A Treatise on Fever

by Southwood Smith

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.