44th. Died.
These acute symptoms mark the very hour when the event occurred which caused them.—See Pathology.
IV. Synochus Gravior with Mixed Affection.
Since it has been repeatedly stated in the preceding pages that, in every case of fever, the brain, the lungs, and the abdomen are diseased, it may appear objectionable to call any particular class of cases mixed, because, according to the very nature of fever, all must be of this character. But for the same reason that we have designated one class of cases cerebral, another thoracic, and a third abdominal, namely, to mark prominence and intensity of affection, it is right to distinguish a fourth, in which all the three systems of organs are simultaneously affected with an equal, or nearly an equal degree of intensity. The term mixed is therefore by no means employed to intimate that the cases not comprehended under it are unmixed, but merely to point out a fact of great practical importance, that cases do occur which are neither in an exquisite degree cerebral, nor thoracic, nor abdominal, but which, at one and the same time, afford the most exquisite specimens of all the three.
From this account of the sense in which the term is employed, it must be obvious that it will include the severest cases that can occur. If a patient be affected with intense cerebral disease he may be in great danger; but if he be affected with an equally intense thoracic disease his danger must be doubled: and if to this be added an equally intense abdominal disease it must be trebled. And accordingly these are just the cases which bid defiance to the most skilful and vigorous measures which the medical art can employ to control them; which seize upon their victim with a force which no human agency can resist nor counteract; which in malignant epidemics destroy life in a few hours or in a single hour, and in ordinary seasons in a few days.
Whenever a severe case occurs without exhibiting any striking prominence of affection in any organ, and when on examining the organs there are found indications of severe affection in all of them, that case is sure to become formidable, and the patient and his physician have reason to congratulate each other if it do not prove fatal. When prominence of affection in any one organ is absent, because all the organs are intensely affected, it constitutes the most formidable case that can occur. And though this kind of case be but too common, yet after all it does not appear to happen as often as it really takes place. Examination after death discloses what was unknown during life. The brain, the lungs, the abdomen are often found to be most extensively diseased, while the indications of disease were confined, perhaps, to the brain and the abdomen, or to the brain and the lungs. Without doubt, the spinal cord and the brain are the grand and original seats of disease; the others are subsequent and consequent, and the principal masks the subordinate. It is when a great number of cases are brought together, and placed in juxta position, that we are impressed, and it is only then that we are duly impressed, with the great proportion of those in which the course of disease is as noiseless as it is destructive; in which its stroke destroys, without its being possible to tell where it falls; in which the physician sees that his patient must die, but in which the anatomist, after the event has happened, can alone pronounce why it was so.
Whatever be the number of organs simultaneously affected, the nature of the affection in each is always the same, and is not in the slightest degree changed by the complication. Disease in the brain is the same, whether the brain alone be prominently affected, or the brain and the intestines, or the brain, the intestines and the lungs. Each organ is liable to its own specific disease, and that disease goes on with the utmost regularity, whether it be the sole organ so far diseased as to suffer a change in its structure, or whether many be simultaneously affected in the same manner.
In like manner the symptoms, when any symptoms are present, are essentially the same, whether the disease exist alone, or whether it be complicated with several others. The symptoms of inflammation of the brain are the same, whether cerebral inflammation alone be present, or whether it be complicated with inflammation and ulceration of the mucous membrane of the intestines. And the symptoms of inflammation and ulceration of the mucous membrane of the intestines are the same, when any symptoms are present, whether these affections exist alone, or whether they are complicated with cerebral inflammation. The occasional absence of symptoms in the subordinate organs, overwhelmed by the preponderance of affection in the principal, is a proof that they are subordinate. It would, therefore, be useless to detail the symptoms which occur in the mixed cases, since they must only be a repetition of those which have been already enumerated. Their concurrence in individual complications, and the modifications they undergo from such particular combinations, will be best understood from the study of the cases.
An examination of large averages clearly shews, what would scarcely have been expected, and what is by no means generally understood, that these mixed cases, instead of being rare, are even frequent. It seems to me to be impossible to study the pathology of those which will now be laid before the reader, without perceiving that the opinion that the seat of fever is invariably fixed in some one organ, is founded in partial, and, therefore, imperfect views; and I earnestly solicit the attention of those who have hitherto contended for the strict locality of that seat, to these very interesting and instructive cases. It was by slow degrees, and after the study of the symptoms as they occur in all varieties, and, if I may so speak, shades of type, in connexion with the morbid changes apparent after death, that I was able to make out, what I have so often stated to be, the true circle of organs upon which this disease always seizes and always preys, and which it often irreparably destroys. In some of these mixed cases, we see marks of irreparable destruction in this entire series of organs; and in every one we see extensive disease in all of them. Coupling, then, as we ought always to couple, these ascertainable and ascertained conditions of the organs in the fatal cases, with the symptoms of derangement manifested by these organs in all cases, whether fatal or not, a body of evidence presents itself, which appears to me to be irresistible, to justify the conclusion that the local seat of fever is at least coextensive with these organs. A repetition of my own conviction cannot, I know, produce conviction in others; I, therefore, again entreat attention to the facts which have produced conviction in me. And in order that the cases to which I am so anxious to direct the attention of the pathological student, may afford him all the information they are capable of communicating, at the least expense of labour to him, they have been arranged in succession, according as dissection shews that, while all the organs are deeply involved, the ravages of disease are most extensive in the organs of the head, or of the thorax, or of the abdomen. The simplest and mildest affections are placed first; the more complicated and severe, as nearly as possible, in the order of their complication and severity; while, in the rapid sketch that is drawn of the symptoms, those which relate to the organ most severely diseased are placed first; and the succession is detailed in order, according as they appear to be antecedents or sequents; or as they are observed to combine to form a train or series. Since cases abundantly illustrating, in this manner, every variety of complication, are given in the pathology, it is unnecessary to add any here.