A Treatise on Fever

by Southwood Smith

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

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

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

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

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

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

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

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

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

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