Chapter VI: Of the Pathology of Fever (2)

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

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

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

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

5. _Vascularity, &c. with Softening of the Brain._

CASE XLVII.

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

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

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

28th. Much prostration; no other change.

30th. Increasing prostration; pulse 120, feeble.

32d. Died.

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

CASE XLVIII.

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

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

18th. Without any material change, died.

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

CASE XLIX.

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

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

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

9th. Slight, but very transient amendment.

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

12th. Died.

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

CASE L.

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

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

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

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

CASE LI.

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

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

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

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

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

10th. Inflammation of parotid gland.

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

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

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

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

_Head._ Much serum both in ventricles and at base. _Thorax._ Viscera healthy. _Abdomen._ Mucous membrane of the ilium ulcerated and extremely dark.

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

CASE XII.

JAMES SOLDEN, æt. 44, plasterer. For symptoms see page 155.

_Head._ Membranes of brain vascular; substance highly vascular; some effusion beneath the arachnoid. _Thorax._ Viscera healthy. _Abdomen._ Mucous membrane of ilium vascular; no ulceration; mesenteric glands enlarged.

CASE XIII.

JOHN CLARK, æt. 17. For symptoms see page 156.

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

From the study of these cases we see that the process of disease is as uniform as that of health, or of any other process of nature; that certain phenomena constantly take place; that they follow a determinate order; that the events seldom or never vary; that their relations to each other never change; that in these cerebral cases of fever a preternatural fulness and apparently increase in the number of the blood-vessels of the brain and spinal cord, or of their membranes is always present; or that if a case do now and then occur in which even _no_ preternatural vascularity can be discovered such an event is exceedingly rare; that this fulness and increase of the blood-vessels is either identical with, or passes into the state of inflammation; that the state of inflammation, after a certain period, produces results which are known to be effects of inflammatory action in other parts of the body; that these products of inflammation consist of a given number; that the whole of that number never concurs in any one case, but that two or more are frequently found in combination; that the laws by which any one of these is formed rather than any other are at present wholly unknown; while instances do occasionally occur, although they are extremely rare, in which the state of mere vascularity alone subsists without the formation of any inflammatory product that can be discovered.

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

Pain in the head, or giddiness, or some other uneasy sensation in this organ, attended with a loss of sleep and with a derangement in all the sensorial faculties,—these are the signs of the presence of the disease in the brain or its membranes. Pain in the back, loins, or limbs, or diminution of the power of voluntary motion—these are the signs which mark the existence of the disease in the spinal cord or its membranes. These symptoms having been present a certain time, and at length succeeded by—diminution of the pain or uneasiness _without a corresponding diminution in the other febrile symptoms_, but with an _increase_ in _some_ of them; for instance, with an increase of the sleeplessness and restlessness: at last, total cessation of all pain or uneasiness, together with a diminution of the sensibility—these are the signs which mark the progress of the disease, and which, in general, denote a transition from the state of mere inflammation to the formation of some inflammatory product. Thus far the change of state is certain and the signs which denote it invariable; to the latter other symptoms are added which occur in the great majority of cases, but not in all; namely, delirium, muscular tremor, involuntary and unconscious stools, acceleration, and in general, increased and increasing weakness of the pulse. Other accessory symptoms still frequently occur and with considerable regularity, but as these are more variable the student is referred to the cases themselves, the study of which can alone teach when they may be expected.

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

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

II. CASES IN ILLUSTRATION OF THE MORBID CHANGES WHICH TAKE PLACE WITHIN
THE CHEST; OR THORACIC CASES.

CASE VII.

ANGELICA FIDGETT.

For symptoms see page 125.

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

CASE VIII.

JOHN POTTER, æt. 21.

For symptoms see page 127.

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

CASE XIV.

ALEXANDER CROMBIE, æt. 19, seaman.

For symptoms see page 159.

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

CASE LII.

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

_Thorax._ Mucous membrane of bronchi inflamed; [pleuræ of right lung covered with coagulable lymph; substance of right lung universally consolidated, and infiltrated with tubercular matter;] left lung gorged. _Abdomen._ [Liver indurated; crisping under the knife; kidneys indurated.] _Head._ Membranes and substance of brain vascular.

CASE LIII.

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

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

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

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

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

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

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

CASE LIV.

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

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

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

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

CASE LV.

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

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

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

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

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

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

CASE LVI.

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

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

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

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

CASE LVII.

ANN WORMINGTON, æt. 24, servant.

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

_Thorax._ Mucous membrane of trachea of dark red colour; epiglottis quite blackened; arytænoid cartilages ulcerated; substance of lungs much gorged. _Abdomen._ Viscera healthy. _Head._ Membranes vascular; substance of brain preternaturally firm.

CASE LVIII.

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

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

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

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

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

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

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

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

25th. Died.

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

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

CASE LIX.

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

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

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

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

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

CASE LX.

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

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

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

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

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

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

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

III. CASES IN ILLUSTRATION OF THE MORBID CHANGES WHICH TAKE PLACE WITHIN
THE ABDOMEN; OR ABDOMINAL CASES.

CASE LXI.

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

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

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

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

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

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

25th. Died.

_Abdomen._ Peritoneal coat of intestines in general vascular; mucous coat of small intestines highly vascular, and indicated approaching ulceration. _Head._ Not examined. _Thorax._ [Pleuræ of both sides adherent throughout; substance of both lungs healthy; slight effusion of serum into pericardium.]

CASE LXII.

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

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

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

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

CASE LXIII.

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

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

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

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

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

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

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

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

CASE LXIV.

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

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

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

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

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

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

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

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

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

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

CASE LXV.

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

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

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

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

CASE LXVI.

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

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

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

4th. Died.

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

CASE LXVII.

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

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

20th. Violent delirium; pulse 92.

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

_Abdomen._ Mucous membrane of ilium vascular, and contained some ulcers; other viscera healthy. _Head._ More fluid than natural between the membranes. _Thorax._ Viscera healthy.

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

CASE LXVIII.

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

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

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

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

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

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

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

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

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

_Abdomen._ Mucous membrane of jejunum, ilium and cæcum highly vascular; that of ilium contained three or four large oval ulcers; other viscera healthy. _Head._ Membranes and substance of brain vascular; more serum than natural in the ventricles. _Thorax._ Viscera healthy.

CASE LXIX.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CASE LXX.

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

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

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

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

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

CASE LXXI.

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

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

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

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

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

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

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

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

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

CASE LXXII.

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

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

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

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

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

CASE LXXIII.

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

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

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

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

CASE LXXIV.

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

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

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

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

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

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

31st. Died.

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

CASE LXXV.

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

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

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

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

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

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

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

CASE X.

SARAH RAVEN, æt. 17. For symptoms see page 140.

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

CASE LXXVI.

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

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

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

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

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

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

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

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

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

CASE LXXVII.

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

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

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

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

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

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

CASE LXXVIII.

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

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

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

12th. Little change; pulse 108.

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

16th. Stools mixed with blood; pulse 117.

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

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

20th. Vomiting; pulse 120, weaker.

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

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

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

CASE LXXIX.

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

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

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

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

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

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

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

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