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LECTURES ON FEVERS: BEING The Lumleian Lectures,
FEBRUARY 4, 1860.
LECTURES
ON
FEVERS:
BEING
however, they differ materially in structure, position, and liability to disease. They are found in the form of small rounded bodies, of the size of millet-seeds, projecting upon the internal surface of the mucous membrane (Fig. 1). They are met with FIG. 1.
The Lumleian Lectures, DELIVERED BEFORE THE
ROYAL COLLEGE OF PHYSICIANS OF LONDON, 1858-59 ; COMPRISING
A DESCRIPTION OF THE DISTINCTIVE CHARACTERS, PATHOLOGY, AND TREATMENT
A
solitary gland from the small intestine of the human subject, magnified. (After Boehm.)
OF
portion of the intestine. Wefind them scattered over the jejunum, but in greatest numbersover the ileum, the valvulse conniventes, as well as in the spaces between them; they occur also in the large intestine, particularly the caecum and appendix vermiformis. Around each gland there is a zone of the orifices of the follicles of Lieberkuhn. Examined by the BY microscope, they appear to be hollow sacs, covered with villi filled with mucus, resembling, on section, a Florence oil-flask, ALEXANDER TWEEDIE, M.D., F.R.S., wide at their blind extremity, tapering towards the surface of FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL, TO THE FOUNDLING HOSPITAL, the mucous membrane, on which they open by a very small EXAMINER IN MEDICINE IN THE UNIVERSITY OF LONDON, I orifice, not easily seen, especially when the gland or sac is ETC. ETC. THE
SEVERAL
FORMS
in every
OF
CONTINUED
FEVER.
empty.
LECTURE III. ENTERIC C
FEVER.
3. The agminate OJ’ aggregate glands are generally known by the name of glands of Peyer, who has minutely described them, though they were previously known to and delineated by Dr.,Grew, a Fellow of this College, in a paper published
FIG. 2.
Synonyms. A natomy of the intestinal glands. Symptoms.o1. Symptoms referable to the nervolts system-pain in the head, somnolence, delirium, spasms, the senses. 2. Symptoms ?’referable to the gastric system-diarrhcea, iratestinal 7tce?K
agminate glands (Peyer’s glands). 1. The glands of Brunn, or Brunner, are arranged in the submucous or areolar tissue of the duodenum, and have the appearance of small granular bodies, to which Brunner gave the name of the second pancreas, to the structure of which gland they bear strong resemblance. They are most numerous in the vicinity of the pylorus, commencing abruptly at the duodenal side of the pyloric valve, and gradually diminishing in number towards its lower portion, until they finally disappear. These bodies, better distinguished by the name of duodenal glands, from their being limited to this portion of the digestive tube, are small compound glands, presenting, when
A
of Peyer’s glands of the adult human subject, from the lowest part of the ileum. (After Bochm,)
patch
under the quaint title " The Comparative Anatomy of the Stomach and Guts," being several lectures read before the Royal Society in the year 1676. Peyer did not publish his description till the following year (1677)* They ought therefore to be called G’reto’6’ glands, or patches, if priority of discovery regulate the question. Each of these glands, the or aggregation of which constitutes a single Peyer’s patch, resembles in every respect the structure of the solitary, being a papilliform body, or vesicle, tapering to a pointed extremity, which projects amongst examined with a powerful lens, the characters of the salivary the tubes of Lieberkubn. They are arranged or collected in oval or elliptical, sometimes circular, groups or glands. They vary both in number and size in different sub- together the long diameter corresponding with that of the injects, and seem to disappear altogether in advanced life. In patches, testine. They are found always on its free border, opposite to no other part of the intestinal canal are similar glands discothat by which the mesentery is attached. These patches seem vered, nor are they known to be liable to any special disease. to belong, in an especial manner, to the ileum, and are found 2. The 3olita?-y glands have been sometimes, but erroneously, chiefly towards the lower portion, becoming more and more described as the glands, or patches of Brunner, from which, De Glandulis lutestinorum. No. 1901 E
gronninb
scattered-less numerous towards the duodenum, in which, however, Peyer once found a single patch. They vary in number, fifteen, twenty, thirty, or even more, being occasionally found. Sometimes they assume the appearance of bands two or three inches long, or occasionally they form irregular clusters, the largest being near the ileo-eaecal valve; in other cases, the patches terminate some inches below the valve. They are variously developed in different subjects, being in some planted in the substance of the mucous membrane, to which they impart a degreeof thickness: in others, they have the appearance of being imbedded in the muscular coat. On examining by the microscope the mucous membrane covering the patches, numerous depressions may be discovered, but each depression is distinct, and is the orifice of one of the follicles or crypts of
which the two
or
patch is composed, and it is not uncommon to find three diseased in the middle of a patch which is otherwise
sound. I may here observe, that Peyer’s patches are most distinct in young subjects; and as they seem to undergo rapid change after death, it is necessary, if an accurate examination is to be made, that the bodies be recent, and, if possible, those selected in which the death has been sudden, or from accident, or from It is some form of acute disease that has proved rapidly fatal. generally supposed, too, that during life they become changed, perhaps atrophied, from age, and after protracted illness. It is not unlikely that the alterations these patches undergo with advancing age may have something to do with the infrequency of enteric fever after the age of fifty. We know very little of the use of the intestinal glands. I have alluded to the resemblance between the duodenal glands and the pancreas in structure; and they are so strictly confined to the portion of intestine with which this gland is intimately connected, that it is probable that the functions of both are of the same nature, and that they form part of the salivary apparatus of the intestinal canal. The same resemblance of structure between the solitary glands and the glands of Peyer has been pointed out. Their functions, therefore, are probably not dissimilar. We know also, that the solitary glands and Peyer’s patches both undergo important alteration in two diseases,-in tubercular phthisis and in enteric fever,-proceeding in both to ulceration, whence results the diarrhoea in the latter stage of the one, and throughout the whole course of the disease, as a general rule, in the other.* It may naturally be inquired, if this lesion of Peyer’s glands be the pathological element in enteric fever, is it to be regarded as the cause of the phenomena in this form of fever, or as the effect of the fever poison on these glands ? The latter view is the more philosophical and correct. We observe in other acute affections morbid poisons giving rise to similar local or specific effects; for example, in smallpox, producing pustulation of the skin; in measles, affecting the skin and mucous membrane of the air passages; and in scarlet fever, the skin, the throat, and frequently, in the severer forms, the glandular or absorbent system. The same compound action has been observed in the plague, the poison acting probably first on the blood, and subsequently on the absorbents, giving rise to the well-known plague buboes. In the same way, the action of the poison which generates enteric fever on the intestinal follicles is explained; and whether its primary operation be on the blood, or on the nervous system, or on both, its specific effect on the intestinal follicles also, is scarcely
the face at times flushed, and at length, from increasing weak. ness, the patient seeks the couch, or prefers to keep to bed
entirely. Towards
night,
there is
more or
less
aggravation
of the
symptoms, accompanied with restlessness, inducing constant change of posture in the vain hope of finding relief; the sleep is disturbed and unrefreshing, the thirst more urgent, and the heat of skin more pungent. Sometimes there is vertigo, or the ears, or occasionally slight epistaxis. Such are the symptoms of the early stage of enteric fever; and though to an experienced observer they are sufficient to indicate the disease, there may be reasonable doubt as to its nature, until its characteristic eruption appears. This is seldom visible before the second week (generally from the eighth to the twelfth day) after the commencement of the symptoms, when, on close examination, a few small circular rose-coloured spots may be discovered, chiefly on the anterior and posterior aspect of the trunk, seldom on the face or extremities. As the characters of this specific eruption will be presently pointed out, I shall only observe that each spot is perfectly distinct, fades or entirely disappears on pressure, and after remaining visible for three or four days disappears, fresh spots coming out every two or three days, and undergoing a like process of eruption and decline. In this way successive crops of these spots appear until the conclusion of the disease. This characteristic eruption, however, as we shall presently see, is occasionally absent. If the abdomen be examined, it will be found more or less distended and resonant; a sensation of gurgling in the right iliac fossa, often accompanied with tenderness, being generally
singing in
perceptible.
The diarrhoea
so
commonly observed
as one
of the
early
symptoms varies in degree; sometimes it is moderate, sometimes profuse and exhausting, and in some cases accompanied
with blood. If the case be mild and uncomplicated, these symptoms continue without marked variation till towards the middle or end of the third week, when a gradual abatement of the more pro. minent, especially of the diarrhoea, portends the approach of convalescence. The change, however, is very gradual. The pulse becomes slower; the alvine discharges less frequent and more consistent; the tongue more clean ; the thirst abates; the heat of skin and restlessness disappear; the sleep is tranquil and refreshing; there is gradual improvement in strength; while the appetite for food returns, and is often so keen as to require great vigilance to prevent its too early indulgence, and consequent risk to convalescence. But the progress of enteric fever does not always run so smoothly. On the contrary, when the stage of convalescence is daily watched for with great anxiety, all the symptoms may continue unabated, or some of them become even aggravated. Thus the headache, which usually passes away towards the end of the second week, may persist, and eventually may be followed by delirium, or by somnolence, gradually passing into coma, more or less profound : the diarrhoea may increase, or a sudden discharge of blood from the bowels arise, which, if it do not destroy life, adds much to the danger: or, again, the intestinal ulceration may extend, inducing progressive emaciation and weakness, from which it may be difficult or impos, sible to restore the patient. Not unfrequently the progress of the fever is interfered with by some form of pulmonary complication. This may be open and easily detected; but in many cases, more especially when there has been early and severe disturbance of the nervous system, it assumes a latent form, questionable. and is recognised only by careful auscultation, which may reBefore describing the individual symptoms in detail, I shall veal either pleurisy, bronchitis, or pneumonia, more or less diffused. Sometimes, and indeed not uncommonly in severe sketch the progress of enteric fever of moderate severity. But let me here observe, that the disease, in the early period cases, there may be both cerebral and pulmonary disease coat least, and often throughout its subsequent stages, is of a existing ; so that the fever may be said in its progress to have involved the most important internal organs. Under such more acute or sthenic character than its prototype, typhus. We have seen also that it occurs at the more early periods of life- extensive complications the issue is seldom doubtful. In proportion to the intensity of the local complication, the most commonly between the ages of fifteen and thirty, seldom after forty, though I have seen it in persons beyond the age of general or febrile symptoms increase; indeed, a low form of secondary or symptomatic fever may be said to supervene. The sixty. It commences slowly and insidiously, so that the patient pulse rises in frequency, and is weak and compressible; the is often able to pursue his ordinary avocations, complaining tongue becomes dry, brown, shrivelled, and often fissured; the teeth and lips covered with brown or black incrustation; only of undefined indisposition, such as irregular chills, loss of the emaciation progressive; the weakness day by day more a or less of and more headache, limbs, thirst, appetite, pain the evacuations passed unconsciously; the sacrum, marked; for and lassitude account. of which he cannot degree languor In the course of a day or two, these symptoms increase, the hips, and other parts subjected to pressure, becoming inflamed passing rapidly into gangrene; or pus may be deposited pulse quickens, there is less inclination for exertion, the tongue and in different parts, more commonly in the joints. to be sometimes bowels furred, the relaxed, disposed It is unnecessary to observe that the ultimate issue, under with abdominal pain, the countenance altered in expression, such complications, must depend on the circumstances pre* sented by each case: the degree or intensity of the local comSee Todd and Bowman, vol. ii., p. 234.
becomes
108
I may here remark that, however much the brain may have day suffered in the progress of this form of fever, permanent mental may linger and eventually recover, or death may result from imperfection, in my experience, rarely follows. After severe gradual exhaustion, seldom before the fifth or sixth week. cerebral disturbance, the powers of the mind are occasionally Many cases are protracted to a much later period; indeed, somewhat, though temporarily, enfeebled; but this condition there is scarcely a limit to the duration of complicated enteric disappears as the patient regains strength. This accords with fever. Or, lastly, the ulcerative process may gradually destroy the experience of Louis, who mentions that he had observed in succession the coats of the intestine, and at length perforate the the intelligence affected during convalescence in one case only, may be speedily cut and in this patient the mental capacity was small. He reperitoneal covering; and thus the patient off. Dr. Jenner notes that when death is the result of the mained for six weeks in a kind of idiotic state, from which, general disease, the fatal termination always occurs before the however, he ultimately slowly recovered. As to the relation between the delirium in this form of fever thirtieth day. Local lesion sufficient to account for death is always found after that date,-proving the natural duration of and the condition of the brain after death, Louis states that, out of twelve subjects, who either had no delirium, or in whom this the general disease to be about four weeks. symptom occurred only momentarily during the last two or I shall now proceed to enter more fully into the consideration three days of life, or for twenty-four hours during the disease, of the individual symptoms of enteric fever. I shall describe -in four, the cortical substance exhibited a slightly rose tint them as they occur-1st, in the nervous system; 2nd, in the throughout its whole circumference; in six, it was perfectly gastric system; 3rd, in the skin; and 4th, the local affections healthy; in one case, it was very much injected, with slight or complications. softening of one of the optic thalami, the entire cerebral mass 1. Symptoms referable to the nervous system.-Of the cerebral being less consistent than usual. So great a variety in the appearances after death, in patients symptoms, one of the more early and constant is pain in the head, observed in the mild as well as in the severe cases. who had no delirium, must lead us to doubt our ability to find Sometimes it is confined to the forehead and temples, some- in appreciable alterations of the brain an explanation of the times it extends ever the head, often in severe cases accom- symptoms of which it is evidently the source, and to render it panied by intolerance of light, conjunctival injection, or throb- more than probable, that those changes may take place in the last days of existence. bing of the carotid and temporal arteries. Louis affirms that pain in the head is one of the most comAlthough the cerebral symptoms in general seem to bear no mon symptoms of acute fevers of every kind, but more frequent relation to, or are not dependent on, any certain or fixed in persons affected with enteric fever than with any other dis- lesion of the brain or its membranes discoverable after death, ease ; and as in the former (enteric fever) it is almost constant, I cannot concur in the idea suggested by Louis, great as and begins with the first accession of the symptoms, its ab- his authority is-that the brain symptoms are dependent on sence at the beginning of a febrile affection, in which other the changes in the intestine, which constitute the peculiar symptoms characteristic of this disease are wanting, would in- anatomical distinction of enteric fever; and for this reason, dicate that the disease is not enteric fever. that in many cases-I will not affirm in the majority-where Somnolence is another very common symptom. In the milder the intestinal lesion has gone on, and ultimately proved fatal, there has been neither delirium nor somnolency at any period cases it is less marked, appears later, and is of short duration. In the more severe, it comes on early, is of longer continuance; of the disease. and in fatal cases, it increases in intensity, until it ends in I am disposed, therefore, to look, not to the solids, but to deep coma and death. Louis investigated this symptom with the blood, as the source of the disturbance of the functions of great minuteness, and found that in patients who recovered, out the brain in this fever, just as we find in ursemio poisoning of fifty-seven in whom the affection was severe, eight had no marked sensorial affection. It may be said that if the changes drowsiness ; in forty, in whom he noted with care, the origin, the blood undergoes be the source of the cerebral symptoms, duration, and degree of this symptom, in no individual did it how are we to account for their absence in exceptional cases? The explanation is, that there is a less amount of feveroccur on the first day of the disease, in only one on the second, in two on the sixth and eighth, generally on the ninth, and in poison in the blood-less than is sufficient to produce the brain The average was on the affection; or it may be that, in some individuals, the cerebral an extreme case, on the fortieth. fourteenth day of the fever, its mean duration was eight days, mass is less susceptible, less easily impressed by the morbid and the extremes of the duration twenty-one days. Somnolence blood,-just as we observe great difference in the effects of is also one of the most marked symptoms of the enteric fever of alcoholic stimulants on the nervous system in different persons. children, and may be looked for at any period of the disease. /S’p
and the stamina or power of the patient to contend plication,such from a formidable disease. He
against to day
109
It seldom spreads to the tympanum; hence loss of hearing is by no means a common result of enteric fever. The sense of taste is generally altered or perverted, articles of food appearing either tasteless, or having a flavour different from what is usual. This may arise partly from the state of the tongue and palate, but in part, if not chiefly, also, from perverted nervous sensation. In some patients the sensibility is perverted-often augmented. This is more commonly noticed in females of the hysteric temperament, in whom the cutaneous and perhaps the muscular systems are morbidly sensitive, the slightest touch apparently causing great pain. It is of importance to discriminate this cutaneous tenderness in the epigastric and abdominal regions from peritoneal inflammation, for which, by a careless and inexperienced observer, it may be mistaken. The diagnosis is determined by observing that there is the same tenderness when pressure is made on any part of the bodythe arm, chest, or lower limbs, for example. Besides, the absence of vomiting and of constipation assists the diagnosis, though I admit there may be in some cases considerable difficulty in coming to a right conclusion. On the other hand, wee must not overlook the possibility of peritonitis springing up in the hysteric diathesis. In such mixed cases, the persistent vomiting, the constipation, thirst, and hot dry skin-the attitude of the patient as she lies on her back with her knees drawn up, and the severe paroxysms of abdominal pain when the belly is untouched-all point to the existence of peritoneal
shrivelled, dry, and cracked or fissured state, the being transverse or longitudinal-more generally transverse ; sometimes exhibiting ulcerations more or less deep. Occasionally, the fur or coating becomes quite black, or a layer or stratum of blood is spread over the dorsum, while the teeth and lips are covered with a similar incrustation. This brown assumes a
fissures
black incrustation, which is due to exudation of blood, in. dicates an unusually severe form of fever, and more especially so when it is tremulous, and protruded and retracted with difficulty. When there is vivid redness of the tongue, the same condition may be observed in the mucous membrane covering the mouth and roof of the palate, uvula, and tonsils, giving rise to various uncomfortable sensations-dryness, heat, pricking, difficulty or pain in swallowing, and often irritating cough-which are also, in some degree, due to the constant passage of the air over those surfaces, when the breathing through the nostrils has become impeded, in consequence of a congested or swolien state of the mucous membrane of the or
nasal
cavity. deglutition, depending on subacute inflammation of the posterior fauces, may arise, and, even when trivial, should never be overlooked, as it may suddenly increase, and, by involving the structures in the vicinity of the glottis, terminate either in angina laryngea or in abscess of the velum or posterior pharynx, which I have repeatedly known to destroy life by its pressure on the rima of the glottis. The patient is often not sufficiently alive to pain to make any cominflammation. plaint, and it is perhaps only by observing the difficulty with Muscular aching, backache, and pain or sense of weariness which fluids are taken, that mischief in the throat is sus. in the extremities, are all referable to the same condition of pected, until (perhaps suddenly) the frightful symptoms of the nervous system-perverted sensibility. laryngitis show too clearly the impending danger. 2. Gastric system.-In the whole catalogue of symptoms Dia7r7aca.-Though diarrhaea is not invariably present in enteric in of enteric none either a are so fever, it is so constantly observed as to constitute one fever, diagnostic important, distinctive or practical point of view, as those referable to the of its characteristic symptoms. The follicular disease, as in gastric organs. This may have been anticipated from the inflammation of the mucous lining of the intestines from ordilesions of this form of fever being chiefly limited to the ab- nary causes, induces frequent action of the bowels, and hence the natural secretions, being evidently a source of irritation, dominal organs. We shall consider the symptoms connected with this system are frequently expelled. In mild cases, the bowels are generally in a natural statein detail, although it is almost unnecessary to remind you, that all of them are not present in every case, or that some of them seldom relaxed; or if there be a tendency to relaxation, it is remarked in the more advanced period of the disease. In the may be more constantly observed than others. In many patients, at the commencement of the disease, there more severe, there is diarrhoea at the beginning and throughout fever, the stools being serous or watery, often accompanied are occasional feelings of nausea, which, if followed by retch- the with griping, and followed, when the diarrhoea has been proor vomiting, may at first give an impression that the patient ing is only suffering from a bilious disorder." This idea is, how- fuse, by exhaustion. Sometimes they are ochre-coloured, or ever, soon put aside by the little mitigation that follows the like pea soup; often dark, resembling coffee-grounds; and occasionally mixed with mucus. vomiting, as well as by the occurrence of other symptoms. Painful
"
From
investigations
into the nature of this bilious fluid
re-
From Louis’
statistics,
we
find that this
symptom occurred
cently recorded by Dr. Frazer, it would appear that it is modi- in all his patients except three; and that out of forty cases fied blood, and that though it may be mixed with bile, it is observed, twenty-two had somewhat frequent and liquid de. frequently entirely free from it. He states that the small jections during the first day of the disease. Of the others, nine began to have diarrhoea between the third and ninth day, masses which float through it, and give it its peculiar colour, and six between the eleventh and fourteenth. It should be are clots in which blood-corpuscles can be seen on microscopic examination. The symptom then evidences an effusion of blood, observed, also, that the three patients who had no diarrhea and, indeed, sometimes alternates in the discharges with red died after the thirteenth and fourteenth days of the disease; blood. Dr. Frazer has been able to restore to it its red colour and on dissection, ulceration of Peyer’s patches was discovered. by supplying oxygen. Why it assumes this green colour is not As to the number of evacuations, out of thirty-two patients in whom this symptom was tecurately noted, he found that in as yet known; but the green colonr assumed by the body while eighteen, the average was eight to ten or more daily; in seven, undergoing decomposition, is an analogous instance.* Sickness and bilious vomiting, geperally accompanied by the diarrhoea was more moderate, the average being four to epigastric pain, now and thm supervene also when the fever six; and in an equal number-viz., seven-it was slight, the is somewhat advanced. According to Louis, when these symp- evacuations rarely exceeding two or three in twenty-four hours, toms (epigastric pain and bilious vomiting) occur late in the Again, the diarrhoea, whether slight or severe, or whether fever, we may infer the existence of a lesion of the mucous or not it appears at the commencement of the disease, varies membrane of the stomach. He found that of thirty fatal cases, in its course. Sometimes, after gradually increasing, it betwenty had nausea, vomiting, or epigastric pain, of whom comes stationary, or it may diminish towards the latter stage eleven exhibited more or less serious alteration of the mucous of the fever. In other instances, such is its caprice, that after membrane of the stomach, the extent of the lesion being, ap- being moderate in the early stages, it suddenly increases in parently, in proportion to the duration of the vomiting; and the advanced. that out of fifty-seven patients, in whom the fever was more or Again, the bowels, instead of being relaxed, may be con. less severe, but who ultimately recovered, forty-three had fined, the evacuations being more or less consistent. In symptoms referable to the stomach-viz., thirty had pain in an excellent paper on Fever by Dr. Wilks," he says: "Asa the epigastrium; nineteen, sickness only; and twenty had rule, the contents of the bowels in fever (typhoid-i. e., enteric) are fluid, but not always so, as another case will show. It vomiting. The tongue, in a considerable proportion of cases, is little was that of a young girl, who had been ill three weeks, and altered from its natural appearance. Louis found it natural, whose bowels were said to have been irregular, but generally or nearly so, in about half the cases analyzed by him-that is, confined, and who came to Guy’s Hospital to die. The moist, without morbid redness, perhaps slightly coated with post-mortem inspection showed the intestine full of firm slimy, whitish or grey fur; it may even preservethis appear- scybala; and on removing these, under each was found an ulcer." ance throughout the course of the fever. But Ml others, after I have often met with similar cases, showing that there maybe having been slightly coated, it becomes more or less red at the ulcerated intestine, and even perforation of the bowel, without edges and tip, and occasionally covered with a dark-brown diarrhoea, instances of which will be found in my Clinical stripe, or fur, on the dorsum. As the fever progresses, it Illustrations of Fever, published thirty years ago. *
*
Dublin Journal. February. 1858.
110
*
Guy’s Hospital Reports, vol. i., New Series.
z’
Intestinal haemorrhage is peculiar, or nearly so, to enteric likely to produce pain and irritation, thereby aggravating any fever, for although it may also occur in ordinary typhus, it is unfavourable symptoms which may have previously existed. very rarely observed. I had a case, some time ago, in the hosI have already alluded to the modifications in opepital, in which this appeared to be the destroying cause, and rating when the stone is large and hard. In required these cases the on opening the body, Peyer’s patches were found to be sound, but the mucous membrane of the lower portion of the ileum, bladder should be cautiously injected; great care must be obcaecum, and commencement of the colon, exhibited a red swollen served not to irritate this organ, either in our attempts to seize appearance. In this patient there was the well-marked mul- or break the stone; the first sitting should be short, the opeberry (typhus) eruption to assist the diagnosis. rator not proceeding further than to break the stone; finally, if The quantity and appearance of the blood vary much; somethe screw, which very rarely happens, the times the amount is so small as to be sufficient only to indicate the the calculus resist once abandoned. must be at tendency to haemorrhage; more generally, however, it i-s much operation of diminished capacity of the bladder preAn evident cause half an ounce to several in more ounces; larger-from, perhaps, sents itself in cases where an enlarged prostate projects into rare instances, as much as twelve or even sixteen ounces have been discharged at once. But as it may be passed in variable the cavity of this organ. This must necessarily reduce the quantify for several days, the total amount cannot be esti- working space and impede our manipulations. In searching mated, except by its influence on the patient’s strength, which for the stone, the revolution of the lithotrite is soon arrested, is seriously, and often fatally, impaired by such a serious drain and it is often difficult to separate the blades to any extent without meeting the projecting lobe of the prostate. Hence on the already prostrated powers. The evacuated blood differs in colour and consistence; some- there is always some difficulty in properly seizing the stone, times it is of a bright red, but this is rare; more generally it is and often considerable pain and irritation in attempting to dark, or almost black, and as to consistence, it is usually thin crush it. In previously noticing these difficulties, I mentioned and uncoagulated, resembling thick treacle; occasionally, it is that a longer instrument than that in ordinary use must be employed, and it should be carried towards the posterior part passed in solid coagulated masses. The source of the blood may be traced to the ileum and of the floor of the bladder before it is opened to seize the stone. Lastly, in a numerous class of cases, as a consequence of procsecum, and to issue both from the ulcerated patches and intervening mucous membrane. In one case under my care in the longed disease, the bladder itself may be permanently conhospital, Dr. Jenner found after death, that water thrown into tracted, or at all events may have a tendency to contract the superior mesenteric artery poured forth freely from the strongly on slight irritation. These cases are difficult to edges of an ulcer, from which, doubtless, the haemorrhage, manage, and require great care. They are not to be undertaken lightly, nor, on the other hand, is the patient to be dewhich was the immediate cause of death, proceeded. prived of the benefit of lithotrity merely because the bladder is unusually contracted and sensitive. It is important to notice, that certain conditions of the urinary organs, such as pain and excessive contractility of the bladder, do not always depend OBSERVATIONS ON LITHOTRITY. on organic mischief, but on the temporary effects of the presence of the foreign body in the organ, and are relieved or disappear BY WILLIAM COULSON, ESQ., as soon as the stone is crushed. Even some indications of chronic SURGEON TO ST. MARY’S HOSPITAL. inflammation, such as a discharge of mucus or muco-purulent matter, with pain and a frequent desire to pass urine, will (Continued from p. 82.) disappear after the first or second sitting. Still, in these cases, as I before remarked, caution must be observed. We must not AT the first sitting the calculus is merely broken, and other persist too long in the operation, lest we excite a degree of inflammation which cannot be subdued. I would lay down as a operations are required before the bladder is entirely freed from rule of practice when no serious organic mischief exists, and the foreign body. The number of operations, and the interval the stone is small, that lithotrity may be attempted and perbetween them, will depend on the circumstances of each case; sisted in as long as unfavourable symptoms do not arise. Everybut the surgeon should always bear in mind the important rule thing which has a tendency to increase the already great of not attempting too much at a time. In simple cases the first sensibility of the bladder must be sedulously avoided. We must only two or three ounces of water, and make the crushing may be borne so well, that the effects of the opera- first inject as sitting short as possible; and in case we cannot seize tion will have disappeared in two or three days. Here the the stone at once, we had better not persist in our efforts. operation may be repeated at the end of a week, and a few After the operation, care should be taken that the fragments sittings, at shorter intervals, will generally be sufficient for the do not collect about the neck of the bladder, an accident likely to occur from the tendency of the organ to contract. Hence cure. In other cases, from the size of the stone or the condition of the importance of keeping the patient on his back, with the of freely washing out the bladder, and of passing the bladder, constitutional disturbance, with considerable local pelvis raised, the catheter when the least stoppage occurs. irritation, soon shows itself. There is fever, frequent desire to ’, However, with all our care, the irritability of the bladder pass urine, with pain at the neck of the bladder and along the may increase to a severe degree. The stone may be broken, urethra. Under these circumstances, the second operation must and on the next or following day great pain and irritation may be deferred until the constitutional and local disturbance has arise from the presence of the fragments, with a constant desire to pass urine, and considerable difficulty in voiding it. A little entirely subsided. The second operation is usually better borne later more unfavourable symptoms set in-high irritative fever, than the first, and four or five sittings, at intervals of as many extreme local irritation, with great pain in passing the fragdays, will be sufficient to complete the cure. ments, or rather in the efforts to pass them (few or none being There is, however, a class of cases in which the operation voided). Now, in a case of this kind, what is to be done? cannot be performed without difficulty, and a certain degree of The attempt to break the stone cannot be renewed, and the strength, which before the crushing was good, is now danger as to the result. By far the most frequent difficulty patient’ssinking. Under these circumstances, are we justified rapidly in contend is the with which we have to want of lithotrity in resorting to lithotomy ? A priori, we might think that the sufficient space in the bladder to work our instruments with succession of one capital operation to another must be attended ease and safety. This difficulty is often caused by the density with too great risk; that the mischief set up by the previous and size of the stone. At first it might not appear how in- lithotrity must render the subsequent lithotomy dangerous, if creased hardness can have this effect, but the capacity of the not fatal; but such is not the case. Lithotomy after lithotrity, though a last resource, is far from bladder (i. e., the space left for the safe working of the instrua hopeless undertaking. The question which first prebeing ments) is relatively diminished in all cases of hard calculi, be- sents itself is-What are the conditions that may compel the cause we are then compelled to employ a lithotrite with longer surgeon to have recourse to the knife after failure with the beak, and to make more extended efforts both to break and lithotrite? As a rule, I would state that whenever lithotrity seize the stone. When the stone is large, it is readily found, has given rise to unfavourable symptoms, which continue in of all treatment, and lead to serious apprehension, the but not easily seized in its best diameter. When hard it is not spite health beingpretty good, lithotomy should be employed general easily reduced to detritus; the fragments are large and without delay. It be required in two classes of cases. angular, the sittings are long, the working of the lithotrite is In one, for instance, when the stone is large, and the first
may
111
LECTURES
ON
FEVERS:
BEING
however, they differ materially in structure, position, and liability to disease. They are found in the form of small rounded bodies, of the size of millet-seeds, projecting upon the internal surface of the mucous membrane (Fig. 1). They are met with FIG. 1.
The Lumleian Lectures, DELIVERED BEFORE THE
ROYAL COLLEGE OF PHYSICIANS OF LONDON, 1858-59 ; COMPRISING
A DESCRIPTION OF THE DISTINCTIVE CHARACTERS, PATHOLOGY, AND TREATMENT
A
solitary gland from the small intestine of the human subject, magnified. (After Boehm.)
OF
portion of the intestine. Wefind them scattered over the jejunum, but in greatest numbersover the ileum, the valvulse conniventes, as well as in the spaces between them; they occur also in the large intestine, particularly the caecum and appendix vermiformis. Around each gland there is a zone of the orifices of the follicles of Lieberkuhn. Examined by the BY microscope, they appear to be hollow sacs, covered with villi filled with mucus, resembling, on section, a Florence oil-flask, ALEXANDER TWEEDIE, M.D., F.R.S., wide at their blind extremity, tapering towards the surface of FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL, TO THE FOUNDLING HOSPITAL, the mucous membrane, on which they open by a very small EXAMINER IN MEDICINE IN THE UNIVERSITY OF LONDON, I orifice, not easily seen, especially when the gland or sac is ETC. ETC. THE
SEVERAL
FORMS
in every
OF
CONTINUED
FEVER.
empty.
LECTURE III. ENTERIC C
FEVER.
3. The agminate OJ’ aggregate glands are generally known by the name of glands of Peyer, who has minutely described them, though they were previously known to and delineated by Dr.,Grew, a Fellow of this College, in a paper published
FIG. 2.
Synonyms. A natomy of the intestinal glands. Symptoms.o1. Symptoms referable to the nervolts system-pain in the head, somnolence, delirium, spasms, the senses. 2. Symptoms ?’referable to the gastric system-diarrhcea, iratestinal 7tce?K
agminate glands (Peyer’s glands). 1. The glands of Brunn, or Brunner, are arranged in the submucous or areolar tissue of the duodenum, and have the appearance of small granular bodies, to which Brunner gave the name of the second pancreas, to the structure of which gland they bear strong resemblance. They are most numerous in the vicinity of the pylorus, commencing abruptly at the duodenal side of the pyloric valve, and gradually diminishing in number towards its lower portion, until they finally disappear. These bodies, better distinguished by the name of duodenal glands, from their being limited to this portion of the digestive tube, are small compound glands, presenting, when
A
of Peyer’s glands of the adult human subject, from the lowest part of the ileum. (After Bochm,)
patch
under the quaint title " The Comparative Anatomy of the Stomach and Guts," being several lectures read before the Royal Society in the year 1676. Peyer did not publish his description till the following year (1677)* They ought therefore to be called G’reto’6’ glands, or patches, if priority of discovery regulate the question. Each of these glands, the or aggregation of which constitutes a single Peyer’s patch, resembles in every respect the structure of the solitary, being a papilliform body, or vesicle, tapering to a pointed extremity, which projects amongst examined with a powerful lens, the characters of the salivary the tubes of Lieberkubn. They are arranged or collected in oval or elliptical, sometimes circular, groups or glands. They vary both in number and size in different sub- together the long diameter corresponding with that of the injects, and seem to disappear altogether in advanced life. In patches, testine. They are found always on its free border, opposite to no other part of the intestinal canal are similar glands discothat by which the mesentery is attached. These patches seem vered, nor are they known to be liable to any special disease. to belong, in an especial manner, to the ileum, and are found 2. The 3olita?-y glands have been sometimes, but erroneously, chiefly towards the lower portion, becoming more and more described as the glands, or patches of Brunner, from which, De Glandulis lutestinorum. No. 1901 E
gronninb
scattered-less numerous towards the duodenum, in which, however, Peyer once found a single patch. They vary in number, fifteen, twenty, thirty, or even more, being occasionally found. Sometimes they assume the appearance of bands two or three inches long, or occasionally they form irregular clusters, the largest being near the ileo-eaecal valve; in other cases, the patches terminate some inches below the valve. They are variously developed in different subjects, being in some planted in the substance of the mucous membrane, to which they impart a degreeof thickness: in others, they have the appearance of being imbedded in the muscular coat. On examining by the microscope the mucous membrane covering the patches, numerous depressions may be discovered, but each depression is distinct, and is the orifice of one of the follicles or crypts of
which the two
or
patch is composed, and it is not uncommon to find three diseased in the middle of a patch which is otherwise
sound. I may here observe, that Peyer’s patches are most distinct in young subjects; and as they seem to undergo rapid change after death, it is necessary, if an accurate examination is to be made, that the bodies be recent, and, if possible, those selected in which the death has been sudden, or from accident, or from It is some form of acute disease that has proved rapidly fatal. generally supposed, too, that during life they become changed, perhaps atrophied, from age, and after protracted illness. It is not unlikely that the alterations these patches undergo with advancing age may have something to do with the infrequency of enteric fever after the age of fifty. We know very little of the use of the intestinal glands. I have alluded to the resemblance between the duodenal glands and the pancreas in structure; and they are so strictly confined to the portion of intestine with which this gland is intimately connected, that it is probable that the functions of both are of the same nature, and that they form part of the salivary apparatus of the intestinal canal. The same resemblance of structure between the solitary glands and the glands of Peyer has been pointed out. Their functions, therefore, are probably not dissimilar. We know also, that the solitary glands and Peyer’s patches both undergo important alteration in two diseases,-in tubercular phthisis and in enteric fever,-proceeding in both to ulceration, whence results the diarrhoea in the latter stage of the one, and throughout the whole course of the disease, as a general rule, in the other.* It may naturally be inquired, if this lesion of Peyer’s glands be the pathological element in enteric fever, is it to be regarded as the cause of the phenomena in this form of fever, or as the effect of the fever poison on these glands ? The latter view is the more philosophical and correct. We observe in other acute affections morbid poisons giving rise to similar local or specific effects; for example, in smallpox, producing pustulation of the skin; in measles, affecting the skin and mucous membrane of the air passages; and in scarlet fever, the skin, the throat, and frequently, in the severer forms, the glandular or absorbent system. The same compound action has been observed in the plague, the poison acting probably first on the blood, and subsequently on the absorbents, giving rise to the well-known plague buboes. In the same way, the action of the poison which generates enteric fever on the intestinal follicles is explained; and whether its primary operation be on the blood, or on the nervous system, or on both, its specific effect on the intestinal follicles also, is scarcely
the face at times flushed, and at length, from increasing weak. ness, the patient seeks the couch, or prefers to keep to bed
entirely. Towards
night,
there is
more or
less
aggravation
of the
symptoms, accompanied with restlessness, inducing constant change of posture in the vain hope of finding relief; the sleep is disturbed and unrefreshing, the thirst more urgent, and the heat of skin more pungent. Sometimes there is vertigo, or the ears, or occasionally slight epistaxis. Such are the symptoms of the early stage of enteric fever; and though to an experienced observer they are sufficient to indicate the disease, there may be reasonable doubt as to its nature, until its characteristic eruption appears. This is seldom visible before the second week (generally from the eighth to the twelfth day) after the commencement of the symptoms, when, on close examination, a few small circular rose-coloured spots may be discovered, chiefly on the anterior and posterior aspect of the trunk, seldom on the face or extremities. As the characters of this specific eruption will be presently pointed out, I shall only observe that each spot is perfectly distinct, fades or entirely disappears on pressure, and after remaining visible for three or four days disappears, fresh spots coming out every two or three days, and undergoing a like process of eruption and decline. In this way successive crops of these spots appear until the conclusion of the disease. This characteristic eruption, however, as we shall presently see, is occasionally absent. If the abdomen be examined, it will be found more or less distended and resonant; a sensation of gurgling in the right iliac fossa, often accompanied with tenderness, being generally
singing in
perceptible.
The diarrhoea
so
commonly observed
as one
of the
early
symptoms varies in degree; sometimes it is moderate, sometimes profuse and exhausting, and in some cases accompanied
with blood. If the case be mild and uncomplicated, these symptoms continue without marked variation till towards the middle or end of the third week, when a gradual abatement of the more pro. minent, especially of the diarrhoea, portends the approach of convalescence. The change, however, is very gradual. The pulse becomes slower; the alvine discharges less frequent and more consistent; the tongue more clean ; the thirst abates; the heat of skin and restlessness disappear; the sleep is tranquil and refreshing; there is gradual improvement in strength; while the appetite for food returns, and is often so keen as to require great vigilance to prevent its too early indulgence, and consequent risk to convalescence. But the progress of enteric fever does not always run so smoothly. On the contrary, when the stage of convalescence is daily watched for with great anxiety, all the symptoms may continue unabated, or some of them become even aggravated. Thus the headache, which usually passes away towards the end of the second week, may persist, and eventually may be followed by delirium, or by somnolence, gradually passing into coma, more or less profound : the diarrhoea may increase, or a sudden discharge of blood from the bowels arise, which, if it do not destroy life, adds much to the danger: or, again, the intestinal ulceration may extend, inducing progressive emaciation and weakness, from which it may be difficult or impos, sible to restore the patient. Not unfrequently the progress of the fever is interfered with by some form of pulmonary complication. This may be open and easily detected; but in many cases, more especially when there has been early and severe disturbance of the nervous system, it assumes a latent form, questionable. and is recognised only by careful auscultation, which may reBefore describing the individual symptoms in detail, I shall veal either pleurisy, bronchitis, or pneumonia, more or less diffused. Sometimes, and indeed not uncommonly in severe sketch the progress of enteric fever of moderate severity. But let me here observe, that the disease, in the early period cases, there may be both cerebral and pulmonary disease coat least, and often throughout its subsequent stages, is of a existing ; so that the fever may be said in its progress to have involved the most important internal organs. Under such more acute or sthenic character than its prototype, typhus. We have seen also that it occurs at the more early periods of life- extensive complications the issue is seldom doubtful. In proportion to the intensity of the local complication, the most commonly between the ages of fifteen and thirty, seldom after forty, though I have seen it in persons beyond the age of general or febrile symptoms increase; indeed, a low form of secondary or symptomatic fever may be said to supervene. The sixty. It commences slowly and insidiously, so that the patient pulse rises in frequency, and is weak and compressible; the is often able to pursue his ordinary avocations, complaining tongue becomes dry, brown, shrivelled, and often fissured; the teeth and lips covered with brown or black incrustation; only of undefined indisposition, such as irregular chills, loss of the emaciation progressive; the weakness day by day more a or less of and more headache, limbs, thirst, appetite, pain the evacuations passed unconsciously; the sacrum, marked; for and lassitude account. of which he cannot degree languor In the course of a day or two, these symptoms increase, the hips, and other parts subjected to pressure, becoming inflamed passing rapidly into gangrene; or pus may be deposited pulse quickens, there is less inclination for exertion, the tongue and in different parts, more commonly in the joints. to be sometimes bowels furred, the relaxed, disposed It is unnecessary to observe that the ultimate issue, under with abdominal pain, the countenance altered in expression, such complications, must depend on the circumstances pre* sented by each case: the degree or intensity of the local comSee Todd and Bowman, vol. ii., p. 234.
becomes
108
I may here remark that, however much the brain may have day suffered in the progress of this form of fever, permanent mental may linger and eventually recover, or death may result from imperfection, in my experience, rarely follows. After severe gradual exhaustion, seldom before the fifth or sixth week. cerebral disturbance, the powers of the mind are occasionally Many cases are protracted to a much later period; indeed, somewhat, though temporarily, enfeebled; but this condition there is scarcely a limit to the duration of complicated enteric disappears as the patient regains strength. This accords with fever. Or, lastly, the ulcerative process may gradually destroy the experience of Louis, who mentions that he had observed in succession the coats of the intestine, and at length perforate the the intelligence affected during convalescence in one case only, may be speedily cut and in this patient the mental capacity was small. He reperitoneal covering; and thus the patient off. Dr. Jenner notes that when death is the result of the mained for six weeks in a kind of idiotic state, from which, general disease, the fatal termination always occurs before the however, he ultimately slowly recovered. As to the relation between the delirium in this form of fever thirtieth day. Local lesion sufficient to account for death is always found after that date,-proving the natural duration of and the condition of the brain after death, Louis states that, out of twelve subjects, who either had no delirium, or in whom this the general disease to be about four weeks. symptom occurred only momentarily during the last two or I shall now proceed to enter more fully into the consideration three days of life, or for twenty-four hours during the disease, of the individual symptoms of enteric fever. I shall describe -in four, the cortical substance exhibited a slightly rose tint them as they occur-1st, in the nervous system; 2nd, in the throughout its whole circumference; in six, it was perfectly gastric system; 3rd, in the skin; and 4th, the local affections healthy; in one case, it was very much injected, with slight or complications. softening of one of the optic thalami, the entire cerebral mass 1. Symptoms referable to the nervous system.-Of the cerebral being less consistent than usual. So great a variety in the appearances after death, in patients symptoms, one of the more early and constant is pain in the head, observed in the mild as well as in the severe cases. who had no delirium, must lead us to doubt our ability to find Sometimes it is confined to the forehead and temples, some- in appreciable alterations of the brain an explanation of the times it extends ever the head, often in severe cases accom- symptoms of which it is evidently the source, and to render it panied by intolerance of light, conjunctival injection, or throb- more than probable, that those changes may take place in the last days of existence. bing of the carotid and temporal arteries. Louis affirms that pain in the head is one of the most comAlthough the cerebral symptoms in general seem to bear no mon symptoms of acute fevers of every kind, but more frequent relation to, or are not dependent on, any certain or fixed in persons affected with enteric fever than with any other dis- lesion of the brain or its membranes discoverable after death, ease ; and as in the former (enteric fever) it is almost constant, I cannot concur in the idea suggested by Louis, great as and begins with the first accession of the symptoms, its ab- his authority is-that the brain symptoms are dependent on sence at the beginning of a febrile affection, in which other the changes in the intestine, which constitute the peculiar symptoms characteristic of this disease are wanting, would in- anatomical distinction of enteric fever; and for this reason, dicate that the disease is not enteric fever. that in many cases-I will not affirm in the majority-where Somnolence is another very common symptom. In the milder the intestinal lesion has gone on, and ultimately proved fatal, there has been neither delirium nor somnolency at any period cases it is less marked, appears later, and is of short duration. In the more severe, it comes on early, is of longer continuance; of the disease. and in fatal cases, it increases in intensity, until it ends in I am disposed, therefore, to look, not to the solids, but to deep coma and death. Louis investigated this symptom with the blood, as the source of the disturbance of the functions of great minuteness, and found that in patients who recovered, out the brain in this fever, just as we find in ursemio poisoning of fifty-seven in whom the affection was severe, eight had no marked sensorial affection. It may be said that if the changes drowsiness ; in forty, in whom he noted with care, the origin, the blood undergoes be the source of the cerebral symptoms, duration, and degree of this symptom, in no individual did it how are we to account for their absence in exceptional cases? The explanation is, that there is a less amount of feveroccur on the first day of the disease, in only one on the second, in two on the sixth and eighth, generally on the ninth, and in poison in the blood-less than is sufficient to produce the brain The average was on the affection; or it may be that, in some individuals, the cerebral an extreme case, on the fortieth. fourteenth day of the fever, its mean duration was eight days, mass is less susceptible, less easily impressed by the morbid and the extremes of the duration twenty-one days. Somnolence blood,-just as we observe great difference in the effects of is also one of the most marked symptoms of the enteric fever of alcoholic stimulants on the nervous system in different persons. children, and may be looked for at any period of the disease. /S’p
and the stamina or power of the patient to contend plication,such from a formidable disease. He
against to day
109
It seldom spreads to the tympanum; hence loss of hearing is by no means a common result of enteric fever. The sense of taste is generally altered or perverted, articles of food appearing either tasteless, or having a flavour different from what is usual. This may arise partly from the state of the tongue and palate, but in part, if not chiefly, also, from perverted nervous sensation. In some patients the sensibility is perverted-often augmented. This is more commonly noticed in females of the hysteric temperament, in whom the cutaneous and perhaps the muscular systems are morbidly sensitive, the slightest touch apparently causing great pain. It is of importance to discriminate this cutaneous tenderness in the epigastric and abdominal regions from peritoneal inflammation, for which, by a careless and inexperienced observer, it may be mistaken. The diagnosis is determined by observing that there is the same tenderness when pressure is made on any part of the bodythe arm, chest, or lower limbs, for example. Besides, the absence of vomiting and of constipation assists the diagnosis, though I admit there may be in some cases considerable difficulty in coming to a right conclusion. On the other hand, wee must not overlook the possibility of peritonitis springing up in the hysteric diathesis. In such mixed cases, the persistent vomiting, the constipation, thirst, and hot dry skin-the attitude of the patient as she lies on her back with her knees drawn up, and the severe paroxysms of abdominal pain when the belly is untouched-all point to the existence of peritoneal
shrivelled, dry, and cracked or fissured state, the being transverse or longitudinal-more generally transverse ; sometimes exhibiting ulcerations more or less deep. Occasionally, the fur or coating becomes quite black, or a layer or stratum of blood is spread over the dorsum, while the teeth and lips are covered with a similar incrustation. This brown assumes a
fissures
black incrustation, which is due to exudation of blood, in. dicates an unusually severe form of fever, and more especially so when it is tremulous, and protruded and retracted with difficulty. When there is vivid redness of the tongue, the same condition may be observed in the mucous membrane covering the mouth and roof of the palate, uvula, and tonsils, giving rise to various uncomfortable sensations-dryness, heat, pricking, difficulty or pain in swallowing, and often irritating cough-which are also, in some degree, due to the constant passage of the air over those surfaces, when the breathing through the nostrils has become impeded, in consequence of a congested or swolien state of the mucous membrane of the or
nasal
cavity. deglutition, depending on subacute inflammation of the posterior fauces, may arise, and, even when trivial, should never be overlooked, as it may suddenly increase, and, by involving the structures in the vicinity of the glottis, terminate either in angina laryngea or in abscess of the velum or posterior pharynx, which I have repeatedly known to destroy life by its pressure on the rima of the glottis. The patient is often not sufficiently alive to pain to make any cominflammation. plaint, and it is perhaps only by observing the difficulty with Muscular aching, backache, and pain or sense of weariness which fluids are taken, that mischief in the throat is sus. in the extremities, are all referable to the same condition of pected, until (perhaps suddenly) the frightful symptoms of the nervous system-perverted sensibility. laryngitis show too clearly the impending danger. 2. Gastric system.-In the whole catalogue of symptoms Dia7r7aca.-Though diarrhaea is not invariably present in enteric in of enteric none either a are so fever, it is so constantly observed as to constitute one fever, diagnostic important, distinctive or practical point of view, as those referable to the of its characteristic symptoms. The follicular disease, as in gastric organs. This may have been anticipated from the inflammation of the mucous lining of the intestines from ordilesions of this form of fever being chiefly limited to the ab- nary causes, induces frequent action of the bowels, and hence the natural secretions, being evidently a source of irritation, dominal organs. We shall consider the symptoms connected with this system are frequently expelled. In mild cases, the bowels are generally in a natural statein detail, although it is almost unnecessary to remind you, that all of them are not present in every case, or that some of them seldom relaxed; or if there be a tendency to relaxation, it is remarked in the more advanced period of the disease. In the may be more constantly observed than others. In many patients, at the commencement of the disease, there more severe, there is diarrhoea at the beginning and throughout fever, the stools being serous or watery, often accompanied are occasional feelings of nausea, which, if followed by retch- the with griping, and followed, when the diarrhoea has been proor vomiting, may at first give an impression that the patient ing is only suffering from a bilious disorder." This idea is, how- fuse, by exhaustion. Sometimes they are ochre-coloured, or ever, soon put aside by the little mitigation that follows the like pea soup; often dark, resembling coffee-grounds; and occasionally mixed with mucus. vomiting, as well as by the occurrence of other symptoms. Painful
"
From
investigations
into the nature of this bilious fluid
re-
From Louis’
statistics,
we
find that this
symptom occurred
cently recorded by Dr. Frazer, it would appear that it is modi- in all his patients except three; and that out of forty cases fied blood, and that though it may be mixed with bile, it is observed, twenty-two had somewhat frequent and liquid de. frequently entirely free from it. He states that the small jections during the first day of the disease. Of the others, nine began to have diarrhoea between the third and ninth day, masses which float through it, and give it its peculiar colour, and six between the eleventh and fourteenth. It should be are clots in which blood-corpuscles can be seen on microscopic examination. The symptom then evidences an effusion of blood, observed, also, that the three patients who had no diarrhea and, indeed, sometimes alternates in the discharges with red died after the thirteenth and fourteenth days of the disease; blood. Dr. Frazer has been able to restore to it its red colour and on dissection, ulceration of Peyer’s patches was discovered. by supplying oxygen. Why it assumes this green colour is not As to the number of evacuations, out of thirty-two patients in whom this symptom was tecurately noted, he found that in as yet known; but the green colonr assumed by the body while eighteen, the average was eight to ten or more daily; in seven, undergoing decomposition, is an analogous instance.* Sickness and bilious vomiting, geperally accompanied by the diarrhoea was more moderate, the average being four to epigastric pain, now and thm supervene also when the fever six; and in an equal number-viz., seven-it was slight, the is somewhat advanced. According to Louis, when these symp- evacuations rarely exceeding two or three in twenty-four hours, toms (epigastric pain and bilious vomiting) occur late in the Again, the diarrhoea, whether slight or severe, or whether fever, we may infer the existence of a lesion of the mucous or not it appears at the commencement of the disease, varies membrane of the stomach. He found that of thirty fatal cases, in its course. Sometimes, after gradually increasing, it betwenty had nausea, vomiting, or epigastric pain, of whom comes stationary, or it may diminish towards the latter stage eleven exhibited more or less serious alteration of the mucous of the fever. In other instances, such is its caprice, that after membrane of the stomach, the extent of the lesion being, ap- being moderate in the early stages, it suddenly increases in parently, in proportion to the duration of the vomiting; and the advanced. that out of fifty-seven patients, in whom the fever was more or Again, the bowels, instead of being relaxed, may be con. less severe, but who ultimately recovered, forty-three had fined, the evacuations being more or less consistent. In symptoms referable to the stomach-viz., thirty had pain in an excellent paper on Fever by Dr. Wilks," he says: "Asa the epigastrium; nineteen, sickness only; and twenty had rule, the contents of the bowels in fever (typhoid-i. e., enteric) are fluid, but not always so, as another case will show. It vomiting. The tongue, in a considerable proportion of cases, is little was that of a young girl, who had been ill three weeks, and altered from its natural appearance. Louis found it natural, whose bowels were said to have been irregular, but generally or nearly so, in about half the cases analyzed by him-that is, confined, and who came to Guy’s Hospital to die. The moist, without morbid redness, perhaps slightly coated with post-mortem inspection showed the intestine full of firm slimy, whitish or grey fur; it may even preservethis appear- scybala; and on removing these, under each was found an ulcer." ance throughout the course of the fever. But Ml others, after I have often met with similar cases, showing that there maybe having been slightly coated, it becomes more or less red at the ulcerated intestine, and even perforation of the bowel, without edges and tip, and occasionally covered with a dark-brown diarrhoea, instances of which will be found in my Clinical stripe, or fur, on the dorsum. As the fever progresses, it Illustrations of Fever, published thirty years ago. *
*
Dublin Journal. February. 1858.
110
*
Guy’s Hospital Reports, vol. i., New Series.
z’
Intestinal haemorrhage is peculiar, or nearly so, to enteric likely to produce pain and irritation, thereby aggravating any fever, for although it may also occur in ordinary typhus, it is unfavourable symptoms which may have previously existed. very rarely observed. I had a case, some time ago, in the hosI have already alluded to the modifications in opepital, in which this appeared to be the destroying cause, and rating when the stone is large and hard. In required these cases the on opening the body, Peyer’s patches were found to be sound, but the mucous membrane of the lower portion of the ileum, bladder should be cautiously injected; great care must be obcaecum, and commencement of the colon, exhibited a red swollen served not to irritate this organ, either in our attempts to seize appearance. In this patient there was the well-marked mul- or break the stone; the first sitting should be short, the opeberry (typhus) eruption to assist the diagnosis. rator not proceeding further than to break the stone; finally, if The quantity and appearance of the blood vary much; somethe screw, which very rarely happens, the times the amount is so small as to be sufficient only to indicate the the calculus resist once abandoned. must be at tendency to haemorrhage; more generally, however, it i-s much operation of diminished capacity of the bladder preAn evident cause half an ounce to several in more ounces; larger-from, perhaps, sents itself in cases where an enlarged prostate projects into rare instances, as much as twelve or even sixteen ounces have been discharged at once. But as it may be passed in variable the cavity of this organ. This must necessarily reduce the quantify for several days, the total amount cannot be esti- working space and impede our manipulations. In searching mated, except by its influence on the patient’s strength, which for the stone, the revolution of the lithotrite is soon arrested, is seriously, and often fatally, impaired by such a serious drain and it is often difficult to separate the blades to any extent without meeting the projecting lobe of the prostate. Hence on the already prostrated powers. The evacuated blood differs in colour and consistence; some- there is always some difficulty in properly seizing the stone, times it is of a bright red, but this is rare; more generally it is and often considerable pain and irritation in attempting to dark, or almost black, and as to consistence, it is usually thin crush it. In previously noticing these difficulties, I mentioned and uncoagulated, resembling thick treacle; occasionally, it is that a longer instrument than that in ordinary use must be employed, and it should be carried towards the posterior part passed in solid coagulated masses. The source of the blood may be traced to the ileum and of the floor of the bladder before it is opened to seize the stone. Lastly, in a numerous class of cases, as a consequence of procsecum, and to issue both from the ulcerated patches and intervening mucous membrane. In one case under my care in the longed disease, the bladder itself may be permanently conhospital, Dr. Jenner found after death, that water thrown into tracted, or at all events may have a tendency to contract the superior mesenteric artery poured forth freely from the strongly on slight irritation. These cases are difficult to edges of an ulcer, from which, doubtless, the haemorrhage, manage, and require great care. They are not to be undertaken lightly, nor, on the other hand, is the patient to be dewhich was the immediate cause of death, proceeded. prived of the benefit of lithotrity merely because the bladder is unusually contracted and sensitive. It is important to notice, that certain conditions of the urinary organs, such as pain and excessive contractility of the bladder, do not always depend OBSERVATIONS ON LITHOTRITY. on organic mischief, but on the temporary effects of the presence of the foreign body in the organ, and are relieved or disappear BY WILLIAM COULSON, ESQ., as soon as the stone is crushed. Even some indications of chronic SURGEON TO ST. MARY’S HOSPITAL. inflammation, such as a discharge of mucus or muco-purulent matter, with pain and a frequent desire to pass urine, will (Continued from p. 82.) disappear after the first or second sitting. Still, in these cases, as I before remarked, caution must be observed. We must not AT the first sitting the calculus is merely broken, and other persist too long in the operation, lest we excite a degree of inflammation which cannot be subdued. I would lay down as a operations are required before the bladder is entirely freed from rule of practice when no serious organic mischief exists, and the foreign body. The number of operations, and the interval the stone is small, that lithotrity may be attempted and perbetween them, will depend on the circumstances of each case; sisted in as long as unfavourable symptoms do not arise. Everybut the surgeon should always bear in mind the important rule thing which has a tendency to increase the already great of not attempting too much at a time. In simple cases the first sensibility of the bladder must be sedulously avoided. We must only two or three ounces of water, and make the crushing may be borne so well, that the effects of the opera- first inject as sitting short as possible; and in case we cannot seize tion will have disappeared in two or three days. Here the the stone at once, we had better not persist in our efforts. operation may be repeated at the end of a week, and a few After the operation, care should be taken that the fragments sittings, at shorter intervals, will generally be sufficient for the do not collect about the neck of the bladder, an accident likely to occur from the tendency of the organ to contract. Hence cure. In other cases, from the size of the stone or the condition of the importance of keeping the patient on his back, with the of freely washing out the bladder, and of passing the bladder, constitutional disturbance, with considerable local pelvis raised, the catheter when the least stoppage occurs. irritation, soon shows itself. There is fever, frequent desire to ’, However, with all our care, the irritability of the bladder pass urine, with pain at the neck of the bladder and along the may increase to a severe degree. The stone may be broken, urethra. Under these circumstances, the second operation must and on the next or following day great pain and irritation may be deferred until the constitutional and local disturbance has arise from the presence of the fragments, with a constant desire to pass urine, and considerable difficulty in voiding it. A little entirely subsided. The second operation is usually better borne later more unfavourable symptoms set in-high irritative fever, than the first, and four or five sittings, at intervals of as many extreme local irritation, with great pain in passing the fragdays, will be sufficient to complete the cure. ments, or rather in the efforts to pass them (few or none being There is, however, a class of cases in which the operation voided). Now, in a case of this kind, what is to be done? cannot be performed without difficulty, and a certain degree of The attempt to break the stone cannot be renewed, and the strength, which before the crushing was good, is now danger as to the result. By far the most frequent difficulty patient’ssinking. Under these circumstances, are we justified rapidly in contend is the with which we have to want of lithotrity in resorting to lithotomy ? A priori, we might think that the sufficient space in the bladder to work our instruments with succession of one capital operation to another must be attended ease and safety. This difficulty is often caused by the density with too great risk; that the mischief set up by the previous and size of the stone. At first it might not appear how in- lithotrity must render the subsequent lithotomy dangerous, if creased hardness can have this effect, but the capacity of the not fatal; but such is not the case. Lithotomy after lithotrity, though a last resource, is far from bladder (i. e., the space left for the safe working of the instrua hopeless undertaking. The question which first prebeing ments) is relatively diminished in all cases of hard calculi, be- sents itself is-What are the conditions that may compel the cause we are then compelled to employ a lithotrite with longer surgeon to have recourse to the knife after failure with the beak, and to make more extended efforts both to break and lithotrite? As a rule, I would state that whenever lithotrity seize the stone. When the stone is large, it is readily found, has given rise to unfavourable symptoms, which continue in of all treatment, and lead to serious apprehension, the but not easily seized in its best diameter. When hard it is not spite health beingpretty good, lithotomy should be employed general easily reduced to detritus; the fragments are large and without delay. It be required in two classes of cases. angular, the sittings are long, the working of the lithotrite is In one, for instance, when the stone is large, and the first
may
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