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                                   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