FEVER, CONTINUED. 



FEVER, CONTINUED. 



and excretion become deranged. The mouth is now dry and parched ; 

 the tongue begins to be covered with fur ; thirst comes on ; the secre- 

 tion 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 : anything 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. 



As soon as the preternatural heat comes on, pain begins to be felt in 

 the head. The pain of the head is often slight at first, and occasion- 

 ally 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, 

 it 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 conti'acted, as if from an involuntary 

 effort to exclude a portion of that stimulus which in health excites no 

 inconvenience, and this state of the eyelids 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, 

 Icred as an organ of touch, is in a like morbid state. An mi- 

 ni 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 

 unrefresbing ; 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. 



\\ .1 li this progressive increase in the affection of the spinal cord and 

 the brain, the derangement in the circulating system is proportionately 

 augmuntvd. 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 charac- 

 teristic of ordinary inflammation. Occasionally, however, a degree ol 

 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 oi 

 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 Jhe tongue is 

 almost always accompanied with thirst, but it is never urgent. There 

 is always a loss of appetite. The bowels are generally constipated, ant 

 the secretions of the whole alimentary canal are vitiated. 



Thus we perceive that the progress of the disease consists in increas 

 ing mental and corporeal weakness ; increasing pain in the back, loins 

 and limbs ; increasing heat of skin, acceleration of pulse, and genera 

 febrile uneasiness, together with the occurrence of pain in the heat! 

 and progressive derangement in the functions of secretion am' 

 excretion. 



The fever in this mild form is now at its height. It remain 

 stationary, or at least with very little change, for an indefinite period 

 generally for some days. The cerebral affection does not increas 

 beyond what hai been described : there are no greater indications o 

 disease in the respiratory organs, and the mucous membrane of th 

 stomach and intestine* does not denote any progressive advancemen 

 in dueam. 



In the great majority of patients in whom the symptom* coutinu 

 thus moderate, the disease disappears about the end of the secou 



week, that is, they are convalescent at that period; but it usually 



equires eight or ten days longer before they have regained sufficient 



;rength to leave the sick chamber. Sometimes, although there is no 



greater severity in the symptoms, the disease is more protracted, and 



tie recovery is not complete until the fourth or even the fifth 



eek. Beyond this period it is very rare for this form of the disease 



o be protracted. 



Almost all who are attacked with the malady in this its mildest 

 orm, recover : but now and then it happens that the symptoms go on 

 vith this degree of moderation xmtil about the end of the second 

 week. Then at the period when it is usual for convalescence to take 

 >lace there is no perceptible improvement ; the patients seem even 

 o grow weaker ; they lie more prostrate in the bed, and they are 

 oon incapable of moving ; still they complain of no pain or uneasiness, 

 nd it is not easy to detect any trace of disease in any organ j yet it 

 s but too evident that they grow worse, and ultimately they sink ex- 

 lausted. In these cases, on examination after death, it is commonly 

 ound that disease has been preying on some vital organ, although its 

 iresence could not be detected during life ; and this termination 

 >f the milder type of fever rarely happens except in aged persons 

 whose constitutions have been enfeebled by previous diseases, or 

 worn out by the various causes which depress and exhaust the powers 

 if life. 



With an occasional exception of this kind, the disease in this form 

 always terminates favourably ; and the first indication of returning 

 lealth 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 

 irst time from an undisturbed slumber, he often spontaneously says 

 that he feels better. Better he may feel, for his febrile uneasiness is 

 ;one ; 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 

 aecomes more animated ; its natural expression returns ; the tongue 

 Begins to clean, and after this state of the system has continued for 

 iwo 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 has been 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. 



The transition of a mild case of fever into a severe one, or the pro- 

 gress of a case severe from the commencement, is accompanied with or 

 depends upon 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 membranes of the intestines. Other organs become affected 

 in the progress of the malady, but these are the organs which in a 

 greater or less degree are invariably diseased, and which therefore 

 must be considered as the true seats of the structural changes that 

 take place in the regular course of fever. Accordingly in all the 

 severer cases, the symptoms, which are only the external indications 

 and expressions of the successive changes that take place in the internal 

 organs, have their seat either in the head, in the thorax, or in the 

 abdomen. Mixed and blended as these symptoms appear in the dif- 

 ferent cases which the practitioner is actually called upon to treat, 

 they seem so complex and variable as to bid defiance to any arrange- 

 ment : when analysed, nothing is more remarkable than their simplicity 

 and their uniformity. 



Previous to the changes of structure that take place in the internal 

 organs, it is probable that the different fluids undergo changes no less 

 important. There is indeed a controversy whether the very first 

 change that takes place does not take place in the fluids, and more 

 especially in the blood. There cannot be a question that a morbid 

 change takes place in the blood at a very early period of fever ; that 

 that change is different at different stages of the disease ; that it is 

 essentially different according to the particular type of fever, and that 

 it is always great in proportion to the severity of the attack. Without 

 entering here into the controversy whether the very first event in the 

 series be a morbid change in the blood, it is manifest that this fluid 

 cannot but become diseased in the progress of fever, because all the 

 processes by which the depuration of the blood is effected are disturbed, 

 and consequently matters which it is the office of these depurating 

 organs to remove from the circulating mass accumulate in it. More- 

 over there is evidence that the constitution of the blood itself becomes 

 deranged, and that the natural proportions of its essential constituents 

 are subverted. Of course, in a state of the system in which the most 

 important secreting organs are diseased, and in which the fluid that 

 affords the common materials from which the secretions are elaborated 



