A Treatise on Fever

by Southwood Smith

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.