John Colebert, æt. 28, admitted into the Fever Hospital August 1, 1828.
Attacked five days ago with chilliness, alternating with heat, pains of limbs, head-ache, and sense of weakness. At present complains of pain of head, with slight giddiness; pains of limbs, especially of back and lower extremities; skin moderately warm; tongue loaded with white fur; much thirst; three stools; respiration natural; no cough, no uneasiness in chest; no epigastric or abdominal tenderness on full pressure; pulse 96, soft.
6th. Skin natural; pain of head gone; pain of back and limbs continues; slept better; tongue more clean; three stools; pulse 102.
7th. Pain of head not returned; pain of limbs better; tongue still cleaning; three stools; pulse 96.
9th. Pain of limbs gone; tongue nearly clean; two stools; pulse 84.
10th. Convalescent.
13th. Dismissed cured.
George Walker, aged 17. Admitted May 5th, 1828.
Six days ago seized with shivering, succeeded by heat, loss of strength, and pain of head. At present complains especially of head-ache; ardent thirst; no pain of chest; no cough; no pain of abdomen, back, or extremities; skin cool; face natural; tongue, except at the point, covered with a thick dirty fur; much thirst; no appetite; sleeps badly; bowels costive, having had no stool for the last three days; pulse 98, of good strength.
7th. Heat of skin nearly natural; pain of head almost gone; no pain of limbs; tongue still much loaded; some thirst; three stools; pulse 72; slept much better.
8th. Tongue much less loaded; less thirst; five stools; pulse 60.
11th. Convalescent.
14th. Return of head-ache, and, on the day following, the tongue again became white; but these symptoms disappeared the succeeding day, and, on the 27th, he was dismissed cured.
These two cases afford fair specimens of the combination of symptoms, and of the degree of their severity, in the synochus of London, as it occurs in its mildest form.
Emma Gladish. Admitted into the hospital on the 12th day of fever. Attack commenced with usual symptoms. The pain in the head, which had been severe for some time, had entirely subsided on the day of her admission. The mind was now quite indistinct; she could scarcely answer any question that was put to her; the eyes were dull and heavy; she had no sleep; there was great restlessness, and occasionally wandering delirium; there was no tenderness of abdomen; the tongue was red, furred and dry; the stools were passed in bed; the pulse 105, of good power.
13th. Sleep rather more tranquil; less wandering; mind a little more distinct; stools still passed in bed; pulse 100.
14th. Much noise through the night; occasionally started out of disturbed sleep with screaming; tongue red, glazed and dry; stools passed in bed; pulse 96.
15th. Rather more sleep; talkative delirium; tongue somewhat cleaner; pulse 100.
16th. Longer and more tranquil sleep; mind more distinct; expression of eyes still dull and heavy; tongue more clean, more moist; stools only partly passed in bed.
17th. More sleep than on the preceding night; mind still more distinct; complains to-day of some tenderness of abdomen on pressure; tongue nearly clean; two stools no longer passed in bed; pulse fallen to 72.
19th. Slept well; mind clearer; eyes more animated; expression of countenance brighter; other symptoms the same.
26th. Continues to improve; skin cool, soft, and moist; pulse 78.
27th. Convalescent; but the convalescence was slow and tedious, as it almost always is after so severe an attack of cerebral disease; she was dismissed cured on the 40th day from the commencement of the attack. The reports of the 15th, 16th, and 17th days illustrate very clearly and strikingly the changes which have already been stated to indicate recovery.
Elizabeth Price, æt. 26, servant; admitted on 11th day of disease. Attacked with ordinary symptoms of fever: at present complains of very severe head-ache; face flushed; intolerance of light; some deafness; mind confused during night; visions of various kinds, such as “waves of the sea rolling,” appear occasionally before her with great vividness; had been on sea four days before she became ill; skin warm; sense of general soreness; abdomen rather hard, but not tender; tongue furred, rather red; much thirst; no appetite; scarcely any sleep, and, when she does, dreams of a frightful nature interrupt her rest; pulse 114, intermittent, of good power, but easily compressed; bowels constipated. C. C. ad ℥xviij. nuchæ. Abradat. Capillitium. Lot. Gelid. cap. Haust. Sennæ Sal. c. m.
12th. More sensible since cupping; mind still confused; occasional wandering; scarcely any sleep; pulse 124, sharp, yet easily compressed.
14th. Quiet night, with considerable sleep; head giddy and slightly painful; respiration hurried, apparently cerebral; pupils active; tongue dry; much thirst; pulse 123. Empl. Lyttæ cap.
15th. Much screaming; great restlessness during night; complains much of head-ache; pupils active; urine copious, but passed in bed; all the stools passed in bed; pulse 108, easily compressed; has visions before her almost constantly; head very hot. Four leeches have been applied to the temples this morning without relief. Affus. Frigid. cap. ℞. Hydrar. Submuriat. gr. ij. Pulv. Scillæ, gr. j. Pulv. Antimon. gr. iij. M. sumat 4tâ q. h.
16th. No screaming; head less painful, especially when in half-erect posture; mind quite sensible now, but much wandering occasionally; pulse 120, feeble; five stools passed in bed.
24th. No material change until this day; sleep now greatly improved; mind much more itself; tongue beginning to clean; pulse 93; ptyalism.
28th. Ptyalism continues; feels greatly better; appetite returning.
From this period she continued to improve, although with several threatenings of relapse; the convalescence was slow and precarious, but she ultimately left the hospital quite well, though not until the 60th day from the commencement of the fever.
Mary Sullivan, æt. 36. Admitted on 14th day of disease; complaint commenced with shivering; pains in the limbs; severe head-ache. Complains now of violent pain of the head; face pallid; expression depressed; scarcely any sleep; abdomen tender on pressure; only one stool for eleven days; tongue foul and dry; pulse 81, not strong; complains, also, of pain under right mamma, preventing inspiration and decubitus. V.S. ad ℥xij. Lotio Gelida cap. Abrad. Capillitium.
15th. Blood with firm buff; pain of head not at all relieved; pain of back, sides, and abdomen severe; no delirium; no sleep; pulse 78, pretty strong. Hirudines viij. temporibus. Pt. Med.
16th. Pain of head much relieved; slept very much better; pulse 66, full and strong.
17th. Pain of head returned, exceedingly severe over the fore-part; pulse 66, full and strong. C.C. ad ℥xij. nuchæ. Pulv. Aper. Mit. h. s. Ol. Ricini c. m.
18th. Pain of head gone; countenance more natural; tongue more clean and moist; pulse 76, more soft. Pt. Med.
20th. Pain of head returned; mind confused; pulse 60, strong and full. C.C. ad ℥viij. nuchæ. Pt. Med.
21st. Pain of head gone; mind confused; pulse 66, pretty strong.
22d. Pain of head returned, but in a slighter degree; mind more confused and dull; scarcely any sleep; tongue more foul; pulse 72, soft. Pt.
24th. No longer conscious of pain; mind quite indistinct; lies prostrate on the back perfectly helpless; incapable of turning on the side; occasional retching; some tenderness of abdomen on pressure; pulse 72, strong and full.
25th. Much restlessness; aspect of countenance greatly depressed; stools passed in bed; pulse 75.
26th. Perfectly senseless; almost constant moaning; extreme restlessness; difficult deglutition; pulse 120.
27th. Not spoken since last report; lies prostrate on back; eyes half open and injected; pulse 102, feeble.
29th. Died.
If the reader can doubt of the condition of the brain in this case, he is requested to turn to the pathology, where the morbid appearances on dissection are detailed. Slowness of the pulse, with severe and obstinate pain in the head, attended with confusion of mind, is always a highly dangerous-symptom: it invariably denotes intense cerebral disease. Whenever there is such a struggle, as this case exhibits, between the physician and the disease, the disease is sure to conquer. For if the physician, terrified at the name or the duration of the malady, while he resolve to use the lancet, hesitate to employ it to the extent of subduing the disease by the first bleedings, the patient is lost. The partial relief afforded by partial measures is most delusive. The malady speedily recovers its lost strength: the patient never does. There is no practitioner who is capable of being taught by experience that can reflect on the history and progress of such a case as this, on the temporary relief afforded by such treatment, on its ultimate failure, and on the appearances presented on dissection, without regretting that more blood was not taken on the 15th and 16th days, and without at the same time resolving, that the aid he offers in future, under similar circumstances, shall be more decisive. The diminution of the pain of the head on the 22d, accompanied with increasing confusion and dullness, with a tongue growing more and more foul, and with a pulse only at 72, might well excite alarm; and accordingly, on the following day, the case was utterly without hope.
There is probably no case of fever, however slight, in which the mucous membrane of the bronchi remains in a perfectly sound state. A certain affection of this membrane, the nature of which will be stated hereafter, appears to be peculiar, to fever, and there is reason to believe that the acutest thoracic affection which is at the same time truly febrile, differs from the mildest case of fever, in which there may be no visible sign of any thoracic disease whatever, only in the degree in which this organ is affected. Sometimes it happens, however, that this membrane is implicated in a more than ordinary degree; and when it is so, it gives rise to peculiar symptoms, constituting the case thoracic. The severity of these thoracic, is not always in proportion to the severity of the febrile symptoms, in like manner as there may be the most intense febrile symptoms, without any indication of thoracic disease: but whenever the thoracic symptoms are sufficiently intense to become prominent, and especially when they occur early or attend on the commencement of fever, they invariably and very considerably aggravate the general febrile symptoms. In these prominent thoracic affections, then, two things happen; first, the symptoms properly constituting the febrile train are modified, and, secondly, new symptoms are added to this train, namely, those which indicate derangement in the respiratory organs.
The new and peculiar symptoms to which a moderately acute and an early thoracic affection gives rise, are the following; namely—
Pain in the chest, sometimes severe, sometimes only slight; sense of stricture or dyspnœa; inability to expand the chest by a full inspiration without pain or uneasiness; cough frequently aggravating the pain; sometimes dry, sometimes accompanied with frothy mucous expectoration. Respiration sometimes slow and heavy, at other times, on the contrary, short and quick; never natural: perhaps the physician may detect thoracic disease in the more obscure, and measure its extent in the more obvious cases, by observing the manner in which the patient breathes, better than by any other single means. The altered respiration is very frequently accompanied with that peculiar noise in breathing which is termed “mucous rattle.”
The pulse, in the commencement of this open and decided chest affection, may not be above 80 or 90; it is hardly ever sharp; it is generally weak; now and then it is full and of good strength; but whatever other character it may possess it is almost always soft. In a few days, as the disease advances, it uniformly rises in frequency and becomes weaker. Towards the end of the disease it is almost always hurried and feeble, although cases occasionally occur in which it is observed at this period to become suddenly slow and intermittent. The tongue is usually foul; commonly moist; but, in severe affections and in their advanced stage, it sometimes becomes dry. The skin is often moderately warm, but it is never intensely hot: it is much more common for it to be cool, and to be of a more dusky colour than natural.
Such are the usual conditions of the respiratory and circulating systems and of the tongue, the great index of the state of the mucous membrane of the alimentary canal, when the thoracic affection increases so as to become prominent and acute. The manner in which it influences the cerebral affection is commonly by hastening the period at which the pain of the head lapses into confusion and stupor. Early insensibility, assuming the form of a muddled or exceedingly confused state of mind, is a very constant symptom of more than ordinary thoracic affection. Accordingly, the delirium which succeeds or which accompanies this state is always low muttering talkativeness, or incoherent wandering, rather than violent delirium, which last is seldom, if ever, found in combination with severe thoracic disease. The pathological condition of the lung perfectly accounts for this modification of the condition of the brain, as will be shewn hereafter.
The following case not only shews the insidious manner in which thoracic disease may come on and the severe form it may ultimately assume; but also, the extent of disease from which it is possible that recovery may take place.
Mary Dillon, æt. 20; destitute. Admitted on the 8th day of fever: attack came on with the ordinary symptoms: at present, no pain of chest; some cough, with copious expectoration; no pain or tenderness of abdomen; tongue not much loaded, but dry; much thirst; no appetite; bowels freely open from medicine; no pain of head; some giddiness; no sleep; skin warm; face flushed; pulse 102.
9th. Pectoral and cerebral symptoms the same; bowels purged; pulse 96.
10th. Only slight cough; pain of head; more giddiness; no sleep; eyes preternaturally bright and glistening; pulse 120.
11th. Only slight cough; pain of head much relieved; slept better; tongue more clean; four stools; pulse 120, strong.
12th. No pain of chest; cough much increased; now very frequent and accompanied with copious expectoration; pulse 136.
15th. Cough more frequent; expectoration purulent and mixed with blood; pulse 126.
17th. Expectorates a larger quantity of purulent matter, mixed with a larger proportion of blood; pulse 102.
20th. Pectoral symptoms unchanged; strength extremely depressed; countenance pallid; skin cool; three stools partly passed in bed; pulse 84; mind confused; almost constant moaning; extensive sloughing ulcers on sacrum and hips.
21st. Pectoral symptoms the same; powers extremely depressed; three stools passed in bed.
22d. No change in the cough or the expectoration; lies quite prostrate and appears to be sinking; four stools passed in bed; pulse 72, rather less feeble.
24th. Cough rather diminished; expectoration unchanged; four stools passed in bed; pulse 84, extremely weak.
25th. No change, excepting that the pulse (78) is rather more strong, and she is scarcely so prostrate.
26th. Skin again hot; tongue again red and dry; no sleep; some delirium; pulse 84, of more strength.
27th. Skin more cool; tongue less red and more moist; pulse 66; some return of appetite.
28th. Cough much diminished; expectorates less; tongue moist, clean, and nearly of natural colour; pulse 72, stronger; countenance more animated.
35th. Cough nearly gone; expectoration much diminished; tongue clean; one stool; countenance improving; strength increasing; wishes for meat; two ounces were allowed.
40th. Sloughs on sacrum and ilium doing well; pulse 90, of more power; still noisy during sleep.
From this period she continued slowly, although gradually, to gain strength, and was dismissed from the hospital on the 57th day, cured.
Angelica Fidgett, æt. 29, married. Admitted on the 16th day of fever. Before admission affected with cold, shivering, sense of faintness, pain of head, uneasiness of chest, and cough. On admission, pain of chest increased by deep inspiration and by cough; cough frequent; pain of the head already subsided: there remain only a sense of weight over the eyes, the expression of which is dull, heavy, and vacant; frequent moaning; no pain of the abdomen on full pressure; pulse 129; tongue foul, moist; skin hot; face flushed.
17th. Respiration slow and laborious; cough; completely comatose; eyes suffused; pulse 120, full, soft; face flushed.
18th. Respiration continues very laborious; mind exceedingly indistinct; much restlessness; pulse 116, still softer.
21st. Examined with the stethoscope: the bronchial roll and crepitus were very distinctly and generally heard.
22d. The respiration continues extremely laborious; frequent cough, without expectoration; low, rambling delirium; pulse 112, weak; tongue foul, moist; general powers greatly depressed.
23d. All the symptoms aggravated. Died on the 24th day of fever.
As thoracic affection may exist in any degree of intensity, so it may indicate itself at any period of the disease: but while sufficiently intense to destroy the structure of the organs in which it has its seat, yet it sometimes gives no indication of its presence, or none until the approach of death. In these cases, the cerebral affection is still more intense than the thoracic, and the manifestation of the symptoms proper to the lung is prevented by the predominance of disease in the brain. Of this, the following case affords a striking example.
John Potter, æt 21. Admitted on the 15th day of fever. Before admission was affected with the usual febrile symptoms, accompanied with severe pain of the head and giddiness. On admission, the pain of the head was nearly gone; there remained considerable vertigo, with some pain in the loins and joints; the mind was exceedingly indistinct, and there was little or no sleep; pulse 80, soft; no indication of pectoral affection.
18th. Symptoms the same; in addition, the abdomen was now tender on full pressure and retracted.
24th. No change observable until this day; no indication of thoracic affection had hitherto been apparent from the commencement of the disease; but, on the morning of the 24th day of fever, dyspnœa suddenly came on, which was attended with a great degree of restlessness; there was also some soreness of throat, but only a slight degree of redness and tumefaction were visible on inspection: with these symptoms he sunk rapidly, and expired in the afternoon.[24]
One of the organs always involved in disease, in a greater or less degree, in fever, is the mucous membrane of the stomach and intestines. In synochus mitior the affection of this organ appears to be slight, and to pass away without producing any change in its structure. But that it is really diseased even in the mildest case, we have sufficient evidence in the invariable derangement which takes place in the functions of the organ throughout its whole course, from the mouth to the anus; and in the constant vitiation of its secretions and excretions. In the severer forms of fever, on the other hand, in the great majority of cases, the affection of the abdomen becomes prominent, and whenever it does so it aggravates all the other febrile symptoms, and adds greatly to the danger of the disease.
Abdominal affection exists under two forms in fever, each of which is attended with distinct and peculiar symptoms. It may be severe from the commencement, and give early and obvious indications of its existence; or it may come on at some subsequent stage of the disease, and then, although the affection be equally severe, the symptoms which denote it are materially different.
1. If the abdominal affection be severe from the commencement, in addition to the ordinary symptoms of fever, there will be present nausea, sometimes retching, and at other times vomiting. It is usual for authors to enumerate these events among the ordinary occurrences of fever; but in a case decidedly cerebral, or in a case decidedly thoracic, they are seldom present. Whenever they occur in the commencement of fever they are the certain signs of an abdominal affection more severe than ordinary; and it will be of the utmost advantage to the patient should the practitioner be aware of this, because it will teach him at once where the main force of the disease is probably to be concentrated.
2. At this early period the bowels are commonly constipated, and on inquiry it will be found that they have been so for some days previously to the attack of fever; but in a day or two after the commencement of this attack they fall into the opposite state and are looser than natural. The concurrence of nausea, retching, vomiting, and purging in the commencement of fever is a certain proof that severe abdominal affection is present, and if not actively treated and effectually checked at this early stage, it will soon render the case formidable, if not hopeless.
3. When the abdominal affection is thus early and open, it is often attended with another symptom which seldom fails to attract attention, namely, pain. Pain of the abdomen, attended with purging, completes the train of local symptoms that occurs at this early period, in the most exquisitely marked cases. It is well worthy of observation, however, that pain is by no means an invariable attendant on the other symptoms, even when the latter are very severe. Whether in these cases the affection of the nervous system be already so great as to lessen the sensibility of the organ, or whatever else may be the cause of it, the fact is certain, and it is one of great practical importance, that pain of the abdomen is not to be expected even in severe abdominal affection; and that though pain may attend upon the affection, yet the affection is often present without pain.
4. Pain of the abdomen upon pressure, and especially upon pressure in the epigastrium, is much less seldom absent than pain of which the patient spontaneously complains.
5. Pain, though it may usher in the abdominal affection, and may even be severe for the first few days, diminishes after a certain time and then ceases altogether, so that it is extremely rare, after the tenth day of fever, for instance, for the patient to complain of pain of the abdomen, even when the abdominal affection is the most intense. Such an event may happen, perhaps when the cerebral affection is more than commonly slight, but it is an exceedingly rare occurrence, and my attention has been particularly drawn to this circumstance from reflecting on the uniformity of the answers which I have obtained from patients obviously labouring under abdominal affection, on my first visit to them in the wards of the hospital. Having commonly been ill from ten to fourteen days, the abdominal affection may by this time be fully developed: on asking them whether they feel any pain in the abdomen, the answer almost invariably received is, “no.” Press gently upon the abdomen, press especially upon the epigastrium, often even in these very cases not the slightest touch can be borne. After pressure has once been made, the patient will frequently do all he can with his hand to prevent its being made a second time. So acutely sensible is he of pain on the least pressure, though wholly unconscious of pain when left to himself. Even when there is not this great degree of tenderness, pain can generally be produced by full pressure.
There is thus a remarkable coincidence between the progress of the symptoms in the abdomen and in the head. We have seen that however intense the cerebral affection, the pain of the head which accompanies it diminishes after a certain time, and in a day or two after it has begun to diminish, ceases altogether. In like manner the pain which ushers in an acute abdominal affection diminishes after a certain time, and soon wholly disappears. After this period, therefore, we should have no more indications of abdominal than we have of cerebral pain were the intestines, like the brain, enclosed in a bony case. When an organ can be touched, it gives us an additional and an invaluable means of ascertaining its morbid condition: and this is one reason why that condition is commonly so much more certainly known in surgical than in medical diseases. What the result would be, could we press the brain as we can the abdomen, after its sensibility is so much diminished as to cease to occasion pain, we do not know; but it would be a bad use indeed to make of the additional means afforded us of ascertaining the condition of the intestines, were we to allow the additional information we thus gain, to obscure our perception of the perfect analogy there is in the progress of both affections. We know that, as the disease advances in both, the pain ceases; but, in the one case, we have the means of ascertaining that there still remains preternatural tenderness on pressure, as in ordinary inflammation, which we are without the means of discovering in the other: still the important practical fact afforded by the history of both is the same, that disease having reached a certain point, the pain diminishes; and having advanced still further entirely disappears.
6. While the pain lessens or ceases as the abdominal affection advances, the purging, on the other hand, continues, often it increases. Purging, succeeding to constipation and to pain, and remaining after the subsidence of the pain, affords an infallible indication of abdominal disease.
7. Together with these decisive signs, which alone are abundantly sufficient to enable us to ascertain the presence of the affection, we have an additional and an exceedingly valuable guide in the peculiar state of the tongue. In these abdominal cases, the tongue is preternaturally red. Sometimes this increased redness is of a bright and vivid colour, and pervades the whole tongue; at others, it is confined to the edges or to the tip, and it is usually remarkably apparent in the latter. While thus vividly red, the body is often loaded with fur; the colour of the fur is often of a dirty-white or greyish colour; but, perhaps, while the edges and the tip are thus intensely red, the most usual colour observed on its body is that of a dirty yellow. In these cases, the papillæ appear much enlarged, and are seen prominent through the fur, vividly red. In this condition of the tongue it always remains moist for some time, and it is not attended with urgent thirst; but, as the intestinal disease advances, the tongue gradually becomes less vividly red and more dry, and as these changes go on, the lips and teeth often become sordid.
Instead of being from the commencement of a vivid redness, the colour of the tongue, in other cases, is of a darker and duller tint; there is less fur upon the body, and that which covers it is of a dirtier and darker tinge; this state of the tongue is always attended with greater thirst: it is apt to become more and sooner dry, and, at the same time, the lips and teeth become more and sooner sordid.
8. In the kind and degree of abdominal affection of which we are now treating, the abdomen is sometimes harder than natural, but it often remains nearly as soft as in health through the greater part of the disease.
9. Of the conditions of the pulse in this affection it is important to take particular notice, on account of the total absence of any striking or apparently distinctive character. It is neither remarkably slow nor very quick; neither unusually hard, nor strong, nor sharp, nor weak, nor intermittent, nor in any degree irregular; its common range is from 80 to 100, beyond which it seldom rises in the acutest cases, until near the termination of the disease; and it is generally soft.
10. Whenever, then, there is a combination of the preceding symptoms, with a pulse about 90, it may be inferred with great certainty, that disease is going on in the intestines. But, as the pain of the abdomen ceases at a certain period, while the purging continues, so, at a still more advanced stage of the disease, the purging also disappears, and the stools return to a more natural condition. Cessation of pain, and an apparent return to healthy secretion and excretion, may seem to indicate a highly favourable change in the disease, and, if accompanied with corresponding amendment in the other symptoms, they may, indeed, be hailed as signs of returning health; but if they occur without a favourable change in the general symptoms, they do not indicate a return to health, but merely the transition of one diseased process into another. What that succession of diseased processes is will be stated hereafter: at present it is sufficient to observe that, without corresponding improvement in other organs, the cessation of purging is a sign not of returning health, but of advancing disease. And so common is the cessation of purging, without amendment, at an advanced stage of abdominal affection, that in a large proportion of the patients who are received into the Fever Hospital, it has ceased before their admission. On the examination of a patient, for the first time, who has been ill from a fortnight to three weeks, it will be stated that the stools are regular, yet if strict inquiry be made, it will often be found that at an earlier stage of the disease from four to five stools, sometimes from eight to ten, were passed in the twenty-four hours without any purgative medicine having been taken. With regard to the state of the evacuations in this affection, then, the succession of events is first constipation, then purging, and next the cessation of purging and the return of the stools to a more natural character.
The preceding signs of abdominal affection are so obvious that they can scarcely fail to lead to the detection of the disease; but the second form under which it exists is attended with much less striking symptoms. It requires great attention and daily examination to discover its presence, and to trace its progress. It steals along its fatal course with a step as silent as it is sure; and the destruction that marks its track is oftentimes alike unfelt by its victim and undiscovered by his most watchful guardian. It does not attack until the sensibility is already greatly diminished in consequence of the progress of cerebral disease. No pain is therefore felt, and the only indication by which it can be detected is tenderness of the abdomen on pressure. But even the fullest pressure, although it generally excite some uneasiness, sometimes produces none whatever. There is often no purging; for when the affection comes on thus late, though the bowels may sometimes be loose, yet they are frequently even constipated. The tongue is generally red at the edges and the tip, loaded with dirty grey or yellow fur, and sometimes dry. The pulse at this advanced period is generally 120. Without doubt this affection greatly aggravates the severity of the fever, and increases the danger of the patient, although we have no means of measuring the extent to which it does so.
On recovering from this state, for recovery does sometimes take place, the first indication of improvement commonly appears in the tongue, which shews a disposition to clean; and what is remarkable, the favourable sign which accompanies this improved condition of the tongue is increased tenderness of the abdomen on pressure. Not that disease in the intestine is increasing, but disease in the brain is lessening, and therefore the patient is now sensible to a stimulus which before produced not the slightest impression. If on the following days the tongue continue to clear; if it grow less red; if at the same time the pulse fall, the sleep return, the sensibility increase, and the countenance become more animated, the patient may be considered as convalescent.
It is not very common, but it does sometimes happen, that a few hours before death the sensibility of the abdomen suddenly increases, and the tenderness on pressure becomes exquisite. This remarkable change is sometimes attended with vomiting, sometimes with hiccup, and is accompanied with extreme restlessness, and a highly excited pulse, while the expression of the countenance is at one time anxious and at another wild, and in this state the patient dies in a few hours. On what change in the intestines this depends will be explained in the pathology.
As illustrations of these different modifications of abdominal affection the following cases are subjoined.
Eleanor House, æt. 18, silk-winder. Before admission attacked with nausea, vomiting, together with the ordinary symptoms of fever. On admission, being the 8th day of the disease, severe pain of abdomen, which is greatly increased on pressure: tongue very red at the point, loaded with fur, through which the papillæ are prominent, moist; urgent thirst; no appetite; bowels said to be natural; some uneasiness of chest; respiration hurried; cannot lie with ease on either side; voice hoarse and feeble; no soreness of throat; no head-ache; no sleep; skin warm; face flushed; pulse 100, of some power, but easily compressed. V.S. ad ℥xvj. Ol. Ricini, ʒiij.
Hora 3tia, p. m. Blood with thick and firm buff; symptoms both of abdominal and thoracic disease diminished. Vespere versus vel eras mane, rep. V.S. ad ℥xvj. si opus sit. Pulv. Aper. Mit. h. s. haustus Sennæ Sal. c. m.
9th. Bled last evening with much relief; proportion of coagulum of blood last drawn great, and covered with firm buff. Much pain in the epigastrium and over the whole abdomen independently of pressure, but greatly aggravated by slight pressure; tongue less loaded, less red, moist; much thirst; pulse 108, sharp, small, easily compressed: Rep. V.S. ad ℥xvj.
10th. “Feels greatly better;” pain of epigastrium gone; none of abdomen when not pressed; full pressure much more easily borne; tongue unchanged; thirst; vomiting; four stools; pulse 108, of the same character.
12th. Pain not diminished on pressure; nausea, vomiting, rejection of a large quantity of green fluid; pulse 118.
16th. Says she is quite free from pain of the abdomen; bears pressure without flinching; no vomiting since last report; four stools; tongue clean and moist; pulse 99; sleeps better, but the mind is dull and confused: wandering delirium through the night; some muscular tremor; skin cool; face flushed.
18th. Pain of abdomen returned; mind confused; delirium.
23d. Says she is without pain, but feels oppressed; pulse 96; slept better; no delirium; face more animated; skin warm; no flushing.
27th. Had been steadily improving until this day, when the pain of the abdomen returned, which is again tender on pressure; tongue clean; one stool; pulse 110.
29th. Pain much relieved since the application of six leeches to the abdomen, followed by a large poultice.
30th. Pain gone: only slight tenderness: pulse 96.
32d. Pain and tenderness again returned; tongue more red; pulse 108.
33d. Six leeches were applied last evening without the slightest relief of the pain or tenderness; tongue red: pulse 96, more weak and soft.
34th. Tenderness considerably diminished; tongue less red; countenance again improved.
35th. Still less tenderness than yesterday; bears pressure much better; tongue nearly natural; two stools.
39th. Improving every day; no pain of abdomen; no tenderness on fullest pressure; bowels quite soft; tongue natural; four stools; pulse 72; appetite good: strength increasing.
44th. No return of uneasiness; continues to gain strength.
57th. Since last report has been daily improving, and is now quite well. Dismissed cured.
Sarah Raven, æt. 17. Admitted on the 22d day of fever; no pain of the abdomen appears to have been complained of from the commencement of the attack; at present no tenderness on the fullest pressure; some distention; tongue covered with yellow fur, moist; bowels loose; pulse 110, sharp; only slight pain in the head; more pain in the limbs; mind dull, confused; deaf.
24th. No pain of abdomen on fullest pressure; tongue the same; only two stools; pulse 124; voice hoarse, feeble; respiration hurried; skin dark, almost livid; mind much more confused; delirium.
25th. No material change.
27th. Insensibility increased to coma; features shrunk; one stool passed in bed; pulse 128; skin livid, cold.
28th. Moribund; died the following day.
On examination after death (see pathology) extensive disease was found in the intestines, although, if the purging on the day of admission be excepted, not the slightest indication of it was given during life.
George English, æt. 25, carpenter. Admitted on the 29th day of fever, with a great degree of tenderness of the abdomen, extending especially over the hypogastric region; bowels said to be regular; pulse 90, of good strength; yet complains much of sense of debility.
30th. Pain of the abdomen continues, especially over the region of the bladder; urine passed in good quantity and freely; three stools; pulse 84.
32d. Tumour has appeared over the region of the bladder, unattended with pain; three stools; pulse 76.
33d. Hypogastrium still tumid, but without pain; other symptoms the same.
43d. No material change until this day, when he was suddenly seized with exceedingly acute pain in the region of the bladder; extreme tenderness on pressure; great restlessness, and great anxiety; vomiting of a yellow-coloured fluid; two stools; pulse 84, extremely feeble.
44th. Died.
These acute symptoms mark the very hour when the event occurred which caused them.—See Pathology.
Since it has been repeatedly stated in the preceding pages that, in every case of fever, the brain, the lungs, and the abdomen are diseased, it may appear objectionable to call any particular class of cases mixed, because, according to the very nature of fever, all must be of this character. But for the same reason that we have designated one class of cases cerebral, another thoracic, and a third abdominal, namely, to mark prominence and intensity of affection, it is right to distinguish a fourth, in which all the three systems of organs are simultaneously affected with an equal, or nearly an equal degree of intensity. The term mixed is therefore by no means employed to intimate that the cases not comprehended under it are unmixed, but merely to point out a fact of great practical importance, that cases do occur which are neither in an exquisite degree cerebral, nor thoracic, nor abdominal, but which, at one and the same time, afford the most exquisite specimens of all the three.
From this account of the sense in which the term is employed, it must be obvious that it will include the severest cases that can occur. If a patient be affected with intense cerebral disease he may be in great danger; but if he be affected with an equally intense thoracic disease his danger must be doubled: and if to this be added an equally intense abdominal disease it must be trebled. And accordingly these are just the cases which bid defiance to the most skilful and vigorous measures which the medical art can employ to control them; which seize upon their victim with a force which no human agency can resist nor counteract; which in malignant epidemics destroy life in a few hours or in a single hour, and in ordinary seasons in a few days.
Whenever a severe case occurs without exhibiting any striking prominence of affection in any organ, and when on examining the organs there are found indications of severe affection in all of them, that case is sure to become formidable, and the patient and his physician have reason to congratulate each other if it do not prove fatal. When prominence of affection in any one organ is absent, because all the organs are intensely affected, it constitutes the most formidable case that can occur. And though this kind of case be but too common, yet after all it does not appear to happen as often as it really takes place. Examination after death discloses what was unknown during life. The brain, the lungs, the abdomen are often found to be most extensively diseased, while the indications of disease were confined, perhaps, to the brain and the abdomen, or to the brain and the lungs. Without doubt, the spinal cord and the brain are the grand and original seats of disease; the others are subsequent and consequent, and the principal masks the subordinate. It is when a great number of cases are brought together, and placed in juxta position, that we are impressed, and it is only then that we are duly impressed, with the great proportion of those in which the course of disease is as noiseless as it is destructive; in which its stroke destroys, without its being possible to tell where it falls; in which the physician sees that his patient must die, but in which the anatomist, after the event has happened, can alone pronounce why it was so.
Whatever be the number of organs simultaneously affected, the nature of the affection in each is always the same, and is not in the slightest degree changed by the complication. Disease in the brain is the same, whether the brain alone be prominently affected, or the brain and the intestines, or the brain, the intestines and the lungs. Each organ is liable to its own specific disease, and that disease goes on with the utmost regularity, whether it be the sole organ so far diseased as to suffer a change in its structure, or whether many be simultaneously affected in the same manner.
In like manner the symptoms, when any symptoms are present, are essentially the same, whether the disease exist alone, or whether it be complicated with several others. The symptoms of inflammation of the brain are the same, whether cerebral inflammation alone be present, or whether it be complicated with inflammation and ulceration of the mucous membrane of the intestines. And the symptoms of inflammation and ulceration of the mucous membrane of the intestines are the same, when any symptoms are present, whether these affections exist alone, or whether they are complicated with cerebral inflammation. The occasional absence of symptoms in the subordinate organs, overwhelmed by the preponderance of affection in the principal, is a proof that they are subordinate. It would, therefore, be useless to detail the symptoms which occur in the mixed cases, since they must only be a repetition of those which have been already enumerated. Their concurrence in individual complications, and the modifications they undergo from such particular combinations, will be best understood from the study of the cases.
An examination of large averages clearly shews, what would scarcely have been expected, and what is by no means generally understood, that these mixed cases, instead of being rare, are even frequent. It seems to me to be impossible to study the pathology of those which will now be laid before the reader, without perceiving that the opinion that the seat of fever is invariably fixed in some one organ, is founded in partial, and, therefore, imperfect views; and I earnestly solicit the attention of those who have hitherto contended for the strict locality of that seat, to these very interesting and instructive cases. It was by slow degrees, and after the study of the symptoms as they occur in all varieties, and, if I may so speak, shades of type, in connexion with the morbid changes apparent after death, that I was able to make out, what I have so often stated to be, the true circle of organs upon which this disease always seizes and always preys, and which it often irreparably destroys. In some of these mixed cases, we see marks of irreparable destruction in this entire series of organs; and in every one we see extensive disease in all of them. Coupling, then, as we ought always to couple, these ascertainable and ascertained conditions of the organs in the fatal cases, with the symptoms of derangement manifested by these organs in all cases, whether fatal or not, a body of evidence presents itself, which appears to me to be irresistible, to justify the conclusion that the local seat of fever is at least coextensive with these organs. A repetition of my own conviction cannot, I know, produce conviction in others; I, therefore, again entreat attention to the facts which have produced conviction in me. And in order that the cases to which I am so anxious to direct the attention of the pathological student, may afford him all the information they are capable of communicating, at the least expense of labour to him, they have been arranged in succession, according as dissection shews that, while all the organs are deeply involved, the ravages of disease are most extensive in the organs of the head, or of the thorax, or of the abdomen. The simplest and mildest affections are placed first; the more complicated and severe, as nearly as possible, in the order of their complication and severity; while, in the rapid sketch that is drawn of the symptoms, those which relate to the organ most severely diseased are placed first; and the succession is detailed in order, according as they appear to be antecedents or sequents; or as they are observed to combine to form a train or series. Since cases abundantly illustrating, in this manner, every variety of complication, are given in the pathology, it is unnecessary to add any here.