A Treatise on Fever

by Southwood Smith

II. Typhus Gravior.

The typhus gravior of authors is extinct; at least I have seen no example of it in London. I have witnessed nothing bearing a tolerable resemblance to this disease, even as it is depicted by Cullen, much less as it is portrayed in the darkly vivid, yet apparently but too faithful colouring of Huxham. This malady seems to have disappeared with the epidemic intermittents and the epidemic dysenteries of the good old times. Whatever there may have been in the condition of our ancestors to excite our envy, there is certainly nothing to provoke it in their diseases.

All the examples of fever which approach in likeness to the descriptions on record of typhus gravior which I have seen, have consisted of the mixed cases of typhus. They have been cases in which the brain, the lungs, and the intestines were all simultaneously and intensely affected. The symptoms may not always denote an equal degree of affection in all these organs; but I have never seen a case in which there were not the most unequivocal signs of intense affection in all of them. For the reason already assigned, such cases must necessarily be the severest that can occur, because the patient may be said to have three diseases instead of one to contend with, each of which alone is sufficient to destroy life, and each of which alone frequently does destroy it.

All the examples of this form of fever which I have observed are referrible to two classes; one in which the arterial action is excessive; the other in which it is oppressed, or rather overwhelmed.

1. In the first, the patient lies insensible, with delirium, perhaps so violent that he cannot be kept in bed without restraint; with extreme restlessness and constant watchfulness; with rapid and panting respiration; with a tender abdomen, perhaps with frequent and involuntary stools, a dry, black, and hard tongue, a quick, yet weak pulse, and the skin universally and pungently hot.

2. In the second he lies insensible, with a cold and dusky skin; with a swollen and livid countenance; with a heavy and oppressed respiration; with a pulse perhaps not to be felt, or, if distinguishable, either so rapid that it cannot be counted, so small that it is like a thread beneath the finger, and so weak that it is lost by the slightest pressure, or else slow, irregular, and intermittent. In this state, the patient is almost as completely paralyzed as in apoplexy, and the attack is almost as rapidly fatal as apoplexy. It constitutes what has been called congestive fever.

Fortunately, these intense forms of the disease are of rare occurrence: they are witnessed only in solitary instances, and they arise either from exposure to a highly-concentrated poison, or from some condition of the constitution, by which that power to resist the influence of noxious agents, which is characteristic of life, is more than commonly diminished or exhausted. They have been conceived to form exquisite specimens of diseases of debility. But where is the debility? Not in the disease, for that is of giant strength; not in the patient, for remove, if you can but remove, a part of the load that oppresses him, and instantly an intensity of action will be set up in the whole system, perhaps as great as it is capable of exerting, and certainly greater than it is capable of sustaining without the most imminent danger. The brain is overwhelmed by the intensity of its affection; the energy that should animate the system, and of which it is the great source, is withheld: but that energy is suspended, not destroyed; and the debility which seems to be the result is not real, but apparent, not direct, but indirect. The giant that lies prostrate on the earth, mastered by superior power, has still a giant’s strength, though he does not at that moment put it forth: give him but the chance of throwing off the load that keeps him down, and he will soon shew you that he is not weak. I have always been struck with the extraordinary clearness and decision with which the acuteness of Sydenham enabled him to make this important distinction, perhaps in the very first case that occurred to him, in which the discrimination was required. Having described, in his own powerful manner, an excellent specimen of congestive fever to which he was called, he states that he ordered the patient to be bled: that the bye-standers regarded the suggestion with horror: that the man seemed at the point of death; that to them it appeared that the abstraction of blood must inevitably extinguish the last remaining spark of life; while to him it was manifest that the patient was in this alarming condition, because he was oppressed by an overwhelming load, and if that could only be lessened, his condition would be the very reverse of what it now seemed: that accordingly, on the removal of some ounces of blood, the state of oppression ceased at once, and fever arose of a true inflammatory nature, for the subdual of which repeated bleedings were required.

It is remarkable, and it is highly characteristic of these intense forms of disease, that their pathology exhibits a striking contrast to that of the less severe affections. No morbid appearances are visible in the organs which seem capable of accounting for death. There are signs of vascularity; the vessels are turgid with blood, and consequently the organs on which they are spent are in a state of congestion. But they seldom if ever exhibit any real appearance of inflammation, and still less do they contain any true inflammatory product. Why? Not on account of debility; but because the force of the disease is so great as to overwhelm the powers of life at the first onset, allowing even of no reaction, and much less of that continued excitement which is part and parcel of the inflammatory state, and which is indispensable to an inflammatory product. Reduce the intensity of the disease a little, bring it just within the limit that is compatible with the continuance of life for a given time, and then the products of inflammation at once appear in the greatest possible purity, variety, and extent.

And this is precisely the fact, as is demonstrated by the condition of the organs, in those ordinary types of fever, the essence of which has been supposed to consist in debility, and which have recently assumed the dignified name of adynamic. That men who are capable of looking only at the most obvious appearances of things, who, satisfied with what they find at the surface, give themselves no concern to discover its source, should continue to mistake the effect for the cause, and to consider as in its own primary and essential nature, that to be debility which is the last result of long-continued and most destructive energy of action, is highly probable; but, on that very account, the fallacy is the more deeply to be deplored; because to these men must sometimes be committed the care of human beings who will fall certain victims to the error. It is easy to disregard the voice of reason when opposed to specious, however fallacious appearances; but it is difficult to withstand the evidence of sense. In justification of the strength of the language I use, I therefore appeal to the pathology I adduce. The notion of debility in the intense forms of fever I look upon to be an error no less palpable in its nature than destructive in its consequences; and if the havoc it produces do not confer upon it a pre-eminence as bad as that of the very disease of which it is supposed to constitute the essence, it at least entitles it, in comparison with every other error in medicine, to the distinction recognized in society, between the hero and the murderer: the one destroys a single human being now and then; but the other numbers its victims by thousands. It may be difficult to eradicate this mischievous opinion where it was first engendered, and where it still continues to be fostered, in the study of the falsely reasoning theorist; but it is easy to confute it at the table of the pathological anatomist; and it must ultimately fall, if not by the pen, by the scalpel.