A Treatise on Fever

by Southwood Smith

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.