III. Synochus Gravior with Abdominal Affection.
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.
Case IX.
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.
Case X.
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.
Case XI.
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.