I. Typhus Mitior, with Cerebral Affection.
Cerebral affection in typhus, as in synochus, presents itself under two degrees of intensity, which may be distinguished by the same terms as in the latter, the subacute and the acute.
1. Typhus Mitior with Subacute Cerebral Affection.
The symptoms which denote this affection in typhus, are perfectly similar to those which have been stated to characterise it in synochus, but they undergo certain modifications, the true nature of which appears to me to have been greatly mistaken, and, after the most careful attention which I have been able to give the subject, the mistake seems to me to be of so much magnitude, that I think whosoever shall effectually correct it, will do the greatest possible service to medicine, and, through it, to his fellow men.
1. There can be no question that, from the very first commencement of the attack, as well as through the whole course of the disease, the prostration of strength, both physical and mental, is greater in typhus than it is in synochus. This greater loss of energy is indicated by every sign that can be conceived to denote it. The loss of power in the muscles which support and move the body is oftentimes so complete, as to be most alarming to the patient and his friends; while the contrast between the vigor and the torpor of the mind, in the course only of a few hours, is most striking. From the full and active exercise of its faculties, it becomes, in that short space of time, quite incapable of performing any intellectual operation. It is confused and stupid, always in a greater degree than in synochus, and sometimes to such a degree, even on the very first day of the attack, as to excite the utmost apprehension in every one around the patient who takes any interest in his fate.
2. The chilliness is, upon the whole, greater and longer-continued than in synochus: yet there is less constantly shivering, and the heat, when it succeeds this state of chilliness, is seldom as great as in the latter; while there are cases in which the heat never exceeds the natural standard.
3. The febrile uneasiness is greater; the restlessness is incessant; the face is pallid; the features are shrunk; the expression of the countenance is most peculiar; it is strikingly indicative of weakness and suffering; the experienced eye can tell at a single glance, even at this early period, to which of the two types that countenance belongs. The pulse is always weaker and more rapid than in the corresponding stage in synochus.
4. There are cases in which the pain of the head is equally severe as in synochus: but this may be justly considered as rare. In general it is less acute. Dullness, confusion, stupor, giddiness, are more common than severe pain, and are often the substitutes for it. Though some degree of pain be generally present, yet it is by no means uncommon for one or more of these sensations to occupy its place completely. Question the patient as much as you please, and he will tell you that he has no pain; but it is evident, from his aspect and his manner, that he has little sensation of any kind. The eye is dull, heavy, stupid, without lustre: the old English word “lac-lustre” expresses its character truly and strikingly. But it is remarkable, that while the pain in the head is only slight, the pains in the back, loins, and extremities, and, as the patient himself says, in the bones, are severe.
5. When pain is present it diminishes sooner and disappears more completely than in synochus: when it is not present, the advancement of the disease is indicated by increasing insensibility, and by the rapid transition of dullness or confusion into a state of stupor approaching to coma. The eye is already muddy, and it soon becomes injected and suffused. The skin over the body is generally warm, sometimes hot: over the head it is often hot. The face is usually pallid, but the pallidness frequently alternates with flushing. The change of dullness into insensibility more or less profound sometimes takes place as early as the second or the third day: it is seldom that it is as late as the seventh or the eighth: it is postponed, when not prevented, by active and appropriate treatment.
6. There is little or no sleep; the restlessness is great; there may be no violence; but there is abundance of inquietude.
7. Delirium is more constantly present than in synochus; and when it comes it comes earlier: its presence is not unusual as early as the sixth or the seventh day; and it may appear still sooner, but that is rare. It consists of low muttering incoherence rather than of loud and violent talkativeness; and is expressed in moaning rather than in screaming.
8. The connexion between delirium and muscular tremor, between muscular tremor and subsultus tendinum, and between both, and the passing of the stools and the urine unconsciously, has already been pointed out. Like delirium, muscular tremor is much more constantly present in typhus than in synochus; and its relation to delirium is so close that it is sometimes observed to supervene on the very same day; frequently on the day following; and, if it appear at all, it is seldom longer absent than the third. Its degree likewise is commonly in proportion to the violence of the delirium; and though early and great delirium may appear without it, yet it very rarely appears without delirium; and in general all these symptoms form one series or train; pain disappearing, confusion of mind increasing, muttering incoherence supervening, and muscular tremor and involuntary and unconscious stools rapidly succeeding.
9. In the commencement of typhus the pulse is sometimes of good strength, and it may not exceed 90 in frequency; but as the disease advances it uniformly becomes weaker, smaller and quicker; so that death rarely takes place before it has reached 120. In the severer cases it is weak, quick, and easily compressed at a very early period.
10. The respiration is often not very obviously affected, but if it be attentively observed it will usually be found to be shorter and quicker than natural.
11. The tongue is always foul on the first or second day; it seldom continues moist longer than three or four days; it is often quite dry as early as the fourth, especially on the body and at the root; the apex and the edges sometimes remain moist a day or two longer; but in a short time the whole tongue becomes perfectly dry and of a brown colour; as the disease advances the colour often changes to a darker and darker hue until it becomes quite black; it is then frequently fissured into deep chaps, while the lips and teeth soon become covered with a black sordes. Were the sensibility not greatly altered, such a condition of the mouth and tongue must be attended with insatiable thirst; yet thirst is often not felt, although at other times it is considerable.
12. In the early stage of typhus the skin is frequently hot; as the disease advances the heat lessens: through the greater portion of the disease it is moderately warm; towards its termination it becomes cool, and some days before death it falls below the natural standard. It is always of a darker colour than in synochus: the whole surface is of a dull and dusky tinge. Sometimes it is covered with dun coloured petechiæ, at others with petechiæ of a florid colour.
13. During its progress, erysipelas, first appearing on the face, then extending over the scalp, and often down the shoulders and back, is very apt to occur. Excoriation on the back and hips often form sloughing sores of great malignity and extent, while enlargement, inflammation and suppuration of glands situated in different parts of the body frequently appear.
14. Typhus terminates much earlier, whether favourably or unfavourably, than synochus; if it terminate unfavourably death frequently takes place as early as the 10th or the 14th day, although if early and appropriate treatment be employed, the force of the disease is sometimes so much lessened that it is as protracted as synochus.
Towards the termination of the disease more or fewer of the symptoms which it has been stated occasionally to occur in synochus,[[25]] supervene; but, as these depend upon particular conditions of the brain, they will be detailed under the pathology.
2. Typhus Mitior, with Acute Cerebral Affection.
In typhus with acute cerebral affection the pain of the head is often not more severe than it is in the subacute; but there is a greater degree of heaviness, or weight, or stupor, or giddiness; the eyes are more and sooner injected and more suffused; the insensibility comes on sooner and is deeper; the delirium appears earlier and is more violent, frequently requiring restraint, and the whole train of symptoms already enumerated, and which it is needless to repeat, are more intense in degree, and succeed each other with greater rapidity.
Case XII.
James Solden, æt. 44, plaisterer. Admitted on the 7th day of fever: attack came on with chilliness; great debility; some pain of head; sense of giddiness and weight; together with symptoms of thoracic disease. At present pain of head entirely gone; it has passed into insensibility; mind quite delirious; almost constant moaning; pulse 96, weak; tongue brown and dry; stools passed in bed; respiration short and hurried; cough without expectoration; tenderness of abdomen on full pressure.
8th. Insensibility more profound; restlessness and delirium increased; respiration more hurried; cough the same; stools passed in bed: pulse 92.
9th. No change.
10th. Died.
Case XIII.
John Clark, æt. 17. Admitted on the 4th day of fever: attack commenced with ordinary symptoms, and was attended with severe pain of the head, which continues at present, and which is attended with a sense of weight; eyes injected and suffused; expression of countenance extremely dejected; sleeps none; skin pungently hot, especially over the scalp; pulse 108, of good power; tongue already brown and quite dry; some thirst; respiration hurried; some uneasiness of chest on coughing; considerable tenderness of abdomen.
5th. Eight ounces of blood which were drawn not sizy; crassamentum loose; pain of head not at all relieved; sense of weight distressing; no sleep; much restlessness; heat over the scalp pungent; pulse 104; tongue more dry; tenderness of abdomen the same; six stools.
6th. Pain of head still severe; mind more confused; passed a more restless night; pulse 116.
10th. Pain of head undiminished; eyes more suffused; extremely restless night, during which delirium came on; this morning muscular tremor has appeared; pulse 124.
12th. Pain of head entirely gone; scarcely at all sensible; constant muttering delirium; muscular tremor with subsultus tendinum; two stools passed in bed; pulse 124; abdomen still painful on firm pressure, and has become swollen and tense.
13th. Insensibility and delirium increased; constant incoherent muttering; extreme prostration; erysipelas has appeared on the forehead, and is spreading to the scalp: pulse 128; two stools passed in bed.
14th. Died.