CHAPTER III.
Of Synochus: Division into Synochus Mitior and Gravior. Succession of Phenomena in Synochus Mitior. Indications afforded of Disease in the Nervous, Circulating, and Excreting Systems. Progress of Disease consisting in progressive Increase in the Derangement of these Functions. Phenomena of Recovery. On what the Transition of Synochus Mitior into Synochus Gravior depends. Classification according to the different Organs in which the several Affections have their Seat. Hence Synochus Gravior with Cerebral Affection—Subacute—Acute: with Thoracic Affection: with Abdominal Affection: with Mixed Affection.
It has been stated that, for the purpose of forming into distinct groups certain assemblages of symptoms which it is important to distinguish, because they bear an important relation to practice, it will be convenient to divide the synochus, the term by which we propose to designate the common fever of this country, as it presents itself in its mild aspect, into two sections, namely, synochus mitior and synochus gravior. For reasons already assigned, it will likewise be important, in treating of these different modifications of fever, to notice in each both the phenomena which form the assemblage, and the order in which they succeed each other.
On careful examination it will be found that the first symptom which denotes the commencement of the ordinary fever of this country, in its mildest form (synochus mitior), is a loss of mental energy. This is by no means the first symptom which attracts attention: it is commonly overlooked for some time, and excites little notice until it has become distressing. Patients in general are incapable of analyzing their sensations or of determining the order of their succession; but if medical men, who are but too subject to be attacked with this disease, will take the trouble to reflect on the order of events as they occurred to themselves, they will probably be satisfied, after the most attentive consideration, that the first indication of disease they felt was a want of power to conduct their ordinary mental operations with ease and vigour. Such at least, perhaps I may be permitted to mention, was the fact in my own case; for, having suffered a severe attack of fever, I have a distinct and vivid recollection of the dulness, confusion, and want of mental energy which I experienced for a considerable time before I was conscious of any corporeal debility.
This affection of the mind consists particularly in indistinctness and consequent confusion in the trains of ideas; in inability to attend to their relations; and, as a necessary result, in the loss of power to think clearly. The individual feels that he is not in a state to form a sound judgment on any subject upon which he may be called to decide.
Closely connected with this mental weakness is the loss of energy in the muscles of voluntary motion. Lassitude is the result. The patient cannot move with his usual vigour, nor even sit without the feeling of weariness. The debility thus seizing upon both body and mind, sometimes occurs in each so nearly simultaneously that, it must be owned, it is difficult to determine in which it appears first.
The next symptom in the order of succession is still more characteristic: it consists in an uneasy sensation which is quite peculiar to this state of the system. No description can convey any idea of it to one who has not felt it; and to him who has felt it the word fever recalls this uneasy feeling so instantaneously and vividly that I apprehend most unprofessional persons conceive it is this very feeling that constitutes the essence of the disease. It is much more distressing than pain: the mere restlessness which accompanies and which forms so large a part of it, any one would gladly exchange for intense pain. In all diseases it is this which makes the sufferer on his midnight pillow exclaim, “oh! that it were morning!” and in the day, “would that it were night!” Though it is so frequent in its occurrence, and so peculiar in its nature, yet I am not aware that it has received any distinct name: it may be called, until a better is suggested, febrile uneasiness.
It is seldom that these symptoms exist long before positive pain is felt. With very few exceptions pain is first felt in the back or loins and then in the limbs. It is rare that this symptom is absent in the commencement of this form of fever, and it often occasions more uneasiness to the patient than any thing else during the first stage of the disease.
Already a remarkable change is commonly visible in the countenance. Its expression is that of dejection: it is often strikingly similar to that of a very weak person suffering from fatigue. The colour of the face is pallid, and the features are somewhat shrunk; but its general aspect is so peculiar and characteristic that an experienced eye can distinguish the disease even at this early period, and without asking a single question.
The skin partakes in a remarkable degree of the debility which so early shows itself in the muscles of locomotion. This is indicated in a striking manner by its increased sensitiveness to the physical agents by which it is surrounded, and by its inability to resist their influence. Ordinary degrees of temperature produce a sensation of cold which is sometimes intolerable: chilliness is felt even in a heated room, or in a warm bed: hence the sensation of cold, sometimes increasing to shivering, which has been considered one of the most constant signs of fever. But this feeling of chilliness by no means depends on external temperature: it is increased by cold, but it exists in spite of an elevated temperature: it arises from an internal cause, and is not to be counteracted by external heat.
While the patient experiences the sensation of cold, there is no diminution of the quantity of caloric in the system. The thermometer applied to any part of the body commonly rises as high as in the state of health, and the skin, touched by the hand of another person, communicates not the feeling of cold, but often, on the contrary, that of preternatural heat. There is no positive abstraction of caloric from the body nor any failure in the process, whatever it be, by which animal heat is generated; there is only altered sensation, in consequence of derangement in the function of the skin. In this form of fever, the chilliness in many cases never amounts to shivering; in others, there is an attack of well-marked rigor, and in others, again, there is either no feeling of cold, or it is so slight that it escapes observation.
The symptoms now enumerated are all clearly referrible to derangement of the function of the spinal cord and brain. There is as yet no affection of any other organ obviously or, at least, much developed. The circulating system, it is true, is just beginning to be affected. The pulse is no longer perfectly natural. It is more languid than in the state of health; sometimes it is also quicker: at other times it is slower; now and then it is scarcely changed in frequency, but its action is invariably weaker than in its sound state.
At the same time the respiration is affected in a corresponding degree: it is shorter and quicker than natural; the chest does not expand so freely, and compensation seems to be sought in an additional number of respirations. Oftentimes neither the pulse nor the respiration appears to be much altered, if the patient remain perfectly still; but if he rise and walk across the room, the pulse instantly becomes rapid, and the respiration is quickened almost to panting.
The transition from the affection of the nervous and sensorial to that of the circulating and the respiratory systems is thus clear and striking. Physiology teaches us how closely these systems are connected, and how mutually they are dependent one upon the other, the closest observers and the ablest experimentalists candidly confessing that they are scarcely able to determine which is the least dependent, or the action of which is the least necessary to the others performance of its functions. The nervous system being first deranged, it is thus consonant to what we know of the healthy function of the animal economy, that the circulating and the respiratory systems should be the next to suffer.
How long the nervous system may continue thus deranged, before any other organs are involved, excepting the circulating and the respiratory, to the extent just stated, is uncertain. There can be no doubt that in this mild form of fever, the range of the duration of this isolated state of disorder, if we may so express it, is from a few hours to several days. The rapidity or the slowness with which other systems of organs become involved seems to depend very much upon the acuteness of the attack. In general, the more acute the fever, the more rapidly the individual phenomena succeed each other, and the entire series becomes complete. But this is not, and it is important to bear in mind that it is not invariably the case: for experience teaches us that the severity and danger of the disease are not diminished by the slowness of its approach; and that cases occur, which are slow in forming, and which do not for awhile excite alarm, that ultimately become truly formidable.
It has been stated that the circulation languishes with the diminished energy in the sensorial faculties, and the loss of power in the muscles of locomotion. After awhile, the pulse which was feebler than natural becomes more full, more strong, and generally more quick than in a sound state; and now the skin, which was cold, becomes preternaturally hot. The previous cold consisted, for the most part, of altered sensation, there being little or no loss of caloric: but the feeling of heat, on the contrary, is the result of an actual increase of temperature; for the heat in the interior of the body, as well as on the surface, rises in some cases several degrees, as is ascertained by the thermometer; the range of increase being from the natural standard 98° to 105°, beyond which it is seldom found to augment in this form of fever. The heat is at first not uniform over the entire surface of the body: it often happens that some parts are cold while others are burning hot. The heat is oftentimes particularly intense over the forehead, or over the back part of the head, or over the whole scalp, while the cheeks are commonly flushed. All these symptoms denote a morbid condition in the action of the heart and arteries. Since the generation of animal heat is so intimately connected with the circulating and the respiratory functions, it is probable that the increase of temperature is the result of some morbid action of the capillary vessels belonging to these systems. What the disordered action of these vessels is, which produces increase of temperature, we do not know, because we do not know what their natural action is which produces the temperature of health: but the object of scientific observation is in some degree accomplished, when it is ascertained that one condition of these functions is invariably connected with a morbidly-diminished temperature; another with a morbidly-augmented temperature; and another with the temperature of health.
Immediately the circulation is thus excited, the functions of secretion and excretion become deranged. The mouth is now dry and parched; the tongue begins to be covered with fur; thirst comes on; the secretion of the liver, probably also of the pancreas, and certainly of the mucous membrane lining the whole alimentary canal, is vitiated, as is proved by the unnatural quantity, colour, and fetor of the evacuations; the urine likewise is altered in appearance, and the skin is not more remarkable for the sense of heat, than for that of dryness and harshness which it communicates to the touch. With the excitement of the pulse and the increase of the heat, the pain in the back and limbs and the general febrile uneasiness are much augmented.
At this period, then, the fever is fully formed; the series of morbid phenomena is complete: any thing more that happens is referrible to degree and to duration, and must be the result of one or other of these circumstances, or of their combined operation. And we now see that the organs affected, constitute precisely that system of organs which has been described as forming the febrile circle: that the symptoms which denote the fever are just the symptoms which indicate a derangement in the several functions performed by these organs; and that the order in which they become successively involved is exactly that which has been assigned.
As soon as the preternatural heat comes on, pain begins to be felt in the head. Dr. Clutterbuck, in describing the general character of the ordinary fever of London states[[23]] that “the first symptom almost invariably complained of is more or less of uneasiness of the head.” If by uneasiness he meant pain, there is, if there be any truth in the preceding observations, a long train of symptoms to intervene before this symptom occurs. That it does ultimately occur is certain: but commonly its place in the series is much later than is here assigned: it is disordered function of the brain, indicated by loss of mental energy, that appears to form the first symptom in this morbid train.
The pain, when it does come, is sometimes slight at first, and occasionally it remains slight throughout the disease; at other times it is pretty severe. Cases sometimes occur, in which, instead of pain, there is only a sense of giddiness, and now and then the uneasy feeling is described as that of lightness: or, on the contrary, as that of heaviness or weight. But whether the feeling be pain, and that pain be slight or severe, or whether it be giddiness, or lightness, or heaviness, it indicates a similar condition of the organ, and requires a similar treatment.
With the accession of pain of the head there is a manifest increase in the disturbance of the sensorial functions. The inability to think, to compare, to reason, to judge, great as it was at the commencement, is now much greater. Instead of being more dull, there are certain states of the mind which now become more acute and vigilant even than in health. Sensation itself, at this period, is invariably acuter than natural, as is indicated in all the organs of sense. The eye cannot well bear the light: there are few cases in which the full glare of day does not excite uneasiness, while in many the ordinary light of a room cannot be borne: in these cases the opening between the eye-lids is frequently observed to be contracted, as if from an involuntary effort to exclude a portion of that stimulus which in health excites no inconvenience, and this state of the eye-lids assists in giving to the eye its dull and heavy expression, so characteristic of fever. The increase of sensibility in the organ of hearing is equally striking. Sounds which were not noticed during health become acutely and even distressingly sensible, while accustomed noises, such as that of a crowded street, are always painful and often intolerable. The skin, considered as an organ of touch, is in a like morbid state. An impression barely sufficient in the state of health to produce sensation excites the feeling of tenderness, and alternations of temperature, which in ordinary states are scarcely perceptible, are painful. The senses of taste and smell, on the contrary, are nearly obliterated, owing to the altered condition of the membranes upon which the sensitive nerves are distributed.
From the earliest attack of the disease the sleep is disturbed and unrefreshing; now scarcely any is obtained; the febrile uneasiness will not allow of repose; the patient cannot remain in any position long, incessantly shifting his place, never eluding his pain. At this stage the sense of uneasiness in the limbs, oftentimes the severity of the pain over the whole body, is peculiarly distressing.
With this progressive increase in the affection of the spinal cord and the brain, the derangement in the circulating system is proportionally augmented. The pulse is invariably altered, both in frequency and character. Generally it rises to 90, sometimes to 100; but in this form of fever it seldom exceeds this number; and occasionally it never rises above 80. The stroke of the pulse is usually stronger and fuller than natural, though it commonly retains its softness, and does not impress the finger with that sensation of sharpness which is characteristic of ordinary inflammation. Occasionally, however, a degree of sharpness may be perceived in it, and it is not easily compressed.
The thin white fur which already had begun to appear on the tongue progressively increases in extent and thickness. The colour of the fur usually changes, as the disease advances, from a dirty-white to an ash-colour; but in this form of the disease the tongue always remains moist, and never becomes brown. This state of the tongue is almost always accompanied with thirst, but it is never urgent. There is always a loss of appetite. The bowels are generally constipated, and the secretions of the whole alimentary canal are vitiated.
Thus we perceive that the progress of the disease consists in increasing mental and corporeal weakness; increasing pain in the back, loins, and limbs; increasing heat of skin, acceleration of pulse, and general febrile uneasiness, together with the occurrence of pain in the head, and progressive derangement in the functions of secretion and excretion.
The fever in this mild form is now at its height. It remains stationary, or at least with very little change for an indefinite period, generally for some days. The cerebral affection does not increase beyond what has been described: there are no greater indications of disease in the respiratory organs, and the mucous membrane of the stomach and intestines does not denote any progressive advancement in disease.
One of the most remarkable circumstances connected with the ordinary fever of this country, in the present day, is the uninterrupted and perfect continuity of its phenomena. As long as the febrile state remains, nothing deserving the name of a remission is in general to be perceived. Occasionally, it is true, a slight increase in the symptoms may be observed towards evening, especially in the heat of the skin; but even this is not common, and it is scarcely ever great enough to deserve the distinction of being called an exacerbation. Much less is there any regularity in the accession and decline of such excitement. In the great majority of cases not the slightest approach to an exacerbation and a remission can be distinguished from the commencement to the termination of the disease. Yet the older writers speak of these events as if they were as palpable as the paroxysms of intermittent and as constant as the return of morning and evening. There cannot therefore be a doubt that the character of the ordinary fever of this metropolis is greatly changed from the character of that which prevailed two centuries ago; and the circumstances which have contributed to produce this change will be considered hereafter.
In the great majority of patients in whom the symptoms continue thus moderate, the disease disappears about the end of the second week; that is, they are convalescent at that period; but it usually requires eight or ten days longer before they have regained sufficient strength to leave the hospital. Sometimes, although there is no greater severity in the symptoms, the disease is more protracted, and the recovery is not complete until the fourth or even the fifth week. Beyond this period it is very rare for this form of the disease to be protracted.
Almost all who are attacked with the malady in this, its mildest form, recover: but now and then it happens that the symptoms go on with this degree of moderation until about the end of the second week. Then at the period when it is usual for convalescence to take place there is no perceptible improvement; the patients seem even to grow weaker; they lie more prostrate in the bed, and they are soon incapable of moving; still they complain of no pain or uneasiness, and it is not easy to detect any trace of disease in any organ; yet it is but too evident that they grow worse, and ultimately they sink exhausted. In these cases, on examination after death, it is commonly found that disease has been preying on some vital organs, although its presence could not be detected during life; and this termination of the milder type of fever rarely happens, excepting in aged persons, whose constitutions have been enfeebled by previous diseases, or worn out by the various causes which depress and exhaust the powers of life.
With an occasional exception of this kind the disease in this form always terminates favourably; and the first indication of returning health is remarkably uniform: it is almost always marked by longer and more tranquil sleep. Instead of that restlessness which is so characteristic of fever, and which forms the most distressing part of it, the patient is observed to lie more still, and on waking for the first time from an undisturbed slumber, he often spontaneously says that he feels better. Better he may well feel, for his febrile uneasiness is gone; the load that oppressed him is shaken off; he is a new being. The pain of the head and of the limbs is so much diminished that often he cannot help expressing his thankfulness at the change. The countenance becomes more animated; its natural expression returns; the tongue begins to clean; and after this state of the system has continued for two or three days, the appetite returns. While these favourable changes are going on, the pulse usually sinks about ten beats below its highest point at the height of the fever; it is not uncommon, however, for it to remain quick during the entire period of convalescence; and for some considerable time it is easily excited on any movement of the body, or any emotion of mind. In some cases, on the contrary, when the attack has been very mild, it sinks considerably below the natural standard, and is intermittent, a sign which I have uniformly observed to be attended with a sure and steady convalescence. In the mean time the appetite becomes keener than natural; the strength gradually improves; and in a short time the patient is restored to his usual health and vigour.
What the condition of the brain and of the organs correlatively affected is, in these the mildest cases, we do not positively know, because we have no opportunity of inspecting them, their favourable termination being nearly without exception. But the more all the phenomena are considered in their entire series, in the order of their succession, in the uniformity, nay, even in the exclusiveness of their seat, as well as in the unchanging sameness of their effects, the more clear the evidence will appear of the soundness of the induction, that the condition of all the organs in all the types of fever is the same in nature, although there be no two cases of any type perfectly the same either in the degree of the affection or in the stage of the morbid process which it excites. If this induction be really just, we must conceive that, in the synochus mitior, while the morbid affection of the organs is slight, the diseased process which it sets up in them stops before it produces any change in their structure.
However this may be, and to leave for the present all matter of inference, and to keep strictly to the matter of fact, we do positively know that the mild forms of fever become severe in consequence of the supervention of inflammation in certain organs. Perfectly unknown as the nature of the primitive febrile affection at present is, yet that in the progress of the disease it does ultimately pass into inflammation is a fact, the evidence of which it is impossible to resist; although the same observation which teaches us this most important truth, teaches us also that the inflammatory action is always considerably modified by the febrile state. How it is so modified, and to what extent, we shall consider hereafter. I have spent much consideration and some labour in the effort to combine the symptoms which attend these severer forms of the disease with the ascertained conditions of the organs upon which such symptoms depend. But since it is of paramount importance that the events which actually take place should be known, and that the order in which they succeed each other should be stated with clearness and exactness; and since I have been able by no method that I could think of to combine the pathology with the history without breaking too much the continuity of the latter, I have been under the necessity of separating these two most intimately connected subjects, and of treating of them under distinct sections. In giving the history of the events, I have detailed them strictly, as far as I am acquainted with them, in the order in which they occur: and I have endeavoured to arrange the cases that constitute the pathology in such a manner, that they shall closely correspond to these events, and clearly illustrate the order of their succession. If I have succeeded according to my wish, the reader in studying the cases will be reminded, as he proceeds, of the successive stages of the history, and if he again revert to the history, after having studied the pathology, he will be reminded of the morbid appearances in the organs which are there described. To afford a clear perception of the connexion between the successive events, as indicated by the symptoms during life, and the progressive changes of structure in various organs, as demonstrated by inspection after death; and thus to establish a strong and indissoluble association in the mind between the morbid condition and its sign, are the objects at which I have aimed. If I have succeeded, I shall have accomplished one of the chief objects of my undertaking.
The transition of a mild case of fever into a severe one, or the progress of a case severe from the commencement, is accompanied with, or depends upon, as will abundantly appear hereafter, certain changes that take place in certain organs. These changes occur with great regularity; the organs in which they take place are always the same; and the symptoms by which they are denoted are uniform. The organs affected are the spinal cord, the brain, the membranes of both, the mucous membrane of the lungs, and the mucous membrane of the intestines. For the reason just assigned the nature of these affections cannot be described in this place, but must be postponed to that part of the work which treats of the pathology. Since however the symptoms are nothing but the signs of these conditions, and the history of the succession of the former, is nothing but an account of the indications of the successive changes that take place in the latter, all the important symptoms must necessarily have their seat in the head, in the thorax, and in the abdomen. Mixed and blended as they appear in the different cases which the practitioner is called upon to treat, nothing can appear more complex or more variable: when analyzed, nothing is more remarkable than their simplicity and their uniformity. In order to perform that analysis with exactness, and to render it really instructive, these symptoms must be contemplated as they arise in the affected organs. These organs, as we have seen, are the cerebral, the thoracic, and the abdominal; the symptoms therefore divide themselves into cerebral, thoracic, and abdominal: there is, indeed, a fourth order, in which all the organs appear to be equally involved; in which the general affection is intense, and which therefore may be appropriately termed mixed. We shall see that cases of this kind constitute by far the most dangerous form of the disease.