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LECTURES ON FEVERS: BEING The Lumleian Lectures,
MARCH 31, 1860. Besides the absence in typhus of primary local disease, the are in many particulars dissimilar. The susceptibility to the influence of the poison varies in different persons, and hence the difference observed in the BEING accession or mode of invasion. Some experience sudden indisposition after exposure to an infected atmosphere, or contact with a person affected with typhus. For example, when nurses attacked after their ministrations to fever patients, they are are DELIVERED BEFORE THE often able to connect their illness with services rendered to an individual patient; and in my own case, I remember to this ROYAL COLLEGE OF PHYSICIANS OF LONDON, day the feeling of being stnwk with fever, after leaving a par185S-59; ticular house, during the epidemic which prevailed at Edinburgh in 1817-18. COMPRISING But more commonly there is a period of inwbation, of longer A DESCRIPTION OF THE DISTINCTIVE or shorter duration, in which various undefined sensationsirregular chills or shivering, nausea, disrelish of food, thirst, CHARACTERS, PATHOLOGY, AND perhaps slight pain in the head, somewhat acceleTREATMENT rated pulse, with languor and muscular aching-are felt for OF days perhaps before the fever can be said, in popular language, to be formed. As the disease progresses, these sensations beTHE SEVERAL FORMS come intensified; there is visible change in the countenance, OF the patient is agitated and restless, while the symptoms of CONTINUED FEVER. general disturbance alluded to are more pronounced, and recur in paroxysms of uncertain duration, but chiefly towards evenBY ing, or in the night, which is spent in wakefulness, or disturbed sleep. ALEXANDER TWEEDIE, M.D., F.R.S., But these symptoms are common to other forms of fever, FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, and even to acute diseases in general, so that it is by their proPHYSICIAN TO THE LONDON FEVER HOSPITAL, TO THE FOUNDLING HOSPITAL, gress and further development that we are enabled to form our EXAMINER IN MEDICINE IN THE UNIVERSITY OF LONDON, ETC. ETC. judgment as to the precise nature of the disease they indicate. 1. There is the peculiar distinctive eruption, (to which I have already cursorily drawn your attention,) known by the LECTURE VII. term typhus rash; or, from its resemblance to the efflorescence of measles, it has been called ?MM6er/ or morbillou8. TYPHUS FEVER. When this eruption is present, it indicates at once, to the exNature of typhus-invasion and progress of the symptoms- perienced eye, this form of fever. A comparison of this rash peculiar to typhus, with the rosetyphus eruption-cerebral symptortls-headache-deliriumsenses-vital funccoma-muscular s
LECTURES
ON
symptoms
FEVERS:
The Lumleian Lectures,
giddiness,
.
No. 1909.
advanced period of the fever, and may gra.dual!y disappear, slowly increase until death ensue. As to degree, there may be every modification from unnatural tranquillity, transient somnolence, to insensibility or deep coma. In the worst cases, generally fatal, the patient lies perfectly unconscious, with the eyelids open as if awake-a condition to which the term coma.
this eruption was present in one hundred and thirty-six, and absent in sixteen. It has been generally observed, too, that when the rash is absent, the fever is mild and of short duration, unless some intercurrent or secondary affection alter the character of the disease. Of the sixteen cases in which it was absent, thirteen were between the ages of four and fifteen, and the remaining three between sixteen and twenty-two. It also appeared, that of the whole number (one hundred and fifty-two),
an
tion was proportionally developed. In the Edinburgh epidemic (183S-9) the mortality of cases with scanty eruption was one in eight; where the rash was abundant it was one in four; the duration of the fever being also between one and three days longer in the one than in the
fever lasts. Vision is seldom affected, except towards the termination of unfavourable cases, when it is a bad omen, more especially if the patient attempt to catch imaginary objects, or pick the bedclothes, under the idea that they are covered with coloured spots. Sometimes, again, patients complain of seeing everything through a mist. The appearance of the eyes varies: in the beginning of the fever, they have a dull, languid appearance; and if the brain become acutely affected, they appear glistening, injected, and painful on exposure to light; or when coma supervenes, they are heavy, deeply injected, and the eyelids half closed. In the fatal stage, they become dim, fixed and glassy. The taste may be either impaired or perverted, so that articles of food are refused, under the idea that they are ill prepared, or have not their usual flavour. Sometimes the sense of taste is entirely lost. The sense of smell, too, is often impaired, or sometimes, like that of taste, altogether lost. The vital functions, comprehending the circulation, respirat’ioll, and animal heat, are always more or less affected. The pulse is generally frequent, soft, and compressible, sometimes irregular; and the heart commonly partakes of the feebleness-its sounds, especially the first or systolic, being scarcely audible. To this cardiac debility is to be ascribed the tendency to syncope when the erect posture is assumed; and hence, aiso, the occasional fatal accidents, when patients, who are very feeble, are allowed to pass their evacuations in the
or
vigil has
been applied. It may be observed, too, that brain affections
are not only seventy-six (exactly a half) were more than twenty-two years more prominently marked, but appear earlier, in typhus than old, and twenty one between the ages of sixteen and twenty- in enteric fever. whole muscular system undergoes two inclusive. The eruption was, therefore, present in every MscMCH’
other.
As it is important to keep in view the distinguishing characters of the typhus eruption, let me restate them :1. It consists of a congeries of spots, which cohere in the form of patches on the trunk and limbs (seldom on the face), of a brownish or mulberry hue, giving a diffused or mottled appearance to those parts of the skin on which it comes out; fading, but not disappearing, on pressure; and differing in those respects from the bright rose spots of enteric fever, which are isolated or distinct, and entirely vanish on firm pressure. 2. The typhus eruption is permanent or persistent -that is, it continues from its first appearance until the fever terminates; differing also in this respect from the rose spotted rash peculiar to enteric fever, which, after running through successive changes, disappears in a few days, and is succeeded by a fresh eruption of spots, which go through the same changes, crop after crop, until the cessation of the fever. 3. Though this eruption may be discovered by careful examination in a large proportion of cases, it is occasionally absent, its absence, however, being rarely observed in adults, more commonly in children; and it will be found that its presence or absence has an important bearing on the character of the fever-its absence more especially indicating a mild
disease. 2. Cel’ebral
night-chair.
The muscles concerned in respiration are often enfeebled, of the most constant symptoms, indeed rarely so that there is inability to inflate the chest freely, when such absent. It may be so slight as not to attract the patient’s an exertion is desirable for the purpose of examining the connotice; but sometimes, for the first week or ten days, it is dition of the pulmonary organs; and to the same cause, the fresevere and persistent, after which it generally abates gradually, quency of breathing-one of the most early as well as certain and finally disappears towards the end of the second week; or, indications of approaching dissolution-may be ascribed. should it continue longer, it comes on at intervals only-in The te?itpei-atu2-c of the skin is sometimes little affected, espethe evening perhaps, or during an exacerbation of the fever. cially in the beginning, and in mild cases. But as the symp.ZMM’tMM.—The intelligence is seldom disturbed in the toms progress, especially if the fever be severe, the heat of milder cases. In the more severe, there is transient confu- skin becomes augmented, particularly during the exacerbations. sion, soon lapsing into delirium, perceptible at first only on Some writers have alluded to a peculiar sensation felt on awaking, or in the night, but becoming more constant as the touching a fever patient, which they describe as of a pungent, fever advances. The character of the delirium varies: it is penetrating character. To this the term caloi- mordax has been sometimes noisy and violent (typhomania), more often low and given. Digestive Systent.-The digestive system, which is so promi. muttering, with tendency to somnolence; in other cases, it partakes of the character of delirium tremens-the form usually nently affected in enteric fever, is little if at all disturbed in observed in spirit-drinkers, or in persons harassed with care. typhus; so that the absence of gastric or intestinal irritation in ordinary typhus, an important point in diagnosis. This symptom (delirium) is rarely noticed before the seventh or eighth day. It may appear, however, earlier or later; but Sickness or vomiting may be said to be rare, nor does the at whatever period it comes on, it continues till the termina- abdomen exhibit externally anything abnormal, there being neither unnatural prominence nor tympanitic distension. Nor tion of the fever. Coma is an occasional symptom. It is rarely absent in a in regard to the condition of the bowels is there any marked greater or less degree in severe cases. It may occur with or deviation from the ordinary habit of the individual: at all without previous delirium, supervene in the early or not until events, if there be a tendency to relaxation, it is accidental ache is
S!Jrnpto1ns.-In the early stage of typhus,
Head-
one
constitutes,
314
and temporary; and the evacuations are feculent, not watery, in enteric fever. It may, therefore, be stated as an axiom -that spontaneous diarrhoea, which is a very prominent symptom of enteric fever, is very rarely observed in ordinary as
typhus.
Again, intestinal haemorrhage, so frequent in the former, rarely occurs in the latter; and if it do occur, depends either on congestion of the mucous membrane of the colon, or haemorrhoids connected with a gorged condition of the portal system.
noticed that persons who have indulged in opium or tobacco are unusually prone to cerebral disturbance in the progress of fever. I well remember being puzzled with strange anomalous symptoms exhibited by a man under my care in the hospital many years ago, when the patient himself, in a state of halfdrunken delirium, implored me to allow him a dose of opium. I acted on the hint, and ordered two grains of solid opium to be given at intervals, which had the happy effect of calming the nervous system, and ultimately inducing sleep. Next day I ascertained that this man had been accustomed to take daily from ten to twenty grains of crude opium, and I thought it the best practice to give him this remedy until convalescence was established. He appeared to get rapidly better after the first
Tongue.-In the beginning of the disease, the tongue is covered with thin white mucus, which in its progress becomes In the more grave more or less brown, thick, and tenacious. cases, this incrustation is still darker, becoming at length almost black or fuliginous, while the tongue itself is shrivelled day opium was prescribed. and fissured, and sometimes coated with blood. I In children, brain affections are by far the most frequent of The teeth and lips are incrusted with a similar exudation of ’, all the secondary lesions in typhus. This might be anticipated dry, offensive mucus, or with bloody sordes, which evidently from the rapid development of the brain and the corresponding issues from the mucous surfaces,-a kind of local hemorrhage, activity of the cerebral circulation in the early periods of life. in fact,-as blood-discs may be discovered on placing a portion It is, therefore, especially necessary to watch in them the first indications of the brain becoming prominently affected. Hence, of this sordes under the microscope. With this dry, parched state of the tongue and fauces, there increased restlessness or impatience, flushing, more constant is often some difficulty in thrusting forward the tongue, or in complaints of pain in the head, intolerance of light and sounds, wakefulness or delirium, should awaken the practitioner to the swallowing, especially when the first efforts are made. The appetite or desire for food is also considerably impaired, probability of impending mischief in the head, if it have not especially for solids; whilst the i!7M)-si’ is generally in proportion already supervened. When there is drowsiness, with or withto the degree or intensity of the general symptoms. But it out intervals of sleep, lapsing into stupor or deep coma, subhas always been regarded as unfavourable, if the patient do arachnoid effusion has occurred and placed the child in the not complain of thirst when the mouth and fauces are very utmost danger. It is very difficult, if not impossible, when
scalp, persistent delirium, and, in the graver cases, by stupor or deep coma, the result of subserous effusion. In all cases of sudden coma, the condition of the kidneys should be watched, the urine often exhibiting traces of albumen, or even of blood, arising from nephritic congestion. These secondary brain affections are, perhaps, the most formidable of the complications met with in typhus. They are especially apt to supervene when persons of intemperate habits become the subjects of typhus, as well as in those who previously had been harassed with anxious care?. I have also
for several hours on either side or on the back without change, the lung will be not only moredull over the side on which he
has been placed, but the respiratory murmurs more loud and less vesicular. Nay, even when this secondary bronchitis exists to a considerable degree, the morbid sounds may be very indistinct--perhaps entirely absent. The reason (according to Dr. Stokes) appears to be, that the finer ramifications of the bronchial tubes are so turgid, that during ordinary breathing the air does not enter them with sufficient force to produce a sound, until the patient makes-which he is not al vavs able to
315
inspiration, when the sounds become audible. If patient recover, as the lung improves, the rale during ordinary breathing becomes more distinct and constant, the increase of rate during ordinary breathing indicating a decrease do-a forced
ON THE
the
of the bronchitic affection. Again, it is often very difficult to distinguish capillary bronchitis from pneumonia. Indeed, it often runs into a low form of inflammation of the pulmonary parenchyma, the whole or greater portion of one lung exhibiting dulness on percussion, with the characteristic fine crepitation of pneumonia. Still the dulness is less complete than in ordinary pneumonia, owing to the pulmonary tissue being in a state of congestion, rather than of consolidation. secondary pneumonia may either arise in this way in the progress of typhus, or it may become openly developed, and recognised by its physical signs. It may creep on slowly and insidiously, assuming, so far as its general signs are concerned, a latent character, there being neither cough, accelerated breathing, nor local uneasiness to indicate its existence, which is only discovered by the aid of physical diagnosis, by which its peculiar crackling sound is revealed. It may be limited to a portion, or involve the whole of one lung, or it may become developed in both-this secondary double pneumonia proving, with rare exceptions, rapidly fatal. The so-called hypostatic pneumonia requires a passing notice as a peculiar condition of the lung, supposed to be produced by the gravitation of the blood in the posterior and depending parts of the pulmonary structure, from long confinement on the back, in consequence of the patient being unable to turn in bed. It occasionally passes into a kind of diffuse consolidation, and is met with chiefly in persons advanced in life. Some patholoaists are inclined to think that it takes place immediately before death, when the act of dying has been protracted. But whether it takes place immediately, or some time previous to dissolution, it arises in the mechanical way I have explained. Pulmoraoy gangrene occasionally occurs as the sequence of secondary pneumonia. It is recognised by the signs indicative of pulmonary excavation-bubbling sound of the breathing at the apex of the lung, with peculiar foetid gangrenous odour of the expectoration and breath. Sometimes the expectorated secretion only is foetid, the breath being inodorous, except when the patient coughs. It is always fatal, according to my
experience. Pleurisy is much less common in typhus than in enteric fever, in which latter there appears to be a proclivity to serous inflammations, while in typhus local congestions predominate. Still, now and then we meet with a low form of pleurisy springing up in the progress of typhus, with or without pneumonia, and leaving after death traces of its existence in the effusion of lymph of limited extent, and extreme tenuity, from the dimin-
ished amount of fibrin in the blood. Heart.-The heart does not appear to undergo any special lesion in typhus. It partakes, however, of the general affection of the solids, so that its contractions, and consequently its sounds, become more or less enfeebled in proportion to the general depression. This alteration is not to be detected in the first stage of the fever, generally not until the end of the second week, when the first or systolic sound becomes more feeble, less prolonged, and more abrupt, so as to be scarcely distinguished from the second or diastolic. In extreme cases, indeed, this sound is nearly extinguished. Hence the importance of ascertaining the power or quality of the heart’s contractions, rather than its frequency or number of pulsations; for it has been observed, that when the first sound is so feeble as to be nearly inaudible, the patient seldom recovers. In this feeble condition of the heart the pulse at the wrist partici-
It is soft, easily compressed, generally rapid, and sometimes irregular; but it is always better to ascertain the force of the circulation by examining the condition of the heart itself, than the pulse in any of the arteries.
pates.
TREAT3iENT treatment of
OF
PROLAPSUS
BY
prolapsus ani by
NITRiC ACID. -The
cauterization with nitric acid, so well known in this country, has not yet apparently reached the knowledge of French surgeons, since two cases thus treated are announced as a surgical novelty by M. E. Hamon, in the last volume of the Tlaerapeutique Médicale (tome Ivii., livraison 12), in the hope of its being useful to make knoa n an operative procedure as expeditious as it is inoffensive in its effects, and thus to benefit those of his colleagues who may find occasion to have recourse to it."
316
INFLUENCE OF TROPICAL CLIMATES ON THE
& TREATMENT OF UTERINE INFLAMMATION.
RISE, PROGRESS,
BY EDWARD JOHN
TILT, M.D., M.R.C.P.L.,
CONSULTING PHYSICIAN TO THE FARRINGDON GENERAL DISPENSARY AND LYING-IN CHARITY.
IT would be very erroneous to suppose that uterine diseases the result of an over-refined state of civilization; they have been found to be of frequent occurrence amongst the unirritable women of uncivilized races by those who have been placed in favourable circumstances of observation. This statement is confirmed by my friend Dr. Stewart, late Professor of Midwifery in the Medical College of Calcutta, and Physician to the Hospital for Native Women, who was forcibly struck by the frequency of uterine diseases amongst the natives of India of both high and low caste. Another friend, Dr. Kirkman Finlay, Superintendent of the Hospital in Trinidad, likewise assures me that in that island the native women are never without suffering from some form or other of uterine disease, and the French creoles aptly indicate their chief cause of suffering by calling it " mal de mre." Although I shall again refer to the probable causes of uterine inflammation amongst the natives of tropical climates, the object of this communication is to investigate the influence of a tropical residence in the production of uterine inflammation amongst our countrywomen; and I intend to limit my remarks to the several varieties of inflammation of the body and neck of the womb, and to such uterine enlargements and displacements of the womb as are often the result of inflammatory were
action. In estimating the comparative frequency of uterine inflammation in the European residents of tropical climates, e must bear in mind that, whether in India or in our other tropical possessions, European women are all young; they leave Great Britain at about twenty, and very seldom remain in India after forty, thus passing in a hot climate the period of life in which uterine inflammation is most common even in temperate regions. This remark is made as a safeguard against exaggeration, but I am fully prepared to admit, with those who have practised in tropical countries, that during their residence there, Europeans are unusually prone to uterine disease. Dr. Stewart does not hesitate to say, that in India eight out of ten of the European female residents are habitually subject to deranged menstruation, leucorrhcea., or to cervical excoriations. Without having practised in tropical climates, I think I may usefully enter upon this investigation, because I have frequently had under my care, during the last ten years, patients invalided by uterine inflammation in the East or West Indies, China, Australia, orthe Brazils; for these different climates may be considered to favour the development of uterine disease in the same way, however different may be their pathology in many other respects. In addition to this favourable opportunity of studying the influence of tropical residence on the rise and progress of uterine disease, my intimacy with Dr. Henry Bennet has made available to me his large experience and correct views on this interesting subject, so that this communication may to a great extent be considered as representing his views as well as my own. This subject has not received due consideration in any work with which I am acquainted; so I deem it useful to submit my views to the medical profession, and to bring the subject under the attention of those who are practising in India and in our numerous tropical possessions, in order that they may fill up the deficiencies of my imperfect sketch. The following questions will be briefly considered :1stly. Why do tropical climates increase the frequency of uterine inflammation amongst those born in temperate regions? 2ndly. What is the influence of tropical climates on the march and progress of uterine inflammation both before and after the patient’s return to a temperate region? 3rdly. Does the treatment of uterine inflammation require to ’ be modified by the peculiar morbid conditions of those who from a tropical to a temperate climate?
return
LECTURES
ON
symptoms
FEVERS:
The Lumleian Lectures,
giddiness,
.
No. 1909.
advanced period of the fever, and may gra.dual!y disappear, slowly increase until death ensue. As to degree, there may be every modification from unnatural tranquillity, transient somnolence, to insensibility or deep coma. In the worst cases, generally fatal, the patient lies perfectly unconscious, with the eyelids open as if awake-a condition to which the term coma.
this eruption was present in one hundred and thirty-six, and absent in sixteen. It has been generally observed, too, that when the rash is absent, the fever is mild and of short duration, unless some intercurrent or secondary affection alter the character of the disease. Of the sixteen cases in which it was absent, thirteen were between the ages of four and fifteen, and the remaining three between sixteen and twenty-two. It also appeared, that of the whole number (one hundred and fifty-two),
an
tion was proportionally developed. In the Edinburgh epidemic (183S-9) the mortality of cases with scanty eruption was one in eight; where the rash was abundant it was one in four; the duration of the fever being also between one and three days longer in the one than in the
fever lasts. Vision is seldom affected, except towards the termination of unfavourable cases, when it is a bad omen, more especially if the patient attempt to catch imaginary objects, or pick the bedclothes, under the idea that they are covered with coloured spots. Sometimes, again, patients complain of seeing everything through a mist. The appearance of the eyes varies: in the beginning of the fever, they have a dull, languid appearance; and if the brain become acutely affected, they appear glistening, injected, and painful on exposure to light; or when coma supervenes, they are heavy, deeply injected, and the eyelids half closed. In the fatal stage, they become dim, fixed and glassy. The taste may be either impaired or perverted, so that articles of food are refused, under the idea that they are ill prepared, or have not their usual flavour. Sometimes the sense of taste is entirely lost. The sense of smell, too, is often impaired, or sometimes, like that of taste, altogether lost. The vital functions, comprehending the circulation, respirat’ioll, and animal heat, are always more or less affected. The pulse is generally frequent, soft, and compressible, sometimes irregular; and the heart commonly partakes of the feebleness-its sounds, especially the first or systolic, being scarcely audible. To this cardiac debility is to be ascribed the tendency to syncope when the erect posture is assumed; and hence, aiso, the occasional fatal accidents, when patients, who are very feeble, are allowed to pass their evacuations in the
or
vigil has
been applied. It may be observed, too, that brain affections
are not only seventy-six (exactly a half) were more than twenty-two years more prominently marked, but appear earlier, in typhus than old, and twenty one between the ages of sixteen and twenty- in enteric fever. whole muscular system undergoes two inclusive. The eruption was, therefore, present in every MscMCH’
other.
As it is important to keep in view the distinguishing characters of the typhus eruption, let me restate them :1. It consists of a congeries of spots, which cohere in the form of patches on the trunk and limbs (seldom on the face), of a brownish or mulberry hue, giving a diffused or mottled appearance to those parts of the skin on which it comes out; fading, but not disappearing, on pressure; and differing in those respects from the bright rose spots of enteric fever, which are isolated or distinct, and entirely vanish on firm pressure. 2. The typhus eruption is permanent or persistent -that is, it continues from its first appearance until the fever terminates; differing also in this respect from the rose spotted rash peculiar to enteric fever, which, after running through successive changes, disappears in a few days, and is succeeded by a fresh eruption of spots, which go through the same changes, crop after crop, until the cessation of the fever. 3. Though this eruption may be discovered by careful examination in a large proportion of cases, it is occasionally absent, its absence, however, being rarely observed in adults, more commonly in children; and it will be found that its presence or absence has an important bearing on the character of the fever-its absence more especially indicating a mild
disease. 2. Cel’ebral
night-chair.
The muscles concerned in respiration are often enfeebled, of the most constant symptoms, indeed rarely so that there is inability to inflate the chest freely, when such absent. It may be so slight as not to attract the patient’s an exertion is desirable for the purpose of examining the connotice; but sometimes, for the first week or ten days, it is dition of the pulmonary organs; and to the same cause, the fresevere and persistent, after which it generally abates gradually, quency of breathing-one of the most early as well as certain and finally disappears towards the end of the second week; or, indications of approaching dissolution-may be ascribed. should it continue longer, it comes on at intervals only-in The te?itpei-atu2-c of the skin is sometimes little affected, espethe evening perhaps, or during an exacerbation of the fever. cially in the beginning, and in mild cases. But as the symp.ZMM’tMM.—The intelligence is seldom disturbed in the toms progress, especially if the fever be severe, the heat of milder cases. In the more severe, there is transient confu- skin becomes augmented, particularly during the exacerbations. sion, soon lapsing into delirium, perceptible at first only on Some writers have alluded to a peculiar sensation felt on awaking, or in the night, but becoming more constant as the touching a fever patient, which they describe as of a pungent, fever advances. The character of the delirium varies: it is penetrating character. To this the term caloi- mordax has been sometimes noisy and violent (typhomania), more often low and given. Digestive Systent.-The digestive system, which is so promi. muttering, with tendency to somnolence; in other cases, it partakes of the character of delirium tremens-the form usually nently affected in enteric fever, is little if at all disturbed in observed in spirit-drinkers, or in persons harassed with care. typhus; so that the absence of gastric or intestinal irritation in ordinary typhus, an important point in diagnosis. This symptom (delirium) is rarely noticed before the seventh or eighth day. It may appear, however, earlier or later; but Sickness or vomiting may be said to be rare, nor does the at whatever period it comes on, it continues till the termina- abdomen exhibit externally anything abnormal, there being neither unnatural prominence nor tympanitic distension. Nor tion of the fever. Coma is an occasional symptom. It is rarely absent in a in regard to the condition of the bowels is there any marked greater or less degree in severe cases. It may occur with or deviation from the ordinary habit of the individual: at all without previous delirium, supervene in the early or not until events, if there be a tendency to relaxation, it is accidental ache is
S!Jrnpto1ns.-In the early stage of typhus,
Head-
one
constitutes,
314
and temporary; and the evacuations are feculent, not watery, in enteric fever. It may, therefore, be stated as an axiom -that spontaneous diarrhoea, which is a very prominent symptom of enteric fever, is very rarely observed in ordinary as
typhus.
Again, intestinal haemorrhage, so frequent in the former, rarely occurs in the latter; and if it do occur, depends either on congestion of the mucous membrane of the colon, or haemorrhoids connected with a gorged condition of the portal system.
noticed that persons who have indulged in opium or tobacco are unusually prone to cerebral disturbance in the progress of fever. I well remember being puzzled with strange anomalous symptoms exhibited by a man under my care in the hospital many years ago, when the patient himself, in a state of halfdrunken delirium, implored me to allow him a dose of opium. I acted on the hint, and ordered two grains of solid opium to be given at intervals, which had the happy effect of calming the nervous system, and ultimately inducing sleep. Next day I ascertained that this man had been accustomed to take daily from ten to twenty grains of crude opium, and I thought it the best practice to give him this remedy until convalescence was established. He appeared to get rapidly better after the first
Tongue.-In the beginning of the disease, the tongue is covered with thin white mucus, which in its progress becomes In the more grave more or less brown, thick, and tenacious. cases, this incrustation is still darker, becoming at length almost black or fuliginous, while the tongue itself is shrivelled day opium was prescribed. and fissured, and sometimes coated with blood. I In children, brain affections are by far the most frequent of The teeth and lips are incrusted with a similar exudation of ’, all the secondary lesions in typhus. This might be anticipated dry, offensive mucus, or with bloody sordes, which evidently from the rapid development of the brain and the corresponding issues from the mucous surfaces,-a kind of local hemorrhage, activity of the cerebral circulation in the early periods of life. in fact,-as blood-discs may be discovered on placing a portion It is, therefore, especially necessary to watch in them the first indications of the brain becoming prominently affected. Hence, of this sordes under the microscope. With this dry, parched state of the tongue and fauces, there increased restlessness or impatience, flushing, more constant is often some difficulty in thrusting forward the tongue, or in complaints of pain in the head, intolerance of light and sounds, wakefulness or delirium, should awaken the practitioner to the swallowing, especially when the first efforts are made. The appetite or desire for food is also considerably impaired, probability of impending mischief in the head, if it have not especially for solids; whilst the i!7M)-si’ is generally in proportion already supervened. When there is drowsiness, with or withto the degree or intensity of the general symptoms. But it out intervals of sleep, lapsing into stupor or deep coma, subhas always been regarded as unfavourable, if the patient do arachnoid effusion has occurred and placed the child in the not complain of thirst when the mouth and fauces are very utmost danger. It is very difficult, if not impossible, when
scalp, persistent delirium, and, in the graver cases, by stupor or deep coma, the result of subserous effusion. In all cases of sudden coma, the condition of the kidneys should be watched, the urine often exhibiting traces of albumen, or even of blood, arising from nephritic congestion. These secondary brain affections are, perhaps, the most formidable of the complications met with in typhus. They are especially apt to supervene when persons of intemperate habits become the subjects of typhus, as well as in those who previously had been harassed with anxious care?. I have also
for several hours on either side or on the back without change, the lung will be not only moredull over the side on which he
has been placed, but the respiratory murmurs more loud and less vesicular. Nay, even when this secondary bronchitis exists to a considerable degree, the morbid sounds may be very indistinct--perhaps entirely absent. The reason (according to Dr. Stokes) appears to be, that the finer ramifications of the bronchial tubes are so turgid, that during ordinary breathing the air does not enter them with sufficient force to produce a sound, until the patient makes-which he is not al vavs able to
315
inspiration, when the sounds become audible. If patient recover, as the lung improves, the rale during ordinary breathing becomes more distinct and constant, the increase of rate during ordinary breathing indicating a decrease do-a forced
ON THE
the
of the bronchitic affection. Again, it is often very difficult to distinguish capillary bronchitis from pneumonia. Indeed, it often runs into a low form of inflammation of the pulmonary parenchyma, the whole or greater portion of one lung exhibiting dulness on percussion, with the characteristic fine crepitation of pneumonia. Still the dulness is less complete than in ordinary pneumonia, owing to the pulmonary tissue being in a state of congestion, rather than of consolidation. secondary pneumonia may either arise in this way in the progress of typhus, or it may become openly developed, and recognised by its physical signs. It may creep on slowly and insidiously, assuming, so far as its general signs are concerned, a latent character, there being neither cough, accelerated breathing, nor local uneasiness to indicate its existence, which is only discovered by the aid of physical diagnosis, by which its peculiar crackling sound is revealed. It may be limited to a portion, or involve the whole of one lung, or it may become developed in both-this secondary double pneumonia proving, with rare exceptions, rapidly fatal. The so-called hypostatic pneumonia requires a passing notice as a peculiar condition of the lung, supposed to be produced by the gravitation of the blood in the posterior and depending parts of the pulmonary structure, from long confinement on the back, in consequence of the patient being unable to turn in bed. It occasionally passes into a kind of diffuse consolidation, and is met with chiefly in persons advanced in life. Some patholoaists are inclined to think that it takes place immediately before death, when the act of dying has been protracted. But whether it takes place immediately, or some time previous to dissolution, it arises in the mechanical way I have explained. Pulmoraoy gangrene occasionally occurs as the sequence of secondary pneumonia. It is recognised by the signs indicative of pulmonary excavation-bubbling sound of the breathing at the apex of the lung, with peculiar foetid gangrenous odour of the expectoration and breath. Sometimes the expectorated secretion only is foetid, the breath being inodorous, except when the patient coughs. It is always fatal, according to my
experience. Pleurisy is much less common in typhus than in enteric fever, in which latter there appears to be a proclivity to serous inflammations, while in typhus local congestions predominate. Still, now and then we meet with a low form of pleurisy springing up in the progress of typhus, with or without pneumonia, and leaving after death traces of its existence in the effusion of lymph of limited extent, and extreme tenuity, from the dimin-
ished amount of fibrin in the blood. Heart.-The heart does not appear to undergo any special lesion in typhus. It partakes, however, of the general affection of the solids, so that its contractions, and consequently its sounds, become more or less enfeebled in proportion to the general depression. This alteration is not to be detected in the first stage of the fever, generally not until the end of the second week, when the first or systolic sound becomes more feeble, less prolonged, and more abrupt, so as to be scarcely distinguished from the second or diastolic. In extreme cases, indeed, this sound is nearly extinguished. Hence the importance of ascertaining the power or quality of the heart’s contractions, rather than its frequency or number of pulsations; for it has been observed, that when the first sound is so feeble as to be nearly inaudible, the patient seldom recovers. In this feeble condition of the heart the pulse at the wrist partici-
It is soft, easily compressed, generally rapid, and sometimes irregular; but it is always better to ascertain the force of the circulation by examining the condition of the heart itself, than the pulse in any of the arteries.
pates.
TREAT3iENT treatment of
OF
PROLAPSUS
BY
prolapsus ani by
NITRiC ACID. -The
cauterization with nitric acid, so well known in this country, has not yet apparently reached the knowledge of French surgeons, since two cases thus treated are announced as a surgical novelty by M. E. Hamon, in the last volume of the Tlaerapeutique Médicale (tome Ivii., livraison 12), in the hope of its being useful to make knoa n an operative procedure as expeditious as it is inoffensive in its effects, and thus to benefit those of his colleagues who may find occasion to have recourse to it."
316
INFLUENCE OF TROPICAL CLIMATES ON THE
& TREATMENT OF UTERINE INFLAMMATION.
RISE, PROGRESS,
BY EDWARD JOHN
TILT, M.D., M.R.C.P.L.,
CONSULTING PHYSICIAN TO THE FARRINGDON GENERAL DISPENSARY AND LYING-IN CHARITY.
IT would be very erroneous to suppose that uterine diseases the result of an over-refined state of civilization; they have been found to be of frequent occurrence amongst the unirritable women of uncivilized races by those who have been placed in favourable circumstances of observation. This statement is confirmed by my friend Dr. Stewart, late Professor of Midwifery in the Medical College of Calcutta, and Physician to the Hospital for Native Women, who was forcibly struck by the frequency of uterine diseases amongst the natives of India of both high and low caste. Another friend, Dr. Kirkman Finlay, Superintendent of the Hospital in Trinidad, likewise assures me that in that island the native women are never without suffering from some form or other of uterine disease, and the French creoles aptly indicate their chief cause of suffering by calling it " mal de mre." Although I shall again refer to the probable causes of uterine inflammation amongst the natives of tropical climates, the object of this communication is to investigate the influence of a tropical residence in the production of uterine inflammation amongst our countrywomen; and I intend to limit my remarks to the several varieties of inflammation of the body and neck of the womb, and to such uterine enlargements and displacements of the womb as are often the result of inflammatory were
action. In estimating the comparative frequency of uterine inflammation in the European residents of tropical climates, e must bear in mind that, whether in India or in our other tropical possessions, European women are all young; they leave Great Britain at about twenty, and very seldom remain in India after forty, thus passing in a hot climate the period of life in which uterine inflammation is most common even in temperate regions. This remark is made as a safeguard against exaggeration, but I am fully prepared to admit, with those who have practised in tropical countries, that during their residence there, Europeans are unusually prone to uterine disease. Dr. Stewart does not hesitate to say, that in India eight out of ten of the European female residents are habitually subject to deranged menstruation, leucorrhcea., or to cervical excoriations. Without having practised in tropical climates, I think I may usefully enter upon this investigation, because I have frequently had under my care, during the last ten years, patients invalided by uterine inflammation in the East or West Indies, China, Australia, orthe Brazils; for these different climates may be considered to favour the development of uterine disease in the same way, however different may be their pathology in many other respects. In addition to this favourable opportunity of studying the influence of tropical residence on the rise and progress of uterine disease, my intimacy with Dr. Henry Bennet has made available to me his large experience and correct views on this interesting subject, so that this communication may to a great extent be considered as representing his views as well as my own. This subject has not received due consideration in any work with which I am acquainted; so I deem it useful to submit my views to the medical profession, and to bring the subject under the attention of those who are practising in India and in our numerous tropical possessions, in order that they may fill up the deficiencies of my imperfect sketch. The following questions will be briefly considered :1stly. Why do tropical climates increase the frequency of uterine inflammation amongst those born in temperate regions? 2ndly. What is the influence of tropical climates on the march and progress of uterine inflammation both before and after the patient’s return to a temperate region? 3rdly. Does the treatment of uterine inflammation require to ’ be modified by the peculiar morbid conditions of those who from a tropical to a temperate climate?
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