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.
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.
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.
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.
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.]
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.
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.
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.]
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.]
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.]
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.
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.
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.
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.
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.
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.]
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.
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.