A Treatise on Fever

by Southwood Smith

A similar want of knowledge exists relative to the condition of the organs in most of the Exanthemata. To supply that want in regard to the various forms of fever that prevail in this metropolis, which, there is good reason to believe, differ but little from the types that appear in other parts of the country, is one of the chief objects for which this work is undertaken.

It is not the object of the present volume to treat of intermittent or of remittent fever, but only of that class which, in ordinary medical language, is termed continued. Of the apparently endless varieties of disease comprehended under the term continued fever, it is found that certain forms occur in this country with great constancy. Each particular assemblage of symptoms occurring in these different forms is said, in ordinary language, to constitute a type or species. Each type or species depends on a particular condition of the circle of organs that has been described. The causes that concur to produce this particular condition of this series of organs, will be treated of in their proper place. But these assemblages of symptoms never occur without being accompanied by these particular conditions of the organs; and these conditions of the organs are never found without having been connected with these assemblages of symptoms. In all the forms of fever hitherto observed this condition of the organs is found to be absolutely the same: it never differs in any thing but intensity; of this the evidence is complete and irresistible: the direct and legitimate inference is, that all these different forms of fever differ in nothing excepting in the intensity of the affection. Were the terms genera, species, variety, merely used as short expressions to denote this fact; to point out and to name different degrees of the same malady, degrees which it is important to discriminate, because they require material modifications of treatment, a clear and precise meaning would be affixed to these words: in nature there would be foundation for the distinction they imply: in practice there might be convenience in their use. But the nosological distinctions at present inseparably associated with these terms, appear to me to be either so vague and unmeaning, or when they cease to be indistinct, to excite notions so false and pernicious, that I think it right to abandon the use of them altogether. The more we investigate the subject, the more satisfied we shall become that continued fever is one disease and only one, however varied, or even opposite, the aspect it may present; but that it differs in intensity in every different case, and that this and this alone is the cause of the different forms it assumes. Many of these diversities it would be frivolous to distinguish: some of them, on the other hand, it is of the highest importance to discriminate. For all useful and practical purposes, it is necessary only to arrange the different assemblages of symptoms into two great classes, the one comprehending the mild and the other the severe forms of the disease. All the forms that continued fever can assume, and all the individual cases that can occur under either, must be mild or severe, and, therefore, must readily find its place under one or other of these divisions. The only real difference in the disease being a difference in degree, it is proper that the principle of the division, by which the varieties it presents are classified, should be founded on this, the only true distinction of which it admits.

It is difficult to frame, and still more difficult to bring into use, new terms; and there is nearly equal inconvenience in using old terms in a new sense: but if the new meaning affixed to an old term be clearly intimated and rigidly adhered to, it is, perhaps, upon the whole, productive of less evil to adopt the old, thus determining and limiting the signification, than to propose a nomenclature entirely novel. For this reason, and only for this reason, I propose to adopt two words, borrowed from the nosology of Cullen, and in common use. These words are here employed merely to express differences of degree relative to one and the same disease. The mild degree may be denoted by the term synochus: throughout this work, this term will be used to express the milder form of fever; that is, its ordinary or common form, or that which it is found most frequently to present in this metropolis, and, I may add, in this country. The severer form, on the other hand, may be designated by the term typhus. Each will be found to present a distinct assemblage of symptoms; each will be found to depend upon a particular condition of certain organs; each will be found to require a peculiar treatment.

For the purpose of distinguishing further important differences, that is, differences which bear an important relation to practice, it will be convenient to divide each of these two great classes into two minor sections. Thus, synochus may be divided into synochus mitior and synochus gravior; and typhus into typhus mitior and typhus gravior. This will afford convenient and ample means of throwing into distinct groups all the varieties of fever that occur in this country, which it can be of any practical importance to distinguish.

This mode of viewing fever as one great and extensive malady never differing in nature, but in every two cases differing in intensity, and giving rise by these differences in intensity to various forms of disease, thus affords a principle of arrangement applicable to all those various forms, which, while it is at once simple and comprehensive, is at the same time in the highest degree practical. It directly leads the mind to the observation of the real, the important differences that exist or that may arise; those differences which must influence and guide the treatment, if it be not altogether blind, and in the worst sense of the term empirical. This principle might easily be extended, and I think with advantage, so as to comprehend the exanthemata, and all the forms of fever which have hitherto been known to exist, or which can arise. Scarlet fever, for example, is continued fever attended with a peculiar eruption upon the skin: at one time it occurs in a mild, at another in an exceedingly severe form: the assemblage of symptoms in the first are precisely those which it is intended to comprehend under the term synochus: the assemblage of symptoms in the second are those which are designated by the term typhus: thus scarlet fever exhibits at one time the synochoid, and at another the typhoid type; the first being what is commonly termed scarlatina benigna, the second scarlatina maligna; and each type is capable of existing in two degrees of severity, one of which may be conveniently distinguished by the term mitior, and the other by that of gravior.

In like manner small-pox is a fever attended with a peculiar eruption upon the skin, which eruption modifies the disease in a very remarkable manner, and gives it a history and progress peculiarly its own; but it is as much a genuine fever as typhus, and ought no more to be taken out of this class on account of the eruption upon the skin, than scarlatina, which likewise modifies, in a very considerable degree, the whole train of febrile symptoms, and is attended with a peculiar condition of some exceedingly important internal organs. Small-pox, like all the diseases of this class, occurs in two widely different forms; the one mild, the other intensely severe: in the first the concourse of symptoms are precisely those of the synochoid, in the second of the typhoid type.[^[22]] And the same I am satisfied is true of the plague, of the yellow fever, and of all the different forms which this great disease, of many aspects and names, but of one uniform and unchanging nature, presents.

These distinctions and names then, though it were easy to raise objections against them, may serve for all useful and practical purposes. They tend to impress upon the mind the great fact that all the modifications of the disease are still only modifications, and do not affect the identity of its nature; and they afford convenient sections under which to detail the symptoms that attend and discriminate the important diversities in degree as they present themselves in practice; to exhibit the condition of the organs upon which those diversities depend, and to explain the treatment which experience teaches to be appropriate to these several states.

The present work will be restricted to the consideration of the modifications of fever which we have proposed to designate by the terms synochus, typhus, and scarlatina.

CHAPTER III.

Of Synochus: Division into Synochus Mitior and Gravior. Succession of Phenomena in Synochus Mitior. Indications afforded of Disease in the Nervous, Circulating, and Excreting Systems. Progress of Disease consisting in progressive Increase in the Derangement of these Functions. Phenomena of Recovery. On what the Transition of Synochus Mitior into Synochus Gravior depends. Classification according to the different Organs in which the several Affections have their Seat. Hence Synochus Gravior with Cerebral Affection—Subacute—Acute: with Thoracic Affection: with Abdominal Affection: with Mixed Affection.