Chapter VI · OF THE PATHOLOGY OF FEVER.

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 177the 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 178confessed, 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: 179investigation 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.

180Predominance 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 181adipose 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 182preternaturally 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, 183but 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 184consistence, 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 185uniform. 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 186without 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 187to 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; 188and 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 189supervene 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 190when 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, 191and 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, 192either 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.

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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 194of 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; 195sleeps 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.

19610th. 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 197red 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 198the 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.

19913th. 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 200to 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 201on 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; 202almost 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 203vertebralis 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.

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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.

20515th. 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.

2066th. 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 207sleep; 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 208heavy; 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 209lung 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.

210

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 211not 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.

212Case 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 213hurried; 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 214the 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, 215which 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 216day 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.]

217Case 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 218with 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.

219Head. 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.

220Case 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.

2218th. 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 222red 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.

John Mullins, æt. 28, servant. Stated to be a relapse after a fever of three weeks duration: at present, lies perfectly senseless; noisy delirium; extreme restlessness; pulse 70.

2232nd day after admission, continues perfectly insensible; respiration slow and stertorous; tongue not to be protruded; stools passed in bed; pulse 60.

6th. Remained nearly in the same state until this morning. Died.

Head. Dura and pia mater highly injected; surface of brain quite dry and hard; substance throughout exceedingly firm, and thickly crowded with bloody points; cerebellum soft; pituitary gland soft; all the ventricles, especially the third, exceedingly enlarged and quite full of limpid serum; communicating passages greatly distended; an ounce of serum at base. Thorax. [Left pleuræ completely adherent; both lungs full of tubercles, many of which in the left lung were softened and others were in a state of suppuration.] Abdomen. Mucous membrane of small intestines inflamed and thickened; no ulceration. [Sigmoid flexure of colon contracted into the form of a small white cord of very narrow calibre, the superior extremity of which was blocked up by a large scybala; and beyond it there was a great accumulation of fæces; spleen very small; right kidney weighed only six drachms; left seven ounces and a half; liver extremely small weighing only two pounds, six drachms; it lay across the epigastrium and adhered by a preternatural membrane to the diaphragm on the left side; mesentery wasted.]

224

5. Vascularity, &c. with Softening of the Brain.

Case XLVII.

Sarah Hampden, æt. 50. No account to be obtained of history of disease, but it is stated that this is the 22d day of her fever: at present mind quite fatuous; some uneasiness of chest; cough; abdomen not tender; tongue red and dry; pulse 99.

24th. Subsultus; urine in bed; no stool.

26th. Mind rather more distinct and more firm; less subsultus; submaxillary gland enlarged and painful; pulse 108.

28th. Much prostration; no other change.

30th. Increasing prostration; pulse 120, feeble.

32d. Died.

Head. Dura mater vascular and thickened; arachnoid white and opake; substance of brain slightly vascular, but very soft; pituitary gland suppurating; all the ventricles distended with serum. Thorax. [Universal adhesion of the pleuræ; lungs studded with tubercles.] Abdomen. Mucous membrane of small intestines inflamed; no ulceration; pancreas very hard; liver much softened.

Case XLVIII.

Virgina M’Mahon, æt. 8, admitted on 14th day 225of scarlet fever. No account can be obtained of previous history; mind quite confused; extreme restlessness; abdomen tender; tongue very red and sore; tarsi red and irritable.

15th. Delirium; moaning; no sleep; more sensible to-day; abdomen less tender; pulse extremely quick and weak.

18th. Without any material change, died.

Head. Arachnoid opake; effusion between it and the pia mater; substance of brain exceedingly soft; two ounces of serum in the ventricles. Thorax. Mucous membrane of trachea and bronchi vascular; bronchial tubes filled with mucus. Abdomen. Mucous membrane of small intestines vascular; mesenteric glands enlarged.

Case XLIX.

Dorcas Wingrove, æt. 23, servant, admitted on the 6th day of fever. Attack commenced with violent pain in the head, preceded by no other symptom that was observed; this pain still continues exceedingly severe, and is confined chiefly to the right eye; mind distinct; no sleep; much restlessness during the night; countenance pallid; no uneasiness of chest; abdomen tender; bowels constipated; tongue pale, clean and moist; pulse 93, weak.

7th. Pain of head undiminished; delirium; three 226stools in bed; tongue brown and quite dry; pulse 100, firm, strong, and sharp. C.C. ad ℥xij. nuchæ.

8th. Pain of head gone; no sleep; noisy delirium; stools in bed; pulse 120, weak.

9th. Slight, but very transient amendment.

11th. Comatose; lies quite prostrate; stools in bed; pulse 130, feeble.

12th. Died.

Head. Membranes vascular; arachnoid opake; corpus striatum in part highly inflamed, in part softening to suppuration; viscera of thorax and abdomen healthy.

Case L.

Thomas Proctor, æt. 45. Date and progress of disease unknown: at present perfectly insensible; extreme restlessness; eyes dull and vacant; tongue dry; pulse scarcely to be distinguished.

2d day after admission. Insensibility the same; almost constant moaning; features sunk; expression of countenance anxious; pulse 118. Next morning died.

Head. [In falciform process of dura mater an ossification, two inches and a half in length and half an inch in breadth, with several similar ossifications along the course of the longitudinal sinus;] the arachnoid and pia mater consolidated into one thick, opake and yellow membrane; substance of brain highly 227vascular and very soft; cerebellum quite disorganized, being broken down into a yellow, puriform mass of matter, a considerable portion of which lay loose on the floor of the cranium; all the ventricles full of serum, in which floated numerous flakes of lymph; base immersed in similar fluid. Thorax. Viscera healthy. Abdomen. Mucous membrane of jejunum and ilium much inflamed, neither thickened nor ulcerated; [liver greatly enlarged; walls of bladder half an inch thick.]

The following is placed at the end of the cerebral cases, not because it illustrates any new circumstance in the condition of the brain, but because, while the symptoms and the pathology are prominently cerebral, it affords one of the most complete examples of the peculiar affection of the joints already referred to.

Case LI.

George Carter, æt. 28. Admitted on the 4th day of scarlet fever: throat sore; deglutition painful; cough; no pain of chest or abdomen; nausea; tendency to vomiting; no pain of head; mind distinct; pulse 108, weak.

5th. No pain; eyes suffused; pulse 120, firmer.

6th. Mind confused; eruption partial, interspersed with papulæ; tongue of strawberry appearance, and rough from prominence of papillæ; pulse 124.

2287th. Delirium, so violent as to require restraint; no sleep; pulse 120.

8th. Eruption changed to copper-colour; tongue dry; pulse 112.

10th. Inflammation of parotid gland.

18th. Tumour of left parotid exceedingly hard and slowly suppurating; slight difficulty in swallowing; pulse 96.

21st. Tumour opened last night and discharged two ounces of bloody pus; pulse 108.

28th. Alternately mended a little and then fell back to his former state until last night, when swelling of right wrist and left knee came on, attended with excruciating pain and great heat without any discoloration: 12 leeches have been applied with considerable relief: mind confused; no sleep; countenance anxious; face flushed; rigors; pulse 135.

24th. Other wrist and knee have begun to swell and are excessively painful; left wrist and knee which had been more easy, again extremely painful; vomiting; respiration hurried; pulse 116, weak. Died.

Head. Much serum both in ventricles and at base. Thorax. Viscera healthy. Abdomen. Mucous membrane of the ilium ulcerated and extremely dark.

All the large joints swollen and red: on opening the knee joints they were found to contain several 229ounces of serum mixed with pus; the cellular tissue in the neighbourhood was partly inflamed, and partly mortified and sloughing: both wrists were in a similar condition.

Case XII.

James Solden, æt. 44, plasterer. For symptoms see page 155.

Head. Membranes of brain vascular; substance highly vascular; some effusion beneath the arachnoid. Thorax. Viscera healthy. Abdomen. Mucous membrane of ilium vascular; no ulceration; mesenteric glands enlarged.

Case XIII.

John Clark, æt. 17. For symptoms see page 156.

Head. Corresponding portions of the pericranium and dura mater detached from the occipital bone to the extent of four inches in length by three in width; coagulated blood effused between the dura mater and the cranium; vessels of the membranes turgid with blood; substance of brain vascular; effusion between the membranes; a little at base. Thorax. Viscera healthy. Abdomen. Mucous membrane of ilium greatly inflamed; cæcum ulcerated.

230From the study of these cases we see that the process of disease is as uniform as that of health, or of any other process of nature; that certain phenomena constantly take place; that they follow a determinate order; that the events seldom or never vary; that their relations to each other never change; that in these cerebral cases of fever a preternatural fulness and apparently increase in the number of the blood-vessels of the brain and spinal cord, or of their membranes is always present; or that if a case do now and then occur in which even no preternatural vascularity can be discovered such an event is exceedingly rare; that this fulness and increase of the blood-vessels is either identical with, or passes into the state of inflammation; that the state of inflammation, after a certain period, produces results which are known to be effects of inflammatory action in other parts of the body; that these products of inflammation consist of a given number; that the whole of that number never concurs in any one case, but that two or more are frequently found in combination; that the laws by which any one of these is formed rather than any other are at present wholly unknown; while instances do occasionally occur, although they are extremely rare, in which the state of mere vascularity alone subsists without the formation of any inflammatory product that can be discovered.

From the study of the history of these same cases 231we further see that the indications of this inflammatory state of the brain and spinal cord or of their membranes are as uniform as the existence of the state itself; that certain symptoms invariably accompany it; that these symptoms not only declare with absolute certainty that this process is going on, but likewise, in general, clearly mark its progress; and that this series of symptoms and the place in which each stands in the series is as follows: namely,

Pain in the head, or giddiness, or some other uneasy sensation in this organ, attended with a loss of sleep and with a derangement in all the sensorial faculties,—these are the signs of the presence of the disease in the brain or its membranes. Pain in the back, loins, or limbs, or diminution of the power of voluntary motion—these are the signs which mark the existence of the disease in the spinal cord or its membranes. These symptoms having been present a certain time, and at length succeeded by—diminution of the pain or uneasiness without a corresponding diminution in the other febrile symptoms, but with an increase in some of them; for instance, with an increase of the sleeplessness and restlessness: at last, total cessation of all pain or uneasiness, together with a diminution of the sensibility—these are the signs which mark the progress of the disease, and which, in general, denote a transition from the state of mere inflammation to the formation of some inflammatory product. 232Thus far the change of state is certain and the signs which denote it invariable; to the latter other symptoms are added which occur in the great majority of cases, but not in all; namely, delirium, muscular tremor, involuntary and unconscious stools, acceleration, and in general, increased and increasing weakness of the pulse. Other accessory symptoms still frequently occur and with considerable regularity, but as these are more variable the student is referred to the cases themselves, the study of which can alone teach when they may be expected.

Since the diseased states of the brain and spinal cord or of their membranes, which the preceding pathology discloses, exist, as is there shown, in all degrees of intensity, so the signs by which these states are denoted may vary from a prominence which it is impossible to overlook to an unobtrusiveness which it requires careful attention to discover. And from causes which we do not yet understand, the prominence of the sign is not always in accordance with the intensity of the state; but the important truth here maintained is, (and the more the practitioner observes, the more satisfied he will become that it is a truth,) that whenever these states exist in sufficient intensity to produce death, their presence may be discovered during life. It is not affirmed that these states can be distinguished one from another; but it is contended that the existence of some one or more of them may be ascertained 233with absolute certainty. As we sometimes see death occur, preceded by the ordinary symptoms of cerebral inflammation, when, on examination after death, nothing can be discerned but preternatural vascularity of the membranes or substance of the brain, without the presence of any inflammatory product that can be distinguished; and as, moreover, when some inflammatory product is generated, we are in total ignorance of the laws by which, in one case, the blood-vessels pour out serum, in another secrete pus, in a third soften, and in a fourth indurate the cerebral substance; so the signs which indicate that these events have taken place are to us, at present, uncertain. There can be no question that the laws, according to which each of these events is produced, are fixed and invariable in their operation; and each may possibly be attended with its specific and therefore diagnostic sign; but it is certain that we have not yet discovered the one nor observed the other. And the preceding cases have been detailed under the heads assigned them, rather with the view of making the pathology clear, than in the hope from this arrangement of affording any guide to practice. In the mean time, what we may know, and ought to know, is when inflammation exists: what we may, in general, further know is, when some product of inflammation has been poured out still more to oppress the brain: to the thoughtful and discerning practitioner it would be without doubt a high satisfaction to be able 234to carry his diagnosis still further, and to ascertain what that product is: the desire to arrive at such precise and perfect knowledge appears to me to be in the highest degree meritorious: the constant and unwearied endeavour to acquire it may not always succeed with reference to the particular object immediately pursued, but it cannot fail to increase his power and to strengthen his habit of observation; and the sure reward of a devotion thus truly honourable and faithful to the duties of his profession, if it should not be, as it may not invariably be, the confidence and the gratitude of his patient, will at least be the proud consciousness that he has deserved both.

Were it possible to ascertain with absolute certainty and with perfect exactness in which of its various modes inflammation of the brain and its membranes terminates, it would be a subject of interest, as far as we can at present perceive, rather to the physiologist and pathologist than to the practical physician. To the latter the great fact which it is of paramount importance that he should know is, that inflammation is going on in the brain of his patient, and that if he cannot put a stop to it in the course of a day or two, it will in that short space of time terminate in some irreparable change of structure, of which death will be the inevitable consequence. This, it is again repeated, it is always in his power to know; and as there is no one fact which can or which ought to have so much influence 235upon his practice, so there is no diagnosis which it is of so much importance that he should acquire the habit of forming.

II. Cases in illustration of the Morbid Changes which take place within the Chest; or Thoracic Cases.

Case VII.

Angelica Fidgett.

For symptoms see page 125.

Thorax. Mucous membrane of bronchi, in all their ramifications, exceedingly inflamed; bronchial tubes full of mucus; [substance of left lung extremely inflamed; left pleuræ adherent; right pleuræ and lung much less severely affected.] Head. Substance of brain vascular. Abdomen. All the viscera healthy except the uterus and its appendages, which were slightly inflamed.

Case VIII.

John Potter, æt. 21.

For symptoms see page 127.

Thorax. Mucous membrane of bronchi, in all their ramifications, of dark red colour; bronchial glands much enlarged; [pleuræ of right side generally adherent; substance of lungs consolidated; pericardium 236contained four ounces of serum;] heart natural. Abdominal and cerebral organs healthy.

Case XIV.

Alexander Crombie, æt. 19, seaman.

For symptoms see page 159.

Thorax. Mucous membrane of bronchi, in all their ramifications, highly vascular; bronchial tubes full of mucus, mixed with pus. Head. Dura mater adherent with preternatural firmness to cranium; substance of brain unusually firm; posterior lobes crisp, and cut almost like cartilage; anterior lobes, when cut into, abound with bloody points; cerebellum exceedingly firm. Abdomen. Peritoneal coat of small intestines in general vascular; eight or ten portions of the jejunum and ilium, to the extent of three or four inches each, intussuscepted; mucous membrane of these parts extensively ulcerated, some of the ulcers circular, the greater number oblong, and at least two inches in length; mucous membrane in general highly vascular, but that surrounding the ulcers less so than the other parts; mesenteric glands corresponding to ulcerated portions of intestine enlarged and vascular; crimson spots on convex surface of liver; gall-bladder distended with a yellowish watery fluid; spleen enlarged, and so soft as to be easily broken down under the finger.

237Case LII.

Thomas Lewis, æt. 51, taylor, admitted on the 8th day of fever. Complaint commenced with general pains, nausea and vomiting, together with cough and dyspnœa. At present there is no pain of chest except on coughing, which produces some uneasiness; cough frequent, with copious sputa; pain of epigastrium; tongue exceedingly parched and dry; much thirst; bowels purged; some pain of head, chiefly in forehead; mind distinct; scarcely any sleep; face pallid; pulse 126, weak. Early next morning died.

Thorax. Mucous membrane of bronchi inflamed; [pleuræ of right lung covered with coagulable lymph; substance of right lung universally consolidated, and infiltrated with tubercular matter;] left lung gorged. Abdomen. [Liver indurated; crisping under the knife; kidneys indurated.] Head. Membranes and substance of brain vascular.

Case LIII.

Mary Sullivan, æt. 40, married, admitted on the 15th day of fever. Some pain of chest; severe cough; much pain of head, with sense of noise; mind dull; scarcely any sleep; face flushed; skin warm; tongue foul and dry; pulse 98.

23816th. Frequent short cough, without expectoration; mind confused, yet sensible when spoken to; pulse 90.

17th. Thoracic and cerebral symptoms unchanged; pulse 111, indistinct.

26th. Cough diminished; sensibility increased; she appeared in all respects better until this day, when the cough became more frequent and the expectoration purulent; pulse 60.

27th. Cough frequent; expectoration the same; respiration short and hurried; pulse 60, intermittent.

30th. Respiration became more and more hurried, and the strength rapidly sunk. Died.

Thorax. Mucous membrane of bronchi inflamed; bronchial tubes full of mucus, mixed with pus; [pleuræ adherent; patches of left lung hepatized.] Abdomen. Liver and spleen extremely softened, breaking down under the fingers into a mass like coagulated blood. Head. Membranes and substance of brain pretty healthy.

Case LIV.

Sarah Peach, æt. 23, married, admitted on the 17th day of fever. Thoracic symptoms came on with the very commencement of the disease: at present there is no pain of the chest, but much cough; respiration short and hurried; colour of the face quite dusky; some pain of head; mind confused; 239pulse 100; abdomen not tender; tongue of beefsteak character; bowels regular.

18th. Cough and hurried respiration continue; dusky colour of face has become livid; delirium; low muttering talkativeness; pulse 116; teeth sordid; stools in bed.

19th. Severity of bronchial symptoms much increased; respiration panting; colour of skin in general, but especially of face, livid; deglutition difficult; pulse 124, weak. Died following morning.

Thorax. Mucous membrane of bronchi inflamed; bronchial tubes filled with mucus, mixed with pus; mucous membrane of trachea vascular; [both lungs studded with miliary tubercles.] Head. Dura mater and arachnoid highly vascular; theca of spinal cord highly vascular; substance of brain vascular. Abdomen. [Spleen contained a small mass of cheesy tubercles near its surface;] patches of mucous membrane of small intestines inflamed, but without ulceration.

Case LV.

Isabella Lora, æt. 12. Admitted on the 3rd day of scarlet fever; throat sore; deglutition painful; slight cough; skin covered with copper-coloured eruption; tongue loaded in middle with white fur; red around edges and at tip; some pain of head; pulse 120.

2404th. Much improved; less pain of throat and head; pulse 96.

14th. Convalescent and gradually gaining strength up to this day; early this morning seized suddenly with rigors attended with vomiting: abdomen tender; three stools; pulse scarcely to be felt; mind distinct.

15th. Left parotid painful, hard and swollen; throat again inflamed; pulse 124.

16th. Early this morning seized with symptoms of severe laryngitis, for which leeches have been applied with partial relief; tonsils and uvula much swollen; respiration exceedingly laborious; pulse 140, sharp. Died same day.

Thorax. Tonsils much enlarged; mucous follicles full of purulent fluid mixed with blood; some of them exceedingly enlarged, and communicating so as to form cavities; membrane covering the upper part of larynx highly vascular and much thickened, especially that about the epiglottis and the arytænoid cartilages; mucous membrane below the rima glottidis healthy; both the parotids, the sublingual, and the maxillary glands enlarged. Abdomen. Peritoneal coat of the intestines inflamed and thickened. Head. Membranes and substance of brain tolerably healthy.

241Case LVI.

Mary Anne Lawrence, æt. 22, servant, admitted on the 5th day of scarlet fever. Throat sore; deglutition painful; slight uneasiness and sense of tightness in chest; frequent cough, with copious expectoration; abdomen not tender; tongue characteristic; skin warm, covered with scarlet eruption; slight pain of head; pulse 126, strong. V.S. ad ℥xvj.

6th. Felt much relief after venesection; dyspnœa returned in the evening, and she was again bled to the extent of sixteen ounces: blood first drawn with firm buff, that of the second bleeding with coagulum firm but not buffy; at present cough severe, short, dry; dyspnœa; pulse 148.

7th. Tightness of chest continues; cough better; pulse 144, tremulous. Died next day.

Thorax. Uvula and surrounding parts much inflamed, but not ulcerated; mucous membrane of trachea inflamed; bronchial tubes inflamed, and filled with frothy mucus; [pleuræ of both lungs adherent; lungs contained a few tubercles; thyroid gland enlarged, and so hard as to be cut with difficulty.] Abdominal and cerebral organs tolerably healthy.

Case LVII.

Ann Wormington, æt. 24, servant.

242After some previous indisposition, seized, the day before admission, with shivering, attended with pain of bowels, nausea and vomiting; throat sore; deglutition painful; scarlet eruption on skin; no uneasiness of chest; no cough; abdomen tender; tongue covered with yellow fur; bowels purged; mind confused; eyes injected and heavy; pulse not to be counted. Died four hours after admission.

Thorax. Mucous membrane of trachea of dark red colour; epiglottis quite blackened; arytænoid cartilages ulcerated; substance of lungs much gorged. Abdomen. Viscera healthy. Head. Membranes vascular; substance of brain preternaturally firm.

Case LVIII.

Margaret Scandling, æt. 26, admitted on the 8th day of fever. No uneasiness of chest; no cough; pain in head; severe pain in limbs and bones; scarcely any sleep; threatening erysipelas on face; abdomen tender; tongue white and dry; no stool for seven days; pulse 88, weak.

10th. No uneasiness of chest; pain of head diminished; pulse 72.

16th. Erysipelas of cheek, spreading to scalp, and attended with considerable pain; tongue dry; pulse 96.

19th. Erysipelas extending; this morning attacked with severe dyspnœa, attended with husky noise in 243inspiration; deglutition extremely difficult. Hirud. x. gutturi. C.C. ad ℥xij. nuchæ. Capiat Hydrar. Submuriat. gr. ij., c. Pulv. Opii, gr. ss. 6ta q. h.

20th. Respiration and deglutition unrelieved; erysipelas of face very painful; mouth sore; mercurial fetor; pulse 120, soft.

21st. Respiration unchanged; deglutition more painful; erysipelas increased, passing into suppuration; delirium; pulse 90.

22d. Difficulty of deglutition undiminished; respiration rather more easy; pulse 98; much pain of head.

23d. No change in the respiration, deglutition, or erysipelas; much discharge from both ears; left elbow attacked with swelling; heat and excessive pain.

25th. Died.

Thorax. Mucous membrane of larynx inflamed; epiglottis much thickened; both arytænoid cartilages in a state of suppuration, right nearly destroyed; cellular substance about the right parotid in a state of suppuration; [pleuræ of right side adherent; substance of both lungs infiltrated.] Head. Membranes and substance of brain vascular; serum in lateral ventricles. Abdomen. [Mucous membrane of small intestines in several points raised in the form of vesicles, containing air;] spleen soft.

N.B. In this case, the erysipelas evidently extended from the external skin to the mucous membrane of the throat and larynx, an event which is 244not very common in fever, but which does occasionally happen. The affection of the elbow-joint was clearly of the same nature as that described in case 51.

Case LIX.

Charles Tyler, æt. 54, chocolate maker, admitted on the 7th day of fever. No pain of chest; slight cough; abdomen tender; tongue loaded and dry; thirst; bowels loose; no pain of head; much pain of loins; some vertigo; mind distinct; no sleep; pulse 90, full and firm. V.S. ad ℥xx.

8th. Pain of head and abdomen gone; pulse 102, full and sharp; blood with very firm buff. Repr. V.S. ad ℥xij.

11th. No return of pain in any organ; mind confused; no sleep; great restlessness; delirium; muscular tremor; respiration short and hurried, with mucous rattle; tongue white and dry; pulse too indistinct to be counted.

12th. Delirium became exceedingly violent soon after yesterday’s visit; there was neither pain nor cough, but he passed by the mouth a considerable quantity of fluid blood; respiration became more and more hurried and he died in the evening.

Thorax. Mucous membrane of the trachea and bronchi inflamed; [the substance of the left lung studded with nodules, consisting of coagulated blood, 245forming the apoplexia pulmonalis of the French writers:] viscera of the head and abdomen healthy.

Case LX.

John Wotton, æt. 46, plaisterer. Admitted on the 7th day of fever: attack commenced with chilliness, succeeded by cough and severe pain in the region of the heart; has had two similar attacks of pain which he soon recovered; at present he has so much pain in the side that he cannot take a full inspiration; frequent cough exciting pain; respiration short and painful; abdomen not tender; tongue white and moist; pain of head; little sleep; pulse 120, full and hard; skin hot.

8th. Pain of chest diminished; can take full inspiration with less uneasiness; cough less frequent; respiration little changed; pulse 102, intermittent.

9th. Respiration much more easy; cough less frequent, with copious mucous expectoration; pulse 108, intermittent.

10th. Says he is quite free from pain everywhere; cough again increased; respirations 50; pulse 110, not intermittent; delirium.

11th. Respirations 60; no sleep; great restlessness; pulse 108, intermittent.

14th. Perfectly insensible; scarcely to be retained in bed; respiration extremely quick; pulse not to be counted. Died.

246Thorax. Mucous membrane of bronchi highly vascular; [left lung adherent to parieties of chest by a layer of coagulable lymph nearly an inch in thickness; substance of lung completely hepatized; pericardium exceedingly thickened throughout, and universally adherent to the heart; heart itself soft and flabby; inner coat of aorta of reddish brown colour.] Head. Vessels of pia mater exceedingly turgid; effusion beneath it and the arachnoid; substance of brain very much softened. Abdomen. Mucous membrane of ilium vascular.

III. Cases in Illustration of the Morbid Changes which take place within the Abdomen; or Abdominal Cases.

Case LXI.

Thomas Hindmarsh, æt. 26. Admitted on the 10th day of fever: too indistinct to give any account of previous symptoms; at present abdomen tender; tongue loaded and dry; bowels purged; mind confused; very deaf; eyes red and suffused; pulse 108, firm.

11th. Abdomen less tender; five stools; insensibility increased; pulse 104.

12th. Abdomen a little tender; tongue quite dry; three stools in bed; noisy delirium; eyes wild and staring; pulse 108.

24713th. Tongue no longer to be protruded; no stool; scarcely at all sensible; eye-lids half closed; pulse 96, firm.

21st. Abdominal and cerebral symptoms little changed; sensible of some pain in chest; cough; dyspnœa; pulse 108.

23d. Abdomen still tender, and now become tympanitic; four stools in bed; perfectly insensible; constant muttering delirium; muscular tremor; large slough on sacrum; pulse 116.

25th. Died.

Abdomen. Peritoneal coat of intestines in general vascular; mucous coat of small intestines highly vascular, and indicated approaching ulceration. Head. Not examined. Thorax. [Pleuræ of both sides adherent throughout; substance of both lungs healthy; slight effusion of serum into pericardium.]

Case LXII.

Isaac Grey, æt. 30. Admitted on 22d day of fever; no account to be obtained of the previous symptoms; at present the abdomen in general is exceedingly tender on pressure, but especially the epigastrium; tongue brown, dry in centre, moist at edges; very tremulous; scarcely at all sensible, yet seems very apprehensive, almost constantly muttering and crying; face flushed; eyes wild; skin speckled with petechiæ; pulse 112.

24823d. Abdomen still very tender; says he is without pain; four stools; delirium; muscular tremor; pulse 100, feeble.

24th. In the early part of last evening became violently delirious, and was extremely restless, constantly tossing his arms about, and throwing off the bed-clothes. Died.

Abdomen. All the coats of the stomach appeared much attenuated; mucous membrane of cardiac extremity so soft as to lacerate under examination; that of pyloric end exhibited numerous minute spots of a deep red colour, as if touched with a paint-brush; peritoneal coat of ilium of dark red colour; other viscera healthy. Head. Arachnoid thickened and opake; considerable effusion between it and the dura mater; substance of brain vascular; half an ounce of serum in each ventricle. Thorax. [Right pleural cavity contained one ounce and a half of bloody fluid, left eight ounces; substance of both lungs much condensed, and on their surface an appearance as if blood had exuded and coagulated. Pericardium contained two ounces of serum: heart healthy.]

Case LXIII.

Hannah Swift, æt. 20, servant. Admitted on the 8th day of fever: abdomen, especially the epigastric region, tender; tongue clean, red, chapped; lips parched and cracked; some pain of head, back, and 249limbs; mind rather confused; pulse 120, soft, and feeble.

9th. The abdomen, which continues tender, has become swollen and tense; two stools.

15th. Abdomen still very tender, swollen, and hard; tongue dry; two stools; vomiting of much green coloured fluid; pain of head gone, but sense of weight in it.

17th. Tenderness of abdomen and vomiting continue; delirium; pulse 100, small and feeble.

19th. Tenderness of abdomen increased; no vomiting; tongue the same; pain of head returned; delirium; erysipelas of face; pulse 109, feeble.

21st. Erysipelas extending to arm; tongue brown, dry, and cracked; much delirium.

22d. Cheeks livid; extremities cold and livid; pulse imperceptible. Died.

Abdomen. Mucous membrane of ilium highly inflamed, and ulcers just forming; other viscera healthy. Head. Dura mater vascular; arachnoid opake; substance of brain vascular; some fluid in ventricles. Thorax. Mucous membrane of bronchi inflamed: tubes filled with mucus mixed with pus: [pleuræ in part adherent; some serous fluid in both cavities; substance of lungs natural.]

Case LXIV.

Thomas Sexton, æt. 18, servant. Admitted on 2503d day of scarlet fever; complaint came on with nausea, vomiting, and pain of the limbs; at present throat sore; deglutition easy; chest free from pain; no cough; abdomen tender, especially in the region of the epigastrium; tongue white in middle, red around margin; no stool for several days, because, as he supposes, he has vomited all his medicine; pain of head; vertigo; face flushed; frequent attacks of epistaxis during his vomiting, always relieving the head-ache; pulse 102; skin warm; no eruption.

4th. Pain of head gone; vertigo continues; eyes dull and heavy; face flushed; no vomiting; pulse 96.

5th. Sense of vertigo lessened; tongue brown and dry; four stools; pulse 84.

7th. Abdomen tender; tongue brown and dry; six stools; pain of head returned; much pain of back; no sleep; delirium.

11th. Less sensible: drowsy; delirium; three stools.

12th. Insensibility increased; drowsiness approaching to coma; cheeks dusky; tongue with dark brown crust, dry; stools in bed; pulse 102, weak.

16th. Abdomen tender; tongue not to be protruded; three stools all in bed; pulse 130, extremely weak; great prostration.

25117th. Countenance sunk; respiration short and hurried; four stools; more prostrate.

18th. No change excepting that the prostration is still greater. Died.

Abdomen. Mucous membrane of ilium and cæcum extremely vascular, and contained several small ulcers, some of which were merely the abraded points of enlarged mucous glands; other glands in the neighbourhood much enlarged but not ulcerated; mesenteric glands very much enlarged; liver mottled; spleen larger than natural; pancreas indurated. Head. Arachnoid highly vascular; substance of brain natural; gelatinous effusion between the arachnoid and pia mater; half an ounce of serum at base. Thorax. Viscera healthy.

Case LXV.

James Gannicott, æt. 8. Duration and progress of disease unknown; abdomen tender; lips and tongue sordid; bowels purged; comatose; pupils dilated, but sensible to light; expression of eyes dull and vacant; pulse 125.

2d day after admission. Abdomen no longer tender; three stools; insensibility continues; frequent screaming; pulse 116.

3d. Perfectly insensible; all nourishment refused; stools and urine in bed; pulse 120. Died next morning.

252Abdomen. Peritoneal coat of ilium vascular; its mucous coat contained numerous ulcers which varied much in size; but all of them were raised above the surface and defined and regular in their margins; mucous glands throughout the entire intestine diseased, and many of them in different stages of disease; some were only enlarged; others enlarged and inflamed; others ulcerated at the apex; others ulcerated throughout; so that the largest ulcers appeared to be diseased glands in the last stage of ulceration; mesenteric glands prodigiously enlarged and hung over the abdominal vessels like a bunch of grapes of the largest size; rest of the intestines healthy excepting that they were much contracted and intussuscepted in several parts. Head. Dura mater adherent with preternatural firmness to the skull; vascular; pia mater highly vascular; substance of brain vascular and firm; slight effusion between the membranes. Thorax. [Pluræ of right side adherent;] substance of both lungs healthy.

Case LXVI.

Henry Todd, æt. 18. Duration and progress of disease unknown; abdomen tender on pressure; tongue coated with dirty yellow crust, red at tip; perfectly insensible; delirium; eyes, glistening; pulse 120, feeble.

2d day after admission. Little change excepting 253that the coma is more deep; abdomen less tender; two stools; pulse 124.

3d. Coma undiminished; respiration short, hurried, rattling; stools in bed; pulse 132; great prostration.

4th. Died.

Abdomen. Mucous membrane of ilium inflamed throughout; lower part of it ulcerated; other viscera healthy. Head. Membranes and substance of brain vascular. Thorax. Mucous membrane of bronchi inflamed; bronchial tubes filled with mucus mixed with pus.

Case LXVII.

Frederick Kilham, æt. 12. Admitted on the 15th day of fever; abdomen tender; tongue not to be seen on account of its being covered with grumous blood from a large ulcer on the right side of the lower jaw; bowels bound; some pain of head; no uneasiness of chest; pulse 114; much emaciation.

16th. Lips and teeth sordid; mind confused; prostration.

20th. Violent delirium; pulse 92.

21st. The ulcer along the lower jaw in the inside of the mouth sloughing and extending; delirium; pulse 96, weak. Died next day.

Abdomen. Mucous membrane of ilium vascular, 254and contained some ulcers; other viscera healthy. Head. More fluid than natural between the membranes. Thorax. Viscera healthy.

Two ulcers in the substance of the cheeks; that on left cheek extended from the angle of the mouth to the last molares, and contained a large black slough a quarter of an inch thick; this ulcer had extended to both gums, denuding the alveolar processes and loosening the teeth; that on the right cheek precisely similar, but less extensive.

Case LXVIII.

Ann Mount, æt. 28, servant. Admitted on 15th day of disease; epigastrium tender; tongue brown and dry; bowels purged; slight pain of head; much vertigo; some cough; pulse 111, very intermittent in the right wrist; less so in the left.

16th. Early this morning attacked with severe pain of the chest and dyspnœa, attended with much headache, for which she has been bled with the removal of the symptoms; pain now quite gone; tongue white; four stools; pulse 120, soft; blood buffy and cupped.

17th. Seized last evening with violent delirium which required restraint; occasional sleep with paroxysms of delirium; face flushed; abdomen not tender; pulse 120, firm. V. S. ad ℥xvi.

18th. No pain of head; no delirium; slept better; 255tongue brown and dry; five stools; pulse 132, firm; blood sizy and deeply cupped. V. S. ad ℥xij.

19th. Complains of “stupid pain of head;” no vertigo; delirium, but less violent; scarcely any sleep; countenance still heavy, but rather more animated than yesterday; abdomen not tender; three stools in bed; pulse 132, firm but soft. C. C. ad ℥xij. nuchæ.

20th. Pain gone; more insensible; countenance more dull and heavy; scarcely any sleep; almost constant moaning; tenderness of abdomen quite gone; tongue brown and dry; lips and teeth sordid; four stools in bed; pulse 144, weak. Vini Albi, ℥ii. Mist. Camph. Fort. 6ta. q. h.

Slept rather better; less moaning; countenance scarcely as collapsed as yesterday; pulse 132, firmer; stools in bed. Augeat. Vinum ad ℥vi.

22d. Scarcely any sleep; almost constant moaning; face flushed; skin covered with cold perspiration; tongue scarcely to be protruded; deglutition difficult; subsultus tendinum; pulse 132.

24th. No change except that the prostration continued to increase. Died.

Abdomen. Mucous membrane of jejunum, ilium and cæcum highly vascular; that of ilium contained three or four large oval ulcers; other viscera healthy. Head. Membranes and substance of brain vascular; more serum than natural in the ventricles. Thorax. Viscera healthy.

256Case LXIX.

Ann Martin, æt. 37, servant. Admitted on the 8th day of fever; complaint came on with ordinary symptoms, attended with nausea and vomiting; at present abdomen not tender; tongue red, cracked and dry; bowels regular; no uneasiness of chest; slight cough with scanty expectoration; pulse 92, very intermittent, beating thrice regularly, then intermitting for a space equal to that of the three pulsations; pain of head gone; some vertigo remains.

9th. Cough with difficult expectoration; respiration hurried; five stools; pulse 104, more regular.

10th. Tongue more fissured; five stools; respiration less hurried and difficult; pulse 112. Two grains of tartar emetic in solution every two hours.

11th. No material change; pulse 116; has taken ten draughts with the tartar emetic, the last four vomited. The draughts to be continued every three hours.

12th. Bronchial affection very much relieved; last four draughts not vomited. Pt. Haustus 4ta. q. h.

13th. Respiration nearly natural; much less cough; pulse 96; tongue moist; four stools, last tinged with blood; abdomen not tender. Tartar emetic omitted on account of appearance of blood in the stools.

25717th. Bronchial affection appears to be quite gone; yet the tongue has again become dry; the pulse has risen to 112; there is scarcely any sleep; and slight muscular tremor is perceptible. Capiat. Vin. Alb. ℥iv. Jus. Bov. i lb.

20th. Respiration again short and hurried; face quite dusky; tongue furred, dry and cracked; pulse 110.

23d. Respiration laborious; cough returned with very copious muco-purulent expectoration, amounting to a pint in the twenty-four hours; pulse 116.

26th. No change; a grain of tartar emetic resumed every four hours. Wine and beef tea to be continued.

28th. Neither vomiting nor purging; respiration more easy; cough diminished; tongue more moist; pulse 116.

29th. Respiration much more natural; cough greatly diminished; tongue clean and moist; pulse 112.

36th. From the period of last report she steadily and progressively improved and became convalescent; on the morning of this day while speaking to the nurse in her usual manner she suddenly fell back and expired.

Abdomen. Mucous membrane of intestines in general inflamed, especially that of ilium and cæcum, which contained some ulcers; peritoneal covering of posterior surface of spleen cartilaginous; other viscera healthy. Thorax. Mucous membrane of 258bronchi highly inflamed; bronchial tubes full of purulent fluid; substance of lungs healthy. Head. Unfortunately, from some accident, the head was not examined.

Case LXX.

Stephen Winter, æt. 78. Duration and previous symptoms of disease unknown; at present abdomen tender; tongue brown and dry; stools natural; respiration wheezing with some cough; slight pain of head; mind composed; muscular tremor; pulse 100, irregular.

2nd day after admission. Abdominal and thoracic symptoms the same; mind more confused; more muscular tremor; pulse 108.

5th. Respiration laborious; mind quite unconscious; constant incoherent talking; pulse 108.

6th. Respiration hurried and laborious; pulse not to be counted; perfectly insensible. Died next morning.

Abdomen. All the coats of the stomach appeared much attenuated; colon contracted into the form of a white cord; its coats in several places thickened, and its mucous membrane ulcerated; liver soft; [gall bladder much thickened, and its cavity so diminished, that it would scarcely admit the end of the finger, filled with two small gall-stones. About five inches of the recti muscles black and infiltrated with blood.] Head. Arachnoid thickened and opake; 259considerable effusion between it and the dura mater; substance of brain firm; ventricles distended with serum. Thorax. All the viscera healthy, [excepting that the coronary arteries were ossified.]

Case LXXI.

Richard Harvey, æt. 19, butcher. Admitted on the 8th day of disease; no account to be obtained of previous symptoms; at present abdomen tender; bowels purged; tongue brown and dry; lips and teeth sordid; pain of head gone; mind confused; delirium requiring restraint; subsultus; pulse 116, weak.

9th. Tenderness of abdomen continues; stools in bed; no sleep; much delirium; scarcely conscious when spoken to; pulse 108, more firm.

10th. Slept better; rather more sensible this morning; pulse again 116.

14th. All nourishment refused; stools and urine in bed; delirium; muscular tremor; pulse 128, weak; extremities cold.

15th. Passed a better night; more sensible; pulse 116.

17th. Extensive slough on sacrum; slough also on right elbow-joint, with erysipelas of surrounding integuments; pulse 108.

21st. Skin covered with petechiæ; slough extending; great prostration.

26035th. No change, excepting that the sloughs were improved in appearance by the chlorate of lime, but the emaciation increased, the strength diminished, and all nourishment was refused excepting wine. Died following day.

Abdomen. Both small and large intestines vascular throughout; mucous membrane of ilium contained several ulcers of considerable magnitude; gall-bladder contained an ounce and half of serous fluid; spleen indurated; other viscera healthy. Head. Substance of brain vascular; effusion between the membranes; more fluid than natural in the ventricles and at base. Thorax. Bronchi natural; substance of right lung gorged with blood and infiltrated with serum; that of left healthy.