Chapter VI: Of the Pathology of Fever (1)

_Importance of connecting the Symptoms with the States of the Organs:
Pathology of Fever comprehends the Morbid Changes that take place in
the Solids and Fluids of the Body. 1. General Pathology of the
Solids, exhibiting a collective View of the Morbid Appearances in
the Head, Thorax, and Abdomen. Cases illustrating such Morbid
Appearances in each of these Cavities. 2. Pathology of the Fluids._

The preceding history of the symptoms of fever can be of no real use unless it be possible to connect it with the events of which those symptoms are the signs. The events consist of certain morbid changes which take place in the series of organs already enumerated. We arrive at the knowledge of these events first by noting the symptoms which occur during life, and their order of succession: and, secondly, by examining the condition of the organs after death in the fatal cases: a comparison of the symptoms, as previously observed, with the state of the organs as subsequently ascertained, teaches us what the symptoms indicate. By carefully observing the symptoms in a large number of cases, we at length become acquainted with all the important symptoms that arise: by carefully examining the organs after death in a large number of cases, we gradually learn all the important changes in structure which they undergo: and by comparing, in all cases, the morbid symptoms with the altered states, we acquire in the end the power of ascertaining, with a high degree of probability, the presence of an event which we cannot see, by the presence of its sign which we can see.

In proportion as our knowledge becomes perfect, we are thus enabled, during life, and at the bed-side of the patient, to see what is going on within his brain, within his lungs, and within his intestines, with as much distinctness and certainty as we could were the cases in which these organs are enclosed, and the organs themselves transparent. The highly interesting and important fact demonstrated by the examination, in the manner of which we have just spoken, of large numbers of fever patients is, that the changes which take place in the organs are uniform; that the symptoms by which these changes are denoted are likewise uniform, and therefore, that it is possible to arrive at a perfect knowledge of the phenomena of fever.

The present state of our knowledge, it must be confessed, is far from being perfect. To a certain extent, however, it is even already sufficiently perfect to afford the physician an invaluable guide in the conduct of his practice; and the steps that are wanting to complete the knowledge we possess (as far as human knowledge can be complete) future labour and perseverance will assuredly supply.

The pathology of fever comprehends the morbid changes that take place in the solids and the fluids of the body. It is probable that the changes in the fluids are wholly dependent upon those which take place in the solids, although the vitiation of the former must necessarily react upon, and increase the derangement of the latter. If it be true, as is highly probable, that the changes in the solids are beyond all comparison of the greatest importance, as not only antecedents, but _invariable_ antecedents, or causes, it may be considered fortunate that our knowledge of their diseases is so much more advanced than our knowledge of the diseases of the humours. The morbid changes of the solids are ascertained with a great degree of exactness, it may almost be said with a great degree of perfection; while those which occur in the fluids are almost wholly unknown. Until very recently physicians satisfied themselves with framing conjectures about their corruption; and knowing with certainty no one vice that they possess, they attributed to them a thousand. Attention is now awakened to the subject: investigation is going on: and before long we shall probably know, with some degree of precision, whether any changes really take place, and what they are: but the researches which have hitherto been made are so few and so imperfect, that it can hardly be said that a single point is satisfactorily made out and firmly established.

In laying before the reader the pathology of the solids, as far as it is yet ascertained, it is my most anxious wish to enable him constantly to make for himself, as he proceeds, the association between the morbid appearances that are found after death, and the symptoms that were present during life. For this reason every case that is adduced to illustrate any morbid change is preceded by a brief account of the symptoms that were observed, day by day, at the bed-side of the patient. For the sake of brevity however, no less than for that of clearness, none but the essential are noticed. The daily reports, of which all the cases cited, are exceedingly condensed forms, are full, and contain, as they necessarily must contain, many repetitions with which it would be worse than useless to burthen this account of them. Even the statement of the remedies that were adopted (excepting in as far as they obviously influenced the symptoms) is omitted, from the conviction that the mind cannot attend without distraction, at one and the same time, to the pathology and the treatment.

Predominance of affection is the principle according to which the cases are arranged, those in which the brain was most affected being classed together under one section—the cerebral; those in which the lungs were most affected under a second—the thoracic; and those in which the intestines were most affected under a third—the abdominal. In like manner, the individual cases under each section are so placed as to succeed each other, as nearly as possible, in the order of their severity.

Before entering into particular details, it may be useful to exhibit a brief outline of the general pathology of fever, shewing, at one view, the general results which are derived from an examination of the collective cases. In this outline the organs in each cavity are noticed in the order of the frequency and extent in which they are found diseased.

I. PATHOLOGY OF THE SOLIDS IN FEVER.

1. _External Appearances of the Body after Death._

The skin is always of a more dusky colour than natural; it is sometimes studded with petechiæ, which in bad cases are large and of a deep purple tint, giving to the body a spotted or speckled appearance.

Externally the body always appears emaciated, and on removing the skin, the greater portion of the adipose substance is found to be absorbed; what remains of it is of an unhealthy yellow colour. The muscular fibre is remarkably dark, and this dark colour extends, as we shall see immediately, to the internal viscera.

2. _Morbid Appearances in the Head._

Of the membranes of the brain, the arachnoid is the most constantly diseased. It is seldom or never in a healthy condition. It is always either more vascular than natural, or when in this respect unchanged, it is altered in structure, being thickened, opake and milky: when in this latter state, a gelatinous fluid is usually effused beneath it. Not uncommonly, it is united at several points to the membranes above and below it. To the dura mater it very often adheres, particularly at the angles of the hemispheres, or along the course of the longitudinal sinus; and, in these cases, the adhesion is always peculiarly firm at the vertex. The dura mater itself is less constantly changed in appearance, although this membrane also is sometimes more vascular than natural, and frequently it either adheres with preternatural firmness to the skull-cap, or, on the contrary, it is quite detached from it, in consequence of effusion between it and the bones of the cranium. To the pia mater, the arachnoid is also very often adherent at several points: it is seldom that the pia mater is changed in structure, but it is generally preternaturally vascular. In like manner, the theca which encloses the spinal cord is frequently highly vascular, and contains a larger quantity of fluid than natural.

The brain itself is seldom or never in a healthy condition; the morbid changes to be distinguished in it differ greatly in degree in different cases, but still, in almost every case, some morbid change is to be discerned. These changes consist of an altered state of its substance, or of its cavities, or of both. The most usual change apparent in its substance is a higher degree of vascularity than natural. This increased vascularity is sometimes confined to the surface; sometimes it is more manifest deep in its substance; and, while common to both, it may exhibit different degrees of intensity in either. When on the surface, this preternatural vascularity is denoted by a greater fullness of the vessels, and, apparently by an increase in their number; when within the substance, by a greater number of bloody points, which are rendered visible by an incision with the scalpel. And in both situations it may exist in all degrees, from a faint blush to a deep and vivid redness. The substance itself is sometimes softer, sometimes firmer than natural. The softening differs in degree and in extent. Sometimes the entire cerebrum is manifestly and considerably softer than natural; at other times, only particular portions of it are found in this softened state. Now and then, but very rarely, abscess is discovered within its substance. It is remarkable that the cerebellum is always considerably softer than the cerebrum: whence these two portions of the organ are often observed to be in opposite states, the cerebrum being frequently preternaturally firm, and the cerebellum being almost always softer than natural. The pituitary gland also is very constantly softened, and often in a state of suppuration. When the cerebrum is preternaturally firm, the firmness is usually general.

The morbid change observable in the cavities of the brain consists in their containing an excess of secretion. This increase of secreted fluid is usually accumulated in the lateral ventricles: the quantity varies from a drachm to several ounces; when thus great, the lateral ventricles themselves are enlarged, the third and fourth ventricles are likewise distended with fluid, and the passages connecting them are proportionally full.

Common as it is to find a preternatural quantity of fluid in the ventricles, it is still more common to find it in excess between the membranes; often between the dura mater and the arachnoid, almost always between the arachnoid and the pia mater. It has been already stated, that the fluid effused between the arachnoid is of a gelatinous appearance and aspect; every where else it possesses the physical properties of serum, being thin, transparent, and of a straw colour: now and then it is thicker in consistence, opake, and even bloody, and sometimes that beneath the membranes contains flakes of lymph, or is mixed with pus.

It is observable that the two morbid conditions now described, that of excessive vascularity and that of increased secretion, are never co-existent. If the vessels of the brain and its membranes are loaded with blood, there is little or no fluid within the former or between the latter: if, on the contrary, the effusion be great, there is little or no appearance of vascularity. Effusion is the effect and the termination of vascularity; it is the ultimate result of vascular action, and the effect having ensued, the cause ceases to be apparent.

The substance of the spinal cord is seldom changed, either in vascularity or in consistence: the morbid changes which this organ undergoes have hitherto been observed only in the membrane that invests it, which, as has been just stated, is not only highly vascular, but likewise contains a much larger quantity of fluid than natural.

3. _Morbid Appearances in the Thorax._

Of all the thoracic viscera, that which is most frequently diseased is the mucous membrane of the bronchi. The disease which takes place in this organ is not only the most constant, whatever be the type or the degree of fever, but it is also the most characteristic of the febrile state. Its disease is specific and uniform. It consists of preternatural redness. The character of this redness distinguishes it from that which is observed in ordinary inflammation. It is uniformly and strikingly darker, the difference in colour being precisely that which subsists between venous and arterial blood. This darkness of colour apparent in the bronchial lining, increases in degree as the tubes of the bronchi diminish in size: while it may be only just discernible in the large trunks, the colour may be nearly black in the minute branches. This change in the natural colour of the membrane is indicative, not only of an increase in its vascularity, but of alteration in its structure. It is almost always attended with a preternatural thickening of its substance, as is demonstrated by cutting through the tube and reflecting the membrane. The tubes themselves contain more or less fluid, which consists of mucus, mixed with pus. Analogous to what has been stated with regard to the vascularity of the brain and to its secretions, when the quantity of secretion contained in the bronchial tubes is great, the degree of vascularity apparent in the membrane is lessened.

In scarlet fever, the morbid changes are somewhat different. The mucous membrane covering the trachea, the larynx with its cartilages, the amygdalæ and the soft palate is inflamed; the redness is of a brighter and more vivid colour than that which has been stated to be characteristic of continued fever without an eruption: it is similar to the characteristic colour of the scarlatina tongue. But what is very remarkable, and what appears to justify the view we have taken of scarlatina and the division we have suggested of its types, when the cases are severe, the colour of the mucous membrane becomes much darker, the deepness of the tinge increasing with the severity of the affection, until, at length, the colour closely resembles that which is peculiar to ordinary fever.

As in continued fever without an eruption, so in scarlatina, the increased vascularity of the mucous membrane is accompanied with a preternatural thickening of its substance. In scarlet fever, that portion of it which covers the epiglottis, the rima glottidis, and the arytænoid cartilages, is especially found in this diseased condition. When this inflammation and thickening passes into the state of ulceration, which it often does, the arytænoid cartilages are the special seat of this process, although the ulceration often extends to the amygdalæ, and sometimes to the root of the tongue.

When in every other respect healthy, the substance of the lungs in fever is so constantly found either engorged with blood or infiltrated with serum, that these changes would seem to form essential parts of the morbid phenomena.

In examining those who die of fever, a great variety and complication of thoracic diseases, in addition to the morbid changes just described, are found. The pleuræ exhibit every degree of vascularity, from the faintest blush of redness to that which is characteristic of the most intense inflammation, and every extent of adhesion, from that of the smallest point to the complete obliteration of the cavity. The usual products of inflammation, namely, the effusion of serum and lymph, and the formation of pus and of adventitious membrane are likewise found equally varying in degree. The parenchyma of the lungs, besides the engorgement and infiltration just adverted to, presents hepatization and tubercular disease in every variety and degree; ulceration and abscess in every extent, and hæmorrhagic and calcareous depositions, together with enlargement and melanosis of the bronchial glands. But, since none of these diseases form any part of the changes of structure which are peculiar to the febrile state, it is sufficient in this place merely to advert to them.

4. _Morbid Appearances in the Abdomen._

On opening the cavity of the abdomen all the viscera contained in it appear, in general, more vascular than natural, and invariably of a darker colour than in the state of health. Several of the organs are affected in a uniform and peculiar manner, but that which is by far the most constantly diseased is the mucous membrane of the small intestines; and especially that portion of it which lines the ileum and the cæcum.

The varieties of disease exhibited by this membrane may be comprehended under three, namely, vascularity, thickening and ulceration.

In all cases increased vascularity is the first stage of disease: in a great proportion of cases this increased vascularity is confined to the inferior extremity of the small intestines, which is often distinctly inflamed when not the slightest deviation from healthy structure is traceable in any other part of the canal.

The second stage of disease consists in thickening of the membrane, or in deposition of matter beneath it, or in both. Preternatural thickening of the membrane is often of very considerable extent: deposition of matter beneath it appears to be confined to the situations of the mucous glands. These glands are found in all states and stages of disease from the least to the greatest enlargement, and from the mere abrasion of their surface to the entire ulceration of their substance. Perhaps one of the glandulæ solitariæ enlarged and covered with inflamed mucous membrane may constitute the only morbid appearance discernible in the intestine; or this deposition may take place in so many of these glands as to present a most extensive surface of disease.

The third stage is that of ulceration, which may supervene when the membrane is affected in either of the modes just described; but the ulcer will not be the same in both cases: in each it will have a different and a distinctive character. If ulceration take place while the mucous coat is in a state of simple vascularity, the ulcer will in general be extensive but superficial; its surface will present a smooth appearance, and its margin will be regular and defined: if, on the contrary, it occur after thickening of the membrane or enlargement of its glands, its characters will be just the reverse: it will be less extensive, but more deep, because it must penetrate a mass of adventitious matter before it can reach the other coats; and, for the same reason, its margin will be more elevated and its surface more ragged. It is in this form of ulcer that perforation of the intestine generally occurs; in which case the mucous and muscular coats alone are ulcerated: the peritoneal gives way from gangrene.

Whenever the mucous membrane is ulcerated, whatever be the form of the ulcer, the corresponding portion of the peritoneal coat is more vascular than natural; and perforation must be attended with inevitable death, on account of the extensive and intense peritonitis excited by the escape of fæces into the peritoneal cavity.

Frequent as ulceration of the mucous membrane is in fever, and characteristic as this lesion is of the febrile state, yet it sometimes appears to be present when it does not really exist. From the quantity of adventitious matter deposited beneath the mucous coat, its surface sometimes becomes irregularly elevated, its valvulæ conniventes obliterated and its aspect smooth and glistening: in this state it may be easily mistaken, on a superficial examination, for ulceration, while more careful observation will shew that the membrane itself remains entire.

Proportioned to the extent and degree of these changes in the intestine are, inflammation, enlargement, induration and suppuration of the mesenteric glands; and invariably those glands which are embedded in that portion of the mesentery attached to the affected intestine, are the most diseased.

It is quite remarkable with what uniformity the spleen is diseased in fever. In almost every case of genuine fever hitherto examined, it has been found altered in appearance and deranged in structure. Its natural purple colour is changed to a deeper and darker tint, and, on the removal of the peritoneum that invests it, its substance, on being slightly touched with the finger, breaks down into an almost fluid mass.

The pancreas, the structure of which is so seldom changed in any other disease, is very constantly deranged in fever. Its morbid condition is invariably the same, and, what is singular, it is exactly the reverse of that produced in the spleen. It is always more firm than natural; often it is exceedingly indurated, and that portion of it which is attached to the duodenum is sometimes nearly cartilaginous.

Each organ having been described in the order of the frequency and extent of the disease it exhibits, we have hitherto said nothing of the mucous membrane of the stomach. This viscus having been regarded in France as the great source and seat of fever, particular attention has been paid to the appearances it exhibits after death. The uniform result of the most careful examination of fatal cases in London is, that the mucous membrane of this organ is less frequently, less severely, and less extensively diseased than any other portion of the same membrane. Occasionally it is more vascular than natural; this vascularity is seldom general; it is almost always confined to its pyloric half; in the few cases in which it has been very great, the membrane has been observed to be thickened and sometimes softened: but no instance has occurred in which it has been the seat of a single ulcer.

Of all the abdominal viscera, the liver is the least frequently deranged in structure, and when it exhibits any morbid change it is both less extensive and less characteristic. The blood contained in it is peculiarly dark and always fluid; its parenchyma is sometimes softer than natural; the gall-bladder contains a large quantity of bile, which is seldom healthy, being almost always in one of two states of disease, either paler and more fluid than natural, or extremely dark and very much inspissated.

The preceding comprehend all the morbid conditions of the abdominal viscera which are peculiar to fever: but the organs of this cavity exhibit other and great varieties of disease, to which, since they form no part of the febrile changes, it is sufficient merely to advert. Such are inflammation of the peritoneum; effusion of lymph upon its surface or of serum into its cavity; agglutination of the intestines; inflammation of the mesentery; false adhesions between the liver, spleen, and mesentery; tubercles in the liver; induration of its substance; tubercles and abscess of the spleen; thickening of the coats of the bladder and inflammation of its mucous membrane: in the female, vascularity and enlargement of the ovaria, to which hydatids are sometimes attached; vascularity of the external surface of the uterus, and inflammation of the os tincæ and of its internal membrane: it is rare to find any appearance of disease in the kidney in either sex.

Such is the circle of organs which are observed to be specifically diseased in fever, and with the most remarkable constancy. We go on to give individual cases in illustration of these morbid changes and of the symptoms with which they are accompanied.

II. CASES IN ILLUSTRATION OF THE MORBID CHANGES WHICH TAKE PLACE WITHIN
THE HEAD: OR CEREBRAL CASES.

1. _Vascularity of Brain, Spinal Cord and Membranes, with Gelatinous or
slight Serous Effusion._

CASE XV.

SARAH AGENBAR, æt. 21, married.

After some previous indisposition, attacked, eight days ago, with the ordinary symptoms of fever. At present, unable to give any account of her illness, or to answer any question: delirium came on four days ago, which still continues; mind quite fatuous; extreme restlessness; no sleep: eyes wild and rolling; tongue not to be protruded; pulse 130, weak and indistinct.

9th. No sleep; delirium the same; pulse 126.

10th. Died.

_Head._ Membranes and substance of the brain highly vascular; no effusion. _Thorax._ Viscera exhibited only slight indications of disease. _Abdomen._ Viscera nearly healthy.

CASE XVI.

MARY WELSH, æt. 55, admitted on the 15th day of fever. Attack came on with ordinary symptoms. Pain of head now gone; some sleep; tongue loaded, moist; pulse 80; skin cool.

21st. No pain; much prostration; tongue dry; pulse 104.

22d. Stupor; mind incoherent; scarcely any sleep; tongue brown and dry; pulse 108; skin hot.

27th. Coma; erysipelas on face; pulse 110.

28th. Coma increased; tongue deeply crusted; erysipelas extending.

29th. Delirium; tongue black; stools passed in bed; erysipelas extending.

30th. Muscular tremor.

35th. Increasing coma and prostration. Died.

_Head._ Arachnoid opake; slight serous effusion; substance of brain and spinal cord vascular. _Thorax._ [28][Ten or twelve ounces of serum in bag of pleuræ; pericardium contained twelve ounces of sero-purulent fluid; that part of it which is reflected over the heart highly inflamed and covered with flakes of coagulable lymph.] _Abdomen._ Viscera healthy.

CASE XVII.

MARGARET GIBBS, æt. 63, widow, admitted on the 43rd day of fever. Pain of head still considerable; sleeps badly; pain of chest on right side; much cough, with purulent expectoration; abdomen tender; tongue loaded, dry; pulse 105.

45th. Pain gone; drowsiness, approaching to coma; no delirium; pulse 100.

48th. Insensibility continues; cough, with bloody sputa; pulse 108.

55th. Prostration; pulse 135, extremely weak; skin cold and clammy.

57th. Died.

_Head._ Arachnoid opake, with gelatinous effusion beneath it; adherent to the dura mater along the longitudinal sinus; substance of brain vascular. _Thorax._ [Pleuræ adherent; slight effusion in left side; substance of lower lobes partly gorged, partly hepatized; melanotic deposits in the parenchyma. _Abdomen._ Both ovaria dropsical; partly converted into cartilage; scirrhous tumour in walls of uterus.]

CASE XVIII.

ELIZABETH RALPH, æt. 65, widow, admitted on the 8th day of fever. From commencement, severe pain of head and abdomen; both continue; mind confused; scarcely any sleep; tongue foul and dry; much thirst; bowels purged; pulse 105.

9th. Pain of head diminished; that of abdomen unrelieved; 8 stools; pulse 108.

10th. Pain of head gone; that of abdomen undiminished; 4 stools.

11th. Pain of head not returned; tenderness of abdomen undiminished; 7 stools; pulse 124.

12th. Tenderness of abdomen unabated; now swollen, hard, and rounded at umbilicus; 7 stools; pulse 125.

14th. Tenderness and purging continue. Died.

_Head._ [Falciform process of dura mater ossified;] substance of brain vascular; more fluid than natural in the ventricles. _Thorax._ [Pleuræ adherent; serous effusion into parenchyma of lungs. _Abdomen._ Peritoneal sac contained several ounces of pus and serum; peritoneum covering the liver coated with coagulable lymph; peritoneal coat of the intestines highly inflamed; colon adherent to the omentum all around;] all its coats so softened as to be easily torn; mucous membrane in general healthy.

CASE XIX.

ELIZABETH GASSET, æt. 32, married, admitted on the 8th day of fever. Attack commenced, in addition to the common symptoms, with violent pain of the bowels. Epigastre still extremely tender; tongue red, clean, moist; no stool for six days; no pain of head or chest; pulse 99.

9th. Tenderness of epigastrium continues; tongue red and dry; no stool; pulse 84; no cerebral nor pectoral symptoms.

10th. Died.

_Head._ Membranes and substance of the brain highly vascular; no effusion. _Thorax._ Viscera healthy. _Abdomen._ [Eight inches of the jejunum intussuscepted within a portion of the same intestine of equal length; the farthest extremity of the intussuscepted part mortified; the mucous membrane of the containing portion highly vascular and in a state of ecchymosis; the intestinal canal, between the constricted portion and the stomach, contracted, and its valvulæ conniventes enlarged and œdematous; the size of the tube beyond the disease much diminished, and the colon, especially, contracted into a mere cord.]

CASE XX.

JOSEPH DANBURY, æt. 20, stone-cutter. Admitted on the 15th day of fever; pain of head, which has never been great, is now very slight; much vertigo; eyes sallow; no uneasiness in chest; some cough; abdomen tender; tongue brown; teeth sordid; much thirst; pulse 108.

26th. Since last report, pain of head never entirely absent; vertigo constant and distressing; pain in the right side of the head much increased to-day, while the vertigo is now gone; delirium; eyes suffused; tongue dry; pulse 120.

36th. The pain of the head and the giddiness have continued to alternate; both are now quite gone; mind confused and dull; expression of countenance wild; muscular tremor; respiration hurried.

37th. Died.

_Head._ Pia mater vascular; substance of brain vascular; slight effusion between the membranes and into the ventricles. _Thorax._ No prominent disease. _Abdomen._ Peritoneal coat of intestines vascular; other viscera healthy.

CASE XXI.

EDWARD FORRESTER, æt. 46, cabinet-maker. Admitted on 6th day of fever. Complaint commenced with severe pain of back, loins, and epigastrium, with sense of ardent heat. At present, pain of head slight; that of epigastrium continues; tongue white, moist; no uneasiness of chest; pulse 90.

7th. Pain of head, limbs and epigastrium; tongue white, dry; pulse 96, full and strong. V.S. ad ℥xij.

8th. Pain of head gone; that of epigastrium diminished; pulse 110; blood not sizy.

10th. Pain of head returned; that of epigastrium diminished; no sleep; delirium; pulse 126.

12th. Pain of head again gone; delirium continues; pulse 110.

13th. No sleep; mind confused; delirium; subsultus tendinum.

15th. Cerebral symptoms undiminished; tongue dry and quite black; lips and teeth covered with black sordes.

19th. Severity of symptoms had diminished; lips, teeth, and tongue had begun to clean; pulse fallen to 96; but the parotid gland to-day painful, enlarged and indurated.

20th. Tumour of parotid increased; all the symptoms greatly aggravated; tongue not to be protruded.

22d. Insensibility amounting to coma.

27th. Insensibility and prostration gradually increased. Died.

_Head._ Arachnoid white and opake; firmly adherent along the vertex to the dura mater. Surface and substance of brain highly vascular; gelatinous effusion between the membranes. _Thorax._ Mucous membrane of bronchi vascular; [pleuræ adherent; lower lobe of left lung partly hepatized, and partly consisting of a mass of suppurating tubercles.] _Abdomen._ Small intestines of extremely dark colour; mucous membrane vascular.

CASE XXII.

MARY SINGLETON, æt. 28, married. Admitted on the 8th day of fever: pain of head slight, confined chiefly to the occiput; pain of left side, with inability to lie on it; no cough; tenderness of abdomen; pulse 111.

9th. After venesection to twelve ounces pain in head, side, and abdomen relieved; blood buffy.

11th. Slight pain of occiput; much pain and tenderness of abdomen; pulse 120.

13th. Cerebral and abdominal symptoms unchanged; tongue brown and dry; eyes yellow.

19th. Pain of head never entirely disappeared, but though always present it was always slight; now respiration hurried; tongue extremely brown and dry; pulse 120; eyes yellow.

20th. Died.

_Head._ Membranes of brain vascular with gelatinous effusion beneath them; and slight serous effusion into ventricles: substance both of cerebrum and cerebellum highly vascular; pituitary gland softened and suppurating. _Thorax._ Mucous membrane of bronchi vascular; substance of both lungs gorged with blood; [pleuræ universally adherent.] _Abdomen._ Mucous membrane of intestines not vascular; but the mesentery highly injected: [liver adherent to diaphragm.]

CASE XXIII.

MARY ANN LAMBERTH, æt. 16, servant. Admitted on 22d day of fever. Pain of head, which has been very severe, is now gone; no tenderness of abdomen on fullest pressure; tongue red, smooth, and chapped; lips and teeth sordid; bowels purged; pulse 108.

30th. Cough with slight expectoration; cheek dusky; no tenderness of abdomen; bowels purged; pulse 120.

35th. Mind confused; much restlessness; no sleep; stools passed in bed; pulse 124, weak. A diffused swelling has appeared about the left wrist, attended with great pain.

36th. Mind more confused; countenance sunk; swelling of wrist increased; pulse not to be counted.

37th. Died.

N.B. Probable that the swelling of the wrist arose from the peculiar affection hereafter to be described.[29]

_Head._ Some effusion beneath the membranes, and at the base of the skull; substance of brain natural; anterior and middle lobes firmly adherent. _Thorax._ Healthy. _Abdomen._ The ilium contained one large and spreading ulcer, the glands around which were darkened and inflamed.

CASE XXIV.

MARY CROUCH, æt. 30. Admitted on the 7th day of fever. At present pain of head gone; some pain of back continues; no sleep; great restlessness; almost constant moaning; no uneasiness of chest; no cough; respiration hurried; pulse 108.

8th. Sleeplessness, hurried respiration, tenderness of abdomen continue; tongue red and glazed.

9th. Delirium; respiration hurried and noisy; lips and teeth sordid.

10th. Subsultus tendinum.

11th. Face livid; dark, bloody-coloured fluid issuing from the mouth; convulsive twitchings of muscles of face and hands. Died.

_Head._ Arachnoid opake; dura mater vascular; substance of brain vascular; some effusion between membranes and into ventricles. _Thorax._ Nearly healthy. _Abdomen._ Mucous membrane of ilium vascular; liver soft.

CASE XXV.

MARY GOODMAN, æt. 50, nurse. Admitted on 4th day of disease: has been in a state of constant intoxication for several days past; has had much pain of head, which is now nearly gone; mind confused; eyes injected; abdomen tender; bowels purged; tongue brown and dry in middle; white at edges; tremulous; pulse 120; skin hot. Died next morning.

_Head._ Sinuses of dura mater turgid with blood; vessels of pia mater greatly congested; an ounce and a half of serum at the base of the skull. Theca vertebralis highly vascular; great congestion of vertebral veins; some effusion of serum at cauda equina. _Thorax._ Healthy. _Abdomen._ Mucous membrane of small intestines vascular; [liver greatly enlarged.]

CASE XXVI.

JOHN EYLES, æt. 25, servant. Admitted on the 10th day of scarlet fever. Throat sore; deglutition painful; eruption fading; no pain of head, chest, or abdomen; tongue red and glazed; lips and teeth sordid; bowels purged; pulse 129.

11th. Voice hoarse; pulse 120; not the slightest pain of head.

14th. Numerous ash-coloured crusts scattered over the internal fauces; countenance anxious; respiration hurried; pulse 108. Died next morning.

_Head._ Arachnoid thick, opake, and unusually firm, with slight effusion beneath it; substance both of cerebrum and cerebellum highly vascular; pituitary gland enlarged and beginning to suppurate. _Thorax._ Larynx inflamed, covered with superficial circular ulcers; tongue aphthous; mouths of ducts on the surface of the amygdalæ ulcerated. _Abdomen._ Mucous membrane of ilium and cæcum highly vascular, not ulcerated; vessels of all the organs exceedingly turgid with blood.

2. _Vascularity of Brain, Membranes, &c. with Effusion of Coagulable
Lymph and Formation of Pus._

CASE XXVII.

JAMES MOULDEN, æt. 17, servant. Admitted on the 5th day of fever; left the hospital three months ago cured of a similar attack. Present relapse came on besides the ordinary symptoms, with severe pain of the head; pain still continues, but it is now only slight; expression of countenance dull and heavy; pulse 92, soft; no thoracic symptoms; no tenderness of abdomen; tongue loaded in middle with yellow fur, red around the edges, moist.

6th. Pain of head continues with sense of weight and intolerance of light; scarcely any sleep; pulse 102.

9th. Pain of head and intolerance of light increased; adnatæ glistening; pulse 94.

10th. Pain of head quite gone; sense of weight and intolerance of light continue; face flushed; pulse 84.

11th. Pain of head returned; no sleep; delirium; pulse 96; tongue brown and dry.

13th. Pain of head and dullness and heaviness of eyes increased; pulse 84; abdomen tender.

14th. Nearly insensible; pulse 90; abdomen tender, swollen, and hard.

15th. Last evening coma increased; respiration became hurried and laborious; great prostration; expired this morning.

_Head._ Membranes highly vascular; a large quantity of coagulable lymph effused at base of the brain. _Thorax._ Mucous membrane of bronchi highly vascular; substance of lungs gorged with blood. _Abdomen._ On mucous membrane of stomach several patches of a dark red colour; mucous membrane of intestines pretty natural. [Spleen studded with soft tubercles of various sizes, some of which contained a cheesy matter; others a puriform fluid; the liver contained a few tubercles of the same nature but smaller.]

CASE XXVIII.

CHARLOTTE CLARKE, æt. 18, servant. Admitted on 3d day of scarlet fever; throat sore; deglutition painful; no pain of chest; some cough; pain of head severe; much pain of limbs; mind distinct; tolerable sleep; no tenderness of abdomen; skin warm, covered with scarlet eruption; tongue characteristic; much thirst; no stool for three days; pulse 126, of good power; V. S. ad ℥xvj.

4th. Blood inflamed; throat continues sore; pain of head gone; pulse 130. Hirud. xij. gutt.

5th. Throat unrelieved; deglutition very painful; no pain of head; pulse 110. Rep. Hirud. x.

6th. Throat nearly well; pulse 116.

16th. Had become convalescent; yesterday evening felt scarcely so well; during the night extremely restless, with much noisy delirium; at present quite prostrate; pulse 117, not weak; respiration hurried; abdomen tender; tongue quite dry; four stools of green colour, all passed in bed; erysipelas on right temple.

17th. Lies quite prostrate; insensible; constant delirium with unceasing moaning; muscular tremor; all the stools passed in bed; pulse 126. Died following morning.

_Head._ Dura mater vascular; some spots of ecchymosis between its laminæ; arachnoid vascular, with effusion of viscid serum between it and pia mater. Between the arachnoid and the pia mater covering the superior part of the right hemisphere a layer of coagulable lymph of a yellow colour, on the removal of which the pia mater beneath it appeared entire. Shreds of coagulable lymph were also found at the base of the brain where there was more serum than natural as well as in the ventricles. Substance of the brain highly vascular. Viscera of thorax and abdomen healthy.

CASE XXIX.

ISAAC COOMBES, æt. 60, weaver. Admitted on 9th day of fever: at present no pain of head; some sleep; face pallid; great prostration; no thoracic or abdominal symptoms.

15th. Convalescent.

21st. Attacked suddenly with shivering, heat, vomiting; no pain of head or of any organ; pulse 96.

22d. Continues quite free from pain, but no sleep; extreme restlessness; great prostration; skin warm and dry; pulse 84. Died following morning.

_Head._ Between the pia mater and the arachnoid a large quantity of coagulable lymph of a yellow colour, with which indeed the arachnoid appeared to be universally lined, and which in some places was very thick. Substance of the brain highly vascular, being exceedingly full of bloody points, and in some places stained; three or four ounces of serum in the ventricles, at the bottom of each of which lay about a drachm of pus. The spinal sheath contained the same kind of substance, while the cord itself presented a healthy appearance. _Thorax._ Right lung gorged with blood and partly hepatized. _Abdomen._ Spleen soft; other viscera healthy.

CASE XXX.

SUSANAH STAMMERS, æt. 9, destitute. Admitted on the 8th day of fever. Attack commenced with severe pain of the head which continues with almost equal violence; little or no sleep; eyes dull and heavy; face flushed; pulse 126; slight uneasiness of chest on full inspiration; no cough; no tenderness of abdomen; tongue loaded with white fur; red at point; bowels purged.

9th. Pain of head quite gone; less sensible; countenance more dull and heavy; pulse 120; abdomen tender.

11th. Delirium, with much talkativeness; pulse 112.

14th. Coma; bowels continue purged.

15th. Abdomen tender, swollen, rounded at navel.

19th. More sensible; more tranquil sleep; delirium gone; pulse 110.

27th. No coma nor delirium; tranquil sleep; tongue moist, cleaning; pulse 108 feeble.

45th. Appeared upon the whole to be convalescing, but in an exceedingly slow and imperfect manner; there was a remarkable vacancy in her countenance, almost amounting to a fatuous expression; and her mind was peevish and childish. On this day she was seized suddenly with convulsions of extreme violence, and died within twenty-four hours after the attack.

_Head._ Arachnoid thickened and opake; effusion of gelatinous fluid beneath it; substance of brain highly vascular; in the inferior cornu of left ventricle a pint of purulent matter, somewhat resembling broken down cortical substance; it lay loose within the cavity. _Thorax._ Superior lobe of right lung gorged and partly hepatized. [Pleuræ of right side adherent;] _Abdomen._ Mucous membrane of cæcum and commencement of colon vascular.

CASE XXXI.

HENRY BREWER, æt. 59, labourer. Admitted on the 10th day of fever: states that he has no pain in the head, and that he is quite free from pain every where excepting in the right side, where he has some uneasiness, which is attended with slight cough; tongue brown and dry; bowels natural; pulse 96.

12th. No pain of head; that of chest gone; sleeps well; pulse 108.

16th. About an hour after yesterday’s visit became suddenly insensible; it has been impossible to rouse him from this coma which still continues profound; respiration stertorous. Died in the course of the day.

_Head_: Dura mater thickened but not vascular; arachnoid thickened and opake; beneath it gelatinous effusion; upon its external surface a large quantity of well-formed pus; a quantity of purulent matter at the base of the brain surrounding the corpora quadrigemina: walls of the fourth ventricle ragged; two ounces of serous fluid in lateral ventricles and at base. _Thorax._ [Pluræ adherent; lower and middle lobes of right lung hepatized.] _Abdomen._ Viscera healthy.

3. _Vascularity of Brain, Membranes, &c. with copious Serous Effusion._

CASE XXXII.

GEORGE BLACKBEARD, æt. 18, servant. Admitted on the 22nd day of fever: complaint commenced with violent head-ache attended with frequent fits of epistaxis; pain of the head still continues, chiefly confined to the occiput; little sleep; eyes injected and suffused; pulse 102, tongue loaded, dry.

23d. Scarcely any pain in the head.

25th. Pain of the head entirely gone; epistaxis.

26th. Delirium: muscular tremor.

28th. Delirium and muscular tremor increased; pulse 112; tongue more dry; lips and teeth sordid.

31st. Died.

_Head._ Membranes and substance of brain vascular; ventricles distended with serum; no characteristic disease in thorax or abdomen.

CASE XXXIII.

ANN HIGGINS, æt. 30, servant. Admitted on the 22d day of fever: pain of head from the commencement very severe; chiefly confined to the right side; still continues, together with severe pain in the limbs; some pain in the right side of chest; cough; abdomen not tender; tongue dry in middle; red and moist around edges and at point; pulse 105, feeble; much prostration; entire surface of the body preternaturally sensible.

23rd. The sensibility which from the commencement has been felt over the whole surface of the body is now particularly acute in the joints; in all of which there is severe pain; pulse 112.

25th. Pain of head gone; mind indistinct; tongue dry: stools passed in bed; pulse 105. Pains in the joints; swelling and redness of left fore-arm.

27th. Mind more and more indistinct; pressure on any part of the body produces extreme pain; joints the same; died next day. At this period attention had not been awakened to the peculiar disease of the joints hereafter to be described; they were not therefore examined; but without doubt the affection was of the same nature.

_Head._ Dura mater vascular, and adhered with preternatural firmness to the skull; pia mater vascular; substance of brain natural; pituitary gland suppurating; the lateral and the third ventricles full of serous fluid; one ounce at base. _Thorax._ [Lungs emphysematous; several points of tubercular suppuration in left.] _Abdomen._ Mucous membrane of small intestines inflamed without ulceration.

CASE XXXIV.

JAMES DENNIE, æt. 28, labourer. Admitted on the 8th day of fever, which attacked with usual symptoms: at present pain of head; little sleep; eyes dull and heavy; some cough; respiration hurried; abdomen not tender; tongue white; pulse 112, weak; prostration.

9th. Pain of head increased; delirium; eyes suffused; cough and hurried respiration continue.

10th. Pain of head gone; constant and violent delirium; no sleep; pulse 108.

11th. Delirium gone; profound coma; muscular tremor; respiration hurried; pulse 108.

12th. Coma deeper; extreme restlessness; respiration more hurried; stools and urine passed in bed. Died.

_Head._ Arachnoid vascular; substance both of cerebrum and cerebellum vascular; all the ventricles full of serum; viscera of thorax and abdomen healthy.

CASE XXXV.

CHARLOTTE WATTS, æt. 9. Previous history of disease unknown: at present scarcely at all sensible; almost constant crying; frequent rolling of the head on the pillow; countenance anxious; pulse not to be counted from her extreme restlessness; respiration hurried; abdomen not tender; lips and teeth sordid. 2d day after admission constant noisy delirium; pulse 120.

17th. Almost imperceptible, but still gradual improvement since last report; more sensible; no delirium; but mind throughout extremely peevish and fretful; stools have constantly been and still are passed in bed; pulse 116.

19th. Large sloughing sores on loins and hips; erysipelas of surrounding integuments; pulse 112, weak.

27th. Sloughs have extended between the shoulders, along the back, and over both hips; great emaciation; extreme prostration; mind continues very fretful; pulse 110, very weak.

37th. Gradually grew weaker and weaker until this day, when she died.

_Head._ Arachnoid vascular; substance of brain and especially medulla oblongata highly vascular; between the arachnoid and the dura mater much limpid serum; all the ventricles distended with a similar fluid. _Thorax._ [Pleuræ adherent. Both lungs contained numerous tubercles in a state of suppuration. A large proportion of right lung hepatized.] _Abdomen._ Viscera healthy.

CASE XXXVI.

MARY SULLIVAN, æt. 26, married. Admitted on the 14th day of disease; pain of head severe from the beginning; continues unabated and even violent; no sleep; face pallid; expression depressed; pulse 81; abdomen tender; tongue foul and dry. V. S. ad ℥xij.

18th. Pain of head gone; delirium; pulse 70, soft; tongue more dry.

24th. Pain of head, which had returned slightly on some of the preceding days, was, from this period, finally lost in insensibility; no longer conscious; prostration; great restlessness; almost constant moaning; occasional retching; pulse 72.

26th. Continues perfectly insensible; all the stools passed in bed; pulse suddenly rose to 120, on the following day fell to 102; eyes half open and injected: no material change till 29th, died.

_Head._ Membranes and substance of brain appeared pretty healthy; all the ventricles enlarged, and contained about three ounces of limpid serum; a considerable quantity, also, at base; some coagulable lymph effused on that part of the arachnoid which covers the tuber annulare. _Thorax._ [Pleuræ adherent; substance of lungs full of tubercles, in different stages of disease.] _Abdomen._ [Liver hard;] other viscera healthy.

CASE XXXVII.

ANN BOON, æt. 14, admitted on 10th day of fever. Attacked in the beginning with severe head-ache, which still continues; abdomen tender; lips and teeth sordid; tongue brown and dry; pulse 120.

11th. Pain of head undiminished; eyes heavy and suffused; delirium; tongue red, dry, and glazed; pulse 108.

13th. Pain of head quite gone; delirium; pulse 118.

19th. Much noise through the night; peevishness during the day; pulse 108.

20th. More insensible; can give no answer to any question; pulse 118.

22d. Constant rolling of the head; pupils dilated; all the stools passed in bed; pulse 108.

29th. Eyes vacant and staring; pupils contracted; head sunk in bed; legs drawn up; stools passed in bed; urine abundant; pulse 117, regular and of good power.

30th. Skin covered in several places with vesicles, which discharge a thin ichor. Died.

_Head._ Membranes and substance of brain vascular; upwards of three ounces of serum in the ventricles and at base; much similar fluid in theca vertebralis. _Thorax._ Viscera healthy. _Abdomen._ Mesenteric glands greatly enlarged; some of them suppurating.

CASE XXXVIII.

RICHARD MACIFF, æt. 30, admitted on the 22d day of fever. No account can be obtained of its previous history: at present he lies quite prostrate and perfectly insensible; eyes wild and rolling; pupils dilated and insensible to light; constantly picking at the objects around him; pulse not to be counted, on account of his extreme restlessness, but it feels like a soft cotton cord, and nearly without pulsation.

23d. Profound coma; senseless muttering; constant muscular tremor; squinting; neither stool nor urine has been passed since admission; pulse 96, soft, not intermittent.

24th. Coma undiminished; one stool passed in bed; urine drawn off by the catheter; pulse 100, extremely feeble.

25th. No change.

26th. Died.

_Head._ Dura mater vascular; arachnoid highly vascular; that portion of it covering the tuber annulare distended into a bag of considerable size, filled with serum; all the ventricles enlarged and distended with serum. _Thorax._ [Right lung contained tubercles in various stages of disease.] _Abdomen._ [Liver of unusually deep red colour; in right and left lobes two small sacs, filled with calcareous matter; on surface of spleen a sac, containing matter similar to that in the liver.]

CASE XXXIX.

WILLIAM TENNANT, æt. 18, tailor. Admitted on the 8th day of fever; at present much pain of head back, and extremities; no sleep; face flushed; epigastrium tender: tongue red round margin, coated in middle; much thirst; pulse 99. V.S. ad ℥x.

9th. Pain of head continues; scarcely any sleep; pulse 96. C.C. ad ℥x. nuchæ.

10th. Pain of head unrelieved, particularly severe over the forehead; face flushed; tongue brown and dry; pulse 92.

11th. Pain of head quite gone; no longer conscious of any uneasiness in the limbs; much drowsiness; delirium; pulse 104.

12th. Rather more sensible; delirium; tongue unchanged; stools and urine passed in bed; pulse 112.

13th. Delirium increased; eyes glistening; pulse 120.

14th. Mind more distinct this morning; much delirium through the night; respiration hurried; pulse 130. Died next morning.

_Head._ Membranes and substance healthy; on the under surface of right hemisphere, corresponding with the middle lobe, a remarkably deep and extensive depression, the deepest part corresponding to the centre of the brain; this depression was lined with the arachnoid, which being reflected formed a sac, that contained 12 ounces of serous fluid, and completely filled the cavity. The cerebral substance beneath and around was perfectly sound and entire. _Thorax._ Viscera healthy. _Abdomen._ Mucous membrane of ilium and cæcum extensively and greatly ulcerated.

4. _Vascularity &c. with preternatural Firmness of Brain._

CASE XL.

THOMAS CONOLLY, æt. 58, labourer. Admitted on 7th day of fever: severe pain of head early in the attack which has continued without intermission, accompanied with vertigo; scarcely any sleep; face flushed; no uneasiness of chest; abdomen not tender; no stool for four days; tongue loaded and dry; pulse 96, weak.

8th. Less pain of head; no improvement in other symptoms; pulse 92.

9th. Scarcely any pain of head; no sleep; delirium; muscular tremor; tongue brown and dry; pulse 111.

10th. Pain quite gone; more insensible; constant talkative delirium; colour of cheek dusky, almost livid; respiration hurried; stools and urine in bed; pulse 112, feeble.

11th. Died.

_Head._ Membranes vascular; arachnoid thickened and opake; substance of brain highly vascular and preternaturally firm; some fluid beneath membranes and in ventricles. _Thorax._ [Pleuræ adherent;] lungs gorged with blood. _Abdomen._ Liver and spleen exceedingly softened, readily breaking down beneath the finger.

CASE XLI.

MARY TIFFIN, æt. 25, servant. Perfectly insensible: no account can be obtained of history or duration of disease: abdomen tender; tongue loaded, moist; pulse 99.

2d day after admission scarcely any sleep; delirium; muscular tremor.

3d. Insensibility continues; constant delirium; has passed neither stool nor urine; latter drawn off by catheter; pulse 124, feeble and fluttering. Died next morning.

_Head._ Dura mater and arachnoid natural; pia mater vascular; substance of brain highly vascular and unusually firm; cerebellum soft; effusion beneath arachnoid and at base. _Thorax._ [Substance of both lungs filled with miliary tubercles.] _Abdomen._ [Liver studded with tubercles, similar to those of the lungs; spleen full of the same kind of tubercles, excepting that they were larger, and some of them were suppurating;] pancreas extremely firm.

CASE XLII.

MARY POULSTON, æt. 50. No account to be obtained of duration of disease: lies quite insensible and prostrate; frequent jactitation of the arms; face flushed; respiration stertorous; cheeks alternately expanding and collapsing during inspiration and expiration; tongue not to be protruded; stools and urine in bed; pulse 138, weak, and easily compressed.

2d. Died.

_Head._ Dura mater vascular; arachnoid thickened and opake; substance of brain highly vascular and firm. _Thorax._ All the viscera perfectly healthy. _Abdomen._ Mucous membrane of intestines vascular, without ulceration; mesentery inflamed; [contained a calcareous deposit of an oval shape included in a cyst.]

CASE XLIII.

WILLIAM ASHLEY, æt. 65, messenger. Admitted on 4th day of fever: slight occasional head-ache; mind distinct; scarcely any sleep; face flushed; no uneasiness of chest or abdomen; slight cough; pulse 81.

5th. Slight head-ache; little sleep; pulse 82.

6th. Pain of head gone; pulse 90.

8th. No pain; mind confused; delirium; stools in bed; pulse 108.

10th. Prostration; pulse 111.

11th. Perfectly insensible; great prostration; deglutition difficult; hiccup; pulse 116, extremely feeble.

12th. Died.

_Head._ Membranes and substances of brain intensely vascular; perhaps as much so as in pure phrenitis; substance exceedingly firm; viscera of thorax and abdomen healthy.

CASE XLIV.

FRANCIS HODGKINSON, æt. 15, servant. Admitted on the 8th day of fever: pain of head and vertigo, which ushered in the attack already gone; mind confused; scarcely any sleep; slight pain of chest on full inspiration; slight cough; abdomen not tender; tongue red at margin, centre covered with yellow fur; pulse 117, easily compressed.

9th. No pain; much confusion; much restlessness; respiration oppressed; tongue still moist; lips and teeth sordid; stools in bed; pulse 112.

13th. Petechiæ; tongue dry; pulse 110.

15th. No material change in symptoms. Died.

_Head._ Membranes vascular; substance exceedingly vascular and firm; some fluid in ventricles and at base. _Thorax._ Lower lobe of left lung of dark red colour and inflamed. _Abdomen._ Mucous membrane of small intestines vascular, and of dark red colour.

CASE XLV.

WILLIAM WHITE, æt. 17, labourer. Admitted on 6th day of fever: pain of head; especially over forehead; mind distinct; some sleep; face flushed; no thoracic or abdominal uneasiness; tongue white and dry; no stool for a week; pulse 126.

7th. Pain of head very severe; pulse 117; V. S. ad ℥xij.

8th. Died this morning most suddenly and unexpectedly, after having complained of violent pain of the head.

_Head_, not examined till three days after death, yet the substance of the brain was exceedingly firm, and seemed to distend and protrude its membranes, so that there seemed something like hypertrophy of its substance; viscera of thorax and abdomen healthy.

CASE XLVI.