A Treatise on Fever

by Southwood Smith

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.