inspection. When the nausea and vomiting are constantwhen every five or ten minutes three or four ounces of yellow bile, resembling the yolk of an egg, are thrown off the stomach-when the urine is yellow and tinges the linen-when there is some degree of tumefaction and uneasiness over the right hypochondrium-when the patient cannot lie on the left side with ease-when there is constipation, and the stools of a clay colour, or where there is bilious diarrhoea-where there is heat and fulness of the anus, often piles,-I think we must admit that the liver is affected.

In these cases the irritation of the stomach and duodenum appears to me to have extended itself to the biliary ducts of the liver. They occur principally in acclimatized individuals, are for the most part remittent in their type, and as far as my experience goes, never fatal, though they often leave behind them a certain degree of irritation and congestion of the parenchyma, which, if neglected, may give rise to acute hepatitis.

Symptoms of Læsions of the Gall-bladder.

These læsions, in all the cases in which they were found after death, consisted of inflammation and thickness of the vesical mucous membrane, contracting the orifice of the cystic duct, and obstructing the free discharge of the bile; they were unaccompanied by any symptoms which could be considered diagnostic.

Symptoms of Læsions of the Kidneys.

When the pains of the loins are violent, and accompanied by suppression of urine, many authors have judged that inflammation of the kidneys existed. In these epidemics, where this læsion appears to have been common, these symptoms perhaps were worthy of attention; but in the cases before us the pains of the loins were often extremely severe, yet no affection of the kidneys was found after death; and in the cases in which it was found, the pain, though great, was not

particularly so. In two cases only have I remarked suppres

sion of urine: in both it occurred towards the close of the disease, and ceased immediately before death.

Symptoms of Læsions of the Spleen.

Although these læsions were frequent, I know of no symptoms which indicated their existence during life. There was neither tumefaction nor apparent uneasiness, and the pain produced by pressure in this region could equally be referred to the stomach. Of course I do not include chronic enlargements of this organ, nor those cases in which the distension was sufficiently great as to enable one to distinguish it by the feel, or to describe its lower margin.

Symptoms of Læsions of the Lungs and Pleura.

In many cases, bronchitis, or pleuropneumonia, are added to the other læsions. We shall have in general little difficulty in discovering them, as the patient will, in all probability, call our attention to pain in some part of his chest, increased on inspiration; or we may notice his cough, or be struck with the nature of the expectoration; in short, many things will make us suspect some affection or other of the chest, even when the symptoms are not well pronounced; and by a more careful examination we may make out its nature. But it now and then happens that the usual symptoms do not exist, or if they do, they are so obscure as to be overlooked. And we are astonished to find after death extensive disease in an organ which we fancied healthy. If we carefully examine the different cavities every day, which we should not omit doing, we perhaps find in some part of the chest generally, in the inferior lobe of one side, a point in which the respiratory murmur is indistinct, or covered by a slight crepitating râle, and that on percussion returns a sound more dull than natural. this engorgement be allowed to go on, it extends over the whole of the lobe, and thence to the remainder of the lung, and the organ becomes destroyed, as we have before described.

If

In one of the cases, congestion of both lungs took place suddenly, and was the cause of death.

Symptoms of a Diseased state of the Blood.

Though we have no particular symptoms characteristic of this change in the vital fluid, yet we can form a pretty correct idea of its having taken place when the skin is of a dusky colour, changing to livid; when the countenance is grim, and has the appearance of being seen through a dark gauze veilwhen there are ecchymoses of the cutis, or subcutaneous cellular tissue, or passive hæmorrhage from some organ, and more certainly when all these symptoms are united. But as this fluidity of the blood may exist without being accompanied by these symptoms, or by only a few of them, and those not particularly marked, we may remain in ignorance of it until we have seen the blood itself taken from the circulation during life, or as it is found in the body after death.

Ecchymoses occur in a very small proportion of the cases visited during the season by a medical man, and petechiæ still more rarely; and there is this difference between them where ecchymoses are observed, the symptoms for the most part are not those which characterise adynamic fever; the tongue remains, in the greater number of cases, pale and moist; the skin at the commencement is of a dusky red, indicating a considerable degree of capillary excitement; and there is often hæmorrhage from some organ. They occur in young and vigorous subjects; and though the case may not terminate fatally, it must be looked upon as one of the most dangerous forms of these diseases, particularly if the type be continued. Petechiæ, on the other hand, are found to occur in old people, or in those who are weakly and ill-fed; they are combined with other symptoms of adynamia, as a dark and dry tongue; sordes on the teeth and gums; great prostration; temporary reveries; picking of the bed-clothes, &c.—a state of things dependent more upon the constitution of the patient than upon the cause which excited the disease. They are, however, occasionally accompanied with passive hæmorrhage, and now and then ap

pear with ecchymosis. It is only at the close of the disease, or at least after it has continued some time, that these appearances are observed; never at its commencement.

Extravasation of a considerable quantity of blood into the cellular texture of the thigh occurred in one case; it induced a great deal of pain, and some tumefaction, but no lividity.

Hæmorrhage.

I have related a case in which hematemesis was the first symptom with which the patient was attacked, and in which, in the course of a few hours, as the general excitement increased, he was seized with cerebral congestion and epistaxis. The fever was inflammatory, the blood was rich and plastic, and the surface of the coagulum was covered with a coat of colourless fibrine. Such hæmorrhages may occur in the course of any disease, and of course are occasionally seen in the inflammatory fevers of the tropics. There are others, as we have seen, which are of a different character; they occur in the course of the disease, generally when the excitement of the capillary circulation is commencing to subside. They appear to be formed by a sanguineous exudation from the exhalent vessels, are observed most frequently from the nose, the anus, and the urethra, and are attributable partly to the increased action of the vessels of the part, and partly to the fluid and thin state of the blood itself. After the application of leeches, we frequently have an artificial hæmorrhage from the orifice formed by these animals, which it is extremely difficult to arrest. It seems to owe its existence to the same causes as the others. We often hear of hæmorrhages proving critical in these diseases. I certainly have never seen anything of the kind, though it may happen that a temporary amelioration follows those of the first form now and then. The second indicate a certain degree of danger, not from the loss of blood, though this may be sufficiently great as materially to increase that which already exists, but because it shows that the disease is of a grave and malignant nature.

Symptoms of Læsions of the Encephalon and its Appendages.

Meningitis was found after death in a proportion of cases amounting almost to one-half. It remains for us to inquire into the symptoms attendant upon this læsion; they will be found, if we refer to the cases, as follows:-Headache, which however diminishes in intensity as the disease advances; stupor, alternating with restlessness; a sensation of faintness on assuming an erect position; more or less insensibility to pain, or to external impressions of any kind, (though it now and then happens that the aching pains of the back and extremities with which the attack sets in, still continue, but are much more obtuse ;) florid or dark redness of the face; impatience of light; injection of the conjunctivæ; brilliancy or dimness of the eyes. These symptoms mark the primary stage of the læsion, and are often observed on the first day of the disease. In a short time the stupor becomes more pronounced, the patient is roused with difficulty, and after pettishly answering a question, which he does as briefly as possible, probably in a monosyllable, falls again into the same state; he suffers no pain, at least he never complains of any; and always, when interrogated on this point, says that he is quite well, or better ; at other times he expresses a great desire for sleep, which he says he has not enjoyed since he has been ill, and to the want of which he attributes his great weakness. When he takes his medicine, or whenever he lifts his hand to his mouth, his arm is observed to tremble greatly, and he generally, to effect his purpose, is obliged to use the two; the gastric symptoms, which probably were very distressing at first, are now scarcely perceptible; the vomiting is rare, or occurs only after drinking; pressure on the epigastrium ceases to give pain, though in the greater number of cases the patient winces, or gently pushes the hand away. In the third stage the stupor continues and is more pronounced, alternating with muttering delirium; when we succeed in rousing him for a moment his answers are incoherent; he no longer recognises the persons about him. Reason generally returns before death, and it is not unfrequently that we meet with cases in which the

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