The slightest glance at the history of the doctrines which have been taught relative to the nature and the seat of fever from remote antiquity, and more especially a consideration of the variety and even the contrariety of the received opinions respecting both, in the present day, but too clearly shew that if the ancients were in error, there cannot be many points with regard to which the moderns are right, since there is scarcely one in which they are agreed. Further observation and investigation are therefore not yet superseded. There is as yet no uniformity of opinion among physicians even whether the primary seat of the disease be in the fluid or the solid parts of which the body is composed. Scarcely is the most ancient doctrine respecting it of which we have any record, that it consists in a morbid derangement of the fluids, and that the excitement which attends it is the result of an effort of Nature to expel the poison received into or generated within the system, obliterated from the imaginations or banished from the reasonings of physicians. When indeed we see a patient in the latter stage of some of the forms of fever with his dark or leaden skin, pouring forth its peculiar and fetid exhalation; with his foul tongue, his offensive breath, his vitiated and almost putrid secretions and excretions, we can understand why this doctrine should have taken a firm hold of the human mind and should have been able to maintain its ground through many centuries. Yet when the phenomena came to be observed with the accuracy with which we know that they were observed and recorded, and examined with the acuteness with which we have abundant evidence that some of the most powerful minds reasoned upon them, we may justly wonder that the order of the events, together with their great variety and opposite nature did not sooner suggest doubts of the accuracy of the theory and give to the inquiries of these celebrated men a new direction. But so far was this from being the case that when Hippocrates, considering the increased heat as the essence of fever, founded his division of the varieties of the disease upon this principle, whence his causus or burning fever, his leipyria, or fever with the parts externally cold and internally hot, and his epialus, or mild fever, with a simultaneous feeling of heat and cold; when he ascribed these different forms of fever to the superabundance of one or other of the four humours, blood, phlegm, yellow and black bile, and considered the disease as the result of a contest on the part of Nature to expel the morbid humour, or to render it inert or harmless by the process of concoction, the mind of Galen so many centuries afterwards, was so well satisfied with this hypothesis, that his powerful genius contented itself with the mere amplification of the conjecture and the addition of similar conjectures of his own. Whence assigning the different sources by which a morbid heat, which he also considers as the essence of fever, may be excited in the body, he states “that the fevers thus produced are modified by the prevalence or putrefaction of one or other of the four humours of Hippocrates; that of the three kinds of intermittent the quotidian arises from the corruption of phlegm, the tertian from that of the yellow and the quartan from that of the black bile; that in whatever part of the body the heat begins it ultimately extends to the heart; that as soon as this happens the general commotion of the vessels commences, and that in this manner Nature is employed in exerting her powers, endeavouring to assimilate the good humours to the parts which are to be nourished and to expel the bad, but that if at any time Nature is unable to expel all the morbid humour either from its thickness, its abundance or its tenacity, or from some obstruction of the passages, or from her own want of power, it will necessarily undergo putrefaction, if it remain long in the body, and produce the most fatal effects unless it be expelled by the process of concoction.” And so many centuries after Galen wrote, Sydenham who brought to the study of medicine one of the most acute, upright and independent minds that ever adorned it, commences a work on fever, which for fidelity of observation, for graphic description, for accurate discrimination, for bold and yet cautious treatment, has been justly considered an almost perfect model, with the following extraordinary assumptions:—
“That reason dictates that a disease is nothing else than Nature’s endeavour to thrust forth with all her might the morbific matter for the health of the patient; that seeing it has pleased God, the Governour of all things, so to constitute human nature that it may be fitted to receive the various impressions that come from abroad, it must necessarily be subject to many diseases; that these diseases proceed partly from particles of air ill agreeing with the body, which having once insinuated themselves into it, are mixed with the blood, and affect the whole with a morbific contagion; and partly from various ferments or putrefaction of humours which are detained in the body beyond due time, either because it was not able to digest them, on account of the incongruity of their quality, or to evacuate them on account of their bulk; that these circumstances being so nearly joined to the human essence that no man can clearly free himself from them, Nature provided for herself such a method and concatenation of symptoms as that she might thereby expel the peccant matter, which would otherwise ruin the whole fabric; that the plague, for instance, is nothing but a complication of symptoms by which Nature casts out the malignant particles, by imposthumes in the emunctories, or by some other eruptions, that were drawn in by the air; that the gout is nothing but Nature’s contrivance to purify the blood of old men, and to purge the deep parts of the body; that when Nature requires the help of a fever, whereby she may be able to separate the vitiated particles from the blood, or otherwise expel them, either by a sweat, a looseness, or some kind of eruption, she accomplishes this object in the whole mass of blood, and that by a violent motion of the parts; that when this object is accomplished suddenly, either by the health or death of the patient, the disease is acute; when, on the contrary, the matter of the disease is of such a nature that it cannot have the assistance of a fever for the separation of it; or when this kind of matter is fixed to any particular part, which is unable to exclude it, or when the blood is vitiated by the continual flow of new matter into it, in these cases, the matter being very slowly or not at all concocted, the diseases which proceed from such unconcocted matter are called chronic: that acute diseases proceed from a secret and inexplicable alteration of the air infecting men’s bodies; that these diseases do not at all depend on a peculiar crasis of the blood and humours any otherwise than the occult influence of the air has imprinted the same upon them; that they continue as long as this secret constitution of the air and no longer; that they do not come at any other time; and that these constitute epidemic fevers; that, on the other hand, acute diseases arise from this or that particular irregularity of particular bodies, which, because they are not produced by a general cause, do not therefore invade many at once; that this species comes every year, and at any time of the year; and that these may be called intercurrent or sporadic, because they happen at any time during the prevalence of epidemics.[[2]]”
That conjectures so gratuitous, and so utterly incompatible with the structure and functions of the animal frame, should at such distant periods of the world, under such different conditions of society, and in such different states of science so entirely possess and satisfy the minds of three of the most extraordinary men that ever illustrated or extended any department of science, will appear the less wonderful when we consider that the doctrines relative to fever which displaced and succeeded these, originated in precisely the same error, and vary in their aspect only in conformity to the progressive advancement of general science. When the structure of the animal body became more generally studied; when the functions performed by its different organs became better understood; when the morbid actions constituting or resulting from the derangement of these functions became more closely investigated, the influence of the nervous system and the effects of vascular action, began to form the subjects of investigation, and from this period the attention of physicians was fixed less upon the fluid than the solid parts of the frame. The properties and motions of the fluids were now clearly seen to be dependent upon the action of the containing solids, and the action of the solids to be under the influence and control of certain laws peculiar to life. Disease, studied under this juster view of the animal economy, immediately assumed a new aspect, and theories arose so much more consonant to the known operations of the living body, so much more explicit in their language and intelligible in their nature, that the ancient doctrines were at once exploded, and the very terms in which they were expressed became suddenly, though, as it now appears, only for a short time obsolete.
Cullen, building upon the foundation laid by Hoffman, rivalling in the number of his pupils, and exceeding in the brilliancy of his success, if not in the perpetuity of his fame, any name of antiquity, achieved with unexampled ease and suddenness this great revolution; and in opposition to the ancient theories taught, that the first change induced in the animal system, by the operation of the exciting causes of fever, is a diminution of the energy of the brain; that all the powers of the body and all the faculties of the mind, that the functions of sensation and motion, the processes of respiration, circulation, and secretion, all fail or are diminished in the general debility; that after a certain time a morbid increase of some of these functions, especially of the circulation, takes place with an augmentation of the heat; that these three states, that of debility, of cold, and of heat, bear to each other the relation of cause and effect; that the first state is the result of the sedative or debilitating influence of contagion, marsh miasmata, cold or any other exciting cause, and the subsequent states the result of the first; that the debility produces all the phenomena of the cold stage, and especially a spasmodic constriction of the extreme arterial vessels; that this spasm or atony of the extreme vessels exists not only on the first attack of the cold stage, but remains during the whole subsequent course of fever; that the spasm of the extreme vessels throws a load of blood on the central parts of the circulating system, which proves a source of irritation to the heart and arteries, and excites them to a greater action; that this increased action, the source of the heat and the other phenomena which constitute the second or hot stage continues till the spasm is relaxed or overcome; and that this excitement of spasm for the purpose of producing the subsequent reaction is a part of the operation of the vis medicatrix naturæ, the innate preserving power of the constitution. “Upon the whole,” says this celebrated theorist, “our doctrine of fever is explicitly this. The remote causes are certain sedative powers applied to the nervous system, which, diminishing the energy of the brain, thereby produce a debility in the whole of the functions, and particularly in the action of the extreme vessels. Such, however, is at the same time the nature of the animal economy, that this debility proves an indirect stimulus to the sanguiferous system; whence, by the intervention of the cold stage, and spasm connected with it, the action of the heart and large arteries is increased, and continues so till it has had the effect of restoring the energy of the brain, of extending this energy to the extreme vessels, of restoring therefore their action, and thereby especially removing the spasm affecting them: upon the removing of which, the excretion of sweat, and other marks of the relaxation of excretories take place.”[[3]]
Whatever may be thought of the superior power of the theory of Brown, the pupil and rival of Cullen, to explain the general phenomena of the living body, whether in a state of health or of disease, the doctrine of the pupil relative to fever, differs in no essential respect from that of the master. Like his predecessor, Brown attributes all fevers to debility; and affirms that the distinctions which physicians have made about the differences of fever are without foundation; that they are all the same, differing only in degree; that the debility during the cold stage is the greatest; that of the hot less; that of the sweating stage which ends in health for the time, is the least of all: hence in a mild degree of the disease, as cold is the most hurtful power, its effect is gradually taken off by the agreeable heat of the bed or of the sun, and the strength thereby gradually drawn forth; that the heart and arteries gradually excited by the heat acquire vigour, and at last having their perspiratory terminations excited by the same stimulus, the most hurtful symptom is thereby removed, the hot fit produced, and afterwards the same process carried on to the breaking out of sweat; that the cause of all these diseases, from the simplest and mildest intermittent to the gaol fever and the plague is the same with that of diseases not febrile, to wit debility; differing only in this, that it is the greatest debility compatible with life, and not long compatible with it.
This very year, from Dublin, from the largest hospital for the reception of fever in the British Empire, precisely the same doctrine has been put forth. “Common epidemic fever,” says Dr. Stoker,[[4]] “especially when contagious, as I have frequently asserted when speaking of its pathology and treatment, has not appeared to me at any time to be essentially inflammatory. Adynamic fever, a denomination for typhus fever, which I shall employ, as I have hitherto done to express the putrid or malignant fever of Sydenham; the slow nervous fever of Huxham; the nervous fever of common language; the synochus, typhus mitior, and gravior of Cullen; the gaol and hospital fever; the fièvres essentielles of the French; the epidemic of the Irish writers; the contagious of Bateman; the typhus of Dr. Armstrong; and the proper idiopathic, or essential fever of Dr. Clutterbuck: whether it exists separately or independently; or is combined with any of the other forms of febrile disease, sporadic or symptomatic.”[[5]] “Typhoid or adynamic fever I consider to be generally symptomatic of morbid changes in the physical characters of the blood, and have, as on former occasions, stated what those morbid changes are—but I have arranged inflammation under the head of symptomatic fever, merely because it is more usually connected with some change in the structure of parts, discoverable after death: on the other hand, typhus fever is connected with morbid changes, that primarily take place in the fluids, and produce morbid actions, and sometimes permanent changes of structure in the said parts. These changes too in the condition of the blood are distinguishable from those which we have stated to occur in inflammation; and the morbid actions excited relatively by those changes in the blood are also distinct. In inflammatory fever on the one hand, increased action, in typhoid fevers on the other, debility, is almost the immediate consequence. On account of this debility being an essential character of typhoid fevers, I denominated them adynamic.”[[6]]
At the close of the last season, in a work,[[7]] the materials of which have been drawn professedly from the London General Hospitals, doctrines so similar have been laid down, that Dr. Stoker says of it—“the views taken, both of the nature and treatment of fever, by Dr. Burne, entirely accord with those which may be found stated in my Medical Reports from the Fever Hospital, as well as in my separate Essays on that subject. And as (when speaking of his denomination of fever) I have already remarked, this leaves, I think, no reasonable doubt of the epidemic fevers of London, having lately become more typhoid or adynamic, than they had formerly been. It is further satisfactory to me to find, that the treatment which I had long since adopted and recommended in our typhoid fevers has been found suitable to the prevention and cure of those in London; and that too in proportion as they have acquired more of that form, with which I was best acquainted.”[[8]] And Dr. Burne himself states, “that the adynamic fever has no local seat; that its nature is a morbid condition of the blood, produced by the operation of the primary cause, the respiration of a contaminated or poisoned atmosphere: that this morbid blood, acting on the brain and nervous system, is of itself sufficient in very many instances to bring about the very great derangement and imperfect performance of all the functions of the organic and of the animal life; which great derangement and imperfect performance of all the functions constitute the phenomena of adynamic fever.”[[9]]
Instead of regarding with these authors a vitiated state of the blood as the essence of fever, Dr. Clanny, on the contrary, believes its proximate cause to be a want of power in the system to form blood. “The proximate cause of typhus fever,” he says, “is a cessation of chylification, and consequently of sanguification, during which time the lymphatics of the whole system act with increased vigour, and in this manner the lymph taken up by them from the system supplies, for the time being, the place of the chyle in the blood, and as long as this state continues the patient labours under an acute disease, heretofore called typhus fever. When the chylopoietic viscera resume their functions the disease gradually recedes, and health is ultimately restored.”[[10]] “Chylification, like secretion, is a function of the brain, which under peculiar circumstances, or states of the atmosphere, is impaired, and in severe cases is suspended altogether: hence typhus fever.”[[11]]
Such are the leading opinions of those who maintain that the seat of fever is in the fluids, in which opinions we perceive a return to the old doctrines, although in the modern version, it is true they are somewhat modified and presented in a somewhat more definite shape.
But in direct opposition to all such views of fever, it is zealously and ably maintained by a large and increasing sect, that this malady is strictly a local disease; that it has its primary and essential seat in one organ, and that it consists of inflammation of that organ. Thus Dr. Clutterbuck, who may be regarded as one of the most distinguished advocates of this opinion, in one of the best works which has ever appeared on the subject, contends that fever of every denomination and every degree is the result of inflammation; that the appearances which have led to the conclusion that it is a general disease primarily affecting every function of the body are fallacious, and that, when strictly examined, it will be found that all general or extensive derangements of the system, are referrible to local disease in one organ. “Fever, in regard to its effects on the system,” he says, “is the most general of all diseases, and gives rise during its progress to the greatest variety of symptoms. These, contemplated in the mass, present nothing but confusion. Like all complicated phenomena, they require to be subjected to strict analysis; that their order may be traced, and their relation to each other and to the exciting cause shewn. To the neglect of this may be ascribed the error, as I conceive it to be, which has been so generally fallen into, of considering fever as an universal disease, or one that affects for the first time the whole system; no one part being supposed to suffer necessarily before the rest. Whereas, when the disease is minutely scrutinized, and its first appearance accurately noticed (which indeed from the slightness and consequent neglect of the first symptoms is rarely done) it will be found to be strictly a topical affection, the general disorder of the system being merely secondary, or symptomatic of this.”[[12]] In another work it is further stated, that all the varieties of idiopathic fever, which differ but in degree, as well as those which arise from specific contagion, as malignant sore throat, scarlet fever, small-pox, and so on, arise from one and the same affection of one and the same organ, and that that affection consists essentially in inflammation.