Chapter VI: Of the Pathology of Fever (4)

This gentleman had been out of health six months previously to the present attack of fever: he had been observed to be gradually losing flesh, and fading; yet he laboured under no complaint that could be ascertained, excepting that his appetite failed; that he could digest well no kind of food; that he was badly nourished and, therefore, weaker in body and less vigorous in mind than usual.

About three weeks before the fever commenced, his stomach-complaints became worse, and for these he requested the advice of his friend Mr. Chaldecott. During this gentleman’s attendance, his patient was one day attacked with slight chilliness, an unusual degree of lassitude, together with pains in the limbs: but the chilliness never amounted to rigor; the general pains were not severe; there was no pain whatever in the head; yet the sudden debility which affected both mind and body was very striking. Still the mind was perfectly distinct; the sleep was sound; the expression of the countenance was natural; the tongue, however, became loaded with white fur; there was some thirst; the pulse varied from 84 to 96, while the temperature and the softness of the skin remained in a healthy state. In this manner he went on about eight or ten days, and, during the whole of this period, he was daily questioned by his medical attendant and examined with much anxiety relative to the condition of the organs in the head, chest and abdomen; but he was steady in affirming that he was free from all uneasiness in the head, and that he had no pain in the chest; nor could any pain be excited by the fullest pressure, either in the epigastrium or in any part of the abdomen. It was observable, however, that he had some cough without expectoration, and that his respiration was short and hurried. His appearance, too, indicated more disease than his sensations; he was obviously worse than he expressed, or than could be accounted for from the apparent affection of any organ, and this excited alarm both in his family and in his medical attendants; and it is always a truly alarming condition.

On the 11th day a remarkable change took place: for two or three hours he was chilly; to this succeeded heat of skin and flushing of the face; what was very alarming, the colour of the flash was purple, while that of the whole face was dusky; there was no cough, but the respiration was short and hurried; the mind was confused and dull, though a coherent answer might still be obtained to any question that was asked; the pulse now rose to 120, there was little or no sleep, but great restlessness during the night, in the course of which delirium appeared, and the next morning there came on muscular tremor. As the day advanced the flushing and heat disappeared; the mind became quite distinct, and the pulse fell to 96. Towards evening he again became restless, the pulse rose to 104, and about one o’clock, a.m. the increased heat, the flushing of the face, the purple colour of the cheek, the dusky appearance of the skin, the short and hurried respiration, and the convulsive action of the muscles all returned, and in a greater degree, while the pulse again rose to 120. From this state he never recovered in the least degree, but became more and more dull, and at length nearly insensible; his debility rapidly increased until it became extreme; he lay quite prostrate on the back, with his arms extended, as if lifeless; the muscular tremor increased; the respiration became extremely short and hurried; the tongue became dry, red, glazed, and sticky; the bowels torpid; the pulse 130; and with these symptoms he expired on the 13th day of fever.

_Head._ Dura mater healthy; arachnoid thickened and opake; much gelatinous effusion between it and the pia mater; substance of brain highly vascular and firm; lateral ventricles distended with fluid, much also at the base. _Thorax._ Mucous membrane of bronchi universally of a dark red colour and lined with a tenacious fluid, which was slightly sticky; bronchial tubes filled with frothy mucus; substance of lungs perfectly healthy. _Abdomen._ Mucous membrane of small intestines generally inflamed; lower part of ilium and commencement of colon filled with large and raised ulcers, some of which were just forming, while others had penetrated through a thick mass of adventitious deposit to the muscular coat of the intestine.

Before closing these illustrations of the pathology of fever, it may be proper to give an example of the modifications which take place when this disease proves fatal in the state of gestation. If fever attack during pregnancy, there is the greatest possible danger of miscarriage, and the great majority of those who miscarry die. There is no complication which requires a more delicate and cautious management; and the management which experience shews to be the best will be stated in the proper place: in the mean time, the following case is given as an illustration of the morbid appearances which are found (and the appearances are very uniform) when abortion is the precursor of death.

CASE CX.

MARY CUTLER, æt. 37, married. Admitted on the 5th day of fever, in the commencement of which, in addition to the ordinary symptoms, there was much nausea; this feeling continues at present, and is now accompanied with vomiting; epigastrium tender; cannot lie without pain in the left side; cough frequent, and exciting uneasiness in the chest; tongue white and dry; bowels bound; some pain of head, especially in the forehead; scarcely any sleep; much pain in the extremities; pain of throat with difficult deglutition; pulse 122; skin warm; six months pregnant.

6th. Much retching and vomiting; tenderness of the epigastrium and abdomen; bowels very loose; tongue white in the middle, red at the edges; severe pain in the chest; great dyspnœa; constant, urgent cough with difficult mucous expectoration; severe pain in the head; no sleep; great restlessness; pulse 150, sharp but compressible. V. S. ad ℥xij.

7th. Buff on blood extremely firm; retching and vomiting gone; pain of side entirely removed; less cough; dyspnœa diminished; pain of head better; slept much better; pulse 120.

9th. After a tolerable night, attacked this morning with urgent dyspnœa, soon became perfectly insensible; was delivered of a fœtus six months old; at present, nearly insensible; respiration hurried and laborious; tongue brown and dry; one stool; pulse 110; skin moderately warm.

10th. Free lochial discharge; all the symptoms greatly improved; tongue white; moist; pulse 84, soft.

13th. Lochial discharge nearly ceased; no pain in head, abdomen, or any where, except the face which is attacked by erysipelas; tongue continues moist and is nearly clean; pulse 108.

14th. Erysipelas increased and extending; tongue, has again become brown and dry; pulse 110.

16th. Erysipelas extending; severe pain in epigastrium and over abdomen, much increased on pressure; distressing sense of nausea but no vomiting; tongue the same; pulse 96, weak and irregular.

17th. Pain of abdomen increased; stools in bed; no sleep; extreme restlessness; respiration hurried and wheezing; pulse 130, weak. Died in the evening.

_Head._ Membranes of brain vascular. _Thorax._ [Pleuræ covering right lung coated with a layer of coagulable lymph; in both pleural cavities a large quantity of serum mixed with flakes of lymph and pus; that part of the pleura of the right side which lines the diaphragm highly inflamed;] substance of both lungs healthy. _Abdomen._ Peritoneum in general more vascular than natural; patches of it in a state of intense inflammation; peritoneal sac contained much serum mixed with flakes of lymph and pus; pelvis of right kidney inflamed; ovaria and uterus of very dark colour and intensely inflamed; other viscera healthy.

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It would be easy to multiply cases to an indefinite extent, but, since those which have been cited exhibit a complete view of the pathology of fever, as far as it has yet been ascertained, any further details would fatigue the reader without instructing him. And what is this pathology? What are the events, the detail of which has occupied us so long? The account of the pathology of fever is the history of inflammation, and the description of the individual changes that take place in the organs that constitute the febrile circle, is an enumeration of various products of inflammation which are formed within them. There is scarcely a fatal case of fever which does not afford, in one or other of the organs of that circle, some inflammatory product; there is no considerable number of fatal cases which does not furnish a specimen of every inflammatory product. And what are the severest cases of fever, and why are they the severest? With the single exception immediately to be stated, the severest cases are those in which, together with a severe primary affection of the nervous system, this inflammatory action is in the greatest degree of intensity, and is seated in the greatest number of organs; and they are the most severe, not only on account of the severity of the primary affection of the nervous system, but also because it is in them that the inflammation is the most intense, and because that inflammation attacks the system at one and the same time in the greatest number of points. From among the preceding cases, fix upon any one in which the powers of life were, from the commencement, the most completely overwhelmed, and in which they were the most rapidly exhausted, and when the brief struggle for existence is over, examine the changes that have taken place in the internal organs—what is it that is found? traces of inflammation, legible, deep, extensive; while, in almost every case, these traces are thus legible, deep, and extensive, in proportion to the apparent intensity of the fever, and to the rapidity with which it extinguished life. In this point of view, how important, how instructive, how invaluable is the lesson which the mixed cases of fever afford! With few and rare exceptions (and in all diseases some exceptions occasionally occur to what appear to be the best established and the most invariable laws) these are the cases in which the symptoms are the most urgent, and in which they run their course with the greatest rapidity; these are the cases in which the debility is the most striking; in which it comes on the most early, and proceeds to the greatest degree of prostration; these are the cases which are the most purely typhoid, the most truly adynamic; these are the cases which, in general, commence with the most sudden and alarming deprivation of physical and mental power; in which all pain and uneasiness are soonest lost in stupor, in which the stupor most rapidly increases to insensibility; in which delirium comes, perhaps, as early as the third or fourth night, accompanied with its attendant, muscular tremor, and too often with its most formidable ally, erysipelas: in which, at this early period, the respiration is short and hurried, the skin dusky, the colour of the cheek purple, the tongue brown and dry, the lips and teeth sordid, the abdomen tender, and the stools loose; in which, in a day or two more, the abdomen is swollen, tense, and tympanitic, the stools passed in bed, the patient prostrate on his back, completely senseless and powerless, while the pulse is 120 or 130, and so feeble that it can scarcely be distinguished. But what is this debility? in what does this adynamic state consist? It consists of a peculiar affection of the nervous system, followed rapidly by intense inflammation of the brain or of its membranes, or of both: by intense inflammation of the mucous membrane of the bronchi, and by intense inflammation or extensive ulceration of the mucous membrane of the intestines. And why is the patient weak or adynamic? Because he is not only assailed by an affection of the nervous system, which deprives the organs of the stimulus necessary to enable them to perform their functions with due vigour, but, at the same moment, inflammation is set up in three of the great systems, the healthy action of which is most essential, not only to strength but to life: thus the citadel is attacked at one time at three of its capital points. It is not asserted that inflammation alone constitutes the state of fever, nor that the danger of the patient is always in exact proportion to the degree of the inflammation. How it differs from inflammation, and what is superadded to the inflammatory state, will be shewn immediately; but it is a most important fact, that the degree of the debility is most intimately connected with the intensity and the extent of the inflammatory action. Now and then, as has been already stated, the intensity of the nervous affection is so great, and so rapidly destructive of life, that there is no time for an inflammatory process to be set up, much less for an inflammatory product to be formed. The patient is struck dead as if by lightning, or by Prussic acid, or by apoplexy. In this country, he does not actually die as instantaneously as he might be destroyed by the electric fluid or by poison, although there are countries, seasons, and particular spots, in which the concentration of the febrile poison appears to be sufficiently great to extinguish life instantaneously; and even in this country, life is sometimes destroyed by a stroke of fever as rapidly as it is by a stroke of apoplexy, when the latter does not prove fatal in the first few hours.

Now the peculiarity in these cases is, that the internal organs, after death, exhibit no signs of inflammation, unless vascularity be inflammation. The organs which, in ordinary cases, are inflamed, are in these cases turgid with blood. Are the terms debility or adynamia appropriate expressions to designate even this condition of the organs? Just as appropriate as they would be to express the condition of a person who is struck dead by lightning, whose muscles are incapable of contraction, and whose blood will not coagulate. Those who apply these terms even to such forms, and, _à fortiori_, to any other forms of fever, must be ignorant either of the nature of the disease, or of the constitution of the human mind. If they know the disease, they know that the patient appears to be weak because the primary operation of the disease is upon the nervous system—an operation which, as has just been stated, while it disturbs that due and equal distribution of nervous influence which is necessary to the healthful action of the organs, and, therefore, to the general strength of the system, is not incompatible with, but promotive of an excitement of the vascular system, which terminates in inflammation. Debility is the last, the ultimate result of the disturbance of the functions of a certain series of organs, but part of this very disturbance of function, and a most important part, a part which exerts the greatest influence over the progress of the disease and the life or death of the patient, consists not in the weakened, but in the augmented strength and the increased activity of the vascular system. To designate the ultimate result upon the system by a term which gives an entirely false view of the individual processes in the economy, by which that ultimate result is produced, must, we repeat, arise either from an ignorance of the true nature of those processes, or from not reflecting on the influence which words exert over the manner in which the human mind conceives of things. For the sake of the progress of the science of medicine, for the sake of rendering the language of medicine the correct expression of the knowledge which the science has actually attained, and, above all, for the sake of accomplishing the great object of medicine, the preservation of human life, it is high time that these terms with which physicians have so long allowed their minds to be abused, should be banished from medical nomenclature, or, at any rate, from that part of its nomenclature which appertains to fever.

II. PATHOLOGY OF THE FLUIDS IN FEVER.

The pathology of the solids in fever, derived from inspection of the fatal cases after death, has already acquired, as we have seen, a high degree of perfection. The pathology of the fluids is scarcely at all known, and the difficulty of arriving at exact and certain results is great. Why the investigation of the morbid changes that take place in the fluids should be a much more arduous task than that of tracing the changes produced in the structure of the organs, is too obvious to need to be pointed out; but those only who have actually engaged in researches of this nature can form a just conception of the number of repetitions that are requisite of the same analysis, of the care required in conducting each, and consequently, of the labour and time it is necessary to devote to the investigation, before satisfactory results can be obtained. The analysis of the animal fluids in their healthy state is far from being perfect; yet their composition in the state of health must be ascertained, as far as it can be ascertained, as a preliminary step: and, in order to discover the morbid changes that take place in the blood, in the urine, in the products of respiration, and in those of transpiration, and still further to determine the nature and extent of such changes in the different types and stages of fever, it is obviously necessary to examine the respective fluids and gases in a great number of cases, and to vary the experiments in a great variety of modes. Experiments of this kind, on an extensive scale, have been undertaken by my friend Mr. Cooper; and, when this work was commenced, they had already advanced so far that there appeared to be a prospect that, before its completion, they would be sufficiently matured to justify us in laying the results before the reader. And that deviations from the state of health, and some of them of great importance, do take place in these fluids, and especially in the blood and the urine, is ascertained. What they are, with what degree of constancy they occur, how far they are respectively connected with the cerebral, the thoracic, the abdominal, and the mixed affections, with different degrees of intensity in these affections, and with different stages of their progress, we hope, at no distant period, to be able to lay fully before the public.

In the mean time, it is of some importance to bear in mind the true place which the results of such experiments, be those results what they may, and be they established with all the clearness and certainty that can be desired, must always hold. Changes in the fluids can only be second in the series of morbid events; they can never hold the first place in that series; they can never be primary antecedents or first causes, but merely sequents or effects. To assign the reason of what must be so obvious to every one who is acquainted with the elements of physiology, would be entirely out of place here, because it would suppose the reader to be wholly ignorant of the functions of the animal economy. Our knowledge of the pathology of fever can never be complete, until we know the morbid changes that take place in the fluids as perfectly as we are acquainted with the alterations of structure that are produced in the solids, and we ought, therefore, to spare no labour to render our knowledge of the former as exact and certain as it is of the latter. But, as far as we can at present see, when this is accomplished, we shall have acquired little that is of practical utility. There is but slight, if there be any ground to hope that, when the humoral pathology shall have arrived at the greatest possible degree of perfection, it will furnish us with any additional means of preventing, curing, or even mitigating the severity of the disease. With that disorder of the system over which we have some control, with those morbid actions which we possess some means of subduing or changing, we are already well acquainted. In our knowledge of the invariable tendency there is to the production of certain changes in the structure of certain organs; in our knowledge of the vascular action by which those alterations are effected, we may be said, in a practical point of view, to be already in possession of the most important part of knowledge which we can ever hope to acquire, unless, indeed, we may indulge the expectation, of which it would be truly melancholy to be deprived, that we may discover a more sure and effectual mode of preventing these organic changes, or of restoring to a sound state the organs that may become diseased. It is this part of the pathology of fever alone that can afford a clear and steady light to conduct us to the safe and effectual treatment of the malady. Every step we take without this invaluable guide must be taken in the dark, and will be, therefore, not only likely to be false, but very likely to be fatal. When, on the contrary, we undertake the management of fever under the direction of this faithful guide, in every measure we venture to adopt we, at least, know at what we aim: we propose to ourselves a definite object which we endeavour to accomplish by an instrumentality with the powers of which we are in some degree acquainted: we may not succeed, but we fail because we want the means to do what we clearly see requires to be done: if we do not arrest the progress of the disease, at least we do not add to its strength by the adoption of violent and desperate expedients, because we feel called upon to do something, yet know not what to attempt; we do not destroy, if we cannot save. The physician, enlightened by the pathology of the disease, who prescribes for a patient in fever, is like a skilful surgeon, who is guided in the performance of a difficult and delicate operation by a knowledge of anatomy so intimate, that every touch of his scalpel exposes a tissue with which he is acquainted, and discloses the site of a vessel with which he is familiar; the object aimed at by the operation may not be obtained, but, at least, the cause of its failure is not that the operator wounds a structure which he ought to have avoided, or opens an artery, of the situation and distribution of which he is ignorant. On the contrary, the physician who prescribes for a patient in fever, without knowing the pathology of the disease, is like a Charlatan, who plunges his instrument boldly into the chest or the abdomen, without knowing where it goes or caring what it wounds; it may possibly open a tumour and let out the disease, but it is more likely to pierce some vital organ and to let out life.