Fevers: their diagnosis, pathology, and treatment

Front matter

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Chapter I

General Doctrines of Fever, (Dr. Christison,) 17

II. Forms of Fever, 29

III. Local Diseases in Fever, 38

IV. Nature of Fever, 39

IV. Exanthematous or Eruptive Fevers, 71

V. Classification of Fevers, 73

CHAPTER n.

Continued Fever, (Dr. Christison,) - - - 74

I. Symptoms of Continued Fever, 74

A. Ephemeral Fever, 75

B. Synocha, or Inflammatory Fever, - 77

C. Synochus, or Typhoid Fever, 100

D. Typhus, 102

II. Secondary Affections in Continued Fever, 113

III. Sequelae, 133

IV. Prevalence, Duration and Mortality, 139

VI. Causes, 157

IX. Prophylaxis of Continued Fever, 232

Chapter III

Tiphoid Fever, (Dr. Clymer,) - - - - 234

I. Definition, 234

III. Secondary Lesions, --------- 238

IV. Symptoms, ----- 239

II. Convalescence, 249

III. Varieties, 250

IV. March, 250

V. Duration, &c, 250

VI. Complications, - 251

V. Differential Diagnosis, .___ 252

VI. Prognosis, 253

IX. Identity of Typhus and Typhoid Fever, 259

X. Typhoid Fever of Children, 266

VI CONTENTS.

CHAPTER IV. Page

Plague, (Dr. Shapter,) .... 268

II. Varieties, 276

III. Sequelae and Complications, - 282

IV. Anatomical Characters, --------- 283

V. Diagnosis, 288

VI. Prognosis, ... - 289

VII. Statistics, 290

VIII. Nature of Plague, 296

IX. Causes, -- 298

X. Prophylactic Measures, - 309

XI. Treatment, 310

Chapter V

Yellow Fever, (Dr. Shapter,) - - - 314

III. Statistics, - 341

IV. Prognosis, 344

VI. Nature, - - 349

Chapter VI

Intermittent Fever, (Dr. Shapter,) - - - 372

I. Premonitory Stage, --372

II. Symptoms of the Paroxysm, -------- 373

III. Complication with Local Affections, - - - - - - 388

IV. Diagnosis, 393

V. Prognosis, 394

VI. Anatomical Characters, - 396

VII. Statistics, 399

VIII. Nature, 403

IX. State of the Blood, 403

X. Exciting Causes, ---- 404

XI. Treatment, - 405

Chapter X

Smael-Pox, (Dr. Gregory,) 469

A. Variola Benigna Discreta, 470

I. Incubation, 470

n. Initiatory or Eruptive Fever, 470

III. Maturation, 472

IV. Anatomical Characters of the Variolous Vesicle, ... - 473 V. Desiccation and Decline, - - 474

B. Variola Confluens, ... - 475

C. Variola Semiconfluens, 482

D. Variola Corymbosa, or Coherent Small-pox, - t 483

E. Variola Maligna, 483

F. Variolse Anomalse, .-----.-. 484

G. Variola Confluens Mitigata, 485

H. Variola Varicelloides, 486

I. Febris Variolosa Sine Eruptione, -----. 486

II. Diagnosis, 487

III. Prognosis, -- 488

IV. Mortality, 490

V. State of the Blood, 492

VI. Anatomical Characters, 493

Variolous Inoculation, 510

I. History, 510

II. Practice of Inoculation, 513

III. Value of Inoculation, 515

I. History, 518

II. Phenomena, 521

III. Theory, 523

Vlll CONTENTS.

CHAPTER XI. Page

Measles, {Dr. George Burrows,) - - - 531

A. Rubeola Vulgaris, 532

B. Rubeola Sine Catarrho, - 534

C. Rubeola Maligna, 534

II. Complications, 536

III. Sequelae, 537

IV. State of the Blood, 538

VI. Diagnosis, 539

VIII. Causes, - 540

IX. Treatment, 543

Chapter XII

Scarlet Fever, {Dr. George Burrows,) - 546

I. Varieties, 546

A. Scarlatina Simplex, 547

B. Scarlatina Anginosa, -------- 549

C. Scarlatina Maligna, -------- 551

D. Scarlatina Sine Exanthemate, 553

II. Sequelae, 553

III. State of the Blood, - - 557

IV. Anatomical Characters, - 558

V. Causes, 559

VII. Prognosis and Mortality, .-- 561

IX. Prophylaxis, 568

Chapter XIII

Puerperal Fevers, {Dr. LococJc,) - - - 570

A. Acute Puerperal Peritonitis, - - 577

III. Treatment, - - 578

B. The Adynamic, or Malignant Puerperal Fever, - - - 581

I. Symptoms, r - 5 ^1

III. Nature, 583

C. Puerperal Intestinal Irritation, 489

III. Diagnosis, 591

D. False Peritonitis, - - ■ 593

E. Milk Fever, 596

II. Treatment, 597

DISSEBTATIONS ON FEVERS.

Chapter I. General Doctrines Of Fever

I. DEFINITION.

[Syn. Pyrexia, Pyrexis. Febris. Fievre, Fr. Fieber, Germ. Febbre, Ital.]

Fever (febris from fervere, to glow, to be hot*) is so named from one of its most prominent symptoms — a sense of increased heat.

The term has a double signification, both in nosographical and in familiar professional language. For sometimes it is applied, especially in the plural number, to all febrile diseases, including primary fevers, eruptive fevers, and acute local inflammations. And at other times it is used, particularly as a singular noun, to denote primary fevers only, or fevers proper ; while, for embracing the whole class of febrile diseases, the more generic term Pyrexiae is commonly employed ; which, however, according to its original meaning, (from Ttvpeoa^febricito, derived from xZp, ignis\,) does not essentially differ from the more specific term, fever.

It is in the restricted signification, implying those febrile diseases where the pyrexia is simple, or not combined, at least necessarily, either with eruptions of the skin, or with local inflammation, that the subject of fever will be here in the first place considered.

Fever has been variously defined. Probably no better definition can be found than the following, a modification of that sanctioned by Cullen : — After a preliminary stage of languor,

[* Fever, febris, from fervere, to boil; or from fervor, effervescence, because it was supposed that the humors in fevers were in a state of motion similar to that of liquids in ebullition. Others derive the word from februare, to purge, to purify y because fever was regarded by many physicians as a salutary operation of nature.]

[t Pyrexia, used by the Greeks to designate fever, is derived from itv^, irvprhf fire, expressive of the heat; which is one of the predominant characters of the febrile state.] 2 weakness and defective appetite — acceleration of the pulse, increased heat, great debility of the limbs, and disturbance of most of the functions, without primary local disease. It is a singular instance, however, of the extreme difficulty of arriving at correct nosographical definitions, that scarcely any one of the characters here assigned is absolutely invariable ; nor is it likely that any other definition will be found, which is not subject to the same defect.

[A definition is wholly inadequate to convey a suitable idea of the morbid phenomena, which, in the aggregate, constitute Idiopathic Fever ; as it is impossible for it to embrace all the forms and varieties they may assume. A description is much more likely to effect it. To attempt this, the most constant, as well as prominent characters, should be selected, and separated from the subordinate or contingent phenomena. The essential symptoms being thus ascertained, the physician is enabled to detect the disease, whatever shape it may assume ; or to distinguish it from any affection for which it might be mistaken, Few of the phenomena are constant, or are present in all the stages of the disease ; and the characteristic features vary much in degree, and in the manner of association. Dr. Copland thus describes Idiopathic Fever : — "It commences with debility and lassitude, which are followed by chills or rigors ; it is generally composed of several invasions or exacerbations ; it implicates the whole of the vital endowments and faculties, the fluids, and the entire organization ; it is acute and dangerous in its course, ivith lesion of the circulation, with alteration of the animal heat and of the secretions, and ivith diminution of vital power; and it is versatile as to its symptoms and type, with efforts at sudden changes or crises" — [Diet. Pract. Med., Am. Ed., by Dr. Lee, p. 1041.)

Debility and lassitude [malaise, fatigue, courbature), are among the earliest and most constant symptoms. They are obviously the effect of some debilitating or depressing influence acting on the nervous system. There is an absolute aversion to all mental and corporeal exertion ; together with general unpleasant and peculiar sensations — as precordial anxiety ; restlessness ; creeping chills along the spine ; horripilations, &c. ; alternating with flushings of heat, with hurried, or suspirous breathing.

Quickened circulation and increased animal temperature have been regarded, by most writers, as the most constant as well as salient phenomena of fever, and probably with justice. Though in some fevers the pulse may be, at times, slower than in health, they are to be regarded as transient, and rare exceptions, easily explicable by reference to existing disorders of innervation, and by no means diminishing the general value of increased rapidity of the pulse in the diagnosis of fever. The temperature v DEFINITION. 19

of the body is variously altered in the different stages of fever. There may be increased heat from the commencement ; though generally the feeling of cold is experienced at the period of invasion; which, however, may be nothing more than a morbid sensation of the patient— the hand of the physician, applied to the surface, at the moment of complaint, detecting an increase instead of diminution of heat ; and the mercury, in a thermometer placed in the axilla, rises several degrees. The elevation of temperature is variable. It is felt by the patient; and is detected by the physician placing his hand upon the body. The thermometer in the axilla, indicates, too, an increased temperature of from 1° to 5°. The sensation of heat felt by the patient is not always in proportion to the actual rise of temperature. It is not, however, a mere increase or diminution of heat which constitutes the whole of this phenomenon ; but a peculiar, a morbid alteration of temperature, hardly admitting of description. There is more or less derangement in the secreting and exhaling functions, indicated by the anorexia, thirst, state of the secretions and excretions, and the hemorrhages which occur. The paroxysmal character of fever is evident in all its forms, whether we regard the regular, well-marked paroxysms of intermittent and remittent, or the perpetual exacerbations of continued fever. It will be shown hereafter, conclusively, it is hoped, that fever involves all the functions and all the constituents of the body. Critical changes or crises are of constant occurrence in idiopathic fever, giving the idea of a depuratory effort of nature — favourable changes frequently supervening. The character of fever is mutable, presenting ever-varying forms and varieties. "Fever," says Dr. South wood Smith, " 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." — ( Treatise, #c, p. 37.)

Dr. Smith goes on to remark, that if three persons, each exhibiting an exquisite specimen of one of the several forms of the disease, were brought into the same ward of an hospital, the external aspect exhibited by each would be so different, that an ordinary observer would fail in discovering any common property, yet the physician would pronounce them at once to suffer from fever. To establish this identity in the professional eye, under such a diversity of aspect, there must be particular phenomena, common to all the varieties and combinations of the disease. To ascertain these essential phenomena has been the object of all writers on the subject from Hippocrates to the present time. But little success has, however, attended these efforts, though the acutest minds in the science have been applied to the analysis. The exposition of Dr. Southwood Smith on this subject — in which some of the errors of those who have pursued this path ' of inquiry, are pointed out, and the proper mode of investigation indicated — is so able and lucid, that we shall offer no apology for transferring it to our pages.

" 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 3 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 inquiry 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 shown 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 apparentlydifferent 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 disco verecLhave 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 anything 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 connection 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 headache ; 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 headache ; 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 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 stronghold 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.