internal and external; it is not surprising, the author remarks, that there should be, at the same time, very little susceptibility of fever from many of its causes. He then proceeds to state some of the consequences of fever, such as impaired organs of sense, paralytic and convulsive disorders, and other affections of the voluntary power, loss of memory, &c all which point out the brain as the seat of the morbid affection.

But is there not much room for fallacy in this mode of reasoning? Are not the sequela of a disease often found at a distance from its primary seat? Shall we assert, that the proximate cause of an intermittent is an affection of the spleen, because we find that organ frequently disordered at the conclusion? Or shall we decide, that the primary seat of diabetes is in the kidneys, because those glands become soft and enlarged during that malady?

We are not perfectly satisfied of the philosophical precision of that sweeping inference, which refers to the same source, all those various phenomena which proper fevers, intermittent, and exanthematous fevers, and others arising from specific contagion, exhibit in their course. It is stating too much to say, that the brain, being the common organ and centre of sympathy, must necessarily be the medium through which all irritation affects the system at large, because we thus include all symptomatic fevers whatever in one group. The observation might be theoretically just, but where is its practical utility? Must we direct our attention and our remedies to the common sensorium, in all instances of general disease? But surely the brain is sometimes the medium of irritation without suffering itself; sometimes it suffers only by sympathy, i.e.continues to suffer no longer than the distant irritation is applied; and sometimes it becomes so far affected, as to suffer derangement after the irritating cause has been withdrawn. The author appears to consider it as affected invariably in the latter way only. But numerous instances of the sympathetic affections of the head, which, though severe, have ceased on the removal of a distant irritation, must recur to the recollection of every practitioner. Having traced the symptoms of fever to the brain, as their primary seat, Dr Clutterbuck proceeds to investigate the nature of the affection of the brain, from which those symptoms originate; and he maintains, that it is either a state of actual inflammation, or at least, a condition nearly allied to it, as it contains the most essential characters of this affection."-p. 100. He points out a great analogy between the phenomena of fever, and those of inflammation; to both, the heat, pain, and throbbing in the head, increased sensibility, the furred tongue, &c. are common, and both are preceded by the same rigors, and reaction;

the

the blood is in the same state, exhibiting the buffy coat, often in both disorders, though it be not essential to either; the exciting causes are in both, in a great measure, the same; fever often alternates with inflammation, which proves the similarity of their nature; and the natural and artificial cure of the two diseases is alike in both, as are also the means of prevention. All these topics the author illustrates at considerable length, with much perspicuity; and his inference is, that fever " is nothing more nor less than a species of phrenitis, or topical inflammation of the brain."

He then compares the characteristic features of fever with those ascribed by authors to phrenitis, and shews, that the two diseases have not been accurately distinguished from each other, even by the best writers. The ordinary character of phrenitis, given by nosologists, is confessedly imperfect, and Dr C. contends, is applicable only to one, and that a rare form of the disease; and he quotes several respectable authorities to prove, that inflammation of the brain has been found, when none of the symptoms commonly ascribed to phrenitis have occurred; and, on the other hand, where there have been no other symptoms than those of common fever, inflammation has been found to have existed in the brain.

The author then proceeds, in a section replete with extensive and judicious reading, (as indeed is the whole of this volume,) to treat of the appearances on dissection: But here, he seems to be half conscious of a deficiency of facts in his favour; and this section is, in great part, an apology for the imperfection of our knowledge of the minute variations of structure in the brain, and for the insufficiency of the records of morbid anatomy, relative to fever. After quoting a few examples of suppuration, &c. in the brain, consequent on malignant fever, Dr C. adds the following observations:

"A host of other instances might be adduced to prove, that fevers of all descriptions very frequently leave behind them visible topical affections of the brain, demonstrating the existence of previous inflammation in that organ. It is not, however, to be imagined, that the appearances now mentioned, are to be found in every case of fever. The essential part of this, as of most other primary diseases, consists, not in the altered struc ture of parts, but in perverted actions; change of structure is a remote effect, a consequence merely of the morbid action, and is what may or may not take place. Hence, if the disease prove fatal before such alteration of structure is induced, (which may be well supposed to happen with respect to an organ, upon the state of which all the functions of the system more or less immediately depend), few or no traces of the disease can be expected to be seen after death.”—p. 174.

Here,

Here, we confess, we are unable to follow our ingenious author. Surely a change in the appearance of an inflamed part, is not a remote consequence. Inflammation, we apprehend, implies a necessary alteration of an organ sufficiently obvious to the eye, ere it can injure, certainly ere it can totally destroy, its functions. But if there are no appearances of inflammation, when the functions of the brain, and life itself, are annihilated, in what degree can we consider it as existing in the majority of instances, which run through a mild course? In the quotations from Dr Donald Monro, it is stated, that "the febrile matter is apt to fall on particular parts, and there to create abscesses, particularly in the brain, the lungs, and the glandular organs."-p. 172. Now this only shews, that inflammation and suppuration of various organs, sometimes one, sometimes another, is apt to occur in consequence of the general vascular action in fevers, or is a cause of them in different instances; and, as it is admitted, that such a circumstance is observed but now and then in the brain, as in those other organs, the most obvious inference is, that the inflammation of the brain is also a secondary consequence, or only occasionally a cause of fever. The author, we think, argues strongly in favour of this notion in the continuation of the passage just quoted.

"The intermissions of fever, during which patients often enjoy an almost total exemption from disease, and the speedy return to perfect health, after their cure, prove that no great derangement of structure can have taken place. That fever does not necessarily kill by destroying the organization of the brain, is shewn also, by the return, in some few in. stances, of the mental faculties, a short time before death, where delirium had been present throughout the previous course of the disease.”—p. 175. Where is the analogy between these phenomena and the symptoms of fatal inflammation in other important viscera? Do the lungs, in a fatal peripneumony, ever admit of an interval of free respiration; or do the intestines, in a mortal enteritis, perform their functions, but for the shortest period, near the close of the disease? And what other organ has its functions destroyed, at one time by a degree of inflammatory action, where there is no perceptible distention of vessels (if that be not a solecism), and at another only by actual disorganization? Dr C. appears to have not altogether avoided the great error of less cautious and more visionary theorists, who consider the evidence, which is in favour of their doctrine, as proving a great deal; but explain away, with facility, the facts that stand in opposition. The de-, cided marks of inflammation in the brain, observed in some patients destroyed by fever, greatly strengthen the author's belief that such inflammation is the universal cause of fever; whilst the absence

absence of all such marks, in many other instances, is not allowed to prove any thing but the imperfection of our senses. Thus also, he admits Dr Donald Monro's evidence in proof of inflammation of the brain, but takes no notice of that of the lungs and the glandular organs, upon which, also, according to Dr Monro, the febrile matter is apt to fall."

Dr C. next details the opinions of the Greek and Arabian physicians, as well as of the modern theorists, down to Home and Cullen, respecting the nature and seat of fever, among which nothing but contrariety is to be found; and in the following section he determines the nosological place of the disease to be properly among the phlegmasia, under the denomination of encephalitis. The term phrenitis he deems objectionable, as it is expressive of delirium or alienation of mind, which, though a very frequent, is not a necessary nor constant attendant on fever.

He then discusses, at great length, in thirteen sections, the nature and effects of the different modes of cure, as they relate to the doctrine of the preceding pages. Our limits will not allow us to follow the author through this very able and comprehensive discussion, which cannot be read without advantage. The work is concluded by a brief recapitulation of the doctrine, and of the arguments in its support.

Although we may not be disposed to surrender our conviction altogether to the doctrines of Dr Clutterbuck, we must allow him the credit of having supported his theory by great strength of evidence, and to have evinced an acute spirit of investigation, as well as considerable medical erudition. Had we never witnessed the various phenomena of fever, we should, perhaps, have risen from the perusal of this volume, satisfied of the truth of the opinions which it contains. But we cannot call to our recollection the general variety of those phenomena, and consider them as originating in one common source, and that inflammation of the brain. Not to mention the want of analogy between the cessations and returns of intermittent fevers, and the symptoms of any visceral inflammation; nor the variety of regular forms, which the exanthemata, and fevers from specific contagion assume, which seem to point to a difference of proximate cause; even in the common fevers of this country, there appears to be a variety of modification, which we are not warranted, either by observation or analogy, in attributing to the one source alluded to; and some circumstances occur in them all, which do not exactly accord with the notion of inflammation. Thus, we sometimes see fevers linger on several weeks, with scarcely any other symptom than loss of strength, impaired digestive power, and quickened circulation. On the contrary, we occasionally observe

a noisy and watchful delirium, like that of intoxication, which shall terminate at once in a few days, perhaps in a short sleep, and no febrile symptoms remain. Even in those severe cases, where every mark of congestion in the head occurs, and the patient sinks with ferrety eyes, subsultus tendinum, and stupor, how often do we see the free use of stimulants speedily rouse him to complete sense, and a considerable degree of strength; nay, even spontaneously the functions of the brain shall be restored, a short time previous to the fatal conclusion. Some of these appearances seem to be referable rather to the stomach than the head; and others, especially the periodical returns, and the sudden changes and intervals of sanity, are more analogous to what we denominate nervous disorders, i. e. to those phenomena in the sensorial and voluntary powers, which are unconnected with inflammation, or, in many cases, with any obvious physical change. There cannot, indeed, be a doubt that the sensorium' is disordered in these cases, and that this disorder is even the essential source of some of the symptoms; but it may, nevertheless, not be the essential cause of the disease. In intoxication, for instance, the brain is disordered, and this gives rise to the hurry of thought, loss of muscular powers, &c.; but the primary seat of the disease is the stomach. Dilute or evacuate its morbid contents, and the functions of the brain are speedily restored. Here is not inflammation; for inflammation goes on independently of the exciting cause; and although it may be contended that there is" a condition nearly allied to" inflammation, the practical indication must, nevertheless, be directed to the stomach. It may be added, too, that we frequently see patients labouring under low fever, who perish from congestion in the lungs; as in the pneumonia typhodes; and dissections have shewn the appearances of inflammation in other organs, under similar circumstances with respect to the fever.

Dr Clutterbuck concludes by stating his hopes, that he will be able to bring forward still more satisfactory evidence of the truth of his doctrine, in the second part of his work. We should be well pleased if he could decidedly shew, that fever is always connected with inflammation in any viscus; as it might tend to convince the great number of routine practitioners, who never hear the name of fever without prescribing wine and bark, at whatever period of the disease, of their mischievous error.

H.

VOL. IV. NO. 13.

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