place in the blood in a living state. It occurs in the excretions of
bile, fæces, and urine, but in this case it does not act as a ferment,
but a stimulus only upon the living body.
[5] Inaugural dissertation, entitled, "An Attempt to disprove the
Putrefaction of the Blood in Living Animals."
2. By similar appearances, with those which have been ascribed to
putrefaction, having been produced by lightning, by violent emotions of
the mind, by extreme pain, and by every thing else which induces sudden
and universal disorganization in the fluids and solids of the body. The
following facts clearly prove that the symptoms which have been supposed
to designate a putrid fever, are wholly the effect of mechanical action
in the blood-vessels, and are unconnected with the introduction of a
putrid ferment in the blood.
Hippocrates relates the case of a certain Antiphillus, in whom a putrid
bilious fever (as he calls it) was brought on by the application of a
caustic to a wound[6].
[6] Epidemics, book iv.
An acute pain in the eye, Dr. Physick informed me, produced the symptoms
of what is called a putrid fever, which terminated in death in five days,
in St. George's hospital, in the year 1789.
Dr. Baynard relates, upon the authority of a colonel Bampfield, that a
stag, which he had chased for some time, stopped at a brook of water in
order to drink. Soon afterwards it fell and expired. The colonel cut its
throat, and was surprised to perceive the blood which issued from it had
a putrid and offensive smell[7].
Dr. Desportes takes notice that a fish, which he calls a sucker, affected
the system nearly in the same manner as the miasmata of the yellow fever.
A distressing vomiting, a coldness of the extremities, and an absence of
pulse, were some of the symptoms produced by it, and an inflammation and
mortification of the stomach and bowels, were discovered after death to
be the effects of its violent operation.
Even opium, in large doses, sometimes produces by its powerful stimulus
the same symptoms which are produced by the stimulus of marsh miasmata.
These symptoms are a slow pulse, coma, a vomiting, cold sweats, a sallow
colour of the face, and a suppression of the discharges by the urinary
passages and bowels.
Error is often perpetuated by words. A belief in the putrefaction of the
blood has done great mischief in medicine. The evil is kept up, under the
influence of new theories, by the epithet putrid, which is still applied
to fever in all our medical books. For which reason I shall reject it
altogether hereafter, and substitute in its room.
[7] Treatise on the Cold Bath.
2. The _gangrenous_ state of fever; for what appear to some physicians to
be signs of putrefaction, are nothing but the issue of a violent
inflammation left in the hands of nature, or accelerated by stimulating
medicines. Thus the sun, when viewed at mid-day, appears to the naked
eye, from the excess of its splendour, to be a mass of darkness, instead
of an orb of light.
The same explanation of what are called putrid symptoms in fever, is very
happily delivered by Mr. Hunter in the following words: "It is to be
observed (says this acute physiologist) that when the attack upon these
organs, which are principally connected with life, proves fatal, that the
effects of the inflammation upon the constitution run through all the
stages with more rapidity than when it happens in other parts; so that at
its very beginning, it has the same effect upon the constitution which is
only produced by the second stage of inflammation in other parts[8]."
[8] Treatise on Inflammation. chap. I. 8.
3. The _synocha_, or the common inflammatory state of fever, attacks
suddenly with chills, and is succeeded by a quick, frequent, and tense
pulse, great heat, thirst, and pains in the bones, joints, breast, or
sides. These symptoms sometimes occur in the plague, the jail and yellow
fever, and the small-pox; but they are the more common characteristics of
pleurisy, gout, and rheumatism. They now and then occur in the influenza,
the measles, and the puerperile fever.
4. The _synochus_ state of fever is known by a full, quick, and round
pulse without tension. The autumnal bilious fever and colic, also the
gout, often appear in this form.
5. There is a state of fever in which the pulse is small, but tense and
quick. The patient, in this state of fever, is seldom confined to his
bed. We observe it sometimes in the chronic rheumatism, and in pulmonary
consumption. The inflammatory state of this grade of fever is proved from
the inefficacy of the volatile tincture of guaiacum and other stimulants
to remove it, and from its yielding so suddenly to blood-letting. I have
called it the _synochula_ state of fever.
6. There is a state of fever inclining more to the synocha, than what is
called the typhus, or low chronic state of fever. I have called it the
_synochoid_ state of fever.
7. The _typhus_ state of fever is generally preceded by all those
circumstances which debilitate the system, both by the action and
abstraction of stimuli. It is known by a weak and frequent pulse, a
disposition to sleep, a torpor of the alimentary canal, tremors of the
hands, a dry tongue, and, in some instances, by a diarrh[oe]a. These
symptoms occur most frequently in what is called the jail, the ship, and
the hospital fever. I heard of it in a few cases in the yellow fever of
1793, and all writers take notice of cases of the plague, which run on
into a slow fever that continues 30 or 40 days. I have seen it succeed
the common bilious fever, pleurisy, and influenza. It has been confounded
with the malignant state of fever, or what is called the typhus gravior;
but it differs widely from it in being accompanied by a feeble excitement
in the blood-vessels, from a feeble stimulus, and by the usual signs of
debility from abstraction in every other part of the body.
From the accession of new stimuli, or an increase in the force of former
ones, this typhus state of fever sometimes assumes, on the 11th, 14th,
and even 20th days, the symptoms of the synocha state of fever. It will
be useful to remember this remark, not only because it establishes the
unity of fever, but because it will justify the use of a remedy, seldom
prescribed after the disease has acquired that name which associates it
with stimulating medicines.
The common name of this state of fever, is the _nervous_ fever. This name
is improper; for it invades the nervous system by pain, delirium, and
convulsions much less than several other states of fever. To prevent the
absurd and often fatal association of ideas upon the treatment of this
state of fever, I have called it, from its duration, the _low chronic_
state of fever. I have adopted the term _low_, from Dr. Butter's account
of the remitting fever of children, in order to distinguish it from
states of fever to be mentioned hereafter, in which the patient is not
confined to his bed. This new name of the typhus or nervous fever
establishes its analogy with several other diseases. We have the acute
and the chronic rheumatism; the acute and chronic pneumony, commonly
called the pleurisy and pulmonary consumption; the acute and chronic
inflammation of the brain, known unfortunately by the unrelated names of
phrenitis, madness, and internal dropsy of the brain. Why should we
hesitate, in like manner, in admitting acute and chronic fever, in all
those cases where no local inflammation attends?
8. The _typhoid_ state of fever is composed of the synocha and low
chronic states of fever. It is the _slow_ nervous fever of Dr. Butter.
The excitement of the blood-vessels is somewhat greater than in the _low_
chronic state of fever. Perhaps the muscular fibres of the blood-vessels,
in this state of fever, are affected by different degrees of stimulus and
excitement. Supposing a pulse to consist of eight cords, I think I have
frequently felt more or less of them tense or relaxed, according as the
fever partook more or less of the synocha, or low chronic states of
fever. This state of fever occurs most frequently in what are called the
hectic and puerperal fevers, and in the scarlatina.
9. The _hectic_ state of fever differs from all the other states of
fever, by the want of regularity in its paroxysms, in which chills,
fevers, and sweats are included; and by the brain, nerves, muscles, and
alimentary canal being but little impaired in their functions by it. It
appears to be an exclusive disease of the blood-vessels. It occurs in the
pulmonary consumption, in some cases of lues, of scrophula, and of the
gout, and after most of the states of fever which have been described.
The force of the pulse is various, being occasionally synochoid, typhoid,
and typhus.
10. Intermissions, or the _intermitting_ and remitting states of fever,
are common to all the states of fever which have been mentioned. But they
occur most distinctly and universally in those which partake of the
bilious diathesis. They have been ascribed to the reproduction of bile,
to the recurrence of debility, and to the influence of the heavenly
bodies upon the system. None of these hypotheses has explained the
recurrence of fever, where the bile has not been in fault, where debility
is uniform, and where the paroxysms of fever do not accord with the
revolutions of any part of the solar system. I have endeavoured to
account for the recurrence of the paroxysm of fever, in common with all
other periodical diseases, by means of a natural or adventitious
association of motions. Dr. Percival has glanced at this law of animal
matter; and Dr. Darwin has explained by it, in the most ingenious manner,
many natural and morbid actions in the human body.
11. There is a state of fever in which the morbid action of the
blood-vessels is so feeble as scarcely to be perceptible. Like the
hectic state of fever, it seldom affects the brain, nerves, muscles, or
alimentary canal. It is known in the southern states of America by the
name of _inward_ fevers. The English physicians formerly described it by
the name of febricula.
These eleven states of fever may be considered as _primary_ in their
nature. All the states which remain to be enumerated belong to some one
of them, or they are compounds of two, three, or more of them. Even these
primary states of fever seldom appear in the simple form in which they
have been described. They often blend their symptoms; and sometimes all
the states appear at different times in the course of a fever. This
departure from a uniformity in the character of fevers must be sought for
in the changes of the weather, in the casual application of fresh
irritants, or in the operation of the remedies which have been employed
to cure them.
To the first class of the states of fever belong the sweating, the
fainting, the burning, and the cold and chilly states of fever.
12. The _sweating_ state of fever occurs in the plague, in the yellow
fever, in the small-pox, the pleurisy, the rheumatism, and in the hectic
and intermitting states of fever. Profuse sweats appeared every other day
in the autumnal fever of 1795 in Philadelphia, without any other symptom
of an intermittent. The English sweating sickness was nothing but a
symptom of the plague. The sweats in all these cases are the effects of
morbid and excessive action, concentrated in the capillary vessels.
13. The _fainting_ state of fever accompanies the plague, the yellow
fever, the small-pox, and some states of pleurisy. It is the effect of
great depression; hence it occurs most frequently in the beginning of
those states of fever.
14. The _burning_ state of fever has given rise to what has been called a
species of fever. It is the causus of authors. Dr. Mosely, who rejects
the epithet of yellow, when applied to the bilious fever, because it is
only one of its accidental symptoms, very improperly distinguishes the
same fever by another symptom, viz. the burning heat of the skin, and
which is not more universal than the yellowness which attends it.
15. The _cold_ and _chilly_ state of fever differs from a common chilly
fit, by continuing four or five days, and to such a degree, that the
patient frequently cannot bear his arms out of the bed. The coldness is
most obstinate in the hands and feet. A _coolness_ only of the skin
attends in some cases, which is frequently mistaken for an absence of
fever.
Having mentioned those states of fever which affect the arterial system
without any, or with but little local disease, I proceed next to
enumerate those states of fever which belong to the
II. Class of the order that was mentioned, in which there are local
affections combined with general fever. They are,
16. The _intestinal_ state of fever. I have been anticipated in giving
this epithet to fever, by Dr. Balfour[9]. It includes the cholera morbus,
diarrh[oe]a, dysentery, and colic. The remitting bilious fever appears,
in all the above forms, in the summer months. They all belong to the
febris introversa of Dr. Sydenham. The jail fever appears likewise
frequently in the form of diarrh[oe]a and dysentery. The dysentery is the
offspring of marsh and human miasmata, but it is often induced in a weak
state of the bowels, by other exciting causes. The colic occasionally
occurs with states of fever to be mentioned hereafter.
[9] Account of the Intestinal Remitting Fever of Bengal.
17. The _pulmonary_ state of fever includes the true and bastard pneumony
in their acute forms; also catarrh from cold and influenza, and the
chronic form of pneumony in what is called pulmonary consumption.
18. The _eruptive_ state of fever includes the small-pox, measles,
erysipelas, miliary fever, chicken-pox, and pemphigus.
19. The _anginose_ state of fever includes all those affections of the
throat which are known by the names of cynanche inflammatoria,
tonsillaris, parotidea, maligna, scarlatina, and trachealis. The cynanche
trachealis is a febrile disease. The membrane which produces suffocation
and death in the wind-pipe is the effect of inflammation. It is said to
be formed, like other membranes which succeed inflammation, from the
coagulable lymph of the blood.
20. The _rheumatic_ state of fever is confined chiefly to the labouring
part of mankind. The topical affection is seated most commonly in the
joints and muscles, which, from being exercised more than other parts of
the body, become more debilitated, and are, in consequence thereof,
excited into morbid and inflammatory action.
21. The _arthritic_ or _gouty_ state of fever differs from the rheumatic,
in affecting, with the joints and muscles, all the nervous and lymphatic
systems, the viscera, and the skin. Its predisposing, exciting, and
proximate causes are the same as the rheumatic and other states of fever.
It bears the same ratio to rheumatism, which the yellow fever bears to
the common bilious fever. It is a fever of more force than rheumatism.
22. The _cephalic_, in which are included the phrenitic, lethargic,
apoplectic, paralytic, hydrocephalic, and maniacal states of fever. That
madness is originally a state of fever, I infer, 1. From its causes, many
of which are the same as those which induce all the other states of
fever. 2. From its symptoms, particularly a full, tense, quick, and
sometimes a slow pulse. 3. From the inflammatory appearances of the blood
which has been drawn to relieve it. And, 4. From the phenomena exhibited
by dissection in the brains of maniacs, being the same as are exhibited
by other inflamed viscera after death. These are, effusions of water or
blood, abscesses, and schirrus. The hardness in the brains of maniacs,
taken notice of by several authors, is nothing but a schirrus (sui
generis), induced by the neglect of sufficient evacuations in this state
of fever. The reader will perceive by these observations, that I reject
madness from its supposed primary seat in the mind or nerves. It is as
much an original disease of the blood-vessels, as any other state of
fever. It is to phrenitis, what pulmonary consumption is to pneumony. The
derangement in the operations of the mind is the effect only of a chronic
inflammation of the brain, existing without an abstraction of muscular
excitement.
23. The _nephritic_ state of fever is often induced by calculi, but it
frequently occurs in the gout, small-pox, and malignant states of fever.
There is such an engorgement, or choaking of the vessels of the kidneys,
that the secretion of the urine is sometimes totally obstructed, so that
the bladder yields no water to the catheter. It is generally accompanied
with a full or tense pulse, great pain, sickness, or vomiting, high
coloured urine, and a pain along the thigh and leg, with occasionally a
retraction of one of the testicles. It exists sometimes without any pain.
Of this I met with several instances in the yellow fever of 1793. I
include diabetes in this state of fever.
24. The _hydropic_ state of fever, in which are included collections of
water, in the lungs, cavity of the thorax, cavity of the abdomen, ovaria,
scrotum, testicles, and lower extremities, and usually preceded, and
generally accompanied with morbid action in the blood-vessels. That
dropsy is a state of fever, I have endeavoured to prove in another
place[10]. Nineteen dropsies out of twenty appear to be original arterial
diseases, and the water, which has been supposed to be their cause, is as
much the effect of preternatural and morbid action in the blood-vessels,
as pus, gangrene, and schirrus are of previous inflammation. This has
been demonstrated, by the late Dr. Cooper, in a man who died of an
ascites in the Pennsylvania hospital. Pus and blood, as well as water,
were found in the cavity of the abdomen. It is no objection to this
theory of dropsy, that we sometimes find water in the cavities of the
body after death, without any marks of inflammation in the contiguous
blood-vessels. We often find pus, both in the living and dead body, under
the same circumstances, where we are sure it was not preceded by any of
the obvious marks of inflammation.
[10] On Dropsies, vol. II.
25. The _hæmorrhagic_ state of fever, in which are included discharges of
blood from the nose, lungs, stomach, liver, bowels, kidneys and bladder,
hæmorrhoidal vessels, uterus, and skin. Hæmorrhages have been divided
into active and passive. It would be more proper to divide them, like
other states of general fever, into hæmorrhages of strong and feeble
morbid action. There is seldom an issue of blood from a vessel in which
there does not exist preternatural or accumulated excitement. We observe
this hæmorrhagic state of fever most frequently in malignant fevers, in
pulmonary consumption, in pregnancy, and in that period of life in which
the menses cease to be regular.
26. The _amenorrhagic_ state of fever occurs more frequently than is
suspected by physicians. A full and quick pulse, head-ach, thirst, and
preternatural heat often accompany a chronic obstruction of the menses.
The inefficacy, and even hurtful effects, of what are called emenagogue
medicines, in this state of the system, without previous depletion, show
the propriety of introducing it among the different states of fever.
I have designedly omitted to take notice of other states of general fever
accompanied with local disease, because they are most frequently
combined with some one or more of those which have been mentioned. They
may all be seen in Dr. Cullen's Synopsis, with their supposed respective
generic characters, under the class of pyrexiæ, and the order of fevers.
We come now in the
III. And last place, to mention the _misplaced_ states of fever. The term
is not a new one in medicine. The gout is said to be misplaced, when it
passes from the feet to the viscera. The periodical pains in the head,
eyes, ears, jaws, hips, and back, which occur in the sickly autumnal
months, and which impart no fulness, force, nor frequency to the pulse,
are all misplaced fevers. There are, besides these, many other local
morbid affections, which are less suspected of belonging to febrile
diseases. The nature of these states of fever may easily be understood,
by recollecting one of the laws of sensation, that is, that certain
impressions, which excite neither sensation nor motion in the part of the
body to which they are applied, excite both in another part. Thus worms,
which are not felt in the stomach or bowels, often produce a troublesome
sensation in the throat, and a stone, which is attended with no pain in
the bladder, produces a troublesome itching in the glans penis. In like
manner, the irritants which produce fever in ordinary cases pass through
the blood-vessels, and convey their usual morbid effects into a remote
part of the body which has been prepared to receive them by previous
debility. That this is the case, I infer further, from fevers being
called back from their misplaced or suffocated situations, by creating an
artificial debility in the arteries by the abstraction of blood. This is
often done in muscular convulsions, and in several diseases of the brain.
Under this class of fevers are included
27. The _chronic hepatic_ state of fever. The causes, symptoms, and
remedies of the liver disease of the East-Indies, as mentioned by Dr.
Girdlestone, all prove that it is nothing but a bilious fever translated
from the blood-vessels, and absorbed, or suffocated, as it were, in the
liver. This view of the chronic hepatitis is important, inasmuch as it
leads to the liberal use of all the remedies which cure bilious fever.
Gall stones and contusions now and then produce a hepatitis, but under no
other circumstances do I believe it ever exists, but as a symptom of
general or latent fever.
28. The hæmorrhoids are frequently a local disease, but they are
sometimes accompanied with pain, giddiness, chills, and an active pulse.
When these symptoms occur, it should be considered as a _hæmorrhoidal_
state of fever.
29. The opthalmia, when it occurs, as it frequently does in sickly
seasons, with a quick and tense pulse, and pains diffused over the whole
head, may properly be called an _opthalmic_ state of fever.
30. The tooth-ach, and
31. Ear-ach, when they arise from colds, and are attended with great
heat, a quick and tense pulse, and pains in the head, are _odontalgic_
and _otalgic_ states of fever.
32. The apthæ, from the pain and fever which attend them, are justly
entitled to the name of the _apthous_ state of fever.
33. The symptoms of scrophula, as described by Dr. Hardy, in his treatise
on the glandular disease of Barbadoes, clearly prove it to be a
_misplaced_ state of fever.
34. The scurvy has lately been proved by Dr. Claiborne, in his inaugural
dissertation, published in the year 1797, to arise from so many of the
causes, and to possess so many of the symptoms, of the low chronic and
petechial states of fever, that I see no impropriety in considering it as
a state of fever.
35. The _convulsive_ or _spasmodic_ state of fever. Convulsions, it is
well known, often usher in fevers, more especially in children. But the
connection between spasmodic affections and fever, in adults, has been
less attended to by physicians. The same causes which produced general
fever and hepatitis in the East-Indies, in some soldiers, produced locked
jaw in others. Several of the symptoms of this disease, as described by
Dr. Girdlestone, such as coldness on the surface of the body, cold sweats
on the hands and feet, intense thirst, a white tongue, incessant
vomitings, and carbuncles, all belong to the malignant state of
fever[11]. By means of blood-letting, and the other remedies for the
violent state of bilious fever, I have seen the convulsions in this
disease translated from the muscles to the blood-vessels, where they
immediately produced _all_ the common symptoms of fever.
[11] Essay on the Spasmodic Affections in India, p. 53, 54, 55.