Memoir of the life and medical opinions of John Armstrong ... To which is added an inquiry into the facts connected with those forms of fever attributed to malaria or marsh effluvium

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Memoir of John Armstrong, M.D 1

Medical Opinions of Dr. Armstrong : —

Chapter I. General View Of Fever

A HE opinions upon which Dr. Armstrong's fame will principally rest with posterity, are those connected with the subject of Fever, upon which he entertained views more comprehensive, and at the same time more definite, than those generally held by the medical authorities in this country.

It has been objected to him, that he is inconsistent with himself; that the opinions he expressed towards the close of his life are opposed to those which he published in the outset of his career. I admit the fact without dispute ; and claim from it an acknowledgement from candid minds, of the integrity of his own*. He always wrote from con-

* " The candour of Dr. Sydenham," says Rush, in his Lecture on the character of this illustrious man, " discovers itself by the readiness with which he acknowledges his having mistaken a nervous fever for a bastard peripneumony. Such instances of magnanimity are very rare in all sciences ; and from the influence VOL. I. I viction ; but the opinions of his youth, engrafted from a foreign stock on the observations which his limited opportunities of judging for himself had furnished, were not those of his adult age. When these opportunities had extended, and become multiplied by time, he perceived what he believed to be the errors of his own and of the generally received doctrines, and was not deterred from exposing them, though in so doing he displayed the weakness of the ground upon which he first aspired to distinction.

His volumes on Fever were originally written at Sunderland, where his experience was very limited compared to what it became after his residence in London, and his appointment to the Fever Hospital ; and I can trace three periods of his life in which he entertained different views upon the subject of the origin of Typhus. He had been taught at Edinburgh that it arose from contagion, — and he adopted the faith. Like all believers who take a creed without due examination, he asserted the truth of that which he had received, and in his early writings brought facts in its support. In his paper on the Origin, Nature, and Prevention of Typhus, communicated in 1822 to the Medical Intelligencer, he says that in 1819 he first began to doubt at least the exclusiveness of this cause, and to associate with it that of malaria : and in his ce-

which they have upon both interest and reputation, are less common among physicians than men of other professions." Rush himself nobly acknowledged his error respecting the contagiousness of yellow fever; and Andral as nobly confessed he had mistaken the seat of inflammation in peripneumony.

lebrated Lecture on Typhus, which is his last publication on the subject, and which appeared in the "Lancet" in the spring of 1825, he rejects the influence of contagion entirely, and insists upon its arising from malaria alone.

I shall proceed to give a general outline of his views of Fever, confining myself principally to those which he entertained at the close of his life ; for it had long been his wish to publish them ; and in the hope that he should find time to do so, he always declined to remodel the elaborate volumes he had printed on the subject.

He divided Fever into Common and Specific, as it arose from what he called common or occasional, and specific causes.

The common causes are those ordinary agents to which mankind in every situation and under all circumstances are exposed. These are classed according to their primary effects : their ultimate effects upon the body when these amount to a powerful impression disturbing the functions and affecting the structure, constituting what he denominated Common Fever ; which not only included the acute inflammatory affections comprised in the Phlegmasia? of Dr. Cullen, but diseases of a similar nature scattered in different parts of his artificial arrangement. It also comprised other disorders not inflammatory, the symptoms and pathology of which, by a legitimate generalization, were shown to depend upon the different stages or degrees of action arising from the exciting causes of fever.

These causes he termed Common Depressants, Stimulants, and Irritants.

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Common Depressants,— such as a low and variable temperature, severe accidents, or surgical operations, pain, fear, &c, are those common agents which enfeeble the energy of the vital powers, diminish the animal heat, the action of the heart and of the muscular system. They produce internal venous congestion ; and when fever ensues, it has three stages, viz. that of oppression, excitement, and collapse.

Common Stimulants, — as a high temperature, strong bodily exertion, powerful exciting emotions of the mind, &c, — affect the whole body, augmenting the energy of the vital powers, increasing the animal heat, the heart's action, and the muscular power ; so that the blood under their influence is rapidly diffused over all parts of the system ; and the fever which is the consequence has but two stages, viz. of excitement and collapse.

Common Irritants, such as fermented liquors, indigestible food, irritating medicines, mechanical impediments to the course of the fluids, &c, primarily affect particular parts of the body, increasing their sensibility, but ultimately operate through the local impression upon the whole system ; sometimes acting as depressants or stimulants, according to the condition of the patient, or other circumstances.

These causes, when they produce acute affections, give rise to common fever, which appears under three forms, each depending upon a peculiar pathological condition ; viz. to —

Common Congestive Fever ; the indications of which are, an oppression of some organ or organs,

GENEItAL VIEW OF FEVER. 117

attended with a sensible diminution of the vital powers from venous congestion.

Common Simple Fever ; which is indicated by an increase of the vital powers, from a state of general excitement, in which no part is particularly affected.

Common Inflammatory Fever; the indications of which are the phaenomena of inflammation in some part or parts, — succeeding to the indications of the two former modifications of fever, or of the second only ; or in some instances, perhaps, preceded by neither of them.

The specific causes of Fever are those occasional agents to which mankind are not universally or ecpially exposed. They operate generally as depressants, and differ from common causes in invariably giving rise to fixed and peculiar, as well as occasionally to variable and common effects ; the specific cause itself always operating on particular structures, probably through the blood, and thus giving rise to a fever of a peculiar or specific kind.

Specific Fever appears equally under a congestive a simple, or inflammatory form ; but the peculiarities which characterize its different varieties depend upon the nature of the exciting cause.

These causes are certain states of the atmosphere, specific coutagions, and poisons.

Dr. Armstrong applied the term infections to those general or partial contaminations of atmosphere which arise from agents external to the human body ; as malaria, and local taints of air : and contagions, to those emanations from the body in which they are formed ; as those of small-pox,

J 18 GENERAL VIEW OF FEVER.

measles, and scarlet fever. It was a questionable subject with him, whether diseases arising from infection are communicable by contagion ; but those which arise from contagion are readily communicable from one person to another. Thus typhus, arising in his opinion from malaria, is probably not a contagious disease ; but small-pox, measles, and scarlet fever, which proceed from contagion, are indefinitely propagated in this way.

These specific causes, when their influence is such as to excite an acute disease, produce fever, which appears under one or all of the three forms above enumerated ; but attended by effects which, depending on the cause, will of course vary with it. These are the internal condition or pathology of typhus, which, arising from malaria, appears under the form of an intermittent, a remittent, or continued fever, in which particular parts are always more or less affected. The other peculiar effects are the pustules and internal condition of small-pox ; the rash, &c. of scarlet fever and measles ; and lastly, the peculiar impressions arising from the different poisons.

The difference between Common and Specific Fever is, that in the first there is nothing fixed as to the locality of the ultimate pathological effects ; while in the second there are some of these which are always uniform in their seat. The reason of this is, that in common fever there is nothing specific in its exciting causes. The functions are disturbed by external agents which do not affect the qualities of the blood ; and when fever arises from their influence, it is always unattended by inflam-

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mation, at least to any appreciable degree, in a sound subject ; and when it occurs in an unsound one, the seat and degree of the inflammation will depend upon individual predisposition, which varies indefinitely in different persons.

But in Specific Fevers it is different ; for these arise from causes which do affect the cmalities of the blood, and are of a nature to act injuriously upon particular parts of the body ; so that one and the same cause produces similar effects in any number of persons exposed to their influence. In these cases, however, individual conditions affect the liability to the reception of the virus ; and local predispositions lead to the phaenomena of inflammation in parts which, under the action of the common causes of fever, would equally have become inflamed ; so that, in many cases, common effects are mixed up with the specific effects of the peculiar exciting cause.

To render this more intelligible. — If many persons are at the same time exposed to the common causes of fever, and it were to result from their action, and be of the inflammatory type, the seat of the inflammation would vary according to the individual predisposition of each person. They would all exhibit the symptons of fever, but different organs and structures would be affected in different cases ; so that the only thing common to all would be the inflammation itself. In one, the mucous membrane of the pharynx or bronchia might be attacked ; in another, the substance of the lungs ; in a third, the pleura, or the mucous or serous membrane of the intestines, — or the brain, the liver, or the kidneys, &c. In common inflammatory fever, therefore, there is nothing determinate but the inflammation itself; because the disturbing cause, having nothing peculiar in it, has no direct tendency of itself to affect any particular part of the body. A general shock has taken place from without, and the evil falls on the weak part. If no such local predisposition exists, then no part is particularly affected, and the fever is one of simple excitement, which, when arising from common causes, is never serious or durable, though very frequent in its occurrence. It may be excitement of a low or high degree, but still no trace of inflammation can be detected ; and the only caution necessary is to reduce the excitement, lest some obscure latent defect should exist, and the part so predisposed ultimately become inflamed. The danger of this occurring is indicated by the degree and duration of the excitement ; and, however trifling the case may appear, it should be watched, lest the fever change its character.

But when several persons are exposed to the exciting causes of speciBc fever, they are all in some respects similarly affected, because the disturbance is occasioned by the introduction of a virus, the nature of which is to affect particular parts of the body. If we suppose that they have been exposed to the contagion of scarlet fever, those who sicken with it will manifest the symptoms of that disease. It may vary in degree, but the disease will in essentials be the same in all, so far as the peculiar effects of the exciting cause go. But, besides these, others may arise out of the predispositions of the individual. In all there will be the rash on the skin, and the inflammation more or less acute of the throat : but other parts may be inflamed, not from the direct influence of the peculiar cause of the fever, but from the excitement to which it has given rise. The brain, for instance, might in one person become inflamed, owing to that organ being predisposed ; and had the person so affected been the victim of fever from common causes, he would, in the stage of excitement, from the local defect have manifested the symptoms of inflammation in the same part, but of course without those of scarlet fever. Yet, in the case I am supposing, he has both : the peculiar symptoms have arisen from a specific cause ; and the other, from the excitement it produced, in consequence of the impression made upon the brain, which, from its latent weakness, was unable to bear the increased afflux of blood, and at the same time maintain the integrity of its functions. So that Specific fever has occasionally common mixed up with peculiar effects ; the last of which are invariable in character, though differing in degree ; while the first have nothing determinate as to their locality, because they arise out of the mere excitement, as in common fever, and thus form complications in specific cases, which will vary with individual predispositions.

Fever, therefore, is an abstract term. Whether it arises from common or specific causes, it appears under three forms, depending upon as many different conditions. It may successively appear under the congestive, the simple, or the inflammatory form, or may consist of one of these only. The congestive and the inflammatory are more fully developed in weak subjects, or those in whom latent defects exist ; and the simple form, in sound ones, who are capable of enduring excitement, without injury to any particular part, because none is predisposed to inflammation.

The conditions, therefore, of venous congestion, of simple excitement, and of inflammation, are all comprised in the term Fever, taken in its most comprehensive sense. In its onset the exciting cause has produced congestion or excitement. If the congestion be not overwhelming, reaction sooner or later follows ; and the case then, as when excitement is primarily induced, is one of simple or inflammatory fever, depending upon the absence or presence of inflammation. Inflammation, therefore, is the ultimate efFect. If the cause be a common one, the case is one of common inflammation in some organs or structures that were predisposed ; — if peculiar, there are then, invariably, specific effects in determinate part*, though the excitement, independent of the nature of the cause, may operate upon existing predispositions, and kindle up inflammation according to their seat or degree. In common fever, therefore, in its fullest development, there is inflammation somewhere, and the symptoms will vary indefinitely according to its seat and complications ; but in the complete development of specific fever there is always a determinate inflammation in particular parts, limited by the nature of the exciting cause ; and though inflammation may appear in other structures which lie beyond the influence of the peculiar cause, this is not fixed as to its locality, but has a wide range over all parts of the body, because it is dependent upon the influence of excitement acting on topical defects, which vary in different persons.

These views, which are admirable for the facility of their practical application, have led the mind of the Profession more distinctly to the consideration of venous congestion, as a part of fever ; and the strong opposition which Dr. Armstrong's sentiments upon this subject first encountered, has in a great degree ceased ; — I may say entirely so, with those who listened to his arguments, or who have candidly considered them. He laid no claims to originality upon this point ; for he has referred to other authors upon the subject, and to a case reported by Sydenham, in which venous congestion was the prominent condition. But he has the merit of more elaborately tracing its connexion with the phaenomena of fever, and of describing its symptoms more precisely than had been done before. He has shown that, like inflammation, it varies in its seat and degree ; that debility is its great predisposing cause, and that while it generally precedes the development of excitement in the commencement of fever, it also frequently occurs in its decline, from the operation of any depressing cause. His explanation of its seat, symptoms and degree, and the discrimination observable in his remarks upon these points, and upon the different modiflcations of treatment, afford one of the finest examples of the character and capacity of his mind.

From the preceding observations, it will appear that Dr. Armstrong's views of Fever are more precise, and at the same time more comprehensive, than those generally entertained in this country previous to the publication of his opinions. It was commonly supposed, on the prevalent authority of Dr. Cullen, that the stage of oppression always attended fever, and that this was uniformly succeeded by that of reaction ; fever, in fact, being made to consist in an increase of the heart's action and of the animal heat, excluding therefore the unmixed congestive form entirely. But Dr. Armstrong has proved that in many cases there is no congestion, and in others that there is no reaction : and he has more explicitly shown how the state of excitement arises ; that it is sometimes direct or indirect in its origin, as well as the cause, and occasionally the effect, of inflammation.

Having briefly explained the leading distinctions of these two varieties of fever, I shall now proceed to consider each more particularly in detail.