A Treatise on Fever

by Southwood Smith

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.