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LECTURES ON FEVERS: BEING The Lumleian Lectures,
FEBRUARY 18, 1860. and more be a perforation of the small intestine." In this short sentence the symptomatology of intestinal perforation is succinctly given. BEING Louis further affirms, and the observation is important, that he has never met with peritonitis in the progress of acute diseases, except as a consequence of perforation of the small intestine in subjects affected with the typhoid affection. DELIVERED BEFORE THE On the other hand, it should be kept in mind that even when this accident (intestinal perforation) occurs, the symptoms may COLLEGE OF PHYSICIANS OF LONDON, not be ROYAL For example, in a case given by so well pronounced. 1859-59; Louis, in which, during cerebral disturbance, perforation occurred and was the cause of death, the only symptoms wereCOMPRISING constant chills, and twelve hours before death the face, hands, and upper part of the chest became of a purple hue. The abA DESCRIPTION OF THE DISTINCTIVE domen, which was much distended, was not painful, except on CHARACTERS, PATHOLOGY, AND firm pressure, which produced a little distortion of the features. TREATMENT On examination after death, a perforation about the size of a OF large pin’s head was found in the ileum, about six inches from the caecum. THE SEVERAL FORMS Though few patients survive more than from twenty-four to OF thirty-six hours, or a few hours longer, after the signs of perCONTINUED FEVER. foration show themselves, instances have occurred in which existence has been prolonged for some days after. Louis had one patient who lived seven days after the development of the BY first symptoms, which were very violent at the commencement, ALEXANDER TWEEDIE, M.D., F.R.S., and were not mitigated until the beginning of the fourth day. In a case under my care in the hospital, the patient survived FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL, TO THE FOUNDLING HOSPITAL, sixteen days. EXAMINER IN MEDICINE IN THE UNIVERSITY OF LONDON, It is well to remember that intestinal perforation may ETC. ETC. happen suddenly when it is little looked for. I have known it occur when convalescence was sunbosed to be progressing so surely and satisfactorily that the patient was allowed to leave the house. Nor is the state of the bowels, either .CI..1.." ..1."’. as to the presence or absence of diarrhoea, to be depended for you will find cases recorded (and I have had on as a
LECTURES ON
FEVERS:
The Lumleian Lectures,
1 1’I 111 V
.I:.cJ:
Y
.I:..I
tympanitis, gurgling. 3. Symptom meteorism or
convalescence,
No. 1903.
accompanied by altered expression in the features, or less speedily by nausea and vomiting, there must
been committed. For example, Louis states that he heard an days, they gradually fade, and ultimately entirely disappear, eminent physician pronounce a patient with the typhoid affec- without leaving a mark or stain. They are replaced by a fresh tion (enteric fever) to have hepatization of the right lung, on eruption, which, after pursuing a precisely similar course, in its the ground that, the abdomen being greatly distended with turn dies away; and in this manner the spots come out and air, a flat sound was elicited, much higher than usual, on per- disappear, until the termination of the fever. Their mean cussing the right back of the chest. Examination of the body duration may be stated to be from eight to nine days. This eruption (rose spots) is, according to M. Taupin, not after death showed the lung to be quite healthy, and the cause of the flat sound to be the liver, which had been pushed very less frequently observed in children than in adults; for out of 121 cases of enteric fever in early life noticed by him, it was high by the great distension of the tympanitic colon. During my attendance, some years ago, on a gentleman with observed in all except eleven, and of these eleven three were enteric fever, an hospital surgeon met me in consultation, in not received into the hospital until three weeks or more after consequence of the alarm excited by the unusual tympanitic the commencement of the disease, during which period the distension. This gentleman mistook the hour appointed for spots might have disappeared. M. Rilliet, on the other hand, observed them in two-thirds of his cases only; but he does not our meeting, and after waiting some time, the medical attendant of the family, who had watched the case with me, was say whether the patients in whom the spots were not seen sent for, and the examination of the patient was proceeded were received into the hospital at a late period of the fever. with. On retiring to an adjoining room, the pathology of the It may, however, be assumed that in children the spots apcase was debated, when this hospital surgeon came to the conpear at an earlier stage of the fever than in adults, for both clusion that the disease was ascites, and, notwithstanding the these writers state, that they observed the eruption generemonstrance of the family attendant, was in the act of pre- rally from the fourth to the eighth day of the fever, sometimes occasionally later. They were found by M. Taupin in scribing elaterium, when I arrived, and took the liberty of sooner, some children as early as the second day, but they generally his and both The stoutly resisting diagnosis therapeutics. disappeared after a day or two. patient after a tedious illness ultimately recovered. It is satisfactory to find from this author, that he had never In the enteric fever of children, this symptom occurs not less frequently than in adults. M. Rilliet met with it, in met with the rose spots in any other infantile disease, except various degrees, in about two-thirds of his cases, but more fre- enteric fever. There is another point in connexion with this spotted erupquently in those who died than in those who recovered. On the whole, it may be inferred that the infrequency of tion that requires passing notice. In some cases it is preceded meteorism in acute diseases, not enteric fever, and its frequency for a day or two by a scarlet efflorescence, very much like and degree in the latter, render it an important diagnosic roseola; when it appears, it is apt to throw doubt on the nature of the disease, and there is even a possibility of its being symptom. mistaken for scarlatina. As the disease progresses, however, the of examined the coactim be region Gurgliaay.-If carefully doubt is soon dispelled. by the fingers of both hands-with the precaution, for obvious theBut this rose-coloured rash is not invariably present. It with of this canal of the intestinal reasons, handling portion is difficult to obtain statistical results on this point that very a gurgling sound may be first care It was elicited. on. The spots may have disappeared, when the pointed out by Chomel, who considered it as one of the signs can be relied of enteric fever. Though it may be frequently discovered, it patient is examined, or they may be so few in number as to is much oftener absent, and cannot therefore be regarded as escape detection. We have not overlooked this matter in the Fever Hospital, for the presence or absence of the characterone of the constantly present diagnostic symptoms of this istic rash is invariably noted; and were I to give an approxidisease. mative idea of the total number of cases in which the rose 3. Skin.-One of the most distinctive characters of enteric appear at any stage of enteric fever, I think ten or fever-not, however, as we shall see, invariably present-is an spots do notcent. will be nearly correct. twelve per of small lenticular scattered rose-coloured spots, eruption chiefly Sudamina.-In the progress of enteric fever, we occasionover the surface of the abdomen and chest, where the cuticle is observe a vesicular eruption, termed, from its resemblance known to be thinnest. Sometimes a few of these spots (from to sweat drops, sudamina, though no one supposes that it has six to twenty) are seen, after careful examination, on the most remote connexion with the function of perspiration. abdomen, or one or two may be discovered on the chest and the is also by the name of miliaria, or miliary rash, and back; when there is an abundant eruption, they are not It known as you are aware, of small, prominent, round, transconsists, limited to the region of the trunk, but may be seen on the parent vesicles, formed by the effusion of limpid fluid under extremities, and even, though rarely, on the face.** Each spot is of a circular shape, varying in size from a point the cuticle. The vesicles are usually about the size of milletto a line and a half, rarely exceeding two lines in diameter, seeds, the intervening spaces retaining the natural colour of skin. slightly raised above the surrounding cuticle, and of a pink-rose healthy This which is an occasional accompaniment of other rash, colour, disappearing on pressure, but returning as soon as the acute maladies, rarely appears before the end of the second is not is Their attended removed. by any eruption pressure unusual sensation, and they seldom appear before the fifth day week of the fever. It comes out more generally on the anterior aspect of the thorax, on the abdomen, inguinal regions, of the fever, more commonly in the second week. M. Louis, who observed these spots very carefully, found neck, and axillæ; seldom on the back or limbs, and never on them readily in twenty-six out of forty-six cases that were the face. Its duration is not uniform; sometimes the vesicles, after continuing prominent for a few days, shrivel, and disap. fatal; and in fifty-seven that recovered, they were discovered in all, except three. It was also noticed to be invariably pre- pear with desquamation; in other cases, they remain visible for eight or ten days. Their average duration, however, may sent in all the cases that were mild. In respect of the period of the disease at which it came out, be stated to be from three to ten days. This eruption d not seem to have any special influence on it was visible in two patients on the sixth day; in three, on the I the symptoms org=’ ress of the fever, though it has more frea seventh; in third of the cases on the tenth; and in ten, it did not appear until between the twentieth and thirtieth day quently been obsed ;= ’’ "’ uses of more than average severity as to its comparative prevalence, out of the disease. In the cases tabulated by Chomel, it was noted than in the of at the Hotel Dieu or La (observed ninety-eight patients in two between the sixth and eighth day; in thirteen, between it was discovered in seventy-six; and it was remarked the eighth and fifteenth; in seven, between the fifteenth and Pitie), that there in these instances, to be very little relation twentieth; in four, between the twentieth and thirtieth; and between theseemed, of the sudamina and the condition of abundance in one, on the thirty-seventh day. the skin as to perspiration. If, however, an average be taken, these rose spots may be This eruption has also been observed in the enteric fever of assumed to come out between the sixth and ninth days after M. Rilliet having noted it in two-thirds of his cases, children; the commencement of the fever : it is certain, at least, that in half the number of patients they are found between those days. and M. Taupin in one hundred and four out of one hundred It would also appear that, except in cases of relapse, fresh rose and twenty-one. M. Rilliet states that it generally appeared between the eleventh and twentieth days, and that its average spots do not appear after the thirtieth day of the fever. duration was from one to six days. Again, these spots do not, as in the typhus eruption, persist My own experience of the occurrence of sudamina, both in after visible or nine the fever, but, throughout remaining eight hospital and private practice, differs in respect of frequency * For permission to exhibit the beautiful wax model of this eruption on the from that of continental physicians. It is comparatively rare table I am indebted to the authorities of Guy’s Hospital. It is a life-like in the enteric fever of this and I do not remember a country; artistic skill has enriched the representation, executed by Mr. Town, whose single instance of its occurrence in private practice. museum of Uuy’s with the most valuable series of pathological models in Europe. Erysipelas.-I may here advert to the occasional appearance -
ally
milde
-
--
160
erysipelas inthe progress of enteric fever, but it is to be re- consequence of portions of the lung being blocked up by the garded as accidental or intercurrent only. It shows itself in intiltrated morbid products. The laryngeal angina alluded to is fortunately much less the wards of the Fever Hospital at certain periods of the year, just as it is known to prevail in other hospitals amongst the frequently met with than either of the preceding lesions, and, medical, but more especially amongst the surgical patients; whether it arise from simple cedematous infiltration or from often appearing suddenly, lasting for a time, and then dis. the typhous deposit, may be recognised by its characteristic appearing. When it gets into the wards, it spreads by con- symptoms--intense agony in the effort of swallowing, succeeded tagion, but it may be also excited by trivial wounds, such as by ringing cough, stridulous sound of the breathing and voice, leech-bites, cupping scarifications, or blistered surfaces. It is with frequent attacks of laryngeal spasm threatening suffocainfinitely more common on the face and head, often apparently tion. PleU1’itic inflammation.-In enteric fever there is a marked commencing in the throat, and thence spreading outwards, through the nose or ear, to the face, scalp, and neck. It seems tendency to inflammation of serous membranes, and hence to have no precise or definite duration, and terminates either in pleuritic inflammation is a frequent complication or secondary resolution, vesication, or purulent infiltration, and, when se- affection. It may not be always recognised by the general vere and extensive, may be, per se, the destroying cause. symptoms alone, but by careful auscultation its presence can Epistaxis. This is another occasional accompaniment of scarcely be overlooked. It is decidedly less frequently observed enteric fever. The amount of blood varies, being sometimes in the typhoid affection of Paris. Thus Louis mentions that small, perhaps only a few drops; more often moderate, seldom out of fifty-seven cases, he only met with one example of of pleurisy as a complication of enteric profuse. It may occur once only, or for several successive it. This to fever does not with the experience of British phyand is not limited accord it of the occurfever, any period days; ring sometimes at the commencement-more commonly when sicians. There appears, as I have already remarked, to be a it is somewhat advanced. It is seldom preceded by any un- peculiar susceptibility in this fever to serous inflmmaation, usual sensations to denote its advent, nor is the patient sen- more especially to pleurisy, and it is well to be on the look-out for it even in mild cases. It is indicated by sudden sible of any change in the symptoms after its cessation. It is observed less frequently in the mild than in the more chills or shivering, pain or stitch in the side on deep inspiraof
-
infrequency
Thus, Louis noted it in about half the cases tion, disinclination to lie on the affected side, hurried breathmild, and in twenty-seven out of thirty-four in whom pleural friction, or a limited degree of dulness, but be always detected. In other, and perhaps the the fever was severe, but not fatal. I am inclined to think these that it is less frequently observed as a concomitant of enteric greater number of cases, however, the disease is less open; fever in this country. Dr. Jenner remarked it in only five there may be little if any pain or stitch, little or no hurry out of fifteen, the particulars of which were obtained from the in the breathing, perhaps only flushing and hot skin, to
severe cases. that were
ing, with may not
indicate that something is wrong. Examination of the chest seldom fails to reveal the secret, by circumscribed creaking heard over the seat of the pleuritic inflammation; or if the mischief has crept on insidiously, the percussion note is dull and the respiratory murmur absent, indicating the existfew drops of blood; and he noticed, that several childret ence of fluid more or less copious in amount. It is remarkable who had been subject to bleeding at the nose before they had how rapidly the fluid accumulates in some cases, and even with little warning of the antecedent inflammation; hence enteric fever, had none at all during the whole period of thei: the necessity of watching, in cases of enteric fever even comillness. 4. Organs of respiration.-Although it cannot be said that paratively mild, for the first approach of pulmonary sympin enteric fever the pulmonary organs are necessarily involved toms, which may surprise us at any stage of the disease, or even in the general disturbance, there are few cases of severity in during convalescence. which they entirely escape. When the pleuritic inflammation occurs on the left side, it The pulmonary complication may be exhibited either in the may spread to the pericardium and even to the valvular appaform of simple catarrh, bronchial catarrh (bronchitis), inflam- ratus of the heart-a complication which, I need scarcely obmation of the pulmonary parenchyma, or of the pleural cover. serve, though not always necessarily fatal, seriously involves ing, each being indicated by its peculiar local or physical the safety of the patient. Again, it should be kept in mind, that fever, either signs. In a considerable number of patients, but especially when enteric or typhus, occasionally supervenes on chest diseases (as there is coexisting brain affection, the pulmonary lesion is well as other organic affections), and may thus become in grafted latent, and can only be detected by careful auscultation. Irre- on the various forms of chronic pulmonary disorders so prevagular accessions of flushing, and general heat of skin, especially lent in this variable climate. The history of each case, if careif accompanied with paroxysms of coughing, are sufficient to fully inquired into, will tend to distinguish this class from those indicate some form of secondary pulmonary affection, the pre- of enteric fever with pulmonary complication, though it must cise nature of which can only be revealed by careful physical be admitted that there is often much difficulty in arriving at a examination. But even such general symptoms are often ab- correct diagnosis. Abdomen.-In the abdomen we rarely meet with peritoneal sent, and the lung disease may remain undiscovered, unless the practitioner is on the watch, and, by repeated local exami- inflammation as a secondary affection, but more generally as nation, detects the existence of the secondary affection of the the result of intestinal perforation. The other lesions found after death-the various changes in lung, which, be it remembered, may suddenly spring up at any period of the fever, and render a mild case severe, or even Peyer’s glands, in the mesenteric glands, and in the spleen-to be afterwards more particularly described-are not to be viewed dangerous, if not fatal. ascribes these various Rokitansky pulmonary complications as complications, but as constituting the true anatomical chato the peculiar typhous deposit (or, as he terms it, typhous racter of this disease. process), which may be effused either on the epiglottis and The various lesions which occur in the progress of enteric larynx, the mucous membrane of the lungs and bronchial glands, or into their parenchyma, producing laryngitis, bron- fever, as might be supposed, not only materially influence the general character and duration of the disease, but may even be chitis, or (the so-called) typho-pneumonia. The bronchial catarrh, however, is perhaps the most common the immediate cause of death. The changes in question, form of pulmonary complication in this country, and is indi- though having in many respects a resemblance to inflammacated by frequent cough, glairy, tough expectoration, wheezing tion, are to be ascribed rather to the specific effect of the fever poison on individual organs, in the same manner as other respiration, and moist râles over the chest. Pneumonia is a much more serious affection. Rokitansky poisons when introduced into the system affect particular structures. We may have, for example, cerebral symptoms-headseems to think that in all cases of severe enteric fever, or indeed in all cases, but especially when the symptoms are ache, delirium, somnolence, and even convulsions, without vaswell marked, there is hypostasis in the lower lobes, which cular turgesoence ; nay, these very symptoms may depend on becomes converted into pneumonia-a gelatinous, glutinous, an anaemic or bloodless condition of the brain, and hence the soft product (similar to that which takes place on the bronchial judgment and caution required in dealingwith these secondary and intestinal surfaces) being effused, and corresponding with the cerebral affections, for were we to prescribe on the supposition existing typhous dyscrasia, which he supposes to be the result that such nervous symptoms were the result of cerebral fulness, of an adynamic state of the system. This lesion is indicated a fatal error might be committed. You may remember that I alluded to the cases observed by chiefly by the local signs: the dulness on percussion; the fine crepitation at first, and afterwards the bronchial breathing, the Louis, in which, though the brain symptoms were prominently
commencement of the disease. As to the occurrence of epistaxis in childhood, it happens oftener before than after fifteen years of age. M. Taupin, foi example, met with it only three times amongst one hundreo and twenty-one children, and in those only to the extent ofa
161
marked, the appearances after death bv no means corresponded mercantile men appearing "on ’change," or clergymen per. with, or accounted for, so much local disturbance. forming their parochial duties,-when on close examination, There are instances, on the other hand, in which the vessels besides the altered countenance, general excitement, and stagof the brain, but more particularly its investing membranes, gering gait, the peculiar rose-coloured spots, relaxation of the are more or less congested, as the symptoms during life evince, bowels, and abdominal distension, showed too clearly the
and in such examples, we find evidence after death of pre- serious nature of the latent or hidden disease. I have known existing vascularity, in the form of redness of the membranes instances in which the patient could not be persuaded that he was seriously ill, until profuse haemorrhage from the bowels or substance of the brain, or of both, and probably of subserous effusion, or even of lymph. But these cases of congestion convinced him that the apprehensions of his friends and mediare much less frequent than the nervous or neurotic, as they cal attendant were not groundless, and I have seen such cases terminate fatally a few days after the first alarm was taken. may be called. In others, the disease may assume the form of common cold; The pulmonary complications, too, though exhibiting the ordinary physical signs by which the idiopathic form is re- there may be cough, accompanied by moist râles over one or cognised, partake less of the acute character ; and if we adopt both lungs, in addition to other signs of latent enteric fever; the opinion of Rokitansky. that they are mainly due to the in- so that the whole phenomena are ascribed to the patient having filtration of that low or caco-plastic material he has denomi- "taken cold." But in a few days the chest affection passes nated the typhous process, it is clear that the whole exudative away, leaving the other symptoms stationary, or, it may be, phenomena are not those of inflammation, strictly so called, somewhat aggravated, until the true nature of the disease bethough in the effort made by the system to throw off this comes revealed by some of the prominent signs of enteric fever. I need scarcely remark to my present audience that such exudation, and we may presume that a temporary local or congestive action is set up, and hence the increased local and latency is not confined to the class of maladies now under con. constitutional disturbance induced. sideration, but is observed in symptomatic fevers, more espe. I have repeatedly alluded to the frequency of inflammation cially subacute pulmonary inflammations-pleurisy and pneu. in which the only general signs to of the pleural covering of the lungs in enteric fever and the more monia, for example indicate the one or the other may be, perhaps, occasional cough, or less copious effusion into the thoracic cavity, and I advert to it now only to point out that, though it is unquestionably an slight acceleration of breathing on unusual exertion, and irregular -
inflammation, the whole phenomena are of a less acute character paroxysms of fever. When the chest is examined, we find than idiopathic or primary pleurisy. It requires also a modified, one side dull, perhaps as high as the scapula, or even the certainly less active treatment, and, as we shall afterwards point clavicle, with absence of respiratory murmur, and, if the effuout when the treatment of those lesions is discussed, a combined sion be considerable, prominence of the intercostal spaces, if not plan of local and constitutional measures, in order to check, perceptible dilatation of one side. But in uncomplicated latent enteric fever, physical diagnosis on the one hand, the local action, and at the same time to does little towards clearing up the mystery, so that we are sustain the vital and nervous powers. If we go to the great centre of the circulating system-the obliged to trust to a minute survey of the symptoms, and to heart-so constantly and variously disturbed in fever, we do contrast them with whatever previous history we can obtain; not find the slightest evidence of in6ammatory action ; on the and, after all, we are too often in the dark, and obliged either contrary, it is either little influenced, or its action may be so to confess our doubts and fears, or make a bold guess as to the weakened that it appears scarcely equal to its ordinary work, nature of the disease. Happily, however, such obscurity is so that its sounds, but especially the first, are nearly inaudible. comparatively rare, and I have drawn your attention to these
It is in this condition of the heart that we find the brain bloodless or an2emic, the patient rambling or unconscious ; the face and lips pale, and the surface cold and perhaps livid. And, moreover, this bloodless state of the brain explains the quantity of alcoholic stimulants occasionally required, both in enteric and in typhus fever, to rouse the dormant powers, and the tolerance of quantities which, if taken by the same individual in his ordinary or healthy state, would probably deeply
intoxicate.
As to the condition of the abdominal organs, if we except specific lesion of the intestinal glands, mesentery, and spleen, we rarely find disease either of the peritoneum or other structures within this cavity. It is true that, when the typhous process has destroyed in succession the coats of the intestine, and the perforating ulcer permits the alimentary contents to become effused into the abdominal cavity, violent peritonitis and rapid death follow. But this is an accidental
the
lesion
only.
of latent fever more with the view of warning you of their occasional occurrence, than of aiding you with the diacases
gnostic signs.
M. Louis, in alluding to latent enteric fever, gives several marked cases in illustration, and has shown that the disease may proceed even to intestinal perforation, without any of the symptoms that usually indicate this fatal lesion. Duration.-In my second lecture, in alluding shortly to the analogy between the two leading varieties of fever (typhus and enteric fevers) and the exanthematous, I mentioned that the duration of the former constituted a point of resemblance to the latter. Let me for a moment draw your attention to the duration of enteric fever, which is important in a diagnostic point of view; for when uncomplicated it certainly has a determinate duration. ’ It is necessary to bear in mind that there is often a wide difference between the duration of the fever and that of the enteric disease; and this applies not only to the class of fevers we are now considering, but to the eruptive. For example, we know that in mild or uncomplicated scarlet fever, the whole phenomena are in general before the end of the second week from the earliest period of its commencement. Let a local or secondary disease, however, spring up, and the duration of the malady may be protracted for weeks. The original or primary fever may have been mild, or of moderate severity only, and, had no intercurrent local disease supervened, would have disappeared as usual in ten or twelve days. We find precisely the same thing happen in enteric fever, to which the same reasoning applies. The average duration of this fever is from twenty to thirty days-that is, if no local disease supervene; and it appears, from united experience, that if the duration exceed thirty days, some complication is the cause of the protracted duration, which may be indefinite, according to its nature and extent. M. Louis, after analyzing the cases observed by him which proved fatal after the thirtieth day-nine in number--found in all of them local lesions sufficient to account for death; which corresponds with the results obtained by Dr. Jennerat the Fever Hospital, not a single case fatal after the thirtieth day having been noted in which, on inspection of the body- there was not a lesion discovered sufficient of itself to destroy life.
Latent enteric fever.-We have been hitherto consideringthe ordinary course of enteric fever, the symptoms of which are generally, in prominent particulars, so well marked as to be readily recognised-at all events by those who are practically . acquainted with the pathology of fevers. Cases, however, occasionally occur, in which, though some of the symptoms may be present, the general aspect of the disease is such as to leave its nature somewhat uncertain. For example, medical aid is sometimes requested by an individual, who is unable to give a better description of his ailments than that for some time previously he has been suffering from undefined indisposition, he is unable to throw off; he complains of lassitude, irregular chills alternating with transient flushes of heat, of being easily fatigued, and unable to pursue his usual employment, and of loss of appetite and restless nights. On further inquiry, it will transpire that the bowels have been irregular, with tenthe whole aildency to griping and purging, and ment has been ascribed, not unreasonably, to what is popularly known as bilious disorder. After a few days, it is manifest that matters do not improve, but are probably getting worse ; the prostration and disinclination to exertion have so much increased, that there is no longer the desire, or even the ability, to keep about, and the patient of his own accord remains at rest. Some, more energetic and enduring than others, make MEDICINES AND MEDICAL STORES FOR THE NAVY an effort to pursue their avocations, and I have known indifigure in the new estimates at £73,000. Last year they were viduals transacting in a measure the ordinary duties of life,- estimated at £60,000.
completed
more
which
consequently
162
LECTURES ON
FEVERS:
The Lumleian Lectures,
1 1’I 111 V
.I:.cJ:
Y
.I:..I
tympanitis, gurgling. 3. Symptom meteorism or
convalescence,
No. 1903.
accompanied by altered expression in the features, or less speedily by nausea and vomiting, there must
been committed. For example, Louis states that he heard an days, they gradually fade, and ultimately entirely disappear, eminent physician pronounce a patient with the typhoid affec- without leaving a mark or stain. They are replaced by a fresh tion (enteric fever) to have hepatization of the right lung, on eruption, which, after pursuing a precisely similar course, in its the ground that, the abdomen being greatly distended with turn dies away; and in this manner the spots come out and air, a flat sound was elicited, much higher than usual, on per- disappear, until the termination of the fever. Their mean cussing the right back of the chest. Examination of the body duration may be stated to be from eight to nine days. This eruption (rose spots) is, according to M. Taupin, not after death showed the lung to be quite healthy, and the cause of the flat sound to be the liver, which had been pushed very less frequently observed in children than in adults; for out of 121 cases of enteric fever in early life noticed by him, it was high by the great distension of the tympanitic colon. During my attendance, some years ago, on a gentleman with observed in all except eleven, and of these eleven three were enteric fever, an hospital surgeon met me in consultation, in not received into the hospital until three weeks or more after consequence of the alarm excited by the unusual tympanitic the commencement of the disease, during which period the distension. This gentleman mistook the hour appointed for spots might have disappeared. M. Rilliet, on the other hand, observed them in two-thirds of his cases only; but he does not our meeting, and after waiting some time, the medical attendant of the family, who had watched the case with me, was say whether the patients in whom the spots were not seen sent for, and the examination of the patient was proceeded were received into the hospital at a late period of the fever. with. On retiring to an adjoining room, the pathology of the It may, however, be assumed that in children the spots apcase was debated, when this hospital surgeon came to the conpear at an earlier stage of the fever than in adults, for both clusion that the disease was ascites, and, notwithstanding the these writers state, that they observed the eruption generemonstrance of the family attendant, was in the act of pre- rally from the fourth to the eighth day of the fever, sometimes occasionally later. They were found by M. Taupin in scribing elaterium, when I arrived, and took the liberty of sooner, some children as early as the second day, but they generally his and both The stoutly resisting diagnosis therapeutics. disappeared after a day or two. patient after a tedious illness ultimately recovered. It is satisfactory to find from this author, that he had never In the enteric fever of children, this symptom occurs not less frequently than in adults. M. Rilliet met with it, in met with the rose spots in any other infantile disease, except various degrees, in about two-thirds of his cases, but more fre- enteric fever. There is another point in connexion with this spotted erupquently in those who died than in those who recovered. On the whole, it may be inferred that the infrequency of tion that requires passing notice. In some cases it is preceded meteorism in acute diseases, not enteric fever, and its frequency for a day or two by a scarlet efflorescence, very much like and degree in the latter, render it an important diagnosic roseola; when it appears, it is apt to throw doubt on the nature of the disease, and there is even a possibility of its being symptom. mistaken for scarlatina. As the disease progresses, however, the of examined the coactim be region Gurgliaay.-If carefully doubt is soon dispelled. by the fingers of both hands-with the precaution, for obvious theBut this rose-coloured rash is not invariably present. It with of this canal of the intestinal reasons, handling portion is difficult to obtain statistical results on this point that very a gurgling sound may be first care It was elicited. on. The spots may have disappeared, when the pointed out by Chomel, who considered it as one of the signs can be relied of enteric fever. Though it may be frequently discovered, it patient is examined, or they may be so few in number as to is much oftener absent, and cannot therefore be regarded as escape detection. We have not overlooked this matter in the Fever Hospital, for the presence or absence of the characterone of the constantly present diagnostic symptoms of this istic rash is invariably noted; and were I to give an approxidisease. mative idea of the total number of cases in which the rose 3. Skin.-One of the most distinctive characters of enteric appear at any stage of enteric fever, I think ten or fever-not, however, as we shall see, invariably present-is an spots do notcent. will be nearly correct. twelve per of small lenticular scattered rose-coloured spots, eruption chiefly Sudamina.-In the progress of enteric fever, we occasionover the surface of the abdomen and chest, where the cuticle is observe a vesicular eruption, termed, from its resemblance known to be thinnest. Sometimes a few of these spots (from to sweat drops, sudamina, though no one supposes that it has six to twenty) are seen, after careful examination, on the most remote connexion with the function of perspiration. abdomen, or one or two may be discovered on the chest and the is also by the name of miliaria, or miliary rash, and back; when there is an abundant eruption, they are not It known as you are aware, of small, prominent, round, transconsists, limited to the region of the trunk, but may be seen on the parent vesicles, formed by the effusion of limpid fluid under extremities, and even, though rarely, on the face.** Each spot is of a circular shape, varying in size from a point the cuticle. The vesicles are usually about the size of milletto a line and a half, rarely exceeding two lines in diameter, seeds, the intervening spaces retaining the natural colour of skin. slightly raised above the surrounding cuticle, and of a pink-rose healthy This which is an occasional accompaniment of other rash, colour, disappearing on pressure, but returning as soon as the acute maladies, rarely appears before the end of the second is not is Their attended removed. by any eruption pressure unusual sensation, and they seldom appear before the fifth day week of the fever. It comes out more generally on the anterior aspect of the thorax, on the abdomen, inguinal regions, of the fever, more commonly in the second week. M. Louis, who observed these spots very carefully, found neck, and axillæ; seldom on the back or limbs, and never on them readily in twenty-six out of forty-six cases that were the face. Its duration is not uniform; sometimes the vesicles, after continuing prominent for a few days, shrivel, and disap. fatal; and in fifty-seven that recovered, they were discovered in all, except three. It was also noticed to be invariably pre- pear with desquamation; in other cases, they remain visible for eight or ten days. Their average duration, however, may sent in all the cases that were mild. In respect of the period of the disease at which it came out, be stated to be from three to ten days. This eruption d not seem to have any special influence on it was visible in two patients on the sixth day; in three, on the I the symptoms org=’ ress of the fever, though it has more frea seventh; in third of the cases on the tenth; and in ten, it did not appear until between the twentieth and thirtieth day quently been obsed ;= ’’ "’ uses of more than average severity as to its comparative prevalence, out of the disease. In the cases tabulated by Chomel, it was noted than in the of at the Hotel Dieu or La (observed ninety-eight patients in two between the sixth and eighth day; in thirteen, between it was discovered in seventy-six; and it was remarked the eighth and fifteenth; in seven, between the fifteenth and Pitie), that there in these instances, to be very little relation twentieth; in four, between the twentieth and thirtieth; and between theseemed, of the sudamina and the condition of abundance in one, on the thirty-seventh day. the skin as to perspiration. If, however, an average be taken, these rose spots may be This eruption has also been observed in the enteric fever of assumed to come out between the sixth and ninth days after M. Rilliet having noted it in two-thirds of his cases, children; the commencement of the fever : it is certain, at least, that in half the number of patients they are found between those days. and M. Taupin in one hundred and four out of one hundred It would also appear that, except in cases of relapse, fresh rose and twenty-one. M. Rilliet states that it generally appeared between the eleventh and twentieth days, and that its average spots do not appear after the thirtieth day of the fever. duration was from one to six days. Again, these spots do not, as in the typhus eruption, persist My own experience of the occurrence of sudamina, both in after visible or nine the fever, but, throughout remaining eight hospital and private practice, differs in respect of frequency * For permission to exhibit the beautiful wax model of this eruption on the from that of continental physicians. It is comparatively rare table I am indebted to the authorities of Guy’s Hospital. It is a life-like in the enteric fever of this and I do not remember a country; artistic skill has enriched the representation, executed by Mr. Town, whose single instance of its occurrence in private practice. museum of Uuy’s with the most valuable series of pathological models in Europe. Erysipelas.-I may here advert to the occasional appearance -
ally
milde
-
--
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erysipelas inthe progress of enteric fever, but it is to be re- consequence of portions of the lung being blocked up by the garded as accidental or intercurrent only. It shows itself in intiltrated morbid products. The laryngeal angina alluded to is fortunately much less the wards of the Fever Hospital at certain periods of the year, just as it is known to prevail in other hospitals amongst the frequently met with than either of the preceding lesions, and, medical, but more especially amongst the surgical patients; whether it arise from simple cedematous infiltration or from often appearing suddenly, lasting for a time, and then dis. the typhous deposit, may be recognised by its characteristic appearing. When it gets into the wards, it spreads by con- symptoms--intense agony in the effort of swallowing, succeeded tagion, but it may be also excited by trivial wounds, such as by ringing cough, stridulous sound of the breathing and voice, leech-bites, cupping scarifications, or blistered surfaces. It is with frequent attacks of laryngeal spasm threatening suffocainfinitely more common on the face and head, often apparently tion. PleU1’itic inflammation.-In enteric fever there is a marked commencing in the throat, and thence spreading outwards, through the nose or ear, to the face, scalp, and neck. It seems tendency to inflammation of serous membranes, and hence to have no precise or definite duration, and terminates either in pleuritic inflammation is a frequent complication or secondary resolution, vesication, or purulent infiltration, and, when se- affection. It may not be always recognised by the general vere and extensive, may be, per se, the destroying cause. symptoms alone, but by careful auscultation its presence can Epistaxis. This is another occasional accompaniment of scarcely be overlooked. It is decidedly less frequently observed enteric fever. The amount of blood varies, being sometimes in the typhoid affection of Paris. Thus Louis mentions that small, perhaps only a few drops; more often moderate, seldom out of fifty-seven cases, he only met with one example of of pleurisy as a complication of enteric profuse. It may occur once only, or for several successive it. This to fever does not with the experience of British phyand is not limited accord it of the occurfever, any period days; ring sometimes at the commencement-more commonly when sicians. There appears, as I have already remarked, to be a it is somewhat advanced. It is seldom preceded by any un- peculiar susceptibility in this fever to serous inflmmaation, usual sensations to denote its advent, nor is the patient sen- more especially to pleurisy, and it is well to be on the look-out for it even in mild cases. It is indicated by sudden sible of any change in the symptoms after its cessation. It is observed less frequently in the mild than in the more chills or shivering, pain or stitch in the side on deep inspiraof
-
infrequency
Thus, Louis noted it in about half the cases tion, disinclination to lie on the affected side, hurried breathmild, and in twenty-seven out of thirty-four in whom pleural friction, or a limited degree of dulness, but be always detected. In other, and perhaps the the fever was severe, but not fatal. I am inclined to think these that it is less frequently observed as a concomitant of enteric greater number of cases, however, the disease is less open; fever in this country. Dr. Jenner remarked it in only five there may be little if any pain or stitch, little or no hurry out of fifteen, the particulars of which were obtained from the in the breathing, perhaps only flushing and hot skin, to
severe cases. that were
ing, with may not
indicate that something is wrong. Examination of the chest seldom fails to reveal the secret, by circumscribed creaking heard over the seat of the pleuritic inflammation; or if the mischief has crept on insidiously, the percussion note is dull and the respiratory murmur absent, indicating the existfew drops of blood; and he noticed, that several childret ence of fluid more or less copious in amount. It is remarkable who had been subject to bleeding at the nose before they had how rapidly the fluid accumulates in some cases, and even with little warning of the antecedent inflammation; hence enteric fever, had none at all during the whole period of thei: the necessity of watching, in cases of enteric fever even comillness. 4. Organs of respiration.-Although it cannot be said that paratively mild, for the first approach of pulmonary sympin enteric fever the pulmonary organs are necessarily involved toms, which may surprise us at any stage of the disease, or even in the general disturbance, there are few cases of severity in during convalescence. which they entirely escape. When the pleuritic inflammation occurs on the left side, it The pulmonary complication may be exhibited either in the may spread to the pericardium and even to the valvular appaform of simple catarrh, bronchial catarrh (bronchitis), inflam- ratus of the heart-a complication which, I need scarcely obmation of the pulmonary parenchyma, or of the pleural cover. serve, though not always necessarily fatal, seriously involves ing, each being indicated by its peculiar local or physical the safety of the patient. Again, it should be kept in mind, that fever, either signs. In a considerable number of patients, but especially when enteric or typhus, occasionally supervenes on chest diseases (as there is coexisting brain affection, the pulmonary lesion is well as other organic affections), and may thus become in grafted latent, and can only be detected by careful auscultation. Irre- on the various forms of chronic pulmonary disorders so prevagular accessions of flushing, and general heat of skin, especially lent in this variable climate. The history of each case, if careif accompanied with paroxysms of coughing, are sufficient to fully inquired into, will tend to distinguish this class from those indicate some form of secondary pulmonary affection, the pre- of enteric fever with pulmonary complication, though it must cise nature of which can only be revealed by careful physical be admitted that there is often much difficulty in arriving at a examination. But even such general symptoms are often ab- correct diagnosis. Abdomen.-In the abdomen we rarely meet with peritoneal sent, and the lung disease may remain undiscovered, unless the practitioner is on the watch, and, by repeated local exami- inflammation as a secondary affection, but more generally as nation, detects the existence of the secondary affection of the the result of intestinal perforation. The other lesions found after death-the various changes in lung, which, be it remembered, may suddenly spring up at any period of the fever, and render a mild case severe, or even Peyer’s glands, in the mesenteric glands, and in the spleen-to be afterwards more particularly described-are not to be viewed dangerous, if not fatal. ascribes these various Rokitansky pulmonary complications as complications, but as constituting the true anatomical chato the peculiar typhous deposit (or, as he terms it, typhous racter of this disease. process), which may be effused either on the epiglottis and The various lesions which occur in the progress of enteric larynx, the mucous membrane of the lungs and bronchial glands, or into their parenchyma, producing laryngitis, bron- fever, as might be supposed, not only materially influence the general character and duration of the disease, but may even be chitis, or (the so-called) typho-pneumonia. The bronchial catarrh, however, is perhaps the most common the immediate cause of death. The changes in question, form of pulmonary complication in this country, and is indi- though having in many respects a resemblance to inflammacated by frequent cough, glairy, tough expectoration, wheezing tion, are to be ascribed rather to the specific effect of the fever poison on individual organs, in the same manner as other respiration, and moist râles over the chest. Pneumonia is a much more serious affection. Rokitansky poisons when introduced into the system affect particular structures. We may have, for example, cerebral symptoms-headseems to think that in all cases of severe enteric fever, or indeed in all cases, but especially when the symptoms are ache, delirium, somnolence, and even convulsions, without vaswell marked, there is hypostasis in the lower lobes, which cular turgesoence ; nay, these very symptoms may depend on becomes converted into pneumonia-a gelatinous, glutinous, an anaemic or bloodless condition of the brain, and hence the soft product (similar to that which takes place on the bronchial judgment and caution required in dealingwith these secondary and intestinal surfaces) being effused, and corresponding with the cerebral affections, for were we to prescribe on the supposition existing typhous dyscrasia, which he supposes to be the result that such nervous symptoms were the result of cerebral fulness, of an adynamic state of the system. This lesion is indicated a fatal error might be committed. You may remember that I alluded to the cases observed by chiefly by the local signs: the dulness on percussion; the fine crepitation at first, and afterwards the bronchial breathing, the Louis, in which, though the brain symptoms were prominently
commencement of the disease. As to the occurrence of epistaxis in childhood, it happens oftener before than after fifteen years of age. M. Taupin, foi example, met with it only three times amongst one hundreo and twenty-one children, and in those only to the extent ofa
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marked, the appearances after death bv no means corresponded mercantile men appearing "on ’change," or clergymen per. with, or accounted for, so much local disturbance. forming their parochial duties,-when on close examination, There are instances, on the other hand, in which the vessels besides the altered countenance, general excitement, and stagof the brain, but more particularly its investing membranes, gering gait, the peculiar rose-coloured spots, relaxation of the are more or less congested, as the symptoms during life evince, bowels, and abdominal distension, showed too clearly the
and in such examples, we find evidence after death of pre- serious nature of the latent or hidden disease. I have known existing vascularity, in the form of redness of the membranes instances in which the patient could not be persuaded that he was seriously ill, until profuse haemorrhage from the bowels or substance of the brain, or of both, and probably of subserous effusion, or even of lymph. But these cases of congestion convinced him that the apprehensions of his friends and mediare much less frequent than the nervous or neurotic, as they cal attendant were not groundless, and I have seen such cases terminate fatally a few days after the first alarm was taken. may be called. In others, the disease may assume the form of common cold; The pulmonary complications, too, though exhibiting the ordinary physical signs by which the idiopathic form is re- there may be cough, accompanied by moist râles over one or cognised, partake less of the acute character ; and if we adopt both lungs, in addition to other signs of latent enteric fever; the opinion of Rokitansky. that they are mainly due to the in- so that the whole phenomena are ascribed to the patient having filtration of that low or caco-plastic material he has denomi- "taken cold." But in a few days the chest affection passes nated the typhous process, it is clear that the whole exudative away, leaving the other symptoms stationary, or, it may be, phenomena are not those of inflammation, strictly so called, somewhat aggravated, until the true nature of the disease bethough in the effort made by the system to throw off this comes revealed by some of the prominent signs of enteric fever. I need scarcely remark to my present audience that such exudation, and we may presume that a temporary local or congestive action is set up, and hence the increased local and latency is not confined to the class of maladies now under con. constitutional disturbance induced. sideration, but is observed in symptomatic fevers, more espe. I have repeatedly alluded to the frequency of inflammation cially subacute pulmonary inflammations-pleurisy and pneu. in which the only general signs to of the pleural covering of the lungs in enteric fever and the more monia, for example indicate the one or the other may be, perhaps, occasional cough, or less copious effusion into the thoracic cavity, and I advert to it now only to point out that, though it is unquestionably an slight acceleration of breathing on unusual exertion, and irregular -
inflammation, the whole phenomena are of a less acute character paroxysms of fever. When the chest is examined, we find than idiopathic or primary pleurisy. It requires also a modified, one side dull, perhaps as high as the scapula, or even the certainly less active treatment, and, as we shall afterwards point clavicle, with absence of respiratory murmur, and, if the effuout when the treatment of those lesions is discussed, a combined sion be considerable, prominence of the intercostal spaces, if not plan of local and constitutional measures, in order to check, perceptible dilatation of one side. But in uncomplicated latent enteric fever, physical diagnosis on the one hand, the local action, and at the same time to does little towards clearing up the mystery, so that we are sustain the vital and nervous powers. If we go to the great centre of the circulating system-the obliged to trust to a minute survey of the symptoms, and to heart-so constantly and variously disturbed in fever, we do contrast them with whatever previous history we can obtain; not find the slightest evidence of in6ammatory action ; on the and, after all, we are too often in the dark, and obliged either contrary, it is either little influenced, or its action may be so to confess our doubts and fears, or make a bold guess as to the weakened that it appears scarcely equal to its ordinary work, nature of the disease. Happily, however, such obscurity is so that its sounds, but especially the first, are nearly inaudible. comparatively rare, and I have drawn your attention to these
It is in this condition of the heart that we find the brain bloodless or an2emic, the patient rambling or unconscious ; the face and lips pale, and the surface cold and perhaps livid. And, moreover, this bloodless state of the brain explains the quantity of alcoholic stimulants occasionally required, both in enteric and in typhus fever, to rouse the dormant powers, and the tolerance of quantities which, if taken by the same individual in his ordinary or healthy state, would probably deeply
intoxicate.
As to the condition of the abdominal organs, if we except specific lesion of the intestinal glands, mesentery, and spleen, we rarely find disease either of the peritoneum or other structures within this cavity. It is true that, when the typhous process has destroyed in succession the coats of the intestine, and the perforating ulcer permits the alimentary contents to become effused into the abdominal cavity, violent peritonitis and rapid death follow. But this is an accidental
the
lesion
only.
of latent fever more with the view of warning you of their occasional occurrence, than of aiding you with the diacases
gnostic signs.
M. Louis, in alluding to latent enteric fever, gives several marked cases in illustration, and has shown that the disease may proceed even to intestinal perforation, without any of the symptoms that usually indicate this fatal lesion. Duration.-In my second lecture, in alluding shortly to the analogy between the two leading varieties of fever (typhus and enteric fevers) and the exanthematous, I mentioned that the duration of the former constituted a point of resemblance to the latter. Let me for a moment draw your attention to the duration of enteric fever, which is important in a diagnostic point of view; for when uncomplicated it certainly has a determinate duration. ’ It is necessary to bear in mind that there is often a wide difference between the duration of the fever and that of the enteric disease; and this applies not only to the class of fevers we are now considering, but to the eruptive. For example, we know that in mild or uncomplicated scarlet fever, the whole phenomena are in general before the end of the second week from the earliest period of its commencement. Let a local or secondary disease, however, spring up, and the duration of the malady may be protracted for weeks. The original or primary fever may have been mild, or of moderate severity only, and, had no intercurrent local disease supervened, would have disappeared as usual in ten or twelve days. We find precisely the same thing happen in enteric fever, to which the same reasoning applies. The average duration of this fever is from twenty to thirty days-that is, if no local disease supervene; and it appears, from united experience, that if the duration exceed thirty days, some complication is the cause of the protracted duration, which may be indefinite, according to its nature and extent. M. Louis, after analyzing the cases observed by him which proved fatal after the thirtieth day-nine in number--found in all of them local lesions sufficient to account for death; which corresponds with the results obtained by Dr. Jennerat the Fever Hospital, not a single case fatal after the thirtieth day having been noted in which, on inspection of the body- there was not a lesion discovered sufficient of itself to destroy life.
Latent enteric fever.-We have been hitherto consideringthe ordinary course of enteric fever, the symptoms of which are generally, in prominent particulars, so well marked as to be readily recognised-at all events by those who are practically . acquainted with the pathology of fevers. Cases, however, occasionally occur, in which, though some of the symptoms may be present, the general aspect of the disease is such as to leave its nature somewhat uncertain. For example, medical aid is sometimes requested by an individual, who is unable to give a better description of his ailments than that for some time previously he has been suffering from undefined indisposition, he is unable to throw off; he complains of lassitude, irregular chills alternating with transient flushes of heat, of being easily fatigued, and unable to pursue his usual employment, and of loss of appetite and restless nights. On further inquiry, it will transpire that the bowels have been irregular, with tenthe whole aildency to griping and purging, and ment has been ascribed, not unreasonably, to what is popularly known as bilious disorder. After a few days, it is manifest that matters do not improve, but are probably getting worse ; the prostration and disinclination to exertion have so much increased, that there is no longer the desire, or even the ability, to keep about, and the patient of his own accord remains at rest. Some, more energetic and enduring than others, make MEDICINES AND MEDICAL STORES FOR THE NAVY an effort to pursue their avocations, and I have known indifigure in the new estimates at £73,000. Last year they were viduals transacting in a measure the ordinary duties of life,- estimated at £60,000.
completed
more
which
consequently
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