The essential phenomena of Fever may therefore be thus summed up:

Non essential phenomena of Fever.—Fever may be accompanied by pain especially of the the head and loins; a sense of heaviness or general lassitude; deficiency of either secretion, or of all of them; dryness of skin; thirst; nausia; scanty and high colored urine; delirium; constipation; jactation; &c. Some one of these symptoms is always present in connexion with inflammatory action, but they constantly vary, and, on that account may be regarded as non essential phenomena.

Varieties of Fever.—Fevers may be divided, with reference to the causes producing them, into two great varieties, viz: Idiopathic and Symptomatic.

The essential elements of all fevers are identical, while their non-essential phenomena constantly vary. Heat; inceased metamorphosis; acceleration of the circulation; and nervous disturbance are the invariable phenomena which distinguish and characterize febrile action. Fever, then, regarded as a pathological entity—a distinct unit, made up of the peculiar morbid conditions just mentioned—is always the same so far as its essential nature is concerned. It is true that the degree of heat, the extent of the metamorphosis, the rapidity of the circulation, and the amount of nervous disturbance are exceedingly variable; but it is equally certain that the mode, order and history of their development are precisely the same under every variety of circumstances. It is therefore a misnomer to denominate fever per se as inflammatory, irritative, &c.; and, hence, the usual classification adopted by writers on this subject, is manifestly unphilosophical because it has no foundation in positive pathological fact.

Fever, however, may associate itself with the Inflammation of a healthy system, or with the Inflammation of a debilitated, impoverished cachectie system.

The first is known as Pyrexia, or true Surgical fever, and is of a sthenic character. Its symptoms are a hot and dry skin; a full, bounding and frequent pulse; the diminution or arrest of the secretions; acidity and high color of the urine; constipation of the bowels; coating of the tongue with a white fur; thirst; languor, heat and pain of head. A disposition is always manifested in this connexion, to remit or intermit, or in other words, the fever is not of a continuous character.

Its abatement is followed by the subsidence of all the symptoms mentioned above:—by a free perspiration;—by abundant discharge of urine abounding in lithates;—by a natural movement of the bowels, or it may be diarrhoea;—by cleansing of the tongue, abatement in the frequency and force of the pulse;—by subsidence of thirst and a general feeling of relief on the part of the patient.

The second which is of a decided asthenic character, presents itself under three forms, viz: Typhoid Fever, Irritative or Nervous Fever, and Hectic Fever.

The true Asthenic or Typhoid Fever occurs principally in persons whose constitutions are enervated by exposure, privation, irregularity of life, grief, or long residence in a vitiated atmosphere.

Symptoms.—The period of depression is marked and much prolonged. The reaction is not of a very active character; there is a disposition to heaviness, stupor, and delirium; the pulse is feeble but quick and frequent; the skin is sometimes moderately hot, then again is particularly dry and burning, and occasionally covered with an abundant perspiration; the cheeks are flushed, and the eyes bright and starring, while the tongue is red, dry and sometimes cracked in its centre.

The abatement of the fever is characterized by a gradual disappearance of all the symptoms; but the patient remains weak and debilitated for months, and the return to health is invariably slow and uncertain.

Should the disease take an unfavorable turn, the pulse grows more feeble and frequent, the tongue dryer and more cracked, the skin cold and mottled; while hiccup, subsultus, dyspnoea or coma comes on and death closes the scene by claiming its victim.

There is always a tendency to visceral complications in connexion with this affection, which not unfrequently decide the fate of the patient. The fever is usually continuous and pathologists locate the especial seat of the disease in the Sympathetic system.

Irritative Fever is a variety of the asthenic form though not of so specific a type as the last. The nervous system is especially concerned; and the affection presents itself in connexion with the systems of those whose mental powers have been over taxed, or whose vital energies have been destroyed by excessive venery, indulgence in drink, constant intellectual labor, &c.

The symptoms which distinguish Irritative fever are a dry and red tongue; a sharp, small, but frequent pulse; subsultus; restlessness and delirium, which soon give place to signs of debility, with coma and cerebral irritation, sudden exacerbations, unequal and irregular remissions; rapid and important changes are also frequent concomitants of this form of disease.

Hectic Fever, is also a variety of the asthenic form, and generally presents itself in conjunction with some organic, serious disease, excessive discharge of any secretion, but more particularly with the formation of abcesses and the production of pus. Emaciation; debility; clear and red tongue; disposition to diarrhoea and profuse perspiration; a frequent and small pulse; slight chills followed by burning of the hands and feet, with a circumscribed flush upon the cheek, indicating derangement of the capillary circulation, are the symptoms which characterize this form of fever.

Hectic is but too frequently the harbinger of a speedy death; and yet, it is really astonishing to observe with what rapidity and completeness many patients recover even after the development of its most characteristic and unfavorable symptomps.

It not unfrequently has the effect also of producing an exhileration of the spirits,—elevating them to such an extent as to preclude all fear of the fatal catastrophy of which it is the sad precursor.

TERMINATIONS OF INFLAMMATION.—Inflammation may terminate either in the repair of the part; in its return to health; in the modification of its function and structure; or in its death.

Repair of the part.—A part whose continuity has been broken or destroyed may be repaired, after the development of Inflammation, either by the immediate organization of the Effused Lymph, or by its more slow and gradual conversion into a structure identical with that of the subjacent tissues or similar to it.

When the repair is immediate, it is called union by the “First Intention,” and when more tardy— being accompanied by the formation of healthy pus, granulation, &c., it is denominated union by the “Second Intention.”

Restoration of the Part to health.—Inflammation may be developed in a part, which has suffered no solution of continuity, under the influence either of some Local or General cause, and, after the manifestation of all the characteristic symptoms, of that process, leave it in its original condition. This is accomplished by the reabsorption of the effused Plasma, either in its nascent state, or after it has been changed into blastema and fibro-cellular tissue. The absorption of the Lymph in its liquid state is denominated Resolution, and is the most favorable termination or effect of Inflammation. Nature, in many cases, labors to make way with effused Lymph in such a manner as will prove least injurious to the surrounding parts as well as to the organism; and, hence, the work of reabsorption is commenced, under its watchful and intelligent guidance, to be perfected or not according to the circumstances of the case. Each petholigical step is then carefully and successfully retraced. The attraction between the Globules and the walls of the vessel, loses its intensity; the stasis of Blood disappears; the Heat, Pain and Swelling abate; and the part assumes its normal status, both as regards function and organization. It sometimes happens, however, that all of these steps are taken suddenly and simultaneously, or occur so rapidly as to be inappreciable. This is styled Delitescence.

Metastasis is the sudden translation of Inflammation from one point to another. This, in a majority of cases, may be regarded as a phenomenon of Nervous Reflex Action—a principle which plays a most important role both in the Physiological and Pathological processes of the organism.

Resolution is the natural, legitimate and most favorable conclusion of the Inflammatory process—a result towards which the efforts of the Practitioner should be invariably directed as the most effectual method of preventing disastrous consequences.

The Absorption of Lymph after its conversion into blastema and fibro-cellular tissue, does not occur to any considerable extent during the height of the inflammation by which it has been produced. There must always be a marked reduction of the morbid action before the absorbent vessels can be forced to take hold of it; but when this point has been once reached the process often goes on with great rapidity. When the Lymph has become completely organized, absorption is, of course, still more difficult, and not unfrequently impossible.

It is more than probable that Lymph even in a liquid state, is not absorbed until it has been dissolved in the fluids of the affected parts, when it is brought more readily under the influence of the absorbent vessels.

Modification of the structure and functions of the Part. Inflammation may also leave the Part modified both as regards function and structure. This modification is due to the influence of certain products of the Inflammatory Process, which should be briefly considered, in connexion with this mode of development, and the nature of the effects produced by them.

The effects or products of Inflammatory Action, which play this important part in the economy are: Induration, Hypertrophy, Atrophy, Effusion of Serum, Formation of Pus, Organization of the effused Lymph, or Transformation of Tissue.

Induration. When the effused lymph is not absorbed it organizes, either forming a sort of internal cicatrix which is harder than the surrounding tissues or increasing the density of the part by augmenting the amount of plastic material within it.

Softening. This results either from the infiltration of effused liquids, or disintegration of the substance of the textures themselves, by which their consistence is diminished.

Hypertrophy. It has been previously shown that the Inflammatory Process not only increases the amount of Blood—the pabulum sent to a given tissue—but also stimulates the appetite of the part, so as to render its nutrition more active and complete. It thus happens, not unfrequently, that tissues, and whole organs are permanently enlarged, as a consequence of Inflammation.—Hypertrophy is essentially a local disease.

Atrophy. Though atrophy is the opposite of Hypertrophy it is not an unusal effect of Inflammation. Nutrition is made up of two elements, which though entirely distinct, the one from the other, are absolutely essential to the perfection of the process. Cell destruction as well as Cell elaboration—the breaking down and the building up of tissue, occur simultainously throughout the whole organism. The term metamorphosis includes both of these processes; and in the normal condition of the system presupposes a perfect equilibrium between them. Under the influence of Inflammation this equilibrium is lost, so that cells may be too readily produced, or too rapidly destroyed. In the one instance Hypertrophy is produced and in the other Atrophy is the result.

Effusion of Serum.—Congestion or the accumulation of Blood in the part affected, constitutes one of the distinguishing features of Inflammation. It is, in fact, an essential element of that process. The vessels thus become filled with an unusual quantity of the circulatory fluid, which distends their coats, and facilitates the pouring out, or the exosmosis of the watery portion of the Blood into subjacent cavities or neighbouring tissues. It is in this way that fluxes are produced and dropsies occur, materially altering the structure of tissues and organs, and interfering with their peculiar functions. All the tissues do not present the same tendency to the effusion of serum in connexion with Inflammatory action. The structures which supply it in greatest abundance are the cellular and serous, the secernent vessels of which are extremely active even when the disease itself is comparatively mild. The mucous membrane of the alimentary canal, particularly that of the Colon and Rectum is frequently the source of large effusions of serum, as is seen in diarrhoea and Cholera Infantum.

The appearance of the serum is usually limpid, though it may be changed by admixture with the secretions, Lymph or Pus. The effusion of Serum is always a phenomenon of Osmosis, while it is controlled by the laws which govern that process, and is dependent upon that principle alike for its production and its cure.

Suppuration or the formation of Pus. The idea was long entertained that Pus was a veritable secretion, poured out from the vessels under certain abnormal circumstances, and subject to all the laws which control the products of secerning organs generally. The researches and arguments or Gulliver, Mandt and Addison have demonstrated the incorrectness of this opinion; and it is now generally agreed among Pathologists, that Pus Corpuscles are modifications of the Exudation Cells, and that suppuration is nothing more nor less than the breaking down or degeneration of the Lymph poured out in connexion with the inflammatory process.

When Lymph is not converted into tissue, or false membranes—because of the blight impressed upon the formative power of the contiguous structures by the Inflammatory action—or fails to organize even into cacoplastic products, a peculiar depreciation takes place in it whereby the corpuscles of the Plastic mass are transformed into Pus Cells, the Blastema degenerates into liquor puris, and Purulent matter takes the place of the more highly organized effusion.

When Pus is formed upon a free surface, it is styled a Purulent secretion; and when elaborated within the structure of a part, it is called an Abscess. Nature usually makes an effort to retain the Pus thus formed within limited bounds, by depositing around it an external boundary of consolidated Lymph, known as the Pyogenic Membrane. This does not secrete Pus as was supposed by Delpech and many others, but is simply the boundary line between the abnormal product and the intact tissues. When this Membrane is absent, it may be regarded as indicative of a want of tone in the system, and as such furnishes a valuable hint to the Surgeon as regards prognosis and treatment. In the above remarks concerning this Pyogenic Membrane, the production of Pus in connexion with abscesses, is only referred to. This fluid is elaborated along the track of wounds extending through tissues of all grades and varieties, with so much rapidity and in such large quanties, as to preclude, even in the most vigorous constitutions, the formation of a protecting membrane, and is, hence, found diffused, in many instances, throughout the subjacent structures.

When Pus is opaque, thick, smooth, slightly glutinous, of a yellowish white color, with a greenish tinge, a faint odour and a alkaline reaction, it is said to be healthy or laudable; when mixed and tinged with blood it is sanious; when thin watery and acrid, ichorous; when it contains cheesy looking flakes, curdy; and when diluted with mucus or serum, muco-pus or suro-pus.

It consists, when laudable, of corpuscles, floating in a homogeneous fluid, styled “liquor puris.” These corpuscles are modifications of the exudation-cells, and are composed of a semi-transparent cell-wall, with two or three nuclei, of large quantities of granular matter, of particles of fibrin, and of disintegrated exudation cells. A multitude of changes, however, may occur in it, altering its composition, and changing its character, which can be detected by the microscope. When the suppurative process has once been set up, it may continue for an indeffinite period, becoming, as it were, the fixed secretion of the part. From mucous membranes particularly, it has been known to last for years.

The symptoms which indicate that Pus is about to be formed, are; a more throbbing pain, a greater swelling and tension of the part, and a red, glazed and shining appearance of the skin, though it is sometimes elaborated without the development of any antecedent local sign.

The symptoms which indicate that Pus has been formed are: the disappearance of the ordinary signs of inflammation; the occurrence of chills or rigors; alternations of heat and cold; abatement of the intensity of the fever, and its assumption, in some instances, of an intermittent character; softening and perhaps quickening of the pulse; and fluctuation in the part, with enlargement also when the fluid is diffused throughout its tissues.

The symptoms which indicate that Pus is escaping from the system in too great a quantity, are: emaciation and loss of strength, a quick, small and compressible pulse; a coated and dry tongue with red tips and edges; flushed cheeks; dilated pupils; profuse sweating; copious purging; large discharges of urine, filled with red deposits; great debility; hypocratic countenance; husky voice; insomnia, &c. There is usually an exacerbation towards evening, and the actions upon the bowels, skin and kidneys alternate with each other, until the patient dies from sheer exhaustion.

The tendency to suppuration is increased by the following circumstances, viz:

The Plastic matter thus destroyed is the food of the tissues involved in the Inflammatory action—the pabulum upon which they depend for the preservation of such properties as are essential to the integrity of their structure and the perfection of their functions.

Again, the purulent fluid by desseminating itself throughout the tissues, or by pressing upon them, so changes the normal status of the part as to disqualify it, either partially or completely, for the performance of its proper offices.

Of the fatal consequences which connect themselves with the presence of Pus in the blood, it is unnecessary to speak in detail here, in as much as they will be more fully discussed in another connexion. It is sufficient to say that the Purulent elements, when thus absorbed or developed, so paralyze the nervous centres and blight the tissues of the organs generally, as to interfere with the action of all the component parts of the organism—suspending nutrition, aborting or altering secretion, robbing the muscles of their tone and power, destroying “nervous influence,” and inducing a complete revolution in the whole system.

Organization. The Plastic Lymph effused in connexion with the Inflammatory process may either Organize or break down into Pus. The term organization includes the conversion of the effusion into tissue, taking its character from the subjacent structures; the development of false membranes: and the formation of certain heteromorphous products, as Tubercle, Cancer, &c. Plastic Lymph possesses an inherent capacity for organization. As soon as it is effused, this tendency manifests itself by the formation of cells and nuclei in great numbers, which connect themselves with each other, and gradually spread out into fibres lying for the most part in parallel lines, and profusely inlaid with granules. Vessels soon show themselves, which are the result either of a new epigenesis, or the contributions of the neighboring structures, the latter being the more common source of supply. Nerves and absorbents, finally appear, but whether they are supplied by the surrounding tissues, or are spontaneously developed from the effused matter, has not been determined by Pathologists. In this manner the effused Lymph either assumes the characters and functions of the tissues with which it is in contact, or forms false membranes. When, however, there is a deficiency of nervous influence in the part or system, a want of plasticity in the effusion itself, or a deficiency of vital power in contiguous tissues, the same attempt at organization is made, but the issue is an aborption, and a product results, of an inferior degree of organization, and lower in the scale of vital endowment, to which the term heteromorphus has been applied. It is in this way that Tubercle and other similar growths are developed, as the effects of Inflammation, complicating the termination of that process, and inducing eventually the most serious consequences to the system.

Inflammation may terminate, leaving behind the higher products thus formed in a state of complete organization, and materially modifying the structure and functions of the part in which they have been developed. An organ, as the Liver or Spleen, which has been hypertrophied, by the organization of Lymph effused into its structure, does not preserve its original status either physically or functionally, and is, hence, modified to an appreciable extent by the precedent morbid action. So likewise, False Membranes, by agglutinating the Intestines, binding together the Costal and Pulmonary Pleura, constricting or contracting the Urethra, &c., &c., materially interfere with the legitimate functions of these parts, and produce disastrous consequences in the economy.

Transformation of Tissues. Each tissue posses the power of appropriating certain elements supplied by the Blood, and of converting them into its own substance. In order that this “formative power” may be legitimately exercised, it is necessary that the structures remain in a condition of health, that the ordinary supply of nervous influence and of proper pabulum be supplied them, and that their normal Physiological status continue intact. The Inflammatory Process interferes with the supply of nervous influence, and destroys the responsive power of the tissues without necessarily depriving them of the elements which constitute their proper food. Instead of converting plastic Lymph into their own substance, they simply impress it with a sufficiency of vital force to insure its organization into tissues of a lower grade, and, hence a spcies of degeneration, or transformation ensues—the original elements of the structures concerned being consumed by the destructive Metamorphosis which takes place in them, in common with all the tissues of the organism. The whole process may be thus summed up:

The most common instances of this degeneration or transformation, are the cellular, mucous, cutaneous, fibrous, calcareous and fatty.

The Fatty degeneration is the most usual universal and important of all, since there is hardly any organ or tissue of the body in which it may not occur. It has been observed in the Lungs, Placenta, Cartilages, Bones, Cornea, Lens, Arteries, Heart, Kidneys, and Liver—particularly of drunkards—, and constitutes one of the most important products with which the Pathologiest has to deal.

It is important to remember that the various tissues possess different degrees of vitality, some being much more highly organized than others; and, hence requiring dissimalar conditions for the full exercise of that power by which plastic Lymph is converted or transformed into their substance. The products now under consideration, differ from the cacoplastic deposits, referred to in another connexion, in being more highly organized, and in the fact of their requiring the exercise of a greater degree of vital energy on the part of the affected tissues in order to insure their development.

All the facts in regard to the organization of the effusion incident to the Inflammatory process may be thus arranged:

Organizing completely, and forming False Membranes, or being converted into the Elements of subjacent tissue.

Organizing incompletely and forming tissues of inferior vital endowment to those affected by the inflammatory action.

Organizing less completely, and forming Heteromorphous products generally.

Not organizing at all, but breaking down into Pus.

Death of the Part.—Inflammation causes the death of the part, in which it occurs in two ways, not materially differing from each other in their essential nature.

These processes, which are at once the effects of the Inflammatory process, and the instrumentalities by which it accomplishes its work of destruction, are Ulceration and Gangrene.

Ulceration.—In atrophy the form and structure of the part remain, while the breaking down and absorption of its elements take place with unusual rapidity—more rapidly, in fact, than they can be reproduced. It sometimes occurs that this power of Inflammation localizes itself, and so completely annihilates the equilibrium between the waste and repair—cell-destruction and cell-elaboration—of a tissue, within certain prescribed limits, as to insure the entire suspension of that Physiological process by which the structure is built up, and to stimulate, to an unusual degree, that destructive metamorphosis by which it is broken down. There results, consequently, a possitive disorganization of the part thus affected, with an actual loss of its substance—forming what is familiarly known as an ulcer.

It is in this way, that ulcers are originally developed, as the result of Inflammatory action, while the particular features which give them character, are impressed upon them by extraneous circumstances. Ulceration is therefore the local, circumscribed destruction of a tissue,—a veritable dissolution in miniature. The several distinct pathological acts concerned in the development of an ulcer may be thus enumerated:

In support of this view of the subject it is only necessary to mention that the debris of the wasted tissue cannot be found either in the Pus which, subsequently fills the ulcer, or in the Blood itself—a fact which demonstrates that their disappearance is due to an exaggeration of the Physiological process by which the destruction of tissue occurs throughout the whole organism—or in other words that they disappear in obedience to the ordinary law of cell-destruction and absorption enforced with extraordinary energy and effect, through the agency of the Inflammatory Process.

For the different varieties of ulcers, with their symptoms, treatment, &c., the reader is referred to the standard works on Surgery.

Gangrene.—Gangrene may be considered as a partial death—the death of one part of the body while the other parts are alive. It may result from the violence of the Inflammation; from an arrest of the Circulation; and from deterioration of the elements of the Blood.

The expression “violence” is used relatively in this connexion—to convey the idea of an Inflammation not intrinsically great, but still too excessive for the part to bear without serious detriment. The same amount of vitality does not reside in all systems, nor is it distributed in equal proportion to the tissues and members of a particular organism. When Inflammation is developed in a tissue or member, the vital force of which has been lowered, and whose “formative-power” is lost, a peculiar modification of structure occurs, to which the term mortification is applied. In a word, the tissues not being supplied with their normal amount of vitality because of its consumption by the Inflammatory Process, and having, therefore, lost the power of appropriating the pabulum necessary for their support, die, as a matter of necessity, while the other portions of the body remain intact. Atrophy indicates that the “formative-power” of the tissues has been diminished, while a sufficiency of vitality remains to preserve their external form and internal organization; ulceration shows that this same power has been lost within circumscribed limits, and that molecular death has been the result; while Gangrene illustrates the fact that this ability to “appropriate and transform,” has been entirely destroyed, even to the extent of entire tissues and members, with such a diminution of vitality as precludes the preservation of their organization, and permits the operation of ordinary chemical affinities.

The circulation may be arrested by the congestion of a part, and by the pressure of effused Lymph, Serum or Pus. In this way the tissues are deprived of their proper food, and really die of starvation.

The blood may be so altered by Inflammation, particularly of a specific character, as to afford no pabulum to the tissues, and to prove the occasion of their death. Thus the Inflammatory action associated with Small Pox, Scarlatina, Erysipelas, Pyæmia, Hospital-Gangrene, Glanders, and other diseases of a specific nature, terminates not unfrequently in the mortification of some part or member of the human frame.

In some instances the dead portion is dissolved away at its circumference by an exudation from the living parts, and is thus separated or sloughed from them; while, if the dead portion be extensive, separation will not be effected before decomposition takes place, and, hence, we have what are known as Gangrene and Sphacelus.

Gangrene may be regarded as the state which precedes and terminates in Sphacelus,—a condition in which there is great diminution, but not a total destruction of the powers of life,—the blood still circulating through the larger vessels,—the nerves retaining some portion of their sensibility, and the part being not yet beyond the recuperative point.

By Sphacelus is meant the positive and irrevocable death of the part,—the loss of its organization, the destruction of its component elements, the suspension of its vital laws, and its complete surrender to chemical principles and affinities.

Gangrene has also been divided into the humid, dry, constitutional and local. But it is not our purpose to consider these varieties in detail, in as much as the same principles are concerned in their development, and similar laws apply to their treatment. When mortification is about to manifest itself as a result of Inflammation, the redness assumes a darker hue; heat and pain abate; and there is a general amelioration of all the symptoms save the swelling which generally increases in consequence of the effusion of Sanguinolent Serum.

When Gangrene terminates in Sphacelus the hue of part becomes dark and dirty—the tissues grow flaccid and cold, while crepitation manifests itself on pressure, and a most offensive odour is evolved.

When the progress of the Gangrenous process is arrested, healthy circulation is developed up to the margin of the diseased portion, while a bright red line—the line of demarcation—indicates the establishment of adhesive Inflammation, and shows that the living parts are to be separated from the dead by a spontaneous effort of nature. This line of demarcation extends to the entire depth of the Gangrene, totally and completely surrounds it, and by a process of interstitial ulceration, removes the dead part, without hemorrhage or other serious inconvenience, leaving a granulating and healthy surface behind, which undergoes cicatrization without much difficulty or delay.

In some instances however, as when Patients have been subjected for a protracted period to the influence of debilitating agencies, the blood does not coagulate in the vessels and hemorrhage of a fatal character occurs.