E-text prepared by MWS, Jens Nordmann, Bryan Ness, and the Online
Distributed Proofreading Team (http://www.pgdp.net) from page images
generously made available by Internet Archive (https://archive.org)
Note: Project Gutenberg also has an HTML version of this
file which includes the original illustrations.
See 58861-h.htm or 58861-h.zip:
(https://www.gutenberg.org/cache/epub/58861/pg58861-images.html)
or
(https://www.gutenberg.org/files/58861/58861-h.zip)
Images of the original pages are available through
Internet Archive. See
https://archive.org/details/b21935142_0003
Project Gutenberg has the other three volumes of this work.
Volume I: see https://www.gutenberg.org/ebooks/58859
Volume II: see https://www.gutenberg.org/ebooks/58860
Volume IV: see https://www.gutenberg.org/ebooks/58862
Transcriber's note:
The ligature oe has been marked as [oe].
Text in italics has been enclosed by underscores (_text_).
The symbol hand pointing has been marked as [hand].
MEDICAL INQUIRIES
AND
OBSERVATIONS.
BY BENJAMIN RUSH, M. D.
PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE,
AND OF CLINICAL PRACTICE, IN THE UNIVERSITY
OF PENNSYLVANIA.
IN FOUR VOLUMES.
VOL. III.
THE SECOND EDITION,
REVISED AND ENLARGED BY THE AUTHOR.
PHILADELPHIA,
PUBLISHED BY J. CONRAD & CO. CHESNUT-STREET, PHILADELPHIA; M. & J.
CONRAD & CO. MARKET-STREET, BALTIMORE; RAPIN, CONRAD, & CO. WASHINGTON;
SOMERVELL & CONRAD, PETERSBURG; AND BONSAL, CONRAD, & CO. NORFOLK.
PRINTED BY T. & G. PALMER, 116, HIGH-STREET.
1805.
* * * * *
CONTENTS OF VOLUME III.
_page_
_Outlines of a theory of fever_ 1
_An account of the bilious yellow fever, as it appeared in
Philadelphia in 1793_ 67
_An account of the bilious yellow fever, as it appeared in
Philadelphia in 1794_ 355
_An account of sporadic cases of bilious yellow fever, as they
appeared in Philadelphia in 1795 and 1796_ 435
* * * * *
OUTLINES
OF A
_THEORY OF FEVER_.
As many of the diseases which are the subjects of these volumes belong to
the class of fevers, the following remarks upon their theory are intended
to render the principles and language I have adopted, in the history of
their causes, symptoms, and cure, intelligible to the reader.
I am aware that this theory will suffer by being published in a detached
state from the general view of the proximate cause of disease which I
have taught in my lectures upon pathology, as well as from its being
deprived of that support which it would receive from being accompanied
with an account of the remedies for fever, and the times and manner of
exhibiting them, all of which would have served to illustrate and
establish the facts and reasonings which are to follow upon this
difficult and interesting inquiry.
I shall not attempt to give a definition of fever. It appears in so many
different forms, that a just view of it can only be given in a minute
detail of all its symptoms and states.
In order to render the theory, which I am about to deliver, more simple
and intelligible, it will be necessary to premise a few general
propositions.
I. Fevers of all kinds are preceded by general debility. This debility is
natural or accidental. The former is the effect of the sanguineous
temperament, and exists at all times in many constitutions. The latter is
induced,
1. By such preternatural or unusual stimuli, as, after first elevating
the excitement of the system above its healthy grade, and thereby wasting
a part of its strength, or what Dr. Brown calls excitability, and Darwin
sensorial power, afterwards reduces it down to that state which I shall
call debility of action. Or,
2. It is induced by such an abstraction of natural stimuli as to reduce
the system _below_ its healthy grade of excitement, and thereby to induce
what Dr. Brown calls _direct_ debility, but what I shall call debility
from abstraction. This general debility is the same, whether brought on
by the former or the latter causes. When induced by the latter, the
system becomes more excitable than when induced by the former causes, and
hence an attack of fever is more frequently invited by it, than by that
state of debility which succeeds the application of an undue portion of
stimulating powers. To this there is an exception, and that is, when the
remote causes of fever act with so much force and rapidity as _suddenly_
to depress the system, without an intermediate elevation of it, and
before sufficient time is given to expend any part of its strength or
excitability, or to produce the debility of action. The system in this
state, is exactly similar to that which arises from a sudden reduction of
its healthy excitement, by the abstraction of stimuli. This debility from
abstraction, moreover, is upon a footing with the debility from action,
when it is of a _chronic_ nature. They both alike expend so much of the
quality or substance of excitability, as to leave the system in a state
in which irritants are seldom able to excite the commotions of fever, and
when they do, it is of a feeble nature, and hence we observe persons who
have been long exposed to debilitating causes of both kinds, often escape
fevers, while those who are _recently_ debilitated, are affected by them,
under the same circumstances of exposure to those causes.
That fevers are preceded by general debility I infer from their causes,
all of which act by reducing the excitement of the system, by the
abstraction of stimuli, or by their excessive or unusual application. The
causes which operate in the former way are,
1. Cold. This is universally acknowledged to be a predisposing cause of
fever. That it debilitates, I infer, 1. From the languor which is
observed in the inhabitants of cold countries, and from the weakness
which is felt in labour or exercise in cold weather. 2. From the effects
of experiments, which prove, that cold air and cold water lessen the
force and frequency of the pulse.
2. The debilitating passions of fear, grief, and despair.
3. All excessive evacuations, whether by the bowels, blood-vessels,
pores, or urinary passages.
4. Famine, or the abstraction of the usual quantity of nourishing food.
The causes which predispose to fever by the excessive or unusual
application of stimuli are,
1. Heat. Hence the greater frequency of fevers in warm climates, and in
warm weather.
2. Intemperance in eating and drinking.
3. Unusual labour or exercise.
4. Violent emotions, and stimulating passions of the mind.
5. Certain causes which act by over-stretching a part, or the whole of
the body, such as lifting heavy weights, external violence acting
mechanically in wounding, bruising, or compressing particular parts,
extraneous substances acting by their bulk or gravity, burning, and the
like[1]. The influence of debility in predisposing to fevers is further
evident from their attacking so often in the night, a time when the
system is more weak than at any other, in the four and twenty hours.
[1] Cullen's First Lines.
II. Debility being thus formed in the system, by the causes which have
been enumerated, a _sudden_ accumulation of excitability takes place,
whereby a predisposition is created to fever. The French writers have
lately called this predisposition "vibratility," by which they mean a
liableness in it to be thrown into vibrations or motions, from
pre-existing debility. It is not always necessary that a fever should
follow this state of predisposition. Many people pass days and weeks
under it, without being attacked by a fever, by carefully or accidentally
avoiding the application of additional stimuli or irritants to their
bodies: but the space between this state of predisposition, when it is
recent, and a fever, is a very small one; for, independently of
additional stimuli, the common impressions which support life sometimes
become irritants, and readily add another link to the chain of causes
which induce fever, and that is,
III. Depression of the whole system, or what Dr. Brown calls indirect
debility. It manifests itself in weakness of the limbs, inability to
stand or walk without pain, or a sense of fatigue, a dry, cool, or cold
skin, chilliness, a shrinking of the hands and face, and a weak or quick
pulse. These symptoms characterize what I have called in my lectures the
forming state of fever. It is not necessary that a paroxysm of fever
should follow this depressed state of the system, any more than the
debility that has been described. Many people, by rest, or by means of
gentle remedies, prevent its formation; but where these are neglected,
and the action of stimuli, whether morbid or natural, are continued,
IV. Re-action is induced, and in this re-action, according to its greater
or less force and extent, consist the different degrees of fever. It is
of an irregular or a _convulsive_ nature. In common cases, it is seated
primarily in the blood-vessels, and particularly in the arteries. These
pervade every part of the body. They terminate upon its whole surface, in
which I include the lungs and alimentary canal, as well as the skin. They
are the outposts of the system, in consequence of which they are most
exposed to cold, heat, intemperance, and all the other external and
internal, remote and exciting causes of fever, and are first roused into
resistance by them.
Let it not be thought, from these allusions, that I admit Dr. Cullen's
supposed vires naturæ medicatrices to have the least agency in this
re-action of the blood-vessels. I believe it to be altogether the effect
of their elastic and muscular texture, and that it is as simply
mechanical as motion from impressions upon other kinds of matter.
That the blood-vessels possess muscular fibres, and that their
irritability or disposition to motion depends upon them, has been
demonstrated by Dr. Vasschuer and Mr. John Hunter, by many experiments.
It has since been proved by Spallanzani, in an attempt to refute it. Even
Dr. Haller, who denies the muscularity and irritability of the
blood-vessels, implies an assent to them in the following words: "There
are nerves which descend for a long way together through the surface of
the artery, and at last vanish in the cellular substance of the vessel,
of which we have a specimen in the external and internal carotids, and in
the arch of the aorta; and from these do not the arteries seem to derive
a muscular and convulsive force very different from that of their simple
elasticity? Does not it show itself plainly in _fevers_, faintings,
palsies, consumptions, and passions of the mind[2]?"
[2] First Lines, sect. 32 of the chapter on arteries.
The re-action or morbid excitement of the arteries discovers itself in
preternatural force, or frequency in their pulsations. In _ordinary_
fever, it is _equally_ diffused throughout the whole sanguiferous
system, for the heart and arteries are so intimately connected, that,
like the bells of the Jewish high-priest, when one of them is touched,
they all vibrate in unison with each other. To this remark there are some
exceptions.
1. The arteries are sometimes affected with great morbid excitement,
while the natural functions of the heart are unimpaired. This occurs in
those states of fever in which patients are able to sit up, and even to
walk about, as in pulmonary consumption, and in hectic fever from all its
causes.
2. The heart and pulmonary artery are sometimes affected with great
morbid excitement, while the pulsations of the arteries on the wrists are
perfectly natural.
3. The morbid excitement of the arteries is sometimes greater on one side
of the body than on the other. This is obvious in the difference in the
number and force of the pulsations in the different arms, and in the
different and opposite appearances of the blood drawn from their veins,
under equal circumstances.
4. The arteries in the head, lungs, and abdominal viscera are sometimes
excited in a high degree, while the arteries in the extremities exhibit
marks of a feeble morbid action. Fevers attended with these and other
deviations from their common phenomena, have been called by Dr. Alibert,
_altaxiques_. They occur most frequently in malignant fevers.
While morbid excitement thus pervades generally or partially the
sanguiferous system, depression and debility are increased in the
alimentary canal, and in the nervous and muscular systems. In the
stomach, bowels, and muscles, this debility is occasioned by their
excitement being abstracted, and translated to the blood-vessels.
I shall now endeavour to illustrate the propositions which have been
delivered, by taking notice of the manner in which fevers are produced by
some of its most obvious and common causes.
Has the body been debilitated by exposure to the cold air? its
excitability is thereby increased, and heat acts upon it with an
accumulated force: hence the frequency of catarrhs, pleurisies, and other
inflammatory fevers in the spring, after a cold winter; and of bilious
remittents in the autumn, when warm days succeed to cold and damp
nights. These diseases are seldom felt for the first time in the open
air, but generally after the body has been exposed to cold, and
afterwards to the heat of a warm room or a warm bed. Mild intermittents
have frequently been observed to acquire an inflammatory type in the
Pennsylvania hospital, in the months of November and December, from the
heat of the stove rooms acting upon bodies previously debilitated and
rendered excitable by cold and disease.
Has there been an abstraction of heat by a sudden shifting of the wind
from the south-west to the north-west or north-east points of the
compass, or by a cold night succeeding to a warm day? a fever is thereby
frequently excited. These sources of fever occur every autumn in
Philadelphia. The miasmata which exist in the body at that time in a
harmless state, are excited into action, in a manner to be mentioned
presently, by the debility from cold, aided in the latter case by the
inaction of sleep, suddenly induced upon the system.
Again: has the body been _suddenly_ debilitated by labour or exercise?
its excitement is thereby diminished, but its excitability is increased
in such a manner that a full meal, or an intemperate glass of wine, if
taken _immediately_ after the fatigue is induced upon the body, excites a
fever: hence the frequency of fevers in persons upon their return from
hunting, surveying, long rides, or from a camp life.
But how shall we account for the production of fever from the measles and
small-pox, which attack so uniformly, and without predisposing debility
from any of its causes which have been enumerated? I answer, that the
contagions of those diseases seldom act so as to produce fever, until the
system is first depressed. This is obvious from their being preceded by
languor, and all the other symptoms formerly mentioned, which constitute
the forming state of fever. The miasmata which induce the plague and
yellow fever, when they are not preceded by the usual debilitating and
predisposing causes, generally induce the same depression of the system,
previously to their exciting fever. Even wounds, and other local
irritants seldom induce fever before they have first produced the
symptoms of depression formerly mentioned. I shall presently mention the
exceptions to this mode of producing fever from contagious miasmata and
local injuries, and show that they do not militate against the truth of
the general proposition that has been delivered.
It may serve still further to throw light upon this part of our subject
to take notice of the difference between the action of stimuli upon the
body predisposed by debility and excitability to fever, and their action
upon it when there is no such predisposition to fever.
In health there is a constant and just proportion between the degrees of
excitement and excitability, and the force of stimuli. But this is not
the case in a predisposition to a fever. The ratio between the action of
stimuli and excitement, and excitability is destroyed; and hence the
former act upon the latter with a force which produces irregular action,
or a convulsion in the arterial system. When the body is debilitated, and
its excitability increased, either by fear, darkness, or silence, a
sudden noise occasions a short convulsion. We awake, in like manner, in a
light convulsion, from the sudden opening of a door, or from the
sprinkling of a few drops of water in the face, after the excitability of
the system has been accumulated by a night's sleep. In a word, it seems
to be a law of the system, that stimulus, in an over-proportion to
excitability, either produces convulsion, or goes so far beyond it, as to
destroy motion altogether in death.
V. There is but one exciting cause of fever, and that is stimulus. Heat,
alternating with cold[3], marsh and human miasmata, contagions and
poisons of all kinds, intemperance, passions of the mind, bruises, burns,
and the like, all act by a stimulating power only, in producing fever.
This proposition is of great application, inasmuch as it cuts the sinews
of the division of diseases from their remote causes. Thus it establishes
the sameness of a pleurisy, whether it be excited by heat succeeding
cold, or by the contagions of the small-pox and measles, or by the
miasmata of the yellow fever.
[3] Perhaps there is no greater enemy to the life of man than cold.
Dr. Sydenham ascribes nearly all fevers to it, particularly to
leaving off winter clothes too soon, and to exposing the body to
cold after it has been heated. These sources of fever, he adds,
destroy more than the plague, sword, or famine.--_Wallis's edition,
vol. I. p. 357._
To this proposition there is a seeming objection. Cold, sleep, immoderate
evacuations, and the debilitating passions of grief and fear (all of
which abstract excitement) appear to induce fever without the
interposition of a stimulus. In all these cases, the _sudden_ abstraction
of excitement destroys the equilibrium of the system, by which means the
blood is diverted from its natural channels, and by acting with
preternatural force in its new directions, becomes an irritant to the
blood-vessels, and thus a stimulating and exciting cause of fever. When
it is induced by cold alone, it is probable so much of the perspirable
matter may be retained as to co-operate, by its irritating qualities, in
exciting the fever.
VI. There is but one fever. However different the predisposing, remote,
or exciting causes of fever may be, whether debility from abstraction or
action, whether heat or cold succeeding to each other, whether marsh or
human miasmata, whether intemperance, a fright, or a fall, still I
repeat, there can be but one fever. I found this proposition upon all the
supposed variety of fevers having but one proximate cause. Thus fire is a
unit, whether it be produced by friction, percussion, electricity,
fermentation, or by a piece of wood or coal in a state of inflammation.
VII. All ordinary fever being seated in the blood-vessels, it follows, of
course, that all those local affections we call pleurisy, angina,
phrenitis, internal dropsy of the brain, pulmonary consumption, and
inflammation of the liver, stomach, bowels, and limbs, are symptoms only
of an original and primary disease in the sanguiferous system. The truth
of this proposition is obvious from the above local affections
succeeding primary fever, and from their alternating so frequently with
each other. I except from this remark those cases of primary affections
of the viscera which are produced by local injuries, and which, after a
while, bring the whole sanguiferous system into sympathy. These cases are
uncommon, amounting, probably, to not more than one in a hundred of all
the cases of local affection which occur in general fever.
In my 4th proposition I have called the action of the arteries
_irregular_ in fever, to distinguish it from that excess of action which
takes place after violent exercise, and from that quickness which
accompanies fear or any other directly debilitating cause. The action of
the arteries here is _regular_, and, when felt in the pulse, affords a
very different sensation from that _jerking_ which we feel in the pulse
of a patient labouring under a fever.
This irregular action is, in other words, a _convulsion_ in the
sanguiferous, but more obviously, in the arterial system.
That this is the case I infer from the strict analogy between symptoms of
fever, and convulsions in the nervous system. I shall briefly mention the
particulars in which this analogy takes place.
1. Are convulsions in the nervous system preceded by debility? So is the
convulsion of the blood-vessels in fever.
2. Does debility induced on the whole, or on a part only, of the nervous
system, predispose to general convulsions, as in tetanus? So we observe
debility, whether it be induced on the whole or on a part of the arterial
system, predisposes to general fever. This is obvious in the fever which
ensues alike from cold applied to every part of the body, or from a
stream of cold air falling upon the neck, or from the wetting of the
feet.
3. Do tremors precede convulsions in the nervous system? So they do the
convulsion of the blood-vessels in fever.
4. Is a coldness in the extremities a precursor of convulsions in the
nervous system? So it is of fever.
5. Do convulsions in the nervous system impart a jerking sensation to the
fingers? So does the convulsion of fever in the arteries, when felt at
the wrists.
6. Are convulsions in the nervous system attended with alternate action
and remission? So is the convulsion of fever.
7. Do convulsions in the nervous system return at regular and irregular
periods? So does fever.
8. Do convulsions in the nervous system, under certain circumstances,
affect the functions of the brain? So do certain states of fever.
9. Are there certain convulsions in the nervous system which affect the
limbs, without affecting the functions of the brain, such as tetanus, and
chorea sancti viti? So there are certain fevers, particularly the common
hectic, which seldom produces delirium, or even head-ach, and frequently
does not confine a patient to his bed.
10. Are there local convulsions in the nervous system, as in the hands,
feet, neck, and eye-lids? So there are local fevers. Intermittents often
appear in the autumn with periodical heat and pains in the eyes, ears,
jaws, and back.
11. Are there certain grades in the convulsions of the nervous system, as
appears in the hydrophobia, tetanus, epilepsy, hysteria, and
hypochondriasis? So there are grades in fevers, as in the plague, yellow
fever, small-pox, rheumatism, and common remitting and intermitting
fevers.
12. Are nervous convulsions most apt to occur in infancy? So are fevers.
13. Are persons once affected with nervous convulsions frequently subject
to them through life? So are persons once affected with fever. The
intermitting fever often returns with successive springs or autumns, and,
in spite of the bark, sometimes continues for many years in all climates
and seasons.
14. Is the strength of the nervous system increased by convulsions? This
is so evident that it often requires four or five persons to confine a
delicate woman to her bed in a convulsive fit. In like manner the
strength of the arterial system is increased in a fever. This strength is
great in proportion to the weakness of every other part of the body.
15. Do we observe certain nervous convulsions to affect some parts of the
nervous system more than others, or, in other words, do we observe
preternatural strength or excitement to exist in one part of the nervous
system, while other parts of the same system exhibit marks of
preternatural weakness or defect of excitement? We observe the same thing
in the blood-vessels in a fever. The pulse at the wrist is often _tense_,
while the force of the heart is very much diminished. A delirium often
occurs in a fever from excess of excitement in the blood-vessels of the
brain, while the pulse at the wrist exhibits every mark of preternatural
weakness.
16. Is there a rigidity of the muscles in certain nervous diseases, as in
catalepsy? Something like this solstice in convulsion occurs in that
state of fever in which the pulse beats but sixty, or fewer strokes in a
minute.
17. Do convulsions go off _gradually_ from the nervous system, as in
tetanus, and chorea sancti viti? So they do from the arterial
blood-vessels in certain states of fever.
18. Do convulsions go off _suddenly_ in any cases from the nervous
system? The convulsion in the blood-vessels goes off in the same manner
by a sweat, or by a hæmorrhage, frequently in the course of a night, and
sometimes in a single hour.
19. Does palsy in some instances succeed to convulsions in the nervous
system? Something like a palsy occurs in fevers of great inflammatory
action in the arteries. They are often inactive in the wrists, and in
other parts of the body, from the immense pressure of the remote cause of
the fever upon them.
From the facts and analogies which have been mentioned, I have been led
to conclude that the common forms of fever are occasioned simply by
irregular action, or convulsion in the blood-vessels.
The history of the phenomena of fever, as delivered in the foregoing
pages, resolves itself into a chain, consisting of the five following
links.
1. Debility from action, or the abstraction of stimuli. When this
debility is induced by action, it is sometimes preceded by elevated
excitement in the blood-vessels, from the first impressions of stimuli
upon them.
2. An increase of their excitability.
3. Stimulating powers applied to them.
4. Depression. And,
5. Irregular action or convulsion.
The whole of the links of this chain are perceptible only when the fever
comes on in a _gradual_ manner. But I wish the reader to remember, that
the same remote cause is often debilitating, stimulating, and depressing,
and that, in certain fevers, the remote cause sometimes excites
convulsions in the blood-vessels without being preceded by preternatural
debility and excitability, and with but little or no depression of the
system. This has often been observed in persons who have been suddenly
exposed to those marsh and human miasmata which produce malignant fevers.
It sometimes takes place likewise in fevers induced by local injuries.
The blood-vessels in these cases are, as it were, taken by storm, instead
of regular approaches.
I might digress here, and show that all diseases, whether they be seated
in the arteries, muscles, nerves, brain, or alimentary canal, are all
preceded by debility; and that their essence consists in irregular
action, or in the absence of the natural order of motion, produced or
invited by predisposing debility. I might further show, that all the
moral, as well as physical evil of the world consists in predisposing
weakness, and in subsequent derangement of action or motion; but these
collateral subjects are foreign to our present inquiry.
Let us now proceed to examine how far the theory which has been delivered
accords with the phenomena of fever.
I shall divide these phenomena into two kinds.
I. Such as are transient, and more or less common to all fevers. These I
shall call _symptoms_ of fever.
II. Such as, being more permanent and fixed, have given rise to certain
specific names. These I shall call _states_ of fever.
I shall endeavour to explain and describe each of them in the order in
which they have been mentioned.
I. Lassitude is the effect of the depression of the whole system, which
precedes fever.
The same cause, when it acts upon the extremities of the blood-vessels,
produces coldness and chills. This is obvious to any person, under the
first impression of the miasmata which bring on fevers, also under the
influence of fatigue, and debilitating passions of the mind. The absence
of chills indicates the sensibility of the external parts of the body to
be suspended or destroyed, as well as their irritability; hence when
death occurs in the fit of an intermittent, there is no chill. A chilly
fit, for the same reason, seldom occurs in the most malignant cases of
fever. It is sometimes excited by blood-letting, only because it weakens
those fevers to such a degree, as to carry the blood-vessels back to the
grade of depression. Coldness and chills are likewise removed by
blood-letting, only because it enables the arteries to re-act in such a
manner as to overcome the depression that induced it. It has been
remarked, that the chilly fit, in common fevers, seldom appears in its
full force until the patient approaches a fire, or lies down on a warm
bed; for in these situations sensibility is restored by the stimulus of
the heat acting upon the extremities of the blood-vessels. The first
impressions of the rays of the sun, in like manner, often produce
coldness and chills in the torpid bodies of old and weakly people.
Tremors are the natural consequence of the abstraction of that support
which the muscles receive from the fulness and tension of the
blood-vessels. It is from this retreat of the blood towards the viscera,
that the capillary arteries lose their fulness and tension; hence they
contract like other soft tubes that are emptied of their contents. This
contraction has been called a spasm, and has improperly been supposed to
be the proximate cause of fever. From the explanation that has been given
of its cause, it appears, like the coldness and chills, to be nothing but
an accidental concomitant, or effect of a paroxysm of fever.
The local pains in the head, breast, and bones in fever, appear to be the
effects of the irregular determination of the blood to those parts, and
to morbid action being thereby induced in them.
The want of appetite and costiveness are the consequences of a defect of
secretion of the gastric juice, and the abstraction of excitement or
natural action from the stomach and bowels.
The inability to rise out of bed, and to walk, is the effect of the
abstraction of excitement from the muscles of the lower limbs.
The dry skin or partial sweats appear to depend upon diminished or
partial action in the vessels which terminate on the surface of the
body.
The high-coloured and pale urine are occasioned by an excess or a
deficiency of excitement in the secretory vessels of the kidneys.
The suppression of the urine seems to arise from what Dr. Clark calls an
engorgement, or choaking of the vessels of the kidneys. It occurs most
frequently in malignant fevers.
Thirst is probably the effect of a preternatural excitement of the
vessels of the fauces. It is by no means a uniform symptom of fever. We
sometimes observe it, in the highest degree, in the last stage of
diseases, induced by the retreat of the last remains of excitement from
every part of the body, to the throat.
The white tongue is produced by a change in the secretion which takes
place in that organ. Its yellow colour is the effect of bile; its dryness
is occasioned by an obstruction of secretion, or by the want of action in
the absorbents; and its dark and black colour, by a tendency to
mortification.
It will be difficult to account for the variety in the degrees and
locality of _heat_ in the body in a fever, until we know more of the
cause of animal heat. From whatever cause it be derived, its excess and
deficiency, as well as all its intermediate degrees, are intimately
connected with more or less excitement in the arterial system. It is not
necessary that this excitement should exist only in the large
blood-vessels. It will be sufficient for the purpose of creating great
heat, if it occur only in the cutaneous vessels; hence we find a hot skin
in some cases of malignant fever in which there is an absence of pulse.
Eruptions seem to depend upon effusions of serum, lymph, or red blood
upon the skin, with or without inflammation, in the cutaneous vessels.
I decline taking notice in this place of the symptoms which are produced
by the debility from action and abstraction, and by the depression of the
system. They appear not only in the temperature of the body, but in all
the different symptoms of fever. It is of importance to know when they
originate from the former, and when from the latter causes, as they
sometimes require very different and opposite remedies to remove them.
It remains only to explain the cause why excess in the force or frequency
of the action of the blood-vessels should succeed debility in a part, or
in the whole of the body, and be connected for days and weeks with
depression and preternatural debility in the nerves, brain, muscles, and
alimentary canal. I shall attempt the explanation of this phenomenon by
directing the attention of the reader to the operations of nature in
other parts of her works.
1. A calm may be considered as a state of debility in the atmosphere. It
predisposes to a current of air. But is this current proportioned to the
loss of the equilibrium of the air? By no means. It is excessive in its
force, and tends thereby to destroy the works both of nature and art.
2. The passions are given to man on purpose to aid the slow and uncertain
operations of reason. But is their action always proportioned to the
causes which excite them? An acute pneumony, brought on by the trifling
injury done to the system by the fatigue and heat of an evening spent in
a dancing assembly, is but a faint representation of the immense
disproportion between a trifling affront, and that excess of passion
which seeks for gratification in poison, assassination, or a duel. The
same disproportion appears between cause and effect in public bodies. A
hasty word, of no mischievous influence, has often produced convulsions,
and even revolutions, in states and empires.
If we return to the human body we shall find in it many other instances
of the disproportion between stimulus and action, besides that which
takes place in the excitement of fever.
3. A single castor oil nut, although rejected by the stomach upon its
first effort in vomiting, has, in one instance that came within my
knowledge, produced a vomiting that continued nearly four and twenty
hours. Here the duration of action was far beyond all kind of proportion
to the cause which excited it.
4. A grain of sand, after being washed from the eye, is often followed by
such an inflammation or excess in the action of the vessels of the eye,
as to require bleeding, purging, and blistering to remove it.
Could we comprehend every part of the sublime and ineffable system of the
divine government, I am sure we should discover nothing in it but what
tended ultimately to order. But the natural, moral, and political world
exhibit every where marks of disorder, and the instruments of this
disorder, are the operations of nature. Her influence is most obvious in
the production of diseases, and in her hurtful or ineffectual efforts to
remove them[4]. In again glancing at this subject I wish it to be
remembered that those operations were not originally the means of
injuring or seducing man, and that I believe a time will come when the
exact relation, between cause and effect, or, in other words, the
dominion of order shall be restored over every action of his body and
mind, and health and happiness again be the result of every movement of
nature.
[4] See the Comparative View of the Diseases of the Indians and of
Civilized Nations. Vol. I.
From the view I have given of the state of the blood-vessels in fever,
the reader will perceive the difference between my opinions and Dr.
Brown's upon this subject. The doctor supposes a fever to consist in
debility. I do not admit debility to be a disease, but place it wholly in
morbid excitement, invited and fixed by previous debility. He makes a
fever to consist in a change only of a _natural_ action of the
blood-vessels. I maintain that it consists in a _preternatural_ and
convulsive action of the blood-vessels. Lastly, Dr. Brown supposes
excitement and excitability to be _equally_ diffused over the whole body,
but in unhealthy proportions to each other. My theory places fever in
excitement and excitability _unequally_ diffused, manifesting themselves,
at the _same time_, in morbid actions, depression, and debility from
abstraction, in different parts of the body. No new excitement from
without is infused into the system by the irritants which excite a fever.
They only destroy its equal and natural distribution; for while the
arteries are in a plus, the muscles, stomach, and bowels are in a minus
state of excitement, and the business of medicine is to equalize it in
the cure of fever, that is, to abstract its excess from the
blood-vessels, and to restore it to the other parts of the body.
II. I come now to apply the theory which I have delivered to the
explanation and description of the different phenomena or states of
fever.
I have said in my sixth proposition that there is but one fever. Of
course I do not admit of its artificial division into genera and species.
A disease which so frequently changes its form and place, should never
have been designated, like plants and animals, by unchangeable
characters. The oak tree and the lion possess exactly the same properties
which they did nearly 6000 years ago. But who can say the same thing of
any one disease? The pulmonary consumption is sometimes transformed into
head-ach, rheumatism, diarrh[oe]a, and mania, in the course of two or
three months, or the same number of weeks. The bilious fever often
appears in the same person in the form of colic, dysentery, inflammation
of the liver, lungs, and brain, in the course of five or six days. The
hypochondriasis and the hysteria seldom fail to exchange their symptoms
twice in the four and twenty hours. Again: the oak tree has not united
with any of the trees of the forest, nor has the lion imparted his
specific qualities to any other animal. But who can apply similar remarks
to any one disease? Phrenitis, gastritis, enteritis, nephritis, and
rheumatism all appear at the same time in the gout and yellow fever. Many
observations of the same kind might be made, to show the disposition of
nearly all other diseases to anastomose with each other. To describe them
therefore by any fixed or specific characters is as impracticable as to
measure the dimensions of a cloud on a windy day, or to fix the component
parts of water by weighing it in a hydrostatic balance. Much mischief
has been done by nosological arrangements of diseases. They erect
imaginary boundaries between things which are of a homogeneous nature.
They degrade the human understanding, by substituting simple perceptions
to its more dignified operations in judgment and reasoning. They gratify
indolence in a physician, by fixing his attention upon the name of a
disease, and thereby leading him to neglect the varying state of the
system. They moreover lay a foundation for disputes among physicians, by
diverting their attention from the simple, predisposing, and proximate,
to the numerous, remote, and exciting causes of diseases, or to their
more numerous and complicated effects. The whole materia medica is
infected with the baneful consequences of the nomenclature of diseases,
for every article in it is pointed only against their names, and hence
the origin of the numerous contradictions among authors who describe the
virtues and doses of the same medicines. By the rejection of the
artificial arrangement of diseases, a revolution must follow in medicine.
Observation and judgment will take the place of reading and memory, and
prescriptions will be conformed to existing circumstances. The road to
knowledge in medicine by this means will likewise be shortened; so that a
young man will be able to qualify himself to practise physic at as much
less expence of time and labour than formerly, as a child would learn to
read and write by the help of the Roman alphabet, instead of Chinese
characters.
In thus rejecting the nosologies of the schools, I do not wish to see
them banished from the libraries of physicians. When consulted as
histories of the effects of diseases only, they may still be useful. I
use the term diseases, in conformity to custom, for, properly speaking,
disease is much a unit as fever. It consists simply of morbid action or
excitement in some part of the body. Its different seats and degrees
should no more be multiplied into different diseases, than the numerous
and different effects of heat and light upon our globe should be
multiplied into a plurality of suns.
The advocates for Dr. Cullen's system of medicine will not, I hope, be
offended by these observations. His immense stock of reputation will
enable him to sustain the loss of his nosology without being impoverished
by it. In my attempts to introduce a new arrangement of fevers, I shall
only give a new direction to his efforts to improve the healing art.
Were it compatible with the subject of the present inquiry, it would be
easy to show, that the same difficulties and evils are to be expected
from Dr. Darwin's division of diseases, as they affect the organs of
sensation and motion, and as they are said to be exclusively related by
association and volition, that have been deprecated from their divisions
and subdivisions by the nosologists. Diseases, like vices, with a few
exceptions, are necessarily undisciplined and irregular. Even the genius
of Dr. Darwin has not been able to compel them to move within lines.
I return from this digression to remark that morbid action in the
blood-vessels, whether it consist in preternatural force and frequency,
or preternatural force without frequency, or frequency without force,
constitutes fever. Excess in the force and frequency in the pulsations of
the arteries have been considered as the characteristic marks of what is
called inflammatory fever. There are, however, symptoms which indicate a
much greater excess of irritating impressions upon the blood-vessels.
These are preternatural slowness, intermissions, and depression in the
pulse, such as occur in certain malignant fevers.
But there is a grade of fever, which transcends in force that which
produces inflammation. It occurs frequently in hydrophobia, dysentery,
colic, and, baron Humboldt lately informed me, upon the authority of Dr.
Comoto, of Vera Cruz, in the yellow fever of that city, when it proves
fatal in a few hours after it attacks. In vain have physicians sought to
discover, by dissections, the cause of fever in those cases, when
followed by death, in the parts of the body in which it was supposed,
from pain and other symptoms, to be principally seated. Those parts have
frequently exhibited no marks of inflammation, nor of the least deviation
from a healthy state. I have ascribed this apparent absence of disease to
the serous vessels being too highly excited, and thereby too much
contracted, to admit the entrance of red blood into them. I wish these
remarks to be remembered by the student of medicine. They have delivered
me from the influence of several errors in pathology; and they are
capable, if properly extended and applied, of leading to many important
deductions in the practice of physic.
I shall now briefly mention the usual effects of fever, or morbid
excitement in the blood-vessels, when not removed by medicine. They are,
1. Inflammation. It is produced by an effusion of red particles of blood
into serous vessels, constituting what Dr. Boerhaave calls error loci. It
is the second grade of fever, and, in fevers of great violence, does not
take place until morbid excitement has continued for some time, or has
been reduced by bleeding.
2. Secretion, or an effusion from rupture, of the serum of the blood,
constituting dropsies.
3. Secretion of lymph or fibrin, forming a membrane which adheres to
certain surfaces in the body.
4. Secretion of pus, also of sloughs.
5. An effusion by rupture, or a congestion of all the component parts of
the blood.
6. Gangrene from the death of the blood-vessels.
7. Rupture of blood-vessels, producing hæmorrhage.
8. Redness, phlegmon, pustules, and petechiæ on the skin, and tubercles
in the lungs, and on the liver and bowels.
9. Schirrus.
10. Calcareous and other earthy matters. Both these take place only in
the feeble and often imperceptible grades of morbid action in the
blood-vessels.
11. Death. This arises from the following causes.
1. Sudden destruction of the excitability of the blood-vessels.
2. A disorganization of parts immediately necessary to life.
3. A change in the fluids, so as to render them destructive to what are
called the vital organs.
4. Debility, from the exhausted or suspended state of the excitability of
the blood-vessels.
All these effects of fever are different according to its grade. Dr.
Blane says fevers are rarely inflammatory in the West-Indies; that is,
they pass rapidly from simple morbid excitement to congestion,
hæmorrhage, gangrene, and death. This remark is confirmed by Dr.
Dalzelle, who says the pneumony in the negroes, in the French West-India
islands, rarely appears in any other form than that of the notha, from
the arteries in the lungs being too much stimulated to produce common
inflammation; but such is the force of morbid excitement in hot climates,
that it sometimes passes suddenly over all its intermediate effects, and
discovers itself only in death. This appears to have taken place in the
cases at Vera Cruz, mentioned by baron Humboldt.
All the different states of fever may be divided,
I. Into such as affect the whole arterial system; but with no, or very
little local disease.
II. Into such as affect the whole arterial system, and are accompanied at
the same time with evident local disease.
III. Into such as appear to pass by the arterial system, and to fix
themselves upon other parts of the body. I shall call these states of
fever _misplaced_.
I. To the first class of the states of fever belong,
1. The malignant. It constitutes the highest grade of morbid diathesis.
It is known by attacking frequently without a chilly fit, by coma, a
depressed, slow, or intermitting pulse, and sometimes by the absence of
pain, and with a natural temperature or coldness of the skin. It occurs
in the plague, in the yellow fever, in the gout, in the small-pox and
measles, in the hydrophobia, and after taking opium and other stimulating
substances. Dr. Quier has described a pleurisy in Jamaica, in which some
of those malignant symptoms took place. They are the effect of such a
degree of impression as to prostrate the arterial system, and to produce
a defect of action from an excess of force. Such is this excess of force,
in some instances, in this state of fever, that it induces general
convulsions, tetanus, and palsy, and sometimes extinguishes life in a few
hours, by means of apoplexy or syncope. From its being accompanied with
these symptoms, it has received the name of _adynamique_ by Dr. Alibert.
The less violent degrees of stimulus in this state of fever produce palsy
in the blood-vessels. It probably begins in the veins, and extends
gradually to the arteries. It seems further to begin in the extremities
of the arteries, and to extend by degrees to their origin in the heart.
This is evident in the total absence of pulse which sometimes takes place
in malignant fevers, four and twenty, and even eight and forty hours
before death. But there are cases in which this palsy affects both the
veins and arteries at the same time. It is probably from this
simultaneous affection of the blood-vessels, that the arteries are found
to be nearly full of blood after death from malignant fevers. The
depressed, and intermitting pulse which occurs in the beginning of these
fevers perhaps depends upon a tendency to palsy in the arteries,
independently of an affection of the heart or brain.
This _prostrate_ state of fever more frequently when left to itself
terminates in petechiæ, buboes, carbuncles, abscesses, and
mortifications, according as serum, lymph, or red blood is effused in the
viscera or external parts of the body. These morbid appearances have been
ascribed to putrefaction, and the fever has received, from its supposed
presence, the name of putrid. The existence of putrefaction in the blood
in a fever is rendered improbable,