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.

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.

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.

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.

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 4t 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.

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 dyspnoea; 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.

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.

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.

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, dyspnoea 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]

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.

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, ?iij.

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.

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.

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.