A Treatise on Fever

by Southwood Smith

5. Now, too, signs of disease in the chest and abdomen are almost always to be distinguished. A case purely cerebral, from the commencement to the termination of the disease, is rarely to be met with. If there be not cough, there is almost always a short and hurried respiration, and more or fewer of the indications of abdominal affection hereafter to be stated. Even in cases the most purely cerebral the tongue always becomes more loaded and often dry; and it is strikingly characteristic of the state of the nervous system, that while the tongue becomes dry, the thirst diminishes.

Thus far it is possible that the disease may proceed towards a fatal termination without proving mortal. It is not often that its course is turned back or stayed after it has made this progress; but still such an event is sometimes witnessed. When it does occur, the amendment, both in its origin and progress, is very similar to that of the favourable change which has already been described. More tranquil and longer-continued sleep is almost always the earliest sign that, in this severe struggle, life has obtained the victory. If, on awaking from such sleep, there be less delirium, were delirium present, or greater tranquillity, were the restlessness urgent; and if there be any increase, although slight, in the sensibility, or any improvement in the expression of the countenance, hope may be entertained that that victory will be won; and hope may become assurance, if the tongue which had been loaded become clean at the edges, or the dry tongue become moist. Even under apparently the most desperate circumstances, if these three symptoms concur, a favourable prognosis may be pronounced with tolerable certainty. Two or three days may elapse after their occurrence, before any remarkable change is observable in the pulse; but it is seldom that they continue twenty-four hours before the pulse falls at least ten beats. Now and then, on leaving a patient in the evening with a pulse at 120, we are surprised and delighted to find it in the morning as low as 100. When the pulse has thus fallen towards the natural standard, when the tongue has begun to clean, and when the skin has become cool and soft, however desperate his condition but a few days before, the patient may be said to be convalescent.

But though this favourable change is sometimes witnessed, yet, from the point at which we left off the description of the progress to a fatal termination, the too common history is, increasing restlessness and sleeplessness; insensibility lapsing into coma; further acceleration of the pulse; greater dryness of the tongue and decreasing strength, until, at length, the powers of life receiving less and less supply from the great systems in which they have their seat, become completely exhausted.

Those who have been placed in situations which have afforded them opportunities of witnessing much of the disease will, I trust, acknowledge that the account now given is an accurate narrative of the symptoms that occur, and of the order in which they succeed, in the great majority of cases. Upon what conditions of what organs they depend will be illustrated in the pathology.

Sometimes to these, other trains of symptoms are added—namely, muscular tremor, frequent and sudden screaming; rolling of the head upon the pillow; constant tossing of the hands about; picking at the bed-clothes or other surrounding objects; partial paralysis of the upper eyelid, so that one or both of the eyes remain half or almost wholly closed; the ball of the eye unsteady or constantly rolling; the expression of the eye and countenance at one time wild and anxious, at another fatuous; squinting; the respiration now slow and laborious, now exceedingly rapid; the pulse either slow, full and regular, or slow and intermittent, or so quick that it cannot be counted, or these states succeeding each other or alternating with each other at short intervals; convulsions; involuntary and unconscious stools—all these symptoms are never found combined in any one case; but certain assemblages of them occur with some degree of constancy, and depend upon certain conditions of the brain and spinal cord. Since, however, the description of these conditions cannot be given here, the further account of the signs which denote them must be postponed until we treat of the pathology of the disease.

2. Synochus Gravior with Acute Cerebral Affection.—Such is the history of the synochus gravior with cerebral affection in its subacute form. When its attack is the most acute, the history is precisely the same, excepting that the symptoms are more severe, and their progress quicker. The head-ache is much more intense; the giddiness is more violent; the sensibility is excessive; the least noise is intolerable; the slightest motion either of the head or of the body aggravates all the symptoms; the eye is muddy, and very soon becomes injected, and is perfectly intolerant of light; the pain in the back, loins, and limbs, is nearly as great as it is in the head. The skin is intensely hot, and sometimes impresses the hand with the sense of pungency; but though every where thus hot and dry, its temperature is peculiarly great over the scalp, so that if the head be shaved, and wet clothes applied, they are quite dry in a minute or two. The febrile uneasiness is excessive; the patient can scarcely remain a moment in the same posture, and he is wholly without sleep. The pulse at one time is strong, full, bounding, and not easily compressed, but even in this acute form it is almost always soft; at least it is very different from the hardness characteristic of an acute attack of pure phrenitis; at another time it is oppressed, the stroke giving an impression directly opposite to that produced by the free and bounding pulse.

But one of the most remarkable modifications of the pulse, one that is characteristic of an exceedingly acute attack of cerebral disease, and one with the import of which it is of the highest consequence to the life of the patient that the practitioner should be perfectly acquainted the moment he meets with it, is the slow and intermitting pulse. Whenever, in the onset of fever, a patient is found with intense head-ache or intense pain in the back and loins, and a slow pulse, the physician ought to be greatly alarmed at the severity of the symptoms that are to follow, and if he do not take the most active measures to break the violence of the disease at this early period, it will be beyond all control in a day or two, and the patient will be dead before the fever is well formed in milder cases. The affection of the brain is sometimes so violent and sudden that the pulse is not only slow, but intermitting, and the respiration is suspirious. Frequent and deep sighing is not uncommon in severe cerebral cases, and it is highly characteristic of intense cerebral affection; but in such a violent attack as that of which we are now speaking, the suspirious breathing, even in the very commencement of the disease, is so great that it cannot be overlooked. This happened in the case of my friend Dr. Dill, whom I saw a few hours after the commencement of an attack of one of these intense forms of fever. I saw him in the afternoon at a public meeting. I met him an hour afterwards at his own apartment. He was still going about engaged in his ordinary occupations; but his countenance was pale as death; his eye was dull and heavy; his mind was confused, and as it seemed to him paralysed; he had other sensations, which were new to him, and which were most distressing; but he had no pain: at that time there was not the slightest pain either in his head or his back or loins: there was only that general and undefined uneasiness which gave to him sufficient warning of what was coming, as the slow and labouring pulse, coupled with the uneasy sensations of which he complained, and the peculiar aspect of his countenance, afforded to me an abundant confirmation that his apprehensions were just. He was bled immediately to the extent of twenty ounces: the blood then drawn was not sizy: he passed a wretched night. I saw him early the following morning: he had now intense headache; his eye was already injected; his skin was not hot but burning; his respiration was suspirious; almost every breath was a sigh, and his pulse was still slower than on the preceding evening, and was now intermittent: blood being drawn to a large extent, the crassamentum was now buffed and cupped; but the detail of the progress of this instructive case must be postponed until we speak of the treatment of fever, because it is still more illustrative of the effects produced by the vigorous application of the appropriate remedies than of the peculiarity of the symptoms which usher in the attack. It may suffice for the present to observe that this case affords not only a striking example of the concurrence of these peculiar symptoms, but also a decisive proof that pain of the head is far from being the first symptom that occurs even in the most intense cerebral attack.

In these acute forms of the disease, if the proper remedies be not vigorously employed, the pain ceases within the fourth day; it rarely extends beyond the fifth; the pain passes into insensibility; delirium comes on, sometimes so violent as to require restraint, but delirium is by no means an invariable concomitant of the other symptoms, even when these are the most violent: when it is present it is almost always rapidly followed by muscular tremors, and these by subsultus tendinum, which now and then usher in general convulsions; but this last event is rare, and I have never yet seen convulsions unaccompanied with a particular condition of the brain hereafter to be described. Sometimes the muscular tremors succeed immediately to the transition of the pain into insensibility, while the insensibility rapidly increases to stupor, and that to profound coma. The breathing is occasionally as stertorous as it is in apoplexy, but this is also rare, and when it does occur, is probably dependent on a peculiar condition of the brain hereafter to be pointed out. Together with these there is a concurrence of a greater or a lesser number of the symptoms enumerated at page 107, but the particular combinations that are found most usually to accompany particular conditions of the brain, it will be most instructive to state in connexion with the pathology.

In synochus with acute cerebral disease there is less indication of thoracic and abdominal affection than in the subacute form, because the intensity of the cerebral disease obscures the signs of derangement in the other organs; but the signs of their derangement are never absent, although they are less obtrusive, and they trace in indelible characters proofs of their activity in the ravages they commit upon their structures in which they have their seat.

Such is the course of synochus under different degrees of violence. When it is combined with subacute cerebral affection, that course is usually terminated in from three to six weeks; when with acute cerebral affection, in from seven to ten days.