In the second case, the patient, a young married woman, was placed in less favourable circumstances; her room was imperfectly lighted and ventilated, her dwelling was situated in a dirty locality, and her attendants were indifferent nurses. A class of symptoms appeared, precisely analogous at first to those described above; but in this case, as the sore throat and eruption faded, great bodily prostration succeeded, attended with griping pains in the bowels and copious diarrhoea. This patient recovered very slowly, but communicated disease to none, although two children slept in the same bed with her, and an infant was at her breast.

The two cases thus described were in the same village (Barnes), and were occurring at the same time; but they were the only cases of the kind in the neighbourhood; and, although identical with cases of mild scarlet fever, so that no other name could possibly be given to them, they passed off without leaving any special sequelæ, and the patients propagated no disease to other persons around who were susceptible. The recollection of these cases has always left on my mind the fact, that there is another poison almost identical in its effects with scarlatinal poison, but which has not the physical properties rendering it capable of distribution and contagion.

ON SCARLET FEVER, AS COMPLICATED WITH ACUTE RHEUMATIC FEVER.

Under the term "dengue," or scarlatinal rheumatism, Dr. Wood of America, and a few other authors, have

described an epidemic, in which certain symptoms of scarlet fever are combined with those of acute rheumatism. Dr. Aitken, in his work on The Practice of Medicine, thus describes this epidemic:-" A peculiar febrile disease, conjoined with sudden severe pains in the small joints, which swell, succeeded by general heat of skin, intense pain in the eyeballs, and the appearance of cutaneous eruption on the third or fourth day. The disease is infectious, with an epidemic tendency."

After describing that the disease has been observed in certain parts of the East and West Indies, and in the southern parts of America, Dr. Aitken, adds-" it" (the disorder) is not known in Great Britain."

Now, while it is true that we have no record of an epidemic of " dengue" in this country, it is certain that we not unfrequently meet with scarlet fever connected with acute rheumatic fever. I believe we were first indebted to Dr. Golding Bird for the mention of this fact. Afterwards, in 1845, at a meeting of the Belfast Medical Society, Dr. Kelso, of Lisburn, read a paper, in which he referred to twenty cases of the kind that occurred under his observation (See report of proceedings of the Belfast Society in the Dublin Hospital Gazette for January 1st, 1846.) More recently, Dr. Ross has noticed very ably a similar conjunction of the scarlatinal and rheumatic disorders.

In April 1850, scarlet fever being then prevalent in the district, I attended a family on Barnes Green

that had been attacked with the prevailing disease. There were four children seized in this household; they were affected nearly at the same time. The introduction of the disease was clearly made out, and the fever took, in every case, the type of scarlatina anginosa. On the second day of the eruption two of the children, both boys, were seized with severe pains in the joints, particularly in the wrists, ankles, and knees, and on the following day there was as clear rheumatic swelling of these joints as in any case of acute rheumatic fever that I have ever witnessed; I saw, myself, at the same time, the scarlatinal skin and throat, the strawberry tongue, and the rheumatic joints. On the following day the rash had much subsided, and the skin, which had before been dry and hot, began to throw out the ordinary acid secretion of rheumatic fever. The next day the cases might be said to have assumed altogether the rheumatic state, and in one child the endocardial membrane became affected. For more than a week these two children appeared to be gradually recovering; but at the end of this period there was a recurrence of the acute rheumatic signs, together with indications of albuminuria. At this same time the two other children, who had passed simply through the scarlatinal disease, became affected with albuminuria, and also with pain and swelling of the joints. The recovery of each was extremely slow, owing chiefly to the frequent recurrence of rheumatic arthritis; but ultimately they did all recover, and that soundly. Singularly enough, during their

convalescence, an elder sister, who had not been affected with either scarlet fever or rheumatism, was seized with erysipelas of the face, and suffered dangerously from that disorder.

I could gain no clue whatever as to the cause of the admixture of the scarlatinal and rheumatismal symptoms in these children. The house in which they lived was opposite to a large mire or pool of water, but was not specially damp; nor were other children, situated near the same pool and also seized with scarlet fever, affected with joint-disorder. Further, I could not make out satisfactorily any proof of hereditary taint as accounting for the rheumatic complication; but there it was, and there was the fact, in spite of any hypothesis to the contrary, that two diseases may exist in the same body at the same time.

THE CHEMICAL PATHOLOGY OF SCARLET FEVER.

In considering the pathology of scarlet fever, it has been too common a practice to classify the disorder as belonging to fevers of the typhous series. Franz Simon enlarged this hypothesis much, by placing scarlet fever under the list of diseases marked by what he has termed hypinosis, or a condition in which there is less fibrine than in healthy blood, and in which the proportion of fibrine to the blood-corpuscles, 2.1: 110, is less than is normal. He bases this classification of scarlet fever on four analyses by Andral and Gavarret ; but it seems to me, even on the evidence of these analysts, that the dis

order is falsely classified. In one of these cases the blood, at a first bleeding, gave an excess of fibrine, viz., 3.1 to 146 of blood-corpuscles; while at the second bleeding this proportion was increased, the fibrine being as 4.0 to 124.3 of blood-corpuscles. In their second case the fibrine was as 3.5 to 136.1 of blood-corpuscles, and in the third 6.8 to 112.2. Surely, then, it cannot be said that analysis of blood puts the disease out of the list of inflammatory disorders. I should urge that, so far as these very deficient inquiries go, they put the malady clearly under the inflammatory series, in which there is no decrease, but rather an increase, of fibrine-hyperinosis.

The pathology, as derived from the symptoms, can, moreover, only be read of as indicating the true inflammatory condition, in the original sense of that term; the circulation is accelerated, the free surfaces are unusually heated (I once saw the thermometer, with the bulb under the tongue, rise to 109° Fahr.), and in the throat and often in the external glands there are the dolor, calor, rubor et tumor. But if nothing else connected the disorder with ailments purely inflammatory in character, such as rheumatism and pneumonia, the condition of the urine would of itself sustain the analogy. In 1850 I observed that it was a frequent thing in scarlet fever to have, with the usually large increase of pigmentary matter, a free deposit of uric acid, as well as a copious deposit of deeply tinged urates. But more careful and longer continued observations have shown