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A
TREATISE ON FEVER.

BY

SOUTHWOOD SMITH, M.D.

PHYSICIAN TO THE LONDON FEVER HOSPITAL.

LONDON:

LONGMAN, REES, ORME, BROWN, AND GREEN,

PATER-NOSTER ROW.

1830.

PRINTED BY G. HAYDEN,

Little College Street, Westminster.

TO

HIS GRACE

THE DUKE OF SOMERSET,

PRESIDENT;

TO

THE VICE-PRESIDENTS,

TO

THE TREASURERS,

AND TO THE

OTHER GENTLEMEN CONSTITUTING THE COMMITTEE,

Of the London Fever Hospital;

IN TESTIMONY

OF HIS ADMIRATION OF THE DILIGENCE

WITH WHICH

THEY LABOUR TO PROMOTE THE PROSPERITY,

AND THE

CARE WITH WHICH THEY WATCH OVER THE INTERESTS OF THIS INSTITUTION;

WHICH,

IN THE MAGNITUDE OF THE BENEFITS IT CONFERS,

NO LESS THAN

IN THE INEXPENSIVENESS OF THE MEANS

BY WHICH,

THROUGH THEIR ECONOMY, IT IS ENABLED TO SECURE THEM,

IS EQUALLED BY FEW ESTABLISHMENTS,

AND

SURPASSED BY NONE;

THIS WORK IS INSCRIBED

BY

THE AUTHOR.

PREFACE.

The following Work is wholly of a practical nature: its object is to ascertain the real phenomena of Fever, and the most safe and effectual treatment of the disease. It was found impossible to include in this volume some researches of a statistical nature which it was at first intended to incorporate in the work.

On looking over the account which has been given of the phenomena, I find that, by an oversight, I have omitted to make any mention of the peculiar odour which belongs to a fever-patient. It is so characteristic that a person, familiar with the disease, might in many cases be able to pronounce, merely from the odour of the effluvia that arises from the body, whether the disease were fever.

I cannot allow this work to go forth to the world, without expressing my obligation to Dr. Dill, for the great assistance he has afforded me in the collection and arrangement of the cases which illustrate the symptoms and the pathology, and in the construction of the tables. And I am happy to avail myself of this occasion to bear my testimony to the excellent history which is drawn up of every case admitted into the house; to the completeness of the record which is kept of the morbid appearances on inspection; to the care which is taken of the sick, in the absence of the physicians; and to the able and zealous manner in which, as the resident medical officer of the Fever Hospital, he performs the arduous duties of his office.

S. S.

36, New Broad Street

Dec. 1829.

CONTENTS.

FEVER, &c.

CHAPTER I.

Further Investigation of Fever necessary: Facilities afforded by the Fever Hospital for prosecuting the Study. Ancient Doctrines relative to the Nature and Seat of Fever. Hippocrates, Galen, Sydenham. Modern Doctrines. Cullen, Brown, Stoker, Burne, Clanny, Clutterbuck, Broussais. Errors common to all these Theorists. Questions to be solved before Fever can be understood. Precise Object of Investigation: proper mode of conducting it.

On my appointment to the office of Physician to the London Fever Hospital, it was stated to me by the treasurer that, among the objects contemplated by the establishment of this institution, two things were conceived to be of paramount importance: first, the accumulation of facts by which the true nature of fever might be more certainly ascertained, and secondly the cautious trial of remedies by which a more sure and successful mode of treating this fatal disease might be discovered. During my connexion with this hospital I have faithfully endeavoured to the utmost of my ability to keep these objects in view, and I now venture to lay before the public the result of my observations, in the hope that they may contribute something, however little, to the stock of knowledge already accumulated.

When we consider how many circumstances connected with the origin and the propagation of fever are wholly unknown, which if known might have a most important influence in preventing its occurrence, in arresting its progress or in lessening its mortality; when we consider in what profound obscurity the very nature of the agents that produce it is still involved; when we consider how easy it is to swell the long catalogue of its symptoms, but how difficult it is to discriminate which, even among the most prominent of the train, are the essential and which the adventitious, and how still more difficult it is to ascertain which are the invariable antecedents and which the invariable sequents, or which the causes and which the effects; when we consider how few comparatively of the external appearances have been ascertained to be the sure and certain signs of any known condition of the internal organs, and how often the existence of several known conditions of the organs remains altogether unsuspected until the demonstration of it is afforded by inspection after death, and when finally on all these accounts we consider how vague the objects must be that are aimed at in the treatment, and consequently how uncertain, how indiscriminate, how fruitlessly inert, how perniciously active, how unsuccessful, how fatal that treatment often is, it must be admitted that fever still presents to us a vast field, in the culture of which the difficulties to be overcome are not slight, and the most diligent labour that can be bestowed upon it may by no means be attended with a sure reward.

Of many branches of science it is truly observed that much time and labour are necessary to establish a single important fact; of some parts of medical science this is eminently the case, but perhaps of none is the observation so just as of that which relates to febrile diseases. It is remarkable how entirely the most distinguished physicians of all ages who have treated of this subject coincide in the feeling, that with regard to this important class of disease it is impossible in the short life allotted to the most aged to do any thing more than add a little knowledge to the common stock. If there be any foundation for this feeling it can only be by every man faithfully endeavouring to contribute what he may be able, be the amount ever so small, that that stock can speedily become large or ever become complete.

In bringing to this common stock my humble mite, that the offering may not be wholly worthless, I have confined myself as much as possible to the detail of the facts that have been observed, and the statement of the results that have been obtained from experience. By giving a connected view of the phenomena I have hoped that I might possibly assist the actual practitioner to form a more adequate conception of the disease and guide him to that particular remedy which experience shews to be best adapted to each of the more important affections he is likely to encounter. Out of the means furnished for the accomplishment of these objects by the receptacle of fever for this great metropolis I have endeavoured to select such specimens of the disease as will place before him a vivid and faithful picture of the most interesting aspects it assumes, and such a detail of treatment as will shew what particular remedies afford the best chance of success in each type and stage, and in the most common and therefore the most important modifications they present. If I have at all succeeded in my aim he will find himself placed in a good measure in the same situation with myself; his attention will be directed to the same phenomena in the order in which they occur in the series, and hence he will have the like means of judging of the relations which these phenomena bear to each other, as well as of the accuracy of the analysis that has been attempted of the more complicated, and the soundness of the inductions that have been made from a comparison of the whole.

The London Fever Hospital is capable of receiving sixty-two patients: in most seasons of the year its wards are full: often there are numerous applications for admission which cannot be received for want of room: there pass through the wards from six to seven hundred patients annually. Two physicians are attached to the institution under whose care the patients are placed alternately in the order in which they are admitted: there is one assistant physician whose duty it is to perform the office of the ordinary physicians when either of these may be incapable of attending, and there is besides a medical officer resident in the house. A history of each case, containing an account of the age, occupation and residence of the patient, together with as full a statement of the symptoms of the disease and of the order of their succession as can be obtained is entered in the journal by the resident medical officer. Each of the ordinary physicians attends daily and enters in his journal a daily report of each of his own cases. The resident medical officer goes round the wards twice a day, namely, early in the morning and late in the evening, to observe if any change requiring attention may have taken place in any patient; and if any such change be observed by the nurses during the interval between these visits they are reported to him by the head nurse without delay; all such events with the modification of treatment they may have required are entered in the journals. Every case that terminates fatally is examined after death, and an account of the morbid appearances is entered in a book kept for the purpose. In this manner, in the progress of years a mass of facts accumulates relating to the statistics, the types, the symptoms, the causes, the diagnosis, the pathology and the treatment of the disease, whether successful or unsuccessful, which both on account of the fullness and accuracy of the record and of the extent of the period it embraces, cannot but be of great value.

I am encouraged in the attempt to make this record, as far as it has yet gone, useful to the public by observing the feeling that prevails among those physicians who have studied fever with the greatest diligence, and who have contributed most to our knowledge of it, that it is a disease which is still little understood and the treatment of which remains extremely vague and uncertain. Perhaps there is no disease so little understood as the ordinary fever of this country and none by the mismanagement of which so much life is lost. Dr. Clutterbuck appears to me therefore to describe the situation of the physician to such an establishment as the Fever Hospital, not more candidly than truly when he says—“It becomes a duty incumbent on those particularly who have been placed in situations favourable for observing the disease, to give the result of their experience to the public, should it tend, in any degree, either to prevention or cure. The enquiry is by no means exhausted, considered either in a theoretical or practical point of view. There is still a want of uniformity of opinion among physicians regarding the nature of the present epidemic, as well as of fever in general: while, I am sorry to add, in practice we are not much better agreed;” and when he further adds;—“To ascertain these modifications” (that is the modifications which require a modification of treatment) “is the great desideratum, which nothing but the most cautious observation, aided by much time, and the joint efforts of numerous individuals, can fully supply.”[^[1]]

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.

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.

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?

The importance of making this analysis has been felt by every person who has directed his attention to this subject from the remotest antiquity down to the present time. That it is not as easy to be made as the necessity of it is plainly to be perceived is abundantly attested by the want of success which has hitherto attended the efforts to perform it of the acutest minds, and the acutest minds, the pride and boast of our science have applied themselves to the task. Notwithstanding their labours however, the analysis made by Hippocrates has been received through succeeding ages with little variation, and continues to be received even in modern times with only slight modification. And yet that reflecting men of every age have not been satisfied with resolving all the essential phenomena of fever into heat, although they have all consented to designate the disease by some term expressive of that property,[^[17]] is attested by proofs no less striking than instructive. We are informed by Van Swieten, that Boerhaave collected with much labour from a great variety of authors all the symptoms which they had observed in different fevers: that from these he threw out such as did not appear in all fevers, and that finding himself obliged to exclude one after another, he was at length greatly surprised to find the catalogue so short; it being ultimately reduced to three; namely shivering, frequent pulse, heat.

This is a sufficient and an interesting proof that this illustrious physician saw the importance of making the analysis in question; it shews also, that his ingenuity suggested probably the best mode of conducting it which a philosopher sitting in his study could devise; and the only proper mode of conducting it the circumstances of his age and country did not place within his reach. Accordingly his success did not equal his labour: for out of the three phenomena which he fixes upon as those that are common to all the varieties of the disease there is not one which is invariably found in any type of it; while in innumerable cases the combination of the three is not found. Shivering does not occur in some of the worst forms of the malady; and where it does, it is confined to the commencement of the attack, or to that of its exacerbations. The pulse, instead of being always more frequent than natural, in some of the most formidable aspects assumed by the disease, has been observed to be as low as forty or even thirty in the minute, and, from the beginning to the termination of the attack, the heat in some cases is below the natural standard, as it generally is in the commencement of the cold stage.

To the catalogue of Boerhaave, Cullen makes the following additions:—“languor, lassitude and other signs of debility, together with derangement of the functions, particularly a want of vigor in the limbs without any primary local affection.” This extension of the catalogue adds in no respect to the excellence of the generalization. It has all the vices which a definition can possess. The characters are not present in all cases; the very opposite are strikingly prominent in many, while the last, “without any primary local affection,” has so direct a tendency to mislead the mind, and positively to prevent it from observing the real phenomena of the disease, that it may well be questioned, whether the introduction of this single phrase into the definition of fever, has not been the occasion of far more practical mischief than has been compensated by any good that has been accomplished, or ever can be accomplished by all the rest of the nosology.

In the last attempt to improve the definition of fever with which I am acquainted, Dr. Wilson Philip says, “If we lay aside Dr. Cullen’s term pyrexia, (which it must be borne in mind is precisely Boerhaave’s brief catalogue) we shall considerably lessen the difficulty of giving such a definition of idiopathic fevers as shall apply to all cases. They may be defined as follows. Languor, lassitude, and other signs of debility, followed by a frequent pulse, and increased heat, without any primary local affection.”[^[18]] Inasmuch as this definition contains fewer words than that proposed by Cullen, it may be liable to fewer objections, but it is less faulty only because it is shorter.

This total failure of men, all of them of unquestionable acuteness, and some of them of splendid genius, in their attempts to discover the common phenomena of fever, affords a strong presumption that they have not pursued their object in the right path. Without doubt, before it is possible to succeed in any scientific investigation, it is necessary to form a distinct conception of the object of inquiry. Fever is not an entity, not a being possessing a peculiar nature; and the object of investigating it, is not to discover in what such nature consists, or what it is that constitutes its essence: but fever is a series of events, and the object of inquiry is to discover what the events are; what the events are that invariably concur in the series; and in what order they constantly succeed each other. When we have discovered this, we have ascertained all that we can ever know of what is termed the nature of fever, as it is this, and only this, that we can ever know of any object or process. Every natural object consists either of one single substance, or of several substances united; and our knowledge of that object is complete when we have ascertained what that single substance is; or what all the separate substances are that combine to form it. Every natural process consists of a number of events, and our knowledge of that process is complete when we have ascertained the events themselves, the order of their succession, and the events to which they give occasion. We can make no real progress in knowledge unless we keep steadily in view the kind of information which it is possible to acquire, and which it is to our purpose to seek; and dispossess our minds of the phantoms which have so long enthralled and abused them.

In relation to our present subject then, the first object of enquiry is, what are the events which invariably concur in fever?

Where shall we look for the events? Not in the symptoms. Symptoms are not events: they are only indications of events: symptoms depend upon states of organs: they are the external and visible signs of internal, and, for the most part, as long as life continues, invisible conditions. It is then to the state of the organs that we must look for the events of which we are in search.

Are there any states of any organs that always exist in fever? Are the states constant? Are the organs affected constant; and can both be ascertained? If this can be truly answered in the affirmative; if it can be proved that there are certain conditions of certain organs which invariably exist in fever, in every type, in every degree, in every stage of it, we shall have arrived at a satisfactory conclusion relative to the first part of our inquiry.

The evidence is as complete as observation during life and inspection after death can make it, that a morbid change does take place in a certain number of organs in every case of fever, from the most trivial intermittent to the most alarming continued fever, from the mildest plague to the most malignant typhus: that at the two extremes of this scale, and at all the intermediate gradations of it, there are certain organs which are always affected, and that the affection in all is similar.

The identity of the organs is inferred from the indications they give of disordered function during life: the identity of the affection is inferred from the similarity of morbid appearances which they exhibit on examination after death.

The organs affected are those which constitute the nervous system; those which constitute the circulating system, and those which constitute the systems of secretion and excretion. The spinal cord and the brain; the heart and the arteries, especially their capillary extremities; the secreting and the excreting organs, which in fact are composed, essentially, of the capillary extremities of the arteries; the secreting and the excreting extremities of these arteries, especially as they terminate in the external skin, and in the mucous membranes, which form the internal skin, this is the chain of diseased organs: derangement in the nervous and sensorial functions: derangement in the circulating function: derangement in the secretory and excretory functions, this is the circle of morbid actions.

There never was a case of fever in which all these organs and affections were not more or less in a morbid state: there never was a concurrence of this morbid state, in this complete circle of organs, without fever. The events which invariably concur in fever, then, are a certain deviation from the healthy state in the nervous and the sensorial functions; a certain deviation from the healthy state in the circulating function; a certain deviation from the healthy state in the functions of secretion and excretion. A deviation from the healthy state in one circle of actions will not present the phenomena of fever; a deviation from the healthy state in two circles of action will not present the phenomena of fever: there must be a deviation in the three circles before fever can exist. Such then are the common phenomena of fever.

For obvious reasons the detail of the proof that these several events really and invariably take place, must be postponed until the phenomena themselves have been stated, or what is termed the history of the disease has been given.

But it is not the invariable concurrence of a particular number of events that is alone sufficient to constitute fever: to this must be added invariableness of concurrence in a particular order. As will be shewn in the proper place, there is complete and irresistible evidence that these events do occur in one invariable order. Derangement in the functions of secretion and excretion never comes first in the series: derangement in the nervous and sensorial functions never comes last in the series: derangement in the function of the circulation never comes either the first or the last in the series, but is always the second in succession.

The order of events then is first, derangement in the nervous and sensorial functions; this is the invariable antecedent: secondly, derangement in the circulating function; this is the invariable sequent: and thirdly, derangement in the secreting and excreting functions; this is the last result in the succession of morbid changes.

Supposing the matter of fact to be as is here stated, and the proof that it is so will be adduced hereafter, it is clear that we are in possession of the true characters of fever. We know the events: we know the order in which they occur: we know therefore what it is that constitutes the disease, and we know consequently what it is by which it is distinguished from every other malady. No other disease exhibits the same train of phenomena in the same order of succession. In inflammation some of the phenomena are the same: but the order in which they concur is not the same; and this affords a clear and universally applicable mark of distinction between fever and inflammation. In inflammation there is similar derangement in the secreting and excreting functions: there is also sometimes similar derangement in the circulating function: but the derangement in the nervous and sensorial functions is seldom if ever similar: the derangement that does take place in these latter functions, while it is apparently different in kind, is certainly and invariably different in the order of its occurrence. In pneumonia, in enteritis, in hepatitis, the spinal cord and the brain are never the organs in which the first indications of disease appear: the earliest indications of disease that can be discovered have their seat in the affected organ itself: it is only after the disease has made some progress that other organs and functions are involved; and apparently, the last to be involved, and certainly the least to suffer, is the nervous system.

We can now then answer the questions so often asked—are fever and inflammation the same? and if not the same in what do they differ? Fever and inflammation are not the same, because the term fever is appropriated to the designation of a certain number of events which occur in a certain series: the term inflammation, on the other hand, expresses another series of events, each event composing this train, succeeding each other in a different order: and the difference between the two series of events is precisely this difference in their individual phenomena and in their order of succession. What the physical and the physiological condition of the organs is, as contrasted with their condition in the state of health, has not yet been made out with regard either to fever or to inflammation: in the present state of our knowledge, therefore, we can neither affirm nor deny any thing respecting either the identity or the difference of that physical and physiological condition of the organs in these two classes of disease. What inflammation is beyond the series of events we are able to observe we do not know: what fever is beyond the series of events we are able to observe we do not know: we compare the events and we see that they differ: and since the use of names is to mark and to express differences, it is right to distinguish these different events by different terms. But though in the present state of our knowledge we are not justified in considering fever and inflammation to be the same, yet the close, perhaps the constant connexion between them, is a fact of the utmost importance to be known, and requires to be incessantly before the view of the practitioner. And of this we shall have but too abundant evidence in the sequel.

Supposing the proofs hereafter to be adduced to be conclusive, that the events in fever and their order really are what has now been stated, how clearly and beautifully does this view of the disease enable us to recognize one and the same malady through all the modifications it undergoes, and therefore through the countless aspects it assumes. Out of the system of organs that are always affected in fever some may be more and some may be less diseased; and it is easy to see how, from this diversity alone, the utmost variety may arise in the external characters of the disease. Thus, at one time, the spinal cord and the brain may be intensely affected: consequently the patient may be seized with violent pains in the limbs; with ferocious head-ache; with early delirium, which may rapidly increase to such a degree of violence as to require restraint: or, on the contrary, all the muscles of voluntary motion may be seized instantaneously with such a loss of energy that they may truly be said to be paralyzed: at the same time the sensorial faculties may be overwhelmed almost as completely as they are in apoplexy: thus may be formed one type of fever: and such a concourse of symptoms is actually found to exist: it ushers in the plague when it first stalks into a devoted city to sweep away its thousands and its tens of thousands.

At another time the disease may seize with peculiar violence upon the organs of secretion, and especially upon those which belong to the digestive apparatus: hence the liver may suddenly pour forth an immense flow of bile, so vitiated in quality as to irritate and inflame whatever it touches, and so abundant in quantity as rapidly to diffuse itself over every part of the body, and to tinge almost every tissue and every fluid: at the same time the stomach and intestines may be involved in such acute disease that the powers of life may be exhausted in a few hours by incessant vomiting and unconquerable purging: thus may be formed another type of fever, and such a concourse of symptoms actually occurs in the yellow fever of the West Indies.

Now we may witness a severe though a less violent affection of the spinal cord and the brain than occurs in plague. There may be present great pain in the back and limbs; intense head-ache; early and violent delirium; a burning skin; a quick and strong pulse; urgent thirst, and constipated bowels: or, on the contrary, there may be not pain of the head, but giddiness; not delirium, but stupor; not a burning hot, but a moderately warm or a cool skin; not a frequent and strong, but a frequent and feeble pulse. In either case we have a fair specimen of the common fever of our own country, the first forming the variety which may be termed acute, the second subacute cerebral.

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.

Thus febrile diseases are commonly divided into idiopathic and symptomatic—a division which is liable to the fundamental objection that the diseases included under the second section are not fevers but inflammations. There are no fevers but idiopathic fevers. It has been shewn that fever differs from inflammation both in the individual phenomena forming the train that constitutes the disease, and in the order in which the several phenomena succeed each other. There are, it is true, individual phenomena common to both; but since the series as well as the order in which the several phenomena stand in the series are different, to call both by the same name can only produce confusion and misconception.

Of true or idiopathic fevers two great divisions are made; one comprehending intermittent and the other continued fevers: a division founded on the occurrence of the trains of the phenomena in an interrupted or in an uninterrupted series. Intermittent fever is further divided into intermittent and remittent, the interruption in the series being said to be complete in the one and incomplete in the other. In continued fever, on the other hand, the trains of phenomena are supposed to proceed in a perfectly uninterrupted series, whence the name continued. The single fact suggested to the mind of the practitioner by this classification is in the highest degree trivial.

Of the particular groups of symptoms which have been brought together under the great class, continued fever, it is impossible to discover any kind of principle which has led to the formation of the distinct assemblages that have been made, or to their nomenclature when thus collected. Synocha, typhus, synochus, are the three genera which modern nosology, in the power and pride of its strength, has put forth as at once distinctive and exhaustive of this class of disease. The aggregate phenomena constituting synocha, form just that particular series which is common to some forms of fever and to all acute inflammations: namely, “Calor plurimum auctus, pulsus frequens, validus, et durus, urina rubra, sensorii functiones parum turbatæ.” The train of symptoms thus brought together do not alone form any variety of fever. The second group of symptoms forming typhus—“morbus contagiosus, calor parum auctus, pulsus parvus, debilis, plerumque frequens, urina parum mutata, sensorii functiones plurimum turbatæ, vires multum imminutæ:” and the third, forming synochus,—“morbus contagiosus, febris ex synocha et typho composita; initio synocha, progressu, et versus finem, typhus,” independently of their being brought together and named according to no known or even assigned principle, are liable to the further and the fatal objection, that they do not even occur in nature.

Even Dr. Wilson Philip, who labours to reconcile to nature and to improve in accuracy and comprehensiveness these classifications and definitions, expressly admits that a simple synocha or typhus is a fever which we rarely, if ever meet with: for that however high the inflammatory symptoms at an early period may be, those of typhus always, at least in this country, sooner or later supervene; and that however well marked the symptoms of typhus may be in the progress of fever, in almost every case, the first symptoms are more or less inflammatory; that the fevers mentioned by authors, under the names synochus and typhus, are in fact no other than varieties of the synochus; that when the symptoms of debility predominate, the fever has been termed typhus; that when, on the contrary, the inflammatory symptoms are most remarkable, and present through the greater part of the disease, it has been called synocha.[^[19]]

Again, while according to this received arrangement a train of symptoms, every one of which is found in acute inflammation, is made a distinct genus of fever, numerous diseases, each forming an exquisite specimen of fever, are totally excluded from the order, and placed at a considerable distance in the nosology. Because scarlatina is a fever attended with a peculiar eruption on the skin; because rubeola is a fever attended with an eruption on the skin also peculiar; because variola is a fever attended with another peculiar eruption, and urticaria with another, these diseases are not made varieties of fever, but, designated by the term exanthemata, are formed into a separate order: while, on the other hand, fevers attended with petechiæ, with papulæ, with aphthæ, with vesicles, are accounted fevers, and accordingly are termed petechial, miliary, aphthous, erysipelatous, vesicular fevers; whence synochus petechialis, synochus miliaris, synochus aphthosus, &c.

Without doubt is right that these varieties of disease should be discriminated and named; but this mode of classifying them has a necessary tendency to divert the mind from dwelling on those essential circumstances which make all of them mere varieties of one great disease; and to fix it upon those comparatively unimportant though obvious circumstances which simply modify the malady without in the least affecting its identity.

It has already been stated that the grouping of the symptoms, or, in other words, the formation of the species of fever cannot be scientifically or usefully accomplished until we have arrived at a perfect knowledge of the condition of the organs upon which the trains depend; and that our knowledge of these conditions is so imperfect, especially with regard to many of the species, that this classification cannot possibly be made at present. It is not even known whether the condition of the organs in intermittent be the same as it is in continued fever. The mere periodicity in the recurrence of the febrile paroxysms by which this class of disease is at present characterised, is an exceedingly unsatisfactory principle of distinction, unless we at the same time knew the state of the system upon which that periodicity depends. The alternate transition of intermittent into remittent and continued, and of continued and remittent into intermittent fever, of which the history of epidemics affords so many striking examples, and of which Sydenham, Pringle, and all the older writers have recorded so many interesting accounts, as events which they themselves daily witnessed, seems to shew that there can be nothing amounting to a generic difference between these several diseases. The type, as far as we have the means of judging, appears to be determined entirely by the intensity of the disease. An intermittent increasing in violence and malignity changes into a remittent or a continued fever, and a continued or remittent, diminishing in violence and malignity, often assumes the form of intermittent. Speaking of the epidemic constitution of the years from 1661 to 1664, Sydenham states that, in the year 1661, the autumnal intermittents which had prevailed for some years broke forth afresh, especially obstinate tertians; that increasing daily until August, at which time they raged fiercely and became extremely mortal, in many places seizing whole families, and destroying great numbers, decreased by degrees until October; and, disappearing at the approach of Winter, were succeeded by a continued fever, which differed from the Autumnal intermittent only in being continued, while the former returned in paroxysms: that both invaded almost alike; that those who violently laboured of either vomited; that in both the skin was dry; the tongue black, the thirst urgent, and that, at their declination, the morbific matter in both was readily exterminated by sweats. “It was manifest,” he adds, “that this fever belonged to the family of intermittents, because it rarely appeared in the Spring: it was a sort of compendium of the intermittents; and, on the contrary, every fit of the intermittent seemed to be a compendium of this fever; so that the difference chiefly consists in this, namely, that the continued fever once begun, perfects its effervescence with the same degree of heat; but the intermittents perform their business by parts, and at several times.”[^[20]]

In like manner, Pringle, among many other examples of the fact, which, indeed, he states to be of constant occurrence, gives an account of an epidemic that prevailed in the army of the Netherlands, and which in its worst form assumed the appearance of an ardent fever. He states that the men were suddenly seized with violent head-ache, and frequently with delirium: that, if sensible, they complained also of grievous pain in the back and loins; intense thirst; burning heat; great sickness and oppression at the stomach, sometimes with vomiting of bile, sometimes with evacuation of bile by stool, accompanied with tenesmus and pains in the back: that this fever generally remitted from the beginning upon bleeding and purging: that if these precautions were omitted, the fever went on in almost a continued form, and that its tendency to putrefaction was so great, that while many had spots and blotches, some had mortifications, which were almost always fatal: that this fever continued to rage throughout August; that it began to abate with the heat in the middle of September; that from this period its violence diminished, and the number attacked gradually decreased; and that now “the remissions became more free, so that insensibly, with the coolness of the weather, this raging fever dwindled into a regular intermittent, and entirely ceased upon the approach of Winter.”[^[21]]

What that condition of the system is, which, in forms of fever that are thus mutually convertible, causes one to persist in an uninterrupted series, another to remit, and another, after disappearing for a time, to recur in distinct and regular paroxysms, is wholly unknown. Sydenham, indeed, cuts the knot and removes the difficulty at once. Speaking of the return of the fits in intermittent, he replies to the inquirer into their cause,—“I would fain know why a horse comes to his growth in seven years and a man at twenty-one; or why some plants flower in May and some in June. I am persuaded that the progress of nature is as certain and regular in this case as in any other, and that the matter of a quartan and tertian ague is subject to Nature’s laws and governed by them, as well as any other bodies whatever.” The regularity of nature in the production of disease, no less than in the maintenance of health, cannot be doubted: but the point in question is not clearly one of those ultimate facts, into the reason of which it is wholly vain for the human mind to inquire.

Hitherto, however, no one appears to have hazarded even a conjecture as to the cause of this striking difference between these two forms of disease; and pathology, as has just been observed, has afforded no clear light to enable us to determine whether the febrile circle of organs is similarly affected in both. Examinations of fatal cases have been made; but none on that large scale and with that accuracy which alone can render them of any value. I have endeavoured to ascertain the morbid appearances in the spinal cord and the brain, and in the mucous membrane of the respiratory and digestive apparatus, from those who have been long engaged in extensive practice in districts in which ague prevails: but I have been able to obtain no satisfactory answer, excepting that intermittent does not kill! Greatly as the severity of intermittent is without doubt diminished, in the present age, yet we cannot receive such an account without blessing the bark of the seventeenth and the skill of the nineteenth century!

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.

It has been stated that, for the purpose of forming into distinct groups certain assemblages of symptoms which it is important to distinguish, because they bear an important relation to practice, it will be convenient to divide the synochus, the term by which we propose to designate the common fever of this country, as it presents itself in its mild aspect, into two sections, namely, synochus mitior and synochus gravior. For reasons already assigned, it will likewise be important, in treating of these different modifications of fever, to notice in each both the phenomena which form the assemblage, and the order in which they succeed each other.

On careful examination it will be found that the first symptom which denotes the commencement of the ordinary fever of this country, in its mildest form (synochus mitior), is a loss of mental energy. This is by no means the first symptom which attracts attention: it is commonly overlooked for some time, and excites little notice until it has become distressing. Patients in general are incapable of analyzing their sensations or of determining the order of their succession; but if medical men, who are but too subject to be attacked with this disease, will take the trouble to reflect on the order of events as they occurred to themselves, they will probably be satisfied, after the most attentive consideration, that the first indication of disease they felt was a want of power to conduct their ordinary mental operations with ease and vigour. Such at least, perhaps I may be permitted to mention, was the fact in my own case; for, having suffered a severe attack of fever, I have a distinct and vivid recollection of the dulness, confusion, and want of mental energy which I experienced for a considerable time before I was conscious of any corporeal debility.

This affection of the mind consists particularly in indistinctness and consequent confusion in the trains of ideas; in inability to attend to their relations; and, as a necessary result, in the loss of power to think clearly. The individual feels that he is not in a state to form a sound judgment on any subject upon which he may be called to decide.

Closely connected with this mental weakness is the loss of energy in the muscles of voluntary motion. Lassitude is the result. The patient cannot move with his usual vigour, nor even sit without the feeling of weariness. The debility thus seizing upon both body and mind, sometimes occurs in each so nearly simultaneously that, it must be owned, it is difficult to determine in which it appears first.

The next symptom in the order of succession is still more characteristic: it consists in an uneasy sensation which is quite peculiar to this state of the system. No description can convey any idea of it to one who has not felt it; and to him who has felt it the word fever recalls this uneasy feeling so instantaneously and vividly that I apprehend most unprofessional persons conceive it is this very feeling that constitutes the essence of the disease. It is much more distressing than pain: the mere restlessness which accompanies and which forms so large a part of it, any one would gladly exchange for intense pain. In all diseases it is this which makes the sufferer on his midnight pillow exclaim, “oh! that it were morning!” and in the day, “would that it were night!” Though it is so frequent in its occurrence, and so peculiar in its nature, yet I am not aware that it has received any distinct name: it may be called, until a better is suggested, febrile uneasiness.

It is seldom that these symptoms exist long before positive pain is felt. With very few exceptions pain is first felt in the back or loins and then in the limbs. It is rare that this symptom is absent in the commencement of this form of fever, and it often occasions more uneasiness to the patient than any thing else during the first stage of the disease.

Already a remarkable change is commonly visible in the countenance. Its expression is that of dejection: it is often strikingly similar to that of a very weak person suffering from fatigue. The colour of the face is pallid, and the features are somewhat shrunk; but its general aspect is so peculiar and characteristic that an experienced eye can distinguish the disease even at this early period, and without asking a single question.

The skin partakes in a remarkable degree of the debility which so early shows itself in the muscles of locomotion. This is indicated in a striking manner by its increased sensitiveness to the physical agents by which it is surrounded, and by its inability to resist their influence. Ordinary degrees of temperature produce a sensation of cold which is sometimes intolerable: chilliness is felt even in a heated room, or in a warm bed: hence the sensation of cold, sometimes increasing to shivering, which has been considered one of the most constant signs of fever. But this feeling of chilliness by no means depends on external temperature: it is increased by cold, but it exists in spite of an elevated temperature: it arises from an internal cause, and is not to be counteracted by external heat.

While the patient experiences the sensation of cold, there is no diminution of the quantity of caloric in the system. The thermometer applied to any part of the body commonly rises as high as in the state of health, and the skin, touched by the hand of another person, communicates not the feeling of cold, but often, on the contrary, that of preternatural heat. There is no positive abstraction of caloric from the body nor any failure in the process, whatever it be, by which animal heat is generated; there is only altered sensation, in consequence of derangement in the function of the skin. In this form of fever, the chilliness in many cases never amounts to shivering; in others, there is an attack of well-marked rigor, and in others, again, there is either no feeling of cold, or it is so slight that it escapes observation.

The symptoms now enumerated are all clearly referrible to derangement of the function of the spinal cord and brain. There is as yet no affection of any other organ obviously or, at least, much developed. The circulating system, it is true, is just beginning to be affected. The pulse is no longer perfectly natural. It is more languid than in the state of health; sometimes it is also quicker: at other times it is slower; now and then it is scarcely changed in frequency, but its action is invariably weaker than in its sound state.

At the same time the respiration is affected in a corresponding degree: it is shorter and quicker than natural; the chest does not expand so freely, and compensation seems to be sought in an additional number of respirations. Oftentimes neither the pulse nor the respiration appears to be much altered, if the patient remain perfectly still; but if he rise and walk across the room, the pulse instantly becomes rapid, and the respiration is quickened almost to panting.

The transition from the affection of the nervous and sensorial to that of the circulating and the respiratory systems is thus clear and striking. Physiology teaches us how closely these systems are connected, and how mutually they are dependent one upon the other, the closest observers and the ablest experimentalists candidly confessing that they are scarcely able to determine which is the least dependent, or the action of which is the least necessary to the others performance of its functions. The nervous system being first deranged, it is thus consonant to what we know of the healthy function of the animal economy, that the circulating and the respiratory systems should be the next to suffer.

How long the nervous system may continue thus deranged, before any other organs are involved, excepting the circulating and the respiratory, to the extent just stated, is uncertain. There can be no doubt that in this mild form of fever, the range of the duration of this isolated state of disorder, if we may so express it, is from a few hours to several days. The rapidity or the slowness with which other systems of organs become involved seems to depend very much upon the acuteness of the attack. In general, the more acute the fever, the more rapidly the individual phenomena succeed each other, and the entire series becomes complete. But this is not, and it is important to bear in mind that it is not invariably the case: for experience teaches us that the severity and danger of the disease are not diminished by the slowness of its approach; and that cases occur, which are slow in forming, and which do not for awhile excite alarm, that ultimately become truly formidable.

It has been stated that the circulation languishes with the diminished energy in the sensorial faculties, and the loss of power in the muscles of locomotion. After awhile, the pulse which was feebler than natural becomes more full, more strong, and generally more quick than in a sound state; and now the skin, which was cold, becomes preternaturally hot. The previous cold consisted, for the most part, of altered sensation, there being little or no loss of caloric: but the feeling of heat, on the contrary, is the result of an actual increase of temperature; for the heat in the interior of the body, as well as on the surface, rises in some cases several degrees, as is ascertained by the thermometer; the range of increase being from the natural standard 98° to 105°, beyond which it is seldom found to augment in this form of fever. The heat is at first not uniform over the entire surface of the body: it often happens that some parts are cold while others are burning hot. The heat is oftentimes particularly intense over the forehead, or over the back part of the head, or over the whole scalp, while the cheeks are commonly flushed. All these symptoms denote a morbid condition in the action of the heart and arteries. Since the generation of animal heat is so intimately connected with the circulating and the respiratory functions, it is probable that the increase of temperature is the result of some morbid action of the capillary vessels belonging to these systems. What the disordered action of these vessels is, which produces increase of temperature, we do not know, because we do not know what their natural action is which produces the temperature of health: but the object of scientific observation is in some degree accomplished, when it is ascertained that one condition of these functions is invariably connected with a morbidly-diminished temperature; another with a morbidly-augmented temperature; and another with the temperature of health.

Immediately the circulation is thus excited, the functions of secretion and excretion become deranged. The mouth is now dry and parched; the tongue begins to be covered with fur; thirst comes on; the secretion of the liver, probably also of the pancreas, and certainly of the mucous membrane lining the whole alimentary canal, is vitiated, as is proved by the unnatural quantity, colour, and fetor of the evacuations; the urine likewise is altered in appearance, and the skin is not more remarkable for the sense of heat, than for that of dryness and harshness which it communicates to the touch. With the excitement of the pulse and the increase of the heat, the pain in the back and limbs and the general febrile uneasiness are much augmented.

At this period, then, the fever is fully formed; the series of morbid phenomena is complete: any thing more that happens is referrible to degree and to duration, and must be the result of one or other of these circumstances, or of their combined operation. And we now see that the organs affected, constitute precisely that system of organs which has been described as forming the febrile circle: that the symptoms which denote the fever are just the symptoms which indicate a derangement in the several functions performed by these organs; and that the order in which they become successively involved is exactly that which has been assigned.

As soon as the preternatural heat comes on, pain begins to be felt in the head. Dr. Clutterbuck, in describing the general character of the ordinary fever of London states[^[23]] that “the first symptom almost invariably complained of is more or less of uneasiness of the head.” If by uneasiness he meant pain, there is, if there be any truth in the preceding observations, a long train of symptoms to intervene before this symptom occurs. That it does ultimately occur is certain: but commonly its place in the series is much later than is here assigned: it is disordered function of the brain, indicated by loss of mental energy, that appears to form the first symptom in this morbid train.

The pain, when it does come, is sometimes slight at first, and occasionally it remains slight throughout the disease; at other times it is pretty severe. Cases sometimes occur, in which, instead of pain, there is only a sense of giddiness, and now and then the uneasy feeling is described as that of lightness: or, on the contrary, as that of heaviness or weight. But whether the feeling be pain, and that pain be slight or severe, or whether it be giddiness, or lightness, or heaviness, it indicates a similar condition of the organ, and requires a similar treatment.

With the accession of pain of the head there is a manifest increase in the disturbance of the sensorial functions. The inability to think, to compare, to reason, to judge, great as it was at the commencement, is now much greater. Instead of being more dull, there are certain states of the mind which now become more acute and vigilant even than in health. Sensation itself, at this period, is invariably acuter than natural, as is indicated in all the organs of sense. The eye cannot well bear the light: there are few cases in which the full glare of day does not excite uneasiness, while in many the ordinary light of a room cannot be borne: in these cases the opening between the eye-lids is frequently observed to be contracted, as if from an involuntary effort to exclude a portion of that stimulus which in health excites no inconvenience, and this state of the eye-lids assists in giving to the eye its dull and heavy expression, so characteristic of fever. The increase of sensibility in the organ of hearing is equally striking. Sounds which were not noticed during health become acutely and even distressingly sensible, while accustomed noises, such as that of a crowded street, are always painful and often intolerable. The skin, considered as an organ of touch, is in a like morbid state. An impression barely sufficient in the state of health to produce sensation excites the feeling of tenderness, and alternations of temperature, which in ordinary states are scarcely perceptible, are painful. The senses of taste and smell, on the contrary, are nearly obliterated, owing to the altered condition of the membranes upon which the sensitive nerves are distributed.

From the earliest attack of the disease the sleep is disturbed and unrefreshing; now scarcely any is obtained; the febrile uneasiness will not allow of repose; the patient cannot remain in any position long, incessantly shifting his place, never eluding his pain. At this stage the sense of uneasiness in the limbs, oftentimes the severity of the pain over the whole body, is peculiarly distressing.

With this progressive increase in the affection of the spinal cord and the brain, the derangement in the circulating system is proportionally augmented. The pulse is invariably altered, both in frequency and character. Generally it rises to 90, sometimes to 100; but in this form of fever it seldom exceeds this number; and occasionally it never rises above 80. The stroke of the pulse is usually stronger and fuller than natural, though it commonly retains its softness, and does not impress the finger with that sensation of sharpness which is characteristic of ordinary inflammation. Occasionally, however, a degree of sharpness may be perceived in it, and it is not easily compressed.

The thin white fur which already had begun to appear on the tongue progressively increases in extent and thickness. The colour of the fur usually changes, as the disease advances, from a dirty-white to an ash-colour; but in this form of the disease the tongue always remains moist, and never becomes brown. This state of the tongue is almost always accompanied with thirst, but it is never urgent. There is always a loss of appetite. The bowels are generally constipated, and the secretions of the whole alimentary canal are vitiated.

Thus we perceive that the progress of the disease consists in increasing mental and corporeal weakness; increasing pain in the back, loins, and limbs; increasing heat of skin, acceleration of pulse, and general febrile uneasiness, together with the occurrence of pain in the head, and progressive derangement in the functions of secretion and excretion.

The fever in this mild form is now at its height. It remains stationary, or at least with very little change for an indefinite period, generally for some days. The cerebral affection does not increase beyond what has been described: there are no greater indications of disease in the respiratory organs, and the mucous membrane of the stomach and intestines does not denote any progressive advancement in disease.

One of the most remarkable circumstances connected with the ordinary fever of this country, in the present day, is the uninterrupted and perfect continuity of its phenomena. As long as the febrile state remains, nothing deserving the name of a remission is in general to be perceived. Occasionally, it is true, a slight increase in the symptoms may be observed towards evening, especially in the heat of the skin; but even this is not common, and it is scarcely ever great enough to deserve the distinction of being called an exacerbation. Much less is there any regularity in the accession and decline of such excitement. In the great majority of cases not the slightest approach to an exacerbation and a remission can be distinguished from the commencement to the termination of the disease. Yet the older writers speak of these events as if they were as palpable as the paroxysms of intermittent and as constant as the return of morning and evening. There cannot therefore be a doubt that the character of the ordinary fever of this metropolis is greatly changed from the character of that which prevailed two centuries ago; and the circumstances which have contributed to produce this change will be considered hereafter.

In the great majority of patients in whom the symptoms continue thus moderate, the disease disappears about the end of the second week; that is, they are convalescent at that period; but it usually requires eight or ten days longer before they have regained sufficient strength to leave the hospital. Sometimes, although there is no greater severity in the symptoms, the disease is more protracted, and the recovery is not complete until the fourth or even the fifth week. Beyond this period it is very rare for this form of the disease to be protracted.

Almost all who are attacked with the malady in this, its mildest form, recover: but now and then it happens that the symptoms go on with this degree of moderation until about the end of the second week. Then at the period when it is usual for convalescence to take place there is no perceptible improvement; the patients seem even to grow weaker; they lie more prostrate in the bed, and they are soon incapable of moving; still they complain of no pain or uneasiness, and it is not easy to detect any trace of disease in any organ; yet it is but too evident that they grow worse, and ultimately they sink exhausted. In these cases, on examination after death, it is commonly found that disease has been preying on some vital organs, although its presence could not be detected during life; and this termination of the milder type of fever rarely happens, excepting in aged persons, whose constitutions have been enfeebled by previous diseases, or worn out by the various causes which depress and exhaust the powers of life.

With an occasional exception of this kind the disease in this form always terminates favourably; and the first indication of returning health is remarkably uniform: it is almost always marked by longer and more tranquil sleep. Instead of that restlessness which is so characteristic of fever, and which forms the most distressing part of it, the patient is observed to lie more still, and on waking for the first time from an undisturbed slumber, he often spontaneously says that he feels better. Better he may well feel, for his febrile uneasiness is gone; the load that oppressed him is shaken off; he is a new being. The pain of the head and of the limbs is so much diminished that often he cannot help expressing his thankfulness at the change. The countenance becomes more animated; its natural expression returns; the tongue begins to clean; and after this state of the system has continued for two or three days, the appetite returns. While these favourable changes are going on, the pulse usually sinks about ten beats below its highest point at the height of the fever; it is not uncommon, however, for it to remain quick during the entire period of convalescence; and for some considerable time it is easily excited on any movement of the body, or any emotion of mind. In some cases, on the contrary, when the attack has been very mild, it sinks considerably below the natural standard, and is intermittent, a sign which I have uniformly observed to be attended with a sure and steady convalescence. In the mean time the appetite becomes keener than natural; the strength gradually improves; and in a short time the patient is restored to his usual health and vigour.

What the condition of the brain and of the organs correlatively affected is, in these the mildest cases, we do not positively know, because we have no opportunity of inspecting them, their favourable termination being nearly without exception. But the more all the phenomena are considered in their entire series, in the order of their succession, in the uniformity, nay, even in the exclusiveness of their seat, as well as in the unchanging sameness of their effects, the more clear the evidence will appear of the soundness of the induction, that the condition of all the organs in all the types of fever is the same in nature, although there be no two cases of any type perfectly the same either in the degree of the affection or in the stage of the morbid process which it excites. If this induction be really just, we must conceive that, in the synochus mitior, while the morbid affection of the organs is slight, the diseased process which it sets up in them stops before it produces any change in their structure.

However this may be, and to leave for the present all matter of inference, and to keep strictly to the matter of fact, we do positively know that the mild forms of fever become severe in consequence of the supervention of inflammation in certain organs. Perfectly unknown as the nature of the primitive febrile affection at present is, yet that in the progress of the disease it does ultimately pass into inflammation is a fact, the evidence of which it is impossible to resist; although the same observation which teaches us this most important truth, teaches us also that the inflammatory action is always considerably modified by the febrile state. How it is so modified, and to what extent, we shall consider hereafter. I have spent much consideration and some labour in the effort to combine the symptoms which attend these severer forms of the disease with the ascertained conditions of the organs upon which such symptoms depend. But since it is of paramount importance that the events which actually take place should be known, and that the order in which they succeed each other should be stated with clearness and exactness; and since I have been able by no method that I could think of to combine the pathology with the history without breaking too much the continuity of the latter, I have been under the necessity of separating these two most intimately connected subjects, and of treating of them under distinct sections. In giving the history of the events, I have detailed them strictly, as far as I am acquainted with them, in the order in which they occur: and I have endeavoured to arrange the cases that constitute the pathology in such a manner, that they shall closely correspond to these events, and clearly illustrate the order of their succession. If I have succeeded according to my wish, the reader in studying the cases will be reminded, as he proceeds, of the successive stages of the history, and if he again revert to the history, after having studied the pathology, he will be reminded of the morbid appearances in the organs which are there described. To afford a clear perception of the connexion between the successive events, as indicated by the symptoms during life, and the progressive changes of structure in various organs, as demonstrated by inspection after death; and thus to establish a strong and indissoluble association in the mind between the morbid condition and its sign, are the objects at which I have aimed. If I have succeeded, I shall have accomplished one of the chief objects of my undertaking.

The transition of a mild case of fever into a severe one, or the progress of a case severe from the commencement, is accompanied with, or depends upon, as will abundantly appear hereafter, certain changes that take place in certain organs. These changes occur with great regularity; the organs in which they take place are always the same; and the symptoms by which they are denoted are uniform. The organs affected are the spinal cord, the brain, the membranes of both, the mucous membrane of the lungs, and the mucous membrane of the intestines. For the reason just assigned the nature of these affections cannot be described in this place, but must be postponed to that part of the work which treats of the pathology. Since however the symptoms are nothing but the signs of these conditions, and the history of the succession of the former, is nothing but an account of the indications of the successive changes that take place in the latter, all the important symptoms must necessarily have their seat in the head, in the thorax, and in the abdomen. Mixed and blended as they appear in the different cases which the practitioner is called upon to treat, nothing can appear more complex or more variable: when analyzed, nothing is more remarkable than their simplicity and their uniformity. In order to perform that analysis with exactness, and to render it really instructive, these symptoms must be contemplated as they arise in the affected organs. These organs, as we have seen, are the cerebral, the thoracic, and the abdominal; the symptoms therefore divide themselves into cerebral, thoracic, and abdominal: there is, indeed, a fourth order, in which all the organs appear to be equally involved; in which the general affection is intense, and which therefore may be appropriately termed mixed. We shall see that cases of this kind constitute by far the most dangerous form of the disease.

I. Synochus Gravior with Cerebral Affection,

occurs under two degrees of intensity: when the cerebral affection is moderate, it may be termed subacute; when great, acute.

1. Synochus with Subacute Cerebral Affection, may be attended for several days with no symptom which has not been already enumerated in the account of the mildest form of the disease. The accession is the same as in synochus mitior: the progress up to a certain period is also the same. But at the time when the pain of the head diminishes in the latter, it increases in the former. Still the pain is often not severe. He who looks for intense pain, and suspects no cerebral affection, unless accompanied with this symptom, will be surprised by what will appear to him the sudden occurrence of new symptoms, such as are immediately to be stated, which will at length open his eyes to the danger of the case, and excite his wonder, which it is not unfrequent to hear expressed, that an affection hitherto so mild, should, without any previous warning, become so formidable, and show but too manifestly that it is beyond control, and will certainly proceed to a fatal termination. The warning was given, but the sign was not understood. The descriptions of disease are commonly taken from its most acute form; and it was long the practice to derive them from this form alone, and the consequences were truly fatal. Even with the best care that can be taken in drawing up the history, these descriptions are exceedingly apt to become ideal, and not real entities: to consist of a collection of all the circumstances that exist in all cases, and not of that particular combination only which is found in any one case: and thus to be not the portrait of any individual, but a fancy picture bearing a general resemblance to all individuals without being the true likeness of any. The consequence is, that at the bed-side of the sick the original from which the picture is supposed to be taken is not to be seen, and the practitioner remains in doubt, if he do not fall into error. Error serious and fatal many have fallen into, and, on this very account, still continue to fall into, with regard to the existence of cerebral disease in fever. Abundant evidence will be given in the pathology, that it is not uncommon for the most unequivocal and extensive changes of structure to take place in the brain and its membranes without severe pain having ever been felt. Pain, however, though it be not great, is almost always present. It is seldom that the pain extends over the whole head; the patient generally points to some particular part where it is peculiarly felt. In the majority of cases the seat of the pain is either in the forehead, or at the temples, or over the eyes; but occasionally it is in the occiput, and extends down the neck, and in these instances it is often severe between the shoulders.

Now and then no pain whatever is felt. Question the patient as much as you please, and he will tell you that he never has felt any pain. In this case giddiness is the substitute. Giddiness in the commencement, and in the early stage of fever, is as certain a sign of cerebral affection as pain. Striking illustrations of this are afforded by several cases detailed in the pathology; by consulting which, the reader will see that precisely the same morbid changes take place in the structure of the brain, although nothing but giddiness be complained of, as occur in those which are attended with the acutest pain. The practitioner will therefore fall into a fatal error who is seduced into security because pain is absent; and who neglects the remedies proper for inflammation of the brain, because the patient complains only of giddiness. If giddiness be combined with pain, or alternate with it, which is not uncommon, the giddiness being slight if the pain be severe, and the pain being slight if the giddiness be distressing, it indicates a more severe affection than if either exist alone.

2. In the majority of cases, as long as the pain continues, the heat of the skin remains considerably above the natural standard. But often the heat over the general surface of the body is not great. Commonly, however, it is hotter than natural over the head, and it is hottest wherever the seat of the pain be fixed: so that the contrast is often striking between the temperature over the forehead or at the occiput, and the heat of the body in general.

3. The dull and heavy expression of the eye is greater than in the milder form of fever. The conjunctiva generally becomes brighter and more glistening than natural: though instead of this the vessels are often more numerous and more turgid than usual, and give it the appearance which is termed “muddled.” The eye at the same time is commonly preternaturally sensible, and cannot bear a strong light, although sometimes no complaint is made if the curtains of the bed be withdrawn, or the window-blind be drawn up.

4. There is usually a corresponding increase in the general sensibility; and what is remarkable, this is quite as much indicated by the increased sensibility to sound as to light. A loud noise is invariably distressing to the patient, and a continuance of it greatly aggravates all the symptoms. Exposure to a glare of light and a loud noise, would alone rapidly change a slight into the severest cerebral affection.

The expression of the countenance is now very peculiar: it cannot be described, but the experienced eye can seldom fail to recognize it. It is indicative of suffering without the strength to bear it: it is not anxious; that expression does not come on until a later period. The face is sometimes flushed, but it is often pallid, which does but add to the peculiar character of its expression.

5. As long as the pain of the head, the giddiness, and the increased sensibility continue, there is invariably a want of sleep. The degree of sleeplessness is not always in proportion to the head-ache or to the other symptoms; but while the latter are present, the former is never absent. That condition of the brain upon which sleep depends appears to be easily disturbed by a great variety of causes; but whatever be capable of affrighting this heavenly visitant, “tired Nature’s sweet restorer,” whether in the mansion, the palace, or the prison, and whether from the bed of healthful slumber or from the couch of sickness, nothing so effectually and so constantly banishes it as that febrile uneasiness of which we have already spoken; and which, instead of declining, as in the milder form of fever, now increases in strength and activity, and will scarcely allow the restless body to remain in one position for a moment. He who has felt its influence in this stage and degree of fever, will admit that there is nothing comparable to the wretchedness it produces, except it be the sweetness of the first waking moment after the first tranquil slumber of returning health.

6. And now, sometimes closing this train of symptoms, but more frequently being the first harbinger of another, delirium appears. Delirium is usually first observed when any slight sound rouses the patient from that disturbed slumber which is the only substitute allowed for sleep. The delirium is seldom violent or long-continued, but, when present, is like the talking of a person during sleep in a disturbed dream. This symptom, however, is by no means invariably present, and when it does come, it often postpones its visit to a somewhat later period.

7. The pulse, during all this time, may not be much quicker than in the mild form; and the state of the tongue and of the evacuations does not materially differ.

Such is the train of symptoms when the brain becomes prominently affected. These symptoms continue without intermission, and with little change, for several days. The period of their duration, when only in this degree of violence, is commonly from eight to ten days: when their character is still milder or more subacute, or when they have been mitigated by appropriate remedies, it may be protracted fifteen days.

About this period a remarkable change takes place; an entirely new train of symptoms supervenes, which is different, and which, indeed, presents a striking contrast, according as the patient is destined for life or death.

If it be for life, that sleep, of the long absence of which we have already spoken, returns; and nothing can more truly express its character than its familiar name, “balmy;” and healing is its influence. From two or three hours of such slumber, the patient awakens a new being. Not that the change is at first striking to an inexperienced eye; but there is no fever nurse who does not recognize it in a moment, and it is not long before the patient tells you that he feels it. The febrile uneasiness is now much diminished: the headache is greatly relieved; and the skin is cooler and softer. The pulse may not yet be altered, or it may be a few beats slower than before, but there is almost always already an improved appearance in the tongue, which shews a beginning disposition to clean. These favourable changes gradually increase. If the sleep the next night be longer and more refreshing, which it generally is, on the following morning a decided improvement is visible in the countenance. The eye is clearer and more lively, and the expression of the countenance is more natural. The skin continues cooler and softer; the tongue is still cleaner, and the pulse, perhaps, slower by a beat or two; and from this period, if no untoward event happen, the convalescence proceeds just as has been described in the return of health in the milder form of fever.

If, on the contrary, the case proceed unfavourably, a totally new train of symptoms at this period sets in.

1. In the first place, the pain of the head obviously, and sometimes strikingly, diminishes. Often it disappears altogether, or, if any uneasiness remain, it is rather a sense of dullness and heaviness than pain. In like manner the giddiness, if that were urgent, is no longer perceptible: but it is remarkable that the pain in the back and loins not unfrequently continues for some time after the headache has disappeared: but, ultimately, that also ceases. The period at which this important change takes place depends upon the severity of the attack, and is materially influenced by the activity or inertness of the treatment. In the subacute form, it usually takes place about the tenth day from the commencement of the disease.

2. Simultaneously with the disappearance of the head-ache, there is a remarkable diminution of the sensibility. The mind is duller and more heavy. The patient may still be roused to answer with tolerable coherence if spoken to; but when left to himself he is confused and stupid. The eyes now become injected: often suffused; and the heaviness and dullness of their expression is increased.

3. It is at this time that delirium, if it appear at all, most commonly comes on. The increasing insensibility, if not attended with decided delirium, is almost always accompanied with moaning or incoherent muttering, especially during the short and interrupted slumbers which form the substitute for sleep.

4. Striking as these changes are in the functions of the spinal cord and brain, those which take place in the number and character of the pulse are no less important. Even in cases the most decidedly subacute, it is seldom that it does not rise ten beats, so that if before it were 90, it will now be 100, and it is always weaker.

5. Now, too, signs of disease in the chest and abdomen are almost always to be distinguished. A case purely cerebral, from the commencement to the termination of the disease, is rarely to be met with. If there be not cough, there is almost always a short and hurried respiration, and more or fewer of the indications of abdominal affection hereafter to be stated. Even in cases the most purely cerebral the tongue always becomes more loaded and often dry; and it is strikingly characteristic of the state of the nervous system, that while the tongue becomes dry, the thirst diminishes.

Thus far it is possible that the disease may proceed towards a fatal termination without proving mortal. It is not often that its course is turned back or stayed after it has made this progress; but still such an event is sometimes witnessed. When it does occur, the amendment, both in its origin and progress, is very similar to that of the favourable change which has already been described. More tranquil and longer-continued sleep is almost always the earliest sign that, in this severe struggle, life has obtained the victory. If, on awaking from such sleep, there be less delirium, were delirium present, or greater tranquillity, were the restlessness urgent; and if there be any increase, although slight, in the sensibility, or any improvement in the expression of the countenance, hope may be entertained that that victory will be won; and hope may become assurance, if the tongue which had been loaded become clean at the edges, or the dry tongue become moist. Even under apparently the most desperate circumstances, if these three symptoms concur, a favourable prognosis may be pronounced with tolerable certainty. Two or three days may elapse after their occurrence, before any remarkable change is observable in the pulse; but it is seldom that they continue twenty-four hours before the pulse falls at least ten beats. Now and then, on leaving a patient in the evening with a pulse at 120, we are surprised and delighted to find it in the morning as low as 100. When the pulse has thus fallen towards the natural standard, when the tongue has begun to clean, and when the skin has become cool and soft, however desperate his condition but a few days before, the patient may be said to be convalescent.

But though this favourable change is sometimes witnessed, yet, from the point at which we left off the description of the progress to a fatal termination, the too common history is, increasing restlessness and sleeplessness; insensibility lapsing into coma; further acceleration of the pulse; greater dryness of the tongue and decreasing strength, until, at length, the powers of life receiving less and less supply from the great systems in which they have their seat, become completely exhausted.

Those who have been placed in situations which have afforded them opportunities of witnessing much of the disease will, I trust, acknowledge that the account now given is an accurate narrative of the symptoms that occur, and of the order in which they succeed, in the great majority of cases. Upon what conditions of what organs they depend will be illustrated in the pathology.

Sometimes to these, other trains of symptoms are added—namely, muscular tremor, frequent and sudden screaming; rolling of the head upon the pillow; constant tossing of the hands about; picking at the bed-clothes or other surrounding objects; partial paralysis of the upper eyelid, so that one or both of the eyes remain half or almost wholly closed; the ball of the eye unsteady or constantly rolling; the expression of the eye and countenance at one time wild and anxious, at another fatuous; squinting; the respiration now slow and laborious, now exceedingly rapid; the pulse either slow, full and regular, or slow and intermittent, or so quick that it cannot be counted, or these states succeeding each other or alternating with each other at short intervals; convulsions; involuntary and unconscious stools—all these symptoms are never found combined in any one case; but certain assemblages of them occur with some degree of constancy, and depend upon certain conditions of the brain and spinal cord. Since, however, the description of these conditions cannot be given here, the further account of the signs which denote them must be postponed until we treat of the pathology of the disease.

2. Synochus Gravior with Acute Cerebral Affection.—Such is the history of the synochus gravior with cerebral affection in its subacute form. When its attack is the most acute, the history is precisely the same, excepting that the symptoms are more severe, and their progress quicker. The head-ache is much more intense; the giddiness is more violent; the sensibility is excessive; the least noise is intolerable; the slightest motion either of the head or of the body aggravates all the symptoms; the eye is muddy, and very soon becomes injected, and is perfectly intolerant of light; the pain in the back, loins, and limbs, is nearly as great as it is in the head. The skin is intensely hot, and sometimes impresses the hand with the sense of pungency; but though every where thus hot and dry, its temperature is peculiarly great over the scalp, so that if the head be shaved, and wet clothes applied, they are quite dry in a minute or two. The febrile uneasiness is excessive; the patient can scarcely remain a moment in the same posture, and he is wholly without sleep. The pulse at one time is strong, full, bounding, and not easily compressed, but even in this acute form it is almost always soft; at least it is very different from the hardness characteristic of an acute attack of pure phrenitis; at another time it is oppressed, the stroke giving an impression directly opposite to that produced by the free and bounding pulse.

But one of the most remarkable modifications of the pulse, one that is characteristic of an exceedingly acute attack of cerebral disease, and one with the import of which it is of the highest consequence to the life of the patient that the practitioner should be perfectly acquainted the moment he meets with it, is the slow and intermitting pulse. Whenever, in the onset of fever, a patient is found with intense head-ache or intense pain in the back and loins, and a slow pulse, the physician ought to be greatly alarmed at the severity of the symptoms that are to follow, and if he do not take the most active measures to break the violence of the disease at this early period, it will be beyond all control in a day or two, and the patient will be dead before the fever is well formed in milder cases. The affection of the brain is sometimes so violent and sudden that the pulse is not only slow, but intermitting, and the respiration is suspirious. Frequent and deep sighing is not uncommon in severe cerebral cases, and it is highly characteristic of intense cerebral affection; but in such a violent attack as that of which we are now speaking, the suspirious breathing, even in the very commencement of the disease, is so great that it cannot be overlooked. This happened in the case of my friend Dr. Dill, whom I saw a few hours after the commencement of an attack of one of these intense forms of fever. I saw him in the afternoon at a public meeting. I met him an hour afterwards at his own apartment. He was still going about engaged in his ordinary occupations; but his countenance was pale as death; his eye was dull and heavy; his mind was confused, and as it seemed to him paralysed; he had other sensations, which were new to him, and which were most distressing; but he had no pain: at that time there was not the slightest pain either in his head or his back or loins: there was only that general and undefined uneasiness which gave to him sufficient warning of what was coming, as the slow and labouring pulse, coupled with the uneasy sensations of which he complained, and the peculiar aspect of his countenance, afforded to me an abundant confirmation that his apprehensions were just. He was bled immediately to the extent of twenty ounces: the blood then drawn was not sizy: he passed a wretched night. I saw him early the following morning: he had now intense headache; his eye was already injected; his skin was not hot but burning; his respiration was suspirious; almost every breath was a sigh, and his pulse was still slower than on the preceding evening, and was now intermittent: blood being drawn to a large extent, the crassamentum was now buffed and cupped; but the detail of the progress of this instructive case must be postponed until we speak of the treatment of fever, because it is still more illustrative of the effects produced by the vigorous application of the appropriate remedies than of the peculiarity of the symptoms which usher in the attack. It may suffice for the present to observe that this case affords not only a striking example of the concurrence of these peculiar symptoms, but also a decisive proof that pain of the head is far from being the first symptom that occurs even in the most intense cerebral attack.

In these acute forms of the disease, if the proper remedies be not vigorously employed, the pain ceases within the fourth day; it rarely extends beyond the fifth; the pain passes into insensibility; delirium comes on, sometimes so violent as to require restraint, but delirium is by no means an invariable concomitant of the other symptoms, even when these are the most violent: when it is present it is almost always rapidly followed by muscular tremors, and these by subsultus tendinum, which now and then usher in general convulsions; but this last event is rare, and I have never yet seen convulsions unaccompanied with a particular condition of the brain hereafter to be described. Sometimes the muscular tremors succeed immediately to the transition of the pain into insensibility, while the insensibility rapidly increases to stupor, and that to profound coma. The breathing is occasionally as stertorous as it is in apoplexy, but this is also rare, and when it does occur, is probably dependent on a peculiar condition of the brain hereafter to be pointed out. Together with these there is a concurrence of a greater or a lesser number of the symptoms enumerated at page 107, but the particular combinations that are found most usually to accompany particular conditions of the brain, it will be most instructive to state in connexion with the pathology.

In synochus with acute cerebral disease there is less indication of thoracic and abdominal affection than in the subacute form, because the intensity of the cerebral disease obscures the signs of derangement in the other organs; but the signs of their derangement are never absent, although they are less obtrusive, and they trace in indelible characters proofs of their activity in the ravages they commit upon their structures in which they have their seat.

Such is the course of synochus under different degrees of violence. When it is combined with subacute cerebral affection, that course is usually terminated in from three to six weeks; when with acute cerebral affection, in from seven to ten days.

As an illustration of each form of the disease, as it is commonly met with in practice, I subjoin the following cases.

Case I.

John Colebert, æt. 28, admitted into the Fever Hospital August 1, 1828.

Attacked five days ago with chilliness, alternating with heat, pains of limbs, head-ache, and sense of weakness. At present complains of pain of head, with slight giddiness; pains of limbs, especially of back and lower extremities; skin moderately warm; tongue loaded with white fur; much thirst; three stools; respiration natural; no cough, no uneasiness in chest; no epigastric or abdominal tenderness on full pressure; pulse 96, soft.

6th. Skin natural; pain of head gone; pain of back and limbs continues; slept better; tongue more clean; three stools; pulse 102.

7th. Pain of head not returned; pain of limbs better; tongue still cleaning; three stools; pulse 96.

9th. Pain of limbs gone; tongue nearly clean; two stools; pulse 84.

10th. Convalescent.

13th. Dismissed cured.

Case II.

George Walker, aged 17. Admitted May 5th, 1828.

Six days ago seized with shivering, succeeded by heat, loss of strength, and pain of head. At present complains especially of head-ache; ardent thirst; no pain of chest; no cough; no pain of abdomen, back, or extremities; skin cool; face natural; tongue, except at the point, covered with a thick dirty fur; much thirst; no appetite; sleeps badly; bowels costive, having had no stool for the last three days; pulse 98, of good strength.

7th. Heat of skin nearly natural; pain of head almost gone; no pain of limbs; tongue still much loaded; some thirst; three stools; pulse 72; slept much better.

8th. Tongue much less loaded; less thirst; five stools; pulse 60.

11th. Convalescent.

14th. Return of head-ache, and, on the day following, the tongue again became white; but these symptoms disappeared the succeeding day, and, on the 27th, he was dismissed cured.

These two cases afford fair specimens of the combination of symptoms, and of the degree of their severity, in the synochus of London, as it occurs in its mildest form.

Case III.

Emma Gladish. Admitted into the hospital on the 12th day of fever. Attack commenced with usual symptoms. The pain in the head, which had been severe for some time, had entirely subsided on the day of her admission. The mind was now quite indistinct; she could scarcely answer any question that was put to her; the eyes were dull and heavy; she had no sleep; there was great restlessness, and occasionally wandering delirium; there was no tenderness of abdomen; the tongue was red, furred and dry; the stools were passed in bed; the pulse 105, of good power.

13th. Sleep rather more tranquil; less wandering; mind a little more distinct; stools still passed in bed; pulse 100.

14th. Much noise through the night; occasionally started out of disturbed sleep with screaming; tongue red, glazed and dry; stools passed in bed; pulse 96.

15th. Rather more sleep; talkative delirium; tongue somewhat cleaner; pulse 100.

16th. Longer and more tranquil sleep; mind more distinct; expression of eyes still dull and heavy; tongue more clean, more moist; stools only partly passed in bed.

17th. More sleep than on the preceding night; mind still more distinct; complains to-day of some tenderness of abdomen on pressure; tongue nearly clean; two stools no longer passed in bed; pulse fallen to 72.

19th. Slept well; mind clearer; eyes more animated; expression of countenance brighter; other symptoms the same.

26th. Continues to improve; skin cool, soft, and moist; pulse 78.

27th. Convalescent; but the convalescence was slow and tedious, as it almost always is after so severe an attack of cerebral disease; she was dismissed cured on the 40th day from the commencement of the attack. The reports of the 15th, 16th, and 17th days illustrate very clearly and strikingly the changes which have already been stated to indicate recovery.

Case IV.

Elizabeth Price, æt. 26, servant; admitted on 11th day of disease. Attacked with ordinary symptoms of fever: at present complains of very severe head-ache; face flushed; intolerance of light; some deafness; mind confused during night; visions of various kinds, such as “waves of the sea rolling,” appear occasionally before her with great vividness; had been on sea four days before she became ill; skin warm; sense of general soreness; abdomen rather hard, but not tender; tongue furred, rather red; much thirst; no appetite; scarcely any sleep, and, when she does, dreams of a frightful nature interrupt her rest; pulse 114, intermittent, of good power, but easily compressed; bowels constipated. C. C. ad ℥xviij. nuchæ. Abradat. Capillitium. Lot. Gelid. cap. Haust. Sennæ Sal. c. m.

12th. More sensible since cupping; mind still confused; occasional wandering; scarcely any sleep; pulse 124, sharp, yet easily compressed.

14th. Quiet night, with considerable sleep; head giddy and slightly painful; respiration hurried, apparently cerebral; pupils active; tongue dry; much thirst; pulse 123. Empl. Lyttæ cap.

15th. Much screaming; great restlessness during night; complains much of head-ache; pupils active; urine copious, but passed in bed; all the stools passed in bed; pulse 108, easily compressed; has visions before her almost constantly; head very hot. Four leeches have been applied to the temples this morning without relief. Affus. Frigid. cap. ℞. Hydrar. Submuriat. gr. ij. Pulv. Scillæ, gr. j. Pulv. Antimon. gr. iij. M. sumat 4tâ q. h.

16th. No screaming; head less painful, especially when in half-erect posture; mind quite sensible now, but much wandering occasionally; pulse 120, feeble; five stools passed in bed.

24th. No material change until this day; sleep now greatly improved; mind much more itself; tongue beginning to clean; pulse 93; ptyalism.

28th. Ptyalism continues; feels greatly better; appetite returning.

From this period she continued to improve, although with several threatenings of relapse; the convalescence was slow and precarious, but she ultimately left the hospital quite well, though not until the 60th day from the commencement of the fever.

Case V.

Mary Sullivan, æt. 36. Admitted on 14th day of disease; complaint commenced with shivering; pains in the limbs; severe head-ache. Complains now of violent pain of the head; face pallid; expression depressed; scarcely any sleep; abdomen tender on pressure; only one stool for eleven days; tongue foul and dry; pulse 81, not strong; complains, also, of pain under right mamma, preventing inspiration and decubitus. V.S. ad ℥xij. Lotio Gelida cap. Abrad. Capillitium.

15th. Blood with firm buff; pain of head not at all relieved; pain of back, sides, and abdomen severe; no delirium; no sleep; pulse 78, pretty strong. Hirudines viij. temporibus. Pt. Med.

16th. Pain of head much relieved; slept very much better; pulse 66, full and strong.

17th. Pain of head returned, exceedingly severe over the fore-part; pulse 66, full and strong. C.C. ad ℥xij. nuchæ. Pulv. Aper. Mit. h. s. Ol. Ricini c. m.

18th. Pain of head gone; countenance more natural; tongue more clean and moist; pulse 76, more soft. Pt. Med.

20th. Pain of head returned; mind confused; pulse 60, strong and full. C.C. ad ℥viij. nuchæ. Pt. Med.

21st. Pain of head gone; mind confused; pulse 66, pretty strong.

22d. Pain of head returned, but in a slighter degree; mind more confused and dull; scarcely any sleep; tongue more foul; pulse 72, soft. Pt.

24th. No longer conscious of pain; mind quite indistinct; lies prostrate on the back perfectly helpless; incapable of turning on the side; occasional retching; some tenderness of abdomen on pressure; pulse 72, strong and full.

25th. Much restlessness; aspect of countenance greatly depressed; stools passed in bed; pulse 75.

26th. Perfectly senseless; almost constant moaning; extreme restlessness; difficult deglutition; pulse 120.

27th. Not spoken since last report; lies prostrate on back; eyes half open and injected; pulse 102, feeble.

29th. Died.

If the reader can doubt of the condition of the brain in this case, he is requested to turn to the pathology, where the morbid appearances on dissection are detailed. Slowness of the pulse, with severe and obstinate pain in the head, attended with confusion of mind, is always a highly dangerous-symptom: it invariably denotes intense cerebral disease. Whenever there is such a struggle, as this case exhibits, between the physician and the disease, the disease is sure to conquer. For if the physician, terrified at the name or the duration of the malady, while he resolve to use the lancet, hesitate to employ it to the extent of subduing the disease by the first bleedings, the patient is lost. The partial relief afforded by partial measures is most delusive. The malady speedily recovers its lost strength: the patient never does. There is no practitioner who is capable of being taught by experience that can reflect on the history and progress of such a case as this, on the temporary relief afforded by such treatment, on its ultimate failure, and on the appearances presented on dissection, without regretting that more blood was not taken on the 15th and 16th days, and without at the same time resolving, that the aid he offers in future, under similar circumstances, shall be more decisive. The diminution of the pain of the head on the 22d, accompanied with increasing confusion and dullness, with a tongue growing more and more foul, and with a pulse only at 72, might well excite alarm; and accordingly, on the following day, the case was utterly without hope.

II. Synochus Gravior with Thoracic Affection.

There is probably no case of fever, however slight, in which the mucous membrane of the bronchi remains in a perfectly sound state. A certain affection of this membrane, the nature of which will be stated hereafter, appears to be peculiar, to fever, and there is reason to believe that the acutest thoracic affection which is at the same time truly febrile, differs from the mildest case of fever, in which there may be no visible sign of any thoracic disease whatever, only in the degree in which this organ is affected. Sometimes it happens, however, that this membrane is implicated in a more than ordinary degree; and when it is so, it gives rise to peculiar symptoms, constituting the case thoracic. The severity of these thoracic, is not always in proportion to the severity of the febrile symptoms, in like manner as there may be the most intense febrile symptoms, without any indication of thoracic disease: but whenever the thoracic symptoms are sufficiently intense to become prominent, and especially when they occur early or attend on the commencement of fever, they invariably and very considerably aggravate the general febrile symptoms. In these prominent thoracic affections, then, two things happen; first, the symptoms properly constituting the febrile train are modified, and, secondly, new symptoms are added to this train, namely, those which indicate derangement in the respiratory organs.

The new and peculiar symptoms to which a moderately acute and an early thoracic affection gives rise, are the following; namely—

Pain in the chest, sometimes severe, sometimes only slight; sense of stricture or dyspnœa; inability to expand the chest by a full inspiration without pain or uneasiness; cough frequently aggravating the pain; sometimes dry, sometimes accompanied with frothy mucous expectoration. Respiration sometimes slow and heavy, at other times, on the contrary, short and quick; never natural: perhaps the physician may detect thoracic disease in the more obscure, and measure its extent in the more obvious cases, by observing the manner in which the patient breathes, better than by any other single means. The altered respiration is very frequently accompanied with that peculiar noise in breathing which is termed “mucous rattle.”

The pulse, in the commencement of this open and decided chest affection, may not be above 80 or 90; it is hardly ever sharp; it is generally weak; now and then it is full and of good strength; but whatever other character it may possess it is almost always soft. In a few days, as the disease advances, it uniformly rises in frequency and becomes weaker. Towards the end of the disease it is almost always hurried and feeble, although cases occasionally occur in which it is observed at this period to become suddenly slow and intermittent. The tongue is usually foul; commonly moist; but, in severe affections and in their advanced stage, it sometimes becomes dry. The skin is often moderately warm, but it is never intensely hot: it is much more common for it to be cool, and to be of a more dusky colour than natural.

Such are the usual conditions of the respiratory and circulating systems and of the tongue, the great index of the state of the mucous membrane of the alimentary canal, when the thoracic affection increases so as to become prominent and acute. The manner in which it influences the cerebral affection is commonly by hastening the period at which the pain of the head lapses into confusion and stupor. Early insensibility, assuming the form of a muddled or exceedingly confused state of mind, is a very constant symptom of more than ordinary thoracic affection. Accordingly, the delirium which succeeds or which accompanies this state is always low muttering talkativeness, or incoherent wandering, rather than violent delirium, which last is seldom, if ever, found in combination with severe thoracic disease. The pathological condition of the lung perfectly accounts for this modification of the condition of the brain, as will be shewn hereafter.

Case VI.

The following case not only shews the insidious manner in which thoracic disease may come on and the severe form it may ultimately assume; but also, the extent of disease from which it is possible that recovery may take place.

Mary Dillon, æt. 20; destitute. Admitted on the 8th day of fever: attack came on with the ordinary symptoms: at present, no pain of chest; some cough, with copious expectoration; no pain or tenderness of abdomen; tongue not much loaded, but dry; much thirst; no appetite; bowels freely open from medicine; no pain of head; some giddiness; no sleep; skin warm; face flushed; pulse 102.

9th. Pectoral and cerebral symptoms the same; bowels purged; pulse 96.

10th. Only slight cough; pain of head; more giddiness; no sleep; eyes preternaturally bright and glistening; pulse 120.

11th. Only slight cough; pain of head much relieved; slept better; tongue more clean; four stools; pulse 120, strong.

12th. No pain of chest; cough much increased; now very frequent and accompanied with copious expectoration; pulse 136.

15th. Cough more frequent; expectoration purulent and mixed with blood; pulse 126.

17th. Expectorates a larger quantity of purulent matter, mixed with a larger proportion of blood; pulse 102.

20th. Pectoral symptoms unchanged; strength extremely depressed; countenance pallid; skin cool; three stools partly passed in bed; pulse 84; mind confused; almost constant moaning; extensive sloughing ulcers on sacrum and hips.

21st. Pectoral symptoms the same; powers extremely depressed; three stools passed in bed.

22d. No change in the cough or the expectoration; lies quite prostrate and appears to be sinking; four stools passed in bed; pulse 72, rather less feeble.

24th. Cough rather diminished; expectoration unchanged; four stools passed in bed; pulse 84, extremely weak.

25th. No change, excepting that the pulse (78) is rather more strong, and she is scarcely so prostrate.

26th. Skin again hot; tongue again red and dry; no sleep; some delirium; pulse 84, of more strength.

27th. Skin more cool; tongue less red and more moist; pulse 66; some return of appetite.

28th. Cough much diminished; expectorates less; tongue moist, clean, and nearly of natural colour; pulse 72, stronger; countenance more animated.

35th. Cough nearly gone; expectoration much diminished; tongue clean; one stool; countenance improving; strength increasing; wishes for meat; two ounces were allowed.

40th. Sloughs on sacrum and ilium doing well; pulse 90, of more power; still noisy during sleep.

From this period she continued slowly, although gradually, to gain strength, and was dismissed from the hospital on the 57th day, cured.

Case VII.

Angelica Fidgett, æt. 29, married. Admitted on the 16th day of fever. Before admission affected with cold, shivering, sense of faintness, pain of head, uneasiness of chest, and cough. On admission, pain of chest increased by deep inspiration and by cough; cough frequent; pain of the head already subsided: there remain only a sense of weight over the eyes, the expression of which is dull, heavy, and vacant; frequent moaning; no pain of the abdomen on full pressure; pulse 129; tongue foul, moist; skin hot; face flushed.

17th. Respiration slow and laborious; cough; completely comatose; eyes suffused; pulse 120, full, soft; face flushed.

18th. Respiration continues very laborious; mind exceedingly indistinct; much restlessness; pulse 116, still softer.

21st. Examined with the stethoscope: the bronchial roll and crepitus were very distinctly and generally heard.

22d. The respiration continues extremely laborious; frequent cough, without expectoration; low, rambling delirium; pulse 112, weak; tongue foul, moist; general powers greatly depressed.

23d. All the symptoms aggravated. Died on the 24th day of fever.

As thoracic affection may exist in any degree of intensity, so it may indicate itself at any period of the disease: but while sufficiently intense to destroy the structure of the organs in which it has its seat, yet it sometimes gives no indication of its presence, or none until the approach of death. In these cases, the cerebral affection is still more intense than the thoracic, and the manifestation of the symptoms proper to the lung is prevented by the predominance of disease in the brain. Of this, the following case affords a striking example.

Case VIII.

John Potter, æt 21. Admitted on the 15th day of fever. Before admission was affected with the usual febrile symptoms, accompanied with severe pain of the head and giddiness. On admission, the pain of the head was nearly gone; there remained considerable vertigo, with some pain in the loins and joints; the mind was exceedingly indistinct, and there was little or no sleep; pulse 80, soft; no indication of pectoral affection.

18th. Symptoms the same; in addition, the abdomen was now tender on full pressure and retracted.

24th. No change observable until this day; no indication of thoracic affection had hitherto been apparent from the commencement of the disease; but, on the morning of the 24th day of fever, dyspnœa suddenly came on, which was attended with a great degree of restlessness; there was also some soreness of throat, but only a slight degree of redness and tumefaction were visible on inspection: with these symptoms he sunk rapidly, and expired in the afternoon.[^[24]]

III. Synochus Gravior with Abdominal Affection.

One of the organs always involved in disease, in a greater or less degree, in fever, is the mucous membrane of the stomach and intestines. In synochus mitior the affection of this organ appears to be slight, and to pass away without producing any change in its structure. But that it is really diseased even in the mildest case, we have sufficient evidence in the invariable derangement which takes place in the functions of the organ throughout its whole course, from the mouth to the anus; and in the constant vitiation of its secretions and excretions. In the severer forms of fever, on the other hand, in the great majority of cases, the affection of the abdomen becomes prominent, and whenever it does so it aggravates all the other febrile symptoms, and adds greatly to the danger of the disease.

Abdominal affection exists under two forms in fever, each of which is attended with distinct and peculiar symptoms. It may be severe from the commencement, and give early and obvious indications of its existence; or it may come on at some subsequent stage of the disease, and then, although the affection be equally severe, the symptoms which denote it are materially different.

1. If the abdominal affection be severe from the commencement, in addition to the ordinary symptoms of fever, there will be present nausea, sometimes retching, and at other times vomiting. It is usual for authors to enumerate these events among the ordinary occurrences of fever; but in a case decidedly cerebral, or in a case decidedly thoracic, they are seldom present. Whenever they occur in the commencement of fever they are the certain signs of an abdominal affection more severe than ordinary; and it will be of the utmost advantage to the patient should the practitioner be aware of this, because it will teach him at once where the main force of the disease is probably to be concentrated.

2. At this early period the bowels are commonly constipated, and on inquiry it will be found that they have been so for some days previously to the attack of fever; but in a day or two after the commencement of this attack they fall into the opposite state and are looser than natural. The concurrence of nausea, retching, vomiting, and purging in the commencement of fever is a certain proof that severe abdominal affection is present, and if not actively treated and effectually checked at this early stage, it will soon render the case formidable, if not hopeless.

3. When the abdominal affection is thus early and open, it is often attended with another symptom which seldom fails to attract attention, namely, pain. Pain of the abdomen, attended with purging, completes the train of local symptoms that occurs at this early period, in the most exquisitely marked cases. It is well worthy of observation, however, that pain is by no means an invariable attendant on the other symptoms, even when the latter are very severe. Whether in these cases the affection of the nervous system be already so great as to lessen the sensibility of the organ, or whatever else may be the cause of it, the fact is certain, and it is one of great practical importance, that pain of the abdomen is not to be expected even in severe abdominal affection; and that though pain may attend upon the affection, yet the affection is often present without pain.

4. Pain of the abdomen upon pressure, and especially upon pressure in the epigastrium, is much less seldom absent than pain of which the patient spontaneously complains.

5. Pain, though it may usher in the abdominal affection, and may even be severe for the first few days, diminishes after a certain time and then ceases altogether, so that it is extremely rare, after the tenth day of fever, for instance, for the patient to complain of pain of the abdomen, even when the abdominal affection is the most intense. Such an event may happen, perhaps when the cerebral affection is more than commonly slight, but it is an exceedingly rare occurrence, and my attention has been particularly drawn to this circumstance from reflecting on the uniformity of the answers which I have obtained from patients obviously labouring under abdominal affection, on my first visit to them in the wards of the hospital. Having commonly been ill from ten to fourteen days, the abdominal affection may by this time be fully developed: on asking them whether they feel any pain in the abdomen, the answer almost invariably received is, “no.” Press gently upon the abdomen, press especially upon the epigastrium, often even in these very cases not the slightest touch can be borne. After pressure has once been made, the patient will frequently do all he can with his hand to prevent its being made a second time. So acutely sensible is he of pain on the least pressure, though wholly unconscious of pain when left to himself. Even when there is not this great degree of tenderness, pain can generally be produced by full pressure.

There is thus a remarkable coincidence between the progress of the symptoms in the abdomen and in the head. We have seen that however intense the cerebral affection, the pain of the head which accompanies it diminishes after a certain time, and in a day or two after it has begun to diminish, ceases altogether. In like manner the pain which ushers in an acute abdominal affection diminishes after a certain time, and soon wholly disappears. After this period, therefore, we should have no more indications of abdominal than we have of cerebral pain were the intestines, like the brain, enclosed in a bony case. When an organ can be touched, it gives us an additional and an invaluable means of ascertaining its morbid condition: and this is one reason why that condition is commonly so much more certainly known in surgical than in medical diseases. What the result would be, could we press the brain as we can the abdomen, after its sensibility is so much diminished as to cease to occasion pain, we do not know; but it would be a bad use indeed to make of the additional means afforded us of ascertaining the condition of the intestines, were we to allow the additional information we thus gain, to obscure our perception of the perfect analogy there is in the progress of both affections. We know that, as the disease advances in both, the pain ceases; but, in the one case, we have the means of ascertaining that there still remains preternatural tenderness on pressure, as in ordinary inflammation, which we are without the means of discovering in the other: still the important practical fact afforded by the history of both is the same, that disease having reached a certain point, the pain diminishes; and having advanced still further entirely disappears.

6. While the pain lessens or ceases as the abdominal affection advances, the purging, on the other hand, continues, often it increases. Purging, succeeding to constipation and to pain, and remaining after the subsidence of the pain, affords an infallible indication of abdominal disease.

7. Together with these decisive signs, which alone are abundantly sufficient to enable us to ascertain the presence of the affection, we have an additional and an exceedingly valuable guide in the peculiar state of the tongue. In these abdominal cases, the tongue is preternaturally red. Sometimes this increased redness is of a bright and vivid colour, and pervades the whole tongue; at others, it is confined to the edges or to the tip, and it is usually remarkably apparent in the latter. While thus vividly red, the body is often loaded with fur; the colour of the fur is often of a dirty-white or greyish colour; but, perhaps, while the edges and the tip are thus intensely red, the most usual colour observed on its body is that of a dirty yellow. In these cases, the papillæ appear much enlarged, and are seen prominent through the fur, vividly red. In this condition of the tongue it always remains moist for some time, and it is not attended with urgent thirst; but, as the intestinal disease advances, the tongue gradually becomes less vividly red and more dry, and as these changes go on, the lips and teeth often become sordid.