Front matter
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Preface To The Third Edition
I have very little to say in sending to the press this third edition of my book on fevers, but to express my obligations to the profession of the United States for the very favorable reception which they have given to it. The general literature of fevers has, with one eminent exception, received no very important contributions since the date of the preceding Preface. The exception to which I refer, consists in a series of papers published within the last year or two by Dr. William Jenner, of London. Their leading purpose is to show by careful and rigorous study and comparison the wide and fundamental differences which the author believes to exist between the several forms, as they have generally been regarded, of continued fever, and especially between the typhoid and the typhus forms. Dr. Jenner's researches have enabled me to add largely to the fulness and completeness of the description of typhus fever ; and I have availed myself liberally of his facts and arguments in elucidation of the important question of the true relations to each other of the two great forms, or species, of continued fever.
I have given no account of the Relapsing Fever of Great Britain, as I do not know that it has ever been met with in the United States.
College of Physicians and Surgeons.
New York, June 1, 1852.
Preface To The Second Edition
It will be seen by those who have read the first edition of my book on fevers that the present is in some respects rather a new work than a new edition of the former. The History of Typhoid and of Typhus Fever remains much in the same state in the present as in the first edition, with such additions and development - only as further observation and study have enabled me to make. The History of Periodical, and of Yellow Fever, constituting one-half of the volume, has been added to the present edition : thus rendering the work what it professes to be, a Systematic and Methodical Treatise on the Fevers of the United States.
November 1, 1847.
Preface To The First Edition
I have written this book, because I thought that I saw a want in medical literature which it might supply. Our science, so far as the great subject of idiopathic fevers is concerned, is passing through a transition period ; and many authorities, that were received as standard and classical only a few years ago, are fast becoming obsolete, at least for American readers. This is particularly true of the leading English treatises on Fever. Neither the works of Fordyce, Armstrong, Southwood Smith, nor Tweedie, nor the elaborate articles on Fever in the Medical Cyclopedias, Libraries, and Dictionaries, can henceforth be regarded as sufficient or even safe guides for American practitioners ; and the remark is applicable to them, not because they are not works of great excellence and value, but for other reasons, which will be abundantly obvious in the course of the following pages. I may simply say, here, that their authors describe principally a fever or form of fever which is rarely met with in this country, and that they do not represent the actual state of our knowledge upon this subject. It must be regarded as especially unfortunate that, until within a few years, the greater part of our information relating to continued fever, has been derived from writers who have treated mostly, and under the same name as that generally used by ourselves, of a disease, or form of disease, differing in many
Xll PREFACE.
important respects from that which is most common with us, and that in this way so great a degree of confusion has been introduced into our notions of fever.
If the radical defect in our literature of continued fever thus indicated had not existed, and if the histories of the disease which have been given to us by Louis, Chomel, and Andral amongst the French, and by Nathan Smith, Dr. James Jackson, Dr. Hale, and some others amongst ourselves, were generally accessible, and generally read, there would have been no want such as I have alluded to ; and, certainly, I should not have added another to the long catalogue of books on fever. A translation, by Dr. Bowditch, of Louis's Researches, was published a few years ago under the auspices of the Massachusetts Medical Society, and has since been in the hands of most of its Fellows. But it is very far from being so generally and thoroughly known as it deserves to be. I may add, that the character of this remarkable work is hardly adapted to the actual wants and tastes of the great majority of our practical men. I may say this, I think, without any risk of giving offence; for no man's admiration of this work can be more unqualified and profound than my own. Constituting as it does one of the few imperishable monuments that have from time to time, and at distant intervals, been raised up along the pathway of our science, it is nevertheless true that, in the present state of the profession in this country — amidst the daily cares and duties of its active members — there are but few who will devote to this object the time and the labor which are necessary thoroughly to comprehend its principles and to master its accurate and minute details. Chomel's Clinical Lectures, so far as I know, have not been published here; Nathan Smith's Essay, excellent as it is, is still very incomplete ; and the Reports of Dr. Jackson and Dr. Hale, besides not professing to treat systematically of the disease, are not generally accessible.
These, in brief, are the reasons which have prompted me to undertake the preparation of this treatise. I thought that the
PREFACE. Xlll
wants -of medical science, here at least, demanded a history and comparison of the two chief forms of continued fever, as they are now ascertained to exist, fuller and more discriminating than had yet been written ; and these wants I have endeavored to supply. My book aims at no other excellence, and no higher merit, than that of being a methodical and compendious summary of the actual state of our knowledge upon two most common and most important diseases. If it has reached this excellence, and if it possesses this merit, I am satisfied.
I have only to add in conclusion, that one of my leading purposes has been to bring out more clearly and strongly than has hitherto been done our means of diagnosis between the different species or forms of fever, and to ascertain and establish their nosological relations. It cannot be necessary to go into any formal vindication of the importance of this diagnosis. Setting it aside altogether, as a matter of science, it is the first essential condition of all sound practice. In the following history it will be noticed that I have spoken of no individual fever excepting the four which are more or less fully described; to wit, Typhoid Fever; Typhus Fever; Periodical Fever, in its three forms of Intermittent, Bilious Remittent, and Congestive ; and Yellow Fever. The simple reason of this is, that I do not know anything of any other distinct fever amongst us. There may be such a disease as the Simple Fever of Fordyce, or the Ephemera of many writers. I know that adults, sometimes, in consequence of great or protracted fatigue, and that children still oftener, from inappreciable causes, are attacked with headache, loss of appetite, debility, and general febrile excitement, not referable to any local origin ; which symptoms, after rest of from one to two or three days, either with or without medicine, usually subside, leaving the individual in good health. But whether this kind of disorder should be looked upon as a distinct established form of fever, seems to me, to say the least of it, very doubtful. As to an Inflammatory Fever distinct from Typhus or Typhoid Fever, I
XIV PREFACE.
can only say, with Nathan Smith, and Chomel, that I have no knowledge of any such disease. 1
1 Mr. James Moore, Surgeon, says : " Synocha, or pure inflammatory fever, is a disease so rare in this country, that many experienced practitioners have doubted its existence." The same writer says that Culleh acknowledged that he never saw the disease.
Dr. Thomas Bateman, a sensible and judicious writer, says: "With respect to Synocha, Dr. Cullen's distinguished successor, Dr. James Gregory, asserted that, during thirty years' practice, he had never seen a purely inflammatory fever unconnected with acute inflammation of some organ ; and my own subsequent experience entirely coincides with that assertion. It cannot be doubted, as Dr. Gregory remarked, that the cansus, or ardent fever of the ancients, was the endemial bilious remittent of hotter climates, and that no continued fever of this country assumes that character." — A Succinct Account of the Contagious Fever, etc., p. 25.
I may add, further, that the affection described by most of our systematic writers under the name of Infantile Remittent Fever, seems to me to have no existence as a distinct disease. Gastro-intestinal irritation, bilious remittent fever, typhoid fever, and still other diseases are confounded under the foregoing term.
September 1, 1842.
Part I. Typhoid Fever
PAGE
Am. I. — Introductory
Art. II. — Names of the Disease
Art. III. — History ....
Art. IV. — Methods of Description .
U
Chapter II
Art. I. — Mode of Access .
Art. II. — Febrile Symptoms
Sec. 1.— Chills.
Sec. 2.— Heat and State of Skin
Sec. 3.— Pulse ....
Art. III. — Thoracic Symptoms
Sec. 1. — Respiration
Sec. 2.— Cough
Sec. 3. — Physical Signs
Art. IV. — Cerebro-spinal, or Nervous Symptoms
Sec. 1. — Headache
Sec. 2. — Pains in the Back and Limbs .
Sec. 4. — Physiognomy .
Sec. 5. — Somnolence
Sec. 6. — Vigilance
Sec. 7. — Senses ....
Sec. 8. — Muscles
Art. V. — Digestive and Abdominal Symptoms
Sec. 1. — Tongue and Mouth
Sec. 2. — Appetite and Thirst .
Sec. 3. — Nausea and Vomiting
Sec. 4.— State of Bowels
XVI
CONTENTS.
Sec. 5. — Abdominal Pains Sec. 6. — Tympanites .
Art. VI. — Miscellaneous Symptoms Sec. 1. — Emaciation Sec. 2. — State of the Urine Sec. 3. — Epistaxis Sec. 4. — Cutaneous Eruptions .
Sec. 5. — Eschars
CHAPTER III. Anatomical Lesions
Art. I. — Lesions of the Circulatory Apparatus
Sec. 1. — Heart and Aorta
Sec. 2.— State of the Blood .
Art. II. — Lesions of the Respiratory Apparatus
Sec. 1. — Lungs
Sec. 2. — Bronchiae, Epiglottis, &c.
Art. III. — Lesions of the Brain and its Membranes Art. IV. — Lesions of the Digestive and Abdominal Organs
Sec. 1. — Pharynx and (Esophagus
Sec. 2. — Stomach
Sec. 3. — Small Intestines
Sec. 4. — Large Intestine . •
Sec. 5. — Lymphatic Glands
Sec. 6. — Spleen
Sec. 7. — Liver .
Sec. 8. — Pancreas; Salivary Glands; Urinary Apparatus; and Sexual Organs Art. V. — General Remarks
Causes.
CHAPTER IV. Sec. 1. — Locality
Sec. 2. — Season
Sec. 3. — Contagion
Sec. 4. — Exemption from Second Attacks
Sec. 5. — Epidemic Influences .
Sec. 8. — Race
Sec. 9. — Occupation .
Sec. 10. — Recency of Residence
Sec. 11. — Filth, Crowding, &c.
Sec. 12. — Exposure; Excesses, &c.
Chapter X. Atment
Art. I. — Dr. Jackson's Method .
Art. II. — Dr. Nathan Smith's Method
Art. III. — Chomel's Method
Art. IV. — Louis's Method ....
Art. V. — Bouillaud's Method
Art. VI. — De Larroque's Method .
Art. VII. — Miscellaneous ....
CHAPTER XL
Chapter II
Art. I. — Mode of Access
N
Art. II. — Febrile Symptoms
Sec. 1.— CMlls
Sec. 2. — Heat and State of Skin
Art. III. — Thoracic Symptoms
Art. IV. — Cerebro-Spinal, or Nervous, Symptoms .
Sec. 1. — Headache, Pains in Back and Limbs
Sec. 3. — Physiognomy ....
Sec. 4. — Senses ....
Sec. 5. — Muscles
Art. V. — Digestive and Abdominal Symptoms
Sec. 1. — Tongue and Mouth
Sec. 2. — Appetite . . .
Sec. 3. — Nausea and Vomiting
Sec. 4. — State of Bowels
Art. VI. — Miscellaneous Symptoms
Sec. 1. — Emaciation
Sec. 2. — State of the Urine
Sec. 3. — Epistaxis
Sec. 4. — Cutaneous Eruptions .
Sec. 5. ( — Eschars
Sec. 6.— State of the Blood .
Chapter III
Art. I. — Lesions of the Thoracic Organs
Sec. 1. — Lungs
Sec. 2. — Larynx and Pharynx .
Sec. 3. — Heart and Blood
Art. II. — Lesions of the Brain
Art. III. — Lesions of the Abdominal Organs
Sec. 1. — Stomach
CONTEXTS.
XIX
Sec. 2. — Intestines Sec. 3. — Miscellaneous Sec. 4. — General Remarks
PAGE
232 236
Chapter II
Art. I. — Mode of Aecess .
Art. II. — Febrile Symptoms
Sec. 1.— Chills
Sec. 2. — Remissions or Type
Sec. 3. — State of Surface
Sec. 4. — Heart and Pulse Art. III. — Thoracic Symptoms Art. IV. — Cerebro-Spinal or Nervous Symptoms
Sec. 1. — Headache ; Pains in Back and Limbs
Sec. 2.— Mind
Sec. 3. — Senses and Physiognomy
Sec. 4. — Muscular Strength
CONTEXTS.
XXI
PACK
Art. V. — Digestive, and Abdominal Symptoms . 361
Sec. 1. — Tongue and Mouth
Sec. 2. — Appetite and Thirst .
Sec. 3. — Nausea and Vomiting
Sec. 4. — Epigastrium and Abdomen
.
Sec. 5. — Bowels
Sec. G. — Urine ....
Chapter III
Art. I. — Lesions of the Thoracic Organs .
.
Sec. 1. — Lungs.
.
Sec. 2. — Heart and Blood
Art. II. — Lesions of the Cerebro-Spinal Apparati is
Sec. 1.— Brain and its Envelops
Art. III. — Lesions of the Abdominal Organs
.
Sec. 1. — Liver ....
Sec. 2.— Spleen
Sec. 3.— Stomach
Sec. 4. — Intestines
Art. IV. — General Remarks
Sec. 1. — Relation of Lesions to Symptoms
Sec. 2. — Importance, Relative and Absolute
CHAPTER IV. Sec. 1. — Locality
Sec. 2. — Season; Temperature: Weather
Sec. 6. — Exposure ; Excesses, &c.
Sec. 7. — Malaria
Chapter V
Art. I. — Bilious Remittent Form .
Art. II. — Congestive Fever
Sec. 1. — Names
Sec. 2. — Type, and Mode of Attack
Sec. 3. — Varieties ; Comatose .
Sec. 4. — Delirious Variety
Sec. 5. — Algid Variety
Sec. 6. — Gastro-Enteric Variety
Art. IJI. — Intermittent Fever
2*
XX11
Duration and March .
Sec. 1. — Duration Sec. 2. — March Sec. 3. — Critical Days Sec. 4. — Eelapses Sec. 5. — Sequelae
CHAPTER X. Treatment
Art. I. — Bilious Remittent Fever .
Sec. 1. — Preliminary ....
Sec. 2.— Bloodletting ....
Sec. 3. — Purgatives . .
Sec. 4. — Cinchona ....
Sec. 5. — Diaphoretics, Refrigerants, &c
Art. II. — Congestive Fever
Art. III. — Intermittent Fever .
CHAPTER XL
CHAPTER II. Symptoms
Art. I. — Mode and Period of Access Art. II. — Febrile Symptoms
Sec. L— Chills ....
Sec. 2. — State of Surface : Sweats
Sec. 3.— Pulse ....
Art. III. — Digestive and Abdominal Symptoms
Sec. 1. — Tongue and Mouth
Sec. 2. — Appetite and Thirst .
Sec. 3. — Nausea and Vomiting .
Sec. 4. — Bowels ; Abdomen ; Epigastrium
Sec. 5. — Urine ....
Art. IV. — Cerebro-Spinal, or Nervous Symptoms
Sec. 1. — Headache and other Local Pains
Sec. 2.— State of Mind
Sec. 3. — Physiognomy .
Sec. 4. — Strength; Muscles; Senses .
Art. V. — Miscellaneous Symptoms
Sec. 1. — Color of Skin .
Sec. 2. — Hemorrhages .
Sec. 3.— Chest ....
466 467
474 47.")
47-".
CHAPTER III. Anatomical Lesions
Art. I. — Lesions of Lungs, Heart, and Blood
Sec. 1. — Lungs
Sec. 2.— Heart ....
Sec. 3.— Blood ....
Art. II. — Lesions of the Cerebro-Spinal Apparatus Art. III. — Lesions of the Abdominal Organs
Sec. 1. — Stomach
Sec. 2. — Intestines
Sec. 3. — Liver ....
Sec. 4. — Gall-Bladder and its Contents
Sec. 5. — Spleen ; Mesenteric Glands ; Urinary Organs
477 477 477
XXIV
CONTENTS.
Art. IV. — Miscellaneous Lesions .
Art. V. — General Remarks
Sec. 1. — Relation between Symptoms and Lesions
Sec. 2. — Causes of Death
PAGE
491 491 491 494
CHAPTER IV. Sec. 1. — Locality
Sec. 2.— Season
Sec. 3. — Temperature and Weather .
Sec. 5. — Sex .
Sec. 7. — Constitution . . .
Sec. 8.— Occupation . . . . N
Sec. 9.— Acclimation .....
Sec. 10.— Exemption from Subsequent Attacks
Sec. 11. —Epidemic Influences ....
Sec. 12.— Sporadic .....
Sec. 13.— Marsh Miasmata
Sec. 14.— Decaying Animal and Vegetable Matter
Sec. 15.— Contagion . . . .
Sec. 16.— Exposure; Fatigue; Excesses, &c. .
Sec. 17.— Essential Poison .....
CHAPTER V. Varieties and Forms
Sec. 1. — Season and Locality Sec. 2. — Forms, or Grades
528 528 529
CHAPTER
VI.
March and Duration .
Sec. 1. — March, or Type
Sec. 2. — Stages
Sec. 3.— Duration
Sec. 4. — Convalescence
Sec. 5. — -Relapses
.
Sec. 6. — Sequelae
.
Sec. 7.— Period of Incubation
.
CHAPTJ
VII.
CONTENTS.
XXV
CHAPTER VIII.
PAGZ
CHAPTER IX.
CHAPTER X.
Treatment . . ' .
Sec. 1. — Preliminary .
Sec. 2. — Mercurials
Sec. 3. — Antiphlogistic Method
Sec. 4. — Cinchona ; Tonics and Stimulants
Sec. 5. — Purgatives
Sec. ('). — Spanish Method
§68
Sec. 7. — Mobile Method
Sec. 8. — Prophylactics .
Sec. 9. — Conclusion
CHAPTER XI.
CHAPTER XII.
Part First
the
OF
TYPHOID FEVEK.
TREATISE ON FEVERS
Chapter I. Preliminary Matters
ARTICLE I.
INTRODUCTORY.
In writing a history of the fevers of the United States, I begin with that of Typhoid Fever, for three reasons.
In the first place, my own knowledge of the disease, derived from personal observation, is much more extensive than of the other forms of fever. My attention was early and strongly called to its investigation by the remarkable work of Louis upon the same disease, as it shows itself in Paris. Many years of my professional life have been passed in the midst of a population especially exposed to some of its predisposing causes, and amongst whom it has very constantly, and at times very extensively, prevailed ; so that a personal acquaintance with this fever, of twenty years' continuance, has given me sufficient opportunity to become somewhat familiar with its character ; more so, at any rate, than with the remaining diseases, which I propose to describe.
In the second place, there is good reason to think that typhoid
fever is more generally and extensively prevalent, in various
parts of the world, than the other distinct forms of essential or
idiopathic fever. This is a point which requires further and more accurate observation for its settlement ; but it is pretty certainly true of the temperate latitudes of Europe and America. The actual extent of its prevalence will be more fully spoken of hereafter.
In the third place, typhoid fever has been more minutely, more accurately, more thoroughly studied, than any other distinct form of essential or idiopathic fever. Although a complex, and in many respects an obscure disease, its diagnosis is, in most cases, easily and positively made out. Its natural history has been very fully investigated, and the results of this investigation faithfully recorded and summed up. Its symptoms, its lesions, its causes, so far as these latter are appreciable, have been very exactly ascertained and settled ; and they have been very patiently compared with the symptoms, the lesions, and the causes of other diseases. This more complete knowledge of the disease renders it a very convenient starting-point, and an exceedingly valuable standard of comparison, in our subsequent study of other forms of fever, more or less related to this, but whose history and character have not been so definitively and precisely established. These, very briefly, are the simple and obvious considerations which induce me to commence this history with a description of typhoid fever.
ARTICLE II.
NAMES OE THE DISEASE.
I have adopted the term typhoid fever as the name of this disease, simply because it is not particularly objectionable, and because it seems to be coming into general use. It is that which is most commonly given to the disease by the French, although many of their writers have coined other, and as they think, more appropriate appellations. Petit and Serres described it, in 1813, under the name of enter o-mesenteric fever. This term, as has been observed by Andral, has the advantage of marking the peculiar lesion of the disease, while it is free from the objection of prejudging, by any implication, its nature or character. Bretonneau calls it a dothinenterite, from the pustular inflammation of the intestine. Cruveilhier and others have applied to it the name of follicular enteritis. Bouillaud has called it typhoidentero-mesenteritis. By the Germans it is commonly called abdominal typhus. By some German writers it is called nervous fever, or gastric nervous fever ; by some it is called intestinal ulcerating typhus, or typhous suppuration of the intestines ; by others, typhus gangliar is, and so on. 1 In New England, it has generally been known under the name of typhus, or typhous fever ; and by many practitioners it still continues to be so designated. Since, however, it has been ascertained that the die differs, in many important respects, from the ty pints- of British writers, it has become manifestly necessary to apply to it some other appellation; and, in conformity to the example of Louis, Gerhard, Jackson, and others, I have chosen that of typhoid fever.
It may be well to say a word here in regard to the identity of the continued fever of New England with the typhoid fever of the French pathologists. This identity is very clearly and positively settled. No one familiar with the dis< it >ho\v< itself in Paris, and as it is described by Louis, ('home], and Andral, and who reads Nathan Smith's description of the typhous fever of New England, can doubt for a moment, so far as the symptomatology is concerned, that such is the case. The identity of the pathological lesions in the fever of the two countries has been more recently established. Dr. E. Bale, Jr., of Boston, published in the Medical Magazine for December, 1833, an account of three dissections of persons, considered by him to have died with this disease. If the diagnosis in these cases could be looked upon as certain and positive, they would constitute, so far as I know, the first published examples of the intestinal lesion of the disease, as it occurs in New England. The diagnosis, however, in all the instances, must be regarded as somewhat doubtful, and the alteration of the intestinal follicles does not seem to have been very clearly or strongly marked. The first authentic and unequivocal cases on record, that I have been able to find, are two, which were published by Dr. Gerhard, in the American Journal of Medical Sciences for February, 1835. In the Medical 3Iagazine for June, 1835, 1 gave a short account of the entero-mesenteric alterations in five cases of unequivocal typhoid fever, which alterations corresponded ex-
1 Edin. Med. and Surg. Journ., vol. xlviii. p. 145.
actly to those described by Louis. I have upon my note-book the anatomical history of two similar cases, which occurred during the months of January and February, 1833, but which were never published. Dr. James Jackson, Jr., then a medical student, observed the intestinal lesion in a clear case of the disease as early as October, 1830, although the account of the observation was not made public till 1835. 1 Dr. Jackson, Jr., after having studied typhoid fever in Paris, aided and guided by the personal instructions of Louis, again saw the disease in Boston ; and in two cases, one of which occurred in 1833, and the other in 1834, he found the characteristic lesion of the intestinal follicles and mesenteric glands. An account of these observations was published in 1835. Dr. Jackson, Sen., in his Report on Typhoid Fever, communicated to the Massachusetts Medical Society in June, 1838, says, that the alteration of Peyer's glands had been noticed at the Massachusetts General Hospital, previous to 1833, in cases which were carefully examined. Since the period above referred to, more extensive and accurate observations by Dr. J. Jackson, Dr. Hale, Dr. Bigelow, Dr. Bowditch, Dr. J. B. S. Jackson, Dr. Shattuck, Jr., Dr. Holmes, and others of Boston ; and by Dr. Gerhard and Dr. Stewardson of Philadelphia, Dr. Swett of New York, and others, have uniformly sustained the correctness of these early conclusions, and demonstrated the entire identity of the typhoid fever of Paris and of the United States.
ARTICLE III.
HISTORY.
By the history of typhoid fever> here, I mean what may be called its literary history — an account of the successive investigations which have led to our actual knowledge of the disease. In order to render this at all full and complete, it would be necessary to go into the history of the entire subject of continued fever, a subject more extensive and more complicated perhaps than any other in the domain of medical science. Neither the design nor the character of my book renders it necessary that I should do this ; I shall content myself with touching simply a few of the more salient points of this history.
1 Memoir of James Jackson, Jr., p. 222, et seq.
HISTORY. 59
The character of typhoid fever — its symptoms, its lesions, its causes, and so on — was first fully and carefully studied by the physicians of the continent of Europe. The first description of its pathological lesions, at all complete and satisfactory, was contained in the work of Prost, published in 1804. Some years subsequent to this, Broussais succeeded in establishing his brilliant and powerful but transitory dynasty, and under its tyrannous domination, the study of continued fever, on the continent, was cramped and misdirected, instead of being properly guided, favored, and advanced. Everything gave way to the bold effrontery of the dogma, that all fevers are dependent upon focal inflammations. In looking back now upon the career and aeli: ments of Broussais, it is astonishing to see with what meek alacrity our science put on and wore the yoke which he fitted to her neck. The exclusive and hypothetical views of Brora were controverted ably, and at length successfully by Andral, Chomcl, and other pathologists; but it is to the great work of Louis that we are indebted for the first complete and comprehensive description of typhoid fever — a description s<> complete, and so comprehensive, that the labors of subsequent observers have hardly added to its materials, or modified its proportions to any appreciable extent. Amongst other continental observers wdio studied particularly the intestinal lesions of the di> were Rcederer and Wagler, Petit and Serres. and Bretonneau. The original researches of Louis and Ohomel were confined to the disease as it shows itself in the adult; within the last few years the typhoid fever of children has been carefully studied, especially by Barthez and Rilliet, and by Taupin. Dr. Richard Bright has given, amongst his very splendid pathological illustrations, some excellent specimens of the intestinal ulcerations of this disease. The important and valuable papers of Dr. Jenner, of London, have already been referred to. The most important publications upon the subject made in this country are those of Nathan Smith, Dr. James Jackson, and Dr. E. Hale, of Boston, and Dr. W. W. Gerhard, of Philadelphia.
ARTICLE IV.
METHODS OF DESCRIPTION.
There are two methods, either of which may be adopted, in the description of a disease. One of these, and that which, with a few exceptions, has been in universal use from the time of Hippocrates to the era of Louis, consists in a general enumeration of the more striking and obvious phenomena of the disease, in their various combinations and progress, constituting a kind of portrait, or picture. The other, which has been followed by many writers within the last fifteen years, especially amongst the French, consists, not merely in this general enumeration of the phenomena, their combinations and progress, but in a thorough and careful analysis of these phenomena ; in a special and particular study of each individual element, which goes to make up the disease ; and in a strict estimate of the relative value and importance of each and all of these several elements. This analytical process, this "searching operation," is applied in study, as well as in description, not only to the symptoms of a disease, but, to a * considerable extent, also, to its pathology, etiology, and therapeutics. Amongst the best examples of the first method, — the physiognomical portraiture of disease, — may be mentioned Sydenham's description of measles and St. Vitus's dance, and Dr. Ware's description of delirium tremens. The first and one of the most perfect examples of the latter is to be found in Louis's Researches upon Phthisis, published in 1825.
Each of these methods has its advantages and its disadvantages, its excellences and its defects. By the first, a more complete and integral picture of the disease is presented at once, to the mind, than can be done by the second. We are enabled to see, at a single glance, the form, the outlines, the features, the physiognomy of the disease. But in many very important particulars, this method is inferior to the second. It is merely a picture of disease ; like all other pictures, more or less like the original, strongly or feebly colored, according to the peculiar taste or ability of the individual artist. It is necessarily wanting in the scientific accuracy of which the second is susceptible. It is less complete, less perfect. The disadvantages of the latter consist in the absence of that wholeness and unity of impression,
METHODS OF DESCRIPTION. 55
which are made by the former. The mind, in order to get at the integral and entire picture, must arrange and combine the scattered materials, which it has studied separately. As one of the leading purposes of the present work is to point out, as far as our actual knowledge will enable us to do so, the characteristic features of each of the four great forms of idiopathic fever ; to establish, as far as possible, a clear and positive diagnosis ; to ascertain the resemblances and the differences between them ; I shall rely almost exclusively upon the last-mentioned method, as the only one capable of leading to these results.
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