Imatges de pÓgina

calculations, which are very liable to error, the following number of fatal cases, in which the period of attack could be ascertained, shews a great predominance of the odd days: of fiftysix cases that proved fatal in the Trusty, within the month, two died on the 6th, 12th, 14th, and 28th days; four on the 7th; five on the 9th; nine on the 11th; ten on the 13th; six on the 17th; three on the 25th; one on the 8th, 10th, 15th, 18th, 19th, 21st, 24th, 26th, 27th, 29th, and 31st; and none previously to the 6th, nor on the 16th, 20th, 22d, and 23d days of the disease.

The appearances on dissection proved strongly illustrative of the frequency of local congestion and inflammation. There was hardly any organ which was not occasionally found diseased; but the parts most commonly altered in appearance and structure were the contents of the thorax, the brain, and the abdominal viscera. Of these the lungs, probably from the coldness of the season, and insufficient clothing, suffered most frequently; and the effects of inflammation were conspicuous in extensive adhesions of their investing membrane to the parietes of the chest, pericardium, and diaphragm; in effusions of coagulable lymph and serum, or the formation of purulent matter.

The heart occasionally, and oftener the pericardium, exhibited patches of inflammation, with spots of effused lymph, and had formed strong attachments. In one patient they adhered so firmly that the heart was torn in attempting to separate them. The quantity of fluid found in the pericardium varied: sometimes it was considerably increased; at others, there was little or none. In a few patients the liquor pericardii was very turbid, and like whey, or partly purulent: in one, there was about four ounces of pus. In several instances (in some where there was a deficiency, but also in others where it contained a portion of fluid) the pericardium was found so thin, dry, shrivelled, and transparent, as to have the most perfect resemblance to a piece of dried bladder. This desiccated appearance, which occurred more frequently in the Argonaut than in the Trusty, is mentioned by Dr Baillie as having been twice found by himself, and much oftener by Mr Hunter. The diaphragm also sometimes exhibited similar dry patches, and oftener erysipelatous inflammation.

Masses of coagulable lymph were occasionally found in the cavities of the heart, and some of a yellower and more fatty appearance than the other; but, instead of being inflammable, they also shrivelled up, and exhibited the character of albumen or fibrine, when exposed to heat. This separation is not uncommon, however, in patients dying of other disorders; and often

takes place after death, and probably in protracted cases previously, or in articulo mortis.

Though strong traces of disease were not so uniformly observed in the brain as in the thorax, yet signs of previous excitement and congestion were often evinced by the fulness of its vessels, the increased vascularity, and sometimes the agglutination of its membranes; and by numerous ramifications of fine, and as if minutely injected capillaries.

Spots or specks of coagulable lymph were sometimes thrown out on the inflamed surface of the dura mater; and effusions of fluid on the outside, or into the ventricles of the brain. In one instance, about four ounces of lymph were found between the meninges; and in some, blood was extravasated on the surface, or in the convolutions of the cerebrum; indeed, effusions of blood or serum had frequently taken place, in those who died with symptoms of compression, about the 18th day.

The abdominal viscera, and their peritoneal covering, often displayed the remains of inflammatory action also, as had been conjectured from the pain on pressure; and the small intestines adhered to each other, and to the wasted omentum. Purulent matter, and serous exudations, containing portions of albumen, were likewise discovered, though less frequently in the abdominal than in the thoracic cavities; and though such effusions, as the consequences of inflammation, are best anticipated by the lancet, yet they may have been sometimes promoted by the intended' remedy, if employed too late to be of service.

The liver was less frequently found diseased than was expected; but it sometimes bore marks of inflammation; and, now and then, its convex surface was of a spotted or erysipelatous appearance.

The gall-bladder was seldomer distended with bile than would have been the case, if purgatives had not been so freely employed. Occasional appearances betokened increased determination to the kidneys and bladder ;-in a few instances the pancreas felt unusually hard, and firm;-the spleen sometimes exhibited disease-and in one or two patients, a cartilaginous deposition, of the size of a crown piece, was found on its surface. There was less affection of the stomach, both before and after death, than I have observed in any other fever.

These are the appearances, noted from the dissections made in the hospital-ships, which I recollect to have seen, or with which I have been favoured, as having most frequently occurred, from the sources I have already acknowledged. Without pretending to enumerate all the nicer changes, or shades of diseased structure, I merely mean to say, that one or more of the viscera be

came the seat of morbid action, to which the burthen of the fever was directed, either primarily, by local predisposition, or particular concurring circumstances; or was transferred secondarily by association.

Very many authorities might here be quoted in support of this alliance between fever and local inflammation; but it will be sufficient to refer to them collected in the works of Drs Clutterbuck, Beddoes, Mills, and other late writers. Mr Burns, in his treatise on Inflammation, says, "that typhus is always attended with an inflammatory affection of the head, and sometimes of the lungs or abdominal viscera, must be acknowledged by every one conversant in dissection."

In speaking of inflammation, however, it is necessary to keep in recollection the occasional red and vascular appearance of a part, which probably has been frequently mistaken for it. Such an appearance of vascular fulness, in the villous coat of the stomach, particularly from venous accumulation, has been often found where no suspicion of previous inflammation could be entertained; as has been well illustrated by Dr Yelloly in a paper of the 4th volume of the Medico-Chirurgical Transactions.

On the other hand, if it be granted that slight inflammations are dissipated after death, it follows, that, to estimate the early and less marked effects of this state, it is necessary that the investigation should take place as soon afterwards as possible. For we should keep in mind the remark of Bichât, that inflamed serous membranes soon lose their redness; and the observation of Drs Rush, Clutterbuck, and others, that congestion, or other morbid states of the brain, produced by disordered action, or minute, yet fatal changes of structure, may have taken place, yet leave little or no marks of disease after death.

Analogous to this, in yellow-fever I have observed the serous capillaries of the tunica conjunctiva red and turgid with blood, which disappeared after dissolution.

It would appear, therefore, that there is danger of error on both sides, unless when the pre-existence of inflammation is rendered unequivocal by adhesions, suppuration, extravasation, effusion, or considerable organic derangement.

Without further enlarging upon these morbid changes, they certainly go far to establish the connection between fever and inflammation in the present, and, by analogy, its frequency in other fevers; for, as far as I am acquainted, traces of inflammation, or of a state nearly allied to it, were discovered in such cases as had appeared to be the most purely idiopathic; and, even when the patient had complained of little or no pain dur

ing the disease, marks of increased determination or congestion were discovered in some organ after death.

It is therefore highly proper to bear in mind the extensive ravages which have been discovered on dissection, particularly in the glandular viscera, and which have oftentimes taken place, either without exciting sensation, or have been attended only with a dull low degree of pain.

Accordingly, it was often very difficult to appreciate, here, the extent of mischief going on, where it was only indicated by the maintenance of obscure febrile action, or by some sympathetic affection; for in some cases it was discovered to be considerable, when the patient had made little or no complaint; and in others, the injury was found to be much greater in a part which had not been suspected, than in that of which he had complained.

I cannot, in consequence, avoid noticing here, the obscurity in which the diagnosis is often involved, and the frequent risk of deception, arising from implicitly receiving, as the seat of the disease, the part referred to by the patient. We should never forget, as Dr Monro well observes in his Morbid Anatomy, that sympathy between near, and even distant organs, renders the source of disease obscure,-and that'distant sensations, and sympathetic feelings, often create the most acute pain, and give the first notice of internal mischief. I need hardly observe, how peculiarly this caution must be applicable in the morbid state of the sensorium, arising from the complicated phenomena constituting fever, when the confusion or indistinctness of the patient's perceptions is so apt to lead him to refer his uneasiness to a wrong source.

The influence of one pain in obscuring another, as a physical law of sensibility, was well known to the father of medicine; nor has it escaped the universal observation of the father of our drama: "But when the greater malady is fixed, the lesser is not felt."

We have so many instances on record of concealed mischief going on in this way, which has not been suspected until developed by dissection, that it is of great consequence to have the errors of sensation, or, more strictly speaking, of reference, in fever, constantly in view; and I trust I shall be pardoned for pressing such sources of fallacy more generally upon the attention; since, by placing less reliance on the more prominent features, and by scrutinizing the minuter shades of disease, we become enabled to estimate the result more correctly.

In dangerous fevers, particularly where the brain is much affected, we have too often but a very inaccurate criterion, if we

measure the extent and danger of diseased action by the pain, or by the state of the pulse, &c. Thus, while in many, these symptoms were amply sufficient to lead to the anticipation of a fatal event, it was difficult to reconcile the uniformity of this result in others, when they were much less considerable.

But, without attempting to reason upon a subject where the pathology is so obscure, and often, perhaps, evanescent, as that of the brain in fever, it may be remarked, that the fatal injury which this organ sustained, seemed oftener to be a secondary than a primary affection, and the consequence of sympathetic connection with some of the other primarily diseased viscera.

The idea of the brain suffering secondarily is farther countenanced by analogy; as, in many cases of wounds and accidents, in different parts of the body, we find that the apparent is often not proportional to the real danger; nor, except by sympathe tic transference to the sensorium, is the local injury sufficient to account for the unfavourable result.

The perfect resemblance between sympathetic and original fever is here well worthy of observation; for often, consequent upon such local injuries, have arisen symptoms possessing all the characteristics of, and not otherwise distinguishable from, idiopathic fever; and indeed to this cause, viewed as an accidental and independent disease, the death of the patient in such cases has been, not unfrequently, but erroneously attributed.

The appearances on dissection which have been enumerated form a commentary on the observation of Riverius: "Febres acutas et malignas rarissimè sine visceris alicujus inflammatione incidere." They strongly demonstrate the propriety of venesection; and, accordingly, the benefit derived from this remedy was great in proportion as it was freely and early employed. When it could be so used, it was natural to expect that, in many instances, the disease would be crushed in its birth; but it seldom could be arrested when the symptoms had made any progress. In such cases, when the tendency to inflammation and congestion was lessened, but not destroyed, it often became necessary to resort to the repeated abstraction of blood; and although I was by no means friendly to this evacuation after the first days of fever were passed, yet that it was occasionally employed in smaller quantity, at a more advanced period, not only without any bad consequence, but with evident relief, I cannot doubt, not from personal observation alone, but from the different reports that were made to me on the subject.

When the fever could be attacked soon after its invasion, a large bleeding, repeated according to its effects, appeared to be the most beneficial practice in the Argonaut; and, if not suf

« AnteriorContinua »