A Treatise on Fever

by Southwood Smith

If the reader can doubt of the condition of the brain in this case, he is requested to turn to the pathology, where the morbid appearances on dissection are detailed. Slowness of the pulse, with severe and obstinate pain in the head, attended with confusion of mind, is always a highly dangerous-symptom: it invariably denotes intense cerebral disease. Whenever there is such a struggle, as this case exhibits, between the physician and the disease, the disease is sure to conquer. For if the physician, terrified at the name or the duration of the malady, while he resolve to use the lancet, hesitate to employ it to the extent of subduing the disease by the first bleedings, the patient is lost. The partial relief afforded by partial measures is most delusive. The malady speedily recovers its lost strength: the patient never does. There is no practitioner who is capable of being taught by experience that can reflect on the history and progress of such a case as this, on the temporary relief afforded by such treatment, on its ultimate failure, and on the appearances presented on dissection, without regretting that more blood was not taken on the 15th and 16th days, and without at the same time resolving, that the aid he offers in future, under similar circumstances, shall be more decisive. The diminution of the pain of the head on the 22d, accompanied with increasing confusion and dullness, with a tongue growing more and more foul, and with a pulse only at 72, might well excite alarm; and accordingly, on the following day, the case was utterly without hope.

II. Synochus Gravior with Thoracic Affection.

There is probably no case of fever, however slight, in which the mucous membrane of the bronchi remains in a perfectly sound state. A certain affection of this membrane, the nature of which will be stated hereafter, appears to be peculiar, to fever, and there is reason to believe that the acutest thoracic affection which is at the same time truly febrile, differs from the mildest case of fever, in which there may be no visible sign of any thoracic disease whatever, only in the degree in which this organ is affected. Sometimes it happens, however, that this membrane is implicated in a more than ordinary degree; and when it is so, it gives rise to peculiar symptoms, constituting the case thoracic. The severity of these thoracic, is not always in proportion to the severity of the febrile symptoms, in like manner as there may be the most intense febrile symptoms, without any indication of thoracic disease: but whenever the thoracic symptoms are sufficiently intense to become prominent, and especially when they occur early or attend on the commencement of fever, they invariably and very considerably aggravate the general febrile symptoms. In these prominent thoracic affections, then, two things happen; first, the symptoms properly constituting the febrile train are modified, and, secondly, new symptoms are added to this train, namely, those which indicate derangement in the respiratory organs.

The new and peculiar symptoms to which a moderately acute and an early thoracic affection gives rise, are the following; namely—

Pain in the chest, sometimes severe, sometimes only slight; sense of stricture or dyspnœa; inability to expand the chest by a full inspiration without pain or uneasiness; cough frequently aggravating the pain; sometimes dry, sometimes accompanied with frothy mucous expectoration. Respiration sometimes slow and heavy, at other times, on the contrary, short and quick; never natural: perhaps the physician may detect thoracic disease in the more obscure, and measure its extent in the more obvious cases, by observing the manner in which the patient breathes, better than by any other single means. The altered respiration is very frequently accompanied with that peculiar noise in breathing which is termed “mucous rattle.”

The pulse, in the commencement of this open and decided chest affection, may not be above 80 or 90; it is hardly ever sharp; it is generally weak; now and then it is full and of good strength; but whatever other character it may possess it is almost always soft. In a few days, as the disease advances, it uniformly rises in frequency and becomes weaker. Towards the end of the disease it is almost always hurried and feeble, although cases occasionally occur in which it is observed at this period to become suddenly slow and intermittent. The tongue is usually foul; commonly moist; but, in severe affections and in their advanced stage, it sometimes becomes dry. The skin is often moderately warm, but it is never intensely hot: it is much more common for it to be cool, and to be of a more dusky colour than natural.

Such are the usual conditions of the respiratory and circulating systems and of the tongue, the great index of the state of the mucous membrane of the alimentary canal, when the thoracic affection increases so as to become prominent and acute. The manner in which it influences the cerebral affection is commonly by hastening the period at which the pain of the head lapses into confusion and stupor. Early insensibility, assuming the form of a muddled or exceedingly confused state of mind, is a very constant symptom of more than ordinary thoracic affection. Accordingly, the delirium which succeeds or which accompanies this state is always low muttering talkativeness, or incoherent wandering, rather than violent delirium, which last is seldom, if ever, found in combination with severe thoracic disease. The pathological condition of the lung perfectly accounts for this modification of the condition of the brain, as will be shewn hereafter.

Case VI.

The following case not only shews the insidious manner in which thoracic disease may come on and the severe form it may ultimately assume; but also, the extent of disease from which it is possible that recovery may take place.

Mary Dillon, æt. 20; destitute. Admitted on the 8th day of fever: attack came on with the ordinary symptoms: at present, no pain of chest; some cough, with copious expectoration; no pain or tenderness of abdomen; tongue not much loaded, but dry; much thirst; no appetite; bowels freely open from medicine; no pain of head; some giddiness; no sleep; skin warm; face flushed; pulse 102.