A
TREATISE ON FEVER.
BY
SOUTHWOOD SMITH, M.D.
PHYSICIAN TO THE LONDON FEVER HOSPITAL.
LONDON:
LONGMAN, REES, ORME, BROWN, AND GREEN,
PATER-NOSTER ROW.
1830.
PRINTED BY G. HAYDEN,
Little College Street, Westminster.
TO
HIS GRACE
THE DUKE OF SOMERSET,
PRESIDENT;
TO
THE VICE-PRESIDENTS,
TO
THE TREASURERS,
AND TO THE
OTHER GENTLEMEN CONSTITUTING THE COMMITTEE,
Of the London Fever Hospital;
IN TESTIMONY
OF HIS ADMIRATION OF THE DILIGENCE
WITH WHICH
THEY LABOUR TO PROMOTE THE PROSPERITY,
AND THE
CARE WITH WHICH THEY WATCH OVER THE INTERESTS OF THIS INSTITUTION;
WHICH,
IN THE MAGNITUDE OF THE BENEFITS IT CONFERS,
NO LESS THAN
IN THE INEXPENSIVENESS OF THE MEANS
BY WHICH,
THROUGH THEIR ECONOMY, IT IS ENABLED TO SECURE THEM,
IS EQUALLED BY FEW ESTABLISHMENTS,
AND
SURPASSED BY NONE;
THIS WORK IS INSCRIBED
BY
THE AUTHOR.
------------------------------------------------------------------------
PREFACE.
The following Work is wholly of a practical nature: its object is to
ascertain the real phenomena of Fever, and the most safe and effectual
treatment of the disease. It was found impossible to include in this
volume some researches of a statistical nature which it was at first
intended to incorporate in the work.
On looking over the account which has been given of the phenomena, I
find that, by an oversight, I have omitted to make any mention of the
peculiar odour which belongs to a fever-patient. It is so characteristic
that a person, familiar with the disease, might in many cases be able to
pronounce, merely from the odour of the effluvia that arises from the
body, whether the disease were fever.
I cannot allow this work to go forth to the world, without expressing my
obligation to Dr. DILL, for the great assistance he has afforded me in
the collection and arrangement of the cases which illustrate the
symptoms and the pathology, and in the construction of the tables. And I
am happy to avail myself of this occasion to bear my testimony to the
excellent history which is drawn up of every case admitted into the
house; to the completeness of the record which is kept of the morbid
appearances on inspection; to the care which is taken of the sick, in
the absence of the physicians; and to the able and zealous manner in
which, as the resident medical officer of the Fever Hospital, he
performs the arduous duties of his office.
_S. S._
_36, New Broad Street
Dec. 1829._
CONTENTS.
Page.
DEDICATION i.
PREFACE iii.
CHAPTER I.
Further Investigation of Fever necessary 1
Facilities afforded by the Fever Hospital for prosecuting the
Study 5
Antient Doctrines relative to the Nature and Seat of Fever 7
Hippocrates, Galen, Sydenham 8
Modern Doctrines relative to the Nature and Seat of Fever 13
Cullen, Brown, Stoker, Burne, Clanny, Clutterbuck, Broussais 14
Errors common to all these Theorists 30
Questions to be solved before Fever can be understood 33
Precise Object of Investigation 34
Proper Mode of conducting it 36
CHAPTER II.
Varieties of Fever 41
Common Phenomena 42
Importance of analyzing the Assemblage of the Symptoms, in order
to ascertain the Common Phenomena 43
Results of the Analysis 45
Organs always diseased in Fever 48
Functions always deranged in Fever 49
Fever not Inflammation 50
Distinction between Fever and Inflammation 52
Common Phenomena of Fever exemplified in Plague 53
in Yellow Fever, 54
in the Varieties of Fever of Great Britain 54
Different Varieties produced by different Intensities 58
Received Classification and Nomenclature defective 60
What is really meant by Genera and Species of Fever 70
True Principle of Arrangement 71
CHAPTER III.
Of Synochus 77
Division into Synochus Mitior and Gravior 77
Succession of Phenomena in Synochus Mitior 78
Indications afforded of Disease in the Nervous, Circulating,
Secreting, and Excreting Systems 81
Progress of Disease consists in progressive Increase in the
Derangement of these Functions 85
Phenomena of Recovery 91
On what the Transition of Synochus Mitior into Synochus Gravior
depends 93
Classification according to the different Organs in which the
several Affections have their Seat 95
Synochus Gravior with Cerebral Affection 96
Subacute Cerebral Affection 96
Acute Cerebral Affection 107
Cases illustrating Synochus Mitior 112
Cases illustrating Synochus Gravior with Subacute Cerebral
Affection 114
Cases illustrating Synochus Gravior with Acute Cerebral Affection 116
Synochus Gravior with Thoracic Affection 120
Cases illustrating Thoracic Affection 123
Synochus Gravior with Abdominal Affection 128
Cases illustrating Abdominal Affection 137
Synochus Gravior with Mixed Affection 142
CHAPTER IV.
Of Typhus 148
Division into Typhus Mitior and Gravior 149
Typhus Mitior, with Subacute Cerebral Affection 149
Cases illustrating Subacute Cerebral Affection 155
Typhus Mitior, with Thoracic Affection 157
Typhus Mitior, Cases illustrating Affection 159
With Abdominal Affection 161
With Mixed Affection 162
Typhus Gravior 162
In what it really consists 162
Dangerous nature of the Error that it consists in Debility 164
CHAPTER V.
Of Scarlatina 168
Characters by which it is distinguished from Continued Fever
without an Eruption 168
Division into Scarlatina Synochodes 171
Typhodes 172
Events which occasionally occur in Fever, but which form no
essential part of it 173
Preternatural Sensibility over the external Surface of the Body;
Excoration and Sloughing; Erysipelas; Inflammation, &c. of the
Glands; peculiar Affection of the Joints 173
CHAPTER VI.
Of the Pathology of Fever 176
Importance of connecting the Symptoms with the States of the
Organs 176
Pathology of Fever comprehends the Morbid Changes that take place
in the Solids and Fluids of the Body 178
I. GENERAL PATHOLOGY OF THE SOLIDS 179
External Appearances of the Body after Death 180
Morbid Appearances in the Head 181
in the Thorax 184
in the Abdomen 187
I. Cases illustrating the Morbid Changes which take place within
the Head, or Cerebral Cases 193
1. Vascularity of Brain, Spinal Cord, and
Membranes, with Gelatinous or slight
Serous Effusion 193
2. Vascularity of Brain, Membranes, &c.
with Effusion of Coagulable Lymph and
Formation of Pus 204
3. Vascularity of Brain, Membranes, &c.
with copious Serous Effusion 210
4. Vascularity, &c. with Preternatural
Firmness of Brain 218
5. Vascularity, &c. with softening of Brain 224
General Results established by preceding
Cases 230
II. Cases illustrating the Morbid Changes which take place within
the Chest, or Thoracic Cases 235
III. Cases illustrating the Morbid Changes which take place
within the Abdomen; or Abdominal Cases 246
General Results established by preceding Cases 287
IV. Cases illustrating the Morbid Changes which take place within
the Head, Thorax, and Abdomen, in the same individual, or Mixed
Cases 291
General Conclusion 322
II. PATHOLOGY OF THE FLUIDS IN FEVER 328
CHAPTER VII.
Of the Relation between the Phenomena of Fever; or the Theory of
the Disease 333
CHAPTER VIII.
Of the Causes of Fever 348
1. Of the Immediate, or Exciting Cause of
Fever 348
2. Of the Remote or Predisposing Causes of
Fever 369
CHAPTER IX.
Of the Treatment of Fever 375
Modification of Treatment required in prominent Cerebral
Affection 398
Thoracic Affection 403
Abdominal Affection 405
Treatment of Scarlet Fever 408
Treatment during Convalescence 418
Appendix 425
FEVER, &c.
CHAPTER I.
_Further Investigation of Fever necessary: Facilities afforded by the
Fever Hospital for prosecuting the Study. Ancient Doctrines relative
to the Nature and Seat of Fever. Hippocrates, Galen, Sydenham.
Modern Doctrines. Cullen, Brown, Stoker, Burne, Clanny, Clutterbuck,
Broussais. Errors common to all these Theorists. Questions to be
solved before Fever can be understood. Precise Object of
Investigation: proper mode of conducting it._
On my appointment to the office of Physician to the London Fever
Hospital, it was stated to me by the treasurer that, among the objects
contemplated by the establishment of this institution, two things were
conceived to be of paramount importance: first, the accumulation of
facts by which the true nature of fever might be more certainly
ascertained, and secondly the cautious trial of remedies by which a more
sure and successful mode of treating this fatal disease might be
discovered. During my connexion with this hospital I have faithfully
endeavoured to the utmost of my ability to keep these objects in view,
and I now venture to lay before the public the result of my
observations, in the hope that they may contribute something, however
little, to the stock of knowledge already accumulated.
When we consider how many circumstances connected with the origin and
the propagation of fever are wholly unknown, which if known might have a
most important influence in preventing its occurrence, in arresting its
progress or in lessening its mortality; when we consider in what
profound obscurity the very nature of the agents that produce it is
still involved; when we consider how easy it is to swell the long
catalogue of its symptoms, but how difficult it is to discriminate
which, even among the most prominent of the train, are the essential and
which the adventitious, and how still more difficult it is to ascertain
which are the invariable antecedents and which the invariable sequents,
or which the causes and which the effects; when we consider how few
comparatively of the external appearances have been ascertained to be
the sure and certain signs of any known condition of the internal
organs, and how often the existence of several known conditions of the
organs remains altogether unsuspected until the demonstration of it is
afforded by inspection after death, and when finally on all these
accounts we consider how vague the objects must be that are aimed at in
the treatment, and consequently how uncertain, how indiscriminate, how
fruitlessly inert, how perniciously active, how unsuccessful, how fatal
that treatment often is, it must be admitted that fever still presents
to us a vast field, in the culture of which the difficulties to be
overcome are not slight, and the most diligent labour that can be
bestowed upon it may by no means be attended with a sure reward.
Of many branches of science it is truly observed that much time and
labour are necessary to establish a single important fact; of some parts
of medical science this is eminently the case, but perhaps of none is
the observation so just as of that which relates to febrile diseases. It
is remarkable how entirely the most distinguished physicians of all ages
who have treated of this subject coincide in the feeling, that with
regard to this important class of disease it is impossible in the short
life allotted to the most aged to do any thing more than add a little
knowledge to the common stock. If there be any foundation for this
feeling it can only be by every man faithfully endeavouring to
contribute what he may be able, be the amount ever so small, that that
stock can speedily become large or ever become complete.
In bringing to this common stock my humble mite, that the offering may
not be wholly worthless, I have confined myself as much as possible to
the detail of the facts that have been observed, and the statement of
the results that have been obtained from experience. By giving a
connected view of the phenomena I have hoped that I might possibly
assist the actual practitioner to form a more adequate conception of the
disease and guide him to that particular remedy which experience shews
to be best adapted to each of the more important affections he is likely
to encounter. Out of the means furnished for the accomplishment of these
objects by the receptacle of fever for this great metropolis I have
endeavoured to select such specimens of the disease as will place before
him a vivid and faithful picture of the most interesting aspects it
assumes, and such a detail of treatment as will shew what particular
remedies afford the best chance of success in each type and stage, and
in the most common and therefore the most important modifications they
present. If I have at all succeeded in my aim he will find himself
placed in a good measure in the same situation with myself; his
attention will be directed to the same phenomena in the order in which
they occur in the series, and hence he will have the like means of
judging of the relations which these phenomena bear to each other, as
well as of the accuracy of the analysis that has been attempted of the
more complicated, and the soundness of the inductions that have been
made from a comparison of the whole.
The London Fever Hospital is capable of receiving sixty-two patients: in
most seasons of the year its wards are full: often there are numerous
applications for admission which cannot be received for want of room:
there pass through the wards from six to seven hundred patients
annually. Two physicians are attached to the institution under whose
care the patients are placed alternately in the order in which they are
admitted: there is one assistant physician whose duty it is to perform
the office of the ordinary physicians when either of these may be
incapable of attending, and there is besides a medical officer resident
in the house. A history of each case, containing an account of the age,
occupation and residence of the patient, together with as full a
statement of the symptoms of the disease and of the order of their
succession as can be obtained is entered in the journal by the resident
medical officer. Each of the ordinary physicians attends daily and
enters in his journal a daily report of each of his own cases. The
resident medical officer goes round the wards twice a day, namely, early
in the morning and late in the evening, to observe if any change
requiring attention may have taken place in any patient; and if any such
change be observed by the nurses during the interval between these
visits they are reported to him by the head nurse without delay; all
such events with the modification of treatment they may have required
are entered in the journals. Every case that terminates fatally is
examined after death, and an account of the morbid appearances is
entered in a book kept for the purpose. In this manner, in the progress
of years a mass of facts accumulates relating to the statistics, the
types, the symptoms, the causes, the diagnosis, the pathology and the
treatment of the disease, whether successful or unsuccessful, which both
on account of the fullness and accuracy of the record and of the extent
of the period it embraces, cannot but be of great value.
I am encouraged in the attempt to make this record, as far as it has yet
gone, useful to the public by observing the feeling that prevails among
those physicians who have studied fever with the greatest diligence, and
who have contributed most to our knowledge of it, that it is a disease
which is still little understood and the treatment of which remains
extremely vague and uncertain. Perhaps there is no disease so little
understood as the ordinary fever of this country and none by the
mismanagement of which so much life is lost. Dr. Clutterbuck appears to
me therefore to describe the situation of the physician to such an
establishment as the Fever Hospital, not more candidly than truly when
he says—“It becomes a duty incumbent on those particularly who have been
placed in situations favourable for observing the disease, to give the
result of their experience to the public, should it tend, in any degree,
either to prevention or cure. The enquiry is by no means exhausted,
considered either in a theoretical or practical point of view. There is
still a want of uniformity of opinion among physicians regarding the
nature of the present epidemic, as well as of fever in general: while, I
am sorry to add, in practice we are not much better agreed;” and when he
further adds;—“To ascertain these modifications” (that is the
modifications which require a modification of treatment) “is the great
desideratum, which nothing but the most cautious observation, aided by
much time, and the joint efforts of numerous individuals, can fully
supply.”[1]
The slightest glance at the history of the doctrines which have been
taught relative to the nature and the seat of fever from remote
antiquity, and more especially a consideration of the variety and even
the contrariety of the received opinions respecting both, in the present
day, but too clearly shew that if the ancients were in error, there
cannot be many points with regard to which the moderns are right, since
there is scarcely one in which they are agreed. Further observation and
investigation are therefore not yet superseded. There is as yet no
uniformity of opinion among physicians even whether the primary seat of
the disease be in the fluid or the solid parts of which the body is
composed. Scarcely is the most ancient doctrine respecting it of which
we have any record, that it consists in a morbid derangement of the
fluids, and that the excitement which attends it is the result of an
effort of Nature to expel the poison received into or generated within
the system, obliterated from the imaginations or banished from the
reasonings of physicians. When indeed we see a patient in the latter
stage of some of the forms of fever with his dark or leaden skin,
pouring forth its peculiar and fetid exhalation; with his foul tongue,
his offensive breath, his vitiated and almost putrid secretions and
excretions, we can understand why this doctrine should have taken a firm
hold of the human mind and should have been able to maintain its ground
through many centuries. Yet when the phenomena came to be observed with
the accuracy with which we know that they were observed and recorded,
and examined with the acuteness with which we have abundant evidence
that some of the most powerful minds reasoned upon them, we may justly
wonder that the order of the events, together with their great variety
and opposite nature did not sooner suggest doubts of the accuracy of the
theory and give to the inquiries of these celebrated men a new
direction. But so far was this from being the case that when
Hippocrates, considering the increased heat as the essence of fever,
founded his division of the varieties of the disease upon this
principle, whence his _causus_ or burning fever, his _leipyria_, or
fever with the parts externally cold and internally hot, and his
_epialus_, or mild fever, with a simultaneous feeling of heat and cold;
when he ascribed these different forms of fever to the superabundance of
one or other of the four humours, blood, phlegm, yellow and black bile,
and considered the disease as the result of a contest on the part of
Nature to expel the morbid humour, or to render it inert or harmless by
the process of concoction, the mind of Galen so many centuries
afterwards, was so well satisfied with this hypothesis, that his
powerful genius contented itself with the mere amplification of the
conjecture and the addition of similar conjectures of his own. Whence
assigning the different sources by which a morbid heat, which he also
considers as the essence of fever, may be excited in the body, he states
“that the fevers thus produced are modified by the prevalence or
putrefaction of one or other of the four humours of Hippocrates; that of
the three kinds of intermittent the quotidian arises from the corruption
of phlegm, the tertian from that of the yellow and the quartan from that
of the black bile; that in whatever part of the body the heat begins it
ultimately extends to the heart; that as soon as this happens the
general commotion of the vessels commences, and that in this manner
Nature is employed in exerting her powers, endeavouring to assimilate
the good humours to the parts which are to be nourished and to expel the
bad, but that if at any time Nature is unable to expel all the morbid
humour either from its thickness, its abundance or its tenacity, or from
some obstruction of the passages, or from her own want of power, it will
necessarily undergo putrefaction, if it remain long in the body, and
produce the most fatal effects unless it be expelled by the process of
concoction.” And so many centuries after Galen wrote, Sydenham who
brought to the study of medicine one of the most acute, upright and
independent minds that ever adorned it, commences a work on fever, which
for fidelity of observation, for graphic description, for accurate
discrimination, for bold and yet cautious treatment, has been justly
considered an almost perfect model, with the following extraordinary
assumptions:—
“That reason dictates that a disease is nothing else than Nature’s
endeavour to thrust forth with all her might the morbific matter for the
health of the patient; that seeing it has pleased God, the Governour of
all things, so to constitute human nature that it may be fitted to
receive the various impressions that come from abroad, it must
necessarily be subject to many diseases; that these diseases proceed
partly from particles of air ill agreeing with the body, which having
once insinuated themselves into it, are mixed with the blood, and affect
the whole with a morbific contagion; and partly from various ferments or
putrefaction of humours which are detained in the body beyond due time,
either because it was not able to digest them, on account of the
incongruity of their quality, or to evacuate them on account of their
bulk; that these circumstances being so nearly joined to the human
essence that no man can clearly free himself from them, Nature provided
for herself such a method and concatenation of symptoms as that she
might thereby expel the peccant matter, which would otherwise ruin the
whole fabric; that the plague, for instance, is nothing but a
complication of symptoms by which Nature casts out the malignant
particles, by imposthumes in the emunctories, or by some other
eruptions, that were drawn in by the air; that the gout is nothing but
Nature’s contrivance to purify the blood of old men, and to purge the
deep parts of the body; that when Nature requires the help of a fever,
whereby she may be able to separate the vitiated particles from the
blood, or otherwise expel them, either by a sweat, a looseness, or some
kind of eruption, she accomplishes this object in the whole mass of
blood, and that by a violent motion of the parts; that when this object
is accomplished suddenly, either by the health or death of the patient,
the disease is acute; when, on the contrary, the matter of the disease
is of such a nature that it cannot have the assistance of a fever for
the separation of it; or when this kind of matter is fixed to any
particular part, which is unable to exclude it, or when the blood is
vitiated by the continual flow of new matter into it, in these cases,
the matter being very slowly or not at all concocted, the diseases which
proceed from such unconcocted matter are called chronic: that acute
diseases proceed from a secret and inexplicable alteration of the air
infecting men’s bodies; that these diseases do not at all depend on a
peculiar crasis of the blood and humours any otherwise than the occult
influence of the air has imprinted the same upon them; that they
continue as long as this secret constitution of the air and no longer;
that they do not come at any other time; and that these constitute
epidemic fevers; that, on the other hand, acute diseases arise from this
or that particular irregularity of particular bodies, which, because
they are not produced by a general cause, do not therefore invade many
at once; that this species comes every year, and at any time of the
year; and that these may be called intercurrent or sporadic, because
they happen at any time during the prevalence of epidemics.[2]”
That conjectures so gratuitous, and so utterly incompatible with the
structure and functions of the animal frame, should at such distant
periods of the world, under such different conditions of society, and in
such different states of science so entirely possess and satisfy the
minds of three of the most extraordinary men that ever illustrated or
extended any department of science, will appear the less wonderful when
we consider that the doctrines relative to fever which displaced and
succeeded these, originated in precisely the same error, and vary in
their aspect only in conformity to the progressive advancement of
general science. When the structure of the animal body became more
generally studied; when the functions performed by its different organs
became better understood; when the morbid actions constituting or
resulting from the derangement of these functions became more closely
investigated, the influence of the nervous system and the effects of
vascular action, began to form the subjects of investigation, and from
this period the attention of physicians was fixed less upon the fluid
than the solid parts of the frame. The properties and motions of the
fluids were now clearly seen to be dependent upon the action of the
containing solids, and the action of the solids to be under the
influence and control of certain laws peculiar to life. Disease, studied
under this juster view of the animal economy, immediately assumed a new
aspect, and theories arose so much more consonant to the known
operations of the living body, so much more explicit in their language
and intelligible in their nature, that the ancient doctrines were at
once exploded, and the very terms in which they were expressed became
suddenly, though, as it now appears, only for a short time obsolete.
Cullen, building upon the foundation laid by Hoffman, rivalling in the
number of his pupils, and exceeding in the brilliancy of his success, if
not in the perpetuity of his fame, any name of antiquity, achieved with
unexampled ease and suddenness this great revolution; and in opposition
to the ancient theories taught, that the first change induced in the
animal system, by the operation of the exciting causes of fever, is a
diminution of the energy of the brain; that all the powers of the body
and all the faculties of the mind, that the functions of sensation and
motion, the processes of respiration, circulation, and secretion, all
fail or are diminished in the general debility; that after a certain
time a morbid increase of some of these functions, especially of the
circulation, takes place with an augmentation of the heat; that these
three states, that of debility, of cold, and of heat, bear to each other
the relation of cause and effect; that the first state is the result of
the sedative or debilitating influence of contagion, marsh miasmata,
cold or any other exciting cause, and the subsequent states the result
of the first; that the debility produces all the phenomena of the cold
stage, and especially a spasmodic constriction of the extreme arterial
vessels; that this spasm or atony of the extreme vessels exists not only
on the first attack of the cold stage, but remains during the whole
subsequent course of fever; that the spasm of the extreme vessels throws
a load of blood on the central parts of the circulating system, which
proves a source of irritation to the heart and arteries, and excites
them to a greater action; that this increased action, the source of the
heat and the other phenomena which constitute the second or hot stage
continues till the spasm is relaxed or overcome; and that this
excitement of spasm for the purpose of producing the subsequent reaction
is a part of the operation of the _vis medicatrix naturæ_, the innate
preserving power of the constitution. “Upon the whole,” says this
celebrated theorist, “our doctrine of fever is explicitly this. The
remote causes are certain sedative powers applied to the nervous system,
which, diminishing the energy of the brain, thereby produce a debility
in the whole of the functions, and particularly in the action of the
extreme vessels. Such, however, is at the same time the nature of the
animal economy, that this debility proves an indirect stimulus to the
sanguiferous system; whence, by the intervention of the cold stage, and
spasm connected with it, the action of the heart and large arteries is
increased, and continues so till it has had the effect of restoring the
energy of the brain, of extending this energy to the extreme vessels, of
restoring therefore their action, and thereby especially removing the
spasm affecting them: upon the removing of which, the excretion of
sweat, and other marks of the relaxation of excretories take place.”[3]
Whatever may be thought of the superior power of the theory of Brown,
the pupil and rival of Cullen, to explain the general phenomena of the
living body, whether in a state of health or of disease, the doctrine of
the pupil relative to fever, differs in no essential respect from that
of the master. Like his predecessor, Brown attributes all fevers to
debility; and affirms that the distinctions which physicians have made
about the differences of fever are without foundation; that they are all
the same, differing only in degree; that the debility during the cold
stage is the greatest; that of the hot less; that of the sweating stage
which ends in health for the time, is the least of all: hence in a mild
degree of the disease, as cold is the most hurtful power, its effect is
gradually taken off by the agreeable heat of the bed or of the sun, and
the strength thereby gradually drawn forth; that the heart and arteries
gradually excited by the heat acquire vigour, and at last having their
perspiratory terminations excited by the same stimulus, the most hurtful
symptom is thereby removed, the hot fit produced, and afterwards the
same process carried on to the breaking out of sweat; that the cause of
all these diseases, from the simplest and mildest intermittent to the
gaol fever and the plague is the same with that of diseases not febrile,
to wit debility; differing only in this, that it is the greatest
debility compatible with life, and not long compatible with it.
This very year, from Dublin, from the largest hospital for the reception
of fever in the British Empire, precisely the same doctrine has been put
forth. “Common epidemic fever,” says Dr. Stoker,[4] “especially when
contagious, as I have frequently asserted when speaking of its pathology
and treatment, has not appeared to me at any time to be essentially
inflammatory. Adynamic fever, a denomination for typhus fever, which I
shall employ, as I have hitherto done to express the putrid or malignant
fever of Sydenham; the slow nervous fever of Huxham; the nervous fever
of common language; the synochus, typhus mitior, and gravior of Cullen;
the gaol and hospital fever; the _fièvres essentielles_ of the French;
the epidemic of the Irish writers; the contagious of Bateman; the typhus
of Dr. Armstrong; and the proper idiopathic, or essential fever of Dr.
Clutterbuck: whether it exists separately or independently; or is
combined with any of the other forms of febrile disease, sporadic or
symptomatic.”[5] “Typhoid or adynamic fever I consider to be generally
symptomatic of morbid changes in the physical characters of the blood,
and have, as on former occasions, stated what those morbid changes
are—but I have arranged inflammation under the head of symptomatic
fever, merely because it is more usually connected with some change in
the structure of parts, discoverable after death: on the other hand,
typhus fever is connected with morbid changes, that _primarily_ take
place in the fluids, and produce morbid actions, and sometimes permanent
changes of structure in the said parts. These changes too in the
condition of the blood are distinguishable from those which we have
stated to occur in inflammation; and the morbid actions excited
relatively by those changes in the blood are also distinct. In
inflammatory fever on the one hand, increased action, in typhoid fevers
on the other, debility, is almost the immediate consequence. On account
of this debility being an essential character of typhoid fevers, I
denominated them adynamic.”[6]
At the close of the last season, in a work,[7] the materials of which
have been drawn professedly from the London General Hospitals, doctrines
so similar have been laid down, that Dr. Stoker says of it—“the views
taken, both of the nature and treatment of fever, by Dr. Burne, entirely
accord with those which may be found stated in my Medical Reports from
the Fever Hospital, as well as in my separate Essays on that subject.
And as (when speaking of his denomination of fever) I have already
remarked, this leaves, I think, no reasonable doubt of the epidemic
fevers of London, having lately become more typhoid or adynamic, than
they had formerly been. It is further satisfactory to me to find, that
the treatment which I had long since adopted and recommended in our
typhoid fevers has been found suitable to the prevention and cure of
those in London; and that too in proportion as they have acquired more
of that form, with which I was best acquainted.”[8] And Dr. Burne
himself states, “that the adynamic fever has no local seat; that its
nature is _a morbid condition of the blood_, produced by the operation
of the primary cause, the respiration of a contaminated or poisoned
atmosphere: that this morbid blood, acting on the brain and nervous
system, is of itself sufficient in very many instances to bring about
the very great derangement and imperfect performance of all the
functions of the organic and of the animal life; which great derangement
and imperfect performance of all the functions constitute the phenomena
of adynamic fever.”[9]
Instead of regarding with these authors a vitiated state of the blood as
the essence of fever, Dr. Clanny, on the contrary, believes its
proximate cause to be a want of power in the system to form blood. “The
proximate cause of typhus fever,” he says, “is a cessation of
chylification, and consequently of sanguification, during which time the
lymphatics of the whole system act with increased vigour, and in this
manner the lymph taken up by them from the system supplies, for the time
being, the place of the chyle in the blood, and as long as this state
continues the patient labours under an acute disease, heretofore called
typhus fever. When the chylopoietic viscera resume their functions the
disease gradually recedes, and health is ultimately restored.”[10]
“Chylification, like secretion, is a function of the brain, which under
peculiar circumstances, or states of the atmosphere, is impaired, and in
severe cases is suspended altogether: hence typhus fever.”[11]
Such are the leading opinions of those who maintain that the seat of
fever is in the fluids, in which opinions we perceive a return to the
old doctrines, although in the modern version, it is true they are
somewhat modified and presented in a somewhat more definite shape.
But in direct opposition to all such views of fever, it is zealously and
ably maintained by a large and increasing sect, that this malady is
strictly a local disease; that it has its primary and essential seat in
one organ, and that it consists of inflammation of that organ. Thus Dr.
Clutterbuck, who may be regarded as one of the most distinguished
advocates of this opinion, in one of the best works which has ever
appeared on the subject, contends that fever of every denomination and
every degree is the result of inflammation; that the appearances which
have led to the conclusion that it is a general disease primarily
affecting every function of the body are fallacious, and that, when
strictly examined, it will be found that all general or extensive
derangements of the system, are referrible to local disease in one
organ. “Fever, in regard to its effects on the system,” he says, “is the
most general of all diseases, and gives rise during its progress to the
greatest variety of symptoms. These, contemplated in the mass, present
nothing but confusion. Like all complicated phenomena, they require to
be subjected to strict analysis; that their order may be traced, and
their relation to each other and to the exciting cause shewn. To the
neglect of this may be ascribed the error, as I conceive it to be, which
has been so generally fallen into, of considering fever as an universal
disease, or one that affects for the first time the whole system; no one
part being supposed to suffer necessarily before the rest. Whereas, when
the disease is minutely scrutinized, and its first appearance accurately
noticed (which indeed from the slightness and consequent neglect of the
first symptoms is rarely done) it will be found to be strictly a
_topical_ affection, the general disorder of the system being merely
_secondary_, or symptomatic of this.”[12] In another work it is further
stated, that all the varieties of idiopathic fever, which differ but in
degree, as well as those which arise from specific contagion, as
malignant sore throat, scarlet fever, small-pox, and so on, arise from
one and the same affection of one and the same organ, and that that
affection consists essentially in inflammation.
A similar doctrine has for some time been taught in France by a man
whose disciples have already spread over every country in Europe, and
are fast diffusing themselves over the new world, and whose devotion to
their master and his system, reminds us of days long past, when the
attachment of the pupil to the sage was as reverential and as
enthusiastic as that ever paid by true knight to lady-fair in the
brightest days of chivalry. “Penetrated by the sublime views of Bichat
as to the sympathies,” say M. M. Coutançeau et Rayer, two of the most
ardent disciples of this school;[13] “rich in numerous facts observed
with a rare sagacity, M. Broussais came to overturn, from the very
foundation, the antique edifice of fevers. In his works as well as in
his lectures, he has applied himself, for many years, to demonstrate,
that the fevers which had been called essential, were nothing more than
local diseases, inflammations, nay even gastro-enterites.”
These writers go on to state that, according to Broussais, all fevers
are of the same nature, those termed malignant differing from other
fevers only by the violence and danger of their congestions; that all
the causes of fever act locally; that, considered in a general and
abstract manner, fever is invariably the result of a _primitive or
sympathetic irritation of the heart_ through the effect of which its
contractions are quickened, and that every irritation sufficiently
intense to produce fever is an inflammation.[14]
There is thus a perfect accordance in the doctrine of these two
celebrated and rival theorists, Clutterbuck and Broussais, respecting
the nature of fever: both are agreed that it is an affection of the
solids of the body and that its essence consists in inflammation: both
are agreed that that inflammation is strictly local, being seated in one
organ: but in determining what that organ is, there is an entire
discrepancy in their opinion. According to Dr. Clutterbuck the organ
universally affected in every variety of idiopathic fever is the brain.
“Out of fifty cases,” he says, “of which I noted down the symptoms with
the greatest minuteness at the bed-side of the sick, generally once and
often twice in the twenty-four hours, throughout the disease, I find
that no two of them correspond in the minute points though they all
agree in the essential one, that is, in a manifest affection of the
brain and its functions; various in degree and probably in extent, with
numerous but accidental complications, from the affection of other
organs.”[15] This affection of the brain, consisting of inflammation, it
necessarily follows, as this author elsewhere states, that fever is
nothing else than a species of phrenitis, or topical inflammation of the
brain; that it might, therefore, be arranged in the order of phlegmasiæ
with pleurisy, enteritis, and other symptomatic fevers, but that since
the term phrenitis has been generally applied to a particular form of
inflammation of the brain and implies delirium, which does not always
occur in fever, although it is a frequent symptom, that of encephalitis
would form a proper denomination for this entire class of diseases, and
might be substituted for the term fever.
Broussais, on the contrary, contends that the primary and essential seat
of inflammation in fever is the mucous membrane of the stomach, or of
the intestines, or both, but especially the former, and that, therefore,
the proper designation of it is _gastro-enteritis_. While it had long
been conceived that inflammation of the digestive organs is the cause of
certain symptomatic fevers, Broussais maintains that the most important
discovery (most important because so intimately connected with the
treatment of the disease) that this affection is the cause of all
fevers, idiopathic as well as symptomatic, and that there are in fact no
essential fevers, is peculiarly and exclusively his own. Thus, according
to this theorist, all the fevers of authors are connected with
gastro-enteritis, simple or complicated. “The simultaneous or successive
inflammation of the stomach and small intestines, designated by this
term,” says M. Rayer, “is of all the phlegmasiæ the most frequent, and
at the same time that which has been oftenest overlooked or mistaken. It
is not designated in any nosological table. Not long ago gastritis
itself was generally looked upon as a very rare disease: of twenty-eight
thousand two hundred and ninety-nine sick admitted into the civil
hospitals of Paris in 1807, six only were designated in the returns as
labouring under inflammation of the stomach, whilst six thousand one
hundred and forty-three were treated for continued or remittent fevers.”
The prevailing doctrines relative to the nature and seat of fever at
present then are two, the direct reverse of each other; one, that it is
a general disease affecting the entire system; that this affection of
the system consists of debility which is manifested first in a loss of
energy of the brain, but which rapidly extends to every organ and every
function, and that consequently _the absence of any primary local
disease_, ought still to form, as it has so long formed, an essential
part of the definition: the other, that it is in the strictest sense a
local disease; that its primary seat is invariably fixed in some one
organ; that the affection itself consists of inflammation; and that that
inflammation is seated, according to one opinion in the brain; according
to the other in the stomach.
As must necessarily be the case, these different and opposite theories
are found to have the most important influence on the practice
recommended by their respective authors in the treatment of the disease.
The advocates of the first deprecate all active interference: the grand
evil to be contended with is debility: the physician can easily weaken,
but he cannot easily strengthen: he can depress to any extent he
desires, but he cannot communicate power as he wishes. In a malady
therefore of which the very essence consists in loss of energy the main
duty of the physician is to husband the strength of the patient with the
most anxious care, this being the chief means, as Cullen expressively
termed it, of obviating the tendency to death. The important inference
is, that every kind and every degree of depletion that can add to the
primary cause of the malady, must be abstained from with the utmost
caution. By the clearest and shortest deduction this will necessarily be
the result to which every mind must come that really believes that
debility is the essence of fever, while he who admits its inflammatory
nature must think it criminal to stand idle by and allow the most
extensive derangements in the structure of vital organs to proceed,
without even an attempt to check them, as long as it is in his power to
use the lancet or to procure leeches. The very order in which the
believers in debility enumerate the remedies they recommend affords a
striking illustration of the extent to which their theory influences
their practice;[16] while the advocates of inflammation state explicitly
that the remedy of the disease is one, and in point of importance one
only, namely, the remedy which all admit to be the only efficient agent
in the treatment of inflammation. “Fever to be treated successfully,”
says Dr. Clutterbuck, “must be treated upon the general principles of
inflammation; but at the same time with the modifications arising out of
the peculiar nature of the organ affected, and in some degree also the
nature of the exciting cause. Blood-letting, which but a few years ago
was looked upon with abhorrence in the cure of contagious fever, and the
utility of which is still far from being generally appreciated, is
proved by ample testimony to be not only the most powerful, but the
safest of remedies.” And in every variety of fever, and in all its
stages, leeches are to be applied to the stomach, according to
Broussais, and scarcely any thing else is to be done except enjoining
rigid starvation. Emetics, purgatives, bark, wine, are all denounced;
nothing but leeches and “diete absolue:” a costive state of the bowels
persisting during five or even ten days is a good symptom and not to be
interfered with.
That men who exhibit such talent for observation and such acute and
active powers of the understanding as many of these authors exemplify in
these very works, should, while writing with so much earnestness against
each other, fall into one and the same error, and that an error so
palpable, is no flattering exhibition of the state of the art of
reasoning among the members of the medical profession. The degree in
which the science of mind is neglected in our age and country, may it
not be justly added? especially in our profession—that science upon the
knowledge of which the conduct of every individual mind is so dependent,
is truly deplorable. Medicine is an inductive science, the cultivator of
which is peculiarly exposed to the danger of making hasty assumptions
and of resting in partial views, yet it is not deemed necessary that he
should be at all disciplined in the art of induction, or should be
cautioned against any sources of fallacy in the practice of making
inferences. All the partial and imperfect views of fever which have now
been brought before the eye of the reader, originate in one or other of
the following errors, obvious as they all are: either that of assuming
as a fact what is merely a conjecture; or that of assigning to the genus
what belongs only to the species; or that of characterising the disease
by what appertains only to a stage; or that of mistaking the effect for
the cause. On careful examination it will appear that one or other of
these errors, which are as serious as they are palpable, has vitiated in
a greater or less degree every generalization of fever that has hitherto
been attempted.
Thus the believers in debility derive their notion of the whole disease
from the phenomena which occur in the first and the last stages only: in
these, it is true, they may find abundant evidence of debility: but then
they overlook the intermediate stage in which there are generally the
most unequivocal indications of increased sensibility in the nervous and
increased action in the vascular systems: in this manner they
characterise the disease by what appertains only to certain stages of
it. Again, when they contend that debility is not only the essence of
fever in general, but is really characteristic of every type of it, they
affirm what is indisputable of fevers in particular seasons, in
particular climates or in particular constitutions; but beyond this
their generalization cannot be extended: in this manner they assign to
the genus what belongs only to the species. And when Cullen goes on to
affirm that the proximate cause of all the morbid phenomena is a “spasm
of the extreme vessels,” he commits the additional and more palpable,
but not less common error, of assigning as an undoubted fact, as a real
and ascertained occurrence, what is only a conjecture, and for which
there is not, and for which he does not even attempt to adduce the
shadow of evidence.
Precisely similar to this is the error of those who for the most part
belong to the same school, and who attribute the essence of fever to a
morbid condition of the blood. The blood may be diseased in fever, but
if it be so, these writers do not _know_ it, or at least they do not
adduce any evidence that they are in possession of such knowledge: they
do not appear so much as to have questioned chemistry; at all events, it
is certain that they have hitherto received no satisfactory answer.
There is no evidence on record that the alleged determination of the
blood takes place in every type and every degree of fever: and if there
were it would still be but one event among many, and one that occurs
late in the series, and therefore could possibly be nothing more than an
effect.
In like manner those who maintain that inflammation of the brain is the
sole cause of fever, assume as an established and admitted fact the
universal and invariable existence of inflammation of the brain in this
disease. Inflammation of the brain, without doubt, is demonstrable of
many individual cases, and of some whole types: but beyond this there is
no proof that the generalization can be carried: the evidence indeed in
regard to many cases is entirely against the assumption, and is as
complete as negative evidence can well be: consequently it must be
admitted that even this hypothesis, in the present state of our
knowledge, is founded on the error of assigning to the whole genus what
belongs only to particular species: and it would be trifling with the
reader to attempt to prove, that this is still more certainly and
strikingly true with regard to inflammation of the mucous membrane of
the stomach and intestines—an affection which in innumerable cases in
which its existence is certain, clearly appears on the slightest
examination of the succession of events, to be an effect and not a
cause.
No comprehensive view can be taken of fever, no just conclusion can be
arrived at relative to its nature and seat until it be studied with a
consciousness of the liability to such errors and a vigilant endeavour
to avoid them. The present investigation has been undertaken with a deep
consciousness of the danger and a watchful and unremitting care to avoid
it. Even if the effort prove to be without success, the example can
scarcely remain without use.
The frequent and formidable disease on the investigation of which we are
entering, cannot be understood until clear and exact answers are
obtained to the following inquiries. 1. What is the series of phenomena
which constitutes fever? 2. What are the particular phenomena which are
common to all its varieties and combinations? 3. What is the order in
which these phenomena occur in the series? 4. What are the organs, and
what are their states, upon which these phenomena depend? 5. What are
the external signs of these internal states, or what are the indications
by which their existence may be known? 6. What is the external noxious
agent or agents, or the exciting cause or causes of the disease? 7. What
is the particular remedy, or the particular combination of remedies
which is best adapted to each state of each organ? When these questions
can be clearly and perfectly answered, and not till then, we shall know
the disease and its treatment. In order to make any real progress in
this knowledge we must therefore prosecute these inquiries. It appears
to me that we are already in possession of ascertained facts, adequate
to answer with a high degree of certainty, though perhaps not with
absolute certainty, several of these questions. In keeping these
inquiries steadily before our view in our investigation there will be
this great advantage, that it will enable us clearly to perceive what we
really know and what still remains to be ascertained.
The phenomena which constitute fever, like those which belong to all the
processes of nature, consist of a certain number of events. The events
which take place in this disease are before our eyes: they are
abundantly familiar to us all: no one man indeed has seen all the forms
of fever which exist, nor observed all the symptoms of those species
which he has witnessed, but accurate records are to be obtained of them
all: records upon which we have this assurance that we may rely, that
all the important events in this disease are so obvious and striking,
and indeed force themselves so powerfully and constantly upon the
notice, that there can be little danger that any one of consequence
should be overlooked. Accordingly medical writings abound with the most
minute, and, as far as can be judged, accurate histories of the symptoms
which accompany all sorts of fevers, whether epidemic or sporadic. It is
not in the observation of symptoms that the danger of error lies,
because these are matters of sense, but the danger arises from a
different source. Supposing, for example, that all the important events
which accompany all the important varieties of fever have been
ascertained, and that thus our first inquiry relative to the series of
phenomena which constitutes the disease, is answered, still as many of
these events are observed to be often absent, while it cannot be doubted
that fever is nevertheless present, we must necessarily enquire in the
next place, what is that particular combination of events which is
_essential_ to the constitution of the disease, an enquiry which
embraces the second question proposed for consideration, namely, what
are the particular phenomena which are common to all the varieties of
fever? Now in singling out this particular series of events from the
great mass, we are liable to several sources of error. In the first
place, we may stop too soon in our enumeration; in the second place, we
may mistake the adventitious for the essential and the essential for the
adventitious, and in the third place, we may overlook the real place
which some particular event holds in the series, and so may suppose that
to be antecedent which was truly sequent, and consequently assign that
as a cause which is only an effect.
The first thing to be done then is to ascertain the concourse of
symptoms, and the second, to determine the order in which they occur:
when these two points have been made out, what is essential and what
adventitious, as well as what is the cause and what the effect, become
at once clear and certain. But the difficulty lies in discerning amidst
the infinite diversity and contrariety of symptoms which the different
modifications of fever present, when we may safely assure ourselves that
we are in possession of all the essential phenomena. Our guide is
_invariableness_ of concurrence. If we can ascertain that a certain
number of events _invariably_ take place in every form and every degree
of fever, these events will give us the particular phenomena which are
common to all the varieties of the disease. If we can further ascertain
that these events _invariably_ concur in a certain order, we shall have
discovered what events bear to each other the relation of cause and
effect. And the establishment of this relation of events, this constant
connexion with each other, this uniform antecedence and sequence appears
to me to be the only theory after which it is consistent with the
principles of sound philosophy to search. If I have endeavoured to
establish this connexion, and have thus ventured, as I conceive, in a
strictly philosophical sense to propose a theory, in doing so, I have
carefully restricted myself to the attempt to deduce a legitimate
conclusion from facts previously ascertained. It does appear to me that
these three points, namely, the common phenomena, the invariableness of
their concurrence, and their mutual relation are satisfactorily
established. Whether I shall be able to communicate this conviction to
the reader I do not know: but I hope he will at least coincide with me
in opinion that this mode of investigating the disease affords us the
best chance of arriving at satisfactory results.
Whatever be the phenomena of fever they depend upon certain states of
the organs. Whatever be the noxious agents or the exciting causes of the
disease, and however they operate, they can induce the disease only by
bringing about a certain condition in a certain number of organs, the
individual events constituting the disease being nothing but certain
changes in these organs. It is therefore of paramount importance to
ascertain what the organs are which are implicated; what the conditions
are which are induced in them; what organ sustains the first assault and
what organs are attacked in succession. The pathology about to be laid
before the reader will demonstrate the first two points: the
establishment of the last two will be attempted by an examination of the
history of the cases.
Without doubt the life or death of the patient depends upon these
conditions of the organs. In a practical point of view therefore, this
is the kind of knowledge with which it is of the greatest importance
that the practitioner should be familiar. Some of these conditions are
indicated by certain signs during life: some of these indications are
obscure, and may be easily overlooked or mistaken by those who have not
acquired an accurate and extensive acquaintance with the disease. On the
other hand, there are external appearances which are extremely apt to
suggest a false notion of the state of the internal organs. These
fallacious appearances are sure to lead those whom they deceive into a
mistaken, often into a mortal practice. Certain conditions of vital
organs, if allowed to remain long, will terminate in fatal changes of
structure. Certain remedies, if applied in due season and with due
vigour, are capable of removing those conditions. Life therefore must
sometimes depend upon the power of making this diagnosis with accuracy.
Of some of these conditions, the diagnostic marks are clear and certain;
those which indicate other conditions, in the present state of our
knowledge, are obscure and uncertain. I have thought no labour too great
to put the reader in possession of all that I have been able to
ascertain with regard to this most important part of the subject. In the
attempt to communicate this information, I am conscious that I may incur
the charge of tediousness, on account of the number of repetitions which
occur, and which I have allowed to remain because I could see no means
of removing them without sacrificing clearness to brevity. Elegance and
conciseness, in a work of this nature, ought not for a moment to be
considered if they endanger its practical usefulness. A knowledge of the
condition of the internal organs, in fever, can alone guide us to a
rational and successful treatment of this most dangerous disease. It is
only by examining the body after death that we can acquire this
information: it is only by observing the symptoms during life and
comparing them with the morbid appearances after death, that we can
discover the signs which indicate the existence of these states. For
these reasons I have not hesitated to give numerous cases and to detail
many dissections. If after the study of these cases and dissections the
practitioner be enabled at the bed-side of the fever patient to discover
with greater precision and certainty than heretofore the condition of
the brain—the condition of the lungs—the condition of the intestines, he
will not think the time he has devoted to the investigation ill spent,
nor shall I think myself without reward for the labour it has cost me to
draw up the record. It is only when from external appearances we are
able to see what is going on within each of the great cavities of the
body, as clearly as we should do if their walls were transparent, that
our interference can be sure of doing good, or secure from doing
mischief: it is this kind and degree of knowledge alone which can teach
us both when to act and what to do; and what is of almost equal
importance, when to stop and to attempt nothing; and if the perusal of
this work should contribute in any measure to the attainment of this
knowledge, I shall not have laboured wholly in vain, “to add something
to the treasury of physic.”