_Of Typhus: Division into Mitior and Gravior, and into Cerebral,
Thoracic, and Abdominal. Typhus Mitior, with Subacute Cerebral
Affection; with Acute Cerebral Affection; with Thoracic Affection;
with Abdominal Affection. Typhus Gravior: in what it really
consists: dangerous Nature of the Error that it consists in
Debility._
The appearance of a person labouring under typhus is so different from
that of a person affected with synochus, that no one ignorant of the
disease, who saw these two patients for the first time, would believe
that both were afflicted with one and the same malady. And yet
dissection after death demonstrates, that the physical condition of the
organs is precisely the same in both; and careful examination of the
symptoms during life, shews that they are really identical, both in
their nature and their succession, however, at first view, they may
appear to differ. The difference between these two diseases arises
entirely from a difference in intensity: still this difference produces
a very important modification in the character of the disease;
important, because it materially affects both the safety of the patient,
and the nature of the remedies that are best adapted to rescue him from
his danger.
Typhus, like synochus, presents itself under two degrees of intensity,
which, like those of the latter, may be conveniently designated by the
terms mitior and gravior. All the important symptoms which belong to
both are found in the same cavities, and relate to the same organs, as
in synochus, and, therefore, must in like manner be divided into
cerebral, thoracic, and abdominal.
I. TYPHUS MITIOR, WITH CEREBRAL AFFECTION.
Cerebral affection in typhus, as in synochus, presents itself under two
degrees of intensity, which may be distinguished by the same terms as in
the latter, the subacute and the acute.
1. _Typhus Mitior with Subacute Cerebral Affection._
The symptoms which denote this affection in typhus, are perfectly
similar to those which have been stated to characterise it in synochus,
but they undergo certain modifications, the true nature of which appears
to me to have been greatly mistaken, and, after the most careful
attention which I have been able to give the subject, the mistake seems
to me to be of so much magnitude, that I think whosoever shall
effectually correct it, will do the greatest possible service to
medicine, and, through it, to his fellow men.
1. There can be no question that, from the very first commencement of
the attack, as well as through the whole course of the disease, the
prostration of strength, both physical and mental, is greater in typhus
than it is in synochus. This greater loss of energy is indicated by
every sign that can be conceived to denote it. The loss of power in the
muscles which support and move the body is oftentimes so complete, as to
be most alarming to the patient and his friends; while the contrast
between the vigor and the torpor of the mind, in the course only of a
few hours, is most striking. From the full and active exercise of its
faculties, it becomes, in that short space of time, quite incapable of
performing any intellectual operation. It is confused and stupid, always
in a greater degree than in synochus, and sometimes to such a degree,
even on the very first day of the attack, as to excite the utmost
apprehension in every one around the patient who takes any interest in
his fate.
2. The chilliness is, upon the whole, greater and longer-continued than
in synochus: yet there is less constantly shivering, and the heat, when
it succeeds this state of chilliness, is seldom as great as in the
latter; while there are cases in which the heat never exceeds the
natural standard.
3. The febrile uneasiness is greater; the restlessness is incessant; the
face is pallid; the features are shrunk; the expression of the
countenance is most peculiar; it is strikingly indicative of weakness
and suffering; the experienced eye can tell at a single glance, even at
this early period, to which of the two types that countenance belongs.
The pulse is always weaker and more rapid than in the corresponding
stage in synochus.
4. There are cases in which the pain of the head is equally severe as in
synochus: but this may be justly considered as rare. In general it is
less acute. Dullness, confusion, stupor, giddiness, are more common than
severe pain, and are often the substitutes for it. Though some degree of
pain be generally present, yet it is by no means uncommon for one or
more of these sensations to occupy its place completely. Question the
patient as much as you please, and he will tell you that he has no pain;
but it is evident, from his aspect and his manner, that he has little
sensation of any kind. The eye is dull, heavy, stupid, without lustre:
the old English word “lac-lustre” expresses its character truly and
strikingly. But it is remarkable, that while the pain in the head is
only slight, the pains in the back, loins, and extremities, and, as the
patient himself says, in the bones, are severe.
5. When pain is present it diminishes sooner and disappears more
completely than in synochus: when it is not present, the advancement of
the disease is indicated by increasing insensibility, and by the rapid
transition of dullness or confusion into a state of stupor approaching
to coma. The eye is already muddy, and it soon becomes injected and
suffused. The skin over the body is generally warm, sometimes hot: over
the head it is often hot. The face is usually pallid, but the pallidness
frequently alternates with flushing. The change of dullness into
insensibility more or less profound sometimes takes place as early as
the second or the third day: it is seldom that it is as late as the
seventh or the eighth: it is postponed, when not prevented, by active
and appropriate treatment.
6. There is little or no sleep; the restlessness is great; there may be
no violence; but there is abundance of inquietude.
7. Delirium is more constantly present than in synochus; and when it
comes it comes earlier: its presence is not unusual as early as the
sixth or the seventh day; and it may appear still sooner, but that is
rare. It consists of low muttering incoherence rather than of loud and
violent talkativeness; and is expressed in moaning rather than in
screaming.
8. The connexion between delirium and muscular tremor, between muscular
tremor and subsultus tendinum, and between both, and the passing of the
stools and the urine unconsciously, has already been pointed out. Like
delirium, muscular tremor is much more constantly present in typhus than
in synochus; and its relation to delirium is so close that it is
sometimes observed to supervene on the very same day; frequently on the
day following; and, if it appear at all, it is seldom longer absent than
the third. Its degree likewise is commonly in proportion to the violence
of the delirium; and though early and great delirium may appear without
it, yet it very rarely appears without delirium; and in general all
these symptoms form one series or train; pain disappearing, confusion of
mind increasing, muttering incoherence supervening, and muscular tremor
and involuntary and unconscious stools rapidly succeeding.
9. In the commencement of typhus the pulse is sometimes of good
strength, and it may not exceed 90 in frequency; but as the disease
advances it uniformly becomes weaker, smaller and quicker; so that death
rarely takes place before it has reached 120. In the severer cases it is
weak, quick, and easily compressed at a very early period.
10. The respiration is often not very obviously affected, but if it be
attentively observed it will usually be found to be shorter and quicker
than natural.
11. The tongue is always foul on the first or second day; it seldom
continues moist longer than three or four days; it is often quite dry as
early as the fourth, especially on the body and at the root; the apex
and the edges sometimes remain moist a day or two longer; but in a short
time the whole tongue becomes perfectly dry and of a brown colour; as
the disease advances the colour often changes to a darker and darker hue
until it becomes quite black; it is then frequently fissured into deep
chaps, while the lips and teeth soon become covered with a black sordes.
Were the sensibility not greatly altered, such a condition of the mouth
and tongue must be attended with insatiable thirst; yet thirst is often
not felt, although at other times it is considerable.
12. In the early stage of typhus the skin is frequently hot; as the
disease advances the heat lessens: through the greater portion of the
disease it is moderately warm; towards its termination it becomes cool,
and some days before death it falls below the natural standard. It is
always of a darker colour than in synochus: the whole surface is of a
dull and dusky tinge. Sometimes it is covered with dun coloured
petechiæ, at others with petechiæ of a florid colour.
13. During its progress, erysipelas, first appearing on the face, then
extending over the scalp, and often down the shoulders and back, is very
apt to occur. Excoriation on the back and hips often form sloughing
sores of great malignity and extent, while enlargement, inflammation and
suppuration of glands situated in different parts of the body frequently
appear.
14. Typhus terminates much earlier, whether favourably or unfavourably,
than synochus; if it terminate unfavourably death frequently takes place
as early as the 10th or the 14th day, although if early and appropriate
treatment be employed, the force of the disease is sometimes so much
lessened that it is as protracted as synochus.
Towards the termination of the disease more or fewer of the symptoms
which it has been stated occasionally to occur in synochus,[25]
supervene; but, as these depend upon particular conditions of the brain,
they will be detailed under the pathology.
2. _Typhus Mitior, with Acute Cerebral Affection._
In typhus with acute cerebral affection the pain of the head is often
not more severe than it is in the subacute; but there is a greater
degree of heaviness, or weight, or stupor, or giddiness; the eyes are
more and sooner injected and more suffused; the insensibility comes on
sooner and is deeper; the delirium appears earlier and is more violent,
frequently requiring restraint, and the whole train of symptoms already
enumerated, and which it is needless to repeat, are more intense in
degree, and succeed each other with greater rapidity.
CASE XII.
JAMES SOLDEN, æt. 44, plaisterer. Admitted on the 7th day of fever:
attack came on with chilliness; great debility; some pain of head; sense
of giddiness and weight; together with symptoms of thoracic disease. At
present pain of head entirely gone; it has passed into insensibility;
mind quite delirious; almost constant moaning; pulse 96, weak; tongue
brown and dry; stools passed in bed; respiration short and hurried;
cough without expectoration; tenderness of abdomen on full pressure.
8th. Insensibility more profound; restlessness and delirium increased;
respiration more hurried; cough the same; stools passed in bed: pulse
92.
9th. No change.
10th. Died.
CASE XIII.
JOHN CLARK, æt. 17. Admitted on the 4th day of fever: attack commenced
with ordinary symptoms, and was attended with severe pain of the head,
which continues at present, and which is attended with a sense of
weight; eyes injected and suffused; expression of countenance extremely
dejected; sleeps none; skin pungently hot, especially over the scalp;
pulse 108, of good power; tongue already brown and quite dry; some
thirst; respiration hurried; some uneasiness of chest on coughing;
considerable tenderness of abdomen.
5th. Eight ounces of blood which were drawn not sizy; crassamentum
loose; pain of head not at all relieved; sense of weight distressing; no
sleep; much restlessness; heat over the scalp pungent; pulse 104; tongue
more dry; tenderness of abdomen the same; six stools.
6th. Pain of head still severe; mind more confused; passed a more
restless night; pulse 116.
10th. Pain of head undiminished; eyes more suffused; extremely restless
night, during which delirium came on; this morning muscular tremor has
appeared; pulse 124.
12th. Pain of head entirely gone; scarcely at all sensible; constant
muttering delirium; muscular tremor with subsultus tendinum; two stools
passed in bed; pulse 124; abdomen still painful on firm pressure, and
has become swollen and tense.
13th. Insensibility and delirium increased; constant incoherent
muttering; extreme prostration; erysipelas has appeared on the forehead,
and is spreading to the scalp: pulse 128; two stools passed in bed.
14th. Died.
II. TYPHUS MITIOR, WITH THORACIC AFFECTION.
Prominent thoracic affection, as we have seen, is not infrequent in
synochus; in typhus it is more constant; and the signs which denote its
existence are more obvious, but they are not precisely the same. The
pain in the chest is less severe; it is more often absent altogether;
while the sense of stricture and the dyspnœa are more urgent. The cough
is more constantly attended with mucous rattle; the respiration is
shorter and more hurried. The skin in general is cooler, and it is
always more dusky. The dark colour of the skin, in severe cases,
becoming quite livid, is one of the most characteristic marks of intense
thoracic affection. The colour of the cheek is at first of a deep and
vivid red; as the disease advances it becomes of a purple tinge, and at
length it is quite livid. In these cases it is not uncommon for the
respiration to be from forty to fifty in a minute. The pulse is
invariably rapid and weak. The cerebral affection is equally peculiar
and characteristic; it never consists of intense excitement; it is never
accompanied with violent delirium; it is indicated by confusion and
stupor passing rapidly into coma; and is attended with low muttering
incoherence or disjointed rambling, the trains of ideas that pass
through the mind being extremely faint, and linked together by no
distinguishable affinity. We know that one of the most essential
conditions to the due exercise of the sensorial faculties is the due
supply of the brain with arterial blood; but in this state of the system
arterial blood does not and cannot circulate through the brain, because
it is not formed in the lung: the patient is in a state approaching to
asphyxia, and in very severe cases he remains for several days in as
perfect a state of asphyxia as seems to be compatible with life. Why
debility should, in these cases, be carried to the utmost possible
extent; why such cases should form the most exquisite specimens of the
adynamic state, need not be pointed out: the disease is concentrated in
the very organ which elaborates the pabulum of life, and that stream
which should convey its vivifying and animating influence to every nook
and point of the system is corrupted at its source.
It is in these cases, too, that the tongue becomes dryer than in any
other; in its advanced stage it is sometimes quite black and even hard,
and is altogether incapable of being protruded. Sometimes it is covered
with a thick, black and hard crust; at other times it is cut into deep
fissures, so as to give it a cracked appearance. These states of the
tongue without doubt arise in part from the excessive dryness,
occasioned by the mouth being kept always open, on account of the
difficulty of respiring.
Such are the most characteristic marks of thoracic affection in typhus;
as an illustration of which, as it occurs, perhaps, in the severest form
ever witnessed in this country, the following case may be cited.
CASE XIV.
ALEXANDER CROMBIE, æt. 19, seaman.
The mate of his vessel states that, notwithstanding some previous
indisposition, three days ago he was on duty; that while on watch, about
eleven o’clock at night, he became too ill to remain at his post, and
that, since that time, he has scarcely spoken a word. At present he is
incapable of giving any account of himself. He is dull, stupid, and,
when roused, is scarcely able to answer coherently; he does not speak,
but he is constantly picking at the bed-clothes; there is extreme
restlessness; the countenance is heavy and inexpressive; the features in
general are swollen, the lips especially, which are also extremely
parched. The entire skin is dusky, but the cheeks are of a deep red
colour, approaching to a purple hue; the integuments of the eye are
dark; the conjunctiva injected; the tongue brown and quite dry; the lips
and teeth sordid; respiration oppressed; occasional cough; pulse from
130 to 140; small and thrilling; skin, especially over the scalp, hot;
tenderness of abdomen on full pressure.
4th. Cerebral symptoms the same; cough frequent, difficult; respiration
short and hurried; pupils dilated, not contracting on exposure to light;
conjunctiva injected; pulse small, hurried, irregular; all the stools
passed in bed; pressure over the abdomen induces cough and apparently
excites pain. Died in the evening. See pathology.
III. TYPHUS MITIOR, WITH ABDOMINAL AFFECTION.
To the account of abdominal affection in typhus, it is necessary to add
nothing to that already given of abdominal affection in synochus,
excepting that, in the former, pain in the abdomen is scarcely ever
felt; tenderness on pressure is less acute, and it is more common for
both to be absent. On the other hand, the abdomen is more often swollen,
hard, tense and tympanitic, while the stools are more early and more
constantly passed involuntarily. It is in this type of fever, also, that
hæmorrhage from the bowels most frequently takes, place—an event not
very uncommon in the severest and the most protracted examples of the
disease. The tongue, also, is less constantly red than in the abdominal
affection of synochus; but it is more uniformly dry, black and cracked.
Since the full exposition of pathology requires that many examples of
this affection should be detailed under that head, and since, however
numerous and striking such examples may be, they can illustrate no
characteristic symptom beyond what has been already stated, it is
unnecessary to cite any cases of it here.
IV. TYPHUS MITIOR, WITH MIXED AFFECTION.
Whenever the brain, the lungs, and the intestines become simultaneously
and prominently affected in typhus, the case no longer assumes the mild,
but lapses into the severer form. We shall, therefore, speak of this
complication under—
II. TYPHUS GRAVIOR.
The typhus gravior of authors is extinct; at least I have seen no
example of it in London. I have witnessed nothing bearing a tolerable
resemblance to this disease, even as it is depicted by Cullen, much less
as it is portrayed in the darkly vivid, yet apparently but too faithful
colouring of Huxham. This malady seems to have disappeared with the
epidemic intermittents and the epidemic dysenteries of the good old
times. Whatever there may have been in the condition of our ancestors to
excite our envy, there is certainly nothing to provoke it in their
diseases.
All the examples of fever which approach in likeness to the descriptions
on record of typhus gravior which I have seen, have consisted of the
mixed cases of typhus. They have been cases in which the brain, the
lungs, and the intestines were all simultaneously and intensely
affected. The symptoms may not always denote an _equal_ degree of
affection in all these organs; but I have never seen a case in which
there were not the most unequivocal signs of intense affection in all of
them. For the reason already assigned, such cases must necessarily be
the severest that can occur, because the patient may be said to have
three diseases instead of one to contend with, each of which alone is
sufficient to destroy life, and each of which alone frequently does
destroy it.
All the examples of this form of fever which I have observed are
referrible to two classes; one in which the arterial action is
excessive; the other in which it is oppressed, or rather overwhelmed.
1. In the first, the patient lies insensible, with delirium, perhaps so
violent that he cannot be kept in bed without restraint; with extreme
restlessness and constant watchfulness; with rapid and panting
respiration; with a tender abdomen, perhaps with frequent and
involuntary stools, a dry, black, and hard tongue, a quick, yet weak
pulse, and the skin universally and pungently hot.
2. In the second he lies insensible, with a cold and dusky skin; with a
swollen and livid countenance; with a heavy and oppressed respiration;
with a pulse perhaps not to be felt, or, if distinguishable, either so
rapid that it cannot be counted, so small that it is like a thread
beneath the finger, and so weak that it is lost by the slightest
pressure, or else slow, irregular, and intermittent. In this state, the
patient is almost as completely paralyzed as in apoplexy, and the attack
is almost as rapidly fatal as apoplexy. It constitutes what has been
called congestive fever.
Fortunately, these intense forms of the disease are of rare occurrence:
they are witnessed only in solitary instances, and they arise either
from exposure to a highly-concentrated poison, or from some condition of
the constitution, by which that power to resist the influence of noxious
agents, which is characteristic of life, is more than commonly
diminished or exhausted. They have been conceived to form exquisite
specimens of diseases of debility. But where is the debility? Not in the
disease, for that is of giant strength; not in the patient, for remove,
if you can but remove, a part of the load that oppresses him, and
instantly an intensity of action will be set up in the whole system,
perhaps as great as it is capable of exerting, and certainly greater
than it is capable of sustaining without the most imminent danger. The
brain is overwhelmed by the intensity of its affection; the energy that
should animate the system, and of which it is the great source, is
withheld: but that energy is suspended, not destroyed; and the debility
which seems to be the result is not real, but apparent, not direct, but
indirect. The giant that lies prostrate on the earth, mastered by
superior power, has still a giant’s strength, though he does not at that
moment put it forth: give him but the chance of throwing off the load
that keeps him down, and he will soon shew you that he is not weak. I
have always been struck with the extraordinary clearness and decision
with which the acuteness of Sydenham enabled him to make this important
distinction, perhaps in the very first case that occurred to him, in
which the discrimination was required. Having described, in his own
powerful manner, an excellent specimen of congestive fever to which he
was called, he states that he ordered the patient to be bled: that the
bye-standers regarded the suggestion with horror: that the man seemed at
the point of death; that to them it appeared that the abstraction of
blood must inevitably extinguish the last remaining spark of life; while
to him it was manifest that the patient was in this alarming condition,
because he was oppressed by an overwhelming load, and if that could only
be lessened, his condition would be the very reverse of what it now
seemed: that accordingly, on the removal of some ounces of blood, the
state of oppression ceased at once, and fever arose of a true
inflammatory nature, for the subdual of which repeated bleedings were
required.
It is remarkable, and it is highly characteristic of these intense forms
of disease, that their pathology exhibits a striking contrast to that of
the less severe affections. No morbid appearances are visible in the
organs which seem capable of accounting for death. There are signs of
vascularity; the vessels are turgid with blood, and consequently the
organs on which they are spent are in a state of congestion. But they
seldom if ever exhibit any real appearance of inflammation, and still
less do they contain any true inflammatory product. Why? Not on account
of debility; but because the force of the disease is so great as to
overwhelm the powers of life at the first onset, allowing even of no
reaction, and much less of that continued excitement which is part and
parcel of the inflammatory state, and which is indispensable to an
inflammatory product. Reduce the intensity of the disease a little,
bring it just within the limit that is compatible with the continuance
of life for a given time, and then the products of inflammation at once
appear in the greatest possible purity, variety, and extent.
And this is precisely the fact, as is demonstrated by the condition of
the organs, in those ordinary types of fever, the essence of which has
been supposed to consist in debility, and which have recently assumed
the dignified name of adynamic. That men who are capable of looking only
at the most obvious appearances of things, who, satisfied with what they
find at the surface, give themselves no concern to discover its source,
should continue to mistake the effect for the cause, and to consider as
in its own primary and essential nature, that to be debility which is
the last result of long-continued and most destructive energy of action,
is highly probable; but, on that very account, the fallacy is the more
deeply to be deplored; because to these men must sometimes be committed
the care of human beings who will fall certain victims to the error. It
is easy to disregard the voice of reason when opposed to specious,
however fallacious appearances; but it is difficult to withstand the
evidence of sense. In justification of the strength of the language I
use, I therefore appeal to the pathology I adduce. The notion of
debility in the intense forms of fever I look upon to be an error no
less palpable in its nature than destructive in its consequences; and if
the havoc it produces do not confer upon it a pre-eminence as bad as
that of the very disease of which it is supposed to constitute the
essence, it at least entitles it, in comparison with every other error
in medicine, to the distinction recognized in society, between the hero
and the murderer: the one destroys a single human being now and then;
but the other numbers its victims by thousands. It may be difficult to
eradicate this mischievous opinion where it was first engendered, and
where it still continues to be fostered, in the study of the falsely
reasoning theorist; but it is easy to confute it at the table of the
pathological anatomist; and it must ultimately fall, if not by the pen,
by the scalpel.