HENRY TODD, æt. 18. Duration and progress of disease unknown; abdomen
tender on pressure; tongue coated with dirty yellow crust, red at tip;
perfectly insensible; delirium; eyes, glistening; pulse 120, feeble.
2d day after admission. Little change excepting that the coma is more
deep; abdomen less tender; two stools; pulse 124.
3d. Coma undiminished; respiration short, hurried, rattling; stools in
bed; pulse 132; great prostration.
4th. Died.
_Abdomen._ Mucous membrane of ilium inflamed throughout; lower part of
it ulcerated; other viscera healthy. _Head._ Membranes and substance of
brain vascular. _Thorax._ Mucous membrane of bronchi inflamed; bronchial
tubes filled with mucus mixed with pus.
CASE LXVII.
FREDERICK KILHAM, æt. 12. Admitted on the 15th day of fever; abdomen
tender; tongue not to be seen on account of its being covered with
grumous blood from a large ulcer on the right side of the lower jaw;
bowels bound; some pain of head; no uneasiness of chest; pulse 114; much
emaciation.
16th. Lips and teeth sordid; mind confused; prostration.
20th. Violent delirium; pulse 92.
21st. The ulcer along the lower jaw in the inside of the mouth sloughing
and extending; delirium; pulse 96, weak. Died next day.
_Abdomen._ Mucous membrane of ilium vascular, and contained some ulcers;
other viscera healthy. _Head._ More fluid than natural between the
membranes. _Thorax._ Viscera healthy.
Two ulcers in the substance of the cheeks; that on left cheek extended
from the angle of the mouth to the last molares, and contained a large
black slough a quarter of an inch thick; this ulcer had extended to both
gums, denuding the alveolar processes and loosening the teeth; that on
the right cheek precisely similar, but less extensive.
CASE LXVIII.
ANN MOUNT, æt. 28, servant. Admitted on 15th day of disease; epigastrium
tender; tongue brown and dry; bowels purged; slight pain of head; much
vertigo; some cough; pulse 111, very intermittent in the right wrist;
less so in the left.
16th. Early this morning attacked with severe pain of the chest and
dyspnœa, attended with much headache, for which she has been bled with
the removal of the symptoms; pain now quite gone; tongue white; four
stools; pulse 120, soft; blood buffy and cupped.
17th. Seized last evening with violent delirium which required
restraint; occasional sleep with paroxysms of delirium; face flushed;
abdomen not tender; pulse 120, firm. V. S. ad ℥xvi.
18th. No pain of head; no delirium; slept better; tongue brown and dry;
five stools; pulse 132, firm; blood sizy and deeply cupped. V. S. ad
℥xij.
19th. Complains of “stupid pain of head;” no vertigo; delirium, but less
violent; scarcely any sleep; countenance still heavy, but rather more
animated than yesterday; abdomen not tender; three stools in bed; pulse
132, firm but soft. C. C. ad ℥xij. nuchæ.
20th. Pain gone; more insensible; countenance more dull and heavy;
scarcely any sleep; almost constant moaning; tenderness of abdomen quite
gone; tongue brown and dry; lips and teeth sordid; four stools in bed;
pulse 144, weak. Vini Albi, ℥ii. Mist. Camph. Fort. 6ta. q. h.
Slept rather better; less moaning; countenance scarcely as collapsed as
yesterday; pulse 132, firmer; stools in bed. Augeat. Vinum ad ℥vi.
22d. Scarcely any sleep; almost constant moaning; face flushed; skin
covered with cold perspiration; tongue scarcely to be protruded;
deglutition difficult; subsultus tendinum; pulse 132.
24th. No change except that the prostration continued to increase. Died.
_Abdomen._ Mucous membrane of jejunum, ilium and cæcum highly vascular;
that of ilium contained three or four large oval ulcers; other viscera
healthy. _Head._ Membranes and substance of brain vascular; more serum
than natural in the ventricles. _Thorax._ Viscera healthy.
CASE LXIX.
ANN MARTIN, æt. 37, servant. Admitted on the 8th day of fever; complaint
came on with ordinary symptoms, attended with nausea and vomiting; at
present abdomen not tender; tongue red, cracked and dry; bowels regular;
no uneasiness of chest; slight cough with scanty expectoration; pulse
92, very intermittent, beating thrice regularly, then intermitting for a
space equal to that of the three pulsations; pain of head gone; some
vertigo remains.
9th. Cough with difficult expectoration; respiration hurried; five
stools; pulse 104, more regular.
10th. Tongue more fissured; five stools; respiration less hurried and
difficult; pulse 112. Two grains of tartar emetic in solution every two
hours.
11th. No material change; pulse 116; has taken ten draughts with the
tartar emetic, the last four vomited. The draughts to be continued every
three hours.
12th. Bronchial affection very much relieved; last four draughts not
vomited. Pt. Haustus 4ta. q. h.
13th. Respiration nearly natural; much less cough; pulse 96; tongue
moist; four stools, last tinged with blood; abdomen not tender. Tartar
emetic omitted on account of appearance of blood in the stools.
17th. Bronchial affection appears to be quite gone; yet the tongue has
again become dry; the pulse has risen to 112; there is scarcely any
sleep; and slight muscular tremor is perceptible. Capiat. Vin. Alb. ℥iv.
Jus. Bov. i lb.
20th. Respiration again short and hurried; face quite dusky; tongue
furred, dry and cracked; pulse 110.
23d. Respiration laborious; cough returned with very copious
muco-purulent expectoration, amounting to a pint in the twenty-four
hours; pulse 116.
26th. No change; a grain of tartar emetic resumed every four hours. Wine
and beef tea to be continued.
28th. Neither vomiting nor purging; respiration more easy; cough
diminished; tongue more moist; pulse 116.
29th. Respiration much more natural; cough greatly diminished; tongue
clean and moist; pulse 112.
36th. From the period of last report she steadily and progressively
improved and became convalescent; on the morning of this day while
speaking to the nurse in her usual manner she suddenly fell back and
expired.
_Abdomen._ Mucous membrane of intestines in general inflamed, especially
that of ilium and cæcum, which contained some ulcers; peritoneal
covering of posterior surface of spleen cartilaginous; other viscera
healthy. _Thorax._ Mucous membrane of bronchi highly inflamed; bronchial
tubes full of purulent fluid; substance of lungs healthy. _Head._
Unfortunately, from some accident, the head was not examined.
CASE LXX.
STEPHEN WINTER, æt. 78. Duration and previous symptoms of disease
unknown; at present abdomen tender; tongue brown and dry; stools
natural; respiration wheezing with some cough; slight pain of head; mind
composed; muscular tremor; pulse 100, irregular.
2nd day after admission. Abdominal and thoracic symptoms the same; mind
more confused; more muscular tremor; pulse 108.
5th. Respiration laborious; mind quite unconscious; constant incoherent
talking; pulse 108.
6th. Respiration hurried and laborious; pulse not to be counted;
perfectly insensible. Died next morning.
_Abdomen._ All the coats of the stomach appeared much attenuated; colon
contracted into the form of a white cord; its coats in several places
thickened, and its mucous membrane ulcerated; liver soft; [gall bladder
much thickened, and its cavity so diminished, that it would scarcely
admit the end of the finger, filled with two small gall-stones. About
five inches of the recti muscles black and infiltrated with blood.]
_Head._ Arachnoid thickened and opake; considerable effusion between it
and the dura mater; substance of brain firm; ventricles distended with
serum. _Thorax._ All the viscera healthy, [excepting that the coronary
arteries were ossified.]
CASE LXXI.
RICHARD HARVEY, æt. 19, butcher. Admitted on the 8th day of disease; no
account to be obtained of previous symptoms; at present abdomen tender;
bowels purged; tongue brown and dry; lips and teeth sordid; pain of head
gone; mind confused; delirium requiring restraint; subsultus; pulse 116,
weak.
9th. Tenderness of abdomen continues; stools in bed; no sleep; much
delirium; scarcely conscious when spoken to; pulse 108, more firm.
10th. Slept better; rather more sensible this morning; pulse again 116.
14th. All nourishment refused; stools and urine in bed; delirium;
muscular tremor; pulse 128, weak; extremities cold.
15th. Passed a better night; more sensible; pulse 116.
17th. Extensive slough on sacrum; slough also on right elbow-joint, with
erysipelas of surrounding integuments; pulse 108.
21st. Skin covered with petechiæ; slough extending; great prostration.
35th. No change, excepting that the sloughs were improved in appearance
by the chlorate of lime, but the emaciation increased, the strength
diminished, and all nourishment was refused excepting wine. Died
following day.
_Abdomen._ Both small and large intestines vascular throughout; mucous
membrane of ilium contained several ulcers of considerable magnitude;
gall-bladder contained an ounce and half of serous fluid; spleen
indurated; other viscera healthy. _Head._ Substance of brain vascular;
effusion between the membranes; more fluid than natural in the
ventricles and at base. _Thorax._ Bronchi natural; substance of right
lung gorged with blood and infiltrated with serum; that of left healthy.
CASE LXXII.
ELIZABETH GORE, æt. 24, servant. Admitted on 22d day of fever: attack
commenced with ordinary symptoms, accompanied with sense of nausea and
some vomiting. At present abdomen not tender; tongue red, moist; lips
and teeth sordid; bowels bound; pain of head gone; that of loins
remains; deafness; no uneasiness of chest; much cough; skin dusky; pulse
120, weak and intermittent.
23d. Abdomen tender; four stools, dark; some pain of head; delirium;
pulse the same.
26th. Stools in bed; no sleep; delirium; respiration hurried and noisy;
cheek dusky; extremities cold.
27th. Deglutition difficult; pulse 128. Died next morning.
_Abdomen._ Mucous membrane of ilium ulcerated; mesenteric gland
excessively enlarged. _Head._ Membrane and substance of the brain
natural; much effusion into the ventricles, and at the base of the
skull. _Thorax._ Viscera of the thorax in other respects perfectly
healthy.
CASE LXXIII.
ANN KENSIT, æt. 20, servant. Admitted on the 8th day of relapse:
perfectly insensible; cannot be roused; no sensation on firmest pressure
over the abdomen; pupils natural; tongue brown and dry; bowels loose;
pulse 124.
9th. Some uneasiness induced by firm pressure over the abdomen, which
has become swollen, tense, and tympanitic; tongue not to be protruded;
lips and teeth sordid; stools in bed; respiration slow and laborious;
face cadaverous; extremities blue.
11th. No change; has never spoken nor shown any degree of sensibility
since admission.
_Abdomen._ Peritoneal coat of intestines in general vascular, that of
small intestines particularly so; numerous patches of the mucous
membrane of the ilium raised by matter deposited beneath it, and
extensively ulcerated; mesenteric glands much enlarged. _Head._
Membranes of brain vascular. _Thorax._ [Pleuræ of both sides adherent;
that of right side vascular; right cavity contained some serous fluid
mixed with flakes of lymph.]
CASE LXXIV.
SARAH HASSELL, æt. 40. Admitted on 8th day of fever; complaint commenced
with usual symptoms, accompanied with much nausea. Abdomen not tender;
tongue furred at root, red and clean at tip and around edges; bowels
purged from the very commencement of the attack; no uneasiness of chest;
cough; pain of head gone; that of back remains; vertigo; pulse 108,
feeble.
9th. No tenderness of abdomen on firmest pressure; tongue brown and dry;
four stools; pulse 108.
12th. Still no tenderness of abdomen; six stools; tongue quite dry;
pulse 120.
16th. Abdominal symptoms unchanged, excepting that the tongue has been
exceeding dry; nearly insensible; delirium; almost constant moaning;
pulse 120, very weak.
25th. Abdominal and cerebral symptoms continue with little change; cough
more frequent with muco-purulent expectoration; pulse 130, very weak.
29th. Quite helpless; pulse scarcely to be distinguished; copious
expectoration of purulent matter.
31st. Died.
_Abdomen._ Ilium contained several large ulcers, especially at its
termination in cæcum; liver enlarged and softened; other viscera
healthy: _Head._ Membranes vascular; arachnoid opake and thickened;
substance of brain vascular; effusion between the membranes; more fluid
than natural in ventricles. _Thorax._ Lungs gorged; mucous membrane of
bronchi vascular; bronchial tubes full of mucus mixed with pus.
CASE LXXV.
EDWARD HAMMOND, æt. 24, servant. Admitted on the 22d day of fever:
attack commenced with usual symptoms, accompanied with loss of appetite
and sense of nausea; at present no tenderness of abdomen; tongue red,
glazed and cracked; bowels purged; no uneasiness in chest; cough with
mucous expectoration; pain of head entirely gone; sensation in general
diminished; mind composed; little sleep; pulse 110, of good power but
easily compressed; much prostration.
23d. No pain acknowledged in any organ; little sensibility; no sleep;
much restlessness; delirium; expression of countenance wild; pulse 108,
firm.
24th. No pain; less sensible; tongue has become brown and dry; three
stools; pulse 124, weak.
25th. More sleep; more tranquil this morning; tongue also is more moist;
but the stools have been passed in bed, and the pulse is 124, weak and
fluttering.
26th. More sleep; much more tranquil; more sensible; tongue more clean
and moist; stools not passed in bed; the pulse notwithstanding is 136,
and the pulsations are not distinct, but run into each other.
28th. Mind distinct; more sleep; tongue continues more moist, but no
stools and no urine have been passed; the latter has been drawn off by
the catheter; pain is now complained of in the right lumbar region;
pulse 123. Died next day.
_Abdomen._ Mucous membrane of ilium ulcerated; pancreas indurated,
nearly of the consistence of cartilage, and of paler colour than
natural; other viscera healthy. _Head._ Membranes natural; half an ounce
of fluid at the base of the skull; substance of brain much softened.
_Thorax._ Viscera healthy.
CASE X.
SARAH RAVEN, æt. 17. For symptoms see page 140.
_Abdomen._ Mucous membrane of small intestines in general inflamed;
lower part of ilium extremely ulcerated. _Head._ Both dura and pia mater
vascular; arachnoid opake; much serum effused between the membranes.
_Thorax._ [Pluræ of both sides adherent; left lung inflamed;] right lung
healthy; other viscera healthy.
CASE LXXVI.
MARY M’GOWAN, æt. 18, servant. Admitted on the 8th day of fever; attack
commenced with usual symptoms; at present, abdomen tender; tongue
thickly coated and dry; lips and teeth sordid; much thirst; bowels
purged; stools dark and offensive; pain of head which has been severe
from the beginning continues, and is most severe over the fore-part;
pulse 116, weak.
9th. Abdomen and tongue the same; pain of head unabated; eyes dull and
heavy; right cheek deeply flushed; pulse 110. C. C. ad ℥x. temporibus.
10th. Abdominal symptoms unchanged; pain of head relieved, but not gone;
pulse 132, weak.
11th. Tongue cleaning; quite moist; three stools; very slight pain of
head; delirium; pulse 120, weak.
12th. Pain of head quite gone; but there is no other change.
13th. No sleep; great restlessness; noisy delirium; pulse 126, weak;
swelling, redness and pain of left parotid.
15th. Tongue has become brown and dry; and respiration difficult and
rattling; face flushed; colour dusky; lies on back quite prostrate;
pulse 136, weak; inflammation of left parotid subsided, but it has now
attacked the right.
16th. Respiration hurried and noisy; skin in general dusky; cheeks
extremely flushed and of deep purple colour; pulse scarcely to be
counted; prostration extreme. Died next day.
_Abdomen._ Peritoneal coat of intestines vascular; several ulcers in
ilium and cæcum; appearance of ulcers peculiar, resembling those of
phthisis rather than those of fever; vermiform process externally
vascular; internally contained a crop of bodies like tubercles or
enlarged glands and so numerous as to form a layer under the mucous
membrane. _Head._ Membranes and substance of brain vascular; more fluid
than natural in the ventricles. _Thorax._ [Pleuræ of left side
adherent;] other viscera healthy.
CASE LXXVII.
WILLIAM WALLER, æt. 24, barge builder, admitted on 22d day of fever. No
tenderness of abdomen on firmest pressure; tongue loaded and dry;
thirst; bowels said to be regular; no uneasiness of chest; some cough;
pain of head, which had been severe, entirely gone; mind dull and
confused; no sleep; face flushed; prostration; great sense of
oppression; pulse 114, tremulous and indistinct.
23d. No change, excepting that the tongue has become brown and dry.
24th. Pulse 120, weaker and more tremulous: other symptoms the same.
27th. Tongue has become extremely dry; thirst urgent; three stools,
mixed with blood; abdomen not tender; pulse 100.
28th. After yesterday’s visit, seized suddenly with violent delirium,
urgent dyspnœa, and copious discharge of blood from the bowels; these
symptoms continued until half past eleven, p. m. when he expired.
_Abdomen._ Mucous membrane of greater part of small intestines much
inflamed; that in lower part of ilium quite black and nearly
sphacelated, containing several spreading ulcers; colon throughout of
darker colour than natural; mucous membrane of rectum highly vascular;
spleen enlarged and softened; [bladder thickened and vascular.] _Head._
Arachnoid opake and milky, covering a large quantity of gelatinous
fluid. _Thorax._ [Pleuræ of left side generally adherent, of right less
extensively adherent;] substance of both lungs healthy.
CASE LXXVIII.
MARGARET PENNIFOLD, æt. 20, servant. Admitted on the 8th day of fever,
which, besides the ordinary symptoms, commenced with pain and tenderness
of bowels: at present, abdomen tender, especially the epigastrium;
tongue very red, sore, and cracked; lips and teeth sordid; much thirst;
some uneasiness of chest on full inspiration; slight cough; some pain of
head, especially in occiput; scarcely any sleep; mind much confused
during the night, scarcely distinct during the day; pulse 105.
9th. No pain; tongue the same; three stools; slept some; mind more
distinct; pulse 100.
11th. No pain; some cough; face flushed; colour of cheek dusky; voice
hoarse.
12th. Little change; pulse 108.
15th. Still says she is free from pain; no tenderness of abdomen on firm
pressure; tongue very red and dry; four stools, mixed with a large
proportion of blood; rather more cough; sleeps well; pulse 116.
16th. Stools mixed with blood; pulse 117.
17th. Three stools, dark and offensive but without blood; pulse 100;
other symptoms the same.
19th. Stools in bed; much prostration; pulse 120, very weak; respiration
difficult.
20th. Vomiting; pulse 120, weaker.
21st. Vomiting continues; six stools; mind confused: pulse 120.
22d. Vomiting has ceased; deglutition difficult; face collapsed and
cadaverous; five stools in bed; great prostration; pulse 117, extremely
weak. Died in the night.
_Abdomen._ Mucous membrane of pyloric end of stomach and of intestines
in general vascular; that of jejunum and ilium very nearly black,
presenting the appearance of extensive ecchymosis; ilium contained an
infinity of elongated ulcers, many of which had penetrated the muscular
coat; the cæcum and the lower part of the colon in a similar condition;
there was no deposition of adventitious matter; but the ulcers were
formed entirely in the coats of the intestine; other viscera healthy.
_Thorax._ Mucous membrane of both bronchi inflamed; bronchial tubes full
of mucus; mucous membrane of larynx perfectly healthy, and without the
least thickening in any part; [apex of left lung adherent to costal
pleura; adhering part of the substance of the lung contained a mass of
tubercles, some of which were passing into the state of suppuration; the
remainder of the lung more vascular than natural, and some parts of it
hepatized; right lung less consolidated, but still more firm and
vascular than natural.] _Head._ Brain and its membranes tolerably
healthy.
CASE LXXIX.
THOMAS BRYAN, æt. 18, labourer. Admitted on the 8th day of fever: at
present pain of abdomen, much increased on pressure; tongue white and
moist; much thirst; bowels loose; pain in right side on full
inspiration; some cough; pain of head and back, which had been severe,
gone; pulse 90.
9th. A few hours after the visit, the pain in the side became
exceedingly severe and was attended with frequent cough. On account of
these symptoms he was bled to the extent of twenty-four ounces, with
immediate and great relief: the pectoral symptoms have not returned;
abdomen still tender; five stools, dark; no pain of head, but the skin
over the scalp is hot, and there is some intolerance of light; pulse
112. Takes a grain and half of calomel, with two of Dover’s powder,
every six hours.
10th. Pain of abdomen continues; vomiting; two stools; pulse 116.
13th. Gums already affected; throat sore; none of the symptoms relieved;
tongue has become brown and dry; five stools; less sensible; much
moaning; pulse 120.
14th. Abdominal symptoms undiminished; five stools; more insensible;
pulse 112.
16th. Insensibility increased to coma; little change in the other
symptoms.
20th. Severe pain in the abdomen, particularly in the region of the
cæcum; tongue brown and dry and quite hard; four stools; pulse 118.
23d. Vomits food and medicine; coma continues; delirium; pulse 118.
24th. No change, excepting that the vomiting ceased, after having taken
a scruple of calomel at a single dose.
26th. Died.
_Abdomen._ Ilium and cæcum much and extensively ulcerated; other viscera
healthy. _Head._ Membrane of brain natural; substance vascular; more
serum than natural in the ventricles; some at the base; much fluid in
the theca vertebralis. _Thorax._ Posterior part of left lung
tuberculated, and infiltrated with purulent matter; upper part of right
lung still more tuberculated and condensed.
CASE LXXX.
ELIZABETH HAMMOND, æt. 50, married. Admitted on the 28th day of fever,
which came on with the ordinary symptoms; at present she is without pain
in any organ; face peculiarly pallid; some cough; pulse 120, and weak.
29th. No tenderness of abdomen; no pain; cough; delirium; pulse 110.
32d. Cough; delirium; pain, redness, swelling, and vesication of left
leg; pulse 120, weak.
35th. Tongue scarcely to be protruded; very tremulous; three stools;
cough; much delirium; pulse 120, very weak; the vena saphena major
easily to be traced along its whole course, being hard, tense, and
painful.
40th. Delirium; muscular tremor; much convulsive twitching of the face;
pulse 130, extremely weak.
40th. Delirium continues; muscular tremor increased; great prostration;
leg more swollen, the tumefaction now extending up the thigh; the
saphena traced to the middle of the thigh where it ends in a varix,
which has for the last two days greatly enlarged; lymphatics along the
course of the vein swollen; integuments of a dusky red colour; much
thickening and hardening of the cellular tissue over the femoral
vessels; says she has no pain in the leg; mind dull and confused, yet
answers coherently when spoken to.
43d. Delirium continues; prostration increases; lips and teeth covered
with dark-coloured sordes; affected leg darker in colour, and colder to
the touch; pulse 120; no tenderness of the abdomen, nor has it been
tender through the whole course of the disease.
44th. Died.
_Abdomen._ Mucous membrane of ilium, cæcum, and commencement of colon
extensively ulcerated; viscera of head and thorax healthy; slight
swelling of the whole left extremity; ankle œdematous; the cellular
tissue along the entire course of the saphena major and femoral vein
exceedingly condensed and hard; on opening the saphena vein there was
found a layer of coagulable lymph lining its whole internal surface,
which was universally vascular and rough; in many places, especially
about the knee, the coats of the vein were very much thickened, so that
the calibre of the vessel was diminished at least one-half its size; the
lower part of the femoral vein was in a similar state, but its superior
portion and the external iliac were little, if at all affected.
CASE LXXXI.
MARY FORD, æt. 30, married. Admitted on the 8th day of fever, which in
addition to the ordinary symptoms, was attended at the commencement with
pain in the abdomen, which continued for some time, but which is now
entirely gone: states that the bowels have been very loose for upwards
of a month past; tongue loaded and red; thirst; no uneasiness of chest;
some cough; pain of head, which was severe in the commencement, quite
gone; pulse 90; great prostration.
9th. No pain in any organ; tongue unchanged; two stools, light and
offensive; delirium.
10th. Four stools in bed; delirium; lies on back quite prostrate; pulse
105, weak.
11th. Tongue not to be protruded; perfectly insensible; pulse 125.
_Abdomen._ Peritoneal coat of small intestines vascular; mucous membrane
of ileum and cæcum contained several large ulcers; in other places the
membrane was entire, but irregularly raised by submucous deposit so as
to present the appearance of large ulcers. _Head._ Arachnoid highly
vascular; effusion beneath all the membranes; more fluid than natural in
the lateral ventricles. _Thorax._ Viscera healthy.
CASE LXXXII.
ELEANOR NORRIS, æt. 12. Was seized eight days ago with sudden loss of
strength, great confusion of mind, and severe pain in the head and
limbs; the pain of the head continues, shooting down along the spinal
cord to the loins; no tenderness of abdomen; tongue white; bowels
purged; pulse 129, of good power.
9th. Tongue has become brown and dry; five stools; scarcely any pain of
head; delirium; pulse 120.
14th. Abdomen now tender on pressure; tongue continues brown and dry;
four stools; pain of back and loins returned; delirium; pulse 130.
15th. Pain of abdomen continues; tongue still browner and more dry; four
stools; delirium; pulse 128.
16th. Deglutition difficult; pulse 120; great prostration.
17th. Stools in bed; delirium and prostration increasing; pulse scarcely
to be counted.
18th. Great restlessness; much delirium; countenance wild and anxious;
pulse exceedingly quick and weak.
20th. Respiration hurried and laborious; pulse not to be counted;
insensible; stools in bed. Died in the night.
_Abdomen._ Mucous membrane of jejunum and ilium extremely ulcerated;
omentum a mere web; all the other viscera healthy. _Head._ Membranes and
substance of brain apparently natural. _Thorax._ [Costal pleura of left
side inflamed and thickened; pulmonary pleura covered with pus; pleural
sac contained two ounces and a half of serum mixed with pus; substance
of left lung nearly healthy; right side healthy; two ounces of serum in
pericardium.]
CASE LXXXIII.
MARIA MOORE, æt. 22, servant. Admitted on the 22nd day of scarlet fever:
throat well; deglutition easy; no pain of chest; none of abdomen; tongue
of dark red colour; bowels purged; some pain of head, especially at
occiput; pulse 98.
23d. Pain of head continues; noisy delirium; pulse 108; abdominal
symptoms the same.
30th. Amended the day following last report, and continued to improve
until this morning, when she was again attacked with soreness of throat
and difficult deglutition; tongue loaded; three stools; pulse 98.
31st. Throat equally painful; deglutition equally difficult; pulse 110.
32nd. After the application of leeches to the throat the pain became
easier and the deglutition less difficult; internal fauces very red;
uvula much swollen.
33d. Throat again better; deglutition easy; pulse 120.
35th. Throat well, but the voice is hoarse; four stools, mixed with
blood; pulse 110.
36th. Respiration hurried; tongue brown, dry, and cracked; lips and
teeth sordid; four stools, mixed with lumps of coagulated blood, partly
passed in bed. Died in evening.
_Abdomen._ Mucous membrane of ilium and cæcum in part highly vascular
and much thickened, in part ulcerated; pancreas indurated; other viscera
healthy. _Thorax._ Epiglottis vascular and thickened; mucous membrane of
arytænoid cartilages ulcerated; mucous membrane of trachea highly
vascular; [pleuræ of both sides adherent; right lung filled with
tubercles; bronchial glands enlarged.] _Head._ Not examined.
CASE LXXXIV.
CHARLES CROSSLEY, æt. 21. Admitted on the 15th day of fever, which came
on with the ordinary symptoms: at present, tenderness of the
epigastrium, and over the whole abdomen; tongue brown, cracked and
tremulous; bowels purged; scarcely any pain of head; mind indistinct;
expression of eyes wild; slight cough; pulse 40, soft.
16th. After six leeches had been applied to the epigastrium the
tenderness was much diminished: says he has now no pain any where; two
stools; expression of countenance the same; pulse 96.
17th. Abdomen has become swollen and hard, not tender on firm pressure;
five stools; tongue unchanged; respiration hurried and noisy; no sleep;
delirium; face pallid; eyes wild and rolling; pulse 100.
16th. Abdomen hard, especially in hepatic region; slightly tender;
vomiting; two stools, mixed with blood; extremities cold.
19th. Abdomen hard, not tender; two copious stools, consisting almost
entirely of blood; tongue the same; pulse 96.
20th. One stool without any feculent matter, consisting entirely of
blood; delirium; muscular tremor.
23d. No stool for two days; having taken two drachms of castor oil, he
had two copious evacuations of very dark colour, mixed with blood;
abdomen more soft, not tender; tongue cracked in the centre, more clean
and moist at edges; cough; pulse 108, soft.
35th. From the morning of last report the hæmorrhage disappeared, sleep
and sensibility returned, the tongue became more clean and moist, the
strength improved, the appetite became keen: he was put upon low diet,
and was allowed three ounces of meat daily and four ounces of wine: he
appeared to be so much recovered, that it was thought he could bear this
liberal allowance; but, immediately on this change of diet, the skin
became hot, the cough returned, he had six stools without medicine, the
delirium re-appeared at night, and the pulse rose to 100; there was not
the slightest pain, either of the head or of the abdomen.
36th. Tongue again brown and dry; three stools; no sleep; much
restlessness; delirium; pulse 108, firm; skin extremely hot.
43d. Stools and urine in bed; delirium; muscular tremor; subsultus
tendinum; pulse 104.
46th. Sloughs have formed on both hips and an abscess in the right
groin.
49th. Abdomen has become swollen, tense, and tympanitic; no stool;
tongue the same; vomits every thing; a large black eschar on sacrum;
much discharge from the ulcer in the groin; cough frequent; pulse 120,
feeble; extreme prostration. Died in the evening.
_Abdomen._ Lower portion of ilium and commencement of cæcum contained
several ulcers, some of which were of large size; [peritoneal cavity
contained two pints of serum, mixed with pus and flakes of lymph;
intestines, liver, and abdominal parietes lined throughout with a coat
of lymph, easily removeable with the scalpel; intestines adherent to
each other and to the parietes of the abdomen.] _Head._ Arachnoid opake
and of milky colour; pia mater highly vascular; much effusion beneath it
and the arachnoid; several drachms of serum in the ventricles, and a
large quantity at the base of the skull; substance of the brain highly
vascular and much softened. _Thorax._ [In each cavity of pleura about
six ounces of fluid; posterior part of lungs condensed; a few recent
adhesions between the pleuræ of the right side;] other viscera healthy.
CASE LXXXV.
MARY BAKER, æt, 23, servant. Admitted on the 22d day of fever, which, in
addition to the ordinary symptoms, came on with nausea, anorexia and
purging; at present complains of a sense of heat in the abdomen without
pain; but there is uneasiness when firmly pressed; tongue white in
middle, red at edges, moist; thirst; bowels stated to be regular; pulse
104; no pain of chest or head.
23d. Abdominal symptoms the same; no sleep; some pain of head; pulse
120, weak; much sense of weakness.
24th. Tongue has become dry; three stools; pain of head gone; some
vertigo; delirium; expression of countenance anxious and sunk; pulse
120.
25th. Tongue more moist; three stools; slept better; expression of
countenance more natural; but the pulse has risen to 130 and is
extremely weak.
26th. More pain of abdomen on pressure; more prostration; delirium
continues; pulse 130, extremely weak. Died next day.
_Abdomen._ Peritoneal coat of small intestines highly vascular; mucous
membrane of lower part of ilium and cæcum full of ulcers, some of which
had penetrated through the muscular to the peritoneal coat; this latter
membrane was very dark and approaching to gangrene; peritoneal cavity
contained a considerable quantity of bloody serum; omentum dark and
inflamed; cardiac extremity of the stomach vascular; other viscera
healthy. _Head._ Dura mater adherent with more firmness than natural to
the skull; other membranes healthy; more fluid than natural in the
ventricles; substance of brain and cerebellum vascular. _Thorax._ Mucous
membrane of both bronchi highly inflamed; [left thoracic cavity
obliterated by old adhesions; left lung completely hepatized; right lung
loaded with blood and serum; right cavity contained a considerable
quantity of blood and serum; heart flaccid; both auricular valves very
dark.]
CASE XI.
GEORGE ENGLISH, æt. 25. For symptoms see page 141.
_Abdomen._ Numerous ragged ulcers in the cæcum, which, having destroyed
the mucous, had laid the muscular coat quite bare; both the muscular and
the peritoneal coats were blackened and in the first stage of
sphacelation; an aperture of about the size of a sixpence had been
formed in them through which a considerable quantity of fæces had
escaped into the peritoneal cavity; in different portions of the mucous
membrane of the other intestines there were slight patches of
inflammation; omentum much thickened, adhering anteriorly to the
abdominal peritoneum and posteriorly to the intestines; the latter were
so agglutinated together, that it was impossible to trace their
convolutions; the peritoneal sac contained four pints and a half of
serum mixed with pus; the peritoneal coat of the liver adhered to the
diaphragm all around, except at one point where a sac was formed which
was filled with serum; substance of liver healthy; other viscera
healthy. _Head._ Dura mater vascular; pia mater highly vascular;
arachnoid healthy; more fluid than natural between the membranes and in
the ventricles; substance of the brain pretty healthy. _Thorax._ [Right
pleura vascular; superior and middle lobes of right lung contained
numerous miliary tubercles; lower lobe, one or two in the first stage of
suppuration; the under surface of this lobe adhered to the diaphragm
with great firmness, shewing that the disease of the abdomen had
extended to the thorax; pleuræ of left side contained two ounces of
bloody serum; substance of left lung healthy; pericardium contained
three ounces and a half of serum; left ventricle of heart full
three-fourths of an inch thick.]
CASE LXXXVI.
WILLIAM BAKER, æt. 26. Admitted on 15th day of fever: no account to be
obtained of previous symptoms: too insensible to give any statement that
can be depended on of his present feelings; points to lower part of
chest and epigastrium as the chief seat of pain; abdomen tender on
pressure; some cough; voice hoarse, husky, and feeble; no pain of head;
pupils contracted; pulse 100, sharp.
16th. Six stools, two passed in bed; hiccup; frequent cough; respiration
laborious; pulse 84.
20th. No perceptible change until to-day, when the stools, six in
number, became mixed with blood; the expectoration is also tinged with
blood; respiration more hurried and difficult; hiccup continues; pulse
120.
23d. Five stools in bed; hiccup gone; no sleep; great restlessness;
pulse the same. Died next morning.
_Abdomen._ Peritoneal coat of intestines vascular; mucous membrane of
small intestines, and especially of ilium, inflamed and ulcerated; near
the caput coli a large ulcer had perforated the peritoneal coat, and
through the opening, which was an inch and a half in diameter, a
quantity of fæculent matter had escaped into the cavity of the
peritoneum; spleen very much softened, easily breaking down under the
finger. _Head._ Pia mater highly vascular; substance of brain slightly
vascular; a small quantity of bloody serum effused into the lateral
ventricles. _Thorax._ Mucous membrane of bronchi of dark red colour;
tubes contained much frothy mucus; substance of both lungs gorged;
[pleuræ of left side contained a pint and half of fluid; pericardium
adherent to the pleura costalis; heart flaccid and pale.]
CASE LXXXVII.
THOMAS KENNIE, æt. 30, labourer. Admitted on 10th day of fever: attack
commenced, besides the ordinary symptoms, with tenderness of abdomen: at
present the abdomen, which is generally tender, is exceedingly so over
the right iliac region; bowels stated to be regular; tongue foul, red
and dry; thirst; some pain of chest on full inspiration and coughing;
cough troublesome; respiration hurried; little sleep; mind confused;
face flushed; pulse 120, weak.
11th. Tenderness of abdomen continues; five stools; respiration hurried,
with occasional cough and viscid expectoration; slight pain of head;
mind distinct; eyes suffused; skin cool, covered with petechiæ. Died
next day.
_Abdomen._ Mucous membrane of small intestines very vascular, that of
ilium intensely so; contained several oval and deep ulcers, one of which
had perforated the peritoneum, the aperture of which was sufficiently
large to allow the apex of the ring finger to pass through it; the
peritoneal cavity contained about a pint of pus; the intestines were all
glued together; the surface of the liver was very dark and much
inflamed. _Head._ Membranes of brain vascular; substance rather
vascular; more fluid than natural in the ventricles. _Thorax._ Viscera
healthy.
CASE LXXXVIII.
DAVID PIGGOTT, æt. 19, furrier. Admitted on the 9th day of fever: at
present, severe pain in the right hypochondrium, stretching towards the
umbilicus, increased on pressure; tongue brown and dry; no stool; slight
cough; some pain of head; eyes suffused; pulse 108, firm. V.S. ad ℥x.
10th. Pain of right hypochondrium gone; tongue the same; no pain of
head; very deaf; slept tolerably; pulse 100, soft.
11th. No pain; tongue unchanged; one copious stool, consisting chiefly
of blood; slept well; mind confused; countenance rather improved; pulse
96.
12th. No pain; two stools, with less admixture of blood; mind distinct;
pulse 110.
13th. Eight stools, scanty, without blood; tongue dry and furred; slept
ill; great prostration; pulse 90. Died next day.
_Abdomen._ Mucous membrane of small intestines in general vascular,
especially that of the ilium and commencement of the colon, in both of
which were numerous ulcerations; one in the former had perforated the
bowel, forming a hole of the size of a sixpence; about a quart of
sero-purulent fluid in the peritoneal cavity; the intestines were glued
together, and their peritoneal coat generally inflamed. _Head._
Membranes of brain vascular; substance natural. _Thorax._ Viscera
healthy.
CASE LXXXIX.
WILLIAM SPOULL, æt. 23, baker. Admitted on the 22d day of fever: no pain
or tenderness of abdomen; tongue red and dry; bowels loose; no pain of
chest; some cough; no pain of head; some of limbs and back; mind
distinct; little sleep; very deaf; pulse 102.
25th. Tongue much furred and fissured; four stools; cough the same;
pulse 108.
26th. Four stools, mixed with blood; respiration hurried.
27th. Tongue more clean, slightly aphthous; three stools without blood;
respiration less hurried; pulse 104.
29th. Severe pain of abdomen, from which he had hitherto been quite
free, came on during the night; at present it continues very severe, is
much increased on pressure; abdomen swollen and tense; four stools
without blood; pulse 112, sharp.
30th. Pain of abdomen not so severe, but still excited by full pressure;
vomited a large quantity of bilious fluid; two stools, dark and slimy;
respiration hurried; countenance sharp and anxious; pulse 124, small.
Died two hours after visit.
_Abdomen._ The mucous membrane, both of the small and large intestines,
in general highly inflamed; the lower third of the ilium, the cæcum and
the colon were full of ulcers, one of which, in the ilium, had
perforated through all the coats of the intestine, and formed, near the
ileo-cæcal valve, a large circular opening, of the size of a crown
piece, through which the contents of the bowel had escaped into the
cavity of the peritoneum; this cavity contained a large quantity of
sero-purulent fluid, mixed with feculent matter; the convolutions of the
intestines were glued together and their peritoneal coat every where
highly inflamed; the spleen, liver, and pancreas were sound. _Head._ The
brain and its membranes were healthy. _Thorax._ Viscera healthy.
* * * * *
The attentive student of the important and instructive cases included
under this section will have perceived that, in the order in which they
stand, they exhibit a complete series of changes in the intestines from
the slightest vascularity to the most intense inflammation; and from
mere elevation and inequality of the mucous membrane, in consequence of
adventitious deposit beneath it, or from the simple and most superficial
abrasion of its surface, to the most extensive and deep ulceration, on
to the ultimate perforation of all the coats of the bowel.
When a number of cases are thus brought together and placed in juxta
position it is impossible not to perceive, and indeed not to be forcibly
struck with the uniformity with which a certain series of changes takes
place. We do not see the same number of morbid appearances in every
case, but we see in every case precisely the same morbid changes as far
as they go, the difference being merely a difference in degree; so that
the description of such a number of cases as has now been detailed would
be tedious on account of its sameness, were it not that the fact they
establish is one which it is of paramount importance to the practitioner
that he should know; and that there appears to be no other means by
which it can be duly impressed upon the mind.
In like manner the uniformity of the symptoms which denote that these
morbid changes are going on, is as remarkable as the regularity with
which the changes themselves occur. Their great peculiarity, which it is
as important to know as it is to understand their indication itself, is
_their want of prominence_. They are always to be discerned, or with
extremely rare exceptions; but they seldom or never force themselves
upon the notice of the careless or extort the attention of the
unobserving: still they are not the less constant in their occurrence
because they come without noise, nor is the indication they give of
their presence less significant because it is unobtrusive. They do not
announce their presence by the excitement of violent paroxysms or by
inducing intense pain, because the state of the system in which they
take place is incompatible with acute sensation of any kind. The
prominent symptoms during life are almost always in the head; the great
changes of structure found after death are always in the intestines; and
this, which the pathologist learns from observation, the physiologist
might have predicted from his knowledge of function. The affection of
the intestines in fever is never a simple or single affection: it never
occurs alone, but always in combination with an affection of the brain;
and the cerebral affection is always antecedent, the intestinal,
invariably subsequent; while the certain consequence of the cerebral
affection is a diminution, and ultimately an abolition of sensation. It
is therefore quite impossible, from the very nature of the derangement
that takes place in the animal economy, that the intestinal affection
should ever be attended with violent pain. Occasionally, indeed, when
the abdominal affection is very much in excess, and the cerebral
affection is unusually slight, severe pain may be felt; but that is
rare, and the total absence of pain, and even the total absence of
tenderness on pressure, is more common. It is not then to the patient’s
own complaint of pain in the abdomen that the practitioner must trust
for the discovery of abdominal affection in fever.
But though the patient seldom complain of pain in the abdomen, yet in
the great majority of cases the abdomen is tender on pressure, and it is
so in all, excepting when the cerebral affection is peculiarly severe or
is very far advanced. These exceptions render this symptom not
absolutely constant, although at the bed-side of the sick the
practitioner will find it very rarely absent. The symptom which is still
more constant, as the reader must have observed in the perusal of the
preceding cases, and which therefore affords a very certain guide to the
detection of the disease, is a loose state of the bowels. Whenever both
concur there can be no doubt of the diseased process which is going on
within the intestine: but as the tenderness may be obscured or lost from
the intensity or advancement of the cerebral affection, so it is very
remarkable that, in the progress of the intestinal disease, the bowels
sometimes become regular and even constipated. The physician who sees
the patient for the first time in this stage of the disease, can
ascertain the condition of the mucous membrane of the intestines only by
obtaining an accurate account of the preceding symptoms. And when it is
possible to procure a distinct and complete history of the disease from
its commencement, it is commonly found that nausea and vomiting were
among the early symptoms, while, as we have seen, the latter is not
unusually present in the more advanced stages. The result of the whole
is that, excepting when the cerebral affection is most intense and
overwhelming, the existence of inflammation and ulceration in the mucous
membrane of the intestines in fever are denoted by signs which are quite
constant, and in the fidelity of the indication of which we may repose
implicit confidence. The importance of the diagnosis may perhaps plead
our excuse for repeating them again. They are tenderness of the abdomen
on pressure; loose stools; redness of the tongue, especially at the tip
and edges, in general preceded by nausea and vomiting, and in the most
exquisitely marked cases, and in their advanced stage, followed by a
mixture of blood in the stools and a swollen, hard and tympanitic state
of the abdomen. All these symptoms by no means always concur in the same
case: but the presence of one or two of them will be sufficient to guide
the attentive observer to the knowledge of the disease.
We have seen that the appearance of blood in the stools is not very
frequent: that the most extensive ulceration may and commonly does exist
without it; still when blood does appear it is generally found in
combination with an ulceration which is not only extensive, but which
has penetrated deep into the coats of the intestine. But although this
be the general fact, yet it must be borne in mind that blood may be
poured out in large quantities without the existence of a single ulcer.
In this case the blood issues from the capillary vessels of the mucous
membrane of the intestine, and when examined after death this membrane
is found to be of a dark red colour, and presents the appearance of
ecchymosis.
IV. CASES IN ILLUSTRATION OF THE MORBID CHANGES WHICH TAKE PLACE WITHIN
THE HEAD, THORAX, AND ABDOMEN, IN THE SAME INDIVIDUAL; OR MIXED CASES.
CASE XC.
MARGARET EADES, æt. 18, dress-maker. Admitted on the 22d day of fever,
which attacked with the ordinary symptoms: at present the mind is dull;
the sensibility diminished; there is scarcely any sleep; the eyes
injected and suffused; the skin hot; the tongue brown and dry; the pulse
120, but there is no pain in any organ.
23d. Insensibility increased to coma; delirium; tongue dry and quite
black; gums bleed on the slightest touch; lips and teeth sordid; four
stools, dark and offensive; pulse 110.
27th. Coma undiminished; almost constant moaning; scarcely any sleep;
three stools of same character; some cough; pulse 124, feeble.
31st. All the symptoms aggravated; extreme prostration; countenance
sunk; cough, without expectoration; respiration with mucous rattle;
stools in bed: pulse 140, extremely feeble. Died next day.
_Head._ Dura mater vascular; arachnoid thickened and opake; substance of
brain highly vascular, in every point thickly studded with red points;
effusion between the membranes and into the ventricles. _Thorax._ Mucous
membrane of bronchi inflamed; substance of lungs partly condensed and
partly tuberculated. _Abdomen._ Mucous membrane of ilium inflamed and
ulcerated; other viscera healthy.
CASE XCI.
WILLIAM MIDDLETON, æt. 18, shoemaker. Admitted on the 5th day of scarlet
fever, which commenced, in addition to the ordinary symptoms, with
exceedingly severe head-ache, which continues undiminished; scarcely any
sleep; eyes red and ferrety; tongue white; bowels loose; pulse 120;
eruption apparent only on the chest; no soreness of throat nor
difficulty of deglutition.
6th. Pain of head nearly gone; more insensible; pulse 126; eruption
fading.
8th. Insensibility increased to coma; adnatæ glistening; tongue brown
and dry; lips and teeth sordid; four stools.
10th. Coma deeper; great restlessness; no sleep; stools in bed; pulse
120, weaker.
11th. Increasing restlessness; tongue not to be protruded; deglutition
difficult; stools and urine in bed; pulse 150, indistinct.
13th. Died.
_Head._ Dura and pia mater highly vascular; arachnoid thickened and
opake; substance of brain highly vascular; effusion between the
membranes, into the ventricles, and at the base. _Thorax._ Mucous
membrane of bronchi vascular; substance of both lungs inflamed.
_Abdomen._ Mucous membrane of ilium ulcerated; other viscera healthy.
CASE XCII.
SARAH SHARP, æt. 18. Admitted on the 22d day of fever: the pain of the
head, which had been severe from the commencement, continues; complains
also of much pain in back and limbs; abdomen tender; tongue fiery red;
bowels purged; pulse 100, soft.
23d. No change, excepting that the tongue has become brown and dry in
the middle, but still remains exceedingly red at the edges; four stools;
pulse 108.
32d. Pain of head quite gone; that of abdomen, which had increased, has
now also disappeared; no sleep; great restlessness; delirium; eyes dull
and heavy; face flushed; tongue red and dry; four stools; pulse 110.
40th. Cerebral symptoms unchanged; no cough or uneasiness of chest; skin
dusky, that of the cheek of a deep purple colour; tongue loaded and dry;
lips and teeth sordid; stools in bed; pulse quick and very feeble; great
prostration.
48th. Coma; discharge from both ears; vomiting; pulse 120, very weak.
50th. Erysipelas of cheek, extending to scalp; much discharge from ears;
tenderness of abdomen again returned; tongue again of fiery red colour;
pulse extremely quick and feeble.
70th. During the whole of the period since last report there has been
occasional vomiting; the erysipelas gradually disappeared; the
sensibility returned; the tongue became clean and moist; the stools
improved, and there was even some return of appetite: on the other hand,
there came on extensive excoriation, and at last sloughing of back and
hips; the emaciation became very great, the prostration extreme, and at
length, on the 86th day from the commencement of the fever, she sunk
exhausted.
_Head._ Membranes of brain highly vascular; substance natural; upwards
of eight ounces of serum in the different cavities. _Thorax._ Mucous
membrane of trachea slightly reddened; bronchi vascular; lungs dark and
much gorged with blood. _Abdomen._ Mucous membrane of intestines
slightly vascular, [but the peritoneal coat highly inflamed, and
contained on its surface a coating of coagulable lymph, which glued the
convolutions of the intestines to each other and to the omentum.]
CASE XCIII.
CHARLES ENGLAND, æt. 22, servant. Admitted on the 11th day of fever:
previous symptoms unknown. At present perfectly insensible; pupils
contracted, insensible to light; face and lips of deep purple colour;
extremities cold; full pressure induces some uneasiness in abdomen; body
of tongue loaded and dry, edges red; deglutition difficult; pulse 100,
feeble.
12th. Some sleep through the night; more sensible to-day; no stool since
admission; pulse 114.
13th. Still more sensible; complains of giddiness; five stools; tongue
beginning to clean.
20th. Had been gradually improving since last report, and the pulse had
fallen to 80; during last night he became extremely restless, with much
delirium; mind now confused; face of a purple colour; tongue red and
glossy; three stools; pulse 120.
21st. Delirium; almost constant moaning; cheeks of purple colour; tongue
brown and glossy; pulse 130, but so indistinct that it can scarcely be
counted; lies extremely prostrate.
22d. Erysipelas of face, extending down the neck; some cough; abdomen
again tender; three copious dark-coloured stools; pulse 130. Died
following day.
_Head._ Scalp loaded with an unusual quantity of blood; the vessels of
all the membranes of the brain exceedingly turgid; a large coagulum of
blood between the dura mater and the arachnoid; substance of the brain
exceedingly soft; an ounce and a half of bloody fluid at the base of the
skull. _Thorax._ Mucous membrane of bronchi extremely vascular;
substance of lungs somewhat condensed and very much gorged; [two ounces
of serum in each pleural cavity.] _Abdomen._ Mucous membrane of ilium
much thickened, softened, and injected, exhibiting a few points of
incipient ulceration; [mucous membrane of bladder thickened and
inflamed; peritoneum lining the pelvis vascular;] other viscera healthy.
CASE XCIV.
JAMES ROBINSON, æt. 25. Admitted on the 8th day of relapse: at present
mind confused; acknowledges no pain in head, chest, or abdomen; tongue
not much loaded, moist; thirst; pulse 60, weak.
9th. No pain; some sleep; occasional delirium; two stools; pulse 78.
10th. Mind dull and heavy; returns no answer when spoken to; pulse the
same.
17th. Little change until to-day; the entire body is now covered with an
efflorescence, consisting of minute papulæ, of a vivid red colour; mind
dull and confused; pulse 120. Died next day.
_Head._ An old fracture over that part of the coronal suture which joins
the parietal bone, seems to have left the brain unaffected; inner
surface of skull perfectly smooth; both membranes and substance of the
brain highly inflamed; pituitary gland suppurated; cerebellum natural.
_Thorax._ [Left lung contained many tubercles in the stage of
suppuration; the apex, which was full of tubercles, adhered to costal
pleura; right side healthy; pericardium contained two ounces of bloody
serum; serous lining of auricles and ventricles of heart highly vascular
and of dark red colour; valves of aorta and of auricles extremely dark;]
no account recorded of the state of the mucous membrane of the bronchi.
_Abdomen._ Omentum vascular; intestines throughout of dark red colour;
all their coats every where exceedingly softened, the peritoneal peeling
off with ease from the muscular; the mucous inflamed, not ulcerated; the
mucous membrane of the stomach vascular; a considerable portion of the
jejunum intussuscepted; other viscera healthy.
CASE XCV.
ANN SMITH, æt. 23, married. Admitted on the 15th day of fever; pain of
head gone; some vertigo remains; no uneasiness of chest; some cough
which excites pain in the abdomen; the latter not very tender even on
full pressure; tongue loaded in middle with white fur, red at edges; no
stool for the last twenty-four hours; pulse 120, weak.
17th. Eruption has appeared over almost the entire skin, consisting of
minute papillæ of a dusky red colour; two stools; pulse 120.
20th. Erysipelas extending over both shoulders; severe pains in the
limbs.
25th. Cough troublesome with copious viscid expectoration; erysipelas
extending from the shoulders to the chest; tongue dry: delirium; pulse
110, weak.
26th. Cough diminished; respiration hurried; stools in bed; pulse 120,
feeble.
27th. Delirium continues; respiration more hurried; pulse extremely
feeble.
28th. Erysipelas still extending; powers sinking; respiration laborious;
stools and urine in bed. Died in evening.
_Head._ Arachnoid vascular; substance of brain vascular; sheath covering
the lumbar portion of the spinal cord highly vascular; cord itself
natural; effusion into the lateral ventricles; plexus choroides and
velum interpositum highly vascular; pituitary gland gritty. _Thorax._
Mucous membrane of bronchi inflamed; substance of left lung intensely
inflamed, being nearly as red as muscle and its lobes adherent;
[corresponding side of pericardium highly vascular; right lung slightly
inflamed; right pleuræ not adherent; left adherent throughout.]
_Abdomen._ Patches of vascularity in mucous membrane of intestines and
over their peritoneal coat; pyloric end of stomach vascular; spleen
soft; other viscera healthy.
CASE XCVI.
JOSEPH BAIRD, æt. 12. Admitted on the 22d day of fever; slight pain of
head; severe pain across the loins; no uneasiness in chest; no cough;
respirations 44; abdomen tender; tongue red, parched; bowels purged;
pulse 134.
33d. Abdomen tender, tumid, tense; four stools; tongue loaded with white
fur; mind distinct; scarcely any sleep; extremely fretful.
34th. No delirium; stools in bed; pulse 114. Died next day.
_Head._ Membranes and substance of the brain vascular; at the surface of
the right posterior lobe, an abscess of considerable size, the floor of
which was formed by the pia mater; gelatinous effusion between the
arachnoid and the pia mater. _Thorax._ Mucous membrane of bronchi
vascular; substance of lungs healthy; [left cavity of pleuræ contained
eight ounces of bloody serum; right six.] _Abdomen._ Peritoneal and
mucous coats of jejunum and ileum vascular; mesenteric glands greatly
enlarged; several of them suppurated; [large quantity of serum mixed
with pus in the peritoneal cavity; omentum much thickened; adhered to
the superior portion of the spleen; to the edge of the left lobe of the
liver, and to the portion of the diaphragm immediately above the spleen;
in this manner it formed the external boundary of an abscess of
considerable size in the substance of the spleen; portions of the sac
itself ulcerated; the rest of the spleen nodulated; these nodules when
cut into were found to consist chiefly of puriform matter contained in
cells; thoracic duct enlarged; receptaculum chyli exceedingly enlarged
and ulcerated.]
CASE XCVII.
CATHERINE FRENCH, æt. 24. Admitted on the 9th day of scarlet fever.
Complaint came on with sudden loss of strength, shivering and violent
pain of head and chest: at present throat sore; deglutition difficult;
some pain of chest; great tenderness of abdomen; nausea and vomiting;
tongue dry, brown and cracked; slight pain of head; eyes dull, heavy and
suffused; pulse 104, pretty strong; no eruption.
23d. The pain of throat, the difficult deglutition, the tenderness of
the abdomen had disappeared; the pulse had fallen to 90, and she
appeared to be gradually recovering until this day, when, preceded by a
slight return of sore throat, erysipelas appeared on the face; no pain
of head; tongue again brown and dry; pulse 96.
24th. No sleep; delirium; erysipelas extending; pulse 108.
38th. Erysipelas has disappeared, but other symptoms are aggravated;
extreme restlessness; much delirium; frequent cough, with scanty
expectoration; tongue brown, dry and cracked; pulse 86.
39th. Respiration difficult; delirium; vomiting; pulse 120.
41st. Respiration rattling; delirium; inclined to sleep; pulse 120.
42d. Respiration increasingly difficult and painful; pulse 129.
43d. Extremely restless; almost constant moaning; countenance anxious;
cough; tongue continues brown and dry; lips and teeth sordid; pulse 122.
44th. Died during the night.
_Head._ An abscess over the posterior extremity of the sagittal suture,
around which for the space of two inches, the pericranium was destroyed,
leaving this portion of the bone bare. Dura mater natural; arachnoid and
pia mater vascular; substance of brain natural; effusion between dura
mater and arachnoid; lateral ventricles full of serum; two ounces at
base. _Thorax._ [Pleuræ of right side covered throughout with pus of
very thick consistence, presenting the appearance of the interior of a
large abscess, contained two pints of fluid consisting of serum, pus and
blood; superior lobe of right lung hepatized and tuberculated; some of
the tubercles in a state of suppuration; middle lobe contained a large
abscess; lower lobe much wasted, blackened, and in many points softened
down to a black fluid; left thoracic cavity contained about one pint of
pure serum; pleuræ very vascular but not adherent; substance of lung
perfectly sound;] condition of mucous membrane of bronchi not stated.
_Abdomen._ Mucous membrane of ilium contained several ulcers; other
viscera healthy.
CASE XCVIII.
JOHN GREEN, æt. 10. Period and progress of disease unknown: throat much
inflamed and ulcerated; deglutition difficult; respiration painful; much
muco-purulent fluid constantly discharged from nostrils; eyes suffused;
lips and teeth sordid; tongue cannot be protruded; pulse cannot be
counted; noisy delirium; several dark-coloured vesicles on hands,
especially in the neighbourhood of the joints. Died the same evening.
_Head._ Membranes slightly vascular; arachnoid and dura mater adherent
at several points; substance of brain slightly vascular; effusion into
ventricles. _Thorax._ Mucous membrane of trachea and bronchi highly
vascular; larynx much inflamed; arytænoid cartilages ulcerated;
epiglottis dark and thickened; [pleuræ adherent throughout; substance of
lungs inflamed.] _Abdomen._ Mucous membrane of intestines vascular;
mesenteric glands enlarged; liver mottled on surface.
CASE XCIX.
ANN LEVITT, æt. 24, married. Admitted on the 16th day of fever, which
came on with severe pain of the head and epigastrium; pain of head is
now gone, giddiness remains; much pain of limbs; scarcely any sleep;
mind confused; eyes dull and heavy; face flushed; no uneasiness of
chest; abdomen extremely tender on pressure; tongue red, parched, and
cracked; lips and teeth sordid; bowels purged; pulse 123.
17th. After the application of ten leeches to the abdomen the tenderness
is much diminished; the pulse fallen to 96; vomiting.
18th. Eight leeches again applied; abdomen now free from pain; vomiting
continues; tongue unchanged; pulse 106.
19th. Vomiting undiminished; eight stools; abdomen again tender.
20th. Vomiting; five stools; pulse 108; slight pain of abdomen on full
pressure.
22d. Abdomen tender, swollen, and tympanitic; eight stools; pulse 96;
great prostration.
24th. Abdomen less tender and tense; still more prostrate.
25th. Stools in bed; pulse scarcely perceptible; features collapsed.
Died in the night.
_Head._ Membranes of brain vascular; substance natural; effusion into
the ventricles and at base; pituitary gland suppurated. _Thorax._ Mucous
membrane of bronchi inflamed; tubes full of mucus, mixed with pus;
[superior lobe of right lung a mass of tubercular disease; one of the
tubercles the size of a pigeon’s egg, in a state of suppuration;
effusion of serum into the left pleural cavity.] _Abdomen._ Mucous
membrane of jejunum and ilium much inflamed; caput coli firmly adherent
to the abdominal peritoneum; large quantity of serum effused into the
hepatic region; substance of liver soft; gall-bladder in a state of
suppuration; contained three large biliary calculi; omentum inflamed;
[two large hydatids attached to the left ovarium.]
CASE C.
ROBERT EBBOTT, æt. 28, labourer. Admitted on the 12th day of fever: pain
of head, which has been severe, is now only slight; frequent sighing; no
pain of chest; frequent dry cough; respiration heavy and suspirious;
abdomen tender; tongue dry, black, and cracked, red at apex; lips and
teeth sordid; bowels purged; pulse 68.
15th. Mind confused; insensibility increasing; abdomen tender; tongue
quite black and extremely dry; teeth sordid; respiration the same; no
stool; pulse 72, feeble. Died next day.
_Head._ Dura mater natural; longitudinal sinus contained a firm cord of
fibrin; arachnoid and pia mater vascular; substance of brain natural;
pituitary gland softened and suppurating; much effusion into the
ventricles; at the base the membranes were elevated into a large bag,
distended with fluid. _Thorax._ Mucous membrane of bronchi vascular;
[right lung adherent to pleura, by a single point, at the upper part of
the inferior lobe; substance contained numerous tubercles; left pleural
cavity obliterated; left lung hepatized throughout, containing tubercles
in every stage of disease; apex of heart adherent to pericardium.]
_Abdomen._ Mucous membrane of ilium and cæcum inflamed and extensively
ulcerated; [liver exceedingly enlarged and hard, almost of cartilaginous
firmness and texture, weighed seven pounds two ounces; right kidney
externally nodulated, internally healthy; left, healthy externally, but,
when cut into, found to contain several abscesses; urinary bladder
small; walls one third of an inch thick.]
CASE CI.
JANE HALLAM, æt. 28, married. Admitted on the 6th day of fever: attacked
with overwhelming loss of strength and severe pain of the head; pain of
head continues, with distressing vertigo; no pain of chest; no cough;
abdomen tender; tongue covered with white fur, but is extremely parched;
thirst urgent; thinks she has had thirty stools within the last
twenty-four hours; mind tolerably distinct.
7th. Pain of head gone; mind much more dull and heavy; abdomen very
tender; tongue has become brown and continues extremely dry; four stools
dark and offensive; pulse 104, soft.
8th. Scarcely any sleep; much restlessness; mind confused; insensibility
increasing; pulse 90, weak. Died next morning.
_Head._ Membranes vascular; substance of brain in general much softened,
but the floors of the ventricles especially were in an exceedingly
softened state. _Thorax._ [Left pleuræ adherent at apex; superior lobe
of left lung hepatized and stuffed with small tubercles; two adhesions
in right pleuræ, one at apex; right lung stuffed with tubercles;]
pericardium and heart healthy; condition of bronchi not stated.
_Abdomen._ Mucous membrane of ilium and cæcum exceedingly vascular, but
not ulcerated; patches of peritoneal coat of stomach vascular; [large
lobe of liver scirrhous;] other viscera healthy.
CASE CII.
JONATHAN STUDD, æt. 27. Admitted on the 28th day of fever; symptoms
throughout appear to have been chiefly thoracic; at present frequent
cough with viscid expectoration; great emaciation; pulse 102, extremely
weak; no pain of head or abdomen; tongue foul; bowels regular; face
pallid.
29th. Cough continues; abdomen not tender; tongue brown and dry in
middle, red at tip and edges; three stools; pulse 100; mind dull and
confused; muscular tremor.
30th. Cough the same; tongue unchanged; lips and teeth sordid; three
stools mixed with blood; delirium; muscular tremor increased; pulse 108.
31st. Abdomen has become tympanitic; three stools mixed with blood;
delirium and muscular tremor increased; pulse 112, weaker.
47th. On the evening of the day of last report he slept better and waked
improved in all respects; this improvement appeared to be steady and
progressive; the stools became natural; the pulse diminished in
frequency and increased in strength; on this morning the stools
continued natural; the pulse was 90, and he still seemed to be gradually
though slowly recovering, when, without the return of any unfavourable
symptom, he suddenly expired.
_Head._ Membranes and substance of brain healthy, but more fluid than
natural in the ventricles. _Thorax._ Mucous membrane of bronchi greatly
inflamed and thickened; bronchial tubes full of mucus mixed with pus;
pleuræ of left side of chest extensively adherent; substance of left
lung healthy excepting some slight patches of hepatization. _Abdomen._
Mucous membrane of small intestines extremely vascular, in many places
presenting the appearance of ecchymosis; at the valve of the colon
several small ulcers; other viscera healthy.
CASE CIII.
JOHN M’CARTY, æt. 22, labourer. Admitted on the 22d day of fever;
complaint commenced with symptoms of severe cold; at present, slight
pain of chest; cough, inducing pain in the abdomen, which is not tender;
pain of head gone; eyes injected and suffused; face flushed; tongue
brown and dry; bowels stated to be regular; pulse 99, weak.
23d. Cough very severe; abdomen not tender; tongue dry, brown and
cracked; four stools; no pain of head; face flushed; eyes ferrety; pulse
90.
24th. Mind more confused; eyes more injected; delirium.
25th. Insensibility increasing; no sleep; tongue more dry and brown;
lips and teeth sordid; four stools; pulse 96.
26th. Constant delirium; stools and urine in bed; pulse 104.
28th. Died.
_Head._ Membranes and substance of brain vascular; more fluid than
natural in ventricles. _Thorax._ Mucous membrane of bronchi vascular;
[pleuræ of right side slightly adherent.] _Abdomen._ Mucous membrane of
jejunum, cæcum and ilium very much ulcerated; spleen soft; other viscera
healthy.
CASE CIV.
SARAH NASH, æt. 14. Admitted on the 22d day of disease; pain of head
appears to have been very severe but it has now wholly subsided; lies
quite insensible; pupils dilated, but contractile; muscles of
extremities quite rigid; hands clenched; arms and legs extended and
inflexible; no tenderness of abdomen on fullest pressure; tongue brown
and dry; no stool for four days; pulse 110, extremely feeble and
indistinct.
23d. Muscles of lower extremities rather less rigid; hands continue
clenched; eyes in general closed; when opened appear injected and
suffused; much grinding of the teeth; great restlessness; noisy
delirium; two stools; pulse 126, stronger.
24th. Great restlessness; scarcely any sleep; almost constant grinding
of the teeth; pulse 129, of good power.
26th. So restless that the pulse cannot be counted; exceedingly peevish;
began to take two grains of calomel with half a grain of opium every
four hours.
27th. Little change excepting that she is now sensible of some pain in
the epigastrium on full pressure, and acknowledges some pain in the
head; pulse 142.
32d. No amendment in the cerebral symptoms, and the strength is
diminished; the mercurial odour is already quite evident, and the mouth
is slightly ulcerated; no ptyalism; pulse 126, weak; calomel and opium
omitted.
36th. Noise and delirium continue; ulceration of mouth gone; pulse 140,
very weak. Calomel and opium were again resumed.
27th. Slight ptyalism; no improvement; pulse 130, extremely weak and
indistinct.
38th. Ptyalism continues; sinking. Died.
_Head._ Membranes vascular; substance of brain much softened; effusion
between all the membranes and into the ventricles. _Thorax._ Bronchi of
both lungs vascular, and contained a large quantity of purulent matter;
right lung much hepatized; left slightly consolidated. _Abdomen._ Ilium
and cæcum very much ulcerated; spleen very firm, contained one tubercle;
other viscera healthy.
CASE CV.
WILLIAM GANDER, æt. 22, servant. Admitted on 15th day of fever; no
account to be obtained of previous symptoms; some pain of head; much
giddiness; mind confused; delirium; expression of eyes wild; face
flushed; abdomen tender; tongue foul at root, moist, very red at apex;
bowels purged; pulse 99, of good power.
16th. No sleep; violent noisy delirium; eyebrows contracted; face
flushed; six stools; pulse 100.
19th. Intensity of cerebral symptoms progressively increasing; constant
violent delirium; muscular tremor; subsultus; tongue cannot be
protruded; pulse 112. Died next day.
_Head._ Membranes vascular; substance of brain natural; four ounces of
serum in the lateral ventricles. _Thorax._ Mucous membrane of trachea
and bronchi highly vascular; other viscera healthy. _Abdomen._ Glands of
the mucous membrane of the intestines in general enlarged, many of them
inflamed; some of them in a state of commencing ulceration, others
completely ulcerated, so that the ilium and lower part of colon were
full of ulcers, which varied in size, from that of a split pea to a
crown piece; mesenteric glands much enlarged and dark; spleen very soft;
other viscera healthy.
CASE CVI.
GEORGE BURY, æt. 9. Admitted on the 11th day of fever: complaint
commenced with nausea, pain of abdomen and severe head-ache; the latter
continues; abdomen, especially epigastrium, tender; tongue red; much
thirst; bowels constipated; pulse 116.
14th. Pain of head gone; countenance extremely pallid; no sleep; great
restlessness; delirium; abdomen still tender; tongue red and dry; eight
stools, dark and offensive; pulse 130. Died next day.
_Head._ Membranes vascular; substance of brain highly vascular;
pituitary gland in a state of suppuration; cerebellum vascular; effusion
between dura mater and arachnoid; one ounce of serum in ventricles, two
at base; pia mater covering the spinal cord highly vascular; substance
of cord natural. _Thorax._ Mucous membrane of bronchi slightly vascular;
tubes contained some mucus, mixed with pus; [left pleuræ slightly
vascular; lower lobe of left lung hepatized; right pleuræ healthy; lower
lobe of right lung also hepatized, and contained several hard
tubercles;] other viscera healthy. _Abdomen._ Mucous membrane of lower
end of ilium and entire cæcum thickly studded with ragged ulcers, raised
and very foul, with indurated margins and irregular surfaces; longest
diameter of ulcers in direction of longitudinal fibres of muscular
coats; mesenteric glands very large, many of them being the size of
almonds; other viscera healthy.
CASE CVII.
JOHN MEREDITH, æt. 23, porter. Admitted on the 22nd day of fever, which
came on, besides the ordinary symptoms, with pain of chest, cough and
hoarseness: states that these symptoms were getting better when, a few
days ago, he was attacked with pain of the abdomen, accompanied with
loose stools: at present the abdomen is exceedingly tender on pressure;
tongue brown and dry in the middle, edges white and moist; bowels
purged; distressing hiccup; pain of head, which was severe in the
commencement, gone; mind dull and heavy, but answers any question
distinctly; countenance anxious; features sunk; pulse 88, feeble; slight
degree of hoarseness and some cough remain.
23d. Tenderness of abdomen undiminished; hiccup continues very
distressing; vomiting; bowels purged; tongue brown and dry; scarcely any
sleep; pectoral symptoms the same; pulse 76.
24th. Tenderness of abdomen, hiccup, vomiting, purging, all increased;
eight stools since last report; much restlessness; pulse 84.
25th. Appeared to be more easy yesterday, but relapsed into his former
state to-day. Died following morning.
_Head._ Membranes vascular; arachnoid thickened and opake; substance of
brain vascular; more fluid than natural in the ventricle. _Thorax._
Mucous membrane of bronchi vascular; other viscera healthy. _Abdomen._
Mucous membranes of small intestines vascular; [peritoneum universally
and greatly inflamed; that covering the intestines coated with a layer
of coagulable lymph, by which their convolutions were united into one
diseased mass; false membranes were formed by this exudation which
extended from the under surface of the liver to the right iliac fossa,
where they formed a cyst, in which eight ounces of purulent matter were
contained; the peritoneum covering the abdominal surface of the
diaphragm inflamed; liver enlarged,] but its substance appeared healthy;
other viscera natural.
CASE CVIII.
ELIZABETH TURNER, æt. 26, servant. Admitted on the 15th day of fever: no
account to be obtained of previous symptoms: at present extremely
restless; much delirium; almost constant talking or moaning; no sleep;
mind quite confused and wandering; when roused to answer a question she
seems sensible for a moment, but immediately lapses into low muttering
incoherence; if asked whether she has any pain in the head she points to
the forehead; says she has no pain in chest or abdomen; no cough;
abdomen not tender.
16th. No sleep; constant restlessness; almost unceasing incoherent
talking; incapable of answering when spoken to; tongue cannot be
protruded; stools in bed; pulse too feeble and indistinct to be counted.
Died in the evening.
_Head._ Dura mater along the course of the longitudinal sinus very
adherent to the arachnoid; arachnoid and pia mater white and opake;
surface and substance of brain highly vascular; surface of cerebellum
vascular; substance healthy; pituitary gland suppurating; more fluid
than natural in the ventricles; an ounce at the base. _Thorax._ Mucous
membrane of bronchi highly inflamed; bronchial tubes filled with mucus
mixed with pus; [pleura costalis of right side vascular; slight effusion
into right pleural cavity, and into parenchyma of right lung; lower lobe
much inflamed; pleuræ of left side adherent; that covering left side of
diaphragm much inflamed; substance of left lung partly inflamed, partly
consolidated.] _Abdomen._ Mucous membrane of small intestines inflamed;
in that of ilium numerous large, raised ulcers; [liver adherent by
several unnatural connexions to diaphragm, spleen and transverse arch of
colon, but its substance was healthy; appendix vermiformis likewise
adherent to abdominal peritoneum;] head of pancreas enlarged; [internal
inguinal glands much enlarged, and some of them impacted with calcareous
matter;] other viscera healthy.
CASE CIX.
MR. W——, æt. 50. The progress of this case having been observed with
great care from the commencement to the termination of the disease, and
affording an excellent illustration of the insidious manner in which the
mixed form of fever sometimes attacks, and of the silent but rapid
progress it makes without exciting alarm, until, at last, symptoms the
most formidable, and which, to those who are not acquainted with the
nature of the malady, appear to be most sudden, supervene, it may be
useful to give a detailed account of it.
This gentleman had been out of health six months previously to the
present attack of fever: he had been observed to be gradually losing
flesh, and fading; yet he laboured under no complaint that could be
ascertained, excepting that his appetite failed; that he could digest
well no kind of food; that he was badly nourished and, therefore, weaker
in body and less vigorous in mind than usual.
About three weeks before the fever commenced, his stomach-complaints
became worse, and for these he requested the advice of his friend Mr.
Chaldecott. During this gentleman’s attendance, his patient was one day
attacked with slight chilliness, an unusual degree of lassitude,
together with pains in the limbs: but the chilliness never amounted to
rigor; the general pains were not severe; there was no pain whatever in
the head; yet the sudden debility which affected both mind and body was
very striking. Still the mind was perfectly distinct; the sleep was
sound; the expression of the countenance was natural; the tongue,
however, became loaded with white fur; there was some thirst; the pulse
varied from 84 to 96, while the temperature and the softness of the skin
remained in a healthy state. In this manner he went on about eight or
ten days, and, during the whole of this period, he was daily questioned
by his medical attendant and examined with much anxiety relative to the
condition of the organs in the head, chest and abdomen; but he was
steady in affirming that he was free from all uneasiness in the head,
and that he had no pain in the chest; nor could any pain be excited by
the fullest pressure, either in the epigastrium or in any part of the
abdomen. It was observable, however, that he had some cough without
expectoration, and that his respiration was short and hurried. His
appearance, too, indicated more disease than his sensations; he was
obviously worse than he expressed, or than could be accounted for from
the apparent affection of any organ, and this excited alarm both in his
family and in his medical attendants; and it is always a truly alarming
condition.
On the 11th day a remarkable change took place: for two or three hours
he was chilly; to this succeeded heat of skin and flushing of the face;
what was very alarming, the colour of the flash was purple, while that
of the whole face was dusky; there was no cough, but the respiration was
short and hurried; the mind was confused and dull, though a coherent
answer might still be obtained to any question that was asked; the pulse
now rose to 120, there was little or no sleep, but great restlessness
during the night, in the course of which delirium appeared, and the next
morning there came on muscular tremor. As the day advanced the flushing
and heat disappeared; the mind became quite distinct, and the pulse fell
to 96. Towards evening he again became restless, the pulse rose to 104,
and about one o’clock, a.m. the increased heat, the flushing of the
face, the purple colour of the cheek, the dusky appearance of the skin,
the short and hurried respiration, and the convulsive action of the
muscles all returned, and in a greater degree, while the pulse again
rose to 120. From this state he never recovered in the least degree, but
became more and more dull, and at length nearly insensible; his debility
rapidly increased until it became extreme; he lay quite prostrate on the
back, with his arms extended, as if lifeless; the muscular tremor
increased; the respiration became extremely short and hurried; the
tongue became dry, red, glazed, and sticky; the bowels torpid; the pulse
130; and with these symptoms he expired on the 13th day of fever.
_Head._ Dura mater healthy; arachnoid thickened and opake; much
gelatinous effusion between it and the pia mater; substance of brain
highly vascular and firm; lateral ventricles distended with fluid, much
also at the base. _Thorax._ Mucous membrane of bronchi universally of a
dark red colour and lined with a tenacious fluid, which was slightly
sticky; bronchial tubes filled with frothy mucus; substance of lungs
perfectly healthy. _Abdomen._ Mucous membrane of small intestines
generally inflamed; lower part of ilium and commencement of colon filled
with large and raised ulcers, some of which were just forming, while
others had penetrated through a thick mass of adventitious deposit to
the muscular coat of the intestine.
Before closing these illustrations of the pathology of fever, it may be
proper to give an example of the modifications which take place when
this disease proves fatal in the state of gestation. If fever attack
during pregnancy, there is the greatest possible danger of miscarriage,
and the great majority of those who miscarry die. There is no
complication which requires a more delicate and cautious management; and
the management which experience shews to be the best will be stated in
the proper place: in the mean time, the following case is given as an
illustration of the morbid appearances which are found (and the
appearances are very uniform) when abortion is the precursor of death.
CASE CX.
MARY CUTLER, æt. 37, married. Admitted on the 5th day of fever, in the
commencement of which, in addition to the ordinary symptoms, there was
much nausea; this feeling continues at present, and is now accompanied
with vomiting; epigastrium tender; cannot lie without pain in the left
side; cough frequent, and exciting uneasiness in the chest; tongue white
and dry; bowels bound; some pain of head, especially in the forehead;
scarcely any sleep; much pain in the extremities; pain of throat with
difficult deglutition; pulse 122; skin warm; six months pregnant.
6th. Much retching and vomiting; tenderness of the epigastrium and
abdomen; bowels very loose; tongue white in the middle, red at the
edges; severe pain in the chest; great dyspnœa; constant, urgent cough
with difficult mucous expectoration; severe pain in the head; no sleep;
great restlessness; pulse 150, sharp but compressible. V. S. ad ℥xij.
7th. Buff on blood extremely firm; retching and vomiting gone; pain of
side entirely removed; less cough; dyspnœa diminished; pain of head
better; slept much better; pulse 120.
9th. After a tolerable night, attacked this morning with urgent dyspnœa,
soon became perfectly insensible; was delivered of a fœtus six months
old; at present, nearly insensible; respiration hurried and laborious;
tongue brown and dry; one stool; pulse 110; skin moderately warm.
10th. Free lochial discharge; all the symptoms greatly improved; tongue
white; moist; pulse 84, soft.
13th. Lochial discharge nearly ceased; no pain in head, abdomen, or any
where, except the face which is attacked by erysipelas; tongue continues
moist and is nearly clean; pulse 108.
14th. Erysipelas increased and extending; tongue, has again become brown
and dry; pulse 110.
16th. Erysipelas extending; severe pain in epigastrium and over abdomen,
much increased on pressure; distressing sense of nausea but no vomiting;
tongue the same; pulse 96, weak and irregular.
17th. Pain of abdomen increased; stools in bed; no sleep; extreme
restlessness; respiration hurried and wheezing; pulse 130, weak. Died in
the evening.
_Head._ Membranes of brain vascular. _Thorax._ [Pleuræ covering right
lung coated with a layer of coagulable lymph; in both pleural cavities a
large quantity of serum mixed with flakes of lymph and pus; that part of
the pleura of the right side which lines the diaphragm highly inflamed;]
substance of both lungs healthy. _Abdomen._ Peritoneum in general more
vascular than natural; patches of it in a state of intense inflammation;
peritoneal sac contained much serum mixed with flakes of lymph and pus;
pelvis of right kidney inflamed; ovaria and uterus of very dark colour
and intensely inflamed; other viscera healthy.
* * * * *
It would be easy to multiply cases to an indefinite extent, but, since
those which have been cited exhibit a complete view of the pathology of
fever, as far as it has yet been ascertained, any further details would
fatigue the reader without instructing him. And what is this pathology?
What are the events, the detail of which has occupied us so long? The
account of the pathology of fever is the history of inflammation, and
the description of the individual changes that take place in the organs
that constitute the febrile circle, is an enumeration of various
products of inflammation which are formed within them. There is scarcely
a fatal case of fever which does not afford, in one or other of the
organs of that circle, some inflammatory product; there is no
considerable number of fatal cases which does not furnish a specimen of
every inflammatory product. And what are the severest cases of fever,
and why are they the severest? With the single exception immediately to
be stated, the severest cases are those in which, together with a severe
primary affection of the nervous system, this inflammatory action is in
the greatest degree of intensity, and is seated in the greatest number
of organs; and they are the most severe, not only on account of the
severity of the primary affection of the nervous system, but also
because it is in them that the inflammation is the most intense, and
because that inflammation attacks the system at one and the same time in
the greatest number of points. From among the preceding cases, fix upon
any one in which the powers of life were, from the commencement, the
most completely overwhelmed, and in which they were the most rapidly
exhausted, and when the brief struggle for existence is over, examine
the changes that have taken place in the internal organs—what is it that
is found? traces of inflammation, legible, deep, extensive; while, in
almost every case, these traces are thus legible, deep, and extensive,
in proportion to the apparent intensity of the fever, and to the
rapidity with which it extinguished life. In this point of view, how
important, how instructive, how invaluable is the lesson which the mixed
cases of fever afford! With few and rare exceptions (and in all diseases
some exceptions occasionally occur to what appear to be the best
established and the most invariable laws) these are the cases in which
the symptoms are the most urgent, and in which they run their course
with the greatest rapidity; these are the cases in which the debility is
the most striking; in which it comes on the most early, and proceeds to
the greatest degree of prostration; these are the cases which are the
most purely typhoid, the most truly adynamic; these are the cases which,
in general, commence with the most sudden and alarming deprivation of
physical and mental power; in which all pain and uneasiness are soonest
lost in stupor, in which the stupor most rapidly increases to
insensibility; in which delirium comes, perhaps, as early as the third
or fourth night, accompanied with its attendant, muscular tremor, and
too often with its most formidable ally, erysipelas: in which, at this
early period, the respiration is short and hurried, the skin dusky, the
colour of the cheek purple, the tongue brown and dry, the lips and teeth
sordid, the abdomen tender, and the stools loose; in which, in a day or
two more, the abdomen is swollen, tense, and tympanitic, the stools
passed in bed, the patient prostrate on his back, completely senseless
and powerless, while the pulse is 120 or 130, and so feeble that it can
scarcely be distinguished. But what is this debility? in what does this
adynamic state consist? It consists of a peculiar affection of the
nervous system, followed rapidly by intense inflammation of the brain or
of its membranes, or of both: by intense inflammation of the mucous
membrane of the bronchi, and by intense inflammation or extensive
ulceration of the mucous membrane of the intestines. And why is the
patient weak or adynamic? Because he is not only assailed by an
affection of the nervous system, which deprives the organs of the
stimulus necessary to enable them to perform their functions with due
vigour, but, at the same moment, inflammation is set up in three of the
great systems, the healthy action of which is most essential, not only
to strength but to life: thus the citadel is attacked at one time at
three of its capital points. It is not asserted that inflammation alone
constitutes the state of fever, nor that the danger of the patient is
always in exact proportion to the degree of the inflammation. How it
differs from inflammation, and what is superadded to the inflammatory
state, will be shewn immediately; but it is a most important fact, that
the degree of the debility is most intimately connected with the
intensity and the extent of the inflammatory action. Now and then, as
has been already stated, the intensity of the nervous affection is so
great, and so rapidly destructive of life, that there is no time for an
inflammatory process to be set up, much less for an inflammatory product
to be formed. The patient is struck dead as if by lightning, or by
Prussic acid, or by apoplexy. In this country, he does not actually die
as instantaneously as he might be destroyed by the electric fluid or by
poison, although there are countries, seasons, and particular spots, in
which the concentration of the febrile poison appears to be sufficiently
great to extinguish life instantaneously; and even in this country, life
is sometimes destroyed by a stroke of fever as rapidly as it is by a
stroke of apoplexy, when the latter does not prove fatal in the first
few hours.
Now the peculiarity in these cases is, that the internal organs, after
death, exhibit no signs of inflammation, unless vascularity be
inflammation. The organs which, in ordinary cases, are inflamed, are in
these cases turgid with blood. Are the terms debility or adynamia
appropriate expressions to designate even this condition of the organs?
Just as appropriate as they would be to express the condition of a
person who is struck dead by lightning, whose muscles are incapable of
contraction, and whose blood will not coagulate. Those who apply these
terms even to such forms, and, _à fortiori_, to any other forms of
fever, must be ignorant either of the nature of the disease, or of the
constitution of the human mind. If they know the disease, they know that
the patient appears to be weak because the primary operation of the
disease is upon the nervous system—an operation which, as has just been
stated, while it disturbs that due and equal distribution of nervous
influence which is necessary to the healthful action of the organs, and,
therefore, to the general strength of the system, is not incompatible
with, but promotive of an excitement of the vascular system, which
terminates in inflammation. Debility is the last, the ultimate result of
the disturbance of the functions of a certain series of organs, but part
of this very disturbance of function, and a most important part, a part
which exerts the greatest influence over the progress of the disease and
the life or death of the patient, consists not in the weakened, but in
the augmented strength and the increased activity of the vascular
system. To designate the ultimate result upon the system by a term which
gives an entirely false view of the individual processes in the economy,
by which that ultimate result is produced, must, we repeat, arise either
from an ignorance of the true nature of those processes, or from not
reflecting on the influence which words exert over the manner in which
the human mind conceives of things. For the sake of the progress of the
science of medicine, for the sake of rendering the language of medicine
the correct expression of the knowledge which the science has actually
attained, and, above all, for the sake of accomplishing the great object
of medicine, the preservation of human life, it is high time that these
terms with which physicians have so long allowed their minds to be
abused, should be banished from medical nomenclature, or, at any rate,
from that part of its nomenclature which appertains to fever.
II. PATHOLOGY OF THE FLUIDS IN FEVER.
The pathology of the solids in fever, derived from inspection of the
fatal cases after death, has already acquired, as we have seen, a high
degree of perfection. The pathology of the fluids is scarcely at all
known, and the difficulty of arriving at exact and certain results is
great. Why the investigation of the morbid changes that take place in
the fluids should be a much more arduous task than that of tracing the
changes produced in the structure of the organs, is too obvious to need
to be pointed out; but those only who have actually engaged in
researches of this nature can form a just conception of the number of
repetitions that are requisite of the same analysis, of the care
required in conducting each, and consequently, of the labour and time it
is necessary to devote to the investigation, before satisfactory results
can be obtained. The analysis of the animal fluids in their healthy
state is far from being perfect; yet their composition in the state of
health must be ascertained, as far as it can be ascertained, as a
preliminary step: and, in order to discover the morbid changes that take
place in the blood, in the urine, in the products of respiration, and in
those of transpiration, and still further to determine the nature and
extent of such changes in the different types and stages of fever, it is
obviously necessary to examine the respective fluids and gases in a
great number of cases, and to vary the experiments in a great variety of
modes. Experiments of this kind, on an extensive scale, have been
undertaken by my friend Mr. Cooper; and, when this work was commenced,
they had already advanced so far that there appeared to be a prospect
that, before its completion, they would be sufficiently matured to
justify us in laying the results before the reader. And that deviations
from the state of health, and some of them of great importance, do take
place in these fluids, and especially in the blood and the urine, is
ascertained. What they are, with what degree of constancy they occur,
how far they are respectively connected with the cerebral, the thoracic,
the abdominal, and the mixed affections, with different degrees of
intensity in these affections, and with different stages of their
progress, we hope, at no distant period, to be able to lay fully before
the public.
In the mean time, it is of some importance to bear in mind the true
place which the results of such experiments, be those results what they
may, and be they established with all the clearness and certainty that
can be desired, must always hold. Changes in the fluids can only be
second in the series of morbid events; they can never hold the first
place in that series; they can never be primary antecedents or first
causes, but merely sequents or effects. To assign the reason of what
must be so obvious to every one who is acquainted with the elements of
physiology, would be entirely out of place here, because it would
suppose the reader to be wholly ignorant of the functions of the animal
economy. Our knowledge of the pathology of fever can never be complete,
until we know the morbid changes that take place in the fluids as
perfectly as we are acquainted with the alterations of structure that
are produced in the solids, and we ought, therefore, to spare no labour
to render our knowledge of the former as exact and certain as it is of
the latter. But, as far as we can at present see, when this is
accomplished, we shall have acquired little that is of practical
utility. There is but slight, if there be any ground to hope that, when
the humoral pathology shall have arrived at the greatest possible degree
of perfection, it will furnish us with any additional means of
preventing, curing, or even mitigating the severity of the disease. With
that disorder of the system over which we have some control, with those
morbid actions which we possess some means of subduing or changing, we
are already well acquainted. In our knowledge of the invariable tendency
there is to the production of certain changes in the structure of
certain organs; in our knowledge of the vascular action by which those
alterations are effected, we may be said, in a practical point of view,
to be already in possession of the most important part of knowledge
which we can ever hope to acquire, unless, indeed, we may indulge the
expectation, of which it would be truly melancholy to be deprived, that
we may discover a more sure and effectual mode of preventing these
organic changes, or of restoring to a sound state the organs that may
become diseased. It is this part of the pathology of fever alone that
can afford a clear and steady light to conduct us to the safe and
effectual treatment of the malady. Every step we take without this
invaluable guide must be taken in the dark, and will be, therefore, not
only likely to be false, but very likely to be fatal. When, on the
contrary, we undertake the management of fever under the direction of
this faithful guide, in every measure we venture to adopt we, at least,
know at what we aim: we propose to ourselves a definite object which we
endeavour to accomplish by an instrumentality with the powers of which
we are in some degree acquainted: we may not succeed, but we fail
because we want the means to do what we clearly see requires to be done:
if we do not arrest the progress of the disease, at least we do not add
to its strength by the adoption of violent and desperate expedients,
because we feel called upon to do something, yet know not what to
attempt; we do not destroy, if we cannot save. The physician,
enlightened by the pathology of the disease, who prescribes for a
patient in fever, is like a skilful surgeon, who is guided in the
performance of a difficult and delicate operation by a knowledge of
anatomy so intimate, that every touch of his scalpel exposes a tissue
with which he is acquainted, and discloses the site of a vessel with
which he is familiar; the object aimed at by the operation may not be
obtained, but, at least, the cause of its failure is not that the
operator wounds a structure which he ought to have avoided, or opens an
artery, of the situation and distribution of which he is ignorant. On
the contrary, the physician who prescribes for a patient in fever,
without knowing the pathology of the disease, is like a Charlatan, who
plunges his instrument boldly into the chest or the abdomen, without
knowing where it goes or caring what it wounds; it may possibly open a
tumour and let out the disease, but it is more likely to pierce some
vital organ and to let out life.