A Treatise on Fever

by Southwood Smith

Instead of being from the commencement of a vivid redness, the colour of the tongue, in other cases, is of a darker and duller tint; there is less fur upon the body, and that which covers it is of a dirtier and darker tinge; this state of the tongue is always attended with greater thirst: it is apt to become more and sooner dry, and, at the same time, the lips and teeth become more and sooner sordid.

8. In the kind and degree of abdominal affection of which we are now treating, the abdomen is sometimes harder than natural, but it often remains nearly as soft as in health through the greater part of the disease.

9. Of the conditions of the pulse in this affection it is important to take particular notice, on account of the total absence of any striking or apparently distinctive character. It is neither remarkably slow nor very quick; neither unusually hard, nor strong, nor sharp, nor weak, nor intermittent, nor in any degree irregular; its common range is from 80 to 100, beyond which it seldom rises in the acutest cases, until near the termination of the disease; and it is generally soft.

10. Whenever, then, there is a combination of the preceding symptoms, with a pulse about 90, it may be inferred with great certainty, that disease is going on in the intestines. But, as the pain of the abdomen ceases at a certain period, while the purging continues, so, at a still more advanced stage of the disease, the purging also disappears, and the stools return to a more natural condition. Cessation of pain, and an apparent return to healthy secretion and excretion, may seem to indicate a highly favourable change in the disease, and, if accompanied with corresponding amendment in the other symptoms, they may, indeed, be hailed as signs of returning health; but if they occur without a favourable change in the general symptoms, they do not indicate a return to health, but merely the transition of one diseased process into another. What that succession of diseased processes is will be stated hereafter: at present it is sufficient to observe that, without corresponding improvement in other organs, the cessation of purging is a sign not of returning health, but of advancing disease. And so common is the cessation of purging, without amendment, at an advanced stage of abdominal affection, that in a large proportion of the patients who are received into the Fever Hospital, it has ceased before their admission. On the examination of a patient, for the first time, who has been ill from a fortnight to three weeks, it will be stated that the stools are regular, yet if strict inquiry be made, it will often be found that at an earlier stage of the disease from four to five stools, sometimes from eight to ten, were passed in the twenty-four hours without any purgative medicine having been taken. With regard to the state of the evacuations in this affection, then, the succession of events is first constipation, then purging, and next the cessation of purging and the return of the stools to a more natural character.

The preceding signs of abdominal affection are so obvious that they can scarcely fail to lead to the detection of the disease; but the second form under which it exists is attended with much less striking symptoms. It requires great attention and daily examination to discover its presence, and to trace its progress. It steals along its fatal course with a step as silent as it is sure; and the destruction that marks its track is oftentimes alike unfelt by its victim and undiscovered by his most watchful guardian. It does not attack until the sensibility is already greatly diminished in consequence of the progress of cerebral disease. No pain is therefore felt, and the only indication by which it can be detected is tenderness of the abdomen on pressure. But even the fullest pressure, although it generally excite some uneasiness, sometimes produces none whatever. There is often no purging; for when the affection comes on thus late, though the bowels may sometimes be loose, yet they are frequently even constipated. The tongue is generally red at the edges and the tip, loaded with dirty grey or yellow fur, and sometimes dry. The pulse at this advanced period is generally 120. Without doubt this affection greatly aggravates the severity of the fever, and increases the danger of the patient, although we have no means of measuring the extent to which it does so.

On recovering from this state, for recovery does sometimes take place, the first indication of improvement commonly appears in the tongue, which shews a disposition to clean; and what is remarkable, the favourable sign which accompanies this improved condition of the tongue is increased tenderness of the abdomen on pressure. Not that disease in the intestine is increasing, but disease in the brain is lessening, and therefore the patient is now sensible to a stimulus which before produced not the slightest impression. If on the following days the tongue continue to clear; if it grow less red; if at the same time the pulse fall, the sleep return, the sensibility increase, and the countenance become more animated, the patient may be considered as convalescent.

It is not very common, but it does sometimes happen, that a few hours before death the sensibility of the abdomen suddenly increases, and the tenderness on pressure becomes exquisite. This remarkable change is sometimes attended with vomiting, sometimes with hiccup, and is accompanied with extreme restlessness, and a highly excited pulse, while the expression of the countenance is at one time anxious and at another wild, and in this state the patient dies in a few hours. On what change in the intestines this depends will be explained in the pathology.

As illustrations of these different modifications of abdominal affection the following cases are subjoined.

Case IX.

Eleanor House, æt. 18, silk-winder. Before admission attacked with nausea, vomiting, together with the ordinary symptoms of fever. On admission, being the 8th day of the disease, severe pain of abdomen, which is greatly increased on pressure: tongue very red at the point, loaded with fur, through which the papillæ are prominent, moist; urgent thirst; no appetite; bowels said to be natural; some uneasiness of chest; respiration hurried; cannot lie with ease on either side; voice hoarse and feeble; no soreness of throat; no head-ache; no sleep; skin warm; face flushed; pulse 100, of some power, but easily compressed. V.S. ad ℥xvj. Ol. Ricini, ʒiij.