A Treatise on Fever

by Southwood Smith

II. Typhus Mitior, with Thoracic Affection.

Prominent thoracic affection, as we have seen, is not infrequent in synochus; in typhus it is more constant; and the signs which denote its existence are more obvious, but they are not precisely the same. The pain in the chest is less severe; it is more often absent altogether; while the sense of stricture and the dyspnœa are more urgent. The cough is more constantly attended with mucous rattle; the respiration is shorter and more hurried. The skin in general is cooler, and it is always more dusky. The dark colour of the skin, in severe cases, becoming quite livid, is one of the most characteristic marks of intense thoracic affection. The colour of the cheek is at first of a deep and vivid red; as the disease advances it becomes of a purple tinge, and at length it is quite livid. In these cases it is not uncommon for the respiration to be from forty to fifty in a minute. The pulse is invariably rapid and weak. The cerebral affection is equally peculiar and characteristic; it never consists of intense excitement; it is never accompanied with violent delirium; it is indicated by confusion and stupor passing rapidly into coma; and is attended with low muttering incoherence or disjointed rambling, the trains of ideas that pass through the mind being extremely faint, and linked together by no distinguishable affinity. We know that one of the most essential conditions to the due exercise of the sensorial faculties is the due supply of the brain with arterial blood; but in this state of the system arterial blood does not and cannot circulate through the brain, because it is not formed in the lung: the patient is in a state approaching to asphyxia, and in very severe cases he remains for several days in as perfect a state of asphyxia as seems to be compatible with life. Why debility should, in these cases, be carried to the utmost possible extent; why such cases should form the most exquisite specimens of the adynamic state, need not be pointed out: the disease is concentrated in the very organ which elaborates the pabulum of life, and that stream which should convey its vivifying and animating influence to every nook and point of the system is corrupted at its source.

It is in these cases, too, that the tongue becomes dryer than in any other; in its advanced stage it is sometimes quite black and even hard, and is altogether incapable of being protruded. Sometimes it is covered with a thick, black and hard crust; at other times it is cut into deep fissures, so as to give it a cracked appearance. These states of the tongue without doubt arise in part from the excessive dryness, occasioned by the mouth being kept always open, on account of the difficulty of respiring.

Such are the most characteristic marks of thoracic affection in typhus; as an illustration of which, as it occurs, perhaps, in the severest form ever witnessed in this country, the following case may be cited.

Case XIV.

Alexander Crombie, æt. 19, seaman.

The mate of his vessel states that, notwithstanding some previous indisposition, three days ago he was on duty; that while on watch, about eleven o’clock at night, he became too ill to remain at his post, and that, since that time, he has scarcely spoken a word. At present he is incapable of giving any account of himself. He is dull, stupid, and, when roused, is scarcely able to answer coherently; he does not speak, but he is constantly picking at the bed-clothes; there is extreme restlessness; the countenance is heavy and inexpressive; the features in general are swollen, the lips especially, which are also extremely parched. The entire skin is dusky, but the cheeks are of a deep red colour, approaching to a purple hue; the integuments of the eye are dark; the conjunctiva injected; the tongue brown and quite dry; the lips and teeth sordid; respiration oppressed; occasional cough; pulse from 130 to 140; small and thrilling; skin, especially over the scalp, hot; tenderness of abdomen on full pressure.

4th. Cerebral symptoms the same; cough frequent, difficult; respiration short and hurried; pupils dilated, not contracting on exposure to light; conjunctiva injected; pulse small, hurried, irregular; all the stools passed in bed; pressure over the abdomen induces cough and apparently excites pain. Died in the evening. See pathology.