in disease. - -One of the most remarkable circumstances connected with the ordinary -fever of this country, in the present day, is the uninterrupted and -perfect continuity of its phenomena. As long as the febrile state -remains, nothing deserving the name of a remission is in general to be -perceived. Occasionally, it is true, a slight increase in the symptoms -may be observed towards evening, especially in the heat of the skin; but -even this is not common, and it is scarcely ever great enough to deserve -the distinction of being called an exacerbation. Much less is there any -regularity in the accession and decline of such excitement. In the great -majority of cases not the slightest approach to an exacerbation and a -remission can be distinguished from the commencement to the termination -of the disease. Yet the older writers speak of these events as if they -were as palpable as the paroxysms of intermittent and as constant as the -return of morning and evening. There cannot therefore be a doubt that -the character of the ordinary fever of this metropolis is greatly -changed from the character of that which prevailed two centuries ago; -and the circumstances which have contributed to produce this change will -be considered hereafter. - -In the great majority of patients in whom the symptoms continue thus -moderate, the disease disappears about the end of the second week; that -is, they are convalescent at that period; but it usually requires eight -or ten days longer before they have regained sufficient strength to -leave the hospital. Sometimes, although there is no greater severity in -the symptoms, the disease is more protracted, and the recovery is not -complete until the fourth or even the fifth week. Beyond this period it -is very rare for this form of the disease to be protracted. - -Almost all who are attacked with the malady in this, its mildest form, -recover: but now and then it happens that the symptoms go on with this -degree of moderation until about the end of the second week. Then at the -period when it is usual for convalescence to take place there is no -perceptible improvement; the patients seem even to grow weaker; they lie -more prostrate in the bed, and they are soon incapable of moving; still -they complain of no pain or uneasiness, and it is not easy to detect any -trace of disease in any organ; yet it is but too evident that they grow -worse, and ultimately they sink exhausted. In these cases, on -examination after death, it is commonly found that disease has been -preying on some vital organs, although its presence could not be -detected during life; and this termination of the milder type of fever -rarely happens, excepting in aged persons, whose constitutions have been -enfeebled by previous diseases, or worn out by the various causes which -depress and exhaust the powers of life. - -With an occasional exception of this kind the disease in this form -always terminates favourably; and the first indication of returning -health is remarkably uniform: it is almost always marked by longer and -more tranquil sleep. Instead of that restlessness which is so -characteristic of fever, and which forms the most distressing part of -it, the patient is observed to lie more still, and on waking for the -first time from an undisturbed slumber, he often spontaneously says that -he feels better. Better he may well feel, for his febrile uneasiness is -gone; the load that oppressed him is shaken off; he is a new being. The -pain of the head and of the limbs is so much diminished that often he -cannot help expressing his thankfulness at the change. The countenance -becomes more animated; its natural expression returns; the tongue begins -to clean; and after this state of the system has continued for two or -three days, the appetite returns. While these favourable changes are -going on, the pulse usually sinks about ten beats below its highest -point at the height of the fever; it is not uncommon, however, for it to -remain quick during the entire period of convalescence; and for some -considerable time it is easily excited on any movement of the body, or -any emotion of mind. In some cases, on the contrary, when the attack has -been very mild, it sinks considerably below the natural standard, and is -intermittent, a sign which I have uniformly observed to be attended with -a sure and steady convalescence. In the mean time the appetite becomes -keener than natural; the strength gradually improves; and in a short -time the patient is restored to his usual health and vigour. - -What the condition of the brain and of the organs correlatively affected -is, in these the mildest cases, we do not positively know, because we -have no opportunity of inspecting them, their favourable termination -being nearly without exception. But the more all the phenomena are -considered in their entire series, in the order of their succession, in -the uniformity, nay, even in the exclusiveness of their seat, as well as -in the unchanging sameness of their effects, the more clear the evidence -will appear of the soundness of the induction, that the condition of all -the organs in all the types of fever is the same in nature, although -there be no two cases of any type perfectly the same either in the -degree of the affection or in the stage of the morbid process which it -excites. If this induction be really just, we must conceive that, in the -synochus mitior, while the morbid affection of the organs is slight, the -diseased process which it sets up in them stops before it produces any -change in their structure. - -However this may be, and to leave for the present all matter of -inference, and to keep strictly to the matter of fact, we do positively -know that the mild forms of fever become severe in consequence of the -supervention of inflammation in certain organs. Perfectly unknown as the -nature of the primitive febrile affection at present is, yet that in the -progress of the disease it does ultimately pass into inflammation is a -fact, the evidence of which it is impossible to resist; although the -same observation which teaches us this most important truth, teaches us -also that the inflammatory action is always considerably modified by the -febrile state. How it is so modified, and to what extent, we shall -consider hereafter. I have spent much consideration and some labour in -the effort to combine the symptoms which attend these severer forms of -the disease with the ascertained conditions of the organs upon which -such symptoms depend. But since it is of paramount importance that the -events which actually take place should be known, and that the order in -which they succeed each other should be stated with clearness and -exactness; and since I have been able by no method that I could think of -to combine the pathology with the history without breaking too much the -continuity of the latter, I have been under the necessity of separating -these two most intimately connected subjects, and of treating of them -under distinct sections. In giving the history of the events, I have -detailed them strictly, as far as I am acquainted with them, in the -order in which they occur: and I have endeavoured to arrange the cases -that constitute the pathology in such a manner, that they shall closely -correspond to these events, and clearly illustrate the order of their -succession. If I have succeeded according to my wish, the reader in -studying the cases will be reminded, as he proceeds, of the successive -stages of the history, and if he again revert to the history, after -having studied the pathology, he will be reminded of the morbid -appearances in the organs which are there described. To afford a clear -perception of the connexion between the successive events, as indicated -by the symptoms during life, and the progressive changes of structure in -various organs, as demonstrated by inspection after death; and thus to -establish a strong and indissoluble association in the mind between the -morbid condition and its sign, are the objects at which I have aimed. If -I have succeeded, I shall have accomplished one of the chief objects of -my undertaking. - -The transition of a mild case of fever into a severe one, or the -progress of a case severe from the commencement, is accompanied with, or -depends upon, as will abundantly appear hereafter, certain changes that -take place in certain organs. These changes occur with great regularity; -the organs in which they take place are always the same; and the -symptoms by which they are denoted are uniform. The organs affected are -the spinal cord, the brain, the membranes of both, the mucous membrane -of the lungs, and the mucous membrane of the intestines. For the reason -just assigned the nature of these affections cannot be described in this -place, but must be postponed to that part of the work which treats of -the pathology. Since however the symptoms are nothing but the signs of -these conditions, and the history of the succession of the former, is -nothing but an account of the indications of the successive changes that -take place in the latter, all the important symptoms must necessarily -have their seat in the head, in the thorax, and in the abdomen. Mixed -and blended as they appear in the different cases which the practitioner -is called upon to treat, nothing can appear more complex or more -variable: when analyzed, nothing is more remarkable than their -simplicity and their uniformity. In order to perform that analysis with -exactness, and to render it really instructive, these symptoms must be -contemplated as they arise in the affected organs. These organs, as we -have seen, are the cerebral, the thoracic, and the abdominal; the -symptoms therefore divide themselves into cerebral, thoracic, and -abdominal: there is, indeed, a fourth order, in which all the organs -appear to be equally involved; in which the general affection is -intense, and which therefore may be appropriately termed mixed. We shall -see that cases of this kind constitute by far the most dangerous form of -the disease. - - - I. SYNOCHUS GRAVIOR WITH CEREBRAL AFFECTION, - -occurs under two degrees of intensity: when the cerebral affection is -moderate, it may be termed subacute; when great, acute. - -1. _Synochus with Subacute Cerebral Affection_, may be attended for -several days with no symptom which has not been already enumerated in -the account of the mildest form of the disease. The accession is the -same as in synochus mitior: the progress up to a certain period is also -the same. But at the time when the pain of the head diminishes in the -latter, it increases in the former. Still the pain is often not severe. -He who looks for intense pain, and suspects no cerebral affection, -unless accompanied with this symptom, will be surprised by what will -appear to him the sudden occurrence of new symptoms, such as are -immediately to be stated, which will at length open his eyes to the -danger of the case, and excite his wonder, which it is not unfrequent to -hear expressed, that an affection hitherto so mild, should, without any -previous warning, become so formidable, and show but too manifestly that -it is beyond control, and will certainly proceed to a fatal termination. -The warning was given, but the sign was not understood. The descriptions -of disease are commonly taken from its most acute form; and it was long -the practice to derive them from this form alone, and the consequences -were truly fatal. Even with the best care that can be taken in drawing -up the history, these descriptions are exceedingly apt to become ideal, -and not real entities: to consist of a collection of all the -circumstances that exist in all cases, and not of that particular -combination only which is found in any one case: and thus to be not the -portrait of any individual, but a fancy picture bearing a general -resemblance to all individuals without being the true likeness of any. -The consequence is, that at the bed-side of the sick the original from -which the picture is supposed to be taken is not to be seen, and the -practitioner remains in doubt, if he do not fall into error. Error -serious and fatal many have fallen into, and, on this very account, -still continue to fall into, with regard to the existence of cerebral -disease in fever. Abundant evidence will be given in the pathology, that -it is not uncommon for the most unequivocal and extensive changes of -structure to take place in the brain and its membranes without severe -pain having ever been felt. Pain, however, though it be not great, is -almost always present. It is seldom that the pain extends over the whole -head; the patient generally points to some particular part where it is -peculiarly felt. In the majority of cases the seat of the pain is either -in the forehead, or at the temples, or over the eyes; but occasionally -it is in the occiput, and extends down the neck, and in these instances -it is often severe between the shoulders. - -Now and then no pain whatever is felt. Question the patient as much as -you please, and he will tell you that he never has felt any pain. In -this case giddiness is the substitute. Giddiness in the commencement, -and in the early stage of fever, is as certain a sign of cerebral -affection as pain. Striking illustrations of this are afforded by -several cases detailed in the pathology; by consulting which, the reader -will see that precisely the same morbid changes take place in the -structure of the brain, although nothing but giddiness be complained of, -as occur in those which are attended with the acutest pain. The -practitioner will therefore fall into a fatal error who is seduced into -security because pain is absent; and who neglects the remedies proper -for inflammation of the brain, because the patient complains only of -giddiness. If giddiness be combined with pain, or alternate with it, -which is not uncommon, the giddiness being slight if the pain be severe, -and the pain being slight if the giddiness be distressing, it indicates -a more severe affection than if either exist alone. - -2. In the majority of cases, as long as the pain continues, the heat of -the skin remains considerably above the natural standard. But often the -heat over the general surface of the body is not great. Commonly, -however, it is hotter than natural over the head, and it is hottest -wherever the seat of the pain be fixed: so that the contrast is often -striking between the temperature over the forehead or at the occiput, -and the heat of the body in general. - -3. The dull and heavy expression of the eye is greater than in the -milder form of fever. The conjunctiva generally becomes brighter and -more glistening than natural: though instead of this the vessels are -often more numerous and more turgid than usual, and give it the -appearance which is termed “muddled.” The eye at the same time is -commonly preternaturally sensible, and cannot bear a strong light, -although sometimes no complaint is made if the curtains of the bed be -withdrawn, or the window-blind be drawn up. - -4. There is usually a corresponding increase in the general sensibility; -and what is remarkable, this is quite as much indicated by the increased -sensibility to sound as to light. A loud noise is invariably distressing -to the patient, and a continuance of it greatly aggravates all the -symptoms. Exposure to a glare of light and a loud noise, would alone -rapidly change a slight into the severest cerebral affection. - -The expression of the countenance is now very peculiar: it cannot be -described, but the experienced eye can seldom fail to recognize it. It -is indicative of suffering without the strength to bear it: it is not -anxious; that expression does not come on until a later period. The face -is sometimes flushed, but it is often pallid, which does but add to the -peculiar character of its expression. - -5. As long as the pain of the head, the giddiness, and the increased -sensibility continue, there is invariably a want of sleep. The degree of -sleeplessness is not always in proportion to the head-ache or to the -other symptoms; but while the latter are present, the former is never -absent. That condition of the brain upon which sleep depends appears to -be easily disturbed by a great variety of causes; but whatever be -capable of affrighting this heavenly visitant, “tired Nature’s sweet -restorer,” whether in the mansion, the palace, or the prison, and -whether from the bed of healthful slumber or from the couch of sickness, -nothing so effectually and so constantly banishes it as that febrile -uneasiness of which we have already spoken; and which, instead of -declining, as in the milder form of fever, now increases in strength and -activity, and will scarcely allow the restless body to remain in one -position for a moment. He who has felt its influence in this stage and -degree of fever, will admit that there is nothing comparable to the -wretchedness it produces, except it be the sweetness of the first waking -moment after the first tranquil slumber of returning health. - -6. And now, sometimes closing this train of symptoms, but more -frequently being the first harbinger of another, delirium appears. -Delirium is usually first observed when any slight sound rouses the -patient from that disturbed slumber which is the only substitute allowed -for sleep. The delirium is seldom violent or long-continued, but, when -present, is like the talking of a person during sleep in a disturbed -dream. This symptom, however, is by no means invariably present, and -when it does come, it often postpones its visit to a somewhat later -period. - -7. The pulse, during all this time, may not be much quicker than in the -mild form; and the state of the tongue and of the evacuations does not -materially differ. - -Such is the train of symptoms when the brain becomes prominently -affected. These symptoms continue without intermission, and with little -change, for several days. The period of their duration, when only in -this degree of violence, is commonly from eight to ten days: when their -character is still milder or more subacute, or when they have been -mitigated by appropriate remedies, it may be protracted fifteen days. - -About this period a remarkable change takes place; an entirely new train -of symptoms supervenes, which is different, and which, indeed, presents -a striking contrast, according as the patient is destined for life or -death. - -If it be for life, that sleep, of the long absence of which we have -already spoken, returns; and nothing can more truly express its -character than its familiar name, “balmy;” and healing is its influence. -From two or three hours of such slumber, the patient awakens a new -being. Not that the change is at first striking to an inexperienced eye; -but there is no fever nurse who does not recognize it in a moment, and -it is not long before the patient tells you that he feels it. The -febrile uneasiness is now much diminished: the headache is greatly -relieved; and the skin is cooler and softer. The pulse may not yet be -altered, or it may be a few beats slower than before, but there is -almost always already an improved appearance in the tongue, which shews -a beginning disposition to clean. These favourable changes gradually -increase. If the sleep the next night be longer and more refreshing, -which it generally is, on the following morning a decided improvement is -visible in the countenance. The eye is clearer and more lively, and the -expression of the countenance is more natural. The skin continues cooler -and softer; the tongue is still cleaner, and the pulse, perhaps, slower -by a beat or two; and from this period, if no untoward event happen, the -convalescence proceeds just as has been described in the return of -health in the milder form of fever. - -If, on the contrary, the case proceed unfavourably, a totally new train -of symptoms at this period sets in. - -1. In the first place, the pain of the head obviously, and sometimes -strikingly, diminishes. Often it disappears altogether, or, if any -uneasiness remain, it is rather a sense of dullness and heaviness than -pain. In like manner the giddiness, if that were urgent, is no longer -perceptible: but it is remarkable that the pain in the back and loins -not unfrequently continues for some time after the headache has -disappeared: but, ultimately, that also ceases. The period at which this -important change takes place depends upon the severity of the attack, -and is materially influenced by the activity or inertness of the -treatment. In the subacute form, it usually takes place about the tenth -day from the commencement of the disease. - -2. Simultaneously with the disappearance of the head-ache, there is a -remarkable diminution of the sensibility. The mind is duller and more -heavy. The patient may still be roused to answer with tolerable -coherence if spoken to; but when left to himself he is confused and -stupid. The eyes now become injected: often suffused; and the heaviness -and dullness of their expression is increased. - -3. It is at this time that delirium, if it appear at all, most commonly -comes on. The increasing insensibility, if not attended with decided -delirium, is almost always accompanied with moaning or incoherent -muttering, especially during the short and interrupted slumbers which -form the substitute for sleep. - -4. Striking as these changes are in the functions of the spinal cord and -brain, those which take place in the number and character of the pulse -are no less important. Even in cases the most decidedly subacute, it is -seldom that it does not rise ten beats, so that if before it were 90, it -will now be 100, and it is always weaker. - -5. Now, too, signs of disease in the chest and abdomen are almost always -to be distinguished. A case purely cerebral, from the commencement to -the termination of the disease, is rarely to be met with. If there be -not cough, there is almost always a short and hurried respiration, and -more or fewer of the indications of abdominal affection hereafter to be -stated. Even in cases the most purely cerebral the tongue always becomes -more loaded and often dry; and it is strikingly characteristic of the -state of the nervous system, that while the tongue becomes dry, the -thirst diminishes. - -Thus far it is possible that the disease may proceed towards a fatal -termination without proving mortal. It is not often that its course is -turned back or stayed after it has made this progress; but still such an -event is sometimes witnessed. When it does occur, the amendment, both in -its origin and progress, is very similar to that of the favourable -change which has already been described. More tranquil and -longer-continued sleep is almost always the earliest sign that, in this -severe struggle, life has obtained the victory. If, on awaking from such -sleep, there be less delirium, were delirium present, or greater -tranquillity, were the restlessness urgent; and if there be _any_ -increase, although slight, in the sensibility, or any improvement in the -expression of the countenance, hope may be entertained that that victory -will be won; and hope may become assurance, if the tongue which had been -loaded become clean at the edges, or the dry tongue become moist. Even -under apparently the most desperate circumstances, if these three -symptoms concur, a favourable prognosis may be pronounced with tolerable -certainty. Two or three days _may_ elapse after their occurrence, before -any remarkable change is observable in the pulse; but it is seldom that -they continue twenty-four hours before the pulse falls at least ten -beats. Now and then, on leaving a patient in the evening with a pulse at -120, we are surprised and delighted to find it in the morning as low as -100. When the pulse has thus fallen towards the natural standard, when -the tongue has begun to clean, and when the skin has become cool and -soft, however desperate his condition but a few days before, the patient -may be said to be convalescent. - -But though this favourable change is sometimes witnessed, yet, from the -point at which we left off the description of the progress to a fatal -termination, the too common history is, increasing restlessness and -sleeplessness; insensibility lapsing into coma; further acceleration of -the pulse; greater dryness of the tongue and decreasing strength, until, -at length, the powers of life receiving less and less supply from the -great systems in which they have their seat, become completely -exhausted. - -Those who have been placed in situations which have afforded them -opportunities of witnessing much of the disease will, I trust, -acknowledge that the account now given is an accurate narrative of the -symptoms that occur, and of the order in which they succeed, in the -great majority of cases. Upon what conditions of what organs they depend -will be illustrated in the pathology. - -Sometimes to these, other trains of symptoms are added—namely, muscular -tremor, frequent and sudden screaming; rolling of the head upon the -pillow; constant tossing of the hands about; picking at the bed-clothes -or other surrounding objects; partial paralysis of the upper eyelid, so -that one or both of the eyes remain half or almost wholly closed; the -ball of the eye unsteady or constantly rolling; the expression of the -eye and countenance at one time wild and anxious, at another fatuous; -squinting; the respiration now slow and laborious, now exceedingly -rapid; the pulse either slow, full and regular, or slow and -intermittent, or so quick that it cannot be counted, or these states -succeeding each other or alternating with each other at short intervals; -convulsions; involuntary and unconscious stools—all these symptoms are -never found combined in any one case; but certain assemblages of them -occur with some degree of constancy, and depend upon certain conditions -of the brain and spinal cord. Since, however, the description of these -conditions cannot be given here, the further account of the signs which -denote them must be postponed until we treat of the pathology of the -disease. - -2. _Synochus Gravior with Acute Cerebral Affection._—Such is the history -of the synochus gravior with cerebral affection in its subacute form. -When its attack is the most acute, the history is precisely the same, -excepting that the symptoms are more severe, and their progress quicker. -The head-ache is much more intense; the giddiness is more violent; the -sensibility is excessive; the least noise is intolerable; the slightest -motion either of the head or of the body aggravates all the symptoms; -the eye is muddy, and very soon becomes injected, and is perfectly -intolerant of light; the pain in the back, loins, and limbs, is nearly -as great as it is in the head. The skin is intensely hot, and sometimes -impresses the hand with the sense of pungency; but though every where -thus hot and dry, its temperature is peculiarly great over the scalp, so -that if the head be shaved, and wet clothes applied, they are quite dry -in a minute or two. The febrile uneasiness is excessive; the patient can -scarcely remain a moment in the same posture, and he is wholly without -sleep. The pulse at one time is strong, full, bounding, and not easily -compressed, but even in this acute form it is almost always soft; at -least it is very different from the hardness characteristic of an acute -attack of pure phrenitis; at another time it is oppressed, the stroke -giving an impression directly opposite to that produced by the free and -bounding pulse. - -But one of the most remarkable modifications of the pulse, one that is -characteristic of an exceedingly acute attack of cerebral disease, and -one with the import of which it is of the highest consequence to the -life of the patient that the practitioner should be perfectly acquainted -the moment he meets with it, is the slow and intermitting pulse. -Whenever, in the onset of fever, a patient is found with intense -head-ache or intense pain in the back and loins, and _a slow pulse_, the -physician ought to be greatly alarmed at the severity of the symptoms -that are to follow, and if he do not take the most active measures to -break the violence of the disease at this early period, it will be -beyond all control in a day or two, and the patient will be dead before -the fever is well formed in milder cases. The affection of the brain is -sometimes so violent and sudden that the pulse is not only slow, but -intermitting, and the respiration is suspirious. Frequent and deep -sighing is not uncommon in severe cerebral cases, and it is highly -characteristic of intense cerebral affection; but in such a violent -attack as that of which we are now speaking, the suspirious breathing, -even in the very commencement of the disease, is so great that it cannot -be overlooked. This happened in the case of my friend Dr. Dill, whom I -saw a few hours after the commencement of an attack of one of these -intense forms of fever. I saw him in the afternoon at a public meeting. -I met him an hour afterwards at his own apartment. He was still going -about engaged in his ordinary occupations; but his countenance was pale -as death; his eye was dull and heavy; his mind was confused, and as it -seemed to him paralysed; he had other sensations, which were new to him, -and which were most distressing; _but he had no pain_: at that time -there was not the slightest pain either in his head or his back or -loins: there was only that general and undefined uneasiness which gave -to him sufficient warning of what was coming, as the slow and labouring -pulse, coupled with the uneasy sensations of which he complained, and -the peculiar aspect of his countenance, afforded to me an abundant -confirmation that his apprehensions were just. He was bled immediately -to the extent of twenty ounces: the blood then drawn was not sizy: he -passed a wretched night. I saw him early the following morning: he had -now intense headache; his eye was already injected; his skin was not hot -but burning; his respiration was suspirious; almost every breath was a -sigh, and his pulse was _still slower_ than on the preceding evening, -and was now _intermittent_: blood being drawn to a large extent, the -crassamentum was now buffed and cupped; but the detail of the progress -of this instructive case must be postponed until we speak of the -treatment of fever, because it is still more illustrative of the effects -produced by the vigorous application of the appropriate remedies than of -the peculiarity of the symptoms which usher in the attack. It may -suffice for the present to observe that this case affords not only a -striking example of the concurrence of these peculiar symptoms, but also -a decisive proof that pain of the head is far from being the _first_ -symptom that occurs even in the most intense cerebral attack. - -In these acute forms of the disease, if the proper remedies be not -vigorously employed, the pain ceases _within the fourth day_; it rarely -extends beyond the fifth; the pain passes into insensibility; delirium -comes on, sometimes so violent as to require restraint, but delirium is -by no means an invariable concomitant of the other symptoms, even when -these are the most violent: when it is present it is almost always -rapidly followed by muscular tremors, and these by subsultus tendinum, -which now and then usher in general convulsions; but this last event is -rare, and I have never yet seen convulsions unaccompanied with a -particular condition of the brain hereafter to be described. Sometimes -the muscular tremors succeed immediately to the transition of the pain -into insensibility, while the insensibility rapidly increases to stupor, -and that to profound coma. The breathing is occasionally as stertorous -as it is in apoplexy, but this is also rare, and when it does occur, is -probably dependent on a peculiar condition of the brain hereafter to be -pointed out. Together with these there is a concurrence of a greater or -a lesser number of the symptoms enumerated at page 107, but the -particular combinations that are found most usually to accompany -particular conditions of the brain, it will be most instructive to state -in connexion with the pathology. - -In synochus with acute cerebral disease there is less indication of -thoracic and abdominal affection than in the subacute form, because the -intensity of the cerebral disease obscures the signs of derangement in -the other organs; but the signs of their derangement are never absent, -although they are less obtrusive, and they trace in indelible characters -proofs of their activity in the ravages they commit upon their -structures in which they have their seat. - -Such is the course of synochus under different degrees of violence. When -it is combined with subacute cerebral affection, that course is usually -terminated in from three to six weeks; when with acute cerebral -affection, in from seven to ten days. - -As an illustration of each form of the disease, as it is commonly met -with in practice, I subjoin the following cases. - - - CASE I. - -JOHN COLEBERT, æt. 28, admitted into the Fever Hospital August 1, 1828. - -Attacked five days ago with chilliness, alternating with heat, pains of -limbs, head-ache, and sense of weakness. At present complains of pain of -head, with slight giddiness; pains of limbs, especially of back and -lower extremities; skin moderately warm; tongue loaded with white fur; -much thirst; three stools; respiration natural; no cough, no uneasiness -in chest; no epigastric or abdominal tenderness on full pressure; pulse -96, soft. - -6th. Skin natural; pain of head gone; pain of back and limbs continues; -slept better; tongue more clean; three stools; pulse 102. - -7th. Pain of head not returned; pain of limbs better; tongue still -cleaning; three stools; pulse 96. - -9th. Pain of limbs gone; tongue nearly clean; two stools; pulse 84. - -10th. Convalescent. - -13th. Dismissed cured. - - - CASE II. - -GEORGE WALKER, aged 17. Admitted May 5th, 1828. - -Six days ago seized with shivering, succeeded by heat, loss of strength, -and pain of head. At present complains especially of head-ache; ardent -thirst; no pain of chest; no cough; no pain of abdomen, back, or -extremities; skin cool; face natural; tongue, except at the point, -covered with a thick dirty fur; much thirst; no appetite; sleeps badly; -bowels costive, having had no stool for the last three days; pulse 98, -of good strength. - -7th. Heat of skin nearly natural; pain of head almost gone; no pain of -limbs; tongue still much loaded; some thirst; three stools; pulse 72; -slept much better. - -8th. Tongue much less loaded; less thirst; five stools; pulse 60. - -11th. Convalescent. - -14th. Return of head-ache, and, on the day following, the tongue again -became white; but these symptoms disappeared the succeeding day, and, on -the 27th, he was dismissed cured. - -These two cases afford fair specimens of the combination of symptoms, -and of the degree of their severity, in the synochus of London, as it -occurs in its mildest form. - - - CASE III. - -EMMA GLADISH. Admitted into the hospital on the 12th day of fever. -Attack commenced with usual symptoms. The pain in the head, which had -been severe for some time, had entirely subsided on the day of her -admission. The mind was now quite indistinct; she could scarcely answer -any question that was put to her; the eyes were dull and heavy; she had -no sleep; there was great restlessness, and occasionally wandering -delirium; there was no tenderness of abdomen; the tongue was red, furred -and dry; the stools were passed in bed; the pulse 105, of good power. - -13th. Sleep rather more tranquil; less wandering; mind a little more -distinct; stools still passed in bed; pulse 100. - -14th. Much noise through the night; occasionally started out of -disturbed sleep with screaming; tongue red, glazed and dry; stools -passed in bed; pulse 96. - -15th. Rather more sleep; talkative delirium; tongue somewhat cleaner; -pulse 100. - -16th. Longer and more tranquil sleep; mind more distinct; expression of -eyes still dull and heavy; tongue more clean, more moist; stools only -partly passed in bed. - -17th. More sleep than on the preceding night; mind still more distinct; -complains to-day of some tenderness of abdomen on pressure; tongue -nearly clean; two stools no longer passed in bed; pulse fallen to 72. - -19th. Slept well; mind clearer; eyes more animated; expression of -countenance brighter; other symptoms the same. - -26th. Continues to improve; skin cool, soft, and moist; pulse 78. - -27th. Convalescent; but the convalescence was slow and tedious, as it -almost always is after so severe an attack of cerebral disease; she was -dismissed cured on the 40th day from the commencement of the attack. The -reports of the 15th, 16th, and 17th days illustrate very clearly and -strikingly the changes which have already been stated to indicate -recovery. - - - CASE IV. - -ELIZABETH PRICE, æt. 26, servant; admitted on 11th day of disease. -Attacked with ordinary symptoms of fever: at present complains of very -severe head-ache; face flushed; intolerance of light; some deafness; -mind confused during night; visions of various kinds, such as “waves of -the sea rolling,” appear occasionally before her with great vividness; -had been on sea four days before she became ill; skin warm; sense of -general soreness; abdomen rather hard, but not tender; tongue furred, -rather red; much thirst; no appetite; scarcely any sleep, and, when she -does, dreams of a frightful nature interrupt her rest; pulse 114, -_intermittent_, of good power, but easily compressed; bowels -constipated. C. C. ad ℥xviij. nuchæ. Abradat. Capillitium. Lot. Gelid. -cap. Haust. Sennæ Sal. c. m. - -12th. More sensible since cupping; mind still confused; occasional -wandering; scarcely any sleep; pulse 124, sharp, yet easily compressed. - -14th. Quiet night, with considerable sleep; head giddy and slightly -painful; respiration hurried, apparently cerebral; pupils active; tongue -dry; much thirst; pulse 123. Empl. Lyttæ cap. - -15th. Much screaming; great restlessness during night; complains much of -head-ache; pupils active; urine copious, but passed in bed; all the -stools passed in bed; pulse 108, easily compressed; has visions before -her almost constantly; head very hot. Four leeches have been applied to -the temples this morning without relief. Affus. Frigid. cap. ℞. Hydrar. -Submuriat. gr. ij. Pulv. Scillæ, gr. j. Pulv. Antimon. gr. iij. M. sumat -4tâ q. h. - -16th. No screaming; head less painful, especially when in half-erect -posture; mind quite sensible now, but much wandering occasionally; pulse -120, feeble; five stools passed in bed. - -24th. No material change until this day; sleep now greatly improved; -mind much more itself; tongue beginning to clean; pulse 93; ptyalism. - -28th. Ptyalism continues; feels greatly better; appetite returning. - -From this period she continued to improve, although with several -threatenings of relapse; the convalescence was slow and precarious, but -she ultimately left the hospital quite well, though not until the 60th -day from the commencement of the fever. - - - CASE V. - -MARY SULLIVAN, æt. 36. Admitted on 14th day of disease; complaint -commenced with shivering; pains in the limbs; severe head-ache. -Complains now of violent pain of the head; face pallid; expression -depressed; scarcely any sleep; abdomen tender on pressure; only one -stool for eleven days; tongue foul and dry; pulse 81, not strong; -complains, also, of pain under right mamma, preventing inspiration and -decubitus. V.S. ad ℥xij. Lotio Gelida cap. Abrad. Capillitium. - -15th. Blood with firm buff; pain of head not at all relieved; pain of -back, sides, and abdomen severe; no delirium; no sleep; pulse 78, pretty -strong. Hirudines viij. temporibus. Pt. Med. - -16th. Pain of head much relieved; slept very much better; pulse 66, full -and strong. - -17th. Pain of head returned, exceedingly severe over the fore-part; -pulse 66, full and strong. C.C. ad ℥xij. nuchæ. Pulv. Aper. Mit. h. s. -Ol. Ricini c. m. - -18th. Pain of head gone; countenance more natural; tongue more clean and -moist; pulse 76, more soft. Pt. Med. - -20th. Pain of head returned; mind confused; pulse 60, strong and full. -C.C. ad ℥viij. nuchæ. Pt. Med. - -21st. Pain of head gone; mind confused; pulse 66, pretty strong. - -22d. Pain of head returned, but in a slighter degree; mind more confused -and dull; scarcely any sleep; tongue more foul; pulse 72, soft. Pt. - -24th. No longer conscious of pain; mind quite indistinct; lies prostrate -on the back perfectly helpless; incapable of turning on the side; -occasional retching; some tenderness of abdomen on pressure; pulse 72, -strong and full. - -25th. Much restlessness; aspect of countenance greatly depressed; stools -passed in bed; pulse 75. - -26th. Perfectly senseless; almost constant moaning; extreme -restlessness; difficult deglutition; pulse 120. - -27th. Not spoken since last report; lies prostrate on back; eyes half -open and injected; pulse 102, feeble. - -29th. Died. - -If the reader can doubt of the condition of the brain in this case, he -is requested to turn to the pathology, where the morbid appearances on -dissection are detailed. Slowness of the pulse, with severe and -obstinate pain in the head, attended with confusion of mind, is always a -highly dangerous-symptom: it invariably denotes intense cerebral -disease. Whenever there is such a struggle, as this case exhibits, -between the physician and the disease, the disease is sure to conquer. -For if the physician, terrified at the name or the duration of the -malady, while he resolve to use the lancet, hesitate to employ it to the -extent of subduing the disease by the first bleedings, the patient is -lost. The partial relief afforded by partial measures is most delusive. -The malady speedily recovers its lost strength: the patient never does. -There is no practitioner who is capable of being taught by experience -that can reflect on the history and progress of such a case as this, on -the temporary relief afforded by such treatment, on its ultimate -failure, and on the appearances presented on dissection, without -regretting that more blood was not taken on the 15th and 16th days, and -without at the same time resolving, that the aid he offers in future, -under similar circumstances, shall be more decisive. The diminution of -the pain of the head on the 22d, accompanied with increasing confusion -and dullness, with a tongue growing more and more foul, and with a pulse -only at 72, might well excite alarm; and accordingly, on the following -day, the case was utterly without hope. - - - II. SYNOCHUS GRAVIOR WITH THORACIC AFFECTION. - -There is probably no case of fever, however slight, in which the mucous -membrane of the bronchi remains in a perfectly sound state. A certain -affection of this membrane, the nature of which will be stated -hereafter, appears to be peculiar, to fever, and there is reason to -believe that the acutest thoracic affection which is at the same time -truly febrile, differs from the mildest case of fever, in which there -may be no visible sign of any thoracic disease whatever, only in the -degree in which this organ is affected. Sometimes it happens, however, -that this membrane is implicated in a more than ordinary degree; and -when it is so, it gives rise to peculiar symptoms, constituting the case -thoracic. The severity of these thoracic, is not always in proportion to -the severity of the febrile symptoms, in like manner as there may be the -most intense febrile symptoms, without any indication of thoracic -disease: but whenever the thoracic symptoms are sufficiently intense to -become prominent, and especially when they occur early or attend on the -commencement of fever, they invariably and very considerably aggravate -the general febrile symptoms. In these prominent thoracic affections, -then, two things happen; first, the symptoms properly constituting the -febrile train are modified, and, secondly, new symptoms are added to -this train, namely, those which indicate derangement in the respiratory -organs. - -The new and peculiar symptoms to which a moderately acute and an early -thoracic affection gives rise, are the following; namely— - -Pain in the chest, sometimes severe, sometimes only slight; sense of -stricture or dyspnœa; inability to expand the chest by a full -inspiration without pain or uneasiness; cough frequently aggravating the -pain; sometimes dry, sometimes accompanied with frothy mucous -expectoration. Respiration sometimes slow and heavy, at other times, on -the contrary, short and quick; never natural: perhaps the physician may -detect thoracic disease in the more obscure, and measure its extent in -the more obvious cases, by observing the manner in which the patient -breathes, better than by any other single means. The altered respiration -is very frequently accompanied with that peculiar noise in breathing -which is termed “mucous rattle.” - -The pulse, in the commencement of this open and decided chest affection, -may not be above 80 or 90; it is hardly ever sharp; it is generally -weak; now and then it is full and of good strength; but whatever other -character it may possess it is almost always soft. In a few days, as the -disease advances, it uniformly rises in frequency and becomes weaker. -Towards the end of the disease it is almost always hurried and feeble, -although cases occasionally occur in which it is observed at this period -to become suddenly slow and intermittent. The tongue is usually foul; -commonly moist; but, in severe affections and in their advanced stage, -it sometimes becomes dry. The skin is often moderately warm, but it is -never intensely hot: it is much more common for it to be cool, and to be -of a more dusky colour than natural. - -Such are the usual conditions of the respiratory and circulating systems -and of the tongue, the great index of the state of the mucous membrane -of the alimentary canal, when the thoracic affection increases so as to -become prominent and acute. The manner in which it influences the -cerebral affection is commonly by hastening the period at which the pain -of the head lapses into confusion and stupor. Early insensibility, -assuming the form of a muddled or exceedingly confused state of mind, is -a very constant symptom of more than ordinary thoracic affection. -Accordingly, the delirium which succeeds or which accompanies this state -is always low muttering talkativeness, or incoherent wandering, rather -than violent delirium, which last is seldom, if ever, found in -combination with severe thoracic disease. The pathological condition of -the lung perfectly accounts for this modification of the condition of -the brain, as will be shewn hereafter. - - - CASE VI. - -The following case not only shews the insidious manner in which thoracic -disease may come on and the severe form it may ultimately assume; but -also, the extent of disease from which it is possible that recovery may -take place. - -MARY DILLON, æt. 20; destitute. Admitted on the 8th day of fever: attack -came on with the ordinary symptoms: at present, no pain of chest; some -cough, with copious expectoration; no pain or tenderness of abdomen; -tongue not much loaded, but dry; much thirst; no appetite; bowels freely -open from medicine; no pain of head; some giddiness; no sleep; skin -warm; face flushed; pulse 102. - -9th. Pectoral and cerebral symptoms the same; bowels purged; pulse 96. - -10th. Only slight cough; pain of head; more giddiness; no sleep; eyes -preternaturally bright and glistening; pulse 120. - -11th. Only slight cough; pain of head much relieved; slept better; -tongue more clean; four stools; pulse 120, strong. - -12th. No pain of chest; cough much increased; now very frequent and -accompanied with copious expectoration; pulse 136. - -15th. Cough more frequent; expectoration purulent and mixed with blood; -pulse 126. - -17th. Expectorates a larger quantity of purulent matter, mixed with a -larger proportion of blood; pulse 102. - -20th. Pectoral symptoms unchanged; strength extremely depressed; -countenance pallid; skin cool; three stools partly passed in bed; pulse -84; mind confused; almost constant moaning; extensive sloughing ulcers -on sacrum and hips. - -21st. Pectoral symptoms the same; powers extremely depressed; three -stools passed in bed. - -22d. No change in the cough or the expectoration; lies quite prostrate -and appears to be sinking; four stools passed in bed; pulse 72, rather -less feeble. - -24th. Cough rather diminished; expectoration unchanged; four stools -passed in bed; pulse 84, extremely weak. - -25th. No change, excepting that the pulse (78) is rather more strong, -and she is scarcely so prostrate. - -26th. Skin again hot; tongue again red and dry; no sleep; some delirium; -pulse 84, of more strength. - -27th. Skin more cool; tongue less red and more moist; pulse 66; some -return of appetite. - -28th. Cough much diminished; expectorates less; tongue moist, clean, and -nearly of natural colour; pulse 72, stronger; countenance more animated. - -35th. Cough nearly gone; expectoration much diminished; tongue clean; -one stool; countenance improving; strength increasing; wishes for meat; -two ounces were allowed. - -40th. Sloughs on sacrum and ilium doing well; pulse 90, of more power; -still noisy during sleep. - -From this period she continued slowly, although gradually, to gain -strength, and was dismissed from the hospital on the 57th day, _cured_. - - - CASE VII. - -ANGELICA FIDGETT, æt. 29, married. Admitted on the 16th day of fever. -Before admission affected with cold, shivering, sense of faintness, pain -of head, uneasiness of chest, and cough. On admission, pain of chest -increased by deep inspiration and by cough; cough frequent; pain of the -head already subsided: there remain only a sense of weight over the -eyes, the expression of which is dull, heavy, and vacant; frequent -moaning; no pain of the abdomen on full pressure; pulse 129; tongue -foul, moist; skin hot; face flushed. - -17th. Respiration slow and laborious; cough; completely comatose; eyes -suffused; pulse 120, full, soft; face flushed. - -18th. Respiration continues very laborious; mind exceedingly indistinct; -much restlessness; pulse 116, still softer. - -21st. Examined with the stethoscope: the bronchial roll and crepitus -were very distinctly and generally heard. - -22d. The respiration continues extremely laborious; frequent cough, -without expectoration; low, rambling delirium; pulse 112, weak; tongue -foul, moist; general powers greatly depressed. - -23d. All the symptoms aggravated. Died on the 24th day of fever. - -As thoracic affection may exist in any degree of intensity, so it may -indicate itself at any period of the disease: but while sufficiently -intense to destroy the structure of the organs in which it has its seat, -yet it sometimes gives no indication of its presence, or none until the -approach of death. In these cases, the cerebral affection is still more -intense than the thoracic, and the manifestation of the symptoms proper -to the lung is prevented by the predominance of disease in the brain. Of -this, the following case affords a striking example. - - - CASE VIII. - -JOHN POTTER, æt 21. Admitted on the 15th day of fever. Before admission -was affected with the usual febrile symptoms, accompanied with severe -pain of the head and giddiness. On admission, the pain of the head was -nearly gone; there remained considerable vertigo, with some pain in the -loins and joints; the mind was exceedingly indistinct, and there was -little or no sleep; pulse 80, soft; no indication of pectoral affection. - -18th. Symptoms the same; in addition, the abdomen was now tender on full -pressure and retracted. - -24th. No change observable until this day; no indication of thoracic -affection had hitherto been apparent from the commencement of the -disease; but, on the morning of the 24th day of fever, dyspnœa suddenly -came on, which was attended with a great degree of restlessness; there -was also some soreness of throat, but only a slight degree of redness -and tumefaction were visible on inspection: with these symptoms he sunk -rapidly, and expired in the afternoon.[24] - - - III. SYNOCHUS GRAVIOR WITH ABDOMINAL AFFECTION. - -One of the organs always involved in disease, in a greater or less -degree, in fever, is the mucous membrane of the stomach and intestines. -In synochus mitior the affection of this organ appears to be slight, and -to pass away without producing any change in its structure. But that it -is really diseased even in the mildest case, we have sufficient evidence -in the invariable derangement which takes place in the functions of the -organ throughout its whole course, from the mouth to the anus; and in -the constant vitiation of its secretions and excretions. In the severer -forms of fever, on the other hand, in the great majority of cases, the -affection of the abdomen becomes prominent, and whenever it does so it -aggravates all the other febrile symptoms, and adds greatly to the -danger of the disease. - -Abdominal affection exists under two forms in fever, each of which is -attended with distinct and peculiar symptoms. It may be severe from the -commencement, and give early and obvious indications of its existence; -or it may come on at some subsequent stage of the disease, and then, -although the affection be equally severe, the symptoms which denote it -are materially different. - -1. If the abdominal affection be severe from the commencement, in -addition to the ordinary symptoms of fever, there will be present -nausea, sometimes retching, and at other times vomiting. It is usual for -authors to enumerate these events among the ordinary occurrences of -fever; but in a case decidedly cerebral, or in a case decidedly -thoracic, they are seldom present. Whenever they occur in the -commencement of fever they are the certain signs of an abdominal -affection more severe than ordinary; and it will be of the utmost -advantage to the patient should the practitioner be aware of this, -because it will teach him at once where the main force of the disease is -probably to be concentrated. - -2. At this early period the bowels are commonly constipated, and on -inquiry it will be found that they have been so for some days previously -to the attack of fever; but in a day or two after the commencement of -this attack they fall into the opposite state and are looser than -natural. The concurrence of nausea, retching, vomiting, and purging in -the commencement of fever is a certain proof that severe abdominal -affection is present, and if not actively treated and effectually -checked at this early stage, it will soon render the case formidable, if -not hopeless. - -3. When the abdominal affection is thus early and open, it is often -attended with another symptom which seldom fails to attract attention, -namely, pain. Pain of the abdomen, attended with purging, completes the -train of local symptoms that occurs at this early period, in the most -exquisitely marked cases. It is well worthy of observation, however, -that pain is by no means an invariable attendant on the other symptoms, -even when the latter are very severe. Whether in these cases the -affection of the nervous system be already so great as to lessen the -sensibility of the organ, or whatever else may be the cause of it, the -fact is certain, and it is one of great practical importance, that pain -of the abdomen is not to be expected even in severe abdominal affection; -and that though pain may attend upon the affection, yet the affection is -often present without pain. - -4. Pain of the abdomen upon pressure, and especially upon pressure in -the epigastrium, is much less seldom absent than pain of which the -patient spontaneously complains. - -5. Pain, though it may usher in the abdominal affection, and may even be -severe for the first few days, diminishes after a certain time and then -ceases altogether, so that it is extremely rare, after the tenth day of -fever, for instance, for the patient to complain of pain of the abdomen, -even when the abdominal affection is the most intense. Such an event may -happen, perhaps when the cerebral affection is more than commonly -slight, but it is an exceedingly rare occurrence, and my attention has -been particularly drawn to this circumstance from reflecting on the -uniformity of the answers which I have obtained from patients obviously -labouring under abdominal affection, on my first visit to them in the -wards of the hospital. Having commonly been ill from ten to fourteen -days, the abdominal affection may by this time be fully developed: on -asking them whether they feel any pain in the abdomen, the answer almost -invariably received is, “no.” Press gently upon the abdomen, press -especially upon the epigastrium, often even in these very cases not the -slightest touch can be borne. After pressure has once been made, the -patient will frequently do all he can with his hand to prevent its being -made a second time. So acutely sensible is he of pain on the least -pressure, though wholly unconscious of pain when left to himself. Even -when there is not this great degree of tenderness, pain can generally be -produced by full pressure. - -There is thus a remarkable coincidence between the progress of the -symptoms in the abdomen and in the head. We have seen that however -intense the cerebral affection, the pain of the head which accompanies -it diminishes after a certain time, and in a day or two after it has -begun to diminish, ceases altogether. In like manner the pain which -ushers in an acute abdominal affection diminishes after a certain time, -and soon wholly disappears. After this period, therefore, we should have -no more indications of abdominal than we have of cerebral pain were the -intestines, like the brain, enclosed in a bony case. When an organ can -be touched, it gives us an additional and an invaluable means of -ascertaining its morbid condition: and this is one reason why that -condition is commonly so much more certainly known in surgical than in -medical diseases. What the result would be, could we press the brain as -we can the abdomen, after its sensibility is so much diminished as to -cease to occasion pain, we do not know; but it would be a bad use indeed -to make of the additional means afforded us of ascertaining the -condition of the intestines, were we to allow the additional information -we thus gain, to obscure our perception of the perfect analogy there is -in the progress of both affections. We know that, as the disease -advances in both, the pain ceases; but, in the one case, we have the -means of ascertaining that there still remains preternatural tenderness -on pressure, as in ordinary inflammation, which we are without the means -of discovering in the other: still the important practical fact afforded -by the history of both is the same, that disease having reached a -certain point, the pain diminishes; and having advanced still further -entirely disappears. - -6. While the pain lessens or ceases as the abdominal affection advances, -the purging, on the other hand, continues, often it increases. Purging, -succeeding to constipation and to pain, and remaining after the -subsidence of the pain, affords an infallible indication of abdominal -disease. - -7. Together with these decisive signs, which alone are abundantly -sufficient to enable us to ascertain the presence of the affection, we -have an additional and an exceedingly valuable guide in the peculiar -state of the tongue. In these abdominal cases, the tongue is -preternaturally red. Sometimes this increased redness is of a bright and -vivid colour, and pervades the whole tongue; at others, it is confined -to the edges or to the tip, and it is usually remarkably apparent in the -latter. While thus vividly red, the body is often loaded with fur; the -colour of the fur is often of a dirty-white or greyish colour; but, -perhaps, while the edges and the tip are thus intensely red, the most -usual colour observed on its body is that of a dirty yellow. In these -cases, the papillæ appear much enlarged, and are seen prominent through -the fur, vividly red. In this condition of the tongue it always remains -moist for some time, and it is not attended with urgent thirst; but, as -the intestinal disease advances, the tongue gradually becomes less -vividly red and more dry, and as these changes go on, the lips and teeth -often become sordid. - -Instead of being from the commencement of a vivid redness, the colour of -the tongue, in other cases, is of a darker and duller tint; there is -less fur upon the body, and that which covers it is of a dirtier and -darker tinge; this state of the tongue is always attended with greater -thirst: it is apt to become more and sooner dry, and, at the same time, -the lips and teeth become more and sooner sordid. - -8. In the kind and degree of abdominal affection of which we are now -treating, the abdomen is sometimes harder than natural, but it often -remains nearly as soft as in health through the greater part of the -disease. - -9. Of the conditions of the pulse in this affection it is important to -take particular notice, on account of the total absence of any striking -or _apparently_ distinctive character. It is neither remarkably slow nor -very quick; neither unusually hard, nor strong, nor sharp, nor weak, nor -intermittent, nor in any degree irregular; its common range is from 80 -to 100, beyond which it seldom rises in the acutest cases, until near -the termination of the disease; and it is generally soft. - -10. Whenever, then, there is a combination of the preceding symptoms, -with a pulse about 90, it may be inferred with great certainty, that -disease is going on in the intestines. But, as the pain of the abdomen -ceases at a certain period, while the purging continues, so, at a still -more advanced stage of the disease, the purging also disappears, and the -stools return to a more natural condition. Cessation of pain, and an -apparent return to healthy secretion and excretion, may seem to indicate -a highly favourable change in the disease, and, _if accompanied with -corresponding amendment in the other symptoms_, they may, indeed, be -hailed as signs of returning health; but if they occur _without_ a -favourable change in the general symptoms, they do not indicate a return -to health, but merely the transition of one diseased process into -another. What that succession of diseased processes is will be stated -hereafter: at present it is sufficient to observe that, without -corresponding improvement in other organs, the cessation of purging is a -sign not of returning health, but of advancing disease. And so common is -the cessation of purging, _without amendment_, at an advanced stage of -abdominal affection, that in a large proportion of the patients who are -received into the Fever Hospital, it has ceased before their admission. -On the examination of a patient, for the first time, who has been ill -from a fortnight to three weeks, it will be stated that the stools are -regular, yet if strict inquiry be made, it will often be found that at -an earlier stage of the disease from four to five stools, sometimes from -eight to ten, were passed in the twenty-four hours without any purgative -medicine having been taken. With regard to the state of the evacuations -in this affection, then, the succession of events is first constipation, -then purging, and next the cessation of purging and the return of the -stools to a more natural character. - -The preceding signs of abdominal affection are so obvious that they can -scarcely fail to lead to the detection of the disease; but the second -form under which it exists is attended with much less striking symptoms. -It requires great attention and daily examination to discover its -presence, and to trace its progress. It steals along its fatal course -with a step as silent as it is sure; and the destruction that marks its -track is oftentimes alike unfelt by its victim and undiscovered by his -most watchful guardian. It does not attack until the sensibility is -already greatly diminished in consequence of the progress of cerebral -disease. No pain is therefore felt, and the only indication by which it -can be detected is tenderness of the abdomen on pressure. But even the -fullest pressure, although it generally excite some uneasiness, -sometimes produces none whatever. There is often no purging; for when -the affection comes on thus late, though the bowels may sometimes be -loose, yet they are frequently even constipated. The tongue is generally -red at the edges and the tip, loaded with dirty grey or yellow fur, and -sometimes dry. The pulse at this advanced period is generally 120. -Without doubt this affection greatly aggravates the severity of the -fever, and increases the danger of the patient, although we have no -means of measuring the extent to which it does so. - -On recovering from this state, for recovery does sometimes take place, -the first indication of improvement commonly appears in the tongue, -which shews a disposition to clean; and what is remarkable, the -favourable sign which accompanies this improved condition of the tongue -is _increased tenderness of the abdomen on pressure_. Not that disease -in the intestine is increasing, but disease in the brain is lessening, -and therefore the patient is now sensible to a stimulus which before -produced not the slightest impression. If on the following days the -tongue continue to clear; if it grow less red; if at the same time the -pulse fall, the sleep return, the sensibility increase, and the -countenance become more animated, the patient may be considered as -convalescent. - -It is not very common, but it does sometimes happen, that a few hours -before death the sensibility of the abdomen suddenly increases, and the -tenderness on pressure becomes exquisite. This remarkable change is -sometimes attended with vomiting, sometimes with hiccup, and is -accompanied with extreme restlessness, and a highly excited pulse, while -the expression of the countenance is at one time anxious and at another -wild, and in this state the patient dies in a few hours. On what change -in the intestines this depends will be explained in the pathology. - -As illustrations of these different modifications of abdominal affection -the following cases are subjoined. - - - CASE IX. - -ELEANOR HOUSE, æt. 18, silk-winder. Before admission attacked with -nausea, vomiting, together with the ordinary symptoms of fever. On -admission, being the 8th day of the disease, severe pain of abdomen, -which is greatly increased on pressure: tongue very red at the point, -loaded with fur, through which the papillæ are prominent, moist; urgent -thirst; no appetite; bowels said to be natural; some uneasiness of -chest; respiration hurried; cannot lie with ease on either side; voice -hoarse and feeble; no soreness of throat; no head-ache; no sleep; skin -warm; face flushed; pulse 100, of some power, but easily compressed. -V.S. ad ℥xvj. Ol. Ricini, ʒiij. - -Hora 3tia, p. m. Blood with thick and firm buff; symptoms both of -abdominal and thoracic disease diminished. Vespere versus vel eras mane, -rep. V.S. ad ℥xvj. si opus sit. Pulv. Aper. Mit. h. s. haustus Sennæ -Sal. c. m. - -9th. Bled last evening with much relief; proportion of coagulum of blood -last drawn great, and covered with firm buff. Much pain in the -epigastrium and over the whole abdomen independently of pressure, but -greatly aggravated by slight pressure; tongue less loaded, less red, -moist; much thirst; pulse 108, sharp, small, easily compressed: Rep. -V.S. ad ℥xvj. - -10th. “Feels greatly better;” pain of epigastrium gone; none of abdomen -when not pressed; full pressure much more easily borne; tongue -unchanged; thirst; vomiting; four stools; pulse 108, of the same -character. - -12th. Pain not diminished on pressure; nausea, vomiting, rejection of a -large quantity of green fluid; pulse 118. - -16th. Says she is quite free from pain of the abdomen; bears pressure -without flinching; no vomiting since last report; four stools; tongue -clean and moist; pulse 99; sleeps better, but the mind is dull and -confused: wandering delirium through the night; some muscular tremor; -skin cool; face flushed. - -18th. Pain of abdomen returned; mind confused; delirium. - -23d. Says she is without pain, but feels oppressed; pulse 96; slept -better; no delirium; face more animated; skin warm; no flushing. - -27th. Had been steadily improving until this day, when the pain of the -abdomen returned, which is again tender on pressure; tongue clean; one -stool; pulse 110. - -29th. Pain much relieved since the application of six leeches to the -abdomen, followed by a large poultice. - -30th. Pain gone: only slight tenderness: pulse 96. - -32d. Pain and tenderness again returned; tongue more red; pulse 108. - -33d. Six leeches were applied last evening without the slightest relief -of the pain or tenderness; tongue red: pulse 96, more weak and soft. - -34th. Tenderness considerably diminished; tongue less red; countenance -again improved. - -35th. Still less tenderness than yesterday; bears pressure much better; -tongue nearly natural; two stools. - -39th. Improving every day; no pain of abdomen; no tenderness on fullest -pressure; bowels quite soft; tongue natural; four stools; pulse 72; -appetite good: strength increasing. - -44th. No return of uneasiness; continues to gain strength. - -57th. Since last report has been daily improving, and is now quite well. -Dismissed cured. - - - CASE X. - -SARAH RAVEN, æt. 17. Admitted on the 22d day of fever; no pain of the -abdomen appears to have been complained of from the commencement of the -attack; at present no tenderness on the fullest pressure; some -distention; tongue covered with yellow fur, moist; bowels loose; pulse -110, sharp; only slight pain in the head; more pain in the limbs; mind -dull, confused; deaf. - -24th. No pain of abdomen on fullest pressure; tongue the same; only two -stools; pulse 124; voice hoarse, feeble; respiration hurried; skin dark, -almost livid; mind much more confused; delirium. - -25th. No material change. - -27th. Insensibility increased to coma; features shrunk; one stool passed -in bed; pulse 128; skin livid, cold. - -28th. Moribund; died the following day. - -On examination after death (see pathology) extensive disease was found -in the intestines, although, if the purging on the day of admission be -excepted, not the slightest indication of it was given during life. - - - CASE XI. - -GEORGE ENGLISH, æt. 25, carpenter. Admitted on the 29th day of fever, -with a great degree of tenderness of the abdomen, extending especially -over the hypogastric region; bowels said to be regular; pulse 90, of -good strength; yet complains much of sense of debility. - -30th. Pain of the abdomen continues, especially over the region of the -bladder; urine passed in good quantity and freely; three stools; pulse -84. - -32d. Tumour has appeared over the region of the bladder, unattended with -pain; three stools; pulse 76. - -33d. Hypogastrium still tumid, but without pain; other symptoms the -same. - -43d. No material change until this day, when he was suddenly seized with -exceedingly acute pain in the region of the bladder; extreme tenderness -on pressure; great restlessness, and great anxiety; vomiting of a -yellow-coloured fluid; two stools; pulse 84, extremely feeble. - -44th. Died. - -These acute symptoms mark the very hour when the event occurred which -caused them.—See Pathology. - - - IV. SYNOCHUS GRAVIOR WITH MIXED AFFECTION. - -Since it has been repeatedly stated in the preceding pages that, in -every case of fever, the brain, the lungs, and the abdomen are diseased, -it may appear objectionable to call any particular class of cases mixed, -because, according to the very nature of fever, all must be of this -character. But for the same reason that we have designated one class of -cases cerebral, another thoracic, and a third abdominal, namely, to mark -prominence and intensity of affection, it is right to distinguish a -fourth, in which all the three systems of organs are simultaneously -affected with an equal, or nearly an equal degree of intensity. The term -mixed is therefore by no means employed to intimate that the cases not -comprehended under it are unmixed, but merely to point out a fact of -great practical importance, that cases do occur which are neither in an -exquisite degree cerebral, nor thoracic, nor abdominal, but which, at -one and the same time, afford the most exquisite specimens of all the -three. - -From this account of the sense in which the term is employed, it must be -obvious that it will include the severest cases that can occur. If a -patient be affected with intense cerebral disease he may be in great -danger; but if he be affected with an equally intense thoracic disease -his danger must be doubled: and if to this be added an equally intense -abdominal disease it must be trebled. And accordingly these are just the -cases which bid defiance to the most skilful and vigorous measures which -the medical art can employ to control them; which seize upon their -victim with a force which no human agency can resist nor counteract; -which in malignant epidemics destroy life in a few hours or in a single -hour, and in ordinary seasons in a few days. - -Whenever a severe case occurs without exhibiting any striking prominence -of affection in any organ, and when on examining the organs there are -found indications of severe affection in all of them, that case is sure -to become formidable, and the patient and his physician have reason to -congratulate each other if it do not prove fatal. When prominence of -affection in any one organ is absent, because all the organs are -intensely affected, it constitutes the most formidable case that can -occur. And though this kind of case be but too common, yet after all it -does not appear to happen as often as it really takes place. Examination -after death discloses what was unknown during life. The brain, the -lungs, the abdomen are often found to be most extensively diseased, -while the indications of disease were confined, perhaps, to the brain -and the abdomen, or to the brain and the lungs. Without doubt, the -spinal cord and the brain are the grand and original seats of disease; -the others are subsequent and consequent, and the principal masks the -subordinate. It is when a great number of cases are brought together, -and placed in juxta position, that we are impressed, and it is only then -that we are duly impressed, with the great proportion of those in which -the course of disease is as noiseless as it is destructive; in which its -stroke destroys, without its being possible to tell where it falls; in -which the physician sees that his patient must die, but in which the -anatomist, after the event has happened, can alone pronounce why it was -so. - -Whatever be the number of organs simultaneously affected, the nature of -the affection in each is always the same, and is not in the slightest -degree changed by the complication. Disease in the brain is the same, -whether the brain alone be prominently affected, or the brain and the -intestines, or the brain, the intestines and the lungs. Each organ is -liable to its own specific disease, and that disease goes on with the -utmost regularity, whether it be the sole organ so far diseased as to -suffer a change in its structure, or whether many be simultaneously -affected in the same manner. - -In like manner the symptoms, when any symptoms are present, are -essentially the same, whether the disease exist alone, or whether it be -complicated with several others. The symptoms of inflammation of the -brain are the same, whether cerebral inflammation alone be present, or -whether it be complicated with inflammation and ulceration of the mucous -membrane of the intestines. And the symptoms of inflammation and -ulceration of the mucous membrane of the intestines are the same, when -any symptoms are present, whether these affections exist alone, or -whether they are complicated with cerebral inflammation. The occasional -absence of symptoms in the subordinate organs, overwhelmed by the -preponderance of affection in the principal, is a proof that they are -subordinate. It would, therefore, be useless to detail the symptoms -which occur in the mixed cases, since they must only be a repetition of -those which have been already enumerated. Their concurrence in -individual complications, and the modifications they undergo from such -particular combinations, will be best understood from the study of the -cases. - -An examination of large averages clearly shews, what would scarcely have -been expected, and what is by no means generally understood, that these -mixed cases, instead of being rare, are even frequent. It seems to me to -be impossible to study the pathology of those which will now be laid -before the reader, without perceiving that the opinion that the seat of -fever is invariably fixed in some _one_ organ, is founded in partial, -and, therefore, imperfect views; and I earnestly solicit the attention -of those who have hitherto contended for the strict locality of that -seat, to these very interesting and instructive cases. It was by slow -degrees, and after the study of the symptoms as they occur in all -varieties, and, if I may so speak, shades of type, _in connexion with -the morbid changes apparent after death_, that I was able to make out, -what I have so often stated to be, the true circle of organs upon which -this disease always seizes and always preys, and which it often -irreparably destroys. In some of these mixed cases, we see marks of -irreparable destruction in this entire series of organs; and in every -one we see extensive disease in all of them. Coupling, then, as we ought -always to couple, these ascertainable and ascertained conditions of the -organs in the fatal cases, with the symptoms of derangement manifested -by these organs in _all_ cases, whether fatal or not, a body of evidence -presents itself, which appears to me to be irresistible, to justify the -conclusion that the local seat of fever is at least coextensive with -these organs. A repetition of my own conviction cannot, I know, produce -conviction in others; I, therefore, again entreat attention to the facts -which have produced conviction in me. And in order that the cases to -which I am so anxious to direct the attention of the pathological -student, may afford him all the information they are capable of -communicating, at the least expense of labour to him, they have been -arranged in succession, according as dissection shews that, while all -the organs are deeply involved, the ravages of disease are most -extensive in the organs of the head, or of the thorax, or of the -abdomen. The simplest and mildest affections are placed first; the more -complicated and severe, as nearly as possible, in the order of their -complication and severity; while, in the rapid sketch that is drawn of -the symptoms, those which relate to the organ most severely diseased are -placed first; and the succession is detailed in order, according as they -appear to be antecedents or sequents; or as they are observed to combine -to form a train or series. Since cases abundantly illustrating, in this -manner, every variety of complication, are given in the pathology, it is -unnecessary to add any here. - - - - - CHAPTER IV. - - _Of Typhus: Division into Mitior and Gravior, and into Cerebral, - Thoracic, and Abdominal. Typhus Mitior, with Subacute Cerebral - Affection; with Acute Cerebral Affection; with Thoracic Affection; - with Abdominal Affection. Typhus Gravior: in what it really - consists: dangerous Nature of the Error that it consists in - Debility._ - - -The appearance of a person labouring under typhus is so different from -that of a person affected with synochus, that no one ignorant of the -disease, who saw these two patients for the first time, would believe -that both were afflicted with one and the same malady. And yet -dissection after death demonstrates, that the physical condition of the -organs is precisely the same in both; and careful examination of the -symptoms during life, shews that they are really identical, both in -their nature and their succession, however, at first view, they may -appear to differ. The difference between these two diseases arises -entirely from a difference in intensity: still this difference produces -a very important modification in the character of the disease; -important, because it materially affects both the safety of the patient, -and the nature of the remedies that are best adapted to rescue him from -his danger. - -Typhus, like synochus, presents itself under two degrees of intensity, -which, like those of the latter, may be conveniently designated by the -terms mitior and gravior. All the important symptoms which belong to -both are found in the same cavities, and relate to the same organs, as -in synochus, and, therefore, must in like manner be divided into -cerebral, thoracic, and abdominal. - - - I. TYPHUS MITIOR, WITH CEREBRAL AFFECTION. - -Cerebral affection in typhus, as in synochus, presents itself under two -degrees of intensity, which may be distinguished by the same terms as in -the latter, the subacute and the acute. - - - 1. _Typhus Mitior with Subacute Cerebral Affection._ - -The symptoms which denote this affection in typhus, are perfectly -similar to those which have been stated to characterise it in synochus, -but they undergo certain modifications, the true nature of which appears -to me to have been greatly mistaken, and, after the most careful -attention which I have been able to give the subject, the mistake seems -to me to be of so much magnitude, that I think whosoever shall -effectually correct it, will do the greatest possible service to -medicine, and, through it, to his fellow men. - -1. There can be no question that, from the very first commencement of -the attack, as well as through the whole course of the disease, the -prostration of strength, both physical and mental, is greater in typhus -than it is in synochus. This greater loss of energy is indicated by -every sign that can be conceived to denote it. The loss of power in the -muscles which support and move the body is oftentimes so complete, as to -be most alarming to the patient and his friends; while the contrast -between the vigor and the torpor of the mind, in the course only of a -few hours, is most striking. From the full and active exercise of its -faculties, it becomes, in that short space of time, quite incapable of -performing any intellectual operation. It is confused and stupid, always -in a greater degree than in synochus, and sometimes to such a degree, -even on the very first day of the attack, as to excite the utmost -apprehension in every one around the patient who takes any interest in -his fate. - -2. The chilliness is, upon the whole, greater and longer-continued than -in synochus: yet there is less constantly shivering, and the heat, when -it succeeds this state of chilliness, is seldom as great as in the -latter; while there are cases in which the heat never exceeds the -natural standard. - -3. The febrile uneasiness is greater; the restlessness is incessant; the -face is pallid; the features are shrunk; the expression of the -countenance is most peculiar; it is strikingly indicative of weakness -and suffering; the experienced eye can tell at a single glance, even at -this early period, to which of the two types that countenance belongs. -The pulse is always weaker and more rapid than in the corresponding -stage in synochus. - -4. There are cases in which the pain of the head is equally severe as in -synochus: but this may be justly considered as rare. In general it is -less acute. Dullness, confusion, stupor, giddiness, are more common than -severe pain, and are often the substitutes for it. Though some degree of -pain be generally present, yet it is by no means uncommon for one or -more of these sensations to occupy its place completely. Question the -patient as much as you please, and he will tell you that he has no pain; -but it is evident, from his aspect and his manner, that he has little -sensation of any kind. The eye is dull, heavy, stupid, without lustre: -the old English word “lac-lustre” expresses its character truly and -strikingly. But it is remarkable, that while the pain in the head is -only slight, the pains in the back, loins, and extremities, and, as the -patient himself says, in the bones, are severe. - -5. When pain is present it diminishes sooner and disappears more -completely than in synochus: when it is not present, the advancement of -the disease is indicated by increasing insensibility, and by the rapid -transition of dullness or confusion into a state of stupor approaching -to coma. The eye is already muddy, and it soon becomes injected and -suffused. The skin over the body is generally warm, sometimes hot: over -the head it is often hot. The face is usually pallid, but the pallidness -frequently alternates with flushing. The change of dullness into -insensibility more or less profound sometimes takes place as early as -the second or the third day: it is seldom that it is as late as the -seventh or the eighth: it is postponed, when not prevented, by active -and appropriate treatment. - -6. There is little or no sleep; the restlessness is great; there may be -no violence; but there is abundance of inquietude. - -7. Delirium is more constantly present than in synochus; and when it -comes it comes earlier: its presence is not unusual as early as the -sixth or the seventh day; and it may appear still sooner, but that is -rare. It consists of low muttering incoherence rather than of loud and -violent talkativeness; and is expressed in moaning rather than in -screaming. - -8. The connexion between delirium and muscular tremor, between muscular -tremor and subsultus tendinum, and between both, and the passing of the -stools and the urine unconsciously, has already been pointed out. Like -delirium, muscular tremor is much more constantly present in typhus than -in synochus; and its relation to delirium is so close that it is -sometimes observed to supervene on the very same day; frequently on the -day following; and, if it appear at all, it is seldom longer absent than -the third. Its degree likewise is commonly in proportion to the violence -of the delirium; and though early and great delirium may appear without -it, yet it very rarely appears without delirium; and in general all -these symptoms form one series or train; pain disappearing, confusion of -mind increasing, muttering incoherence supervening, and muscular tremor -and involuntary and unconscious stools rapidly succeeding. - -9. In the commencement of typhus the pulse is sometimes of good -strength, and it may not exceed 90 in frequency; but as the disease -advances it uniformly becomes weaker, smaller and quicker; so that death -rarely takes place before it has reached 120. In the severer cases it is -weak, quick, and easily compressed at a very early period. - -10. The respiration is often not very obviously affected, but if it be -attentively observed it will usually be found to be shorter and quicker -than natural. - -11. The tongue is always foul on the first or second day; it seldom -continues moist longer than three or four days; it is often quite dry as -early as the fourth, especially on the body and at the root; the apex -and the edges sometimes remain moist a day or two longer; but in a short -time the whole tongue becomes perfectly dry and of a brown colour; as -the disease advances the colour often changes to a darker and darker hue -until it becomes quite black; it is then frequently fissured into deep -chaps, while the lips and teeth soon become covered with a black sordes. -Were the sensibility not greatly altered, such a condition of the mouth -and tongue must be attended with insatiable thirst; yet thirst is often -not felt, although at other times it is considerable. - -12. In the early stage of typhus the skin is frequently hot; as the -disease advances the heat lessens: through the greater portion of the -disease it is moderately warm; towards its termination it becomes cool, -and some days before death it falls below the natural standard. It is -always of a darker colour than in synochus: the whole surface is of a -dull and dusky tinge. Sometimes it is covered with dun coloured -petechiæ, at others with petechiæ of a florid colour. - -13. During its progress, erysipelas, first appearing on the face, then -extending over the scalp, and often down the shoulders and back, is very -apt to occur. Excoriation on the back and hips often form sloughing -sores of great malignity and extent, while enlargement, inflammation and -suppuration of glands situated in different parts of the body frequently -appear. - -14. Typhus terminates much earlier, whether favourably or unfavourably, -than synochus; if it terminate unfavourably death frequently takes place -as early as the 10th or the 14th day, although if early and appropriate -treatment be employed, the force of the disease is sometimes so much -lessened that it is as protracted as synochus. - -Towards the termination of the disease more or fewer of the symptoms -which it has been stated occasionally to occur in synochus,[25] -supervene; but, as these depend upon particular conditions of the brain, -they will be detailed under the pathology. - - - 2. _Typhus Mitior, with Acute Cerebral Affection._ - -In typhus with acute cerebral affection the pain of the head is often -not more severe than it is in the subacute; but there is a greater -degree of heaviness, or weight, or stupor, or giddiness; the eyes are -more and sooner injected and more suffused; the insensibility comes on -sooner and is deeper; the delirium appears earlier and is more violent, -frequently requiring restraint, and the whole train of symptoms already -enumerated, and which it is needless to repeat, are more intense in -degree, and succeed each other with greater rapidity. - - - CASE XII. - -JAMES SOLDEN, æt. 44, plaisterer. Admitted on the 7th day of fever: -attack came on with chilliness; great debility; some pain of head; sense -of giddiness and weight; together with symptoms of thoracic disease. At -present pain of head entirely gone; it has passed into insensibility; -mind quite delirious; almost constant moaning; pulse 96, weak; tongue -brown and dry; stools passed in bed; respiration short and hurried; -cough without expectoration; tenderness of abdomen on full pressure. - -8th. Insensibility more profound; restlessness and delirium increased; -respiration more hurried; cough the same; stools passed in bed: pulse -92. - -9th. No change. - -10th. Died. - - - CASE XIII. - -JOHN CLARK, æt. 17. Admitted on the 4th day of fever: attack commenced -with ordinary symptoms, and was attended with severe pain of the head, -which continues at present, and which is attended with a sense of -weight; eyes injected and suffused; expression of countenance extremely -dejected; sleeps none; skin pungently hot, especially over the scalp; -pulse 108, of good power; tongue already brown and quite dry; some -thirst; respiration hurried; some uneasiness of chest on coughing; -considerable tenderness of abdomen. - -5th. Eight ounces of blood which were drawn not sizy; crassamentum -loose; pain of head not at all relieved; sense of weight distressing; no -sleep; much restlessness; heat over the scalp pungent; pulse 104; tongue -more dry; tenderness of abdomen the same; six stools. - -6th. Pain of head still severe; mind more confused; passed a more -restless night; pulse 116. - -10th. Pain of head undiminished; eyes more suffused; extremely restless -night, during which delirium came on; this morning muscular tremor has -appeared; pulse 124. - -12th. Pain of head entirely gone; scarcely at all sensible; constant -muttering delirium; muscular tremor with subsultus tendinum; two stools -passed in bed; pulse 124; abdomen still painful on firm pressure, and -has become swollen and tense. - -13th. Insensibility and delirium increased; constant incoherent -muttering; extreme prostration; erysipelas has appeared on the forehead, -and is spreading to the scalp: pulse 128; two stools passed in bed. - -14th. Died. - - - II. TYPHUS MITIOR, WITH THORACIC AFFECTION. - -Prominent thoracic affection, as we have seen, is not infrequent in -synochus; in typhus it is more constant; and the signs which denote its -existence are more obvious, but they are not precisely the same. The -pain in the chest is less severe; it is more often absent altogether; -while the sense of stricture and the dyspnœa are more urgent. The cough -is more constantly attended with mucous rattle; the respiration is -shorter and more hurried. The skin in general is cooler, and it is -always more dusky. The dark colour of the skin, in severe cases, -becoming quite livid, is one of the most characteristic marks of intense -thoracic affection. The colour of the cheek is at first of a deep and -vivid red; as the disease advances it becomes of a purple tinge, and at -length it is quite livid. In these cases it is not uncommon for the -respiration to be from forty to fifty in a minute. The pulse is -invariably rapid and weak. The cerebral affection is equally peculiar -and characteristic; it never consists of intense excitement; it is never -accompanied with violent delirium; it is indicated by confusion and -stupor passing rapidly into coma; and is attended with low muttering -incoherence or disjointed rambling, the trains of ideas that pass -through the mind being extremely faint, and linked together by no -distinguishable affinity. We know that one of the most essential -conditions to the due exercise of the sensorial faculties is the due -supply of the brain with arterial blood; but in this state of the system -arterial blood does not and cannot circulate through the brain, because -it is not formed in the lung: the patient is in a state approaching to -asphyxia, and in very severe cases he remains for several days in as -perfect a state of asphyxia as seems to be compatible with life. Why -debility should, in these cases, be carried to the utmost possible -extent; why such cases should form the most exquisite specimens of the -adynamic state, need not be pointed out: the disease is concentrated in -the very organ which elaborates the pabulum of life, and that stream -which should convey its vivifying and animating influence to every nook -and point of the system is corrupted at its source. - -It is in these cases, too, that the tongue becomes dryer than in any -other; in its advanced stage it is sometimes quite black and even hard, -and is altogether incapable of being protruded. Sometimes it is covered -with a thick, black and hard crust; at other times it is cut into deep -fissures, so as to give it a cracked appearance. These states of the -tongue without doubt arise in part from the excessive dryness, -occasioned by the mouth being kept always open, on account of the -difficulty of respiring. - -Such are the most characteristic marks of thoracic affection in typhus; -as an illustration of which, as it occurs, perhaps, in the severest form -ever witnessed in this country, the following case may be cited. - - - CASE XIV. - -ALEXANDER CROMBIE, æt. 19, seaman. - -The mate of his vessel states that, notwithstanding some previous -indisposition, three days ago he was on duty; that while on watch, about -eleven o’clock at night, he became too ill to remain at his post, and -that, since that time, he has scarcely spoken a word. At present he is -incapable of giving any account of himself. He is dull, stupid, and, -when roused, is scarcely able to answer coherently; he does not speak, -but he is constantly picking at the bed-clothes; there is extreme -restlessness; the countenance is heavy and inexpressive; the features in -general are swollen, the lips especially, which are also extremely -parched. The entire skin is dusky, but the cheeks are of a deep red -colour, approaching to a purple hue; the integuments of the eye are -dark; the conjunctiva injected; the tongue brown and quite dry; the lips -and teeth sordid; respiration oppressed; occasional cough; pulse from -130 to 140; small and thrilling; skin, especially over the scalp, hot; -tenderness of abdomen on full pressure. - -4th. Cerebral symptoms the same; cough frequent, difficult; respiration -short and hurried; pupils dilated, not contracting on exposure to light; -conjunctiva injected; pulse small, hurried, irregular; all the stools -passed in bed; pressure over the abdomen induces cough and apparently -excites pain. Died in the evening. See pathology. - - - III. TYPHUS MITIOR, WITH ABDOMINAL AFFECTION. - -To the account of abdominal affection in typhus, it is necessary to add -nothing to that already given of abdominal affection in synochus, -excepting that, in the former, pain in the abdomen is scarcely ever -felt; tenderness on pressure is less acute, and it is more common for -both to be absent. On the other hand, the abdomen is more often swollen, -hard, tense and tympanitic, while the stools are more early and more -constantly passed involuntarily. It is in this type of fever, also, that -hæmorrhage from the bowels most frequently takes, place—an event not -very uncommon in the severest and the most protracted examples of the -disease. The tongue, also, is less constantly red than in the abdominal -affection of synochus; but it is more uniformly dry, black and cracked. - -Since the full exposition of pathology requires that many examples of -this affection should be detailed under that head, and since, however -numerous and striking such examples may be, they can illustrate no -characteristic symptom beyond what has been already stated, it is -unnecessary to cite any cases of it here. - - - IV. TYPHUS MITIOR, WITH MIXED AFFECTION. - -Whenever the brain, the lungs, and the intestines become simultaneously -and prominently affected in typhus, the case no longer assumes the mild, -but lapses into the severer form. We shall, therefore, speak of this -complication under— - - - II. TYPHUS GRAVIOR. - -The typhus gravior of authors is extinct; at least I have seen no -example of it in London. I have witnessed nothing bearing a tolerable -resemblance to this disease, even as it is depicted by Cullen, much less -as it is portrayed in the darkly vivid, yet apparently but too faithful -colouring of Huxham. This malady seems to have disappeared with the -epidemic intermittents and the epidemic dysenteries of the good old -times. Whatever there may have been in the condition of our ancestors to -excite our envy, there is certainly nothing to provoke it in their -diseases. - -All the examples of fever which approach in likeness to the descriptions -on record of typhus gravior which I have seen, have consisted of the -mixed cases of typhus. They have been cases in which the brain, the -lungs, and the intestines were all simultaneously and intensely -affected. The symptoms may not always denote an _equal_ degree of -affection in all these organs; but I have never seen a case in which -there were not the most unequivocal signs of intense affection in all of -them. For the reason already assigned, such cases must necessarily be -the severest that can occur, because the patient may be said to have -three diseases instead of one to contend with, each of which alone is -sufficient to destroy life, and each of which alone frequently does -destroy it. - -All the examples of this form of fever which I have observed are -referrible to two classes; one in which the arterial action is -excessive; the other in which it is oppressed, or rather overwhelmed. - -1. In the first, the patient lies insensible, with delirium, perhaps so -violent that he cannot be kept in bed without restraint; with extreme -restlessness and constant watchfulness; with rapid and panting -respiration; with a tender abdomen, perhaps with frequent and -involuntary stools, a dry, black, and hard tongue, a quick, yet weak -pulse, and the skin universally and pungently hot. - -2. In the second he lies insensible, with a cold and dusky skin; with a -swollen and livid countenance; with a heavy and oppressed respiration; -with a pulse perhaps not to be felt, or, if distinguishable, either so -rapid that it cannot be counted, so small that it is like a thread -beneath the finger, and so weak that it is lost by the slightest -pressure, or else slow, irregular, and intermittent. In this state, the -patient is almost as completely paralyzed as in apoplexy, and the attack -is almost as rapidly fatal as apoplexy. It constitutes what has been -called congestive fever. - -Fortunately, these intense forms of the disease are of rare occurrence: -they are witnessed only in solitary instances, and they arise either -from exposure to a highly-concentrated poison, or from some condition of -the constitution, by which that power to resist the influence of noxious -agents, which is characteristic of life, is more than commonly -diminished or exhausted. They have been conceived to form exquisite -specimens of diseases of debility. But where is the debility? Not in the -disease, for that is of giant strength; not in the patient, for remove, -if you can but remove, a part of the load that oppresses him, and -instantly an intensity of action will be set up in the whole system, -perhaps as great as it is capable of exerting, and certainly greater -than it is capable of sustaining without the most imminent danger. The -brain is overwhelmed by the intensity of its affection; the energy that -should animate the system, and of which it is the great source, is -withheld: but that energy is suspended, not destroyed; and the debility -which seems to be the result is not real, but apparent, not direct, but -indirect. The giant that lies prostrate on the earth, mastered by -superior power, has still a giant’s strength, though he does not at that -moment put it forth: give him but the chance of throwing off the load -that keeps him down, and he will soon shew you that he is not weak. I -have always been struck with the extraordinary clearness and decision -with which the acuteness of Sydenham enabled him to make this important -distinction, perhaps in the very first case that occurred to him, in -which the discrimination was required. Having described, in his own -powerful manner, an excellent specimen of congestive fever to which he -was called, he states that he ordered the patient to be bled: that the -bye-standers regarded the suggestion with horror: that the man seemed at -the point of death; that to them it appeared that the abstraction of -blood must inevitably extinguish the last remaining spark of life; while -to him it was manifest that the patient was in this alarming condition, -because he was oppressed by an overwhelming load, and if that could only -be lessened, his condition would be the very reverse of what it now -seemed: that accordingly, on the removal of some ounces of blood, the -state of oppression ceased at once, and fever arose of a true -inflammatory nature, for the subdual of which repeated bleedings were -required. - -It is remarkable, and it is highly characteristic of these intense forms -of disease, that their pathology exhibits a striking contrast to that of -the less severe affections. No morbid appearances are visible in the -organs which seem capable of accounting for death. There are signs of -vascularity; the vessels are turgid with blood, and consequently the -organs on which they are spent are in a state of congestion. But they -seldom if ever exhibit any real appearance of inflammation, and still -less do they contain any true inflammatory product. Why? Not on account -of debility; but because the force of the disease is so great as to -overwhelm the powers of life at the first onset, allowing even of no -reaction, and much less of that continued excitement which is part and -parcel of the inflammatory state, and which is indispensable to an -inflammatory product. Reduce the intensity of the disease a little, -bring it just within the limit that is compatible with the continuance -of life for a given time, and then the products of inflammation at once -appear in the greatest possible purity, variety, and extent. - -And this is precisely the fact, as is demonstrated by the condition of -the organs, in those ordinary types of fever, the essence of which has -been supposed to consist in debility, and which have recently assumed -the dignified name of adynamic. That men who are capable of looking only -at the most obvious appearances of things, who, satisfied with what they -find at the surface, give themselves no concern to discover its source, -should continue to mistake the effect for the cause, and to consider as -in its own primary and essential nature, that to be debility which is -the last result of long-continued and most destructive energy of action, -is highly probable; but, on that very account, the fallacy is the more -deeply to be deplored; because to these men must sometimes be committed -the care of human beings who will fall certain victims to the error. It -is easy to disregard the voice of reason when opposed to specious, -however fallacious appearances; but it is difficult to withstand the -evidence of sense. In justification of the strength of the language I -use, I therefore appeal to the pathology I adduce. The notion of -debility in the intense forms of fever I look upon to be an error no -less palpable in its nature than destructive in its consequences; and if -the havoc it produces do not confer upon it a pre-eminence as bad as -that of the very disease of which it is supposed to constitute the -essence, it at least entitles it, in comparison with every other error -in medicine, to the distinction recognized in society, between the hero -and the murderer: the one destroys a single human being now and then; -but the other numbers its victims by thousands. It may be difficult to -eradicate this mischievous opinion where it was first engendered, and -where it still continues to be fostered, in the study of the falsely -reasoning theorist; but it is easy to confute it at the table of the -pathological anatomist; and it must ultimately fall, if not by the pen, -by the scalpel. - - - - - CHAPTER V. - - _Of Scarlatina. Characters by which it is distinguished from Continued - Fever, without an Eruption. Division into Scarlatina Synochodes and - Typhodes. Events which occasionally occur in Fever, but which form - no essential Part of it._ - - -The only kind of continued fever attended with an eruption, which it -falls within the compass of the present work to notice, is that of -scarlatina, and, even in relation to this, after the full account which -has been given of the other forms of fever, it will be necessary to -state only the peculiarities by which it is distinguished. - -1. The depression of the nervous system so characteristic of synochus -and typhus, is much less in degree in scarlatina. Neither the physical -nor the mental debility is as great. In the whole attitude and manner of -the patient, as well as in his own sensations, there is less -prostration. The disease is more nearly allied to a pure inflammatory -affection than either of the preceding forms of fever. - -2. Accordingly, the circulation is not only more rapid, but it is also -more strong. It is not uncommon for the pulse to be 140 in a minute; in -severe cases it is seldom below 120. Without being hard, it is more full -and strong and less easily compressed than in the other forms of fever. - -3. Corresponding with the activity and energy of the circulation is the -increase of the temperature; the heat over the whole surface of the body -is often intense and pungent. In this fever, the temperature, as -indicated by the thermometer, rises several degrees higher than in any -other. - -4. The capillary vessels of the external skin, as is shewn by the bright -and vivid colour of its characteristic eruption, are filled with blood. -Often from the crown of the head to the sole of the foot, the external -covering of the body is in a state of inflammation, and this -inflammation constantly terminates in the death of the cuticle, whence -it is thrown off by the process of desquamation. It is not improbable -that the large quantity of blood which is thus spent upon the surface of -the body, and which is thereby diverted from the internal organs, is one -reason why the latter are not so much oppressed as in the other forms of -fever. - -5. Much as the external skin is loaded with blood, the capillary vessels -of the internal skin appear to be equally turgid with it. This is -indicated by the bright and vivid redness of the mucous membrane -covering the mouth, the tongue, the fauces and the throat. That this -redness extends beyond these external parts into the internal organs -there is abundant evidence, because, although we cannot follow it with -the eye, we can trace it by the signs of disordered function which -arise. - -6. Certain parts of the internal skin, as it covers particular organs, -is peculiarly apt to pass into inflammation, and to terminate, like -ordinary inflammation, in ulceration. The principal seats of -inflammation are the throat and the larynx; but that, on the one hand, -the inflammation extends from the throat into the stomach, is evident -from the peculiar tenderness of the epigastrium, which is almost -constant in scarlatina, and which is more acute than in ordinary fever; -and that, on the other hand, it extends from the larynx into the bronchi -and their ramifications, is evident from the symptoms of thoracic -affection, which are at once more prominent and more constant than in -the other forms of fever. The larynx, the cartilages of which are apt to -be destroyed by ulceration, in the severe and mortal cases, is now and -then attacked with a peculiar kind of laryngitis, to be further noticed -in the pathology, which is almost uniformly and most rapidly fatal. - -7. From the preceding observations, the new symptoms which are added to -the febrile train in scarlatina, and which arise out of the modification -of the fever by its complication with an inflammatory condition of the -external and internal skin, are easily understood. They are the -following: namely, - -Scarlet eruption on the skin; vivid and peculiar redness of the mouth, -tongue, fauces and throat: the presence of the disease may usually be -discovered by this peculiar and specific redness of the tongue and -throat alone, although every other characteristic symptom were absent: -pain in the throat, difficult deglutition, huskiness and hoarseness of -the voice. To these must be added other symptoms, which, though they are -sometimes present in ordinary fever, are both more constant and more -severe in scarlatina than in the latter, namely, pain in the chest, -cough, difficult and hurried respiration, duskiness, in severe cases -lividness of the cheek, often, especially in the commencement of the -attack, nausea and vomiting. - -Such are the chief peculiarities by which scarlet fever is -distinguished: in all other respects the condition of the organs, and -the symptoms which denote their disordered state are the same as in -continued fever without an eruption. - -Scarlatina occurs under two forms.—1st, With the symptoms common to -synochus, (scarlatina synochodes) a form which, however severe the -symptoms, if properly treated, rarely proves fatal. In general, it is a -trifling malady, and, when severe, its chief danger consists in its -tendency to pass into the second form, if it be neglected, or if it be -badly treated. Under the most formidable aspect it ever presents, if the -active treatment, which, when the symptoms are severe, ought always to -be employed, be resorted to with promptness and decision, in more than -ninety cases out of a hundred, those symptoms are certainly and -effectually subdued, and the disease, although it may not be cut short -at once, is at once rendered mild and safe. - -2. The second form of the disease (scarlatina typhodes) presents a -striking contrast to the first: it is one of the most highly dangerous -diseases which the practitioner in this country is ever called to -witness. It is invariably attended with the symptoms which have been -described as proper to typhus gravior. And these symptoms may consist -either of those which belong to the first form of typhus gravior, and -which have been already described,[26] or they may be those which -characterize the second, or the congestive form.[27] The former is the -most frequent, but the latter is not uncommon. The most exquisite -specimens of congestive fever which it has happened to me to witness, -have been those afforded by scarlatina: and there is no disease incident -to this climate which is more alarming, more beyond the reach of -remedies, or more rapidly fatal. Though fortunately several years may -sometimes elapse without the occurrence of a single case of it, yet -occasionally seasons return in which many cases happen. I have witnessed -two such seasons in London, and all the persons I remember to have seen -affected with it were near the age of puberty and not beyond that of -thirty. For examples of it the reader is referred to the pathology. - - * * * * * - -Before bringing to a close this account of the general phenomena of -fever, it is necessary briefly to notice some events which, because they -occasionally occur in the progress of the disease, but are not constant, -may be considered as accidental. - -1. It is not very common, but there sometimes takes place an extreme -degree of tenderness over the entire surface of the body. The -sensibility is so much increased that the patient cannot bear, without -pain, the slightest pressure. Several cases have occurred in which the -entire skin was as tender to the touch as the abdomen in some of the -abdominal cases. Whenever this preternatural sensibility occurs, it is -always in connexion with an exceedingly severe form of the disease. - -2. One of the most common occurrences in severe and protracted cases is -excoriation of the skin, and the subsequent formation of a sloughing -sore. In bad and long-continued cases of fever the powers of life are so -much exhausted, and the sources of nourishment are so completely -vitiated, that the skin and the subjacent parts have not vitality -sufficient to bear even the pressure occasioned by the weight of the -body. The most common seats of these sores are the back, the sacrum, and -the hips. They often spread far and eat deep; they are additional -sources of irritation and exhaustion to a frame already reduced to the -last extremity of feebleness, and the scale which seemed to be equally -balanced between life and death, they often turn on the side of death. - -3. In severe and protracted cases, and often coming to destroy the hope -that was beginning to spring up in favour of the patient, erysipelas is -no unusual visitant. It is the outward and visible sign of inward and -always most formidable disease. Many and many are the persons it -destroys who, but for it, would ultimately gain the victory over a -malady with which they have carried on a doubtful contest, perhaps for -fourteen or for one and twenty days. - -4. Pain, swelling, hardness and suppuration of the glands in different -parts of the body are not uncommon. The gland which most commonly -suffers is the parotid, although the submaxillary, the axillary, and -even the inguinal, are occasionally involved. These glandular affections -never take place but in formidable cases, and their occurrence sometimes -changes at once the entire character of the disease, and destroys the -slightest hope of recovery. - -5. Now and then there take place severe pain in the joints, together -with tumefaction and excessive tenderness on pressure. These events -usually come on towards the close of exceedingly bad cases, and they are -often attended with very acute suffering. Neither the occurrence of the -events nor the appearances presented on examination after death, have -hitherto been noticed, as far as I am aware, by any author. Every case -attended with this peculiar affection that I have seen, has proved -rapidly fatal. The condition of the joints, as ascertained by -dissection, will be stated in the pathology. - -Purulent discharge from the ears, deafness, spasmodic contraction of the -extremities, convulsions, all depend upon certain states of the brain, -and will be noticed when these states are spoken of. Numerous maladies -arising from various degrees and complications of disease in the lungs, -heart, pleura, viscera of the abdomen and investing membrane, not -belonging to fever, but adding to its evils, are found on examination -after death, which often fully account for anomalous symptoms that -aggravated the case during life. Of these mention will be made in the -proper place. - - - - - CHAPTER VI. - OF THE PATHOLOGY OF FEVER. - - _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. - - -II. CASES IN ILLUSTRATION OF THE MORBID CHANGES WHICH TAKE PLACE WITHIN - THE HEAD: OR CEREBRAL CASES. - - -1. _Vascularity of Brain, Spinal Cord and Membranes, with Gelatinous or - slight Serous Effusion._ - - - CASE XV. - -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. - - - CASE XVI. - -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. - - - CASE XVII. - -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.] - - - CASE XVIII. - -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. - - - CASE XIX. - -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 -œdematous; the size of the tube beyond the disease much diminished, and -the colon, especially, contracted into a mere cord.] - - - CASE XX. - -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. - - - CASE XXI. - -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. - - - CASE XXII. - -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.] - - - CASE XXIII. - -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. - - - CASE XXIV. - -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. - - - CASE XXV. - -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.] - - - CASE XXVI. - -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. - - - 2. _Vascularity of Brain, Membranes, &c. with Effusion of Coagulable - Lymph and Formation of Pus._ - - - CASE XXVII. - -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.] - - - CASE XXVIII. - -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. - - - CASE XXIX. - -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. - - - CASE XXX. - -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. - - - CASE XXXI. - -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. - - -3. _Vascularity of Brain, Membranes, &c. with copious Serous Effusion._ - - - CASE XXXII. - -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. - - - CASE XXXIII. - -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. - - - CASE XXXIV. - -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. - - - CASE XXXV. - -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. - - - CASE XXXVI. - -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. - - - CASE XXXVII. - -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. - - - CASE XXXVIII. - -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.] - - - CASE XXXIX. - -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._ - - - CASE XL. - -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. - - - CASE XLI. - -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. - - - CASE XLII. - -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.] - - - CASE XLIII. - -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. - - - CASE XLIV. - -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. - - - CASE XLV. - -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. - - - CASE XLVI. - -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.] - - - 5. _Vascularity, &c. with Softening of the Brain._ - - - CASE XLVII. - -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. - - - CASE XLVIII. - -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. - - - CASE XLIX. - -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. - - - CASE L. - -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. - - - CASE LI. - -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. - - - CASE XII. - -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. - - - CASE XIII. - -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. - - - CASE VII. - -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. - - - CASE VIII. - -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. - - - CASE XIV. - -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. - - - CASE LII. - -THOMAS LEWIS, æt. 51, taylor, admitted on the 8th day of fever. -Complaint commenced with general pains, nausea and vomiting, together -with cough and dyspnœa. 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. - - - CASE LIII. - -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. - - - CASE LIV. - -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. - - - CASE LV. - -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. - - - CASE LVI. - -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; dyspnœa 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; dyspnœa; 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. - - - CASE LVII. - -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. - - - CASE LVIII. - -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 dyspnœa, -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. - - - CASE LIX. - -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. - - - CASE LX. - -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. - - - CASE LXI. - -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; dyspnœa; 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.] - - - CASE LXII. - -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.] - - - CASE LXIII. - -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.] - - - CASE LXIV. - -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. - - - CASE LXV. - -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. - - - CASE LXVI. - -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. - - - CASE LXVII. - -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. - - - CASE LXVIII. - -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 -dyspnœa, 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. - - - CASE LXIX. - -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. - - - CASE LXX. - -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.] - - - CASE LXXI. - -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. - - - CASE LXXII. - -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. - - - CASE LXXIII. - -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.] - - - CASE LXXIV. - -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. - - - CASE LXXV. - -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. - - - CASE X. - -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. - - - CASE LXXVI. - -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. - - - CASE LXXVII. - -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 dyspnœa, 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. - - - CASE LXXVIII. - -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. - - - CASE LXXIX. - -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. - - - CASE LXXX. - -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 œdematous; 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. - - - CASE LXXXI. - -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. - - - CASE LXXXII. - -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.] - - - CASE LXXXIII. - -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. - - - CASE LXXXIV. - -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. - - - CASE LXXXV. - -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.] - - - CASE XI. - -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.] - - - CASE LXXXVI. - -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.] - - - CASE LXXXVII. - -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. - - - CASE LXXXVIII. - -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. - - - CASE LXXXIX. - -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. - - * * * * * - -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. - - - CASE XC. - -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. - - - CASE XCI. - -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. - - - CASE XCII. - -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.] - - - CASE XCIII. - -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. - - - CASE XCIV. - -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. - - - CASE XCV. - -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. - - - CASE XCVI. - -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.] - - - CASE XCVII. - -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. - - - CASE XCVIII. - -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. - - - CASE XCIX. - -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.] - - - CASE C. - -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.] - - - CASE CI. - -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. - - - CASE CII. - -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. - - - CASE CIII. - -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. - - - CASE CIV. - -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. - - - CASE CV. - -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. - - - CASE CVI. - -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. - - - CASE CVII. - -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. - - - CASE CVIII. - -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. - - - CASE CIX. - -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. - - - CASE CX. - -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 dyspnœa; 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; dyspnœa diminished; pain of head -better; slept much better; pulse 120. - -9th. After a tolerable night, attacked this morning with urgent dyspnœa, -soon became perfectly insensible; was delivered of a fœtus 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. - - * * * * * - -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. - - - - - CHAPTER VII. - - _Of the Relation between the Phenomena of Fever; or the Theory of the - Disease._ - - -In the preceding chapters it has been shown what are the real events -which take place in fever, the assemblage of which constitutes the -disease: it has also been shown in what order these events succeed each -other, and upon what conditions of what organs they depend. To assign -further the true relation between these events, is to establish the -theory of fever in the only philosophical sense of the term theory: and -that relation must already have suggested itself to the mind of the -attentive reader. - -We have seen that the first indications of disease are clearly traceable -to the nervous system: that the disorder of the functions of the brain -and spinal cord with which the attack always commences, demonstrates -that these organs form the primary seats of the malady: that the -derangement in the functions of these organs is truly _invariable_, and -is invariably the first morbid condition that is observed to take place: -that there never was a case of fever, from the slightest to the most -severe, in which these organs were not in a greater or less degree in a -disordered state, and in which that disordered state did not precede -every other. This affection of the nervous system then, the invariable -antecedent of all that follows, is the primary essential event in the -morbid series which constitutes fever. - -What the real nature of this primary affection of the nervous system is, -we are wholly ignorant, and we ought at once to confess our ignorance. -We have already entered into some considerations, derived from the -difference in the order in which the phenomena of fever and of -inflammation succeed each other, to show that these two diseases are not -identical.[30] When these phenomena are still more attentively -considered, other differences are observable between them, which confirm -the opinion that the two diseases are not the same. Not only is -derangement in the nervous and the sensorial functions invariably the -first in the series of morbid events in fever, while it is not the first -in inflammation, but that derangement is always much greater in the -former than in the latter, and proceeds in a regular and determinate -course, such as has been fully explained in the preceding pages, and to -which there is nothing analogous in the progress of inflammation. - -To the condition of inflammation a peculiar but an unknown condition of -the blood-vessels appears to be indispensable. To the state of fever, no -such condition of any part of the vascular system, as far as we have the -means of judging, is absolutely indispensable, although it be very -commonly coincident. No such condition appears to be present, at least -no such condition has yet been ascertained to be present, either in the -very mildest or in the severest form of the disease: at the latter -extreme of the scale, at least, we might expect to find the most -striking and unequivocal indications of the existence and operation of -inflammation, were that agent really present; and yet it is precisely -here that the ordinary signs of inflammatory action are completely -absent. - -Moreover, we have no example of instantaneous death by the sudden -excitement of inflammation in any organ, or in any number of organs: -inflammation is a process: a certain number of events take place in a -certain order; and there is always, as far as has been hitherto -observed, some interval between these events. A case is recorded in -which inflammation of the bowels (acute enteritis) proved fatal, as was -supposed, in eight hours from the commencement of the attack; but so -rapid was the process, that the intelligent surgeons who witnessed it -doubted whether the time when the disease began could have been noted -accurately: at all events, it does not accord with the best-established -facts relative to the process of inflammation, that it should prove -fatal without the lapse of some hours. Fever, on the contrary, does not -need as much as a single hour to complete the work of death. It is well -known that the poison which, in a certain state of concentration, -produces fever with the ordinary period of duration, in a higher state -of concentration produces instantaneous death; and that, in certain -climates and seasons, it is not uncommon for persons previously in sound -and vigorous health, on exposure to that poison, to sicken and to die in -a shorter space of time than is requisite, under ordinary circumstances, -for the mere formation of the inflammatory process. The state of the -system, in the primary attack of fever, and the state of the system in -inflammation, do not, therefore, appear to be identical. The truth is, -that we do not know what the real state of the system is in either case, -but we see that the phenomena of the one differ from those of the other; -to conclude, therefore, that the states are the same is not a sound -induction. While, then, we are constrained to admit that we know nothing -of the nature of the primary affection of the nervous system in fever, -the closest consideration of all the phenomena alike constrains us to -conclude, that that affection is peculiar and specific. - -This peculiar and specific affection appears to be much more analogous -to the condition into which the nervous system is brought by the -application of certain poisons, than to that which is proper to pure -inflammation. The more closely and extensively the subject is -investigated, the more clear and satisfactory the evidence becomes, that -the great primary cause of fever is a poison, the operation of which, -like that of some other poisons, the nature of which is better -understood, and the action of which has been more completely examined, -is ascertained to be upon the nervous system. How these poisons act upon -the nervous system we do not know, nor can we possibly know, as long as -we remain so profoundly ignorant of the nature of the action of the -nervous system in the state of health. - -It may be considered then as established, that the primary morbid -condition of the body, in fever, consists of an affection of the nervous -system, which there is reason to believe is of a peculiar and specific -nature, although that nature be at present wholly unknown. - -This specific derangement of the nervous system having continued for -some time, the vascular system becomes disturbed. How the nervous system -so influences the vascular as to bring it into the morbid condition into -which it passes, is as unknown to us as the peculiar affection of the -nervous system itself. That there is the most close and intimate -connexion between these two systems, and that they exert over each other -the most important influence both in the state of health and of disease, -are in the present state of our knowledge ultimate facts. - -With two apparent exceptions, (whether these two cases form real -exceptions may still admit of doubt) the vascular derangement connected -with, and dependant upon nervous derangement, passes sooner or later -into true inflammation. Of this we have the most complete and -indubitable evidence—evidence derived both from changes, the known -results of inflammatory action, produced in the structure of organs; and -from the generation of new products, such as are formed by no other -known process but that of inflammation. Almost every change of organic -structure which inflammation is ascertained to be capable of producing, -is found to take place in fever: almost every product which inflammation -is ascertained to be capable of forming, is observed to be generated in -fever: it is not possible to doubt, therefore, that the morbid condition -into which the vascular system is brought in the progress of fever, is -that of inflammation. In what circle of organs inflammation is -peculiarly liable to be excited in this disease, by what particular -character febrile inflammation is distinguished, and what remarkable -differences it exhibits in intensity and extent, have been fully -illustrated. - -It follows, then, that the second event that takes place in the morbid -series constituting fever, is inflammation. - -But however really and constantly inflammation may take place in fever, -and in whatever intensity, and to whatever extent it may be carried, yet -the inflammation is never pure or simple: the condition of the inflamed -organs is never the same as that into which they are brought by mere -phlegmasia: there is always inflammation, and _something else_: and if -what we have so much insisted on be true, this must necessarily be the -case, because the state of inflammation succeeds to another, a distinct, -and a pre-existing condition of the system: that something else is the -unknown, but the peculiar and specific affection of the nervous system, -which has already been stated to be the invariable antecedent of -whatever subsequent affection may take place. Thus this affection of the -nervous system is not only the invariable antecedent of every other -condition, but it is omni-present with every other condition, and its -presence is a most powerfully influential presence; it operates at every -instant, in every organ, and every function of the economy, although, as -we have seen, its operation is peculiarly great, and, as far as we can -perceive, specific in certain organs and functions. The combination of -this nervous affection with inflammation, and the influence which this -combination exerts over the inflammatory state, we express by saying -that the inflammatory state in fever is modified: we see that -inflammation is present, but we see that it is not the same as -inflammation in a pure phlegmasia: we see, as has just been stated, that -there is inflammation, and something else superadded; namely, a peculiar -affection of the nervous system, which gives to the febrile inflammation -a peculiar character, or which modifies it in a specific manner. - -It has been stated that there appear to be two exceptions to the -universality of the presence of inflammation. Of these exceptions, one -is exemplified in the mildest form of the disease. In every case of -fever, the function of the vascular system is disturbed in a greater or -less degree, as has been fully shown: but the doubt is whether that -disturbance invariably pass into the state of inflammation. Since the -morbid condition of the nervous system, in the mildest case, remains -only for a certain period, and then uniformly gives place to the return -of health, there seems to be no possible means of determining this -question. And even in the second case, where the intensity of the -nervous affection is incompatible with life, and death follows with -extreme rapidity, the real condition of the vascular system appears to -be equally doubtful. In both, that condition may possibly be a -modification of one and the same state, and that state may be identical -with inflammation—inflammation existing in different degrees of -intensity. On the other hand, both may differ essentially from the state -of inflammation. The nervous affection in the first may be too slight to -excite inflammatory action, while in the second it may be so -overwhelming as completely to oppress every function of the economy, and -therefore, instead of exciting, may paralyse the capillary -blood-vessels; and consequently paralysis of the capillary vessels, -instead of intense excitement of them, may possibly be the real -condition of the vascular system, for example, in congestive fever. - -But however this may be, the only difficulty in the subject relates to -these two forms of the disease—the very mildest and the very severest. -In all the intermediate cases, the condition of the vascular system is -clear and certain. In all these, there can be no more doubt that that -system is in a state of true inflammation, than there can be that the -capillary vessels of the pleura are in a state of inflammation in -pleuritis. Yet, as we have just stated, in fever the inflammation is -never the same as it is in pleuritis. In fever there is a combination of -a specific affection of the nervous system, with that specific affection -of the vascular system, which constitutes the state of inflammation: in -pleuritis there is the specific affection of the vascular system, -without the specific affection of the nervous; and this combination of -the two affections in fever modifies the nature of febrile inflammation. - -This view of the constitution of fever appears to explain in the most -luminous and complete manner every peculiarity of the febrile state: to -reconcile all its apparent anomalies, with which few who have studied -the subject have not been perplexed: to establish the true distinction -between fever and inflammation; and to show why the phenomena exhibited -by these two affections are so essentially different, and why therefore -each requires a different mode of treatment. In this point of view no -theory was ever more eminently practical, or led to a more guarded -practice. Inflammation does not lose its nature by being combined with -that peculiar affection of the nervous system which converts it into -fever; it only modifies its state: the remedies proper for fever do not -differ from those which are effectual in inflammation; they only require -to be modified in accordance with the modified nature of the disease. He -who believes fever to consist of an affection of the nervous system -alone, every other affection that may be combined with it being -accidental, will rarely think of using the lancet: he who believes fever -to consist of inflammation alone, and overlooks the presence of the -nervous affection, will be apt to carry the employment of the lancet too -far: he alone who embraces the view of both, brings within his own all -the phenomena: he alone adopts a sound theory of the disease, and we now -see that he alone is likely to be led to a sound practice. When the -theory of a disease collects, arranges and points out the true relation -between all its phenomena, there is good reason to conclude that that -theory is sound; but when it moreover directly leads to that treatment -of the malady which experience shows to be the most safe and the most -effectual, its truth is established by every test that can be applied to -it. - -The consideration of the diseased states of the other systems and -functions that take place in fever, need not detain us long. The -respiratory appears to be the next function that becomes deranged. The -intimate and inseparable connexion which physiology teaches us subsists -between the respiratory and the circulating systems, might lead us to -anticipate the fact which pathology demonstrates. We know that the -respiratory system is constructed for the circulating: that the form, -the extent, the complication of the respiratory apparatus depend -entirely upon the quantity of blood that is to be regenerated, and the -degree of perfection with which that regeneration is to be accomplished. -It is therefore impossible that any considerable derangement in the -function of one of these systems should continue long, without being -accompanied with a proportionate derangement in the other. The function -of respiration cannot be materially deranged, without producing a morbid -condition of the blood, that vital fluid which it is the specific object -of the process to purify and regenerate. The function of secretion -depends upon the quality of the blood conveyed to the secreting organ, -upon the action of the capillary vessels of that organ, and upon the -supply of nervous influence received by those vessels; it follows, that -in a disordered state of the nervous, the circulating and the -respiratory organs must be attended with a derangement in the process of -secretion; while the excreting being necessarily connected with the -secreting processes, the vitiation of the one cannot fail to occasion a -corresponding deterioration of the other. - -Thus we see that the organs and functions deranged in fever are closely -and inseparably connected: that no continued disorder can take place in -the one, without producing a proportionate disorder in all the others: -that a peculiar and specific affection of the first, according to the -established laws of the vital economy, invariably produces a peculiar -and specific affection of the second, and the second, a third, and so on -throughout the circle. And now we see why a certain number of organs are -invariably affected in fever; why these organs invariably become -affected in a certain order; why the nature of their affection is -invariably the same; and why, finally, the ultimate condition of the -system, the general result of these individual morbid changes, never -varies. - -Writers on fever in general have confined their account of the phenomena -of this disease to an explanation of the relation between the cold and -the hot fits. Were their success in establishing that relation as -complete as it is defective, they would still have done little or -nothing, by a view so incomprehensive, towards establishing the theory -of fever. Both the cold and the hot fits, about the exposition of which -such a theory is alone concerned, are themselves accidents, since in the -most formidable and dangerous forms of fever, the supposed relation -between these phenomena is not only constantly disturbed, but often the -phenomena themselves do not occur, it being one of the very characters -of some of the intensest fevers, that the temperature is little changed, -and that the diminished temperature which may be, or which may have been -present, is never succeeded by any increase of heat. The true theory of -this, as of every other disease, must be sought in the study of its -pathology, and can be found only by comparing the pathology of the -organs ascertained to be affected with their physiology. The cold stage -of fever, when it exists, is produced by a disturbance of the functions -of the circulation and of the respiration, and these functions are -disturbed, because the organs in which they have their seat no longer -receive their accustomed and their requisite supply of nervous influence -from the nervous system. The hot stage, when it exists, arises from a -disturbance of the same functions: and the reason why we cannot assign -with precision why the same cause produces in the one case a diminished, -and in the other an increased temperature, or why the temperature is -disturbed at all, is because we do not know with precision on what -circumstances in the animal economy the generation of heat depends: when -the physiologist has clearly and completely ascertained all the -circumstances upon which this process depends, the pathologist will -probably have but little difficulty in tracing with equal clearness and -completeness the connexion between the disturbance of that process, and -the commencement of the febrile state. - -In conclusion, then, the doctrine of fever which appears to approximate -most nearly to the truth, may be summed up in few words. The immediate -cause of fever is a poison, which operates primarily and specifically -upon the brain and the spinal cord. The diseased state into which these -organs are brought by the operation of this poison, deprives them of the -power of communicating to the system that supply of stimulus (nervous -and sensorial influence) which is requisite to maintain the functions of -the economy in the state of health. The organs, the seats of the -functions, deprived of their supply of nervous influence, become -deranged, the derangement in each taking place in a fixed order, and in -a determinate manner. Subsequently to the nervous and the sensorial, the -organs the next to suffer are those of the circulation; then those of -respiration; and, ultimately, those which belong to secretion and -excretion. The condition of the nervous system which produces this -derangement in this circle of organs, occasions further, in that portion -of the circulating system which consists of the capillary blood-vessels, -that peculiar state which constitutes inflammation: hence inflammation -is almost always established in one or more of the organs comprehended -in the febrile circle, and sometimes in all of them. The peculiar and -primary affection of the nervous system, which is here assigned as the -cause of inflammation, does not become identical with inflammation, but -superadds the morbid condition of inflammation to its own; does not -lapse into or terminate in the inflammatory state, but accompanies it, -and by this combination modifies in a peculiar manner the inflammatory -process. - -The great practical conclusion to be deduced from this doctrine of fever -is, that while the inflammatory processes that are thus set up in so -many important organs, greatly aggravate the severity of the disease, -and ought to be constantly kept in the view of the practitioner, both on -account of their own peculiar danger, and also because they are perhaps -the only real states over which he has any control, yet that these -inflammatory processes do not alone constitute fever; that their -removal, though essential to the cure, will not complete the cure; that -another, a primary, and a most formidable disease, is at the same time -to be contended with, and that the presence of this distinct and primary -disease requires very important modifications in the treatment of the -inflammatory condition. - - - - - CHAPTER VIII. - - _Of the Causes of Fever._ - - -The causes of fever are of two kinds; first, those which immediately -produce the disease, and secondly, those which bring the system into a -condition capable of being affected by the first: the former, are called -the exciting, the latter, the predisposing causes: a third has been -spoken of in relation to this as well as to other diseases, namely, the -proximate. But what is really meant by the proximate cause of disease -(if the term have any meaning) is the condition of the organ, or of the -system, produced by the operation of the exciting cause: this term, -therefore, designates an effect, not in any proper sense, a cause: it -relates to the disease itself, not to that which produces it. - - - I. OF THE IMMEDIATE, OR EXCITING CAUSE OF FEVER. - -The immediate, or the exciting cause of fever is a poison formed by the -corruption or the decomposition of organic matter. Vegetable and animal -matter, during the process of putrefaction, give off a principle, or -give origin to a new compound, which, when applied to the human body, -produces the phenomena constituting fever. What this principle or -compound is, whether it be one of the constituent substances which enter -into the composition of organised matter, or whether the primary -elements of organised matter, as they are disengaged in the process of -putrefaction, enter into some new combination, and thus generate a new -product, we are wholly ignorant. Of the composition of the poison, of -the laws which regulate its formation, and of its properties when -generated, we know nothing beyond its power to strike the human being -with sickness or death. We know that, under certain circumstances, -vegetable and animal substances will putrify: we know that a poison -capable of producing fever will result from this putrefactive process, -and we know nothing more. - -Of the conditions which are ascertained to be essential to the -putrefactive process of dead organic substance, whether vegetable or -animal, those of heat and moisture are the most certain, and as far as -we yet know, the most powerful. Accordingly, in every situation in which -circumstances concur to produce great moisture, while the heat is -maintained with some steadiness within a certain range, there the -febrile poison is invariably generated in large quantity, and in great -potency. Wherever generated, we have no means of ascertaining its -existence but by the effects it produces on the human body. Now and then -circumstances arise which illustrate these effects in an exceedingly -striking manner. This is the case when large numbers of men, previously -in a state of sound health, are simultaneously exposed to it. Examples -of such occurrences, as numerous and as complete as can be desired, were -long since recorded, among many others, by one very accurate observer, -who is of the number (no small one) of those who have given valuable -lessons to the world, which have been forgotten, and to which it is a -useful labour to recall the attention of the present age. - -“In the beginning of June, 1742,” says Sir John Pringle, in his -Observations on the Diseases of the Army, “the British troops began to -embark for Flanders. There were in all, of foot and cavalry, about -16,000: the winds were favourable, the several passages short, the men -landed in good health, and went into their several garrisons. The -head-quarters were at Ghent. During the Summer and Autumn the weather -was good, the heats moderate, and the country in general healthy. The -British officers continued well, but many of the common men sickened. -Ghent is situated between the high and the low division of Flanders; one -part of the town called St. Peter’s Hill, is much higher than the rest, -and in this, the barracks, having drains and free air, were quite dry; -so that the soldiers who lay there enjoyed perfect health. But those who -were quartered in the lower part of the town (mostly on the -ground-floors of waste houses, unprovided with drains, and of course -damp) were sickly. The battalion of the first regiment of guards was a -remarkable instance of this difference of quarters. Two of the companies -lay on St. Peter’s Hill; the remaining eight in the lower part of the -town, in rooms so very damp, that they could scarce keep their shoes and -belts from moulding. In the month of July, the sick of this battalion -amounted to about 140; of which number only two men belonged to the -companies on the hill, and the rest to those in the lower town.”[31] - -It is further stated, that in the end of August, Ostend having -surrendered, the garrison, consisting of five battalions British, was -conducted to Mons, where they continued about three weeks: that these -men had been so healthy that, when they marched out, upon the -capitulation, they left only ten sick; but that the same corps having -been put into damp barracks at Mons, while the town was surrounded with -an inundation, fever immediately appeared, and prevailed to such an -extent, that in this short space of time 250 were seized with the -disease.[32] - -Of the campaign in 1748, it is stated that the troops had scarcely been -a month in the cantonments, when the returns of the sick amounted to -2000: that afterwards the number became much greater: that those who -were near the marshes suffered by far the most, both in the number and -the violence of the symptoms; that the Greys, cantoned at Vucht (a -village within a league of Bois-le-duc, surrounded with meadows, either -then under water, or but lately drained) were the most sickly; that for -the first fortnight they had no sick, but, after continuing five weeks -in that situation, they returned about 150; after two months, 260, which -was about half the regiment; and at the end of the campaign, they had in -all but 30 men who had never been ill: that a regiment at Nieuland, -where the meadows had been floated all Winter, and were but just -drained, returned sometimes above half their number: that the Scotch -Fuzileers at Dinther, though lying at a greater distance from the -inundations, yet being quartered in a low and moist village, had above -300 ill at one time, while a regiment of dragoons, cantoned only half a -league south-west of Vucht, were in a good measure exempted from the -distress of their neighbours, such was the advantage even of that -distance from the marshes, of the wind blowing mostly from the dry -grounds, and of a situation upon an open heath, somewhat higher than the -rest. - -When the troops were in Zealand, where the poison was in a high degree -of concentration, they had not been a fortnight in the cantonments, -before several of the men belonging to those regiments which were -stationed nearest the inundations, were seized simultaneously with -lassitude and inquietude, a sensation of burning heat, intense thirst, -frequent nausea, sickness and vomiting, aching of the bones, pain in the -back, and violent headache. There were some instances of the head being -so suddenly and violently affected that, without any previous complaint, -the men ran about in a wild manner, and were believed to be mad, till -the solution of the fit by a sweat, and its periodic return, discovered -the true nature of their delirium. Most of the men were first taken ill -upon their return from forage. The regiment being cantoned close upon -the inundations, and many of the quarters being above two leagues from -the place where the magazines were kept, the men were obliged to set out -about four in the morning, in order to get back before the greatest heat -of the day. At this early hour, the meadows and marshes on each side of -the road were covered with a thick fog, of an offensive smell. The party -generally returned before noon; but several of the men, even before they -could get back to their quarters, were already in a violent fever; some, -in this short space of time, were actually delirious; and a few, on -their way home, were so suddenly taken with a phrenzy, as to throw -themselves from their trusses into the water, imagining they were to -swim to their quarters. One man, on reaching home, was suddenly seized -with intense headache, got out of his quarters, and ran about the fields -like one distracted. Three years after this sickness, it was found that -two of the men who were thus suddenly affected with phrenzy, though they -recovered of their fever, had ever since been epileptic, and that all -the rest who had been ill, remained exceedingly liable to returns of an -intermitting fever. - -The suddenness with which fever sometimes attacks individuals on board a -ship, or even an entire ship’s crew, on the approach of the vessel to a -shore where this poison is generated in large quantity, and in a high -state of concentration, illustrates its operation, perhaps, in a still -more striking manner. Dr. Maculloch, who has laboured with great ability -and zeal to recal attention to the most important and long-forgotten -subject of malaria, relates an instance of some men on board a ship, who -were seized, while the vessel was five miles from shore with fatal -cholera, the very instant the land-smell first became perceptible. -Several of these men, who were unavoidably employed on deck, died of the -disease in a few hours. The armourer of the ship, who, before he could -protect himself from the noxious blast, was accidentally delayed on deck -a few minutes, to clear an obstruction in the chain cable, was seized -with the malady while in that act, and was dead in a few hours. - -Dr. Potter states[33] that he witnessed the rise of a most malignant -yellow fever, in a valley in Pennsylvania, which contained numerous -ponds of fresh water, and which, from the heat and dryness of the -season, emitted a most offensive smell: that the fever prevailed most, -and with the greatest degree of malignity among the people who lived -nearest these ponds; and adds an exceedingly instructive case, -illustrative of the generation and operation of this cause of fever, -recorded by Major Prior, in his account of a fever which attacked the -army of the United States at Galliopolis. The source of the malady was -clearly traced to a large pond near the cantonment. When the disease was -most severe, it assumed the continued form, and was accompanied with -yellowness of the skin: when proper means were taken to destroy the -pond, the fever immediately lost its continued form, and became first -remittent, then intermittent, and ultimately disappeared. “The fever,” -says this intelligent officer, “was, I think, justly charged to a large -pond near the cantonment. An attempt had been made two or three years -before to fill it up, by felling a number of large trees that grew on -and near its margin, and by covering the wood thus fallen with earth. -This intention had not been fulfilled. In August, the weather was -extremely hot, and uncommonly dry: the water had evaporated -considerably, leaving a great quantity of muddy water, with a thick -slimy mixture of putrefying vegetables, which emitted a stench almost -intolerable. The inhabitants of the village, principally French, and -very poor, as well as filthy in their mode of living, began to suffer -first, and died so rapidly, that a general consternation seized the -whole settlement. The garrison continued healthy for some days, and we -began to console ourselves with the hope that we should escape -altogether: we were, however, soon undeceived, and the reason of our -exemption heretofore was soon discovered. The wind had blown the air -arising from the pond from the camp; but, as soon as it shifted to the -reverse point, the soldiers began to sicken: in five days, half the -garrison was on the sick list, and in ten, half of them were dead. They -were generally seized with a chill, followed by headache, pains in the -back and limbs, red eyes, constant sickness at stomach, or vomiting, and -generally, just before death, with a vomiting of matter like -coffee-grounds. They were often yellow before, but almost always after -death. The sick died generally on the seventh, ninth, and eleventh days, -though sometimes on the fifth, and on the third. As some decisive -measures became necessary to save the remainder of the troops, I first -thought of changing my quarters, but as the station was in every respect -more eligible than any other, and had been made so by much labour and -expense, I determined to try the experiment of changing the condition of -the pond, from which the disease was believed to have arisen. A ditch -was accordingly cut; what little water remained was conveyed off, and -the whole surface covered with fresh earth. The effects of this scheme -were soon obvious. Not a man was seized with the worst form of the fever -after the work was finished, and the sick were not a little benefitted, -for they generally recovered, though slowly, because the fever became a -common remittent, or gradually assumed the intermitting form. A few -cases of remitting and intermitting fever occurred occasionally, till -frost put an end to it in every form. As soon as the contents of the -pond were changed, by cutting the ditch, the cause, whatever it was, -seems to have been rendered incapable of communicating the disease in -its worst form.” - -Dr. Potter further states that, on one occasion, he saw a lady, who had -been confined three days only, and whom he found in the agonies of -death, with the skin of a deep orange colour, the eyes red and -prominent, the pulse intermittent, and ejecting copiously from the -stomach every eight or ten minutes, the secretion now known by the name -of the black vomit; that she expired in a convulsion, while he sat at -her side; that petechiæ appeared immediately after death, and that -putrefaction succeeded so rapidly, that it was necessary to order -immediate interment: that, shortly afterwards, he was called to a -gentleman who had been ill five days, and who, having expired in an hour -or two after his visit, was removed into the coffin with the utmost -difficulty, the flesh literally dropping from the bones: that, in one -family residing in a house which stood on a level piece of ground, -apparently beyond the reach of noxious exhalation, there being no -stagnant water, as was supposed, within a mile of it, he found the -mother labouring under a bilious remitting fever, which had continued -eleven days; the daughter, seventeen years of age, suffering from a -similar fever; two sons, the one between eight and nine, and the other -six, ill with dysentery; and the father, on the brink of the grave, from -a most malignant fever. There being no apparent cause for the condition -of this afflicted family, the immediate neighbourhood of the house being -free from the ordinary sources of malaria, and the adjacent country -being not unhealthy, the condition of the house itself was minutely -investigated. The cause of the evil was manifest. It appeared that the -present family had resided in the house only about five weeks; that -immediately preceding their occupation of it, a man had died suddenly in -it; that he himself (Dr. Potter) was seized with nausea and general -lassitude, immediately on leaving the house after his first visit; and -that a fever, as he supposes, was arrested by a strong dose of -tartarized antimony, which operated violently by vomiting and purging. -On examining the premises, it was found that the cellar contained water -about two feet deep, which had remained there from the first week in -June, the country having been then inundated by torrents of rain. The -cellar being useless, the door had been closed, and the only vent for -the pestiferous gases was through the floor, which was open in several -places. The family being immediately removed, all the sick became -convalescent from the time they ceased to breathe the air of the place. -The owner of the house hired two men to empty the cellar. These men -having ripped up the floor, and placed a pump in the deepest part of the -water, evacuated the cellar to the dregs in one day. On the second day -after the execution of this task, one of these men was seized with a -chilliness, succeeded by an ardent fever, which terminated with the -usual symptoms of yellow fever; namely, hæmorrhages, yellow skin and -petechiæ, and proved fatal on the third day from the attack: the day -following the seizure of the first, the second man was attacked with -similar symptoms, and died on the seventh day of the disease, with the -black vomit, in addition to the ordinary symptoms of the yellow fever. - -These examples may suffice to illustrate the operation of that febrile -poison which arises chiefly from the decomposition of vegetable matter. -The poison derived from the putrefaction of animal matter is still more -pernicious: its effects are more powerful in degree, and worse in -character; it operates more intensely on the nervous system, and less on -the vascular; and the fevers it produces are invariably of the typhoid -type, and of the continued form. - -Without doubt, a febrile poison, purely of animal origin, in a high -degree of concentration, would kill instantaneously; and when not -intense enough to strike with instantaneous death, it would produce a -continued fever with the typhoid characters, in the greatest possible -degree of completeness and perfection. And this appears to afford the -true solution of the origin of the plague. The more closely the -localities are examined of every situation in which the plague prevails, -the more abundant the sources of putrefying animal matter will appear, -and the more manifest it will become, not only that such matter must be -present, but that it must abound. And this also is one of the truths -which was known to the observers of former times, but which has been -forgotten. Were it not that the professional reading of an age, is -bounded by as strict a line as that which divides century from century; -were it not that no one reads back beyond the authority which happens to -give to the day its prevailing doctrines; were it not that the great -repository of facts treasured up in the volumes of the close observers, -though sometimes the bad reasoners of former days, thus becomes -neglected for the dogmas of some modern writer, who reasons as ill, and -who observes less, the notion that vegetable malaria produces only -intermittent fever, never could have become so prevalent as it is at -present, nor could the influence of animal malaria ever have been so -entirely overlooked. But it chanced that Cullen, in his definition of -intermittent fever, assigned the miasma of marshes as the origin of the -disease, while he makes no mention of animal malaria in his definition -of any of the forms of fever; and as this author superseded all former -authorities, by becoming the great authority of the age, few of his -successors are acquainted in the slightest degree with the writings -anterior to his period: whence it has happened that the numerous and -invaluable facts observed and recorded by his predecessors, relative to -the cause of fever, have been disregarded until they have become wholly -unknown. To cite the antient and the more modern authorities who have -observed and recorded the influence of animal malaria in the product of -plague, would be to enumerate every distinguished writer, from Pliny and -Diodorus Sicculus, down to Galen, from Galen to Mead, and from Mead to -Pringle. - -In assigning the reason why Grand Cairo, in Egypt, is the birth-place -and the cradle of the plague, Mead states that this city is crowded with -vast numbers of inhabitants, who live not only poorly, but nastily; that -the streets are narrow and close; that the city itself is situated in a -sandy plain, at the foot of a mountain, which keeps off the winds that -might refresh the air; that consequently the heat is rendered extremely -stifling; that a great canal passes through the midst of the city, which -at the overflowing of the Nile is filled with water; that on the -decrease of the river, this canal is gradually dried up, and the people -throw into it all manner of filth, carrion, offal, and so on; that the -stench which arises from this, and the mud together, is intolerably -offensive; and that, from this source, the plague constantly springing -up every year, preys upon the inhabitants, and is stopped only by the -return of the Nile, the overflowing of which washes away this load of -filth: that in Ethiopia the swarms of locusts are so prodigious, that -they sometimes cause a famine, by devouring the fruits of the earth, and -when they die, create a pestilence, by the putrefaction of their bodies; -that this putrefaction is greatly increased by the dampness of the -climate which, during the sultry heats of July and August, is often -excessive; that the effluvia which arise from this immense quantity of -putrefying animal substance, combined with so much heat and moisture, -continually generate the plague in its intensest form; and that the -Egyptians of old were so sensible how much the putrefaction of dead -animals contributed towards breeding the plague, that they worshipped -the bird Ibis, from the services it did in devouring great numbers of -serpents, which they observed injured by their stench when dead, as much -as by their bite when alive. - -Nothing can be more striking than the cases recorded by Pringle, and -which daily occurred to him of the production of fever, exquisitely -typhoid, (according to the language of that day, jail and hospital -fever) and of the sudden transition of intermittent and remittent into -the continued and typhoid type, from the presence of a poison clearly -and certainly of animal origin. Whenever wounded soldiers, with -malignant sores, or mortified limbs, were crowded together, or whenever -only a few of such diseased persons were placed in a room with the sick -from other diseases, with those labouring under intermittent and -remittent, for example, a severe and mortal typhus immediately arose; -nay, whenever men, previously in a state of sound health, were too much -crowded together for any considerable time, typhus (jail or hospital -fever) was sure to be produced. The instances of such occurrences that -are detailed, are too numerous to be cited, but they are so clearly -stated, and so striking, that they well deserve to be consulted by -whoever is desirous of clearly tracing the operation of this great cause -of fever. - -But by far the most potent febrile poison, derived from an animal -origin, is that which is formed by exhalations given off from the living -bodies of those who are affected with fever, especially when such -exhalations are pent up in a close and confined apartment. The room of a -fever-patient, in a small and heated apartment in London, with no -perflation of fresh air, is perfectly analogous to a stagnant pool in -Ethiopia, full of the bodies of dead locusts. The poison generated in -both cases is the same; the difference is merely in the degree of its -potency. Nature, with her burning sun, her stilled and pent-up wind, her -stagnant and teeming marsh, manufactures plague on a large and fearful -scale: poverty in her hut, covered with her rags, surrounded with her -filth, striving with all her might, to keep out the pure air, and to -increase the heat, imitates nature but too successfully; the process and -the product are the same, the only difference is in the magnitude of the -result. Penury and ignorance can thus at any time, and in any place, -create a mortal plague. And of this no one has ever doubted. Of the -power of the living body, even when in sound health, much more when in -disease, and above all, when that disease is fever, to produce a poison -capable of generating fever, no one disputes, and the fact has never -been called in question. Thus far the agreement among all medical men, -of all sects, and of all ages, is perfect. - -But it happens that there is another form of animal matter capable of -producing fever: namely, a matter secreted by the living body, -constituting not only a poison, but a peculiar and specific poison. This -specific poison produces not merely fever, but fever with a specific -train of symptoms. In the acknowledgment of this fact, also, the -agreement among all medical men is equally perfect. - -But some contend that the poison generated in the first case, and that -generated in the second, may both be properly called contagions: others -maintain that the application of the same term to two cases so -specifically different, destroys a distinction which it is useful to -preserve, and that it would be more correct, as well as more conducive -to clearness of conception, to call the poison generated in the first -case an infection, and to restrict the term contagion, to designate the -poison generated in the latter. Vast and immeasurable as the difference -appears to be between the contagionists and the anti-contagionists, if -regard be had merely to their language, yet if attention be paid only to -their ideas, to this, and to this only, narrow as the compass is, the -whole controversy is reduced. It resolves itself wholly into the -question, whether one word shall be used to express two cases which -differ from each other in some important circumstances, or whether it -may not be more convenient to employ two terms, and strictly to -appropriate each to designate its own specific class. It must be -manifest that, since both sects are perfectly agreed about the facts, -the dispute can be only verbal. If the one would consent to restrict -their use of the term contagious, for which there is the best authority -and ancient custom, to those diseases which arise from a specific -contagion, and would call those which arise from every other poison -infectious, there would be an end to this apparently interminable, and -in many respects mischievous, controversy. - -Is the febrile poison, whether of vegetable or animal origin, or whether -composed of both, capable of adhering to clothes, apparel, and other -substances, in such a manner as truly to infect them, so that when -applied to the bodies of the healthy, at any distance of place, and at -some distance of time, the specific effects of the poison are produced? -That such substances may be so imbued with the poison of the small-pox, -all admit: that the evidence should not be as complete relative to the -power, or the inability of such substances to convey and communicate the -poison of ordinary continued fever, is alike disgraceful to the state of -our science, and injurious to the cause of humanity. There is no reason -why the question should not be settled with absolute certainty; there is -no manner of difficulty in determining it. Experiments the most direct, -complete, and decisive, might be performed, which, if observed, during -their progress, by competent witnesses, and duly authenticated, might -ascertain the point with sufficient clearness and certainty, to satisfy -not only the present age, but future generations. Once, for all, the -full trial might be made, and if the trial were really full, it need -never be repeated. A series of experiments completely decisive of the -question, as far as regards the fever of our own country, which might be -easily extended to the plague, were some time ago drawn out, and -exertions were made to carry them into effect; but in the prevailing -state of public opinion and feeling, it was found absolutely impossible -to institute them on a scale at all adequate to render them decisive, -without the aid of Government. There seems to be no possible mode of -performing them effectually, unless Government will co-operate, by -granting a free pardon to such convicts, as will voluntarily allow -themselves to be made the subjects of them. The risk to them would be -slight, the evil to the community none; while the danger, the suffering, -the disease, the mortality that would be prevented, to say nothing of -the expense that would be spared by the decision of the question, would -be incalculable. It is earnestly to be hoped that those who have it in -their power to afford the means of putting this question at rest, will -not allow it to remain in its present unsettled state. Science, -commerce, humanity, alike demand that the truth should be ascertained. - -This subject, it is my intention to take up, and to discuss fully in a -future publication, in which will also be investigated some inquiries, -which it has been found impossible to include in the present volume; -such as whether the vegetable and animal poison we have been -considering, be the only true exciting cause of fever; by what means its -general diffusion is effected; on what conditions its propagation -depends; by what measures its extension may be checked, and its power -diminished or destroyed; what circumstances in the modes of life, in the -habits of society, in the structure of houses, in the condition of the -public streets and the common sewers, in the state of the soil over -large districts of the country, as influenced by the mode of -agriculture, drainage, and so on, favour or check the origin and -propagation of this great curse of civilized, no less than of -uncivilized man. It is obvious that these inquiries will include the -investigation of several exceedingly curious and important statistical -questions; and the object of these researches will be accomplished -should they lead to the establishment of any useful principles of -extensive application.[34] - - - II. OF THE REMOTE OR PREDISPOSING CAUSES OF FEVER. - -The remote or the predisposing causes of fever have been stated to be -those circumstances which bring the body into a condition capable of -being affected by the immediate or the exciting cause. Whatever -diminishes the vigorous action of the organs, impairs their functions, -and so weakens the general strength of the system, is capable of -becoming a predisposing cause of fever; and every predisposing cause -acts in one or other of these modes, and becomes a predisposing cause -only and in proportion as it lessens the energy of the system, or -disturbs the balance of its actions, which in fact is to render some -portion of it weak. During a state of vigorous health the body is -endowed with the power of resisting the influence of noxious agents, -which in a less perfect state of health are capable of producing intense -and fatal disease; and the action of all predisposing causes is to -lessen this resisting power, or to weaken the energies of life. - -Of all predisposing causes, the most powerful is the continued presence -and the slow operation of the immediate or the exciting cause. It is a -matter of constant observation, that the febrile poison may be present -in sufficient intensity to affect the health, without being sufficiently -potent to produce fever. In this case the energy of the action of the -organs is diminished, their functions are languidly performed, the -entire system is weakened, and this increases, until at length the power -of resistance is less than the power of the poison. Whenever this -happens, fever is induced; not that the power of the poison may be at -all increased; but the condition of the system is changed, in -consequence of which, it is capable of offering to the noxious agent -that assails it less resistance. - -We have seen that the vegetable or animal poison may exist in sufficient -intensity to produce fever on the slightest exposure to it, without the -operation of any predisposing cause, in a body in the state of the -soundest health, and endowed with the greatest degree of strength. -Examples of this kind are but too frequent in tropical climates. In -countries where the temperature never rises so high, and seldom -continues so long, it is rare that fever is produced immediately, on -exposure to the exciting cause. Concentrated and potent as that poison -is in many parts of Flanders, yet Sir John Pringle states that, in -removing to an unhealthy situation, the men rarely became ill at once; -that they generally continued in tolerable health for some days; and -that recruits recently arrived in the country, resisted the noxious -agent longer than the men who had been long there. Dr. Potter gives a -remarkable example of the same fact, with regard to the yellow fever, -which fell under his own observation, and states other facts, strikingly -illustrative of the influence and operation of the predisposing causes. -Strangers, from certain countries, he informs us, are insusceptible of -yellow fever in America. In the most malignant and protracted epidemics -which afflict that country, these strangers uniformly escape: emigrants -from the West Indies, and other warm latitudes, for example, invariably -resist the cause which produces these maladies in the native -inhabitants. But the curious fact is, that such persons are unable -permanently to resist the operation of the exciting cause; for, after a -residence in America of some years, their constitution is so completely -assimilated by the influence of the climate to that of the American, -that they become equally sensible to its febrile miasma, and are as -exquisitely impressed by them, as the American citizens themselves. The -illustration is equally striking and instructive, if the position be -reversed. The natives of northern climates are extremely susceptible to -the influence of these miasma; that susceptibility is in exact -proportion to the latitude of their country: those from the north of -Europe scarcely ever escape an attack; the natives of Great Britain are -nearly as susceptible to the influence of the poison, while persons even -from the more northern countries of the United States are more liable to -the disease than the citizens of the southern and middle states. - -Dr. Potter performed some experiments, to show that the continual -presence of the exciting cause not only operates upon the general -system, but actually produces a morbid change in the blood, before it -induces fever. During the prevalence of an epidemic, it was observed -that, in all the cases in which the patients were bled, the general -appearance of the blood was precisely the same; that the coagulum was -either of a yellow, or of a deep orange colour, and that a portion of -the red particles was invariably precipitated. It occurred to Dr. Potter -that, if the cause of the disease were contained in the common -atmosphere, the blood of those who had inhaled it a certain time would -exhibit similar phenomena; and that, should this be the case, it would -prove that the cause, before actually producing the disease, brought -about a state of the system, which predisposed it to be affected by the -poison. To ascertain the appearances of the blood in persons who were -exposed to the febrile poison, but who still remained apparently in -perfect health, he drew a quantity of blood from five persons, who had -lived during the whole epidemic season in the most infected parts of the -city. To external appearance and inward feeling, each of these persons -was in sound health. Their blood could in no respect be distinguished -from the blood of those who laboured under the most intense forms of the -prevailing fever. As it was necessary to the conclusiveness of the -experiment that their blood should be compared with the blood of those -who lived in an atmosphere unquestionably pure, Dr. Potter selected an -equal number of persons who dwelt on the hills in Baltimore country, and -drew from each of them ten ounces of blood. The contrast was most -manifest. The serum was neither of a yellow, nor of an orange colour; -there was no red precipitate; the appearances were such as are found in -the blood of persons in perfect health. - -A young gentleman having returned to the city from the western part of -Pennsylvania, on the 10th of September, in a state of sound health, Dr. -Potter drew a few ounces of blood from a vein, on the day of his -arrival; it exhibited no deviation from that of a healthy person. He -remained in the family until the 26th of the month, that is sixteen -days. On the 16th day the bleeding was repeated. The serum had assumed a -deep yellow hue, and a copious precipitation of red globules had -likewise fallen to the bottom of the vessel. - -In these experiments, the blood in six persons indicated the operation -of the morbid cause, while each remained in a state of apparent health. -Of these six persons, four were actually seized with yellow fever during -the prevalence of the epidemic; and the other two, though they escaped -any formal attack, did not escape indisposition. They were affected with -headache, nausea, and other indications of disease, like hundreds -besides, who were never absolutely confined to the house, and who never -took any medicine, but who still experienced in nausea, giddiness, -headache, pain in the extremities, and so on, abundant intimations of -the presence of the poison. - -These examples may suffice to show how the exciting, may itself become a -most powerful predisposing cause. The predisposition to subsequent -attacks, after the system has once suffered from the disease, is very -remarkable; that predisposition remains for a considerable period after -convalescence and apparent recovery. Of this, striking examples -continually occur both with regard to intermittent, and to continued -fever. In fact, the disposition to relapse, remains until the -constitution has recovered its previous strength and vigour, however -distant that period may be. The influence of cold, moisture, fatigue, -intemperance, constipation, anxiety, fear, and all the depressing -passions, are likewise extremely powerful predisposing causes. They -enable a less dose of the poison to produce fever, and they increase the -intensity of the fever when it is established. They all act by weakening -the resisting power inherent in the constitution, that is, by enfeebling -the powers of life. - - - - - CHAPTER IX. - - _Of the Treatment of Fever._ - - -We have seen that the first indication of disease in fever is traceable -to the nervous system; that the nature of this primary affection of the -nervous system is unknown; that it may possibly be the commencement of -inflammation, modified by the nature of the nervous substance, in which -the inflammatory action has its seat, and by the nature of the cause -that excites it, namely, a peculiar poison: or, on the other hand, it -may possibly be something distinct from inflammation, but having a -peculiar tendency to excite it. In either case, the inflammation that is -present in fever, is peculiar and specific, differing essentially from -ordinary or simple inflammation. Whether the affection of the nervous -system consist merely of inflammation of the nervous substance excited -by a peculiar poison; or whether it consist of some unknown condition of -the nervous system to which inflammation is superadded, and by which the -character of that inflammation is modified, the great practical result -is the same, namely, that febrile inflammation and ordinary inflammation -are not identical, and that the difference between the two affections is -such as to require a very considerable modification in the treatment -appropriate to each. - -The only morbid condition of fever, of which we have any knowledge, and -over which the medical art has any control is that of inflammation. -Although, as has been so often stated, inflammation be not the primary -febrile affection, as far as regards the order of events, yet it is, at -least, the primary affection, as far as regards the treatment, if it be -not the sole affection that admits of treatment. The remedies proper for -febrile inflammation do not differ from those which are adapted to -ordinary inflammation; but they differ materially in the mode in which -they ought to be applied, and the extent to which they ought to be -carried. They can be understood neither in their mode nor measure, until -the following questions are determined; namely, What is the precise -object that should be aimed at in the treatment of fever? What is it -which it is most important to do, and which it is in the power of the -medical art to accomplish? An exact and true answer to these questions -will afford an invaluable guide in practice: it will point out with -clearness what is to be attempted; and it will put a stop to useless and -pernicious aims. - -It is in vain to hope to terminate fever by a stroke of art. The pursuit -of a remedy, so long and so earnestly sought, endowed with the power of -cutting short the disease, is to the physician what the search after the -philosopher’s stone was to the alchymist, with this difference, that the -alchymist, engaged in a vain pursuit, lost only his time and labour; but -the physician, engaged in a pursuit equally hopeless, will often, in -addition, lose his patient. Fever cannot be cured instantaneously; and -to bring a fever patient under the influence of agents capable of -exciting a powerful influence upon the system, in the expectation of at -once removing fever, is pregnant with danger; and the expectation upon -which such practice is adopted, must appear fallacious to whoever has -studied the nature of the disease. - -Fever cannot be cured instantaneously: it may be moderated; it may be -gradually subdued; from being violent and dangerous, it may be rendered -mild and safe: the physician may bring it to this condition; and this is -all that he can accomplish. If it come under his care early, and he know -with promptitude and decision at what to aim, he will rarely fail in his -efforts to secure this object. - -Since the various forms or types of fever differ in nothing but the -degree of their intensity, in detailing the treatment, it will be -necessary only to state first of all, the remedies which are appropriate -to the disease; and, secondly, the modification of these remedies, which -may be required by the different degrees of intensity in which it is -commonly found to exist. - -1. The common continued fever of this country, in its mildest form, -requires little or no treatment. There is no affection of any organ -intense enough to need the application of a powerful remedy. All the -organs which constitute the febrile circle are deranged in their -functions, but that derangement is so slight that a cure takes place -spontaneously in the course of a few days. Confinement to the bed; the -abstraction of stimuli; fever diet; a calomel purgative at night, -consisting of one or two grains of calomel with six or ten of rhubarb, -followed in the morning with half an ounce of castor oil; and these -remedies repeated every day, or every alternate day, constitute the -whole treatment which is required. - -2. Whenever the fever passes beyond this, its mildest form, it becomes a -serious disease. It is never for a moment to be trifled with; never for -a moment to be neglected. Because it is moderate in the commencement, it -is not to be presumed that it will continue moderate through its -subsequent course: it may become most formidable; if the proper remedies -are not applied early and vigorously, it generally does become truly -alarming; the train only is apparent; the mine is concealed; the only -safety for the patient is to prevent the train from being kindled; if -that be once kindled, it may be no longer possible to save the patient -from destruction. - -When the mildest case of fever passes to a severer form, what is the -event that happens? What is the change that takes place in the organs? -The preceding pathology will, indeed, have been written in vain, if -there can now be any doubt in the mind of the reader on that point. The -great value of the facts there disclosed is, that they teach us what -happens in organs which we cannot see, and declare to us by the external -signs or symptoms, the internal actions that are going on. Out of the -hundred cases which have now been recorded, and the history of which has -been made known from its commencement to its termination, take any one, -or fix upon any number, in which the symptoms from being slight became -moderate, and from moderate severe, or, in which the symptoms were -severe from the beginning, what is found after death? Inflammation, in -general, rising in degree, and increasing in extent, or both, in -proportion to the intensity of the febrile affection. If this, which may -be justly considered as the law of the disease, be not absolutely -constant and uniform, it may be safely affirmed, at least, that there -are as few apparent exceptions to it, as to any general law that can be -named. - -The object to be aimed at in practice, then, is clear: it is to prevent, -or to remove inflammation. Accomplish this, the fever will not be cured -at once; it will still go on for some time; but it will come sooner to a -close, and it will proceed mildly and safely to its termination. Fail to -accomplish this, and the fever, however mild at first, will increase -more and more in severity until it become truly formidable, and death -take place at last, in consequence of the destruction of the organs by -the process of inflammation. - -If excitement be set up in an organ which has as invariable a tendency -to terminate in inflammation as a stone to fall to the ground, what is -the proper remedy to prevent the transition of excitement into -inflammation? Bleeding. Before we can say that inflammation is -established we may foresee that it will come: if the preceding -excitement be not stopped, we know that it will as surely come as that -blood will flow from a wounded blood-vessel. Because we cannot tell the -precise moment when increased vascular action passes into actual -inflammation, are we quietly to look on and do nothing until we have -made that discovery? We know that inflammation is at hand; we know what -will prevent it, or, at any rate, what has a powerful tendency to -prevent it: shall we not bring into immediate and vigorous use our means -of prevention, or shall we wait until the inflammatory action shall have -given unequivocal and alarming indications of its presence and operation -before we interfere? To trifle in such a manner, to lose these precious -moments when we have such a fearful, such an active, and, if once it be -allowed to become active, such a masterless enemy to contend with as -fever, is as great a folly as it would be when a building is on fire to -stand idle by as long as the fire is smouldering, and to take no measure -to extinguish it until it has burst into flame, nay, not until the flame -has spread from the floor to the ceiling, and from the ceiling to the -roof. We may not be able to see a single spark, but if we see the smoke -and feel the heat, we know that there is fire somewhere, and that -however concealed at present it will soon make itself visible enough, -and that it will consume not only the structure in which it originates, -but others with which it may come in contact if it be not put out. With -equal certainty we know that fever, though apparently mild in the -commencement, will excite inflammation in vital organs, and that that -inflammation, if it be allowed to establish itself, will place the -fabric of the body in the most imminent danger. The physician, in the -first stage of fever, armed with his lancet, is to his patient what the -fireman with his engine, before the flames have had time to kindle, is -to a building that has taken fire. At this early stage, the former can -check inflammation with almost as much ease and certainty as the latter -can prevent the flames from bursting out. On the contrary, the physician -who is called to treat inflammation in the later stage of fever is in -the position of the man who arrives with the apparatus for saving the -house when its stories have been already consumed and its roof has -fallen in. - -Bleeding in fever cannot be performed too early. The very first moment -of excitement, could that be discovered, is precisely the moment when -the employment of this powerful remedy would produce the greatest -effect. The earlier the bleeding, the greater will be the impression -made upon the disease, and the less upon the patient; or, the more -effectually will the inflammatory action be stopped by the loss of the -smallest quantity of blood. - -When inflammation has actually come on, there is then not a moment to be -lost; that inflammation must be stopped; the accomplishment of this -object is the great end which the practitioner should aim at in every -thing he attempts; until he has done this he has done nothing; until he -has done this he ought to give neither sleep to his eyes nor slumber to -his eye-lids; until he has done this he ought to feel that there should -be no rest for himself, because there is no safety for his patient. -Until the inflammation is subdued blood must be taken; be the quantity -it may be necessary to abstract, in order to accomplish this object, -what it may; be the bleedings it may be requisite to repeat what they -may; the vein must be allowed to flow, and it must be opened again and -again until this object is secured. If this golden opportunity be -allowed to escape, and this object be not obtained, the risk is most -imminent. During this early period the physician is master over the -disease; if he allow it to pass away without obtaining the victory, the -disease becomes master over the physician. From that moment his control -over it is gone. Never can he regain his lost advantage. Fever is a -process that advances with a step as steady as time, and like time it -never retraces a step. At a subsequent period its progress may be -sometimes retarded, and now and then it may be weakened; but, after the -lapse of a few days, this is all which the most complete success is then -capable of accomplishing. - -Mere relief of inflammation is nothing; to render a severe inflammation -a less severe inflammation is to do nothing; because the less severe -inflammation may be fatal just as certainly as the more severe: the -inflammation must be subdued, or the case, if not wholly lost, becomes -dangerous and doubtful. - -The abstraction of blood must be carried to the extent of subduing the -inflammation: there is no other limit to the quantity to be taken but -that which is adequate to subdue the inflammation. To attempt to measure -the quantity by drachms or ounces is wholly vain; because, if the remedy -be properly employed, the quantity will vary in every individual case. -To take an ounce more than the subdual of the inflammation requires is -injurious; to take an ounce less is still more pernicious; to take the -quantity necessary to accomplish the object, and no more, is to use the -lancet—that powerful instrument, so dangerous in rash hands, and no less -dangerous in weak, with the discernment and decision of a master. He who -with a knowledge which gives and which justifies boldness and decision, -is able thus to employ this great remedy, is a skilful physician, who -has derived from study and experience the best fruit they can yield: he -who has not yet reached this perfection of his art, (and who among us -can pretend to the attainment?) must still go on to observe and to -learn. - -The object to be accomplished then is clear; that means of obtaining it -are known; and when these means are promptly, boldly, and effectually -employed, what is the result of experience? That after all, the quantity -of blood it is necessary to abstract is not large. The tendency of the -preceding observations is not to countenance frequent and large -abstractions of blood in fever, but to save the blood of the patient, by -taking the due quantity at the proper time. Smaller bleedings will -subdue febrile than pure inflammation. Febrile inflammation, as has been -so often stated, is a modified inflammation, the modification consisting -in less activity in the vascular system and greater depression in the -nervous. Whence a moderate bleeding will make an impression upon febrile -inflammation which can be equalled in pure inflammation only by a large -bleeding. He who takes away sixteen ounces of blood in fever adopts a -bolder and more decisive practice, and brings more effectual relief to -his patient, than he who abstracts thirty ounces of blood in some other -forms of inflammation; and he who takes away six ounces of blood in one -febrile case, does more than he who takes away sixteen in another. But -the question never can be whether the bleeding should be small or large: -that is nothing. The thing to be considered is the condition of the -organs, the state of the system; not the ounces of blood to be taken, -nor the number of periods at which it is to be removed. Abstract blood -to the subdual of the inflammation—that is the rule; abstract blood at -the very commencement of the inflammatory action; if you are in time to -do it, at the very commencement of the febrile excitement. Then little -blood will be lost, and the patient will be safe. And when this is done, -nothing of importance remains to be done. The practitioner who has been -thus active in the commencement will be idle during the future progress -of the disease. Daily as he repeats his visit he will find that his -interference is not required, and will admire to see with what ease a -disease of frightful power is disarmed, and rendered innoxious, if it be -attacked in infancy, and not neglected or trifled with until it be -nurtured to maturity, and allowed, at last, to put forth unchecked the -strength of that maturity. - -If, after the abstraction of sixteen ounces of blood at the commencement -of the attack, the vascular excitement be not completely subdued, in the -course of three or four hours the same quantity must be again taken; and -if, the next morning, that excitement continue, it will probably have -already passed into inflammation; and, therefore, the vein must be once -more opened, and the blood allowed to flow until the pain, wherever -seated, be entirely removed. To check the disease, instead of subduing -it, does not in the least diminish its future strength, and, by -weakening the powers of life, it even hastens the period of mortality. -Nothing is more common than the appearance of typhoid symptoms, on the -second or third day after bleeding has done nothing but lessen the -inflammatory action; whereas, had it been carried somewhat, and -generally only a little, farther, the patient would have been -convalescent at the very period when his danger becomes most imminent. -In cases where general bleeding produces a decided impression on the -inflammation, but does not stop it, cupping, or even leeches, will often -complete what the lancet commenced. - -A due impression having been made upon the inflammation by bleeding, the -subsequent treatment should consist of purgative medicines, given to the -extent of producing three, or at most four stools in the twenty-four -hours: beyond that number no advantage is obtained by purging; more -frequent evacuations, indeed, weaken the patient, but not the disease. -The best purgatives consist of one or two grains of calomel, with six or -eight of rhubarb, repeated every night, or every other night, and -followed the next morning by two drachms, or half an ounce of castor -oil, or by the common senna draught. Cold sponging, if the skin be hot; -acidulated drink, if there be thirst; perfect quiet, a dark room, a -silent nurse, affording prompt attendance, with a noiseless step, a -cheerful countenance, and no words—this, together with three tea-cups -full of thin arrowroot or gruel, in the twenty-four hours, given in -divided portions, at intervals of about two or three hours, comprises -all else that will be required, or that will be useful, until the period -of convalescence. - -Such is the simple, but most efficient treatment appropriate to the -common fever of London and its neighbourhood (and I do not speak of the -treatment proper for any forms of the disease as it exists elsewhere, -and which I have not seen) in its ordinary degree of severity.[35] - -Suppose, however, the proper treatment not to have been applied; suppose -the case to have been neglected or mismanaged; either not to have been -seen at all, or to have been too much contemned; suppose the pain in the -head to have been not severe; that no complaint was made of it; or that -giddiness only was felt; that the skin was not burning hot, but -moderately warm; that the pulse was neither strong, nor bounding, nor -hard; but of moderate strength, and soft; that the mind was tolerably -distinct, and the restlessness not great: why should blood be drawn? -what indication is there for the employment of so violent a remedy in so -mild a case? No symptom is prominent; no symptom is urgent; the case -will do well. - -Such is the view that would be taken by the great majority of -practitioners of this kind of case, and their treatment, without doubt, -would be correspondingly inert. And this is the true origin, in many -cases, of typhus symptoms; of adynamic fever. The disease is allowed to -take its own course; and the product of every fever, at a certain stage -of its process, is adynamia: the physician does not perform his office; -the disease advances; the restlessness increases; there is no sleep; -delirium comes on; muscular tremor begins to be perceptible; the pulse -rises; the sensibility diminishes; and stupor, if it be not already -present, is close at hand. And now the disease, it is sufficiently -obvious, is severe; now, it is admitted, it calls for a powerful remedy; -and, now for the first time, the lancet is thought of. But the bleeding -relieves no symptom; it increases some; the progress of the inflammation -is not checked; the adynamic symptoms are more fully developed; the -patient is more prostrate, and the fever, in all respects of a worse -character: the inference is, that bleeding is a most inefficient and -dangerous remedy in fever; and this inference is deduced from -experience; those who draw the conclusion, judge from what they see; -they disclaim reason; they pretend only to understand and to respect the -lessons of experience. - -I appeal to the attentive observer, whether this be not a faithful -history of the progress and termination of hundreds of fever cases; -whether such a history may not be recorded as of daily occurrence; -whether what has been stated be not commonly the view, the practice, the -result, and the lesson. - -I will not appeal to the different history that belongs to cases that -are differently treated. But I do earnestly appeal to the pathology that -has been stated; that, at least, is experience, and it teaches a lesson, -which it is worse than foolish to despise or to forget. Every symptom -just enumerated, has been detailed over and over again in the cases that -have been laid before the reader: inspection after death must have made -the conditions of the organs, as indicated by those symptoms, familiar -to his mind. Of what avail can bleeding be, when the patient is brought -into the condition which first excites alarm, in the case here supposed? -The blood is no longer in its vessels; it is beneath the membranes, or -in the ventricles, or at the base of the brain; the inflamed capillaries -have done their work upon the cerebral substance and upon its membranes; -and have left proof enough of their activity, in the thickening of the -one, and the softening or the induration of the other. What can -blood-letting do in this state of the organs? What can shaving the head, -and applying cold do? What can blisters do? What can purgatives do? And -above all, what can wine do? Nothing can be done; at least, nothing -effectually or certainly. - -If there be still pain, if the sensibility be little diminished, if the -pulse be not very quick and weak, it may yet be possible to check the -further progress of the inflammation; to prevent the disorganization of -the brain from advancing; but the means to accomplish this, must now be -tried with the most extreme caution: perhaps, in the whole compass of -medical practice, there is no case which requires a nicer discrimination -than this, when it has arrived at this point. The abstraction of a few -ounces of blood may stop the inflammatory action of the vessels before -they have produced such a change of structure as is incompatible with -life, and such as the powers of life cannot repair. But if the -abstraction, even of this minute quantity of blood, at this point of the -inflammatory process, do not put a stop to that process, the remedy will -co-operate with the disease, to depress the powers of life, and will -deprive the patient of what chance of recovery he might otherwise have -had. To decide in a case which requires such nice discernment, and in -which, even with the best discernment that can be exercised, the event -must always be so doubtful, is a task which few physicians, who -understand the nature of it, find either easy or agreeable. - -But instead of bleeding, the proper remedy may possibly be the very -reverse: it may be requisite to afford a stimulus. The change of -structure produced by the inflammatory process may not have proceeded to -such an extent as to be absolutely incompatible with life; but the -powers of life maybe so exhausted by the inflammatory excitement that, -unless aid be brought to them, they will be overpowered, and sink: -afford them appropriate aid, and they will rally, and, although slowly, -ultimately repair the lesion which the organs have sustained. - -This is precisely the condition, and perhaps it is the only condition, -under which stimuli are really beneficial in fever. Whenever such -remedies are indicated, the vascular action is weak, and there appears -to be a want of due supply of arterial blood to the brain. Of all -stimuli, wine or brandy is the best. If it be doubtful whether a -stimulus can be borne, or will prove beneficial, a few ounces of wine -may be administered. It will soon be manifest whether it be the -appropriate remedy. If the restlessness, the heat, the delirium increase -under its use, it will be obvious that it cannot be borne; if, after -some hours, no perceptible impression be made upon any symptom, it is -seldom of the least service, given to any extent, or persevered in for -any length of time. If it be capable of doing any good, some improvement -in the symptoms is commonly perceptible in a few hours after it is first -administered. Sometimes that improvement is sudden and most striking; -more commonly it is slight, slow, but still easy to be seen. If the -pulse become firmer, and especially slower, the tremor slighter, the -delirium milder, the sleep sounder, the skin cooler, and, above all, if -the sensibility increase, and the strength improve, it is then the -anchor of hope. It will save the patient if it be not pushed too far, -and if it be withdrawn as soon as excitement is reproduced, should that -happen, which it often does. - -No certain indication for the administration of wine can be drawn from -one or two symptoms alone: neither from the state of the pulse, nor of -the skin, nor of the tongue; neither from the tremor, nor from the -delirium. There is an aspect about the patient, an expression not in his -countenance only, but in his attitude, in the manner in which he lies -and moves, being, in fact, the general result, as well as the outward -expression of the collective internal diseased states, that tell to the -experienced eye when it is probable that a stimulus will be useful. -Depression, loss of energy in the vascular system, as well as in the -nervous and the sensorial, indicated by a feeble, quick, and easily -compressed pulse, no less than by general prostration, afford the most -certain indications that the exhibition of wine will be advantageous: -and if the skin be at the same time cool and perspiring, the tongue -tremulous, moist, or not very dry, and the delirium consist of low -muttering incoherence, these symptoms will afford so many additional -reasons to hope that it will prove useful. On the contrary, if the skin -be hot, the eye fierce or wild, the delirium loud, noisy, requiring -restraint, and the general motions violent, it is as absurd to give -wine, as to pour oil upon a half-extinguished fire, with the view of -putting out the yet burning embers. - -When wine is indicated, but does not produce a decided effect, brandy -may be substituted. I have seen no benefit arise from giving either in -large quantity. When the condition is really present in which alone it -can be useful, a moderate quantity will accomplish the only purpose it -can serve. In every other condition, wine may be administered to any -extent, (and I have given half a pint every hour) until the stomach -return it, by vomiting, without the slightest impression being made upon -the disease, or any, or scarcely any, upon the system. The malady is in -possession of the seat of sensibility; it has destroyed the organ; it -has abolished the function: what advantage can result from the -application of stimuli? The spirit that could feel their impression, and -answer to it, is gone: organs destroyed by overstimulation, cannot be -regenerated by the application of additional stimuli: the apparatus is -broken; the wheels are clogged; the obstruction lies in that part of the -mechanism in which the main power that works the machinery is generated; -that obstruction cannot be removed; the movements of the machine must -cease. Even when the case is not thus utterly hopeless, wretched is the -physician whose only dependence for the safety of his patient is in -wine. - -These considerations ought not to make us desponding, or inert, even -under the worst circumstances, as long as the case is not absolutely -desperate; but they ought to impress deeply and indelibly upon the mind -of the practitioner who has the first charge of a fever patient, that -the disease must be conquered in the very first days, or it will -conquer, and that there are no means by which that conquest can be -rendered sure or probable, but that afforded by the lancet. - -Very much the same observations apply to the exhibition of opiates. -There is a condition of the system in which an opiate puts a stop to a -state of exhausting agitation and restlessness; procures tranquil sleep; -lessens delirium, and operates most favourably on all the symptoms. This -may be when the skin is cool and perspiring; the tongue moist, or not -very dry; the delirium low, and the pulse and the patient weak. No kind -of opiate in any form in which it can be administered ever proves in the -least degree beneficial whenever the skin is very hot, the tongue very -dry, or the general motions and actions of the patient are violent. - -Now and then the powers of life rally unexpectedly and wonderfully: they -throw off a load which appeared to have oppressed them totally and for -ever. It is therefore the duty of the medical attendant to be always at -hand until the termination even of the most desperate case, and -carefully to watch every change that takes place; for changes may -suddenly occur which may give him a clue to bring in invaluable -assistance. He may be suddenly called upon to give a stimulus; he may be -suddenly called upon to check re-excited and inordinate action. To -describe in words the countless variety of circumstances under which it -may be necessary that he should take very unexpected and decided -measures, and not a few of which may demand of him clear discernment and -nice discrimination, is quite impossible: he can acquire the power of -performing the most difficult and arduous duty he has undertaken only by -studying the disease, and by rendering himself perfectly familiar with -the principle of its treatment. - -When the inflammatory action has proceeded unsubdued and has terminated -in some change of structure, probably accompanied with copious effusion, -as indicated by the symptoms detailed under the cases illustrating -cerebral affection, advantage is sometimes obtained by affecting the -system with mercury. In this condition of the brain it is not easy to -bring the system under the influence of mercury; when it can be -accomplished, the patient is commonly, though not invariably, snatched -from death. In several instances I have known this treatment successful -under apparently the most hopeless circumstances. When the success is -most complete, the convalescence is invariably tardy, and often appears -to be doubtful; the mind for a long time remains feeble, infirm, and -almost fatuous; and, as in the two cases recorded by Pringle, though -such patients recover of their fever, it is long before the nervous and -the sensorial systems are restored to a sound state. The best mode of -exhibiting mercury is in the form of a pill, consisting of two grains of -calomel with half a grain of opium, given every three, four, or six -hours. - -3. To a fever which is severe from the commencement the preceding -observations apply with double force. Then, if the most powerful -remedies are not immediately employed, and if they are not brought to -bear at once upon the severe symptoms in the completest combination, the -case is wholly lost. The delay of an hour is pregnant with danger; the -delay of a few hours places the efficacy of any measures that can be -taken in great uncertainty; and the delay of a day or two renders their -most vigorous application utterly useless. Whereas, knowing, as we now -know, the condition of the organs upon which the severity of every case -depends, and knowing remedies appropriate to that condition of sovereign -efficacy, exceedingly few of such cases would be lost were these -remedies employed with due vigour at the commencement of the attack. The -typhoid symptoms with which it is commonly thought such cases commence -would never appear. The patient would be convalescent, or at least would -labour only under a mild form of fever at the period when, without these -remedies, his condition would be hopeless. The practitioner ought never -for a moment to forget that it is in the power of early and active -treatment to deprive these severe cases of all their severity and, -consequently, of all their danger; but that, after the lapse of a day or -two, all human skill will be exerted in vain. - -It remains to say a word or two relative to the modification of the more -powerful remedies, as the prominent affection may have its seat in the -brain, the lungs, or the intestines. - - - I. OF THE MODIFICATION OF THE TREATMENT IN CEREBRAL AFFECTION. - -The treatment in a cerebral case of moderate severity has been already -sufficiently explained. Blood must be drawn to the subdual of the -inflammation, and if blood be abstracted early, two, or at most three, -moderate bleedings will be all that will be required. - -But when the attack commences with severe cerebral affection, the -bleeding must be proportionally large, and early as it is copious. A -bleeding adequate to subdue a moderate, will be utterly inert in a -severe degree of cerebral disease. I give, as a specimen of what may be -sometimes required, the case of Dr. DILL. I saw my friend at the very -commencement of his attack, and was, therefore, able to carry into -effect what I conceive to be the proper treatment with due promptitude -and vigour. I saw him before there was any pain in the head, or even in -the back, while he was yet only feeble and chilly. The aspect of his -countenance, the state of his pulse, and the answers he returned to two -or three questions, satisfied me of the inordinate, I may say the -ferocious, attack that was at hand. Having taken an emetic without -delay, as soon as its operation was over, blood was taken from the arm -to the extent of twenty ounces. During the night, severe pain in the -limbs, especially in the loins, and intense pain in the head came on. -The blood that was taken on the preceding evening was not inflamed. -Early in the morning he was again bled to the extent of about sixteen -ounces, with great diminution, but not entire removal of the pain: the -pain not lessening, towards the afternoon he was again bled to the same -extent: the pain was now quite gone; the blood from both these bleedings -was intensely inflamed. During the night the pain returned, and, in the -morning, the eyes were dull and beginning to be suffused, while the -pulse continued slow and intermittent, and the respiration suspirious; -but the face was blanched, and the pulse, in addition to its other -characters, was weak. Instead of opening the vein afresh, twelve leeches -were applied to the temples; these very much relieved, but still did not -entirely remove the pain; for this reason, he was cupped to the extent -of sixteen ounces: this operation afforded very great relief, and he -continued easy until the following evening, when the pain returned, and -he was again cupped on the temples to the same extent. Immediate relief -followed this second operation; but, unfortunately, the pain returned -with great violence towards evening, and it was now impossible to carry -the bleeding any farther. Within twenty-four hours, it was plain that -typhoid symptoms in abundance would be present, for the fur on the -tongue was becoming brown, and there was already slight tremor in the -hands. No more blood could be taken with any prospect of advantage, nor -even with safety; yet, without the aid of some powerful remedy the case -was lost. - -The whole scalp was now enveloped in ice, but so intense was the heat of -the head that it was melted in a few minutes, and the clothes, steeped -in the evaporating lotion, dried with extraordinary rapidity. Neither of -these expedients produced the least perceptible effect. - -What was to be done? Recourse was had to a measure the efficacy of which -is but little known and less appreciated; a remedy the power of which is -second only, if, under some circumstances, it be not even superior, to -that of the lancet; a remedy which can never supercede the lancet nor -dispense with it, but which, when added to it, forms by the combination -a treatment so powerful and efficacious that it might render death, from -the acutest cerebral inflammation, as rare as recovery is at present. - -This remedy is known by the name of the cold dash. It consists of -pouring a column of cold water upon the head in a continued stream from -a height of from six to ten feet. The mode of applying it is as follows. -The patient is seated in a large tub; a table is placed at the side of -the tub upon which a man stands, and at as great an elevation as his -arms can reach, pours upon the naked head of the patient a steady but -continued stream of cold or iced water, from a watering-pot without the -rose. The stream is made to fall as nearly as possible upon one and the -same spot. At first the elevation must be slight, for the shock is too -violent if the stream be poured at once from the highest point. There is -a record, that in the East, where ingenuity so long laboured for tyranny -to invent the most exquisite modes of torment, the victim was placed -with his bare head under a small stream of cold water which was so -directed as to fall unceasingly upon one spot. In this instance cruelty -was cheated of its object by its ignorance of the mode in which its -expedient operated. The device was well adapted to kill but not to -produce pain, for insensibility must soon have put an end to suffering. - -Employed as a remedy, there is no degree of burning heat which the -animal economy is capable of producing, no intensity of vascular action, -and no violence of pain that can resist its continued application. -Sooner or later, usually in from ten to twenty minutes, the heat, though -most intense, disappears, the skin becomes cold, the face pallid, the -features shrunk, while the pulse is reduced to a mere thread, and the -pain of the head, however violent and intolerable, entirely ceases. -After the patient has been wiped dry, which he should be as rapidly as -possible, and placed in bed, the symptoms may soon return in all their -violence; the same process will again remove them, and as often as the -former recur the latter must be repeated. Three or four repetitions will -commonly suffice to subdue the most intense cerebral affection. In the -case of Dr. Dill, the relief it brought was instantaneous and most -complete. From a state of intense suffering it rendered him perfectly -easy, and from a state of imminent danger, safe. I had no anxiety about -him from the moment he came out of his tub, although it was necessary to -pass him through the same ordeal three times; but he himself having -tried this remedy on his sister, having in her case witnessed its -efficacy, and now felt it in his own, was extremely desirous that it -should be repeated as soon as he was conscious of any return of pain. In -consequence of its application, together with the copious depletion that -preceded it, at the period when under ordinary treatment, the most -exquisite typhoid symptoms would have been present, he was -convalescent.[36] If we consider how powerful the abstraction of caloric -must be by every fresh current of water that falls upon the head, to -what a mere thread the minute external blood-vessels must be -constringed, and consequently to what an extent the internal must be -affected, we shall not wonder at its efficacy. Powerful as the cold -affusion is when exhibited in its ordinary mode, yet the impression it -makes upon the brain, compared with the effect produced by this remedy, -may be said to be what the application of six leeches to the temples is -to the abstraction of thirty ounces of blood. - -Cold applications to the head, and evaporating or iced lotions, are -useful in mild cases; they may keep up the effect produced by this in -the more severe, but to hope to control the latter by their aid alone, -is to expect to coerce a giant, by twisting around his arms a spider’s -thread. - - - II. OF THE MODIFICATION OF TREATMENT IN THORACIC AFFECTION. - -Fortunately, there is a remedy nearly as powerful and efficacious in -intense thoracic affection, as blood-letting and the cold dash are in -the cerebral. In the severe bronchial affection of fever, blood-letting -is of little avail. It seems to have scarcely any control over the -peculiar affection of the lining membrane of the bronchial tubes, or -even over the inflammation of the substance of the lung, which so often -accompanies the intense form of thoracic disease. It weakens the -patient, without making a decided impression upon the disease. Laennec -states that the pathology of pneumonia could scarcely be learnt under -his practice; for that he treated the disease, not by blood-letting, but -by tartar emetic; and that all his patients recovered. I thought this -one of the exaggerated statements in which medical writers sometimes -delight to indulge; but it immediately occurred to me that this remedy -might prove exceedingly efficacious in the bronchitis of fever. Its -efficacy has surpassed my expectation. It seldom fails if exhibited with -promptitude and decision. The mode in which it is most efficiently -administered, is in doses of two grains, dissolved in an ounce of water, -and repeated every second, third, fourth, or sixth hour, according to -the severity of the case. - -In the slight bronchial affection, which is so constantly present in -fever, nothing is required but the mucilage of gum-arabic, or a little -of the almond emulsion now and then, with the tincture of hyosciamus, or -two or three grains of the compound powder of ipecacuanha, to allay the -irritation of the cough. The inflammation of the mucous membrane, when -slight, spontaneously subsides. - - - III. OF THE MODIFICATION OF THE TREATMENT IN ABDOMINAL AFFECTION. - -No remedy at all comparable in efficacy to the preceding has yet been -discovered for the inflammation of the mucous membrane of the -intestines, which forms so constant and formidable a part of the organic -affection of fever. General bleeding has but little influence over the -disease. If employed early and with due activity, it will prevent the -affection from occurring, but, when once it has supervened, large -bleedings are out of the question, and even small and repeated bleedings -are not as effectual as leeches. In severe cases, the abdomen should be -covered with leeches, and they should be re-applied daily, until the -pain and tenderness are gone, or, at least, have become slight, for it -is often impossible entirely to remove the tenderness. The abdomen -should be covered with a poultice as soon as the leeches fall off. -Afterwards, the application of a linen rag, moistened constantly with -the oleum terebinthinæ, keeps up the effect produced by the leeches, -and, when the affection is slight, may supersede their use altogether. - -When the purging is considerable, five grains of the hydrargyrum cum -cretâ, with five of the pulvis ipecacuanhæ compositus, given every night -or every night and morning, often checks it; if this remedy fail, a -stronger opiate may be exhibited, and sometimes an anodyne enema may be -administered with great advantage. If there be constipation, one or two -drachms of castor oil is the proper laxative. Active or irritating -purgatives are highly injurious. - -When blood is mixed with the stools or there is considerable hæmorrhage -from the intestines, every thing that can irritate the mucous membrane -must be carefully avoided. The mineral acids sometimes appear to check -the discharge. The infusion of roses rendered stronger by the addition -of a few drops of the sulphuric acid, is a convenient mode of -administering such medicines, and the efficacy of the draught is -sometimes improved by the addition of a drachm of the tincture of -hyosciamus. It is not uncommon for copious discharges of blood to -alternate with constipation. In this case the mildest laxative must be -administered with caution. The powers of life are sometimes so -prostrate, that three or four stools, excited by purgative medicines, -are sufficient to exhaust them. A tea-spoonful of castor oil, repeated -at intervals of six hours, is all that should be attempted. Now and then -a stimulant has a greater effect in checking the hæmorrhage than an -astringent, and then the oleum terebinthinæ is the best remedy. - - - IV. We have spoken of a fever still more intense - -even than this, severe as it is, under the name of the intensest form of -fever. And of this, the same may be said as was stated of the mildest, -that there is little or nothing to be done. As far as regards the -treatment, the two extremes of fever, the mildest and the most intense, -meet, for in the first no remedies are required, and in the second, none -are of any avail. In these latter cases, there is no remedy and no -combination of remedies yet known, capable of affording effectual aid. -The abstraction of the smallest quantity of blood is fatal: the -application of the cold bath is out of the question; the warm bath is -inert; the vapour-bath affords rather more prospect of benefit; but the -proper remedies, if any exist, remain to be discovered. - -When a person has swallowed a certain quantity of laudanum, there are -remedies which are capable of counteracting the poison and of saving the -patient. When he has swallowed a larger dose, provided it amount to a -certain quantity, no remedies will avail, excepting the application of -the stomach-pump. Unless the poison be promptly expelled from the -system, adopt with the utmost vigour the best-concerted expedients which -the medical art can supply, the patient will die. A person afflicted -with the intensest form of fever, is in the condition of a person who -has swallowed this large dose of poison. When a pump is invented, -capable of extracting _his_ poison from the brain, he may be saved. - - - V. OF THE TREATMENT OF SCARLET FEVER. - -Little modification is required in the treatment of scarlet fever. The -most important difference between continued fever without and with an -eruption, is the greater predominance of nervous affection in the former -and of inflammatory affection in the latter. Accordingly, in scarlatina -there is not only a greater tendency to inflammation than in ordinary -fever, but the inflammation which is set up in the febrile circle of -organs approximates more to the character of pure inflammation. There is -greater vascular action, with less nervous and sensorial depression. The -consequence is, that blood-letting may be carried to a greater extent, -and will be attended with still more decided and more certain efficacy -than in ordinary fever. After a decided impression has been made upon -the vascular excitement by general bleeding, the application of ten or -twelve leeches to the throat is of sovereign efficacy. If scarlatina be -treated in this manner on the second day, or sometimes even on the -third, though it commence with exceedingly severe symptoms, yet the -patient will be convalescent in the course of three or four days. - -It is not probable that much advantage would be derived from the detail -of numerous cases to illustrate the modification of treatment, and the -circumstances under which particular remedies should be chosen. A few -are subjoined as specimens of the ordinary extent to which bleeding may -be carried, and of the usual conditions under which wine may be -exhibited, and of the results, when favourable, produced by each remedy. - - - CASE CXI. - -MARY ANN HUNT, æt. 24, servant. Admitted on the 14th day of fever: -attack commenced with shivering, succeeded by heat, nausea, and -head-ache; until last night, has had no stool for five days. At present, -no pain of head or chest; much pain of limbs; sleeps well; severe pain -over the epigastrium, increased considerably by coughing and by -pressure; tongue thickly coated with a whitish-yellow fur, through which -the papillæ appear large and prominent; much thirst; no appetite; no -stool to-day; skin warm; catamenia regular; pulse 135, of good strength. - -V.S. ad ℥xxvj. Haust. Sennæ Sal. quam primum. Acid. Mist. pro potu. -Mist. Acet. Amm. C. 6tâ q. h. - -15th. Pain of limbs quite gone; that of epigastrium also entirely -removed; no tenderness on the fullest pressure; tongue more clean; less -thirst; several stools; slept well; skin cool; pulse 84, soft. Blood in -both basons very buffy. Cont. med. - -16th. Continues quite free from pain; tongue nearly clean; two stools; -skin cool, moist; pulse 88. Pt. med. - -18th. No return of pain; tongue clean; pulse 87; four stools; skin -natural. Pt. med. - -22d. Sat up yesterday and the day before, since which the skin has -become more warm, the pulse more quick, and the tongue more loaded, but -there is no local pain, and the bowels are open. - -23d. Pains of limbs returned; slept ill; tongue loaded at root; pulse -110. - -24th. Pains diminished; pulse 100; tongue still furred; skin warm. - -26th. Pains gone; skin cool and moist; tongue the same; two stools; -pulse 100. - -28th. Tongue more clean; skin warm; pulse 76. - -35th. Convalescent. Inf. Case. c. Senna bis. - -41st. Dismissed cured. - - - CASE CXII. - -ELEANOR WELBY, æt. 21, servant. Attacked four days ago with chilliness, -shivering and pain of head. At present, pain of head gone; mind -distinct; little or no sleep; eyes suffused and injected; no uneasiness -of chest nor cough; throat sore, with difficult deglutition; tenderness -of abdomen on pressure; tongue loaded on body with white fur, extremely -red at edges and tip; lips and teeth sordid; some thirst; bowels -regular; pulse 129, of good strength, yet easily compressed; -efflorescence of skin of dark red colour, approaching to a dusky hue. -V.S. ad xvj. Hirud. viij. gutturi. Ol. Ricini, ʒiij. quam primum. Mist. -Acid. pro potu. - -6th. No uneasiness of head; slept ill; eyes suffused and injected; face -swollen; still complains of soreness of throat, which is undiminished; -tongue moist; teeth sordid; lips sordid and cracked; less thirst; three -stools; pulse 120, firm; blood very sizy and cupped. Rep. V.S. ad ℥xiij. -et Hirudines viij. gutturi. Pt. Med. - -7th. Expression of countenance more natural; face less swollen; more -sleep; throat greatly relieved; deglutition quite easy; no tenderness of -abdomen on full pressure; tongue more clean and moist; lips and teeth -less sordid; pulse 111; eruption less distinct. Haustus Sennæ Sal. c. m. - -8th. No uneasiness of head, throat, or abdomen; sleep natural; tongue -beginning to clean, much less red; pulse 114; skin exfoliating. - -9th. Convalescent. - -14th. Has been gradually gaining strength and is now quite well. -Dismissed cured. - - - CASE CXIII. - -MARY JONES, æt. 33, married. Three days ago attacked with shivering, -succeeded by glows of heat, severe pain in the back and lower -extremities, with much head-ache. At present, pain of head severe, -especially over the forehead; mind distinct; scarcely any sleep; no -uneasiness of chest; some cough; abdomen tender on pressure; tongue not -much loaded; some thirst; no appetite; one stool; pulse 108, of some -power.—V.S. ad ℥xvj. Ol. Ricini, ʒiij. q. p. Mist. Acid. pro potu. - -Hora 3tia, p. m. Pain of head diminished since the bleeding, but by no -means removed; much pain of back; some of abdomen; pulse 112, strong, -full, sharp, and not easily compressed. Blood with firm and thick buff. -Rep. V.S. ad ℥xvj. statim. Pulv. Aper. Mit. h. s. - -4th. After the second bleeding last night, the pain was entirely -removed: she slept well, and the pain continued absent until this -morning, when it returned with great severity, or rather violence. She -was bled to the extent of fourteen ounces with immediate and great -relief: blood in both cups with firm buff and proportion of crassamentum -large: at present, the head is quite free from pain; there is scarcely -any pain in the back; no tenderness of the abdomen; tongue loaded in -middle with white fur, moist at edges, of natural colour; four stools; -pulse 120, weak.—Pt. med. - -5th. No return of pain in the head; that of back continues; slept ill; -tongue much more clean and quite moist; four stools; pulse 120, weak; -skin warm and damp. Omit. pulv. Pt. alia med. - -6th. Pain of head returned with great severity last night, for which she -was bled to the extent of four ounces with only temporary relief; no -sleep on account of the severity of the pain; skin hot; entire scalp -extremely hot; face pallid; nothing unnatural in the appearance of the -eye, and no intolerance of light; pulse 120, sharp, but easily -compressed; tongue loaded with white fur; thirst; four stools; buff on -blood pretty firm. - -C. C. ad ℥x. nuchæ. Camphoræ, gr. v. c. Extract. Hyosci. gr. iij. 6ta. -q. h. Pulv. Aper. Mit. h. s. Lotio frigida capiti raso. - -7th. Pain of the head entirely removed since the cupping, and has not -since returned; slept well; face continues very pallid; tongue loaded -with white fur in middle; very pallid; pulse 120, of good strength; -feels quite easy, but very weak. Cont. Pilulæ. Capt. Haust. Quininæ -Sulph. 6ta. q. h. - -8th. No return of pain in the head; some in loins; scarcely any sleep; -tongue the same; four stools; pulse small and extremely weak. Pt. Med. -omnia. Capt. Vini Albi, ℥iv. in dies. - -9th. Free from pain in the head, back, and every organ; scarcely any -sleep; much restlessness; delirium; countenance pallid and sunk; feels -very weak; tongue the same; four stools; pulse 120, not so weak as -yesterday. Pt. Med. Vini Albi ad ℥viij. - -10th. Slept ill; much restlessness and delirium; frequent and deep -sighing; severe pain in the lower extremities recurring in paroxysms; -she says the pain is as if some one were rending her limbs from her; -tongue white, moist; four stools; pulse 110, weak; takes and relishes -her wine. Statim capiat Haustus Anodynus, c. Liq. Opii Sedativi, gtts. -xl. Augt. Vini Albi, ad ℥x. Cont. alia med. - -11th. Long and tranquil sleep after the draught; less delirium; no -sighing; no return of pains in the limbs; mind perfectly distinct; -“feels greatly better;” countenance much more animated; tongue the same; -pulse 108, more strong and firm, but still easily compressed. Cont. Med. -Rept. Haustus Anodynus hora decubitus. - -12th. Slept well all night; “feels very much better to-day;” no return -of pain; complains only of sense of lowness; pulse 96, weak. Pt. Med. -omnia. - -13th. Continues to improve in all respects. - -14th. Feels stronger; pulse 108, of good strength; occasional muscular -tremor. Pt. - -18th. Continues steadily to improve. Pt. Jus. Bov. lbj. in dies. Vini -Albi, ℥vj. - -23d. Convalescent. Omit. Med. Inf. Cascaril. c. Senna, bis. - -33d. Free from complaint. Dismissed cured. - -In this case bleeding was carried to the utmost extent to which it could -be carried with safety, and rather beyond it; but it was one of those -cases in which less was to be apprehended from the bleeding than from -the disease. - - - CASE CXIV. - -FRANCES JACOB, æt. 17, destitute. Four days ago seized with nausea, -vomiting, headache, and other febrile symptoms. At present, much pain of -epigastrium, which is extremely tender on pressure; throat sore; -deglutition very painful; much vertigo; scarcely any headache; no sleep; -mind confused through the night; some pain of chest on full inspiration; -cough, with viscid copious sputa; very considerable dyspnœa; aspect of -countenance leaden-coloured and oppressed; skin warm, of a dusky, -unhealthy red colour; tongue very red, not much loaded; bowels -constipated; pulse 135, tremulous and indistinct. Abradat. Capillitium. -Hirud. viij. faucibus externis. Postea Empl. Emoll. Empl. Lyttæ nuchæ. -Inhal. Vap. Aq. Calid. Garg. c. Borat Sodæ. Ol. Ricini ʒiij. q. p. Pulv. -Aper. Mit. h. s. - -5th. No pain of head; no sleep; mind confused; much low talkative -delirium; still uneasiness of chest on full inspiration; throat less -painful; deglutition more easy; dyspnœa and cough the same; abdomen -tender; tongue unchanged; four stools; pulse 120, feeble and indistinct; -skin covered universally with very unhealthy red, dusky efflorescence. -Pulv. Aper. Mit. h. s. Mist. Camphor, ℥iss. c. Tt. Hyosciami, ʒj. et -Ammon. Carbon, gr. x. 4ta. q. h. Vini Albi, ℥vi. in dies. - -6th. Much delirium; some sleep; skin of same colour; rather more -sensible to-day; says she has no pain of head, but sense of severe -soreness all over her; much cough; four stools; pulse 120, weak. Pt. -Med. et Vin. - -7th. Slept well; less delirium; “feels much better;” countenance greatly -improved; skin more warm; colour much more natural; throat still -painful; deglutition difficult; some tenderness of the epigastrium on -full pressure; scarcely any over the abdomen; tongue red at edges, brown -and dry in middle; much thirst; three stools; pulse 108, soft, not very -weak; lips and mouth surrounded with an herpetic eruption; skin not -abraded, but covered with soft scab. Pt. Med. omnia. - -8th. Slept well; asleep at present; no delirium pulse 108, soft. - -9th. Still more improved; pulse 96, soft. - -13th. Pulse 87; other symptoms the same. Pt. - -14th. Complains more of pain of epigastrium, which is considerably -tender on pressure; other symptoms the same. Catap. Sinap. epigast. Pt. -alia. - -15th. Epigastrium much relieved; other symptoms the same. Pt. - -18th. Convalescent. - -24th. Dismissed cured. - - - CASE CXV. - -MARGARET SKEY, æt. 37, married. Five days ago attacked with sense of -cold, shivering, and heat, together with pains in the bones. At present -complains of pain in small of back; no headache; no pain of chest; some -cough; no tenderness of abdomen; tongue white and dry; much thirst; -bowels constipated; sleeps tolerably; pulse 112. Haust. Sennæ Sal. q. p. -et c. m. Rep. Mist. Acid. pro potu. - -6th. Abdomen very tender; tongue red; four stools; much thirst; skin -warm; face flushed; pulse 100, easily compressed. Hirud. x. abdom. -Postea Catap. Emoll. Rep. alia. - -8th. Much delirium through the night; considerable muscular tremor; pain -of abdomen gone; tongue tremulous, but not much coated; much thirst; -four stools; pulse 100, weak; frequent shivering. R. Quininæ Sulph. gr. -ij. Aq. Rosae, ℥j. M. Sit Haustus, 6tis. q. h. sumendus. Jus. Bov. lbj. -in dies. Rep. alia. - -10th. No sleep; mind confused; two stools passed in bed; urine in bed; -respiration laborious; pulse 90, weak. Alcohol (brandy) ℥iv. ex Aqua per -diem. Pt. Med. - -13th. Slept better; less delirium; two stools not passed in bed; pulse -96. - -15th. More power; stools not passed in bed; other symptoms the same. Pt. - -17th. Strength again rather diminished; tongue rather brown; much -thirst; pulse 100; no pain. Pt. - -21st. Little change, excepting that the tongue is more brown, dry, and -tremulous; pulse 108, extremely feeble; mind distinct; no delirium; two -stools. Aug. Alcohol ad ℥vj. - -22d. Tongue less brown and more moist; pulse 108, stronger; slept well. -Pt. - -24th. Countenance much more animated; tongue more clean, quite moist, -still brown towards root; pulse 110. Pt. - -25th. Countenance still more improved; tongue more clean; no longer -brown; pulse 102, weak. - -26th. Much improved; tongue nearly clean; two stools; pulse 108, weak. - -27th. Gains strength. Alcohol ad ℥iij. - -34th. Convalescent, but still very weak. Cerevis. lbj. Pt. alia. - -45th. Has been gradually, though very slowly gaining strength; tongue -now clean; appetite good; bowels regular (Low Diet); 2 ozs. meat daily. - -52d. Dismissed cured. - - - II. TREATMENT DURING THE CONVALESCENCE. - -The management of the convalescence is one of the most difficult parts -of the treatment and one of the most unsuccessful, not because there is -any thing which requires to be done, nor because there is any disease -which prevents recovery, but because the patient is considered as well -when he is only convalescent. Of the great tendency there is to relapse -during the whole of this period few medical men are sufficiently aware, -and the unprofessional attendants on the sick are totally ignorant of -it. For a long time the brain, the bronchi, and the intestines remain so -irritable that the slightest excitement is capable of renewing the -diseased action which has recently subsided; but without excitement of -some kind, that renewal never takes place. It is the duty of the -physician and the nurse to guard the patient from such excitement, which -they may always do completely; so that whenever there is a relapse, the -physician, or the nurse, or both must be in fault: as long as they -perform their duty with judgment and firmness there is no such thing; -but this part of their duty which is extremely simple, they cannot be -induced to believe to be of importance: no one who has not seen death -happen over and over again from the neglect of it will believe it, and -even those upon whom melancholy experience has impressed the truth most -strongly, constantly allow themselves to be surprised at the slightness -of the excitement by which, and the advanced period of the convalescence -at which relapse may happen. It is not easy for a nurse to resist -incessant importunity and even reproach; and there are suspicions to -which a physician is subjected, which, when he sees that they are -entertained, it requires some moral courage to enable him to bear. -Without doubt he deserves the worst that can attach to him if he allow -the caprice, or the impatience, or the injustice of his patient, or any -earthly consideration to induce him to swerve from the faithful -discharge of the duty he has undertaken. The unreasonableness of the -convalescent, should be considered and treated as the delirium of the -preceding stage. - -The mismanagement of the convalescence consists chiefly in allowing the -patient to rise too early from bed, and to take solid food too soon and -in too large a quantity; and these are by far the most frequent causes -of relapse. Were I to place on record all the instances I have seen of -fatal relapse from these two causes alone, the list would be frightful. -Many patients, the very day they become convalescent, think they ought -to be allowed to get up. They feel well, they think they are so; they -earnestly declare that they are so. They are impatient of bed; they -imagine it keeps them weak: “if you would but allow me to rise how -thankful I should be; how much more it would refresh and strengthen me -than any thing that can now be done.” Such is the language which is -constantly addressed to the physician in the early period of -convalescence, and if he be weak enough to yield to it and allow his -patient to rise, it is a chance if he ever rise again. The most cautious -and experienced physician sometimes finds himself deceived, falling into -the same error with his patient, and thinking him stronger than he is. -Whenever this happens, the physician has great reason for self-reproach, -_because he ought to allow no risk to be run_. Often, however, in -private practice, the physician is allowed to have no control whatever -over the management of the convalescence—he is dismissed as soon as the -patient is out of apparent and urgent danger; dismissed hastily, often -to be more hastily recalled to witness the death of him whom every one -thought to be well. - -But if merely rising from bed at too early a period occasion the death -of great numbers, eating heartily of solid food is a still more frequent -and certain cause of it. The appetite is generally keen immediately -after fever has subsided: if animal food be allowed as soon as the -appetite craves for it relapse is sure to be produced. Often and often -have I seen fatal cerebral and abdominal inflammation excited in a few -hours after the commission of this error. I do not expect, by any -language at my command, to communicate to others my own conviction of -its danger. I know that such a conviction can be produced in no one who -has not an opportunity of observing the convalescence of large numbers; -and I know that no one who has such an opportunity can be without it. - -There are three conditions under which this danger is peculiarly -imminent. First, when the disease has been unusually severe and -protracted. The more intense the fever and the longer it has lasted, the -more are all the organs enfeebled, and the longer do they retain the -irritability of weakness, In this state, anything beyond the gentlest -stimulus will induce vascular excitement, which will rapidly pass into -inflammation. - -Secondly, when the disease was severe in the commencement, and has been -promptly subdued by active treatment. Whenever copious bleeding brings -on a precocious convalescence, that convalescence is invariably -uncertain and infirm. It is always steady as long as it is properly -protected, but it has not strength equal to its apparent health: it is -as tender and fragile as it is sensitive: the least noxious agent -impresses it; the least stimulus overpowers it. The patient is suddenly -relieved from a load that oppressed him; the organs react with -preternatural vigor; they have enough to do to sustain the reaction of -the system: stimulate them still further by animal food and wine, and -they will be sure to be over done; and this artificial excitement will -be as fatal as the excitement of disease. It can be of little -consequence to the patient whether he die of malaria or of chicken. - -Thirdly, when the disease was slight in the commencement and through its -subsequent progress, but the convalescence proved tardy and imperfect. -In this case, animal food and wine are pernicious and highly dangerous, -and often prove more fatal than a severe form of fever. Nothing is -advantageous or safe for such a patient but perfect rest and quiet and -the blandest farinaceous diet. - -I have now laid before the reader all that I have been able to learn of -this frequent and most formidable disease. I am conscious that some of -the views which have been exhibited are opposed to the prevalent -doctrines of the day, and that some parts of the treatment recommended -must appear to many unnecessary and hazardous. But since I have -suggested no doctrine which has not been deduced from a long and careful -study of the phenomena, and recommended no practice which has not been -derived from large experience, I trust that the former will not be -rejected without examination, nor the latter condemned until its failure -have been witnessed. I have opposed with earnestness, perhaps some may -think with vehemence, certain opinions and modes of practice which I -conceive to be pregnant with evil; but as I have never intended the -slightest reproach or blame to the advocates of the doctrines I condemn, -so I shall feel truly grateful to any one who will point out any mistake -into which I may have fallen. Those who have studied this disease with -the best success are the most sensible how much remains to be done to -render our knowledge of it perfect and our treatment of it effectual. -Many are the dark spots that still remain upon this part of the field of -knowledge; many are the labourers that must work long and skilfully -before they are removed; while, if the successful investigation of -medical science in general contribute largely to the well-being of man, -the successful study of this branch of it must be pre-eminently -beneficial. It is computed that upwards of one-half of the human race -perish by this fell disease in one or other of its forms: when this fact -is coupled with the truth disclosed by the annexed tables, which shew at -what age this malady is most prevalent and fatal, we become duly -impressed with the importance of labouring to render our knowledge of -this dreadful disease complete, that we may lessen, as far as possible, -the suffering of our common nature, and extend to its utmost limit the -term of human life, too brief when most protracted, but constantly cut -short by this great enemy of our race, just as adolescence is ripening -into manhood. - - - - - APPENDIX. - - -The annexed Tables furnish, in general, their own commentary. The facts -established by some of them are curious and important. I lay them before -the reader without observation, at present; but I shall have occasion to -return to them hereafter. - - - _Meteorological Table, with reference to Admissions and Deaths, for - 1825._ - - ┌──────┬──────┬───────┬─────────┬─────────┬────────────────────┬──────────────┐ - │Weeks.│Admis-│Deaths.│ Heat. │Moisture.│ Wind. │ Weather. │ - │ │sions.│ │ │ │ │ │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ 〃 │ 〃 │ 〃 │Max. Min.│Max. Min.│ 〃 │ 〃 │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ 1│ 6│ 0│ 54 32½│ 964 685│West. North. │Fine. │ - │ 2│ 9│ 2│ 46 34│ 966 755│North. East. │Hazy. │ - │ 3│ 16│ 1│ 46 34│1000 763│West. North. │Cloudy. │ - │ 4│ 13│ 4│ 50½ 32│ 984 711│North. North-West. │Cloudy. Hazy. │ - │ 5│ 7│ 1│ 51 30│ 839 614│West. West by North.│Fine. │ - │ 6│ 10│ 2│ 48 33│ 971 783│South-West, WbN. │Fine. Hazy. │ - │ 7│ 9│ 1│ 51 38│ 870 820│East. West. │Cloudy. Rain. │ - │ 8│ 8│ 3│ 47 36│ 962 659│East. North. │Cloudy. │ - │ 9│ 4│ 0│ 46 36│ 932 538│West, North-West. │Fine. Cloudy. │ - │ 10│ 8│ 2│ 52 34│ 966 658│West. North. │Dark. C. Hazy.│ - │ 11│ 2│ 0│ 48 31│ 862 452│North. East. │Cloudy. Fine. │ - │ 12│ 5│ 3│ 52 39│1000 598│East. South-East. │C. H. Dark. │ - │ 13│ 12│ 1│ 61 42│ 807 347│East. North. │Fine. Hazy. │ - │ 14│ 10│ 2│ 62 41½│ 904 522│East. North-West. │Fine. Cloudy. │ - │ 15│ 19│ 3│ 63 46│ 844 470│North. West. │Fine. Cloudy. │ - │ 16│ 7│ 2│ 63 53│ 901 553│West. East. │Cloudy. D. F. │ - │ 17│ 12│ 1│ 71 54│ 801 538│South. East. │Rain. Cloudy. │ - │ 18│ 4│ 1│ 67 52│ 907 516│South-West. North. │Cloudy. Rain. │ - │ 19│ 10│ 1│ 63 53│ 712 516│North. East. │Cloudy. Fine. │ - │ 20│ 11│ 2│ 74 53│ 765 442│East. West. North. │Cloudy. Fine. │ - │ 21│ 6│ 3│ 66 54│ 905 466│West. West. │Cloudy. Rain. │ - │ 22│ 6│ 3│ 81 63│ 748 449│South. North. West. │Fine. Cloudy. │ - │ 23│ 5│ 1│ 80 59│ 774 404│North. East. │Fine. Cloudy. │ - │ 24│ 18│ 2│ 71 57│ 721 421│North-West. South. │Cloudy. Fine. │ - │ 25│ 11│ 2│ 72 58│ 800 472│North-West. East. │Cloudy. Hazy. │ - │ 26│ 8│ 0│ 84 57│ 937 439│West. South-West. │Fine. │ - │ 27│ 10│ 2│ 87 75│ 727 437│East. South-East. │Fine. │ - │ 28│ 13│ 1│ 78 63│ 850 429│East. North. │Fine. Cloudy. │ - │ 29│ 9│ 2│ 86 65│ 660 357│West. South-West. │Cloudy. Rain. │ - │ 30│ 15│ 2│ 70 65│ 793 488│West. North-West. │Cloudy. │ - │ 31│ 20│ 0│ 69 62│ 855 660│West. North. │Cloudy. │ - │ 32│ 22│ 2│ 70 60│ 793 488│West. North-West. │Cloudy. │ - │ 33│ 13│ 1│ 69 62│ 855 575│West. North. │Cloudy. │ - │ 34│ 10│ 1│ 76 60│ 971 635│East. North-East. │Cloudy. Rain. │ - │ 35│ 16│ 5│ 73 61│ 949 598│North. West. │Cloudy. Fine. │ - │ 36│ 12│ 5│ 68 60│ 770 554│West. North. │Fine. Cloudy. │ - │ 37│ 11│ 3│ 69 63│ 971 749│South. West. │Cloudy. Rain. │ - │ 38│ 19│ 3│ 70 54│ 968 700│South. West. │Cloudy. │ - │ 39│ 19│ 2│ 67 52│ 937 717│West. North-East. │Fine. Rain. │ - │ 40│ 10│ 2│ 65 58│ 935 749│West. South-East. │Rain. Cloudy. │ - │ 41│ 13│ 3│ 63 55│ 935 652│West. North. S-East.│Cloudy. │ - │ 42│ 15│ 2│ 63 40│ 937 618│West. West. │Rain. │ - │ 43│ 13│ 3│ 54 37│ 924 627│West. North-West. │Cloudy. │ - │ 44│ 15│ 1│ 57 48│ 879 713│West. West. │Cloudy. │ - │ 45│ 10│ 3│ 56 38│ 961 705│West. West. │Cloudy. │ - │ 46│ 14│ 3│ 44 31│1000 557│North. North. │Foggy. Rain. │ - │ 47│ 16│ 4│ 53 36│ 943 781│West. West. │Cloudy. Rain. │ - │ 48│ 12│ 4│ 62 40│ 968 767│West. West. │Cloudy. Rain. │ - │ 49│ 14│ 2│ 50 36│1000 790│West. North-East. │Foggy. Cloudy.│ - │ 50│ 11│ 0│ 52 38│1000 762│West. East. │Foggy. │ - │ 51│ 11│ 4│ 51 41│ 967 763│West. South. │Foggy. Cloudy.│ - │ 52│ 9│ 1│ 47 28│ 971 585│West. West. │Cloudy. │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ Total│ 588│ 104│ │ │ │ │ - └──────┴──────┴───────┴─────────┴─────────┴────────────────────┴──────────────┘ - - - _Meteorological Table, with reference to Admissions and Deaths, for - 1826._ - - ┌──────┬──────┬───────┬─────────┬─────────┬────────────────────┬──────────────┐ - │Weeks.│Admis-│Deaths.│ Heat. │Moisture.│ Wind. │ Weather. │ - │ │sions.│ │ │ │ │ │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ 〃 │ 〃 │ 〃 │Max. Min.│Max. Min.│ 〃 │ 〃 │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ 1│ 4│ 0│ 40 33│ 968 794│East. East. │Cloudy. Fine. │ - │ 2│ 10│ 3│ 33 21│ 910 612│North. North. │Hazy. │ - │ 3│ 10│ 1│ 42 17│ 963 745│East. North. │Fine. Cloudy. │ - │ 4│ 9│ 1│ 40 31│1000 783│West. East. │Cloudy. Foggy.│ - │ 5│ 9│ 4│ 50 39│ 966 709│South. East. │Foggy. Cloudy.│ - │ 6│ 15│ 1│ 52 33│1000 702│South. West. │Rain. Fine. │ - │ 7│ 10│ 5│ 52 39│ 968 110│South. South-East. │Fine. Cloudy. │ - │ 8│ 8│ 1│ 52 35│1000 680│West. West. │Fine. │ - │ 9│ 7│ 3│ 53 40│ 940 624│West. West. │Cloudy. │ - │ 10│ 7│ 1│ 62 39│ 970 698│West. East. │Fine. │ - │ 11│ 13│ 2│ 52 37│ 963 500│East. North. │Fine. Hazy. │ - │ 12│ 12│ 3│ 57 44│ 87 74│West. North. │Fine. │ - │ 13│ 12│ 2│ 62 56│ 60 76│West. West. │Cloudy. │ - │ 14│ 13│ 1│ 62 58│ 63 81│East. East. │Fine. │ - │ 15│ 9│ 0│ 54 49│ 72 80│West. West. │Cloudy. Fine. │ - │ 16│ 15│ 3│ 56 50│ 61 74│East. North-East. │Fine. Cloudy. │ - │ 17│ 5│ 5│ 58 52│ 59 68│East. East. │Fine. │ - │ 18│ 14│ 0│ 66 56│ 63 69│East. West. │Fine. │ - │ 19│ 10│ 5│ 66 59│ 60 76│East. East. │Rainy. │ - │ 20│ 9│ 1│ 65 59│ 63 68│East. West. │Cloudy. │ - │ 21│ 12│ 1│ 73 66│ 60 68│N-East. N-East. │Fine. │ - │ 22│ 18│ 2│ 74 68│ 63 90│West. East. │Fine. │ - │ 23│ 20│ 1│ 74 65│ 80 95│East. North. │Fine. │ - │ 24│ 15│ 1│ 78 74│ 65 86│East. South. │Cloudy. Fine. │ - │ 25│ 14│ 2│ 78 74│ 66 76│West. West. │Cloudy. │ - │ 26│ 14│ 0│ 74 74│ 53 79│West. West. │Fine. │ - │ 27│ 17│ 2│ 74 62│ 66 76│West. West. │Fine. │ - │ 28│ 14│ 1│ 78 67│ 61 72│North. East. │Fine. │ - │ 29│ 18│ 4│ 78 68│ 59 75│East. North. │Fine. Cloudy. │ - │ 30│ 10│ 3│ 73 49│ 61 92│North. North-East. │Rain. Fine. │ - │ 31│ 19│ 2│ 84 55│ 60 84│East. North-East. │Variable. │ - │ 32│ 16│ 1│ 78 55│ 65 84│North-East. West. │Variable. │ - │ 33│ 20│ 1│ 73 65│ 59 79│West. South-West. │Variable. │ - │ 34│ 15│ 4│ 85 60│ 50 72│West. South-West. │Cloudy. Fair. │ - │ 35│ 15│ 2│ 79 57│ 65 75│West. South-West. │Cloudy. Fair. │ - │ 36│ 14│ 3│ 73 40│ 69 91│West. South-West. │Cloudy. Fair. │ - │ 37│ 19│ 2│ 69 47│ 71 88│West. West. │Fine. │ - │ 38│ 19│ 2│ 71 51│ 73 93│East. North-East. │Fine. │ - │ 39│ 15│ 1│ 69 44│ 74 91│East. South-West. │Cloudy. Rain. │ - │ 40│ 12│ 3│ 70 41│ 75 88│S-West. S-West. │Foggy. │ - │ 41│ 14│ 1│ 67 42│ 75 89│S-West. S-West. │Foggy. Rain. │ - │ 42│ 14│ 2│ 66 45│ 76 96│South. South-West. │Foggy. Cloudy.│ - │ 43│ 12│ 5│ 69 40│ 80 96│West. North-West. │Foggy. Rain. │ - │ 44│ 17│ 1│ 56 40│ 78 98│West. West. │Foggy. Rain. │ - │ 45│ 10│ 2│ 50 31│ 78 98│West. North-West. │Foggy. │ - │ 46│ 10│ 4│ 53 33│ 82 97│West. North-West. │Cloudy. │ - │ 47│ 13│ 1│ 47 38│ 75 93│East. North-East. │Rain. │ - │ 48│ 8│ 1│ 50 30│ 74 93│West. South-West. │Fine. Foggy. │ - │ 49│ 18│ 3│ 54 33│ 82 98│West. North-West. │Cloudy. Rain. │ - │ 50│ 16│ 4│ 54 45│ 87 99│S-West. S-West. │Fair. Foggy. │ - │ 51│ 14│ 3│ 49 33│ 85 98│East. North-East. │Foggy. Fair. │ - │ 52│ 11│ 3│ 52 34│ 85 98│N-East. N-East. │Foggy. │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ Total│ 676│ 110│ │ │ │ │ - └──────┴──────┴───────┴─────────┴─────────┴────────────────────┴──────────────┘ - - - _Meteorological Table, with reference to Admissions and Deaths, for - 1827._ - - ┌──────┬──────┬───────┬─────────┬─────────┬────────────────────┬──────────────┐ - │Weeks.│Admis-│Deaths.│ Heat. │Moisture.│ Wind. │ Weather. │ - │ │sions.│ │ │ │ │ │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ 〃 │ 〃 │ 〃 │Max. Min.│Max. Min.│ 〃 │ 〃 │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ 1│ 10│ 1│ 49 18│ 98 74│West. North. │Fair. │ - │ 2│ 7│ 2│ 53 31│ 98 85│West. South-West. │Rain. Fair. │ - │ 3│ 14│ 0│ 53 25│ 96 76│West. North-East. │Cloudy. Fair. │ - │ 4│ 8│ 1│ 42 18│ 95 81│West. North-East. │Cloudy. Foggy.│ - │ 5│ 12│ 3│ 46 27│ 98 75│East. North-East. │Fair. │ - │ 6│ 6│ 1│ 41 28│ 93 75│East. North-East. │Fair. │ - │ 7│ 9│ 3│ 40 19│ 87 80│East. North-East. │Fine. │ - │ 8│ 13│ 1│ 40 29│ 89 72│East. North-East. │Fair. Cloudy. │ - │ 9│ 10│ 0│ 50 30│ 98 82│West. South-West. │Cloudy. │ - │ 10│ 10│ 1│ 56 32│ 93 78│West. South-West. │Fair. Rain. │ - │ 11│ 12│ 0│ 56 32│ 88 77│West. North-West. │Fair. │ - │ 12│ 4│ 0│ 48 35│ 97 75│West. West. │Fair. │ - │ 13│ 10│ 1│ 58 35│ 89 76│West. West. │Cloudy. Fair. │ - │ 14│ 2│ 0│ 67 46│ 98 75│West. North-East. │Fine. │ - │ 15│ 8│ 0│ 58 41│ 92 72│West. West. │Fine. │ - │ 16│ 19│ 4│ 52 39│ 92 78│East. North-East. │Cloudy.Rain. │ - │ 17│ 6│ 2│ 71 34│ 88 68│Variable. Variable. │Fair. │ - │ 18│ 11│ 1│ 72 44│ 95 79│West. South-West. │Cloudy. │ - │ 19│ 14│ 1│ 59 34│ 94 72│East. North-East. │Fair. │ - │ 20│ 16│ 0│ 70 46│ 88 75│East. South-West. │Fair. │ - │ 21│ 12│ 2│ 72 45│ 90 73│West. West. │Cloudy. │ - │ 22│ 21│ 0│ 70 45│ 92 78│West. West. │Cloudy. │ - │ 23│ 9│ 0│ 70 48│ 92 74│West. West. │Fair. │ - │ 24│ 23│ 2│ 75 52│ 92 71│East. West. │Fair. │ - │ 25│ 13│ 1│ 74 50│ 87 73│West. West. │Fair. │ - │ 26│ 23│ 5│ 72 58│ 98 77│West. West. │Rain. Fair. │ - │ 27│ 13│ 1│ 79 55│ 92 74│Variable. Variable. │Fair. │ - │ 28│ 15│ 0│ 80 53│ 82 70│East. North-East. │Fair. │ - │ 29│ 15│ 2│ 76 56│ 82 68│East. East. │Cloudy. │ - │ 30│ 17│ 1│ 84 57│ 92 78│West. West. │Cloudy. Fair. │ - │ 31│ 17│ 3│ 80 53│ 84 72│West. West. │Cloudy. Fair. │ - │ 32│ 17│ 2│ 72 50│ 86 74│West. West. │Cloudy. │ - │ 33│ 16│ 2│ 72 54│ 93 74│East. North-East. │Fair. │ - │ 34│ 18│ 5│ 78 52│ 90 75│East. North-East. │Fair. │ - │ 35│ 20│ 2│ 78 53│ 93 78│East. North-East. │Cloudy. Fair. │ - │ 36│ 14│ 6│ 68 51│ 96 80│East. Fair. │Cloudy. │ - │ │ │ │ │ │ North-East. │ │ - │ 37│ 17│ 6│ 71 51│ 91 78│East. Fair. │Cloudy. │ - │ │ │ │ │ │ North-East. │ │ - │ 38│ 16│ 1│ 64 49│ 91 81│West. Fair. │Cloudy. │ - │ │ │ │ │ │ South-West. │ │ - │ 39│ 14│ 0│ 64 52│ 100 87│West. South-East. │Cloudy. │ - │ 40│ 16│ 2│ 61 47│ 100 95│West. West. │Cloudy. │ - │ 41│ 13│ 2│ 64 43│ 98 86│West. West. │Fair. Cloudy. │ - │ 42│ 15│ 2│ 63 57│ 98 85│West. South-East. │Foggy. │ - │ 43│ 16│ 2│ 60 37│ 100 89│S-East. S-West. │Fair. Cloudy. │ - │ 44│ 23│ 2│ 57 39│ 99 78│West. North-West. │Foggy. │ - │ 45│ 13│ 3│ 60 39│ 98 92│West. North-West. │Fair. Cloudy. │ - │ 46│ 5│ 0│ 52 40│ 100 86│East. South-East. │Foggy. │ - │ 47│ 12│ 1│ 45 25│ 100 83│N-West. N-West. │Fair. │ - │ 48│ 15│ 3│ 53 41│ 100 96│West. West. │Cloudy. Rain. │ - │ 49│ 9│ 0│ 56 36│ 97 80│West. West. │Fair. │ - │ 50│ 9│ 2│ 55 38│ 98 86│West. West. │Rain. Fair. │ - │ 51│ 9│ 3│ 55 39│ 98 97│West. West. │Rain. │ - │ 52│ 17│ 1│ 52 31│ 98 87│West. South-West. │Foggy. │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ Total│ 676│ 87│ │ │ │ │ - └──────┴──────┴───────┴─────────┴─────────┴────────────────────┴──────────────┘ - - - _Meteorological Table, with reference to Admissions and Deaths, for - 1828._ - - ┌──────┬──────┬───────┬─────────┬─────────┬────────────────────┬──────────────┐ - │Weeks.│Admis-│Deaths.│ Heat. │Moisture.│ Wind. │ Weather. │ - │ │sions.│ │ │ │ │ │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ 〃 │ 〃 │ 〃 │Max. Min.│Max. Min.│ 〃 │ 〃 │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ 1│ 8│ 3│ 50 33│ 98 96│East. West. │Cloudy. │ - │ 2│ 9│ 0│ 47 28│ 99 85│East. South-East. │Cloudy. Snow. │ - │ 3│ 11│ 1│ 56 38│ 99 86│East. North-East. │Rain. Cloudy. │ - │ 4│ 14│ 3│ 53 40│ 98 90│West. West. │Cloudy. │ - │ 5│ 11│ 1│ 54 39│ 96 90│West. West. │Rain. Fair. │ - │ 6│ 8│ 2│ 54 28│ 98 90│West. East. │Cloudy. Snow. │ - │ 7│ 11│ 0│ 41 28│ 98 90│West. West. │Fine. │ - │ 8│ 13│ 2│ 52 36│ 98 90│East. West. │Cloudy. Rain. │ - │ 9│ 7│ 1│ 57 38│ 98 94│West. West. │Fair. │ - │ 10│ 11│ 1│ 55 31│ 98 76│East. North-West. │Fair. │ - │ 11│ 18│ 2│ 62 44│ 94 86│West. West. │Fine. │ - │ 12│ 5│ 0│ 64 36│ 98 92│West. West. │Fair. Hail. │ - │ 13│ 13│ 2│ 52 33│ 98 92│East. North-East. │Foggy. Rain. │ - │ 14│ 8│ 3│ 53 35│ 98 82│East. North. │Cloudy. │ - │ 15│ 15│ 1│ 61 38│ 98 95│East. South-West. │Rain. Fine. │ - │ 16│ 14│ 4│ 61 43│ 98 94│West. West. │Rain. │ - │ 17│ 14│ 2│ 65 39│ 97 80│West. West. │Fair. │ - │ 18│ 16│ 3│ 68 45│ 98 75│West. East. │Fair. │ - │ 19│ 10│ 0│ 66 43│ 98 80│East. West. │Fair. │ - │ 20│ 16│ 2│ 68 47│ 92 85│East. South-East. │Fair. │ - │ 21│ 8│ 2│ 68 47│ 98 90│East. South-East. │Rain. Fair. │ - │ 22│ 8│ 1│ 71 52│ 98 78│West. West. │Fair. │ - │ 23│ 3│ 0│ 70 51│ 94 77│West. West. │Fair. Rain. │ - │ 24│ 13│ 1│ 73 54│ 78 75│N-West. N-West. │Fair. │ - │ 25│ 13│ 1│ 73 56│ 96 75│S-East. S-East. │Rain. Fair. │ - │ 26│ 12│ 1│ 80 55│ 96 79│N-West. N-West. │Fine. │ - │ 27│ 8│ 1│ 79 56│ 100 91│West. West. │Cloudy. │ - │ 28│ 18│ 0│ 77 65│ 74 43│S-West. S-West. │Cloudy. Rain. │ - │ 29│ 11│ 1│ 73 55│ 66 48│N-West. N-West. │Cloudy. │ - │ 30│ 24│ 2│ 73 51│ 50 49│N-West. N-West. │Fine. │ - │ 31│ 13│ 0│ 72 66│ 51 49│East. East. │Rain. Fine. │ - │ 32│ 14│ 2│ 74 53│ 50 49│S-East. S-East. │Fine. │ - │ 33│ 18│ 3│ 74 44│ 52 40│West. South-West. │Cloudy. Rain. │ - │ 34│ 12│ 2│ 68 42│ 50 47│S-East. S-East. │Fine. │ - │ 35│ 22│ 1│ 73 56│ 54 50│S-West. S-West. │Foggy. Fine. │ - │ 36│ 11│ 4│ 66 45│ 55 51│West by North. West.│Foggy. Rain. │ - │ 37│ 16│ 1│ 63 48│ 56 51│West. West. │Foggy. Fine. │ - │ 38│ 10│ 3│ 63 39│ 55 50│N-West. N-West. │Foggy. Fine. │ - │ 39│ 17│ 4│ 63 38│ 68 52│East. South-West. │Foggy. Fine. │ - │ 40│ 14│ 4│ 53 39│ 68 55│East. South-East. │Fine. │ - │ 41│ 8│ 0│ 53 26│ 67 55│S-East. S-East. │Fine.Foggy. │ - │ 42│ 13│ 2│ 56 26│ 75 55│S-East. S-East. │Fine. │ - │ 43│ 8│ 1│ 63 42│ 64 55│East. North-West. │Fine. Foggy. │ - │ 44│ 5│ 5│ 54 39│ 68 58│East. North. N-East.│Fine. Cloudy. │ - │ 45│ 4│ 0│ 44 35│ 67 53│S-East. South. │Fine. Foggy. │ - │ │ │ │ │ │ S-East. │ │ - │ 46│ 12│ 3│ 54 28│ 74 63│East. South-East. │Rain. Cloudy. │ - │ 47│ 7│ 1│ 56 41│ 68 56│S-West. S-West. │Fine. │ - │ 48│ 13│ 0│ 59 35│ 68 56│West. North-West. │Fine. Cloudy. │ - │ 49│ 13│ 1│ 53 38│ 65 64│West. S. South-West.│Foggy. Rain. │ - │ 50│ 10│ 1│ 56 40│ 68 65│West. West. │Fine. Cloudy. │ - │ 51│ 9│ 0│ 57 41│ 65 65│N-West. W. N-West. │Fine. │ - │ 52│ 9│ 0│ 45 36│ 69 65│S-West. S-East. │Foggy. Rain. │ - ├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤ - │ Total│ 597│ 81│ │ │ │ │ - └──────┴──────┴───────┴─────────┴─────────┴────────────────────┴──────────────┘ - - -Occupation of Patients, with reference to Susceptibility, for one year. - - Servants 150 - Labourers 126 - Shoemakers 18 - Tailors 17 - Fruiterers 13 - Carpenters 10 - Weavers 10 - Bricklayers 8 - Bakers 6 - Dress Makers 6 - Painters 5 - Plasterers 5 - Sailors 5 - Printers 3 - Sawyers 3 - Butchers 3 - Porters 3 - Sweeps 3 - Chair Women 3 - Pot-boys 3 - Shop-boys 3 - Silversmiths 2 - Grocers 2 - Furriers 2 - Curriers 2 - Woodmen 2 - Grooms 2 - Skinners 2 - Fishmongers 2 - Gardeners 2 - Corkcutters 2 - Farmers 2 - Braidmakers 2 - Watchmakers 2 - Cagemakers 1 - Guncapmakers 1 - Blacksmiths 1 - Combmakers 1 - Coppersmiths 1 - Firemen 1 - Distillers 1 - Masons 1 - Cabinetmakers 1 - Milkmen 1 - Saddlers 1 - Ferulemakers 1 - Coachbuilders 1 - Mercers 1 - Bargebuilders 1 - Cheesemongers 1 - Sawmakers 1 - Clockmakers 1 - Upholstresses 1 - Poulterers 1 - Destitute 230 - ——— - Total 679 - - - Sex of Patient, with reference to Susceptibility. - - ┌────────────┬────────────┬────────────┬────────────┐ - │ 1825. │ 1826. │ 1827. │ 1828. │ - ├────────────┼────────────┼────────────┼────────────┤ - │Males 289│Males 325│Males 337│Males 278│ - │Females, 299│Females, 351│Females, 339│Females, 319│ - │ ———│ ———│ ———│ ———│ - │ Total, 588│ Total, 676│ Total, 676│ Total, 597│ - └────────────┴────────────┴────────────┴────────────┘ - - - Sex of Patient, with reference to Mortality. - - ┌────────────┬────────────┬────────────┬────────────┐ - │ 1825. │ 1826. │ 1827. │ 1828. │ - ├────────────┼────────────┼────────────┼────────────┤ - │Males 53│Males 56│Males 48│Males 33│ - │Females, 51│Females, 54│Females, 38│Females, 48│ - │ ———│ ———│ ———│ ———│ - │ Total, 104│ Total, 110│ Total, 86│ Total, 81│ - └────────────┴────────────┴────────────┴────────────┘ - - - Locality of Patient, with reference to Susceptibility. - - Country Unhealthy. Town Unhealthy. Town Healthy. - - Servants 12 31 96 - Labourers 0 88 48 - Destitute 0 43 50 - - - Table of Ages, with reference to Susceptibility. - - ┌────────────┬────────────┬────────────┬────────────┐ - │ Age, for │ Age, for │ Age, for │ Age, for │ - │ 1825. │ 1826. │ 1827. │ 1828. │ - ├────────┬───┼────────┬───┼────────┬───┼────────┬───┤ - │Under 10│ 42│Under 10│ 27│Under 10│ 25│Under 10│ 31│ - │ 15│ 67│ 15│ 87│ 15│ 70│ 15│ 80│ - │ 20│172│ 20│170│ 20│163│ 20│136│ - │ 25│133│ 25│143│ 25│164│ 25│107│ - │ 30│ 81│ 30│102│ 30│107│ 30│ 84│ - │ 35│ 29│ 35│ 46│ 35│ 35│ 35│ 47│ - │ 40│ 28│ 40│ 37│ 40│ 50│ 40│ 45│ - │ 45│ 10│ 45│ 28│ 45│ 20│ 45│ 21│ - │ 50│ 10│ 50│ 13│ 50│ 13│ 50│ 17│ - │ 55│ 10│ 55│ 7│ 55│ 8│ 55│ 6│ - │ 60│ 1│ 60│ 5│ 60│ 13│ 60│ 14│ - │ 65│ 1│ 65│ 3│ 65│ 2│ 65│ 6│ - │ 70│ 2│ 70│ 3│ 70│ 4│ 70│ 1│ - │ 75│ 1│ 75│ 4│ 75│ 2│ 75│ 2│ - │ 80│ 1│ 80│ 1│ 80│ 0│ 80│ 0│ - │ 85│ 0│ 85│ 0│ 85│ 0│ 85│ 0│ - │ │———│ │———│ │———│ │———│ - │ Total │588│ Total │676│ Total │676│ Total │597│ - ╘════════╧═══╧════════╧═══╧════════╧═══╧════════╧═══╛ - - - Table of Ages, with reference to Mortality. - - ┌────────────┬────────────┬────────────┬────────────┐ - │ Age, for │ Age, for │ Age, for │ Age, for │ - │ 1825. │ 1826. │ 1827. │ 1828. │ - ├────────┬───┼────────┬───┼────────┬───┼────────┬───┤ - │Under 10│ 3│Under 10│ 1│Under 10│ 5│Under 10│ 4│ - │ 15│ 5│ 15│ 10│ 15│ 5│ 15│ 5│ - │ 20│ 29│ 20│ 35│ 20│ 16│ 20│ 12│ - │ 25│ 25│ 25│ 14│ 25│ 17│ 25│ 11│ - │ 30│ 17│ 30│ 20│ 30│ 18│ 30│ 12│ - │ 35│ 2│ 35│ 3│ 35│ 1│ 35│ 4│ - │ 40│ 7│ 40│ 7│ 40│ 10│ 40│ 7│ - │ 45│ 6│ 45│ 4│ 45│ 5│ 45│ 5│ - │ 50│ 4│ 50│ 5│ 50│ 4│ 50│ 7│ - │ 55│ 3│ 55│ 1│ 55│ 2│ 55│ 1│ - │ 60│ 0│ 60│ 3│ 60│ 1│ 60│ 4│ - │ 65│ 0│ 65│ 2│ 65│ 0│ 65│ 3│ - │ 70│ 2│ 70│ 1│ 70│ 0│ 70│ 0│ - │ 75│ 1│ 75│ 2│ 75│ 2│ 75│ 1│ - │ 80│ 0│ 80│ 2│ 80│ 0│ 80│ 0│ - │ 85│ 0│ 85│ 0│ 85│ 0│ 85│ 0│ - │ │———│ │———│ │———│ │———│ - │ Total │104│ Total │110│ Total │ 86│ Total │ 76│ - ╘════════╧═══╧════════╧═══╧════════╧═══╧════════╧═══╛ - - - _Relation between Date of Attack, Admission and Cure, in 600 Cases._ - - ┌────────────────────┬────────────────────┬────────────────────┐ - │ Admitted on. │ Dismissed on │Duration of Disease.│ - ├────────────────┬───┼────────────────┬───┼────────────────┬───┤ - │1st Day of Fever│ 2│11th Day │ 11│11 Days │ 11│ - │ │ │12 │ 2│12 │ 2│ - │2 │ 6│13 │ 6│13 │ 6│ - │ │ │14 │ 8│14 │ 8│ - │3 │ 29│15 │ 4│15 │ 4│ - │ │ │16 │ 9│16 │ 9│ - │4 │ 47│17 │ 7│17 │ 7│ - │ │ │18 │ 15│18 │ 15│ - │5 │ 54│19 │ 14│19 │ 14│ - │ │ │20 │ 15│20 │ 15│ - │6 │ 43│21 │ 18│21 │ 18│ - │ │ │22 │ 11│22 │ 11│ - │7 │138│23 │ 19│23 │ 19│ - │ │ │24 │ 27│24 │ 27│ - │8 │ 35│25 │ 15│25 │ 15│ - │ │ │26 │ 17│26 │ 17│ - │9 │ 25│27 │ 24│27 │ 24│ - │ │ │28 │ 22│28 │ 22│ - │10 │ 20│29 │ 25│29 │ 25│ - │ │ │30 │ 13│30 │ 13│ - │11 │ 4│31 │ 13│31 │ 13│ - │ │ │32 │ 15│32 │ 15│ - │12 │ 7│33 │ 12│33 │ 19│ - │ │ │34 │ 12│34 │ 12│ - │13 │ 4│35 │ 16│35 │ 16│ - │ │ │36 │ 13│36 │ 13│ - │14 │ 71│37 │ 24│37 │ 24│ - │ │ │38 │ 14│38 │ 14│ - │15 │ 11│39 │ 12│39 │ 12│ - │ │ │40 │ 10│40 │ 10│ - │17 │ 3│41 │ 8│41 │ 8│ - │ │ │42 │ 7│42 │ 7│ - │18 │ 2│43 │ 7│43 │ 7│ - │ │ │44 │ 15│44 │ 15│ - │19 │ 1│45 │ 7│45 │ 7│ - │ │ │46 │ 6│46 │ 6│ - │21 │ 43│47 │ 7│47 │ 7│ - │ │ │48 │ 3│48 │ 3│ - │28 │ 8│49 │ 8│49 │ 8│ - │ │ │50 │ 6│50 │ 6│ - │30 │ 2│51 │ 7│51 │ 7│ - │ │ │52 │ 4│52 │ 4│ - │42 │ 2│53 │ 2│53 │ 2│ - │ │ │54 │ 5│54 │ 5│ - │56 │ 1│55 │ 1│55 │ 1│ - │ │ │56 │ 1│56 │ 1│ - │60 │ 1│57 │ 4│57 │ 4│ - │ │ │58 │ 3│58 │ 3│ - │Unknown │ 21│59 │ 2│59 │ 2│ - │ │ │60 │ 5│60 │ 5│ - │ │ │62 │ 1│62 │ 1│ - │ │ │Beyond 62 │ 24│Beyond 62 │ 24│ - │ │ │Unknown │ 16│Unknown │ 16│ - └────────────────┴───┴────────────────┴───┴────────────────┴───┘ - - - Relation between date of Attack, Admission, and Death, for one year, - comprehending 84 Cases. - - - Admitted on - - 3d day of fever 5 - 4 4 - 5 2 - 6 4 - 7 11 - 8 6 - 9 3 - 10 3 - 11 2 - 13 1 - 14 13 - 17 1 - 21 16 - 28 5 - 30 1 - 42 3 - Unknown 4 - - ────────────────────────── - - Died on - - 7th day of fever 1 - 8 2 - 9 2 - 10 4 - 11 7 - 12 2 - 13 1 - 14 6 - 15 2 - 16 2 - 17 2 - 18 1 - 19 1 - 20 5 - 21 3 - 22 1 - 23 2 - 24 4 - 25 2 - 26 1 - 27 3 - 28 3 - 29 1 - 30 3 - 31 4 - 32 1 - 33 1 - 35 4 - 36 2 - 37 2 - 40 1 - 41 1 - 42 1 - 60 2 - Unknown 4 - - ────────────────────────── - - Died on - - 1st day after admission 4 - 2 5 - 3 11 - 4 8 - 5 5 - 6 8 - 7 5 - 8 2 - 9 1 - 10 5 - 11 4 - 12 4 - 13 1 - 14 7 - 15 1 - 16 3 - 18 1 - 19 2 - 20 1 - 28 1 - 30 1 - 34 2 - 44 1 - - - Proportions of Type out of 300 Cases. - - Synochus 235 - Typhus Mitior 21 - Typhus Gravior 1 - Scarlatina 40 - Intermittent 1 - Remittent 2 - - - Proportions of Internal Characteristic Affection out of 300 Cases. - - Cerebral 66 - Thoracic 79 - Abdominal 60 - Mixed 95 - - - Proportions of External Accidental Affection out of 300 Cases. - - Erysipelatous 11 - Glandular 6 - Cynancheal 5 - Herpetic 3 - Laryngeal 1 - Phlegmatial 1 - Rheumatic 1 - ─────────────────────────────────────── - Miscarriage 7 - Preternatural Cutaneous Sensibility 4 - - - * * * * * - - PRINTED BY G. HAYDEN, LITTLE COLLEGE STREET, WESTMINSTER. - ------ - -Footnote 1: - - Observations on the Treatment of Epidemic Fever, &c. By Henry - Clutterbuck, M.D., p. 3–9. - -Footnote 2: - - Sydenham’s Works, p. 1, 2, &c. - -Footnote 3: - - Cullen, First Lines, S. 46. - -Footnote 4: - - Pathological Observations, Part II. on Continued Fever, &c. By W. - Stoker, M.D. p. 32. - -Footnote 5: - - Ibid. p. 34. - -Footnote 6: - - Pathological Observations, &c. pp. 73, 74. - -Footnote 7: - - A Practical Treatise on the Typhus or Adynamic Fever, by John Burne, - M.D. - -Footnote 8: - - Pathological Observations on Continued Fever, &c. p. 110. - -Footnote 9: - - Practical Treatise, &c. p. 161. - -Footnote 10: - - A Lecture upon Typhus Fever, by W. R. Clanny, M.D. p. 12. - -Footnote 11: - - Ibid., p. 16. - -Footnote 12: - - Observations on the Prevention and Treatment of the Epidemic Fever, by - Henry Clutterbuck, M.D. p. 5, 6. - -Footnote 13: - - See a paper in the Medico-Chirurgical Review, for 1828, entitled An - Eclectic Review on Fever. - -Footnote 14: - - Broussais’ exposition of his own doctrine in his own words is as - follows. On doit regarder comme nécessairement affectés, dans une - maladie, les tissus dont l’irritation est constante durant la vie, et - qui en offrent toujours des traces après la mort. Or, les phénomènes - de la sur-excitation des muqueuses, et surtout de la gastrique, ne - manquent jamais, dans le typhus fébrile, puisque leurs symptômes sont - identiques avec ceux des gastro-entérites sporadiques; tandis que ceux - des autres phlegmasies ne s’y montrent qu’accidentellement. Ensuite, - lorsque les personnes affectées de typhus out le malheur de succomber, - on trouve toujours ces membranes rouges, brunes ou noires, pendant que - les autres tissus n’offrent d’alteration que dans certaines - circonstances accidentelles: done l’irritation des membranes muqueuses - est inséparable du typhus fébrile. - - Les typhus fébriles sont donc des gastro-entérites, ordinairement - compliquèes de catarrhes pulmonaires; ces deux phlegmasies sont le - résultat d’un véritable empoisonnement, plus ou moins analogue à celui - des champignons et des poissons gâtées, et qui en a tous les - caractères. - - Le foie, principal annexe du canal digestif, est irrité - secondairement, et sa sécrétion est plus ou moins augmentée. Plus le - miasme est actif, plus cette lésion est marquée le typhus carcéraires - plus la chaleur est intense, plus l’irritation du foie est - inflammatoire (la fièvre jaune.) - - Le cerveau n’est inflammé primitivement que par l’effet de certaines - circonstances qui ont fait prédominer l’action dans son tissu; telles - sont les affections morales, la nostalgie, les chaleurs, etc.; mais il - souffre toujours beaucoup par sympathie et quelquefois au point que - son irritation passe au degré de la phlegmasie, et devient aussi grave - que si elle était primitive.—_Examen. de la Doctrine Medicale, par F. - J. V. Broussais, p. 112–114._ - - Il n’y a de difference entre les gastrites qui sont ici dépeintes et - ces fièvres, que celle qui dépend du degré; car les gastrites aigües - qu’on ne peut pas arrêter arrivent toujours ou à l’ataxic ou a - l’adynamic, dont les symptômes ne different pas de ceux du typhus. - D’ailleurs, la gastrite dont il est ici question est déjà pour les - ontologists, une fièvre ataxique.—_Histoire des Phlegmasies, par F. J. - V. Broussais, Vol. III. p. 39._ - -Footnote 15: - - Observations on the Prevention and Treatment of Epidemic Fever, &c. - pp. 11–12. - -Footnote 16: - - Thus Dr. Stoker states that the remedies “may be arranged according to - their relative importance in the treatment of fever, in the following - order; viz. In mixed fever, 1. Cleanliness. 2. Ventilation. 3. Cool - regimen. 4. Plentiful dilution. 5. Purgatives. 6. Topical bleeding. 7. - Antimonial or James’s Powder. In Typhoid Fever. 1. Yeast or barm. 2. - Wine. 3. Aperients. 4. Emetics. 5. Blisters. 6. Tepid or cold - affusion. 7. Peruvian bark.”—_Pathological Observations &c., p. 111._ - In neither of these catalogues is general bleeding mentioned at all: - in the first, topical bleeding is mentioned, but it is placed the last - but one in the list, while in the second, allusion even to topical - bleeding is wholly omitted. And Dr. Clanny states that the first - proposition relative to the cure is how to restore sanguification, or - how to afford fresh chyle to the blood; that although in full habits, - at the commencement of typhus fever, general blood-letting is often - attended with good effects, yet we should remember that if we take one - ounce too much, we may thereby prevent sanguification altogether; that - therefore it is better to have a sufficient quantity of lymphatic - blood in the system them to run the risk of having too little of the - pabulum vitæ, for the purpose of carrying on the functions of life, - and that in fact venesection is not called for in nine cases out of - ten of typhus fever. Let me caution young practitioners, he adds, - against the repeated use of the lancet, when the buffy coat shews - itself, for in many cases, which have come under my notice, I have - observed the buffy coat to be present after repeated bleedings, AND - WHICH COULD NOT BE ATTRIBUTED TO ANY OTHER CAUSE THAN - DEBILITY.—_Lecture on Fever, pp. 21–2–3._ - -Footnote 17: - - It is remarkable that the word which expresses fever, both in the - Greek and the Latin languages, signifies to burn or to boil, and it is - probable that this state of the system is denoted in most modern - languages by some term bearing a similar meaning. - -Footnote 18: - - A Treatise on Fevers, &c. By A. P. Wilson Philip, M.D. p. 10. - -Footnote 19: - - Treatise on Fever, &c. By A. P. Wilson Philip, M.D. p. 12. - -Footnote 20: - - Sydenham’s Works, Chap. 3, p. 11. - -Footnote 21: - - Sir John Pringle on the Diseases of the Army, p. 66, &c. - -Footnote 22: - - In scarlatina the affection of the skin modifies the febrile symptoms, - as has just been said, considerably: in small-pox exceedingly. If, on - this account, any one enamoured of nosological distinctions should - wish to separate these varieties of disease, it might be done by - dividing continued fever into— - - 1. Continued fever without an eruption; - - Synochus mitior, Typhus mitior, - —— gravior, —— gravior: - - 2. Continued fever with an eruption; - - Scarlatina, Variola, - Synochodes, Synochodes, - Typhodes, Typhodes: - - and so on of all the Exanthemata. - - Although the eruption may, and without doubt does give rise to some - peculiar symptoms and so modifies the fever, yet the true character of - the disease, or _the disease as a subject of medical treatment_, - depends entirely on the nature, that is in truth on the intensity of - the fever. If, therefore, the Exanthemata can find no place under the - genus fever consistently with the principles of nosological - arrangement, it appears to me that these artificial distinctions ought - to be abandoned: because it is better to reject nosology, than to - overlook or to mistake pathology. - -Footnote 23: - - Observations on the Prevention and Treatment of Epidemic Fever, by - Henry Clutterbuck, M.D. p. 15. - -Footnote 24: - - See pathology—chest cases. John Potter. - -Footnote 25: - - See page 107. - -Footnote 26: - - See page 163, 1. - -Footnote 27: - - See page 163, 2. - -Footnote 28: - - Those morbid appearances which, not being constant in fever, must be - considered as accidental, are placed in brackets throughout this - chapter. - -Footnote 29: - - See Case L. - -Footnote 30: - - See page 51. et seq. - -Footnote 31: - - Observations on the Diseases of the Army, by Sir John Pringle, Bart., - p. 11. et seq. - -Footnote 32: - - Observations on the Diseases of the Army, by Sir John Pringle, Bart., - p. 36. - -Footnote 33: - - See a Memoir on Contagion, more especially as it respects the Yellow - Fever, &c., by N. Potter, M.D., Baltimore. - -Footnote 34: - - In pursuing these researches, I hope to have the advantage of the - co-operation of my friend Dr. Dill. - -Footnote 35: - - It would be trifling, while treating of so momentous a subject as the - proper management of fever, which requires the prompt, vigorous, and - yet cautious exhibition of the most powerful remedies, to spend any - time in discussing the merits of saline, refrigerant, diaphoretic, - antimonial medicines, and the rest of the apparatus, which - unfortunately continues to hold the place of direct, honourable, and - well-earned (if any thing can be well-earned) remuneration to the - practitioner. - -Footnote 36: - - Watchful of the convalescence as experience had taught us it is - necessary to be after so severe an attack, still he was allowed to put - himself too forward. When to all appearance recovered, though still - weak, he undertook a journey of fifty miles, that he might the more - completely re-establish his health in the country. He had not arrived - at his journey’s end an hour before he relapsed. He was again bled, - and the cold dash was applied a second time with success. From the - commencement to the termination of the disease, 120 pounds of blood - were abstracted in this case. - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - - 1. Silently corrected typographical errors and variations in spelling. - 2. Retained anachronistic, non-standard, and uncertain spellings as - printed. - 3. Enclosed italics font in _underscores_. - - - - - -End of Project Gutenberg's A Treatise on Fever, by Thomas Southwood-Smith - -*** END OF THIS PROJECT GUTENBERG EBOOK A TREATISE ON FEVER *** - -***** This file should be named 60419-0.txt or 60419-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/0/4/1/60419/ - -Produced by Richard Tonsing, Chris Curnow, and the Online -Distributed Proofreading Team at http://www.pgdp.net - - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. Special rules, set forth in the General Terms of Use part -of this license, apply to copying and distributing Project -Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm -concept and trademark. Project Gutenberg is a registered trademark, -and may not be used if you charge for the eBooks, unless you receive -specific permission. If you do not charge anything for copies of this -eBook, complying with the rules is very easy. You may use this eBook -for nearly any purpose such as creation of derivative works, reports, -performances and research. They may be modified and printed and given -away--you may do practically ANYTHING in the United States with eBooks -not protected by U.S. copyright law. Redistribution is subject to the -trademark license, especially commercial redistribution. - -START: FULL LICENSE - -THE FULL PROJECT GUTENBERG LICENSE -PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK - -To protect the Project Gutenberg-tm mission of promoting the free -distribution of electronic works, by using or distributing this work -(or any other work associated in any way with the phrase "Project -Gutenberg"), you agree to comply with all the terms of the Full -Project Gutenberg-tm License available with this file or online at -www.gutenberg.org/license. - -Section 1. General Terms of Use and Redistributing Project -Gutenberg-tm electronic works - -1.A. By reading or using any part of this Project Gutenberg-tm -electronic work, you indicate that you have read, understand, agree to -and accept all the terms of this license and intellectual property -(trademark/copyright) agreement. If you do not agree to abide by all -the terms of this agreement, you must cease using and return or -destroy all copies of Project Gutenberg-tm electronic works in your -possession. If you paid a fee for obtaining a copy of or access to a -Project Gutenberg-tm electronic work and you do not agree to be bound -by the terms of this agreement, you may obtain a refund from the -person or entity to whom you paid the fee as set forth in paragraph -1.E.8. - -1.B. "Project Gutenberg" is a registered trademark. It may only be -used on or associated in any way with an electronic work by people who -agree to be bound by the terms of this agreement. There are a few -things that you can do with most Project Gutenberg-tm electronic works -even without complying with the full terms of this agreement. See -paragraph 1.C below. There are a lot of things you can do with Project -Gutenberg-tm electronic works if you follow the terms of this -agreement and help preserve free future access to Project Gutenberg-tm -electronic works. See paragraph 1.E below. - -1.C. The Project Gutenberg Literary Archive Foundation ("the -Foundation" or PGLAF), owns a compilation copyright in the collection -of Project Gutenberg-tm electronic works. Nearly all the individual -works in the collection are in the public domain in the United -States. If an individual work is unprotected by copyright law in the -United States and you are located in the United States, we do not -claim a right to prevent you from copying, distributing, performing, -displaying or creating derivative works based on the work as long as -all references to Project Gutenberg are removed. Of course, we hope -that you will support the Project Gutenberg-tm mission of promoting -free access to electronic works by freely sharing Project Gutenberg-tm -works in compliance with the terms of this agreement for keeping the -Project Gutenberg-tm name associated with the work. You can easily -comply with the terms of this agreement by keeping this work in the -same format with its attached full Project Gutenberg-tm License when -you share it without charge with others. - -1.D. The copyright laws of the place where you are located also govern -what you can do with this work. Copyright laws in most countries are -in a constant state of change. If you are outside the United States, -check the laws of your country in addition to the terms of this -agreement before downloading, copying, displaying, performing, -distributing or creating derivative works based on this work or any -other Project Gutenberg-tm work. The Foundation makes no -representations concerning the copyright status of any work in any -country outside the United States. - -1.E. Unless you have removed all references to Project Gutenberg: - -1.E.1. The following sentence, with active links to, or other -immediate access to, the full Project Gutenberg-tm License must appear -prominently whenever any copy of a Project Gutenberg-tm work (any work -on which the phrase "Project Gutenberg" appears, or with which the -phrase "Project Gutenberg" is associated) is accessed, displayed, -performed, viewed, copied or distributed: - - This eBook is for the use of anyone anywhere in the United States and - most other parts of the world at no cost and with almost no - restrictions whatsoever. You may copy it, give it away or re-use it - under the terms of the Project Gutenberg License included with this - eBook or online at www.gutenberg.org. If you are not located in the - United States, you'll have to check the laws of the country where you - are located before using this ebook. - -1.E.2. If an individual Project Gutenberg-tm electronic work is -derived from texts not protected by U.S. copyright law (does not -contain a notice indicating that it is posted with permission of the -copyright holder), the work can be copied and distributed to anyone in -the United States without paying any fees or charges. If you are -redistributing or providing access to a work with the phrase "Project -Gutenberg" associated with or appearing on the work, you must comply -either with the requirements of paragraphs 1.E.1 through 1.E.7 or -obtain permission for the use of the work and the Project Gutenberg-tm -trademark as set forth in paragraphs 1.E.8 or 1.E.9. - -1.E.3. If an individual Project Gutenberg-tm electronic work is posted -with the permission of the copyright holder, your use and distribution -must comply with both paragraphs 1.E.1 through 1.E.7 and any -additional terms imposed by the copyright holder. Additional terms -will be linked to the Project Gutenberg-tm License for all works -posted with the permission of the copyright holder found at the -beginning of this work. - -1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm -License terms from this work, or any files containing a part of this -work or any other work associated with Project Gutenberg-tm. - -1.E.5. Do not copy, display, perform, distribute or redistribute this -electronic work, or any part of this electronic work, without -prominently displaying the sentence set forth in paragraph 1.E.1 with -active links or immediate access to the full terms of the Project -Gutenberg-tm License. - -1.E.6. You may convert to and distribute this work in any binary, -compressed, marked up, nonproprietary or proprietary form, including -any word processing or hypertext form. However, if you provide access -to or distribute copies of a Project Gutenberg-tm work in a format -other than "Plain Vanilla ASCII" or other format used in the official -version posted on the official Project Gutenberg-tm web site -(www.gutenberg.org), you must, at no additional cost, fee or expense -to the user, provide a copy, a means of exporting a copy, or a means -of obtaining a copy upon request, of the work in its original "Plain -Vanilla ASCII" or other form. Any alternate format must include the -full Project Gutenberg-tm License as specified in paragraph 1.E.1. - -1.E.7. Do not charge a fee for access to, viewing, displaying, -performing, copying or distributing any Project Gutenberg-tm works -unless you comply with paragraph 1.E.8 or 1.E.9. - -1.E.8. You may charge a reasonable fee for copies of or providing -access to or distributing Project Gutenberg-tm electronic works -provided that - -* You pay a royalty fee of 20% of the gross profits you derive from - the use of Project Gutenberg-tm works calculated using the method - you already use to calculate your applicable taxes. The fee is owed - to the owner of the Project Gutenberg-tm trademark, but he has - agreed to donate royalties under this paragraph to the Project - Gutenberg Literary Archive Foundation. Royalty payments must be paid - within 60 days following each date on which you prepare (or are - legally required to prepare) your periodic tax returns. Royalty - payments should be clearly marked as such and sent to the Project - Gutenberg Literary Archive Foundation at the address specified in - Section 4, "Information about donations to the Project Gutenberg - Literary Archive Foundation." - -* You provide a full refund of any money paid by a user who notifies - you in writing (or by e-mail) within 30 days of receipt that s/he - does not agree to the terms of the full Project Gutenberg-tm - License. You must require such a user to return or destroy all - copies of the works possessed in a physical medium and discontinue - all use of and all access to other copies of Project Gutenberg-tm - works. - -* You provide, in accordance with paragraph 1.F.3, a full refund of - any money paid for a work or a replacement copy, if a defect in the - electronic work is discovered and reported to you within 90 days of - receipt of the work. - -* You comply with all other terms of this agreement for free - distribution of Project Gutenberg-tm works. - -1.E.9. If you wish to charge a fee or distribute a Project -Gutenberg-tm electronic work or group of works on different terms than -are set forth in this agreement, you must obtain permission in writing -from both the Project Gutenberg Literary Archive Foundation and The -Project Gutenberg Trademark LLC, the owner of the Project Gutenberg-tm -trademark. Contact the Foundation as set forth in Section 3 below. - -1.F. - -1.F.1. Project Gutenberg volunteers and employees expend considerable -effort to identify, do copyright research on, transcribe and proofread -works not protected by U.S. copyright law in creating the Project -Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm -electronic works, and the medium on which they may be stored, may -contain "Defects," such as, but not limited to, incomplete, inaccurate -or corrupt data, transcription errors, a copyright or other -intellectual property infringement, a defective or damaged disk or -other medium, a computer virus, or computer codes that damage or -cannot be read by your equipment. - -1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right -of Replacement or Refund" described in paragraph 1.F.3, the Project -Gutenberg Literary Archive Foundation, the owner of the Project -Gutenberg-tm trademark, and any other party distributing a Project -Gutenberg-tm electronic work under this agreement, disclaim all -liability to you for damages, costs and expenses, including legal -fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT -LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE -PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE -TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE -LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR -INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH -DAMAGE. - -1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a -defect in this electronic work within 90 days of receiving it, you can -receive a refund of the money (if any) you paid for it by sending a -written explanation to the person you received the work from. If you -received the work on a physical medium, you must return the medium -with your written explanation. The person or entity that provided you -with the defective work may elect to provide a replacement copy in -lieu of a refund. If you received the work electronically, the person -or entity providing it to you may choose to give you a second -opportunity to receive the work electronically in lieu of a refund. If -the second copy is also defective, you may demand a refund in writing -without further opportunities to fix the problem. - -1.F.4. Except for the limited right of replacement or refund set forth -in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO -OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT -LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE. - -1.F.5. Some states do not allow disclaimers of certain implied -warranties or the exclusion or limitation of certain types of -damages. If any disclaimer or limitation set forth in this agreement -violates the law of the state applicable to this agreement, the -agreement shall be interpreted to make the maximum disclaimer or -limitation permitted by the applicable state law. The invalidity or -unenforceability of any provision of this agreement shall not void the -remaining provisions. - -1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the -trademark owner, any agent or employee of the Foundation, anyone -providing copies of Project Gutenberg-tm electronic works in -accordance with this agreement, and any volunteers associated with the -production, promotion and distribution of Project Gutenberg-tm -electronic works, harmless from all liability, costs and expenses, -including legal fees, that arise directly or indirectly from any of -the following which you do or cause to occur: (a) distribution of this -or any Project Gutenberg-tm work, (b) alteration, modification, or -additions or deletions to any Project Gutenberg-tm work, and (c) any -Defect you cause. - -Section 2. Information about the Mission of Project Gutenberg-tm - -Project Gutenberg-tm is synonymous with the free distribution of -electronic works in formats readable by the widest variety of -computers including obsolete, old, middle-aged and new computers. It -exists because of the efforts of hundreds of volunteers and donations -from people in all walks of life. - -Volunteers and financial support to provide volunteers with the -assistance they need are critical to reaching Project Gutenberg-tm's -goals and ensuring that the Project Gutenberg-tm collection will -remain freely available for generations to come. In 2001, the Project -Gutenberg Literary Archive Foundation was created to provide a secure -and permanent future for Project Gutenberg-tm and future -generations. To learn more about the Project Gutenberg Literary -Archive Foundation and how your efforts and donations can help, see -Sections 3 and 4 and the Foundation information page at -www.gutenberg.org Section 3. Information about the Project Gutenberg -Literary Archive Foundation - -The Project Gutenberg Literary Archive Foundation is a non profit -501(c)(3) educational corporation organized under the laws of the -state of Mississippi and granted tax exempt status by the Internal -Revenue Service. The Foundation's EIN or federal tax identification -number is 64-6221541. Contributions to the Project Gutenberg Literary -Archive Foundation are tax deductible to the full extent permitted by -U.S. federal laws and your state's laws. - -The Foundation's principal office is in Fairbanks, Alaska, with the -mailing address: PO Box 750175, Fairbanks, AK 99775, but its -volunteers and employees are scattered throughout numerous -locations. Its business office is located at 809 North 1500 West, Salt -Lake City, UT 84116, (801) 596-1887. Email contact links and up to -date contact information can be found at the Foundation's web site and -official page at www.gutenberg.org/contact - -For additional contact information: - - Dr. Gregory B. Newby - Chief Executive and Director - gbnewby@pglaf.org - -Section 4. Information about Donations to the Project Gutenberg -Literary Archive Foundation - -Project Gutenberg-tm depends upon and cannot survive without wide -spread public support and donations to carry out its mission of -increasing the number of public domain and licensed works that can be -freely distributed in machine readable form accessible by the widest -array of equipment including outdated equipment. Many small donations -($1 to $5,000) are particularly important to maintaining tax exempt -status with the IRS. - -The Foundation is committed to complying with the laws regulating -charities and charitable donations in all 50 states of the United -States. Compliance requirements are not uniform and it takes a -considerable effort, much paperwork and many fees to meet and keep up -with these requirements. We do not solicit donations in locations -where we have not received written confirmation of compliance. To SEND -DONATIONS or determine the status of compliance for any particular -state visit www.gutenberg.org/donate - -While we cannot and do not solicit contributions from states where we -have not met the solicitation requirements, we know of no prohibition -against accepting unsolicited donations from donors in such states who -approach us with offers to donate. - -International donations are gratefully accepted, but we cannot make -any statements concerning tax treatment of donations received from -outside the United States. U.S. laws alone swamp our small staff. - -Please check the Project Gutenberg Web pages for current donation -methods and addresses. Donations are accepted in a number of other -ways including checks, online payments and credit card donations. To -donate, please visit: www.gutenberg.org/donate - -Section 5. General Information About Project Gutenberg-tm electronic works. - -Professor Michael S. Hart was the originator of the Project -Gutenberg-tm concept of a library of electronic works that could be -freely shared with anyone. For forty years, he produced and -distributed Project Gutenberg-tm eBooks with only a loose network of -volunteer support. - -Project Gutenberg-tm eBooks are often created from several printed -editions, all of which are confirmed as not protected by copyright in -the U.S. unless a copyright notice is included. Thus, we do not -necessarily keep eBooks in compliance with any particular paper -edition. - -Most people start at our Web site which has the main PG search -facility: www.gutenberg.org - -This Web site includes information about Project Gutenberg-tm, -including how to make donations to the Project Gutenberg Literary -Archive Foundation, how to help produce our new eBooks, and how to -subscribe to our email newsletter to hear about new eBooks. - |