Southwood Smith

“ The poison generated in both cases is the same; the difference is merely in the degree of its potency. Nature, with her burning sun, her stilled and pent-up wind, her stagnant and teeming marsh, manufactures plague on a large and fearful scale: poverty in her hut, covered with her rags, surrounded with her filth, striving with all her might, to keep out the pure air, and to increase the heat, imitates nature but too successfully ”

“ 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. ”

“ To assign the reason of what must be so obvious to every one who is acquainted with the elements of physiology, would be entirely out of place here, because it would suppose the reader to be wholly ignorant of the functions of the animal economy. Our knowledge of the pathology of fever can never be complete, until we know the morbid changes that take place in the fluids as perfectly as we are acquainted with the alterations of structure that are produced in the solids, and we ought, therefore, to spare no labour to render our knowledge of the former as exact and certain as it is of the latter. ”

“ Whatever be the number of organs simultaneously affected, the nature of the affection in each is always the same, and is not in the slightest degree changed by the complication. Disease in the brain is the same, whether the brain alone be prominently affected, or the brain and the intestines, or the brain, the intestines and the lungs. Each organ is liable to its own specific disease, and that disease goes on with the utmost regularity, whether it be the sole organ so far diseased as to suffer a change in its structure, or whether many be simultaneously affected in the same manner. ”

“ While the patient experiences the sensation of cold, there is no diminution of the quantity of caloric in the system. The thermometer applied to any part of the body commonly rises as high as in the state of health, and the skin, touched by the hand of another person, communicates not the feeling of cold, but often, on the contrary, that of preternatural heat. There is no positive abstraction of caloric from the body nor any failure in the process, whatever it be, by which animal heat is generated; there is only altered sensation, in consequence of derangement in the function of the skin. ”

“ It is not easy for a nurse to resist incessant importunity and even reproach; and there are suspicions to which a physician is subjected, which, when he sees that they are entertained, it requires some moral courage to enable him to bear. Without doubt he deserves the worst that can attach to him if he allow the caprice, or the impatience, or the injustice of his patient, or any earthly consideration to induce him to swerve from the faithful discharge of the duty he has undertaken. ”

“ 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. ”

“ 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. ”

“ 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 ”

“ The eye cannot well bear the light: there are few cases in which the full glare of day does not excite uneasiness, while in many the ordinary light of a room cannot be borne: in these cases the opening between the eye-lids is frequently observed to be contracted, as if from an involuntary effort to exclude a portion of that stimulus which in health excites no inconvenience, and this state of the eye-lids assists in giving to the eye its dull and heavy expression, so characteristic of fever. The increase of sensibility in the organ of hearing is equally striking. ”

“ We may not be able to see a single spark, but if we see the smoke and feel the heat, we know that there is fire somewhere, and that however concealed at present it will soon make itself visible enough, and that it will consume not only the structure in which it originates, but others with which it may come in contact if it be not put out. With equal certainty we know that fever, though apparently mild in the commencement, will excite inflammation in vital organs, and that that inflammation, if it be allowed to establish itself, will place the fabric of the body in the most imminent danger. ”

“ Slowness of the pulse, with severe and obstinate pain in the head, attended with confusion of mind, is always a highly dangerous-symptom: it invariably denotes intense cerebral disease. Whenever there is such a struggle, as this case exhibits, between the physician and the disease, the disease is sure to conquer. For if the physician, terrified at the name or the duration of the malady, while he resolve to use the lancet, hesitate to employ it to the extent of subduing the disease by the first bleedings, the patient is lost. ”

“ The affection of the brain is sometimes so violent and sudden that the pulse is not only slow, but intermitting, and the respiration is suspirious. Frequent and deep sighing is not uncommon in severe cerebral cases, and it is highly characteristic of intense cerebral affection; but in such a violent attack as that of which we are now speaking, the suspirious breathing, even in the very commencement of the disease, is so great that it cannot be overlooked. ”

“ 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. ”

“ 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 ”

“ Although the eruption may, and without doubt does give rise to some peculiar symptoms and so modifies the fever, yet the true character of the disease, or the disease as a subject of medical treatment, depends entirely on the nature, that is in truth on the intensity of the fever. If, therefore, the Exanthemata can find no place under the genus fever consistently with the principles of nosological arrangement, it appears to me that these artificial distinctions ought to be abandoned: because it is better to reject nosology, than to overlook or to mistake pathology. ”

“ The patient is struck dead as if by lightning, or by Prussic acid, or by apoplexy. In this country, he does not actually die as instantaneously as he might be destroyed by the electric fluid or by poison, although there are countries, seasons, and particular spots, in which the concentration of the febrile poison appears to be sufficiently great to extinguish life instantaneously; and even in this country, life is sometimes destroyed by a stroke of fever as rapidly as it is by a stroke of apoplexy, when the latter does not prove fatal in the first few hours. ”

“ On the contrary, if the skin be hot, the eye fierce or wild, the delirium loud, noisy, requiring restraint, and the general motions violent, it is as absurd to give wine, as to pour oil upon a half-extinguished fire, with the view of putting out the yet burning embers. ”

“ The management of the convalescence is one of the most difficult parts of the treatment and one of the most unsuccessful, not because there is any thing which requires to be done, nor because there is any disease which prevents recovery, but because the patient is considered as well when he is only convalescent. Of the great tendency there is to relapse during the whole of this period few medical men are sufficiently aware, and the unprofessional attendants on the sick are totally ignorant of it. ”

“ This mode of viewing fever as one great and extensive malady never differing in nature, but in every two cases differing in intensity, and giving rise by these differences in intensity to various forms of disease, thus affords a principle of arrangement applicable to all those various forms, which, while it is at once simple and comprehensive, is at the same time in the highest degree practical. It directly leads the mind to the observation of the real, the important differences that exist or that may arise ”

“ It is a matter of constant observation, that the febrile poison may be present in sufficient intensity to affect the health, without being sufficiently potent to produce fever. In this case the energy of the action of the organs is diminished, their functions are languidly performed, the entire system is weakened, and this increases, until at length the power of resistance is less than the power of the poison. ”

“ He who looks for intense pain, and suspects no cerebral affection, unless accompanied with this symptom, will be surprised by what will appear to him the sudden occurrence of new symptoms, such as are immediately to be stated, which will at length open his eyes to the danger of the case, and excite his wonder, which it is not unfrequent to hear expressed, that an affection hitherto so mild, should, without any previous warning, become so formidable, and show but too manifestly that it is beyond control, and will certainly proceed to a fatal termination. ”

“ What the physical and the physiological condition of the organs is, as contrasted with their condition in the state of health, has not yet been made out with regard either to fever or to inflammation: in the present state of our knowledge, therefore, we can neither affirm nor deny any thing respecting either the identity or the difference of that physical and physiological condition of the organs in these two classes of disease. ”

“ It is well known that the poison which, in a certain state of concentration, produces fever with the ordinary period of duration, in a higher state of concentration produces instantaneous death; and that, in certain climates and seasons, it is not uncommon for persons previously in sound and vigorous health, on exposure to that poison, to sicken and to die in a shorter space of time than is requisite, under ordinary circumstances, for the mere formation of the inflammatory process. ”

“ 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. ”

“ Whatever diminishes the vigorous action of the organs, impairs their functions, and so weakens the general strength of the system, is capable of becoming a predisposing cause of fever; and every predisposing cause acts in one or other of these modes, and becomes a predisposing cause only and in proportion as it lessens the energy of the system, or disturbs the balance of its actions, which in fact is to render some portion of it weak. ”

“ 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. ”

“ Whenever a severe case occurs without exhibiting any striking prominence of affection in any organ, and when on examining the organs there are found indications of severe affection in all of them, that case is sure to become formidable, and the patient and his physician have reason to congratulate each other if it do not prove fatal. When prominence of affection in any one organ is absent, because all the organs are intensely affected, it constitutes the most formidable case that can occur. ”

“ When he has swallowed a larger dose, provided it amount to a certain quantity, no remedies will avail, excepting the application of the stomach-pump. Unless the poison be promptly expelled from the system, adopt with the utmost vigour the best-concerted expedients which the medical art can supply, the patient will die. A person afflicted with the intensest form of fever, is in the condition of a person who has swallowed this large dose of poison. When a pump is invented, capable of extracting his poison from the brain, he may be saved. ”