healthy persons. He remained in my family till the 26th of the month, and on that day I repeated the bloodletting. The serum had assumed a deep yellow hue, and a copious precipitate of red globules had fallen to the bottom of the receiving vessel."

CHAPTER V.

CHANGES OF THE ORGANS, AND TISSUES, AND APPARATUS OF THE BODIES OF THOSE WHO HAVE DIED WITH THE DIFFERENT TYPES OF MALARIAL FEVER, INTERMITTENT, REMITTENT, AND CONGESTIVE-COMPARISON OF THESE CHANGES WITH THE PHENOMENA OF MALARIAL FEVER, AND WITH SIMILAR CHANGES IN OTHER DISEASES, AND WITH THE ORGANS, TISSUES, AND APPARATUS OF MEN AND ANIMALS IN THE NORMAL CONDITION.

Exterior skin-Muscular system. Head-dura-mater, arachnoid membrane, piamater, cerebrum, cerebellum, medulla oblongata, ventricles of brain, &c. Nervous phenomena of fever, compared with post-mortem examinations. Chest-Lungs, heart. Alimentary and intestinal canal-Mouth, tongue, œsophagus, stomach, duodenum, jejunum, ileum, colon, rectum, glands of Peyer, solitary glands. Liver-Slate and bronze color of liver; changes of blood of liver; malarial liver contains animal starch, but no hepatic sugar; bile. Spleen-Slate color of spleen; pulp of spleen; alterations of structure. Kidneys-Supra-renal capsules. Bladder.

THE following observations are based upon a careful examination and comparison of the symptoms of three hundred cases of malarial fever; fifteen post-mortem examinations of the bodies of those who had died from the different types of malarial fever, intermittent, remittent, and congestive; numerous examinations of the bodies of those who had died from various diseases, as phthisis pulmonalis, pneumonia, pleurisy, dysentery, diarrhoea, cirrhosis of the liver, fatty degeneration of the liver, dropsy, hemorrhage, apoplexy, cancer, intemperance, scarlet fever, diabetes, Bright's disease, enlargement of the lymphatic glands, typhoid fever, and yellow fever, and upon the careful dissection and microscopical examination of the organs, tissues, and apparatus of several hundred fishes, reptiles, birds, and mammalia.

Exterior.--In the severe cases of malarial fever, which terminate in a short time, the muscular system, and the fat surrounding the muscles, did not appear reduced to any great extent. In cases of

long standing, especially those which had been neglected, there was great loss of flesh and fat, and the body and limbs presented an emaciated appearance, unless the tissues were infiltrated with serum. As a general rule the cadaverous rigidity was well marked.

In many cases the surface presented a sallow hue; and in one violent case of congestive fever, several hours before death, as the patient lay in a profound stupor, the whole surface assumed a golden yellow color, similar to that of the serum which issued from a blistered surface over his epigastrium.

In the majority of cases, the color of the skin of the superior parts, after death, presented a pale, bloodless appearance; whilst the skin of the inferior (dependent) portions presented a mottled purplish color. This dark purplish color of the dependent parts gradually diminished towards the superior uppermost parts of the body in the recumbent posture, and appeared in every instance to have been due to the gradual settling of the blood in the capillaries of the most dependent parts towards the close of life, when the general and capillary circulations were feeble. For this reason the lips and gums were almost always pale, and almost white. The lungs, and liver, and kidneys, and intestines, and stomach, and brain in many, if not in every case, presented similar evidences of the gradual settling of the blood in the vessels and capillaries of the most dependent parts towards the close of life, when the feeble circulation was readily overcome by the force of gravitation. If stimulants and sinapisms had been freely used in the last hours, the settling of the blood in the most dependent parts was not so marked.

CEREBRO-SPINAL NERVOUS SYSTEM.

As far as my observations have extended, in malarial fever the dura mater was always normal-the arachnoid membrane pearlcolored, opalescent in some cases, in others perfectly transparent and normal in appearance—the blood vessels of the pia mater congested with blood, but always without any marks of inflammation; subarachnoid fluid in almost all cases clear, and transparent, and in one or two cases colored by the presence of colored corpuscles; in severe cases of a golden color; the amount varied in different cases, sometimes exceeding, but most generally falling short of the usual amount-the blood vessels of the brain generally filled with blood-structures of the brain appeared in almost every case normal, altered neither in consistency nor appearance; blood was effused upon the brain in only two instances.

The opalescent pearl color of the arachnoid membrane in spots, was of little diagnostic value, because it was by no means uniform. In like manner, the variations in the amount of the subarachnoid fluid and cerebro-spinal fluid was of little diagnostic value, because its chief use is mechanical, and Magendie has shown that it can be rapidly secreted and rapidly absorbed without any disturbance of the functions of the brain; and further, that even in the normal condition it varies greatly in amount, from two drachms to two ounces; and Cotunnius, the original discoverer of this fluid, states that in experiments upon the bodies of twenty adults, the amount of this fluid varied from four to five ounces.

In asserting that the structures of the brain in malarial fever were, as a general rule, altered neither in consistence nor in appearance, we do so only upon the evidence afforded by sight and touch; we do therefore by no means affirm this to be a fact established upon an immutable basis. How difficult is it to prove the mode of action of the malarial poison upon the nervous system, especially when it may act in a manner analogous to that of certain violent poisons, which we know will occasion almost instantaneous death, without producing a single pathological alteration recognizable by the most delicate chemical tests, or the most rigid microscopical examination. We know that some substances, as chloroform, will produce sudden death, in some cases, where there is no assignable cause, either in the structures or forces of the patient, or in the pathological alterations produced, or in its accustomed action. This peculiar action is said to be due to the idiosyncrasy of the patient. May not the fatal action of the malarial poison be due, in some cases, to the idiosyncrasy of the patient? The question is, What is an idiosyncrasy? No one has ever demonstrated whether these peculiarities of constitution depend upon the physical and chemical structures and relations of the solids and fluids, or upon the relations of the physical, chemical, vital, nervous, and muscular forces, or upon both sets of relations combined. We must admit that to determine accurately the alterations of the nervous appa.. ratus, under the action of various morbific and remedial agents, it is absolutely necessary that the structures of the different parts of the nervous apparatus should be submitted to a rigid chemical and microscopical analysis. Numberless insuperable difficulties lie in the way of complete microscopical and chemical analyses. It is impossible to obtain the substances for analysis until several hours after death, and, in substances so liable to change, important altera

tions may take place, even in this short time. It is impossible to separate the blood entirely from the nervous elements; and the presence of a varying amount of blood, of varying constitution, would of itself be sufficient to vitiate the results of every analysis which had for its object the determination of the chemical changes induced by a most subtle poison. Notwithstanding this imperfect state of pathological science; notwithstanding that we have no facts to warrant the assertion that the malarial poison acts primarily or exclusively upon one system of nerves or the other; we should, nevertheless, analyze the phenomena as far as our means of analysis extend, and use all the well established facts to the extent of their bearing and significance. We will proceed to do this.

As far as my observations extend, the pathological alterations of the structures of the brain and spinal marrow do not correspond to the symptoms during life. The most universal phenomenon appears to be the stagnation and accumulation of the blood in the bloodvessels and capillaries of the brain and pia mater. This accumulation of the blood in the vessels of the brain and pia mater appears to be due neither to inflammation nor to irritation, but simply to a stagnation of the blood, similar to the stagnation and accumulation of the blood in the vessels of the large organs.

This view is conclusively sustained by the results of treatment. In numerous cases I have seen the wildest delirium calmed, the intellect aroused into full vigor from the most profound coma, and the most alarming cerebral symptoms vanish under the free use of stimulants and sinapisms, with or without the sulphate of quinia. When the sulphate of quinia was withheld, the effects of the stimu lants and sinapisms would be but temporary; whilst, when it was administered in sufficient quantities, the restoration of the intellectual functions and the removal of the cerebral symptoms were permanent. Now, is this the action of stimulants or of sulphate of quinia upon an irritated or inflamed brain? These facts alone demonstrate conclusively that the cerebro-spinal system is not the seat of irritation or inflammation in malarial fever, if we limit irritation and inflammation to the meaning universally adopted; and that if irritation and inflammation of the cerebro-spinal system do arise in the progress of malarial fever, they are by no means universal phenomena dependent upon the definite and universal action of the malarial poison.

To what, then, must we refer the aberrated nervous phenomena of malarial fever? Whilst we cannot answer this question fully and absolutely in the present imperfect, undeveloped state of phy

siology and pathology, we can point out and demonstrate three distinct causes: 1st, the alterations of the blood; 2d, the disturbances of the general and capillary circulations; and 3d, the direct depressing effects of the malarial poison upon the nervous appa

ratus.

1st. The Altered Blood.-We have shown in the preceding chapter that the colored blood-corpuscles are not only greatly and rapidly diminished in malarial fever, but that they often lose the saline constituents. We have every reason to believe that the bloodcorpuscles, taken collectively, perform the offices of an immense gland for the elaboration of the materials for the nutrition of the muscular and nervous systems. We have further shown that the coloring matters of the serum are increased, and the coloring mat ters of the bile retained, in the blood of malarial fever. And I shall hereafter show that the constitution of the urine is greatly altered in the severest forms of malarial fever, and that some of its most important constituents are either not formed at all, or, if formed, are not eliminated. We have also shown that the fibrin is altered both in quantity and in quality.

Here, then, we have profound alterations of the blood which must induce corresponding disturbances in the muscular and nervous systems, and in all the organs and tissues which derive their nutrition from the blood. Here, then, we have profound alterations in the constituents of the blood which must produce corresponding disturbances in the general and capillary circulations, and in the chemical changes in the capillaries and surrounding tissues upon which depend the capillary circulation, and, in fact, the development and maintenance of all the forces-physical, muscular, and nervous. As a general rule, the general and capillary circulations are greatly disturbed in congestive fever. These disturbances are manifested in the quick, thumping action of the heart, the small, feeble, rapid pulse, the panting, full respiration, the want of correspond ence between the temperatures of the trunk and extremities, the aberration of the physical, chemical, muscular, and nervous pheno mena, and in the stagnation of the blood in the different organs and tissues. The stagnation of the blood in the organs, tissues, and apparatus, is due to disturbances in the sympathetic and cerebrospinal system, disturbances in the general circulation, disturbances in the quantities and qualities of the constituents of the blood, and arrest or perversion of the chemical changes of the capillaries. It is well established that the circulation of the blood through the