A Treatise on Fever

by Southwood Smith

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.

I. Synochus Gravior with Cerebral Affection,

occurs under two degrees of intensity: when the cerebral affection is moderate, it may be termed subacute; when great, acute.

1. Synochus with Subacute Cerebral Affection, may be attended for several days with no symptom which has not been already enumerated in the account of the mildest form of the disease. The accession is the same as in synochus mitior: the progress up to a certain period is also the same. But at the time when the pain of the head diminishes in the latter, it increases in the former. Still the pain is often not severe. He who looks for intense pain, and suspects no cerebral affection, unless accompanied with this symptom, will be surprised by what will appear to him the sudden occurrence of new symptoms, such as are immediately to be stated, which will at length open his eyes to the danger of the case, and excite his wonder, which it is not unfrequent to hear expressed, that an affection hitherto so mild, should, without any previous warning, become so formidable, and show but too manifestly that it is beyond control, and will certainly proceed to a fatal termination. The warning was given, but the sign was not understood. The descriptions of disease are commonly taken from its most acute form; and it was long the practice to derive them from this form alone, and the consequences were truly fatal. Even with the best care that can be taken in drawing up the history, these descriptions are exceedingly apt to become ideal, and not real entities: to consist of a collection of all the circumstances that exist in all cases, and not of that particular combination only which is found in any one case: and thus to be not the portrait of any individual, but a fancy picture bearing a general resemblance to all individuals without being the true likeness of any. The consequence is, that at the bed-side of the sick the original from which the picture is supposed to be taken is not to be seen, and the practitioner remains in doubt, if he do not fall into error. Error serious and fatal many have fallen into, and, on this very account, still continue to fall into, with regard to the existence of cerebral disease in fever. Abundant evidence will be given in the pathology, that it is not uncommon for the most unequivocal and extensive changes of structure to take place in the brain and its membranes without severe pain having ever been felt. Pain, however, though it be not great, is almost always present. It is seldom that the pain extends over the whole head; the patient generally points to some particular part where it is peculiarly felt. In the majority of cases the seat of the pain is either in the forehead, or at the temples, or over the eyes; but occasionally it is in the occiput, and extends down the neck, and in these instances it is often severe between the shoulders.

Now and then no pain whatever is felt. Question the patient as much as you please, and he will tell you that he never has felt any pain. In this case giddiness is the substitute. Giddiness in the commencement, and in the early stage of fever, is as certain a sign of cerebral affection as pain. Striking illustrations of this are afforded by several cases detailed in the pathology; by consulting which, the reader will see that precisely the same morbid changes take place in the structure of the brain, although nothing but giddiness be complained of, as occur in those which are attended with the acutest pain. The practitioner will therefore fall into a fatal error who is seduced into security because pain is absent; and who neglects the remedies proper for inflammation of the brain, because the patient complains only of giddiness. If giddiness be combined with pain, or alternate with it, which is not uncommon, the giddiness being slight if the pain be severe, and the pain being slight if the giddiness be distressing, it indicates a more severe affection than if either exist alone.

2. In the majority of cases, as long as the pain continues, the heat of the skin remains considerably above the natural standard. But often the heat over the general surface of the body is not great. Commonly, however, it is hotter than natural over the head, and it is hottest wherever the seat of the pain be fixed: so that the contrast is often striking between the temperature over the forehead or at the occiput, and the heat of the body in general.

3. The dull and heavy expression of the eye is greater than in the milder form of fever. The conjunctiva generally becomes brighter and more glistening than natural: though instead of this the vessels are often more numerous and more turgid than usual, and give it the appearance which is termed “muddled.” The eye at the same time is commonly preternaturally sensible, and cannot bear a strong light, although sometimes no complaint is made if the curtains of the bed be withdrawn, or the window-blind be drawn up.

4. There is usually a corresponding increase in the general sensibility; and what is remarkable, this is quite as much indicated by the increased sensibility to sound as to light. A loud noise is invariably distressing to the patient, and a continuance of it greatly aggravates all the symptoms. Exposure to a glare of light and a loud noise, would alone rapidly change a slight into the severest cerebral affection.

The expression of the countenance is now very peculiar: it cannot be described, but the experienced eye can seldom fail to recognize it. It is indicative of suffering without the strength to bear it: it is not anxious; that expression does not come on until a later period. The face is sometimes flushed, but it is often pallid, which does but add to the peculiar character of its expression.

5. As long as the pain of the head, the giddiness, and the increased sensibility continue, there is invariably a want of sleep. The degree of sleeplessness is not always in proportion to the head-ache or to the other symptoms; but while the latter are present, the former is never absent. That condition of the brain upon which sleep depends appears to be easily disturbed by a great variety of causes; but whatever be capable of affrighting this heavenly visitant, “tired Nature’s sweet restorer,” whether in the mansion, the palace, or the prison, and whether from the bed of healthful slumber or from the couch of sickness, nothing so effectually and so constantly banishes it as that febrile uneasiness of which we have already spoken; and which, instead of declining, as in the milder form of fever, now increases in strength and activity, and will scarcely allow the restless body to remain in one position for a moment. He who has felt its influence in this stage and degree of fever, will admit that there is nothing comparable to the wretchedness it produces, except it be the sweetness of the first waking moment after the first tranquil slumber of returning health.