A Treatise on Fever

by Southwood Smith

A similar doctrine has for some time been taught in France by a man whose disciples have already spread over every country in Europe, and are fast diffusing themselves over the new world, and whose devotion to their master and his system, reminds us of days long past, when the attachment of the pupil to the sage was as reverential and as enthusiastic as that ever paid by true knight to lady-fair in the brightest days of chivalry. “Penetrated by the sublime views of Bichat as to the sympathies,” say M. M. Coutançeau et Rayer, two of the most ardent disciples of this school;[^[13]] “rich in numerous facts observed with a rare sagacity, M. Broussais came to overturn, from the very foundation, the antique edifice of fevers. In his works as well as in his lectures, he has applied himself, for many years, to demonstrate, that the fevers which had been called essential, were nothing more than local diseases, inflammations, nay even gastro-enterites.”

These writers go on to state that, according to Broussais, all fevers are of the same nature, those termed malignant differing from other fevers only by the violence and danger of their congestions; that all the causes of fever act locally; that, considered in a general and abstract manner, fever is invariably the result of a primitive or sympathetic irritation of the heart through the effect of which its contractions are quickened, and that every irritation sufficiently intense to produce fever is an inflammation.[^[14]]

There is thus a perfect accordance in the doctrine of these two celebrated and rival theorists, Clutterbuck and Broussais, respecting the nature of fever: both are agreed that it is an affection of the solids of the body and that its essence consists in inflammation: both are agreed that that inflammation is strictly local, being seated in one organ: but in determining what that organ is, there is an entire discrepancy in their opinion. According to Dr. Clutterbuck the organ universally affected in every variety of idiopathic fever is the brain. “Out of fifty cases,” he says, “of which I noted down the symptoms with the greatest minuteness at the bed-side of the sick, generally once and often twice in the twenty-four hours, throughout the disease, I find that no two of them correspond in the minute points though they all agree in the essential one, that is, in a manifest affection of the brain and its functions; various in degree and probably in extent, with numerous but accidental complications, from the affection of other organs.”[^[15]] This affection of the brain, consisting of inflammation, it necessarily follows, as this author elsewhere states, that fever is nothing else than a species of phrenitis, or topical inflammation of the brain; that it might, therefore, be arranged in the order of phlegmasiæ with pleurisy, enteritis, and other symptomatic fevers, but that since the term phrenitis has been generally applied to a particular form of inflammation of the brain and implies delirium, which does not always occur in fever, although it is a frequent symptom, that of encephalitis would form a proper denomination for this entire class of diseases, and might be substituted for the term fever.

Broussais, on the contrary, contends that the primary and essential seat of inflammation in fever is the mucous membrane of the stomach, or of the intestines, or both, but especially the former, and that, therefore, the proper designation of it is gastro-enteritis. While it had long been conceived that inflammation of the digestive organs is the cause of certain symptomatic fevers, Broussais maintains that the most important discovery (most important because so intimately connected with the treatment of the disease) that this affection is the cause of all fevers, idiopathic as well as symptomatic, and that there are in fact no essential fevers, is peculiarly and exclusively his own. Thus, according to this theorist, all the fevers of authors are connected with gastro-enteritis, simple or complicated. “The simultaneous or successive inflammation of the stomach and small intestines, designated by this term,” says M. Rayer, “is of all the phlegmasiæ the most frequent, and at the same time that which has been oftenest overlooked or mistaken. It is not designated in any nosological table. Not long ago gastritis itself was generally looked upon as a very rare disease: of twenty-eight thousand two hundred and ninety-nine sick admitted into the civil hospitals of Paris in 1807, six only were designated in the returns as labouring under inflammation of the stomach, whilst six thousand one hundred and forty-three were treated for continued or remittent fevers.”

The prevailing doctrines relative to the nature and seat of fever at present then are two, the direct reverse of each other; one, that it is a general disease affecting the entire system; that this affection of the system consists of debility which is manifested first in a loss of energy of the brain, but which rapidly extends to every organ and every function, and that consequently the absence of any primary local disease, ought still to form, as it has so long formed, an essential part of the definition: the other, that it is in the strictest sense a local disease; that its primary seat is invariably fixed in some one organ; that the affection itself consists of inflammation; and that that inflammation is seated, according to one opinion in the brain; according to the other in the stomach.

As must necessarily be the case, these different and opposite theories are found to have the most important influence on the practice recommended by their respective authors in the treatment of the disease. The advocates of the first deprecate all active interference: the grand evil to be contended with is debility: the physician can easily weaken, but he cannot easily strengthen: he can depress to any extent he desires, but he cannot communicate power as he wishes. In a malady therefore of which the very essence consists in loss of energy the main duty of the physician is to husband the strength of the patient with the most anxious care, this being the chief means, as Cullen expressively termed it, of obviating the tendency to death. The important inference is, that every kind and every degree of depletion that can add to the primary cause of the malady, must be abstained from with the utmost caution. By the clearest and shortest deduction this will necessarily be the result to which every mind must come that really believes that debility is the essence of fever, while he who admits its inflammatory nature must think it criminal to stand idle by and allow the most extensive derangements in the structure of vital organs to proceed, without even an attempt to check them, as long as it is in his power to use the lancet or to procure leeches. The very order in which the believers in debility enumerate the remedies they recommend affords a striking illustration of the extent to which their theory influences their practice;[^[16]] while the advocates of inflammation state explicitly that the remedy of the disease is one, and in point of importance one only, namely, the remedy which all admit to be the only efficient agent in the treatment of inflammation. “Fever to be treated successfully,” says Dr. Clutterbuck, “must be treated upon the general principles of inflammation; but at the same time with the modifications arising out of the peculiar nature of the organ affected, and in some degree also the nature of the exciting cause. Blood-letting, which but a few years ago was looked upon with abhorrence in the cure of contagious fever, and the utility of which is still far from being generally appreciated, is proved by ample testimony to be not only the most powerful, but the safest of remedies.” And in every variety of fever, and in all its stages, leeches are to be applied to the stomach, according to Broussais, and scarcely any thing else is to be done except enjoining rigid starvation. Emetics, purgatives, bark, wine, are all denounced; nothing but leeches and “diete absolue:” a costive state of the bowels persisting during five or even ten days is a good symptom and not to be interfered with.

That men who exhibit such talent for observation and such acute and active powers of the understanding as many of these authors exemplify in these very works, should, while writing with so much earnestness against each other, fall into one and the same error, and that an error so palpable, is no flattering exhibition of the state of the art of reasoning among the members of the medical profession. The degree in which the science of mind is neglected in our age and country, may it not be justly added? especially in our profession—that science upon the knowledge of which the conduct of every individual mind is so dependent, is truly deplorable. Medicine is an inductive science, the cultivator of which is peculiarly exposed to the danger of making hasty assumptions and of resting in partial views, yet it is not deemed necessary that he should be at all disciplined in the art of induction, or should be cautioned against any sources of fallacy in the practice of making inferences. All the partial and imperfect views of fever which have now been brought before the eye of the reader, originate in one or other of the following errors, obvious as they all are: either that of assuming as a fact what is merely a conjecture; or that of assigning to the genus what belongs only to the species; or that of characterising the disease by what appertains only to a stage; or that of mistaking the effect for the cause. On careful examination it will appear that one or other of these errors, which are as serious as they are palpable, has vitiated in a greater or less degree every generalization of fever that has hitherto been attempted.

Thus the believers in debility derive their notion of the whole disease from the phenomena which occur in the first and the last stages only: in these, it is true, they may find abundant evidence of debility: but then they overlook the intermediate stage in which there are generally the most unequivocal indications of increased sensibility in the nervous and increased action in the vascular systems: in this manner they characterise the disease by what appertains only to certain stages of it. Again, when they contend that debility is not only the essence of fever in general, but is really characteristic of every type of it, they affirm what is indisputable of fevers in particular seasons, in particular climates or in particular constitutions; but beyond this their generalization cannot be extended: in this manner they assign to the genus what belongs only to the species. And when Cullen goes on to affirm that the proximate cause of all the morbid phenomena is a “spasm of the extreme vessels,” he commits the additional and more palpable, but not less common error, of assigning as an undoubted fact, as a real and ascertained occurrence, what is only a conjecture, and for which there is not, and for which he does not even attempt to adduce the shadow of evidence.

Precisely similar to this is the error of those who for the most part belong to the same school, and who attribute the essence of fever to a morbid condition of the blood. The blood may be diseased in fever, but if it be so, these writers do not know it, or at least they do not adduce any evidence that they are in possession of such knowledge: they do not appear so much as to have questioned chemistry; at all events, it is certain that they have hitherto received no satisfactory answer. There is no evidence on record that the alleged determination of the blood takes place in every type and every degree of fever: and if there were it would still be but one event among many, and one that occurs late in the series, and therefore could possibly be nothing more than an effect.

In like manner those who maintain that inflammation of the brain is the sole cause of fever, assume as an established and admitted fact the universal and invariable existence of inflammation of the brain in this disease. Inflammation of the brain, without doubt, is demonstrable of many individual cases, and of some whole types: but beyond this there is no proof that the generalization can be carried: the evidence indeed in regard to many cases is entirely against the assumption, and is as complete as negative evidence can well be: consequently it must be admitted that even this hypothesis, in the present state of our knowledge, is founded on the error of assigning to the whole genus what belongs only to particular species: and it would be trifling with the reader to attempt to prove, that this is still more certainly and strikingly true with regard to inflammation of the mucous membrane of the stomach and intestines—an affection which in innumerable cases in which its existence is certain, clearly appears on the slightest examination of the succession of events, to be an effect and not a cause.