A Treatise on Fever

by Southwood Smith

When a number of cases are thus brought together and placed in juxta position it is impossible not to perceive, and indeed not to be forcibly struck with the uniformity with which a certain series of changes takes place. We do not see the same number of morbid appearances in every case, but we see in every case precisely the same morbid changes as far as they go, the difference being merely a difference in degree; so that the description of such a number of cases as has now been detailed would be tedious on account of its sameness, were it not that the fact they establish is one which it is of paramount importance to the practitioner that he should know; and that there appears to be no other means by which it can be duly impressed upon the mind.

In like manner the uniformity of the symptoms which denote that these morbid changes are going on, is as remarkable as the regularity with which the changes themselves occur. Their great peculiarity, which it is as important to know as it is to understand their indication itself, is their want of prominence. They are always to be discerned, or with extremely rare exceptions; but they seldom or never force themselves upon the notice of the careless or extort the attention of the unobserving: still they are not the less constant in their occurrence because they come without noise, nor is the indication they give of their presence less significant because it is unobtrusive. They do not announce their presence by the excitement of violent paroxysms or by inducing intense pain, because the state of the system in which they take place is incompatible with acute sensation of any kind. The prominent symptoms during life are almost always in the head; the great changes of structure found after death are always in the intestines; and this, which the pathologist learns from observation, the physiologist might have predicted from his knowledge of function. The affection of the intestines in fever is never a simple or single affection: it never occurs alone, but always in combination with an affection of the brain; and the cerebral affection is always antecedent, the intestinal, invariably subsequent; while the certain consequence of the cerebral affection is a diminution, and ultimately an abolition of sensation. It is therefore quite impossible, from the very nature of the derangement that takes place in the animal economy, that the intestinal affection should ever be attended with violent pain. Occasionally, indeed, when the abdominal affection is very much in excess, and the cerebral affection is unusually slight, severe pain may be felt; but that is rare, and the total absence of pain, and even the total absence of tenderness on pressure, is more common. It is not then to the patient’s own complaint of pain in the abdomen that the practitioner must trust for the discovery of abdominal affection in fever.

But though the patient seldom complain of pain in the abdomen, yet in the great majority of cases the abdomen is tender on pressure, and it is so in all, excepting when the cerebral affection is peculiarly severe or is very far advanced. These exceptions render this symptom not absolutely constant, although at the bed-side of the sick the practitioner will find it very rarely absent. The symptom which is still more constant, as the reader must have observed in the perusal of the preceding cases, and which therefore affords a very certain guide to the detection of the disease, is a loose state of the bowels. Whenever both concur there can be no doubt of the diseased process which is going on within the intestine: but as the tenderness may be obscured or lost from the intensity or advancement of the cerebral affection, so it is very remarkable that, in the progress of the intestinal disease, the bowels sometimes become regular and even constipated. The physician who sees the patient for the first time in this stage of the disease, can ascertain the condition of the mucous membrane of the intestines only by obtaining an accurate account of the preceding symptoms. And when it is possible to procure a distinct and complete history of the disease from its commencement, it is commonly found that nausea and vomiting were among the early symptoms, while, as we have seen, the latter is not unusually present in the more advanced stages. The result of the whole is that, excepting when the cerebral affection is most intense and overwhelming, the existence of inflammation and ulceration in the mucous membrane of the intestines in fever are denoted by signs which are quite constant, and in the fidelity of the indication of which we may repose implicit confidence. The importance of the diagnosis may perhaps plead our excuse for repeating them again. They are tenderness of the abdomen on pressure; loose stools; redness of the tongue, especially at the tip and edges, in general preceded by nausea and vomiting, and in the most exquisitely marked cases, and in their advanced stage, followed by a mixture of blood in the stools and a swollen, hard and tympanitic state of the abdomen. All these symptoms by no means always concur in the same case: but the presence of one or two of them will be sufficient to guide the attentive observer to the knowledge of the disease.

We have seen that the appearance of blood in the stools is not very frequent: that the most extensive ulceration may and commonly does exist without it; still when blood does appear it is generally found in combination with an ulceration which is not only extensive, but which has penetrated deep into the coats of the intestine. But although this be the general fact, yet it must be borne in mind that blood may be poured out in large quantities without the existence of a single ulcer. In this case the blood issues from the capillary vessels of the mucous membrane of the intestine, and when examined after death this membrane is found to be of a dark red colour, and presents the appearance of ecchymosis.

IV. Cases in Illustration of the Morbid Changes which take place within the Head, Thorax, and Abdomen, in the same Individual; or Mixed Cases.

Case XC.

Margaret Eades, æt. 18, dress-maker. Admitted on the 22d day of fever, which attacked with the ordinary symptoms: at present the mind is dull; the sensibility diminished; there is scarcely any sleep; the eyes injected and suffused; the skin hot; the tongue brown and dry; the pulse 120, but there is no pain in any organ.

23d. Insensibility increased to coma; delirium; tongue dry and quite black; gums bleed on the slightest touch; lips and teeth sordid; four stools, dark and offensive; pulse 110.

27th. Coma undiminished; almost constant moaning; scarcely any sleep; three stools of same character; some cough; pulse 124, feeble.

31st. All the symptoms aggravated; extreme prostration; countenance sunk; cough, without expectoration; respiration with mucous rattle; stools in bed: pulse 140, extremely feeble. Died next day.