Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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upon the mucous membrane of the small intestines.

1. The congestive state, by which the whole membrane appears
swollen, injected and covered with slime, worse so, however, on its
lower portion in the neighborhood of the valvula Bauhini.

2. The state of infiltration, by which the general redness and swell-
ing gradually disappear and become concentrated to the solitary and
Peyer's glands in the Itwer part of the ileum.

3. The state of softening, by which the swelling of the glands is



TYPHUS ABDOMINALIS. 573

absorbed, or the glands burst and become covered witli a dry crumbly
crust, or they burst and discharge their contents without getting cov-
ered with a crust.

4. The state of ulceration, by which the affected glands suppurate
and form the typhoid ulcer. These ulcers are round when originating
out of a solitary follicle, and elliptic when originating out of Peyer's
plaques; their size varies from that of hemp-seed or pea to the size of
half a dollar. Their basis is the submucous cellular tissue which
lines the muscularis of the gut.

The symptoms and course of typhoid fever are the following : The
patient has generally several days previous to the attack a sense of
general indisposition, weakness and debility, with headache, dizziness
and soreness of the limbs, and sometimes repeated attacks of bleeding
from the nose, or none of all. The attack itself begins almost always
with a more or less violent chill, or repeated chilly sensations, but
sometimes without a chill. It is therefore not always possible to fix
accurately the time of the disease. The chill is followed by heat,
which keeps a regular, quite characteristic typical rise and fall every
day for the first week, in this manner, that the temperature of the body
increases from morning till evening one degree, and again falls from
evening to next morning one-half a degree. For example, if a patient's
temperature rises on the first evening to 38, 5°, it will be next morn-
ing 38° ; next night 39°, and the following morning 38, 5°, and so on,
gradually climbing higher and higher. This is so pathognostic a sign
of typhoid fever that Wunderlich, who has made the most accurate
observations on this score, says : "la the first week it is so much the
rule that the temperature rises one degree from morning till evening,
and falls again from evening to tbe following morning one-half a
degree, that we may exclude typhus from our diagnosis, if the tem-
perature amounts already on the first or second day to 40°, or likewise,
if it does not reach within the fourth and sixth day an evening aggra-
vation of at least 39, 5°." When Wunderlich further adds, ''that it
would likewise exclude typhus if there were already an evening-
diminution of temperature towards the latter part of the first week,"
he may be perfectly right, if it be understood that the patient be let
alone, or be treated altopathically. Homoeopathic treatment shows
other results ; the well-selected homoeopathic remedy may nip the
fever in the bud within the first days of its existence.

With, the temperature rises also the pulse, amounting generally
during the first week from ninety to one hundred beats per minute ;



574 FEVEES.

sitting up, bodily exertion, or mental excitement, is apt to accelerate
it considerably, even to twenty to thirty beats.

With all this the patient complains of great weakness and prostra-
tion, severe headache, dizziness, flickering before the eyes, and ring-
ing in the ears; his sleep is restless and disturbed by tiresome
dreams, sometimes of the same thinar over and over ag-ain : he calls
out in sleep or talks incoherently. "When awake he is fully con-
scious but indifferent, answering questions slowly and reluctantly.
His thirst is great, his appetite gone, and his taste pappy, disagree-
able. The bowels are in the first days frequently constipated, but
change towards the end of the first week to diarrhoea. There is in
many cases repeated bleeding from the nose, and already at this time
a catarrhal irritation in the chest. The face is flushed ; especially the
cheeks look dark red as long as the patient lies quietly on his back ;
but it turns pale and sunken when he sits up a while. The tongue is
soft, flabby, showing the imprints of the teeth, and is covered by a
slight whitish fur, which gradually is thrown off, leaving the tongue
moist, smooth, and red, as though it were covered with a fine, gold-
beater's skin ; it soon, however, grows dry. In cases where the
tongue is thickly coated, this covering commences to disappear
either on the tip and edges, whereby the white-yellowish coating
becomes encircled by a gradually broader growing, deep, red belt,
or it disappears at first in the centre, and constitutes that well-known,
dry, red streak in the middle of the tongue, which is frequently
broader at the point of the tongue, and forms, in this way, a kind of
triangle, with its base down at the tip.

The abdomen at this time appears somewhat bloated and is sensi-
tive to strong pressure. A deep pressure upon the ileo-csecal region
may cause a gurgling noise in that region, especially if there be
already diarrhoea present. The spleen is swollen, which can be
detected by percussing the patient when he lies upon his right side.
Finally, there appear toward the end of the first week single, pale,
reddish, lentil-sized roseola-spots upon the epigastrium and adjacent
parts of the chest and abdomen.

In the second loeeh the temperature of the body ranges between
40, 5° and 41, 6° ; towards morning there i^ only a slight remission,
and the pulse grows softer, weaker, and more frequent, from one- hun-
dred and ten to one hundred and twenty beats. The dizziness
increases, the ringing in the ears changes to hardness of hearing,
which is generally dependent upon a catarrhal affection of the
Eustachian tubes and tympanum. The expression of the face becomes



TYPHUS ABDOMINALIS. 575

more and more stupid, and the indifference of mind increases. By-
and-bj the consciousness of the patient becomes clouded and he sinks
gradually in a state of somnolence and stupor. Although the tongue
is as dry as " chip," yet he utters no desire for drink ; takes it, how-
ever, when offered, very greedily. When asked to show his tongue,
he does not seem to comprehend at first, but finally, with great effort,
he brings it forth, pointed and trembling. Stool and urine pass off
involuntarily. The patient lies always on his back, and having lost
consciousness of all muscular power, the body follows its own weight
and the patient slides gradually down in bed, without any effort of
his own to change this position. The mental operations are still
going on ; we see it on the now-and-then trembling lips, as efforts to
speak, and in the low murmuring of unintelligible words now and
then. This is febris nervosa stupida.

Other patients, although likewise mentally disconnected with the
exterior world, neither knowing nor understanding what is going on
about them, manifest a vivid, dreamful perturbation of the mind.

They are in constant agitation, throw off' the covers, try to get out
of bed and to escape, talk loud or lisp som.e unintelligible words, ges-
ticulate and become angry when interfered with. Their obstinacy in
gaining their imaginary ends is sometimes astonishing, when all at once
it changes to some other object. In other cases there seems to be no
intelligible connection between the constantly-changing phantasmata,
with which they seem to be haunted. This agitation of the mind is
generally greatest during the night. This is febris nervosa versatilis.
There are again cases where both of these states make a regular turn ;
the febris stupida prevailing through the day, and the febris versatilis
through the night.

During this week the bowels are almost always loose, owing to the
catarrhal affections of the intestines ; the cheeks have a brownish-red
or bluish color ; the eyelids are half closed ; the conjunctiva is injected ;
the nose is thoroughly dry, and the nostrils are blackened as of soot.
On the gums and teeth we observe sordes ; the tongue is covered with
a brownish crust, which gradually grows black from the admixture of
blood ; it is stiff, making swallowing quite difficult. The abdomen is
inflated like a drum ; the spleen has grown still larger, and the roseola-
spots have, in some cases, likewise increased, and are joined by
numerous sudamina. On the chest, physical examination reveals
solidification of the dependent parts of the lungs, and far-spread catar-
rhal affections. There is a less full percussion sound, weak vesicular



576 FEVEES.

breathing, fine, bubbling rattles in the dependent parts, and loud
rlionchi everywhere else.

The tliird week does not bring any amelioration as yet. The tem-
perature of the body is still on the increase, and the morning remis-
sions are quite indistinct. Only where the case turns favorably, there
is in the second half of the third week a decided improvement in this
respect. Whilst the evening temperature still rises to 40 — 41°, the
morning temperature shows only 38 or 39°.

The prostration reaches, in this week, its climax ; the patient slides
down in bed ; there is a constant jerking of the tendons ; somnolence
and stupor are complete, and stools and urine are passed unconsciously,
or the urine is retained in consequence of a paralysis of the detrusor
vesicae ; the roseola-spots commence to get paler, whilst the sudamina
increases more and more, and in some cases there appear petechiee.
To all this associates an erythema in the region of the sacrum, which,
by throwing off the epidermis, is soon converted into a bed-sore —
decubitus. This is, indeed, the week when the mortality of typhus-
patients is the greatest, whilst in favorable cases its latter part is the
turning point. We observe then a gradual abatement of all the above-
detailed symptoms. The stupor changes into a natural sleep, con-
sciousness gradually returns; diarrhoea, respiration, pulse, counte-
nance, all improve.

This improvement continues in the fourth iveeh, or in some instances
commences then, and finally passes over into the state of reconvales-
cence. During this time nearly all the patients lose their hair, which,
however, is soon followed by a new crop.

This is about the course which a majority of typhoid fever cases
run. Besides this, however, there are a number of variations, of
which the following are the most important.

The ahortive typhoid fever is, in every respect, much lighter, and
corresponds to the "gastric fever or nervous fever "^ of older writers.
Although it shows all the symptoms of a regular typhoid fever, yet
they are all much milder ; the temperature of the body never reaches
such an intensity, and already on the eighth or ninth day there is a
considerable morning remission, which sinks at the end of the second or
during the third week to a normal state, with only slight aggravations in
the evening. Still the patients gain quite slowly their usual strength.

The typhus ambulatorius is a peculiar form, corresponding to the
" walking cases" of yellow fever, by which the patient complains only
of general debility and exhaustion, but still attends to his business,
until all of a sudden he sinks under the signs of perforation of the



TYPHUS ABDOMINALIS. 577

intestines or intestinal hemorrliage. In such cases it seems that the
poison has localized exclusively in the intestines, without affecting
the general circulation.

The typhus tumuUuarius, on the other hand, sets in at once so vio-
lently, that the temperature of the body rises already in the first week
to 41° and above, and the pulse to 120 and 180 ; all other symptoms
are correspondingly severe, so that the disease reaches its climax
towards the end of the first or in the beginning of the second week.
Such cases are mostly fatal at this early period^ or the symptoms
grow milder again in the second week, and take then the usual
course.

The pneumo -typhus and broncho- typhus are forms in which the poi-
son seems to localize principally in the chest, causing hypostasis of
the lungs, pneumonia, or violent bronchitis, whilst the characteristic
affections of the small intestines are comparatively light, or even
wanting.

In still other cases the normal progress of the disease is interrupted
by an intercurring perforation of the intestines^ when the typhoid ulcers
eat through the muscularis and serosa of the gut. This is always
followed either by a partial or diffuse peritonitis, the symptoms of
which compare under the corresponding chapter. The most reliable
sign, however, of perforation, during typhus, is tympanites or the sud-
den escape of gas into the peritoneal sac, which presses the liver back
from off the thoracic wall, and causes, on percussion, in place of the
dull, liver-sound, a clear tympanitic sound.

Or the natural progress of the disease is interrupted by an inter-
curring hemorrhage from the bowels. This takes place either in conse-
quence of arrosions of blood-vessels near the ulcers, or in consequence
of the bursting of overfilled capillaries. It causes bloody stools, and
if profuse, collapse and a sudden sinking of the temperature, which
sometimes restores consciousness for a while, but generally ends fatally
in consequence of the exhaustion which it produces. Less dangerous
are the intercurring profuse hemorrhages from the nose, which take
place sometimes in the second or third week of typhus, and the
hemorrhages from the luomb in female patients. But as both are the
consequence of a highly-debilitated state of the system, none of them
can be considered as a favorable sign.

Or the whole course of the disease is protracted by the slow healing
process of the intestinal ulcers. In such cases we find the typhus fol-
lowed by a low, asthenic fever for weeks afterwards, or in fact there
is no cessation of the fever ; the sensorium remains clouded ; the

a7



578 FEVEES.

weakness increases; the emaciation grows excessive; the bed-sores
enlarge ; any part of the body wherever its own weight rests upon,
shows the signs of decubitus. Many of these patients die about the
fifth or sixth week, as such a far-spread decubitus alone seems to be
sufficient to consume the little strength that is left.

As sequelse of typhus may be mentioned : neuralgia, partial paral-
ysis, partial anaesthesia, mental disturbances, tabes, ansemia and hy-
dreemia. It is not unfrequent that, during the period of reconval-
escence, phthisis pulmonalis is developed.

Titer apeutic Hints.

Apis, according to Wolf, in the presence of: apathic conditions,
unconsciousness, stupor, with murmuring delirium, hardness of hear-
ing, inability to talk and to put out the tongue, which is cracked,
sore, ulcerated, or covered with vesicles; difficulty in swallowing,
great soreness and bloatedness of the abdomen ; constipation, or fre-
quent, painful, foul, bloody, and involuntary discharges from the
bowels ; unconscious flow of urine ; dry burning skin, or partial,
clammy sweats; trembling and jerking of the limbs; white miliary
eruption on the chest and abdomen, greatest weakness and sliding
down in bed ; frequently changing, weak and intermitting pulse.

Arnica, stupefied condition ; sits as if in thought, yet thinks of
nothing, like a waking dream ; forgets the word while speaking ; con-
fusion of the head ; loss of consciousness ; delirium ; great weakness,
weariness and bruised soreness, which compels to lie down, and yet
every position feels too hard; unrefreshing sleep, with anxious
dreams, talking, and loud blowing in, and expirations ; bleeding from
the nose; trembling of the lower lip; dry tongue, with a brown
streak in the middle ; putrid smell from the mouth ; distention of the
abdomen ; involuntary discharge of feces and urine ; pleuritic stitches
at every inspiration ; great sinking of strength.

Arsen., especially for weak or debilitated individuals, old age and
children; in slow, protracted cases, with mild delirium; loss of con-
sciousness ; great restlessness and anxiety, manifesting itself in con-
stantly moving head and limbs, whilst the trunk lies still, on account
of too great weakness ; picking of the bed-clothes ; sopor ; face dis-
torted, sunken, anxious, hippocratic ; cheeks burning hot, with cir-
cumscribed redness; eyes staring, glistening or sunken, dull and
watery, or closed wi^h sticky matter ; hardness of hearing ; lips dry
and cracked ; lips, gums and teeth covered with brown or black slime ;
tonc^ue red and dry, cracked ; stiff; like a piece of \Yood ; black tongue-;



TYPHUS. 579

speecli unintelligible, lisping, stammering, as tliougli the tongue were
too heavy ; excessive thirst, but little drinking at a time ; the fluid
rolls audibly down into the stomach ; vomiting and retching ; burning
in stomach and bowels, sensitive to pressure ; meteoristic distention
of the abdomen ; constipation or looseness of the bowels ; brownish or
watery, bloody, foul, involuntary discharges ; involuntary discharge
of urine or retention of urine. Yoice weak and trembling, or hoarse,
coarse or crowing ; breathing short and anxious, oppressed, rattling ;
dry cough ; fetid breath. On chest and abdomen roseola-spots ; white
miliary eruption, even petechite; decubitus; excessive prostration
and rapid emaciation ; pungent, hot, dry skin, like parchment ; cold,
clammy perspiration ; pulse frequent, small, trembling. A cadaver-
ous smell scents the whole atmosphere. All symptoms worse about
and soon after midnight.

• Baptisia, " she cannot go to sleep, because she cannot get herself
together. Her head feels as though scattered about, and she tosses
about the bed to get the pieces together." (Dr. Bell, of Augusta, Maine.)
Dull, stupefying headache, confusion of ideas ; delirious stupor ; dark,
red face, with a besotted expression ; injected eyes ; coated tongue,
brown and dry, particularly in the centre, or dry and red ; sordes on
the teeth ; fetid breath ; fetid sweat ; fetid discharges from the bowels;
fetid urine; great debility and nervous prostration; ulcerations;
chilliness all day ; heat at night ; chilliness, with soreness of the whole
body.

Bellad., during the early stage, especially of tumultuous cases,
when there is great congestion to the brain, with great drowsiness,
and an inability to go to sleep, and frequent starting during sleep ;
violent delirium, with attempts to run aAvay, to strike, bite, or spit on
his attendants ; sparkling, staring eyes ; throbbing of the carotid and
temporal arteries, and also in the forehead ; deafness ; burning heat
and redness of the face ; distortions of the mouth ; dryness of nose,
mouth, and throat ; tongue with red margin and white centre ;
trembling and heaviness of the tongue, with stammering as if drunk ;
sore throat and dry cough from bronchial irritation.

Bryon., in any stage when there is delirium, especially at night
about the affairs of the previous day or business matters ; visions,
especially when shutting the eyes ; irritableness ; peevishness ; easily
offended ; hasty speech ; headache ; dull, pressive, or stitching, tear-
ing pains, worse from motion and opening the eyes; eyes dull,
watery ; hardness of hearing ; dryness of nose ; lips dry, brown,
cracked ; tongue coated thick, white, or yellowish ; later, brown and



580 FEVERS.

dr J ; dry feeling in the mouth, without any thirst or else great thirst,
with drinking large quantities at a time ; bitter taste in the mouth ;
nausea ; retching ; great soreness in the pit of the stomach to touch
or motion ; bowels constipated ; hard cough, with stitching pain in
the chest and region of the liver; bronchitis; great lassitude and
weakness ; wants to lie quiet ; pain in all the limbs when moving ;
restless sleep, with groaning and moaning, and frequent movements
of the mouth, like chewing ; eruption of white, miliary rash, with
anxiety in the region of the heart ; sighing, groaning, and moaning,
and a peculiar, sour smell of the body, with or without sweat.

Calc. c, according to Goullon, during the aggravations, which pre-
cede the outbreak of the miliary rash, about the fourteenth day of
the disease : palpitation of the heart, tremulous pulse, anxiety, rest-
lessness, redness of the face, delirium, jerkings, especially in children ;
short, hacking cough ; excessive diarrhoea. Besides this, it may be
indicated at the very onset, and then cut ojff all further progress in
persons inclined to grow fat ; after great anxiety and worriment of
mind ; utter sleeplessness from over-activity of the mind ; it is the
same disagreeable idea which always rouses the patient as often as he
falls into a light slumher ; constant tickling under the middle of the
sternum, causing a hacking cough, worse from talking or moving;
during coughing, painful shocks in the head ; the brain feels hot and
burning. Lippe.

Carbo veg., often at the brink of death a saviour, in those states of
collapse, dissolution of blood, and paralytic conditions, which seem
rapidly to invade the whole organism. All this is indicated by
stupor, out of which the patient can scarcely be roused for moments ;
the eyes are dull, without lustre, and the pupils without reaction
against light ; the hearing is gone ; the face is pale, sunken, hippo-
cratic, cold ; there are hemorrhages from mouth and nose ; the
tongue is sometimes moist and sticky; other times parched and
cracked, heavy, scarcely movable; bluish or pale; the pit of the
stomach is bloated ; the abdomen meteoristic, with loud rumbling and
gurgling of wind in the intestines; there is colliquative diarrhoea,
brownish, grayish, or bloody, of a cadaverous smell, and involuntary.
The cough has ceased, and the collecting secretions cause loud,
rattling breathing, a sign of beginning paralysis of the lungs ; the
circulation is without energy ; the blood stagnates in the capillaries,
and causes cyanotic blueness of face, lips, and tongue ; ecchymotio
spots here and there ; decubitus ; the pulse is extremely weak, fre-
quent, small, scarcely perceptible ; face and extremities grow cold



TYPHUS. 581

and become covered witli cold perspiration — all signs of beginning
paralysis of tlie heart ; in short, the patient offers a picture of com-
plete torpor of all vital functions, thus differing entirely from that of
Arsenicum, which is always more or less associated with erethism of
the system.

China, especially where there is painless diarrhoea, bloatedness of
the abdomen, hemorrhages, and slowly-progressing reconvalescence
after such weakening influences.

Coccul., in such cases which are mainly characterized by adeprima-
tion of the nervous system, showing little or no disturbance in the
vegetative sphere of the system, except enlargement of the spleen.
There is a slowness of comprehension; he don't find the right ex-
pressions for his ideas ; what has passed he cannot remember ; he
talks muttering, mumbling ; it costs him great effort to speak the
words plainly ; and then again for a short while he is very irritable,
cannot endure either noise or contradiction, and speaks hastily. Most
of the time, however, he sits in silence or feels an unconquerable in-
clination to sleep ; his eyelids are heavy, fall shut, as if paralyzed ; the
drowsiness may increase to coma. There is dizziness in the head,
especially when rising up in bed, with nausea, compelling to lie
down again ; ringing in the ears ; heat in the head and chilliness in
the remaining body ; pappy taste in the mouth ; belching ; nausea ;
distention and rumbling in the abdomen ; great general weakness and
weariness ; great heaviness in the feet ; attacks of trembling and
jerking of the eyelids, muscles of the face, and limbs, and fits of faint-
ing from bodily movement, with spasmodic distortion of the facial
muscles.

Colchicum, according to Wells, great weakness, as if after exertion.
If the patient be raised up the head falls constantly backwards, and
the mouth opens to the widest extent. Sudden sinking of the forces,
so that in ten hours he can hardly speak or walk ; cadaverous aspect
and extreme prostration ; emaciation ; lying on the back ; comatose ;
eyes half open ; respiration audible and accelerated ; hands and feet
cold ; trunk hot and extremities cold ; skin dry ; sweating ; sup-
pressed, cutaneous transpiration ; forehead covered with cold sweat ;
pulse small and contracted, quick, and hardly perceptible, small and
frequent, quick, and thready ; pulseless ; delirium, with cephalalgia ;
intellect beclouded, though he gives correct answers to questions ;
unless questioned, he says nothing of his condition, which does not



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 58 of 65)