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.”