taking the enemata four and five times a day appeared to nourish him to the extent that he was able to bear the erect posture, which he could not a fortnight previously owing to vertigo. The aguish attacks were also severe, and he took constantly about twenty grains of quinine in the enemata, which had the effect of relieving him, but produced deafness and singing in the ears.

In June the voice began to be affected; the expectoration, which had become white and frothy, was again purulent and offensive. The efforts to swallow were attended with much exhaustion, and the struggles to get fluid down were very great. The loss of voice at the end of June was unchanged; the "stinging, burning pain" greater, and debility increasing; the expectoration very copious. Notwithstanding his condition, about the middle of the month he ate a fair dinner of lamb and asparagus for three or four days consecutively, swallowing it all. Then came a cold wind and increased dysphagia.

In July, early in the month, he applied himself a four-grain solution of nitrate of silver to the pharynx five times. This increased the "stinging, burning pain" greatly for two hours after each application, but no beneficial result of any kind was obtained. Chills and profuse sweats attacked him every evening, and the aphonia continued. During July he gradually became weaker, and the quantity of fluid taken by the mouth was about a pint to a pint and a half of milk daily. It may be mentioned that nearly all the time he was at Brighton, up to the last few days of his life, he looked fresh and healthy-a circumstance somewhat remarkable.

By his own desire, he went out in the early part of August in an open carriage, but all his symptoms were becoming worse; the breathing short and asthmatic, and the air-passages clogged with mucus. The rectum also became uncertain in its power of retention, and the enemata were sometimes returned. On August 11th, at twenty minutes past eight, he died, maintaining his consciousness to within a few minutes of his death.

His friend Mr. Wildbore wrote of him, but a few days before his death, "It is wonderful to me how he bears up against his disease. He is ever thoughtful of and kind and considerate to all around him, and most grateful for the least kindness or attention shown him; always interested in professional questions, and ever active in mind upon those subjects which have chiefly occupied his attention. He is most patient, and perfectly resigned." All who knew and watched him during the progress of his disease, and witnessed the high courage and true resignation with which he submitted to his sufferings and to the prospect of death, will feel that Mr. Wildbore's estimation and record of him was only what was just to the character of the greatest of English physiologists.

The post-mortem examination of the body was made by Dr. Ransom, of Nottingham, thirty-eight hours after death, in the pre

a very apparent manner, at first excessively thin, but towards the twelfth day it has nearly regained its natural thickness; but the mucous membrane remains a little redder than in the normal condition.

The phenomena which attract our attention the most in scarlatina, are the nervous symptoms. It is proper to say that their intensity in this disease is so special, that they alone, in a great many cases, will suffice to separate it from any other exanthematous. fever. Never, or very seldom at least, is rougeola announced by any severe cerebral symptoms, with the exception of eclampsia; and as in fact it is only in this respect that any possible confusion can be made between rougeola and scarlatina, the intensity of these symptoms alone establishes a capital difference between these two diseases.

They are present from the beginning; from the first day they exhibit themselves by delirium. This is not the case in mild scarlatina, but in its severe form it is seldom absent. When the disease is serious, it is as well marked as in the most severe typhoid fevers; it appears with the eruption, persists until the period of desquamation, or more correctly speaking, until the fever falls.

Delirium is not the only manifestation of nervous disorders; they are also shown by carphologia, jactitation, coma, and in some cases by coma vigil; in a word, all the forms of typhoid nervous symptoms are met with.

In infants it is not uncommon to witness attacks of eclampsia in the first two or three days of the disease. The convulsions have, however, a very different character, as regards their seriousness, than have the initial convulsions of rougeola and variola; for while those of variola are considered by certain authors, Sydenham among others (whose opinion I do not partake), as being of a favorable augury,-while the initial eclampsia in rougeola is generally regarded as a symptom of very slight value, the attacks of eclampsia occurring the first or second day in scarlatina are, upon the contrary, of great gravity. This gravity is still greater if they arise in the third period of the disease, when there is general cedema; we shall have again to speak of its signification; we shall have to say that then the convulsions are often fatal symp

toms.

Even in adults examples are not wanting. Epileptiform symptoms appear the second or third day of the scarlatina, in those persons particularly, who have been subject to attacks of epilepsy, these initial convulsions are repeated, coma succeeds, and death comes in the first twenty-four hours after their appearance.

There is still another marked nervous phenomenon of a very bad prognostic. I speak of dyspnoea, which is, however, not attributed to any material lesion of the lung, a dyspnoea which is met with its mournful signification in a great number of septic diseases, in puerperal typhus, the typhus of camps, in cholera, etc.,

dyspnoea which you have been able to witness in that woman recently delivered, who was so suddenly carried off by scarlatina. Independently of these disorders inherent to the disturbances of cerebral and spinal innervation, there are others which are allied to perturbations sustained by the ganglionary system, and which I shall point out to you.

You, doubtless, are acquainted with the wonderful works of M. Claude Bernard, upon the section of the ganglionary nerves; you know that this section produces in the parts to which the filaments of nerves are distributed, not a paralysis, but, on the contrary, an exaggeration of certain functions, particularly of calorification and of secretion. The learned Professor of the College of France has shown you how, by cutting the sympathetic filaments which go to the ear and face of the rabbit, an elevation of temperature is produced in these parts, which may rise from 4 to 5 degrees higher than the normal temperature; he has shown you that by cutting the ganglionary nerves of the coronary plexus, considerable hypersecretion of the gastric mucous membrane results. From these experiments you will draw the conclusion, that each time that caloricity is increased in an animal, there will be reason to infer some disturbance in the ganglionary nervous system, rather than in the functions of the cerebro-spinal system. But there is certainly no disease which is accompanied by a general elevation of temperature as high as scarlatina. In those affected with scarlatina, in fact, the thermometer introduced into the rectum, or placed in the armpit, has marked 40 to 41 degrees centigrade. This elevation of temperature can only be explained by the disturbances in the ganglionary innervation, which are also shown in other functions, under the subjection of the grand sympathetic, as the incessant bilious vomitings which persist in some persons four, five, and six days, and the abundant intractable diarrhoeas. Graves had pointed out this polycholie in scarlatina independent of any phlegmasia.

The non-inflammatory nature of these symptoms it is important to note. If, in fact, impressed with the idea of inflammation, which the heat of the skin seems to indicate, you endeavor to combat the diarrhoea and the vomitings by antiphlogistics, you will adopt the worst medication, in fact the most perilous treatment that can be adopted for scarlatina, for of all the eruptive fevers, scarlatina is the last one which requires this kind of treatment, seldom beneficial in rougeola or variola.

Besides the nervous symptoms which I have just indicated, others arise, sometimes at the commencement, rarely, it is true, at this period; these are hæmorrhages-hæmorrhages from the mucous membrane, subcutaneous hæmorrhages, renal hemorrhages. These hæmorrhages belong, however, rather to the third period of the disease, and we shall see that in its declination hæmaturia in particular, coincides frequently with the anasarca of scarlatina, of which I shall have to speak.

In studying the relation existing between the severity of the disease and the intensity of the eruption, it will be seen that certain authors have committed a great fault in this respect, and the greater because they may lead into error those physicians who are not familiar with scarlatina. They say, in fact, that when the eruption is well developed, very bright, or, to use a vulgar expression, well out, the patient runs fewer chances of having any serious symptoms. Well, it should be said of scarlatina what is said of variola, its severity is in direct ratio with the intensity of the eruption. In a discrete scarlatina the danger is ordinarily less than in confluent scarlatina, as in a discrete variola there is less to fear than in a confluent variola. In both of these exanthemata, the more intense the eruption, the more serious the symptoms and the greater the danger. Such are the facts established by observation during the course of epidemics.

Scarlatina, I have insisted, does not even resemble itself; identical, be it understood, in its essence, it is not so in its forms. In some cases, after ten or twelve hours of fever, an insignificant eruption appears upon the neck and body, and two or three days afterwards this eruption and the fever which attended it have disappeared, the patient has hardly felt sick, desquamation goes on, it takes place by little bands, then after five to six days the disease is cured, and if the patient does not expose himself to cold, or commit any imprudence, it passes entirely off. The disease has been so simple, that in certain families it passes unnoticed.

Between this mild form and that more severe form, the outlines of which I have already traced for you, there are intermediate forms. Malignant scarlatina, I have told you, becomes a terrible scourge, equal to the most fearful pestilential diseases.

I now come to speak of a few particular symptoms of scarlatina, which I have indicated en passant, and which it is necessary I should dwell upon more in detail.

And first, of the angina of scarlatina.-[Am. Med. Monthly.

[To be continued next month.]

On Hæmaturia after Scarlet Fever. By WM. R. Basham, M. D., Physician to the Westminster Hospital, and Lecturer on the Practice of Medicine.

HÆMATURIA AFTER SCARLET FEVER; ANASARCA; PULMONARY AND CEREBRAL COMPLICATIONS; CONVULSIONS; DEATH. If further proof were necessary, to establish the doctrine that the morbid sequelae of scarlet fever are to be traced to the imperfect elimination of the original virus, it might be found in cases in which the morbid symptoms of this secondary stage are not limited to renal disturbance, but where serious complications, both of the cerebral as well as the respiratory functions, co-exist. In these

cases, where cerebral symptoms become developed during the presence of general dropsy, the urine being highly albuminous, with abundant exudation of the renal epithelium, there can be no hesitation in attributing the convulsions, coma, and death, to uræmic poisoning. The symptoms are strictly analogous to one form of cerebral disturbance frequently observed in cases of renal degeneration in adults, in whom the function of the kidneys is limited to the excretion of the water and albuminous constituents of the blood, and fails to eliminate the urea, the retention of which, acting as a poison in the blood, manifests its virulent power by the most fatal indications. It might therefore be assumed that these symptoms are referrible rather to the renal incompetency than to the febrile poison. Proximately, doubtless they are so; but it has been already shown in a previous lecture that the incipient stage of the renal disorder, the congestion, the hæmaturia, are not accidental conditions, but arise undeniably from the secondary effects of the original febrile virus. There can be no difficulty, then, in tracing the convulsions and fatal termination as much to the imperfect elimination of the scarlatina poison as to the intensity with which the system was in the first instance impregnated.

CASE. Adolphus L, aged six, was admitted into Burdett ward Feb. 10th. The child is reported to have had scarlet fever about a month since, and he has been attending as an out-patient for the last three days, but the gravity of the symptoms rendered him a fit object for admission. There is a considerable degree of constitutional disturbance, febrile heat of skin; pulse rapid; the tongue red, and inclined to become dry; the whole surface of the body is anasarcous; the face is pallid, sodden, and puffy to a great extent under the eye-lids; the scrotum is much distended and the prepuc ecedematous; no indication of ascites. There is a purulent discharge from the left ear. The chest is moderately resonant throughout, but there are coarse moist mucous murmurs all over the left side, and with considerable bronchial wheezing on both sides; the respirations are 24; the pulse 96; frequent cough and fits of dyspnoea; heart sounds natural. The urine is moderate in quantity, smoky in appearance, specific gravity 1.014, abundantly albuminous. The mother states that for several days in the previous week the urine was of a blood-red colour. The urine, examined by the microscope, exhibited many free blood-corpuscles; much amorphous granular matter, stained with hæmatin; and numerous fibrinous castes filled with blood-discs. Warm baths were ordered; the compound jalap powder, as a purgative; and saline medicine, with three drops of the tincture of digitalis to each dose. Two days afterwards the urine remained the same in quantity, but became much higher in specific gravity, 1.020. Free purging with the compound jalap powder was established on the 15th, with great advantage to the symptoms, the skin becoming cool, and the tongue less red and moist, the patient eagerly taking