II. Synochus Gravior with Thoracic Affection.
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.
Case VI.
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.
Case VII.
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.
Case VIII.
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]]