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page-break-before: always; - page-break-after: always; } - div.titlepage p {text-align: center; text-indent: 0em; font-weight: bold; - line-height: 1.5; margin-top: 3em; } - .ph1 { text-indent: 0em; font-weight: bold; font-size: xx-large; - margin: .67em auto; page-break-before: always; } - </style> - </head> - <body> - - -<pre> - -The Project Gutenberg EBook of A Treatise on Fever, by Thomas Southwood-Smith - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll -have to check the laws of the country where you are located before using -this ebook. - - - -Title: A Treatise on Fever - -Author: Thomas Southwood-Smith - -Release Date: October 4, 2019 [EBook #60419] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK A TREATISE ON FEVER *** - - - - -Produced by Richard Tonsing, Chris Curnow, and the Online -Distributed Proofreading Team at http://www.pgdp.net - - - - - - -</pre> - - -<div class='tnotes covernote'> - -<p class='c000'><b>Transcriber’s Note:</b></p> - -<p class='c000'>The cover image was created by the transcriber and is placed in the public domain.</p> - -</div> - -<div class='titlepage'> - -<div> - <h1 class='c001'><span class='large'>A</span><br /> TREATISE ON FEVER.</h1> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='small'>BY</span></div> - <div class='c003'><span class='xlarge'>SOUTHWOOD SMITH, M.D.</span></div> - <div class='c003'><span class='xsmall'>PHYSICIAN TO THE LONDON FEVER HOSPITAL.</span></div> - <div class='c002'><span class='large'>LONDON:</span></div> - <div class='c003'>LONGMAN, REES, ORME, BROWN, AND GREEN,</div> - <div><span class='small'>PATER-NOSTER ROW.</span></div> - <div class='c003'><span class='large'>1830.</span></div> - </div> -</div> - -</div> - -<div class='nf-center-c0'> -<div class='nf-center c004'> - <div>PRINTED BY G. HAYDEN,</div> - <div><span class='small'>Little College Street, Westminster.</span></div> - </div> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c004'> - <div><span class='pageno' id='Page_i'>i</span><span class='small'>TO</span></div> - <div class='c003'>HIS GRACE</div> - <div><span class='xlarge'>THE DUKE OF SOMERSET,</span></div> - <div>PRESIDENT;</div> - <div class='c003'><span class='small'>TO</span></div> - <div>THE VICE-PRESIDENTS,</div> - <div class='c003'><span class='small'>TO</span></div> - <div>THE TREASURERS,</div> - <div class='c003'><span class='small'>AND TO THE</span></div> - <div>OTHER GENTLEMEN CONSTITUTING THE COMMITTEE,</div> - <div class='c003'>Of the London Fever Hospital;</div> - <div class='c003'>IN TESTIMONY</div> - <div class='c003'>OF HIS ADMIRATION OF THE DILIGENCE</div> - <div><span class='small'>WITH WHICH</span></div> - <div>THEY LABOUR TO PROMOTE THE PROSPERITY,</div> - <div><span class='small'>AND THE</span></div> - <div>CARE WITH WHICH THEY WATCH OVER THE INTERESTS OF THIS INSTITUTION;</div> - <div class='c003'><span class='small'>WHICH,</span></div> - <div>IN THE MAGNITUDE OF THE BENEFITS IT CONFERS,</div> - <div><span class='small'>NO LESS THAN</span></div> - <div>IN THE INEXPENSIVENESS OF THE MEANS</div> - <div><span class='small'>BY WHICH,</span></div> - <div>THROUGH THEIR ECONOMY, IT IS ENABLED TO SECURE THEM,</div> - <div class='c003'>IS EQUALLED BY FEW ESTABLISHMENTS,</div> - <div class='c003'><span class='small'>AND</span></div> - <div>SURPASSED BY NONE;</div> - <div class='c003'>THIS WORK IS INSCRIBED</div> - <div class='c003'><span class='small'>BY</span></div> - <div class='c003'><span class='large'>THE AUTHOR.</span></div> - </div> -</div> - -<div class='pbb'> - <hr class='pb c003' /> -</div> - -<div class='chapter'> - <span class='pageno' id='Page_iii'>iii</span> - <h2 class='c005'>PREFACE.</h2> -</div> - -<p class='c006'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_iv'>iv</span>I cannot allow this work to go forth to -the world, without expressing my obligation -to Dr. <span class='sc'>Dill</span>, 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.</p> - -<div class='lg-container-r'> - <div class='linegroup'> - <div class='group'> - <div class='line'><em>S. S.</em></div> - </div> - </div> -</div> - -<div class='lg-container-l'> - <div class='linegroup'> - <div class='group'> - <div class='line'><em>36, New Broad Street</em></div> - <div class='line'><em>Dec. 1829.</em></div> - </div> - </div> -</div> - -<div class='chapter'> - <span class='pageno' id='Page_v'>v</span> - <h2 class='c005'>CONTENTS.</h2> -</div> - -<table class='table0' summary='CONTENTS'> - <tr> - <th class='c008' colspan='2'> </th> - <th class='c009'><span class='small'>Page.</span></th> - </tr> - <tr> - <td class='c008' colspan='2'><span class='sc'>Dedication</span></td> - <td class='c009'><a href='#Page_i'>i</a>.</td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'><span class='sc'>Preface</span></td> - <td class='c009'><a href='#Page_iii'>iii</a>.</td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER I.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Further Investigation of Fever necessary</td> - <td class='c009'><a href='#Page_1'>1</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Facilities afforded by the Fever Hospital for prosecuting the Study</td> - <td class='c009'><a href='#Page_5'>5</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Antient Doctrines relative to the Nature and Seat of Fever</td> - <td class='c009'><a href='#Page_7'>7</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Hippocrates, Galen, Sydenham</td> - <td class='c009'><a href='#Page_8'>8</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Modern Doctrines relative to the Nature and Seat of Fever</td> - <td class='c009'><a href='#Page_13'>13</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Cullen, Brown, Stoker, Burne, Clanny, Clutterbuck, Broussais</td> - <td class='c009'><a href='#Page_14'>14</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Errors common to all these Theorists</td> - <td class='c009'><a href='#Page_30'>30</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Questions to be solved before Fever can be understood</td> - <td class='c009'><a href='#Page_33'>33</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Precise Object of Investigation</td> - <td class='c009'><a href='#Page_34'>34</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Proper Mode of conducting it</td> - <td class='c009'><a href='#Page_36'>36</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER II.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Varieties of Fever</td> - <td class='c009'><a href='#Page_41'>41</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Common Phenomena</td> - <td class='c009'><a href='#Page_42'>42</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Importance of analyzing the Assemblage of the Symptoms, in order to ascertain the Common Phenomena</td> - <td class='c009'><a href='#Page_43'>43</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Results of the Analysis</td> - <td class='c009'><a href='#Page_45'>45</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Organs always diseased in Fever</td> - <td class='c009'><a href='#Page_48'>48</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Functions always deranged in Fever</td> - <td class='c009'><a href='#Page_49'>49</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Fever not Inflammation</td> - <td class='c009'><a href='#Page_50'>50</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Distinction between Fever and Inflammation</td> - <td class='c009'><a href='#Page_52'>52</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Common Phenomena of Fever exemplified in Plague</td> - <td class='c009'><a href='#Page_53'>53</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>in Yellow Fever,</td> - <td class='c009'><a href='#Page_54'>54</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>in the Varieties of Fever of Great Britain</td> - <td class='c009'><a href='#Page_54'>54</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Different Varieties produced by different Intensities</td> - <td class='c009'><a href='#Page_58'>58</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'><span class='pageno' id='Page_vi'>vi</span>Received Classification and Nomenclature defective</td> - <td class='c009'><a href='#Page_60'>60</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>What is really meant by Genera and Species of Fever</td> - <td class='c009'><a href='#Page_70'>70</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>True Principle of Arrangement</td> - <td class='c009'><a href='#Page_71'>71</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER III.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Of Synochus</td> - <td class='c009'><a href='#Page_77'>77</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Division into Synochus Mitior and Gravior</td> - <td class='c009'><a href='#Page_77'>77</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Succession of Phenomena in Synochus Mitior</td> - <td class='c009'><a href='#Page_78'>78</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Indications afforded of Disease in the Nervous, Circulating, Secreting, and Excreting Systems</td> - <td class='c009'><a href='#Page_81'>81</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Progress of Disease consists in progressive Increase in the Derangement of these Functions</td> - <td class='c009'><a href='#Page_85'>85</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Phenomena of Recovery</td> - <td class='c009'><a href='#Page_91'>91</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>On what the Transition of Synochus Mitior into Synochus Gravior depends</td> - <td class='c009'><a href='#Page_93'>93</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Classification according to the different Organs in which the several Affections have their Seat</td> - <td class='c009'><a href='#Page_95'>95</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Synochus Gravior with Cerebral Affection</td> - <td class='c009'><a href='#Page_96'>96</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>Subacute Cerebral Affection</td> - <td class='c009'><a href='#Page_96'>96</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>Acute Cerebral Affection</td> - <td class='c009'><a href='#Page_107'>107</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Cases illustrating Synochus Mitior</td> - <td class='c009'><a href='#Page_112'>112</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Cases illustrating Synochus Gravior with Subacute Cerebral Affection</td> - <td class='c009'><a href='#Page_114'>114</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Cases illustrating Synochus Gravior with Acute Cerebral Affection</td> - <td class='c009'><a href='#Page_116'>116</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Synochus Gravior with Thoracic Affection</td> - <td class='c009'><a href='#Page_120'>120</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Cases illustrating Thoracic Affection</td> - <td class='c009'><a href='#Page_123'>123</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Synochus Gravior with Abdominal Affection</td> - <td class='c009'><a href='#Page_128'>128</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Cases illustrating Abdominal Affection</td> - <td class='c009'><a href='#Page_137'>137</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Synochus Gravior with Mixed Affection</td> - <td class='c009'><a href='#Page_142'>142</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER IV.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Of Typhus</td> - <td class='c009'><a href='#Page_148'>148</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Division into Typhus Mitior and Gravior</td> - <td class='c009'><a href='#Page_149'>149</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Typhus Mitior, with Subacute Cerebral Affection</td> - <td class='c009'><a href='#Page_149'>149</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Cases illustrating Subacute Cerebral Affection</td> - <td class='c009'><a href='#Page_155'>155</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Typhus Mitior, with Thoracic Affection</td> - <td class='c009'><a href='#Page_157'>157</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'><span class='pageno' id='Page_vii'>vii</span>Typhus Mitior, Cases illustrating Affection</td> - <td class='c009'><a href='#Page_159'>159</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>With Abdominal Affection</td> - <td class='c009'><a href='#Page_161'>161</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>With Mixed Affection</td> - <td class='c009'><a href='#Page_162'>162</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Typhus Gravior</td> - <td class='c009'><a href='#Page_162'>162</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>In what it really consists</td> - <td class='c009'><a href='#Page_162'>162</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Dangerous nature of the Error that it consists in Debility</td> - <td class='c009'><a href='#Page_164'>164</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER V.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Of Scarlatina</td> - <td class='c009'><a href='#Page_168'>168</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Characters by which it is distinguished from Continued Fever without an Eruption</td> - <td class='c009'><a href='#Page_168'>168</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Division into Scarlatina Synochodes</td> - <td class='c009'><a href='#Page_171'>171</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>Typhodes</td> - <td class='c009'><a href='#Page_172'>172</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Events which occasionally occur in Fever, but which form no essential part of it</td> - <td class='c009'><a href='#Page_173'>173</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Preternatural Sensibility over the external Surface of the Body; Excoration and Sloughing; Erysipelas; Inflammation, &c. of the Glands; peculiar Affection of the Joints</td> - <td class='c009'><a href='#Page_173'>173</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER VI.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Of the Pathology of Fever</td> - <td class='c009'><a href='#Page_176'>176</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Importance of connecting the Symptoms with the States of the Organs</td> - <td class='c009'><a href='#Page_176'>176</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Pathology of Fever comprehends the Morbid Changes that take place in the Solids and Fluids of the Body</td> - <td class='c009'><a href='#Page_178'>178</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>I. <span class='sc'>General Pathology of the Solids</span></td> - <td class='c009'><a href='#Page_179'>179</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>External Appearances of the Body after Death</td> - <td class='c009'><a href='#Page_180'>180</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Morbid Appearances in the Head</td> - <td class='c009'><a href='#Page_181'>181</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>in the Thorax</td> - <td class='c009'><a href='#Page_184'>184</a></td> - </tr> - <tr> - <td class='c008'> </td> - <td class='c008'>in the Abdomen</td> - <td class='c009'><a href='#Page_187'>187</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>I. Cases illustrating the Morbid Changes which take place within the Head, or Cerebral Cases</td> - <td class='c009'><a href='#Page_193'>193</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>1. Vascularity of Brain, Spinal Cord, and Membranes, with Gelatinous or slight Serous Effusion</td> - <td class='c009'><a href='#Page_193'>193</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>2. Vascularity of Brain, Membranes, &c. with Effusion of Coagulable Lymph and Formation of Pus</td> - <td class='c009'><a href='#Page_204'>204</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'><span class='pageno' id='Page_viii'>viii</span> </td> - <td class='c008'>3. Vascularity of Brain, Membranes, &c. with copious Serous Effusion</td> - <td class='c009'><a href='#Page_210'>210</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>4. Vascularity, &c. with Preternatural Firmness of Brain</td> - <td class='c009'><a href='#Page_218'>218</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>5. Vascularity, &c. with softening of Brain</td> - <td class='c009'><a href='#Page_224'>224</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>General Results established by preceding Cases</td> - <td class='c009'><a href='#Page_230'>230</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>II. Cases illustrating the Morbid Changes which take place within the Chest, or Thoracic Cases</td> - <td class='c009'><a href='#Page_235'>235</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>III. Cases illustrating the Morbid Changes which take place within the Abdomen; or Abdominal Cases</td> - <td class='c009'><a href='#Page_246'>246</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>General Results established by preceding Cases</td> - <td class='c009'><a href='#Page_287'>287</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>IV. Cases illustrating the Morbid Changes which take place within the Head, Thorax, and Abdomen, in the same individual, or Mixed Cases</td> - <td class='c009'><a href='#Page_291'>291</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>General Conclusion</td> - <td class='c009'><a href='#Page_322'>322</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>II. <span class='sc'>Pathology of the Fluids in Fever</span></td> - <td class='c009'><a href='#Page_328'>328</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER VII.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Of the Relation between the Phenomena of Fever; or the Theory of the Disease</td> - <td class='c009'><a href='#Page_333'>333</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER VIII.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Of the Causes of Fever</td> - <td class='c009'><a href='#Page_348'>348</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>1. Of the Immediate, or Exciting Cause of Fever</td> - <td class='c009'><a href='#Page_348'>348</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>2. Of the Remote or Predisposing Causes of Fever</td> - <td class='c009'><a href='#Page_369'>369</a></td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><td class='c010' colspan='3'>CHAPTER IX.</td></tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Of the Treatment of Fever</td> - <td class='c009'><a href='#Page_375'>375</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Modification of Treatment required in prominent Cerebral Affection</td> - <td class='c009'><a href='#Page_398'>398</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>Thoracic Affection</td> - <td class='c009'><a href='#Page_403'>403</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008'> </td> - <td class='c008'>Abdominal Affection</td> - <td class='c009'><a href='#Page_405'>405</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Treatment of Scarlet Fever</td> - <td class='c009'><a href='#Page_408'>408</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Treatment during Convalescence</td> - <td class='c009'><a href='#Page_418'>418</a></td> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c008' colspan='2'>Appendix</td> - <td class='c009'><a href='#Page_425'>425</a></td> - </tr> -</table> - -<div class='section ph1'> - -<div class='nf-center-c0'> -<div class='nf-center c004'> - <div>FEVER, &c.</div> - </div> -</div> - -</div> - -<div class='chapter'> - <span class='pageno' id='Page_1'>1</span> - <h2 class='c005'>CHAPTER I.</h2> -</div> - -<p class='c011'><em>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.</em></p> - -<p class='c006'>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, -<span class='pageno' id='Page_2'>2</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_3'>3</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_4'>4</span>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 -<span class='pageno' id='Page_5'>5</span>of the more complicated, and the soundness -of the inductions that have been made from a comparison -of the whole.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_6'>6</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_7'>7</span>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.”<a id='r1' /><a href='#f1' class='c012'><sup>[1]</sup></a></p> - -<p class='c007'>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 -<span class='pageno' id='Page_8'>8</span>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 -<span class='pageno' id='Page_9'>9</span>division of the varieties of the disease upon this -principle, whence his <em>causus</em> or burning fever, his -<em>leipyria</em>, or fever with the parts externally cold and -internally hot, and his <em>epialus</em>, 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 -<span class='pageno' id='Page_10'>10</span>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:—</p> - -<p class='c007'>“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 -<span class='pageno' id='Page_11'>11</span>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 -<span class='pageno' id='Page_12'>12</span>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.<a id='r2' /><a href='#f2' class='c012'><sup>[2]</sup></a>”</p> - -<p class='c007'>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 -<span class='pageno' id='Page_13'>13</span>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 -<span class='pageno' id='Page_14'>14</span>suddenly, though, as it now appears, only for a short -time obsolete.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_15'>15</span>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 <i><span lang="la" xml:lang="la">vis medicatrix naturæ</span></i>, 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 -<span class='pageno' id='Page_16'>16</span>other marks of the relaxation of excretories take -place.”<a id='r3' /><a href='#f3' class='c012'><sup>[3]</sup></a></p> - -<p class='c007'>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 -<span class='pageno' id='Page_17'>17</span>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.</p> - -<p class='c007'>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,<a id='r4' /><a href='#f4' class='c012'><sup>[4]</sup></a> -“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 <i><span lang="fr" xml:lang="fr">fièvres essentielles</span></i> 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.”<a id='r5' /><a href='#f5' class='c012'><sup>[5]</sup></a> -“Typhoid or adynamic fever I consider to be generally -symptomatic of morbid changes in the physical -<span class='pageno' id='Page_18'>18</span>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 <em>primarily</em> -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.”<a id='r6' /><a href='#f6' class='c012'><sup>[6]</sup></a></p> - -<p class='c007'>At the close of the last season, in a work,<a id='r7' /><a href='#f7' class='c012'><sup>[7]</sup></a> 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 -<span class='pageno' id='Page_19'>19</span>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.”<a id='r8' /><a href='#f8' class='c012'><sup>[8]</sup></a> And Dr. Burne -himself states, “that the adynamic fever has no -local seat; that its nature is <em>a morbid condition of -the blood</em>, 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.”<a id='r9' /><a href='#f9' class='c012'><sup>[9]</sup></a></p> - -<p class='c007'>Instead of regarding with these authors a vitiated -state of the blood as the essence of fever, Dr. Clanny, -<span class='pageno' id='Page_20'>20</span>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.”<a id='r10' /><a href='#f10' class='c012'><sup>[10]</sup></a> -“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.”<a id='r11' /><a href='#f11' class='c012'><sup>[11]</sup></a></p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_21'>21</span>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 -<span class='pageno' id='Page_22'>22</span>slightness and consequent neglect of the first symptoms -is rarely done) it will be found to be strictly a -<em>topical</em> affection, the general disorder of the system -being merely <em>secondary</em>, or symptomatic of this.”<a id='r12' /><a href='#f12' class='c012'><sup>[12]</sup></a> -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.</p> - -<p class='c007'>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;<a id='r13' /><a href='#f13' class='c012'><sup>[13]</sup></a> “rich in numerous facts -observed with a rare sagacity, M. Broussais came to -overturn, from the very foundation, the antique -<span class='pageno' id='Page_23'>23</span>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.”</p> - -<p class='c007'>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 <em>primitive or sympathetic -irritation of the heart</em> through the effect of which -its contractions are quickened, and that every irritation -sufficiently intense to produce fever is an -inflammation.<a id='r14' /><a href='#f14' class='c012'><sup>[14]</sup></a></p> - -<p class='c007'><span class='pageno' id='Page_24'>24</span>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 -<span class='pageno' id='Page_25'>25</span>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.”<a id='r15' /><a href='#f15' class='c012'><sup>[15]</sup></a> 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.</p> - -<p class='c007'>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 <em>gastro-enteritis</em>. -<span class='pageno' id='Page_26'>26</span>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.”</p> - -<p class='c007'>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 -<span class='pageno' id='Page_27'>27</span>in a loss of energy of the brain, but which rapidly -extends to every organ and every function, and that -consequently <em>the absence of any primary local disease</em>, -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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_28'>28</span>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;<a id='r16' /><a href='#f16' class='c012'><sup>[16]</sup></a> 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. -<span class='pageno' id='Page_29'>29</span>“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.</p> - -<p class='c007'><span class='pageno' id='Page_30'>30</span>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 -<span class='pageno' id='Page_31'>31</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_32'>32</span>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 <em>know</em> 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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_33'>33</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_34'>34</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_35'>35</span>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 <em>essential</em> 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 -<span class='pageno' id='Page_36'>36</span>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.</p> - -<p class='c007'>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 <em>invariableness</em> of concurrence. If we can ascertain -that a certain number of events <em>invariably</em> 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 <em>invariably</em> -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 -<span class='pageno' id='Page_37'>37</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_38'>38</span>will demonstrate the first two points: the establishment -of the last two will be attempted by an examination -of the history of the cases.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_39'>39</span>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 -<span class='pageno' id='Page_40'>40</span>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.”</p> - -<div class='chapter'> - <span class='pageno' id='Page_41'>41</span> - <h2 class='c005'>CHAPTER II.</h2> -</div> - -<p class='c011'><em>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.</em></p> - -<p class='c006'>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 -<span class='pageno' id='Page_42'>42</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_43'>43</span>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?</p> - -<p class='c007'>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 -<span class='pageno' id='Page_44'>44</span>by some term expressive of that property,<a id='r17' /><a href='#f17' class='c012'><sup>[17]</sup></a> 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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_45'>45</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_46'>46</span>that has been accomplished, or ever can be accomplished -by all the rest of the nosology.</p> - -<p class='c007'>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.”<a id='r18' /><a href='#f18' class='c012'><sup>[18]</sup></a> -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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_47'>47</span>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.</p> - -<p class='c007'>In relation to our present subject then, the first -object of enquiry is, what are the events which invariably -concur in fever?</p> - -<p class='c007'>Where shall we look for the events? Not in the -symptoms. Symptoms are not events: they are -<span class='pageno' id='Page_48'>48</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_49'>49</span>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.</p> - -<p class='c007'>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 <em>invariably</em> 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 -<span class='pageno' id='Page_50'>50</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_51'>51</span>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 <em>never</em> the organs in which -the <em>first</em> 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 -<span class='pageno' id='Page_52'>52</span>last to be involved, and certainly the least to suffer, -is the nervous system.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_53'>53</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_54'>54</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_55'>55</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_56'>56</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_57'>57</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_58'>58</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_59'>59</span>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 <em>the</em> 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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_60'>60</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_61'>61</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_62'>62</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_63'>63</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_64'>64</span>through the greater part of the disease, it has been -called synocha.<a id='r19' /><a href='#f19' class='c012'><sup>[19]</sup></a></p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_65'>65</span>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.</p> - -<p class='c007'>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. -<span class='pageno' id='Page_66'>66</span>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 -<span class='pageno' id='Page_67'>67</span>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.”<a id='r20' /><a href='#f20' class='c012'><sup>[20]</sup></a></p> - -<p class='c007'>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 -<span class='pageno' id='Page_68'>68</span>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.”<a id='r21' /><a href='#f21' class='c012'><sup>[21]</sup></a></p> - -<p class='c007'>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.</p> - -<p class='c007'>Hitherto, however, no one appears to have hazarded -<span class='pageno' id='Page_69'>69</span>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!</p> - -<p class='c007'>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.</p> - -<p class='c007'>It is not the object of the present volume to treat of -<span class='pageno' id='Page_70'>70</span>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 -<span class='pageno' id='Page_71'>71</span>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, -<span class='pageno' id='Page_72'>72</span>by which the varieties it presents are classified, -should be founded on this, the only true distinction -of which it admits.</p> - -<p class='c007'>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.</p> - -<p class='c007'>For the purpose of distinguishing further important -differences, that is, differences which bear an -<span class='pageno' id='Page_73'>73</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_74'>74</span>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.</p> - -<p class='c007'>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.<a id='r22' /><a href='#f22' class='c012'><sup>[22]</sup></a> And the same I am -<span class='pageno' id='Page_75'>75</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_76'>76</span>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.</p> - -<p class='c007'>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_77'>77</span> - <h2 class='c005'>CHAPTER III.</h2> -</div> - -<p class='c011'><em>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.</em></p> - -<p class='c006'>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 -<span class='pageno' id='Page_78'>78</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>This affection of the mind consists particularly in -<span class='pageno' id='Page_79'>79</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_80'>80</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_81'>81</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_82'>82</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_83'>83</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_84'>84</span>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 -<span class='pageno' id='Page_85'>85</span>functions is invariably connected with a morbidly-diminished -temperature; another with a morbidly-augmented -temperature; and another with the temperature -of health.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_86'>86</span>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.</p> - -<p class='c007'>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<a id='r23' /><a href='#f23' class='c012'><sup>[23]</sup></a> that “the <em>first</em> 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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_87'>87</span>or severe, or whether it be giddiness, or lightness, -or heaviness, it indicates a similar condition of the -organ, and requires a similar treatment.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_88'>88</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_89'>89</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>One of the most remarkable circumstances connected -with the ordinary fever of this country, in the -<span class='pageno' id='Page_90'>90</span>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.</p> - -<p class='c007'>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. -<span class='pageno' id='Page_91'>91</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_92'>92</span>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.</p> - -<p class='c007'><span class='pageno' id='Page_93'>93</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_94'>94</span>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 -<span class='pageno' id='Page_95'>95</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_96'>96</span>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.</p> - -<h3 class='c013'>I. <span class='sc'>Synochus Gravior with Cerebral Affection</span>,</h3> -<p class='c014'>occurs under two degrees of intensity: when the cerebral -affection is moderate, it may be termed subacute; -when great, acute.</p> - -<p class='c007'>1. <em>Synochus with Subacute Cerebral Affection</em>, -may be attended for several days with no symptom -which has not been already enumerated in the account -<span class='pageno' id='Page_97'>97</span>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 -<span class='pageno' id='Page_98'>98</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_99'>99</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_100'>100</span>“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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_101'>101</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>7. The pulse, during all this time, may not be -much quicker than in the mild form; and the state -<span class='pageno' id='Page_102'>102</span>of the tongue and of the evacuations does not materially -differ.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_103'>103</span>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.</p> - -<p class='c007'>If, on the contrary, the case proceed unfavourably, -a totally new train of symptoms at this period sets in.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_104'>104</span>usually takes place about the tenth day from the -commencement of the disease.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_105'>105</span>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.</p> - -<p class='c007'>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 <em>any</em> 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 -<span class='pageno' id='Page_106'>106</span>with tolerable certainty. Two or three days <em>may</em> -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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_107'>107</span>what conditions of what organs they depend will be -illustrated in the pathology.</p> - -<p class='c007'>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.</p> - -<p class='c007'>2. <em>Synochus Gravior with Acute Cerebral Affection.</em>—Such -is the history of the synochus gravior -<span class='pageno' id='Page_108'>108</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_109'>109</span>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 <em>a slow pulse</em>, 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 -<span class='pageno' id='Page_110'>110</span>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; <em>but -he had no pain</em>: 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 <em>still -slower</em> than on the preceding evening, and was now -<em>intermittent</em>: 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 -<span class='pageno' id='Page_111'>111</span>symptoms, but also a decisive proof that pain of the -head is far from being the <em>first</em> symptom that occurs -even in the most intense cerebral attack.</p> - -<p class='c007'>In these acute forms of the disease, if the proper -remedies be not vigorously employed, the pain ceases -<em>within the fourth day</em>; 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 -<span class='pageno' id='Page_112'>112</span>the brain, it will be most instructive to state in connexion -with the pathology.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>As an illustration of each form of the disease, -as it is commonly met with in practice, I subjoin the -following cases.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case I.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Colebert</span>, æt. 28, admitted into the Fever -Hospital August 1, 1828.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_113'>113</span>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.</p> - -<p class='c007'>6th. Skin natural; pain of head gone; pain of -back and limbs continues; slept better; tongue -more clean; three stools; pulse 102.</p> - -<p class='c007'>7th. Pain of head not returned; pain of limbs -better; tongue still cleaning; three stools; pulse 96.</p> - -<p class='c007'>9th. Pain of limbs gone; tongue nearly clean; -two stools; pulse 84.</p> - -<p class='c007'>10th. Convalescent.</p> - -<p class='c007'>13th. Dismissed cured.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case II.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>George Walker</span>, aged 17. Admitted May 5th, -1828.</p> - -<p class='c007'>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.</p> - -<p class='c007'>7th. Heat of skin nearly natural; pain of head -<span class='pageno' id='Page_114'>114</span>almost gone; no pain of limbs; tongue still much -loaded; some thirst; three stools; pulse 72; slept -much better.</p> - -<p class='c007'>8th. Tongue much less loaded; less thirst; five -stools; pulse 60.</p> - -<p class='c007'>11th. Convalescent.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case III.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Emma Gladish.</span> 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.</p> - -<p class='c007'><span class='pageno' id='Page_115'>115</span>13th. Sleep rather more tranquil; less wandering; -mind a little more distinct; stools still passed in -bed; pulse 100.</p> - -<p class='c007'>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.</p> - -<p class='c007'>15th. Rather more sleep; talkative delirium; -tongue somewhat cleaner; pulse 100.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>19th. Slept well; mind clearer; eyes more animated; -expression of countenance brighter; other -symptoms the same.</p> - -<p class='c007'>26th. Continues to improve; skin cool, soft, and -moist; pulse 78.</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_116'>116</span><span class='sc'>Case IV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Elizabeth Price</span>, 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, <em>intermittent</em>, of good -power, but easily compressed; bowels constipated. -C. C. ad ℥xviij. nuchæ. Abradat. Capillitium. Lot. -Gelid. cap. Haust. Sennæ Sal. c. m.</p> - -<p class='c007'>12th. More sensible since cupping; mind still -confused; occasional wandering; scarcely any sleep; -pulse 124, sharp, yet easily compressed.</p> - -<p class='c007'>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.</p> - -<p class='c007'>15th. Much screaming; great restlessness during -night; complains much of head-ache; pupils active; -urine copious, but passed in bed; all the stools -<span class='pageno' id='Page_117'>117</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>24th. No material change until this day; sleep -now greatly improved; mind much more itself; -tongue beginning to clean; pulse 93; ptyalism.</p> - -<p class='c007'>28th. Ptyalism continues; feels greatly better; -appetite returning.</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case V.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Sullivan</span>, 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 -<span class='pageno' id='Page_118'>118</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>16th. Pain of head much relieved; slept very -much better; pulse 66, full and strong.</p> - -<p class='c007'>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.</p> - -<p class='c007'>18th. Pain of head gone; countenance more natural; -tongue more clean and moist; pulse 76, more -soft. Pt. Med.</p> - -<p class='c007'>20th. Pain of head returned; mind confused; -pulse 60, strong and full. C.C. ad ℥viij. nuchæ. -Pt. Med.</p> - -<p class='c007'>21st. Pain of head gone; mind confused; pulse -66, pretty strong.</p> - -<p class='c007'>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.</p> - -<p class='c007'>24th. No longer conscious of pain; mind quite -indistinct; lies prostrate on the back perfectly helpless; -incapable of turning on the side; occasional -<span class='pageno' id='Page_119'>119</span>retching; some tenderness of abdomen on pressure; -pulse 72, strong and full.</p> - -<p class='c007'>25th. Much restlessness; aspect of countenance -greatly depressed; stools passed in bed; pulse 75.</p> - -<p class='c007'>26th. Perfectly senseless; almost constant moaning; -extreme restlessness; difficult deglutition; pulse -120.</p> - -<p class='c007'>27th. Not spoken since last report; lies prostrate -on back; eyes half open and injected; pulse 102, -feeble.</p> - -<p class='c007'>29th. Died.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_120'>120</span>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.</p> - -<h3 class='c013'><span class='sc'>II. Synochus Gravior with Thoracic Affection.</span></h3> - -<p class='c015'>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 -<span class='pageno' id='Page_121'>121</span>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.</p> - -<p class='c007'>The new and peculiar symptoms to which a moderately -acute and an early thoracic affection gives -rise, are the following; namely—</p> - -<p class='c007'>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 -<span class='pageno' id='Page_122'>122</span>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.”</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_123'>123</span>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case VI.</span></div> - </div> -</div> - -<p class='c007'>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.</p> - -<p class='c007'><span class='sc'>Mary Dillon</span>, 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.</p> - -<p class='c007'>9th. Pectoral and cerebral symptoms the same; -bowels purged; pulse 96.</p> - -<p class='c007'>10th. Only slight cough; pain of head; more -<span class='pageno' id='Page_124'>124</span>giddiness; no sleep; eyes preternaturally bright and -glistening; pulse 120.</p> - -<p class='c007'>11th. Only slight cough; pain of head much -relieved; slept better; tongue more clean; four -stools; pulse 120, strong.</p> - -<p class='c007'>12th. No pain of chest; cough much increased; -now very frequent and accompanied with copious -expectoration; pulse 136.</p> - -<p class='c007'>15th. Cough more frequent; expectoration purulent -and mixed with blood; pulse 126.</p> - -<p class='c007'>17th. Expectorates a larger quantity of purulent -matter, mixed with a larger proportion of blood; -pulse 102.</p> - -<p class='c007'>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.</p> - -<p class='c007'>21st. Pectoral symptoms the same; powers extremely -depressed; three stools passed in bed.</p> - -<p class='c007'>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.</p> - -<p class='c007'>24th. Cough rather diminished; expectoration -unchanged; four stools passed in bed; pulse 84, -extremely weak.</p> - -<p class='c007'>25th. No change, excepting that the pulse (78) -is rather more strong, and she is scarcely so prostrate.</p> - -<p class='c007'><span class='pageno' id='Page_125'>125</span>26th. Skin again hot; tongue again red and dry; -no sleep; some delirium; pulse 84, of more strength.</p> - -<p class='c007'>27th. Skin more cool; tongue less red and more -moist; pulse 66; some return of appetite.</p> - -<p class='c007'>28th. Cough much diminished; expectorates less; -tongue moist, clean, and nearly of natural colour; -pulse 72, stronger; countenance more animated.</p> - -<p class='c007'>35th. Cough nearly gone; expectoration much -diminished; tongue clean; one stool; countenance -improving; strength increasing; wishes for meat; -two ounces were allowed.</p> - -<p class='c007'>40th. Sloughs on sacrum and ilium doing well; -pulse 90, of more power; still noisy during sleep.</p> - -<p class='c007'>From this period she continued slowly, although -gradually, to gain strength, and was dismissed from -the hospital on the 57th day, <em>cured</em>.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case VII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Angelica Fidgett</span>, 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 -<span class='pageno' id='Page_126'>126</span>pressure; pulse 129; tongue foul, moist; skin hot; -face flushed.</p> - -<p class='c007'>17th. Respiration slow and laborious; cough; -completely comatose; eyes suffused; pulse 120, full, -soft; face flushed.</p> - -<p class='c007'>18th. Respiration continues very laborious; mind -exceedingly indistinct; much restlessness; pulse -116, still softer.</p> - -<p class='c007'>21st. Examined with the stethoscope: the bronchial -roll and crepitus were very distinctly and generally -heard.</p> - -<p class='c007'>22d. The respiration continues extremely laborious; -frequent cough, without expectoration; low, -rambling delirium; pulse 112, weak; tongue foul, -moist; general powers greatly depressed.</p> - -<p class='c007'>23d. All the symptoms aggravated. Died on the -24th day of fever.</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_127'>127</span><span class='sc'>Case VIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Potter</span>, 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.</p> - -<p class='c007'>18th. Symptoms the same; in addition, the abdomen -was now tender on full pressure and retracted.</p> - -<p class='c007'>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.<a id='r24' /><a href='#f24' class='c012'><sup>[24]</sup></a></p> - -<div> - <span class='pageno' id='Page_128'>128</span> - <h3 class='c013'><span class='sc'>III. Synochus Gravior with Abdominal Affection.</span></h3> -</div> - -<p class='c015'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>1. If the abdominal affection be severe from the -<span class='pageno' id='Page_129'>129</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_130'>130</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_131'>131</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_132'>132</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_133'>133</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_134'>134</span>more and sooner dry, and, at the same time, -the lips and teeth become more and sooner sordid.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 <em>apparently</em> -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.</p> - -<p class='c007'>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, <em>if accompanied -with corresponding amendment in the other symptoms</em>, -<span class='pageno' id='Page_135'>135</span>they may, indeed, be hailed as signs of returning -health; but if they occur <em>without</em> 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, <em>without amendment</em>, 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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_136'>136</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_137'>137</span>condition of the tongue is <em>increased tenderness of -the abdomen on pressure</em>. 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>As illustrations of these different modifications of -abdominal affection the following cases are subjoined.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case IX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Eleanor House</span>, æt. 18, silk-winder. Before admission -<span class='pageno' id='Page_138'>138</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>10th. “Feels greatly better;” pain of epigastrium -gone; none of abdomen when not pressed; full -pressure much more easily borne; tongue unchanged; -<span class='pageno' id='Page_139'>139</span>thirst; vomiting; four stools; pulse 108, of the -same character.</p> - -<p class='c007'>12th. Pain not diminished on pressure; nausea, -vomiting, rejection of a large quantity of green fluid; -pulse 118.</p> - -<p class='c007'>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.</p> - -<p class='c007'>18th. Pain of abdomen returned; mind confused; -delirium.</p> - -<p class='c007'>23d. Says she is without pain, but feels oppressed; -pulse 96; slept better; no delirium; face more animated; -skin warm; no flushing.</p> - -<p class='c007'>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.</p> - -<p class='c007'>29th. Pain much relieved since the application -of six leeches to the abdomen, followed by a large -poultice.</p> - -<p class='c007'>30th. Pain gone: only slight tenderness: pulse -96.</p> - -<p class='c007'>32d. Pain and tenderness again returned; tongue -more red; pulse 108.</p> - -<p class='c007'>33d. Six leeches were applied last evening without -<span class='pageno' id='Page_140'>140</span>the slightest relief of the pain or tenderness; tongue -red: pulse 96, more weak and soft.</p> - -<p class='c007'>34th. Tenderness considerably diminished; tongue -less red; countenance again improved.</p> - -<p class='c007'>35th. Still less tenderness than yesterday; bears -pressure much better; tongue nearly natural; two -stools.</p> - -<p class='c007'>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.</p> - -<p class='c007'>44th. No return of uneasiness; continues to gain -strength.</p> - -<p class='c007'>57th. Since last report has been daily improving, -and is now quite well. Dismissed cured.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case X.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Sarah Raven</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_141'>141</span>25th. No material change.</p> - -<p class='c007'>27th. Insensibility increased to coma; features -shrunk; one stool passed in bed; pulse 128; skin -livid, cold.</p> - -<p class='c007'>28th. Moribund; died the following day.</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>George English</span>, 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.</p> - -<p class='c007'>30th. Pain of the abdomen continues, especially -over the region of the bladder; urine passed in good -quantity and freely; three stools; pulse 84.</p> - -<p class='c007'>32d. Tumour has appeared over the region of the -bladder, unattended with pain; three stools; pulse -76.</p> - -<p class='c007'>33d. Hypogastrium still tumid, but without pain; -other symptoms the same.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_142'>142</span>pressure; great restlessness, and great anxiety; vomiting -of a yellow-coloured fluid; two stools; pulse 84, -extremely feeble.</p> - -<p class='c007'>44th. Died.</p> - -<p class='c007'>These acute symptoms mark the very hour when -the event occurred which caused them.—See Pathology.</p> - -<h3 class='c013'>IV. <span class='sc'>Synochus Gravior with Mixed Affection.</span></h3> - -<p class='c015'>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.</p> - -<p class='c007'><span class='pageno' id='Page_143'>143</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_144'>144</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_145'>145</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_146'>146</span>the reader, without perceiving that the opinion -that the seat of fever is invariably fixed in some -<em>one</em> 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, -<em>in connexion with the morbid changes apparent after -death</em>, 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 <em>all</em> 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 -<span class='pageno' id='Page_147'>147</span>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_148'>148</span> - <h2 class='c005'>CHAPTER IV.</h2> -</div> - -<p class='c011'><em>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.</em></p> - -<p class='c006'>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 -<span class='pageno' id='Page_149'>149</span>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.</p> - -<p class='c007'>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.</p> - -<h3 class='c013'>I. <span class='sc'>Typhus Mitior, with Cerebral Affection.</span></h3> - -<p class='c015'>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.</p> - -<h4 class='c016'>1. <em>Typhus Mitior with Subacute Cerebral Affection.</em></h4> - -<p class='c015'>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 -<span class='pageno' id='Page_150'>150</span>shall effectually correct it, will do the greatest possible -service to medicine, and, through it, to his fellow -men.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_151'>151</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>5. When pain is present it diminishes sooner and -disappears more completely than in synochus: when -<span class='pageno' id='Page_152'>152</span>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.</p> - -<p class='c007'>6. There is little or no sleep; the restlessness is -great; there may be no violence; but there is abundance -of inquietude.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_153'>153</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_154'>154</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>14. Typhus terminates much earlier, whether favourably -<span class='pageno' id='Page_155'>155</span>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.</p> - -<p class='c007'>Towards the termination of the disease more or -fewer of the symptoms which it has been stated occasionally -to occur in synochus,<a id='r25' /><a href='#f25' class='c012'><sup>[25]</sup></a> supervene; but, as -these depend upon particular conditions of the brain, -they will be detailed under the pathology.</p> - -<h4 class='c016'>2. <em>Typhus Mitior, with Acute Cerebral Affection.</em></h4> - -<p class='c015'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>James Solden</span>, æt. 44, plaisterer. Admitted on -<span class='pageno' id='Page_156'>156</span>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.</p> - -<p class='c007'>8th. Insensibility more profound; restlessness and -delirium increased; respiration more hurried; cough -the same; stools passed in bed: pulse 92.</p> - -<p class='c007'>9th. No change.</p> - -<p class='c007'>10th. Died.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Clark</span>, 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.</p> - -<p class='c007'>5th. Eight ounces of blood which were drawn not -<span class='pageno' id='Page_157'>157</span>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.</p> - -<p class='c007'>6th. Pain of head still severe; mind more confused; -passed a more restless night; pulse 116.</p> - -<p class='c007'>10th. Pain of head undiminished; eyes more suffused; -extremely restless night, during which delirium -came on; this morning muscular tremor has -appeared; pulse 124.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>14th. Died.</p> - -<h3 class='c013'>II. <span class='sc'>Typhus Mitior, with Thoracic Affection.</span></h3> - -<p class='c015'>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 -<span class='pageno' id='Page_158'>158</span>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 -<span class='pageno' id='Page_159'>159</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Alexander Crombie</span>, æt. 19, seaman.</p> - -<p class='c007'><span class='pageno' id='Page_160'>160</span>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.</p> - -<p class='c007'>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.</p> - -<div> - <span class='pageno' id='Page_161'>161</span> - <h3 class='c013'>III. <span class='sc'>Typhus Mitior, with Abdominal Affection.</span></h3> -</div> - -<p class='c015'>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.</p> - -<p class='c007'>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.</p> - -<div> - <span class='pageno' id='Page_162'>162</span> - <h3 class='c013'>IV. <span class='sc'>Typhus Mitior, with Mixed Affection.</span></h3> -</div> - -<p class='c015'>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—</p> - -<h3 class='c013'>II. <span class='sc'>Typhus Gravior.</span></h3> - -<p class='c015'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_163'>163</span>denote an <em>equal</em> 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_164'>164</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_165'>165</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_166'>166</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_167'>167</span>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_168'>168</span> - <h2 class='c005'>CHAPTER V.</h2> -</div> - -<p class='c011'><em>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.</em></p> - -<p class='c006'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>2. Accordingly, the circulation is not only more -rapid, but it is also more strong. It is not uncommon -<span class='pageno' id='Page_169'>169</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_170'>170</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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,</p> - -<p class='c007'><span class='pageno' id='Page_171'>171</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_172'>172</span>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.</p> - -<p class='c007'>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,<a id='r26' /><a href='#f26' class='c012'><sup>[26]</sup></a> or they may be those which characterize -the second, or the congestive form.<a id='r27' /><a href='#f27' class='c012'><sup>[27]</sup></a> 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 -<span class='pageno' id='Page_173'>173</span>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.</p> - -<hr class='c017' /> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_174'>174</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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. -<span class='pageno' id='Page_175'>175</span>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.</p> - -<p class='c007'>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_176'>176</span> - <h2 class='c005'>CHAPTER VI.<br /> OF THE PATHOLOGY OF FEVER.</h2> -</div> - -<p class='c011'><em>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.</em></p> - -<p class='c006'>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 -<span class='pageno' id='Page_177'>177</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>The present state of our knowledge, it must be -<span class='pageno' id='Page_178'>178</span>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.</p> - -<p class='c007'>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 <em>invariable</em> 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: -<span class='pageno' id='Page_179'>179</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_180'>180</span>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.</p> - -<p class='c007'>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.</p> - -<h3 class='c013'>I. <span class='sc'>Pathology of the Solids in Fever.</span></h3> - -<h4 class='c016'>1. <em>External Appearances of the Body after Death.</em></h4> - -<p class='c015'>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.</p> - -<p class='c007'>Externally the body always appears emaciated, -and on removing the skin, the greater portion of the -<span class='pageno' id='Page_181'>181</span>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.</p> - -<h4 class='c016'>2. <em>Morbid Appearances in the Head.</em></h4> - -<p class='c015'>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 -<span class='pageno' id='Page_182'>182</span>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_183'>183</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_184'>184</span>consistence, opake, and even bloody, and sometimes -that beneath the membranes contains flakes of lymph, -or is mixed with pus.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<h4 class='c016'>3. <em>Morbid Appearances in the Thorax.</em></h4> - -<p class='c015'>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 -<span class='pageno' id='Page_185'>185</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_186'>186</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>In examining those who die of fever, a great variety -and complication of thoracic diseases, in addition -<span class='pageno' id='Page_187'>187</span>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.</p> - -<h4 class='c016'>4. <em>Morbid Appearances in the Abdomen.</em></h4> - -<p class='c015'>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; -<span class='pageno' id='Page_188'>188</span>and especially that portion of it which -lines the ileum and the cæcum.</p> - -<p class='c007'>The varieties of disease exhibited by this membrane -may be comprehended under three, namely, -vascularity, thickening and ulceration.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>The third stage is that of ulceration, which may -<span class='pageno' id='Page_189'>189</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_190'>190</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_191'>191</span>and that portion of it which is attached to -the duodenum is sometimes nearly cartilaginous.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_192'>192</span>either paler and more fluid than natural, or extremely -dark and very much inspissated.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<div> - <span class='pageno' id='Page_193'>193</span> - <h3 class='c013'>II. <span class='sc'>Cases in illustration of the Morbid Changes which take place within the Head: or Cerebral Cases.</span></h3> -</div> - -<h5 class='c016'>1. <em>Vascularity of Brain, Spinal Cord and Membranes, with Gelatinous or slight Serous Effusion.</em></h5> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Sarah Agenbar</span>, æt. 21, married.</p> - -<p class='c007'>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.</p> - -<p class='c007'>9th. No sleep; delirium the same; pulse 126.</p> - -<p class='c007'>10th. Died.</p> - -<p class='c007'><em>Head.</em> Membranes and substance of the brain -highly vascular; no effusion. <em>Thorax.</em> Viscera exhibited -only slight indications of disease. <em>Abdomen.</em> -Viscera nearly healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Welsh</span>, æt. 55, admitted on the 15th day -<span class='pageno' id='Page_194'>194</span>of fever. Attack came on with ordinary symptoms. -Pain of head now gone; some sleep; tongue loaded, -moist; pulse 80; skin cool.</p> - -<p class='c007'>21st. No pain; much prostration; tongue dry; -pulse 104.</p> - -<p class='c007'>22d. Stupor; mind incoherent; scarcely any sleep; -tongue brown and dry; pulse 108; skin hot.</p> - -<p class='c007'>27th. Coma; erysipelas on face; pulse 110.</p> - -<p class='c007'>28th. Coma increased; tongue deeply crusted; -erysipelas extending.</p> - -<p class='c007'>29th. Delirium; tongue black; stools passed in -bed; erysipelas extending.</p> - -<p class='c007'>30th. Muscular tremor.</p> - -<p class='c007'>35th. Increasing coma and prostration. Died.</p> - -<p class='c007'><em>Head.</em> Arachnoid opake; slight serous effusion; -substance of brain and spinal cord vascular. <em>Thorax.</em> -<a id='r28' /><a href='#f28' class='c012'><sup>[28]</sup></a>[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.] <em>Abdomen.</em> Viscera -healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Margaret Gibbs</span>, æt. 63, widow, admitted on -the 43rd day of fever. Pain of head still considerable; -<span class='pageno' id='Page_195'>195</span>sleeps badly; pain of chest on right side; -much cough, with purulent expectoration; abdomen -tender; tongue loaded, dry; pulse 105.</p> - -<p class='c007'>45th. Pain gone; drowsiness, approaching to coma; -no delirium; pulse 100.</p> - -<p class='c007'>48th. Insensibility continues; cough, with bloody -sputa; pulse 108.</p> - -<p class='c007'>55th. Prostration; pulse 135, extremely weak; -skin cold and clammy.</p> - -<p class='c007'>57th. Died.</p> - -<p class='c007'><em>Head.</em> Arachnoid opake, with gelatinous effusion -beneath it; adherent to the dura mater along the longitudinal -sinus; substance of brain vascular. <em>Thorax.</em> -[Pleuræ adherent; slight effusion in left side; -substance of lower lobes partly gorged, partly hepatized; -melanotic deposits in the parenchyma. <em>Abdomen.</em> -Both ovaria dropsical; partly converted into -cartilage; scirrhous tumour in walls of uterus.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Elizabeth Ralph</span>, 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.</p> - -<p class='c007'>9th. Pain of head diminished; that of abdomen -unrelieved; 8 stools; pulse 108.</p> - -<p class='c007'><span class='pageno' id='Page_196'>196</span>10th. Pain of head gone; that of abdomen undiminished; -4 stools.</p> - -<p class='c007'>11th. Pain of head not returned; tenderness of -abdomen undiminished; 7 stools; pulse 124.</p> - -<p class='c007'>12th. Tenderness of abdomen unabated; now -swollen, hard, and rounded at umbilicus; 7 stools; -pulse 125.</p> - -<p class='c007'>14th. Tenderness and purging continue. Died.</p> - -<p class='c007'><em>Head.</em> [Falciform process of dura mater ossified;] -substance of brain vascular; more fluid than natural -in the ventricles. <em>Thorax.</em> [Pleuræ adherent; serous -effusion into parenchyma of lungs. <em>Abdomen.</em> -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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Elizabeth Gasset</span>, 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.</p> - -<p class='c007'>9th. Tenderness of epigastrium continues; tongue -<span class='pageno' id='Page_197'>197</span>red and dry; no stool; pulse 84; no cerebral nor -pectoral symptoms.</p> - -<p class='c007'>10th. Died.</p> - -<p class='c007'><em>Head.</em> Membranes and substance of the brain -highly vascular; no effusion. <em>Thorax.</em> Viscera -healthy. <em>Abdomen.</em> [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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Joseph Danbury</span>, 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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_198'>198</span>the vertigo is now gone; delirium; eyes suffused; -tongue dry; pulse 120.</p> - -<p class='c007'>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.</p> - -<p class='c007'>37th. Died.</p> - -<p class='c007'><em>Head.</em> Pia mater vascular; substance of brain -vascular; slight effusion between the membranes -and into the ventricles. <em>Thorax.</em> No prominent -disease. <em>Abdomen.</em> Peritoneal coat of intestines vascular; -other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Edward Forrester</span>, 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.</p> - -<p class='c007'>7th. Pain of head, limbs and epigastrium; tongue -white, dry; pulse 96, full and strong. V.S. ad ℥xij.</p> - -<p class='c007'>8th. Pain of head gone; that of epigastrium diminished; -pulse 110; blood not sizy.</p> - -<p class='c007'>10th. Pain of head returned; that of epigastrium -diminished; no sleep; delirium; pulse 126.</p> - -<p class='c007'>12th. Pain of head again gone; delirium continues; -pulse 110.</p> - -<p class='c007'><span class='pageno' id='Page_199'>199</span>13th. No sleep; mind confused; delirium; subsultus -tendinum.</p> - -<p class='c007'>15th. Cerebral symptoms undiminished; tongue -dry and quite black; lips and teeth covered with -black sordes.</p> - -<p class='c007'>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.</p> - -<p class='c007'>20th. Tumour of parotid increased; all the symptoms -greatly aggravated; tongue not to be protruded.</p> - -<p class='c007'>22d. Insensibility amounting to coma.</p> - -<p class='c007'>27th. Insensibility and prostration gradually increased. -Died.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> Mucous -membrane of bronchi vascular; [pleuræ adherent; -lower lobe of left lung partly hepatized, and -partly consisting of a mass of suppurating tubercles.] -<em>Abdomen.</em> Small intestines of extremely dark colour; -mucous membrane vascular.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Singleton</span>, 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 -<span class='pageno' id='Page_200'>200</span>to lie on it; no cough; tenderness of abdomen; -pulse 111.</p> - -<p class='c007'>9th. After venesection to twelve ounces pain in -head, side, and abdomen relieved; blood buffy.</p> - -<p class='c007'>11th. Slight pain of occiput; much pain and tenderness -of abdomen; pulse 120.</p> - -<p class='c007'>13th. Cerebral and abdominal symptoms unchanged; -tongue brown and dry; eyes yellow.</p> - -<p class='c007'>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.</p> - -<p class='c007'>20th. Died.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> Mucous membrane -of bronchi vascular; substance of both lungs -gorged with blood; [pleuræ universally adherent.] -<em>Abdomen.</em> Mucous membrane of intestines not vascular; -but the mesentery highly injected: [liver -adherent to diaphragm.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Ann Lamberth</span>, æt. 16, servant. Admitted -on 22d day of fever. Pain of head, which has been -very severe, is now gone; no tenderness of abdomen -<span class='pageno' id='Page_201'>201</span>on fullest pressure; tongue red, smooth, and chapped; -lips and teeth sordid; bowels purged; pulse -108.</p> - -<p class='c007'>30th. Cough with slight expectoration; cheek -dusky; no tenderness of abdomen; bowels purged; -pulse 120.</p> - -<p class='c007'>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.</p> - -<p class='c007'>36th. Mind more confused; countenance sunk; -swelling of wrist increased; pulse not to be counted.</p> - -<p class='c007'>37th. Died.</p> - -<p class='c007'>N.B. Probable that the swelling of the wrist arose -from the peculiar affection hereafter to be described.<a id='r29' /><a href='#f29' class='c012'><sup>[29]</sup></a></p> - -<p class='c007'><em>Head.</em> Some effusion beneath the membranes, and -at the base of the skull; substance of brain natural; -anterior and middle lobes firmly adherent. <em>Thorax.</em> -Healthy. <em>Abdomen.</em> The ilium contained one large -and spreading ulcer, the glands around which were -darkened and inflamed.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Crouch</span>, æt. 30. Admitted on the 7th day -of fever. At present pain of head gone; some pain -of back continues; no sleep; great restlessness; -<span class='pageno' id='Page_202'>202</span>almost constant moaning; no uneasiness of chest; -no cough; respiration hurried; pulse 108.</p> - -<p class='c007'>8th. Sleeplessness, hurried respiration, tenderness -of abdomen continue; tongue red and glazed.</p> - -<p class='c007'>9th. Delirium; respiration hurried and noisy; -lips and teeth sordid.</p> - -<p class='c007'>10th. Subsultus tendinum.</p> - -<p class='c007'>11th. Face livid; dark, bloody-coloured fluid issuing -from the mouth; convulsive twitchings of muscles -of face and hands. Died.</p> - -<p class='c007'><em>Head.</em> Arachnoid opake; dura mater vascular; -substance of brain vascular; some effusion between -membranes and into ventricles. <em>Thorax.</em> Nearly -healthy. <em>Abdomen.</em> Mucous membrane of ilium -vascular; liver soft.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Goodman</span>, 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.</p> - -<p class='c007'><em>Head.</em> 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 -<span class='pageno' id='Page_203'>203</span>vertebralis highly vascular; great congestion of vertebral -veins; some effusion of serum at cauda equina. -<em>Thorax.</em> Healthy. <em>Abdomen.</em> Mucous membrane -of small intestines vascular; [liver greatly enlarged.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Eyles</span>, 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.</p> - -<p class='c007'>11th. Voice hoarse; pulse 120; not the slightest -pain of head.</p> - -<p class='c007'>14th. Numerous ash-coloured crusts scattered -over the internal fauces; countenance anxious; respiration -hurried; pulse 108. Died next morning.</p> - -<p class='c007'><em>Head.</em> 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. -<em>Thorax.</em> Larynx inflamed, covered with superficial -circular ulcers; tongue aphthous; mouths of ducts -on the surface of the amygdalæ ulcerated. <em>Abdomen.</em> -Mucous membrane of ilium and cæcum highly -vascular, not ulcerated; vessels of all the organs exceedingly -turgid with blood.</p> - -<div> - <span class='pageno' id='Page_204'>204</span> - <h4 class='c016'>2. <em>Vascularity of Brain, Membranes, &c. with Effusion of Coagulable Lymph and Formation of Pus.</em></h4> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>James Moulden</span>, 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.</p> - -<p class='c007'>6th. Pain of head continues with sense of weight -and intolerance of light; scarcely any sleep; pulse -102.</p> - -<p class='c007'>9th. Pain of head and intolerance of light increased; -adnatæ glistening; pulse 94.</p> - -<p class='c007'>10th. Pain of head quite gone; sense of weight -and intolerance of light continue; face flushed; -pulse 84.</p> - -<p class='c007'>11th. Pain of head returned; no sleep; delirium; -pulse 96; tongue brown and dry.</p> - -<p class='c007'>13th. Pain of head and dullness and heaviness of -eyes increased; pulse 84; abdomen tender.</p> - -<p class='c007'>14th. Nearly insensible; pulse 90; abdomen -tender, swollen, and hard.</p> - -<p class='c007'><span class='pageno' id='Page_205'>205</span>15th. Last evening coma increased; respiration -became hurried and laborious; great prostration; -expired this morning.</p> - -<p class='c007'><em>Head.</em> Membranes highly vascular; a large -quantity of coagulable lymph effused at base of -the brain. <em>Thorax.</em> Mucous membrane of bronchi -highly vascular; substance of lungs gorged with -blood. <em>Abdomen.</em> 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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Charlotte Clarke</span>, 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.</p> - -<p class='c007'>4th. Blood inflamed; throat continues sore; -pain of head gone; pulse 130. Hirud. xij. gutt.</p> - -<p class='c007'>5th. Throat unrelieved; deglutition very painful; -no pain of head; pulse 110. Rep. Hirud. x.</p> - -<p class='c007'><span class='pageno' id='Page_206'>206</span>6th. Throat nearly well; pulse 116.</p> - -<p class='c007'>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.</p> - -<p class='c007'>17th. Lies quite prostrate; insensible; constant -delirium with unceasing moaning; muscular tremor; -all the stools passed in bed; pulse 126. Died following -morning.</p> - -<p class='c007'><em>Head.</em> 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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Isaac Coombes</span>, æt. 60, weaver. Admitted on -9th day of fever: at present no pain of head; some -<span class='pageno' id='Page_207'>207</span>sleep; face pallid; great prostration; no thoracic -or abdominal symptoms.</p> - -<p class='c007'>15th. Convalescent.</p> - -<p class='c007'>21st. Attacked suddenly with shivering, heat, -vomiting; no pain of head or of any organ; -pulse 96.</p> - -<p class='c007'>22d. Continues quite free from pain, but no sleep; -extreme restlessness; great prostration; skin warm -and dry; pulse 84. Died following morning.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> -Right lung gorged with blood and partly hepatized. -<em>Abdomen.</em> Spleen soft; other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Susanah Stammers</span>, 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 -<span class='pageno' id='Page_208'>208</span>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.</p> - -<p class='c007'>9th. Pain of head quite gone; less sensible; -countenance more dull and heavy; pulse 120; -abdomen tender.</p> - -<p class='c007'>11th. Delirium, with much talkativeness; pulse -112.</p> - -<p class='c007'>14th. Coma; bowels continue purged.</p> - -<p class='c007'>15th. Abdomen tender, swollen, rounded at navel.</p> - -<p class='c007'>19th. More sensible; more tranquil sleep; delirium -gone; pulse 110.</p> - -<p class='c007'>27th. No coma nor delirium; tranquil sleep; -tongue moist, cleaning; pulse 108 feeble.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> Superior lobe of right -<span class='pageno' id='Page_209'>209</span>lung gorged and partly hepatized. [Pleuræ of right -side adherent;] <em>Abdomen.</em> Mucous membrane of -cæcum and commencement of colon vascular.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXXI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Henry Brewer</span>, 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.</p> - -<p class='c007'>12th. No pain of head; that of chest gone; sleeps -well; pulse 108.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head</em>: 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. <em>Thorax.</em> [Pluræ adherent; -lower and middle lobes of right lung hepatized.] -<em>Abdomen.</em> Viscera healthy.</p> - -<div> - <span class='pageno' id='Page_210'>210</span> - <h4 class='c016'>3. <em>Vascularity of Brain, Membranes, &c. with copious Serous Effusion.</em></h4> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXXII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>George Blackbeard</span>, 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.</p> - -<p class='c007'>23d. Scarcely any pain in the head.</p> - -<p class='c007'>25th. Pain of the head entirely gone; epistaxis.</p> - -<p class='c007'>26th. Delirium: muscular tremor.</p> - -<p class='c007'>28th. Delirium and muscular tremor increased; -pulse 112; tongue more dry; lips and teeth sordid.</p> - -<p class='c007'>31st. Died.</p> - -<p class='c007'><em>Head.</em> Membranes and substance of brain vascular; -ventricles distended with serum; no characteristic -disease in thorax or abdomen.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXXIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Ann Higgins</span>, 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 -<span class='pageno' id='Page_211'>211</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> [Lungs -emphysematous; several points of tubercular suppuration -in left.] <em>Abdomen.</em> Mucous membrane of -small intestines inflamed without ulceration.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_212'>212</span><span class='sc'>Case XXXIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>James Dennie</span>, 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.</p> - -<p class='c007'>9th. Pain of head increased; delirium; eyes suffused; -cough and hurried respiration continue.</p> - -<p class='c007'>10th. Pain of head gone; constant and violent -delirium; no sleep; pulse 108.</p> - -<p class='c007'>11th. Delirium gone; profound coma; muscular -tremor; respiration hurried; pulse 108.</p> - -<p class='c007'>12th. Coma deeper; extreme restlessness; respiration -more hurried; stools and urine passed in -bed. Died.</p> - -<p class='c007'><em>Head.</em> Arachnoid vascular; substance both of -cerebrum and cerebellum vascular; all the ventricles -full of serum; viscera of thorax and abdomen -healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXXV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Charlotte Watts</span>, 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 -<span class='pageno' id='Page_213'>213</span>hurried; abdomen not tender; lips and teeth sordid. -2d day after admission constant noisy delirium; -pulse 120.</p> - -<p class='c007'>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.</p> - -<p class='c007'>19th. Large sloughing sores on loins and hips; erysipelas -of surrounding integuments; pulse 112, weak.</p> - -<p class='c007'>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.</p> - -<p class='c007'>37th. Gradually grew weaker and weaker until -this day, when she died.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> [Pleuræ adherent. Both -lungs contained numerous tubercles in a state of -suppuration. A large proportion of right lung hepatized.] -<em>Abdomen.</em> Viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXXVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Sullivan</span>, æt. 26, married. Admitted on -the 14th day of disease; pain of head severe from -<span class='pageno' id='Page_214'>214</span>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.</p> - -<p class='c007'>18th. Pain of head gone; delirium; pulse 70, -soft; tongue more dry.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> [Pleuræ -adherent; substance of lungs full of tubercles, in -different stages of disease.] <em>Abdomen.</em> [Liver hard;] -other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXXVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Ann Boon</span>, æt. 14, admitted on 10th day of fever. -Attacked in the beginning with severe head-ache, -<span class='pageno' id='Page_215'>215</span>which still continues; abdomen tender; lips and -teeth sordid; tongue brown and dry; pulse 120.</p> - -<p class='c007'>11th. Pain of head undiminished; eyes heavy -and suffused; delirium; tongue red, dry, and glazed; -pulse 108.</p> - -<p class='c007'>13th. Pain of head quite gone; delirium; pulse -118.</p> - -<p class='c007'>19th. Much noise through the night; peevishness -during the day; pulse 108.</p> - -<p class='c007'>20th. More insensible; can give no answer to -any question; pulse 118.</p> - -<p class='c007'>22d. Constant rolling of the head; pupils dilated; -all the stools passed in bed; pulse 108.</p> - -<p class='c007'>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.</p> - -<p class='c007'>30th. Skin covered in several places with vesicles, -which discharge a thin ichor. Died.</p> - -<p class='c007'><em>Head.</em> Membranes and substance of brain vascular; -upwards of three ounces of serum in the -ventricles and at base; much similar fluid in theca -vertebralis. <em>Thorax.</em> Viscera healthy. <em>Abdomen.</em> -Mesenteric glands greatly enlarged; some of them -suppurating.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XXXVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Richard Maciff</span>, æt. 30, admitted on the 22d -<span class='pageno' id='Page_216'>216</span>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.</p> - -<p class='c007'>23d. Profound coma; senseless muttering; constant -muscular tremor; squinting; neither stool nor -urine has been passed since admission; pulse 96, -soft, not intermittent.</p> - -<p class='c007'>24th. Coma undiminished; one stool passed in -bed; urine drawn off by the catheter; pulse 100, -extremely feeble.</p> - -<p class='c007'>25th. No change.</p> - -<p class='c007'>26th. Died.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> [Right lung contained tubercles -in various stages of disease.] <em>Abdomen.</em> -[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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_217'>217</span><span class='sc'>Case XXXIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>William Tennant</span>, 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.</p> - -<p class='c007'>9th. Pain of head continues; scarcely any sleep; -pulse 96. C.C. ad ℥x. nuchæ.</p> - -<p class='c007'>10th. Pain of head unrelieved, particularly severe -over the forehead; face flushed; tongue brown and -dry; pulse 92.</p> - -<p class='c007'>11th. Pain of head quite gone; no longer conscious -of any uneasiness in the limbs; much drowsiness; -delirium; pulse 104.</p> - -<p class='c007'>12th. Rather more sensible; delirium; tongue -unchanged; stools and urine passed in bed; pulse -112.</p> - -<p class='c007'>13th. Delirium increased; eyes glistening; pulse -120.</p> - -<p class='c007'>14th. Mind more distinct this morning; much -delirium through the night; respiration hurried; -pulse 130. Died next morning.</p> - -<p class='c007'><em>Head.</em> 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 -<span class='pageno' id='Page_218'>218</span>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. -<em>Thorax.</em> Viscera healthy. <em>Abdomen.</em> Mucous membrane -of ilium and cæcum extensively and greatly -ulcerated.</p> - -<h4 class='c016'>4. <em>Vascularity &c. with preternatural Firmness of Brain.</em></h4> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XL.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Thomas Conolly</span>, 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.</p> - -<p class='c007'>8th. Less pain of head; no improvement in other -symptoms; pulse 92.</p> - -<p class='c007'>9th. Scarcely any pain of head; no sleep; delirium; -muscular tremor; tongue brown and dry; -pulse 111.</p> - -<p class='c007'>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.</p> - -<p class='c007'>11th. Died.</p> - -<p class='c007'><span class='pageno' id='Page_219'>219</span><em>Head.</em> Membranes vascular; arachnoid thickened -and opake; substance of brain highly vascular -and preternaturally firm; some fluid beneath membranes -and in ventricles. <em>Thorax.</em> [Pleuræ adherent;] -lungs gorged with blood. <em>Abdomen.</em> Liver -and spleen exceedingly softened, readily breaking -down beneath the finger.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XLI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Tiffin</span>, æt. 25, servant. Perfectly insensible: -no account can be obtained of history or duration -of disease: abdomen tender; tongue loaded, -moist; pulse 99.</p> - -<p class='c007'>2d day after admission scarcely any sleep; delirium; -muscular tremor.</p> - -<p class='c007'>3d. Insensibility continues; constant delirium; -has passed neither stool nor urine; latter drawn off -by catheter; pulse 124, feeble and fluttering. Died -next morning.</p> - -<p class='c007'><em>Head.</em> Dura mater and arachnoid natural; pia -mater vascular; substance of brain highly vascular -and unusually firm; cerebellum soft; effusion beneath -arachnoid and at base. <em>Thorax.</em> [Substance -of both lungs filled with miliary tubercles.] <em>Abdomen.</em> -[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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_220'>220</span><span class='sc'>Case XLII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Poulston</span>, 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.</p> - -<p class='c007'>2d. Died.</p> - -<p class='c007'><em>Head.</em> Dura mater vascular; arachnoid thickened -and opake; substance of brain highly vascular and -firm. <em>Thorax.</em> All the viscera perfectly healthy. -<em>Abdomen.</em> Mucous membrane of intestines vascular, -without ulceration; mesentery inflamed; [contained -a calcareous deposit of an oval shape included in a -cyst.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XLIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>William Ashley</span>, 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.</p> - -<p class='c007'>5th. Slight head-ache; little sleep; pulse 82.</p> - -<p class='c007'>6th. Pain of head gone; pulse 90.</p> - -<p class='c007'><span class='pageno' id='Page_221'>221</span>8th. No pain; mind confused; delirium; stools -in bed; pulse 108.</p> - -<p class='c007'>10th. Prostration; pulse 111.</p> - -<p class='c007'>11th. Perfectly insensible; great prostration; -deglutition difficult; hiccup; pulse 116, extremely -feeble.</p> - -<p class='c007'>12th. Died.</p> - -<p class='c007'><em>Head.</em> Membranes and substances of brain intensely -vascular; perhaps as much so as in pure -phrenitis; substance exceedingly firm; viscera of -thorax and abdomen healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XLIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Francis Hodgkinson</span>, 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.</p> - -<p class='c007'>9th. No pain; much confusion; much restlessness; -respiration oppressed; tongue still moist; lips -and teeth sordid; stools in bed; pulse 112.</p> - -<p class='c007'>13th. Petechiæ; tongue dry; pulse 110.</p> - -<p class='c007'>15th. No material change in symptoms. Died.</p> - -<p class='c007'><em>Head.</em> Membranes vascular; substance exceedingly -vascular and firm; some fluid in ventricles and -at base. <em>Thorax.</em> Lower lobe of left lung of dark -<span class='pageno' id='Page_222'>222</span>red colour and inflamed. <em>Abdomen.</em> Mucous membrane -of small intestines vascular, and of dark red -colour.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XLV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>William White</span>, 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.</p> - -<p class='c007'>7th. Pain of head very severe; pulse 117; V. S. -ad ℥xij.</p> - -<p class='c007'>8th. Died this morning most suddenly and unexpectedly, -after having complained of violent pain -of the head.</p> - -<p class='c007'><em>Head</em>, 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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XLVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Mullins</span>, 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.</p> - -<p class='c007'><span class='pageno' id='Page_223'>223</span>2nd day after admission, continues perfectly insensible; -respiration slow and stertorous; tongue -not to be protruded; stools passed in bed; pulse 60.</p> - -<p class='c007'>6th. Remained nearly in the same state until -this morning. Died.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> [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.] <em>Abdomen.</em> 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.]</p> - -<div> - <span class='pageno' id='Page_224'>224</span> - <h4 class='c016'>5. <em>Vascularity, &c. with Softening of the Brain.</em></h4> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XLVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Sarah Hampden</span>, 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.</p> - -<p class='c007'>24th. Subsultus; urine in bed; no stool.</p> - -<p class='c007'>26th. Mind rather more distinct and more firm; -less subsultus; submaxillary gland enlarged and -painful; pulse 108.</p> - -<p class='c007'>28th. Much prostration; no other change.</p> - -<p class='c007'>30th. Increasing prostration; pulse 120, feeble.</p> - -<p class='c007'>32d. Died.</p> - -<p class='c007'><em>Head.</em> 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. -<em>Thorax.</em> [Universal adhesion of the pleuræ; lungs -studded with tubercles.] <em>Abdomen.</em> Mucous membrane -of small intestines inflamed; no ulceration; -pancreas very hard; liver much softened.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XLVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Virgina M’Mahon</span>, æt. 8, admitted on 14th day -<span class='pageno' id='Page_225'>225</span>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.</p> - -<p class='c007'>15th. Delirium; moaning; no sleep; more sensible -to-day; abdomen less tender; pulse extremely -quick and weak.</p> - -<p class='c007'>18th. Without any material change, died.</p> - -<p class='c007'><em>Head.</em> Arachnoid opake; effusion between it and -the pia mater; substance of brain exceedingly soft; -two ounces of serum in the ventricles. <em>Thorax.</em> Mucous -membrane of trachea and bronchi vascular; -bronchial tubes filled with mucus. <em>Abdomen.</em> Mucous -membrane of small intestines vascular; mesenteric -glands enlarged.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XLIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Dorcas Wingrove</span>, 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.</p> - -<p class='c007'>7th. Pain of head undiminished; delirium; three -<span class='pageno' id='Page_226'>226</span>stools in bed; tongue brown and quite dry; pulse -100, firm, strong, and sharp. C.C. ad ℥xij. nuchæ.</p> - -<p class='c007'>8th. Pain of head gone; no sleep; noisy delirium; -stools in bed; pulse 120, weak.</p> - -<p class='c007'>9th. Slight, but very transient amendment.</p> - -<p class='c007'>11th. Comatose; lies quite prostrate; stools in -bed; pulse 130, feeble.</p> - -<p class='c007'>12th. Died.</p> - -<p class='c007'><em>Head.</em> Membranes vascular; arachnoid opake; -corpus striatum in part highly inflamed, in part softening -to suppuration; viscera of thorax and abdomen -healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case L.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Thomas Proctor</span>, 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.</p> - -<p class='c007'>2d day after admission. Insensibility the same; -almost constant moaning; features sunk; expression -of countenance anxious; pulse 118. Next morning -died.</p> - -<p class='c007'><em>Head.</em> [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 -<span class='pageno' id='Page_227'>227</span>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. <em>Thorax.</em> -Viscera healthy. <em>Abdomen.</em> Mucous membrane of -jejunum and ilium much inflamed, neither thickened -nor ulcerated; [liver greatly enlarged; walls of bladder -half an inch thick.]</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>George Carter</span>, 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.</p> - -<p class='c007'>5th. No pain; eyes suffused; pulse 120, firmer.</p> - -<p class='c007'>6th. Mind confused; eruption partial, interspersed -with papulæ; tongue of strawberry appearance, -and rough from prominence of papillæ; pulse -124.</p> - -<p class='c007'><span class='pageno' id='Page_228'>228</span>7th. Delirium, so violent as to require restraint; -no sleep; pulse 120.</p> - -<p class='c007'>8th. Eruption changed to copper-colour; tongue -dry; pulse 112.</p> - -<p class='c007'>10th. Inflammation of parotid gland.</p> - -<p class='c007'>18th. Tumour of left parotid exceedingly hard -and slowly suppurating; slight difficulty in swallowing; -pulse 96.</p> - -<p class='c007'>21st. Tumour opened last night and discharged -two ounces of bloody pus; pulse 108.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> Much serum both in ventricles and at -base. <em>Thorax.</em> Viscera healthy. <em>Abdomen.</em> Mucous -membrane of the ilium ulcerated and extremely -dark.</p> - -<p class='c007'>All the large joints swollen and red: on opening -the knee joints they were found to contain several -<span class='pageno' id='Page_229'>229</span>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>James Solden</span>, æt. 44, plasterer. For symptoms -see page 155.</p> - -<p class='c007'><em>Head.</em> Membranes of brain vascular; substance -highly vascular; some effusion beneath the arachnoid. -<em>Thorax.</em> Viscera healthy. <em>Abdomen.</em> Mucous -membrane of ilium vascular; no ulceration; -mesenteric glands enlarged.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Clark</span>, æt. 17. For symptoms see page -156.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> Viscera healthy. <em>Abdomen.</em> Mucous -membrane of ilium greatly inflamed; cæcum -ulcerated.</p> - -<p class='c007'><span class='pageno' id='Page_230'>230</span>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 <em>no</em> -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.</p> - -<p class='c007'>From the study of the history of these same cases -<span class='pageno' id='Page_231'>231</span>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,</p> - -<p class='c007'>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 -<em>without a corresponding diminution in the other -febrile symptoms</em>, but with an <em>increase</em> in <em>some</em> 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. -<span class='pageno' id='Page_232'>232</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_233'>233</span>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 -<em>some</em> 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 -<span class='pageno' id='Page_234'>234</span>to carry his diagnosis still further, and to ascertain -<em>what</em> 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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_235'>235</span>upon his practice, so there is no diagnosis which -it is of so much importance that he should acquire -the habit of forming.</p> - -<h3 class='c013'>II. <span class='sc'>Cases in illustration of the Morbid Changes which take place within the Chest; or Thoracic Cases.</span></h3> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case VII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Angelica Fidgett.</span></p> - -<p class='c007'>For symptoms see page 125.</p> - -<p class='c007'><em>Thorax.</em> 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.] <em>Head.</em> Substance -of brain vascular. <em>Abdomen.</em> All the viscera healthy -except the uterus and its appendages, which were -slightly inflamed.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case VIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Potter</span>, æt. 21.</p> - -<p class='c007'>For symptoms see page 127.</p> - -<p class='c007'><em>Thorax.</em> 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 -<span class='pageno' id='Page_236'>236</span>contained four ounces of serum;] heart natural. -<em>Abdominal</em> and <em>cerebral</em> organs healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Alexander Crombie</span>, æt. 19, seaman.</p> - -<p class='c007'>For symptoms see page 159.</p> - -<p class='c007'><em>Thorax.</em> Mucous membrane of bronchi, in all -their ramifications, highly vascular; bronchial tubes -full of mucus, mixed with pus. <em>Head.</em> 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. <em>Abdomen.</em> 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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_237'>237</span><span class='sc'>Case LII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Thomas Lewis</span>, 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.</p> - -<p class='c007'><em>Thorax.</em> 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. -<em>Abdomen.</em> [Liver indurated; crisping under the -knife; kidneys indurated.] <em>Head.</em> Membranes and -substance of brain vascular.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Sullivan</span>, 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.</p> - -<p class='c007'><span class='pageno' id='Page_238'>238</span>16th. Frequent short cough, without expectoration; -mind confused, yet sensible when spoken to; -pulse 90.</p> - -<p class='c007'>17th. Thoracic and cerebral symptoms unchanged; -pulse 111, indistinct.</p> - -<p class='c007'>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.</p> - -<p class='c007'>27th. Cough frequent; expectoration the same; -respiration short and hurried; pulse 60, intermittent.</p> - -<p class='c007'>30th. Respiration became more and more hurried, -and the strength rapidly sunk. Died.</p> - -<p class='c007'><em>Thorax.</em> Mucous membrane of bronchi inflamed; -bronchial tubes full of mucus, mixed with pus; -[pleuræ adherent; patches of left lung hepatized.] -<em>Abdomen.</em> Liver and spleen extremely softened, -breaking down under the fingers into a mass like -coagulated blood. <em>Head.</em> Membranes and substance -of brain pretty healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Sarah Peach</span>, 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; -<span class='pageno' id='Page_239'>239</span>pulse 100; abdomen not tender; tongue of beefsteak -character; bowels regular.</p> - -<p class='c007'>18th. Cough and hurried respiration continue; -dusky colour of face has become livid; delirium; -low muttering talkativeness; pulse 116; teeth sordid; -stools in bed.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Thorax.</em> Mucous membrane of bronchi inflamed; -bronchial tubes filled with mucus, mixed with pus; -mucous membrane of trachea vascular; [both lungs -studded with miliary tubercles.] <em>Head.</em> Dura mater -and arachnoid highly vascular; theca of spinal cord -highly vascular; substance of brain vascular. <em>Abdomen.</em> -[Spleen contained a small mass of cheesy -tubercles near its surface;] patches of mucous membrane -of small intestines inflamed, but without ulceration.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Isabella Lora</span>, 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.</p> - -<p class='c007'><span class='pageno' id='Page_240'>240</span>4th. Much improved; less pain of throat and -head; pulse 96.</p> - -<p class='c007'>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.</p> - -<p class='c007'>15th. Left parotid painful, hard and swollen; -throat again inflamed; pulse 124.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Thorax.</em> 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. <em>Abdomen.</em> Peritoneal -coat of the intestines inflamed and thickened. -<em>Head.</em> Membranes and substance of brain tolerably -healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_241'>241</span><span class='sc'>Case LVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Anne Lawrence</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>7th. Tightness of chest continues; cough better; -pulse 144, tremulous. Died next day.</p> - -<p class='c007'><em>Thorax.</em> 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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Ann Wormington</span>, æt. 24, servant.</p> - -<p class='c007'><span class='pageno' id='Page_242'>242</span>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.</p> - -<p class='c007'><em>Thorax.</em> Mucous membrane of trachea of dark -red colour; epiglottis quite blackened; arytænoid cartilages -ulcerated; substance of lungs much gorged. -<em>Abdomen.</em> Viscera healthy. <em>Head.</em> Membranes vascular; -substance of brain preternaturally firm.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Margaret Scandling</span>, 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.</p> - -<p class='c007'>10th. No uneasiness of chest; pain of head diminished; -pulse 72.</p> - -<p class='c007'>16th. Erysipelas of cheek, spreading to scalp, -and attended with considerable pain; tongue dry; -pulse 96.</p> - -<p class='c007'>19th. Erysipelas extending; this morning attacked -with severe dyspnœa, attended with husky noise in -<span class='pageno' id='Page_243'>243</span>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.</p> - -<p class='c007'>20th. Respiration and deglutition unrelieved; -erysipelas of face very painful; mouth sore; mercurial -fetor; pulse 120, soft.</p> - -<p class='c007'>21st. Respiration unchanged; deglutition more -painful; erysipelas increased, passing into suppuration; -delirium; pulse 90.</p> - -<p class='c007'>22d. Difficulty of deglutition undiminished; respiration -rather more easy; pulse 98; much pain of -head.</p> - -<p class='c007'>23d. No change in the respiration, deglutition, or -erysipelas; much discharge from both ears; left elbow -attacked with swelling; heat and excessive pain.</p> - -<p class='c007'>25th. Died.</p> - -<p class='c007'><em>Thorax.</em> 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.] <em>Head.</em> -Membranes and substance of brain vascular; serum -in lateral ventricles. <em>Abdomen.</em> [Mucous membrane -of small intestines in several points raised in the form -of vesicles, containing air;] spleen soft.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_244'>244</span>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Charles Tyler</span>, 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.</p> - -<p class='c007'>8th. Pain of head and abdomen gone; pulse 102, -full and sharp; blood with very firm buff. Repr. -V.S. ad ℥xij.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Thorax.</em> Mucous membrane of the trachea and -bronchi inflamed; [the substance of the left lung -studded with nodules, consisting of coagulated blood, -<span class='pageno' id='Page_245'>245</span>forming the apoplexia pulmonalis of the French -writers:] viscera of the head and abdomen healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Wotton</span>, 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.</p> - -<p class='c007'>8th. Pain of chest diminished; can take full inspiration -with less uneasiness; cough less frequent; -respiration little changed; pulse 102, intermittent.</p> - -<p class='c007'>9th. Respiration much more easy; cough less frequent, -with copious mucous expectoration; pulse -108, intermittent.</p> - -<p class='c007'>10th. Says he is quite free from pain everywhere; -cough again increased; respirations 50; pulse 110, -not intermittent; delirium.</p> - -<p class='c007'>11th. Respirations 60; no sleep; great restlessness; -pulse 108, intermittent.</p> - -<p class='c007'>14th. Perfectly insensible; scarcely to be retained -in bed; respiration extremely quick; pulse not to -be counted. Died.</p> - -<p class='c007'><span class='pageno' id='Page_246'>246</span><em>Thorax.</em> 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.] -<em>Head.</em> Vessels of pia mater exceedingly turgid; effusion -beneath it and the arachnoid; substance of -brain very much softened. <em>Abdomen.</em> Mucous membrane -of ilium vascular.</p> - -<h3 class='c013'>III. <span class='sc'>Cases in Illustration of the Morbid Changes which take place within the Abdomen; or Abdominal Cases.</span></h3> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Thomas Hindmarsh</span>, 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.</p> - -<p class='c007'>11th. Abdomen less tender; five stools; insensibility -increased; pulse 104.</p> - -<p class='c007'>12th. Abdomen a little tender; tongue quite dry; -three stools in bed; noisy delirium; eyes wild and -staring; pulse 108.</p> - -<p class='c007'><span class='pageno' id='Page_247'>247</span>13th. Tongue no longer to be protruded; no stool; -scarcely at all sensible; eye-lids half closed; pulse -96, firm.</p> - -<p class='c007'>21st. Abdominal and cerebral symptoms little -changed; sensible of some pain in chest; cough; -dyspnœa; pulse 108.</p> - -<p class='c007'>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.</p> - -<p class='c007'>25th. Died.</p> - -<p class='c007'><em>Abdomen.</em> Peritoneal coat of intestines in general -vascular; mucous coat of small intestines highly vascular, -and indicated approaching ulceration. <em>Head.</em> -Not examined. <em>Thorax.</em> [Pleuræ of both sides adherent -throughout; substance of both lungs healthy; -slight effusion of serum into pericardium.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Isaac Grey</span>, 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.</p> - -<p class='c007'><span class='pageno' id='Page_248'>248</span>23d. Abdomen still very tender; says he is without -pain; four stools; delirium; muscular tremor; -pulse 100, feeble.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> 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. <em>Head.</em> Arachnoid thickened and -opake; considerable effusion between it and the dura -mater; substance of brain vascular; half an ounce -of serum in each ventricle. <em>Thorax.</em> [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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Hannah Swift</span>, 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 -<span class='pageno' id='Page_249'>249</span>limbs; mind rather confused; pulse 120, soft, and -feeble.</p> - -<p class='c007'>9th. The abdomen, which continues tender, has -become swollen and tense; two stools.</p> - -<p class='c007'>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.</p> - -<p class='c007'>17th. Tenderness of abdomen and vomiting continue; -delirium; pulse 100, small and feeble.</p> - -<p class='c007'>19th. Tenderness of abdomen increased; no vomiting; -tongue the same; pain of head returned; -delirium; erysipelas of face; pulse 109, feeble.</p> - -<p class='c007'>21st. Erysipelas extending to arm; tongue brown, -dry, and cracked; much delirium.</p> - -<p class='c007'>22d. Cheeks livid; extremities cold and livid; -pulse imperceptible. Died.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of ilium highly inflamed, -and ulcers just forming; other viscera -healthy. <em>Head.</em> Dura mater vascular; arachnoid -opake; substance of brain vascular; some fluid in -ventricles. <em>Thorax.</em> 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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Thomas Sexton</span>, æt. 18, servant. Admitted on -<span class='pageno' id='Page_250'>250</span>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.</p> - -<p class='c007'>4th. Pain of head gone; vertigo continues; eyes -dull and heavy; face flushed; no vomiting; pulse -96.</p> - -<p class='c007'>5th. Sense of vertigo lessened; tongue brown -and dry; four stools; pulse 84.</p> - -<p class='c007'>7th. Abdomen tender; tongue brown and dry; -six stools; pain of head returned; much pain of -back; no sleep; delirium.</p> - -<p class='c007'>11th. Less sensible: drowsy; delirium; three -stools.</p> - -<p class='c007'>12th. Insensibility increased; drowsiness approaching -to coma; cheeks dusky; tongue with -dark brown crust, dry; stools in bed; pulse 102, -weak.</p> - -<p class='c007'>16th. Abdomen tender; tongue not to be protruded; -three stools all in bed; pulse 130, extremely -weak; great prostration.</p> - -<p class='c007'><span class='pageno' id='Page_251'>251</span>17th. Countenance sunk; respiration short and -hurried; four stools; more prostrate.</p> - -<p class='c007'>18th. No change excepting that the prostration -is still greater. Died.</p> - -<p class='c007'><em>Abdomen.</em> 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. -<em>Head.</em> Arachnoid highly vascular; substance -of brain natural; gelatinous effusion between the -arachnoid and pia mater; half an ounce of serum -at base. <em>Thorax.</em> Viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>James Gannicott</span>, 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.</p> - -<p class='c007'>2d day after admission. Abdomen no longer tender; -three stools; insensibility continues; frequent -screaming; pulse 116.</p> - -<p class='c007'>3d. Perfectly insensible; all nourishment refused; -stools and urine in bed; pulse 120. Died -next morning.</p> - -<p class='c007'><span class='pageno' id='Page_252'>252</span><em>Abdomen.</em> 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. <em>Head.</em> 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. <em>Thorax.</em> [Pluræ of right -side adherent;] substance of both lungs healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Henry Todd</span>, 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.</p> - -<p class='c007'>2d day after admission. Little change excepting -<span class='pageno' id='Page_253'>253</span>that the coma is more deep; abdomen less tender; -two stools; pulse 124.</p> - -<p class='c007'>3d. Coma undiminished; respiration short, hurried, -rattling; stools in bed; pulse 132; great -prostration.</p> - -<p class='c007'>4th. Died.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of ilium inflamed -throughout; lower part of it ulcerated; other viscera -healthy. <em>Head.</em> Membranes and substance of -brain vascular. <em>Thorax.</em> Mucous membrane of -bronchi inflamed; bronchial tubes filled with mucus -mixed with pus.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Frederick Kilham</span>, 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.</p> - -<p class='c007'>16th. Lips and teeth sordid; mind confused; -prostration.</p> - -<p class='c007'>20th. Violent delirium; pulse 92.</p> - -<p class='c007'>21st. The ulcer along the lower jaw in the inside -of the mouth sloughing and extending; delirium; -pulse 96, weak. Died next day.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of ilium vascular, -<span class='pageno' id='Page_254'>254</span>and contained some ulcers; other viscera healthy. -<em>Head.</em> More fluid than natural between the membranes. -<em>Thorax.</em> Viscera healthy.</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Ann Mount</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>18th. No pain of head; no delirium; slept better; -<span class='pageno' id='Page_255'>255</span>tongue brown and dry; five stools; pulse 132, -firm; blood sizy and deeply cupped. V. S. ad ℥xij.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>Slept rather better; less moaning; countenance -scarcely as collapsed as yesterday; pulse 132, firmer; -stools in bed. Augeat. Vinum ad ℥vi.</p> - -<p class='c007'>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.</p> - -<p class='c007'>24th. No change except that the prostration -continued to increase. Died.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of jejunum, ilium -and cæcum highly vascular; that of ilium contained -three or four large oval ulcers; other viscera healthy. -<em>Head.</em> Membranes and substance of brain vascular; -more serum than natural in the ventricles. -<em>Thorax.</em> Viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_256'>256</span><span class='sc'>Case LXIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Ann Martin</span>, 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.</p> - -<p class='c007'>9th. Cough with difficult expectoration; respiration -hurried; five stools; pulse 104, more regular.</p> - -<p class='c007'>10th. Tongue more fissured; five stools; respiration -less hurried and difficult; pulse 112. Two -grains of tartar emetic in solution every two hours.</p> - -<p class='c007'>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.</p> - -<p class='c007'>12th. Bronchial affection very much relieved; -last four draughts not vomited. Pt. Haustus -4ta. q. h.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_257'>257</span>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.</p> - -<p class='c007'>20th. Respiration again short and hurried; face -quite dusky; tongue furred, dry and cracked; pulse -110.</p> - -<p class='c007'>23d. Respiration laborious; cough returned with -very copious muco-purulent expectoration, amounting -to a pint in the twenty-four hours; pulse 116.</p> - -<p class='c007'>26th. No change; a grain of tartar emetic resumed -every four hours. Wine and beef tea to be continued.</p> - -<p class='c007'>28th. Neither vomiting nor purging; respiration -more easy; cough diminished; tongue more moist; -pulse 116.</p> - -<p class='c007'>29th. Respiration much more natural; cough -greatly diminished; tongue clean and moist; pulse -112.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> 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. <em>Thorax.</em> Mucous membrane of -<span class='pageno' id='Page_258'>258</span>bronchi highly inflamed; bronchial tubes full of -purulent fluid; substance of lungs healthy. <em>Head.</em> -Unfortunately, from some accident, the head was -not examined.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Stephen Winter</span>, 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.</p> - -<p class='c007'>2nd day after admission. Abdominal and thoracic -symptoms the same; mind more confused; more -muscular tremor; pulse 108.</p> - -<p class='c007'>5th. Respiration laborious; mind quite unconscious; -constant incoherent talking; pulse 108.</p> - -<p class='c007'>6th. Respiration hurried and laborious; pulse not -to be counted; perfectly insensible. Died next -morning.</p> - -<p class='c007'><em>Abdomen.</em> 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.] <em>Head.</em> Arachnoid thickened and opake; -<span class='pageno' id='Page_259'>259</span>considerable effusion between it and the dura mater; -substance of brain firm; ventricles distended with -serum. <em>Thorax.</em> All the viscera healthy, [excepting -that the coronary arteries were ossified.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Richard Harvey</span>, 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.</p> - -<p class='c007'>9th. Tenderness of abdomen continues; stools in -bed; no sleep; much delirium; scarcely conscious -when spoken to; pulse 108, more firm.</p> - -<p class='c007'>10th. Slept better; rather more sensible this -morning; pulse again 116.</p> - -<p class='c007'>14th. All nourishment refused; stools and urine -in bed; delirium; muscular tremor; pulse 128, -weak; extremities cold.</p> - -<p class='c007'>15th. Passed a better night; more sensible; pulse -116.</p> - -<p class='c007'>17th. Extensive slough on sacrum; slough also on -right elbow-joint, with erysipelas of surrounding integuments; -pulse 108.</p> - -<p class='c007'>21st. Skin covered with petechiæ; slough extending; -great prostration.</p> - -<p class='c007'><span class='pageno' id='Page_260'>260</span>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.</p> - -<p class='c007'><em>Abdomen.</em> 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. <em>Head.</em> -Substance of brain vascular; effusion between the -membranes; more fluid than natural in the ventricles -and at base. <em>Thorax.</em> Bronchi natural; substance -of right lung gorged with blood and infiltrated -with serum; that of left healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Elizabeth Gore</span>, 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.</p> - -<p class='c007'>23d. Abdomen tender; four stools, dark; some -pain of head; delirium; pulse the same.</p> - -<p class='c007'>26th. Stools in bed; no sleep; delirium; respiration -<span class='pageno' id='Page_261'>261</span>hurried and noisy; cheek dusky; extremities -cold.</p> - -<p class='c007'>27th. Deglutition difficult; pulse 128. Died -next morning.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of ilium ulcerated; -mesenteric gland excessively enlarged. <em>Head.</em> Membrane -and substance of the brain natural; much -effusion into the ventricles, and at the base of the -skull. <em>Thorax.</em> Viscera of the thorax in other respects -perfectly healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Ann Kensit</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>11th. No change; has never spoken nor shown -any degree of sensibility since admission.</p> - -<p class='c007'><em>Abdomen.</em> 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 -<span class='pageno' id='Page_262'>262</span>extensively ulcerated; mesenteric glands much -enlarged. <em>Head.</em> Membranes of brain vascular. -<em>Thorax.</em> [Pleuræ of both sides adherent; that of -right side vascular; right cavity contained some serous -fluid mixed with flakes of lymph.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Sarah Hassell</span>, 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.</p> - -<p class='c007'>9th. No tenderness of abdomen on firmest pressure; -tongue brown and dry; four stools; pulse 108.</p> - -<p class='c007'>12th. Still no tenderness of abdomen; six stools; -tongue quite dry; pulse 120.</p> - -<p class='c007'>16th. Abdominal symptoms unchanged, excepting -that the tongue has been exceeding dry; nearly -insensible; delirium; almost constant moaning; -pulse 120, very weak.</p> - -<p class='c007'>25th. Abdominal and cerebral symptoms continue -with little change; cough more frequent with muco-purulent -expectoration; pulse 130, very weak.</p> - -<p class='c007'>29th. Quite helpless; pulse scarcely to be distinguished; -copious expectoration of purulent matter.</p> - -<p class='c007'><span class='pageno' id='Page_263'>263</span>31st. Died.</p> - -<p class='c007'><em>Abdomen.</em> Ilium contained several large ulcers, -especially at its termination in cæcum; liver enlarged -and softened; other viscera healthy: <em>Head.</em> Membranes -vascular; arachnoid opake and thickened; -substance of brain vascular; effusion between the -membranes; more fluid than natural in ventricles. -<em>Thorax.</em> Lungs gorged; mucous membrane of bronchi -vascular; bronchial tubes full of mucus mixed -with pus.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Edward Hammond</span>, 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.</p> - -<p class='c007'>23d. No pain acknowledged in any organ; little -sensibility; no sleep; much restlessness; delirium; -expression of countenance wild; pulse 108, -firm.</p> - -<p class='c007'>24th. No pain; less sensible; tongue has become -brown and dry; three stools; pulse 124, weak.</p> - -<p class='c007'><span class='pageno' id='Page_264'>264</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of ilium ulcerated; -pancreas indurated, nearly of the consistence of -cartilage, and of paler colour than natural; other -viscera healthy. <em>Head.</em> Membranes natural; half -an ounce of fluid at the base of the skull; substance -of brain much softened. <em>Thorax.</em> Viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case X.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Sarah Raven</span>, æt. 17. For symptoms see page -140.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of small intestines -in general inflamed; lower part of ilium extremely -ulcerated. <em>Head.</em> Both dura and pia mater vascular; -arachnoid opake; much serum effused between -<span class='pageno' id='Page_265'>265</span>the membranes. <em>Thorax.</em> [Pluræ of both sides -adherent; left lung inflamed;] right lung healthy; -other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary M’Gowan</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>10th. Abdominal symptoms unchanged; pain of -head relieved, but not gone; pulse 132, weak.</p> - -<p class='c007'>11th. Tongue cleaning; quite moist; three stools; -very slight pain of head; delirium; pulse 120, -weak.</p> - -<p class='c007'>12th. Pain of head quite gone; but there is no -other change.</p> - -<p class='c007'>13th. No sleep; great restlessness; noisy delirium; -pulse 126, weak; swelling, redness and -pain of left parotid.</p> - -<p class='c007'>15th. Tongue has become brown and dry; and -<span class='pageno' id='Page_266'>266</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> 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. <em>Head.</em> -Membranes and substance of brain vascular; more -fluid than natural in the ventricles. <em>Thorax.</em> [Pleuræ -of left side adherent;] other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>William Waller</span>, 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.</p> - -<p class='c007'><span class='pageno' id='Page_267'>267</span>23d. No change, excepting that the tongue has -become brown and dry.</p> - -<p class='c007'>24th. Pulse 120, weaker and more tremulous: -other symptoms the same.</p> - -<p class='c007'>27th. Tongue has become extremely dry; thirst -urgent; three stools, mixed with blood; abdomen -not tender; pulse 100.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> 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.] <em>Head.</em> Arachnoid opake -and milky, covering a large quantity of gelatinous -fluid. <em>Thorax.</em> [Pleuræ of left side generally adherent, -of right less extensively adherent;] substance -of both lungs healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Margaret Pennifold</span>, æt. 20, servant. Admitted -on the 8th day of fever, which, besides the ordinary -symptoms, commenced with pain and tenderness of -<span class='pageno' id='Page_268'>268</span>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.</p> - -<p class='c007'>9th. No pain; tongue the same; three stools; -slept some; mind more distinct; pulse 100.</p> - -<p class='c007'>11th. No pain; some cough; face flushed; colour -of cheek dusky; voice hoarse.</p> - -<p class='c007'>12th. Little change; pulse 108.</p> - -<p class='c007'>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.</p> - -<p class='c007'>16th. Stools mixed with blood; pulse 117.</p> - -<p class='c007'>17th. Three stools, dark and offensive but without -blood; pulse 100; other symptoms the same.</p> - -<p class='c007'>19th. Stools in bed; much prostration; pulse 120, -very weak; respiration difficult.</p> - -<p class='c007'>20th. Vomiting; pulse 120, weaker.</p> - -<p class='c007'>21st. Vomiting continues; six stools; mind confused: -pulse 120.</p> - -<p class='c007'>22d. Vomiting has ceased; deglutition difficult; -face collapsed and cadaverous; five stools in bed; -great prostration; pulse 117, extremely weak. Died -in the night.</p> - -<p class='c007'><span class='pageno' id='Page_269'>269</span><em>Abdomen.</em> 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. <em>Thorax.</em> 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.] <em>Head.</em> -Brain and its membranes tolerably healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Thomas Bryan</span>, 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 -<span class='pageno' id='Page_270'>270</span>full inspiration; some cough; pain of head and back, -which had been severe, gone; pulse 90.</p> - -<p class='c007'>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.</p> - -<p class='c007'>10th. Pain of abdomen continues; vomiting; two -stools; pulse 116.</p> - -<p class='c007'>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.</p> - -<p class='c007'>14th. Abdominal symptoms undiminished; five -stools; more insensible; pulse 112.</p> - -<p class='c007'>16th. Insensibility increased to coma; little change -in the other symptoms.</p> - -<p class='c007'>20th. Severe pain in the abdomen, particularly -in the region of the cæcum; tongue brown and dry -and quite hard; four stools; pulse 118.</p> - -<p class='c007'>23d. Vomits food and medicine; coma continues; -delirium; pulse 118.</p> - -<p class='c007'>24th. No change, excepting that the vomiting -<span class='pageno' id='Page_271'>271</span>ceased, after having taken a scruple of calomel at a -single dose.</p> - -<p class='c007'>26th. Died.</p> - -<p class='c007'><em>Abdomen.</em> Ilium and cæcum much and extensively -ulcerated; other viscera healthy. <em>Head.</em> Membrane -of brain natural; substance vascular; more -serum than natural in the ventricles; some at the -base; much fluid in the theca vertebralis. <em>Thorax.</em> -Posterior part of left lung tuberculated, and infiltrated -with purulent matter; upper part of right lung still -more tuberculated and condensed.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Elizabeth Hammond</span>, 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.</p> - -<p class='c007'>29th. No tenderness of abdomen; no pain; -cough; delirium; pulse 110.</p> - -<p class='c007'>32d. Cough; delirium; pain, redness, swelling, -and vesication of left leg; pulse 120, weak.</p> - -<p class='c007'>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.</p> - -<p class='c007'>40th. Delirium; muscular tremor; much convulsive -<span class='pageno' id='Page_272'>272</span>twitching of the face; pulse 130, extremely -weak.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>44th. Died.</p> - -<p class='c007'><em>Abdomen.</em> 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; -<span class='pageno' id='Page_273'>273</span>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Ford</span>, 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.</p> - -<p class='c007'>9th. No pain in any organ; tongue unchanged; -two stools, light and offensive; delirium.</p> - -<p class='c007'>10th. Four stools in bed; delirium; lies on back -quite prostrate; pulse 105, weak.</p> - -<p class='c007'>11th. Tongue not to be protruded; perfectly -insensible; pulse 125.</p> - -<p class='c007'><em>Abdomen.</em> 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 -<span class='pageno' id='Page_274'>274</span>deposit so as to present the appearance of -large ulcers. <em>Head.</em> Arachnoid highly vascular; -effusion beneath all the membranes; more fluid than -natural in the lateral ventricles. <em>Thorax.</em> Viscera -healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Eleanor Norris</span>, 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.</p> - -<p class='c007'>9th. Tongue has become brown and dry; five -stools; scarcely any pain of head; delirium; -pulse 120.</p> - -<p class='c007'>14th. Abdomen now tender on pressure; tongue -continues brown and dry; four stools; pain of back -and loins returned; delirium; pulse 130.</p> - -<p class='c007'>15th. Pain of abdomen continues; tongue still -browner and more dry; four stools; delirium; -pulse 128.</p> - -<p class='c007'>16th. Deglutition difficult; pulse 120; great -prostration.</p> - -<p class='c007'>17th. Stools in bed; delirium and prostration -increasing; pulse scarcely to be counted.</p> - -<p class='c007'>18th. Great restlessness; much delirium; countenance -<span class='pageno' id='Page_275'>275</span>wild and anxious; pulse exceedingly quick -and weak.</p> - -<p class='c007'>20th. Respiration hurried and laborious; pulse -not to be counted; insensible; stools in bed. Died -in the night.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of jejunum and ilium -extremely ulcerated; omentum a mere web; all the -other viscera healthy. <em>Head.</em> Membranes and substance -of brain apparently natural. <em>Thorax.</em> [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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Maria Moore</span>, 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.</p> - -<p class='c007'>23d. Pain of head continues; noisy delirium; -pulse 108; abdominal symptoms the same.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_276'>276</span>31st. Throat equally painful; deglutition equally -difficult; pulse 110.</p> - -<p class='c007'>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.</p> - -<p class='c007'>33d. Throat again better; deglutition easy; pulse -120.</p> - -<p class='c007'>35th. Throat well, but the voice is hoarse; four -stools, mixed with blood; pulse 110.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> Mucous membrane of ilium and cæcum -in part highly vascular and much thickened, in part -ulcerated; pancreas indurated; other viscera healthy. -<em>Thorax.</em> 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.] <em>Head.</em> Not examined.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Charles Crossley</span>, 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 -<span class='pageno' id='Page_277'>277</span>of head; mind indistinct; expression of eyes wild; -slight cough; pulse 40, soft.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>16th. Abdomen hard, especially in hepatic region; -slightly tender; vomiting; two stools, mixed with -blood; extremities cold.</p> - -<p class='c007'>19th. Abdomen hard, not tender; two copious -stools, consisting almost entirely of blood; tongue -the same; pulse 96.</p> - -<p class='c007'>20th. One stool without any feculent matter, consisting -entirely of blood; delirium; muscular tremor.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_278'>278</span>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.</p> - -<p class='c007'>36th. Tongue again brown and dry; three stools; -no sleep; much restlessness; delirium; pulse 108, -firm; skin extremely hot.</p> - -<p class='c007'>43d. Stools and urine in bed; delirium; muscular -tremor; subsultus tendinum; pulse 104.</p> - -<p class='c007'>46th. Sloughs have formed on both hips and an -abscess in the right groin.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> 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 -<span class='pageno' id='Page_279'>279</span>each other and to the parietes of the abdomen.] -<em>Head.</em> 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. <em>Thorax.</em> [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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Baker</span>, 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.</p> - -<p class='c007'>23d. Abdominal symptoms the same; no sleep; -some pain of head; pulse 120, weak; much sense -of weakness.</p> - -<p class='c007'>24th. Tongue has become dry; three stools; -pain of head gone; some vertigo; delirium; expression -of countenance anxious and sunk; pulse -120.</p> - -<p class='c007'><span class='pageno' id='Page_280'>280</span>25th. Tongue more moist; three stools; slept -better; expression of countenance more natural; -but the pulse has risen to 130 and is extremely -weak.</p> - -<p class='c007'>26th. More pain of abdomen on pressure; more -prostration; delirium continues; pulse 130, extremely -weak. Died next day.</p> - -<p class='c007'><em>Abdomen.</em> 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. <em>Head.</em> -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. <em>Thorax.</em> 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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_281'>281</span><span class='sc'>Case XI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>George English</span>, æt. 25. For symptoms see -page 141.</p> - -<p class='c007'><em>Abdomen.</em> 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. <em>Head.</em> 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. -<em>Thorax.</em> [Right pleura vascular; superior and middle -lobes of right lung contained numerous miliary tubercles; -<span class='pageno' id='Page_282'>282</span>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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>William Baker</span>, 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.</p> - -<p class='c007'>16th. Six stools, two passed in bed; hiccup; -frequent cough; respiration laborious; pulse 84.</p> - -<p class='c007'>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.</p> - -<p class='c007'>23d. Five stools in bed; hiccup gone; no sleep; -great restlessness; pulse the same. Died next -morning.</p> - -<p class='c007'><span class='pageno' id='Page_283'>283</span><em>Abdomen.</em> 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. <em>Head.</em> Pia mater highly vascular; substance -of brain slightly vascular; a small quantity -of bloody serum effused into the lateral ventricles. -<em>Thorax.</em> 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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Thomas Kennie</span>, 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; -<span class='pageno' id='Page_284'>284</span>little sleep; mind confused; face flushed; pulse -120, weak.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> 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. <em>Head.</em> Membranes of brain vascular; -substance rather vascular; more fluid than -natural in the ventricles. <em>Thorax.</em> Viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>David Piggott</span>, 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.</p> - -<p class='c007'>10th. Pain of right hypochondrium gone; tongue -<span class='pageno' id='Page_285'>285</span>the same; no pain of head; very deaf; slept tolerably; -pulse 100, soft.</p> - -<p class='c007'>11th. No pain; tongue unchanged; one copious -stool, consisting chiefly of blood; slept well; mind -confused; countenance rather improved; pulse 96.</p> - -<p class='c007'>12th. No pain; two stools, with less admixture -of blood; mind distinct; pulse 110.</p> - -<p class='c007'>13th. Eight stools, scanty, without blood; tongue -dry and furred; slept ill; great prostration; pulse -90. Died next day.</p> - -<p class='c007'><em>Abdomen.</em> 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. <em>Head.</em> -Membranes of brain vascular; substance natural. -<em>Thorax.</em> Viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case LXXXIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>William Spoull</span>, 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.</p> - -<p class='c007'><span class='pageno' id='Page_286'>286</span>25th. Tongue much furred and fissured; four -stools; cough the same; pulse 108.</p> - -<p class='c007'>26th. Four stools, mixed with blood; respiration -hurried.</p> - -<p class='c007'>27th. Tongue more clean, slightly aphthous; -three stools without blood; respiration less hurried; -pulse 104.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Abdomen.</em> 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 -<span class='pageno' id='Page_287'>287</span>coat every where highly inflamed; the spleen, liver, -and pancreas were sound. <em>Head.</em> The brain and its -membranes were healthy. <em>Thorax.</em> Viscera healthy.</p> - -<hr class='c017' /> - -<p class='c007'>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.</p> - -<p class='c007'>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; -<span class='pageno' id='Page_288'>288</span>and that there appears to be no other means by which -it can be duly impressed upon the mind.</p> - -<p class='c007'>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 <em>their want of prominence</em>. -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, -<span class='pageno' id='Page_289'>289</span>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.</p> - -<p class='c007'>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: -<span class='pageno' id='Page_290'>290</span>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 -<span class='pageno' id='Page_291'>291</span>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.</p> - -<p class='c007'>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.</p> - -<h3 class='c013'>IV. <span class='sc'>Cases in Illustration of the Morbid Changes which take place within the Head, Thorax, and Abdomen, in the same Individual; or Mixed Cases.</span></h3> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XC.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Margaret Eades</span>, æt. 18, dress-maker. Admitted -on the 22d day of fever, which attacked with -the ordinary symptoms: at present the mind is -<span class='pageno' id='Page_292'>292</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>27th. Coma undiminished; almost constant moaning; -scarcely any sleep; three stools of same character; -some cough; pulse 124, feeble.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> 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. -<em>Thorax.</em> Mucous membrane of bronchi inflamed; -substance of lungs partly condensed and partly tuberculated. -<em>Abdomen.</em> Mucous membrane of ilium -inflamed and ulcerated; other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XCI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>William Middleton</span>, æt. 18, shoemaker. Admitted -on the 5th day of scarlet fever, which commenced, -in addition to the ordinary symptoms, with -<span class='pageno' id='Page_293'>293</span>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.</p> - -<p class='c007'>6th. Pain of head nearly gone; more insensible; -pulse 126; eruption fading.</p> - -<p class='c007'>8th. Insensibility increased to coma; adnatæ glistening; -tongue brown and dry; lips and teeth sordid; -four stools.</p> - -<p class='c007'>10th. Coma deeper; great restlessness; no sleep; -stools in bed; pulse 120, weaker.</p> - -<p class='c007'>11th. Increasing restlessness; tongue not to be -protruded; deglutition difficult; stools and urine in -bed; pulse 150, indistinct.</p> - -<p class='c007'>13th. Died.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> Mucous membrane -of bronchi vascular; substance of both lungs -inflamed. <em>Abdomen.</em> Mucous membrane of ilium -ulcerated; other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XCII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Sarah Sharp</span>, æt. 18. Admitted on the 22d day -of fever: the pain of the head, which had been severe -from the commencement, continues; complains -<span class='pageno' id='Page_294'>294</span>also of much pain in back and limbs; abdomen -tender; tongue fiery red; bowels purged; pulse -100, soft.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>48th. Coma; discharge from both ears; vomiting; -pulse 120, very weak.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_295'>295</span>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.</p> - -<p class='c007'><em>Head.</em> Membranes of brain highly vascular; substance -natural; upwards of eight ounces of serum in -the different cavities. <em>Thorax.</em> Mucous membrane -of trachea slightly reddened; bronchi vascular; lungs -dark and much gorged with blood. <em>Abdomen.</em> 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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XCIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Charles England</span>, 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.</p> - -<p class='c007'>12th. Some sleep through the night; more sensible -to-day; no stool since admission; pulse 114.</p> - -<p class='c007'>13th. Still more sensible; complains of giddiness; -five stools; tongue beginning to clean.</p> - -<p class='c007'><span class='pageno' id='Page_296'>296</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>22d. Erysipelas of face, extending down the neck; -some cough; abdomen again tender; three copious -dark-coloured stools; pulse 130. Died following -day.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> -Mucous membrane of bronchi extremely vascular; -substance of lungs somewhat condensed and very -much gorged; [two ounces of serum in each pleural -cavity.] <em>Abdomen.</em> 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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_297'>297</span><span class='sc'>Case XCIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>James Robinson</span>, 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.</p> - -<p class='c007'>9th. No pain; some sleep; occasional delirium; -two stools; pulse 78.</p> - -<p class='c007'>10th. Mind dull and heavy; returns no answer -when spoken to; pulse the same.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> [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 -<span class='pageno' id='Page_298'>298</span>bronchi. <em>Abdomen.</em> 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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XCV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Ann Smith</span>, 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.</p> - -<p class='c007'>17th. Eruption has appeared over almost the entire -skin, consisting of minute papillæ of a dusky -red colour; two stools; pulse 120.</p> - -<p class='c007'>20th. Erysipelas extending over both shoulders; -severe pains in the limbs.</p> - -<p class='c007'>25th. Cough troublesome with copious viscid expectoration; -erysipelas extending from the shoulders -to the chest; tongue dry: delirium; pulse 110, -weak.</p> - -<p class='c007'>26th. Cough diminished; respiration hurried; -stools in bed; pulse 120, feeble.</p> - -<p class='c007'><span class='pageno' id='Page_299'>299</span>27th. Delirium continues; respiration more hurried; -pulse extremely feeble.</p> - -<p class='c007'>28th. Erysipelas still extending; powers sinking; -respiration laborious; stools and urine in bed. Died -in evening.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> 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.] <em>Abdomen.</em> -Patches of vascularity in mucous membrane of intestines -and over their peritoneal coat; pyloric end -of stomach vascular; spleen soft; other viscera -healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XCVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Joseph Baird</span>, 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.</p> - -<p class='c007'><span class='pageno' id='Page_300'>300</span>33d. Abdomen tender, tumid, tense; four stools; -tongue loaded with white fur; mind distinct; -scarcely any sleep; extremely fretful.</p> - -<p class='c007'>34th. No delirium; stools in bed; pulse 114. -Died next day.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> -Mucous membrane of bronchi vascular; substance -of lungs healthy; [left cavity of pleuræ contained -eight ounces of bloody serum; right six.] <em>Abdomen.</em> -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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_301'>301</span><span class='sc'>Case XCVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Catherine French</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>24th. No sleep; delirium; erysipelas extending; -pulse 108.</p> - -<p class='c007'>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.</p> - -<p class='c007'>39th. Respiration difficult; delirium; vomiting; -pulse 120.</p> - -<p class='c007'>41st. Respiration rattling; delirium; inclined to -sleep; pulse 120.</p> - -<p class='c007'><span class='pageno' id='Page_302'>302</span>42d. Respiration increasingly difficult and painful; -pulse 129.</p> - -<p class='c007'>43d. Extremely restless; almost constant moaning; -countenance anxious; cough; tongue continues -brown and dry; lips and teeth sordid; pulse 122.</p> - -<p class='c007'>44th. Died during the night.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> [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. -<em>Abdomen.</em> Mucous membrane of ilium contained -several ulcers; other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_303'>303</span><span class='sc'>Case XCVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Green</span>, 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.</p> - -<p class='c007'><em>Head.</em> Membranes slightly vascular; arachnoid -and dura mater adherent at several points; substance -of brain slightly vascular; effusion into ventricles. -<em>Thorax.</em> 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.] <em>Abdomen.</em> Mucous membrane -of intestines vascular; mesenteric glands enlarged; -liver mottled on surface.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case XCIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Ann Levitt</span>, 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; -<span class='pageno' id='Page_304'>304</span>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.</p> - -<p class='c007'>17th. After the application of ten leeches to the -abdomen the tenderness is much diminished; the -pulse fallen to 96; vomiting.</p> - -<p class='c007'>18th. Eight leeches again applied; abdomen now -free from pain; vomiting continues; tongue unchanged; -pulse 106.</p> - -<p class='c007'>19th. Vomiting undiminished; eight stools; abdomen -again tender.</p> - -<p class='c007'>20th. Vomiting; five stools; pulse 108; slight -pain of abdomen on full pressure.</p> - -<p class='c007'>22d. Abdomen tender, swollen, and tympanitic; -eight stools; pulse 96; great prostration.</p> - -<p class='c007'>24th. Abdomen less tender and tense; still more -prostrate.</p> - -<p class='c007'>25th. Stools in bed; pulse scarcely perceptible; -features collapsed. Died in the night.</p> - -<p class='c007'><em>Head.</em> Membranes of brain vascular; substance -natural; effusion into the ventricles and at base; -pituitary gland suppurated. <em>Thorax.</em> 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.] <em>Abdomen.</em> -<span class='pageno' id='Page_305'>305</span>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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case C.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Robert Ebbott</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> 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. -<span class='pageno' id='Page_306'>306</span><em>Thorax.</em> 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.] <em>Abdomen.</em> 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.]</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Jane Hallam</span>, 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.</p> - -<p class='c007'>7th. Pain of head gone; mind much more dull -and heavy; abdomen very tender; tongue has become -<span class='pageno' id='Page_307'>307</span>brown and continues extremely dry; four -stools dark and offensive; pulse 104, soft.</p> - -<p class='c007'>8th. Scarcely any sleep; much restlessness; mind -confused; insensibility increasing; pulse 90, weak. -Died next morning.</p> - -<p class='c007'><em>Head.</em> Membranes vascular; substance of brain in -general much softened, but the floors of the ventricles -especially were in an exceedingly softened state. -<em>Thorax.</em> [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. -<em>Abdomen.</em> 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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Jonathan Studd</span>, 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.</p> - -<p class='c007'>29th. Cough continues; abdomen not tender; -tongue brown and dry in middle, red at tip and -<span class='pageno' id='Page_308'>308</span>edges; three stools; pulse 100; mind dull and confused; -muscular tremor.</p> - -<p class='c007'>30th. Cough the same; tongue unchanged; lips -and teeth sordid; three stools mixed with blood; -delirium; muscular tremor increased; pulse 108.</p> - -<p class='c007'>31st. Abdomen has become tympanitic; three -stools mixed with blood; delirium and muscular -tremor increased; pulse 112, weaker.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> Membranes and substance of brain healthy, -but more fluid than natural in the ventricles. <em>Thorax.</em> -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. <em>Abdomen.</em> -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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_309'>309</span><span class='sc'>Case CIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John M’Carty</span>, 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.</p> - -<p class='c007'>23d. Cough very severe; abdomen not tender; -tongue dry, brown and cracked; four stools; no pain -of head; face flushed; eyes ferrety; pulse 90.</p> - -<p class='c007'>24th. Mind more confused; eyes more injected; -delirium.</p> - -<p class='c007'>25th. Insensibility increasing; no sleep; tongue -more dry and brown; lips and teeth sordid; four -stools; pulse 96.</p> - -<p class='c007'>26th. Constant delirium; stools and urine in bed; -pulse 104.</p> - -<p class='c007'>28th. Died.</p> - -<p class='c007'><em>Head.</em> Membranes and substance of brain vascular; -more fluid than natural in ventricles. <em>Thorax.</em> -Mucous membrane of bronchi vascular; [pleuræ of -right side slightly adherent.] <em>Abdomen.</em> Mucous -membrane of jejunum, cæcum and ilium very much -ulcerated; spleen soft; other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_310'>310</span><span class='sc'>Case CIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Sarah Nash</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>24th. Great restlessness; scarcely any sleep; almost -constant grinding of the teeth; pulse 129, of -good power.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>32d. No amendment in the cerebral symptoms, -<span class='pageno' id='Page_311'>311</span>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.</p> - -<p class='c007'>36th. Noise and delirium continue; ulceration of -mouth gone; pulse 140, very weak. Calomel and -opium were again resumed.</p> - -<p class='c007'>27th. Slight ptyalism; no improvement; pulse -130, extremely weak and indistinct.</p> - -<p class='c007'>38th. Ptyalism continues; sinking. Died.</p> - -<p class='c007'><em>Head.</em> Membranes vascular; substance of brain -much softened; effusion between all the membranes -and into the ventricles. <em>Thorax.</em> Bronchi of both -lungs vascular, and contained a large quantity of -purulent matter; right lung much hepatized; left -slightly consolidated. <em>Abdomen.</em> Ilium and cæcum -very much ulcerated; spleen very firm, contained -one tubercle; other viscera healthy.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>William Gander</span>, 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.</p> - -<p class='c007'>16th. No sleep; violent noisy delirium; eyebrows -<span class='pageno' id='Page_312'>312</span>contracted; face flushed; six stools; pulse -100.</p> - -<p class='c007'>19th. Intensity of cerebral symptoms progressively -increasing; constant violent delirium; muscular -tremor; subsultus; tongue cannot be protruded; -pulse 112. Died next day.</p> - -<p class='c007'><em>Head.</em> Membranes vascular; substance of brain -natural; four ounces of serum in the lateral ventricles. -<em>Thorax.</em> Mucous membrane of trachea and -bronchi highly vascular; other viscera healthy. <em>Abdomen.</em> -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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CVI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>George Bury</span>, 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.</p> - -<p class='c007'>14th. Pain of head gone; countenance extremely -pallid; no sleep; great restlessness; delirium; abdomen -<span class='pageno' id='Page_313'>313</span>still tender; tongue red and dry; eight stools, -dark and offensive; pulse 130. Died next day.</p> - -<p class='c007'><em>Head.</em> 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. -<em>Thorax.</em> 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. <em>Abdomen.</em> -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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CVII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>John Meredith</span>, 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 -<span class='pageno' id='Page_314'>314</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>24th. Tenderness of abdomen, hiccup, vomiting, -purging, all increased; eight stools since last report; -much restlessness; pulse 84.</p> - -<p class='c007'>25th. Appeared to be more easy yesterday, but -relapsed into his former state to-day. Died following -morning.</p> - -<p class='c007'><em>Head.</em> Membranes vascular; arachnoid thickened -and opake; substance of brain vascular; more fluid -than natural in the ventricle. <em>Thorax.</em> Mucous membrane -of bronchi vascular; other viscera healthy. -<em>Abdomen.</em> 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 -<span class='pageno' id='Page_315'>315</span>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CVIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Elizabeth Turner</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><em>Head.</em> 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 -<span class='pageno' id='Page_316'>316</span>vascular; substance healthy; pituitary gland -suppurating; more fluid than natural in the ventricles; -an ounce at the base. <em>Thorax.</em> 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.] <em>Abdomen.</em> 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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CIX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mr. W——</span>, 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 -<span class='pageno' id='Page_317'>317</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_318'>318</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_319'>319</span>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.</p> - -<p class='c007'><em>Head.</em> 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. <em>Thorax.</em> 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. <em>Abdomen.</em> -<span class='pageno' id='Page_320'>320</span>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.</p> - -<p class='c007'>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CX.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Cutler</span>, 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, -<span class='pageno' id='Page_321'>321</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>10th. Free lochial discharge; all the symptoms -greatly improved; tongue white; moist; pulse 84, soft.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_322'>322</span>14th. Erysipelas increased and extending; tongue, -has again become brown and dry; pulse 110.</p> - -<p class='c007'>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.</p> - -<p class='c007'>17th. Pain of abdomen increased; stools in bed; -no sleep; extreme restlessness; respiration hurried -and wheezing; pulse 130, weak. Died in the -evening.</p> - -<p class='c007'><em>Head.</em> Membranes of brain vascular. <em>Thorax.</em> -[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. <em>Abdomen.</em> 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.</p> - -<hr class='c017' /> - -<p class='c007'>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 -<span class='pageno' id='Page_323'>323</span>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 -<span class='pageno' id='Page_324'>324</span>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 -<span class='pageno' id='Page_325'>325</span>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 -<span class='pageno' id='Page_326'>326</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_327'>327</span>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, <i><span lang="la" xml:lang="la">à fortiori</span></i>, 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 -<span class='pageno' id='Page_328'>328</span>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.</p> - -<h3 class='c013'>II. <span class='sc'>Pathology of the Fluids in Fever.</span></h3> - -<p class='c015'>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 -<span class='pageno' id='Page_329'>329</span>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 -<span class='pageno' id='Page_330'>330</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_331'>331</span>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 -<span class='pageno' id='Page_332'>332</span>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_333'>333</span> - <h2 class='c005'>CHAPTER VII.</h2> -</div> - -<p class='c011'><em>Of the Relation between the Phenomena of Fever; -or the Theory of the Disease.</em></p> - -<p class='c006'>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.</p> - -<p class='c007'>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 <em>invariable</em>, -and is invariably the first morbid condition that -is observed to take place: that there never was -<span class='pageno' id='Page_334'>334</span>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.</p> - -<p class='c007'>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.<a id='r30' /><a href='#f30' class='c012'><sup>[30]</sup></a> -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.</p> - -<p class='c007'>To the condition of inflammation a peculiar but -<span class='pageno' id='Page_335'>335</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_336'>336</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_337'>337</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_338'>338</span>both in the state of health and of disease, are in the -present state of our knowledge ultimate facts.</p> - -<p class='c007'>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.</p> - -<p class='c007'>It follows, then, that the second event that takes -place in the morbid series constituting fever, is inflammation.</p> - -<p class='c007'><span class='pageno' id='Page_339'>339</span>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 <em>something else</em>: -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 -<span class='pageno' id='Page_340'>340</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_341'>341</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_342'>342</span>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 -<span class='pageno' id='Page_343'>343</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_344'>344</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_345'>345</span>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, -<span class='pageno' id='Page_346'>346</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_347'>347</span>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.</p> - -<p class='c007'>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_348'>348</span> - <h2 class='c005'>CHAPTER VIII.</h2> -</div> - -<p class='c011'><em>Of the Causes of Fever.</em></p> - -<p class='c006'>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.</p> - -<h3 class='c013'>I. <span class='sc'>Of the Immediate, or Exciting Cause of Fever.</span></h3> - -<p class='c015'>The immediate, or the exciting cause of fever is a -poison formed by the corruption or the decomposition -<span class='pageno' id='Page_349'>349</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_350'>350</span>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.</p> - -<p class='c007'>“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 -<span class='pageno' id='Page_351'>351</span>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.”<a id='r31' /><a href='#f31' class='c012'><sup>[31]</sup></a></p> - -<p class='c007'>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 -<span class='pageno' id='Page_352'>352</span>appeared, and prevailed to such an extent, that in -this short space of time 250 were seized with the -disease.<a id='r32' /><a href='#f32' class='c012'><sup>[32]</sup></a></p> - -<p class='c007'>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 -<span class='pageno' id='Page_353'>353</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_354'>354</span>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_355'>355</span>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.</p> - -<p class='c007'>Dr. Potter states<a id='r33' /><a href='#f33' class='c012'><sup>[33]</sup></a> 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 -<span class='pageno' id='Page_356'>356</span>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, -<span class='pageno' id='Page_357'>357</span>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.”</p> - -<p class='c007'>Dr. Potter further states that, on one occasion, -<span class='pageno' id='Page_358'>358</span>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, -<span class='pageno' id='Page_359'>359</span>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 -<span class='pageno' id='Page_360'>360</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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. -<span class='pageno' id='Page_361'>361</span>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 -<span class='pageno' id='Page_362'>362</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_363'>363</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_364'>364</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_365'>365</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_366'>366</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_367'>367</span>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 -<span class='pageno' id='Page_368'>368</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_369'>369</span>should they lead to the establishment of any -useful principles of extensive application.<a id='r34' /><a href='#f34' class='c012'><sup>[34]</sup></a></p> - -<h3 class='c013'>II. <span class='sc'>Of the Remote or Predisposing Causes of Fever.</span></h3> - -<p class='c015'>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.</p> - -<p class='c007'><span class='pageno' id='Page_370'>370</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_371'>371</span>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 -<span class='pageno' id='Page_372'>372</span>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.</p> - -<p class='c007'>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. -<span class='pageno' id='Page_373'>373</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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; -<span class='pageno' id='Page_374'>374</span>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.</p> - -<p class='c007'>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_375'>375</span> - <h2 class='c005'>CHAPTER IX.</h2> -</div> - -<p class='c011'><em>Of the Treatment of Fever.</em></p> - -<p class='c006'>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, -<span class='pageno' id='Page_376'>376</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_377'>377</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_378'>378</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_379'>379</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>The object to be aimed at in practice, then, is -clear: it is to prevent, or to remove inflammation. -<span class='pageno' id='Page_380'>380</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_381'>381</span>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 -<span class='pageno' id='Page_382'>382</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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. -<span class='pageno' id='Page_383'>383</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_384'>384</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_385'>385</span>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.</p> - -<p class='c007'><span class='pageno' id='Page_386'>386</span>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_387'>387</span>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.</p> - -<p class='c007'>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.<a id='r35' /><a href='#f35' class='c012'><sup>[35]</sup></a></p> - -<p class='c007'><span class='pageno' id='Page_388'>388</span>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_389'>389</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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. -<span class='pageno' id='Page_390'>390</span>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.</p> - -<p class='c007'>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, -<span class='pageno' id='Page_391'>391</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_392'>392</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_393'>393</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_394'>394</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_395'>395</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_396'>396</span>perfectly familiar with the principle of its treatment.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_397'>397</span>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.</p> - -<p class='c007'>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.</p> - -<div> - <span class='pageno' id='Page_398'>398</span> - <h3 class='c013'>I. <span class='sc'>Of the Modification of the Treatment in Cerebral Affection.</span></h3> -</div> - -<p class='c015'>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.</p> - -<p class='c007'>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. <span class='sc'>Dill</span>. 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 -<span class='pageno' id='Page_399'>399</span>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 -<span class='pageno' id='Page_400'>400</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_401'>401</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_402'>402</span>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.<a id='r36' /><a href='#f36' class='c012'><sup>[36]</sup></a> If we -consider how powerful the abstraction of caloric -<span class='pageno' id='Page_403'>403</span>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.</p> - -<p class='c007'>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.</p> - -<h3 class='c013'>II. <span class='sc'>Of the Modification of Treatment in Thoracic Affection.</span></h3> - -<p class='c015'>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 -<span class='pageno' id='Page_404'>404</span>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.</p> - -<p class='c007'>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.</p> - -<div> - <span class='pageno' id='Page_405'>405</span> - <h3 class='c013'>III. <span class='sc'>Of the Modification of the Treatment in Abdominal Affection.</span></h3> -</div> - -<p class='c015'>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.</p> - -<p class='c007'>When the purging is considerable, five grains of -the hydrargyrum cum cretâ, with five of the pulvis -ipecacuanhæ compositus, given every night or every -<span class='pageno' id='Page_406'>406</span>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.</p> - -<p class='c007'>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.</p> - -<h3 class='c013'>IV. We have spoken of a fever still more intense</h3> -<p class='c015'><span class='pageno' id='Page_407'>407</span>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.</p> - -<p class='c007'>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 <em>his</em> poison -from the brain, he may be saved.</p> - -<div> - <span class='pageno' id='Page_408'>408</span> - <h3 class='c013'>V. <span class='sc'>Of the Treatment of Scarlet Fever.</span></h3> -</div> - -<p class='c015'>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.</p> - -<p class='c007'>It is not probable that much advantage would be -derived from the detail of numerous cases to illustrate -<span class='pageno' id='Page_409'>409</span>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.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CXI.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Ann Hunt</span>, 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.</p> - -<p class='c007'>V.S. ad ℥xxvj. Haust. Sennæ Sal. quam primum. -Acid. Mist. pro potu. Mist. Acet. Amm. C. 6tâ q. h.</p> - -<p class='c007'>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.</p> - -<p class='c007'>16th. Continues quite free from pain; tongue -<span class='pageno' id='Page_410'>410</span>nearly clean; two stools; skin cool, moist; pulse -88. Pt. med.</p> - -<p class='c007'>18th. No return of pain; tongue clean; pulse 87; -four stools; skin natural. Pt. med.</p> - -<p class='c007'>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.</p> - -<p class='c007'>23d. Pains of limbs returned; slept ill; tongue -loaded at root; pulse 110.</p> - -<p class='c007'>24th. Pains diminished; pulse 100; tongue still -furred; skin warm.</p> - -<p class='c007'>26th. Pains gone; skin cool and moist; tongue -the same; two stools; pulse 100.</p> - -<p class='c007'>28th. Tongue more clean; skin warm; pulse 76.</p> - -<p class='c007'>35th. Convalescent. Inf. Case. c. Senna bis.</p> - -<p class='c007'>41st. Dismissed cured.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CXII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Eleanor Welby</span>, 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, -<span class='pageno' id='Page_411'>411</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>8th. No uneasiness of head, throat, or abdomen; -sleep natural; tongue beginning to clean, much less -red; pulse 114; skin exfoliating.</p> - -<p class='c007'>9th. Convalescent.</p> - -<p class='c007'>14th. Has been gradually gaining strength and is -now quite well. Dismissed cured.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CXIII.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Mary Jones</span>, æt. 33, married. Three days ago -attacked with shivering, succeeded by glows of heat, -severe pain in the back and lower extremities, with -<span class='pageno' id='Page_412'>412</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'><span class='pageno' id='Page_413'>413</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>10th. Slept ill; much restlessness and delirium; -<span class='pageno' id='Page_414'>414</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>13th. Continues to improve in all respects.</p> - -<p class='c007'>14th. Feels stronger; pulse 108, of good strength; -occasional muscular tremor. Pt.</p> - -<p class='c007'>18th. Continues steadily to improve. Pt. Jus. -Bov. lbj. in dies. Vini Albi, ℥vj.</p> - -<p class='c007'>23d. Convalescent. Omit. Med. Inf. Cascaril. c. -Senna, bis.</p> - -<p class='c007'>33d. Free from complaint. Dismissed cured.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_415'>415</span>which less was to be apprehended from the bleeding -than from the disease.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='sc'>Case CXIV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Frances Jacob</span>, 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.</p> - -<p class='c007'>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. -<span class='pageno' id='Page_416'>416</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>8th. Slept well; asleep at present; no delirium -pulse 108, soft.</p> - -<p class='c007'>9th. Still more improved; pulse 96, soft.</p> - -<p class='c007'>13th. Pulse 87; other symptoms the same. Pt.</p> - -<p class='c007'>14th. Complains more of pain of epigastrium, -which is considerably tender on pressure; other -symptoms the same. Catap. Sinap. epigast. Pt. -alia.</p> - -<p class='c007'>15th. Epigastrium much relieved; other symptoms -the same. Pt.</p> - -<p class='c007'>18th. Convalescent.</p> - -<p class='c007'>24th. Dismissed cured.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='pageno' id='Page_417'>417</span><span class='sc'>Case CXV.</span></div> - </div> -</div> - -<p class='c007'><span class='sc'>Margaret Skey</span>, 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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>13th. Slept better; less delirium; two stools not -passed in bed; pulse 96.</p> - -<p class='c007'><span class='pageno' id='Page_418'>418</span>15th. More power; stools not passed in bed; -other symptoms the same. Pt.</p> - -<p class='c007'>17th. Strength again rather diminished; tongue -rather brown; much thirst; pulse 100; no pain. -Pt.</p> - -<p class='c007'>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.</p> - -<p class='c007'>22d. Tongue less brown and more moist; pulse -108, stronger; slept well. Pt.</p> - -<p class='c007'>24th. Countenance much more animated; tongue -more clean, quite moist, still brown towards root; -pulse 110. Pt.</p> - -<p class='c007'>25th. Countenance still more improved; tongue -more clean; no longer brown; pulse 102, weak.</p> - -<p class='c007'>26th. Much improved; tongue nearly clean; two -stools; pulse 108, weak.</p> - -<p class='c007'>27th. Gains strength. Alcohol ad ℥iij.</p> - -<p class='c007'>34th. Convalescent, but still very weak. Cerevis. -lbj. Pt. alia.</p> - -<p class='c007'>45th. Has been gradually, though very slowly -gaining strength; tongue now clean; appetite good; -bowels regular (Low Diet); 2 ozs. meat daily.</p> - -<p class='c007'>52d. Dismissed cured.</p> - -<div> - <span class='pageno' id='Page_419'>419</span> - <h3 class='c013'>II. <span class='sc'>Treatment during the Convalescence.</span></h3> -</div> - -<p class='c015'>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 -<span class='pageno' id='Page_420'>420</span>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_421'>421</span>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, <em>because he ought to -allow no risk to be run</em>. 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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_422'>422</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_423'>423</span>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.</p> - -<p class='c007'>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.</p> - -<p class='c007'>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 -<span class='pageno' id='Page_424'>424</span>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.</p> - -<div class='chapter'> - <span class='pageno' id='Page_425'>425</span> - <h2 class='c005'>APPENDIX.</h2> -</div> - -<p class='c006'>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.</p> - -<div> - <span class='pageno' id='Page_427'>427</span> - <h3 class='c013'><em>Meteorological Table, with reference to Admissions and Deaths, for 1825.</em></h3> -</div> - -<table class='table1' summary='Meteorological Table'> -<colgroup> -<col width='8%' /> -<col width='8%' /> -<col width='10%' /> -<col width='5%' /> -<col width='5%' /> -<col width='5%' /> -<col width='5%' /> -<col width='28%' /> -<col width='20%' /> -</colgroup> - <tr> - <th class='btt bbt blt c018' rowspan='2'>Weeks.</th> - <th class='btt bbt blt c018' rowspan='2'>Admissions.</th> - <th class='btt bbt blt c018' rowspan='2'>Deaths.</th> - <th class='btt bbt blt c018' colspan='2'>Heat.</th> - <th class='btt bbt blt c018' colspan='2'>Moisture.</th> - <th class='btt bbt blt c018' rowspan='2'>Wind.</th> - <th class='btt bbt blt brt c018' rowspan='2'>Weather.</th> - </tr> - <tr> - - - - <th class='bbt blt c018'>Max.</th> - <th class='bbt c018'>Min.</th> - <th class='bbt blt c018'>Max.</th> - <th class='bbt c018'>Min.</th> - - - </tr> - <tr> - <td class='blt c019'>1</td> - <td class='blt c019'>6</td> - <td class='blt c019'>0</td> - <td class='blt c019'>54</td> - <td class='c019'>32½</td> - <td class='blt c019'>964</td> - <td class='c019'>685</td> - <td class='blt c020'>West. North.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>2</td> - <td class='blt c019'>9</td> - <td class='blt c019'>2</td> - <td class='blt c019'>46</td> - <td class='c019'>34</td> - <td class='blt c019'>966</td> - <td class='c019'>755</td> - <td class='blt c020'>North. East.</td> - <td class='blt brt c020'>Hazy.</td> - </tr> - <tr> - <td class='blt c019'>3</td> - <td class='blt c019'>16</td> - <td class='blt c019'>1</td> - <td class='blt c019'>46</td> - <td class='c019'>34</td> - <td class='blt c019'>1000</td> - <td class='c019'>763</td> - <td class='blt c020'>West. North.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>4</td> - <td class='blt c019'>13</td> - <td class='blt c019'>4</td> - <td class='blt c019'>50½</td> - <td class='c019'>32</td> - <td class='blt c019'>984</td> - <td class='c019'>711</td> - <td class='blt c020'>North. North-West.</td> - <td class='blt brt c020'>Cloudy. Hazy.</td> - </tr> - <tr> - <td class='blt c019'>5</td> - <td class='blt c019'>7</td> - <td class='blt c019'>1</td> - <td class='blt c019'>51</td> - <td class='c019'>30</td> - <td class='blt c019'>839</td> - <td class='c019'>614</td> - <td class='blt c020'>West. West by North.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>6</td> - <td class='blt c019'>10</td> - <td class='blt c019'>2</td> - <td class='blt c019'>48</td> - <td class='c019'>33</td> - <td class='blt c019'>971</td> - <td class='c019'>783</td> - <td class='blt c020'>South-West, WbN.</td> - <td class='blt brt c020'>Fine. Hazy.</td> - </tr> - <tr> - <td class='blt c019'>7</td> - <td class='blt c019'>9</td> - <td class='blt c019'>1</td> - <td class='blt c019'>51</td> - <td class='c019'>38</td> - <td class='blt c019'>870</td> - <td class='c019'>820</td> - <td class='blt c020'>East. West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>8</td> - <td class='blt c019'>8</td> - <td class='blt c019'>3</td> - <td class='blt c019'>47</td> - <td class='c019'>36</td> - <td class='blt c019'>962</td> - <td class='c019'>659</td> - <td class='blt c020'>East. North.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>9</td> - <td class='blt c019'>4</td> - <td class='blt c019'>0</td> - <td class='blt c019'>46</td> - <td class='c019'>36</td> - <td class='blt c019'>932</td> - <td class='c019'>538</td> - <td class='blt c020'>West, North-West.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>10</td> - <td class='blt c019'>8</td> - <td class='blt c019'>2</td> - <td class='blt c019'>52</td> - <td class='c019'>34</td> - <td class='blt c019'>966</td> - <td class='c019'>658</td> - <td class='blt c020'>West. North.</td> - <td class='blt brt c020'>Dark. C. Hazy.</td> - </tr> - <tr> - <td class='blt c019'>11</td> - <td class='blt c019'>2</td> - <td class='blt c019'>0</td> - <td class='blt c019'>48</td> - <td class='c019'>31</td> - <td class='blt c019'>862</td> - <td class='c019'>452</td> - <td class='blt c020'>North. East.</td> - <td class='blt brt c020'>Cloudy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>12</td> - <td class='blt c019'>5</td> - <td class='blt c019'>3</td> - <td class='blt c019'>52</td> - <td class='c019'>39</td> - <td class='blt c019'>1000</td> - <td class='c019'>598</td> - <td class='blt c020'>East. South-East.</td> - <td class='blt brt c020'>C. H. Dark.</td> - </tr> - <tr> - <td class='blt c019'>13</td> - <td class='blt c019'>12</td> - <td class='blt c019'>1</td> - <td class='blt c019'>61</td> - <td class='c019'>42</td> - <td class='blt c019'>807</td> - <td class='c019'>347</td> - <td class='blt c020'>East. North.</td> - <td class='blt brt c020'>Fine. Hazy.</td> - </tr> - <tr> - <td class='blt c019'>14</td> - <td class='blt c019'>10</td> - <td class='blt c019'>2</td> - <td class='blt c019'>62</td> - <td class='c019'>41½</td> - <td class='blt c019'>904</td> - <td class='c019'>522</td> - <td class='blt c020'>East. North-West.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>15</td> - <td class='blt c019'>19</td> - <td class='blt c019'>3</td> - <td class='blt c019'>63</td> - <td class='c019'>46</td> - <td class='blt c019'>844</td> - <td class='c019'>470</td> - <td class='blt c020'>North. West.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>16</td> - <td class='blt c019'>7</td> - <td class='blt c019'>2</td> - <td class='blt c019'>63</td> - <td class='c019'>53</td> - <td class='blt c019'>901</td> - <td class='c019'>553</td> - <td class='blt c020'>West. East.</td> - <td class='blt brt c020'>Cloudy. D. F.</td> - </tr> - <tr> - <td class='blt c019'>17</td> - <td class='blt c019'>12</td> - <td class='blt c019'>1</td> - <td class='blt c019'>71</td> - <td class='c019'>54</td> - <td class='blt c019'>801</td> - <td class='c019'>538</td> - <td class='blt c020'>South. East.</td> - <td class='blt brt c020'>Rain. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>18</td> - <td class='blt c019'>4</td> - <td class='blt c019'>1</td> - <td class='blt c019'>67</td> - <td class='c019'>52</td> - <td class='blt c019'>907</td> - <td class='c019'>516</td> - <td class='blt c020'>South-West. North.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>19</td> - <td class='blt c019'>10</td> - <td class='blt c019'>1</td> - <td class='blt c019'>63</td> - <td class='c019'>53</td> - <td class='blt c019'>712</td> - <td class='c019'>516</td> - <td class='blt c020'>North. East.</td> - <td class='blt brt c020'>Cloudy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>20</td> - <td class='blt c019'>11</td> - <td class='blt c019'>2</td> - <td class='blt c019'>74</td> - <td class='c019'>53</td> - <td class='blt c019'>765</td> - <td class='c019'>442</td> - <td class='blt c020'>East. West. North.</td> - <td class='blt brt c020'>Cloudy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>21</td> - <td class='blt c019'>6</td> - <td class='blt c019'>3</td> - <td class='blt c019'>66</td> - <td class='c019'>54</td> - <td class='blt c019'>905</td> - <td class='c019'>466</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>22</td> - <td class='blt c019'>6</td> - <td class='blt c019'>3</td> - <td class='blt c019'>81</td> - <td class='c019'>63</td> - <td class='blt c019'>748</td> - <td class='c019'>449</td> - <td class='blt c020'>South. North. West.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>23</td> - <td class='blt c019'>5</td> - <td class='blt c019'>1</td> - <td class='blt c019'>80</td> - <td class='c019'>59</td> - <td class='blt c019'>774</td> - <td class='c019'>404</td> - <td class='blt c020'>North. East.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>24</td> - <td class='blt c019'>18</td> - <td class='blt c019'>2</td> - <td class='blt c019'>71</td> - <td class='c019'>57</td> - <td class='blt c019'>721</td> - <td class='c019'>421</td> - <td class='blt c020'>North-West. South.</td> - <td class='blt brt c020'>Cloudy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>25</td> - <td class='blt c019'>11</td> - <td class='blt c019'>2</td> - <td class='blt c019'>72</td> - <td class='c019'>58</td> - <td class='blt c019'>800</td> - <td class='c019'>472</td> - <td class='blt c020'>North-West. East.</td> - <td class='blt brt c020'>Cloudy. Hazy.</td> - </tr> - <tr> - <td class='blt c019'>26</td> - <td class='blt c019'>8</td> - <td class='blt c019'>0</td> - <td class='blt c019'>84</td> - <td class='c019'>57</td> - <td class='blt c019'>937</td> - <td class='c019'>439</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>27</td> - <td class='blt c019'>10</td> - <td class='blt c019'>2</td> - <td class='blt c019'>87</td> - <td class='c019'>75</td> - <td class='blt c019'>727</td> - <td class='c019'>437</td> - <td class='blt c020'>East. South-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>28</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>78</td> - <td class='c019'>63</td> - <td class='blt c019'>850</td> - <td class='c019'>429</td> - <td class='blt c020'>East. North.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>29</td> - <td class='blt c019'>9</td> - <td class='blt c019'>2</td> - <td class='blt c019'>86</td> - <td class='c019'>65</td> - <td class='blt c019'>660</td> - <td class='c019'>357</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>30</td> - <td class='blt c019'>15</td> - <td class='blt c019'>2</td> - <td class='blt c019'>70</td> - <td class='c019'>65</td> - <td class='blt c019'>793</td> - <td class='c019'>488</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>31</td> - <td class='blt c019'>20</td> - <td class='blt c019'>0</td> - <td class='blt c019'>69</td> - <td class='c019'>62</td> - <td class='blt c019'>855</td> - <td class='c019'>660</td> - <td class='blt c020'>West. North.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>32</td> - <td class='blt c019'>22</td> - <td class='blt c019'>2</td> - <td class='blt c019'>70</td> - <td class='c019'>60</td> - <td class='blt c019'>793</td> - <td class='c019'>488</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>33</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>69</td> - <td class='c019'>62</td> - <td class='blt c019'>855</td> - <td class='c019'>575</td> - <td class='blt c020'>West. North.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>34</td> - <td class='blt c019'>10</td> - <td class='blt c019'>1</td> - <td class='blt c019'>76</td> - <td class='c019'>60</td> - <td class='blt c019'>971</td> - <td class='c019'>635</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>35</td> - <td class='blt c019'>16</td> - <td class='blt c019'>5</td> - <td class='blt c019'>73</td> - <td class='c019'>61</td> - <td class='blt c019'>949</td> - <td class='c019'>598</td> - <td class='blt c020'>North. West.</td> - <td class='blt brt c020'>Cloudy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>36</td> - <td class='blt c019'>12</td> - <td class='blt c019'>5</td> - <td class='blt c019'>68</td> - <td class='c019'>60</td> - <td class='blt c019'>770</td> - <td class='c019'>554</td> - <td class='blt c020'>West. North.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>37</td> - <td class='blt c019'>11</td> - <td class='blt c019'>3</td> - <td class='blt c019'>69</td> - <td class='c019'>63</td> - <td class='blt c019'>971</td> - <td class='c019'>749</td> - <td class='blt c020'>South. West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>38</td> - <td class='blt c019'>19</td> - <td class='blt c019'>3</td> - <td class='blt c019'>70</td> - <td class='c019'>54</td> - <td class='blt c019'>968</td> - <td class='c019'>700</td> - <td class='blt c020'>South. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>39</td> - <td class='blt c019'>19</td> - <td class='blt c019'>2</td> - <td class='blt c019'>67</td> - <td class='c019'>52</td> - <td class='blt c019'>937</td> - <td class='c019'>717</td> - <td class='blt c020'>West. North-East.</td> - <td class='blt brt c020'>Fine. Rain.</td> - </tr> - <tr> - <td class='blt c019'>40</td> - <td class='blt c019'>10</td> - <td class='blt c019'>2</td> - <td class='blt c019'>65</td> - <td class='c019'>58</td> - <td class='blt c019'>935</td> - <td class='c019'>749</td> - <td class='blt c020'>West. South-East.</td> - <td class='blt brt c020'>Rain. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>41</td> - <td class='blt c019'>13</td> - <td class='blt c019'>3</td> - <td class='blt c019'>63</td> - <td class='c019'>55</td> - <td class='blt c019'>935</td> - <td class='c019'>652</td> - <td class='blt c020'>West. North. S-East.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>42</td> - <td class='blt c019'>15</td> - <td class='blt c019'>2</td> - <td class='blt c019'>63</td> - <td class='c019'>40</td> - <td class='blt c019'>937</td> - <td class='c019'>618</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Rain.</td> - </tr> - <tr> - <td class='blt c019'>43</td> - <td class='blt c019'>13</td> - <td class='blt c019'>3</td> - <td class='blt c019'>54</td> - <td class='c019'>37</td> - <td class='blt c019'>924</td> - <td class='c019'>627</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>44</td> - <td class='blt c019'>15</td> - <td class='blt c019'>1</td> - <td class='blt c019'>57</td> - <td class='c019'>48</td> - <td class='blt c019'>879</td> - <td class='c019'>713</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>45</td> - <td class='blt c019'>10</td> - <td class='blt c019'>3</td> - <td class='blt c019'>56</td> - <td class='c019'>38</td> - <td class='blt c019'>961</td> - <td class='c019'>705</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>46</td> - <td class='blt c019'>14</td> - <td class='blt c019'>3</td> - <td class='blt c019'>44</td> - <td class='c019'>31</td> - <td class='blt c019'>1000</td> - <td class='c019'>557</td> - <td class='blt c020'>North. North.</td> - <td class='blt brt c020'>Foggy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>47</td> - <td class='blt c019'>16</td> - <td class='blt c019'>4</td> - <td class='blt c019'>53</td> - <td class='c019'>36</td> - <td class='blt c019'>943</td> - <td class='c019'>781</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>48</td> - <td class='blt c019'>12</td> - <td class='blt c019'>4</td> - <td class='blt c019'>62</td> - <td class='c019'>40</td> - <td class='blt c019'>968</td> - <td class='c019'>767</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>49</td> - <td class='blt c019'>14</td> - <td class='blt c019'>2</td> - <td class='blt c019'>50</td> - <td class='c019'>36</td> - <td class='blt c019'>1000</td> - <td class='c019'>790</td> - <td class='blt c020'>West. North-East.</td> - <td class='blt brt c020'>Foggy. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>50</td> - <td class='blt c019'>11</td> - <td class='blt c019'>0</td> - <td class='blt c019'>52</td> - <td class='c019'>38</td> - <td class='blt c019'>1000</td> - <td class='c019'>762</td> - <td class='blt c020'>West. East.</td> - <td class='blt brt c020'>Foggy.</td> - </tr> - <tr> - <td class='blt c019'>51</td> - <td class='blt c019'>11</td> - <td class='blt c019'>4</td> - <td class='blt c019'>51</td> - <td class='c019'>41</td> - <td class='blt c019'>967</td> - <td class='c019'>763</td> - <td class='blt c020'>West. South.</td> - <td class='blt brt c020'>Foggy. Cloudy.</td> - </tr> - <tr> - <td class='bbt blt c019'>52</td> - <td class='bbt blt c019'>9</td> - <td class='bbt blt c019'>1</td> - <td class='bbt blt c019'>47</td> - <td class='bbt c019'>28</td> - <td class='bbt blt c019'>971</td> - <td class='bbt c019'>585</td> - <td class='bbt blt c020'>West. West.</td> - <td class='bbt blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='bbt blt c019'>Total</td> - <td class='bbt blt c019'>588</td> - <td class='bbt blt c019'>104</td> - <td class='bbt blt c019'> </td> - <td class='bbt c019'> </td> - <td class='bbt blt c019'> </td> - <td class='bbt c019'> </td> - <td class='bbt blt c020'> </td> - <td class='bbt blt brt c020'> </td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_428'>428</span> - <h3 class='c013'><em>Meteorological Table, with reference to Admissions and Deaths, for 1826.</em></h3> -</div> - -<table class='table1' summary='Meteorological Table'> -<colgroup> -<col width='8%' /> -<col width='8%' /> -<col width='10%' /> -<col width='5%' /> -<col width='5%' /> -<col width='5%' /> -<col width='5%' /> -<col width='28%' /> -<col width='20%' /> -</colgroup> - <tr> - <th class='btt bbt blt c018' rowspan='2'>Weeks.</th> - <th class='btt bbt blt c018' rowspan='2'>Admissions.</th> - <th class='btt bbt blt c018' rowspan='2'>Deaths.</th> - <th class='btt bbt blt c018' colspan='2'>Heat.</th> - <th class='btt bbt blt c018' colspan='2'>Moisture.</th> - <th class='btt bbt blt c018' rowspan='2'>Wind.</th> - <th class='btt bbt blt brt c018' rowspan='2'>Weather.</th> - </tr> - <tr> - - - - <th class='bbt blt c018'>Max.</th> - <th class='bbt c018'>Min.</th> - <th class='bbt blt c018'>Max.</th> - <th class='bbt c018'>Min.</th> - - - </tr> - <tr> - <td class='blt c019'>1</td> - <td class='blt c019'>4</td> - <td class='blt c019'>0</td> - <td class='blt c019'>40</td> - <td class='c019'>33</td> - <td class='blt c019'>968</td> - <td class='c019'>794</td> - <td class='blt c020'>East. East.</td> - <td class='blt brt c020'>Cloudy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>2</td> - <td class='blt c019'>10</td> - <td class='blt c019'>3</td> - <td class='blt c019'>33</td> - <td class='c019'>21</td> - <td class='blt c019'>910</td> - <td class='c019'>612</td> - <td class='blt c020'>North. North.</td> - <td class='blt brt c020'>Hazy.</td> - </tr> - <tr> - <td class='blt c019'>3</td> - <td class='blt c019'>10</td> - <td class='blt c019'>1</td> - <td class='blt c019'>42</td> - <td class='c019'>17</td> - <td class='blt c019'>963</td> - <td class='c019'>745</td> - <td class='blt c020'>East. North.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>4</td> - <td class='blt c019'>9</td> - <td class='blt c019'>1</td> - <td class='blt c019'>40</td> - <td class='c019'>31</td> - <td class='blt c019'>1000</td> - <td class='c019'>783</td> - <td class='blt c020'>West. East.</td> - <td class='blt brt c020'>Cloudy. Foggy.</td> - </tr> - <tr> - <td class='blt c019'>5</td> - <td class='blt c019'>9</td> - <td class='blt c019'>4</td> - <td class='blt c019'>50</td> - <td class='c019'>39</td> - <td class='blt c019'>966</td> - <td class='c019'>709</td> - <td class='blt c020'>South. East.</td> - <td class='blt brt c020'>Foggy. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>6</td> - <td class='blt c019'>15</td> - <td class='blt c019'>1</td> - <td class='blt c019'>52</td> - <td class='c019'>33</td> - <td class='blt c019'>1000</td> - <td class='c019'>702</td> - <td class='blt c020'>South. West.</td> - <td class='blt brt c020'>Rain. Fine.</td> - </tr> - <tr> - <td class='blt c019'>7</td> - <td class='blt c019'>10</td> - <td class='blt c019'>5</td> - <td class='blt c019'>52</td> - <td class='c019'>39</td> - <td class='blt c019'>968</td> - <td class='c019'>110</td> - <td class='blt c020'>South. South-East.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>8</td> - <td class='blt c019'>8</td> - <td class='blt c019'>1</td> - <td class='blt c019'>52</td> - <td class='c019'>35</td> - <td class='blt c019'>1000</td> - <td class='c019'>680</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>9</td> - <td class='blt c019'>7</td> - <td class='blt c019'>3</td> - <td class='blt c019'>53</td> - <td class='c019'>40</td> - <td class='blt c019'>940</td> - <td class='c019'>624</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>10</td> - <td class='blt c019'>7</td> - <td class='blt c019'>1</td> - <td class='blt c019'>62</td> - <td class='c019'>39</td> - <td class='blt c019'>970</td> - <td class='c019'>698</td> - <td class='blt c020'>West. East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>11</td> - <td class='blt c019'>13</td> - <td class='blt c019'>2</td> - <td class='blt c019'>52</td> - <td class='c019'>37</td> - <td class='blt c019'>963</td> - <td class='c019'>500</td> - <td class='blt c020'>East. North.</td> - <td class='blt brt c020'>Fine. Hazy.</td> - </tr> - <tr> - <td class='blt c019'>12</td> - <td class='blt c019'>12</td> - <td class='blt c019'>3</td> - <td class='blt c019'>57</td> - <td class='c019'>44</td> - <td class='blt c019'>87</td> - <td class='c019'>74</td> - <td class='blt c020'>West. North.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>13</td> - <td class='blt c019'>12</td> - <td class='blt c019'>2</td> - <td class='blt c019'>62</td> - <td class='c019'>56</td> - <td class='blt c019'>60</td> - <td class='c019'>76</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>14</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>62</td> - <td class='c019'>58</td> - <td class='blt c019'>63</td> - <td class='c019'>81</td> - <td class='blt c020'>East. East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>15</td> - <td class='blt c019'>9</td> - <td class='blt c019'>0</td> - <td class='blt c019'>54</td> - <td class='c019'>49</td> - <td class='blt c019'>72</td> - <td class='c019'>80</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>16</td> - <td class='blt c019'>15</td> - <td class='blt c019'>3</td> - <td class='blt c019'>56</td> - <td class='c019'>50</td> - <td class='blt c019'>61</td> - <td class='c019'>74</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>17</td> - <td class='blt c019'>5</td> - <td class='blt c019'>5</td> - <td class='blt c019'>58</td> - <td class='c019'>52</td> - <td class='blt c019'>59</td> - <td class='c019'>68</td> - <td class='blt c020'>East. East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>18</td> - <td class='blt c019'>14</td> - <td class='blt c019'>0</td> - <td class='blt c019'>66</td> - <td class='c019'>56</td> - <td class='blt c019'>63</td> - <td class='c019'>69</td> - <td class='blt c020'>East. West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>19</td> - <td class='blt c019'>10</td> - <td class='blt c019'>5</td> - <td class='blt c019'>66</td> - <td class='c019'>59</td> - <td class='blt c019'>60</td> - <td class='c019'>76</td> - <td class='blt c020'>East. East.</td> - <td class='blt brt c020'>Rainy.</td> - </tr> - <tr> - <td class='blt c019'>20</td> - <td class='blt c019'>9</td> - <td class='blt c019'>1</td> - <td class='blt c019'>65</td> - <td class='c019'>59</td> - <td class='blt c019'>63</td> - <td class='c019'>68</td> - <td class='blt c020'>East. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>21</td> - <td class='blt c019'>12</td> - <td class='blt c019'>1</td> - <td class='blt c019'>73</td> - <td class='c019'>66</td> - <td class='blt c019'>60</td> - <td class='c019'>68</td> - <td class='blt c020'>N-East. N-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>22</td> - <td class='blt c019'>18</td> - <td class='blt c019'>2</td> - <td class='blt c019'>74</td> - <td class='c019'>68</td> - <td class='blt c019'>63</td> - <td class='c019'>90</td> - <td class='blt c020'>West. East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>23</td> - <td class='blt c019'>20</td> - <td class='blt c019'>1</td> - <td class='blt c019'>74</td> - <td class='c019'>65</td> - <td class='blt c019'>80</td> - <td class='c019'>95</td> - <td class='blt c020'>East. North.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>24</td> - <td class='blt c019'>15</td> - <td class='blt c019'>1</td> - <td class='blt c019'>78</td> - <td class='c019'>74</td> - <td class='blt c019'>65</td> - <td class='c019'>86</td> - <td class='blt c020'>East. South.</td> - <td class='blt brt c020'>Cloudy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>25</td> - <td class='blt c019'>14</td> - <td class='blt c019'>2</td> - <td class='blt c019'>78</td> - <td class='c019'>74</td> - <td class='blt c019'>66</td> - <td class='c019'>76</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>26</td> - <td class='blt c019'>14</td> - <td class='blt c019'>0</td> - <td class='blt c019'>74</td> - <td class='c019'>74</td> - <td class='blt c019'>53</td> - <td class='c019'>79</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>27</td> - <td class='blt c019'>17</td> - <td class='blt c019'>2</td> - <td class='blt c019'>74</td> - <td class='c019'>62</td> - <td class='blt c019'>66</td> - <td class='c019'>76</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>28</td> - <td class='blt c019'>14</td> - <td class='blt c019'>1</td> - <td class='blt c019'>78</td> - <td class='c019'>67</td> - <td class='blt c019'>61</td> - <td class='c019'>72</td> - <td class='blt c020'>North. East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>29</td> - <td class='blt c019'>18</td> - <td class='blt c019'>4</td> - <td class='blt c019'>78</td> - <td class='c019'>68</td> - <td class='blt c019'>59</td> - <td class='c019'>75</td> - <td class='blt c020'>East. North.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>30</td> - <td class='blt c019'>10</td> - <td class='blt c019'>3</td> - <td class='blt c019'>73</td> - <td class='c019'>49</td> - <td class='blt c019'>61</td> - <td class='c019'>92</td> - <td class='blt c020'>North. North-East.</td> - <td class='blt brt c020'>Rain. Fine.</td> - </tr> - <tr> - <td class='blt c019'>31</td> - <td class='blt c019'>19</td> - <td class='blt c019'>2</td> - <td class='blt c019'>84</td> - <td class='c019'>55</td> - <td class='blt c019'>60</td> - <td class='c019'>84</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Variable.</td> - </tr> - <tr> - <td class='blt c019'>32</td> - <td class='blt c019'>16</td> - <td class='blt c019'>1</td> - <td class='blt c019'>78</td> - <td class='c019'>55</td> - <td class='blt c019'>65</td> - <td class='c019'>84</td> - <td class='blt c020'>North-East. West.</td> - <td class='blt brt c020'>Variable.</td> - </tr> - <tr> - <td class='blt c019'>33</td> - <td class='blt c019'>20</td> - <td class='blt c019'>1</td> - <td class='blt c019'>73</td> - <td class='c019'>65</td> - <td class='blt c019'>59</td> - <td class='c019'>79</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Variable.</td> - </tr> - <tr> - <td class='blt c019'>34</td> - <td class='blt c019'>15</td> - <td class='blt c019'>4</td> - <td class='blt c019'>85</td> - <td class='c019'>60</td> - <td class='blt c019'>50</td> - <td class='c019'>72</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Cloudy. Fair.</td> - </tr> - <tr> - <td class='blt c019'>35</td> - <td class='blt c019'>15</td> - <td class='blt c019'>2</td> - <td class='blt c019'>79</td> - <td class='c019'>57</td> - <td class='blt c019'>65</td> - <td class='c019'>75</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Cloudy. Fair.</td> - </tr> - <tr> - <td class='blt c019'>36</td> - <td class='blt c019'>14</td> - <td class='blt c019'>3</td> - <td class='blt c019'>73</td> - <td class='c019'>40</td> - <td class='blt c019'>69</td> - <td class='c019'>91</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Cloudy. Fair.</td> - </tr> - <tr> - <td class='blt c019'>37</td> - <td class='blt c019'>19</td> - <td class='blt c019'>2</td> - <td class='blt c019'>69</td> - <td class='c019'>47</td> - <td class='blt c019'>71</td> - <td class='c019'>88</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>38</td> - <td class='blt c019'>19</td> - <td class='blt c019'>2</td> - <td class='blt c019'>71</td> - <td class='c019'>51</td> - <td class='blt c019'>73</td> - <td class='c019'>93</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>39</td> - <td class='blt c019'>15</td> - <td class='blt c019'>1</td> - <td class='blt c019'>69</td> - <td class='c019'>44</td> - <td class='blt c019'>74</td> - <td class='c019'>91</td> - <td class='blt c020'>East. South-West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>40</td> - <td class='blt c019'>12</td> - <td class='blt c019'>3</td> - <td class='blt c019'>70</td> - <td class='c019'>41</td> - <td class='blt c019'>75</td> - <td class='c019'>88</td> - <td class='blt c020'>S-West. S-West.</td> - <td class='blt brt c020'>Foggy.</td> - </tr> - <tr> - <td class='blt c019'>41</td> - <td class='blt c019'>14</td> - <td class='blt c019'>1</td> - <td class='blt c019'>67</td> - <td class='c019'>42</td> - <td class='blt c019'>75</td> - <td class='c019'>89</td> - <td class='blt c020'>S-West. S-West.</td> - <td class='blt brt c020'>Foggy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>42</td> - <td class='blt c019'>14</td> - <td class='blt c019'>2</td> - <td class='blt c019'>66</td> - <td class='c019'>45</td> - <td class='blt c019'>76</td> - <td class='c019'>96</td> - <td class='blt c020'>South. South-West.</td> - <td class='blt brt c020'>Foggy. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>43</td> - <td class='blt c019'>12</td> - <td class='blt c019'>5</td> - <td class='blt c019'>69</td> - <td class='c019'>40</td> - <td class='blt c019'>80</td> - <td class='c019'>96</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Foggy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>44</td> - <td class='blt c019'>17</td> - <td class='blt c019'>1</td> - <td class='blt c019'>56</td> - <td class='c019'>40</td> - <td class='blt c019'>78</td> - <td class='c019'>98</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Foggy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>45</td> - <td class='blt c019'>10</td> - <td class='blt c019'>2</td> - <td class='blt c019'>50</td> - <td class='c019'>31</td> - <td class='blt c019'>78</td> - <td class='c019'>98</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Foggy.</td> - </tr> - <tr> - <td class='blt c019'>46</td> - <td class='blt c019'>10</td> - <td class='blt c019'>4</td> - <td class='blt c019'>53</td> - <td class='c019'>33</td> - <td class='blt c019'>82</td> - <td class='c019'>97</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>47</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>47</td> - <td class='c019'>38</td> - <td class='blt c019'>75</td> - <td class='c019'>93</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Rain.</td> - </tr> - <tr> - <td class='blt c019'>48</td> - <td class='blt c019'>8</td> - <td class='blt c019'>1</td> - <td class='blt c019'>50</td> - <td class='c019'>30</td> - <td class='blt c019'>74</td> - <td class='c019'>93</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Fine. Foggy.</td> - </tr> - <tr> - <td class='blt c019'>49</td> - <td class='blt c019'>18</td> - <td class='blt c019'>3</td> - <td class='blt c019'>54</td> - <td class='c019'>33</td> - <td class='blt c019'>82</td> - <td class='c019'>98</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>50</td> - <td class='blt c019'>16</td> - <td class='blt c019'>4</td> - <td class='blt c019'>54</td> - <td class='c019'>45</td> - <td class='blt c019'>87</td> - <td class='c019'>99</td> - <td class='blt c020'>S-West. S-West.</td> - <td class='blt brt c020'>Fair. Foggy.</td> - </tr> - <tr> - <td class='blt c019'>51</td> - <td class='blt c019'>14</td> - <td class='blt c019'>3</td> - <td class='blt c019'>49</td> - <td class='c019'>33</td> - <td class='blt c019'>85</td> - <td class='c019'>98</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Foggy. Fair.</td> - </tr> - <tr> - <td class='bbt blt c019'>52</td> - <td class='bbt blt c019'>11</td> - <td class='bbt blt c019'>3</td> - <td class='bbt blt c019'>52</td> - <td class='bbt c019'>34</td> - <td class='bbt blt c019'>85</td> - <td class='bbt c019'>98</td> - <td class='bbt blt c020'>N-East. N-East.</td> - <td class='bbt blt brt c020'>Foggy.</td> - </tr> - <tr> - <td class='bbt blt c019'>Total</td> - <td class='bbt blt c019'>676</td> - <td class='bbt blt c019'>110</td> - <td class='bbt blt c019'> </td> - <td class='bbt c019'> </td> - <td class='bbt blt c019'> </td> - <td class='bbt c019'> </td> - <td class='bbt blt c020'> </td> - <td class='bbt blt brt c020'> </td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_429'>429</span> - <h3 class='c013'><em>Meteorological Table, with reference to Admissions and Deaths, for 1827.</em></h3> -</div> - -<table class='table1' summary='Meteorological Table'> -<colgroup> -<col width='8%' /> -<col width='8%' /> -<col width='10%' /> -<col width='5%' /> -<col width='5%' /> -<col width='5%' /> -<col width='5%' /> -<col width='28%' /> -<col width='20%' /> -</colgroup> - <tr> - <th class='btt bbt blt c018' rowspan='2'>Weeks.</th> - <th class='btt bbt blt c018' rowspan='2'>Admissions.</th> - <th class='btt bbt blt c018' rowspan='2'>Deaths.</th> - <th class='btt bbt blt c018' colspan='2'>Heat.</th> - <th class='btt bbt blt c018' colspan='2'>Moisture.</th> - <th class='btt bbt blt c018' rowspan='2'>Wind.</th> - <th class='btt bbt blt brt c018' rowspan='2'>Weather.</th> - </tr> - <tr> - - - - <th class='bbt blt c018'>Max.</th> - <th class='bbt c018'>Min.</th> - <th class='bbt blt c018'>Max.</th> - <th class='bbt c018'>Min.</th> - - - </tr> - <tr> - <td class='blt c019'>1</td> - <td class='blt c019'>10</td> - <td class='blt c019'>1</td> - <td class='blt c019'>49</td> - <td class='c019'>18</td> - <td class='blt c019'>98</td> - <td class='c019'>74</td> - <td class='blt c020'>West. North.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>2</td> - <td class='blt c019'>7</td> - <td class='blt c019'>2</td> - <td class='blt c019'>53</td> - <td class='c019'>31</td> - <td class='blt c019'>98</td> - <td class='c019'>85</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Rain. Fair.</td> - </tr> - <tr> - <td class='blt c019'>3</td> - <td class='blt c019'>14</td> - <td class='blt c019'>0</td> - <td class='blt c019'>53</td> - <td class='c019'>25</td> - <td class='blt c019'>96</td> - <td class='c019'>76</td> - <td class='blt c020'>West. North-East.</td> - <td class='blt brt c020'>Cloudy. Fair.</td> - </tr> - <tr> - <td class='blt c019'>4</td> - <td class='blt c019'>8</td> - <td class='blt c019'>1</td> - <td class='blt c019'>42</td> - <td class='c019'>18</td> - <td class='blt c019'>95</td> - <td class='c019'>81</td> - <td class='blt c020'>West. North-East.</td> - <td class='blt brt c020'>Cloudy. Foggy.</td> - </tr> - <tr> - <td class='blt c019'>5</td> - <td class='blt c019'>12</td> - <td class='blt c019'>3</td> - <td class='blt c019'>46</td> - <td class='c019'>27</td> - <td class='blt c019'>98</td> - <td class='c019'>75</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>6</td> - <td class='blt c019'>6</td> - <td class='blt c019'>1</td> - <td class='blt c019'>41</td> - <td class='c019'>28</td> - <td class='blt c019'>93</td> - <td class='c019'>75</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>7</td> - <td class='blt c019'>9</td> - <td class='blt c019'>3</td> - <td class='blt c019'>40</td> - <td class='c019'>19</td> - <td class='blt c019'>87</td> - <td class='c019'>80</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>8</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>40</td> - <td class='c019'>29</td> - <td class='blt c019'>89</td> - <td class='c019'>72</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fair. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>9</td> - <td class='blt c019'>10</td> - <td class='blt c019'>0</td> - <td class='blt c019'>50</td> - <td class='c019'>30</td> - <td class='blt c019'>98</td> - <td class='c019'>82</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>10</td> - <td class='blt c019'>10</td> - <td class='blt c019'>1</td> - <td class='blt c019'>56</td> - <td class='c019'>32</td> - <td class='blt c019'>93</td> - <td class='c019'>78</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Fair. Rain.</td> - </tr> - <tr> - <td class='blt c019'>11</td> - <td class='blt c019'>12</td> - <td class='blt c019'>0</td> - <td class='blt c019'>56</td> - <td class='c019'>32</td> - <td class='blt c019'>88</td> - <td class='c019'>77</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>12</td> - <td class='blt c019'>4</td> - <td class='blt c019'>0</td> - <td class='blt c019'>48</td> - <td class='c019'>35</td> - <td class='blt c019'>97</td> - <td class='c019'>75</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>13</td> - <td class='blt c019'>10</td> - <td class='blt c019'>1</td> - <td class='blt c019'>58</td> - <td class='c019'>35</td> - <td class='blt c019'>89</td> - <td class='c019'>76</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy. Fair.</td> - </tr> - <tr> - <td class='blt c019'>14</td> - <td class='blt c019'>2</td> - <td class='blt c019'>0</td> - <td class='blt c019'>67</td> - <td class='c019'>46</td> - <td class='blt c019'>98</td> - <td class='c019'>75</td> - <td class='blt c020'>West. North-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>15</td> - <td class='blt c019'>8</td> - <td class='blt c019'>0</td> - <td class='blt c019'>58</td> - <td class='c019'>41</td> - <td class='blt c019'>92</td> - <td class='c019'>72</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>16</td> - <td class='blt c019'>19</td> - <td class='blt c019'>4</td> - <td class='blt c019'>52</td> - <td class='c019'>39</td> - <td class='blt c019'>92</td> - <td class='c019'>78</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Cloudy.Rain.</td> - </tr> - <tr> - <td class='blt c019'>17</td> - <td class='blt c019'>6</td> - <td class='blt c019'>2</td> - <td class='blt c019'>71</td> - <td class='c019'>34</td> - <td class='blt c019'>88</td> - <td class='c019'>68</td> - <td class='blt c020'>Variable. Variable.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>18</td> - <td class='blt c019'>11</td> - <td class='blt c019'>1</td> - <td class='blt c019'>72</td> - <td class='c019'>44</td> - <td class='blt c019'>95</td> - <td class='c019'>79</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>19</td> - <td class='blt c019'>14</td> - <td class='blt c019'>1</td> - <td class='blt c019'>59</td> - <td class='c019'>34</td> - <td class='blt c019'>94</td> - <td class='c019'>72</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>20</td> - <td class='blt c019'>16</td> - <td class='blt c019'>0</td> - <td class='blt c019'>70</td> - <td class='c019'>46</td> - <td class='blt c019'>88</td> - <td class='c019'>75</td> - <td class='blt c020'>East. South-West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>21</td> - <td class='blt c019'>12</td> - <td class='blt c019'>2</td> - <td class='blt c019'>72</td> - <td class='c019'>45</td> - <td class='blt c019'>90</td> - <td class='c019'>73</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>22</td> - <td class='blt c019'>21</td> - <td class='blt c019'>0</td> - <td class='blt c019'>70</td> - <td class='c019'>45</td> - <td class='blt c019'>92</td> - <td class='c019'>78</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>23</td> - <td class='blt c019'>9</td> - <td class='blt c019'>0</td> - <td class='blt c019'>70</td> - <td class='c019'>48</td> - <td class='blt c019'>92</td> - <td class='c019'>74</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>24</td> - <td class='blt c019'>23</td> - <td class='blt c019'>2</td> - <td class='blt c019'>75</td> - <td class='c019'>52</td> - <td class='blt c019'>92</td> - <td class='c019'>71</td> - <td class='blt c020'>East. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>25</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>74</td> - <td class='c019'>50</td> - <td class='blt c019'>87</td> - <td class='c019'>73</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>26</td> - <td class='blt c019'>23</td> - <td class='blt c019'>5</td> - <td class='blt c019'>72</td> - <td class='c019'>58</td> - <td class='blt c019'>98</td> - <td class='c019'>77</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Rain. Fair.</td> - </tr> - <tr> - <td class='blt c019'>27</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>79</td> - <td class='c019'>55</td> - <td class='blt c019'>92</td> - <td class='c019'>74</td> - <td class='blt c020'>Variable. Variable.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>28</td> - <td class='blt c019'>15</td> - <td class='blt c019'>0</td> - <td class='blt c019'>80</td> - <td class='c019'>53</td> - <td class='blt c019'>82</td> - <td class='c019'>70</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>29</td> - <td class='blt c019'>15</td> - <td class='blt c019'>2</td> - <td class='blt c019'>76</td> - <td class='c019'>56</td> - <td class='blt c019'>82</td> - <td class='c019'>68</td> - <td class='blt c020'>East. East.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>30</td> - <td class='blt c019'>17</td> - <td class='blt c019'>1</td> - <td class='blt c019'>84</td> - <td class='c019'>57</td> - <td class='blt c019'>92</td> - <td class='c019'>78</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy. Fair.</td> - </tr> - <tr> - <td class='blt c019'>31</td> - <td class='blt c019'>17</td> - <td class='blt c019'>3</td> - <td class='blt c019'>80</td> - <td class='c019'>53</td> - <td class='blt c019'>84</td> - <td class='c019'>72</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy. Fair.</td> - </tr> - <tr> - <td class='blt c019'>32</td> - <td class='blt c019'>17</td> - <td class='blt c019'>2</td> - <td class='blt c019'>72</td> - <td class='c019'>50</td> - <td class='blt c019'>86</td> - <td class='c019'>74</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>33</td> - <td class='blt c019'>16</td> - <td class='blt c019'>2</td> - <td class='blt c019'>72</td> - <td class='c019'>54</td> - <td class='blt c019'>93</td> - <td class='c019'>74</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>34</td> - <td class='blt c019'>18</td> - <td class='blt c019'>5</td> - <td class='blt c019'>78</td> - <td class='c019'>52</td> - <td class='blt c019'>90</td> - <td class='c019'>75</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>35</td> - <td class='blt c019'>20</td> - <td class='blt c019'>2</td> - <td class='blt c019'>78</td> - <td class='c019'>53</td> - <td class='blt c019'>93</td> - <td class='c019'>78</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Cloudy. Fair.</td> - </tr> - <tr> - <td class='blt c019'>36</td> - <td class='blt c019'>14</td> - <td class='blt c019'>6</td> - <td class='blt c019'>68</td> - <td class='c019'>51</td> - <td class='blt c019'>96</td> - <td class='c019'>80</td> - <td class='blt c020'>East. Fair. North-East.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>37</td> - <td class='blt c019'>17</td> - <td class='blt c019'>6</td> - <td class='blt c019'>71</td> - <td class='c019'>51</td> - <td class='blt c019'>91</td> - <td class='c019'>78</td> - <td class='blt c020'>East. Fair. North-East.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>38</td> - <td class='blt c019'>16</td> - <td class='blt c019'>1</td> - <td class='blt c019'>64</td> - <td class='c019'>49</td> - <td class='blt c019'>91</td> - <td class='c019'>81</td> - <td class='blt c020'>West. Fair. South-West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>39</td> - <td class='blt c019'>14</td> - <td class='blt c019'>0</td> - <td class='blt c019'>64</td> - <td class='c019'>52</td> - <td class='blt c019'>100</td> - <td class='c019'>87</td> - <td class='blt c020'>West. South-East.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>40</td> - <td class='blt c019'>16</td> - <td class='blt c019'>2</td> - <td class='blt c019'>61</td> - <td class='c019'>47</td> - <td class='blt c019'>100</td> - <td class='c019'>95</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>41</td> - <td class='blt c019'>13</td> - <td class='blt c019'>2</td> - <td class='blt c019'>64</td> - <td class='c019'>43</td> - <td class='blt c019'>98</td> - <td class='c019'>86</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>42</td> - <td class='blt c019'>15</td> - <td class='blt c019'>2</td> - <td class='blt c019'>63</td> - <td class='c019'>57</td> - <td class='blt c019'>98</td> - <td class='c019'>85</td> - <td class='blt c020'>West. South-East.</td> - <td class='blt brt c020'>Foggy.</td> - </tr> - <tr> - <td class='blt c019'>43</td> - <td class='blt c019'>16</td> - <td class='blt c019'>2</td> - <td class='blt c019'>60</td> - <td class='c019'>37</td> - <td class='blt c019'>100</td> - <td class='c019'>89</td> - <td class='blt c020'>S-East. S-West.</td> - <td class='blt brt c020'>Fair. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>44</td> - <td class='blt c019'>23</td> - <td class='blt c019'>2</td> - <td class='blt c019'>57</td> - <td class='c019'>39</td> - <td class='blt c019'>99</td> - <td class='c019'>78</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Foggy.</td> - </tr> - <tr> - <td class='blt c019'>45</td> - <td class='blt c019'>13</td> - <td class='blt c019'>3</td> - <td class='blt c019'>60</td> - <td class='c019'>39</td> - <td class='blt c019'>98</td> - <td class='c019'>92</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Fair. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>46</td> - <td class='blt c019'>5</td> - <td class='blt c019'>0</td> - <td class='blt c019'>52</td> - <td class='c019'>40</td> - <td class='blt c019'>100</td> - <td class='c019'>86</td> - <td class='blt c020'>East. South-East.</td> - <td class='blt brt c020'>Foggy.</td> - </tr> - <tr> - <td class='blt c019'>47</td> - <td class='blt c019'>12</td> - <td class='blt c019'>1</td> - <td class='blt c019'>45</td> - <td class='c019'>25</td> - <td class='blt c019'>100</td> - <td class='c019'>83</td> - <td class='blt c020'>N-West. N-West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>48</td> - <td class='blt c019'>15</td> - <td class='blt c019'>3</td> - <td class='blt c019'>53</td> - <td class='c019'>41</td> - <td class='blt c019'>100</td> - <td class='c019'>96</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>49</td> - <td class='blt c019'>9</td> - <td class='blt c019'>0</td> - <td class='blt c019'>56</td> - <td class='c019'>36</td> - <td class='blt c019'>97</td> - <td class='c019'>80</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>50</td> - <td class='blt c019'>9</td> - <td class='blt c019'>2</td> - <td class='blt c019'>55</td> - <td class='c019'>38</td> - <td class='blt c019'>98</td> - <td class='c019'>86</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Rain. Fair.</td> - </tr> - <tr> - <td class='blt c019'>51</td> - <td class='blt c019'>9</td> - <td class='blt c019'>3</td> - <td class='blt c019'>55</td> - <td class='c019'>39</td> - <td class='blt c019'>98</td> - <td class='c019'>97</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Rain.</td> - </tr> - <tr> - <td class='bbt blt c019'>52</td> - <td class='bbt blt c019'>17</td> - <td class='bbt blt c019'>1</td> - <td class='bbt blt c019'>52</td> - <td class='bbt c019'>31</td> - <td class='bbt blt c019'>98</td> - <td class='bbt c019'>87</td> - <td class='bbt blt c020'>West. South-West.</td> - <td class='bbt blt brt c020'>Foggy.</td> - </tr> - <tr> - <td class='bbt blt c019'>Total</td> - <td class='bbt blt c019'>676</td> - <td class='bbt blt c019'>87</td> - <td class='bbt blt c019'> </td> - <td class='bbt c019'> </td> - <td class='bbt blt c019'> </td> - <td class='bbt c019'> </td> - <td class='bbt blt c020'> </td> - <td class='bbt blt brt c020'> </td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_430'>430</span> - <h3 class='c013'><em>Meteorological Table, with reference to Admissions and Deaths, for 1828.</em></h3> -</div> - -<table class='table1' summary='Meteorological Table'> -<colgroup> -<col width='8%' /> -<col width='8%' /> -<col width='10%' /> -<col width='5%' /> -<col width='5%' /> -<col width='5%' /> -<col width='5%' /> -<col width='28%' /> -<col width='20%' /> -</colgroup> - <tr> - <th class='btt bbt blt c018' rowspan='2'>Weeks.</th> - <th class='btt bbt blt c018' rowspan='2'>Admissions.</th> - <th class='btt bbt blt c018' rowspan='2'>Deaths.</th> - <th class='btt bbt blt c018' colspan='2'>Heat.</th> - <th class='btt bbt blt c018' colspan='2'>Moisture.</th> - <th class='btt bbt blt c018' rowspan='2'>Wind.</th> - <th class='btt bbt blt brt c018' rowspan='2'>Weather.</th> - </tr> - <tr> - - - - <th class='bbt blt c018'>Max.</th> - <th class='bbt c018'>Min.</th> - <th class='bbt blt c018'>Max.</th> - <th class='bbt c018'>Min.</th> - - - </tr> - <tr> - <td class='blt c019'>1</td> - <td class='blt c019'>8</td> - <td class='blt c019'>3</td> - <td class='blt c019'>50</td> - <td class='c019'>33</td> - <td class='blt c019'>98</td> - <td class='c019'>96</td> - <td class='blt c020'>East. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>2</td> - <td class='blt c019'>9</td> - <td class='blt c019'>0</td> - <td class='blt c019'>47</td> - <td class='c019'>28</td> - <td class='blt c019'>99</td> - <td class='c019'>85</td> - <td class='blt c020'>East. South-East.</td> - <td class='blt brt c020'>Cloudy. Snow.</td> - </tr> - <tr> - <td class='blt c019'>3</td> - <td class='blt c019'>11</td> - <td class='blt c019'>1</td> - <td class='blt c019'>56</td> - <td class='c019'>38</td> - <td class='blt c019'>99</td> - <td class='c019'>86</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Rain. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>4</td> - <td class='blt c019'>14</td> - <td class='blt c019'>3</td> - <td class='blt c019'>53</td> - <td class='c019'>40</td> - <td class='blt c019'>98</td> - <td class='c019'>90</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>5</td> - <td class='blt c019'>11</td> - <td class='blt c019'>1</td> - <td class='blt c019'>54</td> - <td class='c019'>39</td> - <td class='blt c019'>96</td> - <td class='c019'>90</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Rain. Fair.</td> - </tr> - <tr> - <td class='blt c019'>6</td> - <td class='blt c019'>8</td> - <td class='blt c019'>2</td> - <td class='blt c019'>54</td> - <td class='c019'>28</td> - <td class='blt c019'>98</td> - <td class='c019'>90</td> - <td class='blt c020'>West. East.</td> - <td class='blt brt c020'>Cloudy. Snow.</td> - </tr> - <tr> - <td class='blt c019'>7</td> - <td class='blt c019'>11</td> - <td class='blt c019'>0</td> - <td class='blt c019'>41</td> - <td class='c019'>28</td> - <td class='blt c019'>98</td> - <td class='c019'>90</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>8</td> - <td class='blt c019'>13</td> - <td class='blt c019'>2</td> - <td class='blt c019'>52</td> - <td class='c019'>36</td> - <td class='blt c019'>98</td> - <td class='c019'>90</td> - <td class='blt c020'>East. West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>9</td> - <td class='blt c019'>7</td> - <td class='blt c019'>1</td> - <td class='blt c019'>57</td> - <td class='c019'>38</td> - <td class='blt c019'>98</td> - <td class='c019'>94</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>10</td> - <td class='blt c019'>11</td> - <td class='blt c019'>1</td> - <td class='blt c019'>55</td> - <td class='c019'>31</td> - <td class='blt c019'>98</td> - <td class='c019'>76</td> - <td class='blt c020'>East. North-West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>11</td> - <td class='blt c019'>18</td> - <td class='blt c019'>2</td> - <td class='blt c019'>62</td> - <td class='c019'>44</td> - <td class='blt c019'>94</td> - <td class='c019'>86</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>12</td> - <td class='blt c019'>5</td> - <td class='blt c019'>0</td> - <td class='blt c019'>64</td> - <td class='c019'>36</td> - <td class='blt c019'>98</td> - <td class='c019'>92</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair. Hail.</td> - </tr> - <tr> - <td class='blt c019'>13</td> - <td class='blt c019'>13</td> - <td class='blt c019'>2</td> - <td class='blt c019'>52</td> - <td class='c019'>33</td> - <td class='blt c019'>98</td> - <td class='c019'>92</td> - <td class='blt c020'>East. North-East.</td> - <td class='blt brt c020'>Foggy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>14</td> - <td class='blt c019'>8</td> - <td class='blt c019'>3</td> - <td class='blt c019'>53</td> - <td class='c019'>35</td> - <td class='blt c019'>98</td> - <td class='c019'>82</td> - <td class='blt c020'>East. North.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>15</td> - <td class='blt c019'>15</td> - <td class='blt c019'>1</td> - <td class='blt c019'>61</td> - <td class='c019'>38</td> - <td class='blt c019'>98</td> - <td class='c019'>95</td> - <td class='blt c020'>East. South-West.</td> - <td class='blt brt c020'>Rain. Fine.</td> - </tr> - <tr> - <td class='blt c019'>16</td> - <td class='blt c019'>14</td> - <td class='blt c019'>4</td> - <td class='blt c019'>61</td> - <td class='c019'>43</td> - <td class='blt c019'>98</td> - <td class='c019'>94</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Rain.</td> - </tr> - <tr> - <td class='blt c019'>17</td> - <td class='blt c019'>14</td> - <td class='blt c019'>2</td> - <td class='blt c019'>65</td> - <td class='c019'>39</td> - <td class='blt c019'>97</td> - <td class='c019'>80</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>18</td> - <td class='blt c019'>16</td> - <td class='blt c019'>3</td> - <td class='blt c019'>68</td> - <td class='c019'>45</td> - <td class='blt c019'>98</td> - <td class='c019'>75</td> - <td class='blt c020'>West. East.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>19</td> - <td class='blt c019'>10</td> - <td class='blt c019'>0</td> - <td class='blt c019'>66</td> - <td class='c019'>43</td> - <td class='blt c019'>98</td> - <td class='c019'>80</td> - <td class='blt c020'>East. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>20</td> - <td class='blt c019'>16</td> - <td class='blt c019'>2</td> - <td class='blt c019'>68</td> - <td class='c019'>47</td> - <td class='blt c019'>92</td> - <td class='c019'>85</td> - <td class='blt c020'>East. South-East.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>21</td> - <td class='blt c019'>8</td> - <td class='blt c019'>2</td> - <td class='blt c019'>68</td> - <td class='c019'>47</td> - <td class='blt c019'>98</td> - <td class='c019'>90</td> - <td class='blt c020'>East. South-East.</td> - <td class='blt brt c020'>Rain. Fair.</td> - </tr> - <tr> - <td class='blt c019'>22</td> - <td class='blt c019'>8</td> - <td class='blt c019'>1</td> - <td class='blt c019'>71</td> - <td class='c019'>52</td> - <td class='blt c019'>98</td> - <td class='c019'>78</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>23</td> - <td class='blt c019'>3</td> - <td class='blt c019'>0</td> - <td class='blt c019'>70</td> - <td class='c019'>51</td> - <td class='blt c019'>94</td> - <td class='c019'>77</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fair. Rain.</td> - </tr> - <tr> - <td class='blt c019'>24</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>73</td> - <td class='c019'>54</td> - <td class='blt c019'>78</td> - <td class='c019'>75</td> - <td class='blt c020'>N-West. N-West.</td> - <td class='blt brt c020'>Fair.</td> - </tr> - <tr> - <td class='blt c019'>25</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>73</td> - <td class='c019'>56</td> - <td class='blt c019'>96</td> - <td class='c019'>75</td> - <td class='blt c020'>S-East. S-East.</td> - <td class='blt brt c020'>Rain. Fair.</td> - </tr> - <tr> - <td class='blt c019'>26</td> - <td class='blt c019'>12</td> - <td class='blt c019'>1</td> - <td class='blt c019'>80</td> - <td class='c019'>55</td> - <td class='blt c019'>96</td> - <td class='c019'>79</td> - <td class='blt c020'>N-West. N-West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>27</td> - <td class='blt c019'>8</td> - <td class='blt c019'>1</td> - <td class='blt c019'>79</td> - <td class='c019'>56</td> - <td class='blt c019'>100</td> - <td class='c019'>91</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>28</td> - <td class='blt c019'>18</td> - <td class='blt c019'>0</td> - <td class='blt c019'>77</td> - <td class='c019'>65</td> - <td class='blt c019'>74</td> - <td class='c019'>43</td> - <td class='blt c020'>S-West. S-West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>29</td> - <td class='blt c019'>11</td> - <td class='blt c019'>1</td> - <td class='blt c019'>73</td> - <td class='c019'>55</td> - <td class='blt c019'>66</td> - <td class='c019'>48</td> - <td class='blt c020'>N-West. N-West.</td> - <td class='blt brt c020'>Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>30</td> - <td class='blt c019'>24</td> - <td class='blt c019'>2</td> - <td class='blt c019'>73</td> - <td class='c019'>51</td> - <td class='blt c019'>50</td> - <td class='c019'>49</td> - <td class='blt c020'>N-West. N-West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>31</td> - <td class='blt c019'>13</td> - <td class='blt c019'>0</td> - <td class='blt c019'>72</td> - <td class='c019'>66</td> - <td class='blt c019'>51</td> - <td class='c019'>49</td> - <td class='blt c020'>East. East.</td> - <td class='blt brt c020'>Rain. Fine.</td> - </tr> - <tr> - <td class='blt c019'>32</td> - <td class='blt c019'>14</td> - <td class='blt c019'>2</td> - <td class='blt c019'>74</td> - <td class='c019'>53</td> - <td class='blt c019'>50</td> - <td class='c019'>49</td> - <td class='blt c020'>S-East. S-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>33</td> - <td class='blt c019'>18</td> - <td class='blt c019'>3</td> - <td class='blt c019'>74</td> - <td class='c019'>44</td> - <td class='blt c019'>52</td> - <td class='c019'>40</td> - <td class='blt c020'>West. South-West.</td> - <td class='blt brt c020'>Cloudy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>34</td> - <td class='blt c019'>12</td> - <td class='blt c019'>2</td> - <td class='blt c019'>68</td> - <td class='c019'>42</td> - <td class='blt c019'>50</td> - <td class='c019'>47</td> - <td class='blt c020'>S-East. S-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>35</td> - <td class='blt c019'>22</td> - <td class='blt c019'>1</td> - <td class='blt c019'>73</td> - <td class='c019'>56</td> - <td class='blt c019'>54</td> - <td class='c019'>50</td> - <td class='blt c020'>S-West. S-West.</td> - <td class='blt brt c020'>Foggy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>36</td> - <td class='blt c019'>11</td> - <td class='blt c019'>4</td> - <td class='blt c019'>66</td> - <td class='c019'>45</td> - <td class='blt c019'>55</td> - <td class='c019'>51</td> - <td class='blt c020'>West by North. West.</td> - <td class='blt brt c020'>Foggy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>37</td> - <td class='blt c019'>16</td> - <td class='blt c019'>1</td> - <td class='blt c019'>63</td> - <td class='c019'>48</td> - <td class='blt c019'>56</td> - <td class='c019'>51</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Foggy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>38</td> - <td class='blt c019'>10</td> - <td class='blt c019'>3</td> - <td class='blt c019'>63</td> - <td class='c019'>39</td> - <td class='blt c019'>55</td> - <td class='c019'>50</td> - <td class='blt c020'>N-West. N-West.</td> - <td class='blt brt c020'>Foggy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>39</td> - <td class='blt c019'>17</td> - <td class='blt c019'>4</td> - <td class='blt c019'>63</td> - <td class='c019'>38</td> - <td class='blt c019'>68</td> - <td class='c019'>52</td> - <td class='blt c020'>East. South-West.</td> - <td class='blt brt c020'>Foggy. Fine.</td> - </tr> - <tr> - <td class='blt c019'>40</td> - <td class='blt c019'>14</td> - <td class='blt c019'>4</td> - <td class='blt c019'>53</td> - <td class='c019'>39</td> - <td class='blt c019'>68</td> - <td class='c019'>55</td> - <td class='blt c020'>East. South-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>41</td> - <td class='blt c019'>8</td> - <td class='blt c019'>0</td> - <td class='blt c019'>53</td> - <td class='c019'>26</td> - <td class='blt c019'>67</td> - <td class='c019'>55</td> - <td class='blt c020'>S-East. S-East.</td> - <td class='blt brt c020'>Fine.Foggy.</td> - </tr> - <tr> - <td class='blt c019'>42</td> - <td class='blt c019'>13</td> - <td class='blt c019'>2</td> - <td class='blt c019'>56</td> - <td class='c019'>26</td> - <td class='blt c019'>75</td> - <td class='c019'>55</td> - <td class='blt c020'>S-East. S-East.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>43</td> - <td class='blt c019'>8</td> - <td class='blt c019'>1</td> - <td class='blt c019'>63</td> - <td class='c019'>42</td> - <td class='blt c019'>64</td> - <td class='c019'>55</td> - <td class='blt c020'>East. North-West.</td> - <td class='blt brt c020'>Fine. Foggy.</td> - </tr> - <tr> - <td class='blt c019'>44</td> - <td class='blt c019'>5</td> - <td class='blt c019'>5</td> - <td class='blt c019'>54</td> - <td class='c019'>39</td> - <td class='blt c019'>68</td> - <td class='c019'>58</td> - <td class='blt c020'>East. North. N-East.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>45</td> - <td class='blt c019'>4</td> - <td class='blt c019'>0</td> - <td class='blt c019'>44</td> - <td class='c019'>35</td> - <td class='blt c019'>67</td> - <td class='c019'>53</td> - <td class='blt c020'>S-East. South. S-East.</td> - <td class='blt brt c020'>Fine. Foggy.</td> - </tr> - <tr> - <td class='blt c019'>46</td> - <td class='blt c019'>12</td> - <td class='blt c019'>3</td> - <td class='blt c019'>54</td> - <td class='c019'>28</td> - <td class='blt c019'>74</td> - <td class='c019'>63</td> - <td class='blt c020'>East. South-East.</td> - <td class='blt brt c020'>Rain. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>47</td> - <td class='blt c019'>7</td> - <td class='blt c019'>1</td> - <td class='blt c019'>56</td> - <td class='c019'>41</td> - <td class='blt c019'>68</td> - <td class='c019'>56</td> - <td class='blt c020'>S-West. S-West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='blt c019'>48</td> - <td class='blt c019'>13</td> - <td class='blt c019'>0</td> - <td class='blt c019'>59</td> - <td class='c019'>35</td> - <td class='blt c019'>68</td> - <td class='c019'>56</td> - <td class='blt c020'>West. North-West.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>49</td> - <td class='blt c019'>13</td> - <td class='blt c019'>1</td> - <td class='blt c019'>53</td> - <td class='c019'>38</td> - <td class='blt c019'>65</td> - <td class='c019'>64</td> - <td class='blt c020'>West. S. South-West.</td> - <td class='blt brt c020'>Foggy. Rain.</td> - </tr> - <tr> - <td class='blt c019'>50</td> - <td class='blt c019'>10</td> - <td class='blt c019'>1</td> - <td class='blt c019'>56</td> - <td class='c019'>40</td> - <td class='blt c019'>68</td> - <td class='c019'>65</td> - <td class='blt c020'>West. West.</td> - <td class='blt brt c020'>Fine. Cloudy.</td> - </tr> - <tr> - <td class='blt c019'>51</td> - <td class='blt c019'>9</td> - <td class='blt c019'>0</td> - <td class='blt c019'>57</td> - <td class='c019'>41</td> - <td class='blt c019'>65</td> - <td class='c019'>65</td> - <td class='blt c020'>N-West. W. N-West.</td> - <td class='blt brt c020'>Fine.</td> - </tr> - <tr> - <td class='bbt blt c019'>52</td> - <td class='bbt blt c019'>9</td> - <td class='bbt blt c019'>0</td> - <td class='bbt blt c019'>45</td> - <td class='bbt c019'>36</td> - <td class='bbt blt c019'>69</td> - <td class='bbt c019'>65</td> - <td class='bbt blt c020'>S-West. S-East.</td> - <td class='bbt blt brt c020'>Foggy. Rain.</td> - </tr> - <tr> - <td class='bbt blt c019'>Total</td> - <td class='bbt blt c019'>597</td> - <td class='bbt blt c019'>81</td> - <td class='bbt blt c019'> </td> - <td class='bbt c019'> </td> - <td class='bbt blt c019'> </td> - <td class='bbt c019'> </td> - <td class='bbt blt c020'> </td> - <td class='bbt blt brt c020'> </td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_431'>431</span> - <h3 class='c013'>Occupation of Patients, with reference to Susceptibility, for one year.</h3> -</div> - -<table class='table2' summary=''> - <tr> - <td class='c021'>Servants</td> - <td class='c022'>150</td> - </tr> - <tr> - <td class='c021'>Labourers</td> - <td class='c022'>126</td> - </tr> - <tr> - <td class='c021'>Shoemakers</td> - <td class='c022'>18</td> - </tr> - <tr> - <td class='c021'>Tailors</td> - <td class='c022'>17</td> - </tr> - <tr> - <td class='c021'>Fruiterers</td> - <td class='c022'>13</td> - </tr> - <tr> - <td class='c021'>Carpenters</td> - <td class='c022'>10</td> - </tr> - <tr> - <td class='c021'>Weavers</td> - <td class='c022'>10</td> - </tr> - <tr> - <td class='c021'>Bricklayers</td> - <td class='c022'>8</td> - </tr> - <tr> - <td class='c021'>Bakers</td> - <td class='c022'>6</td> - </tr> - <tr> - <td class='c021'>Dress Makers</td> - <td class='c022'>6</td> - </tr> - <tr> - <td class='c021'>Painters</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>Plasterers</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>Sailors</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>Printers</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Sawyers</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Butchers</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Porters</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Sweeps</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Chair Women</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Pot-boys</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Shop-boys</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Silversmiths</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Grocers</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Furriers</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Curriers</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Woodmen</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Grooms</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Skinners</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Fishmongers</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Gardeners</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Corkcutters</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Farmers</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Braidmakers</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Watchmakers</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Cagemakers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Guncapmakers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Blacksmiths</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Combmakers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Coppersmiths</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Firemen</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Distillers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Masons</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Cabinetmakers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Milkmen</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Saddlers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Ferulemakers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Coachbuilders</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Mercers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Bargebuilders</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Cheesemongers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Sawmakers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Clockmakers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Upholstresses</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Poulterers</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Destitute</td> - <td class='c022'>230</td> - </tr> - <tr> - <td class='c021'> </td> - <td class='c022'><hr /></td> - </tr> - <tr> - <td class='c023'>Total</td> - <td class='c022'>679</td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_432'>432</span> - <h3 class='c013'>Sex of Patient, with reference to Susceptibility.</h3> -</div> - -<table class='table3' summary='Sex of Patient'> - <tr> - <th class='btt bbt blt brt c018' colspan='2'>1825.</th> - <th class='btt bbt brt c018' colspan='2'>1826.</th> - <th class='btt bbt brt c018' colspan='2'>1827.</th> - <th class='btt bbt brt c018' colspan='2'>1828.</th> - </tr> - <tr> - <td class='blt c024'>Males</td> - <td class='brt c019'>289</td> - <td class='c024'>Males</td> - <td class='brt c019'>325</td> - <td class='c024'>Males</td> - <td class='brt c019'>337</td> - <td class='c024'>Males</td> - <td class='brt c019'>278</td> - </tr> - <tr> - <td class='blt c024'>Females,</td> - <td class='brt c019'>299</td> - <td class='c024'>Females,</td> - <td class='brt c019'>351</td> - <td class='c024'>Females,</td> - <td class='brt c019'>339</td> - <td class='c024'>Females,</td> - <td class='brt c019'>319</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='brt c019'><hr /></td> - <td class='c024'> </td> - <td class='brt c019'><hr /></td> - <td class='c024'> </td> - <td class='brt c019'><hr /></td> - <td class='c024'> </td> - <td class='brt c019'><hr /></td> - </tr> - <tr> - <td class='bbt blt c018'>Total,</td> - <td class='bbt brt c019'>588</td> - <td class='bbt c018'>Total,</td> - <td class='bbt brt c019'>676</td> - <td class='bbt c018'>Total,</td> - <td class='bbt brt c019'>676</td> - <td class='bbt c018'>Total,</td> - <td class='bbt brt c019'>597</td> - </tr> -</table> - -<h3 class='c013'>Sex of Patient, with reference to Mortality.</h3> - -<table class='table3' summary='Sex of Patient'> - <tr> - <th class='btt bbt blt brt c018' colspan='2'>1825.</th> - <th class='btt bbt brt c018' colspan='2'>1826.</th> - <th class='btt bbt brt c018' colspan='2'>1827.</th> - <th class='btt bbt brt c018' colspan='2'>1828.</th> - </tr> - <tr> - <td class='blt c024'>Males</td> - <td class='brt c019'>53</td> - <td class='c024'>Males</td> - <td class='brt c019'>56</td> - <td class='c024'>Males</td> - <td class='brt c019'>48</td> - <td class='c024'>Males</td> - <td class='brt c019'>33</td> - </tr> - <tr> - <td class='blt c024'>Females,</td> - <td class='brt c019'>51</td> - <td class='c024'>Females,</td> - <td class='brt c019'>54</td> - <td class='c024'>Females,</td> - <td class='brt c019'>38</td> - <td class='c024'>Females,</td> - <td class='brt c019'>48</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='brt c019'><hr /></td> - <td class='c024'> </td> - <td class='brt c019'><hr /></td> - <td class='c024'> </td> - <td class='brt c019'><hr /></td> - <td class='c024'> </td> - <td class='brt c019'><hr /></td> - </tr> - <tr> - <td class='bbt blt c018'>Total,</td> - <td class='bbt brt c019'>104</td> - <td class='bbt c018'>Total,</td> - <td class='bbt brt c019'>110</td> - <td class='bbt c018'>Total,</td> - <td class='bbt brt c019'>86</td> - <td class='bbt c018'>Total,</td> - <td class='bbt brt c019'>81</td> - </tr> -</table> - -<h3 class='c013'>Locality of Patient, with reference to Susceptibility.</h3> - -<table class='table2' summary='Locality of Patient'> - <tr> - <th class='c021'></th> - <th class='c023'>Country Unhealthy.</th> - <th class='c023'>Town Unhealthy.</th> - <th class='c025'>Town Healthy.</th> - </tr> - <tr><td> </td></tr> - <tr> - <td class='c021'>Servants</td> - <td class='c026'>12</td> - <td class='c026'>31</td> - <td class='c022'>96</td> - </tr> - <tr> - <td class='c021'>Labourers</td> - <td class='c026'>0</td> - <td class='c026'>88</td> - <td class='c022'>48</td> - </tr> - <tr> - <td class='c021'>Destitute</td> - <td class='c026'>0</td> - <td class='c026'>43</td> - <td class='c022'>50</td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_433'>433</span> - <h3 class='c013'>Table of Ages, with reference to Susceptibility.</h3> -</div> - -<table class='table3' summary='Table of Ages'> - <tr> - <th class='btt bbt blt c018' colspan='2'>Age, for 1825.</th> - <th class='btt bbt blt c018' colspan='2'>Age, for 1826.</th> - <th class='btt bbt blt c018' colspan='2'>Age, for 1827.</th> - <th class='btt bbt blt brt c018' colspan='2'>Age, for 1828.</th> - </tr> - <tr> - <td class='blt brt c019'>Under 10</td> - <td class='c019'>42</td> - <td class='blt brt c019'>Under 10</td> - <td class='c019'>27</td> - <td class='blt brt c019'>Under 10</td> - <td class='c019'>25</td> - <td class='blt brt c019'>Under 10</td> - <td class='brt c019'>31</td> - </tr> - <tr> - <td class='blt brt c019'>15</td> - <td class='c019'>67</td> - <td class='blt brt c019'>15</td> - <td class='c019'>87</td> - <td class='blt brt c019'>15</td> - <td class='c019'>70</td> - <td class='blt brt c019'>15</td> - <td class='brt c019'>80</td> - </tr> - <tr> - <td class='blt brt c019'>20</td> - <td class='c019'>172</td> - <td class='blt brt c019'>20</td> - <td class='c019'>170</td> - <td class='blt brt c019'>20</td> - <td class='c019'>163</td> - <td class='blt brt c019'>20</td> - <td class='brt c019'>136</td> - </tr> - <tr> - <td class='blt brt c019'>25</td> - <td class='c019'>133</td> - <td class='blt brt c019'>25</td> - <td class='c019'>143</td> - <td class='blt brt c019'>25</td> - <td class='c019'>164</td> - <td class='blt brt c019'>25</td> - <td class='brt c019'>107</td> - </tr> - <tr> - <td class='blt brt c019'>30</td> - <td class='c019'>81</td> - <td class='blt brt c019'>30</td> - <td class='c019'>102</td> - <td class='blt brt c019'>30</td> - <td class='c019'>107</td> - <td class='blt brt c019'>30</td> - <td class='brt c019'>84</td> - </tr> - <tr> - <td class='blt brt c019'>35</td> - <td class='c019'>29</td> - <td class='blt brt c019'>35</td> - <td class='c019'>46</td> - <td class='blt brt c019'>35</td> - <td class='c019'>35</td> - <td class='blt brt c019'>35</td> - <td class='brt c019'>47</td> - </tr> - <tr> - <td class='blt brt c019'>40</td> - <td class='c019'>28</td> - <td class='blt brt c019'>40</td> - <td class='c019'>37</td> - <td class='blt brt c019'>40</td> - <td class='c019'>50</td> - <td class='blt brt c019'>40</td> - <td class='brt c019'>45</td> - </tr> - <tr> - <td class='blt brt c019'>45</td> - <td class='c019'>10</td> - <td class='blt brt c019'>45</td> - <td class='c019'>28</td> - <td class='blt brt c019'>45</td> - <td class='c019'>20</td> - <td class='blt brt c019'>45</td> - <td class='brt c019'>21</td> - </tr> - <tr> - <td class='blt brt c019'>50</td> - <td class='c019'>10</td> - <td class='blt brt c019'>50</td> - <td class='c019'>13</td> - <td class='blt brt c019'>50</td> - <td class='c019'>13</td> - <td class='blt brt c019'>50</td> - <td class='brt c019'>17</td> - </tr> - <tr> - <td class='blt brt c019'>55</td> - <td class='c019'>10</td> - <td class='blt brt c019'>55</td> - <td class='c019'>7</td> - <td class='blt brt c019'>55</td> - <td class='c019'>8</td> - <td class='blt brt c019'>55</td> - <td class='brt c019'>6</td> - </tr> - <tr> - <td class='blt brt c019'>60</td> - <td class='c019'>1</td> - <td class='blt brt c019'>60</td> - <td class='c019'>5</td> - <td class='blt brt c019'>60</td> - <td class='c019'>13</td> - <td class='blt brt c019'>60</td> - <td class='brt c019'>14</td> - </tr> - <tr> - <td class='blt brt c019'>65</td> - <td class='c019'>1</td> - <td class='blt brt c019'>65</td> - <td class='c019'>3</td> - <td class='blt brt c019'>65</td> - <td class='c019'>2</td> - <td class='blt brt c019'>65</td> - <td class='brt c019'>6</td> - </tr> - <tr> - <td class='blt brt c019'>70</td> - <td class='c019'>2</td> - <td class='blt brt c019'>70</td> - <td class='c019'>3</td> - <td class='blt brt c019'>70</td> - <td class='c019'>4</td> - <td class='blt brt c019'>70</td> - <td class='brt c019'>1</td> - </tr> - <tr> - <td class='blt brt c019'>75</td> - <td class='c019'>1</td> - <td class='blt brt c019'>75</td> - <td class='c019'>4</td> - <td class='blt brt c019'>75</td> - <td class='c019'>2</td> - <td class='blt brt c019'>75</td> - <td class='brt c019'>2</td> - </tr> - <tr> - <td class='blt brt c019'>80</td> - <td class='c019'>1</td> - <td class='blt brt c019'>80</td> - <td class='c019'>1</td> - <td class='blt brt c019'>80</td> - <td class='c019'>0</td> - <td class='blt brt c019'>80</td> - <td class='brt c019'>0</td> - </tr> - <tr> - <td class='blt brt c019'>85</td> - <td class='c019'>0</td> - <td class='blt brt c019'>85</td> - <td class='c019'>0</td> - <td class='blt brt c019'>85</td> - <td class='c019'>0</td> - <td class='blt brt c019'>85</td> - <td class='brt c019'>0</td> - </tr> - <tr> - <td class='blt brt c019'> </td> - <td class='c019'><hr /></td> - <td class='blt brt c019'> </td> - <td class='c019'><hr /></td> - <td class='blt brt c019'> </td> - <td class='c019'><hr /></td> - <td class='blt brt c019'> </td> - <td class='brt c019'><hr /></td> - </tr> - <tr> - <td class='bbtd blt brt c018'>Total</td> - <td class='bbtd c019'>588</td> - <td class='bbtd blt brt c018'>Total</td> - <td class='bbtd c019'>676</td> - <td class='bbtd blt brt c018'>Total</td> - <td class='bbtd c019'>676</td> - <td class='bbtd blt brt c018'>Total</td> - <td class='bbtd brt c019'>597</td> - </tr> -</table> - -<h3 class='c013'>Table of Ages, with reference to Mortality.</h3> - -<table class='table3' summary='Table of Ages'> - <tr> - <th class='btt bbt blt c018' colspan='2'>Age, for 1825.</th> - <th class='btt bbt blt c018' colspan='2'>Age, for 1826.</th> - <th class='btt bbt blt c018' colspan='2'>Age, for 1827.</th> - <th class='btt bbt blt brt c018' colspan='2'>Age, for 1828.</th> - </tr> - <tr> - <td class='blt brt c019'>Under 10</td> - <td class='c019'>3</td> - <td class='blt brt c019'>Under 10</td> - <td class='c019'>1</td> - <td class='blt brt c019'>Under 10</td> - <td class='c019'>5</td> - <td class='blt brt c019'>Under 10</td> - <td class='brt c019'>4</td> - </tr> - <tr> - <td class='blt brt c019'>15</td> - <td class='c019'>5</td> - <td class='blt brt c019'>15</td> - <td class='c019'>10</td> - <td class='blt brt c019'>15</td> - <td class='c019'>5</td> - <td class='blt brt c019'>15</td> - <td class='brt c019'>5</td> - </tr> - <tr> - <td class='blt brt c019'>20</td> - <td class='c019'>29</td> - <td class='blt brt c019'>20</td> - <td class='c019'>35</td> - <td class='blt brt c019'>20</td> - <td class='c019'>16</td> - <td class='blt brt c019'>20</td> - <td class='brt c019'>12</td> - </tr> - <tr> - <td class='blt brt c019'>25</td> - <td class='c019'>25</td> - <td class='blt brt c019'>25</td> - <td class='c019'>14</td> - <td class='blt brt c019'>25</td> - <td class='c019'>17</td> - <td class='blt brt c019'>25</td> - <td class='brt c019'>11</td> - </tr> - <tr> - <td class='blt brt c019'>30</td> - <td class='c019'>17</td> - <td class='blt brt c019'>30</td> - <td class='c019'>20</td> - <td class='blt brt c019'>30</td> - <td class='c019'>18</td> - <td class='blt brt c019'>30</td> - <td class='brt c019'>12</td> - </tr> - <tr> - <td class='blt brt c019'>35</td> - <td class='c019'>2</td> - <td class='blt brt c019'>35</td> - <td class='c019'>3</td> - <td class='blt brt c019'>35</td> - <td class='c019'>1</td> - <td class='blt brt c019'>35</td> - <td class='brt c019'>4</td> - </tr> - <tr> - <td class='blt brt c019'>40</td> - <td class='c019'>7</td> - <td class='blt brt c019'>40</td> - <td class='c019'>7</td> - <td class='blt brt c019'>40</td> - <td class='c019'>10</td> - <td class='blt brt c019'>40</td> - <td class='brt c019'>7</td> - </tr> - <tr> - <td class='blt brt c019'>45</td> - <td class='c019'>6</td> - <td class='blt brt c019'>45</td> - <td class='c019'>4</td> - <td class='blt brt c019'>45</td> - <td class='c019'>5</td> - <td class='blt brt c019'>45</td> - <td class='brt c019'>5</td> - </tr> - <tr> - <td class='blt brt c019'>50</td> - <td class='c019'>4</td> - <td class='blt brt c019'>50</td> - <td class='c019'>5</td> - <td class='blt brt c019'>50</td> - <td class='c019'>4</td> - <td class='blt brt c019'>50</td> - <td class='brt c019'>7</td> - </tr> - <tr> - <td class='blt brt c019'>55</td> - <td class='c019'>3</td> - <td class='blt brt c019'>55</td> - <td class='c019'>1</td> - <td class='blt brt c019'>55</td> - <td class='c019'>2</td> - <td class='blt brt c019'>55</td> - <td class='brt c019'>1</td> - </tr> - <tr> - <td class='blt brt c019'>60</td> - <td class='c019'>0</td> - <td class='blt brt c019'>60</td> - <td class='c019'>3</td> - <td class='blt brt c019'>60</td> - <td class='c019'>1</td> - <td class='blt brt c019'>60</td> - <td class='brt c019'>4</td> - </tr> - <tr> - <td class='blt brt c019'>65</td> - <td class='c019'>0</td> - <td class='blt brt c019'>65</td> - <td class='c019'>2</td> - <td class='blt brt c019'>65</td> - <td class='c019'>0</td> - <td class='blt brt c019'>65</td> - <td class='brt c019'>3</td> - </tr> - <tr> - <td class='blt brt c019'>70</td> - <td class='c019'>2</td> - <td class='blt brt c019'>70</td> - <td class='c019'>1</td> - <td class='blt brt c019'>70</td> - <td class='c019'>0</td> - <td class='blt brt c019'>70</td> - <td class='brt c019'>0</td> - </tr> - <tr> - <td class='blt brt c019'>75</td> - <td class='c019'>1</td> - <td class='blt brt c019'>75</td> - <td class='c019'>2</td> - <td class='blt brt c019'>75</td> - <td class='c019'>2</td> - <td class='blt brt c019'>75</td> - <td class='brt c019'>1</td> - </tr> - <tr> - <td class='blt brt c019'>80</td> - <td class='c019'>0</td> - <td class='blt brt c019'>80</td> - <td class='c019'>2</td> - <td class='blt brt c019'>80</td> - <td class='c019'>0</td> - <td class='blt brt c019'>80</td> - <td class='brt c019'>0</td> - </tr> - <tr> - <td class='blt brt c019'>85</td> - <td class='c019'>0</td> - <td class='blt brt c019'>85</td> - <td class='c019'>0</td> - <td class='blt brt c019'>85</td> - <td class='c019'>0</td> - <td class='blt brt c019'>85</td> - <td class='brt c019'>0</td> - </tr> - <tr> - <td class='blt brt c019'> </td> - <td class='c019'><hr /></td> - <td class='blt brt c019'> </td> - <td class='c019'><hr /></td> - <td class='blt brt c019'> </td> - <td class='c019'><hr /></td> - <td class='blt brt c019'> </td> - <td class='brt c019'><hr /></td> - </tr> - <tr> - <td class='bbtd blt brt c018'>Total</td> - <td class='bbtd c019'>104</td> - <td class='bbtd blt brt c018'>Total</td> - <td class='bbtd c019'>110</td> - <td class='bbtd blt brt c018'>Total</td> - <td class='bbtd c019'>86</td> - <td class='bbtd blt brt c018'>Total</td> - <td class='bbtd brt c019'>76</td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_434'>434</span> - <h3 class='c013'><em>Relation between Date of Attack, Admission and Cure, in 600 Cases.</em></h3> -</div> - -<table class='table3' summary='Relation between Date of Attack, Admission and Cure'> - <tr> - <th class='btt bbt blt c018' colspan='2'>Admitted on.</th> - <th class='btt bbt blt c018' colspan='2'>Dismissed on</th> - <th class='btt bbt blt brt c018' colspan='2'>Duration of Disease.</th> - </tr> - <tr> - <td class='blt c024'>1st Day of Fever</td> - <td class='blt c019'>2</td> - <td class='blt c024'>11th Day</td> - <td class='blt c019'>11</td> - <td class='blt c024'>11 Days</td> - <td class='blt brt c019'>11</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>12</td> - <td class='blt c019'>2</td> - <td class='blt c024'>12</td> - <td class='blt brt c019'>2</td> - </tr> - <tr> - <td class='blt c024'>2</td> - <td class='blt c019'>6</td> - <td class='blt c024'>13</td> - <td class='blt c019'>6</td> - <td class='blt c024'>13</td> - <td class='blt brt c019'>6</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>14</td> - <td class='blt c019'>8</td> - <td class='blt c024'>14</td> - <td class='blt brt c019'>8</td> - </tr> - <tr> - <td class='blt c024'>3</td> - <td class='blt c019'>29</td> - <td class='blt c024'>15</td> - <td class='blt c019'>4</td> - <td class='blt c024'>15</td> - <td class='blt brt c019'>4</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>16</td> - <td class='blt c019'>9</td> - <td class='blt c024'>16</td> - <td class='blt brt c019'>9</td> - </tr> - <tr> - <td class='blt c024'>4</td> - <td class='blt c019'>47</td> - <td class='blt c024'>17</td> - <td class='blt c019'>7</td> - <td class='blt c024'>17</td> - <td class='blt brt c019'>7</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>18</td> - <td class='blt c019'>15</td> - <td class='blt c024'>18</td> - <td class='blt brt c019'>15</td> - </tr> - <tr> - <td class='blt c024'>5</td> - <td class='blt c019'>54</td> - <td class='blt c024'>19</td> - <td class='blt c019'>14</td> - <td class='blt c024'>19</td> - <td class='blt brt c019'>14</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>20</td> - <td class='blt c019'>15</td> - <td class='blt c024'>20</td> - <td class='blt brt c019'>15</td> - </tr> - <tr> - <td class='blt c024'>6</td> - <td class='blt c019'>43</td> - <td class='blt c024'>21</td> - <td class='blt c019'>18</td> - <td class='blt c024'>21</td> - <td class='blt brt c019'>18</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>22</td> - <td class='blt c019'>11</td> - <td class='blt c024'>22</td> - <td class='blt brt c019'>11</td> - </tr> - <tr> - <td class='blt c024'>7</td> - <td class='blt c019'>138</td> - <td class='blt c024'>23</td> - <td class='blt c019'>19</td> - <td class='blt c024'>23</td> - <td class='blt brt c019'>19</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>24</td> - <td class='blt c019'>27</td> - <td class='blt c024'>24</td> - <td class='blt brt c019'>27</td> - </tr> - <tr> - <td class='blt c024'>8</td> - <td class='blt c019'>35</td> - <td class='blt c024'>25</td> - <td class='blt c019'>15</td> - <td class='blt c024'>25</td> - <td class='blt brt c019'>15</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>26</td> - <td class='blt c019'>17</td> - <td class='blt c024'>26</td> - <td class='blt brt c019'>17</td> - </tr> - <tr> - <td class='blt c024'>9</td> - <td class='blt c019'>25</td> - <td class='blt c024'>27</td> - <td class='blt c019'>24</td> - <td class='blt c024'>27</td> - <td class='blt brt c019'>24</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>28</td> - <td class='blt c019'>22</td> - <td class='blt c024'>28</td> - <td class='blt brt c019'>22</td> - </tr> - <tr> - <td class='blt c024'>10</td> - <td class='blt c019'>20</td> - <td class='blt c024'>29</td> - <td class='blt c019'>25</td> - <td class='blt c024'>29</td> - <td class='blt brt c019'>25</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>30</td> - <td class='blt c019'>13</td> - <td class='blt c024'>30</td> - <td class='blt brt c019'>13</td> - </tr> - <tr> - <td class='blt c024'>11</td> - <td class='blt c019'>4</td> - <td class='blt c024'>31</td> - <td class='blt c019'>13</td> - <td class='blt c024'>31</td> - <td class='blt brt c019'>13</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>32</td> - <td class='blt c019'>15</td> - <td class='blt c024'>32</td> - <td class='blt brt c019'>15</td> - </tr> - <tr> - <td class='blt c024'>12</td> - <td class='blt c019'>7</td> - <td class='blt c024'>33</td> - <td class='blt c019'>12</td> - <td class='blt c024'>33</td> - <td class='blt brt c019'>19</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>34</td> - <td class='blt c019'>12</td> - <td class='blt c024'>34</td> - <td class='blt brt c019'>12</td> - </tr> - <tr> - <td class='blt c024'>13</td> - <td class='blt c019'>4</td> - <td class='blt c024'>35</td> - <td class='blt c019'>16</td> - <td class='blt c024'>35</td> - <td class='blt brt c019'>16</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>36</td> - <td class='blt c019'>13</td> - <td class='blt c024'>36</td> - <td class='blt brt c019'>13</td> - </tr> - <tr> - <td class='blt c024'>14</td> - <td class='blt c019'>71</td> - <td class='blt c024'>37</td> - <td class='blt c019'>24</td> - <td class='blt c024'>37</td> - <td class='blt brt c019'>24</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>38</td> - <td class='blt c019'>14</td> - <td class='blt c024'>38</td> - <td class='blt brt c019'>14</td> - </tr> - <tr> - <td class='blt c024'>15</td> - <td class='blt c019'>11</td> - <td class='blt c024'>39</td> - <td class='blt c019'>12</td> - <td class='blt c024'>39</td> - <td class='blt brt c019'>12</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>40</td> - <td class='blt c019'>10</td> - <td class='blt c024'>40</td> - <td class='blt brt c019'>10</td> - </tr> - <tr> - <td class='blt c024'>17</td> - <td class='blt c019'>3</td> - <td class='blt c024'>41</td> - <td class='blt c019'>8</td> - <td class='blt c024'>41</td> - <td class='blt brt c019'>8</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>42</td> - <td class='blt c019'>7</td> - <td class='blt c024'>42</td> - <td class='blt brt c019'>7</td> - </tr> - <tr> - <td class='blt c024'>18</td> - <td class='blt c019'>2</td> - <td class='blt c024'>43</td> - <td class='blt c019'>7</td> - <td class='blt c024'>43</td> - <td class='blt brt c019'>7</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>44</td> - <td class='blt c019'>15</td> - <td class='blt c024'>44</td> - <td class='blt brt c019'>15</td> - </tr> - <tr> - <td class='blt c024'>19</td> - <td class='blt c019'>1</td> - <td class='blt c024'>45</td> - <td class='blt c019'>7</td> - <td class='blt c024'>45</td> - <td class='blt brt c019'>7</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>46</td> - <td class='blt c019'>6</td> - <td class='blt c024'>46</td> - <td class='blt brt c019'>6</td> - </tr> - <tr> - <td class='blt c024'>21</td> - <td class='blt c019'>43</td> - <td class='blt c024'>47</td> - <td class='blt c019'>7</td> - <td class='blt c024'>47</td> - <td class='blt brt c019'>7</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>48</td> - <td class='blt c019'>3</td> - <td class='blt c024'>48</td> - <td class='blt brt c019'>3</td> - </tr> - <tr> - <td class='blt c024'>28</td> - <td class='blt c019'>8</td> - <td class='blt c024'>49</td> - <td class='blt c019'>8</td> - <td class='blt c024'>49</td> - <td class='blt brt c019'>8</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>50</td> - <td class='blt c019'>6</td> - <td class='blt c024'>50</td> - <td class='blt brt c019'>6</td> - </tr> - <tr> - <td class='blt c024'>30</td> - <td class='blt c019'>2</td> - <td class='blt c024'>51</td> - <td class='blt c019'>7</td> - <td class='blt c024'>51</td> - <td class='blt brt c019'>7</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>52</td> - <td class='blt c019'>4</td> - <td class='blt c024'>52</td> - <td class='blt brt c019'>4</td> - </tr> - <tr> - <td class='blt c024'>42</td> - <td class='blt c019'>2</td> - <td class='blt c024'>53</td> - <td class='blt c019'>2</td> - <td class='blt c024'>53</td> - <td class='blt brt c019'>2</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>54</td> - <td class='blt c019'>5</td> - <td class='blt c024'>54</td> - <td class='blt brt c019'>5</td> - </tr> - <tr> - <td class='blt c024'>56</td> - <td class='blt c019'>1</td> - <td class='blt c024'>55</td> - <td class='blt c019'>1</td> - <td class='blt c024'>55</td> - <td class='blt brt c019'>1</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>56</td> - <td class='blt c019'>1</td> - <td class='blt c024'>56</td> - <td class='blt brt c019'>1</td> - </tr> - <tr> - <td class='blt c024'>60</td> - <td class='blt c019'>1</td> - <td class='blt c024'>57</td> - <td class='blt c019'>4</td> - <td class='blt c024'>57</td> - <td class='blt brt c019'>4</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>58</td> - <td class='blt c019'>3</td> - <td class='blt c024'>58</td> - <td class='blt brt c019'>3</td> - </tr> - <tr> - <td class='blt c024'>Unknown</td> - <td class='blt c019'>21</td> - <td class='blt c024'>59</td> - <td class='blt c019'>2</td> - <td class='blt c024'>59</td> - <td class='blt brt c019'>2</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>60</td> - <td class='blt c019'>5</td> - <td class='blt c024'>60</td> - <td class='blt brt c019'>5</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>62</td> - <td class='blt c019'>1</td> - <td class='blt c024'>62</td> - <td class='blt brt c019'>1</td> - </tr> - <tr> - <td class='blt c024'> </td> - <td class='blt c019'> </td> - <td class='blt c024'>Beyond 62</td> - <td class='blt c019'>24</td> - <td class='blt c024'>Beyond 62</td> - <td class='blt brt c019'>24</td> - </tr> - <tr> - <td class='bbt blt c024'> </td> - <td class='bbt blt c019'> </td> - <td class='bbt blt c024'>Unknown</td> - <td class='bbt blt c019'>16</td> - <td class='bbt blt c024'>Unknown</td> - <td class='bbt blt brt c019'>16</td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_435'>435</span> - <h3 class='c013'>Relation between date of Attack, Admission, and Death, for one year, comprehending 84 Cases.</h3> -</div> -<table class='table0' summary=''> - <tr><th class='c010' colspan='2'>Admitted on</th></tr> - <tr><td> </td></tr> - <tr> - <td class='c021'>3d day of fever</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>4</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>5</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>6</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>7</td> - <td class='c022'>11</td> - </tr> - <tr> - <td class='c021'>8</td> - <td class='c022'>6</td> - </tr> - <tr> - <td class='c021'>9</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>10</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>11</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>13</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>14</td> - <td class='c022'>13</td> - </tr> - <tr> - <td class='c021'>17</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>21</td> - <td class='c022'>16</td> - </tr> - <tr> - <td class='c021'>28</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>30</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>42</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Unknown</td> - <td class='c022'>4</td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><th class='c010' colspan='2'>Died on</th></tr> - <tr><td> </td></tr> - <tr> - <td class='c021'>7th day of fever</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>8</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>9</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>10</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>11</td> - <td class='c022'>7</td> - </tr> - <tr> - <td class='c021'>12</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>13</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>14</td> - <td class='c022'>6</td> - </tr> - <tr> - <td class='c021'>15</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>16</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>17</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>18</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>19</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>20</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>21</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>22</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>23</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>24</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>25</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>26</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>27</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>28</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>29</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>30</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>31</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>32</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>33</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>35</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>36</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>37</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>40</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>41</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>42</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>60</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>Unknown</td> - <td class='c022'>4</td> - </tr> - <tr><td> </td></tr> - <tr><td> </td></tr> - <tr><th class='c010' colspan='2'>Died on</th></tr> - <tr><td> </td></tr> - <tr> - <td class='c021'>1st day after admission</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>2</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>3</td> - <td class='c022'>11</td> - </tr> - <tr> - <td class='c021'>4</td> - <td class='c022'>8</td> - </tr> - <tr> - <td class='c021'>5</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>6</td> - <td class='c022'>8</td> - </tr> - <tr> - <td class='c021'>7</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>8</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>9</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>10</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>11</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>12</td> - <td class='c022'>4</td> - </tr> - <tr> - <td class='c021'>13</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>14</td> - <td class='c022'>7</td> - </tr> - <tr> - <td class='c021'>15</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>16</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>18</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>19</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>20</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>28</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>30</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>34</td> - <td class='c022'>2</td> - </tr> - <tr> - <td class='c021'>44</td> - <td class='c022'>1</td> - </tr> -</table> - -<div> - <span class='pageno' id='Page_436'>436</span> - <h3 class='c013'>Proportions of Type out of 300 Cases.</h3> -</div> - -<table class='table2' summary=''> - <tr> - <td class='c021'>Synochus</td> - <td class='c022'>235</td> - </tr> - <tr> - <td class='c021'>Typhus Mitior</td> - <td class='c022'>21</td> - </tr> - <tr> - <td class='c021'>Typhus Gravior</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Scarlatina</td> - <td class='c022'>40</td> - </tr> - <tr> - <td class='c021'>Intermittent</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Remittent</td> - <td class='c022'>2</td> - </tr> -</table> - -<h3 class='c013'>Proportions of Internal Characteristic Affection out of 300 Cases.</h3> - -<table class='table2' summary=''> - <tr> - <td class='c021'>Cerebral</td> - <td class='c022'>66</td> - </tr> - <tr> - <td class='c021'>Thoracic</td> - <td class='c022'>79</td> - </tr> - <tr> - <td class='c021'>Abdominal</td> - <td class='c022'>60</td> - </tr> - <tr> - <td class='c021'>Mixed</td> - <td class='c022'>95</td> - </tr> -</table> - -<h3 class='c013'>Proportions of External Accidental Affection out of 300 Cases.</h3> - -<table class='table2' summary=''> - <tr> - <td class='c021'>Erysipelatous</td> - <td class='c022'>11</td> - </tr> - <tr> - <td class='c021'>Glandular</td> - <td class='c022'>6</td> - </tr> - <tr> - <td class='c021'>Cynancheal</td> - <td class='c022'>5</td> - </tr> - <tr> - <td class='c021'>Herpetic</td> - <td class='c022'>3</td> - </tr> - <tr> - <td class='c021'>Laryngeal</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='c021'>Phlegmatial</td> - <td class='c022'>1</td> - </tr> - <tr> - <td class='bbt c021'>Rheumatic</td> - <td class='bbt c022'>1</td> - </tr> - <tr> - <td class='c021'>Miscarriage</td> - <td class='c022'>7</td> - </tr> - <tr> - <td class='c021'>Preternatural Cutaneous Sensibility</td> - <td class='c022'>4</td> - </tr> -</table> - -<hr class='c027' /> - -<div class='nf-center-c0'> - <div class='nf-center'> - <div><span class='small'>PRINTED BY G. HAYDEN, LITTLE COLLEGE STREET, WESTMINSTER.</span></div> - </div> -</div> - -<hr class='c028' /> -<div class='footnote' id='f1'> -<p class='c007'><a href='#r1'>1</a>. Observations on the Treatment of Epidemic Fever, &c. By -Henry Clutterbuck, M.D., p. 3–9.</p> -</div> -<div class='footnote' id='f2'> -<p class='c007'><a href='#r2'>2</a>. Sydenham’s Works, p. 1, 2, &c.</p> -</div> -<div class='footnote' id='f3'> -<p class='c007'><a href='#r3'>3</a>. Cullen, First Lines, S. 46.</p> -</div> -<div class='footnote' id='f4'> -<p class='c007'><a href='#r4'>4</a>. Pathological Observations, Part II. on Continued Fever, &c. -By W. Stoker, M.D. p. 32.</p> -</div> -<div class='footnote' id='f5'> -<p class='c007'><a href='#r5'>5</a>. Ibid. p. 34.</p> -</div> -<div class='footnote' id='f6'> -<p class='c007'><a href='#r6'>6</a>. Pathological Observations, &c. pp. 73, 74.</p> -</div> -<div class='footnote' id='f7'> -<p class='c007'><a href='#r7'>7</a>. A Practical Treatise on the Typhus or Adynamic Fever, by -John Burne, M.D.</p> -</div> -<div class='footnote' id='f8'> -<p class='c007'><a href='#r8'>8</a>. Pathological Observations on Continued Fever, &c. p. 110.</p> -</div> -<div class='footnote' id='f9'> -<p class='c007'><a href='#r9'>9</a>. Practical Treatise, &c. p. 161.</p> -</div> -<div class='footnote' id='f10'> -<p class='c007'><a href='#r10'>10</a>. A Lecture upon Typhus Fever, by W. R. Clanny, M.D. p. 12.</p> -</div> -<div class='footnote' id='f11'> -<p class='c007'><a href='#r11'>11</a>. Ibid., p. 16.</p> -</div> -<div class='footnote' id='f12'> -<p class='c007'><a href='#r12'>12</a>. Observations on the Prevention and Treatment of the Epidemic -Fever, by Henry Clutterbuck, M.D. p. 5, 6.</p> -</div> -<div class='footnote' id='f13'> -<p class='c007'><a href='#r13'>13</a>. See a paper in the Medico-Chirurgical Review, for 1828, -entitled An Eclectic Review on Fever.</p> -</div> -<div class='footnote' id='f14'> -<p class='c007'><a href='#r14'>14</a>. Broussais’ exposition of his own doctrine in his own words -is as follows. <span lang="fr" xml:lang="fr">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.</span></p> - -<p class='c007'><span lang="fr" xml:lang="fr">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.</span></p> - -<p class='c007'><span lang="fr" xml:lang="fr">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.)</span></p> - -<p class='c007'><span lang="fr" xml:lang="fr">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.—<cite>Examen. de la -Doctrine Medicale, par F. J. V. Broussais, p. 112–114.</cite></span></p> - -<p class='c007'><span lang="fr" xml:lang="fr">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.—<cite>Histoire des Phlegmasies, par F. -J. V. Broussais, Vol. III. p. 39.</cite></span></p> -</div> -<div class='footnote' id='f15'> -<p class='c007'><a href='#r15'>15</a>. Observations on the Prevention and Treatment of Epidemic -Fever, &c. pp. 11–12.</p> -</div> -<div class='footnote' id='f16'> -<p class='c007'><a href='#r16'>16</a>. 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.”—<cite>Pathological Observations &c., p. 111.</cite> 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, <span class='fss'>AND -WHICH COULD NOT BE ATTRIBUTED TO ANY OTHER CAUSE THAN DEBILITY</span>.—<cite>Lecture -on Fever, pp. 21–2–3.</cite></p> -</div> -<div class='footnote' id='f17'> -<p class='c007'><a href='#r17'>17</a>. 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.</p> -</div> -<div class='footnote' id='f18'> -<p class='c007'><a href='#r18'>18</a>. A Treatise on Fevers, &c. By A. P. Wilson Philip, M.D. -p. 10.</p> -</div> -<div class='footnote' id='f19'> -<p class='c007'><a href='#r19'>19</a>. Treatise on Fever, &c. By A. P. Wilson Philip, M.D. p. 12.</p> -</div> -<div class='footnote' id='f20'> -<p class='c007'><a href='#r20'>20</a>. Sydenham’s Works, Chap. 3, p. 11.</p> -</div> -<div class='footnote' id='f21'> -<p class='c007'><a href='#r21'>21</a>. Sir John Pringle on the Diseases of the Army, p. 66, &c.</p> -</div> -<div class='footnote' id='f22'> -<p class='c007'><a href='#r22'>22</a>. 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—</p> - -<div class='lg-container-l c029'> - <div class='linegroup'> - <div class='group'> - <div class='line'>1. Continued fever without an eruption;</div> - </div> - <div class='group'> - <div class='line in1'>Synochus mitior, Typhus mitior,</div> - <div class='line in1'>—— gravior, —— gravior:</div> - </div> - <div class='group'> - <div class='line'>2. Continued fever with an eruption;</div> - </div> - <div class='group'> - <div class='line in1'>Scarlatina, Variola,</div> - <div class='line in1'>Synochodes, Synochodes,</div> - <div class='line in1'>Typhodes, Typhodes:</div> - </div> - </div> -</div> - -<p class='c030'>and so on of all the Exanthemata.</p> - -<p class='c007'>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 <em>the disease as a subject of medical -treatment</em>, 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.</p> -</div> -<div class='footnote' id='f23'> -<p class='c007'><a href='#r23'>23</a>. Observations on the Prevention and Treatment of Epidemic -Fever, by Henry Clutterbuck, M.D. p. 15.</p> -</div> -<div class='footnote' id='f24'> -<p class='c007'><a href='#r24'>24</a>. See pathology—chest cases. John Potter.</p> -</div> -<div class='footnote' id='f25'> -<p class='c007'><a href='#r25'>25</a>. See page <a href='#Page_107'>107</a>.</p> -</div> -<div class='footnote' id='f26'> -<p class='c007'><a href='#r26'>26</a>. See page <a href='#Page_163'>163</a>, 1.</p> -</div> -<div class='footnote' id='f27'> -<p class='c007'><a href='#r27'>27</a>. See page <a href='#Page_163'>163</a>, 2.</p> -</div> -<div class='footnote' id='f28'> -<p class='c007'><a href='#r28'>28</a>. Those morbid appearances which, not being constant in fever, -must be considered as accidental, are placed in brackets throughout -this chapter.</p> -</div> -<div class='footnote' id='f29'> -<p class='c007'><a href='#r29'>29</a>. See Case L.</p> -</div> -<div class='footnote' id='f30'> -<p class='c007'><a href='#r30'>30</a>. See page <a href='#Page_51'>51</a>. et seq.</p> -</div> -<div class='footnote' id='f31'> -<p class='c007'><a href='#r31'>31</a>. Observations on the Diseases of the Army, by Sir John -Pringle, Bart., p. 11. et seq.</p> -</div> -<div class='footnote' id='f32'> -<p class='c007'><a href='#r32'>32</a>. Observations on the Diseases of the Army, by Sir John -Pringle, Bart., p. 36.</p> -</div> -<div class='footnote' id='f33'> -<p class='c007'><a href='#r33'>33</a>. See a Memoir on Contagion, more especially as it respects -the Yellow Fever, &c., by N. Potter, M.D., Baltimore.</p> -</div> -<div class='footnote' id='f34'> -<p class='c007'><a href='#r34'>34</a>. In pursuing these researches, I hope to have the advantage of -the co-operation of my friend Dr. Dill.</p> -</div> -<div class='footnote' id='f35'> -<p class='c007'><a href='#r35'>35</a>. 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.</p> -</div> -<div class='footnote' id='f36'> -<p class='c007'><a href='#r36'>36</a>. 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.</p> -</div> - -<div class='pbb'> - <hr class='pb c003' /> -</div> -<div class='tnotes'> - -<div class='chapter'> - <h2 class='c005'>TRANSCRIBER’S NOTES</h2> -</div> - <ol class='ol_1 c002'> - <li>Silently corrected typographical errors and variations in spelling. - - </li> - <li>Retained anachronistic, non-standard, and uncertain spellings as printed. - </li> - </ol> - -</div> - - - - - - - - -<pre> - - - - - -End of Project Gutenberg's A Treatise on Fever, by Thomas Southwood-Smith - -*** END OF THIS PROJECT GUTENBERG EBOOK A TREATISE ON FEVER *** - -***** This file should be named 60419-h.htm or 60419-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/0/4/1/60419/ - -Produced by Richard Tonsing, Chris Curnow, and the Online -Distributed Proofreading Team at http://www.pgdp.net - - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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