Another classification is derived from the prominent symptoms in the majority of the cases which occur simultaneously, and fever is spoken of as fever with head symptoms, fever with chest symptoms, and fever with abdominal symptoms. _The name in most common use, both in this country and abroad, in connection vrith this division, is gastric fever, or abdominal typhus ; and next to that, nervous fever.
This brings us to the complications, symptomatic or simply concomitant of fever. The prominent feature of the disease must never be lost sight of, that it is not inflammatory. The blood is in a state of depressed, not exalted vitality. This is exhibited by lassitude and weakness, great in proportion to heat and dryness of skin, and by feebleness of pulse, increasing in the ratio of its frequency ; it is a condition of asthenio pyrexia, in opposition to inflammatory fever, or sthenic pyrexia.
Local congestions occur in its course; and in consequence of the irritation thus caused, a sort of inflammatory action may be produced. In the peritoneum there may be actual inflammation in consequence of ulceration or perforation of the bowel; but these secondary actions are not of the elements of fever.
a. In the head we have delirium, insomnia, unconsciousness, coma. That these are not due to inflammation is proved by the history of the case. They have been gradually developed, be ginning with restlessness at night, occasional muttering at that time with perfect consciousness by day ; there has been no intol erance of light; the headache is diffused and general; the pupils have not been early contracted; the symptoms have only attained in the later stages to their maximum, and even then they still continue to be much more marked at night; they are accompanied by listlessness and depression, as opposed to excitement. Deaf ness is a very common condition in severe cases of fever, some times persisting, more or less, during the whole period of recovery. It would seem to be only one expression of the general obtuse ness of all the senses, which is often so remarkable.
b. In the lungs congestion almost always cornea on more or leas from position, and especially in those cases where the blood is most altered in character. This is not true pneumonia ; it only degenerates into low inflammation in consequence of the stagna tion of the blood in the pulmonary capillaries. Here, too, the history points out that cough and rusty sputa have not been the early indications of the attack, but have supervened during its continuance. A condition of the mucous membrane allied to that of the skin in fever may produce a certain amount of bron chitis. This sometimes occurs early; but it will be remarked
that the febrile state is far greater than any that experience teaches us can be caused by bronchitis, however acute; in addition to the febrile state accompanying acute bronchitis, when it depends on an inflammatory condition of the membrane, is sthenic ; that of fever itself is essentially asthenic. The combina tion of fever and bronchitis, bearing the name of influenza, will be noticed afterwards.
c. There may be tension and tenderness of the abdomen. Here we have quite a different class of phenomena ; for ulceration of the intestines is peculiarly a concomitant of fever—not in every case, but in so large a number of instances as to show that the affection of the mucous glands of the bowel—which, if unchecked, passes into ulceration—is a primary morbid state in certain forms of this disease. In some instances it would appear that, when other vital organs are more severely implicated, the poison re mains in a quiescent state ; and after death merely elevated pro minent patches of glands are found, while in other instances they rapidly run into a state of ulceration. Of this phenomenon it is still more true than of the passive congestions already noticed, that subsequently, a condition of real inflammation of a low type occurs; in fact, ulceration is itself an action of this kind ; and as it extends to the other coats of the bowel, and especially the peri toneal covering, the symptoms become more and more closely allied to abdominal inflammation.
hi its earlier stage the state of the stools shows the tendency to ulceration; and after a very short time slight tenderness comes on, which may be soonest detected in the right iliac fossa--often not noticed by the patient, not complained ot ind not produced by slight handling, but shown to exist, when gentle, firm, deep pressure is made, by its causing a pinching of the features, and transient expression of anxiety, accompanied by a gurgling sensa tion. Subsequently great tympanitic distension occurs from loss of muscular contractility, which is an evidence of more decided inflammatory action ; and this may pass, by almost unnoticed gradation, into peritonitis, or may end in sudden rupture and ex travasation of the bowel contents. The tongue, as already noticed, shows in such circumstances a tendency to peel, especially along the centre ; it bec,omes red and shining, often dry at the same time, and subsequently, chapped, aphthous, ulcerated.