Case CXI.
Case CXI.
Case CXI.
Mary Ann Hunt, æt. 24, servant. Admitted on the 14th day of fever: attack commenced with shivering, succeeded by heat, nausea, and head-ache; until last night, has had no stool for five days. At present, no pain of head or chest; much pain of limbs; sleeps well; severe pain over the epigastrium, increased considerably by coughing and by pressure; tongue thickly coated with a whitish-yellow fur, through which the papillæ appear large and prominent; much thirst; no appetite; no stool to-day; skin warm; catamenia regular; pulse 135, of good strength.
V.S. ad ℥xxvj. Haust. Sennæ Sal. quam primum. Acid. Mist. pro potu. Mist. Acet. Amm. C. 6tâ q. h.
15th. Pain of limbs quite gone; that of epigastrium also entirely removed; no tenderness on the fullest pressure; tongue more clean; less thirst; several stools; slept well; skin cool; pulse 84, soft. Blood in both basons very buffy. Cont. med.
16th. Continues quite free from pain; tonguenearly clean; two stools; skin cool, moist; pulse 88. Pt. med.
18th. No return of pain; tongue clean; pulse 87; four stools; skin natural. Pt. med.
22d. Sat up yesterday and the day before, since which the skin has become more warm, the pulse more quick, and the tongue more loaded, but there is no local pain, and the bowels are open.
23d. Pains of limbs returned; slept ill; tongue loaded at root; pulse 110.
24th. Pains diminished; pulse 100; tongue still furred; skin warm.
26th. Pains gone; skin cool and moist; tongue the same; two stools; pulse 100.
28th. Tongue more clean; skin warm; pulse 76.
35th. Convalescent. Inf. Case. c. Senna bis.
41st. Dismissed cured.
Case CXII.
Case CXII.
Case CXII.
Eleanor Welby, æt. 21, servant. Attacked four days ago with chilliness, shivering and pain of head. At present, pain of head gone; mind distinct; little or no sleep; eyes suffused and injected; no uneasiness of chest nor cough; throat sore, with difficult deglutition; tenderness of abdomen on pressure; tongue loaded on body with white fur, extremely red at edges and tip; lips and teeth sordid; some thirst; bowels regular; pulse 129, of good strength,yet easily compressed; efflorescence of skin of dark red colour, approaching to a dusky hue. V.S. ad xvj. Hirud. viij. gutturi. Ol. Ricini, ʒiij. quam primum. Mist. Acid. pro potu.
6th. No uneasiness of head; slept ill; eyes suffused and injected; face swollen; still complains of soreness of throat, which is undiminished; tongue moist; teeth sordid; lips sordid and cracked; less thirst; three stools; pulse 120, firm; blood very sizy and cupped. Rep. V.S. ad ℥xiij. et Hirudines viij. gutturi. Pt. Med.
7th. Expression of countenance more natural; face less swollen; more sleep; throat greatly relieved; deglutition quite easy; no tenderness of abdomen on full pressure; tongue more clean and moist; lips and teeth less sordid; pulse 111; eruption less distinct. Haustus Sennæ Sal. c. m.
8th. No uneasiness of head, throat, or abdomen; sleep natural; tongue beginning to clean, much less red; pulse 114; skin exfoliating.
9th. Convalescent.
14th. Has been gradually gaining strength and is now quite well. Dismissed cured.
Case CXIII.
Case CXIII.
Case CXIII.
Mary Jones, æt. 33, married. Three days ago attacked with shivering, succeeded by glows of heat, severe pain in the back and lower extremities, withmuch head-ache. At present, pain of head severe, especially over the forehead; mind distinct; scarcely any sleep; no uneasiness of chest; some cough; abdomen tender on pressure; tongue not much loaded; some thirst; no appetite; one stool; pulse 108, of some power.—V.S. ad ℥xvj. Ol. Ricini, ʒiij. q. p. Mist. Acid. pro potu.
Hora 3tia, p. m. Pain of head diminished since the bleeding, but by no means removed; much pain of back; some of abdomen; pulse 112, strong, full, sharp, and not easily compressed. Blood with firm and thick buff. Rep. V.S. ad ℥xvj. statim. Pulv. Aper. Mit. h. s.
4th. After the second bleeding last night, the pain was entirely removed: she slept well, and the pain continued absent until this morning, when it returned with great severity, or rather violence. She was bled to the extent of fourteen ounces with immediate and great relief: blood in both cups with firm buff and proportion of crassamentum large: at present, the head is quite free from pain; there is scarcely any pain in the back; no tenderness of the abdomen; tongue loaded in middle with white fur, moist at edges, of natural colour; four stools; pulse 120, weak.—Pt. med.
5th. No return of pain in the head; that of back continues; slept ill; tongue much more clean and quite moist; four stools; pulse 120, weak; skin warm and damp. Omit. pulv. Pt. alia med.
6th. Pain of head returned with great severity last night, for which she was bled to the extent of four ounces with only temporary relief; no sleep on account of the severity of the pain; skin hot; entire scalp extremely hot; face pallid; nothing unnatural in the appearance of the eye, and no intolerance of light; pulse 120, sharp, but easily compressed; tongue loaded with white fur; thirst; four stools; buff on blood pretty firm.
C. C. ad ℥x. nuchæ. Camphoræ, gr. v. c. Extract. Hyosci. gr. iij. 6ta. q. h. Pulv. Aper. Mit. h. s. Lotio frigida capiti raso.
7th. Pain of the head entirely removed since the cupping, and has not since returned; slept well; face continues very pallid; tongue loaded with white fur in middle; very pallid; pulse 120, of good strength; feels quite easy, but very weak. Cont. Pilulæ. Capt. Haust. Quininæ Sulph. 6ta. q. h.
8th. No return of pain in the head; some in loins; scarcely any sleep; tongue the same; four stools; pulse small and extremely weak. Pt. Med. omnia. Capt. Vini Albi, ℥iv. in dies.
9th. Free from pain in the head, back, and every organ; scarcely any sleep; much restlessness; delirium; countenance pallid and sunk; feels very weak; tongue the same; four stools; pulse 120, not so weak as yesterday. Pt. Med. Vini Albi ad ℥viij.
10th. Slept ill; much restlessness and delirium;frequent and deep sighing; severe pain in the lower extremities recurring in paroxysms; she says the pain is as if some one were rending her limbs from her; tongue white, moist; four stools; pulse 110, weak; takes and relishes her wine. Statim capiat Haustus Anodynus, c. Liq. Opii Sedativi, gtts. xl. Augt. Vini Albi, ad ℥x. Cont. alia med.
11th. Long and tranquil sleep after the draught; less delirium; no sighing; no return of pains in the limbs; mind perfectly distinct; “feels greatly better;” countenance much more animated; tongue the same; pulse 108, more strong and firm, but still easily compressed. Cont. Med. Rept. Haustus Anodynus hora decubitus.
12th. Slept well all night; “feels very much better to-day;” no return of pain; complains only of sense of lowness; pulse 96, weak. Pt. Med. omnia.
13th. Continues to improve in all respects.
14th. Feels stronger; pulse 108, of good strength; occasional muscular tremor. Pt.
18th. Continues steadily to improve. Pt. Jus. Bov. lbj. in dies. Vini Albi, ℥vj.
23d. Convalescent. Omit. Med. Inf. Cascaril. c. Senna, bis.
33d. Free from complaint. Dismissed cured.
In this case bleeding was carried to the utmost extent to which it could be carried with safety, and rather beyond it; but it was one of those cases inwhich less was to be apprehended from the bleeding than from the disease.
Case CXIV.
Case CXIV.
Case CXIV.
Frances Jacob, æt. 17, destitute. Four days ago seized with nausea, vomiting, headache, and other febrile symptoms. At present, much pain of epigastrium, which is extremely tender on pressure; throat sore; deglutition very painful; much vertigo; scarcely any headache; no sleep; mind confused through the night; some pain of chest on full inspiration; cough, with viscid copious sputa; very considerable dyspnœa; aspect of countenance leaden-coloured and oppressed; skin warm, of a dusky, unhealthy red colour; tongue very red, not much loaded; bowels constipated; pulse 135, tremulous and indistinct. Abradat. Capillitium. Hirud. viij. faucibus externis. Postea Empl. Emoll. Empl. Lyttæ nuchæ. Inhal. Vap. Aq. Calid. Garg. c. Borat Sodæ. Ol. Ricini ʒiij. q. p. Pulv. Aper. Mit. h. s.
5th. No pain of head; no sleep; mind confused; much low talkative delirium; still uneasiness of chest on full inspiration; throat less painful; deglutition more easy; dyspnœa and cough the same; abdomen tender; tongue unchanged; four stools; pulse 120, feeble and indistinct; skin covered universally with very unhealthy red, dusky efflorescence.Pulv. Aper. Mit. h. s. Mist. Camphor, ℥iss. c. Tt. Hyosciami, ʒj. et Ammon. Carbon, gr. x. 4ta. q. h. Vini Albi, ℥vi. in dies.
6th. Much delirium; some sleep; skin of same colour; rather more sensible to-day; says she has no pain of head, but sense of severe soreness all over her; much cough; four stools; pulse 120, weak. Pt. Med. et Vin.
7th. Slept well; less delirium; “feels much better;” countenance greatly improved; skin more warm; colour much more natural; throat still painful; deglutition difficult; some tenderness of the epigastrium on full pressure; scarcely any over the abdomen; tongue red at edges, brown and dry in middle; much thirst; three stools; pulse 108, soft, not very weak; lips and mouth surrounded with an herpetic eruption; skin not abraded, but covered with soft scab. Pt. Med. omnia.
8th. Slept well; asleep at present; no delirium pulse 108, soft.
9th. Still more improved; pulse 96, soft.
13th. Pulse 87; other symptoms the same. Pt.
14th. Complains more of pain of epigastrium, which is considerably tender on pressure; other symptoms the same. Catap. Sinap. epigast. Pt. alia.
15th. Epigastrium much relieved; other symptoms the same. Pt.
18th. Convalescent.
24th. Dismissed cured.
Case CXV.
Case CXV.
Case CXV.
Margaret Skey, æt. 37, married. Five days ago attacked with sense of cold, shivering, and heat, together with pains in the bones. At present complains of pain in small of back; no headache; no pain of chest; some cough; no tenderness of abdomen; tongue white and dry; much thirst; bowels constipated; sleeps tolerably; pulse 112. Haust. Sennæ Sal. q. p. et c. m. Rep. Mist. Acid. pro potu.
6th. Abdomen very tender; tongue red; four stools; much thirst; skin warm; face flushed; pulse 100, easily compressed. Hirud. x. abdom. Postea Catap. Emoll. Rep. alia.
8th. Much delirium through the night; considerable muscular tremor; pain of abdomen gone; tongue tremulous, but not much coated; much thirst; four stools; pulse 100, weak; frequent shivering. R. Quininæ Sulph. gr. ij. Aq. Rosae, ℥j. M. Sit Haustus, 6tis. q. h. sumendus. Jus. Bov. lbj. in dies. Rep. alia.
10th. No sleep; mind confused; two stools passed in bed; urine in bed; respiration laborious; pulse 90, weak. Alcohol (brandy) ℥iv. ex Aqua per diem. Pt. Med.
13th. Slept better; less delirium; two stools not passed in bed; pulse 96.
15th. More power; stools not passed in bed; other symptoms the same. Pt.
17th. Strength again rather diminished; tongue rather brown; much thirst; pulse 100; no pain. Pt.
21st. Little change, excepting that the tongue is more brown, dry, and tremulous; pulse 108, extremely feeble; mind distinct; no delirium; two stools. Aug. Alcohol ad ℥vj.
22d. Tongue less brown and more moist; pulse 108, stronger; slept well. Pt.
24th. Countenance much more animated; tongue more clean, quite moist, still brown towards root; pulse 110. Pt.
25th. Countenance still more improved; tongue more clean; no longer brown; pulse 102, weak.
26th. Much improved; tongue nearly clean; two stools; pulse 108, weak.
27th. Gains strength. Alcohol ad ℥iij.
34th. Convalescent, but still very weak. Cerevis. lbj. Pt. alia.
45th. Has been gradually, though very slowly gaining strength; tongue now clean; appetite good; bowels regular (Low Diet); 2 ozs. meat daily.
52d. Dismissed cured.
II.Treatment during the Convalescence.
The management of the convalescence is one of the most difficult parts of the treatment and one of the most unsuccessful, not because there is any thing which requires to be done, nor because there is any disease which prevents recovery, but because the patient is considered as well when he is only convalescent. Of the great tendency there is to relapse during the whole of this period few medical men are sufficiently aware, and the unprofessional attendants on the sick are totally ignorant of it. For a long time the brain, the bronchi, and the intestines remain so irritable that the slightest excitement is capable of renewing the diseased action which has recently subsided; but without excitement of some kind, that renewal never takes place. It is the duty of the physician and the nurse to guard the patient from such excitement, which they may always do completely; so that whenever there is a relapse, the physician, or the nurse, or both must be in fault: as long as they perform their duty with judgment and firmness there is no such thing; but this part of their duty which is extremely simple, they cannot be induced to believe to be of importance: no one who has not seen death happen over and over again from the neglect of it will believe it, and even thoseupon whom melancholy experience has impressed the truth most strongly, constantly allow themselves to be surprised at the slightness of the excitement by which, and the advanced period of the convalescence at which relapse may happen. It is not easy for a nurse to resist incessant importunity and even reproach; and there are suspicions to which a physician is subjected, which, when he sees that they are entertained, it requires some moral courage to enable him to bear. Without doubt he deserves the worst that can attach to him if he allow the caprice, or the impatience, or the injustice of his patient, or any earthly consideration to induce him to swerve from the faithful discharge of the duty he has undertaken. The unreasonableness of the convalescent, should be considered and treated as the delirium of the preceding stage.
The mismanagement of the convalescence consists chiefly in allowing the patient to rise too early from bed, and to take solid food too soon and in too large a quantity; and these are by far the most frequent causes of relapse. Were I to place on record all the instances I have seen of fatal relapse from these two causes alone, the list would be frightful. Many patients, the very day they become convalescent, think they ought to be allowed to get up. They feel well, they think they are so; they earnestly declare that they are so. They are impatient of bed; they imagine it keeps them weak: “if youwould but allow me to rise how thankful I should be; how much more it would refresh and strengthen me than any thing that can now be done.” Such is the language which is constantly addressed to the physician in the early period of convalescence, and if he be weak enough to yield to it and allow his patient to rise, it is a chance if he ever rise again. The most cautious and experienced physician sometimes finds himself deceived, falling into the same error with his patient, and thinking him stronger than he is. Whenever this happens, the physician has great reason for self-reproach,because he ought to allow no risk to be run. Often, however, in private practice, the physician is allowed to have no control whatever over the management of the convalescence—he is dismissed as soon as the patient is out of apparent and urgent danger; dismissed hastily, often to be more hastily recalled to witness the death of him whom every one thought to be well.
But if merely rising from bed at too early a period occasion the death of great numbers, eating heartily of solid food is a still more frequent and certain cause of it. The appetite is generally keen immediately after fever has subsided: if animal food be allowed as soon as the appetite craves for it relapse is sure to be produced. Often and often have I seen fatal cerebral and abdominal inflammation excited in a few hours after the commission of this error. I do not expect, by any language at mycommand, to communicate to others my own conviction of its danger. I know that such a conviction can be produced in no one who has not an opportunity of observing the convalescence of large numbers; and I know that no one who has such an opportunity can be without it.
There are three conditions under which this danger is peculiarly imminent. First, when the disease has been unusually severe and protracted. The more intense the fever and the longer it has lasted, the more are all the organs enfeebled, and the longer do they retain the irritability of weakness, In this state, anything beyond the gentlest stimulus will induce vascular excitement, which will rapidly pass into inflammation.
Secondly, when the disease was severe in the commencement, and has been promptly subdued by active treatment. Whenever copious bleeding brings on a precocious convalescence, that convalescence is invariably uncertain and infirm. It is always steady as long as it is properly protected, but it has not strength equal to its apparent health: it is as tender and fragile as it is sensitive: the least noxious agent impresses it; the least stimulus overpowers it. The patient is suddenly relieved from a load that oppressed him; the organs react with preternatural vigor; they have enough to do to sustain the reaction of the system: stimulate them still further by animal food and wine, and they will be sure to beover done; and this artificial excitement will be as fatal as the excitement of disease. It can be of little consequence to the patient whether he die of malaria or of chicken.
Thirdly, when the disease was slight in the commencement and through its subsequent progress, but the convalescence proved tardy and imperfect. In this case, animal food and wine are pernicious and highly dangerous, and often prove more fatal than a severe form of fever. Nothing is advantageous or safe for such a patient but perfect rest and quiet and the blandest farinaceous diet.
I have now laid before the reader all that I have been able to learn of this frequent and most formidable disease. I am conscious that some of the views which have been exhibited are opposed to the prevalent doctrines of the day, and that some parts of the treatment recommended must appear to many unnecessary and hazardous. But since I have suggested no doctrine which has not been deduced from a long and careful study of the phenomena, and recommended no practice which has not been derived from large experience, I trust that the former will not be rejected without examination, nor the latter condemned until its failure have been witnessed. I have opposed with earnestness, perhaps some may think with vehemence, certain opinions and modes of practice which I conceive to be pregnant with evil; but as I have never intended the slightest reproachor blame to the advocates of the doctrines I condemn, so I shall feel truly grateful to any one who will point out any mistake into which I may have fallen. Those who have studied this disease with the best success are the most sensible how much remains to be done to render our knowledge of it perfect and our treatment of it effectual. Many are the dark spots that still remain upon this part of the field of knowledge; many are the labourers that must work long and skilfully before they are removed; while, if the successful investigation of medical science in general contribute largely to the well-being of man, the successful study of this branch of it must be pre-eminently beneficial. It is computed that upwards of one-half of the human race perish by this fell disease in one or other of its forms: when this fact is coupled with the truth disclosed by the annexed tables, which shew at what age this malady is most prevalent and fatal, we become duly impressed with the importance of labouring to render our knowledge of this dreadful disease complete, that we may lessen, as far as possible, the suffering of our common nature, and extend to its utmost limit the term of human life, too brief when most protracted, but constantly cut short by this great enemy of our race, just as adolescence is ripening into manhood.