_Of Synochus: Division into Synochus Mitior and Gravior. Succession of
Phenomena in Synochus Mitior. Indications afforded of Disease in the
Nervous, Circulating, and Excreting Systems. Progress of Disease
consisting in progressive Increase in the Derangement of these
Functions. Phenomena of Recovery. On what the Transition of Synochus
Mitior into Synochus Gravior depends. Classification according to
the different Organs in which the several Affections have their
Seat. Hence Synochus Gravior with Cerebral Affection—Subacute—Acute:
with Thoracic Affection: with Abdominal Affection: with Mixed
Affection._
It has been stated that, for the purpose of forming into distinct groups
certain assemblages of symptoms which it is important to distinguish,
because they bear an important relation to practice, it will be
convenient to divide the synochus, the term by which we propose to
designate the common fever of this country, as it presents itself in its
mild aspect, into two sections, namely, synochus mitior and synochus
gravior. For reasons already assigned, it will likewise be important, in
treating of these different modifications of fever, to notice in each
both the phenomena which form the assemblage, and the order in which
they succeed each other.
On careful examination it will be found that the first symptom which
denotes the commencement of the ordinary fever of this country, in its
mildest form (synochus mitior), is a loss of mental energy. This is by
no means the first symptom which attracts attention: it is commonly
overlooked for some time, and excites little notice until it has become
distressing. Patients in general are incapable of analyzing their
sensations or of determining the order of their succession; but if
medical men, who are but too subject to be attacked with this disease,
will take the trouble to reflect on the order of events as they occurred
to themselves, they will probably be satisfied, after the most attentive
consideration, that the first indication of disease they felt was a want
of power to conduct their ordinary mental operations with ease and
vigour. Such at least, perhaps I may be permitted to mention, was the
fact in my own case; for, having suffered a severe attack of fever, I
have a distinct and vivid recollection of the dulness, confusion, and
want of mental energy which I experienced for a considerable time before
I was conscious of any corporeal debility.
This affection of the mind consists particularly in indistinctness and
consequent confusion in the trains of ideas; in inability to attend to
their relations; and, as a necessary result, in the loss of power to
think clearly. The individual feels that he is not in a state to form a
sound judgment on any subject upon which he may be called to decide.
Closely connected with this mental weakness is the loss of energy in the
muscles of voluntary motion. Lassitude is the result. The patient cannot
move with his usual vigour, nor even sit without the feeling of
weariness. The debility thus seizing upon both body and mind, sometimes
occurs in each so nearly simultaneously that, it must be owned, it is
difficult to determine in which it appears first.
The next symptom in the order of succession is still more
characteristic: it consists in an uneasy sensation which is quite
peculiar to this state of the system. No description can convey any idea
of it to one who has not felt it; and to him who has felt it the word
fever recalls this uneasy feeling so instantaneously and vividly that I
apprehend most unprofessional persons conceive it is this very feeling
that constitutes the essence of the disease. It is much more distressing
than pain: the mere restlessness which accompanies and which forms so
large a part of it, any one would gladly exchange for intense pain. In
all diseases it is this which makes the sufferer on his midnight pillow
exclaim, “oh! that it were morning!” and in the day, “would that it were
night!” Though it is so frequent in its occurrence, and so peculiar in
its nature, yet I am not aware that it has received any distinct name:
it may be called, until a better is suggested, febrile uneasiness.
It is seldom that these symptoms exist long before positive pain is
felt. With very few exceptions pain is first felt in the back or loins
and then in the limbs. It is rare that this symptom is absent in the
commencement of this form of fever, and it often occasions more
uneasiness to the patient than any thing else during the first stage of
the disease.
Already a remarkable change is commonly visible in the countenance. Its
expression is that of dejection: it is often strikingly similar to that
of a very weak person suffering from fatigue. The colour of the face is
pallid, and the features are somewhat shrunk; but its general aspect is
so peculiar and characteristic that an experienced eye can distinguish
the disease even at this early period, and without asking a single
question.
The skin partakes in a remarkable degree of the debility which so early
shows itself in the muscles of locomotion. This is indicated in a
striking manner by its increased sensitiveness to the physical agents by
which it is surrounded, and by its inability to resist their influence.
Ordinary degrees of temperature produce a sensation of cold which is
sometimes intolerable: chilliness is felt even in a heated room, or in a
warm bed: hence the sensation of cold, sometimes increasing to
shivering, which has been considered one of the most constant signs of
fever. But this feeling of chilliness by no means depends on external
temperature: it is increased by cold, but it exists in spite of an
elevated temperature: it arises from an internal cause, and is not to be
counteracted by external heat.
While the patient experiences the sensation of cold, there is no
diminution of the quantity of caloric in the system. The thermometer
applied to any part of the body commonly rises as high as in the state
of health, and the skin, touched by the hand of another person,
communicates not the feeling of cold, but often, on the contrary, that
of preternatural heat. There is no positive abstraction of caloric from
the body nor any failure in the process, whatever it be, by which animal
heat is generated; there is only altered sensation, in consequence of
derangement in the function of the skin. In this form of fever, the
chilliness in many cases never amounts to shivering; in others, there is
an attack of well-marked rigor, and in others, again, there is either no
feeling of cold, or it is so slight that it escapes observation.
The symptoms now enumerated are all clearly referrible to derangement of
the function of the spinal cord and brain. There is as yet no affection
of any other organ obviously or, at least, much developed. The
circulating system, it is true, is just beginning to be affected. The
pulse is no longer perfectly natural. It is more languid than in the
state of health; sometimes it is also quicker: at other times it is
slower; now and then it is scarcely changed in frequency, but its action
is invariably weaker than in its sound state.
At the same time the respiration is affected in a corresponding degree:
it is shorter and quicker than natural; the chest does not expand so
freely, and compensation seems to be sought in an additional number of
respirations. Oftentimes neither the pulse nor the respiration appears
to be much altered, if the patient remain perfectly still; but if he
rise and walk across the room, the pulse instantly becomes rapid, and
the respiration is quickened almost to panting.
The transition from the affection of the nervous and sensorial to that
of the circulating and the respiratory systems is thus clear and
striking. Physiology teaches us how closely these systems are connected,
and how mutually they are dependent one upon the other, the closest
observers and the ablest experimentalists candidly confessing that they
are scarcely able to determine which is the least dependent, or the
action of which is the least necessary to the others performance of its
functions. The nervous system being first deranged, it is thus consonant
to what we know of the healthy function of the animal economy, that the
circulating and the respiratory systems should be the next to suffer.
How long the nervous system may continue thus deranged, before any other
organs are involved, excepting the circulating and the respiratory, to
the extent just stated, is uncertain. There can be no doubt that in this
mild form of fever, the range of the duration of this isolated state of
disorder, if we may so express it, is from a few hours to several days.
The rapidity or the slowness with which other systems of organs become
involved seems to depend very much upon the acuteness of the attack. In
general, the more acute the fever, the more rapidly the individual
phenomena succeed each other, and the entire series becomes complete.
But this is not, and it is important to bear in mind that it is not
invariably the case: for experience teaches us that the severity and
danger of the disease are not diminished by the slowness of its
approach; and that cases occur, which are slow in forming, and which do
not for awhile excite alarm, that ultimately become truly formidable.
It has been stated that the circulation languishes with the diminished
energy in the sensorial faculties, and the loss of power in the muscles
of locomotion. After awhile, the pulse which was feebler than natural
becomes more full, more strong, and generally more quick than in a sound
state; and now the skin, which was cold, becomes preternaturally hot.
The previous cold consisted, for the most part, of altered sensation,
there being little or no loss of caloric: but the feeling of heat, on
the contrary, is the result of an actual increase of temperature; for
the heat in the interior of the body, as well as on the surface, rises
in some cases several degrees, as is ascertained by the thermometer; the
range of increase being from the natural standard 98° to 105°, beyond
which it is seldom found to augment in this form of fever. The heat is
at first not uniform over the entire surface of the body: it often
happens that some parts are cold while others are burning hot. The heat
is oftentimes particularly intense over the forehead, or over the back
part of the head, or over the whole scalp, while the cheeks are commonly
flushed. All these symptoms denote a morbid condition in the action of
the heart and arteries. Since the generation of animal heat is so
intimately connected with the circulating and the respiratory functions,
it is probable that the increase of temperature is the result of some
morbid action of the capillary vessels belonging to these systems. What
the disordered action of these vessels is, which produces increase of
temperature, we do not know, because we do not know what their natural
action is which produces the temperature of health: but the object of
scientific observation is in some degree accomplished, when it is
ascertained that one condition of these functions is invariably
connected with a morbidly-diminished temperature; another with a
morbidly-augmented temperature; and another with the temperature of
health.
Immediately the circulation is thus excited, the functions of secretion
and excretion become deranged. The mouth is now dry and parched; the
tongue begins to be covered with fur; thirst comes on; the secretion of
the liver, probably also of the pancreas, and certainly of the mucous
membrane lining the whole alimentary canal, is vitiated, as is proved by
the unnatural quantity, colour, and fetor of the evacuations; the urine
likewise is altered in appearance, and the skin is not more remarkable
for the sense of heat, than for that of dryness and harshness which it
communicates to the touch. With the excitement of the pulse and the
increase of the heat, the pain in the back and limbs and the general
febrile uneasiness are much augmented.
At this period, then, the fever is fully formed; the series of morbid
phenomena is complete: any thing more that happens is referrible to
degree and to duration, and must be the result of one or other of these
circumstances, or of their combined operation. And we now see that the
organs affected, constitute precisely that system of organs which has
been described as forming the febrile circle: that the symptoms which
denote the fever are just the symptoms which indicate a derangement in
the several functions performed by these organs; and that the order in
which they become successively involved is exactly that which has been
assigned.
As soon as the preternatural heat comes on, pain begins to be felt in
the head. Dr. Clutterbuck, in describing the general character of the
ordinary fever of London states[23] that “the _first_ symptom almost
invariably complained of is more or less of uneasiness of the head.” If
by uneasiness he meant pain, there is, if there be any truth in the
preceding observations, a long train of symptoms to intervene before
this symptom occurs. That it does ultimately occur is certain: but
commonly its place in the series is much later than is here assigned: it
is disordered function of the brain, indicated by loss of mental energy,
that appears to form the first symptom in this morbid train.
The pain, when it does come, is sometimes slight at first, and
occasionally it remains slight throughout the disease; at other times it
is pretty severe. Cases sometimes occur, in which, instead of pain,
there is only a sense of giddiness, and now and then the uneasy feeling
is described as that of lightness: or, on the contrary, as that of
heaviness or weight. But whether the feeling be pain, and that pain be
slight or severe, or whether it be giddiness, or lightness, or
heaviness, it indicates a similar condition of the organ, and requires a
similar treatment.
With the accession of pain of the head there is a manifest increase in
the disturbance of the sensorial functions. The inability to think, to
compare, to reason, to judge, great as it was at the commencement, is
now much greater. Instead of being more dull, there are certain states
of the mind which now become more acute and vigilant even than in
health. Sensation itself, at this period, is invariably acuter than
natural, as is indicated in all the organs of sense. The eye cannot well
bear the light: there are few cases in which the full glare of day does
not excite uneasiness, while in many the ordinary light of a room cannot
be borne: in these cases the opening between the eye-lids is frequently
observed to be contracted, as if from an involuntary effort to exclude a
portion of that stimulus which in health excites no inconvenience, and
this state of the eye-lids assists in giving to the eye its dull and
heavy expression, so characteristic of fever. The increase of
sensibility in the organ of hearing is equally striking. Sounds which
were not noticed during health become acutely and even distressingly
sensible, while accustomed noises, such as that of a crowded street, are
always painful and often intolerable. The skin, considered as an organ
of touch, is in a like morbid state. An impression barely sufficient in
the state of health to produce sensation excites the feeling of
tenderness, and alternations of temperature, which in ordinary states
are scarcely perceptible, are painful. The senses of taste and smell, on
the contrary, are nearly obliterated, owing to the altered condition of
the membranes upon which the sensitive nerves are distributed.
From the earliest attack of the disease the sleep is disturbed and
unrefreshing; now scarcely any is obtained; the febrile uneasiness will
not allow of repose; the patient cannot remain in any position long,
incessantly shifting his place, never eluding his pain. At this stage
the sense of uneasiness in the limbs, oftentimes the severity of the
pain over the whole body, is peculiarly distressing.
With this progressive increase in the affection of the spinal cord and
the brain, the derangement in the circulating system is proportionally
augmented. The pulse is invariably altered, both in frequency and
character. Generally it rises to 90, sometimes to 100; but in this form
of fever it seldom exceeds this number; and occasionally it never rises
above 80. The stroke of the pulse is usually stronger and fuller than
natural, though it commonly retains its softness, and does not impress
the finger with that sensation of sharpness which is characteristic of
ordinary inflammation. Occasionally, however, a degree of sharpness may
be perceived in it, and it is not easily compressed.
The thin white fur which already had begun to appear on the tongue
progressively increases in extent and thickness. The colour of the fur
usually changes, as the disease advances, from a dirty-white to an
ash-colour; but in this form of the disease the tongue always remains
moist, and never becomes brown. This state of the tongue is almost
always accompanied with thirst, but it is never urgent. There is always
a loss of appetite. The bowels are generally constipated, and the
secretions of the whole alimentary canal are vitiated.
Thus we perceive that the progress of the disease consists in increasing
mental and corporeal weakness; increasing pain in the back, loins, and
limbs; increasing heat of skin, acceleration of pulse, and general
febrile uneasiness, together with the occurrence of pain in the head,
and progressive derangement in the functions of secretion and excretion.
The fever in this mild form is now at its height. It remains stationary,
or at least with very little change for an indefinite period, generally
for some days. The cerebral affection does not increase beyond what has
been described: there are no greater indications of disease in the
respiratory organs, and the mucous membrane of the stomach and
intestines does not denote any progressive advancement in disease.
One of the most remarkable circumstances connected with the ordinary
fever of this country, in the present day, is the uninterrupted and
perfect continuity of its phenomena. As long as the febrile state
remains, nothing deserving the name of a remission is in general to be
perceived. Occasionally, it is true, a slight increase in the symptoms
may be observed towards evening, especially in the heat of the skin; but
even this is not common, and it is scarcely ever great enough to deserve
the distinction of being called an exacerbation. Much less is there any
regularity in the accession and decline of such excitement. In the great
majority of cases not the slightest approach to an exacerbation and a
remission can be distinguished from the commencement to the termination
of the disease. Yet the older writers speak of these events as if they
were as palpable as the paroxysms of intermittent and as constant as the
return of morning and evening. There cannot therefore be a doubt that
the character of the ordinary fever of this metropolis is greatly
changed from the character of that which prevailed two centuries ago;
and the circumstances which have contributed to produce this change will
be considered hereafter.
In the great majority of patients in whom the symptoms continue thus
moderate, the disease disappears about the end of the second week; that
is, they are convalescent at that period; but it usually requires eight
or ten days longer before they have regained sufficient strength to
leave the hospital. Sometimes, although there is no greater severity in
the symptoms, the disease is more protracted, and the recovery is not
complete until the fourth or even the fifth week. Beyond this period it
is very rare for this form of the disease to be protracted.
Almost all who are attacked with the malady in this, its mildest form,
recover: but now and then it happens that the symptoms go on with this
degree of moderation until about the end of the second week. Then at the
period when it is usual for convalescence to take place there is no
perceptible improvement; the patients seem even to grow weaker; they lie
more prostrate in the bed, and they are soon incapable of moving; still
they complain of no pain or uneasiness, and it is not easy to detect any
trace of disease in any organ; yet it is but too evident that they grow
worse, and ultimately they sink exhausted. In these cases, on
examination after death, it is commonly found that disease has been
preying on some vital organs, although its presence could not be
detected during life; and this termination of the milder type of fever
rarely happens, excepting in aged persons, whose constitutions have been
enfeebled by previous diseases, or worn out by the various causes which
depress and exhaust the powers of life.
With an occasional exception of this kind the disease in this form
always terminates favourably; and the first indication of returning
health is remarkably uniform: it is almost always marked by longer and
more tranquil sleep. Instead of that restlessness which is so
characteristic of fever, and which forms the most distressing part of
it, the patient is observed to lie more still, and on waking for the
first time from an undisturbed slumber, he often spontaneously says that
he feels better. Better he may well feel, for his febrile uneasiness is
gone; the load that oppressed him is shaken off; he is a new being. The
pain of the head and of the limbs is so much diminished that often he
cannot help expressing his thankfulness at the change. The countenance
becomes more animated; its natural expression returns; the tongue begins
to clean; and after this state of the system has continued for two or
three days, the appetite returns. While these favourable changes are
going on, the pulse usually sinks about ten beats below its highest
point at the height of the fever; it is not uncommon, however, for it to
remain quick during the entire period of convalescence; and for some
considerable time it is easily excited on any movement of the body, or
any emotion of mind. In some cases, on the contrary, when the attack has
been very mild, it sinks considerably below the natural standard, and is
intermittent, a sign which I have uniformly observed to be attended with
a sure and steady convalescence. In the mean time the appetite becomes
keener than natural; the strength gradually improves; and in a short
time the patient is restored to his usual health and vigour.
What the condition of the brain and of the organs correlatively affected
is, in these the mildest cases, we do not positively know, because we
have no opportunity of inspecting them, their favourable termination
being nearly without exception. But the more all the phenomena are
considered in their entire series, in the order of their succession, in
the uniformity, nay, even in the exclusiveness of their seat, as well as
in the unchanging sameness of their effects, the more clear the evidence
will appear of the soundness of the induction, that the condition of all
the organs in all the types of fever is the same in nature, although
there be no two cases of any type perfectly the same either in the
degree of the affection or in the stage of the morbid process which it
excites. If this induction be really just, we must conceive that, in the
synochus mitior, while the morbid affection of the organs is slight, the
diseased process which it sets up in them stops before it produces any
change in their structure.
However this may be, and to leave for the present all matter of
inference, and to keep strictly to the matter of fact, we do positively
know that the mild forms of fever become severe in consequence of the
supervention of inflammation in certain organs. Perfectly unknown as the
nature of the primitive febrile affection at present is, yet that in the
progress of the disease it does ultimately pass into inflammation is a
fact, the evidence of which it is impossible to resist; although the
same observation which teaches us this most important truth, teaches us
also that the inflammatory action is always considerably modified by the
febrile state. How it is so modified, and to what extent, we shall
consider hereafter. I have spent much consideration and some labour in
the effort to combine the symptoms which attend these severer forms of
the disease with the ascertained conditions of the organs upon which
such symptoms depend. But since it is of paramount importance that the
events which actually take place should be known, and that the order in
which they succeed each other should be stated with clearness and
exactness; and since I have been able by no method that I could think of
to combine the pathology with the history without breaking too much the
continuity of the latter, I have been under the necessity of separating
these two most intimately connected subjects, and of treating of them
under distinct sections. In giving the history of the events, I have
detailed them strictly, as far as I am acquainted with them, in the
order in which they occur: and I have endeavoured to arrange the cases
that constitute the pathology in such a manner, that they shall closely
correspond to these events, and clearly illustrate the order of their
succession. If I have succeeded according to my wish, the reader in
studying the cases will be reminded, as he proceeds, of the successive
stages of the history, and if he again revert to the history, after
having studied the pathology, he will be reminded of the morbid
appearances in the organs which are there described. To afford a clear
perception of the connexion between the successive events, as indicated
by the symptoms during life, and the progressive changes of structure in
various organs, as demonstrated by inspection after death; and thus to
establish a strong and indissoluble association in the mind between the
morbid condition and its sign, are the objects at which I have aimed. If
I have succeeded, I shall have accomplished one of the chief objects of
my undertaking.
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.
6. And now, sometimes closing this train of symptoms, but more
frequently being the first harbinger of another, delirium appears.
Delirium is usually first observed when any slight sound rouses the
patient from that disturbed slumber which is the only substitute allowed
for sleep. The delirium is seldom violent or long-continued, but, when
present, is like the talking of a person during sleep in a disturbed
dream. This symptom, however, is by no means invariably present, and
when it does come, it often postpones its visit to a somewhat later
period.
7. The pulse, during all this time, may not be much quicker than in the
mild form; and the state of the tongue and of the evacuations does not
materially differ.
Such is the train of symptoms when the brain becomes prominently
affected. These symptoms continue without intermission, and with little
change, for several days. The period of their duration, when only in
this degree of violence, is commonly from eight to ten days: when their
character is still milder or more subacute, or when they have been
mitigated by appropriate remedies, it may be protracted fifteen days.
About this period a remarkable change takes place; an entirely new train
of symptoms supervenes, which is different, and which, indeed, presents
a striking contrast, according as the patient is destined for life or
death.
If it be for life, that sleep, of the long absence of which we have
already spoken, returns; and nothing can more truly express its
character than its familiar name, “balmy;” and healing is its influence.
From two or three hours of such slumber, the patient awakens a new
being. Not that the change is at first striking to an inexperienced eye;
but there is no fever nurse who does not recognize it in a moment, and
it is not long before the patient tells you that he feels it. The
febrile uneasiness is now much diminished: the headache is greatly
relieved; and the skin is cooler and softer. The pulse may not yet be
altered, or it may be a few beats slower than before, but there is
almost always already an improved appearance in the tongue, which shews
a beginning disposition to clean. These favourable changes gradually
increase. If the sleep the next night be longer and more refreshing,
which it generally is, on the following morning a decided improvement is
visible in the countenance. The eye is clearer and more lively, and the
expression of the countenance is more natural. The skin continues cooler
and softer; the tongue is still cleaner, and the pulse, perhaps, slower
by a beat or two; and from this period, if no untoward event happen, the
convalescence proceeds just as has been described in the return of
health in the milder form of fever.
If, on the contrary, the case proceed unfavourably, a totally new train
of symptoms at this period sets in.
1. In the first place, the pain of the head obviously, and sometimes
strikingly, diminishes. Often it disappears altogether, or, if any
uneasiness remain, it is rather a sense of dullness and heaviness than
pain. In like manner the giddiness, if that were urgent, is no longer
perceptible: but it is remarkable that the pain in the back and loins
not unfrequently continues for some time after the headache has
disappeared: but, ultimately, that also ceases. The period at which this
important change takes place depends upon the severity of the attack,
and is materially influenced by the activity or inertness of the
treatment. In the subacute form, it usually takes place about the tenth
day from the commencement of the disease.
2. Simultaneously with the disappearance of the head-ache, there is a
remarkable diminution of the sensibility. The mind is duller and more
heavy. The patient may still be roused to answer with tolerable
coherence if spoken to; but when left to himself he is confused and
stupid. The eyes now become injected: often suffused; and the heaviness
and dullness of their expression is increased.
3. It is at this time that delirium, if it appear at all, most commonly
comes on. The increasing insensibility, if not attended with decided
delirium, is almost always accompanied with moaning or incoherent
muttering, especially during the short and interrupted slumbers which
form the substitute for sleep.
4. Striking as these changes are in the functions of the spinal cord and
brain, those which take place in the number and character of the pulse
are no less important. Even in cases the most decidedly subacute, it is
seldom that it does not rise ten beats, so that if before it were 90, it
will now be 100, and it is always weaker.
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.
As an illustration of each form of the disease, as it is commonly met
with in practice, I subjoin the following cases.
CASE I.
JOHN COLEBERT, æt. 28, admitted into the Fever Hospital August 1, 1828.
Attacked five days ago with chilliness, alternating with heat, pains of
limbs, head-ache, and sense of weakness. At present complains of pain of
head, with slight giddiness; pains of limbs, especially of back and
lower extremities; skin moderately warm; tongue loaded with white fur;
much thirst; three stools; respiration natural; no cough, no uneasiness
in chest; no epigastric or abdominal tenderness on full pressure; pulse
96, soft.
6th. Skin natural; pain of head gone; pain of back and limbs continues;
slept better; tongue more clean; three stools; pulse 102.
7th. Pain of head not returned; pain of limbs better; tongue still
cleaning; three stools; pulse 96.
9th. Pain of limbs gone; tongue nearly clean; two stools; pulse 84.
10th. Convalescent.
13th. Dismissed cured.
CASE II.
GEORGE WALKER, aged 17. Admitted May 5th, 1828.
Six days ago seized with shivering, succeeded by heat, loss of strength,
and pain of head. At present complains especially of head-ache; ardent
thirst; no pain of chest; no cough; no pain of abdomen, back, or
extremities; skin cool; face natural; tongue, except at the point,
covered with a thick dirty fur; much thirst; no appetite; sleeps badly;
bowels costive, having had no stool for the last three days; pulse 98,
of good strength.
7th. Heat of skin nearly natural; pain of head almost gone; no pain of
limbs; tongue still much loaded; some thirst; three stools; pulse 72;
slept much better.
8th. Tongue much less loaded; less thirst; five stools; pulse 60.
11th. Convalescent.
14th. Return of head-ache, and, on the day following, the tongue again
became white; but these symptoms disappeared the succeeding day, and, on
the 27th, he was dismissed cured.
These two cases afford fair specimens of the combination of symptoms,
and of the degree of their severity, in the synochus of London, as it
occurs in its mildest form.
CASE III.
EMMA GLADISH. Admitted into the hospital on the 12th day of fever.
Attack commenced with usual symptoms. The pain in the head, which had
been severe for some time, had entirely subsided on the day of her
admission. The mind was now quite indistinct; she could scarcely answer
any question that was put to her; the eyes were dull and heavy; she had
no sleep; there was great restlessness, and occasionally wandering
delirium; there was no tenderness of abdomen; the tongue was red, furred
and dry; the stools were passed in bed; the pulse 105, of good power.
13th. Sleep rather more tranquil; less wandering; mind a little more
distinct; stools still passed in bed; pulse 100.
14th. Much noise through the night; occasionally started out of
disturbed sleep with screaming; tongue red, glazed and dry; stools
passed in bed; pulse 96.
15th. Rather more sleep; talkative delirium; tongue somewhat cleaner;
pulse 100.
16th. Longer and more tranquil sleep; mind more distinct; expression of
eyes still dull and heavy; tongue more clean, more moist; stools only
partly passed in bed.
17th. More sleep than on the preceding night; mind still more distinct;
complains to-day of some tenderness of abdomen on pressure; tongue
nearly clean; two stools no longer passed in bed; pulse fallen to 72.
19th. Slept well; mind clearer; eyes more animated; expression of
countenance brighter; other symptoms the same.
26th. Continues to improve; skin cool, soft, and moist; pulse 78.
27th. Convalescent; but the convalescence was slow and tedious, as it
almost always is after so severe an attack of cerebral disease; she was
dismissed cured on the 40th day from the commencement of the attack. The
reports of the 15th, 16th, and 17th days illustrate very clearly and
strikingly the changes which have already been stated to indicate
recovery.
CASE IV.
ELIZABETH PRICE, æt. 26, servant; admitted on 11th day of disease.
Attacked with ordinary symptoms of fever: at present complains of very
severe head-ache; face flushed; intolerance of light; some deafness;
mind confused during night; visions of various kinds, such as “waves of
the sea rolling,” appear occasionally before her with great vividness;
had been on sea four days before she became ill; skin warm; sense of
general soreness; abdomen rather hard, but not tender; tongue furred,
rather red; much thirst; no appetite; scarcely any sleep, and, when she
does, dreams of a frightful nature interrupt her rest; pulse 114,
_intermittent_, of good power, but easily compressed; bowels
constipated. C. C. ad ℥xviij. nuchæ. Abradat. Capillitium. Lot. Gelid.
cap. Haust. Sennæ Sal. c. m.
12th. More sensible since cupping; mind still confused; occasional
wandering; scarcely any sleep; pulse 124, sharp, yet easily compressed.
14th. Quiet night, with considerable sleep; head giddy and slightly
painful; respiration hurried, apparently cerebral; pupils active; tongue
dry; much thirst; pulse 123. Empl. Lyttæ cap.
15th. Much screaming; great restlessness during night; complains much of
head-ache; pupils active; urine copious, but passed in bed; all the
stools passed in bed; pulse 108, easily compressed; has visions before
her almost constantly; head very hot. Four leeches have been applied to
the temples this morning without relief. Affus. Frigid. cap. ℞. Hydrar.
Submuriat. gr. ij. Pulv. Scillæ, gr. j. Pulv. Antimon. gr. iij. M. sumat
4tâ q. h.
16th. No screaming; head less painful, especially when in half-erect
posture; mind quite sensible now, but much wandering occasionally; pulse
120, feeble; five stools passed in bed.
24th. No material change until this day; sleep now greatly improved;
mind much more itself; tongue beginning to clean; pulse 93; ptyalism.
28th. Ptyalism continues; feels greatly better; appetite returning.
From this period she continued to improve, although with several
threatenings of relapse; the convalescence was slow and precarious, but
she ultimately left the hospital quite well, though not until the 60th
day from the commencement of the fever.
CASE V.
MARY SULLIVAN, æt. 36. Admitted on 14th day of disease; complaint
commenced with shivering; pains in the limbs; severe head-ache.
Complains now of violent pain of the head; face pallid; expression
depressed; scarcely any sleep; abdomen tender on pressure; only one
stool for eleven days; tongue foul and dry; pulse 81, not strong;
complains, also, of pain under right mamma, preventing inspiration and
decubitus. V.S. ad ℥xij. Lotio Gelida cap. Abrad. Capillitium.
15th. Blood with firm buff; pain of head not at all relieved; pain of
back, sides, and abdomen severe; no delirium; no sleep; pulse 78, pretty
strong. Hirudines viij. temporibus. Pt. Med.
16th. Pain of head much relieved; slept very much better; pulse 66, full
and strong.
17th. Pain of head returned, exceedingly severe over the fore-part;
pulse 66, full and strong. C.C. ad ℥xij. nuchæ. Pulv. Aper. Mit. h. s.
Ol. Ricini c. m.
18th. Pain of head gone; countenance more natural; tongue more clean and
moist; pulse 76, more soft. Pt. Med.
20th. Pain of head returned; mind confused; pulse 60, strong and full.
C.C. ad ℥viij. nuchæ. Pt. Med.
21st. Pain of head gone; mind confused; pulse 66, pretty strong.
22d. Pain of head returned, but in a slighter degree; mind more confused
and dull; scarcely any sleep; tongue more foul; pulse 72, soft. Pt.
24th. No longer conscious of pain; mind quite indistinct; lies prostrate
on the back perfectly helpless; incapable of turning on the side;
occasional retching; some tenderness of abdomen on pressure; pulse 72,
strong and full.
25th. Much restlessness; aspect of countenance greatly depressed; stools
passed in bed; pulse 75.
26th. Perfectly senseless; almost constant moaning; extreme
restlessness; difficult deglutition; pulse 120.
27th. Not spoken since last report; lies prostrate on back; eyes half
open and injected; pulse 102, feeble.
29th. Died.
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.
9th. Pectoral and cerebral symptoms the same; bowels purged; pulse 96.
10th. Only slight cough; pain of head; more giddiness; no sleep; eyes
preternaturally bright and glistening; pulse 120.
11th. Only slight cough; pain of head much relieved; slept better;
tongue more clean; four stools; pulse 120, strong.
12th. No pain of chest; cough much increased; now very frequent and
accompanied with copious expectoration; pulse 136.
15th. Cough more frequent; expectoration purulent and mixed with blood;
pulse 126.
17th. Expectorates a larger quantity of purulent matter, mixed with a
larger proportion of blood; pulse 102.
20th. Pectoral symptoms unchanged; strength extremely depressed;
countenance pallid; skin cool; three stools partly passed in bed; pulse
84; mind confused; almost constant moaning; extensive sloughing ulcers
on sacrum and hips.
21st. Pectoral symptoms the same; powers extremely depressed; three
stools passed in bed.
22d. No change in the cough or the expectoration; lies quite prostrate
and appears to be sinking; four stools passed in bed; pulse 72, rather
less feeble.
24th. Cough rather diminished; expectoration unchanged; four stools
passed in bed; pulse 84, extremely weak.
25th. No change, excepting that the pulse (78) is rather more strong,
and she is scarcely so prostrate.
26th. Skin again hot; tongue again red and dry; no sleep; some delirium;
pulse 84, of more strength.
27th. Skin more cool; tongue less red and more moist; pulse 66; some
return of appetite.
28th. Cough much diminished; expectorates less; tongue moist, clean, and
nearly of natural colour; pulse 72, stronger; countenance more animated.
35th. Cough nearly gone; expectoration much diminished; tongue clean;
one stool; countenance improving; strength increasing; wishes for meat;
two ounces were allowed.
40th. Sloughs on sacrum and ilium doing well; pulse 90, of more power;
still noisy during sleep.
From this period she continued slowly, although gradually, to gain
strength, and was dismissed from the hospital on the 57th day, _cured_.
CASE VII.
ANGELICA FIDGETT, æt. 29, married. Admitted on the 16th day of fever.
Before admission affected with cold, shivering, sense of faintness, pain
of head, uneasiness of chest, and cough. On admission, pain of chest
increased by deep inspiration and by cough; cough frequent; pain of the
head already subsided: there remain only a sense of weight over the
eyes, the expression of which is dull, heavy, and vacant; frequent
moaning; no pain of the abdomen on full pressure; pulse 129; tongue
foul, moist; skin hot; face flushed.
17th. Respiration slow and laborious; cough; completely comatose; eyes
suffused; pulse 120, full, soft; face flushed.
18th. Respiration continues very laborious; mind exceedingly indistinct;
much restlessness; pulse 116, still softer.
21st. Examined with the stethoscope: the bronchial roll and crepitus
were very distinctly and generally heard.
22d. The respiration continues extremely laborious; frequent cough,
without expectoration; low, rambling delirium; pulse 112, weak; tongue
foul, moist; general powers greatly depressed.
23d. All the symptoms aggravated. Died on the 24th day of fever.
As thoracic affection may exist in any degree of intensity, so it may
indicate itself at any period of the disease: but while sufficiently
intense to destroy the structure of the organs in which it has its seat,
yet it sometimes gives no indication of its presence, or none until the
approach of death. In these cases, the cerebral affection is still more
intense than the thoracic, and the manifestation of the symptoms proper
to the lung is prevented by the predominance of disease in the brain. Of
this, the following case affords a striking example.
CASE VIII.
JOHN POTTER, æt 21. Admitted on the 15th day of fever. Before admission
was affected with the usual febrile symptoms, accompanied with severe
pain of the head and giddiness. On admission, the pain of the head was
nearly gone; there remained considerable vertigo, with some pain in the
loins and joints; the mind was exceedingly indistinct, and there was
little or no sleep; pulse 80, soft; no indication of pectoral affection.
18th. Symptoms the same; in addition, the abdomen was now tender on full
pressure and retracted.
24th. No change observable until this day; no indication of thoracic
affection had hitherto been apparent from the commencement of the
disease; but, on the morning of the 24th day of fever, dyspnœa suddenly
came on, which was attended with a great degree of restlessness; there
was also some soreness of throat, but only a slight degree of redness
and tumefaction were visible on inspection: with these symptoms he sunk
rapidly, and expired in the afternoon.[24]
III. SYNOCHUS GRAVIOR WITH ABDOMINAL AFFECTION.
One of the organs always involved in disease, in a greater or less
degree, in fever, is the mucous membrane of the stomach and intestines.
In synochus mitior the affection of this organ appears to be slight, and
to pass away without producing any change in its structure. But that it
is really diseased even in the mildest case, we have sufficient evidence
in the invariable derangement which takes place in the functions of the
organ throughout its whole course, from the mouth to the anus; and in
the constant vitiation of its secretions and excretions. In the severer
forms of fever, on the other hand, in the great majority of cases, the
affection of the abdomen becomes prominent, and whenever it does so it
aggravates all the other febrile symptoms, and adds greatly to the
danger of the disease.
Abdominal affection exists under two forms in fever, each of which is
attended with distinct and peculiar symptoms. It may be severe from the
commencement, and give early and obvious indications of its existence;
or it may come on at some subsequent stage of the disease, and then,
although the affection be equally severe, the symptoms which denote it
are materially different.
1. If the abdominal affection be severe from the commencement, in
addition to the ordinary symptoms of fever, there will be present
nausea, sometimes retching, and at other times vomiting. It is usual for
authors to enumerate these events among the ordinary occurrences of
fever; but in a case decidedly cerebral, or in a case decidedly
thoracic, they are seldom present. Whenever they occur in the
commencement of fever they are the certain signs of an abdominal
affection more severe than ordinary; and it will be of the utmost
advantage to the patient should the practitioner be aware of this,
because it will teach him at once where the main force of the disease is
probably to be concentrated.
2. At this early period the bowels are commonly constipated, and on
inquiry it will be found that they have been so for some days previously
to the attack of fever; but in a day or two after the commencement of
this attack they fall into the opposite state and are looser than
natural. The concurrence of nausea, retching, vomiting, and purging in
the commencement of fever is a certain proof that severe abdominal
affection is present, and if not actively treated and effectually
checked at this early stage, it will soon render the case formidable, if
not hopeless.
3. When the abdominal affection is thus early and open, it is often
attended with another symptom which seldom fails to attract attention,
namely, pain. Pain of the abdomen, attended with purging, completes the
train of local symptoms that occurs at this early period, in the most
exquisitely marked cases. It is well worthy of observation, however,
that pain is by no means an invariable attendant on the other symptoms,
even when the latter are very severe. Whether in these cases the
affection of the nervous system be already so great as to lessen the
sensibility of the organ, or whatever else may be the cause of it, the
fact is certain, and it is one of great practical importance, that pain
of the abdomen is not to be expected even in severe abdominal affection;
and that though pain may attend upon the affection, yet the affection is
often present without pain.
4. Pain of the abdomen upon pressure, and especially upon pressure in
the epigastrium, is much less seldom absent than pain of which the
patient spontaneously complains.
5. Pain, though it may usher in the abdominal affection, and may even be
severe for the first few days, diminishes after a certain time and then
ceases altogether, so that it is extremely rare, after the tenth day of
fever, for instance, for the patient to complain of pain of the abdomen,
even when the abdominal affection is the most intense. Such an event may
happen, perhaps when the cerebral affection is more than commonly
slight, but it is an exceedingly rare occurrence, and my attention has
been particularly drawn to this circumstance from reflecting on the
uniformity of the answers which I have obtained from patients obviously
labouring under abdominal affection, on my first visit to them in the
wards of the hospital. Having commonly been ill from ten to fourteen
days, the abdominal affection may by this time be fully developed: on
asking them whether they feel any pain in the abdomen, the answer almost
invariably received is, “no.” Press gently upon the abdomen, press
especially upon the epigastrium, often even in these very cases not the
slightest touch can be borne. After pressure has once been made, the
patient will frequently do all he can with his hand to prevent its being
made a second time. So acutely sensible is he of pain on the least
pressure, though wholly unconscious of pain when left to himself. Even
when there is not this great degree of tenderness, pain can generally be
produced by full pressure.
There is thus a remarkable coincidence between the progress of the
symptoms in the abdomen and in the head. We have seen that however
intense the cerebral affection, the pain of the head which accompanies
it diminishes after a certain time, and in a day or two after it has
begun to diminish, ceases altogether. In like manner the pain which
ushers in an acute abdominal affection diminishes after a certain time,
and soon wholly disappears. After this period, therefore, we should have
no more indications of abdominal than we have of cerebral pain were the
intestines, like the brain, enclosed in a bony case. When an organ can
be touched, it gives us an additional and an invaluable means of
ascertaining its morbid condition: and this is one reason why that
condition is commonly so much more certainly known in surgical than in
medical diseases. What the result would be, could we press the brain as
we can the abdomen, after its sensibility is so much diminished as to
cease to occasion pain, we do not know; but it would be a bad use indeed
to make of the additional means afforded us of ascertaining the
condition of the intestines, were we to allow the additional information
we thus gain, to obscure our perception of the perfect analogy there is
in the progress of both affections. We know that, as the disease
advances in both, the pain ceases; but, in the one case, we have the
means of ascertaining that there still remains preternatural tenderness
on pressure, as in ordinary inflammation, which we are without the means
of discovering in the other: still the important practical fact afforded
by the history of both is the same, that disease having reached a
certain point, the pain diminishes; and having advanced still further
entirely disappears.
6. While the pain lessens or ceases as the abdominal affection advances,
the purging, on the other hand, continues, often it increases. Purging,
succeeding to constipation and to pain, and remaining after the
subsidence of the pain, affords an infallible indication of abdominal
disease.
7. Together with these decisive signs, which alone are abundantly
sufficient to enable us to ascertain the presence of the affection, we
have an additional and an exceedingly valuable guide in the peculiar
state of the tongue. In these abdominal cases, the tongue is
preternaturally red. Sometimes this increased redness is of a bright and
vivid colour, and pervades the whole tongue; at others, it is confined
to the edges or to the tip, and it is usually remarkably apparent in the
latter. While thus vividly red, the body is often loaded with fur; the
colour of the fur is often of a dirty-white or greyish colour; but,
perhaps, while the edges and the tip are thus intensely red, the most
usual colour observed on its body is that of a dirty yellow. In these
cases, the papillæ appear much enlarged, and are seen prominent through
the fur, vividly red. In this condition of the tongue it always remains
moist for some time, and it is not attended with urgent thirst; but, as
the intestinal disease advances, the tongue gradually becomes less
vividly red and more dry, and as these changes go on, the lips and teeth
often become sordid.
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.
Hora 3tia, p. m. Blood with thick and firm buff; symptoms both of
abdominal and thoracic disease diminished. Vespere versus vel eras mane,
rep. V.S. ad ℥xvj. si opus sit. Pulv. Aper. Mit. h. s. haustus Sennæ
Sal. c. m.
9th. Bled last evening with much relief; proportion of coagulum of blood
last drawn great, and covered with firm buff. Much pain in the
epigastrium and over the whole abdomen independently of pressure, but
greatly aggravated by slight pressure; tongue less loaded, less red,
moist; much thirst; pulse 108, sharp, small, easily compressed: Rep.
V.S. ad ℥xvj.
10th. “Feels greatly better;” pain of epigastrium gone; none of abdomen
when not pressed; full pressure much more easily borne; tongue
unchanged; thirst; vomiting; four stools; pulse 108, of the same
character.
12th. Pain not diminished on pressure; nausea, vomiting, rejection of a
large quantity of green fluid; pulse 118.
16th. Says she is quite free from pain of the abdomen; bears pressure
without flinching; no vomiting since last report; four stools; tongue
clean and moist; pulse 99; sleeps better, but the mind is dull and
confused: wandering delirium through the night; some muscular tremor;
skin cool; face flushed.
18th. Pain of abdomen returned; mind confused; delirium.
23d. Says she is without pain, but feels oppressed; pulse 96; slept
better; no delirium; face more animated; skin warm; no flushing.
27th. Had been steadily improving until this day, when the pain of the
abdomen returned, which is again tender on pressure; tongue clean; one
stool; pulse 110.
29th. Pain much relieved since the application of six leeches to the
abdomen, followed by a large poultice.
30th. Pain gone: only slight tenderness: pulse 96.
32d. Pain and tenderness again returned; tongue more red; pulse 108.
33d. Six leeches were applied last evening without the slightest relief
of the pain or tenderness; tongue red: pulse 96, more weak and soft.
34th. Tenderness considerably diminished; tongue less red; countenance
again improved.
35th. Still less tenderness than yesterday; bears pressure much better;
tongue nearly natural; two stools.
39th. Improving every day; no pain of abdomen; no tenderness on fullest
pressure; bowels quite soft; tongue natural; four stools; pulse 72;
appetite good: strength increasing.
44th. No return of uneasiness; continues to gain strength.
57th. Since last report has been daily improving, and is now quite well.
Dismissed cured.
CASE X.
SARAH RAVEN, æt. 17. Admitted on the 22d day of fever; no pain of the
abdomen appears to have been complained of from the commencement of the
attack; at present no tenderness on the fullest pressure; some
distention; tongue covered with yellow fur, moist; bowels loose; pulse
110, sharp; only slight pain in the head; more pain in the limbs; mind
dull, confused; deaf.
24th. No pain of abdomen on fullest pressure; tongue the same; only two
stools; pulse 124; voice hoarse, feeble; respiration hurried; skin dark,
almost livid; mind much more confused; delirium.
25th. No material change.
27th. Insensibility increased to coma; features shrunk; one stool passed
in bed; pulse 128; skin livid, cold.
28th. Moribund; died the following day.
On examination after death (see pathology) extensive disease was found
in the intestines, although, if the purging on the day of admission be
excepted, not the slightest indication of it was given during life.
CASE XI.
GEORGE ENGLISH, æt. 25, carpenter. Admitted on the 29th day of fever,
with a great degree of tenderness of the abdomen, extending especially
over the hypogastric region; bowels said to be regular; pulse 90, of
good strength; yet complains much of sense of debility.
30th. Pain of the abdomen continues, especially over the region of the
bladder; urine passed in good quantity and freely; three stools; pulse
84.
32d. Tumour has appeared over the region of the bladder, unattended with
pain; three stools; pulse 76.
33d. Hypogastrium still tumid, but without pain; other symptoms the
same.
43d. No material change until this day, when he was suddenly seized with
exceedingly acute pain in the region of the bladder; extreme tenderness
on pressure; great restlessness, and great anxiety; vomiting of a
yellow-coloured fluid; two stools; pulse 84, extremely feeble.
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.