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.
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.