phrenitis*, he endeavours to support by a review of the symp toms and causes of fever, by the appearances on dissection, and by the mode of treatment which he maintains to be the most unsuccessful in it.

The first position which he endeavours to establish is, that there is no general disease. He takes a rapid survey of diseases in the order in which they stand in Dr Cullen's Nosology. After observing that the phlegmasie, hæmorrhagia, and profluvia are es sentially local diseases, he observes," with regard to the remaining orders of the pyrexia, the febres, and exanthemata, it will be my business hereafter to shew, that they form no real exception to the general rule above suggested." He then makes some observations on the classes of neuroses, cachexia, and locales, and observes, that if there is any general disease, we should expect to see it in cases where venereal and other poisons are received into the circulating system, and, consequently, applied to every part of the body; not recollecting that most noxious substances are injurious only to certain parts of the system. Tartarised an timony may be applied to the mouth with little or no effect, but in the stomach it excites violent efforts; ginger cannot be held in the mouth, but in the stomach and bowels it occasions little or no sensation; the variolous matter introduced under the skin of the predisposed, excites inflammation and fever, but it may be swallowed without any sensible effects.

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Dr Clutterbuck then proceeds, "From what has been said, therefore, it may be concluded, that, properly speaking, there is no such thing as an universal disease," seeming to forget, that he has referred the reader to some future part of his work for the proofs of febres and exanthemata being local diseases. And, without any farther observations on this head, he remarks, in the second paragraph of the second chapter, but, I have endeavoured to shew, in the preceding pages, that neither this nor any other disease is entitled to the denomination of general or universal."

In the first of the foregoing quotations, he refers to a succeeding part of the work, in the others to a preceding, for the proofs that fever is not a general disease; and, in the pages which intervene between these passages, there is no attempt to prove this position. The preliminary observations then, in which Dr Clutterbuck endeavours to prove, that there is no general disease,

"In conformity then, with the view of fever above given," Dr Clutterbuck observes, 66 we should consider it as a topical affection of the brain, founded in inflammation; in a word, as a variety of phrenitis." See Part I. page 228 of Dr Clutterbuck's work.

disease, properly so called, may be overlooked in the discussion before us. If it can be proved, that fever is not such a disease, it must be by a review of its phenomena: the succeeding part of Dr Clutterbuck's work contains this review, in which I am now to follow him.

Dr Clutterbuck endeavours to prove, that the symptoms which immediately arise from an affection of the brain, constituting derangement of the animal functions, are the only essential and primary symptoms of fever, the derangement of the vital and natural functions being only secondary or accidental. I shall first follow Dr Clutterbuck in his observations on this head, and then compare the symptoms of fever and phrenitis.

In the second section of the second chapter, he has, with minuteness and accuracy, detailed the various affections of the animal functions observed in fever, from which it unequivocally appears, as every one will be ready to admit, that the functions of the brain are generally much deranged in this disease. But are not the functions of the stomach as much, and much more uniformly, deranged in fever? Fever is often present to a great degree, nay, even proves fatal, without derangement of the mental functions, but never without derangement of all the functions of the stomach. May we not, then, by a parallel mode of reasoning say, that the stomach, rather than the brain, is the seat of fever?

It appears to me, that Dr Clutterbuck has not sufficiently considered the manner in which the brain is necessarily affected by the various states of the circulation. The blood being returned from it by canals that are destitute of muscular power, and in which, consequently, the motion of the blood is supported wholly by the visa tergo, when the rapidity of the circulation is increased by any cause, there must necessarily be a turgescence of the vessels of the head, the canals, through which the blood is returned from the brain, not being excited to increased action to counterbalance the increased action of the vessels which bring the blood to this organ. This seems to be a provision of nature, in order to afford the brain a copious supply of blood, at times when much nervous energy is required; for running, or any other exercise which considerably quickens the circulation, occasions the same turgescence of the vessels of the head, flushing of the countenance, and beating of the temples, and, if longcontinued

*The blood not being returned from the internal parts of the head, with a velocity corresponding to the increased velocity with which it is sent thither, a larger portion of it passes by the external vessels; hence the flushing of the countenance, beating of the temporal arteries, &c. which attend an increased velocity of the circulation.

continued, the same headach and uneasiness which the first stage of fever does. These are the unavoidable consequences of an increased velocity of the circulation; and wherever this exists, therefore, be it from what cause it may, it is superfluous to look for any other cause of such symptoms.

If, on the other hand, we diminish the force of the circulation, by abstracting, for example, part of the blood, we find, that as the strength of the pulse is reduced, the vigour of the brain is in the same degree lessened. The sight wavers, the feeling becomes indistinct, and syncope supervenes. If the bioodletting is repeated, subsultus tendinum, spasms, general convulsions, in short, all the nervous symptoms which attend the second stage of fever shew themselves. We know then, that a weakened circulation is capable of producing these symptoms; when, therefore, we observe them accompanying such a state of the circulation, it is superfluous, and, consequently, inconsistent with just reasoning, to look for any other cause of them. These observations it is necessary to keep in view, in perusing what I am about to say of the state of the vital and natural functions in fever.

"The vital functions," Dr Clutterbuck observes," namely, respiration and the circulation of the blood, are liable to be variously affected in fever, but in a secondary way oniy." With this sentence he begins his observations on the state of the vital functions in fever; and the only argument he adduces in support of it is, that the pulse in fever is sometimes as slow, or slower than in health.

I think Dr Clutterbuck would not have laid so much stress on this single fact, if he had recollected how rarely it is observed in fever, and how many local affections are constantly supervening in this disease, capable of disturbing its usual course. Had Dr Clutterbuck ever seen fever with a slow pulse, he would have mentioned it, as he quotes the observations of several other writers to prove that such cases exist. I never saw such a case Now, Dr Clutterbuck and myself have seen at least some hundred cases of fever, in all of which the pulse was uniformly more frequent than in health. A physician, I believe, may practice forty years in this country, and not see a case of simple fever in which the pulse is as slow as in health. May we not hence alone infer, that when a slow pulse is observed in fever, some thing has happened to disturb the usual course of the disease: but we have more direct proof that this is the case. Most of the writers Dr Clutterbuck quotes, respecting the slow pulse in fevers, practised in warm countries, where fevers, unattended by any local affection, are seldom seen. Thus, Dr Clutterbuck himself mentions,

mentions, from Dr Wittman's account of a malignant fever of Syria, that, in the worst cases, the pulse was hardly changed; > but he also observes that the pupils were dilated. In Dr Chisholm's account of the fever of Grenada, there is a very easy explanation of both symptoms. In many of his patients also, the pulse was slow, and the pupil dilated; and, on opening the head after death, he found a collection of water in the ventricles, an appearance which we know, from dissection, does not belong to simple fever.

Besides, this slow pulse is no proof of the healthy state of the circulating system. In these complicated cases its frequency is sometimes about the same as in health; but this seems to be accidental, for it as often falls below the natural frequency. In the fever of Philadelphia, in which there was always evident marks of some local affection, Dr Rush found it as low as 30*. Such cases as these cannot, surely, be adduced to prove that, in simple fever, the state of the circulation does not correspond with that of the nervous system.

Let us take a cursory view of the progress of simple fever. At the commencement, when the patient complains of a sense of general debility, when the limbs totter, the tongue trembles, the mind becomes feeble, unsteady and anxious, the sight wavers, the hearing is confused, the smell and taste often lost, and the feeling indistinct; along with these symptoms the pulse is weak, small, frequent, perhaps irregular, the breathing frequent, feeble, and interrupted with sighing, the features, and other extreme parts, shrink, the various secretions begin to fail, the tongue becomes clammy, the throat dry and rough, the appetite is impaired with thirst and constipated bowels, the urine limpid, and in small quantity, and the skin cold, pale, dry, and shrivelled. By degrees we see this state of general debility changing to one of a different nature. The strength of the pulse increases, the breathing becomes fuller and less feeble; the blood is now impelled with vigour into the extreme vessels; the paleness, shrinking, and coldness of the skin is succeeded by turgescence, redness, and heat; instead of the feebleness which attends the first stage of fever, the muscles now acquire a preternatural vigour ; the sensibility, instead of being impaired, is now morbidly accute, and various other symptoms, denoting an increased force of circulation, gradually shew themselves. These symptoms of inereased excitement continue till the vital powers begin to be exhausted; and, in proportion as this happens, does not the ner

Vous

Towards the fatal termination of fevers, indeed, the pulse, at the wrist, sometimes beats less frequently than the heart.

vous system shew corresponding marks of debility? Or, if the increased action of the heart and arteries be lessened by artificial means, by abstracting, for example, a considerable quantity of blood, does not the same debility of the circulating, followed by the same debility of the nervous system, ensue, only more early than when the fever is left to run its natural course?

In considering the state of the animal functions in fever, Dr Clutterbuck begins with an observation, surely very inconsistent with every thing we know of the nature of this disease, that the power of the interstitial absorbents continues equal to what it is in health, or is even increased. This he infers from the wasting of the body in fever. But the wasting in simple fever is never very rapid, and is readily accounted for by the interruption of the powers of assimilation. That the power of the absorbents is impaired in fever, appears from the stagnation, and consequent putrefaction of the various secreted fluids. Why does the saliva, the secretion by the skin, &c. acquire a putrid smell in typhus, if the power of the absorbents, whose office it is constantly to remove such parts of these fluids as become useless or noxious, is unimpaired or increased?

Under the head of animal functions, Dr Clutterbuck necessa rily notices the affection of the stomach which so uniformly attends fever, but, consistently with the opinion he defends, he considers it the consequence of the diseased state of the brain. No doubt diseases of the brain influence the state of the stomach in various ways; but, in the present instance, there is a strong objection to Dr Clutterbuck's mode of reasoning, because, in fever, the affection of the stomach almost uniformly precedes that of the brain; and indeed, in many fevers, particularly those from contagion, some affection of the stomach is often the first symptom. On what principle, then, can we regard the affection of the brain as primary, and that of the stomach as symptomatic, in this disease? To prove that such affections of the stomach frequently arise from diseases of the brain, is going but a very short way; the converse of this is equally true: many of the affections of the brain, observed in fever, are such as arise from diseased states of the stomach.

It would be easy to shew, from direct experiment, that when the stomach and bowels are affected by opium received into the system, it is not, as Dr Clutterbuck supposes, through the me dium of the brain.

Such are the arguments which Dr Cultterbuck derives from the symptoms of fever, in support of his hypothesis. It will place the preceding observations in a clearer point of view, to compare together the symptoms of fever and phrenitis.