IV. Cases in Illustration of the Morbid Changes which take place within the Head, Thorax, and Abdomen, in the same Individual; or Mixed Cases.
Case XC.
Margaret Eades, æt. 18, dress-maker. Admitted on the 22d day of fever, which attacked with the ordinary symptoms: at present the mind is dull; the sensibility diminished; there is scarcely any sleep; the eyes injected and suffused; the skin hot; the tongue brown and dry; the pulse 120, but there is no pain in any organ.
23d. Insensibility increased to coma; delirium; tongue dry and quite black; gums bleed on the slightest touch; lips and teeth sordid; four stools, dark and offensive; pulse 110.
27th. Coma undiminished; almost constant moaning; scarcely any sleep; three stools of same character; some cough; pulse 124, feeble.
31st. All the symptoms aggravated; extreme prostration; countenance sunk; cough, without expectoration; respiration with mucous rattle; stools in bed: pulse 140, extremely feeble. Died next day.
Head. Dura mater vascular; arachnoid thickened and opake; substance of brain highly vascular, in every point thickly studded with red points; effusion between the membranes and into the ventricles. Thorax. Mucous membrane of bronchi inflamed; substance of lungs partly condensed and partly tuberculated. Abdomen. Mucous membrane of ilium inflamed and ulcerated; other viscera healthy.
Case XCI.
William Middleton, æt. 18, shoemaker. Admitted on the 5th day of scarlet fever, which commenced, in addition to the ordinary symptoms, with exceedingly severe head-ache, which continues undiminished; scarcely any sleep; eyes red and ferrety; tongue white; bowels loose; pulse 120; eruption apparent only on the chest; no soreness of throat nor difficulty of deglutition.
6th. Pain of head nearly gone; more insensible; pulse 126; eruption fading.
8th. Insensibility increased to coma; adnatæ glistening; tongue brown and dry; lips and teeth sordid; four stools.
10th. Coma deeper; great restlessness; no sleep; stools in bed; pulse 120, weaker.
11th. Increasing restlessness; tongue not to be protruded; deglutition difficult; stools and urine in bed; pulse 150, indistinct.
13th. Died.
Head. Dura and pia mater highly vascular; arachnoid thickened and opake; substance of brain highly vascular; effusion between the membranes, into the ventricles, and at the base. Thorax. Mucous membrane of bronchi vascular; substance of both lungs inflamed. Abdomen. Mucous membrane of ilium ulcerated; other viscera healthy.
Case XCII.
Sarah Sharp, æt. 18. Admitted on the 22d day of fever: the pain of the head, which had been severe from the commencement, continues; complains also of much pain in back and limbs; abdomen tender; tongue fiery red; bowels purged; pulse 100, soft.
23d. No change, excepting that the tongue has become brown and dry in the middle, but still remains exceedingly red at the edges; four stools; pulse 108.
32d. Pain of head quite gone; that of abdomen, which had increased, has now also disappeared; no sleep; great restlessness; delirium; eyes dull and heavy; face flushed; tongue red and dry; four stools; pulse 110.
40th. Cerebral symptoms unchanged; no cough or uneasiness of chest; skin dusky, that of the cheek of a deep purple colour; tongue loaded and dry; lips and teeth sordid; stools in bed; pulse quick and very feeble; great prostration.
48th. Coma; discharge from both ears; vomiting; pulse 120, very weak.
50th. Erysipelas of cheek, extending to scalp; much discharge from ears; tenderness of abdomen again returned; tongue again of fiery red colour; pulse extremely quick and feeble.
70th. During the whole of the period since last report there has been occasional vomiting; the erysipelas gradually disappeared; the sensibility returned; the tongue became clean and moist; the stools improved, and there was even some return of appetite: on the other hand, there came on extensive excoriation, and at last sloughing of back and hips; the emaciation became very great, the prostration extreme, and at length, on the 86th day from the commencement of the fever, she sunk exhausted.
Head. Membranes of brain highly vascular; substance natural; upwards of eight ounces of serum in the different cavities. Thorax. Mucous membrane of trachea slightly reddened; bronchi vascular; lungs dark and much gorged with blood. Abdomen. Mucous membrane of intestines slightly vascular, [but the peritoneal coat highly inflamed, and contained on its surface a coating of coagulable lymph, which glued the convolutions of the intestines to each other and to the omentum.]
Case XCIII.
Charles England, æt. 22, servant. Admitted on the 11th day of fever: previous symptoms unknown. At present perfectly insensible; pupils contracted, insensible to light; face and lips of deep purple colour; extremities cold; full pressure induces some uneasiness in abdomen; body of tongue loaded and dry, edges red; deglutition difficult; pulse 100, feeble.
12th. Some sleep through the night; more sensible to-day; no stool since admission; pulse 114.
13th. Still more sensible; complains of giddiness; five stools; tongue beginning to clean.
20th. Had been gradually improving since last report, and the pulse had fallen to 80; during last night he became extremely restless, with much delirium; mind now confused; face of a purple colour; tongue red and glossy; three stools; pulse 120.
21st. Delirium; almost constant moaning; cheeks of purple colour; tongue brown and glossy; pulse 130, but so indistinct that it can scarcely be counted; lies extremely prostrate.
22d. Erysipelas of face, extending down the neck; some cough; abdomen again tender; three copious dark-coloured stools; pulse 130. Died following day.
Head. Scalp loaded with an unusual quantity of blood; the vessels of all the membranes of the brain exceedingly turgid; a large coagulum of blood between the dura mater and the arachnoid; substance of the brain exceedingly soft; an ounce and a half of bloody fluid at the base of the skull. Thorax. Mucous membrane of bronchi extremely vascular; substance of lungs somewhat condensed and very much gorged; [two ounces of serum in each pleural cavity.] Abdomen. Mucous membrane of ilium much thickened, softened, and injected, exhibiting a few points of incipient ulceration; [mucous membrane of bladder thickened and inflamed; peritoneum lining the pelvis vascular;] other viscera healthy.
Case XCIV.
James Robinson, æt. 25. Admitted on the 8th day of relapse: at present mind confused; acknowledges no pain in head, chest, or abdomen; tongue not much loaded, moist; thirst; pulse 60, weak.
9th. No pain; some sleep; occasional delirium; two stools; pulse 78.
10th. Mind dull and heavy; returns no answer when spoken to; pulse the same.
17th. Little change until to-day; the entire body is now covered with an efflorescence, consisting of minute papulæ, of a vivid red colour; mind dull and confused; pulse 120. Died next day.
Head. An old fracture over that part of the coronal suture which joins the parietal bone, seems to have left the brain unaffected; inner surface of skull perfectly smooth; both membranes and substance of the brain highly inflamed; pituitary gland suppurated; cerebellum natural. Thorax. [Left lung contained many tubercles in the stage of suppuration; the apex, which was full of tubercles, adhered to costal pleura; right side healthy; pericardium contained two ounces of bloody serum; serous lining of auricles and ventricles of heart highly vascular and of dark red colour; valves of aorta and of auricles extremely dark;] no account recorded of the state of the mucous membrane of the bronchi. Abdomen. Omentum vascular; intestines throughout of dark red colour; all their coats every where exceedingly softened, the peritoneal peeling off with ease from the muscular; the mucous inflamed, not ulcerated; the mucous membrane of the stomach vascular; a considerable portion of the jejunum intussuscepted; other viscera healthy.
Case XCV.
Ann Smith, æt. 23, married. Admitted on the 15th day of fever; pain of head gone; some vertigo remains; no uneasiness of chest; some cough which excites pain in the abdomen; the latter not very tender even on full pressure; tongue loaded in middle with white fur, red at edges; no stool for the last twenty-four hours; pulse 120, weak.
17th. Eruption has appeared over almost the entire skin, consisting of minute papillæ of a dusky red colour; two stools; pulse 120.
20th. Erysipelas extending over both shoulders; severe pains in the limbs.
25th. Cough troublesome with copious viscid expectoration; erysipelas extending from the shoulders to the chest; tongue dry: delirium; pulse 110, weak.
26th. Cough diminished; respiration hurried; stools in bed; pulse 120, feeble.
27th. Delirium continues; respiration more hurried; pulse extremely feeble.
28th. Erysipelas still extending; powers sinking; respiration laborious; stools and urine in bed. Died in evening.
Head. Arachnoid vascular; substance of brain vascular; sheath covering the lumbar portion of the spinal cord highly vascular; cord itself natural; effusion into the lateral ventricles; plexus choroides and velum interpositum highly vascular; pituitary gland gritty. Thorax. Mucous membrane of bronchi inflamed; substance of left lung intensely inflamed, being nearly as red as muscle and its lobes adherent; [corresponding side of pericardium highly vascular; right lung slightly inflamed; right pleuræ not adherent; left adherent throughout.] Abdomen. Patches of vascularity in mucous membrane of intestines and over their peritoneal coat; pyloric end of stomach vascular; spleen soft; other viscera healthy.
Case XCVI.
Joseph Baird, æt. 12. Admitted on the 22d day of fever; slight pain of head; severe pain across the loins; no uneasiness in chest; no cough; respirations 44; abdomen tender; tongue red, parched; bowels purged; pulse 134.
33d. Abdomen tender, tumid, tense; four stools; tongue loaded with white fur; mind distinct; scarcely any sleep; extremely fretful.
34th. No delirium; stools in bed; pulse 114. Died next day.
Head. Membranes and substance of the brain vascular; at the surface of the right posterior lobe, an abscess of considerable size, the floor of which was formed by the pia mater; gelatinous effusion between the arachnoid and the pia mater. Thorax. Mucous membrane of bronchi vascular; substance of lungs healthy; [left cavity of pleuræ contained eight ounces of bloody serum; right six.] Abdomen. Peritoneal and mucous coats of jejunum and ileum vascular; mesenteric glands greatly enlarged; several of them suppurated; [large quantity of serum mixed with pus in the peritoneal cavity; omentum much thickened; adhered to the superior portion of the spleen; to the edge of the left lobe of the liver, and to the portion of the diaphragm immediately above the spleen; in this manner it formed the external boundary of an abscess of considerable size in the substance of the spleen; portions of the sac itself ulcerated; the rest of the spleen nodulated; these nodules when cut into were found to consist chiefly of puriform matter contained in cells; thoracic duct enlarged; receptaculum chyli exceedingly enlarged and ulcerated.]
Case XCVII.
Catherine French, æt. 24. Admitted on the 9th day of scarlet fever. Complaint came on with sudden loss of strength, shivering and violent pain of head and chest: at present throat sore; deglutition difficult; some pain of chest; great tenderness of abdomen; nausea and vomiting; tongue dry, brown and cracked; slight pain of head; eyes dull, heavy and suffused; pulse 104, pretty strong; no eruption.
23d. The pain of throat, the difficult deglutition, the tenderness of the abdomen had disappeared; the pulse had fallen to 90, and she appeared to be gradually recovering until this day, when, preceded by a slight return of sore throat, erysipelas appeared on the face; no pain of head; tongue again brown and dry; pulse 96.
24th. No sleep; delirium; erysipelas extending; pulse 108.
38th. Erysipelas has disappeared, but other symptoms are aggravated; extreme restlessness; much delirium; frequent cough, with scanty expectoration; tongue brown, dry and cracked; pulse 86.
39th. Respiration difficult; delirium; vomiting; pulse 120.
41st. Respiration rattling; delirium; inclined to sleep; pulse 120.
42d. Respiration increasingly difficult and painful; pulse 129.
43d. Extremely restless; almost constant moaning; countenance anxious; cough; tongue continues brown and dry; lips and teeth sordid; pulse 122.
44th. Died during the night.
Head. An abscess over the posterior extremity of the sagittal suture, around which for the space of two inches, the pericranium was destroyed, leaving this portion of the bone bare. Dura mater natural; arachnoid and pia mater vascular; substance of brain natural; effusion between dura mater and arachnoid; lateral ventricles full of serum; two ounces at base. Thorax. [Pleuræ of right side covered throughout with pus of very thick consistence, presenting the appearance of the interior of a large abscess, contained two pints of fluid consisting of serum, pus and blood; superior lobe of right lung hepatized and tuberculated; some of the tubercles in a state of suppuration; middle lobe contained a large abscess; lower lobe much wasted, blackened, and in many points softened down to a black fluid; left thoracic cavity contained about one pint of pure serum; pleuræ very vascular but not adherent; substance of lung perfectly sound;] condition of mucous membrane of bronchi not stated. Abdomen. Mucous membrane of ilium contained several ulcers; other viscera healthy.
Case XCVIII.
John Green, æt. 10. Period and progress of disease unknown: throat much inflamed and ulcerated; deglutition difficult; respiration painful; much muco-purulent fluid constantly discharged from nostrils; eyes suffused; lips and teeth sordid; tongue cannot be protruded; pulse cannot be counted; noisy delirium; several dark-coloured vesicles on hands, especially in the neighbourhood of the joints. Died the same evening.
Head. Membranes slightly vascular; arachnoid and dura mater adherent at several points; substance of brain slightly vascular; effusion into ventricles. Thorax. Mucous membrane of trachea and bronchi highly vascular; larynx much inflamed; arytænoid cartilages ulcerated; epiglottis dark and thickened; [pleuræ adherent throughout; substance of lungs inflamed.] Abdomen. Mucous membrane of intestines vascular; mesenteric glands enlarged; liver mottled on surface.
Case XCIX.
Ann Levitt, æt. 24, married. Admitted on the 16th day of fever, which came on with severe pain of the head and epigastrium; pain of head is now gone, giddiness remains; much pain of limbs; scarcely any sleep; mind confused; eyes dull and heavy; face flushed; no uneasiness of chest; abdomen extremely tender on pressure; tongue red, parched, and cracked; lips and teeth sordid; bowels purged; pulse 123.
17th. After the application of ten leeches to the abdomen the tenderness is much diminished; the pulse fallen to 96; vomiting.
18th. Eight leeches again applied; abdomen now free from pain; vomiting continues; tongue unchanged; pulse 106.
19th. Vomiting undiminished; eight stools; abdomen again tender.
20th. Vomiting; five stools; pulse 108; slight pain of abdomen on full pressure.
22d. Abdomen tender, swollen, and tympanitic; eight stools; pulse 96; great prostration.
24th. Abdomen less tender and tense; still more prostrate.
25th. Stools in bed; pulse scarcely perceptible; features collapsed. Died in the night.
Head. Membranes of brain vascular; substance natural; effusion into the ventricles and at base; pituitary gland suppurated. Thorax. Mucous membrane of bronchi inflamed; tubes full of mucus, mixed with pus; [superior lobe of right lung a mass of tubercular disease; one of the tubercles the size of a pigeon’s egg, in a state of suppuration; effusion of serum into the left pleural cavity.] Abdomen. Mucous membrane of jejunum and ilium much inflamed; caput coli firmly adherent to the abdominal peritoneum; large quantity of serum effused into the hepatic region; substance of liver soft; gall-bladder in a state of suppuration; contained three large biliary calculi; omentum inflamed; [two large hydatids attached to the left ovarium.]
Case C.
Robert Ebbott, æt. 28, labourer. Admitted on the 12th day of fever: pain of head, which has been severe, is now only slight; frequent sighing; no pain of chest; frequent dry cough; respiration heavy and suspirious; abdomen tender; tongue dry, black, and cracked, red at apex; lips and teeth sordid; bowels purged; pulse 68.
15th. Mind confused; insensibility increasing; abdomen tender; tongue quite black and extremely dry; teeth sordid; respiration the same; no stool; pulse 72, feeble. Died next day.
Head. Dura mater natural; longitudinal sinus contained a firm cord of fibrin; arachnoid and pia mater vascular; substance of brain natural; pituitary gland softened and suppurating; much effusion into the ventricles; at the base the membranes were elevated into a large bag, distended with fluid. Thorax. Mucous membrane of bronchi vascular; [right lung adherent to pleura, by a single point, at the upper part of the inferior lobe; substance contained numerous tubercles; left pleural cavity obliterated; left lung hepatized throughout, containing tubercles in every stage of disease; apex of heart adherent to pericardium.] Abdomen. Mucous membrane of ilium and cæcum inflamed and extensively ulcerated; [liver exceedingly enlarged and hard, almost of cartilaginous firmness and texture, weighed seven pounds two ounces; right kidney externally nodulated, internally healthy; left, healthy externally, but, when cut into, found to contain several abscesses; urinary bladder small; walls one third of an inch thick.]
Case CI.
Jane Hallam, æt. 28, married. Admitted on the 6th day of fever: attacked with overwhelming loss of strength and severe pain of the head; pain of head continues, with distressing vertigo; no pain of chest; no cough; abdomen tender; tongue covered with white fur, but is extremely parched; thirst urgent; thinks she has had thirty stools within the last twenty-four hours; mind tolerably distinct.
7th. Pain of head gone; mind much more dull and heavy; abdomen very tender; tongue has become brown and continues extremely dry; four stools dark and offensive; pulse 104, soft.
8th. Scarcely any sleep; much restlessness; mind confused; insensibility increasing; pulse 90, weak. Died next morning.
Head. Membranes vascular; substance of brain in general much softened, but the floors of the ventricles especially were in an exceedingly softened state. Thorax. [Left pleuræ adherent at apex; superior lobe of left lung hepatized and stuffed with small tubercles; two adhesions in right pleuræ, one at apex; right lung stuffed with tubercles;] pericardium and heart healthy; condition of bronchi not stated. Abdomen. Mucous membrane of ilium and cæcum exceedingly vascular, but not ulcerated; patches of peritoneal coat of stomach vascular; [large lobe of liver scirrhous;] other viscera healthy.
Case CII.
Jonathan Studd, æt. 27. Admitted on the 28th day of fever; symptoms throughout appear to have been chiefly thoracic; at present frequent cough with viscid expectoration; great emaciation; pulse 102, extremely weak; no pain of head or abdomen; tongue foul; bowels regular; face pallid.
29th. Cough continues; abdomen not tender; tongue brown and dry in middle, red at tip and edges; three stools; pulse 100; mind dull and confused; muscular tremor.
30th. Cough the same; tongue unchanged; lips and teeth sordid; three stools mixed with blood; delirium; muscular tremor increased; pulse 108.
31st. Abdomen has become tympanitic; three stools mixed with blood; delirium and muscular tremor increased; pulse 112, weaker.
47th. On the evening of the day of last report he slept better and waked improved in all respects; this improvement appeared to be steady and progressive; the stools became natural; the pulse diminished in frequency and increased in strength; on this morning the stools continued natural; the pulse was 90, and he still seemed to be gradually though slowly recovering, when, without the return of any unfavourable symptom, he suddenly expired.
Head. Membranes and substance of brain healthy, but more fluid than natural in the ventricles. Thorax. Mucous membrane of bronchi greatly inflamed and thickened; bronchial tubes full of mucus mixed with pus; pleuræ of left side of chest extensively adherent; substance of left lung healthy excepting some slight patches of hepatization. Abdomen. Mucous membrane of small intestines extremely vascular, in many places presenting the appearance of ecchymosis; at the valve of the colon several small ulcers; other viscera healthy.
Case CIII.
John M’Carty, æt. 22, labourer. Admitted on the 22d day of fever; complaint commenced with symptoms of severe cold; at present, slight pain of chest; cough, inducing pain in the abdomen, which is not tender; pain of head gone; eyes injected and suffused; face flushed; tongue brown and dry; bowels stated to be regular; pulse 99, weak.
23d. Cough very severe; abdomen not tender; tongue dry, brown and cracked; four stools; no pain of head; face flushed; eyes ferrety; pulse 90.
24th. Mind more confused; eyes more injected; delirium.
25th. Insensibility increasing; no sleep; tongue more dry and brown; lips and teeth sordid; four stools; pulse 96.
26th. Constant delirium; stools and urine in bed; pulse 104.
28th. Died.
Head. Membranes and substance of brain vascular; more fluid than natural in ventricles. Thorax. Mucous membrane of bronchi vascular; [pleuræ of right side slightly adherent.] Abdomen. Mucous membrane of jejunum, cæcum and ilium very much ulcerated; spleen soft; other viscera healthy.
Case CIV.
Sarah Nash, æt. 14. Admitted on the 22d day of disease; pain of head appears to have been very severe but it has now wholly subsided; lies quite insensible; pupils dilated, but contractile; muscles of extremities quite rigid; hands clenched; arms and legs extended and inflexible; no tenderness of abdomen on fullest pressure; tongue brown and dry; no stool for four days; pulse 110, extremely feeble and indistinct.
23d. Muscles of lower extremities rather less rigid; hands continue clenched; eyes in general closed; when opened appear injected and suffused; much grinding of the teeth; great restlessness; noisy delirium; two stools; pulse 126, stronger.
24th. Great restlessness; scarcely any sleep; almost constant grinding of the teeth; pulse 129, of good power.
26th. So restless that the pulse cannot be counted; exceedingly peevish; began to take two grains of calomel with half a grain of opium every four hours.
27th. Little change excepting that she is now sensible of some pain in the epigastrium on full pressure, and acknowledges some pain in the head; pulse 142.
32d. No amendment in the cerebral symptoms, and the strength is diminished; the mercurial odour is already quite evident, and the mouth is slightly ulcerated; no ptyalism; pulse 126, weak; calomel and opium omitted.
36th. Noise and delirium continue; ulceration of mouth gone; pulse 140, very weak. Calomel and opium were again resumed.
27th. Slight ptyalism; no improvement; pulse 130, extremely weak and indistinct.
38th. Ptyalism continues; sinking. Died.
Head. Membranes vascular; substance of brain much softened; effusion between all the membranes and into the ventricles. Thorax. Bronchi of both lungs vascular, and contained a large quantity of purulent matter; right lung much hepatized; left slightly consolidated. Abdomen. Ilium and cæcum very much ulcerated; spleen very firm, contained one tubercle; other viscera healthy.
Case CV.
William Gander, æt. 22, servant. Admitted on 15th day of fever; no account to be obtained of previous symptoms; some pain of head; much giddiness; mind confused; delirium; expression of eyes wild; face flushed; abdomen tender; tongue foul at root, moist, very red at apex; bowels purged; pulse 99, of good power.
16th. No sleep; violent noisy delirium; eyebrows contracted; face flushed; six stools; pulse 100.
19th. Intensity of cerebral symptoms progressively increasing; constant violent delirium; muscular tremor; subsultus; tongue cannot be protruded; pulse 112. Died next day.
Head. Membranes vascular; substance of brain natural; four ounces of serum in the lateral ventricles. Thorax. Mucous membrane of trachea and bronchi highly vascular; other viscera healthy. Abdomen. Glands of the mucous membrane of the intestines in general enlarged, many of them inflamed; some of them in a state of commencing ulceration, others completely ulcerated, so that the ilium and lower part of colon were full of ulcers, which varied in size, from that of a split pea to a crown piece; mesenteric glands much enlarged and dark; spleen very soft; other viscera healthy.
Case CVI.
George Bury, æt. 9. Admitted on the 11th day of fever: complaint commenced with nausea, pain of abdomen and severe head-ache; the latter continues; abdomen, especially epigastrium, tender; tongue red; much thirst; bowels constipated; pulse 116.
14th. Pain of head gone; countenance extremely pallid; no sleep; great restlessness; delirium; abdomen still tender; tongue red and dry; eight stools, dark and offensive; pulse 130. Died next day.
Head. Membranes vascular; substance of brain highly vascular; pituitary gland in a state of suppuration; cerebellum vascular; effusion between dura mater and arachnoid; one ounce of serum in ventricles, two at base; pia mater covering the spinal cord highly vascular; substance of cord natural. Thorax. Mucous membrane of bronchi slightly vascular; tubes contained some mucus, mixed with pus; [left pleuræ slightly vascular; lower lobe of left lung hepatized; right pleuræ healthy; lower lobe of right lung also hepatized, and contained several hard tubercles;] other viscera healthy. Abdomen. Mucous membrane of lower end of ilium and entire cæcum thickly studded with ragged ulcers, raised and very foul, with indurated margins and irregular surfaces; longest diameter of ulcers in direction of longitudinal fibres of muscular coats; mesenteric glands very large, many of them being the size of almonds; other viscera healthy.
Case CVII.
John Meredith, æt. 23, porter. Admitted on the 22nd day of fever, which came on, besides the ordinary symptoms, with pain of chest, cough and hoarseness: states that these symptoms were getting better when, a few days ago, he was attacked with pain of the abdomen, accompanied with loose stools: at present the abdomen is exceedingly tender on pressure; tongue brown and dry in the middle, edges white and moist; bowels purged; distressing hiccup; pain of head, which was severe in the commencement, gone; mind dull and heavy, but answers any question distinctly; countenance anxious; features sunk; pulse 88, feeble; slight degree of hoarseness and some cough remain.
23d. Tenderness of abdomen undiminished; hiccup continues very distressing; vomiting; bowels purged; tongue brown and dry; scarcely any sleep; pectoral symptoms the same; pulse 76.
24th. Tenderness of abdomen, hiccup, vomiting, purging, all increased; eight stools since last report; much restlessness; pulse 84.
25th. Appeared to be more easy yesterday, but relapsed into his former state to-day. Died following morning.
Head. Membranes vascular; arachnoid thickened and opake; substance of brain vascular; more fluid than natural in the ventricle. Thorax. Mucous membrane of bronchi vascular; other viscera healthy. Abdomen. Mucous membranes of small intestines vascular; [peritoneum universally and greatly inflamed; that covering the intestines coated with a layer of coagulable lymph, by which their convolutions were united into one diseased mass; false membranes were formed by this exudation which extended from the under surface of the liver to the right iliac fossa, where they formed a cyst, in which eight ounces of purulent matter were contained; the peritoneum covering the abdominal surface of the diaphragm inflamed; liver enlarged,] but its substance appeared healthy; other viscera natural.
Case CVIII.
Elizabeth Turner, æt. 26, servant. Admitted on the 15th day of fever: no account to be obtained of previous symptoms: at present extremely restless; much delirium; almost constant talking or moaning; no sleep; mind quite confused and wandering; when roused to answer a question she seems sensible for a moment, but immediately lapses into low muttering incoherence; if asked whether she has any pain in the head she points to the forehead; says she has no pain in chest or abdomen; no cough; abdomen not tender.
16th. No sleep; constant restlessness; almost unceasing incoherent talking; incapable of answering when spoken to; tongue cannot be protruded; stools in bed; pulse too feeble and indistinct to be counted. Died in the evening.
Head. Dura mater along the course of the longitudinal sinus very adherent to the arachnoid; arachnoid and pia mater white and opake; surface and substance of brain highly vascular; surface of cerebellum vascular; substance healthy; pituitary gland suppurating; more fluid than natural in the ventricles; an ounce at the base. Thorax. Mucous membrane of bronchi highly inflamed; bronchial tubes filled with mucus mixed with pus; [pleura costalis of right side vascular; slight effusion into right pleural cavity, and into parenchyma of right lung; lower lobe much inflamed; pleuræ of left side adherent; that covering left side of diaphragm much inflamed; substance of left lung partly inflamed, partly consolidated.] Abdomen. Mucous membrane of small intestines inflamed; in that of ilium numerous large, raised ulcers; [liver adherent by several unnatural connexions to diaphragm, spleen and transverse arch of colon, but its substance was healthy; appendix vermiformis likewise adherent to abdominal peritoneum;] head of pancreas enlarged; [internal inguinal glands much enlarged, and some of them impacted with calcareous matter;] other viscera healthy.
Case CIX.
Mr. W——, æt. 50. The progress of this case having been observed with great care from the commencement to the termination of the disease, and affording an excellent illustration of the insidious manner in which the mixed form of fever sometimes attacks, and of the silent but rapid progress it makes without exciting alarm, until, at last, symptoms the most formidable, and which, to those who are not acquainted with the nature of the malady, appear to be most sudden, supervene, it may be useful to give a detailed account of it.
This gentleman had been out of health six months previously to the present attack of fever: he had been observed to be gradually losing flesh, and fading; yet he laboured under no complaint that could be ascertained, excepting that his appetite failed; that he could digest well no kind of food; that he was badly nourished and, therefore, weaker in body and less vigorous in mind than usual.
About three weeks before the fever commenced, his stomach-complaints became worse, and for these he requested the advice of his friend Mr. Chaldecott. During this gentleman’s attendance, his patient was one day attacked with slight chilliness, an unusual degree of lassitude, together with pains in the limbs: but the chilliness never amounted to rigor; the general pains were not severe; there was no pain whatever in the head; yet the sudden debility which affected both mind and body was very striking. Still the mind was perfectly distinct; the sleep was sound; the expression of the countenance was natural; the tongue, however, became loaded with white fur; there was some thirst; the pulse varied from 84 to 96, while the temperature and the softness of the skin remained in a healthy state. In this manner he went on about eight or ten days, and, during the whole of this period, he was daily questioned by his medical attendant and examined with much anxiety relative to the condition of the organs in the head, chest and abdomen; but he was steady in affirming that he was free from all uneasiness in the head, and that he had no pain in the chest; nor could any pain be excited by the fullest pressure, either in the epigastrium or in any part of the abdomen. It was observable, however, that he had some cough without expectoration, and that his respiration was short and hurried. His appearance, too, indicated more disease than his sensations; he was obviously worse than he expressed, or than could be accounted for from the apparent affection of any organ, and this excited alarm both in his family and in his medical attendants; and it is always a truly alarming condition.
On the 11th day a remarkable change took place: for two or three hours he was chilly; to this succeeded heat of skin and flushing of the face; what was very alarming, the colour of the flash was purple, while that of the whole face was dusky; there was no cough, but the respiration was short and hurried; the mind was confused and dull, though a coherent answer might still be obtained to any question that was asked; the pulse now rose to 120, there was little or no sleep, but great restlessness during the night, in the course of which delirium appeared, and the next morning there came on muscular tremor. As the day advanced the flushing and heat disappeared; the mind became quite distinct, and the pulse fell to 96. Towards evening he again became restless, the pulse rose to 104, and about one o’clock, a.m. the increased heat, the flushing of the face, the purple colour of the cheek, the dusky appearance of the skin, the short and hurried respiration, and the convulsive action of the muscles all returned, and in a greater degree, while the pulse again rose to 120. From this state he never recovered in the least degree, but became more and more dull, and at length nearly insensible; his debility rapidly increased until it became extreme; he lay quite prostrate on the back, with his arms extended, as if lifeless; the muscular tremor increased; the respiration became extremely short and hurried; the tongue became dry, red, glazed, and sticky; the bowels torpid; the pulse 130; and with these symptoms he expired on the 13th day of fever.
Head. Dura mater healthy; arachnoid thickened and opake; much gelatinous effusion between it and the pia mater; substance of brain highly vascular and firm; lateral ventricles distended with fluid, much also at the base. Thorax. Mucous membrane of bronchi universally of a dark red colour and lined with a tenacious fluid, which was slightly sticky; bronchial tubes filled with frothy mucus; substance of lungs perfectly healthy. Abdomen. Mucous membrane of small intestines generally inflamed; lower part of ilium and commencement of colon filled with large and raised ulcers, some of which were just forming, while others had penetrated through a thick mass of adventitious deposit to the muscular coat of the intestine.
Before closing these illustrations of the pathology of fever, it may be proper to give an example of the modifications which take place when this disease proves fatal in the state of gestation. If fever attack during pregnancy, there is the greatest possible danger of miscarriage, and the great majority of those who miscarry die. There is no complication which requires a more delicate and cautious management; and the management which experience shews to be the best will be stated in the proper place: in the mean time, the following case is given as an illustration of the morbid appearances which are found (and the appearances are very uniform) when abortion is the precursor of death.
Case CX.
Mary Cutler, æt. 37, married. Admitted on the 5th day of fever, in the commencement of which, in addition to the ordinary symptoms, there was much nausea; this feeling continues at present, and is now accompanied with vomiting; epigastrium tender; cannot lie without pain in the left side; cough frequent, and exciting uneasiness in the chest; tongue white and dry; bowels bound; some pain of head, especially in the forehead; scarcely any sleep; much pain in the extremities; pain of throat with difficult deglutition; pulse 122; skin warm; six months pregnant.
6th. Much retching and vomiting; tenderness of the epigastrium and abdomen; bowels very loose; tongue white in the middle, red at the edges; severe pain in the chest; great dyspnœa; constant, urgent cough with difficult mucous expectoration; severe pain in the head; no sleep; great restlessness; pulse 150, sharp but compressible. V. S. ad ℥xij.
7th. Buff on blood extremely firm; retching and vomiting gone; pain of side entirely removed; less cough; dyspnœa diminished; pain of head better; slept much better; pulse 120.
9th. After a tolerable night, attacked this morning with urgent dyspnœa, soon became perfectly insensible; was delivered of a fœtus six months old; at present, nearly insensible; respiration hurried and laborious; tongue brown and dry; one stool; pulse 110; skin moderately warm.
10th. Free lochial discharge; all the symptoms greatly improved; tongue white; moist; pulse 84, soft.
13th. Lochial discharge nearly ceased; no pain in head, abdomen, or any where, except the face which is attacked by erysipelas; tongue continues moist and is nearly clean; pulse 108.
14th. Erysipelas increased and extending; tongue, has again become brown and dry; pulse 110.
16th. Erysipelas extending; severe pain in epigastrium and over abdomen, much increased on pressure; distressing sense of nausea but no vomiting; tongue the same; pulse 96, weak and irregular.
17th. Pain of abdomen increased; stools in bed; no sleep; extreme restlessness; respiration hurried and wheezing; pulse 130, weak. Died in the evening.
Head. Membranes of brain vascular. Thorax. [Pleuræ covering right lung coated with a layer of coagulable lymph; in both pleural cavities a large quantity of serum mixed with flakes of lymph and pus; that part of the pleura of the right side which lines the diaphragm highly inflamed;] substance of both lungs healthy. Abdomen. Peritoneum in general more vascular than natural; patches of it in a state of intense inflammation; peritoneal sac contained much serum mixed with flakes of lymph and pus; pelvis of right kidney inflamed; ovaria and uterus of very dark colour and intensely inflamed; other viscera healthy.
It would be easy to multiply cases to an indefinite extent, but, since those which have been cited exhibit a complete view of the pathology of fever, as far as it has yet been ascertained, any further details would fatigue the reader without instructing him. And what is this pathology? What are the events, the detail of which has occupied us so long? The account of the pathology of fever is the history of inflammation, and the description of the individual changes that take place in the organs that constitute the febrile circle, is an enumeration of various products of inflammation which are formed within them. There is scarcely a fatal case of fever which does not afford, in one or other of the organs of that circle, some inflammatory product; there is no considerable number of fatal cases which does not furnish a specimen of every inflammatory product. And what are the severest cases of fever, and why are they the severest? With the single exception immediately to be stated, the severest cases are those in which, together with a severe primary affection of the nervous system, this inflammatory action is in the greatest degree of intensity, and is seated in the greatest number of organs; and they are the most severe, not only on account of the severity of the primary affection of the nervous system, but also because it is in them that the inflammation is the most intense, and because that inflammation attacks the system at one and the same time in the greatest number of points. From among the preceding cases, fix upon any one in which the powers of life were, from the commencement, the most completely overwhelmed, and in which they were the most rapidly exhausted, and when the brief struggle for existence is over, examine the changes that have taken place in the internal organs—what is it that is found? traces of inflammation, legible, deep, extensive; while, in almost every case, these traces are thus legible, deep, and extensive, in proportion to the apparent intensity of the fever, and to the rapidity with which it extinguished life. In this point of view, how important, how instructive, how invaluable is the lesson which the mixed cases of fever afford! With few and rare exceptions (and in all diseases some exceptions occasionally occur to what appear to be the best established and the most invariable laws) these are the cases in which the symptoms are the most urgent, and in which they run their course with the greatest rapidity; these are the cases in which the debility is the most striking; in which it comes on the most early, and proceeds to the greatest degree of prostration; these are the cases which are the most purely typhoid, the most truly adynamic; these are the cases which, in general, commence with the most sudden and alarming deprivation of physical and mental power; in which all pain and uneasiness are soonest lost in stupor, in which the stupor most rapidly increases to insensibility; in which delirium comes, perhaps, as early as the third or fourth night, accompanied with its attendant, muscular tremor, and too often with its most formidable ally, erysipelas: in which, at this early period, the respiration is short and hurried, the skin dusky, the colour of the cheek purple, the tongue brown and dry, the lips and teeth sordid, the abdomen tender, and the stools loose; in which, in a day or two more, the abdomen is swollen, tense, and tympanitic, the stools passed in bed, the patient prostrate on his back, completely senseless and powerless, while the pulse is 120 or 130, and so feeble that it can scarcely be distinguished. But what is this debility? in what does this adynamic state consist? It consists of a peculiar affection of the nervous system, followed rapidly by intense inflammation of the brain or of its membranes, or of both: by intense inflammation of the mucous membrane of the bronchi, and by intense inflammation or extensive ulceration of the mucous membrane of the intestines. And why is the patient weak or adynamic? Because he is not only assailed by an affection of the nervous system, which deprives the organs of the stimulus necessary to enable them to perform their functions with due vigour, but, at the same moment, inflammation is set up in three of the great systems, the healthy action of which is most essential, not only to strength but to life: thus the citadel is attacked at one time at three of its capital points. It is not asserted that inflammation alone constitutes the state of fever, nor that the danger of the patient is always in exact proportion to the degree of the inflammation. How it differs from inflammation, and what is superadded to the inflammatory state, will be shewn immediately; but it is a most important fact, that the degree of the debility is most intimately connected with the intensity and the extent of the inflammatory action. Now and then, as has been already stated, the intensity of the nervous affection is so great, and so rapidly destructive of life, that there is no time for an inflammatory process to be set up, much less for an inflammatory product to be formed. The patient is struck dead as if by lightning, or by Prussic acid, or by apoplexy. In this country, he does not actually die as instantaneously as he might be destroyed by the electric fluid or by poison, although there are countries, seasons, and particular spots, in which the concentration of the febrile poison appears to be sufficiently great to extinguish life instantaneously; and even in this country, life is sometimes destroyed by a stroke of fever as rapidly as it is by a stroke of apoplexy, when the latter does not prove fatal in the first few hours.
Now the peculiarity in these cases is, that the internal organs, after death, exhibit no signs of inflammation, unless vascularity be inflammation. The organs which, in ordinary cases, are inflamed, are in these cases turgid with blood. Are the terms debility or adynamia appropriate expressions to designate even this condition of the organs? Just as appropriate as they would be to express the condition of a person who is struck dead by lightning, whose muscles are incapable of contraction, and whose blood will not coagulate. Those who apply these terms even to such forms, and, à fortiori, to any other forms of fever, must be ignorant either of the nature of the disease, or of the constitution of the human mind. If they know the disease, they know that the patient appears to be weak because the primary operation of the disease is upon the nervous system—an operation which, as has just been stated, while it disturbs that due and equal distribution of nervous influence which is necessary to the healthful action of the organs, and, therefore, to the general strength of the system, is not incompatible with, but promotive of an excitement of the vascular system, which terminates in inflammation. Debility is the last, the ultimate result of the disturbance of the functions of a certain series of organs, but part of this very disturbance of function, and a most important part, a part which exerts the greatest influence over the progress of the disease and the life or death of the patient, consists not in the weakened, but in the augmented strength and the increased activity of the vascular system. To designate the ultimate result upon the system by a term which gives an entirely false view of the individual processes in the economy, by which that ultimate result is produced, must, we repeat, arise either from an ignorance of the true nature of those processes, or from not reflecting on the influence which words exert over the manner in which the human mind conceives of things. For the sake of the progress of the science of medicine, for the sake of rendering the language of medicine the correct expression of the knowledge which the science has actually attained, and, above all, for the sake of accomplishing the great object of medicine, the preservation of human life, it is high time that these terms with which physicians have so long allowed their minds to be abused, should be banished from medical nomenclature, or, at any rate, from that part of its nomenclature which appertains to fever.