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practitioners, though we doubt whether all who have noticed it, regarded or treated it as fever. We do not, in fact, consider the name a very appropriate one, but it ma}' serve for the nursery; and the author has much stronger pretensions to reputation than those which he might derive from naming a disease which has been termed marasmus, consumption, worm fever, bilious fever, typhus, &c. according to the taste or the judgment of the writer. Now, in our opinion, these are names of diseases entirely distinct from each other, and we also conceive we frequently meet with a remittent fever •very different from the complaint before us. In some respects then, it is advantageous for a man not to be burthened with much reading: he may more securely investigate the Case presented to him as it really appears, without being disturbed by names and authorities that might shake his judgment. What unlearned man, for instance, seeing a child whose appetite and strength had gradually sunk, with an inaptitude for exertion, irregularity in the bowels, and a wasting of the whole body, would think of typhus fever, or indeed of any sort of fever? But such is the commencement of the remittent /ever.
"After these symptoms have continued for some time, the patient has several accessions of slight fever, more particularly towards evening; during which he evinces a strong propensity to sleep, seeks a recumbent posture, and is exceedingly peevish. The tongue at this period has seldom an unhealthy appearance, because digestion is not yet completely suspended. The pulse is an hundred or more in a lainute.
'• In this situation the patient will sometimes continue during several weeks, and at others will be suddenly attacked towards evening with a more violent paroxysm of fever; which is frequently considered by the parents to be the commencement of his disease. It is generally preceded by a shivering fit and vomiting, but seldom terminates with perspiration, the skin being remarkably dry through nearly the whole course of the complaint. The pulse during the paroxysm beats from an hundred and thirty to an hundred and sixty in. a minute, and the respiration is performed with corresponding velocity. The cheeks are flushed, and the sleepiness is increased to an extreme degree, but is frequently interrupted with starts, expressions of pain about the belly, slight delirium, and sometimes with convulsions. A cough is noticed at this time, which generally continues through the whole of the illness, together with an almost constant picking of the skin about the eyes, nose, lips, and fingers.
"The duration of the febrile paroxysm is usually one or two hours, bnt in some instances will extend through the whole night, after which a remission takes place, and the patient becomes more wakeful and inclined for amusement, or it will sometimes terminate in sleep of a refreshing nature. The pulse now beats from an hundred and twenty to an hundred and thirty.
"The return of these exacerbations is uncertain: mo-it commonly there is one in the forenoon, one in the afternoon, and one in the night. The last is usually the longest and most violent. When the fever runs very high, we have much difficulty in observing any distinct remissions.
"There is much variation in the temperature of the body, the head, belly, and palms of the hands being more hot than any other parts on the surface.
"In some instances, the 'head is more affected even to a degree of raving, and one or other of the excretions is always remarkably increased. After this the patient becomes quieter than usual, says little, complains of nothing, and is not disposed to answer questions. He seldom asks for any tiling, but in general takes his food or drink, when it is offered him. The trunk of his body keeps to one posture, and he rarely moves his lower limbs; but his arms or hands are almost constantly in motion when he is awake. Sometimes he is flinging about his arms; sometimes he lies with his hands stretched down on the lower part of his belly, and his knees drawn up. At other times he is much employed in picking, not only his nose and lips, but even his tongue, eyes, and other parts of his face, till they become sore and chopped; and he gapes that he may reach his tongue, for he has not the power of putting it out of his mouth. At last his indifference as to answering questions ends in an impossibility of giving answers, for he is deprived both of speech and voice; and his jaws, in some cases, are so locked that nothing but liquids can be got into his mouth, and these with a good deal of difficulty. At this period, which seems to be the height of the disease, he slumbers, and is most composed, as usual, during the exacerbations; and in the remissions he performs the same gesticulations. From the time that there are settled symptoms of lowness, his eyes are reddish, dull, and inattentive; his countenance is marked with distress; his tongue,, gums, teeth, and lips, are covered with a blackish fur; he is particularly uneasy before stools, or great explosions of wind; his urine and stools are involuntary, and yet he is quite sensible.'
"'The state of the belly is Uncertain; but the stools are always unnatural, either as to their color, consistence, contents, or smell. Most commonly they are morbid in all these respects, for they are either whiter or darker than natural: they arc always more offensive,are seldom without a great deal of slime, and sometimes consist of nothing but slime.'*
"' Digestion seems perfectly at a stand, for the food which is taken into the stomach will often bs brought up unaltered, though it shall have remained down a considerable lime. The intestines also seem, to be in a manner paralysed: they exert no action on the food, for it passes off like a mass of putrid vegetable and animal matter, which, bas.been some time subjected to heat and moisture, without its having
* " 'Treatise on the Infantile Remittent Fever, by W. Butter. M.D.'—Callow, London."
the smallest resemblance, either in appearance or smell, to those fseces, where the powers of digestion have-been exerted.
««-« When the disease has continued some time, the appetite is so totally destroyed, that for six or eight days together I have known the whole nourishment consist of about half a pint of toast and water in the twenty-four hours.'*
"I have frequently known that the patient has taken nothing but ■water, excepting his medicines, for lour or five weeks together, and yet has ultimately recovered."
These are the leading and most usual symptoms of the complaint. But Mr. Coley has noticed some others, as petechice, and a discoloration and separation of the epidermis, in the advanced stage of the complaint.
The diseases it is likely to be confounded with, are enlargement of the mesenteric glands, and hydrocephalus interims. The author also mentions inflammation of the lungs, which we should have thought hardly possible, had he not stated that he had known many instances of such a gross blunder.
"It may be distinguished from enlargement ofthe mesenteric glands, by the accession of fever occurring in the latter generally in the evening only; by the patient being more restless at that time, instead of being inclined to sleep, as in remittent fever; by the intestinal evacuations having but little alteration from their natural appearance, that is to say no more generally than what may be supposed to arise from a defective absorption of chyle; by a peculiar mark of distress in the countenance; by the sleep being for the most part undisturbed; and by the length of time the complaint has existed. The fever accompanying enlargement of the absorbent glands in the mesentery, is of a hectic nature, generally terminates with profuse perspiration, and, in every instance that T have seen, has been free from delirium."
If any of our readers think they cannot distinguish the remittent fever from inflammation of the lungs, we refer them to Mr. Coley's treatise, where they will find the distinction very minutely drawn. The disease, we doubt not, is often confounded with hydrocephalus internus: we shall, therefore, quote this part of Mr. Coley's diagnosis.
"The symptoms denoting hydrocephalus internus cannot be confounded with the other disease, until effusion has taken place to such an extent as to compress the brain and impair its functions. In its previous stage a manifest difference must have been observable, from the acuteness of the pain in the head, from the intolerance of light, from the agitation or tossing of the head, and from the absence of
* " ' A Practical Treatise on Various Diseases of the Abdominal Viscera, by C. R. Pemberton, M.D.'—1806. G. and W. Nicol, London."
sleep;. sleep, to which must be added, the healthy slate of the bowels. It might also be suspected that this disease is commencing when the above symptoms have been observed to succeed much irritation about the gums during the formation and evolution of the deciduous teeth; as-it is not uncommon for it to arise from the inflammation of the membrane lining the alveolar processes, or of the capsules of the teeth being translated by the operation of sympathy, or some other cause, to the membranes of the brain.
"When effusion has commenced, the symptoms are such as proceed from compression on the brain from other causes, as squinting, interrupted or stertorous breathing,* paralysis generally on one side of the body, insensibility to external stimuli. At length the pupili are dilated and insensible, the pulse intermits, the eye-lids are half closed, the evacuations are involuntary, and in this stage of the disease those from the bowels are often of a greenish or other unhealthy appearance, f- The countenance is pale, the muscles of the face are generally distorted, and convulsions often arise and continue from the time the apoplectic symptoms commence, till death closes the scene.
* "The patient in this state generally performs about three respirations, and then ceases to breathe for some time, after which respiration commences again for three or four times, and so on. This interruption arises from the comparative insensibility of the lungs, in consequence of a fluid effused on the brain, compressing the origin of the nerves. The circulation of venous blood, which takes place after the oxygen has been all absorbed from the pulmonary air-cells, produces a disagreeable or painful sensation, called suffocation, which rouses the diaphragm and the other inspiratory muscles into action, and a deep inspiration comes on, followed generally by two or three smaller inspirations, by which means the painful sensation is removed. When the pressure on the brain is very great, the heart neglects its duty, which occasions an intermitting pulse. This arises from the sensibility or irritability of that viscus being so much impaired, as to suffer the venous blood to accumulate in the right auricle, till the pressure of it produces a stimulus that excites it into action, and the circulation goes on again."
f *' It may seem extraordinary that in the early part of this disease no affection of the bowels should exist, and that it should make its appearance as the original disorder advances. The cause of it is a torpor of the liver and of the stomach and bowels, produced by the pressure of the fluid effused on the brain, and particularly on that portion of the great sympathetic nerve which proceeds from it, and extends to those important viscera. In consequence of this, the healthy secretions of those organs are suspended or obliterated, and the faeces are of nearly the same disordered appearance as in remittent fever. When this occurs exclusively from pressure on the brain, and is unaccompanied with remittent fever, I have aiwaj* considered it a dangerous, and have generally found it a fatal symptom."
no. 175. ii , "In
"In this complaint (he muttering expressions are incoherent, the streamings are acute and loud, and, as was before observed, the patient cannot be roused to attend to anything, being like one in a profound sleep. While the sense of pain continues, the hands are constantly carried towards the head.
'* In the delirium or stupor of remittent fever, the attention of the patient may be excited for a few moments by strong external impressions, as by talking loudly to him, or by sudden agitations of his body, and there is never any tossing of his head from one side to the other, but, on the contrarv, the child is disposed to be still, and to remain in one posture, unless roused by the officioiisness and anxiety of his friends or attendants. The face is flushed, and the eye-lids are closed, or, if wide open, they have a foolish disagreeable kind of stare, which is particularly conspicuous in (hose cases where the patients possess a perfect knowledge of every thing that is going forward, but are unable to articulate. The respiration is quick, but not interrupted; and the pulse never intermits excepting in cases of extreme debility. There is no squinting; the pupils are sometimes contracted, and sometimes dilated, according to the degree of stupor; and when temporary paralysis happens, it is in those parts which are subservitnt to the poner of volition. The hands are seldom carried up towards the head, and when they are, we may perceive that the intention is that of picking the skin about the face, and not that of expressing pain in the head. When convulsions happen, it is impossible during their continuance to distinguish the two diseases, but after they have ceased, if they may have proceeded from remittent fever, the faculties of the patient will be restored.
"The tongue, in both diseases, is furred when the bowels are affected.
"In addition to what has been stated, it may be remarked, that in every case of hydrocephalus interims that has come under my care, I have observed, belbre any attack of the disease, a peculiar dullness about' the eyes, with some dilatation of the pupils, which have appeared to dispose the children to keep the head in a prone position, or to incline it to one side."
For the author's account of the remote causes of the complaint, we must refer to his work. The proximate cause he considers to be a torpor or defective action of some part or of the whole of the chylopbietic system.
"When this has taken place, digestion is at a stand, and the food, instead of being converted into ehyle for the nourishment of the body, undergoes a kind of putrefactive fermentation, which is considerably promoted by the heat of the body and accidental constipation. This mass of highly disordered contents occasions considerable irritation in the bowels, which is evinced by the occasional pains, by the itching of the skin on the face, and various other parts, and by the general .restlessness of the patient; and if it be not removed, the fever soon commences."
"As remittent fever advances, it has been before remarked that