fever, a strawberry-red tongue, with large papillæ, sore throat, and injected fauces. Two days later the rose spots continued in great numbers, and the scarlet rash persisted. Two days after this the scarlet rash was fading, but the rose spots continued out for a few days longer. A week after the disappearance of the scarlet rash there was copious desquamation. The patient made a good recovery.

Illustration XLVIII.-A boy, aged fourteen, was admitted, August 25th, 1858, from a house in which there had been other cases of pythogenic fever. He had the symptoms of pythogenic fever in a mild form, and with no very well-marked abdominal symptoms. Rose spots made their appearance on the thirteenth day, in sparing numbers, and continued coming out in successive crops. On the twenty-second day there were still some rose spots, and also a general scarlet rash having all the general characters of that of scarlet fever. The tongue was moist, with thick white fur and large red papillæ; the throat sore; the tonsils enlarged and red, and coated with a white membraniform deposit. On the same day the pulse had risen from 72 to 132, and the temperature under the tongue from 99° to 104° Fahr. After three or four days both the eruptions disappeared. On the twenty-fifth day the tonsils were so large as almost to meet, and the tongue was clean, red, and of a strawberry aspect. On the twenty-seventh day desquamation commenced. Convalescence was delayed by tedious swellings in the neck, one of which terminated in abscess. When this boy was admitted, a scarlet fever patient lay in the adjoining bed, and there were many other cases in the same ward.

Q. Typhus and Pythogenic Fever.-The doctrine of the compatibility of two of the exanthemata has an important bearing upon that of the non-identity of typhus and pythogenic fever. They who maintain that the poisons of the two fevers are identical, have appealed triumphantly to certain cases in which they have observed the eruptions of the two fevers to co-exist. Now, allowing for a moment that the facts in all these cases have been correct, the conclusions which have been drawn are based upon a doctrine which is utterly fallacious. The co-existence of two eruptions no more implies an identity of the two diseases, than it does in the case of variola and scarlet fever, or of scarlet and pythogenic fever. But there can be little doubt that, in the majority of cases, the facts themselves, from the manner in which they have been described, must be viewed with no small distrust. On few subjects does so much confusion prevail in the profession as with regard to the eruptions of continued fevers. A very common mistake is to imagine that petechiæ constitute the characteristic eruption of typhus, a mistake which has been strengthened by "petechial fever" being one of the appellations applied to the disease; and it has been argued, from a patient presenting both "rose spots" and "petechiæ," that the eruptions of pythogenic fever and typhus have co-existed. But petechiae do not constitute the characteristic eruption of typhus; and they are met with in the course of pythogenic fever, in the same way as they show themselves in the course of variola, scarlatina, and many other affections. All they who have had much practical experience in studying both typhus and pythogenic fever, will admit that it is excessively rare to find the measly eruption characteristic of the one, co-existing with the rose spots characteristic of the other. In my essay upon the Etiology of Continued Fevers, published in the Medico-Chirurgical Transactions (vol. xli. p. 275), I expressed an opinion that such a co-existence was possible; but I maintained then, as I do now, that no argument could be based upon such a co-existence as to the identity of the typhus and pythogenic poison, any more than we should employ a similar argument to show that variola and scarlet fever, or scarlet fever and pythogenic fever, were one and the same. I shall now proceed to detail the facts which testify to the possibility of typhus and pythogenic fever co-existing.

Such facts might be naturally looked for under circumstances in which a patient labouring under the one disease has been exposed to the contagion of the other, as for example in the London Fever Hospital. When the doubtfully contagious character of pythogenic fever (already alluded to) is remembered, it will not be wondered at that patients admitted with typhus have seldom contracted the former disease. During a

One was

period of ten years I have only been able to find the notes of two such cases. that of a female, aged twenty-one, who, with seven others of the same family, was admitted with well-marked typhus, and who, in the third week of convalescence, had an attack of pythogenic fever, the symptoms of which, however, were mild and not very characteristic. The second case will be shortly alluded to. On the other hand, it has been by no means rare for patients admitted with pythogenic fever to contract typhus during their stay in hospital. But, in most cases, this has been in the fifth to eighth week of convalescence from the first fever, and two or three weeks after the patients have been removed to the convalescent ward, a circumstance which is explained by the patients in the convalescent ward being thrown into more intimate relations with one another, and by typhus being avowedly more contagious during convalescence than during the height of the disease. In the following instances, however, the eruptions and other symptoms of the two diseases were almost contemporaneous.

Illustration XLIX.- A female, aged twenty-two, had an attack of pythogenic fever, which was attributed to the putrid emanations from a bad drain. She was admitted into the London Fever Hospital. The primary attack lasted three weeks. After a fortnight she had a relapse, with a return of the "rose spots," and the day after this there was a subcutaneous "typhus mottling," along with drowsiness, heaviness, and other symptoms of typhus.

Illustration L-A male, aged twenty-five, was admitted with well-marked pythogenic fever. On the 27th day there was a great aggravation of the symptoms, with much headache and stupor, and in addition to several rose-coloured spots there was a distinct subcutaneous mottling. The diarrhoea still persisted. Four days later the subcutaneous mottling had become developed into a well-marked typhus rash. The patient recovered.

Illustration LI.-A female, aged twenty-seven, was admitted on the third day of an attack of typhus. The rash began to fade about the fifteenth day, but there was no abatement of the general febrile symptoms. On the eighteenth day there was watery diarrhoea, tympanitic abdomen, and several rose spots. The latter symptoms continued for about a fortnight, after which the patient gradually recovered.

It not unfrequently happens that patients are exposed to the poisons of both typhus and pythogenic fever before their admission into a hospital. In my researches, elsewhere published, I have endeavoured to show that the poison of pythogenic fever is generated in the emanations from decaying animal matter, and that of typhus by the respiration of an atmosphere charged with the exhalations of living bodies, although in the majority of cases the latter disease is propagated by contagion. Now, if a certain poison can generate one group of symptoms, and another poison generate another, surely it is but reasonable to expect that a combination of the two poisons may give rise to a morbid condition of an intermediate character, without its being necessary to conclude from the existence of such a hybrid affection that the first two morbid conditions have been merely different manifestations of the same poison.

The three following instances were made the subject of repeated and most careful observations by myself:

Illustration LII.-In December, 1857, a girl, aged sixteen, was admitted into the Fever Hospital from 17, Windmill-row, Lambeth; ill a week. Her body was covered with an unmistakeable mulberry (typhus) rash, and she presented all the usual symptoms of typhus-dry, brown tongue; confined bowels; heavy confused expression; small pupils; and low, wandering delirium. The case attracted particular notice, as typhus was at that time very uncommon. Two days after the symptoms underwent a complete change. The mulberry rash (which was certainly not the scarlet rash which occasionally precedes the eruption of pythogenic fever) faded, and was succeeded by rose spots, which came out in successive crops for more than a week, and were accompanied by diarrhoea and abdominal tenderness. The tongue became moist and red; the pupils,

dilated; and the drowsiness and wandering vanished. This girl was a hawker; for some weeks had been very destitute, and a fortnight before she had slept for two or three nights at another house, in the same bed with a girl who had "fever." This second girl, with her mother and sisters, was admitted into the Lambeth Workhouse; but the father and brother were admitted into the Fever Hospital with well-marked typhus. On the other hand, Dr. Odling, the officer of health for Lambeth, informed me that the courtway in front of No. 17, Windmill-row, was badly paved and badly drained; and that, although the cesspools in the house had been done away with, the habits of the inmates had rendered the privy arrangements as insalubrious as before. This girl was therefore exposed both to the contagion of typhus, and to the causes which there is reason to believe generate pythogenic fever.

Illustration LIII.—A man, aged twenty, a street hawker, was admitted into the Fever Hospital, October 15th, 1858, from 7, Feathers' court, Drury-lane. This man had diarrhoea, and the characteristic tongue of pythogenic fever; but on the other hand (what is more peculiar to typhus), he had delirium coming on so early as the third day. From the eighth up to the twenty-second day he had distinct "rose spots" coming out in successive crops; and, in addition, there was from the seventh to the eleventh day a faint mottling on the arms and trunk, precisely similar to the eruption of typhus. This man's brother and sister were both laid up at home with fever. Both had diarrhoea, and in both the body was covered with an eruption compared by the mother to that of measles. Now, pythogenic fever was at the time very prevalent in London, so that it was not to be wondered at if the patients should be exposed to its exciting causes; but typhus was scarcely to be met with, and it became interesting to determine whether these patients had been exposed to the causes which are known to generate it. In the first place it was ascertained that they were very destitute, and destitution is known to be the great predisposing cause of typhus; and secondly, the room in which they lived was over-crowded-five adults sleeping in a room seventeen feet square and eight feet high, with one door and one window, so that, making no allowance for furniture, each individual had only about three hundred cubic feet of space. There were no means of ventilation. The single window was seldom or never opened.

Illustration LIV.—A girl, aged six, was admitted into the Fever Hospital, September 13th, 1858, from 3, Horse-shoe-court, Cow-cross, Holborn. On the eighth day of her illness rose spots were observed, perfectly characteristic, lasting for a few days and then succeeded by others up to the eighteenth day. On the ninth day, and lasting for four days, in addition to these rose spots, there was a distinct subcutaneous mottling, not disappearing on pressure, and precisely resembling the eruption of typhus. The general symptoms more resembled those of typhus than of pythogenic fever. There was no diarrhoea, and throughout there was much tendency to stupor and slight delirium. Three other children from the same family were admitted about the same time into St. Bartholomew's. All of them, according to the mother, had a rash resembling that of measles; but all had also diarrhoea, and in one boy rose spots were noted during his stay in St. Bartholomew's. Pythogenic fever at the time was very prevalent in London. Typhus was almost unknown; yet in the house from which these patients came the causes known to generate typhus existed in a marked degree. The house itself was situated at the top of a closed court, and the room in which the father, mother, and five children lived and slept was at the top of a narrow stair in this house, and measured fourteen feet in length, thirteen and a half in breadth, and seven and a half in height, a space which, even making no allowance for furniture, allowed only two hundred cubic feet of air to each individual.

Lastly, it seems not improbable that a co-existence of two different diseases may have accounted for the anomalous symptoms observed in the two following instances:

Illustration LV.-An outbreak of fever occurred in autumn, 1857, in Dudley-street, Paddington, in which I am assured by Dr. Sanderson* that there were some cases which presented the characters of both typhus and pythogenic fever, including the

* Dr. Sanderson has had ample opportunities of studying the two fevers at the London Fever Hospital.

presence of the two eruptions. I have elsewhere shown that in Paddington there are various causes to account for the generation of pythogenic fever, and that typhus is there extremely rare. It becomes interesting, then, to ascertain under what circumstances typhus, or something resembling it, may there originate. Now, in the houses in which these "mixed cases" occurred, the two causes which I have supposed to generate typhus and pythogenic fever were present in a marked degree. First, the residents were principally dustwomen, and the houses were daily stocked with selections from the street-sweepings of the metropolis, such as old grease-pots, &c., materials sufficiently prone to decomposition in hot weather. But, secondly, these two houses were overcrowded to such a degree that compulsory measures had to be adopted to diminish the number of inmates. Cases of fever occurred at the same time in other houses of the same street, which were not overcrowded; but these were pure examples of pythogenic fever.

Secondly, Illustration LVI.-M. Landouzy* has given an account of a remarkable fever which prevailed at the gaol at Rheims, in the autumn of 1840. Many of the symptoms during life, including the eruption, were those of typhus; but the intestines after death presented the lesions characteristic of pythogenic fever. Now, from the locality and the season of the year, one would have expected the latter; and in addition to these canses, we are informed that there was a most disagreeable odour in the gaol (proceeding from the grease of the woollen fabrics manufactured by the prisoners ?). That the fever was really pythogenic fever is proved by the lesions found after death. On the other hand, a cause was not wanting to account for the symptoms of typhus during life; and, it must be remembered, that a copious mulberry rash would entirely mask a few rose-coloured spots, even if these were present. The circumstance to which the fever was mainly attributed, was the over-crowding of the prisoners. The number which the gaol was calculated to hold was from one hundred and thirty to one hundred and fifty; but a month or two previous to the outbreak of the fever, this had been raised to one hundred and ninety.

The illustrations cited in this essay might have been greatly multiplied; and it might have been shown that the paludal poison, and the poisons of syphilis, the plague, cholera, and influenza, are compatible not only with one another, but also with the poisons of the diseases already enumerated. Enough, however, I trust, has been done to prove that the doctrine of the incompatibility of two or more contagious diseases is erroneous; and consequently that, upon the mere occasional co-existence of the peculiar eruptions of typhus and pythogenic fever, no argument can be based as to the identity of the poisons of these two diseases.

ART. III.

On some Points in the Clinical History of Asthma. By HYDE SALTER, M.D., F.R.S., Assistant Physician to Charing Cross Hospital.

PHENOMENA OF A PAROXYSM.

Premonitory and initiatory symptoms-Drowsiness, dyspeptic symptoms, headache, excitability, profuse diuresis, neuralgic pains-Time of attack, the early morning; why ?-Description of access of paroxysm-Appearance of the asthmatic in the height of the paroxysm-Pulse-Itching under the chin-Muscular phenomena-Enlargement of capacity of chest-Auscultatory signs-Conclusions.

IN considering the phenomena of asthma, I shall take first the phenomena of a paroxysm, and then the phenomena of the disease generally; and I shall adopt this • Archives Gén. de Méd., troisième série, vol. xiii. p. 7.

order because the phenomena of the paroxysm are so much more pronounced and marked, and constitute so much the body of the malady-while those of the disease generally, in opposition to those of the paroxysm, are rather the phenomena of the intervals, and consist of certain permanent conditions influencing the paroxysms, or produced by them.

As in epilepsy we have premonitory symptoms, in the form of the aura epileptica, spectra, and other subjective phenomena; then the establishment of the paroxysm; then those conditions of the nervous and muscular systems which constitute its climax; and then its abatement and the post-epileptic sleep: so in asthma we have certain precursory symptoms, and then the attack in its accession, perfect establishment, and departure.

The precursory symptoms of a fit of asthma are liable to great variety in different individuals; some persons never experience any, but having been guilty of some imprudence, or the regular period of an attack having recurred, the seizure of the dyspnoea upon them is the first indication of its approach. But I think that the majority of asthmatics do know that an attack is coming on them by certain feelings in themselves, or certain conditions of which they are aware. These symptoms generally show themselves on the night previous to the attack; but in some cases for a longer time. The patient will feel himself very drowsy and sleepy, will be unable to hold his head up or keep his eyes open, and that without having undergone any particular fatigue or done anything that could account for it.* I remember one case in which this was very strikingly marked, the asthmatic always knew when he was going to be ill the next day by the extreme drowsiness that overpowered him at night; he would go sound asleep over his reading or writing, or whatever he might be engaged in, and that at an early hour of the evening. It was in vain for him to rouse himself, in spite of all his efforts, and in spite of the prophecies of those about him that he was going to be ill, and his own convictions of what awaited him, to bed he must go. And probably any resistance of these feelings would have been of no avail, and would neither have postponed nor modified the attack; the asthma was not the result of the heaviness, but the heaviness merely indicated the approach of the asthma; it was the commencement of that particular nervous condition of which the succeeding respiratory phenomena were but the more complete development; in fact, it must be looked upon as an integral part of the paroxysm. I find this precursory drowsiness to be the commonest of all the premonitory symptoms of asthma.

Others, again, know by extreme wakefulness and unusual mental activity and buoyancy of spirits, that an attack awaits them; and I knew one case in which an attack of ophthalmia always ushered in the asthma: the man was liable to inflammation of his conjunctiva; it was always worse before his attacks than at any other time, and he invariably knew by the state of his eyes when he was going to suffer a paroxysm. It might be thought that this was a case of mere catarrh, that the asthma was caused by the inflammation of the eyes creeping down through the nasal mucous membrane into the air-passages; but this was clearly not the case—1 -there was no coryza, no bronchitis-the ophthalmia was strumous, and I believe that an exacerbation of the strumous cachexia, a more debilitated, and therefore a more irritable condition of system, was the cause alike of the inflammation of the conjunctiva and the spasm of the air tubes. At other times the precursory symptoms are connected with the stomach, and consist of loss of appetite, flatulence, costiveness, and certain peculiar uneasy sensations in the epigastrium; but here I think we have something more than mere premonitory signs; I think the relation of these symptoms to the spasm which follows is often that of cause and effect.

Of all the circumstances attending the commencement of an asthmatic paroxysm, none is more constant than the time at which it occurs. This is almost invariably in the early morning, from three to six o'clock. There are some cases in which the usual time is the evening-some just after getting into bed, before going to sleep, and some

*Floyer was perfectly aware of this premonitory sign, having noticed it in his own person. "There appears," he a great dulness and fullness of the head, with a slight headache, and great sleepiness on the evening before the

says,

fit."

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