_Varieties of Fever. Common Phenomena. Importance of this Analysis.
Results of the Analysis. Organs always diseased in Fever: Functions
always deranged in Fever. Fever not Inflammation: Distinction
between these two States of Disease. Common Phenomena of Fever
exemplified in Plague, in Yellow Fever, in the Varieties of the
Fever of our own Country. Different Varieties produced by different
Intensities of the same Affections. Received Classification and
Nomenclature defective. What is really meant by Genera and Species
of Fever. True Principle of Arrangement._
Fever is a genus consisting of several species, and each species
presents many varieties. The external characters of these varieties and
the internal states upon which they depend, are so opposite, that no two
diseases in any two parts of the catalogue of nosology present a more
diversified appearance, or require a more varied treatment, than may be
the case with two different types of fever. The fever of one country is
not the same as the fever of any other country; in the same country, the
fever of one season is not the same as the fever of any other season;
and even the fever of the same season is not the same in any two
individuals. Many of the circumstances which constitute these varieties
in the fevers of different seasons and of individual persons, are slight
and trivial; but some of them are of the greatest possible importance,
and those diversities, especially, which distinguish the fevers of
different climates, are intimately connected with the causes, whatever
they be, which render the disease mild or severe, and, consequently,
comparatively innoxious or fearfully mortal.
Something there is, however, which, amidst this astonishing diversity,
preserves the identity of the disease so completely and so obviously,
that there never has existed any dispute about that identity, under any
aspect which it has hitherto been observed to assume; so that all
physicians, without exception, unhesitatingly accord the name of fever
to the mildest form of the common fever of this country, to the yellow
fever of the West Indies, and to the plague of Constantinople and of
Egypt. Bring three persons, each exhibiting an exquisite specimen of one
of these several forms of the disease into the same ward of an hospital,
the external aspect presented by each would be so different, that an
unprofessional observer would probably be able to discover in these
modifications of the same malady no common property: yet there is no
physician who would not, in each case, instantly pronounce the disease
to be fever. There must, therefore, be something that establishes the
identity of the disease under this diversity of aspect. What is that
something? Whatever it be, it must be common to all the varieties of
fever. Thus we are led at once to the second inquiry which we proposed
to keep before us in this investigation, namely, what are the particular
phenomena which are common to all the varieties and combinations of the
disease?
The importance of making this analysis has been felt by every person who
has directed his attention to this subject from the remotest antiquity
down to the present time. That it is not as easy to be made as the
necessity of it is plainly to be perceived is abundantly attested by the
want of success which has hitherto attended the efforts to perform it of
the acutest minds, and the acutest minds, the pride and boast of our
science have applied themselves to the task. Notwithstanding their
labours however, the analysis made by Hippocrates has been received
through succeeding ages with little variation, and continues to be
received even in modern times with only slight modification. And yet
that reflecting men of every age have not been satisfied with resolving
all the essential phenomena of fever into heat, although they have all
consented to designate the disease by some term expressive of that
property,[17] is attested by proofs no less striking than instructive.
We are informed by Van Swieten, that Boerhaave collected with much
labour from a great variety of authors all the symptoms which they had
observed in different fevers: that from these he threw out such as did
not appear in all fevers, and that finding himself obliged to exclude
one after another, he was at length greatly surprised to find the
catalogue so short; it being ultimately reduced to three; namely
shivering, frequent pulse, heat.
This is a sufficient and an interesting proof that this illustrious
physician saw the importance of making the analysis in question; it
shews also, that his ingenuity suggested probably the best mode of
conducting it which a philosopher sitting in his study could devise; and
the only proper mode of conducting it the circumstances of his age and
country did not place within his reach. Accordingly his success did not
equal his labour: for out of the three phenomena which he fixes upon as
those that are common to all the varieties of the disease there is not
one which is invariably found in any type of it; while in innumerable
cases the combination of the three is not found. Shivering does not
occur in some of the worst forms of the malady; and where it does, it is
confined to the commencement of the attack, or to that of its
exacerbations. The pulse, instead of being always more frequent than
natural, in some of the most formidable aspects assumed by the disease,
has been observed to be as low as forty or even thirty in the minute,
and, from the beginning to the termination of the attack, the heat in
some cases is below the natural standard, as it generally is in the
commencement of the cold stage.
To the catalogue of Boerhaave, Cullen makes the following
additions:—“languor, lassitude and other signs of debility, together
with derangement of the functions, particularly a want of vigor in the
limbs without any primary local affection.” This extension of the
catalogue adds in no respect to the excellence of the generalization. It
has all the vices which a definition can possess. The characters are not
present in all cases; the very opposite are strikingly prominent in
many, while the last, “without any primary local affection,” has so
direct a tendency to mislead the mind, and positively to prevent it from
observing the real phenomena of the disease, that it may well be
questioned, whether the introduction of this single phrase into the
definition of fever, has not been the occasion of far more practical
mischief than has been compensated by any good that has been
accomplished, or ever can be accomplished by all the rest of the
nosology.
In the last attempt to improve the definition of fever with which I am
acquainted, Dr. Wilson Philip says, “If we lay aside Dr. Cullen’s term
pyrexia, (which it must be borne in mind is precisely Boerhaave’s brief
catalogue) we shall considerably lessen the difficulty of giving such a
definition of idiopathic fevers as shall apply to all cases. They may be
defined as follows. Languor, lassitude, and other signs of debility,
followed by a frequent pulse, and increased heat, without any primary
local affection.”[18] Inasmuch as this definition contains fewer words
than that proposed by Cullen, it may be liable to fewer objections, but
it is less faulty only because it is shorter.
This total failure of men, all of them of unquestionable acuteness, and
some of them of splendid genius, in their attempts to discover the
common phenomena of fever, affords a strong presumption that they have
not pursued their object in the right path. Without doubt, before it is
possible to succeed in any scientific investigation, it is necessary to
form a distinct conception of the object of inquiry. Fever is not an
entity, not a being possessing a peculiar nature; and the object of
investigating it, is not to discover in what such nature consists, or
what it is that constitutes its essence: but fever is a series of
events, and the object of inquiry is to discover what the events are;
what the events are that invariably concur in the series; and in what
order they constantly succeed each other. When we have discovered this,
we have ascertained all that we can ever know of what is termed the
nature of fever, as it is this, and only this, that we can ever know of
any object or process. Every natural object consists either of one
single substance, or of several substances united; and our knowledge of
that object is complete when we have ascertained what that single
substance is; or what all the separate substances are that combine to
form it. Every natural process consists of a number of events, and our
knowledge of that process is complete when we have ascertained the
events themselves, the order of their succession, and the events to
which they give occasion. We can make no real progress in knowledge
unless we keep steadily in view the kind of information which it is
possible to acquire, and which it is to our purpose to seek; and
dispossess our minds of the phantoms which have so long enthralled and
abused them.
In relation to our present subject then, the first object of enquiry is,
what are the events which invariably concur in fever?
Where shall we look for the events? Not in the symptoms. Symptoms are
not events: they are only indications of events: symptoms depend upon
states of organs: they are the external and visible signs of internal,
and, for the most part, as long as life continues, invisible conditions.
It is then to the state of the organs that we must look for the events
of which we are in search.
Are there any states of any organs that always exist in fever? Are the
states constant? Are the organs affected constant; and can both be
ascertained? If this can be truly answered in the affirmative; if it can
be proved that there are certain conditions of certain organs which
invariably exist in fever, in every type, in every degree, in every
stage of it, we shall have arrived at a satisfactory conclusion relative
to the first part of our inquiry.
The evidence is as complete as observation during life and inspection
after death can make it, that a morbid change does take place in a
certain number of organs in every case of fever, from the most trivial
intermittent to the most alarming continued fever, from the mildest
plague to the most malignant typhus: that at the two extremes of this
scale, and at all the intermediate gradations of it, there are certain
organs which are always affected, and that the affection in all is
similar.
The identity of the organs is inferred from the indications they give of
disordered function during life: the identity of the affection is
inferred from the similarity of morbid appearances which they exhibit on
examination after death.
The organs affected are those which constitute the nervous system; those
which constitute the circulating system, and those which constitute the
systems of secretion and excretion. The spinal cord and the brain; the
heart and the arteries, especially their capillary extremities; the
secreting and the excreting organs, which in fact are composed,
essentially, of the capillary extremities of the arteries; the secreting
and the excreting extremities of these arteries, especially as they
terminate in the external skin, and in the mucous membranes, which form
the internal skin, this is the chain of diseased organs: derangement in
the nervous and sensorial functions: derangement in the circulating
function: derangement in the secretory and excretory functions, this is
the circle of morbid actions.
There never was a case of fever in which all these organs and affections
were not more or less in a morbid state: there never was a concurrence
of this morbid state, in this complete circle of organs, without fever.
The events which _invariably_ concur in fever, then, are a certain
deviation from the healthy state in the nervous and the sensorial
functions; a certain deviation from the healthy state in the circulating
function; a certain deviation from the healthy state in the functions of
secretion and excretion. A deviation from the healthy state in one
circle of actions will not present the phenomena of fever; a deviation
from the healthy state in two circles of action will not present the
phenomena of fever: there must be a deviation in the three circles
before fever can exist. Such then are the common phenomena of fever.
For obvious reasons the detail of the proof that these several events
really and invariably take place, must be postponed until the phenomena
themselves have been stated, or what is termed the history of the
disease has been given.
But it is not the invariable concurrence of a particular number of
events that is alone sufficient to constitute fever: to this must be
added invariableness of concurrence in a particular order. As will be
shewn in the proper place, there is complete and irresistible evidence
that these events do occur in one invariable order. Derangement in the
functions of secretion and excretion never comes first in the series:
derangement in the nervous and sensorial functions never comes last in
the series: derangement in the function of the circulation never comes
either the first or the last in the series, but is always the second in
succession.
The order of events then is first, derangement in the nervous and
sensorial functions; this is the invariable antecedent: secondly,
derangement in the circulating function; this is the invariable sequent:
and thirdly, derangement in the secreting and excreting functions; this
is the last result in the succession of morbid changes.
Supposing the matter of fact to be as is here stated, and the proof that
it is so will be adduced hereafter, it is clear that we are in
possession of the true characters of fever. We know the events: we know
the order in which they occur: we know therefore what it is that
constitutes the disease, and we know consequently what it is by which it
is distinguished from every other malady. No other disease exhibits the
same train of phenomena in the same order of succession. In inflammation
some of the phenomena are the same: but the order in which they concur
is not the same; and this affords a clear and universally applicable
mark of distinction between fever and inflammation. In inflammation
there is similar derangement in the secreting and excreting functions:
there is also sometimes similar derangement in the circulating function:
but the derangement in the nervous and sensorial functions is seldom if
ever similar: the derangement that does take place in these latter
functions, while it is apparently different in kind, is certainly and
invariably different in the order of its occurrence. In pneumonia, in
enteritis, in hepatitis, the spinal cord and the brain are _never_ the
organs in which the _first_ indications of disease appear: the earliest
indications of disease that can be discovered have their seat in the
affected organ itself: it is only after the disease has made some
progress that other organs and functions are involved; and apparently,
the last to be involved, and certainly the least to suffer, is the
nervous system.
We can now then answer the questions so often asked—are fever and
inflammation the same? and if not the same in what do they differ? Fever
and inflammation are not the same, because the term fever is
appropriated to the designation of a certain number of events which
occur in a certain series: the term inflammation, on the other hand,
expresses another series of events, each event composing this train,
succeeding each other in a different order: and the difference between
the two series of events is precisely this difference in their
individual phenomena and in their order of succession. What the physical
and the physiological condition of the organs is, as contrasted with
their condition in the state of health, has not yet been made out with
regard either to fever or to inflammation: in the present state of our
knowledge, therefore, we can neither affirm nor deny any thing
respecting either the identity or the difference of that physical and
physiological condition of the organs in these two classes of disease.
What inflammation is beyond the series of events we are able to observe
we do not know: what fever is beyond the series of events we are able to
observe we do not know: we compare the events and we see that they
differ: and since the use of names is to mark and to express
differences, it is right to distinguish these different events by
different terms. But though in the present state of our knowledge we are
not justified in considering fever and inflammation to be the same, yet
the close, perhaps the constant connexion between them, is a fact of the
utmost importance to be known, and requires to be incessantly before the
view of the practitioner. And of this we shall have but too abundant
evidence in the sequel.
Supposing the proofs hereafter to be adduced to be conclusive, that the
events in fever and their order really are what has now been stated, how
clearly and beautifully does this view of the disease enable us to
recognize one and the same malady through all the modifications it
undergoes, and therefore through the countless aspects it assumes. Out
of the system of organs that are always affected in fever some may be
more and some may be less diseased; and it is easy to see how, from this
diversity alone, the utmost variety may arise in the external characters
of the disease. Thus, at one time, the spinal cord and the brain may be
intensely affected: consequently the patient may be seized with violent
pains in the limbs; with ferocious head-ache; with early delirium, which
may rapidly increase to such a degree of violence as to require
restraint: or, on the contrary, all the muscles of voluntary motion may
be seized instantaneously with such a loss of energy that they may truly
be said to be paralyzed: at the same time the sensorial faculties may be
overwhelmed almost as completely as they are in apoplexy: thus may be
formed one type of fever: and such a concourse of symptoms is actually
found to exist: it ushers in the plague when it first stalks into a
devoted city to sweep away its thousands and its tens of thousands.
At another time the disease may seize with peculiar violence upon the
organs of secretion, and especially upon those which belong to the
digestive apparatus: hence the liver may suddenly pour forth an immense
flow of bile, so vitiated in quality as to irritate and inflame whatever
it touches, and so abundant in quantity as rapidly to diffuse itself
over every part of the body, and to tinge almost every tissue and every
fluid: at the same time the stomach and intestines may be involved in
such acute disease that the powers of life may be exhausted in a few
hours by incessant vomiting and unconquerable purging: thus may be
formed another type of fever, and such a concourse of symptoms actually
occurs in the yellow fever of the West Indies.
Now we may witness a severe though a less violent affection of the
spinal cord and the brain than occurs in plague. There may be present
great pain in the back and limbs; intense head-ache; early and violent
delirium; a burning skin; a quick and strong pulse; urgent thirst, and
constipated bowels: or, on the contrary, there may be not pain of the
head, but giddiness; not delirium, but stupor; not a burning hot, but a
moderately warm or a cool skin; not a frequent and strong, but a
frequent and feeble pulse. In either case we have a fair specimen of the
common fever of our own country, the first forming the variety which may
be termed acute, the second subacute cerebral.
Now again we may witness a concurrence of symptoms very similar to the
latter in the commencement of the attack, only that there is from the
beginning greater prostration of strength; and a rapid increase in the
derangement of the nervous and sensorial functions: together with a
brown and dry tongue; a tender abdomen, and dark and offensive stools:
thus may be formed another type of fever to which is commonly assigned
the name of typhus.
In each of these cases the most urgent symptoms have their seat only in
one set of the organs that compose the circle which we have said to be
involved; but in every case all the other organs included in that circle
are as really, though not as intensely diseased. When the spinal cord
and the brain are so violently affected that the patient appears to be
struck with paralysis or apoplexy, the attention is not strongly drawn
to the state of the mucous membrane of the digestive apparatus; to the
nature of the secretions and excretions of which it is the source; to
the temperature of the system, or to the condition of the circulation:
because the affection of the nervous system being overwhelming, and all
the other affections being comparatively trifling, it is natural that
the former should, in a manner, absorb the mind of the observer; yet, if
the skin, the pulse, the tongue, the evacuations are examined, all will
be found to be in a morbid state, and that morbid state will bear a
certain proportion to the affection of the nervous system.
In like manner when the organs of the digestive apparatus form the
strong hold of the disease, the morbid condition of the spinal cord and
brain, and the altered action of the heart and arteries, may attract
less notice; but that morbid condition will be not the less real, and
will contribute its portion of disease to the general derangement of the
system, not the less certainly because the indications of its existence
may be less obtrusive.
And in the milder forms which the fever of our own country presents, in
the most intense cerebral affection with which we ever meet, there will
always be present unequivocal indications of deranged function both in
the heart and arteries, and in the organs of secretion and excretion:
while in cases in which the brain may be tolerably clear; in which there
may be little or no headache; little or no pain in the limbs; no
delirium; in which the disease may be chiefly seated in the mucous
membrane of the stomach and intestines, and the prominent symptoms be,
pain of the epigastrium, tenderness on pressure over the whole abdomen,
a red tongue, and frequent stools, still if we examine the state of the
pulse, if we look at the quality and the distribution of the nervous
influence, if we observe the operations of the sensorial faculties, we
shall find these functions to be as truly, though not as intensely
deranged as if the full force of the disease were spent upon the organs
in which these functions have their seat.
Thus, although all these organs are invariably affected in every case of
fever, yet in no two cases are all these organs affected in the same
degree. Sometimes one system is more affected than another; sometimes
one organ of one system, and these different degrees of affection, in
these different systems, are variously combined and modified. How great
then must necessarily be the diversity of symptoms presented by the
different forms of fever! How incalculable are the varieties that result
from difference of intensity alone. One degree of affection of the
brain, for example, will occasion violent headache, constant
watchfulness, great restlessness, a peculiar expression of the eye, and
intolerance of light; in another there will be no headache, or none of
which the patient will complain; there will be sleep though it be
disturbed and unrefreshing; there will be no peculiar expression of the
eye, and no intolerance of light. By one degree of affection the
sensibility will be rendered preternaturally intense; by another it will
be totally obliterated: one will produce violent delirium, another, only
slight wandering, or unrefreshing slumber: one, violence requiring
restraint; another, profound coma. In the circulating system the
symptoms will alike vary. One degree will produce a quick, strong and
hard pulse; another, a quick, small and feeble pulse; another, a slow
and intermittent pulse. A similar diversity will be found in the
temperature of the body: in one, the heat will be little changed; in
another, it will be below the natural standard; in a third, it will be
intense, and the organs of secretion and excretion will equally vary in
the extent of their morbid changes.
Thus, from one and the same affection of one and the same organ, not
only different but opposite symptoms will be produced in all the organs
involved in what we may call the febrile circle. When to this variety
are added diversities occasioned by various stages of the diseased
processes that are going on in the system; by the previous state of the
organs affected; by the reaction of the affected organs one upon
another, producing innumerable and ever varying combinations of
different intensities of affection, in different sets of organs; and by
the treatment to which the whole have been subjected, we cannot wonder
if the symptoms of fever appear to be countless.
That no two cases of fever can ever be precisely the same, and that it
must be vain to seek for the common phenomena of the disease in the
external symptoms, must now be obvious: and why success can never attend
the search after these common phenomena in such symptoms as “shivering,
frequent pulse, heat,” must be equally manifest. These as well as all
other symptoms depend upon the state of the organs. But we have seen
that in one degree of the same affection of the same series of organs
there may be shivering; excited pulse; burning heat; while in another
degree there may be no shivering, a slow pulse and a cold skin: so that
from one and the same affection, differing only in the degree of its
intensity, the symptoms may not only vary but be directly opposite. The
proper object of pursuit in all these enquiries, therefore, is the real
nature of the affection, and the symptoms are of consequence only as
they are indications of the existence of that affection. Symptoms are
not _the_ thing in which observation should terminate, but signs of the
thing without the knowledge of which, in every individual case that may
come under his care, the practitioner ought never to be at rest, and to
the discovery of which they serve as guides.
It is then in the organs alone that we can find a perfect uniformity:
but their condition is as fixed and invariable as the return of day and
night. All the operations of nature are uniform. When, in any case, we
have succeeded in discovering what the operation is, we see that it
never varies. The same causes, under the same circumstances, always
produce the same effects. The causes of fever, whatever they be, under
the same circumstances, always produce the same conditions of the
organs. In proportion as we ascertain with clearness and precision what
these conditions are, we observe that they recur in all cases with the
most undeviating regularity, and when our knowledge of them shall have
become complete, it is probable that we shall find that they are as
constant in their return as that of the sun after its setting, and that
they no more change in their nature or progress than the sun deviates
from its path.
The all important thing for the practitioner to know, then, it can never
be too often repeated, is what these conditions are. It is greatly to be
regretted that we do not know with precision the condition of the most
important organs in the intense fevers of other climates. The condition
of the most important organs in the various types of fever as they occur
in our own country, we do now know with precision, and the main object
of the present work is to give an account of these conditions, and of
the signs which denote them.
It is found that particular conditions of particular sets of organs give
rise to certain groups of symptoms: these groups of symptoms have been
supposed to form different genera and species, and have received
specific names. Were the nomenclature of these genera and species of
fever perfect, the name would in each case be expressive of the
condition of the organs upon which the assemblage of symptoms it denotes
depends, and perhaps in some greatly advanced state of our science, when
these conditions have been perfectly ascertained and have become
perfectly familiar, an approximation to this desirable classification
and naming may be attempted with success. The state of our knowledge,
however, enables no one to undertake the task at present, and in the
mean time the slightest glance at the divisions which have been
attempted of this class of diseases, is but too sufficient to shew the
total absence of that kind of information, which, if there be any truth
in the preceding observations, it is alone of value to possess.
Thus febrile diseases are commonly divided into idiopathic and
symptomatic—a division which is liable to the fundamental objection that
the diseases included under the second section are not fevers but
inflammations. There are no fevers but idiopathic fevers. It has been
shewn that fever differs from inflammation both in the individual
phenomena forming the train that constitutes the disease, and in the
order in which the several phenomena succeed each other. There are, it
is true, individual phenomena common to both; but since the series as
well as the order in which the several phenomena stand in the series are
different, to call both by the same name can only produce confusion and
misconception.
Of true or idiopathic fevers two great divisions are made; one
comprehending intermittent and the other continued fevers: a division
founded on the occurrence of the trains of the phenomena in an
interrupted or in an uninterrupted series. Intermittent fever is further
divided into intermittent and remittent, the interruption in the series
being said to be complete in the one and incomplete in the other. In
continued fever, on the other hand, the trains of phenomena are supposed
to proceed in a perfectly uninterrupted series, whence the name
continued. The single fact suggested to the mind of the practitioner by
this classification is in the highest degree trivial.
Of the particular groups of symptoms which have been brought together
under the great class, continued fever, it is impossible to discover any
kind of principle which has led to the formation of the distinct
assemblages that have been made, or to their nomenclature when thus
collected. Synocha, typhus, synochus, are the three genera which modern
nosology, in the power and pride of its strength, has put forth as at
once distinctive and exhaustive of this class of disease. The aggregate
phenomena constituting synocha, form just that particular series which
is common to some forms of fever and to all acute inflammations: namely,
“Calor plurimum auctus, pulsus frequens, validus, et durus, urina rubra,
sensorii functiones parum turbatæ.” The train of symptoms thus brought
together do not alone form any variety of fever. The second group of
symptoms forming typhus—“morbus contagiosus, calor parum auctus, pulsus
parvus, debilis, plerumque frequens, urina parum mutata, sensorii
functiones plurimum turbatæ, vires multum imminutæ:” and the third,
forming synochus,—“morbus contagiosus, febris ex synocha et typho
composita; initio synocha, progressu, et versus finem, typhus,”
independently of their being brought together and named according to no
known or even assigned principle, are liable to the further and the
fatal objection, that they do not even occur in nature.
Even Dr. Wilson Philip, who labours to reconcile to nature and to
improve in accuracy and comprehensiveness these classifications and
definitions, expressly admits that a simple synocha or typhus is a fever
which we rarely, if ever meet with: for that however high the
inflammatory symptoms at an early period may be, those of typhus always,
at least in this country, sooner or later supervene; and that however
well marked the symptoms of typhus may be in the progress of fever, in
almost every case, the first symptoms are more or less inflammatory;
that the fevers mentioned by authors, under the names synochus and
typhus, are in fact no other than varieties of the synochus; that when
the symptoms of debility predominate, the fever has been termed typhus;
that when, on the contrary, the inflammatory symptoms are most
remarkable, and present through the greater part of the disease, it has
been called synocha.[19]
Again, while according to this received arrangement a train of symptoms,
every one of which is found in acute inflammation, is made a distinct
genus of fever, numerous diseases, each forming an exquisite specimen of
fever, are totally excluded from the order, and placed at a considerable
distance in the nosology. Because scarlatina is a fever attended with a
peculiar eruption on the skin; because rubeola is a fever attended with
an eruption on the skin also peculiar; because variola is a fever
attended with another peculiar eruption, and urticaria with another,
these diseases are not made varieties of fever, but, designated by the
term exanthemata, are formed into a separate order: while, on the other
hand, fevers attended with petechiæ, with papulæ, with aphthæ, with
vesicles, are accounted fevers, and accordingly are termed petechial,
miliary, aphthous, erysipelatous, vesicular fevers; whence synochus
petechialis, synochus miliaris, synochus aphthosus, &c.
Without doubt is right that these varieties of disease should be
discriminated and named; but this mode of classifying them has a
necessary tendency to divert the mind from dwelling on those essential
circumstances which make all of them mere varieties of one great
disease; and to fix it upon those comparatively unimportant though
obvious circumstances which simply modify the malady without in the
least affecting its identity.
It has already been stated that the grouping of the symptoms, or, in
other words, the formation of the species of fever cannot be
scientifically or usefully accomplished until we have arrived at a
perfect knowledge of the condition of the organs upon which the trains
depend; and that our knowledge of these conditions is so imperfect,
especially with regard to many of the species, that this classification
cannot possibly be made at present. It is not even known whether the
condition of the organs in intermittent be the same as it is in
continued fever. The mere periodicity in the recurrence of the febrile
paroxysms by which this class of disease is at present characterised, is
an exceedingly unsatisfactory principle of distinction, unless we at the
same time knew the state of the system upon which that periodicity
depends. The alternate transition of intermittent into remittent and
continued, and of continued and remittent into intermittent fever, of
which the history of epidemics affords so many striking examples, and of
which Sydenham, Pringle, and all the older writers have recorded so many
interesting accounts, as events which they themselves daily witnessed,
seems to shew that there can be nothing amounting to a generic
difference between these several diseases. The type, as far as we have
the means of judging, appears to be determined entirely by the intensity
of the disease. An intermittent increasing in violence and malignity
changes into a remittent or a continued fever, and a continued or
remittent, diminishing in violence and malignity, often assumes the form
of intermittent. Speaking of the epidemic constitution of the years from
1661 to 1664, Sydenham states that, in the year 1661, the autumnal
intermittents which had prevailed for some years broke forth afresh,
especially obstinate tertians; that increasing daily until August, at
which time they raged fiercely and became extremely mortal, in many
places seizing whole families, and destroying great numbers, decreased
by degrees until October; and, disappearing at the approach of Winter,
were succeeded by a continued fever, which differed from the Autumnal
intermittent only in being continued, while the former returned in
paroxysms: that both invaded almost alike; that those who violently
laboured of either vomited; that in both the skin was dry; the tongue
black, the thirst urgent, and that, at their declination, the morbific
matter in both was readily exterminated by sweats. “It was manifest,” he
adds, “that this fever belonged to the family of intermittents, because
it rarely appeared in the Spring: it was a sort of compendium of the
intermittents; and, on the contrary, every fit of the intermittent
seemed to be a compendium of this fever; so that the difference chiefly
consists in this, namely, that the continued fever once begun, perfects
its effervescence with the same degree of heat; but the intermittents
perform their business by parts, and at several times.”[20]
In like manner, Pringle, among many other examples of the fact, which,
indeed, he states to be of constant occurrence, gives an account of an
epidemic that prevailed in the army of the Netherlands, and which in its
worst form assumed the appearance of an ardent fever. He states that the
men were suddenly seized with violent head-ache, and frequently with
delirium: that, if sensible, they complained also of grievous pain in
the back and loins; intense thirst; burning heat; great sickness and
oppression at the stomach, sometimes with vomiting of bile, sometimes
with evacuation of bile by stool, accompanied with tenesmus and pains in
the back: that this fever generally remitted from the beginning upon
bleeding and purging: that if these precautions were omitted, the fever
went on in almost a continued form, and that its tendency to
putrefaction was so great, that while many had spots and blotches, some
had mortifications, which were almost always fatal: that this fever
continued to rage throughout August; that it began to abate with the
heat in the middle of September; that from this period its violence
diminished, and the number attacked gradually decreased; and that now
“the remissions became more free, so that insensibly, with the coolness
of the weather, this raging fever dwindled into a regular intermittent,
and entirely ceased upon the approach of Winter.”[21]
What that condition of the system is, which, in forms of fever that are
thus mutually convertible, causes one to persist in an uninterrupted
series, another to remit, and another, after disappearing for a time, to
recur in distinct and regular paroxysms, is wholly unknown. Sydenham,
indeed, cuts the knot and removes the difficulty at once. Speaking of
the return of the fits in intermittent, he replies to the inquirer into
their cause,—“I would fain know why a horse comes to his growth in seven
years and a man at twenty-one; or why some plants flower in May and some
in June. I am persuaded that the progress of nature is as certain and
regular in this case as in any other, and that the matter of a quartan
and tertian ague is subject to Nature’s laws and governed by them, as
well as any other bodies whatever.” The regularity of nature in the
production of disease, no less than in the maintenance of health, cannot
be doubted: but the point in question is not clearly one of those
ultimate facts, into the reason of which it is wholly vain for the human
mind to inquire.
Hitherto, however, no one appears to have hazarded even a conjecture as
to the cause of this striking difference between these two forms of
disease; and pathology, as has just been observed, has afforded no clear
light to enable us to determine whether the febrile circle of organs is
similarly affected in both. Examinations of fatal cases have been made;
but none on that large scale and with that accuracy which alone can
render them of any value. I have endeavoured to ascertain the morbid
appearances in the spinal cord and the brain, and in the mucous membrane
of the respiratory and digestive apparatus, from those who have been
long engaged in extensive practice in districts in which ague prevails:
but I have been able to obtain no satisfactory answer, excepting that
intermittent does not kill! Greatly as the severity of intermittent is
without doubt diminished, in the present age, yet we cannot receive such
an account without blessing the bark of the seventeenth and the skill of
the nineteenth century!
A similar want of knowledge exists relative to the condition of the
organs in most of the Exanthemata. To supply that want in regard to the
various forms of fever that prevail in this metropolis, which, there is
good reason to believe, differ but little from the types that appear in
other parts of the country, is one of the chief objects for which this
work is undertaken.
It is not the object of the present volume to treat of intermittent or
of remittent fever, but only of that class which, in ordinary medical
language, is termed continued. Of the apparently endless varieties of
disease comprehended under the term continued fever, it is found that
certain forms occur in this country with great constancy. Each
particular assemblage of symptoms occurring in these different forms is
said, in ordinary language, to constitute a type or species. Each type
or species depends on a particular condition of the circle of organs
that has been described. The causes that concur to produce this
particular condition of this series of organs, will be treated of in
their proper place. But these assemblages of symptoms never occur
without being accompanied by these particular conditions of the organs;
and these conditions of the organs are never found without having been
connected with these assemblages of symptoms. In all the forms of fever
hitherto observed this condition of the organs is found to be absolutely
the same: it never differs in any thing but intensity; of this the
evidence is complete and irresistible: the direct and legitimate
inference is, that all these different forms of fever differ in nothing
excepting in the intensity of the affection. Were the terms genera,
species, variety, merely used as short expressions to denote this fact;
to point out and to name different degrees of the same malady, degrees
which it is important to discriminate, because they require material
modifications of treatment, a clear and precise meaning would be affixed
to these words: in nature there would be foundation for the distinction
they imply: in practice there might be convenience in their use. But the
nosological distinctions at present inseparably associated with these
terms, appear to me to be either so vague and unmeaning, or when they
cease to be indistinct, to excite notions so false and pernicious, that
I think it right to abandon the use of them altogether. The more we
investigate the subject, the more satisfied we shall become that
continued fever is one disease and only one, however varied, or even
opposite, the aspect it may present; but that it differs in intensity in
every different case, and that this and this alone is the cause of the
different forms it assumes. Many of these diversities it would be
frivolous to distinguish: some of them, on the other hand, it is of the
highest importance to discriminate. For all useful and practical
purposes, it is necessary only to arrange the different assemblages of
symptoms into two great classes, the one comprehending the mild and the
other the severe forms of the disease. All the forms that continued
fever can assume, and all the individual cases that can occur under
either, must be mild or severe, and, therefore, must readily find its
place under one or other of these divisions. The only real difference in
the disease being a difference in degree, it is proper that the
principle of the division, by which the varieties it presents are
classified, should be founded on this, the only true distinction of
which it admits.
It is difficult to frame, and still more difficult to bring into use,
new terms; and there is nearly equal inconvenience in using old terms in
a new sense: but if the new meaning affixed to an old term be clearly
intimated and rigidly adhered to, it is, perhaps, upon the whole,
productive of less evil to adopt the old, thus determining and limiting
the signification, than to propose a nomenclature entirely novel. For
this reason, and only for this reason, I propose to adopt two words,
borrowed from the nosology of Cullen, and in common use. These words are
here employed merely to express differences of degree relative to one
and the same disease. The mild degree may be denoted by the term
synochus: throughout this work, this term will be used to express the
milder form of fever; that is, its ordinary or common form, or that
which it is found most frequently to present in this metropolis, and, I
may add, in this country. The severer form, on the other hand, may be
designated by the term typhus. Each will be found to present a distinct
assemblage of symptoms; each will be found to depend upon a particular
condition of certain organs; each will be found to require a peculiar
treatment.
For the purpose of distinguishing further important differences, that
is, differences which bear an important relation to practice, it will be
convenient to divide each of these two great classes into two minor
sections. Thus, synochus may be divided into synochus mitior and
synochus gravior; and typhus into typhus mitior and typhus gravior. This
will afford convenient and ample means of throwing into distinct groups
all the varieties of fever that occur in this country, which it can be
of any practical importance to distinguish.
This mode of viewing fever as one great and extensive malady never
differing in nature, but in every two cases differing in intensity, and
giving rise by these differences in intensity to various forms of
disease, thus affords a principle of arrangement applicable to all those
various forms, which, while it is at once simple and comprehensive, is
at the same time in the highest degree practical. It directly leads the
mind to the observation of the real, the important differences that
exist or that may arise; those differences which must influence and
guide the treatment, if it be not altogether blind, and in the worst
sense of the term empirical. This principle might easily be extended,
and I think with advantage, so as to comprehend the exanthemata, and all
the forms of fever which have hitherto been known to exist, or which can
arise. Scarlet fever, for example, is continued fever attended with a
peculiar eruption upon the skin: at one time it occurs in a mild, at
another in an exceedingly severe form: the assemblage of symptoms in the
first are precisely those which it is intended to comprehend under the
term synochus: the assemblage of symptoms in the second are those which
are designated by the term typhus: thus scarlet fever exhibits at one
time the synochoid, and at another the typhoid type; the first being
what is commonly termed scarlatina benigna, the second scarlatina
maligna; and each type is capable of existing in two degrees of
severity, one of which may be conveniently distinguished by the term
mitior, and the other by that of gravior.
In like manner small-pox is a fever attended with a peculiar eruption
upon the skin, which eruption modifies the disease in a very remarkable
manner, and gives it a history and progress peculiarly its own; but it
is as much a genuine fever as typhus, and ought no more to be taken out
of this class on account of the eruption upon the skin, than scarlatina,
which likewise modifies, in a very considerable degree, the whole train
of febrile symptoms, and is attended with a peculiar condition of some
exceedingly important internal organs. Small-pox, like all the diseases
of this class, occurs in two widely different forms; the one mild, the
other intensely severe: in the first the concourse of symptoms are
precisely those of the synochoid, in the second of the typhoid type.[22]
And the same I am satisfied is true of the plague, of the yellow fever,
and of all the different forms which this great disease, of many aspects
and names, but of one uniform and unchanging nature, presents.
These distinctions and names then, though it were easy to raise
objections against them, may serve for all useful and practical
purposes. They tend to impress upon the mind the great fact that all the
modifications of the disease are still only modifications, and do not
affect the identity of its nature; and they afford convenient sections
under which to detail the symptoms that attend and discriminate the
important diversities in degree as they present themselves in practice;
to exhibit the condition of the organs upon which those diversities
depend, and to explain the treatment which experience teaches to be
appropriate to these several states.
The present work will be restricted to the consideration of the
modifications of fever which we have proposed to designate by the terms
synochus, typhus, and scarlatina.