disease. These varieties might, properly enough, be described in this place; but I think it better to defer this description until after the anatomical lesions of the disease, and the relations, so far as these have been ascertained, between the symptoms and the lesions, have been given. I shall thus be enabled to present to the reader a more distinct, individualized, and unbroken picture of the disease, with its ordinary and average features, than can otherwise be done. The varieties in its march, in its severity, in the grouping and combination of its numerous symptoms, will then be considered, in their place, amongst the other complex elements in the natural history of the disease.

CHAPTER III.

ANATOMICAL LESIONS.

CHOMEL, in his very excellent and full description of the pathological alterations in typhoid fever, divides them into two classes, consisting, respectively, of those which are constant and characteristic, and of those which are occasional. Louis does not attempt to follow any natural or systematic arrangement. In the present history, as a matter of convenience, I shall pursue, as far as this can well be done, the same general order in the succession of subjects, that I adopted in the detail of symptoms; pointing out, under each head, the connections between the symptoms of the disease, and the lesions. of the organs, so far as this connection has been ascertained.

ARTICLE I.

LESIONS OF THE CIRCULATORY APPARATUS.

SEC. I.-Heart and Aorta. The most striking and common alteration of the heart consists in a diminution of its consistence. Louis found this organ natural, in volume, color, and consistence, in onehalf of his cases. In seventeen of forty-six cases, the softening was very well marked. Its tissue could be very readily torn and broken down. At the same time, the heart is exceedingly flaccid, assuming, when removed from the body, a collapsed and flattened shape. The softening of the texture, and the general flaccidity, are most commonly found together, though they may exist separately. Under these circumstances, the cut surfaces of the heart have a dull, dry appearance, and the walls of the ventricles are, in most cases, diminished in thickness. These changes in the condition of the heart are usually accompanied with alterations in its color. The muscular tissue and the external surface are pale, in many cases, with a violet or livid tinge. The internal surface is sometimes pale, and

Louis's Researches on Typhoid Fever, vol. i. p. 331.

sometimes of a more or less deep, violet red. The alterations are found more frequently and more strongly marked, in cases which have terminated early, than in those which have been prolonged. Of fifteen cases examined by Dr. Jenner, the heart was firm or healthy in consistence in five; soft and flabby, or flabby only in five; the right ventricle flabby, the left normal, in one. Of four cases no note on this point was made, but the heart was probably healthy. The average duration of the disease in the five cases in which the heart was flabby, was twenty-two days; in the five cases in which it was healthy, the average duration was twenty-eight days.1

It would seem that, at the Massachusetts General Hospital, lesions of the heart are of less frequent occurrence. Of twenty-eight cases noticed in Dr. Hale's remarks, only two or three are said to have been "rather flaccid." It ought, however, to be remembered, that this term might be applied to the same condition of the heart by one observer, and withheld by another. There have been differences of opinion, amongst pathologists, in regard to the nature of these lesions. I do not think there is any satisfactory evidence that they are inflammatory.

The aorta is frequently more or less changed in color, on its internal surface. This change existed in somewhat more than onehalf of Louis's cases. It consists of a morbid redness, more or less intense, sometimes in the form of bands or patches, sometimes generally diffused over the whole surface, and extending to the bifurcation of the aorta, or even considerably beyond it. This redness reaches through the inner, and affects, though in a less degree, the middle membrane of the cardiac cavities. The intensity of the morbid color is generally in proportion to the softening and flaccidity of the tissue of the heart. It is always found in connection with the presence of blood in the aorta; and it is important to remark, further, that the most extreme cases of softening of the heart commonly coexist with the presence of a dark, soft, non-fibrinous clot of blood in its cavities, or with blood not coagulated, but containing bubbles of air.2

The cause and nature of this reddening of the inner coats of the aorta have been the subjects of much investigation and much controversy. There is no place for any account of them here. I will

1 Jenner, &c., p. 80.

2 Louis's Researches on Typhoid Fever, vol. i. p. 333.

merely say that the opinion of Louis seems to me most in accordance with all the phenomena which enter into the solution of the question; and that opinion is, that this redness is the result of imbibition, by the tissues, of the coloring matter of the blood--the imbibition depending upon a special condition of the blood, or of the tissues, or, perhaps, of both. There is no conclusive evidence, at any rate, that the redness is the result of inflammation.

SEC. II.-State of the Blood. The most frequent alteration in the character of the blood consists in the diminution of the natural proportion of its fibrin. In some cases, the cavities of the heart, especially the right, contain fibrinous concretions of a whitish or yellowish color; but more commonly, the blood is in the form of dark coagula, or entirely fluid. Of thirty cases, wherein the blood. contained in the heart and aorta was carefully examined by Chomel, he found small and scanty fibrinous concretions in six, dark coagula in nine, and dark fluid blood in fifteen. The occasional presence of air in this uncoagulated blood has already been noticed. Ac cording to the observations of Louis, the appearance of the blood contained in the cavities of the heart, as has just been intimated, varies with the condition of this organ. When its consistence was natural, he found, especially in the right cavities, yellowish or whitish fibrinous coagula, more or less firm; when it was considerably softened, he found non-fibrinous coagula; and when the softening was very great, instead of coagula, he found only a small quantity of fluid blood containing air.

Blood drawn from the veins, during life, rarely exhibits the buffy coat; and when this is present, it is generally soft, gelatinous, or infiltrated, and of a grayish or greenish color. This character of the blood has been particularly noticed by Louis, Chomel, and Bouillaud; and the results of their observations have been abundantly verified by the subsequent and more accurate researches of Andral and Gavarret. They found that, in typhoid fever, the proportion of fibrin in the blood was never increased above its natural standard; but on the contrary that, in many cases, this proportion was very much diminished; and, furthermore, that the degree of this diminution was very uniformly proportionate to the severity of the disease. These observers found a similar alteration of the blood in the eruptive fevers, while in all cases of simple acute inflammation, the quantity of fibrin was above its natural standard.

ARTICLE II.

LESIONS OF THE RESPIRATORY APPARATUS.

SEC. I.-Lungs. Neither the symptoms nor the lesions go to show that the lungs play any very important part in the numerous and complicated phenomena of typhoid fever. Louis found them nearly natural in fifteen of forty-six cases; about the same proportion in which he found them so in other acute diseases, excluding, of course, those of the lungs themselves. Chomel found them healthy in ten of forty-two cases. The most characteristic alteration is described particularly by Louis, and, so far as I am aware, had not been noticed by other writers. It is of frequent occurrence in the fever of our own country. It has been called splenization or carnification of the lung. The latter term may be well enough, but the former is wholly inappropriate; the appearance of the lung being entirely unlike that of the spleen. The portion of lung thus carnified, is of a deep bluish-red color; it has a tough, leathery feel; the finger penetrates and breaks it down with difficulty; it is wholly destitute of air, and sinks readily in water. When it is cut, the smooth surface is directly covered with a thick, red fluid. This peculiar lesion almost always occupies a circumscribed portion of the lower and posterior lobe of one or both lungs. It is quite unlike, in almost every respect, the second stage of inflammation, although the term hepatization has sometimes been applied to it. It is not indicated by any peculiar symptom during life. Dr. Jenner gives the following description of this lesion, which he calls Lobular non-granular Consolidation. "Externally, a portion of lung in this condition has a mottled aspect; here and there are patches, varying in size from a single lobule to half or more of a lobe, of a deep bluish, chocolate, violet, or purplish slate color, bounded by a well-defined angular margin, crossed, if it includes more than one or two lobules; and mapped out into smaller patches, by dull opaque whitish lines. On closer inspection, the outline and the whitish lines intersecting the patches, are seen to be thickened interlobular septa.

"Scattered in the midst of the larger patches, are frequently found one or more comparatively healthy lobules, of a pale brightish pink color, contrasting strongly with the hue of the surrounding tissue. Here and there, near the border of the large patches, may be seen, occasionally, lobules, the centres of which have assumed