The object in view, is to direct the student how to proceed in the investigation of any case submitted t,o him, in such a manner as may naturally lead to his forming a correct judgment regard ing its nature and causes. With this purpose we have directed attention in the preceding chapter to certain signs and symptoms which have especially reference to the general condition of the patient, and have endeavored to show what conclusions may be legitimately drawn from them when taken along with the history of the case. We have also inquired what the patient has to complain ot The next step is to take a rapid survey of the various organs, and also to examine more closely any one in which evidence is given of an abnormal state by: the sensations of the patient, or by facts elicited in inquiring into the history of the case.
A reference to the table of diseases shows, however, that there is a large class in which loc,a1 disorder, as manifested by symp toms belonging to particular organs, is only secondary and subsi diary to the general disease. With regard to such, thd most important facts are those which have a relation to the general condition ; and while the examination of the various organs must be by no means omitted, the evidence is chiefly negative. Occasionally more positive results are obtained, and then the examination must be more minute. The plan which I would venture to recommend, is to bear in mind the order of arrange ment in which the organs are placed in our table of diseases, aud to ask such general questions regarding each in succession as may lead to the conclusion that they are or are not in a normal state. We inquire whether there be headache, giddiness, or insomnia : whether there be pain in the chest, cough, shortness of breathing, or palpitation ; sickness, flatulence, &c. The care with which this is done must depend upon whether the whole history pf the case and category of symptoms correspond to the special disease which we are inclined to assume as their cause, or whether there be anything unusual or unaccounted for in the notes of these which have been made.
The first point to be determined is the presence or absence of a febrile state. The best evidence of its existence is the combi nation of general symptoms, pointed out in the early part of the preceding chapter, when there is also a history of a comparatively recent origin. When symptoms of fever are present in a case of longer duration, its history must be more closely investigated; because, on the one hand, we may find that, with a certain amount of general or local ailment, the patient has been able to go about his usual avocations till within a very short period, when more severe illness has set in with rigors, alternate flushings, and chilli ness, &c.; or, on the other hand, we may find that the fever is
only an aggravation of long-continued suffering, and caused by exhaustion supervening.
Rigor is an important, but not an essential, element in febrile disturbance; it attends on most acute diseases, but occasionally it is not observed. When present., it often serves to mark the commencement of the illness, and is therefore of value in the history of the case. Recurring frequently in the course of the attack, and described as " cold chills," it is especially character istic of continued fever. In inflammations it may frequently be observed in a severe form at the outset, and then is .more com monly absent till suppuration commences, when the occurrence of rigor is very significant. Its periodical recurrence is the chief distinguishing feature of ague.
The next point for consideration is, whether these general symptoms make up the whole of the disease, or whether it accom panies inflammation of some particular organ ; whether (to use the hard words of science) the pyrexia be idiopathic or symp tomatic • and this can only be ascertained by the negative results obtained from examining in detail each of the various organs. A suspicion or.guess may be formed from the circumstance, that when the skin is hot and dry, and the pulse feeble and frequent, we are more likely to have fever to deal with ; and that when the skin is moist, the pulse firm and less frequent, the chances are in favor of inflammation. Pain, when complained of may at once point out the seat of the disease when inflammation is present; but it is often absent ; and in fever the sensation is only one of general pain or uneasiness, often spoken of as "pains in the bones." Pain must be localized; that which is general, in the bones or in the mus cles, a feeling of aching rather than pain, often accompanies fever; when the joints are affected and the limbs are more distinctly painful and tender, rheu matism is most probably its cause.
The essential element of fever is so entirely beyond the reach of our present means of investigation, that its diagnosis is par tially imperfect. It must be made out to the satisfaction of the inquirer that no local disease exists of which febrile disturbance is a symptom, and that those local derangements which do exist, are the legitimate consequences of natural signs of the presence of fever poison in the blood. Hence, if any loe,a1 disorder be present, of which pyrexia is not a symptom, that must be for the present set aside as not belonging to an inquiry into the causes of fever ; and if no local inflammation be discovered, the febrile state must be taken as evidence of fever simply.