LECTURES ON FEVERS: BEING The Lumleian Lectures,

MARCH 3, 1860. In small

LECTURES ON

portions (partial cerebritis) it is 6ften found, but as an idiopathic disease only.

FEVERS:

BEING

The Lumleian Lectures, DELIVERED BEFORE THE

ROYAL COLLEGE OF PHYSICIANS OF LONDON,

1858-59; COMPRISING

A DESCRIPTION OF THE DISTINCTIVE

CHARACTERS, PATHOLOGY, AND TREATMENT OF

THE

SEVERAL

FORMS

OF

CONTINUED

FEVER.

BY

ALEXANDER

TWEEDIE, M.D., F.R.S.,

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL, TO THE FOUNDLING HOSPITAL, EXAMINER IN MEDICINE IN THE UNIVERSITY OF LONDON, ETC. ETC.

The more common appearances, when the cerebral affection has been severe, are those of congestion-viz., injection of both the cortical (grey) and medullary (white) matter-a decided rosy tint of the former, and injection of the latter (shown by numerous red points), being apparent when a section of the brain is made. Louis found the cortical substance more or less of a rosy hue in seventeen out of the forty-six cases, and it was more frequent amongst those who died between the eighth and fifteenth days than in those who died after this period. The medullary matter was injected more or less in all excepting seven, and this injection-generally in proportion to the colour of the cortical substance-was very marked in seven subjects, four of whom died before the fifteenth day; it was observed also in all who died between the eighth and fifteenth. It thus appears that injection of both portions of the brain (grey and white) is almost invariably more pronounced, as well as constantly present, in patients who die in the early stage of enteric fever. In regard to the consistence of the brain, it does not appear that there is any alteration in this respect from its ordinary condition. Softening is very rarely met with. Louis alludes to two cases only: in one, the softening was seated in the optic thalami, but there were no special symptoms which could be said to indicate this lesion; in the other, the softening occurred in the septum lucidum, but in this case the symptoms were male Tn",..kAiI

Sel’ous effusion into the ventricles, more or less abundant, (the average quantity being three drachms,) is not uncommon,

especially in patients who die after protracted fever. The injection of the pia mater and of the medullary substance, ENTERIC FEVER. the rose colour of the cortical substance, and the firmness of the entire mass, appear to be frequent and more marked, according Pathological anatomy. 1. Ne2°vous system:the brain to the more or less rapid manner in which the patient has cerebellum-pons Varolii-medulla spinalis. 2. Organs of died. On the contrary, when the fever has been protracted, respiration:larynx-bronchia-brogm7tial glande-pleztraunder the arachnoid, or effusion of serous fluid into pulmonary tissue-pulmonary hypostasis-cadave1’ic pulmo- effusion nary hyperaemia. 3. Organs of circulation: hea1’t-l)eri- the ventricles, with diminished consistence of the brain subcardium-muscular structure-aorta-condition of the blood stance, are the changes observed. (Louis.) The cerebelluar2 is in its normal state in a large proportion of ira the heart. cases, even when there is preternatural vascularity of the brain. GENTLEMEN,—Having considered the symptoms which cha- In the exceptional cases, and these are few, the changes are Tacterize enteric fever, I shall next bring under your notice the moderate injection of the grey as well as of the white matter, with slight softening. pathological anatomy or anatomical characters of the disease. The pons Va1’olii is generally unaltered, the only deviation 1. The .B?’
-

the brain tissue. The dura mater is almost invariably in its normal condition -idiopathic inflammation of this membrane, except after external

injury, being very rare.

The amchnoid membrane is, in some instances, more or less opaque, sometimes slightly thickened; occasionally a moderate amount of limpid or sometimes turbid serosity is effused into the snb-arachnoid tissue; or perhaps a small quantity of lymph, in the form of a delicate false membrane, on the cerebral arachnoid. Effusion of blood into the arachnoid cavity-an occasional lesion in typhus-is rarely, if ever, observed in enteric

fever. The pia matel’, in more or less

more

injected,

the

those who die between the

than half the

injection being

cases more

examined,

is

apparent in

eighth and twentieth days

of the

disease. Bmin tissue.-The anatomical characters of genuine inflammation of the cerebral substance may be said to be never observed in the most acute forms of fever. Indeed, well-marked inflammation of the entire brain tissue is a lesion so exceedngly rare, that its occurrence is doubted by many pathologists.

No. 1905.

eye of the most expert anatomist. Though the blood evidently undergoes changes in all fevers, the most notable being a marked diminution of the natural proportion of fibrine, our knowledge of this subject must be admitted to be very vague and unsatisfactory. But the nervous system is evidently materially influenced by the morbid blood, many of the symptoms often ascribed to cerebral hypersemia. being more probably due to its effects on the brain or its investing membranes. And these remarks apply to the form of fever now under consideration. I shall not, however, pursue this subject at present, but reserve it for another opportunity. 2. Ol’gans of Pesl--)ii-ati-o7z.-In alluding to the pulmonary affections that occasionally spring up in the course of enteric I pointed out the important part they play in the phenomena of the disease, and that, after death, various changes in the lung are discovered, which, however, are to be regarded as accidental or intercurrent only. These lesions are the result congestion, or of asthenic inflammation, or, accordof previous ing to Rokitansky, of the typhous deposit, in the affected

fever,

tissues.

Larynx. -The mucous membrane of the epiglottis and is generally unaltered; sometimes it is red and some-

’B larynx

what swollen.

In

some

cases,

a,

thin exudation

covers

the

’I

Although these changes are generally limited to the posterior epiglottis, and dipw into the larynx, constituting the laryngotyphus of Rokitansky. It is frequently observed in the pharynx and inferior lobes, they may be found in the apex, or even and larynx simultaneously. Beneath this exudation may be in the central portions of the lung. found ulceration, superficial and limited, or deep-seated and Pneumonia.- When the pulmonary hyperoemia has been of of some extent. We sometimes find, too, cedematous or sub- a more acute character, we find other changes in the lung. mucous infiltration of the epiglottis, and membrane covering They, too, are usually observed in the inferior portions, the the arytenoid cartilages, with or without muco-purulent fluid upper and central being less frequently the seat of pneumonic in the laryngeal sacculi. inflammation. On examining an inflamed portion, it exhibits A dangerous, though less common, lesion of the throat is a violet-red colour, more or less solid, non-crepitant, and sinks the formation of an abscess in the pharynx, often in the im- in water. When cut into, from the cellular or areolar tissue of mediate vicinity of the larynx, and, though perhaps of no the lung being blocked up by the exuded products, the diseased great extent, may be so situated as to press on the epiglottis, ’i portions acquire a granular appearance, resembling the strucand materially interfere with respiration. I have known, in ’, ture of the liver-in other words, they are hepatized. The more many instances, fatal results ensue from such purulent forma- I advanced stage of pulmonary hyperasmia, (grey hepatization) or tions. They often remain undetected till revealed by exami- the ulterior change (purulent infiltration) is very rarelyobserved in secondary pneumonia. nation after death. These lesions may involve the whole or a greater portion of .B/’oMc/na.—The mucous membrane lining the bronchial tubes, in a considerable proportion of cases, retains its natural one lung (lobar pneumonia), or they may be limited to indipale-pink colour and delicate structure; in others, there is vidual lobules, the intervening lung structure being normal diffused congestion, the membrane being dusky-red, swollen, (lobular pneumonia). and covered with a blood-streaked, viscid secretion, especially I may here allude to the notion sometimes entertained, that observable in the lower lobes. Sometimes the secretion has a pulmonary tuberculosis is an occasional sequence of enteric puriform appearance, indicating long pre-existing bronchitis, fever. This idea by no means accords with my own experience on which the fever has probably supervened. orwith that of physicians who have had large opportunities of obA singular opinion is entertained by Rokitansky, that this servation. It has originated in tracing the changes that take condition of the bronchial membrane exists in many cases as a place in the air-cells in pneumonia, which, as is well known, primary broncho-typhus, the general disease-in fact, the consist in inflammation of their structure, and the gradual obwhole phenomena of fever-being originally localized, as it literation they undergo by the inflammatory products. When were, in this tissue alone, avoiding all other mucous surfaces, the cells are filled with such plastic material the diseased mass even that of the intestine, for which the typhous process, in becomes solidified, and the cut surface has a granular appear. general, shows the most decided preference. This speculative ance. These changes, which are only the advanced stage of conjecture may or may not receive confirmation on further in- vesicular pneumonia, constitute the lesion described as Bayle’s vestigation, but it certainly is not at present considered even pulmonary granulations, which from its supposed resemblance in some external characters to the pulmonary parenchyma probable by British pathologists. The Bionclzial glands occasionally undergo an alteration when infiltrated with tubercular deposit, has been mistaken similar to that which I shall presently describe as affecting the for it; and in this way may be explained those cases of pulmomesenteric: they are swollen, of a dark colour, and infiltrated nary tuberculosis which have been said to follow fevers. with typhous matter. These glands (the bronchial), like the Splenization.-Amongst the pulmonary lesions or secondary mesenteric, have been supposed to undergo ulterior changes- affections of this form of fever (and peculiar to it alone), but to become softened, and, with or without perforation of the differing in some respects from the changes induced in the adjacent mediastinum, to give rise to pleurisy. This I have lung tissue by common non-specific pulmonary hypersemia, is that distinguished by the term splenization, from its resemnever met with. Pleura.-The pleural mzenzbrane of the lungs and th01’acic blance, in some respects, to the structure of the spleen. It parietes, as formerly noticed, not unfrequently becomes inflamed has also been called carnification. Dr. Jenner has given in enteric fever, so that after death the usual evidence of this examples, from the records of the Fever Hospital, in which this secondary lesion is discovered. It may have been either circum- lobular non-granular consolidation was found after death. It was scribed or partial, with or without effusion in moderate or con- first, I believe, pointed out by Louis, and has been since recognised siderable amount, the exudation presenting the various characters by the late Dr. Bartlett as a lesion frequently observed in the it is known to assume when it occurs as a primary or idiopathic enteric fever of the United States, and, as already stated, it disease. The effusion, however, generally shows that the pre- has not escaped the notice of British physicians. It has been existing inflammation has been of a less sthenic character, the well described by Rokitansky as a higher degree of hyperæmia, admixture of plastic exudation being always in proportion to in which the parenchyma of the lung becomes saturated, as it the more or less acute nature of the pleurisy. When of longer were, with blood, so that it assumes a dark-red or slate-purple standing, the fluid, more or less abundant in quantity, assumes colour. When the affected lung is minutely examined, it has a the puriform character-the condition also observed in those mottled appearance externally, in which may be seen darkcases in which the pleurisy had existed in a latent form. It will be generally found, too, that the inflammatory process coloured patches or portions, of varying sizes, of a someis not limited to the pleural membrane, but has spread to the what dense or solid structure, easily torn, but still crepitous. subjacent pulmonary tissue, constituting the pleuro-pneumonia If the diseased portions are cut into, dark fluid blood escapes; and when plunged into water, they still float. In a more of systematic authors. serous fluid, in varying quantity, sometimes mixed with advanced stage of this lesion, the diseased patches increase in density, and cease to crepitate or to float in water, and when blood, is occasionally found in one or both pleural cavities. From the absence of adhesions between the surfaces, and of deep incisions are made, very little blood can be squeezed from physical signs during life, these serous exudations probably the cut surfaces. When the air is entirely removed, with the occur among the final changes that precede death. exception of the gaping mouths of blood vessels, no trace of pulThe Pulmonary Tissue. -When pulmonary inflammation has monary structure is discernible, but only a tough, disorganized, sprung up in the progress of enteric fever, the changes in the friable mass, very unlike the granular appearance of consolidalung generally correspond with the nature, extent, and dura- tion in ordinary pneumonia. tion of the local affection during life. But that the pulmonary Pulmonary hypostasis.-This term has been applied to a lesions do not constitute an essential element in the pathology particular condition of the lung in which a passive congestion of fevers is shown by the fact, that they occur in nearly the ---astasis-takes place in the posterior and inferior portions, same proportion in other acute maladies. Still they arise in in persons who have been long confined to bed by protracted diseases. It has been, therefore, occasionally detected when so considerable a number of cases as to require special notice. The changes in question are referable to one general con- fevers and other acute maladies have been of unusually long

duration. dition—hypersemia. The course of this hypostatic congestion is slow and inCongestiol1.-There may be simply congestion or engorgement, chiefly of the posterior and inferior portions of the lung, active ; and it has been supposed, in some instances, in in consequence of the gravitation of the blood to the more de- exhausted subjects, to have laid the foundation of latent inpendent parts. When a piece of congested lung is cut into, flammation of the lungs. it exhibits a dark-red colour; the lung tissue is swollen and Cadaverie pulmonary 7type-rce?nia. - This change -postsomewhat dense, and filled with a frothy, sanguineous, or mortem hypej’semia of the lungs-should be distinguished from sero-sanguineous secretion. According to the degree in which the hypostatic congestion just noticed, which always takes these changes have taken place, the portions, when plunged place during life. In consequence of prolonged imbibition in into watpl’- ma.v not sink. these cases, the pleural membrane not only becomes discoloured, 212 nr TrB!lU

be said) she only knew from those who chanced to be around her when it happened. Her bowels, she added, had been sluggish; but had yielded to full doses of ordinary aperients. Her face was sallow and cachectic in hue; though perhaps not more so than fatigue and unrest, with close confinement in sick rooms, would have accounted for. Quite intelligent and even precise in her answers, there was something about her face and gestures-a slow, drowsy mode of answering, with a kind of half smile-which I remembered to have once or twice met with before, though I could not for the moment recollect where. Moderately dilated pupils; limbs perfect as to sensation and motion, but threatening almost to give way under her, as though from debility; a slow measured pulse of only 40 to 45 per minute; a trace (and only a trace) of sugar in the otherwise healthy urine; such were the only other symptoms which I could add to her own account of herself. ’’ On further inquiry, it appeared that the pain she complained of was referred to the vertex generally, and to the skull immeinflammation. In a memoir read before the Academy of Medicine in 1830, diately below it. It was constant; but often increased for Andral threw out the suggestion that this cardiac softening some hours to a maximum of severity at four or five P.M. It might be regarded as the result of commencing cadaveric de- was unaffected by pressure; increased by a supine posture. composition, favoured by circumstances which it is difficult to The slowness of the pulse was mainly attributable to the proappreciate. This view, however, was combated by Louis, who traction of the heart’s pause; the duration of its systole being maintained that the softening probably commences before death, little affected, still less that of its diastole. I could find and is therefore a lesion, not a post-mortem phenomenon; and nothing wrong in the abdomen; save a slight, but perceptible, diminution of its respiratory movements. more especially so, when it is remembered that the frequency " To questions suggested by the periodicity of the pain, she and severity of the softening are more marked according as the fever is more early fatal. Thus, he found the heart answered that until the last few months she had been residing softened in nearly half of those patients who died between the for many years in a very aguish district of the western couneighth and the twentieth days of the fever; in a third of those ties ; but without ever experiencing anything more than malwho died from the twentieth to the thirtieth; and in a some- aise. These symptoms, which remained absolutely unchanged what smaller proportion amongst those who died later: and he for several days without any return of the epileptic fit, were all adds, that had he included cases omitted, in which the softening the materials for a diagnosis. the surface of the brain, and "Cerebral disease, was less marked, the proportion would have been much larger. . He brings forward another cogent argument-that no similar located at its base, probably extending to the fourth ventricle lesion (softening) was found in any other muscles; but they - so far, I found myself at once inclined to push my conjectures retained their natural colour and consistence. respecting the malady. Or rather, you will observe it was not In the aorta, the only deviation from the normal state is the malady that I was conjecturing, but what might very more or less redness of the inner membrane, (in some cases likely be only its separable accidents: its situation in width diffused generally, in others in patches,) spreading some.way and depth. The nature of that abnormal deposit, which was into the descending aorta and the large arterial branches. It causing the irritation and pressure indicated by her symptoms, is found to extend to the middle coat, and is frequently, if not I found it difficult any way to conjecture. always, accompanied with cardiac softening. It is both more My physiognomical clue, as I fancied it might turn out, me Both the instances I was thinking of frequently observed and more marked in patients who die in the early than in the advanced periods of the fever. The recurred to my memory while I afterwards brooded over her notion that this redness (of the internal lining of the aorta) is case. They had been meningeal (and probably syphilitic) deto be ascribed to hyperæmic changes has been exploded as posits ; in one case, fatal by repeated epilepsy without sympuntenable, the more satisfactory explanation being, that it is toms of pressure; in the other case, rapidly cured by a course of mercury, in spite of a complication with partial tetanus, to merely staining from imbibition. The blood contained in the chambers of the heart varies leave the patient healthy for years afterwards. " Did the patient’s aguish residence, her cachectic look, her according to the condition of this organ. When its consistence is normal, fibrinous clots, more or less firm, are found. When periodic exacerbations of pain, indicate an aguish disorder ? To it is softened, the blood is defibrinated, and in soft semi-fluid this it could be only answered, that the spleen and liver were of normal size; the heart’s sounds healthy in character; the masses in the auricles and ventricles; when the softening is extreme, the blood is fluid, in small quantity, and mixed menses unaffected. She had, however, once or twice lost from one to two drachms of blood per anum, and apparently not with air-bubbles. from haemorrhoids. "Again, even if aguish, was it congestion or haemorrhage? CLINICAL REMARKS, BY DR. BRINTON, One could hardly imagine it anything short of the latter : a downright extravasation, even if a mere slow oozing, from the AT THE ROYAL FREE HOSPITAL. Dia mater. " Again, how did suchaview agree with the intense abdominal OBSCURE BRAIN DISEASE. NECROPSY. pain ? How with the constipation present ? How also with the great irritation (as shown by the pulse, the urine, the epiare "THE patient whose body we going to examine was ad- leptic fit,) produced-an irritation exceeding what a slow and mitted into the hospital about three weeks ago, in what seemed scanty oozing of blood might generally be expected to excite? to be an epileptic fit. She was convulsed and insensible, foam- Or how with the slight mental disturbance present ? " After all, however, this seemed the conjecture which united ingslightly at the mouth, and breathingsomewhat stertorously. its favour most of the circumstances of the case. And hence, In the course of about half an hour, this state gradually passed it had confessedly but a doubtful value, I was comthough into a deep sleep, the drowsiness left by which had not quite pelled to make it the basis of a very careful tentative treatdisappeared when I saw her on the following day. She was ment. a slender, " All suspicion of syphilis -was quite excluded, and the respectable-looking woman of about thirty, a widow who had for some time past earned her living as a nurse, patient’s gums had been slightly touched with mercury before for which duty one could imagine her gentle and intelligent her admission. Hence, not only was this equivocal remedy rendered unnecessary, but iodide of potassium demeanour well fitted her. She had been weak- and exhausted seemed additionally as a means of both removing the former advisable ; for some months past; a condition she attributed to the anxiety drug, and of perhaps remedying the aguish poison and its reand unrest of one or two arduous attendances upon sick per- sults. sons. About three weeks before admission, she was seized "Beginning then with purgatives, and finding that these had with violent abdominal pain; soon attended by a severe dull absolutely no effect, and that counter-irritation (as by blisters the of the neck) was equally useless, I proceeded in a pain, and feeling of weight, in the head. These were all her day or nape two to administer iodide of potassium, with the same symptoms, she stated, prior to the fit; of which (it need hardly negative results. Quinine was then ordered in two-grain doses.

but a certain quantity of sanguineous serosity occasionally makes its way into the pleural sac. 3. Organs of Oirculation. -There are few changes in the organs of circulation in enteric fever. Heart.-The pericardium is generally, almost invariably, in its natural state. It occasionally contains an inconsiderable amount of serous fluid, but without traces of pre-existing inflammation. The musculaj" structure, in about one-half, or perhaps in a still larger proportion of the cases examined, is normal. When there is deviation from the natural state, the chief alteration is softening. The walls lose their natural cohesion or strength, are diminished in thickness, and easily lacerated. When removed from the body, the organ is somewhat flaccid, and readily collapses; its tissue, when cut into, as well as the internal lining, being pale, or sometimes stained dark-redappearances which should not be mistaken for the effect of

involving

failed

altogether.

in

to

213