A Treatise on Fever

by Southwood Smith

No comprehensive view can be taken of fever, no just conclusion can be arrived at relative to its nature and seat until it be studied with a consciousness of the liability to such errors and a vigilant endeavour to avoid them. The present investigation has been undertaken with a deep consciousness of the danger and a watchful and unremitting care to avoid it. Even if the effort prove to be without success, the example can scarcely remain without use.

The frequent and formidable disease on the investigation of which we are entering, cannot be understood until clear and exact answers are obtained to the following inquiries. 1. What is the series of phenomena which constitutes fever? 2. What are the particular phenomena which are common to all its varieties and combinations? 3. What is the order in which these phenomena occur in the series? 4. What are the organs, and what are their states, upon which these phenomena depend? 5. What are the external signs of these internal states, or what are the indications by which their existence may be known? 6. What is the external noxious agent or agents, or the exciting cause or causes of the disease? 7. What is the particular remedy, or the particular combination of remedies which is best adapted to each state of each organ? When these questions can be clearly and perfectly answered, and not till then, we shall know the disease and its treatment. In order to make any real progress in this knowledge we must therefore prosecute these inquiries. It appears to me that we are already in possession of ascertained facts, adequate to answer with a high degree of certainty, though perhaps not with absolute certainty, several of these questions. In keeping these inquiries steadily before our view in our investigation there will be this great advantage, that it will enable us clearly to perceive what we really know and what still remains to be ascertained.

The phenomena which constitute fever, like those which belong to all the processes of nature, consist of a certain number of events. The events which take place in this disease are before our eyes: they are abundantly familiar to us all: no one man indeed has seen all the forms of fever which exist, nor observed all the symptoms of those species which he has witnessed, but accurate records are to be obtained of them all: records upon which we have this assurance that we may rely, that all the important events in this disease are so obvious and striking, and indeed force themselves so powerfully and constantly upon the notice, that there can be little danger that any one of consequence should be overlooked. Accordingly medical writings abound with the most minute, and, as far as can be judged, accurate histories of the symptoms which accompany all sorts of fevers, whether epidemic or sporadic. It is not in the observation of symptoms that the danger of error lies, because these are matters of sense, but the danger arises from a different source. Supposing, for example, that all the important events which accompany all the important varieties of fever have been ascertained, and that thus our first inquiry relative to the series of phenomena which constitutes the disease, is answered, still as many of these events are observed to be often absent, while it cannot be doubted that fever is nevertheless present, we must necessarily enquire in the next place, what is that particular combination of events which is essential to the constitution of the disease, an enquiry which embraces the second question proposed for consideration, namely, what are the particular phenomena which are common to all the varieties of fever? Now in singling out this particular series of events from the great mass, we are liable to several sources of error. In the first place, we may stop too soon in our enumeration; in the second place, we may mistake the adventitious for the essential and the essential for the adventitious, and in the third place, we may overlook the real place which some particular event holds in the series, and so may suppose that to be antecedent which was truly sequent, and consequently assign that as a cause which is only an effect.

The first thing to be done then is to ascertain the concourse of symptoms, and the second, to determine the order in which they occur: when these two points have been made out, what is essential and what adventitious, as well as what is the cause and what the effect, become at once clear and certain. But the difficulty lies in discerning amidst the infinite diversity and contrariety of symptoms which the different modifications of fever present, when we may safely assure ourselves that we are in possession of all the essential phenomena. Our guide is invariableness of concurrence. If we can ascertain that a certain number of events invariably take place in every form and every degree of fever, these events will give us the particular phenomena which are common to all the varieties of the disease. If we can further ascertain that these events invariably concur in a certain order, we shall have discovered what events bear to each other the relation of cause and effect. And the establishment of this relation of events, this constant connexion with each other, this uniform antecedence and sequence appears to me to be the only theory after which it is consistent with the principles of sound philosophy to search. If I have endeavoured to establish this connexion, and have thus ventured, as I conceive, in a strictly philosophical sense to propose a theory, in doing so, I have carefully restricted myself to the attempt to deduce a legitimate conclusion from facts previously ascertained. It does appear to me that these three points, namely, the common phenomena, the invariableness of their concurrence, and their mutual relation are satisfactorily established. Whether I shall be able to communicate this conviction to the reader I do not know: but I hope he will at least coincide with me in opinion that this mode of investigating the disease affords us the best chance of arriving at satisfactory results.

Whatever be the phenomena of fever they depend upon certain states of the organs. Whatever be the noxious agents or the exciting causes of the disease, and however they operate, they can induce the disease only by bringing about a certain condition in a certain number of organs, the individual events constituting the disease being nothing but certain changes in these organs. It is therefore of paramount importance to ascertain what the organs are which are implicated; what the conditions are which are induced in them; what organ sustains the first assault and what organs are attacked in succession. The pathology about to be laid before the reader will demonstrate the first two points: the establishment of the last two will be attempted by an examination of the history of the cases.

Without doubt the life or death of the patient depends upon these conditions of the organs. In a practical point of view therefore, this is the kind of knowledge with which it is of the greatest importance that the practitioner should be familiar. Some of these conditions are indicated by certain signs during life: some of these indications are obscure, and may be easily overlooked or mistaken by those who have not acquired an accurate and extensive acquaintance with the disease. On the other hand, there are external appearances which are extremely apt to suggest a false notion of the state of the internal organs. These fallacious appearances are sure to lead those whom they deceive into a mistaken, often into a mortal practice. Certain conditions of vital organs, if allowed to remain long, will terminate in fatal changes of structure. Certain remedies, if applied in due season and with due vigour, are capable of removing those conditions. Life therefore must sometimes depend upon the power of making this diagnosis with accuracy. Of some of these conditions, the diagnostic marks are clear and certain; those which indicate other conditions, in the present state of our knowledge, are obscure and uncertain. I have thought no labour too great to put the reader in possession of all that I have been able to ascertain with regard to this most important part of the subject. In the attempt to communicate this information, I am conscious that I may incur the charge of tediousness, on account of the number of repetitions which occur, and which I have allowed to remain because I could see no means of removing them without sacrificing clearness to brevity. Elegance and conciseness, in a work of this nature, ought not for a moment to be considered if they endanger its practical usefulness. A knowledge of the condition of the internal organs, in fever, can alone guide us to a rational and successful treatment of this most dangerous disease. It is only by examining the body after death that we can acquire this information: it is only by observing the symptoms during life and comparing them with the morbid appearances after death, that we can discover the signs which indicate the existence of these states. For these reasons I have not hesitated to give numerous cases and to detail many dissections. If after the study of these cases and dissections the practitioner be enabled at the bed-side of the fever patient to discover with greater precision and certainty than heretofore the condition of the brain—the condition of the lungs—the condition of the intestines, he will not think the time he has devoted to the investigation ill spent, nor shall I think myself without reward for the labour it has cost me to draw up the record. It is only when from external appearances we are able to see what is going on within each of the great cavities of the body, as clearly as we should do if their walls were transparent, that our interference can be sure of doing good, or secure from doing mischief: it is this kind and degree of knowledge alone which can teach us both when to act and what to do; and what is of almost equal importance, when to stop and to attempt nothing; and if the perusal of this work should contribute in any measure to the attainment of this knowledge, I shall not have laboured wholly in vain, “to add something to the treasury of physic.”

CHAPTER II.

Varieties of Fever. Common Phenomena. Importance of this Analysis. Results of the Analysis. Organs always diseased in Fever: Functions always deranged in Fever. Fever not Inflammation: Distinction between these two States of Disease. Common Phenomena of Fever exemplified in Plague, in Yellow Fever, in the Varieties of the Fever of our own Country. Different Varieties produced by different Intensities of the same Affections. Received Classification and Nomenclature defective. What is really meant by Genera and Species of Fever. True Principle of Arrangement.

Fever is a genus consisting of several species, and each species presents many varieties. The external characters of these varieties and the internal states upon which they depend, are so opposite, that no two diseases in any two parts of the catalogue of nosology present a more diversified appearance, or require a more varied treatment, than may be the case with two different types of fever. The fever of one country is not the same as the fever of any other country; in the same country, the fever of one season is not the same as the fever of any other season; and even the fever of the same season is not the same in any two individuals. Many of the circumstances which constitute these varieties in the fevers of different seasons and of individual persons, are slight and trivial; but some of them are of the greatest possible importance, and those diversities, especially, which distinguish the fevers of different climates, are intimately connected with the causes, whatever they be, which render the disease mild or severe, and, consequently, comparatively innoxious or fearfully mortal.

Something there is, however, which, amidst this astonishing diversity, preserves the identity of the disease so completely and so obviously, that there never has existed any dispute about that identity, under any aspect which it has hitherto been observed to assume; so that all physicians, without exception, unhesitatingly accord the name of fever to the mildest form of the common fever of this country, to the yellow fever of the West Indies, and to the plague of Constantinople and of Egypt. Bring three persons, each exhibiting an exquisite specimen of one of these several forms of the disease into the same ward of an hospital, the external aspect presented by each would be so different, that an unprofessional observer would probably be able to discover in these modifications of the same malady no common property: yet there is no physician who would not, in each case, instantly pronounce the disease to be fever. There must, therefore, be something that establishes the identity of the disease under this diversity of aspect. What is that something? Whatever it be, it must be common to all the varieties of fever. Thus we are led at once to the second inquiry which we proposed to keep before us in this investigation, namely, what are the particular phenomena which are common to all the varieties and combinations of the disease?