following morning the arms, the forehead up to the roots of the hair, and the face generally, will be covered with large elevated patches of a bright red colour, more vivid than measles, and more defined than scarlatina, much resembling nettle-rash, especially in the circumstance of their disappearance on pressure and instant recurrence when that pressure is removed. They vary in hue at different times, being occasionally purplish, especially on the hands; and again resuming their bright tint without any apparent cause. On the second day the efflorescence is found over the whole trunk, and the sensation produced by it is not that of tingling and heat alone, but of intense itching. To allay this the patient scratches himself incessantly, until he has removed the cuticle in numerous places over his body and extremities, leaving patches of encrusted blood and subsequent scabs wherever this abrasion has taken place. The eruption is very well marked about the third and fourth days; the outline around the edges of each patch being then more distinct than before, and bearing a greater contrast to the central portion. It declines about the sixth day, and terminates by a general desquamation of the cuticle. In this respect, as well as in its definite duration, it is needless to remark, that it differs altogether from nettle-rash." Before discussing the pathology of this eruption, it may not be uninteresting to compare the account given of it by Dr. Babington in 1832, with that of those excellent observers Reinhardt and Leubuscher in 1849*, especially as the observations were made in two epidemics, and the patients had been under different treatment during the primary symptoms.

These writers continue thus:

"We observed this, in many instances very characteristic rash, in 15 cases. It appeared without any observable change in the general condition of the patient; without restlessness, heat, quickening of the pulse, or other symptoms generally attendant upon the development of an acute cutaneous eruption. In many cases, particularly in young and strong subjects, a diffused redness of the skin preceded the exanthem. It was particularly marked on the hands and face, where it was occasionally so bright, and attended with so much swelling, as to have the appearance of erysipelas. After 12 or 24 hours the swelling decreased, and the redness was more partial. In some places it gradually lessened and disappeared altogether, whilst it continued unchanged in others. At this time there appeared over the hands and arms numerous large, irregular, and for the most part indistinctly defined, red patches. Where the diffused redness

* Op. Citat., p. 469.

and swelling were absent, the exanthem appeared first in the form of large, irregular, undefined erythematous patches. Sooner or later these became gradually concentrated into the exanthem. The skin was then covered with small round defined spots, from the size of a pin's head to a linseed, more or less bright in colour, and not elevated above the skin. This gradual development of the exanthem could be best seen on the hands and feet, on the other parts of the body it was not generally preceded by any diffused redness. The exanthematous spots subsequently increased in size, and when near together became confluent and produced a roseolous appearance. In some cases the eruption remained in this condition but increasing for 24 or 36 hours, and then after two or three days became pale and disappeared altogether with a fine branny exfoliation of the skin. This abortion of the exanthem, if it may be so called, occurred in 3 out of 15 cases; in these it was limited to the extremities, and principally affected the joints. The exanthem generally, however, underwent a further development, the spots became raised, and at the same time increased in circumference, forming an eruption like measles. By a further increase in size, and a greater elevation of the skin, wheals like urticaria were formed as large as a lentil or a silver penny. This similarity to urticaria was in some instances greater from the wheals being in part paler in the centre than at the periphery. As the exanthem advanced, these wheals enlarged, at the same time their centres generally became depressed, and the edge was more raised above the skin. They either remained distinct or were more or less confluent, as about the joints, elbows, shoulders, and knees. In this stage the exanthem lasted from one to two days, sometimes from three to five, before it underwent any particular change. It afterwards became pale, gradually sunk to the level of the skin and formed yellowish or reddish yellow, indistinctly-defined patches, which faded, and were followed by exfoliation of the cuticle. For the most part, this was in small branny scales, but in two instances, where the rash was extensive, the cuticle, especially on the hands and feet, separated, as after scarlet fever, in large membranous laminæ."

That this exanthem is not of frequent occurrence, and when it happens but of subordinate pathological importance, we may conclude from the fact, that in the communications received by the College, it was spoken of in only a few instances, and then somewhat incidentally. It appears to be nearly allied to urticaria febrilis, nor do we think the objection that it differs from this affection in having a more or less definite duration and terminates by desquamation, a valid

one, since the same occurs in urticaria febrilis, which, according to Willan, lasts seven or eight days, and terminates by slight exfoliations of the cuticle.

In its abortive forms, where it did not become developed in wheals, the eruption had not unfrequently the characters of erythema papulatum.

It was independent of any form of treatment which had been employed in the preceding stage of the disease, and occurred sometimes in mild cases where the patient had been kept to cold water or other simple diluents, as well as in the severe forms where stimuli had been freely administered. Although it is not ascertained what were the proximate conditions which determined its appearance, yet, since similar eruptions are known to be intimately dependent upon disorders of the gastro-intestinal mucous membrane, and these are, after an attack of Cholera, frequent, we cannot but refer it in a general way to such a source, admitting, as we must in ordinary urticaria and erythema, that the individual peculiarities which determine its presence are not obvious.

Other appearances occasionally occur during reaction, such as petechiae in the lower extremities, erysipelas of the face and furuncles.

Predisposing

causes of

Whatever may be the nature of the Cholera poison,

it requires no definite predisposing conditions in the Cholera. system to enable it to produce its effects. It was fatal at all ages, nearly equally to both sexes, and neither the weakness of infancy, the vigour of manhood, nor the decrepitude of age, was a safeguard against its inroads.

Age.

The total number of deaths in England in 1849, from Cholera and diarrhoea together, was, with a few exceptions, in which the age was not named, and 20 persons over 95 years not included, 72,110, as follows:

DEATHS from CHOLERA and DIARRHEA from Birth to 95 Years.

By dividing the whole term of life into periods, we obtain the following results:

These numbers give the absolute mortality at the different periods of life, but, in order to obtain a correct idea of the influence of age, it is necessary to compare them with the number of persons living at

* Registrar-General's Report on the Mortality of Cholera, 1848–49.

these periods, by which the mortality per cent. is determined to be as follows:

DIAGRAM I.

Mortality from the Epidemic of 1849 per cent. of Persons living at different

Such a calculation shows that the epidemic was, in proportion to the number of persons living, most fatal to infants and persons over 55; that the mortality was lowest from 5 to 15; and that from the latter age upwards, it rose by an almost regular gradation, being among infants nearly six times greater than among children of 10 years, xlii.

* Op. Citat., p.