1K-..U PHYSIOLOGICAL PYRETOLOGY; OR, A W£2SAVHSSB ON aPBBVSHiSS ACCORDING TO THE PRINCIPLES OF THE NEW MEDICAL DOCTRINE. BT F. G. BOISSEAU, DOCTOR IN MEDICINE OF THE FACULTY OF PARIS, MEMBER OF THE ACADEMIES OF MEDICINE OF PARIS AND MADRID, OF THE MEDICAL SOCIETY OF EMULATION, OF THE FHYSICO-MEDICAL SOCIETY OF MOSCOW, OF THE SOCIETIES OF MEDICINE OF BRUSSELS, LOUVAIN, MARSEILLES, METZ, AND TOURS, AND OF THE SOCIETY OF AGRICULTURE OF CHALONS. Novi veteribus non opponendi, sed quoad fieri potest, perpetuo jungendi foedere.—Baglivi. FIRST AMERICAN, FROM THE FOURTH FRENCH EDITION. TRANSLATED BY J. R. KNOX, M. D. CAREY & LEA. 1832. v-'BB V CSAp• . )83& RJt^#" 33^7/ i^'^ Entered according to the Act of Congress in the year 1832, by Cakit & Lea, in the District Court for the. Eastern District of Pennsylvania. >oS&DIC*/*s o. PREFACE. To dissipate the prejudices entertained by some phy- sicians against the application of pathological anatomy and physiology to the investigation of the seat and na- ture of fevers; to contribute to the dissemination of truths, the value of which can no longer be contested, since they have given rise to a more rational, and, what is of greater importance, a more efficacious treatment of these diseases; to show that, if the French medical doc- trine is new, when considered as a system, it can, never- theless, appeal in attestation of its truth to the authority of past ages, and even to the experience of its adversa- ries ; finally, to reduce within the limits of observation, principles which have been generalized with too much boldness. Such were the objects which I proposed to myself in the publication of this work, which first ap- peared in 1823. This edition has received numerous additions, which principally refer to the anatomical researches recently made, with a view to throw light on the nature and seat of various fevers, to quarantines, and the epidemics of the Morea and Gibraltar. In consequence of the em- ployment of a smaller type, the size of the volume has not been increased. Having been induced by the continued favour of the public, to believe that this work had not been devoid of utility, the only reward which a scientific author can IV PREFACE. propose to himself, I undertook to publish a work of greater extent, in which I applied to pathology * in ge- neral, the method and principles by which I had con- ducted my researches on fevers. I do not aspire to the celebrity of a reformer; my ob- ject is simply to offer students and practitioners, who have not an opportunity of following the progress of me- dical discovery, a faithful exposition of the present state of the science of disease, in reference to diagnosis and treatment. The observations of the ancients and mo- derns have furnished the elements of this work, which is designed as an introduction to that attentive and pro- found study of the science and art of curing, which it is the duty of every physician to prosecute. Paris, November « of the organ itself. 73. Organic alterations are not visible when the or- moire de M. Vacquie sur Vasthenie, couronne par le Societe Medicale d'emu- Iation in 1830. INTRODUCTION. 27 gan is deeply seated, or is covered by another, when they occur in the centre of an organ, or in its most delicate parts, for we are unacquainted with the intimate struc- ture of the tissues. There are sometimes also alterations of function. 74. Alterations of function are always connected with alterations of structure. When the latter are not appa- rent, we conjecture their nature from the character of the former. 75. There are, consequently, in the state of disease, organic modifications which are concealed, and others which are manifest, {symptoms,) and it is from the latter that we judge of the former. 76. Often, after a most careful examination, the only symptoms we can discover are lesions of function, and in such cases it is frequently thought that the disease is one which affects the entire organism, and falls upon no organ in particular. 77. The different natural or artificial groups of symp- toms, have received the name of disease. The ancients, to designate a group of symptoms, made use of a word, which it will be useful to revive, viz: syndrome. This denomination will be more proper than that of prodrome, which has synonyms in the French language. The de- signation of metadrome might be assigned to the organic changes discovered after death. A multiplicity of pari- phrases would thus be avoided. 78. Since it is impossible to trace back disease to de- rangement of the molecular action of the diseased organs, we must, as frequently as possible, discover its causes in the sensible alteration of their structure. Since symp- toms depend on altered structure, we can only cause their cessation by remedying the organic alteration, which has produced them. We must not, then, suffer ourselves to 28 INTRODUCTION. be arrested by the contemplation of symptoms, but we must go back, whenever it is possible, to the nature and seat of the disease, that is to say, of the appreciable or- ganic alteration. 79. To know the seat of a disease, is to know the or- gans whose lesion gives rise to the symptoms which cha- racterize it; to know its nature, is to know in what con- sists the organic alteration which constitutes it. The internal causes which are sensible, and whose existence is proved by autopsy, can alone be the object of medi- cine ; we should, therefore, in investigating the external and sensible effects and accidents of maladies, endeavour to arrive at a knowledge of their internal causes: the only means consists in the observation of the state of the principal viscera of those who die of every description of disease; these viscera are the internal organs of the three cavities of the body. 80. The nature and seat of this alteration are often very different from what the symptoms superficially ex- amined, would seem to announce. It is not always easy to determine the seat of disease during life; unequivocal traces of its existence are often discovered after death; but sometimes they disappear completely at the moment of the cessation of organic action. 81. All errors in pathology are derived from the four following sources: 1st, The attention has been given for too long a time to the study of symptoms alone. 2dly, Symptoms have been considered as always giving a faithful representation of the state of the parts, which, during life, cannot be inspected. 3dly, We have hitherto neglected to determine the organs, upon which each morbific and therapeutic Vent primarily exerts its influence, and the laws which co- INTRODUCTION. 29 vern the propagation of this influence from one organ to another, or to several. 4thly, It has been thought that these agents should act upon the whole organism, at the same time, as they are observed to act upon a single one. 5thly, Finally, many among them have been thought to act upon the whole organism at once, because the whole organism appears to be affected in consequence of their action. 82. The union of anatomy, physiology, pathological anatomy, pathology, and therapeutics, which have been too long separated, will, it is hoped, correct these er- rors. The union of these different parts of the sci- ence of man, considered in the structure, action, altera- tion, and restoration of his organs, has not yet been ef- fected, because this science is still but little advanced; but to deny the utility of what has been done, because much still remains to be done, is to expose oneself to the just reproach of ignorance or prejudice. 83. Before prescribing remedial measures, it is pro- per, as far as the case and the actual state of the science permits, to attend to the following rules:— 1st, To neglect no means of discovering what organ habitually predominated in the subject before the attack, what have been the morbific agents which have acted upon it, and upon what organ they primarily acted. 2dly, To trace, by the aid of the information, given by the patient and his attendants, the propagation of the morbific influence from organ to organ. 3dly, To refer each symptom to the organ in which it manifests itself. 4thly, By this means to discover all the organs more or less affected. 5thly, To draw a parallel between these data, and the 30 INTRODUCTION. symptoms which manifest themselves in the organs which we know to be predominant in men in general, and in the patient in particular. 6thly, Not to permit ourselves to be led into error by the intensity of certain symptoms, which are more pro- minent than others; to distinguish those which come di- rectly from the organ primitively or most violently in- vaded, from those occasioned by the organs secondarily or slightly affected. 7thly, Finally, from a comparative examination of the morbific cause, of the individual predisposition, of the principal seat of the symptoms, and their nature, to de- duce the nature and seat of the disease; that is, of the organic alteration which is the principal cause of the symptoms. 84. The nature and seat of this alteration being known or presumed, we must choose among therapeutic agents; those which are most proper to cause its cessation, or at least to diminish its intensity. 85. All these agents increase or diminish action, pri- marily in one organ, and secondarily, in one or more of the others. There are none which act upon the whole economy at once. It is by inducing salutary modifica- tions, at first, in a single organ, and afterwards in seve- ral, that they restore the functions to their normal state. 86. These agents are sometimes applied exclusively and directly to the diseased organ, but more frequently to some other organ which has a relation of action to it. In the latter case, it is almost always to some part of the external or internal surface of the body, that we apply them, sometimes to the cellular tissue ; they are seldom introduced directly into the vessels. 87. Diseases, when abandoned to themselves, are spon- taneously cured, when they have but a slight degree of INTRODUCTION. 31 intensity, or when they affect but a small number of or- gans. Death is the consequence when they are very in- tense, when they invade a great number of organs, or even a single organ, the integrity of which is important to the maintenance of the action of several others. 88. A disease becomes more intense in proportion as it has been badly treated. In any particular country, violent diseases are the more common in proportion as the medical doctrines which prevail there are more er- roneous. Yet mortality considered in general, is always nearly the same, because nature, by an admirable law, remedies, in a given time, this, as it does every other kind of destruction. The danger and efficacy of medi- cine are only important in relation to individuals.* 89. When the malady terminates favourably, the symptoms diminish either gradually or almost suddenly: in the latter case, there ordinarily supervene evacua- tions, to which a high degree of importance has for a long time been attached, designated collectively by the name of crises: the happy termination of the disease has been attributed to them; while, in reality, they are only the effects, or the signs of this termination. 90. It has been pretended that crises occur on parti- cular days, during which it is necessary to abstain from active measures, through the fear of disturbing the sa- lutary process of nature; these days, however, have not yet been designated with absolute certainty. 91. At the present day, it would be idle to speak of crises, were it not that the theory of the ancients upon this point, has induced many physicians to think that they should wait for these reputed salutary movements of nature, should do nothing through fear of disturbing them, and should not even attempt to provoke or to imi- * See ray article on mortality, in the Encyclopedic Moderne. 32 INTRODUCTION. tate them. It is evident that the best means for the pro- duction of crises, is to neglect nothing that may dimi- nish the intensity of the morbid process, limit its extent or direct it, if we may so express it, towards the least important organs. 92. Expectation is not indicated unless we are igno- rant of the nature and seat of the disease; when the dis- ease is slight; when it is evident that its duration will be short, or that it will terminate without treatment; finally, when the patient declines submitting to remedial mea- sures. 7. Of Sur-excitation, or Irritation. 93. Irritation, that is, the state of an organ in which vital action has risen above the degree necessary for the maintenance of life, is the most frequent, the most grave, and, consequently, the most remarkable of the two pre- mature morbid states. 94. Irritation is never general or uniform in the whole organism, because the causes which produce it always act locally, and because, in consequence of indi- vidual organic predominance, some particular organ, ac- cording to the constitution of the subject, is found to be alone affected, or more affected than others, by the pro- pagation of this irritating influence. 95. Irritation is the result of 1st, An excess of action on the part of external agents, upon some part of the internal or external surface of the body. 2dly, The propagation of this action to a part func- tionally connected with one of the surfaces. 3dly, The temporary abstraction of stimulants from an organ, possessed of very exalted excitability; INTRODUCTION. 33 4thly, Or, finally, the debilitation of an important or- gan, which gives rise to sur-activity or irritation in an- other. 96. Thus, directly or indirectly, irritation developes itself, primarily, in a single organ. Irritation established in an organ by any cause, direct or indirect, may exist, at least, during a certain time, without revealing any symptom of its existence, even when intense and situated in an important organ. We discover after death in a great number of subjects, profound organic alterations, which have no connexion with the disease which termi- nated life, and which have given rise to no symptoms— alterations perfectly resembling those, the slow forma- tion of which is accompanied, in a great number of other subjects, with manifest symptoms of irritation. 97. Irritation often occasions profound alteration of structure, which we recognise during life, when the functions are deranged by the progress of these altera- tions: otherwise, wre do not discover them until after death. 98. An irritation may occasion death without giving rise to any characteristic sign of its seat during life, and without leaving traces discoverable after death. We have then nothing to guide us in determining the seat of disease, except the analogy of the morbid phenomena observed during life, in these unfrequent cases; to those of the more ordinary cases, in which irritation gives rise to unequivocal signs of its seat, and leaves corresponding traces in the organs. 99. When irritation manifests itself to our senses, if its intensity be slight and the organ visible, we discover a redness, scarcely discernible, the heat a little increased, or merely a slight excess of sensibility, an unusual ener- gy of the function, {sthenic neurosis.) When the or- 5 34 INTRODUCTION. gan is internally situated, however intense the redness, it is not visible; and there is often neither heat nor pain; there then remains no other index of irritation than sur- activity, or even languor of function, either of that or- gan itself or of some other. 100. This sur-activity must not be confounded with a native or habitual excess of energy in an organ, strongly developed, either prematurely, or under the influence of a lively habitual stimulation. This excess of energy may continue a long time without constituting the state of disease, (hypertrophy.) 101. The second degree of irritation is announced by pain, a more decided redness, often by an exaltation, sometimes by a diminution of the most apparent func- tion of the diseased organ. This degree is often misun- derstood, or if the effects are observed, the nature and seat are mistaken. 102. Redness well developed, a lively heat, intense pain, swelling, the suspension of secretion and excretion, and the increase of absorption, characterize a more ele- vated degree of irritation, which, diminishes gradually, {resolution,) or determines one of the following results: The re-establishment, sometimes in a sudden manner, of the exhalations, the secretions, or excretions, {criti- cal evacuations.) A morbid sanguineous, serous, mucous, or purulent secretion, {hemorrhagy, serous effusion, mucous flux, suppuration.) A sort of disintegration of the organic molecules, sometimes with spontaneous solution of continuity, {ra- mollissement or softening, ulceration, perforation.) The sudden extinction of organic action and the death of the part, {gangrene.) Finally, a transition to the chronic state, whence re- INTRODUCTION. 35 suits a transformation or a degeneration of the irritated tissues, {analogous or heterologous accidental tissues.) 103. Such are the effects of the principal shades of irri- tation, that is to say, the phenomena which we observe in an organ subjected to a slight or very violent or prolonged action of the morbific causes which result in the local exal- tation of vital action. If it were necessary to designate all the shades of irritation, they would be as numerous as the organs of the body, and the different diseases to which they are liable. Those which we have pointed out may serve as terms of comparison: like all others, they are only degrees of intensity, or duration of the same mor- bid state, which produces consequences more or less con- spicuous, and alters more or less the part in which it ex- ists, according to its extent, its profundity, the number of tissues it affects, and the length of time it has conti- nued. The signs of the highest and of the lowest grade are the same; varying only in intensity, in the diverse phe- nomena which depend on the organic structure, and in the modification which they determine in the organs. 104. It has hitherto been customary to give the name of inflammation to the state of a part which is red, hot, painful and swelled; the use of this term may be conti- nued, provided it be understood that it designate, not a morbid state, sui generis, but a certain degree of irrita- tion, with an afflux of blood, more considerable than is necessary for the accomplishment of the nutrition and the functions of the organ; sufficiently intense and fixed to menace its integrity; finally, characterized by heat, redness, swelling and pain, or by one or more of these symptoms, according to its intensity, and the part it oc- cupies. 105. To designate by the term nervous irritation, that of the nervous filaments, which are supposed to accom- 36 INTRODUCTION. pany the ultimate vascular ramifications; to give the name of inflammation to the irritation of the sanguine capil- lary vessels; of sub-inflammation to the irritation of the exhalents and absorbents, is to place the seat of disease in parts of which our senses can take little cognizance. This is to fall back into an hypothesis, unwarrantable in theory, and pernicious in practice; to establish subtle distinc- tions, which sound logic rejects, because pathological anatomy disavows them. There are no signs in the ac- tual state of science, by which we can determine that irritation has not extended beyond the nervous filaments, or that it is confined to the sanguine or lymphatic capil- laries. As no one has seen the absorbent and exhalent capillaries, no one can know when their irritation exists. Finally, since every malady is an organic lesion, this denomination should not be reserved to designate altera- tions of texture. Neurosis, inflammation, sub-inflam- mation, hemorrhagy, are words which represent, not diseases, but groups of symptoms, the effect of irritation, or shades of irritation. These symptoms vary infinitely in their number, their intensity, and their succession; so that the same organ often presents, in succession, signs of neurosis, of inflammation, of hemorrhagy, and again those of inflammation, until all these morbid phe- nomena cease, while frequently the irritation still persists. 106. The only nervous irritations are those of distinct nerves, of the spinal marrow and brain, and of the ner- vous ganglions, and the only vascular irritations are those of the arteries, the veins, and the visible lymphatic and chyliferous vessels. 107. When a thick, melliform matter is abundantly secreted on the surface of the cutis vera, when the blood is poured out on the surface of a mucous membrane, we must be content to say, that these parts are sur-excited. INTRODUCTION. 37 irritated; that, in consequence of this sur-excitation, there is an excess of secretion, abnormal secretion, se- cretory irritation, hemorrhagic irritation of those tis- sues. There exists, without doubt, in the first, an or- ganic condition different from that of the second: what are these conditions? this we are incapable of determin- ing; what we are certain of, is, that they are two effects of sur-excitation. 108. The division of irritation into continued, remit- tent, and intermittent, is a better founded and more im- portant distinction. On the skin, and on the parts of the mucous membranes bordering upon it, irritation is ob- served to affect these different types, as is demonstrated by the facts collected by Cassimer Medicus,* from the most attentive observers of every age. Since the phenomena of external irritation cease, when this irritation itself ceases, and reappear with it, or assume greater inten- sity, when it increases, when we observe analogous phe- nomena, evidently derived from an irritation of the vis- cera, to cease, reappear, or become exasperated, the conclusion is most just, that the irritation which produced them has ceased, reappeared, or become exasperated. Whatever may be the explanation which is given of the intermittence of irritation, it is a fact which we must believe, even though unable to account for it. Pinel has well remarked, that a disease does not change its na- ture in changing its type: by this observation he gave a considerable impulse to science. 109. The functions of an irritated organ are sometimes exalted and sometimes diminished; and hence, in the case of a patient in whom the functions languish, we must not hastily conclude that there is primitive weakness or as- thenia. * Traitfe des Maladies periodiques sans fievres. Paris, 1770. 38 INTRODUCTION. 110. The duration of irritation varies from a single instant to several days, months, or years. It is not un- common for it to continue during the life of the patient. Yet it frequently terminates after the lapse of a certain time, which is usually of the same length for each par- ticular organ or tissue; at other times, its duration is in- definite, whatever may be its seat. In the first case, af- ter having gradually risen to the highest degree of in- tensity, it diminishes insensibly, the organ resumes the free exercise of its functions; the discharge of which it has become the seat disappears; or, if it existed before the disease, it returns to its ordinary state: if the irri- tated tissue is exposed or has been laid open by the knife, cicatrization takes place: the irritation in this case is said to be acute. 111. When the irritation becomes chronic, the part frequently presents neither redness, heat, nor pain; the swelling or the discharge continues, a solution of conti- nuity occurs, or accidental tissues slowly develope them- selves. 112. Such is the progress of irritation when confined to a single organ. But when it is very intense, or oc- cupies an organ intimately connected with the heart, with the brain, or the mucous membranes, or even when the irritation, though slight, developes itself in a sub- ject in whom these viscera are habitually or accidental- ly very excitable, the disease extends itself in the orga- nism. Several organs suffer, with the organ that has felt the first impression of the morbific cause, {sympa- thy.) To the local phenomena of which we have just spoken, are added in a greater or less number, those in- dicating irritation of the heart, the hair, the muscles and the mucous membranes, and sometimes those indi- cating the astheny of these organs. These sympathetic INTRODUCTION. 39 phenomena sometimes reduce themselves to a simple aug- mentation or diminution of the exercise of the functions. When they predominate over the local phenomena, re- sulting from the organ primarily injured, there is danger of mistaking the nature and seat of the disease, unless we are able to penetrate the obscurity of the symptoms presented by this mixture of force and weakness. When the disease is acute, the circulation disturbed, the heat of the surface increased or diminished, and there is no prominent sign of local lesion, and no mode of determin- ing to what class or species of neurosis, inflammation, hemorrhage, or organic lesion, to refer it, it is said that it is an essential fever: at least such has been the course pursued until within a few years. Since the labours of M. Broussais, the necessity has been recognised of no longer confining our attention, in studying the nature of diseases, to the most prominent symptoms; we must en- deavour to discover in every disease which appears to be general, the local irritation which has given rise to it. 113. But there is a fundamental truth, to which Brous- sais has not called attention; viz. that the acute or chro- nic irritation of any tissue or organ, may be succeeded by astheny of this tissue, or organ, whether the local or sympathetic signs of irritation persist, or cease with it, and that the sympathetic phenomena of irritation may continue after the irritation itself has disappeared. Thus when we observe a mixture of the morbid phenomena of strength and weakness, we must not only trace them to the primitive irritation, which has produced them, but likewise determine whether the irritation persists with them, or has ceased; or, finally, whether it is replaced by astheny of the organ, in which it was seated, or of any other organ. This I conceive to be the fundamental principle which 40 INTRODUCTION. should guide the pathologist in the study of irritation and its consequences, and the practitioner in the treat- ment of disease. M. Lallemand has lately given an admirable demon- stration of this pathological view.* 8. Of Sub-ex citation, or Astheny. 114. Astheny is the state of an organ, in which the action is below the degree necessary for the maintenance of life. This morbid state, though less frequently pri- mitive than irritation, and less capable of producing dis- organization, should not be studied less carefully than the latter. 115. General astheny is as rare as local astheny is com- mon. The former, however, occurs at the termination of many mortal diseases; but then, whether primary or se- condary, it is irremediable. In almost all diseases, we observe a secondary local astheny. A person suffering is ordinarily but little disposed to motion, and even when he desires to move, his muscles slowly and incompletely obey his will, or, if they are brought into action, they determine irregular movements, on account of some mus- cles contracting more feebly than others. But this as- theny and this muscular spasm are the effect of an ir- ritation, whose influence propagates itself to the brain. 116. The muscles are not the only organs, which ex- hibit this apparent weakness. The same diminution of function may occur from the affection of any organ, which is irritated. Consequently, we may admit, for the sake of distinction, an astheny of function, and an asthe- ny of nutrition, or of molecular action. The first is * Cinquieme Lettre sur l'Encephale, Paris, 1830. INTRODUCTION. 41 generally a symptom of an irritation, and rarely the ef- fect of the second. 117. The distinction, which we have just established, it is not always easy to make in practice; but, as astheny has hitherto been more frequently imagined than studied, this distinction will not be without utility. 118. The astheny of an organ is the effect, 1st, Of the diminution or of the complete and pro- longed abstraction of the stimulants, which act habitually upon it. 2d, Of the diminution of the exciting influence which the organs exercise over each other. 3d, Of the excessive stimulation of an important or- gan, the slightest alteration of which is opposed to the continuance of action, in its usual degree, in all the others: this organ then acts exclusively for the interest of its own preservation, if we may express ourselves thus; its nutritive action is exalted, although its sympa- thetic functions languish. 119. A slight astheny gives rise to no morbid pheno- mena; whatever be its seat, it is always of short dura- tion. If frequently repeated, it may give rise to irrita- tion of an organ, which sympathizes with the affected organ. 120. Intense astheny is characterized by loss of co- lour, flaccidity, and want of heat in the tissue in which it occurs, and by a sort of insensibility; the functions of the tissue diminish in activity or cease entirely. 121. When astheny is very marked in character or prolonged in duration, it is often observed that a tran- sient irritation suddenly replaces it, and immediately disappears, determining the complete extinction of vital action in the part, (gangrene.) 122. Primitive astheny cannot determine chronic dis 6 42 INTRODUCTION. organization, except in subjects naturally very irritable, in whom the circulatory action is accidentally languid; in individuals of this constitution, slight irritation, often inappreciable, occurs from time to time, and favours dis- organization, or the slowness of the circulation alone pro- duces it. 123. Astheny, consecutive to irritation, is a frequent cause of disorganization, it is to this we must refer the production of accidental tissues, possessing an activity inferior to that of the parts in the midst of which they are developed. By alternating with irritation, it deter- mines the formation of accidental tissues without analo- gy in the organism, tissues in which irritation ultimately predominates, and becomes permanent, giving rise to ul- ceration. 124. The stomach itself may fall into astheny: M. Broussais gives to gastro-intestinal astheny, the name of adynamic languor of the digestive passages. 125. Gastric asthenia should be studied with care, were it only because of its power of determining gastri- tis. Indeed, in this viscus, as in the organs of sense, as- theny, the consequence of a defect of stimulation, is promptly followed by an exaltation of sensibility. But if the absence of all stimulation continues, the excitabi- lity ultimately becomes exhausted; the organ becomes insensible, if it be one of those which transmit external impressions to the brain; death occurs, if it be the sto- mach, either from want of materials, or because the gas- tric mucous membrane ceases to communicate to the brain the impressions, without which the latter organ cannot act. These impressions are more immediately necessary than the nutritive materials, since the admi- nistration of a stimulating drink excites cerebral action INTRODUCTION. 43 more than the most nourishing substances, which are not of a stimulating nature. 126. It is only astheny of the brain, of the spinal marrow, of the heart, the lungs, and the stomach that can directly occasion death. 127. If the astheny of an organ excite irritation in it, the former ceases as soon as the latter is established; there is no asthenic irritation any more than there is ir- ritative astheny: for, we repeat it, astheny of nutrition must not be confounded with astheny of function. 128. It is not more easy to distinguish astheny of the nervous filaments from that of the vessels, than it is to distinguish their irritation; that of the lymphatic capil- laries is not more distinct, for, if paleness and a relaxed state of en bon point, seem to announce it; these symp- toms appear to be referrible to one of the shades of as- theny of the lungs rather than to any other cause. 129. Astheny of the arteries appears to have little in- fluence, if we consider that they are but instruments, which are nearly passive, in the circulation. In the veins, astheny is better characterized; it is recognised by varices, by violet spots which form under the epi- dermis, by the blue tint of the skin; but what occurs on the skin, does not always take place in the mucous mem- branes, which are frequently in a state diametrically op- posite. 130. Astheny of the heart produces different effects, according as it occurs in the arterial or venous side of this organ.—There results syncope, dropsy, or scurvy, according as the weakness is chronic or sudden. 131. It has for a long time been believed that hemor- rhagy without manifest signs of irritation, was the effect of astheny of the capillary vessels: in this case it is ne- cessary that the heart should preserve a force of impul- 44 INTRODUCTION. sion, superior to the force of resistance of the capilla- ries. Even here the hemorrhagy does not establish it- self, except after the occurrence of a slight irritation, which, after having determined the presence of a great- er quantity of blood, leaves the part in a state of astheny. 132. Morbid fluxes in general are never occasioned solely by astheny of the capillary vessels, unless it be at the instant of death: we, however, often observe the sweat to cease on the approach of death, although the weakness must then be more considerable than at any former period. 133. We are led to believe, that astheny, like irrita- tion, may be intermittent, but many researches remain to be made on this important point of doctrine, which the reformed theory of intermittent fevers cannot but elucidate. 134. In general, astheny continues but a short time, because man has recourse to stimulants of every kind, when he experiences its first symptoms, until, finally, he suddenly or gradually exhausts his excitability, by a stimulation too violent, or too often repeated. 135. The astheny of an organ renders it more ac- cessible to the causes of irritation, as well as all the other organs, even when they do not participate in its weakness. This fact, worthy of remark, is one of those which no one contests; but we must not from this con- clude that the irritation which supervenes in a debili- tated organ or subject, is astheny. 136. M. Broussais, struck by the incontestable fre- quency of irritation, shows himself too exclusive in con- sidering astheny only a consequence of sur-excitation in an important organ. If he grants that primitive as- theny contributes to disorganization, he denies that it occurs in fevers, which prevents his attempting to disco- INTRODUCTION. 45 ver the cases, in which stimulants may be employed with success in these maladies. 9. Of Organic Action, considered with Relation to Therapeutics. 137. Since diseases are only organic irritation, or as- theny, always primitively local, never uniformly extend- ed over the whole organism, and often co-existing; to cure them, it is necessary, after having distinguished the irritated and the weakened organs, to stimulate the lat- ter, and to debilitate the former, in such a manner, as not to exasperate the morbid state of the one, in attempt- ing to calm that of the other. Especially, we must not indulge the chimerical hope of increasing excitability in an absolute manner; we can only regulate organic ac- tion, which is exalted in one part and depressed in ano- ther. When excitability is positively diminished, no- thing can restore it to its primitive state. On this sub- ject, the Brunonians have shared to a certain point the error of the alchymists; the latter, sought the divine arcanum which should prolong life, while the former be- lieved they had found in opium, wine and bark, specifics, to prevent its extinction before the latest period allowed by nature. 138. When a disease manifests itself by phenomena, which extend to several organs, we must endeavour to recognise the organ, whose lesion gives rise to that of the others, for the purpose of determining whether it be proper to debilitate or to strengthen it, to increase or diminish its vital activity, with a view to cause the dis- appearance of the sympathetic phenomena, whatever may be their nature, whether they appear to announce 46 INTRODUCTION. force or weakness in the organs in which they manifest themselves. 139. The first rule in therapeutics is to remove every morbific cause still acting, and to prevent the applica- tion of others. 140. Irritation may be combatted by diverse means, which are all effieacious, when they are judiciously ap- plied, and of which none should be prescribed indiffer- ently in all cases of irritation. 141. To reduce action in an irritated organ, we must, in the first place, reduce the number and energy of the stimulants, which habitually act upon it, and then dimi- nish the sum of the materials which enter into the com- position of the organism, always by diet, often by phle- botomy, sometimes by arteriotomy. The indications afterwards, are, to diminish the quantity of blood which traverses this organ, by the abstraction of blood from its capillary vessels, or from those which are nearest to it; 2dly, To place it in contact with substances called refrigerant, emollient, or narcotic. 142. If the organ be so situated that we cannot hope to take away blood directly from its capillary vessels, we must not neglect to practise this operation on the organ which is nearest to it: diet must be insisted upon, and frequently venesection must be resorted to. Refrige- rants, emollients, and narcotics must be applied to the skin, or the mucous membranes. 143. To these means, which constitute what is pro- perly called the anti-irritative method, otherwise deno- minated the antiphlogistic, should frequently be added the employment of irritants, placed in contact with a tissue, more or less remote from the irritated organ. These irritants are, first, rubefacients, vesicatories, and escharotics, applied to the skin; secondly, emetics and INTRODUCTION. 47 purgatives, fixed and diffusible stimulants, and tonics applied to the mucous membranes. These means belong to the derivative method, when the organ to which they are applied, is not the irritated organ. 144. There are cases in which the direct application of stimulants, tonics, irritants, rubefacients, vesications, and even escharotics, causes the cessation of the irrita- tion by accelerating, or by preventing the consequences. This constitutes the disturbing method, (methode per- turbatrice.) In the internal organs, especially, it is al- most always dangerous, either in its immediate or its re- mote effects. 145. When irritation is intense, the anti-irritative me- thod alone is suitable. 146. When by this method, the intensity of the irri- tation has been diminished, or wThen it is slight, the de' rivative method is often very advantageous: but if we mistake the degree of irritation, if the principal organs are very excitable, and particularly the heart, the brain, or the mucous membranes; if we produce an action which is too violent, or too near the diseased organ, the irritation increases in place of diminishing; or instead of a single irritation, we often have a second, sometimes more serious than the first. 147. If we consider how high a degree of excitabili- ty is possessed by the mucous membranes, the facility and promptitude with which their irritation disturbs the organism, and occasions the disorganization of their tis- sue, we will perceive the necessity of being very re- served in the employment of the disturbing method in treating the irritation of these membranes, and even of the viscera in their vicinity. These means are not to be used except with a caution which should never be re- garded as timidity. Since Hecquet, Chirac, Baglivi, 48 INTRODUCTION. Rega, Van Swieten, Pomme, and so many other obser- vers have exposed the fatal effects of the abuse of these means in the treatment of internal irritations; since the anatomical labours of M. Prost have confirmed the state- ments of these high authorities;—finally, since M. Brous- sais has demonstrated what these authors discovered, it is no longer allowable to administer empirically these powerful agents, in every case in which the weakness of the muscular system seems to indicate their use. 148. Yet the disturbing method has been employed externally with incontestable success, and this has led to the presumption that it may sometimes be resorted to in- ternally with advantage, with the exception of rubefa- cients, vesicatories, and escharotics, which, however, some physicians do not hesitate to prescribe in this man- ner. This presumption is converted into certainty by a small number of facts, which have hitherto been badly interpreted. 149. Intermittent irritation should be treated accord- ing to the same principles as continued irritation, but during the intermission, we may apply to the organ sti- mulants, which prevent the return of irritation, and we even sometimes cause its disappearance, by applying sti- mulants to the organ at the instant when it is irritated. This last case is analogous to those in which the same means cures a continued irritation: experience, however appears to demonstrate that in certain internal intermit- tent irritations, we may resort to this method in prefe- rence to any other to save the life of the patient.* This * This passage, which dates from 1823, is a reply to those persons, who whether with bad or good intentions, criticize without reading, and impute absurdities to authors, whose success annoys them: it is time that prejudice and ignorance should cease to accuse us of being ignorant of the results of experience in the treatment of intermittent diseases. INTRODUCTION. 49 peculiarity forms no exception to the principles which have just been laid down. 150. The rules which govern us in the treatment of irritation, are those which we should follow in the treat- ment of astheny, which depends directly on irritation; but when it is primative, when it persists after the irri- tation, when it menaces the life of the patient, in con- sequence of the seat which it occupies, it claims the at- tention of the practitioner and presents special indica- tions. 151. After removing as far as possible every thing that might increase or keep up astheny, we must add to the mass of materials which enter into the organism, or renew them by the use of good aliment cautiously given, if the patient has been on an unwholesome or slender diet, we must restore the stimulants of which the organ has been deprived, and apply to it medicinal substances, stimulants and tonics, commencing with small doses, and gradually augmenting them. When the organ cannot be placed in contact with these therapeutic agents, we ap- ply them to the skin, or the mucous membranes, that the impression produced, may be propagated to it. When we act upon the skin, we frequently have recourse to rubefacients, vesicatories, and escharotics. Adventu- rous practitioners do not fear to employ internally, sub- stances which are not less active, and the effects of which are often fatal. 152. We may act upon several organs at a time, even when the weakened organ is so situated that nothing pre- vents our acting directly upon it. We may even have recourse to the stimulation of several organs, when as- theny appears to extend to the whole organism: we must then, however, avoid the parts which might be suscep- tible of irritation, under the influence of stimulants. 7 50 INTRODUCTION. 153. In the direct administration of these means, we must never forget that a weakened organ is often very accessible to the influence of the causes of irritation, and that what is employed under the title of a medicine, may become a destructive agent, particularly when applied to the mucous membranes; for we generally run very little risk in stimulating, even very energetically, the skin. 154. When it is proposed to stimulate a weakened or- gan, it is important to inquire whether there be not in some other part of the organism, some irritation which may be sympathetically increased; we must particularly avoid applying stimulants to a part which is already ir- ritated, or has formerly been so to a high degree or in a permanent manner. 155. Stimulations, of too active a kind or too often repeated, exhaust the excitability instead of reviving it, when they do not excite irritation. 156. The preceding remarks relate to the direct anti- asthenic method, local or general. The direct treatment of irritation, in consecutive astheny, constitutes the indi- rect anti-asthenic method, opposed to the derivative me- thod of irritation. 157. Should the success of this method be considered as proving that the irritation of one organ depends some- times on the astheny of another, the conclusion would be just. In certain cases, indeed, a cure is effected only in consequence of the strengthening of a weakened organ: this is what occurs, when at the commencement of an at- tack of fever, occasioned by the impression of cold, the fever is made to cease by heating the skin. But the case is different when to cure an irritated organ, we stimulate another organ, whose action is in no respect weakened: in this case there is a real derivation. 158. Astheny has not hitherto been studied in each INTRODUCTION. 51 organ. It is desirable that this important point should be made a subject of research: we should then discover to what point the intermittent astheny of an organ may contribute to the production of periodical diseases; and we should know whether every alteration of texture is dependent entirely upon irritation, as is thought by some pathologists, or is entirely independent of it, as others believe; the elucidation of these points would throw light upon the therapeutics of these maladies, which are as yet abandoned to empiricism. 159. If acceleration and slowness of organic action, if irritation and astheny, never resulted in any thing more than disturbance of function, the principles which have just been laid down would suffice for all cases of dis- ease which could present themselves. But to the afflux, which is the effect of irritation, to the congestion which follows astheny, often succeed profound alterations in the texture of the organs. 160. These alterations may, in my opinion, persist af- ter the irritation or astheny has ceased. These two mor- bid states frequently return and alternate with each other in the affected organs. It is then necessary to show what course the practitioner should pursue in a case, the treat- ment of which is so difficult and inefficacious, and may so readily prove injurious. 161. Unequivocal signs of irritation frequently accom- pany alterations of texture; vital action often appears to be in no respect deranged in the organ affected; more frequently, however, its functions are languid, of what- ever nature the derangement of vital action may at first have been. Often, after the lapse of an indefinite peri- od, high irritation occurs in the altered tissue, and death is the consequence. 162. Since most of the alterations of texture develope 5% INTRODUCTION. themselves under the direct or sympathetic effect of sti- mulating causes, it is proper, in most cases, to oppose to them the means appropriate to the treatment of irritation: this is often requisite even when every thing appears to announce the astheny of an organ. We should here re- call the distinction, established between astheny of func- tion, so often consecutive to irritation, and astheny of nu- trition, so unfrequent in general, although it is more com- mon in chronic than in acute diseases. But it is not upon the anti-irritative local method that we must insist: re- gimen, derivatives, and sometimes stimulation of organs, very near the affected one, constitute the means to which we must have recourse, with the precaution of discon- tinuing our measures, as soon as the signs of irritation reappear or increase. It is remarkable that in a small number of cases, this irritation is renewed with advan- tage, provided it be for a very short time, and be prompt- ly remedied by the anti-irritative method. 163. In the treatment of alteration of texture, the lo- cal treatment rarely suffices to act efficaciously, upon the diseased organ; to renew its composition it is necessary in some sort, to renew the composition of the whole or- ganism. 164. It must not hence be concluded, that the mani- fest local lesion is connected with a general latent lesion; but only that we cannot act profoundly upon the nutri- tive action of an organ, but by acting upon that of all the others; since to effect this end, it is necessary to mo- dify chylosis and hematosis, and to excite in diverse or- gans a sur-excitation which occasions the diminution of local irritation, to which the alteration of texture is al- most always primitively to be referred 165 General organic lesions, then, exist no more than general vital lesions: there is, however, this difference INTRODUCTION. 53 between organic and vital lesions, that in the latter, it is often sufficient to act upon the diseased organ, while in the former, it is almost always necessary to act upon several points of the organism at the same time. 166. There are, it is said, general diseases, since cer- tain maladies are occasioned by an alteration of the blood, as a general lesion of the nervous or sanguine system. What are these diseases? what are these alterations of the blood? are these alterations unconnected with a pri- mitive state of the organs? and, in the first place, what is the normal state of the blood? Until these questions have been answered, we must adhere to what we know of the organic solids, rather than have recourse to ima- ginary hypothesis, concerning the fluids which they con- tain. As to general lesions of the nervous system, are there any which do not commence by a nervous filament or by one of the centres of this system? Who denies the generalization? But who does not know that it can- not be primitive in an assemblage of so many parts, sub- jected to influences, all differing from one another. As to general lesions of the vascular system, there is no proof that they are ever completely so; in proportion as it is uncommon to see them apparently primitive, so is it frequent to see them secondary. We disavow no fact of humeral pathology, whether nervous or vascular; but wish to establish a science of diagnosis and indications, based upon some rare facts, some groups of symptoms, separated from their antece- dents, and some autopsic examinations: this is to make a system, and to act in the very manner which our adver- saries so strenuously reprobate; this is to rush into dark- ness, while they applaud themselves as alone possessed of light. Let us study the physiology and pathology of each or- 54 INTRODUCTION. gan, and classify under each organ the facts which be- long to it: if we discover any thing positive with regard to the blood, or any other of the fluids, let us refer it to the physiological and pathological history of the organs which elaborate and carry them. If this natural course were adopted, the deficiencies of our knowledge would be perfectly apparent, and would be remedied as science advanced. 166. From the general remarks which have been made we may conclude, 1st, That every disease is local; 2dly, that every disease is, primitively, an irritation or an as- theny; 3dly, that these two morbid states may co-exist in the same subject in different organs; 4thly, that they may succeed each other in the same organ; 5thly, that to treat diseases successfully, we must go back to the ir- ritated or weakened organ, whose influence is felt by the economy; which organ it is generally necessary to debi- litate, though sometimes to stimulate, directly or sympa- thetically; 6thly, finally, that intermittent diseases and alterations of texture should be treated according to the same principles as continued acute diseases, with the ex- ception of the modification which results from their more or less rapid progress, their degree of danger, the inter- mission which permits us to act in the absence of the disease,* or the profound and permanent shock which the texture of the organ has sustained. Besides these rules for the treatment of disease, we may mention those happy and indescribable inspirations, which belong to consummate experience and a rare degree of skill; inspi- rations, which should never be erected into rules, and whose results should not be opposed to those of general observation. * Journal Universelle des Sciences Medicales, tome 7, page 248. INTRODUCTION. 55 167. The art of observing, says Senebier, consists in penetrating the qualities of the subjects which we stu- dy, in tracing their effects, seizing their resemblances, and their differences, discovering their relations, and de- termining the cause of a given effect, from the different conditions of this effect, or its analogy to other effects. 168. Experience, says Zimmerman, is the knowledge of the art of curing, which is acquired from judicious observations, and experiments; it presupposes the histo- rical knowledge of its object, the capacity of remarking and distinguishing all the parts; erudition furnishes his- torical knowledge; the spirit of observation teaches us to see, and genius to draw conclusions. To have seen much, then, does not constitute experience; the simple inspection teaches nothing, nor yet is the attentive ob- servation of a fact what is meant by true experience: it is only a most happy organization, and a philosophical spirit that can qualify us to seek it in the works of the learned, and in the bosom of nature. 169. Theory is the knowledge logically arranged, of all the phenomena which we observe in the organs during life, and after death. A theory which should connect together the scattered facts of medical science, would render, says Darwin, men endowed with mediocrity of talent, capable of exercising the healing art; it would likewise render it possible to distinguish the true disci- ples of medicine, from those who have nothing in their favour but impudence and address: reflection is theory. 170. True practice is the exercise of the art of ob- serving and treating diseased organs, under the inspira- tion of knowledge and reflection. PHYSIOLOGICAL PYRETOL.OGY, At que herfele magna quSstio esse potest an non essentiales febres peculisrem affectfonem partium aliquarum internarum sequantur. Baillou. CHAPTER L Of Fevers in General. Pathological Anatomy has revealed the seat and nature of a great number of diseases, and, in many of them, its decisions have been incontrovertible; but autopsic examination does not always discover manifest organic alterations. Disease has been divided into two classes, of which one comprehends all the affections which depend on organic modifications, discernible after death, and the other all those which leave no sensible traces of their existence.* Nervous diseases and fevers have been comprehend- ed among the latter. To guide him in determining the nature and seat of a disease which terminates happily, or which leaves no trace after a fatal termination, the physician has the physio- logical analysis of the symptoms, the causes of the disease, and the effects of treatment. Thus, the study of the causes, the symp- toms, and the traces of disease, as well as of the effects produced by the therapeutic agents, and the comparison of these diverse phe- nomena with those of the organic modifications in a state of health, constitute the whole method to be followed in investigating the * Anatomie Pathologique, dernier cours de Bichat, Paris, 1825, in 8v&. 8 58 PHYSIOLOGICAL PYRETOLOGY. nature, seat, and treatment of disease. But this method should be applied in its whole extent; otherwise the knowledge acquired is imperfect, or our researches result in error. To seek the in- dications so fulfilled exclusively in the causes, the symptoms, the morbid traces, or the properties attributed in the schools to me- dicines, is to contract the field of observation, to abridge the data from which our conclusions must be drawn, and to reduce prac- tice to certain systematic or routine views. Considered in their symptoms alone, there are some diseases whose phenomena are so characteristic that we cannot fail to recognise their nature and seat. Such are pneumonia, coryza, pulmonary cataarh, &c. These diseases are few in number, and in some of their shades it is not always easy to determine the seat of the affection. There are other diseases whose symptoms have not hitherto led to a knowledge of their seat and nature, or ra- ther, whose symptoms, badly interpreted, have often led to mis- taken views as to their nature and seat. Among these are fe- vers, with the consideration of which we shall be exclusively oc- cupied. In the writings, which bear the name of Hippocrates, there is nothing resembling the manner of considering fever, which has been prevalent in latter times. When the Hippocratic school made use of the words, ws, vrvgeTot, they never intended to desig- nate a class, a genus, a species of disease, but only a symptom: viz. the burning heat of the skin;* and if they often employed these two expressions without particularizing the other symp- toms, it was because they naturally reminded them of most of those which ordinarily accompany the morbid heat.t It is only in the writings of Galen that the word wt^ros is used in the sense which the Latins have given to the word febris and which we have so long assigned to the word fever. Let it be remarked, that patients, and even physicians, use the latter word in the same sense in which Hippocrates employed the word we have just * Qai primi omnium medicinse initia et quasi fundamenta jacerunt, quam ipsi rudem adhuc et incultam rerum cognitionem haberunt, nomina morbis confixerunt, non ex rei essentia, cui primum et maxime medemur, sed ex eo quod serte primum occurreret. Fernel, 1656, in 4to, tome II. page 58. f If the word fever be still retained in the language of science, it is desira- ble that this signification alone should he attached to it OF FEVEP.S IX GENERAL. 59 mentioned. Thus, when a patient experiences heat of the skin, and when the physician observes this symptom, they both pro- nounce the word, fever, without attaching to it any other idea than that of the heat which exists. Hippocrates does not appear to have contemplated a division of fever, according to their symptoms, by the expressionsphricodes, lyngodes, lypyriennes, ardentes, et epiales, which occur so frequently in his writings; he did not intend to designate so many distinct species of fever. Nosologists have in vain endeavoured to refer these pretended species of fever to those which were known to them. * M. Broussais appears to have been ignorant that the father of medicine did not make of fever an entity, and that essential fe- vers are not to be met with in his writings. From Galen to the present time, most physicians have applied themselves particularly to the study of the diagnosis, the progno- sis, and therapeutics of fevers: some have more particularly oc- cupied themselves in dividing them into orders, genera, and spe- cies; and the paramount importance of determining their nature and seat has finally been recognised. The history of pyretology might then be divided into three parts, of which the first should comprehend symptomatic pyretology, the second, methodic pyretology, and the third, physiological pyretology. Thus, among physicians, some have laid the foundations of science by collecting facts; others have endeavoured to build up the edifice of science by connecting facts together according to their resem- blance; and, finally, others are persuaded that the only method which can conduct to a profound knowledge of fevers, and their most efficacious treatment, is to compare the patient with a man in health, and the febrile symptoms with the traces discernible in the organs after death; to seek for the organ in which resides the focus of these morbid phenomena, and to determine the means most proper to remedy the lesion of this organ. The utility of investigating the nature and seat of fevers has always been recognised; but physiology and anatomy were, in former times, too imperfectly understood to enable physicians to de- rive much advantage from researches of this kind, the prosecu- * Laennec; Propositions sur la Doctrine d'Hippocrate, relativement a la Medicine Pratique; Paris, 1804, in 4to, p. 19. 60 PHYSIOLOGICAL PYRETOLOGY. tion of which forms the distinctive character of the modern French medical doctrine, as presented by M. Broussais. Fevers are so numerous and so different in appearance that it would be impossible to give a general description of them. There is not a single derangement of function or of tissue, which may not be observed in some of these maladies. They have then no specific symptom or pathognomonic sign: the acceleration of pulse cannot be given as such, for it is present in diseases which are not fevers, and in certain fevers it is absent. We can, however, arrange under different heads the phenomena which we most ordinarily observe in fevers on account of their analogy, their frequent co-existence, their real or apparent de- pendence and their habitual succession. Thus, sometimes we observe heat of skin, force and frequency of pulse, extreme exaltation of sensibility, excessive irritability of certain parts, and even inflammation of some particular part: all those symptoms, in fine, which announce a well characterized re- action. Sometimes, on the contrary, the skin is cold, the pulse languid, the senses blunted, and the sensibility as it were annihi- lated; certain tissues appear no longer to react under the influence of stimulants: in a word, every thing appears to announce pro- found weakness. At other times we observe an embarrassing alternation of the phenomena which denote reaction, and of those which characterize organic weakness. This abstract view of the febrile symptoms has led to the esta- blishment of the following species of fever; viz. The inflammatory, sanguine, sthenic or irritative fever; syno- cha. The putrid, asthenic or adynamic fever; synochus. The malignant, nervous, ataxic or typhoid fever: febris atacta. But sur-excitation, prostration and ataxy do not manifest them- selves in a manner so uniform as these names seem to indicate. Sur-excitation is found at the commencement of most fevers, ataxy at the latter period of a great number, prostration at the termination of all those which prove fatal: these two last forms rarely occur without having been preceded by reaction, of greater or less duration. From the earliest times of medicine, it has been known that in OP FEVERS IN GENERAL. 61 fevers characterized by an intense excitation, this morbid state manifested itself by inflammatory symptoms alone, or by inflam- matory symptoms united to those which appear to announce a su- perabundance of bile and mucosities. The progress of observation has shown that excitation is sometimes more highly developed in the stomach, and at other times in the secretory apparatus, formed by the gastro-intestinal mucous membrane: this observation has led to the division of the fever of irritation, into, The inflammatory or angiotenic fever; synocha. The bilious, gastric, meningo-gastric fever: febris biliosa. The pituitary, mucous, adeno-meningeal; febris mucosa. Very observable differences in the symptoms and course of ty- phus have caused this fever to be considered as a remarkable va- riety of fever, adynamic and ataxic at the same time. With ataxie fevers have been classed the yellow fever and the plague or adeno-nervous fever. By the combination of these diverse denominations, it has been thought, that all the shades of febrile diseases could be indica- ted, or, as they are termed, the complicated fevers: hence, the name of inflammatory gastric fever, or causus of the ancients: gastro-adynamic fever, mucous ataxic fever, &c. When the symptoms of these fevers succeed each other, and pursue their course without complete interruption, they are called continued fevers. Most of them, at certain hours every day, or on certain days, augment in intensity, and the sufferings of the patient increases. This transient exaltation of symptoms has received the name of paroxysm or exacerbation, according as it is, or is not preceded by a rigour, followed by heat and sweat: the symptoms of reaction alone ordinarily undergo this increase of intensity. We likewise give the same name to the appearance of these symptoms, when at certain hours, or on certain days, fixed or indeterminate, they temporarily take the place of other symp- toms, instead of only surpassing them in intensity and mingling themselves, so to speak, with them. In those cases in which the paroxysms return at periods which are fixed, or nearly so, the disease continuing in the intervals which separate them, it re- ceives the name of intermittent fever. Fevers abandoned to themselves, or subjected to treatment, con- tinue during some days, often one or more weeks, rarely more 62 PHYSIOLOGICAL PYRETOLOGY. than a month and a half: if they continue for a longer time, they lose the name of fevers, and are referred to diverse chronic dis- eases. There are other fevers which last only for the space of one or more hours, cease for one or two days; return, cease again, re-appear at fixed epochs; and thus continue to appear by pa- roxysms, separated by intervals of health: these are intermittent fevers. These fevers terminate naturally or by the aid of art, after the occurrence of some attacks, or they pass into the con- tinued type, or they became suddenly fatal; or, finally, they pass into the chronic state, and are prolonged indefinitely: on this account, they have been divided into benignant, pernicious, and chronic. To these fevers must be added the hectic fever, which is at first intermittent, afterwards continued, and often remittent in its type. The hectic fever is the constant concomitant of a great number of hectic affections. Such have been the most general results of the exclusive study of symptoms; nothing connected with this subject has been neglected; their analogies and their differences have been subjected to an analysis more or less happy in its results. Every thing relative to the invasion, the type, the progress, duration, and termination of these diseases, has been noted with a diligence worthy of all praise; but the only manner, in which their proximate cause has been inves- tigated, has been by seeking for it in the humours, the principle of life, and the vital forces and properties. In the midst of these idle discussions, occasioned by researches so badly directed, the seat and nature of fevers remained nearly unknown. The connexion established by the ancients between symptoms and morbific causes, was based upon pure hypothesis. All re- searches with regard to that connexion, which physiology reveals and pathological anatomy confirms, has at length been neglected, despised, and even proscribed. The causes of each species of fever have been confusedly accumulated in the general description of the disease, without any attempt to determine upon what organs they primitively exerted their influence, or how this influence, always local at first, is propagated to a greater or less extent to the rest of the organism, according to the age, the sex or the predisposition of the individual. FEVERS IN GENERAL. 63 In consequence of this vicious method, nothing has been seen in fevers from their very commencement but irritation, ady- namy, and ataxy, invading the whole organism. No attention has been given to the important fact, that in most fevers, one part of the economy is generally in a state of manifest excitation, while the rest of the organism is languishing or suffering from a combination of excitation and weakness, difficult to ex- plain without the aid of physiology. On the appearance of the signs of prostration, those of excitation which have preceded them or which still continued, are immediately forgotten. Farther- more, every external local irritation, well developed, incontesta- ble, with some signs or even without any sign of reaction in the circulatory system, whenever it appeared, ceased, and reappeared, at fixed epochs, in the manner of the attacks which constituted intermittent fevers, has been regarded as a general febrile dis- ease, disguised under the appearance of an affection purely local, and according to this strange theory, has been established the genus of masked intermittent fevers. This is undoubtedly the most striking example of the abuse of analogy and the most forced of all the classifications attempted by the human mind. All this is to be attributed to the exclusive and superficial study of symptoms, to which too much importance has been as- signed, to a vicious and forced generalization of ideas, to the rejection of sound physiological reasoning; to the want of an etio- logy founded upon a just comparison of the phenomena of health and those of disease, to preconceived ideas of the nature and seat of fevers; to negligence in making autopsic examinations, to the indifference and even fear manifested with regard to this mode of investigation, in the case of fevers, and, to sum up all in a few words, to the separation of physiology, pathology, and therapeu- tics, and especially to the imperfection of pathological anatomy. The science of man is undoubtedly so vast that to facilitate its study it must be divided. But the result of this indispensable divi- sion has been, that each individual has confined himself tothat part of the science which best accorded with his peculiar turn of mind, or to the cultivation of which he had been led by circum- stances. The progress of one part of the science has been totally devoid of any beneficial bearing upon the advancement of the other parts. Errors have thus passed uncorrected; and, strange 64 PHYSIOLOGICAL PYRETOLOGY. to say, science itself has at last been considered as not only insuffi- cient, but even pernicious in the exercise of art. The greatest service rendered to medicine by M. Broussais is his having de- monstrated the necessity of a union of all the branches of the science of man. The progress which science has made since the promulgation of this grand idea, has induced many physicians to acknowledge that in the midst of this general disturbance, which, according to them, characterizes fever, every point of the economy is not equally affected; but they assert that the local affection which appears to dominate, and which most generally leaves unequivo- cal traces after death, is nothing but a dependent affection, a con- sequence or effect of the general affection, always primitive, which constitutes fever; as if hepatization of the lungs, observed in the dead body, were to be attributed to the heat of the skin, the force and frequency of the pulse, and the cough observed during life in the course of pneumonia. Pinel has rendered a signal service to science, in divesting pyretology of the antiquated theories in which facts had been bu- ried, and by continually directing the attention by his advice, by his example, in his writings, in his course and at the bed-side, to the observation of phenomena. By classing together in six dis- tinct groups the febrile symptoms which ordinarily manifest them- selves together, or in an order of succession little liable to change, he established six orders of fevers, the characters of which were more clearly traced than those of the different fevers admitted in the ancient schools. He has thus carried to its highest degree of perfection what he denominates nosographic pyretology. He has done more: he has endeavoured to refer some of these orders of fevers to the part of the body which appeared to be particu- larly affected in them. He would have advanced farther in the path of truth, which he himself had opened, if, not content with having given to fevers denominations founded upon certain ex- ternal appearances, and upon the signs of certain functional lesions, denominations which, he says, are by no means designed to ex- press the nature of these maladies, he had known all the impor- tance of an investigation of their seat; if he had devoted himself with ardour to this investigation, instead of presenting it as the object of a curiosity purely speculative; as a mere recreation of the FEVERS IN GENERAL. ' 65 mind, and as perfectly destitute of any practical bearing. At all events he has done too much to allow the reproach of not having done more. Since 1798, his pyretology has been in the hands of all the French physicians; it has been naturalized in Spain; the Hippo- cratic physicians of Germany have bestowed upon it merited praises; those suffrages are based upon the incontestable services which this learned professor has rendered to medical science, in perfecting the art of describing and classifying disease, rather than upon the actual merit of this production, which has suffered the fate reserved for every scientific work, after the lapse of a number of years. It still, however, serves either tacitly or avowedly as the basis of instruction in the school of medicine of Paris. A great number of physicians, who do not openly adopt it, have no other views on the subject of fever than those of Pinel. We may regard his book as the expression or summary result of most of the works, undertaken on the doctrine of fever, until the year 1814; but since that period pathology has made an immense progress, by its more intimate union with physiology, and by the progress of many branches of pathological anatomy. It is time to introduce into the body of science the researches which have been made during some years past with regard to the seat and nature of fevers. A physician who would present the actual state of pyretology should take for his point of de- parture the work of Pinel. Every other plan, in place of af- fording new light to the practical physician, and offering a faith- ful guide to the student, placed between two different doctrines, would only disturb the ideas of the one, and place the other in a painful state of uncertainty, or occasion an unjust contempt of one or other of the two doctrines, or even, what would be more dangerous, give rise to the opinion, that medicine has no fixed principles, and is only a changeable product of the imagination. In the remarks which have just been made, we have pointed out the object and plan of this book. I shall not confine myself to the province of the historian. I shall search for truth among the contending parties. Our object is not to advocate the views of particular professors, but to borrow from one his method of observation, and from another, his ideas upon the investigation of the affected organs, 9 66 PHYSIOLOGICAL PYRETOLGY. and the alterations which they undergo. The truth of this grand principle is no longer contested, we shall not therefore stop to demonstrate that we must no longer confine ourselves to the study of the invasion, the symptoms, the course, the type, and termination of fevers. The doctrine of sympathies presented by Hippocrates, disguised under the most fantastical forms by Vanhelmont, maintained with warmth by Bordeu, calculated by Barthez, developed and or- ganized by the genius of Bichat, united with pathological anato- my by Broussais, has conducted the latter to the establishment of the following principles: Every disease is primitively local; Like the phlegmasia?, all fevers are only local diseases; All fevers are the consequence of gastro-enteritis. * The first of these positions, and consequently the second, are incontestable; because, 1st. No morbific cause acts at the same time upon all the or- gans. 2dly. The symptoms never extend to all the organs. 3dly. The symptoms are never equally intense in all the or- gans. 4thly. In diseases which appear to be general, the disorder al- ways commences at a single point, whence it extends to others. 5thly. No disease, how general soever it may appear to be, leaves characteristic traces in all the organs. 6thly. After sudden death, an examination of the body ordi- narily shows, that the lesion of a single organ is sufficient to ar- rest the action of all the others. It should then be admitted, that all the diseases to which we give the name of fever are primitively local, and, by analogy, those which destroy life instantaneously, as apoplexy does, an affection which no one thinks of ranking among general diseases. * On this subject, M. Broussais expresses himself in the following manner; viz. When an organ is sufficiently irritated to light up fever, this effect is never produced except through the intervention of the united irritation of the heart and mucous membranes, and.particularly of the gastric mucous membrane." Journ. Univ. des. Sciences, Med. t. viii. p. 143. All the essential fevers of authors are to be referred to gastro-enteritis, simple or complicated." Deux. exam. 1.1, n. 34. FEVERS IN GENERAL. 67 But, in our opinion, all fevers are not to be attributed to gas- tro-enteritis, not even all those denominated essential, because, 1st The causes of fevers do not act solely upon the gastro-in- testinal mucous membrane. 2dly. Although this membrane often receives the direct or sympathetic influence of the febrile cause, in the former case, it does not always receive it alone, and in the second, it often re- ceives it only in a very feeble manner. 3dly. Every organ, being like this membrane, capable of act- ing sympathetically on the heart, the vessels, the lungs, and the organs of secretion, upon the nerves, the ganglions, the brain, the muscles, &c, can, in like manner, occasion the development of the symptoms which we name febrile. 4thly. It is frequently the case that a careful study of the causes, and an attentive examination of the symptoms, demon- strate that the gastro-intestinal mucous membrane is sound, or too slightly injured to warrant the assertion, that it has provoked the development of the malady. 5thly. Sometimes, we not only do not find any trace after death in this membrane, but we discover profound lesions in other parts of the body. To behold in fevers only an affection, sui generis, invading the whole economy, is totally at variance with the actual state of pathological anatomy, and physiology; but, I believe it is equally contrary to these two sciences, to lay it down as a princi- ple, that there is no fever without inflammation of the stomach and intestines. These two opinions, diametrically opposed to each other, are very widely spread, because they are exclusive; and, consequently, calculated to please superficial and enthusias- tic minds. It has been, and still is necessary to combat them. Between these two extremes, there are many other opinions, which I shall pass in review, and I shall point out those which appear to me to have the greatest semblance of truth. Such appear to me the principles upon which should be con- ducted the study of fevers, in an investigation of their nature and seat; that is to say, we should inquire what organs are af- fected in these diseases, and what lesion they-s«ffer, by a physi- ological analysis of the causes which determine them, the symp- toms which characterize them, and the traces which they leave 68 PHYSIOLOGICAL PYRETOLOGY. after death. This work is not devoted to polemical discussion; it is an exposition of what is taught with regard to the seat and nature of fevers, by phenomenology, etiology, physiology, and pathological anatomy: it is, in one word, physiological pyreto- logy; in the sense which I attach to this expression, I give this work to the public, with the desire that the practitioner may there find the means of comparing the results of his clinical la- bours with the actual state of pathology, and may be enabled to proceed to a new series of observations, calculated to confirm or combat the new principles. I likewise indulge the hope that it will prove a useful guide to students in their theoretical and prac- tical studies. A new era is commencing in medicine. The edifice of sci- ence is not to be rebuilt, but additions are to be made to it, and many parts, which time has destroyed, are to be replaced. It is to be desired, that each physician, anxious to contribute to the perfecting of the science of disease, should make himself mas- ter of a portion of the ancient pathology, compare with it the observations, of his predecessors and contemporaries, and there- suits of his practice, arrange the whole according to the lights furnished by the most recent progress of pathological anatomy, and physiology, and present the facts of which we are possessed, in a manner corresponding to the actual state of the medical sci- ence. INFLAMMATORY FEVERS* 69 CHAPTER II. Of Inflammatory Fevers. The words, nvfetos f &vex»js, so often repeated in the works that bear the name of Hippocrates, do not indicate an inflammatory fever, in the sense assigned to this expression at the present day, but only a state of continued burning heat. It was only after the lapse of time, that the name synocha came to designate the species of fever, in which the inflammatory phenomena predo- minate over all the others, and appear to extend to the whole or- ganism. It has been denominated in succession, synocha or continued, simple or not putrid, continent, sanguine, in- flammatory; it afterwards received the name of angiotenic. M. Recamier has given it the name of the sthenic hematosic fever. If we collect all that has been written upon the symptoms and causes of this disease, we shall obtain the following description: the invasion of inflammatory fever is ordinarily announced by one or more of the following phenomena; viz., general malaise, hea- viness, flushing of the face, nasal hemorrhages, dizziness, verti- go, heat in the chest, palpitations, increase of appetite, succeed- ed by inappetence, a sensation of weight in the abdomen, con- stipation, interruption of the menses, of the hemorrhoidal flux, ardor urinae, painful weight in the loins, dryness of the skin, and a sense of fulness, tension, and painful swelling of the abdominal extremities, when the patient is standing. This state lasts one or more days, sometimes a week or more. The invasion is almost always sudden, even when it has been announced by precursory signs. The subject suddenly expe- riences towards the end of the night, or in the morning, a rigor, which is sometimes slight or almost imperceptible, promptly followed by heat of the skin; this heat, which is habituous and mild to the touch, seems to diminish under the pressure of 70 PHYSIOLOGICAL PYRETOLOGY. the hand. The face is red and vultuous, (vultueuse,)* and the turgescence sometimes extends to the whole body, the surface of which sometimes presents a rosy tint; the eyes are brilliant and tearful, the conjunctiva injected, the eyelids tense and painful, the patient is troubled with dizziness and vertigo: objects appear of a red or very bright colour, a bright light offends the eyes, slight noises fatigue the ear, the nostrils are dry, the sense of smell becomes obtuse. A painful heaviness is felt in the head, particularly at its anterior part, and along the spine. The pa- tient is prostrated, he sleeps little, and his sleep is interrupted by sudden waking and troubled by dreams; at other times, there is a state of somnolence; the intellectual faculties are sometimes dis- turbed; the extremities are, as it were, benumbed, or slight con- vulsive movements are perceived in them. The tongue is white or red, particularly at its point, and on its edges, always moist in the commencement, and when the disease is not very intense, the lips are dry, and there is a disagreeable taste in the mouth; sometimes there is thirst, slight nausea, and sensibility at the epigastrium; at other times, the patient complains of none of these symptoms: there is sometimes inappetence, sometimes a marked disgust for food, two states we must not confound; or- dinarily, there is constipation. The pulse is generally large, full, strong, accelerated and rebounding; sometimes soft and concentrated, when the patient experiences intense pain in some part of the body; the carotid and temporal arteries often beat with force, and the veins are swelled; respiration is frequent, hot, and quick, without being painful. The urine is small in quantity, and of a deep red colour in the commencement of the disease; afterwards it is more abundant and turbid, and deposites a lateritious sediment These symptoms, which are never all observed at once, are more intense during the evening and night, than in the morn- ing. After having lasted during twenty-four hours, two, three, four, seven, or fourteen days, they gradually diminish, without the occurrence of any evacuation; or there supervene general sweats, hot and abundant, hemorrhage from the nose in young persons, from the vulva in women, or from the anus in persons * This word is used to indicate the state of the face when it is red, and apparently swelled. INFLAMMATORY FEVERS. 71 subject to hemorrhoids; an abundant flow of urine, with or with- out white sediment; sometimes mucous sputa; more rarely, co- pious dejections of matters resembling grounds; recovery then takes place in a few days; it occurs almost suddenly after a he- morrhage. Convalescence is short and relapses unfrequent. This happy termination is not the most frequent; more ordinarily, many of the symptoms are observed to increase in intensity, to such a degree as to call for all the attention of the physician, and the disease is prolonged beyond a week, or even two weeks. It is then said that the inflammatory fever is complicated with a local inflammation, if there appear unequivocal signs of an afflux of blood, or of a phlegmasia in the head, the chest, or the abdo- men, or in the skin, or the cellular tissue of the extremities, constituting apoplexy, arachnoiditis, encephalitis, angina, pleu- risy, peripneumony, pericarditis, carditis, aortitis, angiotitis, hepatitis, gastritis, enteritis, nephritis, cystitis, an exanthem or phlegmon. When the augmented intensity, and the symptoms which su- pervene do not appear to announce one of these inflammations, it is said that the inflammatory fever is converted into agastric, adynamic, cerebral, ataxic, ataxo-adynamic, yellow, typhoid or pestilential fever, according to the character of the predomi- nant symptoms. The inflammatory fever then terminates in health or it changes its name, and it is thus that it is said never to occasion death but when it determines the inflammation of an important organj or is converted into another malady. Practitioners recognise three varieties of inflammatory fever; viz: 1st, Ephemera, the symptoms of which have little intensity, often terminates without evacuation, sometimes by a slight per- spiration, a simple moisture of the skin, by fecal discharges or an inconsiderable hemorrhage, after having continued 20 hours, 1, 2, 3, 4, days or more; 2dly, Synocha or inflammatory fever, properly so called, the symptoms of which are very strongly de- veloped, and which does not terminate without an evacuation, either occurring spontaneously or produced by art, and which lasts one or two weeks; 3dly, grave synocha or inflammatory fever, in which the pulse seems depressed at the same time that 72 PHYSIOLOGICAL PYRETOLOGY. it is hard, the limbs are benumbed, the prostration is extreme, and the tongue dry and brown. These varieties are only shades or degrees, or the result of the extension of the same malady. It is proper to mention them, but it would be irrational to confine to this division our analysis of the symptoms of inflammatory fever. These three varieties of inflammatory fever differ not only as it regards intensity of irritation, but as it regards the seat of dis- ease. In one of them, for example, the third, the heart is more strongly affected than in the two others; perhaps it is even in- flamed in this variety, whilst in the two others, and particular- ly in the first, it is only irritated, strongly sur-excited. Inflammatory fever is most frequently sporadic, but it may likewise affect a great number of persons at one time, in the sea- sons and in the countries which favour its development, and thus become epidemic or endemic. With regard to the prognosis, we must say with Pinel, that it is always favourable, with the exception of the cases in which the symptoms increase in intensity in any particular point of the organism, in such a manner as to threaten a phlegmasia, or such a violence of febrile reaction as may occasion death. For a long time the manifestation of the symptoms of inflam- matory fever was attributed to a superabundance of the blood, or only of its red part, to the friction of this liquid against the walls of the vessels, to a spasm of the small vessels of the skin, or to tension of the vascular fibres. At the present day there is but one opinion with regard to the nature of this fever. All agree that the phenomena which characterize it, depend upon a sthenia, an excitation, an irritation, an angiotenia, a hyperemia, or an inflammation, synonymous words, which designate an excess of vital activity in the affected part or parts; whence arise, exalta- tion of sensibility, pain, acceleration of pulse, the temporary sus- pension of some secretions and augmentation of others, weakness or oppression of muscular force. We shall not here stop to exam- ine how well founded are the arguments of the physicians who admit an essential difference between the irritation which deter- mines an essential fever, and the inflammation which o-ives rise to a symptomatic fever: what is to be said upon this subject will more properly find its place in the chapter appropriated to INFLAMMATORY FEVERS. 73 the comparative study of the essential and symptomatic fevers. Another course could not be followed without giving rise to repetitions on the occasion of each fever. If there be a general agreement with regard to the nature of the lesion, which gives rise to the symptoms of inflammatory fever, this harmony does not equally exist with regard to the seat of this lesion. Some physicians, judging from the aspect of the patient superficially examined, think that the lesion occu- pies the totality of the body, although there is not always, and in every part, an augmentation of action, since the secretion of urine is at first suspended, the muscles contract with difficul- ty, the pulse is sometimes soft, concentrated, and small, and the cerebral functions less active. Many physicians, while they admit a universal irritation, ac- knowledge that it is more manifest in the sanguine system, consi- dered in a general manner; others limit it to the arteries, some to the heart, some to the great vessels, many to the sanguine capillary systems. It is considered by some as involving the whole circu- . latory system, but the general and uniform irritation of all the organs is not less chimerical than the temper amentum tempera- turn. M. Broussais asserts, that it occupies, primitively and specially, the mucous membranes, particularly the gastric mucous membranes. M. Alard places it in the skin and sub-cutaneous cellular membrane.* " Synocha," says Brown, " is nothing else than a phlegmasia, composed of a sthenic diathesis, insufficient to light up an inflam- mation, and of a pyrexia; what is peripneumony, rheumatism, or any other phlegmasia, but a synocha, with a diathesis sufficiently strong to produce an inflammation?" "What," says Tomasini, " is synocha, but a slight degree of phrenitis, of angina, or of rheu- matism?" Reil attributed synocha to an exaltation of the irrita- bility of all the sanguine vessels, arterial and venous, with integrity of action. In the epidemic of Nantz, Bagard proved by post mortem ex- aminations that the prevalent inflammatory fever was but a peri- carditis. J. P. Frank ascribed inflammatory fever to irritability and augmented action of the heart and arteries. In violent inflam- *Du Siege et de la Nature des Maladies. Paris, 1821. in 8vo. tome II. p. 28. 10 74 PHYSIOLOGICAL PYRETOLOGY. matory fevers, with extreme agitation of the heart and vessels, he remarks, " We have, for the first time, observed a deep and inflammatory redness on the internal surface of these vessels, and even of the whole venous system; we have had many op- portunities of showing, under the same circumstances, partial phlogosis, commencing with the aorta." In the pathological part of the article Heart, of the Dictionnaire Abregt des Sciences Medicates, I made the following remarks in 1821, viz.: " The irritation of this organ has hitherto been described un- der the name of simple fever, of inflammatory fever, or epheme- ral synocha; it is found in the highest degree in synocha, pro- perly so called, and in all the fevers characterized by the symp- toms of an acceleration of the circulatory movement" M. Bouillaud, in his interesting Treatise on Diseases of the Heart, published in 1824, does not hesitate to say that there almost always exists an irritation more or less considerable of the aorta, when- ever a fever of an extremely violent character is developed, but that in this case it is not only the aorta, but the entire circulatory system, and the heart itself, that partakes of the irritation. He has observed the red ramollissement of the heart, after graver fe- vers of a very violent character. M. Bouillaud thinks that the seat of inflammatory fever is in the system of the heart and sanguine vessels.* " This disease consists essentially," says he, " in an in- flammation or simple irritation of the circulatory apparatus; it bears the same relation to this apparatus in general, that a local phlegmasia does to the sanguine capillaries of the organ in which it is seated: the latter is, so to speak, but a local fever, while the former is a general one. What proves, according to him, that this comparison is correct, and that the facts in these two cases are identic, is, that the former in the majority of cases, is derived solely from the extension, the generalization of the latter, that is to say, it is a local phlegmasia, which has become general, either through the intervention of sympathy, or in some other manner; whence he concludes, that inflammatory fever is nothing but fever, properly so called, considered in a general and abstract manner. M. Bouillaud has examined with much care the red- ness presented by the internal surface of the heart, the arteries, * Traite Clinique des Fievres. Paris, 1826, in 8vo. chez J. B. Baliere. INFLAMMATORY FEVERS. 75 and the veins, in an extent more or less considerable; he regards them as appearances peculiar to inflammatory fever, either simple or complicated, with some other phlegmasia. " As to the altera- tion of the blood in inflammatory fever, we only know," says he, " that blood taken from the veins, is hotter, thicker, and more co- agulable than in health; that it is almost immediately covered by a grayish or whitish crust, of variable thickness, and known by the name of the inflammatory crust To support these opinions, he cites three cases, in which the subjects, having presented symp- toms of inflammatory fever, there were found traces of phleg- masia in the heart and aorta, in the first and second; in the heart, the arteries and the veins, in the third. But the first presented, likewise, traces of meningitis and bronchitis, and the lungs were gorged with blood; the second presented traces of pleuropneu- monia; the stomach and duodenum, as well as the small intes- tines, exhibited traces of inflammation in the third. There is no doubt that inflammation of a part of the sanguine vascular system, particularly if it be of any extent, may give rise to the phenomena of inflammatory fever. But it cannot be denied that these same phenomena may be produced in a subject, pos- sessed of exquisite sensibility, or of great vascular energy, by a local inflammation of slight intensity, and very limited extent, by the mere propagation of irritation to the heart, without the existence of a real phlegmasia during life, and without the ap- pearance of redness after death, in the irritated part of the vascular system. Nor is it at all necessary that irritation should extend itself gradually until it reaches the heart. Through its nervous connexions, it may be sufficiently excited to beat more frequently than in its ordinary state. According to M. Andral, the red tint presented by the inter- nal surface of the heart and the vessels, in subjects who have fallen victims to continued fevers, has nothing to do with the production of any of these fevers; it does not even contribute to the production of any of their symptoms; this red tint is found indifferently at the termination of all diseases, after those accom- panied by fever, as well as those unattended by it; it should be considered as a phenomenon belonging to the dead body, the more or less rapid production of which depends on certain con- ditions, which may all be resolved into a single one: the ten- 76 PHYSIOLOGICAL PYRETOLOGY. dency of the body to a more or less rapid putrefaction.* Fur- thermore, M. Andral has only six times observed the redness of the heart in eighty-six subjects, who had died with all the symp- toms of grave fevers. M. Bouillaud has found this alteration eleven times in forty-nine examinations; as it respects the ves- sels, their redness is mentioned by M. Bouillaud eight times in the same number of cases. M. Louis found an unusual redness in the heart, three times, and in the aorta twenty times in fifty- four subjects.! From the circumstance of this redness being observed after various diseases with or without fever, M. An- dral concludes that it is unconnected with a morbid state. Yet, when we consider that it has been found eleven times in thirty- two cases of organic lesions of the heart, it is evident that the tendency to putrefaction does not account for it so clearly as he appears to think. The vivisection of animals during acute ma- ladies, attended by fever, is indispensable to the solution of this problem. Researches of this kind are the more desirable, since M. An- dral, notwithstanding the very decided language of the proposi- tions, which we have just cited, has since declared, that the red- ness of the heart might occur during life, and be connected with an active or passive afflux of blood to this organ. He was con- vinced of this by the examination of horses, affected during the epizootic malady, in 1824; and which he opened immediately after they were killed. MM. Dupuy and Boulay had previ- ously made similar observations; and it may be observed, that this redness did not present any very marked difference from that produced after death, by exposing the heart of a horse to the air or sun. Furthermore, M. Andral found a lively redness of the internal membrane of the right cavities of the heart, in a subject who had died after symptoms of pericarditis, such as sudden attacks of suffocation, palpitations, &c.; in another, after having presented symptoms of hypertrophy of the heart; and, finally, in others, who, affected with disease of the heart, had died in the midst of an exacerbation, which had suddenly su- pervened. It is evident, therefore, that M. Andral was in er- ror, when he asserted that the redness of the circulatory passages * Clinique, 1830. f Recherches Anatomique. Paris, 1829, in 8vo. chez J. B. Balliere. INFLAMMATORY FEVERS. 77 always took place after death. His critique of the opinion of M. Bouillaud, went beyond the truth.* M. Andral asserts, in the same work, that inflammatory fever often seems to recognise no other point of departure than blood too rich in fibrine; that this fever is often only an effect of a ge- neral sanguine congestion of the gastro-pulmonary mucous mem- brane. It is proper that the ideas of this author should be mentioned; they are remarkable for the uncertainty which characterizes them, and which forms a singular contrast to the solidity of his anatomical labours. According to M. Gendrin, the examination of those who have succumbed in inflammatory fever, or fallen victims to a grave phlegmasia which it has determined, discovers in every case, or- gans more or less affected in their structure, most frequently the lungs, and very frequently, also, the gastro-intestinal mucous membrane are the organs which suffer. It is farther necessary that there should be a large and very complete collection of facts, to enable us to decide whether the whole sanguineous system can in reality be inflamed; it will then be proper to inquire what point of this system is the focus of in- flammation. The only principles, which, in our opinion, can be laid down upon this subject, are the following, viz.: the more hard, full, frequent, and quick is the pulse, the more reason is there to suspect inflammation of the right cavities of the heart, and of the large arterial trunks; when to these phenomena, we see succeed those which have been designated under the name of false adynamic fever, without symptoms of gastro-enteritis, wc have reason to suspect that the inflammation extends over the whole heart, that it has become more profound in the tissue of this viscus, or even that it extends to a part of the venous sys- tem, according to the opinion of M. Ribes, who supposes ady- namy to depend on phlebitis. It is difficult to pronounce in a positive manner upon this point of doctrine, on account of the limited number of facts possessed by each observer. When a greater number of facts shall have been accumulated, caution will be necessary, lest we fail to no- tice organs inflamed simultaneously with the heart and vessels. * Precis d'Anatomie Pathologique. Paris, 1830. 78 PHYSIOLOGICAL PYRETOLOGY. This, at least, is certain, that there are inflammatory fevers, in which one part only is affected, whilst in others, especially in those which reach a very high degree of intensity, the irritation extends to many organs, as has been very judiciously remarked by Reil: this is easily proved by an analysis of the causes and symptoms of inflammatory fever. An abundance of blood, rich in fibrine, is one of the circum- stances most favourable to the development of the irritation, more or less extended, which determines the diverse morbid states, collectively designated under the name of inflammatory fever. It is caused by an excess of alimentation, or by the pre- dominance of the lungs, which is recognised by the florid com- plexion and skin, the amplitude of the chest, and the force and fulness of the pulse. The fulness of the capillary vessels of a single organ, is also a circumstance favourable to the development of the irritation which produces synocha. This primitive local plethora is often found in subjects who are considered weak and languishing, be- cause they are pale and thin. It is in these subjects that we find cerebral plethora, when they apply themselves assiduously to study, or when they suffer from mental anxiety; pulmonary- plethora, when the structure of their chests, and the confirma- tion of their lungs predispose them to it, particularly if they in- dulge to excess in the pleasures of venery. Abdominal plethora occurs in persons, and particularly in infants, who eat voracious- ly and make use of too substantial a diet; uterine plethora in girls who have not yet menstruated, and in women, at the pe- riod of the cessation of the menstrual discharge. Secondary lo- «al plethora is observed when persons, who are habitually in a state of general plethora, accidentally stimulate one of their or- gans. The circumstances which prepare, favour, or determine the development of the irritation which constitutes synocha, are the following viz., youth and adolescence, periods of life at which the blood is more exciting, and the tissues more excitable, the pe- riod of puberty in boys, and particularly that of the commence- ment of menstruation in girls, the suppression of hemorrhages, and habitual evacuations, natural or artificial, which gives rise to an accidental plethora, or prevents its removal; prolonged INFLAMMATORY FEVERS. 79 watching, excessive study, mental disquietude, which acts upon the brain, and causes a continual afflux of blood to it; prolonged and rapid running, singing, and crying aloud, which strongly ex- cites the organs of respiration; the impression of substances which strongly stimulate the digestive passages, or any other part of the mucous membranes; the sudden cooling of the skin when it is hot and moist, which necessitates a vicarious action in the mucous membranes; insolation, and every thing capable of irritating the skin; the sudden disappearance of affections of this tissue, which, according to the experience of all times, influences the internal organs; finally, wounds, contusions, and all mechanical lesions, which divide, tear, or irritate the skin, the cellular tissue, the parenchymatous structure, the membranes, the muscles and the bones. None of these morbific causes, predisposing or occasional, are the result of an action which affects the whole of the body. The predisposing causes reside in the sanguineous system; they result from a nutrition, operated by digestive organs, endowed with too great rigour.—If general plethora be developed in this case, it cannot be said that it is in consequence of a gastritis; for the stomach is not excited beyond its physiological condition, as long as its functions are performed without embarrassment, pain or languor. Besides, general plethora alone is never capa- ble of determining synocha; it is necessary that an afflux towards some particular organ be established, for these symptoms to ma- nifest themselves; it is necessary that the equilibrium be de- ranged, from which health results, and this equilibrium cannot be deranged but by a great natural excitability, or the acciden- tal sur-excitation of an organ. Now, it will be seen, on the slightest reflection, that the occasional causes which have just been pointed out, act upon some organ in particular. All the organs being connected with each other, and with the heart, by means of vessels and nerves, the morbific impression acts first upon an organ, which sometimes communicates it, as it has just been remarked, to the centre of the circulation; and sometimes to another organ, through which it is transmitted to the heart. In these two cases, the organ primitively affected, often ceases to be so, after having transmitted the morbific influence to an- other; the same thing sometimes occurs in the case of the organ 80 PHYSIOLOGICAL PYRETOLOGY. which has secondarily received this influence, so that the circu- latory system appears to be, and sometimes in reality, is alone affected in these instances; and this has occasioned the seat of the affections, confounded under the name of inflammatory fever, to be placed in this system. Sometimes the morbific cause seems to affect more especially, the lining membrane of the great vessels, and this is one of the causes in which the circulatory system is alone affected; but it would be incorrect to have in view only such cases, which per- haps are not so common, as they are thought at the present day, which moreover are but little known, and which do not exclude the morbid state of another tissue. When the stomach has received, primitively or secondarily, the impression, and it ordinarily receives it simultaneously with the heart, on account of its intimate connexion with all the other organs, it retains it in part even when it influences the heart and sets it in motion. It is then often affected in synocha, but this is generally to a very slight degree, and it would be very wrong to pay exclusive attention to it, because there would be a risk of overlooking the morbid state, often more important, of other organs. An examination of the patient, proves, according to M. Brous- sais, that the capillaries of the skin, those of the cellular tissue and of the articulations, are not in a state of phlegmasia. If they were, we should have, he remarks, either the symptoms of ery- sipelas, or those of the other cutaneous phlegmasia, or of phleg- mon in general, or the signs of rheumatism or gout. Such is the error, into which all pathologists fall, who deny the exist- ence of inflammation, unless when the symptoms are so evident, that it would be folly to dispute them. It may be admitted, that in inflammatory fever, there is not precisely what is called erysipelas, phlegmon, rheumatism or gout. But in certain in- flammatory fevers, caused by insolation, or by a forced, or rapid, or long continued march, it is evident, that there is intense irri- tation, even inflammation, of the skin, the sub-cutaneous and inter-muscular cellular tissue, and the articulations; since the skin is red, hot, and painful, especially when touched; since there is a sensation of heat in the articulations, which are painful, es- pecially when the parts which form them are put in motion. INFLAMMATORY FEVERS. 81 M. Broussais, forgetting that it is the part of the pathologist to seize the most fugitive shades of irritation, asserts that in in- flammatory fever there is no sign of inflammation of the brain, the chest, the peritoneum, the liver, the spleen, the kidneys, or the arteries: he is correct, if he refers to the signs of inflamma- tion ordinarily recognised by authors. But the irritation of the digestive mucous membrane has not exclusively the privilege of confining its development to the obscure degree, which suffices to determine the phenomena of inflammatory fever. The same authors, who have overlooked the slight shades of gastritis and enteritis, have likewise overlooked those of the phlegmasia?, or, if the expression be preferred, of the irritations of the other vis- cera, and M. Broussais himself is chargeable with this oversight. The description of inflammatory fever, given by nosologists, is not very favourable to his opinion: for we there find few symp- toms, which can be referred to gastritis, or enteritis, while we observe very marked symptoms evidently attributable to irrita- tion of the encephalon, the uterus, the muscles and articulations. In vain might M. Broussais assert that this irritation, how ma- nifest soever it may be, is but the index of a latent gastric irri- tation: this would be to subordinate what is evident to what is to be demonstrated. We assert that nothing demonstrates that the inflammatory fever of authors is always a gastro-enteritis: 1st, because there is not, in all inflammatory fevers, thirst, red- ness of the point and edges of the tongue, epigastric sensibility and pain, which are the unequivocal signs of gastritis; 2dly, be- cause anorexia does not constantly exist in this fever, and even if it always existed, it alone could prove nothing, for simple in- appetence is not an infallible sign of gastritis; 3dly, because the cephalalgia in synocha often exhibits other characters than those of the cephalalgia produced by inflammation of the stomach; 4thly, because the contusive pains and the inaptitude for exer- cise in the locomotive muscles may depend on encephalitis as well as on gastritis. When redness of the edges and point of the tongue, a disgust for food, and thirst occur, there is undoubtedly gastritis; but it remains to be decided whether the irritation of the stomach is primitive or secondary. M. Broussais affirms too positively that encephalic irritation always determines that of the digestive vis- 11 82 PHYSIOLOGICAL PYRETOLOGY. cera. It is well known to all practitioners that gastric irritation very frequently gives rise to encephalic irritation. If it be im- portant in all diseases to know the organ primitively injured, it is no less useful to discover it in the case under consideration. In what manner can we resolve our doubts when a number of viscera appear to be irritated in inflammatory fever? By an at- tentive study of the organic predisposition of the subject, his idiosyncrasy, and the mode of action of the morbific causes, to which he has been subjected, as well as of his morbid predispo- sition, at the moment they acted upon him. In this manner we shall be enabled to decide what organ received the first mor- bific impression, to what organ it has been transmitted, and, finally, what organ has received and retained it. We shall know in this manner what is the painful mobile, (douleroux mobile,) to use the language of M. Broussais, which produces all the symptoms by its more or less extended influence over the orga- nism. The circumstances in which the subject has been placed, previous to the invasion of the disease, will indicate in some sort, the progress of the morbific action; the symptoms will indicate the part in which this action is fixed. We have just seen, that among the causes of inflammatory fever, some act particularly upon the brain, some stimulate the muscular system, and the articulations, some accelerate the ac- tion of the lungs, and that there are some, which actively irri- tate the stomach or the skin. These causes do not always confine their influence to the or- gans upon which they specially act; for example, a violent fit of grief may not affect the brain so violently as to throw it into a state of disease, while nevertheless it affects it sufficiently to give rise, through it, to a sympathetic gastritis. In this case the organic predominance, the peculiar morbid predisposition, final- ly, the nature and seat of the symptoms, which are most intense, will be sufficient to enable us to recognise the organ, in which the morbific influence has definitively fixed itself: if it be neces- sary to discover the organ primitively affected, it is not less im- portant to know the organ which is most affected. In most of the inflammatory fevers, we find force, frequency, fulness, and quickness of pulse, and a halituous (halitueuse) heat of the skin. These symptoms, which indicate that the irritation INFLAMMATORY FEVERS. 83 has been transmitted to the centre of the circulatory system, are generally more easily recognised, than those which indicate the organ or organs principally affected: they are the expression of what is denominated general reaction, and the result of the connexion which associates all the organs with the heart and ar- terial system. These are the symptoms which have given rise, sometimes, to the opinion that this system alone was affected in synocha, and at other times to the belief that there was a lesion of the whole economy in this disease. But the arterial system does not constitute the whole of the economy, and even when it is the first to manifest its morbid state, it would be wrong to conclude that it was the first affected, or it will be necessary to admit that peripneumony, when it is first announced by symp- toms of a lesion of the arterial system, is nothing else than sy- nocha. When the symptoms which denote irritation of the heart and the arteries appear to exist alone, it is, at least most generally, because the point which has suffered, is not sufficient- ly affected to occasion very marked local symptoms, although suf- ficiently so, to excite the action of the heart When these symp- toms cease promptly, before we are able to discover in what or- gan irritation commenced, as sometimes happens in ephemeral fever, we can have little reason to lament our ignorance on this point, since the disease is benign and its duration short. But when the local irritation arrives at a certain stage, it is impor- tant to recognise its seat, and this is easily accomplished. If the encephalon retain a large share of the irritative morbi- fic action, the eyes are red, tearful, and sparkling; the patient cannot bear the light; there is tensive pain over the whole extent of the cranium, or only along the sinuses, before and behind, and particularly at the temples; the temporal arteries beat with such force as to be audible to the patient; the face is red, or it becomes red and hot by sudden flushes, and there is tinnitus aurium; the ears are affected with a sense of fulness; the nose is dry, and its internal membrane more red than ordinary. The pulse is quick and full, and has but little frequency, the tongue is white, the appetite is gone, there is no thirst and no disgust for food. After three, four, five, or six days, these symptoms diminish; a nasal hemorrhage frequently supervenes. If the irritation continues, all the symptoms are exasperated, and the in- 84 PHYSIOLOGICAL PYRETOLOGY. tellectual faculties become troubled: but in this case, in the medi- cal language of the present day, the disease is no longer syno- cha, but a cerebral ataxic fever; or, if the symptoms of encepha- lic irritation predominate, and are so manifest that they cannot be mistaken, the disease is an encephalitis or a meningitis. The augmentation of the intensity of the cerebral symptoms can only announce an increased intensity of the internal morbid state, and not the development of a different disease. This re- flection applies to the following shades of synocha. Plethora, conjoined with the stimulating action of excessive atmospheric heat, one of the principal effects of which appears to be the acceleration of the pulsation of the heart; the active stimulation of this viscus by a copious repast, although it may not give rise to irritation of the stomach; a vivid mental emotion, the effect of which, not being confined to the brain, exercises a special influence over the heart, and finally the energetic excita- tion occasioned by the plethora, resulting from the ligature of an arterial trunk, are all circumstances which influence the heart in a particular manner. This organ beats with more force and frequency than usual; the pulse is quick, frequent, large and strong, flushes of heat are experienced in the head, the chest, and the abdomen: the patient suffers from a sense of general fulness, oppression, and stupor. The heat of the skin is augmented; it is neither pungent nor halituous, (halitueuse,) the tongue pre- sents no change, there is no thirst and no disgust for food, but simply a want of appetite. This state continues one, two, three or more days, unless some other organ, besides the heart, be- come irritated in such a manner as to add to the stimulation of the latter organ. A slight perspiration generally announces the termination of a disease, which presents the most simple aspect of fever, under which it has ever been described. Authors have designated this state by the name of the effect of fulness of blood, when it supervenes after the ligature of a principal artery. When this slight carditis is not owing to the contraction of the arterial system, the attempt has been unsuccessfully made to dis- cover the organ, the irritation of which provokes the develop- ment of these symptoms, because the obvious idea, of examining the heart, does not present itself. Galen perceived the impor- tant part which this organ performed in the manifestation of the INFLAMMATORY FEVERS. 85 febrile symptoms, for he defined fever in the following manner, viz: an extreme heat developed in the heart, and extending thence over the whole body. When the irritating causes have exercised their influence in the first place on the stomach and intestines, or when they have extended their influence to these viscera, without involving other organs in the irritation; in one word, when the stomach and intestines are primarily or secondarily irritated, we observe intense thirst, a redness of the edges of the tongue, disgust for hot drinks, and for food, particularly of a rich kind, a sense of weight and pain at the epigastrium; at least, when pressure is made upon this part. To these local symptoms are joined the following sympathetic ones: a hard, quick and frequent pulse, a lancinating pain above the orbits about the frontal sinuses, con- tusive pains in the joints and in the limbs; a pungent heat and dryness of the skin. This state lasts from two to four days, or is prolonged till about the seventh day, unless some remedial measures are resorted to. A favourable termination is announced by a diminution of the symptoms, by a discharge of urine, a diarrhoea, a sweat, and sometimes by a nasal hemorrhage or the appearance of hemorrhoids in individuals who are subject to them. But more generally, from the third to the fourth day, we observe the supervention of the symptoms of gastric, ady- namic, or ataxic fever, which will be treated of in the following chapters, or those of gastritis as described by authors of the last age. When a slight bronchial irritation, or an inflammation of the lung of little intensity, gives rise to the symptoms common to all synochal fevers, we recognise the organ principally affected by the embarrassed respiration, the shortness of the inspirations, the sense of heat referred to the chest, and by the sudden and transient pains in the sides of this cavity—pains to which the patient pays but little attention, unless when questioned; and, finally, by the cough which recurs from time to time. The pulse is frequent, large, full, often soft, the skin presents a hali- tuous heat A slight perspiration, or a copious sweat, announces the termination of the disease, which rarely persists longer than three or four days, without manifesting unequivocal symptoms of bronchitis, pneumonia, or pleurisy. Under the name of milk fever has been designated the ephe- 86 PHYSIOLOGICAL PYRETOLOGY. meral synocha, which arises from irritation of the mammae, af- ter delivery, when these organs, stimulated sympathetically by the uterus, begin to secrete milk. The swelling of the mam- mas, which become hard and sensible to the touch, the heat, op- pression, and even pain experienced in these parts, sufficiently indicate the organ, whose irritation excites the contraction of the heart, and gives rise to symptoms of synocha. Gastric irritation often accompanies that of the mammas, but it is generally of lit- tle intensity. Synocha, occasioned by irritation of the uterus, is character- ized by a sense of weight in the lumbar region, whence the pain extends into the hypogastrium and the vagina; by a distressing weight about the uterine region; by pruritus in passing the urine; by rigors returning at intervals, and followed by a disagreeable sense of heat, which from the abdomen extends over the whole body, and particularly to the head; by a numbness of the thighs, and of the inferior extremities, which are sometimes painful, and by somnolency. To these symptoms are united a full and bounding pulse, the tongue often presents no change; there is no appetite, although there does not exist a disgust for food; there is little or no thirst; the skin is hot and moist The menstrual discharge, or a metrorrhagy, more or less abundant, often a copious sweat, or a discharge of sedimentous urine, sometimes a nasal hemorrhage announces the termination of this state, which only continues six or seven days, and frequently terminates before the fourth. The symptoms sometimes assume an intensity, which prevents all mistake as to the existence of metritis. An irritation of the kidneys, or of the internal membrane of the bladder, may give rise to an inflammatory fever. We re- cognise the first by a sense of weight in the lumbar region, by repeated rigors, by the suppression or the scantiness of the urine, by the painful and repeated discharge of urine, which is voided in small quantities at first, but afterwards copiously, and sometimes carries with it calculi. The signs of the second are tensive pain in the hypogastrium, a continual desire to pass the urine, a painful and repeated discharge of it, which is passed in but small quantities. This last species of synocha terminates sometimes by the discharge of abundant mucosities by, the ure- thra, and oftener by a copious sweat. INFLAMMATORY FEVERS. 87 When the skin is more irritated than any of the other organs, it is hot and of a rosy colour; it appears swelled or raised by the subjacent cellular membrane; pressure occasions uneasiness, and even pain in it; it is at first dry and rough, and afterwards co- vered with an abundant and hot sweat; the patient experiences a disagreeable sense of tension, on the surface of the body, as well as in the head. The pulse is very quick and frequent; the urine is scanty in the commencement, and abundant when the skin returns to its normal condition. A diaphoresis gene- rally announces the termination of the disease. The inflammation, and the pain in the articulations, in the muscles, in the parts divided by any instrument of violence, or by a surgical instrument, sufficiently indicate the seat of the ir- ritation, which occasions the acceleration, the frequency, and. quickness of pulse in the synocha, which accompanies con- tusions and wounds, or is occasioned by a forced march, a resi- dence in a damp or cold place, the influence of which is princi- pally felt by the synovial membranes, and the fibrous and muscu- lar tissues. The synocha produced in this manner, continues as long as these causes continue to act; it ceases with them, and may be prolonged several weeks. The irritation, may, also, by in- volving a number of organs, give rise to the phenomena of gas- tric and other fevers, as we shall show in treating of traumatic fever. It is deemed superfluous to point out, in this place, the signs which announce that an inflammatory fever is caused by oph- thalmia, laryngitis, otitis, hepatitis, splenitis, pericarditis, &c. It would be necessary to pass in review all the inflammations: there are some which it would be impossible to mistake at the first glance. Others, are too obscure to be distinguished before they have attained such a degree of intensity, that the disease loses the name of inflammatory fever, or they do not generally develop themselves but in conjunction with a more important ir- ritation. Where the conviction is thoroughly entertained of the neces- sity of discovering the organ whose irritation is the principal source of the symptoms, with a view to prevent the conversion, as they say, of the-inflammatory fever into a more grave one 88 PHYSIOLOGICAL PYRETOLOGY. or into a dangerous inflammation; in other words, to prevent the aggravation of the primitive inflammation, or its extension to se- veral important organs, nothing will be neglected that may con- duce to the success of this investigation; the difficulty of which is peculiarly great in the case of infants, owing to their incapaci- ty to describe their feelings. I have observed the symptoms of inflammatory fever in two infants at the breast, one of whom was suffering from otitis, and the other from cystitis. I did not recognise the first of these diseases, until after the discharge of a puriform matter from the external auditory passage. The painful and repeated discharge of urine induced me to suspect the second, all doubts of which were entirely removed on observing the little patient whom I .attended with M. Regnault, pass by the urethra a false mem- brane, and a turbid whitish urine. The child affected with oti- tis, incessantly tossed his head on the pillow; and always endea- voured to lie on the affected side; but my attention was not drawn to this symptom until after the discharge from the ear. I had directed the application of leeches to the temples of this infant, considering the symptoms as derived from a cerebral ir- ritation. Leeches had been applied to the abdomen of the other, and he had been several times plunged into an emollient bath. They both recovered. Should it be remarked that I have just described the first ef- fects of encephalic, gastric, or bronchial irritation, and not in- flammatory fever, I should reply that no pyretologist would re- fuse to recognise the inflammatory fever in these cases of disease, which nature every day presents to our eyes; as could readily be demonstrated by a reference to the cases collected by P. For- rest,* F. Hoffman,t Pinel,$ and M. Recamier.§ M. Navieres states, that in 1802, there prevailed, during the autumn, an epi- demic inflammatory fever, in the commune of St. Martin des Champs, near Mantes. Whenever this disease attacked subjects of a bilious or phlegmatic temperament, or those, who being of * Observ. et Curat. Med. Paris, 1650, in 8vo. t Opera Omnia, Geneve, 1748, in folio, vol. ii. p. 106, 115. \ Medicine Clinique, Paris, 1815, in 8vo. p. 19. $ F. Aygaleng, Dissertation sur la Fievre Angiotenique, Paris, an. viii. in 8vo. INFLAMMATORY FEVERS., 89 a sanguine temperament, or suffering under the suppression of a hemorrhage, had been bled once or twice, the following symp- toms were observed, viz: headache, more or less acute, beating of the temporal arteries, tearful eyes, animated face, a moist tongue, white or red; general lassitude of the limbs, pain in the loins, an halituous or moderate heat, a pulse full, strong and well developed; red urine, insomnolence, no perceptible exacer- bation, cough without expectoration, deafness, diarrhoea with colic; from the fifth to the sixth day, no headache, but a heavi- ness of the head. The case was different in the instances in which blood-letting had not been practised; to the preceding symptoms were joined the following, from the tenth to the fifteenth day; face puffy and erysipelatous, pulse small and concentrated, moderate heat or a dry skin, slight delirium, drowsiness, dryness of the tongue, ardent thirst, complete deafness. One or two bleedings, prac- tised at this period, according to the constitution of the in- dividual, sometimes calmed the symptoms; but where the ir- ritation of the vascular system was extreme, either in conse- quence of the suppression of an habitual hemorrhage, or of inju- dicious treatment, (repeated purgation, wine, rich soups,) the disease assumed a third period, marked by the following symp- toms, viz: tongue covered with dry and grayish black scales; oppression, furious delirium, pulse small and concentrated, par- tial sweats, sometimes obstinate constipation, and meteorism; aphtha?, face bloated and pale, a circumscribed redness of the cheeks, when there is a complication of pneumonia; the neck and one of the arms, very large, tense, shining, erysipelatous; paroxysm in the evening, during which the face was animated and the delirium still more furious. The patients asked for cider, apples, cheese, answered with propriety questions addressed to them, but in the most laconic manner: they frequently wandered from the subject, and it was necessary to repeat inquiries very often before an answer was obtained. In these cases the disease did not terminate until from the thirty-first to the thirty-seventh day. Sometimes, at the com- mencement of convalescence, there supervenes a phlegmasia, such as an inflammatory swelling of the side of the face, or a perip- neumony. This epidemic attacks indifferently all ages and sexes. 12 90 PHYSIOLOGICAL PYRETOLOGY. Of 554 inhabitants, 150 were affected. M. Navieres lost an in- fant two years of age on the thirteenth day, a boy of seven years on the thirteenth, a girl of nineteen on the sixtieth day, and a woman aged 57, on the fifty-second day. This disease had car- ried off from thirty to forty persons in the preceding years. He employed blood-letting from the commencement of the attack, when the subjects had suffered a suppression of an habitual he- morrhage; at the second period repeated blood-letting sometimes did not arrest the progress of the disease. The drink was acidu- lated barley water, sorrel water, veal or chicken water, infusion of mallows, nitrous whey, occasionally a light decoction of tama- rinds. Emollient lavements were prescribed. In the second and third period, any diluent nitrous emulsion, pediluvia, and wine and water at the termination. A single time, sinapisms and blis- ters were employed; it was in a case of suppressed diarrhoea; the chest and the brain were threatened; the patient lay for the space of half an hour without exhibiting any sign of life.* It is to be regretted that no post mortem examinations were made in the few cases of fatal termination. This account is ne- vertheless interesting, particularly in consequence of the care with which the author has marked, in the exposition of the symptoms, the influence of the treatment upon their appearance and their intensity. If from the general description of this epidemic we descend to the description of particular cases, to which we would refer the reader, the first presents us with an irritation of the bronchia, which in consequence of a purgative, extended to the stomach and intestines; the second, an irritation of the bronchia, of the stomach, and the arachnoid membrane; the third a gastro-bron- chial irritation; the fourth, a gastro-arachnoid irritation, and a fatal pneumonia; the fifth, a gastro-bronchial irritation; the sixth, a fatal gastro-enteritis; the seventh, an entero-bronchitis; the eighth, a similar irritation of greater intensity; the ninth, an enteritis; the tenth, an inflammation of the stomach, of the pe- ritoneum and the bronchia; finally, the eleventh an entero-bron- chitis. It must not be forgotten that this diagnosis is founded upon a statement of cases necessarily incomplete, since, at that * Dissertation sur une Epidemie de Fievres Inflammatoires, Paris, 1804, in4to. INFLAMMATORY FEVERS. 91 period, the obscure shades of these inflammations were not known; which probably occasioned many of their characteristic phenomena to be passed over unobserved. Were I to enter upon a detailed analysis of the cases collected by Hoffman, by Stoll, and by Pringle, it would be easy to de- monstrate that in every case there was a predominant irritation of one or more organs. Sometimes, says Pringle, we do not remark that one part is more affected than another; we only per- ceive some general symptoms of inflammation, and we then call the disease simply, inflammatory fever; although in these cases it is probable that some of the more indolent parts of the sys- tem are inflamed. The diverse irritations of little intensity, the phenomena of which I have been pointing out, are not always isolated. The irritation of the heart occurs in all inflammatory fevers, whatever may be the organ primitively irritated; very often gastric irrita- tion coexists with it, and, in many cases, the irritation of the en- cephalon manifests itself at the same time. Then the fever presents the greatest number of symptoms, which have been assigned to it, as pathognomonic signs. The cardiac irritation gives no ground for apprehension, except as it may provoke, keep up, or increase the irritation of another organ; but even in this case, there is still an organ to which the physician must more particularly direct his attention, and it would be as dangerous as irrational, to combat only a general irritation, that is to say, blind- ly employ the antiphlogistic treatment. It remains for me to point out the relative frequency of the principal irritations which may give rise to the phenomena of these fevers. The digestive apparatus being most exposed to morbific causes, because of all the causes of disease, the most frequent are those which depend upon food and drink, and because most of the causes which act upon the skin, act sympathetically, by preference, upon the digestive mucous membrane, gastro-enteritis is most generally the proximate cause of inflammatory fever in adults. The case is not altogether the same with infants, and it is still less so with women. Among the first, the head is not less frequently affected than the stomach, perhaps it is even more frequently the seat of irritation. Among women, and particularly among young girls, the uterus is the organ most frequently af- 92 PHYSIOLOGICAL PYRETOLOGY. fected. During adolescence, the chest is the part most liable to be affected. In young persons, who are devoted to the study of the sciences, which require exercise of the brain, and who are not exposed to the putrid miasms of anatomical rooms, the ence- phalon is the part from which the irritation is radiated. Among subjects who have an energetic heart and a well developed arterial system, the centre of the circulation is the principal point of irri- tation. In winter and in cold countries the mueous respiratory membrane is most frequently affected, and the digestive appara- tus during summer, and in countries which are dry and hot, hot and damp, or cold and damp. The inflammatory fever is endemic in dry and elevated coun- tries, and on the mountains exposed to cold winds. It is rarely epidemic, that is to say, the epidemic irritations seldom preserve that degree of mildness and obscurity, which prevents the dis- covery of the seat of the affection, and which occasions the atten- tion to be given only to the sympathetic symptoms, common to all the inflammatory fevers. When, however, these fevers are epidemic, they are most frequently occasioned by gastro-enteritis, bronchitis, or pneumonia, and are frequently observed to assume the adynamic character. The investigation of the seat of inflammatory fever is with propriety insisted upon, because it is the most important point of theoretical and practical medicine. I consider myself justified in laying it down as a principle, that this fever, such as authors have described it, is nothing but the first scene, if I may so ex- press it, of all the primitive or sympathetic irritations, attend- ed with symptoms of irritation of the heart. What shall we say of that species of uncertain, general disease spoken of by authors, which, after having menaced a diversity of points, at last fixes itself upon a single one? It is evident that they have confounded a plethoric condition and sur-activity of the circulation, which predisposes to inflammation, with a posi- tively morbid condition, generally determined by a local cause of irritation, the action of which is favoured by the general con- dition of the economy. Besides, this predisposition is not so common as they pretend: most frequently it is the result of a local excitation, moderate, but yet sufficiently strong to give in- creased activity to the organic movement in a number of organs. INFLAMMATORY FEVERS. 93 It is not my object to study what is called the termination of an inflammatory fever by a phlegmasia, or, in other words, the augmentation of the local irritation, which manifests itself finally by symptoms so intense, that they can no longer be mistaken. I shall only remark, that this conversion or termination is a pow- erful argument in favour of my opinion of the nature of inflam- matory fever, and against the opinion of M. Broussais, and still more that of Pinel. The belief that the phlegmasias might complicate inflammatory fever, or that the latter might be con- verted into a local inflammation, is derived from the fact, that in the synocha, occasioned by gastro-enteritis, or by any other irritation, obscured by the extreme intensity of the sympathetic phenomena, we sometimes observe the supervention of well characterized pneumonia, encephalitis, metritis, or arthritis; that is to say, that to the inflammation which is called fever, because its nature and seat are unknown, there is joined an inflammation which is called inflammation, because its seat and nature are known. Among the diverse terminations of inflammatory fever, (and the sense I attach to this expression is now known,) there are several which I shall consider in the following chapters; it is of these that the gastric fever, the adynamic, the ataxic, &c. have been made. Treatment of the Inflammatory Fever. From all that precedes, the following conclusions result: 1st The inflammatory fever is only a primitive or sympathe- tic irritation of one of the points of the digestive or respiratory mucous membrane"; of the hair, the Uterus, the skin, of a joint, of some point of the muscular system, of one or more parts of the body, influencing the heart, or, finally, of the heart itself. 2dly. As this irritation often manifests itself by local symptoms little marked, he must study with great attention its causes, the idiosyncrasy of the subject, and the symptoms, to discover it in the midst of the sympathetic phenomena which it occasions. 3dly. Many organs may be sufficiently irritated to attract al- most equally the attention of the physician. 4thly. It is important to recognise the seat, more or less ex- tended, of the irritation which constitutes the inflammatory fever 94 PHYSIOLOGICAL PYRETOLOGY. with the view of opposing its development, and preventing what is called the termination of this fever by an inflammation, by ano- ther fever, or its complications. 5thly. In the treatment of this disease, regard must be had to the previous as well as the present condition of the patient, and the treatment, consequently, must be based on these two series of considerations; that is to say, that, to dissipate the local irritation which constitutes the inflammatory fever, it is necessary to direct our remedial measures especially against it, after we have corn- batted the predisposition which has preceded it. Whatever be the seat of this irritation, the treatment consists in repose, abstinence, blood-letting, emollients internally and ex- ternally employed, and derivations of the least irritating charac- ter. If the inflammatory fever were a general irritation of the vessels, my task would terminate here; at farthest, it would only be necessary to enter into some details, in relation to the great- er or less activity of the treatment, according to the intensity of the symptoms and the strength and age of the patient. But since the seat of the irritation varies, since each irritated organ affects the organism in a peculiar manner; since it is of impor- tance to ascertain the existence of encephalitis, angina, pneu- monia or gastritis, and since inflammatory fever may be occa- sioned by any of these, it becomes my duty to enter into details which formerly would have been superfluous. In the disease under consideration, there have existed pri- mitively an excessive alimentation and great activity of the sto- mach, the lungs, and the heart, or these conditions may not have existed. In the first case, whatever be the seat of irritation, a rigid diet and blood-letting are indicated. In the second, the diet may be less severe; and blood-letting may even be dispensed with in some cases in which the disease is of slight intensity. Blood-letting may likewise be dispensed with when the gastric mucous membrane is the seat of the principal irritation provided the cardiac irritation be not very intense. When blood-letting is indicated, it is not a matter of indiffe- rence whether it be taken from the neck, the arm or the foot- the seat of the irritation, if it be very intense, must decide this point We must bleed from the arm when the lungs, the pleura the peritoneum, the liver and the uterus are menaced; when the INFLAMMATORY FEVERS. 95 encephalon is the seat of irritation, blood must be taken from the jugular vein or the temporal artery, more frequently from the foot. We must bleed copiously, and not fear to repeat the ope- ration, if the hardness of the pulse continue, if it be vibrating, and particularly if it become small without ceasing to be hard, for in that case, there is ground to fear that the heart may be se- verely affected. After venesection, or where it is not thought necessary to practise it, if the irritation be intense or prolonged, the applica- tion of leeches, as near as possible to the seat of the disease, is indicated. We should say that it is always indicated, if experi- ence did not prove that we may often omit it with impunity, and that we may do so in every synocha of slight intensity; for example, rest and diet are sufficient in that which arises from ir- ritation of the mammas, when these organs are about to secrete milk. However, there are more inconveniences to be apprehend- ed than advantages to be expected from the omission of blood- letting; and experience daily proves, that from the neglect of this curative measure, the inflammatory fever degenerates into inflammation, into gastric, adynamic, or ataxic fever. The me- thodical employment of leeches is never injurious; they may even be used to an improper extent, without any serious incon- venience, in inflammmatory fever. The abstraction of blood is very generally recommended in synocha; but venesection has been recommended in preference to leeching. Venesection is not so generally dreaded in this fever as in the others. Pinel himself recommends it There are no fixed rules to determine the number of times ve- nesection and leeches are to be resorted to, or the quantity of blood to be abstracted each time, as this is entirely regulated by the idiosyncrasy of the patient, the intensity of the irritation and the nature of the affected organ. In general, one copious bleeding is sufficient; it is seldom the case that more than two are necessary, except in the case of men who have large lungs, an energetic heart, strongly developed muscles, an abundant and very stimulating blood; in the case of suppressed periodical hemorrhage, and in females who are suf- fering from suppression of the menses, or who have attained the period of their cessation, or who present the signs of plethora, 96 PHYSIOLOGICAL PYRETOLOGY. often observed after the cessation of the menses. All these cir- cumstances may render it proper to bleed more than twice.— The quantity abstracted each time should not be less than twelve ounces; we may go as far as sixteen or twenty ounces, in the case of the individuals I have just mentioned, without exceeding this quantity; it is better to repeat the operation. In general it is preferable to produce a sudden depletion by an abundant abstraction of blood, and, subsequently, to take each time a smaller quantity of blood, unless, which is so frequently the case, there occur suddenly an increased violence of the dis- ease, tending to become permanent, and threatening the life of the patient—in this case, we must not hesitate to have recourse to a bleeding equally copious with the first We should especially repeat blood-letting, if the lungs are af- fected or only threatened: a fact which may be discovered by the embarrassed respiration, and the oppression, which is soon accompanied with pain. When carditis is suspected, the abstrac- tion of blood should neither be too copious, nor too frequently repeated.—The irritation of the lungs, as well as that of the pe- ritoneum, may require more than one bleeding, sometimes it is sufficient to resort immediately to the application of a large num- ber of leeches, and, as has been remarked, they should be pre- ferred to venesection, whenever the stomach is irritated. This organ and the small intestines being frequently affected, either primitively, or, at the same time, with the encephalon, the heart, the uterus or the lungs, the application of leeches to the abdo- men, and especially to the epigastric region, is one of the means to which we should most frequently resort in inflammatory fe- vers; and it is one of the measures that contribute most power- fully to prevent the degeneration of this fever into a fever of a bad character. But the application of leeches to the abdomen is not always sufficient to prevent the development of what is called cerebral fever. To obtain this result, we must, even when the state of the digestive organ is such as to require the application of leeches to the abdomen, apply them to the temples, behind the ear, or to the legs, with the view of preventing or combatting the pro- gress of the encephalic irritation; sometimes we must even re- sort to venesection, and practise it at the foot.— INFLAMMATORY FEVERS. 97 The leeches should be applied to the sub-maxillary region, if there be angina; to the sternum or above this bone, or upon the trachea, when there is bronchitis, trachitis, or laryngitis; to the side of the chest, if there be pleurisy; to the praecordial region, if the pericardium or heart are powerfully affected; to the right hypochondrium, in the case of hepatitis; to the anus, when the large intestines are irritated; to the perineum, to the hypogas- trium or the lumbar region, if the bladder or the kidneys are particularly irritated; to the vulva, the thighs or legs, when the irritation is seated in the uterus, and to the joints, when they are the seat of intense pain. In adults, less than eight or ten leeches should not be applied, and, this number being rarely sufficient, it is necessary to renew their application. It is often useful to commence with a greater number, fifteen, twenty, or even thirty, particularly if venesec- tion has not been resorted to previously.—The flow of blood should never be suddenly arrested on the removal of the leeches. Their bites determine an afflux of blood, which may be injuri- ous, in proportion to its vicinity to the irritated part The blood, therefore, should be permitted to flow freely for one or two hours at least, after the removal of the leeches, and sometimes a much longer time, provided syncope does not occur, which is generally a favourable omen. The effect of this prolonged flow of blood is, that the afflux diminishes by degrees, that the irritated point loses a certain quantity of blood, and that the mass of this liquid is slowly diminished; we are thus enabled to abstract a greater quantity of blood without danger, by means of leeches, than by venesection, which produces a sudden de- pletion. The application of forty, fifty, sixty, eighty leeches, or even more, are rarely indicated, except in cases of peritonitis and pleurisy, where, at the commencement, venesection has not been practised, as should always be done, when the prompt abstrac- tion of a large quantity of blood is necessary; an indication which is fulfilled but imperfectly, even by the application of a great number of leeches. Were not this work particularly designed for the student, these details should not be insisted upon, but they are thought too important to pass over them in silence. The same motive 13 98 PHYSIOLOGICAL PYRETOLOGY. induces me to combat some prejudices, still very generally en- tertained, with regard to the effects of the application of leeches. This mode of abstracting blood weakens, it is said, and injures the organ of sight: leeches draw the blood towards the inflamed part and fix it there, when they are applied very near the seat of disease: in weakening the vital action of a part they may de- termine gangrene: they do not deplete so directly as phleboto- my, and have no advantage over it; their action differing in nothing from it, unless it be in this, that they have the inconve- nience of producing their effect more slowly: they occasion he- morrhoids when applied to the anus: they often occasion as many little phlegmons as there are bites, giving rise to an abun- dant secretion of pus over an extended portion of skin: finally, it is often very difficult, sometimes impossible, to arrest the flow of blood from the bites, and this hemorrhagy may occasion death. If all these remarks were well founded, it would certainly be- hoove us to renounce the employment of a means that would multiply so greatly the chances of failure. But this is far from being the case: depletion by leeches is, undoubtedly, of all active therapeutic means, the least capable of producing injurious ef- fects, even when abused. I do not think it necessary to answer those reproaches, which this method shares in common with the lancet The question is simply this, must we have recourse to the abstraction of blood when it is indicated; the remarks which have been made upon the subject suffice to point out the cases in which leeches should be preferred to the lancet. The apprehension of weakening the sight is a popular error which I would pass by unnoticed, were it not entertained by some respectable practitioners. This prejudice has originated in the fact, that the sight has sometimes been observed to become weak, and even extinct, in a short time after the application of leeches around the orbits, to the anus, or to the legs, in cases of painful irritation of the eyes, and of obstinate and repeated in- ternal ophthalmia, which so often precedes alteration of struc- ture in the most important parts of this organ; thus the aggrava- tion or appearance of a disease, which could not be cured or prevented, has been imputed to the employment of leeches. The afflux of blood to the irritated part, and the pain some- times increase after the application of leeches; this takes place INFLAMMATORY FEVERS. 99 when in an intense inflammation, situated not far from the skin, a small number of leeches is applied, and especially when the blood is not permitted to flow after their application. This in- convenience is easily avoided, since it is sufficient not to be too reserved in the number of leeches employed, and to encourage the flow of blood after their removal. It has not yet been proved that the transition from inflamma- tion to gangrene may be the effect of the application of leeches: this is one of those groundless apprehensions, to which an ex- piring theory has given birth, and which experience contradicts. It is certainly improper in any case to abstract too much blood, but the opposite error is still more dangerous in its tendency. The slowness with which this mode of blood-letting acts, is one of its most precious advantages, where the use of the lancet might occasion a dangerous debility of the circulatory system, or favour a fatal local congestion. The little phlegmons, occasioned by the bites, rarely occur when the leeches are well chosen; besides, these inflammatory tumours are an excellent derivative of the irritation which is to be combatted. Inflammation of the subcutaneous cellular tis- sue and the collection of pus which results from it, are a very rare effect of the application of leeches; they occur only on the abdomen, and always yield to proper treatment. This inflam- mation, which has appeared to me to contribute to the cure by the powerful revulsion it occasions, only manifests itself at the instant of the commencement of convalescence. It is absurd to dread the hemorrhage which may succeed the application of leeches, when it may be so easily remedied, by means of styptics, by cauterization, with the concentrated acids, the nitrate of silver cut to a sharp point, or a probe of copper brought to a white heat When this accident is appre- hended, and the physician does not reside in the vicinity of the patient, in the country, for example, a small quantity of sul- phuric acid may be intrusted to some intelligent person among the friends of the patient, who is to be instructed in the manner of using it, in case syncope supervene before the flow of blood ceases. Scarified cups are to a certain extent a substitute for leeches, when these animals cannot be procured; but in this case it is ne- 100 PHYSIOLOGICAL PYRETOLOGY. cessary to use the cup with pump and lancets described by MM. Sarlandiere* and Domours, or practise deep scarifications, and reapply the cup several times upon the same place, to abstract the necessary quantity of blood, to provoke a more con- siderable afflux, and an ecchymosis analogous to that occasioned by leeches. When, in inflammatory fever, the idiosyncrasy of the subject, the nature of the cause, and especially the symptoms, announce that the febrile movement is occasioned by gastro-enteritis, ab- stinence, which is indicated in every acute irritation, must be most rigidly enforced, even in the treatment of children and old persons. In every other case, it may be less severe: the broth of veal, chicken, or of frogs may even be allowed, care being taken to prohibit its use when the redness of the edges of the tongue announce the extension of the primitive irritation to the stomach. We must likewise enforce an absolute diet when there exists from the commencement of the disease a complication of gastro-enteritis with encephalitis. Experience alone can show how far it may be proper to depart from the severity of these principles under certain circumstances: it must not be forgotten, that if the irritation often terminates happily, it likewise frequent- ly happens that it increases, extends, and becomes complicated. The ph)^sician will then regret his compliance with the im- portunity of the patient and his attendants, or perhaps he will have to accuse the prejudices of his first medical education. I do not hesitate to confess, that I am here pointing out a .rock upon which I have already so frequently split, that I consider it due to the interests of truth to make the avowal. It is only since the signs of gastric irritation have been point- ed out by M. Broussais, that it is possible to understand the importance attributed by Hippocrates to diet, according to the results of his experience. The admirers of the father of medi- cine, who very frequently pay little respect to his decisions, would do well to follow the precepts which he has given with regard to regimen, in the acute diseases, instead of setting them aside through the vain pretence that the moderns live less frugal- ly than the ancients. * Bdellometre, Paris, 1819. in 8vo. INFLAMMATORY FEVERS. 101 When the patient experiences no thirst, if the tongue be in its ordinary state, or if it be whitish, it will be sufficient to prescribe for his drink, water, either pure, or charged with a small quan- tity of mucilage, of gum Arabic, or of fecula, moderately sweet- ened with sugar or honey, taken in small quantities at a time, and repeated according to circumstances. If thirst be complained of, we recommend water acidulated with the juice of lemons, gooseberries, cherries, or with vinegar, or the drink may be orangeade, orgeat or clarified whey. All these drinks, taken at the temperament of the apartment, contribute to calm or prevent the irritation of the digestive organs; they replace without incon- venience the aliments which might excite, or aggravate this irri- tation, and they remedy constipation. This last symptom indi- cates the use of drinks, such as veal water, the decoction of prunes or tamarinds, of lavements of pure water, or of mucila- ginous lavements, or of those which are rendered laxative by the addition of honey, vinegar or some neutral salt. It is always useful to evacuate the fecal matters, which may have accumulated in the intestines. A remarkable melioration of the symptoms is always observed after this evacuation, which, however, we should be careful not to provojte by means of purga- tive potions or ptisans, which might occasion high irritation of the stomach and intestines. It is sometimes beneficial to solicit, gently, the secretion of urine by means of water, to which is added a small quantity of the nitrate of potash. But this drink does not produce the desired effect, and may add to the sympathetic phenomena of irritation, when it has its seat in the gastro-intestinal mucous membrane. The use of it is, on the other hand, eminently in- dicated, when the irritation is seated in the skin or in the liver. This salt should be administered in emulsions, with which however, camphor should not be incorporated, as it sometimes is, without good assignable reason. Potions with the oil of sweet almonds, at best useless, are positively injurious when there exists the slightest irritation of the stomach. Practitioners accustomed to permit maladies to pass undis- turbed through their periods, may deride the strictness of these precepts. Let us not, however, overlook the fact, that, in ar- resting the progress of what is denominated inflammatory fever, 102 PHYSIOLOGICAL PYRETOLOGY. we very often prevent the development of maladies, always for- midable, and very frequently fatal. Besides, principles cannot be laid down too rigorously:—the careful application of them is unfortunately very rare. The employment of tonics in synocha, has hitherto been very injudiciously treated of, the precepts on this head have been con- fined to the vague recommendation of baths, semicupia, emol- lient fomentations, and refrigerant applications. Rubefacients and other derivatives have scarcely been mentioned. When the invasion of the disease has been preceded by signs of general plethora, we must not too promptly have recourse to tonics> of whatever kind they may be, as these applications may in certain cases be dangerous. The plethora must first be reme- died by blood-letting. If the local irritation continue very in- tense, leeches should afterwards be applied to the part indicated by the seat of the disease, previously to the employment of de- rivatives. If the irritation be seated in the head, pediluvia of hot water, rendered slightly irritating by the addition of salt, vinegar, or ashes, should be prescribed in the morning, and es- pecially on the approach of night, with the view of preventing the exacerbations. (.Should the irritation persist, the feet should be plunged in very hot water, and kept in it for some minutes; leeches should then be applied above the ankles, and the feet again placed in water, not so hot as the first, and be permitted to remain in it from 10 to 30 minutes. The feet should then be taken out and enveloped in hot cloths, and the blood permitted to flow as long as it may be necessary. There are few cases in which Jhis energetic mode of proceeding does not promptly cause the cessation of this afflux of blood towards the head. The application of ice-cold water, or of a cloth wet with cold vinegar to the forehead, powerfully seconds these remedial mea- sures. Irritation of the pharynx is advantageously treated by irritating pediluvia after blood-letting. Cataplasms, moderately hot, applied around the neck, are often useful. When the irritation is seated in the trachea or the chest, pe- diluvia are not indicated; it is sufficient to take blood from the parietes of the thorax or from the neck, to defend the patient from cold, to apply cataplasms to the neck or the sternum, and to prescribe mucilaginous drinks, or even sugar and water alone, INFLAMMATORY FEVERS. 103 taken very hot, which is the very best of sudorifics and expec- torants. I cannot here enter into the details of the treatment appropri- ate to laryngitis, simple or complicated-, known under the name of croup,* or of many other inflammations of the neck and head; but I must repeat that the best manner of preventing or curing them is to resort to the antiphlogistic treatment, imme- diately on the appearance of the first phenomena of inflammato- ry fever. Pediluvia are not suitable in synocha produced by the irritation of one of the viscera of the abdomen unless it be the uterus. But the same rules apply in the latter case to that of the encephalon; to derive advantage from the pediluvia, the general and local plethora must first be combatted. In every irritation that occasions a remarkable acceleration of the action of the heart, energetic rubefacients, and still more ve- sicatory applications should be rejected. The mildest sinapisms, by inflaming the skin, add to the irritation of the heart. Vesi- catories increase that of the kidneys and the bladder. All these means are peculiarly dangerous when the redness and swelling of the skin announce that this tissue is more irritated than any of those which participate in the morbid condition. Even pe- diluvia are then contra-indicated; the internal use of emollients and refrigerants must be insisted upon, and the patient equally preserved from a sudden chilling of the skin and from too ele- vated a temperature. It is almost unnecessary to remark that emetics, purgatives, still more emeto-cathartics and stimulants, as well as tonics, are totally inadmissible in the treatment of inflammatory fever, what- ever may be the seat of the irritation constituting it, and that they are particularly dangerous in gastro-enteritis. Emetics, purgatives, and blisters, may be prescribed in the treatment of some inflammations, but they are improper in those which are announced by the symptoms of synocha. Beyond the Alps and in England, emetics and cathartics are ranked with the anti-phlogistic remedies, and recommended in * See my articles Bronchitis and Croup, and all those which relate to in- ternal phlegmasia?, in the Dictionnaire Abrege des Sciences Medicates, and my Nosographie Organique. Desruelles, Traite du Croup, Paris, 1824, in 8vo. 104 PHYSIOLOGICAL PYRETOLOGY. treatment of inflammatory fevers, because the evacuations which they produce occasion a prostration of muscular energy. These means certainly do debilitate, for they abstract materials from the economy, but at the same time they irritate the intestinal mucous membrane. Now, the irritation of this membrane often increases the intensity of the symptoms, much more than the abstraction of nutritive materials diminishes it When the inflammatory fever results from gastro-enteritis, what must be the result of a practice so irrational? We must believe that this treatment, in some cases, occasions the cessation of the sympathetic phenomena, since it is affirmed by distinguished practitioners, but without doubt, the most frequent result is the inflammation of the gas- tric or intestinal mucous membrane, which, although not an- nounced at first by signs easy to be recognised, yet sooner or later produces the most deplorable consequences. As every na- tion pays some tribute to error, we at least may felicitate our- selves that we have not to accuse ourselves upon this point: there are few errors so fraught with danger. The treatment of epidemic inflammatory fever, is the same as that of sporadic cases; for the nature and seat of the disease is the same in both, except, that when we have treated a number of cases, we have an opportunity of determining from the com- mencement of the disease, what will be its principal seat, but we must not forget that this particularity depends more frequent- ly upon idiosyncrasy than upon the morbific cause. We should especially endeavour to prevent the degeneration of the inflam- matory fever, that is to say, we should prevent the local irrita- tion which constitutes it, from becoming exasperated and extend- ing to several important organs. It is then that we must not permit ourselves to be intimidated by the fear of the superven- tion of astheny, or as they say, of a fatal adynamy. Venesection, or the application of leeches, often relieves the profound prostration into which the patient has fallen, in conse- quence of the excessive irritation of the heart, which becomes painful and beats with difficulty. By diminishing the blood, and consequently moderating its stimulant action, the heart is acted upon precisely in the same manner as the stomach is in- fluenced by diet The treatment of M. Navieres in the epidemic of St. Martin INFLAMMATORY FEVERS. 105 des Champs, was as rational as it could be at that epoch; indeed, few practitioners would have evinced so much sagacity; for at that time, the debilitating effects of blood-letting were much dreaded. At the present day, by a more severe system of diet and by the employment of leeches, in addition to general blood- letting, we succeed in abridging greatly the duration of diseases of this kind. This violent irritation of the heart, more common in epide- mic inflammatory fever, than in sporadic synocha, never occurs but when the patients are abandoned to nature. Are there then cases in which it is proper to abandon them in this manner? Since we have pointed out what theory suggests and experience demonstrates, wTith regard to the treatment of synocha, the so- lution of this problem becomes more easy. And, in the first place, what is meant by abandoning the disease to nature? Is it meant that the patient should continue to follow his occupations, that he should walk, work, eat and drink, and, in a word, act as in a state of health? Certainly, no one entertains such an idea of the method of expectation. The warmest partisans of this me- thod recommend repose, diet, the use of mucilaginous or aci- dulated drinks. It is then evident that all that is meant by this method is the exclusion of the abstraction of blood, except in some very rare cases. It is certain that many inflammatory fe- vers are cured, as I have already said, without the employment of any species of blood-letting; but the works of experienced observers are filled with examples of inflammations developed as a result of inflammatory fever: all authors agree that this fe- ver very often precedes the appearance of other fevers, particu- larly in epidemics. Now, admitting the supposition, which is contrary to every kind of probability, that the disease which succeeds the inflammatory fever, or which, to use their language, supervenes and complicates it, has no connexion with it, a sup- position which nothing justifies, which on the contrary every thing contradicts, still it cannot but be admitted, that in arresting inflammatory fevers at their commencement, by sanguineous emissions, the development of the secondary inflammation or fever, will, in the greatest number of cases, if not in all, be presented. This proposition is evident with regard to the tran- sition of synocha into manifest inflammation; the succeeding 14 106 PHYSIOLOGICAL PYRETOLOGY. part of this work will, I hope, prove that it is not less true with regard to the fevers which succeed inflammatory fever, or which complicate it Convalescence is always rapid after inflammato- ry fevers, whatever be the organ principally irritated. When the pulse has resumed its normal condition, when the head is free and the skin without morbid heat, the subject may immedi- ately return to his usual regimen, by gradually increased quan- tities. We would only recommend moderation in eating, even after the entire restoration of health, with the view of avoiding the renewal of the general plethora, which may have preceded the fever. He must avoid as much as possible a new exposure to the causes which have determined the invasion of the disease. He should particularly avoid returning too promptly to the use of wine, coffee and all drinks and aliments that actively excite the heart; moderate exercise in the open air, the use of light unstimu- lating food, such as fruits and pot-herbs, not capable of occasion- ing flatulence, continence, and repose of the brain, will complete the cure. If after the disappearance of the symptoms which indicate the acceleration of the circulatory movements there remain pain of the head, a slight cough, an obstruction of the chest, some op- pression, palpitation, redness of the tongue, and a sense of weight at the epigastrium, or pain in the lumbar region, at the hypogastric or umbilical region, it is necessary, notwithstanding the return of the pulse to its primitive condition, not to permit the convalescent to satisfy his appetite before the disappearance of all traces of the morbid condition. A continuance of the means employed in the course of the disease, against the prin- cipal irritation, will hasten the progress of convalescence: these means, however, should be used less actively. It is easy to deduce, from what precedes, the rules to be ob- served with a view to the preservation from inflammatory fevers; and the avoidance of relapses, which, however, are not very common. With regard to the precept of giving tonics in convalescence from inflammatory fevers, it is sufficient to indicate the practice, to demonstrate its absurdity. I might here speak of the treatment of inflammatory fever, INFLAMMATORY FEVERS. 107 complicated with an inflammation or another fever; but in treating of each of the fevers, which shall form the subject of the following chapters, I shall discuss their relations with the inflammatory fever. I think enough has been said to show, that when an inflammation appears to supervene upon an inflam- matory fever, there is an augmentation of the intensity of the disease, and not change of nature, or a complication, unless indeed the irritation, confined at first to a single organ, extend to one or more different organs, with such an intensity that it develops in the latter, a manifest inflammation. In both cases, the ener- getic employment of the antiphlogistic method, upon the dif- ferent points of the organism, which are inflamed, suffices to arrest the progress, extension, and repetition of the phlegmasia. We must not, under the vain pretext of avoiding protracted convalescence, hesitate to practise all the necessary vascular depletion; for before making the inquiry what will be the na- ture of the convalescence, we must do every thing that is neces- sary to bring the patient to this happy state. Protracted conva- lescence and prolonged debility are more frequently owing to the persistence of an irritation feebly combatted by a timid prac- titioner, than to diet and the loss of blood. 108 PHYSIOLOGICAL PYRETOLOGY. CHAPTER III. Of Gastric Fever. When we compare the opinions of the ancients and of the moderns, with regard to a disease, we at once perceive that if the latter have employed words that correspond at least in ap- pearance with those of the ancients, yet their ideas differ more than the words of their respective languages. Hippocrates has not designated bilious fevers by name, he has merely described acute diseases with heat and evacuation of bilious matters. Galen was the first who divided continued fevers into sanguine and bilious. I do not imagine I shall be reproached with not having regarded his distinction of the fever of one week, and that of fifteen days or three weeks; but I should remark that the physician of Pergamos considered the bilious fever only as a variety of the ardent fever. He had then seen, notwithstanding his humoral theory, the analogy of bilious to inflammatory fever. This analogy could not but be observed, and it would not escape the observa- tion of certain physicians of the present day, had Galen confined himself to a description of the symptoms, as Hippocrates did, instead of seeking notions with regard to the nature of the dis- ease, in the alvine evacuations of the patient. Baillou was the first to give the name of gastric fever to the disease which Hoffman had named choleric fever, Baglivi the mesenteric fever, Pinel the meningo-gastric, and Recamier the bilious pepsic fever: Baillou, disregarding the bilious symptoms, has not separated the gastric from the inflammatory fever, but confounded them under the name of synocha. If this union pos- sess some advantages, it is not exempt from inconvenience. For an accurate description of what might be denominated pure bilious fever, we must read the works of Stoll and Tissot. Finke has described, under the name of anomalous bilious fever, di- GASTRIC FEVER. 109 verse morbid states which he attributed to the proximate cause of bilious fever. I. P. Frank has followed the footsteps of bis predecessors. Pinel has only reproduced, in other terms, the humoral theories of the Galenists; giving the name of gastric embarrassment to the state denominated by them turgescence of the bile, or bilious saburra. Let us here take a summary view of the descriptions given by all these authors. Bilious or gastric fevers are announced by the loss of taste and appetite, a repugnance to food, particularly to meats and rich soups; by the bitter taste and clamminess of the mouth, a white or yellow covering of the tongue, fetor of the breath, general lassitude, a painful sense of weight in the heart, the back, the loins, and the extremities, pallid complexion, the greenish yellow colour of the conjunctiva and of the part around the lips and the alae nasi. This state may continue from one day to a month or more. In this space of time other symptoms gene- rally supervene. Thus, we observe, 1st A sense of weight, of pulsation, and even of pain at the epigastrium; frequent and nidorous eructations, nausea and vo- miting of bilious matters, {gastric embarrassment.) 2dly. Colics, borborygmi, tension, and swelling of the abdo- men, constipation, or a diarrhoea of. matters of a greenish yellow colour, pains in the inferior extremities, particularly in the knees, {internal embarrassment.) 3dly. These two series of symptoms frequently manifest themselves at the same time, {gastro-intestinal embarrass- ment. ) 4thly. Often, after these phenomena have continued some days, one or more weeks, or even a month, a rigor occurs, the pulse is small and concentrated, the skin is dry and becomes the seat of a burning pungent heat; the pulse becomes frequent, full, and hard; the thirst, anorexia, disgust for food, and bitterness of the mouth augment; the patient desires cold and acidulated drinks; he experiences pain in the frontal region, a sense of las- situde and contusive pains in the back and in the limbs, which can no longer sustain him. Entirely occupied by these sensa- tions, he sometimes scarcely perceives the pain he at first felt at the epigastrium; but when the slightest pressure is made upon 110 PHYSIOLOGICAL PYRETOLOGY. this part, he shows by his complaints, that the pain has not ceased. The tongue becomes dry and manifestly red at its edges, and at its point; it is more thickly coated; a yellowish tint, more or less deep, is spread over the whole surface of the body. The patient, more irascible than usual, does not sleep, or his sleep is interrupted, and is not refreshing, {bilious fever.) Upon the morning succeeding the day upon which the rigor oc- curs, it reappears. It generally commences about the back, and is accompanied with trembling, the pulse becomes small and con- centrated; the dryness, the pungent heat of the skin, and the thirst increase, the face becomes red and animated; the pulse re- sumes its force and hardness, and after the lapse of half an hour, or one or more hours, the surface becomes moist without losing the character of pungency, which distinguishes it, and the pa- tient finds himself nearly in the same state in which he was be- fore the paroxysm, which, with more or less intensity, is re- peated under the quotidian, tertian, quartan, or double tertian type, and, sometimes, under an irregular type. There are sometimes only simple paroxysms, that is to say, exacerbations of the symptoms, without a return of the rigor and smallness of the pulse; it is then a continued fever: when the paroxysms are better characterized, it is remittent. In the first case, it gene- rally continues from seven to twenty-one days and upwards if the treatment, generally recommended by authors, be resorted to; in the second, the duration is from fourteen to forty days. When this fever terminates favourably, the change is an- nounced by a general diaphoresis, warm and mild to the touch; dry urine depositing a rose-coloured or lateritious sediment, a diarrhoea, or vomiting of mucosities or bile. More frequently the symptoms amend gradually, without the Occurrence of the evacuations, which have just been mentioned; but, in all cases, the skin becomes moist and pleasant to the touch; the urine flows more freely than before, and deposites a sediment more or less analogous to that which has just been mentioned. It is far from being the case that we always obtain the cure of bilious fever; frequently, (not occasionally, as Pinel says,) it passes, between the third and the seventh day, to the state of adynamic, ataxic, yellow fever, &c.; or it becomes complicated with a manifest inflammation of the lungs, and frequently termi- GASTRIC FEVER. Ill nates fatally, if the usual treatment be employed. At other times, it assumes the intermittent type. Pinel has said of the bi- lious, as well as of the inflammatory fever, that it never terminates fatally, except in cases of complication, and that the prognosis is never unfavourable. His predecessors did not express them- selves thus, because none, equally with him, separated fevers from their precursory symptoms and their sequelae: it is, how- ever, certain that death does not occur, while none but the symp- toms assigned to gastric fever, by this professor, are observed. This fever is not always preceded by gastric or intestinal embarrassment; frequently it is preceded by no precursory sign. Sometimes it supervenes in the course of an inflammatory fever, in consequence of gastric irritation: in this case, there is only an increased intensity of the gastric symptoms, and of those of the ir- ritation of the heart; constituting the causus of the ancients, and the bilious or gastric inflammatory fever of the moderns. This fever may, like simple bilious fever, degenerate into an adynamic or ataxic fever, or become complicated with a decided inflammation; it very seldom passes into the intermittent type. 5thly. After the symptoms of gastro-intestinal embarrass- ment have continued some days, the gastric sensibility some- times becomes an acute pain, lacerating and insupportable; the patient vomits, and at the same time passes by the anus, the debris of food, imperfectly digested, and bilious matter, of a greenish, grayish, or blackish colour, or resembling the lees of wine; he is affected with hickup, tenesmus, and a burning thirst; he suf- fers from a sense of burning heat in the abdomen, while his- hands, and more especially his feet, remain cold; the surface ge- nerally is dry, while his head and chest are covered with a cold and clammy sweat; the epigastric region is tense, hot, and pain- ful, as well as all the anterior parts of the abdominal parietesj, the face is shrivelled, the features are greatly altered, and ex- press suffering, the calves of the legs are affected with painful cramps, the patient throws himself across his bed upon his ab- domen, or remains motionless in the most complete prostrations frequently he is affected with delirium, and his limbs are agi- tated by convulsive movements, {cholera.) The cholera is not always preceded by symptoms of gastro 112 PHYSIOLOGICAL PYRETOLOGY. intestinal embarrassment; it is sometimes announced suddenly by a violent rigor, coldness of skin, and smallness of the pulse, which continue during the development of the symptoms of the disease. After one or more hours, or in six or seven days at farthest, the symptoms cease rather suddenly, or they assume increased intensity; the vomiting becomes more and more fre- quent, as well as the hickup and syncope; delirium supervenes, or augments; the convulsive movements are redoubled; if the pa- tient retain a consciousness of his existence, he complains of burning thirst, and intense pains, and, finally, falls into a stupor and expires. On opening the body, the mucous membrane of the colon, duodenum, and stomach, is found thickened, vividly red in some points, of a brownish red and sphacelated in other points; the alimentary canal is often wonderfully contracted; these cir- cumstances, according to the remark of M. Geoffroi, banish all doubt with regard to the inflammatory nature of cholera. M. Keraudren has published an account of the cholera morbus of India, in which he informs us, that post mortem examination displayed unequivocal traces of inflammation, when the fatal ter- mination did not occur too suddenly. M. Gravier has published observations establishing the same fact. The causes of these different affections are; adult age, old age, the bilious temperament, debility, an excessive sensibility; a re- sidence in hot and damp climates, and in paludal districts, living in hospitals, prisons, ships, and camps; summer, particularly the termination of this season, and the commencement of autumn, excessive alimentation, the use of certain indigestible or irri- tating articles of food, such as black meats, fat, oil, beans, onions, pine-apples, poisonous mushrooms, the cold drinks taken during perspiration, alcoholic drinks, the sweet wines, very irritating medicines, emetics and cathartics of a very violent kind, or in- judiciously administered, acids, the antimonial and arsenical pre- parations, the presence of worms in the intestines or stomach; a sedentary life, or immoderate exercise, a transport of rage, the depressing moral affections, assiduous application to study, inso- lation, the suppression of the cutaneous transpiration, of the gout, the itch, the herpetic affections; finally, dentition. GASTRIC FEVER. 113 Let me not be accused of having given at pleasure an inco- herent picture; I quote almost verbatim.* From the time of Galen, until the end of the last age, the production of the diseases of which I have just enumerated the symptoms and the remote causes, predisposing and occasional, have been attributed to the superabundance or the acrid quality of the bile, at first in the liver, and afterwards passing into the stomach and intestines. Cullen himself was not altogether free from this error, which was entertained, if not in its totality, at least to a great extent, by Tissot, Finke, Selle and Stoll. J. P. Frank vacillated between an obsolete theory and the truth/when Pinel declared against Brown, who attributed the bilious fever to debility, and against the other authors whom I have just men- tioned. In accordance with Fordyce, his language is as follows, viz: " Every thing seems to demonstrate that the principal seat of these fevers is in the alimentary canal, especially the sto- mach and duodenum, no less than in the organs secreting the bile and pancreatic juice." But he sees in the disease only an augmentation of febrile irritability, and he admits a kind of oc- cult cause, which, he says, is at present, and doubtlessly will be long unknown. M. Tomasini endeavours to prove that bilious fevers, and other analogous affections, are only phlegmasiae of the liver, which extend more or less to the stomach and intes- tines. This was a happy correction of the opinion of Galen, who, as I have just remarked, recognised the irritation of the primae viae. M. Broussais has gone farther, and has proved that the stomach is, in reality, the principal seat of bilious fevers. When we study with care the causes of these fevers, we per- ceive, that if some act primarily upon the brain, as wounds of the head, violent anger, depressing moral affections, prolonged study, watching; others act upon the skin, as insolation, the sud- den cooling of this tissue, and the disappearance of the phleg- masiae, of which it is the seat; or upon the articulations, as evinced by the sudden cessation of pain, affecting these parts, in consequence of exposure to cold; yet, that they direct their action, finally, towards the digestive canal, and especially the stomach, which is the most irritable part of it. For a more ob- * Nosogr. Phil., 5th ed. tome 1, p. 74, et suiv. 15 114 PHYSIOLOGICAL PYRETOLOGY. vious reason, these parts become irritated when their internal surface is placed in contact with food of too exciting a quality, stimulating drinks, irritating poisons, the agent designated by the name of miasms, exhalations, etc. The direct or sympathetic effect of these different causes is more powerful, when the subject has arrived at the period of life at which we observe the existence of gastro-hepatic predo- minance, indicated by the desire of stimulating food and drink, energy of digestion, habitual constipation, and the yellow tint of the skin, which characterizes the inhabitants of hot countries, and particularly of hot and damp climates. This predominance of the stomach and liver, which Bordeu well recognised, in- creases in summer, and particularly towards the decline of this season, when the heat, without ceasing to be intense, becomes united with humidity. The influence of this predominance con- tinues even during autumn, provided there be a continuance of heat, or the heats of summer have been excessive. To the usual signs of gastro-hepatic predominance are then joined prostration, fatigue, a sense of contusion in the limbs, and particularly in the articulations, precursory signs of the irritation which succeeds the active stimulation of the stomach. If the irritation be not very high, and be confined to the stomach, we observe the symp- toms which have been collectively designated under the name of gastric embarrassment. If the irritation be confined to the in- testines, we have intestinal embarrassment. When both these parts of the intestinal canal partake of the irritation, it consti- tutes gastro-intestinal embarrassment; if the irritation be- come aggravated, it gives rise to the phenomena of bilious or gastric fever. Finally, when the irritation supervenes sudden- ly, or becomes suddenly exasperated in the stomach, the duode- num or the colon, bile is abundantly evacuated upwards and downwards, and the abdomen is affected with violent pains: this constitutes cholera. There is one variety of gastric embarrassment, with which it is important to be acquainted. The tongue, covered with a foul and thick coating, is not red at its edges; the mouth is bitter and clammy; the appetite is nearly the same, or it is merely dimi- nished, there being no disgust for food; the excrements are a dirty gray or a deep gray, and not coloured with bile. This state GASTRIC FEVER. 115 is sometimes coexistent with entire integrity of the stomach and intestines; the irritation exists only in the liver, or at most in the duodenum; the stomach is free from irritation. Yet, in old persons and in certain individuals, whom it is difficult to charac- terize, irritation of the stomach exists, although the edges of the tongue are not red, and there is neither thirst nor nausea; if, however, we press upon the epigastric region, we occasion pain. When the irritation is sufficiently intense and extensive, to give rise to a reaction of the heart, and constitute gastric or bi- lious fever, three series of symptoms result, one of which per- tains to the digestive apparatus and its connexions, One to the heart, and, finally, one to the encephalon. These different symptoms present themselves under four different shades, which I deem it necessary to point out with care, since they present special indications. The first shade is characterized by pain at the epigastrium, in- creased by pressure, redness of the point and edges of the tongue, dryness of this organ, the middle of which is covered with a slight coating, of a very faint yellow colour, by impaired appe- tite, thirst, a desire for cool acid drinks, which, notwithstand- ing sometimes increase the pain of the stomach, even when ad- ministered in small quantities; by nausea and the vomiting of mucosities without bile; frequency of the pulse, which is strong without being hard, burning heat of the skin, which presents no particular colour, with the exception of a deep redness of the face, which sometimes exists, a sense of painful weight in the frontal sinuses; finally, by constipation and scantiness of the urine, which is of a citron colour, or entirely colourless. This shade is certainly the one which decided Pinel to reject the name of bilious fever, and to substitute that of meningo-gastric fe- ver: it, in fact, presents none of the symptoms which are called bilious; the irritation is confined to the stomach and small intes- tine. There is in this fever a more intense degree of gastro-en- teritis than in the inflammatory fever occasioned by gastro-irri- tation; but the irritation is less intense than in the adynamic fe- ver, properly so called. The second shade is characterized by the following symptoms; viz. pain in the epigastrium and right hypochondrium, a thick and yellow coating of the middle of the tongue, which is dry, 116 PHYSIOLOGICAL PYRETOLOGY. while the edges and point are red, bitterness of the mouth, of- ten an invincible repugnance to food, particularly to meat or rich soups; thirst, and a strong desire for acid drinks, which are always taken with pleasure, and retained by the stomach, when they are given in small quantities; a vomiting of bilious matters of a yellowish or greenish colour; frequency and extreme hardness of pulse; a pungent and burning heat of the skin, which, as well as the conjunctiva, is tinged with yellow over a part or the whole of its extent, acute pain in the forehead, the temples, and the base of the cranium; constipation, scarcity of urine, which is thick and of a deep yellow colour. By these traits we recognise the bilious synocha of the humoralists, and the bilious inflammatory fever of the pyretologists: it is an intense irrita- tion of the stomach, which extends to the liver; in fact, one of the varieties of gastro-hepatitis. The third shade has certain symptoms superadded to those of the preceding. To the coating and redness of the edges of the tongue, which is often very marked, and to the slight bit- terness of the mouth, are added pains about the umbilicus, a sort of painful bar extending from flank to flank, a diarrhoea of green or yellow bilious matters, often very abundant and fetid. The thirst is considerable, and the appetite is diminished; still the pa- tient has a vague desire for food, without being able to mention any particular article which he prefers; the sense of taste is less perverted than in the preceding variety; the epigastrium is less painful, and the thirst greater; there is no vomiting, the skin is not yellow; the urine is limpid, and the pulse more increased in frequency than in hardness. The irritation principally oc- cupies the intestines, and especially the colon; the liver is active- ly stimulated, and abundantly secretes bile, which is poured into the duodenum, and passes thence into the rest of the intestinal tube: this is one of the varieties of entero-hepatitis. The fourth shade is announced by a union of the second and third symptoms; and if it supervene suddenly, with a high degree of violence, it constitutes cholera, the symptoms of which I have already described. If the morbid phenomena proceed with less rapidity, the disease presents the most complete pic- ture of all the bilious symptoms. In both cases it is to be re- ferred to gastro-entero-hepatitis. GASTRIC FEVER. 117 These shades of the bilious affections are not all equally fre- quent. That which is derived from gastritis, or from a simple gas- tro-enteritis, is ordinary. The shades, in which irritation of the liver is manifest, are epidemic, in years the summers of which are very hot, and particularly, when the season is at the same time hot and damp. They are endemic in countries, in which these two atmospheric conditions are united in a high degree; and particularly when the air is impregnated with marshy ex- halations, or any other deleterious gaseous matter. Particular kinds of food may render the occurrence of bilious epidemics very frequent, provided the seasons are at all favourable to their development. Such was the origin of the epidemic of Lausanne, described by Tissot;* of that of Teclemburgh, described by Finke;t and of that of Becetre, described by Pinel. J In most of the shades of gastric or bilious affections, we ob- serve symptoms which announce a sympathetic suffering of the encephalon; the pain is not always confined to the frontal sinuses: when it occupies the anterior region of the cranium, it cannot be doubted that the brain and its membranes are sympathetically irritated: hence proceed the headache, which is sometimes in- tolerable, an extreme sensibility of the organs of sight and hear- ing, and delirium, which if not well marked, is at least sufficient- ly so to render it impossible not to recognise at. These symp- toms announce a dangerous complication, the extension of the irritation to the encephalon. It is absurd not to pay attention to it, under the pretext that it is only a sympathetic phenomenon. It exacts a special treatment, if we wish to prevent the conver- sion of the bilious fever into the state of ataxic fever: cough, with yellowish expectorations, is also sometimes conjoined with the symptoms of bilious fever, especially when the hepatic irri- tation predominates. We should then examine with care the state of the chest, to be assured that respiration is not embar- rassed; that it exists equally on both sides of the thorax, that percussion produces a clear sound, and that inspiration is not painful; the stethescope should be employed with a view to guarding against inflammation of the pleura and the lungs. * Histoire Epidemise Biliosae. Lausaniensis, ann. 1755. f Des Maladies Bilieuses; trad, de Lugol. in 8vo, Paris, 1815. J Nosogr. Phil., tome 1. p. 60. 118 PHYSIOLOGICAL PYRETOLOGY. It has been said that bilious affections may terminate by a diar- rhoea or by bilious vomiting: this is the same thing as asserting that bilious diseases cease when their symptoms have ceased. In the first shade of gastric fever, when the gastric irritation abates, the secretion of bile is sometimes suddenly re-established; this secretion, flowing into an organ still irritated, is expelled. If its presence has not exasperated the irritation of the stomach, this irritation continues to decrease, and it is then thought that the evacuation of the bile has determined the cure. The same thing occurs when the bile is poured into the intestines; if it does not prevent the diminution of the intestinal irritation, it is supposed to have contributed to the cure. It is difficult to un- derstand how the ancients reconciled this pretended utility of the bilious evacuation with their opinion of the acrimony of this fluid. All observers of reputation, and Finke himself, have avowed that bilious fevers may terminate without evacuations. The appearance of the urine is often changed towards the de- cline of these diseases. This fact is incontestable, but its import- ance has been magnified. We generally observe a lateritious sediment; it is of an orange colour when the liver has partici- pated in the irritation. A general and hot sweat often announces the restoration of the viscera to their normal condition. In gene- ral, an abatement of the pungency and heat of the skin and of the vomiting and diarrhoea, and a return of appetite are good omens. The most encouraging of all the favourable signs, in those shades of the disease, in which the stomach alone, or the stomach and liver, are affected, is the return of the tongue to its ordinary state. However, in the variety which I have attributed to entero- hepatitis, the tongue sometimes becomes clean and moist with- out a cessation of the morbid condition. With the exception of cholera, the prognosis in gastric or bi- lious diseases is never unfavourable as long as there are no other symptoms than those which have just been mentioned; at least it cannot be said that the bilious fever terminates fatally, since, whenever the symptoms become exasperated, and prostration, delirium, and other cerebral symptoms manifest themselves, the disease loses its name, and assumes that of grave bilious fever, adynamic or ataxic fever, the yellow fever, the plague, &c. Pathological anatomy then teaches nothing directly with re- GASTRIC FEVER. 119 gard to the nature and seat of gastric and intestinal embarrassment and of bilious fevers: I have, therefore, in all that has been said in reference to this point, only considered what we learn from the causes and symptoms. The remarks that shall be made with regard to the post mortem traces of gastro-adynamic and ataxic fevers may be applied to simple gastric fever, deducting what is due to the adynamic and ataxic symptoms. Yet the seat and nature of cholera, which is well known and is not disputed, except by a small number of physicians, and the analogy of the very intense symptoms of this disease, with the less intense symptoms of other bilious diseases, are proofs sufficiently strong in favour of our opinion of the identity of the morbid condi- tion in the bilious diseases, gastritis, hepatitis, and enteritis, admitted by nosologists. This truth, at the present day incon- testable, was undoubtedly known to Dehaen, who can only be reproached with the abuse of leeches. It redounds to the credit of this celebrated physician, that in recognising the in- flammatory character of the diseases which he treated, he evinced his superiority to Stoll, wThose attention was occupied only with pretended disorders of the bile, and who attached too much importance to the aspect of the skin, the tongue, and the matters discharged by the mouth and anus, and too little to the results of autopsic examination. He appears still more inexcu- sable when we read the following passage: " It terminates fa- tally, 1st, by the metastasis of the bilious humour to an import- ant part of the economy, as the brain, the lungs, the cavities of the chest, of the pericardium, as we learn from dissections: 2dly, By an internal erysipelas, sometimes gangrenous; 3dly, By an- thrax of the intestines; by a putrid degeneration supervening spon- taneously, or in consequence of bad treatment." Nothing proves more strikingly how much the humoral theories fascinated the best observers and blinded their judgment. M. Rodet, veterinary surgeon, has published an interesting ar- ticle, viz: " Notice sur une Epizootie de Fievre Gastrigues Ob- servie a Rouen en 1814." He here demonstrates with certainty the existence of gastro-enteritis: unfortunately, none of the horses were opened during the course of the disease. How has it hap- pened, that no veterinary surgeon has yet conceived the idea, of resorting to vivisections, and thus resolving the most important 120 PHYSIOLOGICAL PYRETOLOGY. question of practical medicine. This reproach bears only upon the professors of the schools of veterinary surgery, who alone can be expected to engage in expensive experiments. The vi- visection of diseased animals is one of the means which I have pointed out in my Thesis li upon the classifications," as capa- ble of contributing much towards the perfecting of pathology. M. Bouillaud, has reported seven cases of bilious or memin- go-gastric fever, in which, on dissection, he found injection, red- ness, thickening, softening, and friability of the gastro-intesti- nal mucous membrane. He has reported also, the results of his experiments upon animals, with a view of determining a phleg- masia of this membrane.* The analogy of the syrmptoms ob- served in animals, and particularly of the organic alterations dis- covered on dissection, with those observed in man, render these experiments valuable. Researches of this kind should be en- couraged. Treatment of Gastric Fever. We find nothing upon indigestion, in our general treatises on medicine, and very little upon dyspepsia, to which nosolo- gists have been content to assign a place among the neuroses of the stomach. The attentive study, however, of these two morbid conditions throws the strongest light upon the nature of gastric fever. Has the name of indigestion been regarded as too tri- vial to find a place in scientific works? Is the term gastric em- barrassment more respectable? and would it be unworthy of the physician to employ the words of his vernacular tongue? Indigestion occurs when we introduce into a sound stomach an excessive quantity of food, or food of a gross and irritating quality; and when into a stomach already irritated, we introduce, even in small quantities, food otherwise wholesome. In the first case, the presence of too great a quantity of food determines ir- ritation of the stomach, the digestive action of which exerts it- self in vain to alter the substances, which are subjected to its action. In the second case, this irritation is the effect of an irri- tating quality of the food. In the third case, the irritation of the * Traite Clinique et Experimental des Fievres dite essentielles, Paris, 1826, in 8vo, p. 86. GASTRIC FEVER. 121 stomach augments under the influence of food, which, under other circumstances, would have been perfectly innoxious. In these three cases, then, there is primitive or consecutive irrita- tion of the stomach, and an imperfect alteration of the food, a state which is well designated by the wrord indigestion. We observe all the symptoms of well marked gastric irritation with coated tongue, bitter and clammy mouth, acrid, nidorous eruc- tations, particularly when the undigested aliments prolong their stay in the stomach. These aliments, imperfectly digested, are a powerful cause of irritation, which finally ceases to act upon this viscus, either in consequence of the expulsion of its contents by vomiting, occurring naturally or produced by art, or in con- sequence of their passing into the intestines, which they gene- rally irritate in such a manner as to produce acute colic pains, and all the phenomena of intestinal embarrassments. After the expulsion of these substances by the mouth or anus, we easily ascertain the fact of their imperfect digestion: they are often mixed with mucus or bile, even when the subject was in perfect health before the occurrence of indigestion. There then remain only the symptoms of simple gastric or gastro-intestinal irrita- tion; that is to say, the tongue becomes clean, although its edges are still red, the mouth ceases to be clammy and bitter, the ni- dorous eructation, the fetid gas, as also the disgust for food, dis- appear; but the distress, pain, and heat at the epigastrium, and around the navel, continue, as well as the vomiting and nausea, the diarrhoea and tenesmus, until, finally, all the symptoms gra- dually disappear. This is not always the case. When the heart and brain feel forcibly the influence of the gastric irritation, especially when the undigested food is not evacuated, and recourse is had to to- nics and pretended stomachics, the pulse becomes frequent and hard, small and concentrated, and sometimes continues so during the continuance of the disease; stupor, syncope, and convulsions sometimes occur, the extremities become cold, a cold sweat covers the body, and the epigastric region becomes hot and painful. In some persons of little irritability, indigestion produces only a disgust for food, a sense of weight in the stomach, a sort of 16 J22 PHYSIOLOGICAL PYRETOLOGY. rumination, and few or no other symptoms of gastric irritation: the stools are unfrequent, gray or whitish, and without colic. In general, hot drinks sweetened with sugar and slightly aro- matic, are the best remedy for indigestion; the drinking of hot water, by provoking vomiting, and lavements of the same na- ture, are in general all that is necessary, but they must be fol- lowed up by cold drinks. These facts throw great light upon the treatment of gastric or bilious diseases: they show that all the symptoms of these diseases proceed from irritation of the stomach and intestines, that the presence of certain substances in these organs may provoke or keep up irritation; that the evacuation of these matters is indi- cated, but that it does not suffice for the cure of the disease, which consists in a gastric, intestinal, or gastro-intestinal irrita- tion, involving the liver to a greater or less extent, that stimu- lants may increase this irritation, cause its extension to the brain, and render it dangerous; that in certain cases the only indication is to evacuate the contents of the intestinal canal, to cause the cessation of the indigestion. Furthermore, in numerous cases the administration of emetics, of too violent a character, is fol- lowed by the development of all the symptoms of the most in- tense gastric fever, with or without bilious symptoms. From the time of Hippocrates to the present day, the treat- ment of gastric affections has consisted in the expulsion, by eme- tics or cathartics, of the irritating matter which was always sup- posed to exist in the digestive passages. It was, however, perceived from time to time by attentive observers, that these evacuations did not always produce the good effect which was expected from them, and from this fact they drew the conclu- sion, that to derive all possible advantage from them, they must not be administered too soon, or be employed, except after having had recourse to certain means, capable of ensuring their efficacy. Hippocrates himself recommended to defer the evacuation of the morbific matter until it had been concocted. This principle is in opposition to his theory; for, if the fever be the effect of the crudity of this matter, why wait for its concoction, before ex- pelling it. Tissot has insisted upon the advantages of delayants; Stoll has pointed out the inconvenience of purgatives; Pinel has GASTRIC FEVER. 123 followed them in these two points of doctrine, but, after the ex- ample of Stoll, he advises to commence with an emetic, or an emeto-cathartic, should there exist the slightest symptoms, or even a single symptom of gastric embarrassment Now, since, according to his theory, there are no gastric fe- vers without symptoms of embarrassment of the digestive pas- sages, since he places the signs of this embarrassment among the symptoms of these fevers; the consequence is, that we must always commence the treatment by the administration of an evacuant; and since the signs of gastric are more common than those of intestinal embarrassment, and since in most cases they accompany the latter, the result is, that an emetic is almost con- stantly indicated in the commencement of gastric fevers. In case of gastro-intestinal embarrassment, the emetic is still re- sorted to, since he here recommends an emeto-cathartic. This author has, it is true, spoken of bilious inflammatory fever, or ardent fever; but he has assigned the name of bilious inflammatory fever to one of little intensity, purely gastric, that is to say, one which presents no bilious or saburral symptom. That I may not be accused of imputing language to Pinel, which he has not used, I shall give in his own words, a passage which has, un- happily, been regarded as an axiom in practical medicine: " If this state of primae viae, {gastric embarrassment,) manifest it- self either in its simplicity, or in one of its diverse complica- tions, I employ an emetic, administered either with or without copious draughts of water: one or two of these symptoms well characterized are sufficient to determine me." This aphorism has produced incalculable evils: they have been pointed out by M. Broussais, who, in a clearer manner than any other writer, has shown the dangerous consequences resulting from the abuse of emetics. If, instead of employing himself in invectives against the partisans of antimony, Gui Patin had col- lected with care conclusive facts, the cause he advocated would have triumphed, and humanity have been spared many a groan. To keep principally in view the irritation of the stomach, the intestines and the liver, and to distinguish the cases, few in num- ber, in which recourse must be had to evacuants, is the funda- mental principle which should, at the present day, guide the practitioner in the treatment of gastric affections. 124 PHYSIOLOGICAL PYRETOLOGY. When in a patient, we observe only redness of the edges and point of the tongue, a whiteness of the centre of this organ, anorexia, acid eructations, a marked aversion to wine, a sense of weight at the epigastrium, and no other symptoms, except weak- ness of the legs, it is easy to recognise irritation of the stomach, of the slightest grade. This slight degree of gastritis requires a rigorous diet, the use of cold mucilaginous or acidulated drinks, sweetened with sugar, or even the simple use of cool and pure water, according to the taste of the patient, and moderate exer- cise in the open air. If these symptoms augment in intensity, the tongue becomes dry, and the redness of the edges is brighter, red points appear in its middle, and are conspicuous amidst the whiteness of this part; the want of appetite becomes a real aversion to food, the epigastrium becomes painful, the skin hot, the pulse hard and frequent. The remedial measures which have just been pointed out, are no longer sufficient; we must add to them the applica- tion of leeches to the epigastrium, and of flannels or cloths steeped in a decoction of mucilaginous plants to the abdomen. Two or three leeches must be applied, in the case of infants at the breast; from three to eight, in children approaching the age of seven; and from ten to twelve, in adults. In every case the blood must be permitted to flow, after the fall of the leeches, as has already been observed, and for the reasons assigned in the preceding chapter. Thus far the most skilful nosologist might be defied to decide whether the fever be inflammatory, properly so called, or a gas- tric fever. To the physiological physician the problem is easily resolved: the disease is gastritis, and nothing must be neglected to prevent its becoming aggravated. When these means have not been employed, or when they have been found insufficient to arrest the progress of the disease, or, finally, when medical aid is not resorted to, until the disease has made a considerable progress, there is, in addition to the pre- ceding symptoms, vomiting, and all the phenomena which have been enumerated as characterizing gastric fever, without bilious symptoms; the highest degree of which is the ardent fevers of the ancients. Under these circumstances, the application of fif- teen, twenty, or thirty leeches must be made without delay, the GASTRIC FEVER. 125 blood must be permitted to flow until we observe a meliora- tion sufficiently great to afford us hopes of a cure: the applica- tion must be renewed as the intensity of the disease and the force of the vascular system indicate the necessity. In general, it is better to establish an almost continual flow of blood by a small number of bites, twelve or sixteen, for example, than to renew the application of leeches; but we should not hesitate to repeat it, when the symptoms persist in all their violence. It is here that we have an opportunity of appreciating, at its true va- lue, the prognosis of gastric fevers, which, they say, is always fa- vourable, provided the disease be not converted into one of bad character: a proposition which signifies that the disease is not grave, as long as it has but little intensity. Acidulated drinks are sometimes too stimulating, unless the quantity of acid be very small, but, however mild they may be, they must be renounced the moment the patient complains of griping of the stomach, after taking them. Vinegar and water is almost always hurtful; lemonade is generally useful, and orangeade still more so in most cases; gooseberry-water may be substituted for it, although it does not agree so well with most stomachs; the decoction of cherries, and other ascescent fruits may be used with advantage; whey is often very suitable. Mucilaginous drinks sometimes disagree with the stomach, not because they occasion great irritation, but because they pro- duce a sense of weight in it, and render the mouth clammy. A slight decoction of mallows, of dog-grass, or even barley water, although the latter is improper when it is too thick, are often preferable to gum arabic. The same remark applies likewise to a decoction of the crumbs of bread. Pure water, which so few patients drink willingly, on ac- count of their prejudices, is in a great number of cases the best of all drinks. But it is frequently necessary to add to it a little sugar or liquorice. Hecquet has justly extolled the use of water in gastric affections;* in this he agrees with Hippocrates, Galen, and Celsus. The quantity and the temperature of the drinks is not a mat- ter of indifference. If the patient has little thirst, he must not * De la Digestion. Paris, 1747. 126 PHYSIOLOGICAL PYRETOLOGY. be obliged to drink much, but he must not be permitted to re- main a long time without drinking. If the thirst be urgent, we may prescribe as much as two pints of liquid, but he must be advised to drink but little at a time. This precaution must be rigidly observed, particularly when there is vomiting. Fre- quently but a spoonful of liquid must be given at a time, and that only at distant intervals. In all cases, nothing must be ne- glected to discover the drink which produces the least irritation of the stomach, and the idiosyncrasy of the patient must al- ways be regarded. The drinks should generally be given cold; but they should be hot, if there are rigors. In general, it is proper on this point to consult the taste of the patient, who is ordinarily the best judge. In case of obstinate vomiting, if we are desirous of arresting it, we must prescribe cold drinks—if to promote it, warm drinks. There are certain shades of gastric irritation which require the administration of very hot drinks: perhaps idiosyncrasy has much to do with the existence of these varieties. If I have said that we must prescribe an absolute diet, even when the irritation is slight, it is because diet is the most ef- ficient remedy for this disease in all its degrees: a means which in many cases entirely dissipates it, and the omission of which often renders all other means unavailing. Not only must we forbid the use of meats and all rich food, as all authors recom- mend in the treatment of gastritis, a precept which may almost be considered idle, since the first symptom of the disease is a re- pugnance to food, particularly of this character; but we must likewise proscribe both, which patients are often compelled to take against their will, or which they call for, notwithstanding their aversion, in the hope that it will strengthen them. M. Broussais has not gone too far in asserting that the lightest broths may occasion fatal relapses. This is one of those practical truths that cannot be too generally inculcated, but which will be resist- ed for a long time, on account of the aversion of patients to an absolute diet, and the less excusable prejudices of the physician. A slight decoction of sorrel is beneficial, when acidulous drinks are supported by the stomach: it may be substituted for them in most cases, but we must not add to them either butter or salt. Simple emulsions, recently prepared, and orgeat, when there GASTRIC FEVER. 127 is much heat of the skin, water charged with a small quantity of carbonic acid, when there is nausea, may be prescribed, provided the irritability of the stomach be not very marked. The minute details which I have given, are necessary: many of a similar character will be found in the course of this work, since it is necessary to attend to them to prevent the aggravation of diseases, and their fatal termination. With many of these details physicians are acquainted; there are others to which they unfortunately attach too little importance. Of some among these principles, many physicians are ignorant: it is important that the student be not left in ignorance with regard to any of them, since they constitute valuable elements of success. I know, and the remark is intended for the physician as well as for the patient, I know that we may sometimes deviate from the narrow path pointed out by experience; but in this case the disease is of longer continuance, than when a more severe regimen is observed. It is much more common to see it, un- der these circumstances, become aggravated, extend to a num- ber of organs, attain a high degree of intensity, and often oc- casion the death of the patient, who has not obeyed his physi- cian, or who, through the inattention of his physician, has not been preserved from the influence of the causes capable of ag- gravating his disease. It is here that a proper opportunity of- fers to enforce the necessity of absolute diet, because it is par- ticularly indicated in gastric fevers: the remarks that have been made upon this subject are, throughout, applicable to the treat- ment of the diverse shades of gastritis, which shall be treated of in the following chapters. Nourishment should not be allowed until the pulse has lost its frequency, and the skin its heat Emollient fomentations are very useful; they should be resorted to, whenever there is much heat at the epigastrium: they have also the advantage of keeping up the flow of blood after the fall of the leeches. But, to be productive of good effects, they should be preserved, if not at a very elevated temperature, at least at such a degree of heat, that the patient may experience no sen- sation of cold, when the cloths are renewed, or while they are in contact with the skin; emollient fomentations maybe substituted 128 PHYSIOLOGICAL PYRETOLOGY. for baths, to which we cannot have recourse when the circula- tion is accelerated and the head painful. The constipation which attends gastric irritation, is not a for- midable symptom; but since it is demonstrated that the delay of fecal matter in the intestines, occasions headache and heat of the skin, it is proper to prescrible lavements of water, which may be either pure or mucilaginous, or acidulated, or mixed with oil or with honey. The pain in the head, which so frequently accompanies gas- tric irritation, generally disappears with it, when our remedial attempts are successful. But if the headache be intense, and pre- dominate over the other symptoms, pediluvia, cold applications to the forehead and leeches to the temples, are indicated, just as though there were no gastric irritation; for it is of importance to prevent the development of arachnoiditis, which is to be feared from the fixed character and intensity of the pain and its confine- ment to the frontal region. I shall again discuss this point, when upon the subject of ataxic fever. Such are the only therapeutic means to which we should have recourse in gastric irritations, with or without the phenomena of reaction of the heart, and without bilious symptoms. This treatment is not less suitable in intestinal irritation and in those cases in which both the stomach and bowels are involved. When to the signs of gastric irritation with or without febrile symptoms, are superadded those which announce that the irri- tation is shared by the secretory apparatus of the bile, we must in the first place have recourse to the same means; then all the symptoms diminish gradually in intensity, or those of gastric ir- ritation diminish, while the bilious symptoms continue, or final- ly the latter cease while the former continue. In the last case we must insist upon the means which have been pointed out. In the former we must continue to employ them as though the irritation were confined to the stomach; in the second we must have recourse to leeches applied to the right hypochondrium or anus, persevere in the use of acidulated drinks and prescribe the warm bath. When no pain is perceived in the hypochondrium, even when strong pressure is made upon this region, when there is no uneasy sense of pain and numbness extending thence to the right shoulder, when the skin does not change its colour, when GASTRIC FEVER. 129 the urine is not of a deep yellow and the excrements of a whi- tish gray, when the tongue is uniformly and thickly coated, when there is no thirst, and no pain at the epigastrium even when strong pressure is made, no heat of the skin and no ac- celeration or hardness of the pulse, we may prescribe an emetic, provided the disgust, the bitterness of the mouth, and the other symptoms do not yield to the means which have been advised. Wherever there is heat of the skin, acceleration of the pulse, and redness of the tongue, emetics are contra-indicated; nor, to render their employment improper, is it necessary that the pulse should be hard and the tongue dry and cracked; consequently, in every gastric fever, properly so called, whether it be ardent or the ordinary fever of our country, and especially in the bi- lious fevers of hot countries, an emetic should never be adminis- tered. It can never be prescribed with impunity until after the cessation, not only of the febrile symptoms, but likewise of the symptoms peculiar to gastric irritation. When the latter symp- toms are not exasperated by the exhibition of the emetic, those of the biliary apparatus frequently are, and thus the fever is ex- asperated, and becomes more formidable. It would not be rational to prescribe an emetic in all cases of gastric embarrassment, unattended by signs of irritation of the stomach. There are no candid practitioners who do not acknow- ledge, that, to their great surprise, they have often seen this state grow worse, even after the emetic had produced the desired effect of causing abundant evacuations of bile. What succeeds best, in conjunction with acidulated drinks largely administered, are laxatives, such as the supertartrate of pot-ash, and lavements containing a small dose of the sulphate of soda or of magnesia. These evacuants have none of the inconveniences of emetics, provided the intestines are not irritated; for, in this latter case, they increase the heat and dryness of the skin, the uneasiness and thirst. When we prescribe an emetic, tartarised antimony is to be preferred, because the action of this medicine is sure and its ef- fects well known. But it must always be administered with caution, and never in a dose of three grains at the commence- ment, as is sometimes done; much less should this dose be thrice repeated. It3 combination with ipecacuanha is always irrational/ 17 130 PHYSIOLOGICAL PYRETOLOGY. It is especially at the commencement of gastric fevers, and during the existence of the state denominated gastric embar- rassment, that an emetic has been prescribed. It has been as- serted that it dissipates this embarrassment, the duration of which is sometimes so protracted, and that it unmasks the gastric fever, which succeeds it; that, administered in the course of this fever, it simplifies it, and in general produces a salutary shock. Let us examine whether all these advantages are to be expected. An emetic does not put an end to all cases of gastric embar- rassment, since it so often happens that the fever declares itself after their exhibition. It is not in reality advantageous, except in the case of persons subject to bilious diarrhoea, of short con- tinuance; of those who have contracted the habit of taking an emetic at certain periods of the year; of those who eat vora- ciously of gross and stimulating articles of food; of corpulent and pale persons of lax fibre and of little irritability; in cold and damp climates, and in northern countries. In this manner is to be explained the success of Stoll, Finite, and many other physi- cians, who practised in countries, the inhabitants of which, en- dowed with little sensibility, make use of an indigestible diet, and are addicted to excesses. When the gastric fever develops itself in the train of gastric embarrassment, after the exhibition of an emetic, that is to say, when, after its administration, the skin becomes dry, hot, and pungent to the touch; the pulse frequent, quick, and hard; the thirst intense, the mouth dry and the tongue red at its edges, is it not evident, that, instead of having unmasked the fever, the emetic has determined it, by exasperating the gastric irritation, even when it has dissipated the bilious symptoms? Now, the advantage which the patient derives from the disappearance of these symptoms, which are generally secondary, is more than counterbalanced by the augmentation of the principal irritation. It is, moreover, far from being the case that the bilious symptoms always yield to an emetic, particularly when the phenomena, which I have just enumerated, develop themselves, or assume increased intensity. More frequently, as I have already said, all the gastric, hepatic, and sympathetic symptoms become exas- perated. Nothing less than blindness of the grossest kind would GASTRIC FEVER. 131 behold in this exacerbation of the disease only a salutary effect of the remedial measure resorted to. Stoll has strongly recommended emetics in the course of bi- lious fevers; but he would have the patient prepared for their exhibition, by bleeding, the antiphlogistic regimen, and diluents, when the patient is young or in the vigour of life, of rigid fibre or plethora, when inflammations are prevalent, and finally, when a heating regimen and stimulating medicines have been used. Doubtless he would have unhesitatingly rejected the idea of sim- plifying these fevers, by the premature administration of evacu- ants. If this celebrated partisan of emetics thought it necessary to have recourse to preparatory means, is it not absurd to reject these means, at the present day as at least useless, and to pretend that this preparation is attended with the inconvenience of occa- sioning the loss of a precious period, and of retarding the cure. It is only after the administration of acidulated, mucilaginous, and refrigerant drinks, that an emetic can be prescribed with ad- vantage: under these circumstances, alone, it simplifies the dis- ease by provoking the secretory action which must succeed the dry irritation of the gastric membrane. To render this measure innocent in the first stage of the irritation, it is necessary that the latter be slight. Nothing justifies, I repeat it, the administration of an emetic, when, from the commencement of the disease, the skin is acrid and hot, the pulse frequent and hard, the tongue dry and the thirst intense. When we are called to a patient, to whom at the commencement or at any other period of the fever, an emetic has been prescribed, we should entirely discard the idea of a pretended simplification, and have immediate recourse to local antiphlogistic means, should there be the least increase of inten- sity in the gastric symptoms, or any reason to apprehend it, whether the bilious symptoms have disappeared or whether they persist with the signs of gastric irritation. What is meant by the favourable shock occasioned by the emetic? Does it indicate the abundant transpiration which this medicine determines, and the afflux towards the head, so often dangerous, which it occasions? or, is the expression used to de- signate a special and unknown action? This last hypothesis me- rits no consideration. As to the sur-excitation, more or less permanent, of th» skin, determined by the action of this thera- 132 PHYSIOLOGICAL PYRETOLOGY. peutic agent, there is an important distinction to be observed, which has not yet been made with sufficient care. The sur-ex- citation of the skin and the perspiration always occur during vo- miting; but the melioration of the state of the stomach, the in- testines, and the liver, follows it only in a very limited number of cases. It is not, then, to these sympathetic phenomena, pure- ly secondary, that we should attribute the diminution of the ir- ritation of the digestive passages, when we are so fortunate as to obtain it. This opinion would be equally erroneous with that of those authors who attribute the cure of fever to the profuse perspiration observed at the decline of many febrile diseases. It is proper to remark, that emetics sometimes procure a marked melioration during some hours, or for the space of one or more days, but that, after this period has elapsed, we observe a renewal of all the symptoms, provided the subject be at all dis- posed to gastro-enteritis. How great is the imprudence of those physicians, who, notwithstanding the return of the symptoms, repeat the administration of this medicine! In vain they cite certain cases in which they have triumphed over the malady, by means of a second, or even a third emetic. Like most of the rare cases of the successful employment of therapeutic agents, those instances have been productive of the most unhappy re- sults to humanity, because they have induced practitioners to prescribe emetics, in a number of circumstances, in which they are deleterious. From not comparing attentively the few in- stances of success with the numerous failures, they constantly do harm, without the probability of ever being useful. M. Chaufford is of opinion, that emetics may prove useful when administered four or five days after the entire cessation of the fever, when the head is altogether free from any affection, the tongue remaining saburral and the appetite languishing. He administers, in such cases, twenty grains of ipecacuanha; the patient should drink copiously; this dose is sufficient in most cases without resorting to purgatives. * Cathartics may be less injurious than emetics, because the lat- ter often extend their action, not only to the stomach, but also to the intestines, while the former irritate the mucous membrane of the intestines alone, the irritation of which is usually of short * Traite sur les Fievres. Paris, 1825. GASTRIC FEVER. 133 duration. But, like emetics, they exalt the intensity of the symptoms, by exasperating the gastro-intestinal irritation, when- ever they are administered at the commencement or during the course of the gastric fever. They cannot be given with impu- nity, except at the decline of gastro-intestinal irritation, and only in a small number of cases, analogous to those which admit of the employment of emetics. They should be preferred to the latter in old men and in persons who have contracted the habit of purging themselves every year at certain periods. It would be superfluous to demonstrate the absurdity of the advice given by the partisans of the humoral pathology to purge on alternate days; but I cannot pass over in silence the dangers of the combination of an emetic and cathartic. If when admi- tered singly each of these two measures is rarely useful, ordinarily dangerous, often fatal, what will be the result of combined ac- tion ! Perhaps the danger of an emetic would not be so great but on account of its frequently extending, as I have just re- marked, its irritating action not only to the duodenum but like- wise to the rest of the intestine. By the well directed em- ployment of the most rigid diet, of drinks, acidulated, or only sweetened, of the local abstraction of blood, of fomentations and emollient lavements, we obtain the cure of gastric affections sometimes in one day, generally in a few days, and most fre- quently before the seventh day. We do not see them under this treatment continue during two or three weeks, and much less for the space of a month or six months, as so often happens when the emetic treatment is pursued. After we have procured the prompt disappearance of the gas- tric symptoms, the bilious symptoms sometimes persist for some days, without heat of skin and acceleration of pulse, a fact that indicates the continuance of the irritation of the liver. In this case a saline cathartic may sometimes be prescribed with advan- tage: it is generally sufficient to continue the diet, but with less rigour, as well as the employment of acidulated drinks, to ob- tain the cure of the latter symptoms. I shall be reproached by some with having insisted so much on the disadvantage of evacuants in the treatment of gastric fe- vers, while others will be dissatisfied that I have not altogether proscribed their employment. I do not flatter myself that I have 134 PHYSIOLOGICAL PYRETOLOGY. pointed out with perfect accuracy the cases in which these means are indicated. I have, however, made the attempt, firmly per- suaded that there is no therapeutic agent which we may not em- ploy with advantage in certain cases, and believing that men whose works form an epoch in the history of medicine should not be treated with disrespect. Diarrhoea is one of those symptoms of gastric fever, which prove how little is to be expected from the employment of eva- cuants. When it occurs, one of the most efficacious means of arresting it, is an absolute diet The patient should be directed to drink little at a time, and only of mucilaginous fluids, hot and sweetened with sugar; aci- dulous drinks should be avoided, cataplasms should be applied hot to the abdomen, coldness of the feet should be prevented or remedied by the application of hot bricks enveloped in cloths, or by any similar expedient. The application of leeches on dif- ferent points of the abdomen, and particularly above the region of the groin, or to the anus, is often necessary, and always useful. To what curative means must we resort in cholera? We are not in possession of a sufficient number of well observed facts, to warrant a positive answer to this question. Sydenham has proved that in these cases, even the mildest evacuants are always dangerous, and that mucilaginous, acidulated and edulcerated li- quids, given abundantly in drink, and even in lavement, assuage the violence of this terrible disease, and often entirely arrest its progress. He has observed, that narcotics, prescribed at the commencement, diminish the pain, but at the same time occa- sion stupor, without meliorating the condition of the patient. He is of opinion that they should not be prescribed until after the disappearance of the violent symptoms, or when the subject is entirely prostrated by the disease. Every one at the present day agrees with this celebrated physician with regard to the dan- ger of emetics and purgatives in cholera, and the utility of the drinks denominated diluents. But are there, in reality, cases in which the employment of narcotics is proper? Are there not cases in which the local abstraction of blood is indicated? These questions can be resolved by experience alone. It is much to be wished that physicians practising in the south of Europe, in GASTRIC FEVER. 135 Africa, in the East Indies, and in the hot climates of America, would direct their attention to these points. The inefficacy, and even the danger of general blood-letting in cholera, should not, in my opinion, prevent the employment of topical depletion. I have seen this mode of abstracting blood arrest, often almost in- stantaneously, colics of the most violent character, which if treated by other means, or abandoned to nature, would have con- tinued with the same violence for many days. The nature of the symptoms of cholera, and the unequivocal traces of inflam- mation discovered after death, favour the opinion that local blood- letting might diminish the ravages committed in hot countries, especially in India, by this disease, which is more fatal in those countries than in the north, and even in the south of Europe. The state of the skin should not be neglected. Excessive heat occasions a sur-excitation of the membrane, the sudden cessation of which, occasioned by a draught of cold air, is the most fre- quent occasional cause of gastric and hepatic maladies in hot cli- mates. In all diseases, and of course in cholera, it is necessary, pre- viously to the application of leeches, to recall the blood to the skin, when it is cold and pale, otherwise they will not bite or flow. In this case, stimulants of the mildest kind, or the most diffusible, such as hot water sweetened with sugar, with the ad- dition of a small quantity of ether, hot fomentations, the vapour- bath may happily fulfil the indication of restoring the activity of the skin. When, in the course of gastric fever, there arises irritation of the bronchia, of the pulmonary parenchyma, of the pleura, of the kidneys, or the bladder, it is often necessary to apply leeches to the sternal region or to the sides of the chest, to the loins, or to the perineum or even to resort to venesection, and the other means appropriate to the inflammation of each of these organs. It would often be dangerous to rely upon the disappearance of those secondary phlegmasiae with that which they complicate, and to permit them to make a progress which nothing afterwards might be competent to arrest. Inflammation of the peritoneum sometimes supervenes upon that of the stomach and intestines, or replaces the affection of the latter organs; the diarrhoea ceases, the abdomen becomes 136 PHYSIOLOGICAL PYRETOLOGY. painful in most parts; the body shrinks, the pulse becomes small; gastric fever then assumes the adynamic character, and conse- quently is classed among those fevers which shall be considered in a subsequent part of this treatise. Finke has described, under the name of anomalous bilious fevers, irritations of the encephalon, of the skin, of the mucous membrane, of the pharynx, of the bronchia, of the articulations, of the kidneys, of the inferior extremity of the rectum, some- times produced by a prevalent gastro-intestinal irritation, with or without hepatitis, at other times primitive, and which, in the latter case, were cured by provoking a transient gastro-enteritis, by the employment of emetics and purgatives. When an epidemic gastritis or enteritis, prevail in a country, all the inhabitants are not affected, because, although all are ex- posed to the causes, which, by irritating the digestive organs, cause the epidemic, yet all have not the same idiosyncrasy. In some, these organs alone are affected, in others the irritation ex- tends to the lungs, the encephalon, and the kidneys, affecting them not merely to that feeble degree which is observed in all cases of gastro-enteritis with sympathetic phenomena, but with great intensity. In the latter cases, when the symptoms of the irritation of the digestive organs, and those of the irritation of one of the organs just named, are of equal intensity, there is said to exist a complication of one fever with another, or with a phlegmasia. If, on the other hand, the irritation of the lungs, of the encephalon, or of any other organ, be manifest, and that of the digestive organs, obscure or not at all observed, physi- cians preoccupied by the malady which they observe in the greater number of persons, committed to their care, imagine they see it every where,—see it when it does not exist, and ad- mit but two varieties of the epidemic disease; viz. the one, true, open, legitimate; the other, false, anomalous, spurious: for both these conditions they make use of the same curative means. The result of this practice is as follows: in case the digestive organs are free from irritation, the emetics and purgatives, some- times arrest the anomalous affection with surprising promptitude; because the digestive organs are predisposed to irritation by the prevailing morbific causes. The irritation caused by the eva- cuants resulting from a transient cause, generally ceases with GASTRIC FEVER. 137 this cause, and the disease is cured; but, if the predisposition to gastric irritation be very marked, the evacuants determine a gastro-enteritis. The affection, against which the remedial mea- sures were directed, even in this case, sometimes ceases, although more frequently it continues: in place of an irritation confined to a single organ, there now^exists a complicated gastric fever; that is to say, an irritation of the stomach, complicated with an intense irritation of an organ more or less remote from the di- gestive apparatus. It results from this exposition of facts, that we should be very reserved in the employment of evacuants in the treatment of ir- ritations, which manifest themselves, during the prevalence of a gastric epidemic, even when the digestive organs do not partake of the irritation; that it is better to treat these irritations as though they originated under any other circumstances, and, finally, that when the gastric or hepatic irritation is conjoined with the affec- tion, we must employ local antiphlogistics in the case of all the or- gans which partake of the irritation, and not resort to evacuants under the vain pretext of restoring the disease to its true cha- racter. Epidemic gastric diseases require the same treatment as spo- radic cases; the "principles are the same; the application of them should only vary on account of the idiosyncrasy of the subject, and the intensity, seat, and extent of the irritation. At what period of gastric fevers and of similar affections, should we allow the successive use of broth, soup, of cooked fruits, and, finally, of solid food? Broth should not be allowed until the heat of the skin has ceased to be acrid to the touch, and this mem- brane presents no trace of morbid heat, until the pulse has ceased to be tense and frequent, and the edges of the tongue are no longer red. It is proper to mix the broth with a decoction of gooseberries, of lettuce, or of beet: to render it less irritating af- terwards, there may be added a slight decoction of rice, barley, bread, or grouts, and by degrees the patient advances to the use of soup, and, finally, resumes his habitual diet During convales- cence, a long time should elapse before the use of wine is allowed, and even wine and water should not soon be used. Before al- lowing the use of meat, it is proper to give the patient acid fruits 18 138 PHYSIOLOGICAL PYRETOLOGY. cooked with sugar, and fresh vegetables cooked in water, and but slightly seasoned. If there be constipation, but little food must be allowed while lavements are to be administered, and the patient should drink veal-water, a decoction of sorrel, of tamarinds, or of prunes, honey and water, or whey. Therr* are only two cases in which purging will be proper; viz. first, when, after a return to the ordinary regimen, the tongue becomes foul, and the appetite di- minishes or disappears, without any preternatural heat of the skin, or acceleration of pulse; and, secondly, when the patient has contracted the habit of taking medicines of precaution, at stated periods. It must not be forgotten, that a purgative may renew all the symptoms. If this principle be kept in view, the danger of abusing evacuants will be avoided. A severe regimen, the use of vegetables, the continuance of diluent drinks, moderate exercise, the cold bath in the case of young subjects, taken either before or after sun-set, according to the climate, are the most proper means of preventing the relapses so frequent after gastric fevers. These relapses are almost al- ways attributed to an indigestion. This is easily accounted for, when we consider that gastric fever is only an irritation of the centre of the digestive system; to prevent which I cannot be- lieve, that any experienced physician of the present day, would prescribe bitters, with the view of restoring the tone of the sto- mach. This Brunonian practice, is probably now abandoned by those who formerly recommended it, and whose names, there- fore, need not be mentioned. The administration of tonics at the decline of bilious fevers, far from rendering convalescence short, tends directly to its prolongation. MUCOUS FEVER. 139 CHAPTER IV. Of Mucous Fever. Selle, has designated by the name of pituitous fever, and M. Recamier, by the name of pepsic mucous fever, the diseases preceded and accompanied by the following phenomena; viz. a cold and damp atmospheric constitution, food of a bad quality, or in small quantity, or the total want of it; the tongue charged with a mucous substance, white, and, as it were, lardaceous, which likewise covers the mouth and pharynx; a mucous coat, covering the blood and formed in layers, the interstices between which are filled with serosity: the clot dissolved, a slow, feeble, and intermittent pulse; the urine clear and limpid. These cha- racters, taken from Sarcone, give but an imperfect idea of the fevers observed by this physician, and of those which Roederer and Wagler have described with so much care. Pinel has en- deavoured to give an exact summary of the observations of these three physicians. His description of the disease is as follows; viz. A sense of general malaise, of weight in the limbs, disturbed sleep, loss of appetite and acid eructations, often announce the invasion of the mucous fever, which commences in the evening or during the night, with a sense of cold without trembling, felt first in the feet, and afterwards pervading the whole body. The symptoms of this fever, are the following; viz. a whitish and moist covering of the tongue, a viscous, and sometimes an abundant salivary secretion, a sour or nauseous taste, aphthae in the throat, on the parietes of the mouth and on the lips; thirst, generally of little intensity, want of appetite, and sometimes a marked repugnance for food, acid or nidorous eructations, a sense of weight at the epigastrium, and a swelling of this part, nau- sea, a vomiting of white viscous and transparent matters, insipid 140 PHYSIOLOGICAL PYRETOLOGY. or acid; sensibility of the abdomen awakened by pressure; co- lics, flatulency; sometimes constipation; at other times a diar- rhoea of matters similar to those ejected by vomiting, which are sometimes bloody, and the evacuation of which is attended with tenesmus; frequently a passage of intestinal worms by the mouth or by the anus; the urine suppressed or very abundant, of a ci- tron colour at the commencement, thick, troubled, white or red- dish, with a sediment which is grayish, about the middle of the disease, and lateritious towards the termination: it is sometimes passed with difficulty and even with pain. The temperature of the surface is not more elevated than in health. When the skin is hot, it is only so at intervals, and this heat does not appear acrid, except after a prolonged touch. The cutaneous transpi- ration is rather diminished than augmented, without the skin being very dry: there is often a partial sour sweat, which occurs especially during the night, in the morning, and during sleep, principally towards the decline of the disease. Diverse erup- tions appear on the skin during the night, disappear, and mani- fest themselves anew. The pulse, sometimes differing but little from the natural state, is generally weak and small, and often slower than in health; but in the evening and during the night, it becomes frequent. The patient experiences a sense of weight and pain at the top and back of the head,—is affected with som- nolency and with vertigo, when he sits up, and frequently suf- fers from a confusion of ideas: his mental powers are prostrated; he is sleepless,—always dejected; restless and despondent; he is constantly complaining, and suffers from contusive pains, often insupportable, in the hypochondria, along the limbs, and in the articulations. To those symptoms, are frequently joined others, such as in- termission of the pulse, a dry cough, dilatation of the pupils, augmented lachrymal secretion, hollowness and brilliancy of the eyes, itchiness of the nostrils, pains at the root of the nose, pe- culiar noises in the ear, deafness, grinding of the teeth, trismus, risus sardonicus, palpitation, dyspepsia, praecordial distress, pricking pains at the epigastrium, partial or general convulsive movements. These symptoms, according to Van Den Bosch, Rhan, and Bruning, indicate the presence of worms in the di- gestive passages; but Dehaen has proved, and the experience MUCOUS FEVER. 141 of every day confirms the fact, that all these phenomena may exist independently of worms. The mucous fever does not always follow a uniform course: we observe exacerbations, and even distinct paroxysms; some- times occurring at indeterminate periods, though generally in the evenings or during the night. They usually recur every day, though often with the quartan type, sometimes, with the double tertian, and more rarely with the tertian type. There is a re- markable slowness of the pulse at the termination of those exa- cerbations, and the heat and sweat is but little augmented. The paroxysms are often very long and interrupted by irregular ri- gors. The duration of this fever, varies from fifteen to forty days and upwards. It seldom terminates in a week, and its continu- ance is longer in proportion as the paroxysms are more marked. It terminates, 1st, by a return to health, after vomiting, diar- rhoea, aphthae, pustules, or a miliary eruption, general sweats, a flow of urine with a slight sediment, which is white, lateri- tious, or yellow; or, finally, after an abundant salivation: these symptoms may manifest themselves at variable periods, which it has been in vain attempted to determine; 2dly, by the deve- lopment of unequivocal symptoms of rheumatism, pleurisy, or peripneumony; 3dly, by death, after an obstinate diarrhoea, a pleurisy, an obscure peripneumony or arachnitis, excessive par- tial sweats, an increase of the symptoms of weakness or of the nervous symptoms; 4thly, by a chronic affection of the bron- chia, of the lungs, of the viscera of the abdomen, by anasarca or ascitis. In the latter cases, the fever often becomes intermit- tent, and is indefinitely prolonged. The complication of the mucous with the inflammatory fever, admitted by Roederer and Wagler, is contested by Pinel. The complication with the bilious fever has been observed by the same authors, and by Plenciz. To the principal phenomena of mucous fever are then joined some of those of the bilious fever; such as force and hardness of the pulse, at least at intervals; a greater degree of thirst, the presence of bile in the matters vomit- ed, and in the alvine dejections. The mucous fever, according to Pinel, may be complicated with high inflammation of the alimentary canal, tending to gangrene, a comatose state, with 142 PHYSIOLOGICAL PYRETOLOGY. an intense affection of the lungs, or with any other inflamma- tion: complications which reverse the ordinarily favourable prognosis of this disease. Relapses are frequent in the convalescence from mucous fever. It has been said of the mucous, as well as of the gastric fever, that it could not occasion death except by complicating itself with adynamy or ataxy; but before this theory was proposed, we were in possession of admirable descriptions of the traces left by the disease, which I shall describe in a summary man- ner. In 1761, at Gottingen, Roederer and Wagler found, on post mor- tem examination, the albumen distended by a fetid gas, and serosi- ty in the cavity of the peritoneum; 2dly, the serous membranes of the intestines covered with bluish, blackish, and gangrenous spots, more or less extended and numerous; 3dly, the gastro- intestinal mucous membrane always thickened, inflamed, red,* bluish, ash-coloured, blackish, gangrenous, spotted with red points, with aphthae, with vegetations, or little pustules formed by follicles largely developed, and very apparent, and covered with a thick, and frequently a tenacious mucus: the intestines often filled with lumbrici. The alterations of this membrane generally involved the stomach and small intestines, particularly the duodenum, which sometimes was alone affected. The sto- mach was rarely devoid of redness, but the follicles were less de- veloped, except near the pylorus; the membrane of the great intes- tine frequently participated in the alterations of that of the small intestines, and was, even more frequently than the latter, af- fected with vegetations, and covered with ulcerated spots; 4thly, the mesentery inflamed or gangrenous, principally in the parts of this membrane which corresponded with the inflamed or gangre- nous portions of the intestines; 5thly, the mesenteric glands fre- quently enlarged, hard, inflamed, red, or brown, especially those which corresponded to the same portions of the intestines; 6thly, the liver generally granulated, often very much enlarged, hard, * Semper in canali alimentari ham externse quam internse inflammationis notae observantur. Roederer et Wagler, De Morbo Mucoso. Goettingues, 1743, p. 242 et 249. This quotation is not unnecessary, since the expressions of these excellent observers have been singularly misquoted. MUCOUS FEVER. 143 sometimes red or blackish at its surface, the spleen of a deep blue; large and soft, or small and hard; 7thly, the lungs often adherent, inflamed, hepatized, gorged with mucosity, sometimes purulent, often tuberculous, the bronchia frequently red; the bronchial glands often enlarged, black, and hard; the pericardium more or less filled with a serosity which was sometimes bloody. During the epidemic mucous fever observed at Naples, in 1764, by Sarcone, Cotugno, Gervasi, and other celebrated prac- titioners, the examination of the body gave the following re- sults:— More frequently, says Sarcone, the internal changes did not cor- respond to the violence of the most formidable symptomsof the dis- ease, particularly when convulsions have been the principal pheno- mena, and when the patient had fallen a victim to their violence in the course of the first week, or, at the farthest, in the com- mencement of the second week. But when the disease had mani- fested an extreme degree of activity, great changes were observed in the body. When meteorism had preceded death, the viscera of the abdomen displayed, on examination, unequivocal signs of the highest degree of corruption. Most frequently the intes- tines were marked with livid irradiations, or with spots resem- bling petechiae. Their cavity was almost always covered with a tenacious and shining mucus, sometimes of an ash colour, at other times, yellow, and resembling a species of membrane, which, when detached, discovered the subjacent part inflamed, or gangrenous. The alterations were not always more serious in the small than in the large intestines. Frequently the latter were wonderfully swelled, covered with mucus, and a foul mat- ter of various aspect, and extremely fetid. They were gene- rally swelled unequally, and as it were, strangulated in certain points; this phenomenon was observed particularly in the colon, which was sometimes found loaded with dry and hard fecal mat- ter: worms are not always found. The great intestine was ge- nerally erysipelatous in those who had been affected with a diar- rhoea, which had passed into dysentery, and continued until death. This appearance sometimes extended to the small intestines. In this case, the mucous membrane appeared to be destroyed in cer- tain points, and, in some places, was absolutely wanting: in cer- tain places which were thus denuded, there transuded a sanguino- 144 PHYSIOLOGICAL PYRETOLOGY. lent matter. In other parts of this intestine, there was a sort of incrustation of thick and shining mucus, under which the mem- branes were usually found red, covered with small white pus- tules, resembling aphthae, or marked with spots which were livid, or pale and ash-coloured. In two patients who had suffered from dysentery, the rectum was found affected with an erysipelatous inflammation. In the cavity of the duodenum, and in its vici- nity, the bile had left traces of its passage: what these traces were, has not been stated. The stomach generally appeared di- minished in size. Most of the victims of this epidemic had suffered much from hunger. The parts of this viscus which were most sensibly changed were the cardia and the pylorus: these parts appeared erysipelatous, or marked with sanguineous irradiations, or too morbidly white, or of a deep and sometimes of a gangrenous red. The mucous membrane of the stomach was covered with a tenacious mucus, or with a small quantity of a yellow or greenish matter. This mucus and tenacious cover- ing, extended as far as the oesophagus, where it formed a kind of false membrane. When there had been no alvine dejections, the gall-bladder was gorged with bile. The substance of the kidney was always found vitiated, when death had been preceded by a violent hiccough. Cotugno states, that he had observed that the mesenteric glands, nearest to the intestines, were increased in size. On one occasion, only, the traces of inflammation of the diaphragm were observed. The pleura was covered with a thick false membrane. Large extravasations of serosity, or of a pure sanguineous matter, were almost always found in the chest. The lungs were often hepatized, and, asx it were, emphysematous. On opening the chest, they appeared swelled and distended; but, upon being divided or pricked, they contracted instantaneously. Demauro found serosity upon the brain, and in the ventricles, the meninges hard, thick, and steeped in a thick and tenacious lymph. The history of the epidemic of Naples, has often been cited: but the anatomical researches have been passed over in silence, because they did not fall in with the prevailing theories. Sar- cone himself did not know how to turn them to advantage: we may, however, remark, with this physician, that it is useless to advocate post mortem examinations with those who consider MUCOUS FEVER. 145 them unnecessary, because such opinions generally result from vanity or ignorance. " Cadavera hominum morbis denatorum medico secunda sunt mamisque inquinandae ut inveniat quae morbi sit sedes, quae causa, quis exitus antecedentum symptoma- tum; qui demum effectuum omnium in antecedenti morbo obser- vatorum eventus."* " The opening of bodies," says Lepecq,t " ought to inform us what organs have suffered lesion, and in what their morbid alterations consist." The pathological anatomy of the alimentary canal will find a more appropriate place in the following chapter. The following causes have been assigned to the mucous fever; viz. infancy, old age, the female sex, a lymphatic temperament, a state of languor or paleness, chlorosis, a constitution weak- ened by scurvy, or chronic intermittent fever; 2dly, A resi- dence in low, damp, marshy districts, deprived of the solar rays; the season of autumn; cold ground with humidity; want of clean- liness, the bath after meals, the suppression of habitual cutaneous diseases, of arthritis or rheumatism; 3dly, The want of food, or, at least, of fresh vegetables, the use of indigestible food, such as farinaceous articles, not fermented, unripe, sweet or acid fruits, damaged provisions, muddy, brackish water, the privation of wine where it has been habitually used, the abuse of emetics and purgatives, intestinal worms, organic lesions of the abdo- men, such as tabes mesenterica, excessive evacuations, chronic catarrh; 4thly, The abuse of venery, prolonged watching, ex- cessive study, inactivity, or too active a life, habitual depressing, moral affections, &c. In the preceding chapters it has been thought unnecessary to insist on the nature of inflammatory and gastric fevers: since, for the sake of avoiding repetition, this point will be discussed in a general manner at the end of this work, and since few physicians of the present day deny that these fevers are caused by irritation. As there are many who do not entertain the same opinion with regard to the mucous fever, I must enter into some details to prove that this fever consists in an irritation which is not of a pe- culiar nature, and which is not general. * Baglivi Praxis Medica, 1. 1, c. 5. t Collection d'Observations sur les Maladies et Constitutions epidemiques. Parie, 1776, 3 vol., in 4to. 19 146 PHYSIOLOGICAL PYRETOLOGY. It cannot now be necessary to refute the opinions of Galen, of Charles de Pois, Selle, Stoll, Sarcone, Roederer, Wagler, and J. P. Frank, with regard to the influence of the serosity, the gluten, and the phlegm in the production of the mucous fever. Not- withstanding his aversion to the humoral pathology, Pinel does not appear to be far from admitting that superabundant or vitiated mucosities, contained in the alimentary canal, may produce this fever. Yet he remarks, " We cannot but recognise a primitive affection, that is to say, a peculiar irritation of the mucous mem- brane of the primae viae; which, by a sort of sympathetic corres- pondence with the other symptoms of the animal economy, pro- duces the order of mucous fevers."* But, before he recognises in this vague manner the irritation of the stomach and intes- tines, which produces these fevers, he insists upon the necessity of remedying the atony of the viscera, the atonic relaxation which appears inseparable from the affection of the mucous mem- branes, of preventing a long continuance of the irritating matters in the alimentary canal, as well as of obviating the too debili- tating effect of evacuants. The incoherency of this theory and of these precepts is so striking that it needs no demonstration. It is supposed that the causes of mucous fever act by debili- tating; but there is not one of these causes which is not found among those which determine the most highly characterized inflammations; we cannot, therefore, judge of their mode of acting from the nature of the diseases which they produce, nor can we determine the latter, from the circumstance of these causes con- ducing to their production. The vital action, far from being languid in infants, is, on the contrary, more energetic than in adults, at least in the circulatory and digestive systems, and even in the brain. In every infant, one of these organs predominates, but in general the digestive system is the most active. It is, therefore, not surprising that the mucous fever is a common dis- ease of this early period. In old men it is in the digestive ap- paratus that the vital action persists longest; their stomachs are said to be always deranged, and this is true: but this derange- ment is generally a sur-excitation, which manifests itself only in a disturbance of function, on account of the weakness of the sym- * Nos. Phil, tome 1, p. 133. MUCOUS FEVER. 147 pathies at this age. Women are not weaker than men; they are even in general more irritable, and their digestive apparatus is more subject to irritation than that of men: it cannot then be wondered, that in an epidemic mucous fever, they are more rea- dily affected. Paleness, slowness of motion, muscular weak- ness, whether habitual or dependent upon convalescence from any disease, do not prove that the digestive organs are labouring under atony; the contrary is more frequently the case. There is certainly atony of the circulation in chlorosis and scurvy, but this atony forms a condition favourable to the development of any irritation whatever; if during this state no cause sur-excites the digestive organs, the phenomena of mucous fever will never manifest themselves. It is certain that cold and humidity debilitate the skin, at least at first;, but it is not less certain that these two atmospheric con- ditions determine at the same time a sympathetic increase of ac- tivity in one or more internal parts: this is proved by the in- creased lachrymal secretion, by coryza, leucorrhoea, odontalgia, angina, bronchitis, pleurisy, pneumonia?f pain in the forehead, the temples, the breasts, the praecordial region, the epigastrium, the loins, the hypogastrium, the testicles, the articulations, and the limbs, occasioned by the humid cold, according to the pre- disposition of the individual and the other circumstances to which he has been subjected. I have too frequently observed, both in my own person and in others, the stimulating influence of cold and humidity united, to permit me to entertain the slightest doubt upon the subject. This stimulation is most frequently felt in the digestive organs, especially if the patient has been using an improper diet; those organs being the most excitable of all those that form the human body. We cannot, therefore, be»surprised that humid cold produces the mucous fever, since the seat of these fevers is the digestive apparatus. The absence of the solar rays is doubtless one cause of debility; affecting first the skin, then the brain, and in succession the rest of the body; but can this cause alone produce the mucous fever? Want of cleanliness, by diminishing more or less the perspirato- ry action of the skin, the suppression of the irritations of this tissue, or of those of the articulations, the nerves, and the mus- cles, predisposes to this fever, only by determining a supplemen- 148 PHYSIOLOGICAL PYRETOLOGY. tory activity in the digestive organs. If the bath after meals has ever occasioned the mucous fever, the fact is not a surprising one; for, to produce this result, it is only necessary that it give rise to an indigestion. The privation of food may occasion, if not a mucous fever, pro- perly so called, at least the principal phenomena which characte- rize it. An abstinence of four days during health, from every thing except water, has assured me of this fact in my own per- son; but it is not true, that these phenomena are occasioned by weakness of the stomach. The physicians who have devised this wild etiology could have had no idea of the painful sensations at the epigastrium, and the sudden perspiration experienced in these cases. The tongue is red at its edges and point, and covered with a thick and white coat in the middle, the thirst is excessive; the skin burning, and the stomach so little weakened that a spoonful of wine occasions pains, such as are experienced in a commencing, though already well characterized gastritis. To place organic diseases of the abdomen, and especially the tabes mesenterica, among the causes of mucous fever, cannot but confuse the reader. What organic lesions are meant? Is not the tabes mesenterica recognised at the present day as a mesen- teritis, sometimes primitive, much more frequently owing to chronic enteritis? The bare assertion that the presence of worms in the digestive organs is one of the causes of this fever, is not sufficient; the fact requires proof: this neither has been nor can be given. All that can be said upon this subject is, that the ir- ritation which constitutes the mucous fever, is often accompanied by the presence of these animals in the alimentary canal, but we are in complete ignorance as to any effect they may have in the production of this fever: they merit much less attention than has been bestowed upon them. In vain has Lepecq pointed out the following signs of their presence, which, he thinks, should deter- mine the physician to adopt measures for their expulsion: nau- sea, syncope, pains pervading the whole body more violent in the head, and especially in the thighs, when they are rather gnawing than accompanied with a sense of weight; morsusven- triculi, colics, flatulence, a transient prominence of the abdo- men, vertigo, delirium ceasing and returning suddenly, convul- sions, tremors of the limbs, tremulous motions of the lips, phren- MUCOUS FEVER. 149 sy, a desire to bite, variation of the pulse, which is sometimes strong and at other times depressed, small, frequent, unequal, and intermittent. None of the morbid phenomena announce with certainty their existence; unless there are found pieces of the worms, or whole worms; they are seldom seen in the mat- ters vomited, more frequently in the alvine dejections. M. Bremser admits no other certain and infallible sign of their ex- istence.* Even in those cases in which the evacuation of worms has been observed, the symptoms attributed to their action upon the gastro-intestinal mucous membrane very frequently continue, when, on examination, none are found in the alimentary canal. Georget has, with reason, attributed to a lesion (which I must remark is often sympathetic,) of the encephalon, the symptoms which have generally been ascribed to worms, t Brera has ju- diciously remarked, that the evacuants resorted to for the expul- sion of worms, often do not act efficaciously, unless emollients have been previously administered. Pinel deserves great praise for having banished the order of verminous fevers admitted by Selle and many others; but he should not have ranked worms among the causes of the mucous fever, since they themselves are only an effect of the causes which produce this fever. The assertion has been made in too general a manner, that ex- cessive evacuations debilitate: if they diminish muscular action, they exalt sensibility, unless they are accompanied by too lively a sensation, as in coitus; but even this act is not succeeded by a general debilitation; the brain is rather in an apoplectic than in an asthenic state; the head is heavy and painful; there is a ten- dency to sleep; or a sense of pain in the stomach, and an irresisti- ble desire for food, which indicates an excitement of the gastric passages, analogous to that produced by long abstinence. The same remarks may be-made with regard to repeated watching; profound meditation, and melancholy, which destroy the ap- petite, only when the brain having become painful, produces a sympathetic irritation of the stomach. * Traite sur les Vers Intestinaux des Hommes. Paris, 1824, in 8vo. f De la Physiologie du Systeme Nerveux, Specialment du Cerveau, Recherches sur les Maladies Nerveuses. Paris, 1821, tome 1, p. 420, in 8vo; chez J. B. Balliere. 150 PHYSIOLOGICAL PYRETOLOGY. It is not correct to assert in a general manner that indolence or too active a life debilitates. Indolence weakens only the organs which remain inactive; and the assertion, moreover, is not rigo- rously true, since repose excites the organs of sense; inordinate exercise determines pain in the muscles and a cerebral sur-ex- citement, which render repose necessary, rather than debility of these parts. It may fairly be concluded, from this examination of the causes of the mucous fever, that if some of them have a debilitating influence, yet none have this effect upon the whole economy; that none of them debilitate the digestive organs, and that, on the contrary, all the occasional causes of this fever act by stimulating directly or sympatheticlly the gastro-intestinal mucous mem- brane. The physiological study, therefore, of these two orders of causes points to gastro-intestinal irritation as the proximate cause of this fever. This is also demonstrated by the unequi- vocal symptoms, (although they are frequently less apparent than in gastric fever,) of gastro-enteritis, observed in the mucous fever. Finally, on examination after death, traces of inflamma- tion of the gastro-intestinal canal are almost constantly discovered; consequently, the principal phenomena of the mucous fever are generally to be traced to gastro-enteritis. Roederer and Wagler have attempted to establish a distinction between the traces of simple mucous fever and those of inflam- matory mucous fever; but the result of their observations shows that the difference is only in degree. It remains to give an account of the mucous symptoms which particularly characterize this fever. These symptoms are the white and thick coating of the tongue, the nauseous taste, the vomiting and dejections of mucous and glairy matters. What do these symptoms indicate? An augmentation of the secretion of the gastro-intestinal mucous membrane. This increase of secretion does not announce an irritation sui generis, a specific irritation differing from the irritation without augmented secretion, (at least at the commencement and in the highest stage of the dis- ease,) which constitutes the gastric fever. This increased secre- tion, which appears from the commencement of the irritation of the gastro-intestinal mucous membrane, which augments and diminishes with it, cannot be the cause of this irritation. The MUCOUS FEVER. 151 existence of this irritation is incontestable; irritation cannot co- exist with atony in the same organ; this secretion then is not the result of atony, of relaxation of the gastro-intestinal mucous membrane, but of irritation of this membrane. Should the ques- tion be asked why the gastro-enteritis, constituting mucous fever, is accompanied by mucous symptoms, which are not observed in the gastric fever, the answer is easy: the question should not be why; but when and how: now, the experience of all times and all places has proved that an increase of secretion mani- fests itself, whenever the gastro-enteritis is the result of humid cold, of the use of gross rather than of stimulating food, in certain subjects of soft skins and pale tissues. To this the distinction, which has so little foundation in nature, between inflammation, properly so called, and catarrhal inflammation, or catarrh, reduces itself. Pinel, having admitted the identity of these two morbid states, was inconsistent in attributing the mucous fever to irritation sui generis. It may be ad- mitted that the follicles of the gastro-intestinal mucous mem- brane may feel more sensibly the influence of humid cold, since it suppresses the secretory action of the skin, and the mucous membranes supply the deficient action by an increased secretion. The anatomical researches of Roederer and Wagler tend to de- monstrate this proposition. Perhaps a sufficient distinction is not made in pathology between the follicles and the membrane in which they exist. However cautious we should be, not unne- cessarily to multiply the tissues of the body, this distinction ap- pears admissible, although it is likewise certain, that the mucous membrane itself is inflamed in the mucous fever. Cold and humidity do not affect the gastro-intestinal mucous membrane alone: it is not uncommon to observe coryza and bronchitis preceding the gastro-enteritis, which constitutes the mucous fever. Bronchitis frequently persists during the whole course of the latter; the irritation often propagates itself to the pulmonary parenchyma, or repeats itself in the pleura; a perip- neumony, or a pleurisy often misunderstood, then complicates the gastro-enteritis, increasing the danger of the disease, and frequently passing into the chronic state after the cure of the 152 PHYSIOLOGICAL PYRETOLOGY. gastro-intestinal irritation. The latter, also, very frequently be- comes chronic, and when it extends its influence to the perito- neum, it determines ascites. Nothing is more common than to observe the different irritations which give rise to the mu- cous fever: at length, ceasing to provoke the action of the heart, and prolonging themselves indefinitely. This result is more frequently witnessed from the circumstance of these irritations being ordinarily treated, by a method inappropriate to the na- ture of the disease. The greater number of facts which I have been able to col- lect, since the publication of the first edition of this work, a more careful consideration of those which I collected in the army, and a more attentive study of the treatises on epidemics, have convinced me, that simple bronchitis may occasion most of the phenomena, the collection of which, constitutes the mucous fever; that in old men, an acute inflammation, though not of the most intense character, of the mucous membrane of the bladder, may produce a similar effect; that an inflammation of the articu- lations after a forced march, during a wet season, may give rise to the same symptoms; that, in this case, the inflammation fre- quently ceases in the joints, and manifests itself in the digestive organs, or it develops itself in the latter, without ceasing in the former; that there are many cases in which the small or the great intestine alone is inflamed, the stomach preserving its normal condition. It is, however, true, that the mucous fever is gene- rally a gastro-enteritis: but to be only acquainted with what is most frequent, and to be ignorant of the exceptions, must ex- pose the physician to reverses and regrets. There is not only a gastro-enteritis in mucous fever, when it is accompanied by taciturn delirium, agitated dreams, vertigo, somnolence, or obstinate insomnolence, when the disease conti- nues many weeks, and we observe periodical returns of these dangerous symptoms, without exacerbation of the gastric and mucous symptoms. The encephalon is then affected to a cer- tain degree: this may have been the case from the commencement of the disease, or even previously, owing to the influence of cer- tain causes, or it may have arisen during the disease, under the influence of the gastro-enteritis. In this case, is observed, what MUCOUS FEVER. 153 is considered a complication of the mucous with the adynamic and ataxic fevers, or the conversion of the first into one of the latter, or, finally, its transition to the state of typhus. After the remarks which have been made with regard to the powerful action of cold and humidity united, of abstinence and the use of indigestible food, it can easily be conceived, that the mucous fever should showr itself epidemically in autumn, at the beginning of winter, and even at the end of the spring, when this season has been somewhat cold and there have been early rains. *It will readily be understood, that the cold and humid atmospheric constitution acts with greater force in low, damp, foggy places, covered with forests: in these places, this fever is found to prevail epidemically, not only during cold and damp seasons, but even when these two atmospheric conditions are by no means marked. When a very .hot summer is succeeded by a damp and uncom- monly cold autumn, the influence of the heat being still felt in the secretory apparatus of the bile, at the same time that the cold and humid atmosphere acts upon the digestive organs, there is observed, in many patients, a union of the symptoms of gas- tro-intestinal irritation with those of the augmentation of the bilious and mucous secretions. When during exposure to the causes which produce the mucous fever, an individual indulges in excesses of the table, making an immoderate use of succulent articles of food, generous wines, and spirituous liquors: this concurrence of symptoms is often observed. Such is the double source from which is derived the bilioso-mucous fever, or the complication of the gastric or bilious with the mucous fever: it is impossible in any other manner to account for the complica- tion of two diseases of the same nature, the seat of which is nearly the same. The complication of the inflammatory and the mucous fever, is not so chimerical as Pinel imagined: it is observed when the causes of the epidemic prevalence of the latter disease, are so intense as to affect those individuals in whom the circulatory ap- paratus is possessed of great force, or when to the gastroenteri- tis, which principally constitutes mucous fever, is added an in- flammation, sometimes latent, frequently misunderstood, of the lungs. To the gastric and mucou3 symptoms there are united 20 154 PHYSIOLOGICAL PYRETOLOGY. the signs of a high excitation of the heart, together with the phe- nomena of the thoracic phlegmasia; the cheeks are flushed, the pulse is full, hard and strong, and the skin very hot. Treatment of the Mucous Fever. The inference from the preceding observation, is, that the diseases which are designated by the name of mucous fever, are most frequently primitive gastro-enteritis, developed under the influence of humidity, cold and a bad regimen, and usually af- fecting subjects, whose mucous membranes are disposed to se- crete abundant mucosities: that the irritation often involves the whole extent of the air-passages, and of the digestive organs; that the gastro-enteritis may be accompanied by an arthritis, a pleurisy, or a peripneumony, either latent or manifest, by an ir- ritation of the encephalon, by a high irritation of the heart, or finally, by a sympathetic irritation of the biliary apparatus. These circumstances constitute so many shades which it is im- portant to recognise, as the treatment is not absolutely the same for all. The gastro-enteritis, which ordinarily constitutes the mucous fever, presents, likewise, shades of intensity to which it is im- portant to pay attention. Thus, the signs of irritation are well characterized, unequivocal, with or without diarrhoea, and the disease proceeds with rapidity; or the phenomena of gastro-en- teritis are obscure, of slight intensity, to a certain degree ob- scured by those which announce an abundant secretion of muco- sity, or a mucous turgescence of the diseased membranes. All these shades require a modification of the treatment. There are, if I mistake not, at least eight varieties of mucous fever, which the desire of nosological simplification has occa- sioned to be passed over without observation, which, however, it would be irrational to treat by a method absolutely the same, as pyretologists have advised. Let us, in a few words, pass in review their opinions with regard to the treatment of this fever. Servile imitators of their predecessors, Selle, Stoll, and J. P. Frank, have only had in view the expulsion of the glutinous mu- cous or pituitous matter, to which they attributed the disease. "The first indication," says Selle, "is the evacuation of the phlegm which covers the internal surface of the intestines." MUCOUS FEVER. 155 * ritic fever, described by Morton and Lautter, are a violent chill, general cold and intense pain of the chest, augmenting in inspi- ration, dyspnoea, extreme weakness; the pulse is at first small and formicant, afterwards hard and frequent; there is generally cough, the thirst is often excessive, and the tongue dry. This fever, which is not common, is only an intermittent inflamma- tion of the pleura or lungs; and this is so true that on the first paroxysm it is always mistaken for a continued peripneumony or pleurisy; it is only when the symptoms are observed to cease, the apyrexia to be established, and the symptoms to return again that the disease changes its name. Laennec observed an existence of pernicious peripneumonic fever. The subject was a man thirty-five years of age, robust and museular, he entered the hospital with a recent syphilis, the treatment of which had been imperfect. The sudorific ptisan and mercurial frictions were ordered. On the sixth day of his admission he had a paroxysm of intermittent fever of conside- rable violence, and he stated that he had had one on the evening of the day but one previous. A third paroxysm occurred on the third day after; but it was entirely different from the pre- ceding paroxysms. It commenced with a more considerable ri- gor, was accompanied with a violent headache, extreme dyspnoea, and hemoptysis. The chest having been explored about the middle of the paroxysm, the respiratory murmur was found unal- tered except at the root of the lungs, where it was masked by a rale crepitant well characterized, principally on the right side. Laennec, without hesitation, declared the disease a double pneu- monia in its initial stage: tartar emetic, six grains; sulphate of quinine eighteen grains, to be taken in three doses. The patient vomited a little and had but one stool; the next day, he thought himself cured. But as the rale crepitant had not entirely dis- appeared with the cessation of the febrile paroxysm, the two prescriptions were continued. The following paroxysm was very short; the rale crepitant was slightly developed, and the 55 434 PHYSIOLOGICAL PYRETOLOGY. hemoptysis reappeared; but the fever had scarcely ceased, when all the symptoms disappeared, (that is to say, as soon as the dis- ease ceased, it no longer existed.) The tartar emetic was dis- continued on the fifth day, the respiration having become pure and natural; the sulphate of quinine was continued for some days. The patient was now cured of the fever, and the anti-sy- philitic treatment, which had been suspended, was resumed. Three weeks after, the intermittent fever reappeared; it was now simple and benign, and a few doses of the sulphate of quinine en- tirely arrested it; the patient remained six weeks longer in the hospital, and left it in good health. This fact is important, since Laennec demonstrated by the stethescope the existence of a peripneumonia giving rise to ter- tian febrile paroxysms of a pernicious aspect, and diminishing in the apyrexia. That this case may be properly appreciated, and lest it should be thought that the inflammation of the lungs was the effect, and not the cause of the fever, it should be remarked, 1st, That Harvey found a thick blood engorged in the lungs, in dissecting subjects who had died in the cold stage of intermittent fever, after anhelation, sighing, prostration, a small, frequent, and irregular pulse; 2dly, That traces of inflammation found in the whole extent of the internal membrane of the trachea and bronchia, after poisoning by corrosive sublimate, have recently induced M. A. Devergie to believe that this salt acts also upon the lungs, although, as he remarks, experiments on animals have given no indication of this influence. Now, in the case which has just been mentioned, the patient was treated by mercurial frictions, and it was during this treatment that the peripneumo- nic fever was developed. The preparation of the metal was not the same; but it is not uncommon to observe acute or chronic inflammation of the lungs in venereal patients, treated by mer- cury under any form. On this subject I would refer the reader to the profound and able treatise of M. Jourdan on venereal dis- eases, in which all theoretical and practical questions relative to syphilis are laid down and discussed with equal talent and good faith. The cylinder of Laennec, so useful in detecting the pulmona- ry inflammations which often complicate gastro-enteritis and ce- rebral phlegmasiae, will be of still greater service in an investi- INTERMITTENT FEVER. 435 gation of the seat of intermittent fevers; and there is every rea- son to believe that the employment of this instrument will show that peripneumony does not occur only in pernicious fevers. Venesection, practised before the administration of the qui- nine, would have increased its remedial powers, and, perhaps, by preventing any farther paroxysms, would have rendered its employment unnecessary. We are indebted to M. Fleury for a remarkable case of perip- neumonic fever, or rather of tertian peripneumony. A man, for- ty-five years of age, of sanguine temperament, of well developed form, and high complexion, entered the hospital on the 17th of November, 1828, to be treated for a bronchitis, to which he said he was very subject. Until the 24th of the same month, he presented nothing peculiar; but, on this day, he was seized with acute and deep pain in the right side, with painful and anxious inspiration. The cough, which seemed to be relieved by de- mulcents, became frequent, and was accompanied with a consi- derable expectoration of sputa of yellowish red colour. The fever, from which he was suffering, had commenced with long and violent rigors. The sound given by the thorax, when care- fully struck, was dull over the posterior and superior part of the lung, and auscultation proved that the organ was with difficulty permeable to the air: demulcent ptisan, white looch, thirty leeches to the painful point, emollient cataplasms. The fever passed through the usual stages, and in the evening there was a copious diaphoresis. On the following day the apyrexia was complete; all the symptoms of pneumonia ceased, and the sputa became mucous, although still abundant. This state continued during the whole day; but, on the 26th, about four o'clock in the morning, the fever declared itself anew, by rigors as in- tense as those of the preceding paroxysm by dyspnoea, by a lan- cinating pain in the side; in a word, by all the symptoms of very intense pneumonia. As soon as a state of calm was re- stored, and the equilibrium of the vital forces re-established, to procure which, hot and demulcent drinks were administered, and bottles filled with hot water applied-to the patient, the sputa be- came very bloody: twelve ounces of blood were taken, and the white linctus and cataplasms were prescribed. From this time M. Fleury suspected an intermittent pneumonia, and proposed to administer the quinine in the evening of the same day. The 436 PHYSIOLOGICAL PYRETOLOGY. fever continuing, but with abated force, the quinine could not be administered. On,the following day the apyrexia was com- plete; all the peripneumonic symptoms had disappeared, and the patient, restored to a state of perfect calm, thought himself out of danger. M. Fleury took advantage of the intermission, and ordered a clyster of the decoction of bark, to which ten grains of the sulphate of quinine were added; and in the course of the day he administered a febrifuge potion. The fever appeared again, but the sputa were only slightly streaked with blood, the rigor only manifested itself in the feet, and the pneumonic symp- toms presented nothing alarming. Simple lavements of the de- coction of quinine were continued for some time on the days of intermission, and emollients on the intermediate days, and the patient in a short time recovered his health. In the dyspnosic or asthmatic variety, the pain is of little in- tensity, or there is no pain, the difficulty of respiration exces- sive, suffocation imminent, no sputa, although the cough is very s strong. The state of the heart not having been explored with care, and in many cases the oppression having continued after the cessation of the paroxysm, it is probable, under this name, benign gastric intermittents have been described, developed in subjects whose bronchia, lungs, or heart have been affected with some chronic disease. The catarrhal variety, described by Comparetti, differs little from the peripneumonic; although, in the case observed by this physician, the face, the throat, and the eyes were red, the cough dry, and more violent in the evening, the head painful, equally with the chest, and the taste depraved; convulsions and stupor supervened. What advantage is derived from assigning a parti- cular name, altogether insignificant, to an intermittent irritation of the bronchial mucous membrane, with sympathetic irritation at first of the digestive mucous membrane, and afterwards of the membranes of the brain? The latter organs are affected in eve- ry case of pernicious intermittent which attains a high degree of intensity. Irritation of the stomach and intestines is a very usual concomitant of irritation of the bronchial mucous mem- brane. We should in the pernicious fevers which arise from irritation of the respiratory organs, as well as in those derived from an ir- ritation of the encephalon, endeavour to dissipate the gastro-en- INTERMITTENT FEVER. 437 teritis, because the continuance of the latter during the apyrexia may counteract the contralizant action {action contralisante) of the bark. 4th. The syncopal is distinguished from the other varieties in which fainting occurs, by the fact, that in this disease the patient faints whenever he is moved, or attempts the slightest move- ment; he does not complain of pain, but of great weakness, his face and neck are covered with sweat, his eyes hollow and dull, pulse small, depressed, and frequent; syncope recurs every in- stant, no matter what precautions are taken. Should this variety of the pernicious intermittent fever be classed among those in which the heart is principally affected? I do not think so; although I conform to the general opinion, which considers the heart as the seat of the proximate cause of syncope. Syncope occurs because pulsations of the heart are suspended: but is not this suspension of the action of an organ, so little exposed to the direct impression of morbific causes it- self, the effect of a morbid state of the brain? The laws which preside over the action of the heart in a state of health, favour this opinion. The cardilic pernicious fever, of which M. Coutanceau* has reported several cases, appears to be dependant, rather than the preceding upon an active irritation of the heart. One of the pa- tients complained, during the paroxysm, not only of violent pal- pitations of the heart, but also of a cruel pain, which resembled the sensation of a biting in this organ. This pain having at- tained a certain degree of intensity, determined that indefinable sensation which precedes and announces syncope; the patient was deprived of all his senses, except that of hearing; he heard what was said and wished to speak, but was incapable. During this state, the arterial pulse and respiration were suspended, the pul- sations of the heart were weaker and slower than usual. The attacks of syncope generally continued for a quarter of an hour, and they were longer in proportion to the interval between them, which continued an hour or two. The first pernicious parox- ysm which had been preceded by two others, so slight as to be scarcely perceptible, had been calmed by the application of leeches; bark and opium diminished the intensity of the third, * Notice sur les Fievres pernicieuses qui ont regne epidemiquement a Bor ■ deaux en 1809. Paris, in 8vo. p. 60. 438 PHYSIOLOGICAL PYRETOLOGY. and a fourth did not occur. The two other cases, observed by the same author, cannot be considered as belonging to the cardi- tic variety, because, although there was syncope, the patient did not experience that acute sensation of biting, of torsion, which the patient mentioned above, experienced in so high a degree. May not an acute pain in the superior part of the stomach, have been mistaken for a pain seated in the heart, or its connexions ? If this was the case, the two last varieties are only shades of the cardialgic pernicious fever. 5th. The Uterine pernicious fever, either simple or with si- multaneous irritation of the stomach and uterus, has, I think, been observed by Gaillard. The paroxysms were characterized by vomiting and a metrorrhagy, which continued even into the apyrexia; the tongue was whitish, the face pale, the pulse small, concentrated, frequent, the abdomen tense and painful; the least motion renewed the vomiting and hemorrhage. A combination of fixed and diffusable stimulants of narcotics and tonics, ap- peared to determine the cure of this fever, in which the uterus was, perhaps, more affected than the stomach, although vomit- ing occurred: for it is well known how frequently this symptom is determined by an irritation of the uterus. 6th. The nephritic, described by Morton, was so evidently the result of an irritation, excited in the substance of the kidneys by the presence of calculi, that we are astonished to find this author endeavouring to discover an unknown proximate cause, when the true one was so obvious. The two patients had passed renal calculi. We find in the great work of Morgagni, several cases of death occurring with rapidity at the termination of the symp- toms, the collection of which presents what is observed in the diseases, to which the name of pernicious fever is given: in these cases, on dissection, calculi were found in the uterus and kid- neys. We may easily conceive, that an acute irritation of these parts may occasion an irremediable lesion of the brain, since the simple incision of the skin is sufficient, in a great operation, to render the patient delirious; since, also, death often follows this delirium. The cystic, described by M. Coutanceau, was primitively cardialgic; the pain of the stomach was replaced by a pain in the region of the bladder, a pain which was only relieved by INTERMITTENT FEVER. 439 bark. The presence of bougies in the urethra, and chronic ir- ritations of this canal, sometimes occasion pernicious attacks. 7th. The rheumatic or arthritic, described by Morton, was characterized by pains, at first tensive, gravative, contusive; af- terwards, lancinating: they prevented the movement of the limbs. They were accompanied with heat, sometimes transient, and sometimes ardent, with praecordial anxiety, with unquencha- ble thirst, with profound prostration, and with depression of the pulse. In this case, the gastro-enteritis was not equivocal, but it would be difficult to decide whether the pain of the limbs was sympathetic or primitive. 8th. We might class with pernicious intermittent fevers, the algid, in which the rigor and cold are excessive, the heat which only succeeds very slcfwly is inconsiderable, the thirst unquench- able, the tongue dry and brown: there is, likewise, syncope, and deglutition is embarrassed or impossible; every thing seems to announce the approach of death, and, consequently, a profound affection of the encephalon. The excessive coldness of the sur- face of the body, announcing only a violent internal congestion: this symptom may be found in all the varieties of pernicious in- termittent fevers, although it is most frequently the effect of gas- tro-enteritis. If a protracted rigor seems to constitute the whole paroxysm in the algid fever, in the diaphoretic, on the contrary, the hot stage commences so promptly, there is scarcely time to recog- nise the cold stage, almost immediately on the establishment of the hot stage, an abundant sweat flows from all parts. This sweat is thick, clammy, often cold, sometimes it does not appear until the termination of the paroxysm. The pulse is frequent, but weak and small, the respiration short and difficult, the mus- cular strength is completely prostrated, while the intellectual fa- culties are unimpaired. All these symptoms are not observed, except after those of the most intense gastric irritation; but, in many cases, the patient experiences the most violent pains in the limbs, which appear to indicate that the brain performs a very active part in the morbid condition, notwithstanding the integ- rity of the intellectual "functions. The diaphoretic pernicious has sometimes succeeded the comatose; a fact, which shows, as M. Alibert properly remarks, that the numerous forms assumed by pernicious fevers, do not belong to a special and constant cha- 440 PHYSIOLOGICAL PYRETOLOGY. . racter, but should be considered as simple varieties.* I must re- mark, that the skin is not an organ of sufficient importance, and that the sweat is never sufficiently abundant, to warrant the opi- nion that the danger is due to the state of this tissue in the dia- phoretic fever. The sweat, like the sensation of cold, is only a sympathetic symptom of the intense irritation, which consti- tutes the disease, the seat of which should be investigated. The exanthematic, petechial pernicious fever, described by Comparetti, was only a variety of the gastro-intestinal, since it was characterized by pain, a sense of constriction of the sto- mach, and sometimes with a vomiting, accompanied by thirst. The eruption of red spots, after which the symptoms diminished in intensity, and the pulse became large and soft; and, lastly, its frequency was only a secondary symptom, which did not an- nounce in the skin a morbid condition capable of occasioning death. A case of this kind, reported by M. Alibert, appears to me to belong to cerebral pernicious fever. It is unfortunate, that this subject was claimed by his relations, and, therefore, could not be examined. The icteric pernicious fever of Gilbert, presents but a sin- gle symptom more than those of the gastro-intestinal irritation, which constituted the disease. These pernicious fevers have all been observed either with the tertian or double tertian type; in the latter case, the perni- cious paroxysms occur on alternate days; they are separated by paroxysms of benign intermittent, at least at the commencement: for, in a short time, they not only assume a well characterized double tertian type, but even become sub-intrant. We, how- ever, find in authors some cases of pernicious fever of the quar- tan type. After having briefly described the numerous varieties of per- nicious intermittent fevers, and having made a few remarks with regard to their seat and nature, it remains to consider them in general under these two points of view. Among the characteristic phenomena of these fevers, we most frequently observe those which announce irritation of the sto- mach and intestines, and, afterwards, those which indicate cere- bral irritation; next come the symptoms which indicate that the * Op. cit, p. 27. INTERMITTENT FEVER. 441 heart, the lungs, the pleura, the uterus, the kidneys, the blad- der, are, if not the only point, at least one of the points of de- parture of the morbific action; finally, the skin presents various sympathetic phenomena, which only merit attention when we view them in connexion with all the others. If gastro-enteritis occurs in the most pernicious intermittents, the irritation is al- ways shared by the brain in a very high degree. The case is the same in every pernicious fever, peripneumonic, pleuritic, nephritic, &c. Finally, it is probable that gastro-enteritis oc- curs more frequently than we should be led to think, from the account of authors, since they have not always exactly indicated the state of the tongue and abdomen. We cannot but recognise in most carotic pernicious fevers, primitive irritations of the en- cephalon. Whence I draw the conclusion, that all pernicious intermittent fevers are not gastro-enterites, and that there is no pernicious intermittent fever, whatever may be its seat, which may not assume the pernicious character, when the brain parti- cipates in it. All the arguments which I used in demonstrating that benign intermittents, are of the same nature with continued fevers, apply equally to pernicious intermittents. The symptoms are the same, but some of them are more marked. The causes are the same. If marsh exhalations give rise to pernicious intermittent fever more frequently than to malignant continued fever, this is not enough to establish an essential difference between them, since the difference arises only from the mode of action of the cause, and from the idiosyncrasy of the patient. If pathological anatomy has not yet demonstrated that benign intermittent is of the same nature with continued fever, it has not done more to demonstrate, the identity of the latter with the pernicious intermittent. The last are common in some districts, and at certain seasons when they do not prove fatal, they dimi- nish in intensity, and pass to the chronic state, like the benign. As yet but a very small number of subjects has been examined after pernicious intermittent, because sufficient importance has not been attached to this kind of research. Why should these investigations have been pursued in pernicious fevers, when they were scarcely made in cases of malignant fever? However, it appears from some facts reported in the works of Spigel, Harvey, Bonet, Lancisi, Hoffman, Morgagni, Aurivill, Senac, Lieutaud, 56 442 PHYSIOLOGICAL PYRETOLOGY. and MM. Alibert, Fizeau, and Broussais,* that after intermit- tents which proved fatal after a few paroxysms, there were ge- nerally found unequivocal traces of acute or chronic inflamma- tion of the stomach, intestines, and liver. The spleen almost always presented a softening of its texture, which is probably the result of an inflammation of this organ. Sometimes traces of inflammation have been observed in the meninges, in the brain, and in the lungs. If these facts are not sufficiently numerous to warrant us in deducing from them decisive conclusions, in favour of our opinion with regard to the nature and seat of intermittent fevers in general, and of pernicious fevers in particular, they tend to show that farther researches in pathological anatomy, as they are conducted at the present day, will tend to demonstrate the identity of the nature and seat of continued and intermittent fevers. We cannot too urgently solicit the physicians of those countries in which pernicious fevers prevail, to engage in these researches, and to neglect no opportunity of enriching science with facts which may demonstrate the truth of the new pyreto- logical doctrine. Death sometimes occurring in the cold stage, most frequently in the hot, very seldom in the sweating stage, often after the disease has assumed the continued form, these different circumstances, which may vary the result of their in- vestigations, should be carefully noted. M. Bailly, profiting by his long residence at Rome, has re- ported a great number of autopsic examinations, of which I shall present a summary. At the termination of pernicious intermittent fevers, in which the encephalic symptoms predominated, such as coma, delirium, convulsions, he always found traces of arachnitis or encephali- tis, united or isolated, always traces of gastritis or enteritis, of- ten of splenitis; sometimes of hepatitis, peritonitis or pneumo- nitis, with or without traces of lesion in the cranium. After pernicious fevers, with a predominance of abdominal symptoms, traces of inflammation of the stomach and intestines were con- stantly found; they were very frequently accompanied by those of splenitis, which in certain cases were alone perceptible; in- flammation of the gall bladder, in a few cases, accompanied these * Many of these facts are given in the " Essai sur les Irritations Inter- mittentes," of M. P. J. Montgellaz, a work which, notwithstanding 6ome er- rors, deserves to be read. INTERMITTENT FEVER. 443 phlegmasiae. Gastritis seldom existed alone. In,.one subject the arachnoid, the encephalon, the intestines, the spleen, the peri- toneum and pericardium, all presented traces of phlegmasia. The spleen was frequently found ruptured. After pernicious algid fevers, also, traces of inflammation were detected in the en- cephalon and abdominal viscera. When there had been promi- nent pectoral symptoms, serious lesions of the lungs were dis- covered; in one of the subjects there were cavities in these or- gans. The importance of these anatomical researches are great; they tend to confirm the information we possess with regard to continued fevers, and what we presume from analogy with re- gard to intermittent fevers. * M. Gassand has published two cases of pernicious fever, im- portant as it regards pathological anatomy. A Swiss drummer, aged twenty-seven years, of bilioso-san- guine temperament, had several febrile paroxysms at the com- mencement of August; he took brandy and pepper with a view to arrest them, but did not succeed. After three unsuccessful trials, finding himself very ill, he determined to enter the hos- pital on the morning of the 15th; the paroxysm commenced with great coldness of the whole body, accompanied with grind- ing of the teeth. After this stage, which continued two hours, the pain of the head became insupportable, the heat of the epi- gastrium very considerable, and the pulse assumed a remarkable fulness and frequency; the patient urinated with difficulty: in the evening the paroxysm terminated in a clammy and fetid sweat. The paroxysm of the 17th was more violent. Sixteen ounces of blood were taken and twelve grains of the sulphate of quinine administered in a potion. On the 18th, the paroxysm returned, but in a less violent manner. Abstinence, gum-water, sulphate of quinine twelve grains. On the 19th, no paroxysm. Severe regimen, six grains of the sulphate of quinine. The pa- tient had no fever for six days, and was allowed some mild articles of food, when on the 24th, he procured a bottle of wine which he drank in part. In the evening of the same day he was seized with an intense and prolonged cold stage; his teeth chattered for three hours; with all the covering that could be put upon him it was impossible to warm him. This stage having passed, a * E. M. Bailly, Traite Anatomico-Pathologique des Fievres Intermittentes simple et pernicieuses; Paris, 1825, in 8vo. 444 PHYSIOLOGICAL PYRETOLOGY. corresponding hot stage succeeded. There was now agitation and delirium; the patient wished to make his escape; the at- tendants seized him at the moment he was climbing the gate of the hospital, and carried him to his bed, where he was watched until morning. On the 25th, the head and chest were covered with a cold sweat, the patient attempted to vomit, but threw up only a little bile. He answered no question, the dilated pupils, the fixed eyes, sparkling and haggard, indicated a cerebral congestion of the most intense character. Respiration was stertorous, the pulse full and very frequent. There were convulsive move- ments. The patient being incapable of swallowing any thing, a lavement of the decoction of bark, containing thirty grains of the sulphate of quinine, was administered. Venesection was practised, and at the same time the patient was placed in a warm bath, while cold effusions were employed to the head. At six o'clock in the evening there was a melioration, the patient spoke and took two potions containing the sulphate of quinine in high doses. On the 26th, a violent paroxysm: sulphate of qui- nine, thirty leeches to the jugulars, mustard poultices to the feet. On thie 27th, continuation of the paroxysm of the 26th; tetanic rigidity of the whole body, immobility of the eyes and eye-lids, sonorous respiration; general sweat of a fetid odour, frequent and involuntary dejections; deglutition impossible. Lavement of bark, blisters to the limbs. At five o'clock in the evening remission almost imperceptible. At eleven at night exacerbation, intermittent rale. Death occurred on the 28th at two o'clock in the morning. Sanguine effusion between the two folds of the arachnoid, which was red, thick and a little opaque; the tissue of the encephalon appeared softened, its vessels, as well as those of the plexus choroides, were considerably injected. The lateral ventricles contained three or four ounces of serosity. There was nothing remarkable in the thorax. The stomach presented two patches of a deep red towards the pyloric orifice; the mucous membrane appeared somewhat softened; the jejunum and ilium especially, presented at intervals some reddish spots; the large intestine was in its natural state. A soldier, aged twenty-three years, of a nervoso-lymphatic temperament, entered the hospital on the 13th of September, 1828, on the third day of a quotidian intermittent. Diverse symp- toms, particularly a pain deeply seated in the abdomen, diarrhoea INTERMITTENT FEVER. 445 and cephalalgy, led to the belief of a gastro-enteritis, which it was important to combat in the first place. Rice and milk, so- lution of gum Arabic, mustard pediluvium; emollient fomenta- tions to the abdomen. These means were ineffectual, and on the 18th, thirty leeches were applied to the abdomen and a rigorous diet was prescribed. This topical blood letting produced a melioration of the symptoms. Yet the diarrhoea returned; the skin, always acrid and burning to the touch, assumed a bluish yellow tint, the pulse became accelerated, the prostration, which became more prominent, still apparently permitted the applica- tion of twenty leeches, on the 21st, to the umbilical region and anus. On the 22d, insomnolence was continual, the thirst very intense, and the patient uttered groans during the whole night; the skin was in a perspirable state, the prostration extreme, but there was complete apyrexia. Broth morning and evening, fric- tions on the limbs, with a camphorated decoction of bark and a gummy potion with a grain of the gummy extract of opium, of which the patient drank only the half, at about 9 o'clock in the evening. The next day, at six o'clock in the morning, the pa- tient was found in a comatose state, which had manifested itself at seven o'clock on the preceding evening. Involuntary excre- tions, and a copious sweat had occurred about five o'clock. The pulse was large and full, and exceeded ninety-two pulsations in a minute. The patient, when pinched, opened his eyes a little, and then closed them without answering or seeming to understand what was said to him; respiration was stertorous and deep, and deglutition impossible. In hopes that the paroxysm would terminate happily, M. Gassand prescribed a lavement of bark with ten grains of the sulphate of quinine, and in ten hours the patient recovered his speech and senses; he did not retain the injection, and he swallowed with less difficulty two grains of quinine, which were to be repeated every hour. But they were not administered, and in the evening M. Gassand administered some grains in syrup. The same symptoms as those of the pre- ceding night reappeared with more intensity. On the morning of the 24th, a comatose state more profound than the evening before; greater insensibility, tracheal rale. A fetid odour was exhaled with the insensible transpiration. The pulse was pro- found and very frequent. He was moribund in the afternoon, and death occurred at five o'clock in the evening. The body 446 PHYSIOLOGICAL PYRETOLOGY. was examined five hours after. Straw-coloured tint of the skin. The glans and the anterior third of the penis were greenish and sphacelated. The external aspect of the brain, and particularly of the cerebellum, was of a singular bluish red; the vessels were extremely gorged with blood, and the arachnoid, covering the cerebral hemispheres, above and before, was infiltrated with an abundant clear serosity; this membrane being itself very red, owing to sanguine infiltration. The stomach presented, inter- nally a very slight inflammatory redness; the colour was much deeper over a surface which might be covered with the hollow of the band. The other viscera presented nothing remark- able. M. Gaste has reported a post mortem examination, which tends to show that the oedema of the lungs performs a part in some intermittent fevers. Huct, aged twenty-two years, of fair complexion, lymphatic, without beard, appearing as though he had scarcely attained the age of puberty, entered the hospital in December, 1828, for a tertian fever which yielded to the sulphate of quinine, and reappeared a great many times after the employ- ment of this remedy and other febrifuge measures. The flesh of the patient was singularly soft, the skin of a very decided straw colour: his gums became inflamed and ulcerated, his breath was fetid, and the cellular tissue appeared to be generally infiltrated. Still he had a voracious appetite; he took little exercise, his apa- thy and indifference were extraordinary, and, as he was very tired of his protracted stay in the hospital, his dismission was granted on the 11th of March, 1829, with the request that he might be exempted from service for a definite period. He re- turned on the following June, in a state of remarkable bloating and infiltration, with respiration so greatly impeded that death seemed near. He was put upon a rigid diet, in the use of gum- my drinks, or of veal broth medicated with nitre. He some- times laid upon the back, at others times on the side, but often sat up in bed, being threatened with suffocation. Both sides of the chest sounded well on percussion; the skin was of a very clear and bluish yellow; the indifference of the patient was ex- treme; he was discontented with every thing which was done for him. Finally, he died on the 20th of June, after a long ago- ny, during which he expectorated much serous fluid. The two sides of the thorax sounded well on percussion. Both lungs ad- INTERMITTENT FEVER. 447 hered to the thoracic parietes; their tissue was pale, and had the appearance of having been macerated for a long time. From the incisions made into their substance, there flowed a very abun- dant serosity, very faintly coloured with red; the incisions, exa- mined attentively, presented a surface marked with small eleva- tions, similar to those which appear on the skin in consequence of cold. The heart was very large and flaccid. The pericar- dium contained more than a demilitre of citron-coloured serosi- ty. The stomach and digestive canal were pale and softened.* Pernicious intermittents do not differ from the benign, with this exception; that in the former, the principal symptoms, those which indicate the seat of the disease, are manifest, and are easily distinguished from the well characterized sympathetic symptoms which may accompany them. Considered in their nature, ac- cording to their symptoms, these fevers are then only more in- tense than benign intermittents; considered in their seat, they present more frequently an affection of the encephalon, always of a serious character, and this is a new proof of their analogy to continued fever. "There is no doubt,'' says F. Hoffman, "that the membranes of the spinal marrow, having the same structure, the same na- ture, and the same use as those of the brain, may be affected with a spasmodic constriction; and that this very often occurs, particularly in fevers, and especially in intermittent fever; for the remarkable shivering, affecting the whole body, the coldness, the constriction of the pores and vessels of the skin, its pale- ness, as well as the yawning and pandiculations, are nervous af- fections which originate in the spinal marrow, and the pain which is felt about the first lumbar vertebra, at the commence- ment of most febrile movements, is an additional fact in support of this opinion." This opinion, which was reproduced in 1821, by M. Alard, was again brought forward in 1825 by M. Rayer, but with mo- difications which render it erroneous, by applying it exclusively to intermittent fever, which would thus become a cerebro-spinal neurosis, like epilepsy and hysteria, while continued fevers would be inflammations of one or more organs. It is even as- '* Gaste, Journ. Univ. des Sc. Med. 448 PHYSIOLOGICAL PYRETOLOGY. serted that intermittent differ from continued fevers, as much as that which exists differs from that which does not exist* The complete absurdity of this proposition must be ob- vious to every one. M. E. M. Bailly lays it down as a principle, that in the morn- ing, at the moment of our rising, congestion ceases in the brain and establishes itself in the stomach, owing to the vertical posi- tion, and that then the influence of the nervous system is more strongly felt over the whole body; that, on the other*hand, when we retire to bed, cerebral congestion establishes itself, the con- gestion of the stomach and the nervous influence cease, owing to the horizontal position. According to him, the intermittent fever is only an exaggeration of this series of organic acts. The principal proof which he adduces, is, that animals which are not subject to this alternation of the vertical and horizontal position are not affected with intermittent fevers in places in which they prevail epidemically. > M. Bailly does not, however, assert that they are never affected, but merely that they are less frequent- ly affected than the human species. Candour is evinced in this limitation of the proposition; but the fact that the exemption of the lower animals is not demonstrated,! invalidates the principal proof of M. Bailly. This physician adds, that animals subject- ed to the conditions which develop intermittent fevers among men, suffer from continued diseases, and this fact is certainly fa- vourable to his opinion; but he adds, "We find in animals,after continued diseases, the same organic alterations as in man after intermittent fever." Now, certainly, diseases which are refer- rible to the same causes, and which leave after them the same alterations, cannot but be identical in their nature. M. Bailly * Diet, de Med., XII. p. 390. f M. Lecharpentier mentions a case of intermittent fever in a horse, re- ported by Fromage. He adds, that if intermittent fever belongs particular- ly to the human race on account of their more exalted sensibility, and espe- cially on account of the organization of their skin, we yet daily observe in domestic quadrupeds, external local periodical affections, which are evident- ly the effect of the effluvia of damp and marshy places; such is particularly the intermittent irritation of the ball of the eye in the monodactyles, and particularly in young horses at the time of dentition: this disease is in the commencement completely intermittent, and is then curable by bark. {Me- moire sur la Periodicite, lu, en 1825, a la Society Medicale VEmulation.) INTERMITTENT FEVER. 449 should, from this fact, have concluded that continued epizootic diseases, and intermittent epidemics, differ merely in their type. But he only draws the conclusion, that the same causes deter- mine intermittent diseases in man, and continued diseases in brutes; for this reason only, that the former, while awake, is in the vertical position, and while asleep, in a horizontal* one, while the position of the latter is at all times horizontal. If there was no other difference between men and animals than that of posi- tion, M. Bailly might, perhaps, have discovered the cause of the difference of their diseases; but it remains for him to prove that this is the only, or the primary difference which exists between the organization of the human species and the lower animals. It is hardly necessary to remark, that in the countries in which men are affected with intermittent diseases, and animals with continued diseases, there are some men who, from the same causes, contract continued diseases, notwithstanding their pos- tures during sleeping and waking. The theory, then, of M. Bailly is erroneous in its fundamental position. If he persists in asserting that the intermittent fever is the exaggeration of the modifications produced in the organism by the alternation of night and day, we shall readily agree with him, provided he will likewise recognise this exaggeration, of a permanent character, in continued fever. Finally, it must be granted, that when the exaggeration of a congestion leaves after it traces of inflamma- tion, by no means equivocal, it cannot but be an inflammation. Such is the result of the anatomical researches of M. Bailly; he has, in part, realized the desire expressed in the first edition of this work, and wTe are no longer permitted to doubt that in- termittent fevers are owing to inflammations, as well as conti- nued fevers. " In all the post mortem examinations," he re- marks, " which I have made of those who died of pernicious intermittent fevers, I have always found unequivocal traces of an inflammation, which, in intensity, generally much surpassed the inflammatory lesions which are observed after continued fe- vers." The traces of which he speaks were not equivocal; for he adds, " It is already perceived that I do not speak here of those organic alterations which are often the subject of discus- sion between physicians of opposite sentiments; some being led by their theory to see nothing morbid in appearances, in which others cannot but recognise structural derangement. I speak 57 450 PHYSIOLOGICAL PYRETOLOGY. now of disorganizations so palpable as to allow of but one opi- nion."* Treatment of Pernicious Intermittent Fevers. If it be'improper to permit benign intermittents to pursue their course, it is much more so not to oppose energetically per- nicious intermittents, from the moment they are recognised; for they almost always occasion death in the second, third, fourth, or, at the latest, in the fifth paroxysm. I say almost always, because I am induced to believe, from some facts, that these fe- vers, abandoned to nature, are not always fatal.! But the ex- ceptions are so few in number, that wTe are bound to keep the rule always in view. When, in the course of a paroxysm of intermittent fever^ which has hitherto been benign, certain symptoms assume the highest degree of intensity, or unfavourable symptoms super- vene, which had not hitherto made their appearance; when the cold stage is excessively prolonged, at the same time that the pulse remains small and concentrated, and the features undergo a profound alteration, it is to be apprehended that the next at- tack will be pernicious, particularly if fevers of this character are prevalent. If the apyrexia is complete, the bark must be instantly admi- nistered, in a mean dose, without waiting for the disease to be- come more intense; for the first duty of the physician is to cure, and not to try experiments. If, notwithstanding the employment of the bark, the parox- ysm recurs with the phenomena of one of the pernicious fevers already described, there is not a moment to be lost: however short may be the succeeding apyrexia, we must seize this favour- able moment to administer the bark, not with reserve, but in a full dose. When the physician is called in during a Very short apyrexia, which has been preceded by one or more pernicious paroxysms, he must instantly administer the bark in large doses, lest he * Traite Anatomico-Pathologique des Fievres Intermittentes. Paris, 1825, in 8vo. t See my Additions to the CEuvres de Medicine Pratique de Pujol. Paris, 1823. INTERMITTENT FEVER. 451 should have to reproach himself with having permitted a pre- cious moment to pass unimproved, which perhaps will not re- turn. When the paroxysms are sub-intrant, the moment of the de- cline of the one, and the commencement of the other, must be taken for the exhibition of the bark. After the administration of the bark, should the paroxysms return, with symptoms not less alarming, or even more intense, we must endeavour to discover whether the inefficacy of the bark is in consequence of its bad quality, or of the smallness of the dose. If, on the other hand, there is reason to suppose that the bark has itself exasperated or provoked the gastric irritation, if the tongue is dry at its centre and red on its edges, and if the epi- gastrium is painful during the apyrexia, the success of the next dose of the bark must be ensured by acidulated drinks and the application of leeches to the epigastrium. If the paroxysm returns, but without the symptoms which threaten a fatal termination, it is not necessary to augment the dose of this substance, but its employment must be continued. Finally, if the paroxysm does not return, the employment of the bark must be continued in the same dose for several days, afterwards in doses gradually decreasing for one or even several weeks, in the same manner as though the paroxysm was ex- pected; that is to say, in administering the bark, that period of the day must be avoided on which the paroxysms formerly oc- curred. Whenever the pernicious character of intermittent fever is re- cognised, the bark should always be given in substance, in pure water, or in some distilled water, and as long as possible before the paroxysm which we wish to prevent; the dose should be at least six drams, often an ounce and a half, sometimes two ounces, and even more: Sims gave as much as six ounces. The half or at least the third, is to be taken at once, and the remainder in doses, gradually decreasing, in such a manner that the whole may be taken before the presumed instant of the paroxysm, should it occur. In proportion to the quantity of bark taken in a short space of time, will be the certainty of its effects. 452 PHYSIOLOGICAL PYRETOLOGY. If the fever is a double tertian, a strong dose of bark should be directed against the pernicious paroxysm, and a smaller one against that which does not. present this character. It has been proposed to administer the bark in doses of one or two drams only, with a view to mitigate the intensity of the pa- roxyms, without making them cease entirely. The advantages of this method are very problematical, except in certain cases, in which the stomach retains its irritation during the apyrexia; for, under these circumstances, a less considerable dose of bark may act with almost as much energy as a stronger dose given under other circumstances, without, however, provoking vo- miting. When the irritation of the stomach is manifest, even in the apyrexia, and when we are obliged to administer the bark at the decline, or even in the course of the paroxysm, and consequent- ly, when the stomach is for the most part irritated* finally, in pernicious fevers, which are evidently gastric, the rejection of the bark is sometimes prevented, as well as the pains of the sto- mach, which it occasions under such circumstances, and its effi- cacy is ensured by associating it with opium. Far from being advantageous in pernicious carotic or cephalalgic fevers, this combination might augment the stupor or pain of the head; might we not resort to it with success in pernicious, convulsive or de- lirious fevers? In cases in which deglutition has been impossible, -the danger imminent, and the gastro-enteritis so violent, even in the apy- rexia, that the stomach obstinately rejected the bark, it has sometimes been successfully administered in a lavement con- taining half an ounce or an ounce of this medicine, to four ounces of water, or the patient has been plunged in a bath of a strong decoction of bark. Frictions with the tincture of bark have been equally advan- tageous in certain cases. When we are called in during the paroxysm of pernicious fever, if there have been two, and especially if there have been three paroxysms of the same nature, and if there be reason to appre- hend that it will terminate fatally, Torti advises the instant administration of bark, without waiting for the apyrexia, at the risk of its being rejected, and even at the risk of seeing it aggravate INTERMITTENT FEVER. 453 the state of the patient. Others, among whom are Senac and M. Alibert, think that this desperate method should not be resorted to, except when the stomach and intestines are free from all irritation. Would it be proper, whenever we are called in during the course of the paroxysm, to combat instantly the irritation by the antiphlogistic treatment, as though it were continued, and to wait for the apyrexia, to administer the bark? If we only con- sidered the good effects of this method in many benign inter- mittents, we should be tempted to answer affirmatively; but if, under such treatment, the patient should die during the pa- roxysm, how severely should we reproach ourselves! When the stomach is greatly irritated, the bark cannot be ad- ministered without danger: to give it under such circumstances, is to risk all to save all. When the stomach is not irritated, or is only slightly so, the bark may be administered, and with the less danger; since, should symptoms of gastritis supervene, there will always be time to combat them: besides, there is nothing to prevent the employment, at the same time, of the antiphlogistic and derivative means, indicated by the cerebral, pulmonary, or other irritation which constitutes the disease. In the course of a pernicious paroxysm, when the symptoms announce a violent irritation, it would be hazardous to prescribe bark in any form. We must then limit ourselves to the em- ployment of the antiphlogistic measures employed, with a refe- rence to the irritated organs, revulsives applied to the skin with a view to hasten the termination of the paroxysm, and obtain an intermission. Are there pernicious fevers in which we should endeavour to fulfil preliminary indications, such, for example, as combating the plethora or the saburra of the primae viae, during the apy- rexia, before giving the bark? Torti has decidedly condemned this method. Many practitioners think that they should some- times ensure the action of the bark by the previous employment of blood-letting, emetics and purgatives, according to the inflam- matory, bilious or mucous character of the paroxysms. It is certain that these three measures have sometimes appeared to fa- vour the action of the bark; blood-letting has been advantage- ously practised, especially in subjects disposed to cerebral con- gestion, to inflammations of the viscera, and particularly of the lungs. This problem is certainly one of the most difficult to 454 PHYSIOLOGICAL PYRETOLOGY. ' solve in therapeutics. To arrive at as satisfactory a solution as pos- sible, let it be remarked, in the first place, that there is not always time to employ any of these measures in the treatment of perni- cious fevers. When the apyrexia is short, wTe must take advan- tage of it, to prescribe the bark. When the apyrexia is not so short as to necessitate the administration of this medicine imme- diately on the termination of the paroxysm, we should not only bleed, if there are marked signs of sur-excitation of the heart, but also apply a large number of leeches to the epigastrium; when there are symptoms of gastric embarrassment, and still more if these is manifest irritation of the stomach and intestines, I re- commend a great number of leeches, for instance from twenty to forty; since, in consequence of the urgency of the case, we can- not permit the blood to flow for a long time, and we must be on our guard against the occurrence of syncopes whenever the leeches are full we must remove them, arrest the flow of blood, administer the bark, and cover the surface of the body with hot cloths. There is every reason to believe that this treatment should be preferred to emetics and purgatives, when the disease is owing, either entirely, or in a great measure, to gastro-en- teritis. " Do not at the commencement treat as pernicious," says J. P. Frank, " an intermittent fever which presents a certain de- gree of intensity in its symptoms; do not believe that bark al- ways suffices for the cure of this disease; pernicious fevers have also their complications, which are by no means rare, sometimes plethora or a sanguine congestion of the head, the spinal mar- row, the chest or the abdomen require blood-letting, especially topical blood-letting by leeches and cups; sometimes, in conse- quence of these preliminary means, the malignity of the disease en- tirely disappears, and the disease assumes a more benign aspect." With the view to procure a longer apyrexia, and consequently the time necessary for the administration of the bark, Giannini plunged his patients into cold baths, to abridge the duration of the paroxysm, and hasten the development of the hot and sweat- ing stages. This rash practice must be rejected by every pru- dent physician, convinced of this truth, that although he cannot always cure, he should never injure. During the administration of the bark, the patient should avoid every cause of irritation, all mental emotion, and every thing INTERMITTENT FEVER. 455 that might have a tendency to operate unfavourably on the brain or stomach. The regimen in the apyrexia, and the general care of the pa- tient during the paroxysm, should be the same as in benign in- termittents. When the bark decidedly exasperates the paroxysms, and prolongs them notwithstanding every thing that may be done to prevent this result, all that' it remains in our power to do is to seek in derivatives of the skin, in blood-letting, in cold applica- tions to the head, and hot pediluvia, opium and the acids, the means, too often ineffectual, of arresting the progress of the dis- ease. If the fever becomes continued, we must abandon all hope of curing it by means of bark, and treat it according to the princi- ples laid down in the chapter upon continued ataxic fevers. The experienced practitioner, alone, can distinguish between sub-intrant intermittent fever, which may sometimes be success- fully combatted with the bark, from the intermittent fever pass- ing into the continued type, and in which, consequently, this medium must be hurtful. How has it escaped observation, that if the bark is generally injurious, or, at least, inefficacious, when administered during the paroxysms of intermittent fever, it must be still more im- proper in continued fever? I have shown that the bark being administered during the apyrexia, its tonic quality does not ne- cessarily prove that benign intermittents are not owing to an ir- ritation. The same remarks apply to pernicious fevers in gene- ral; but in the choleric, the cardialgic, and dysenteric variety, this application becomes more difficult, and in appearance less sa- tisfactory. It is objected that the bark cures intermittent fever even when the pain continues during the apyrexia, and when they are sub-intrant. This proposition is too general; the au- thors who have advanced it, have only mentioned those cases which they have successfully treated, andJ cannot but remark, on the present occasion, that of all those who have traced the history of epidemic pernicious fevers, there are few who have confessed that death has ever been hastened or determined by this febrifuge. When death occurs, it is always, according to them, because the bark was not administered sufficiently soon, or was exhibited in too feeble a dose, or was of an inferior qua- 456 PHYSIOLOGICAL PYRETOLOGY. lity. They seem not even to have imagined that the violence of the disease could ever bid defiance to the powers of the medi- cine. M. Alibert has not, however, omitted to record cases in which the patients have died in consequence of having taken the bark immediately before the paroxysm. During his residence in Holland, M. Broussais observed that no intermittent fevers, accompanied with cardialgia, vomiting, and colic, were successfully combated by the barkx. In Italy he witnessed the death of a patient, by no means plethoric, affected with a tertian fever, which, after the first dose, became quoti- dian, and then continued. On dissection he detected manifest inflammation of the lungs and stomach: the latter organ had been very sensible. Another subject, placed at first under the same circumstances, was cured by lemonade, and other relaxants and sedatives, which were ineffectual in the former. From this time M. Broussais divided patients affected with intermittent fever into two classes: 1st, Those who could bear bitters and bark; 2dly, Those whose stomachs required milder means. It was soon demonstrated to him that these diseases do not generally become mortal, except in consequence of inflam- mation of the viscera. Tartar emetic gave an increased degree of intensity to the irritation of the digestive organs; bark, wine, and bitters changed it into a phlogosis of a permanent and fixed character, and the fever became continued: it was necessary to resort to mucilaginous and acidulated drinks. Tartar emetic was the least injurious of these means, with the exception of ipeca- cuanha: all emetics, however, even those which consisted only of pure water, or of water mixed with oil, honey, or butter, were injurious: the vomiting, which was excited, continued sometimes during several days; at other times a single emetic caused the transition of the fever to the continued type. " Fi- nally," says M. Broussais, " I have seen death supervene during the operation of the remedy, and I have had cause to congratu- late myself that I witnessed this unfortunate result in the prac- tice of others, before I had exposed myself to a similar re- verse."* If emetics and bitters have produced such results in intermit- tent fevers, which do not appear to be pernicious, is there not * Histoire des Phlegmasies Chroniques, 2d edit. p. 127—136. INTERMITTENT FEVER. 457 reason to believe that the bark may not always be efficacious, and that it may even hasten death in those cases which evident- ly present this character, when the digestive passages are the principal seat of the irritation? I do not wish to dissuade from the employment of bark in pernicious fevers, nor to depreciate the results of the experience of physicians justly celebrated; but only to guard young practitioners against those authors who ad- vise to persevere boldly in the employment of bark, even when it increases the intensity of these fevers. I think it is proper, in this place, to make some general re- flections with regard to the action of bark in intermittent fevers, whether benign or pernicious, compared with the effects of this medicine in continued fevers, even at the risk of falling into re- petitions, which perhaps may not be devoid of utility. If the brain is entirely free from lesion, or nearly so, in be- nign intermittents, it is more affected at the commencement of many pernicious intermittents; it is profoundly irritated in all cases of the latter, when they have arrived at the highest degree of intensity, as well as in continued fevers. It is, therefore, ne- cessary to endeavour principally to prevent the sympathetic af- fection of this organ, or to diminish, by a powerful revulsion, the irritation which it experiences. Such is likewise the object to be kept in view in continued fevers; but, in the latter, the visceral irritation which provokes that of the brain is continued; that of the brain is likewise so, whether it be premature or secon- dary. How can we expect to operate a salutary derivation when the irritation continues in all its force until it has extinguished the vital action? It is on this account that the bark, far from curing continued ataxic fever, aggravates it. In ataxic intermit- tents, on the contrary, by seizing the instant when the abdomi- nal irritation has ceased, to employ the means which may pre- vent its return, we prevent with certainty the cerebral irritation which might follow; and the case is the same with an intermit- tent irritation of the heart, the lungs, or any other organ. If the encephalon alone is irritated, we likewise, in this case, at- tempt to operate a revulsion by anticipation, if we may so ex- press it, with the view of preventing the return of the irritation of the organ which is most essential to the maintenance of life. It is time then that the successful employment of the bark in pernicious fevers should cease to authorize the prodigal exhibi- 58 458 PHYSIOLOGICAL PYRETOLOGY. tion of it in continued fevers, and that its success in this case should no longer be opposed to a theory which it confirms in- stead of confuting. The cases in which the bark is administered with advantage, even when the stomach is irritated in the apyrexia, and those in which it is successfully administered in the intermission, scarce- ly perceptible, which separates the paroxysms of sub-intrant in- termittents, or even in the course of the paroxysm when it is feared that it may prove fatal, should be considered as rare ex- ceptions; to which, principles, established upon facts much more numerous, should not be sacrificed; and which, moreover, it is sufficient to relate, to demonstrate that they are not opposed to these principles. When the stomach is still irritated in the apyrexia, it is always much less so than during the paroxysm, but the bark is often re- jected, and more frequently inefficacious, except when this or- gan is perfectly sound during the apyrexia. The gastric irrita- tion persists in the interval of the paroxysm of pernicious car- dialgic fever more than in any other; this is also the fever in which we should fear most the failure of this remedy. When it does not fail, the patient often suffers for years, or even during his whole life, from painful digestion; he is subject to derange- ment of the stomach from the slightest cause, having exchanged an acute gastritis, which threatened his life, for a chronic gastri- tis, the effect of the remedy which has saved his life. This change is certainly preferable to death, and we should not hesi- tate to produce it; but we should be aware that we are substi- tuting for an acute mortal disease, a chronic one, which will re- quire the employment of emollients and regimen, when all fear of the return of the pernicious periodical exacerbation shall have ceased. In sub-intrant fevers, the bark fails very often, or it induces the continued type; and, if it sometimes cures the intermittent fever, it more frequently gives rise to a mortal continued fever. What stronger proof could we have of the inflammatory nature of pernicious intermittent fever, and of the excitant and non- specific action of bark, in the latter, as well as in continued fe- ver? When the sub-intrant fever is apoplectic or syncopal, the bark succeeds more frequently than in the sub-intrant cardialgic or choleric, because the digestive passages are more irritated in INTERMITTENT FEVER. 459 the latter: this fact forms another proof in favour of the opinion which I consider it my duty to advocate. A very limited num- ber of cases have been reported in which a cure has been ob- tained, although the bark was given during the paroxysm through an apprehension that it might terminate fatally. The more nearly intermittent fever approaches the continued, the less efficacious is the bark, and the more does it lose its anti- febrile qualities to manifest only irritating qualities. Is it not evident, however, that the action of this medicine upon the mu- cous membrane of the stomach must be the same in both cases. However different may be the nature of these diseases, it cannot change that of the medicine; consequently, the difference in the results of the action of the remedy is derived from the diffe- rence of the organic state: now, since it has been demonstrated, that the organs are affected in intermittent fever in the same man- - ner as in continued fever, and that the only difference between them is, that in the one the organic morbid condition is continued, while in the other it is intermittent or subject to exacerbations which provoke the manifestation of the sympathies, I hence conclude, that if the bark cures the former and not the latter, the reason is, that in intermittent fevers it acts upon organs which are sound or feebly irritated, while in continued fevers it acts upon organs strongly irritated. M. Tommasini divides intermittent fever into hypersthenic, resulting from excess of stimulus and determined by exciting causes; hyposthenic, derived from a contra-stimulus, and de- termined by depressing causes; and irritative, resulting from a disturbance of excitement, to a development of the sympathies of relation, in consequence of material causes which, at least primitively, are neither exciting nor depressing. In accordance with these views, he admits, 1st, that certain intermittents cease after some paroxysms without the aid of art, in consequence of the sweat; 2d, that others are arrested by the occurrence of some changes in the circumstances of the patient, not necessari- ly requiring the bark, which may be replaced by any other bit- ter, by unaccustomed aliment, or an unusual sensation; 3d, that blood-letting, diet and the contra-stimulants, among which are bark and bitters, cure other intermittent fevers which would not yield to stimulants, such as opium and wine, and which would even be rendered continued --by the latter; these fevers may be 460 PHYSIOLOGICAL PYRETOLOGY. cured without bark, and to render the bark effectual it must be preceded by blood-letting, and associated with contra-stimulating means: the bark administered alone, arrests the paroxysms, but they reappear, the disease not having been eradicated; these are the fevers which he denominates hypersthenic; 4th, that there are intermittents of a character diametrically opposite, in which blood letting, emetics, purgatives, not only do not succeed, but even aggravate the fever, and that they cannot be cured except by stimulants, such as opium and wine, or stimulants combined with bark; in these fevers the bark given alone would occasion interminable diarrhoea; these are the hyposthenic fevers; finally, he thinks that certain intermittent fevers, caused by the inges- tion of gross aliments, cannot be arrested exc'ept by the expul- sion of the indigestible substance which occasions them; he has never seen cases of this character, but he believes in their oc- currence on the testimony of respectable observers: these are the irritative fevers. Bark, according to M. Tommasini, is not anti-febrile, but ra- ther an anti-periodic; he by no means regards it as the specific of intermittent fevers, since he accords the power of curing them to blood-letting, diet, change of habits, to all the bitters, to the excitants which he calls contra-stimulants, and even to those which he calls stimulants. With regard to the morbid states with which intermittent fe- vers are connected, he says, that among them there are some which do not determine any organic alteration, notwithstanding the repetition of the paroxysms; that others occasion by this re- petition local congestions, which may remain after the fever; that some have for their cause an analogous morbid condition which continues after them, and destroys the patient a long time after the cessation of the fever; and finally, that in others there exists no ancient morbid condition of the viscera to which we may attri- bute the fatal termination of the disease; that death is determined either by an excess of stimulus, as in pleuritic or soporose per- nicious fever; or by the last degree of depression, as in the algic, syncopal and sudatory pernicious fevers. Justice forbids us to apply the rules of criticism to these pa- thological and therapeutic opinions, before they have been pub- lished and developed by M. Tommasini. INTERMITTENT FEVER. 461 CHAPTER XIII. Of Erratic, flnomal, Partial and Masked Intermittent Fevers. The paroxysms which characterize intermittent fevers, do not always return at fixed epochs: they are sometimes observed to be separated by very short intervals, at other times by very long ones; in the latter case they are very seldom pernicious: this ir- regularity of type most generally indicates that the disease which then assumes the name of erratic intermittent fever, will be tedious and difficult of cure. The bark is here less efficacious than in intermittent fevers of a regular type; it is especially by a total change of habits, of the manner of living and of the re- gimen that we must seek to restore the health. In this respect we cannot establish other rules than those which have been laid down in the course of the present work, when discussing the diverse indications which intermittent fevers may present. It is especially when these fevers are irregular or erratic that they pass into the chronic state. Cases have been mentioned in which one half of the body, de- termined either by a horizontal or vertical section, was affected with a rigor, while the other half was affected with an intense heat; other causes have been cited, in which the rigor, the hot and sweating stages, pursued their courses simultaneously; we are assured that the cold sometimes succeeds the hot stage, {fievres anomale.) Finally, the cold, the hot and the sweating stages sometimes manifest themselves only in a single member, the feet, the hands, or even on one side of the head, {local, partial or topical fever.) Without attaching too much importance to these rare cases, may we not say that nature presents them to us as it were to prove that the type merits but a secondary attention; that the character of the symptoms is a much more important object of 462 PHYSIOLOGICAL PYRETOLOGY. attention, with a view to discover the nature of the lesion which they announce, and the seat of this lesion; and, that if the in- termission is to be taken into consideration, it is only because ex- perience has demonstrated that we should seize this favourable instant for the employment of powerful curative means? In a work which will always be read with profit,* Frederick Cassimer Medicus has collected all the cases of periodical lesions ivithout fever, reported in the works of his cotemporaries and predecessors; among these, are cases of apoplexy, epilepsy, trem- bling, stupor, insomnolence, chorea, mania, hypochondriasis, hysteria, syncope, cold, heat, sweat, cutaneous eruption, icterus, cyano-dermia, lassitude, dropsy, paralysis, cephalalgia, vertigo, ophthalmia, blindness, ophthalmo-dynia, sneezing, epistaxis, redness of the nose, coryza, odontalgia, alveolar hemorrhagy, ulcer of the gums, aphonia, laughter, buccal hemorrhage, ptya- lism, otalgia, deafness, loss of memory, distortion of the fea- tures, luxation, asthma, cough, hemoptysis, pleuro-dynia, cardi- algia, hiccough, haematemesis, boulimia, want of appetite, thirst, or want of thirst, vomiting, diarrhoea, colic, hemorrhoids, ne- phralgia, retention of urine, diabetes, haematuria, gonorrhoea, pruritus of the vulva, abortion, umbilical hemorrhage, tumefac- tion, with throbbing in the hepatic region, ulcer on the penis, on the finger, hemorrhage from the toes, the fingers, or the knee, pains in the arm, erysipelas, cramps, &c. Let it not be thought strange, that I should cite this long list of intermittent diseases, or symptoms; I do so with a view to demonstrate that there is scarcely any morbid phenomena, or any disease which may not return periodically, or any organ which does not sometimes be- come the seat of a periodical derangement. In reading the work of Medicus, and the scientific annals of a more recent date, we are impressed with the conviction that intermittent diseases are much more frequent than they are generally thought. When we discard all preconceived opinions, and attentively consider the subject of periodical diseases without fever, the question naturally presents itself—what has caused these dis- eases to be considered as masked fevers, instead of being com- pared in the first place with continued diseases of the same na- evre, traduit de Lallemand par INTERMITTENT FEVER. 463 ture, and, in the second place, with pernicious fevers which do not differ from the first, except in this, that they ordinarily com- mence with paroxysms unattended with immediate danger, and are accompanied with sympathetic phenomena called febrile. It would then have been perceived, that benign and pernicious intermittent fevers do not differ from intermittent diseases with- out fever, except that the local irritation which constitutes the latter does not give rise to sympathetic phenomena in the same manner as the local irritation, more or less intense, more or less extended to several organs, and more or less shared by the sto- mach, which constitutes intermittent fever. I have just said that pernicious fevers generally commence with benign paroxysms, and are generally accompanied with sympa- thetic phenomena; because, in fact, these diseases may manifest themselves from the first, with the formidable train of symp- toms which characterize them, and sometimes be marked by no febrile symptom: in this case, it is difficult for the most skilful to determine whether there is pernicious intermittent fever, or per- nicous intermittent disease without fever; for it is generally ad- mitted, that masked fevers may be pernicious. These pretended fevers are themselves occasionally accompanied with some fe- brile symptoms,- according to Medicus; a circumstance which in- creases the perplexity of this involved theory. The denomination of masked fever is so little appropriate to the diseases which it designates, that even in.the ancient pyre- tological theory, it must have appeared ridiculous to men of in- telligence. This denomination should then be banished from the medical vocabulary, or only remain as a monument of error. To demonstrate that periodical diseases have a certain affinity to paroxysmal fevers, Medicus calls the attention to the striking analogy of the symptoms of the first, to the symptoms of perni- cious fevers, the transition of these diseases into each other, their intermittence, the lateritious sediment of the urine observed in both, and the necessity of submitting both to the same curative means. Periodical diseases without fever are seldom cured, ex- cept by bark. We must then admit with Sydenham, Van- Swieten, Huxham, Dehaen, Stoerk, Lautter, and Medicus, that these diseases are of the same nature, but far from concluding that periodical local diseases, without febrile symptoms, are masked fevers, that is to say, (in the language of most physi- 464 PHYSIOLOGICAL PYRETOLOGY. cians,) general diseases, disguised under the form of local dis- eases: we must avail ourselves of this luminous classification, as a strong argument in favour of the new doctrine, which consi- ders fevers of every type as groups of symptoms, occupying, apparently, the whole body, but in reality, produced by a local irritation. " Most periodical diseases," says Medicus, << have their cause in the abdomen, and especially in the stomach and intestinal ca- nal: an excessive irritability of these viscera, is the first cause of them; it is in the correspondence of the stomach and intestines with the other parts of the body, that these diseases originate; medical experience, and post mortem examination, have proved to me that it is most frequently in the abdomen, and not in the part affected with pain and disorder, that the visible cause of the disease exists. If Medicus had not mingled these profound views with hy- pothetical opinions, with regard to the influence of the bile and phlegm, and if his works in pathological anatomy had been more satisfactory, how greatly would he have accelerated the progress of pathological physiology! But, however he may have restricted his opinion with regard to the seat of these dis- eases, it is not correct to assert, that most of them have their seat in the digestive organs. How often do we see them cease, under the influence of direct local means. Medicus himself says, that Rabner cured himself of a hemicrania, from which he had' suffered for five years, by applying leeches to the suffering part. If gastro-enteritis is very frequent in benign intermittent fevers, and even in pernicious fevers, it is much less frequent in pe- riodical diseases without fever: it is in this particular that the former differs from the latter; and it is on this account that the bark is almost always employed with impunity in masked fevers, which are not seated in the stomach. A complete history of intermittent irritations and inflamma- tions, simple, and especially complicated, acute and chronic, with or without sympathetic symptoms, is still a desideratum. M. Broussais, from whom it might have been expected, has not even attempted to trace that of intermittent gastritis. REMITTENT FEVER. 465 CHAPTER XIV, Of Remittent Fever. Among pyretologists, some have omitted remittent fevers, and some have confounded alljcontinued fevers under this name; others, with more propriety, have restricted the latter denomi- nation to continued fevers, which present exacerbations; and they have called those remittent fevers* which in an uninter- rupted course present paroxysms analogous to those of intermit- tent fevers. According to Stoll, remittent fever should be considered as com- posed of two fevers, into which it should (be separated as into its two elements: the continued and intermittent, both of which be- ing produced-in the same individual at the same time, by the same or different causes, by the nature of the epidemic, by the me- thod of treatment, constitute the remittent. Pinel remarks with much sagacity, that this mode of viewing the disease is erro- neous, and that it may exercise a dangerous influence upon the treatment, by giving rise to the opinion that the intermittent part of the disease may be attacked directly by bark, to render the continued part more simple. Baumes considers remittent fever as a mixed kind of pyrexia, forming a shade between con- tinued and intermittent fever; belonging, however, more parti- cularly to the latter. Thus he approximates to the sentiment of Stoll, while he endeavours to differ widely from him. Baumes thinks that we should consider as remittent fevers even those, the return of which, nearly periodical, are not, or are no longer announced by a rigor: he adds, and this opinion is remarkable, that between the remittent and intermittent fever the difference is only in degree. Finally, the same author thinks, with Laut- * These fevers have been variously designated by the names of paroxysmal, Bub-continued, exacerbantes, proportionnees. 59 466 PHYSIOLOGICAL PYRETOLOGY. ter, that the exacerbation or paroxysm, and the remission should be spontaneous, to constitute remittent fever. However scholas- tic this idea may appear, it is, nevertheless founded upon obser- vation. All continued fevers would be remittent, if we desig- nated thus all cases in which there supervenes an exacerbation, or even a paroxysm, because the patient has been exposed to cold; or a remission, because he has been bled. Continued fever becomes remittent, when we observe the fol- lowing symptoms: Before the paroxysm, heavy, unrefreshing, or interrupted sleep, mouth foul on awaking, pain, or simply weight of the head, eyes heavy, or red, and dejected, sadness, disgust, disa- greeable sense of heat, felt principally in the palms of the hands, and soles of the feet. In the paroxysm, malaioe, sense of great lassitude, of tension in the muscles, of rigidity in the articulations, a movement of ex- tension in some, and of tension in others, a more or less irresisti- ble inclination to sleep, paleness and lividity of the nails, coldness of the end of the nose, and tips of the fingers, difficult respiration,! painful inspiration, frequent pandiculation and yawning, sensa- tion of cold on the skin at intervals, obtuse pains in the limbs, universal trembling, chattering of the teeth, paleness of the face and lips, somnolence, and sometimes slight delirium, small dry cough, considerable thirst, with dry, clammy, or bitter mouth, frequent desire to urinate, urine scanty and pale, sometimes tur- bid, pulse small, frequent, wiry, occasionally convulsive move- ments, great anxiety; when the patient is very irritable, impa- tience. This period declines insensibly; the rigors," trembling, and convulsive movements by degrees become less frequent; the pulse is alternately developed and concentrated; slight flushes of heat interrupt the sense of chilliness; copious vomiting super- venes; sometimes there is a kind of syncope, a mild and general heat succeeds, and the pulse becomes decidedly accelerated; the nausea and vomiting generally cease, and the urine flows; some- times, though not so frequently, it is red and hot; the patient is hot and uncovers himself, the face is red, the breath is hot, the eyes brilliant, the skin dry and hot, the thirst excessive, the res- piration less embarrassed, but more frequent, the pulse full and strong, equal, or frequent and quick, the pulsations of the tem- poral and carotid arteries are sensibly felt, and sometimes very REMITTENT FEVER. 467 marked delirium supervenes; sometimes pimples make their appearance, or a red eruption resembling urticaria; pains of the back, loins, joints, and head; all the symptoms increase in in- tensity during a certain time, and continue at the highest state of intensity for a longer or shorter period; then the alternation or diminution, and return to a state of violence begins to occur; afterwards the symptoms decline,, the skin is by turns dry, burning, temperate, and moist; it then becomes soft and per- spirable; the urine flows abundantly; it is of a citron colour, thick, sedimentous, sometimes depositing a lateritious sediment, the perspiration is re-established; sweats or bilious stools, and sometimes both, terminate the paroxysm. After the paroxysm, the patient experiences a melioration of his condition; he sometimes even believes that the disease has ceased: with the exception of a painful sense of fatigue, of bit- terness of the mouth, fetor of the breath, some remaining heat of the skin, and a disposition to rigor, we observe all the symptoms which existed before the commencement of the paroxysm. Such is, according to Baumes, the description of an intense and well characterized remittent fever; it is the same as that of intermittent fever. Consequently, the remarks which have been made with regard to the latter are applicable, in this respect, to the remittent fever. But Baumes has not confined himself to the description of benign intermittent fever; he has pointed out the symptoms of that which presents a character of malignity; he has described the pernicious remittent fever, which has been passed over in silence by most of our cotemporaries. "From the commencement of this fever," he remarks, "the pulse is soft, weak, small and profound, often unequal; the prin- cipal symptoms are nausea, obstinate vomitings, cardialgia, anx- iety; serous, bilious, very liquid diarrhoea; swelling of the face, deafness, somnolence, deep pains, delirium rather tranquil than furious, lethargic affection, difficulty of respiration, meteorism of the abdomen, uncertainty of the movements. In some epide- mics, only, the pulse is of considerable violence. Before the paroxysm commences the patients are depressed, suffer from ver- tigo, and are threatened with fainting. Great coldness suddenly supervenes, with pains which appear to come from the spinal marrow; the pulse is deep, and its vibrations*, which are scarcely sensible, are confused; the patient, motionless and cold, experi- 468 PHYSIOLOGICAL PYRETOLOGY. ences weight of the epigastrium, and vomits green bile. After^ • wards an acrid heat is developed, and the pulse rises slowly; then, even when it rises, it is more weak, soft and small thjin in ordinary cases, and it retains its irregularity; the skin is rough, dry and hot, and its heat of a more biting {mcrdicante) charac- ter than in continued fever, and is not covered with sweat until after the lapse of ten, twelve or fifteen hours. After the parox- ysm the fatigue is extreme; there remains an impression of heat in the mouth and interior of the body; the pulse is still similar to that of the access, or it is less frequent than the natural pulse; there is a discharge by the mouth and anus of serous, bilious, green and fetid matters. The following paroxysms occur at shorter intervals, and manifest greater violence; the morbid phe- nomena increase in intensity, and after the fourth, fifth or sixth paroxysm, the remission is scarcely perceptible; the disease has assumed the continued form, and has acquired an extreme vio- lence; the urine is limpid: the life of the patient is in the great- est danger. Baumes has sagaciously remarked that all these symptoms are far from being constant in their occurrence either in the benign or in the pernicious remittent fever; and that sometimes the re- mission in consequence of the calm of the circulation may be mistaken for an intermission, if the state of the pulse be alone regarded; but when all the circumstances of the patient are con- sidered, it is not difficult to distinguish the remission from the intermission, except in certain cases, in which the disease is equi- vocal; for nature sports with all our classifications without ex- ception. Baumes thinks, besides, without appearance of reason, that the number of pernicious remittents is greater than that of pernicious intermittents; but, to pronounce on this subject, it is necessary to be in possession of a series of well observed facts and nosological tables, kept with care in all the countries in which pernicious fevers prevail. There are, according to Baumes, three sorts of remittent fe- vers. The first comprehends all fevers the paroxysms of which commence with a rigor; the second comprehends all those the ex- acerbations of which commence either by coldness of the whole body, or only by a coldness of the extremities, or of the nose, or by a dry and more or less sharp cough; the third compre- hends all those, the paroxysms of which do not exhibit in their REMITTENT FEVER, 469 commencement either rigor or partial coldness, and are remark- able only for the exacerbation of the fever and the augmentation of the acrid heat, and other febrile phenomena, which decrease after having risen to their highest degree of intensity. The first or the first and second paroxysms of remittent fever, of the two last kinds, commence with a rigor which is generally considerable, and all the paroxysms terminate by sweating and the discharge of sedimentous urine. Fevers of the first kind more nearly resemble intermittent than continued fever, but the reverse is the case with those of the third kind. As it respects danger, Baumes distinguishes remittent into benign, less benign, when the paroxysm is attended with delirium, oppression, a dis- tressing cough, moderate meteorism; and grave, when there su- pervene in the exacerbations, faintness, syncope, or a phrenitic delirium, or a soporose or apoplectic affection; convulsive move- ments, a considerable or painful meteorism; symptoms of pleu- risy, of pneumonia, hepatitis, dysentery, of an inflammation of the abdomen, and when the pulse becomes soft, small, and une- qual. With regard to the inflammatory symptoms, they are the effect of the fever, if they are subordinate to it, that is to say, if the fever has manifested itself without them, if they have not appeared until the second or third paroxysm, or even at a period somewhat earlier, if they have no traces or only very obscure traces in the remission. If, on the contrary, the inflammatory symptoms have appeared before the fever, or at the same time with it, if they continue with rigor during the remission, the fe- ver is subordinate to the local inflammation, or it pursues its course simultaneously with it. In consequence of this distinc- tion, Baumes divides remittent fevers into encephalic, soporose, hepatic, pleuritic, dysenteric; and he reports the history of a pneumonic remittent fever, which he observed during the au- tumn of 1782. It is evident that this exact account of the ancient opinions with regard to remittent fevers, so ably given by Baumes, pre- sents the history not of an acute febrile remittent disease* but of the remittence of acute diseases of a febrile character; that is to say, attended with disturbance of the circulation. In this de- scription we find enumerated all the phenomena observed in con- tinued and intermittent fevers, with the same variety of inten- sity and a new combination. We have a mixture of the symp- 470 PHYSIOLOGICAL PYRETOLOGY. toms of acute irritation and disorganization of the brain and its membranes, of the stomach, the intestines, the peritoneum, the lungs, the pleura, the heart, and, in a word, of all the viscera. These affections give rise to remittent as well as to continued and intermittent fevers; they are irritations and inflammations occupying one or more organs, and appearing to the eyes of a superficial observer to invade the whole organism, some of the phenomena of which are permanent and others periodic; so that the disease might be said to recommence more or less frequent- ly without having, however, ceased for a single instant. It may be readily perceived that such a state must always be very seri- ous, provided it is at all prolonged. As remittent fevers have been considered as composed of a continued and intermittent fever, they have always been regard- ed as resulting from the causes which produce both, but espe- cially from those which give rise to the latter. As these causes have already been mentioned, they shall not be repeated here. We shall only mention, as meriting the attention of observers, the opinion of Alexander, of Chiannini, and of Ramel, who think that fogs and the extreme atmospheric humidity of marshy coun- tries produce periodical fevers. Without denying, with them, the existence of marsh miasmata, which, however, is not well demonstrated, it is certain that this humidity, especially in con- sequence of the heat which is joined with it, must have a very considerable effect in the production of diseases which affect the intermittent or remittent type. Baumes thinks that humidity is not sufficient to produce this effect, and that it can only give rise to simple cachexy and hemorrhage; but he forgets that, be- sides this cause, there exist all those which are capable of irritating the viscera,and that intermittence and remittence are perhaps only derived from the state of the skin, which is incessantly macerated, so to speak, in a humid and hot air: we know that a diminution of action in one organ, predisposes the others to active congestions, to an afflux of blood. All this is in favour of the opinion of M. Roche, with regard to the cause of intermittence. M. Robert Thomas says, that in post mortem examination of those who die of remittent fever, we generally find congestions of blood in the liver, inflammations of the digestive passages, and alterations of the brain. I have opened, or seen opened, in a practice of forty-five REMITTENT FEVER. 471 years, many persons who had died of fevers, and have always observed congestions in the viscera which are naturally san- guine, collections of bile or mucosity in the apparatus of biliary and intestinal organs. These disorders were generally accom- panied with sanguine, serous or mixed sanguinolent, or sanious effusions; the membranous organs were often thickened; the pa- renchymatous organs were either renitent or soft, filled with granulations which were likewise found in the affected mem- branes: finally, the internal surfaces sometimes tearing with con- siderable facility presented either the net-work of vessels which entered into their formation strongly distended, and as it were injected or large red spots, occasionally blackish points or true eschars. He adds, that the disorders were principally observed in the head when the air had been cold and dry; in the abdomen when it had been dry and hot; in the chest when there had been rapid alternations of heat and cold, of dry and damp weather, with a predominance of dryness* Baumes, then, acknowledges that the same morbid traces are detected after remittent and continued fevers. M. Bailly has recently proved at Rome, that the traces are also the same after pernicious intermittents; consequently, the identity of the seat and nature of these three orders of fever is demonstrated. Remittent fevers are more frequently quotidian than the in- termittents; they are less frequently tertian; they are sometimes double tertian, and seldom quartan: according to Sauvages, Co- lombier and Baumes, every sub-intrant fever is remitteht; it is certainly difficult, in such a case, to determine whether the disease is remittent or intermittent. Baumes thinks that the double quotidian and most other double intermittents, should be considered as remittents. Such are the difficulties and subtleties in which we are involved, when we attach too much importance to the type of diseases, and when we make special and distant affections of diseases, the types of which differ, although the phenomena are the same in both. . Baumes admits remittent fevers, with inflammatory, putrid or nervous tendencies, with a catarrhal, bilious or gastric state. Pi- nel questions the existence of an inflammatory remittent fever, admitted by Macbride, but he admits a gastric remittent fever. The diseases of this kind which Pinel observed affected old men; they occurred in the Salpetriere, and they appeared towards 472 PHYSIOLOGICAL PYRETOLOGY. the decline of autumn; they were produced by all the causes, physical and moral, of fevers: like gastric continued fevers, they were characterized by supra-orbitar headache, a mucous or yel- lowish covering of the tongue, a sense of bitterness in the mouth, with pain of the epigastrium. Who can mistake here the symp- toms of gastro-enteritis, especially if we add to them, as he does in several cases, diarrhoea or constipation, of a more or less ob- stinate character, and continued vomiting. Even when skilful- ly treated, they prolonged themselves, he remarked, even to the fortieth or forty-second day, and sometimes terminated to- wards the end of the second week. Pinel described, likewise, a mucous remittent fever, charac- terized by the frequent return of abdominal pains, a painful dis- charge of urine, a sort of salivation, a mucous tongue, horripila- tions in the night, augmented heat often interrupted with rigors, apthae, paroxysms which, towards the decline of the disease, de- generate into simple exacerbations. The duration of diseases of this kind, is not shorter than that of gastric remittent fevers. He, with reason, refers the hemitritoea of the ancients, and of Spigel, to the mucous remittent fever. He admits incidentally, that the adynamic fever may be remittent, and considers as such, many pretended cases of adynamic intermittent fever. We have frequently observed gastro-enterites with symptoms called adynamic, and well characterized exacerbations, preceded by a cold stage of little intensity and followed by sweating which was neither very copious nor very hot. Pinel has classed with atax-" ic fevers, pernicious remittent fevers, called sub-intrant, because their paroxysms encroach upon each other. These diseases are more dangerous than pernicious intermittents; it is much to be desired that some physician having charge of a hospital in a country in which these diseases prevail, should produce an ana- tomical and clinical history of these diseases, equally elaborate with that of Torti, with regard to their symptoms and thera- peutics. We shall dwell no longer on the causes, symptoms, nature and seat of remittent fevers, and we request the reader to apply to them the remarks which have been made with regard to the nature and seat of continued and intermittent fevers. We should only add, that if intermittent fevers sometimes become remittent, the latter frequently become continued. We have very lately REMITTENT FEVER. 473 observed this series of transitions in a female, who presented all the phenomena of a hepatitis, at first intermittent, and succes- sively remittent, continued, and again intermittent. Remittent fevers of little intensity, are only dangerous in con- sequence of their tendency to provoke profound and apyretic al- terations in the viscera; they seldom threaten the life of the pa- tient; they often resist with obstinacy every kind of treatment, and do not cease until after the lapse of a month or six weeks. Intense remittent fevers are, on the contrary, very dangerous; they threaten immediately the life of the patient, and often prove fatal in a few paroxysms. Blood-letting sometimes, emetics and purgatives often, bark always: such is the treatment generally recommended against well characterized remittents by authors who have adopted, without modification, the opinions of the ancients. We have seen above, that Pinel combated the opinion of Stoll, because it led to the prodigal employment of bark in remittent fevers: Pinel recommends the same treatment in these fevers as in the conti- nued type; he, however, advises, in consequence of their great duration, to sustain the strength of the patient with wine and wa- ter, rice and barley-water, cooked fruits, beer mixed with an equal quantity of water; it is not until the decline that he re- commends tonics, wine of wormwood, extract of juniper-berry and more substantial nourishment. With regard to ataxic re- mittents, which are almost always tertian or double tertian, he recommends, after the example of Torti, the employment of bark as in ataxic intermittents. Remittent fever may, in our opinion, be with advantage dis- tinguished into two species: the first species comprehends those cases, which are attended with no symptoms of imminent dan- ger and the other comprehends those in which the paroxysms approach each other, and become more and more alarming, in consequence of the lesion of the nervous system, and especially of the encephalon which characterizes them. To the first, we assign the name of benign, and to the second, that of pernicious, in the same manner as in intermittent fevers, and without at- taching any particular importance to these denominations. Benign remittent fevers should, according to Pinel, be treated in the same manner as analogous continued fevers; but this au- thor did not perceive that the existence of paroxysms required 60 474 PHYSIOLOGICAL PYRETOLOGY. particular attention, and that it was important to abridge the long duration of these diseases, with a view to prevent the ob- scure and chronic phlegmasiae, which frequently follow them. Stoll asserts with reason, that we should pay more regard to the continued symptoms, than to those of the paroxysms, except when the latter present the pernicious character; that remittent fevers should not all be treated according to the same method; that blood-letting may be useful, while, on the other hand, the bark converts a remittent fever into a continued, a grave or ar- dent fever, when the paroxysms do not announce any imminent danger. These remarks should be understood as relating only to the impropriety of a treatment adopted, with the view of put- ting an end to the paroxysms by bark alone; Stoll may with ad- vantage be opposed to Torti and Baumes. But we must not hence conclude that we should renounce every remedy but bark in the course of the paroxysm, with the view of abridging the latter, rendering them less intense, and preparing the return of the disease to the continued type. Experience has demonstrated to us, since the first publication of this work, that we must com- bat with energy the paroxysms themselves, in the same manner as we should act in case of a complication supervening in a con- tinued disease. There are, then, two sources of indications in the present diseases—the remission and the paroxysm. During the remission we must act precisely in the game man- ner as though the disease were continued, or at most, had only simple exacerbations of little intensity; it is consequently unne- cessary to repeat here what we have said; and what we shall say of the treatment of continued fevers. But we should here re- mark, that it is never proper in benign remittent fevers, to ad- minister the bark during the remission, unless we have pre- viously, by the employment of emollients and the local abstrac- tion of blood, converted the remission into a true intermission, an event of frequent occurrence, when we employ the antiphlo- gistic treatment. Otherwise, we incur the danger of converting a benign intermittent fever into a grave continued fever. When it has been judged expedient to abstract a large quantity of blood during the paroxysm, it is proper to permit the patient to enjoy complete repose during the succeeding remission, and only to employ emollients internally, with sometimes an evacuant lave- ment, or a rubefacient applied to the skin, if the circulation is not perceptibly accelerated. REMITTENT FEVER. 475 It was in the remission that emetics and purgatives were for- merly administered; they may be advantageously used when the remission has been replaced by an intermission: in this case, they are sometimes useful in persons of little irritability; this, at least, may be said of purgatives, for emetics more frequently provoke than cure remittent fevers. This fact is very important, and should not be forgotten. During the paroxysm we should employ the same treatment as in a continued fever which had attained its highest degree of intensity. This principle has not hitherto been laid clown with sufficient distinctness; but there is an important distinction to be made, viz. that in the cold stage we must act as though we were treating a disease at its commencement, and it is only in the hot stage that we must resort to the active treatment which we have recommended; whilst, in the sweating stage, the only thing ne- cessary is to prevent the patient uncovering himself incautious- ly, becoming cold, eating; in one wrord, prevent his deranging in any manner the movement from the centre to the circumfe- rence, which should be favoured by some agreeable warm drink, given in very small doses. During the intensity of the paroxysm we must study which is the organ most affected, the lesion of which is most hazardous to the patient, or, at least, presents the most prominent patholo- gical condition; we must then resort to the most natural means, which are clearly indicated in gastritis, enteritis, hepatitis, arach- nitis; in one word, against the irritation which gives rise to the symptoms of the paroxysm. Pernicious remittent fevers should be treated according to the same principles, with this difference, that when the antiphlogistic means have been employed with promptness and decision, in the hot stage of the paroxysm, the bark should be given> in the re- mission, if the danger is urgent, the life of the patient threat- ened, if there have been already two, three, much more if there have been four pernicious paroxysms. This is the most difficult case in practical medicine. This method succeeds very well when the irritation which constitutes the paroxysm exists only in the encephalon. When it is recent, and when the digestive passages are but slightly, or not at all irritated; perhaps, like- wise, when the irritation is seated any where else than in the di- gestive passages, though it may occupy an abdominal organ. It 476 PHYSIOLOGICAL PYRETOLOGY. has been likewise observed to succeed in cases in which the gas- tro-enteritis was still manifest during the remission. The folly which does not comprehend, and the improbity which misrepre- sents, have accused us of denying cases of this kind. A fact is more precious in our eyes than the most laboured theory; and, if we attach importance to theory, it is only on account of its connexion with practice. We repeat, that it is not more asto- nishing to observe the cure of gastro-enteritis, in consequence of the application of bark to the stomach, than to see an ophthal- mia cured by the application of a collyrium of alum, an erysi- pelas by the application of a blister, a boil by the application of citric acid, a urethritis by the injection of sulphate of zinc; but we have never said that bark acted as a blister; we know that the bark does not cause the removal of the epidermis, especial- ly where it does not exist; we know that this substance is not an excitant—an evacuant phlegmasick—but rather a tonic, a de- siccative phlegmasick, a tannant, and that one or another of these effects predominate according to the state of the organ and the individual predisposition. Nothing is more unworthy of a man of sense and information than to attribute to a single medicine the absolute quality of a febrifuge, an anti-periodic, when it has been demonstrated that this substance, in cases in which it ap- pears to be most decidedly indicated, sometimes increases the fever, and that by giving it during convalescence, in the days corresponding to those of the paroxysms, it reproduces them, as Baumes has said, and as we ourselves have remarked. However imposing may be the authority of Torti, there is cer- tainly danger in incautiously prescribing the bark in pernicious remittents, because this medicine often aggravates benign inter- mittents, which yet present an apyrexia of sufficient duration, and still more sub-intrant benign intermittents. Ramazzini has observed epidemic intermittent fevers in which the bark was more dangerous than useful, doubtless because the digestive or- gans continued irritated in the apyrexia: much more, conse- quently, may this medicine be injurious when it is administered without preparation in remittent fevers. We formerly said that these fevers often resisted, or yielded only temporarily to blood- letting; but this is in consequence of our not having recourse to this measure, except in the remission: since we have practised it, at the instant when the paroxysm is in its highest degree of REMITTENT FEVER. 477 intensity, we either abridge it considerably, and the following remission is frequently a true intermission, which permits us to administer the bark, or the paroxysm diminishes only in inten- sity, and the patient has now only a continued fever, which we must combat by the application of leeches at the time of the sim- ple exacerbations, which take the place of the paroxysms. The existence of remittent fevers, forming so natural a transi- tion from continued to intermittent fevers, presents an insur- mountable obstacle to the adoption of any theory in which in- termittent fevers are considered as being of a different nature from continued fevers: otherwise we must suppose that remit- tent fevers are of two different natures at one time, or of two alternating natures. 478 PHYSIOLOGICAL PYRETOLOGY. CHAPTER XV. Of Chronic Fevers. Fevers, whatever be their type, often prolong themselves during months, and even years, but not always with the degree of intensity which they present when acute. Before passing to the chronic state, continued fevers seem to cease altogether, or else some of their symptoms persist after the immediate danger has passed. Intermittents, in passing to this state, do not always become on this account less intense; but frequently the parox- ysms do not appear at periods equally definite, as in the com- mencement of the disease. A continued acute fever is some- times followed by a chronic intermittent fever, which towards the fatal termination generally resumes the continued type. The name of Splanchnic has been given to chronic inter- mittent fevers which are accompanied, or rather which are oc- casioned, by a manifest lesion of one of the abdominal viscera. When chronic fevers have continued for a long time, and sometimes even in the first weeks of their existence, whatever be their type, a remarkable diminution of strength is observed, and an emaciation, which generally proceeds with rapidity: these fevers are then called hectic. Debility and marasmus are more rapidly established in conti- nued chronic fevers, which more readily assume the name of hectic fevers; it is different in chronic intermittent fevers, the paroxysms of which, separated by intervals more or less conside- rable, allow, at least for some months, a renewal of the strength and nutritive materials. The time during which the strength remains unimpaired, and the body free from emaciation, in chronic continued fevers, has been but little investigated. It was by fixing his attention upon this important subject of observation, that M. Broussais recog- CHRONIC FEVERS. 479 nised the distinctive characters of several phlegmasiae, of which he has given the history in his important work upon these in- flammations. I cannot do better than to refer the reader to this immortal production, which is one of those books which will survive through all ages. We are indebted to the same author for a history of hectic* fever, superior to the work of Truka upon this disease. M. Broussais defines hectic fever—a continued slow fever, of a long and indeterminate duration, with consumption of the forces, and emaciation; and, to complete the symptoms of this morbid state, he adds the following characters: "Febrile move- ment, slow and continued, with exacerbations in the evening, most frequently after eating; sometimes of an irregular charac- ter, during which the patient experiences a sense of heat in the palms of the hands and soles of the feet, and after which they have abundant sweats, which debilitate them greatly; emacia- tion, more or less rapid in proportion to the activity of the fe- ver, and the abundance of the sweats and diarrhoea." He ad- mits three degrees or periods of this fever: in the first it is obscure, irregular, and the functions but little altered; in the second, the pulse, which is always small, quick, and frequent, becomes accelerated in the exacerbations, during which heat of the hands and feet manifests itself, and copious and debilitating sweats occur; the emaciation is then rapid: finally, in the third, all the symptoms are very intense, and the emaciation is carried to the degree of marasmus; the patient resembles a skeleton, co- vered with a dry and clay-coloured skin. This author distinguishes hectic fevers, derived from a le- sion of the action of a single system, from those which depend upon a lesion of action in several systems. This division be- ing founded upon an incomplete analysis of the phenomena and causes of the disease, an analysis, the defective character of which M. Broussais has himself recognised, I shall not dwell upon it. But among the different species of hectic fever which he admitted,"when he wrote his Dissertation on these diseases, there are several which are deserving of all our attention: these * Researches upon Hectic Fever, considered as dependent upon a lesion of action of the different systems, without organic disease. Paris, 1803, in 8vo. 480 PHYSIOLOGICAL PYRETOLOGY. are the gastric, the pectoral, the genital, the hemorrhagic, the cutaneous, and the moral. To the first he assigns the following distinctive characters: anorexia, dryness of the mouth, copious secretion of saliva, dif- ficult digestion, accompanied by a sense of weight, eructation, vomiting, cardialgia, praecordial uneasiness; sometimes, he re- marks, the appetite continues, or is increased, but the digestion is always laborious. In infants who have just been weaned there is also lienteria, and sometimes boulimia. To these symp- toms are sometimes added, bitterness, and a clammy state of the mouth, a yellowish white or mucous coating of the tongue: sen- sibility of the epigastrium, and supra-orbitar headache. When the disease has been exasperated by improper food, by high sea- soning and cordials, the cardialgia and uneasiness are more dis- tressing, and there is a sense of heat at the epigastrium. Some- times food of the mildest character occasions acute pains, and is often rejected by the stomach. Finally, paleness, dilatation of the pupil, itchiness of the nostrils, acidity of the breath, saliva- tion, pains in the abdomen, mucous diarrhoea, and still more the discharge of worms, indicate the presence of these animals in the digestive apparatus. These symptoms do not permit us, at the present day, to mistake a chronic gastritis with habitual acceleration of the pulse, and a more or less regular exacerbation of this accelera- tion. We should, I think, attribute to the same organic cause hectic fevers, arising from prolonged lactation, since the result of this kind of excess is an increase of the digestive action; and, finally, an inflammation of the stomach. The pectoral hectic fever has the following characteristic symptoms: 1st, Sometimes an acute pain in the larynx, a con- vulsive cough, with redness of the face, fear of sudden suffocation, sometimes ceasing suddenly; the trachea is then the seat of chro- nic irritation, the proximate cause of this fever; 2dly, Sometimes a strong and frequent cough, an expectoration often purulent and abundant, dyspnoea, a general pain of the chest, a sense of uneasiness and weight under the sternum: the bronchial mucous membrane is then the seat of the irritation which provokes the fever; 3dly, Sometimes we observe signs of the chronic phleg- masia of the pulmonary parenchyma, or of the lungs, upon which it is not necessary to dwell in this work. Thus the pec- CHRONIC FEVERS. 481 toral hectic fever depends upon a laryngitis, a bronchitis, a pe- ripneumonia, or, finally, a chronic pleurisy. The signs of gas- tritis are frequently, though not always, associated with these inflammations. The characters of the genital hectic, are a discharge of a mu- cous, whitish, yellowish, or greenish matter, more or less acrid and fetid, a sense of scalding and pruritus in the vagina and ure- thra. Anorexia, dyspepsia, pains at the epigastrium, the loins, and the thighs, generally accompany this discharge, and indicate that chronic inflammation of the stomach generally accompanies that of the genital mucous membrane. We should class with this hectic fever, that which arises from chronic inflammation of the bladder, known under the name of catarrh of this organ. Hectic, in consequence of excessive hemorrhage, should not be attributed to weakness, the result of loss of blood. Every hemorrhage being the result of an irritation of the bronchial or gastric mucous membrane, or of some other par.t, the fever re- sults from the irritation which is the seat of the hemorrhage. Hemorrhage from wounds, and considerable losses of blood, from whatever cause, do not occasion fever except indirectly, and only when the action of the gastric passages repairs by a more rapid digestive action, the loss of materials sustained by the econom)'. Hectic fevers succeeding the disappearance or suppression of periodic or habitual hemorrhages, are the result of a supplementary irritation, which establishes itself either in the digestive passages, the lungs, the genital apparatus, and per- haps in other parts, such as the liver. The same principle ap- plies to hectic arising from suppression of the perspiration. The fever in which excessively copious perspiration occurs, does not, on this account, differ from the others; for it is not a single ad- ditional symptom, nor the intensity of a single symptom which can establish a fundamental difference between two diseases. Hectic fever, in consequence of any chronic inflammation whatever of the skin, sometimes exists with, and sometimes without symptoms of chronic gastritis: this consideration is not unimportant, in a practical point of view. Hectic, arising from a moral cause, is, according to M. Brous- sais marked by the following symptoms: a sad and morose air, aversion to society, the predominance of some particular idea, a neglect of the duties of life, and even a neglect to satisfy the 61 482 PHYSIOLOGICAL PYRETOLOGY. wants of nature; we, likewise frequently observe palpitations, mournful sighs, tears, a profound alteration of the features and pulse, if the patient be suffering from nostalgia, and his country or persons dear to him are made the subjects of conversation. This fever, evidently, depends upon a cerebral irritation, accom- panied or not by gastritis; but, to complete the picture, we must add to it all the characteristic signs of melancholy, epilepsy, and catalepsy, which are often accompanied with the symptoms com- mon to all hectic fevers. I shall not pursue farther the exposition of the phenomena, so variously presented by subjects affected with hectic fever. It could easily be demonstrated, that there is not a single organ, however unimportant, which may not, when it is the seat of a chronic inflammation, give rise to the symptoms of this fever. I shall not enter upon an investigation of the causes of hectic fever; they are those of all chronic inflammations: like those of acute fevers, they never act at the same time upon the whole economy, nor do they always involve the gastric mucous mem- brane, although this membrane most frequently feels their in- fluence. Death is necessarily the natural termination of the hectic fever, unless a happy change supervene either spontaneously, or in consequence of medical treatment. It is always more difficult to cure than acute fevers, with the exception of the adynamic and ataxic, and the facility of its treatment must always be in proportion to the attention with which the nature and seat of the organic lesions, always local, which occasion it, are studied. The subject of M. Broussais' thesis, was the hectic fever, in- dependent of any irremediable lesion in the structure of the or- gans; on this subject, it is not possible to establish rules of a very positive character. All that can be said, is, that the case is not hopeless as long as the patient is not reduced to the last de- gree of marasmus, and is free from a dropsy or diarrhoea, which would carry him off in a short time. The distinction which M. Broussais has thought proper more recently to establish between the hectic oi pain and the hectic of resorption, appears to me of little utility and of doubtful pro- priety. When an organ which has undergone a profound altera- tion in its tissue, begins to suppurate, hectic fever becomes aggra- vated; when the pus does not find an issue externally, it forms a new cause of irritation, and adds to the intensity of the fever; CHRONIC FEVERS. 483 finally, when the introduction of air into the focus of disease adds anew to the irritation, the fever becomes still more intense: upon these facts the distinction of M. Broussais is founded. The diarrhoea which so often attends the last period of hectic, always depends, as M. Broussais has demonstrated, upon inflammation of the intestines; it is the symptom of a sympathetic inflamma- tion which aggravates the primitive and which precipitates the fatal termination. On post mortem examination, we almost always discover pro- found and unequivocal traces of inflammation in one or more viscera. These traces, being profound, the organic tissues en- tirely altered, destroyed, or in a state of suppuration, the symp- toms observed during life, and the death of the patient, are rea- dily attributed to them. There is no hesitation about admitting the secondary or symptomatic nature of the hectic fever. What then should cause a different mode of reasoning when we find similar traces of less predominance, after acute fevers? If there be nothing repugnant to reason in attributing death to a morbid state, which leaves very marked traces after having occasioned phenomena of little prominence,, how can we refuse to attribute death to a lesion of the same nature; which leaves, it is true, less profound traces of its existence, but which gives rise to very re- markable though rapid phenomena during life? There are cases of hectic fever of very unfrequent occurrence, and of which I have observed a single example, in which autop- sy reveals no lesion. Must we then conclude, that this fever is owing to the affection of no organ? To draw this conclusion, would be to misapply the researches of pathological anatomy, and to shut our eyes against the lights furnished by the symptoms. These cases are, I repeat, very unfrequent; in most of those which have been reported, it is probable that chronic inflamma- tion of the mucous membrane of the digestive organs, of the arachnoid, or of the brain has existed, although it has escaped observation. Even in the case which I have mentioned, I would not affirm that the arachnoid was free from lesion, for at the time when I saw the case I was but little acquainted with certain pathological states of this membrane. We know, at the pre- sent day, that nostalgia does not occasion death except by super- inducing chronic gastritis or chronic inflammation of the menin- ges; I should add, of the brain likewise, if the signs of chronic encephalitis were better known. Gastric hectic fevers are the 484 PHYSIOLOGICAL PYRETOLOGY. most common; next in point of frequency are the peripneumo- nic and pleuritic, almost always complicated with the former, es- pecially in their latter period. The treatment of hectic fevers caused by chronic inflamma- tion of the lungs, was but imperfectly known when M. Brous- sais published his History of the Chronic Phlegmasiae. The importance of guarding against irritation of the mucous mem- brane of the stomach, lest inflammation of this membrane should supervene on that of the lungs, and accelerate the fatal termina- tion, was not sufficiently understood. The treatment of gastric hectic fevers was completely misunderstood, because the state of the internal membrane of the stomach and intestines in these fevers was imperfectly known. As to the others, the remedial' measures resorted to in them were dictated by a vague idea of debility. After having paid a tribute to the errors of his mas- ters, M. Broussais demonstrated, in a superior manner, the ne- cessity of limiting the treatment of these fevers to the adminis- tration of diluent, mucilaginous, edulcorated and sometimes aci- dulated drinks; to suppuratives of the skin and cellular mem- brane, when these means do not augment the irritation against which they are employed; to the removal of every irritating cause capable of affecting, not only the irritated organ, but like- wise those which are sympathetically connected with it. At the present day, M. Broussais adds to these simple means, an exposition of which may be found in his History of the Chronic Phlegmasiae, leeches applied in small numbers and more or less frequently, as near as possible to the inflamed organ. Such appears to be the general method to be followed in the treatment of hectic fevers, in addition to the observance of all the rules of Hygeine, and the severe regimen indicated in most cases, especially when the digestive passages are the seat of in- flammation. The success of this method is by no means fre- quent; but, were bitters and excitants of every kind, formerly so lavishly prescribed in these diseases, of greater efficacy? Had they not the disadvantage of neutralizing the good effects of emollients, the advantages of which were however recognised. Moreover, to affirm that blood-letting in small quantity, and the exhibition of emollients should constitute the basis of treatment in these fevers, is not to exclude the employment of certain to- nics when the indication presents itself. I deem it unnecessary to demonstrate the error of certain prac- CHRONIC FEVERS. 485 titioners, who still persist in the exhibition of bark, in hopes of curing hectic fever when they are totally incapable of operating upon the proximate cause of this disease. They obtain this re- sult only by augmenting the inflammation of the stomach, when this organ is the seat of the disease, or by determining a gastri- tis when the inflammation resides in another organ. Thus, with a view to the removal of symptoms, purely secondary, they aug- ment the intensity of the primitive disease, or rather they create, so to speak, another disease; a remarkable example of the unhap- py results of therapeutic methods founded solely upon the study of symptoms. When, however, the stomach is free from disease, and when the local symptoms of chronic irritation occupying another or- gan are but little marked and the subject not very irritable, we may attempt to render the paroxysms less frequent by the exhi- bition of the sulphate of quinine; but we must direct its employ- ment with a prudent reserve, and remember that we can only ex- pect to palliate the disease and not to cure. A symptom, the removal of which is often attempted, is the sweat and colliquation of hectic fevers, which, it is said, exhausts the patient, and should be moderated because it is not critical. I have seldom seen the means used with a view to diminish or arrest this evacuation succeed, and when they have produced this effect, I have constantly observed an exasperation of the fever or the local symptoms of the disease. That this abundant and almost continual loss of the nutritive materials of the system con- tributes to the destruction of the patient, cannot be denied; but that with a view to oppose it, it is proper to stimulate the gas- tric mucous membrane is in direct opposition to the principles of sound physiology: experience demonstrates the bad effects of tonic and astringent means in such cases. All that can be done is to cover the body with dry and hot cloths, often renewed as jfoon as this symptom establishes itself, and to administer a cold acidulated drink if the state of the stomach and lungs permit. Since it is proved, that hectic fever is only a collection of the symptoms which characterize a chronic irritation, the sympathe- tic influence of which extends to the heart, it is only by attack- ing this irritation that we must combat the sympathetic pheno- mena which characterize the disease. It is proper, in a practical point of view, to distinguish two varieties of hectic fever, the one with and the other without gas- 486 PHYSIOLOGICAL PYRETOLOGY. trie irritation; in the second, we may occasionally employ cer- tain stimulants as derivatives, but with great caution, from the apprehension of producing the bad effects which I have men- tioned; whilst in the first, that is to say, in that in which the gastric passages are primitively or sympathetically irritated, every attempt at derivation must be hurtful, by accelerating the progress of a disease which tends to destroy the organism. When, notwithstanding the means used for their cure, and sometimes in consequence of these means, intermittent fevers prolong themselves indefinitely, the digestive functions become deranged, and, if the stomach has not hitherto been irritated, it becomes so, not only in paroxysms but in a continued manner; the gastritis increases at each exacerbation, and becomes every day more intense; signs of chronic inflammation of the liver and spleen manifest themselves; these viscera acquire an extra- ordinary size, and become painful on pressure: this is what is so improperly denominated obstructions. The intermittent fever, as I have already remarked, then assumes the name of splanch- nic. The patient constantly grows thin and weak; the febrile paroxysms generally become erratic; at other times they return or assume the tertian or quartan type; by degrees they pass to the continued remittent type, especially when the alteration of the tissue of the organs affected tends to suppuration or ulcera- tion. The fever is, however, frequently observed to remain intermittent. It finally terminates in marasmus, which acquires the highest degree of intensity, and the patient dies dropsical or worn out by diarrhoea. Chronic intermittent fevers present so great a variety, that it is impossible to give a general description of them; there are still important researches to be made upon this as upon so many other interesting points of pathology. On dissection, we most frequently detect profound alterations in the tissue of the abdominal viscera, in the liver, spleen, me- sentery, epiploon, pancreas, kidneys, ovaria and uterus. They are, likewise, found in the thoracic viscera. Traces of inflam- mation are often found in the peritoneum, pleura, and pericar- dium. In a word, we detect the same organic lesions, as after chronic continued or hectic fevers properly so called. By what strange contradiction is it that the same authors, who have attributed the symptoms of chronic continued fever to the affection of the viscera, which, on dissection, were found altered CHRONIC FEVERS. 487 in their structure, have attributed these same lesions to chronic intermittent fever when dissection revealed them after the latter disease? It is not, we confess, the scirrhus of the liver, nor the friability of the skin, nor the declining of the peritoneum, nor the hydrops pericardii, nor the ascites found after death; it is not, we say, these disorders, which have given rise to the fe- brile paroxysms; but these alterations indicate that the viscera, in which they are observed, have been the seat of an irritation, of which the febrile paroxysms were but the symptoms, and which has itself determined these alterations of texture. The author of a treatise on intermittent fevers, attributed to Senac, and all those who have treated of organic lesions pre- sented by subjects after chronic intermittents, have scarcely mentioned the state of the gastro-intestinal mucous membrane, because they were unacquainted with the traces, often slight, which inflammation, even the most intense, leaves in this mem- brane. The author* just mentioned, remarks that in men who have died suddenly after a meal, when they appeared to be cured of the fever, the stomach has been found very much dilated, and containing water and food; that after prolonged intermittents, the intestines are often much dilated in certain parts of their extent, and contracted in others, that the colon especially pre- sents contractions in its descending portion, a little above the rectum. The affection of the abdominal viscera, rendered manifest by an analysis of the symptoms and by dissection, although it has not yet been sufficiently studied, demonstrates that when inter- mittents pass to the chronic state, they necessarily become gas- tric. If we reflect upon the results of treatment, we shall rea- dily find proofs of this assertion; who does not know that these fevers are generally attacked in vain by bark? One of the most interesting problems in pathology, is, doubt- less, to discover what principles should direct the practitioner in the treatment of intermittent fevers, with a view to the pre- vention or cure of the obstructions? The best means, as we have already remarked, of preventing structural alteration of the viscera in intermittent fever, is to ar- rest the disease as soon as possible, by the administration of bark, * De recondita Febrium Interimttentium turn Remittentium natura et earum curatione. Geneva, 1769, in 8vo. p. 196-198. 488 PHYSIOLOGICAL PYRETOLOGY. after the careful employment of regimen and blood-letting, and the removal of the causes which might reproduce the disease. When obstructions exist, if they are ancient, or have existed one or more years, there is no hope of obtaining their resolution: some happy exceptions confirm rather than confute this proposi- tion. In such a case, all we can do is to guard against any thing which may aggravate the condition of the patient If the gastric passages are but little irritated, if the obstruc- tions have been of but few months' continuance, we may attempt to arrest their progress by administering bark with the view of putting a stop to the periodical congestions, which gradually ag- gravate the morbid condition of the viscera. We have some- times the satisfaction of witnessing the disappearance of tume- factions of the spleen, liver and mesenteric ganglions, which, to all appearance, had been hopeless. Cold or hot water charged with a small quantity of salts, abounding in carbonic acid gas, gaseous and slightly saline waters, sulphurous waters administered internally and in baths, are often of great advantage, and prefe- rable to all other deobstruants. In the course of this treatment, the local abstraction of blood from the epigastric region, from the right or left hypochondrium or anus, may become necessary. The regimen should be accommodated to the state of the stomach, and should always be severe. When the obstructions are recent, the gastric irritation is almost always unequivocal; the viscera are painful on pressure; we must then be careful not to administer the bark before we have employed local bloodletting, regimen, baths and aqueous drinks; we must not, however, delay the employment of this medicine as soon as the state of the stomach seems capable of supporting it. In this manner we frequently prevent the deve- lopment of dropsy, a formidable secondary affection, the treat- ment of which, cannot find a place in this work, and which al- most always announces a fatal termination. These principles of treatment should, in my opinion, take the place of those which would inculcate either the indiscriminate employment or rejection of this medicine, whenever there ex- ist any signs of obstruction. When chronic intermittent fevers pass to the continued type, the administration of the bark cannot but be injurious: the treat- ment must, in this case, be entirely palliative, until death termi- nates the sufferings of the patient. OF SIMPLE, COMPLICATED FEVERS, &C. 489 CHAPTER XVI. Of Simple and Complicated Fevers; of Essential or Primi' tive Fevers; of Symptomatic or Secondary Fevers, and of Humoral Fevers. Had I attempted, at the commencement of this work, to give an exact idea of the real value of these denominations, I could not have avoided the interminable discussions to which the sub- ject has given rise; but in the present case, my task has become easy. Formerly, that was called a simple fever, which appeared to be exempt from all association with a local, inflammatory, bi- lious, nervous or verminous state, or with a fever of any other character. If the use of this term be continued, it should only be employed to designate, every irritation of a single organ, the influence of which extends to the heart; and still more properly, a primitive irritation of this organ which is partaken to a greater or less extent by the vessels. Complicated fevers present diverse combinations of inflamma- tory, bilious, adynamic, &c. symptoms; that is to say, in these diseases several organs simultaneously irritated, contribute to call the sympathies into play. The name of essential fever has been appropriated to designate acute diseases, in which there appears to exist no local irritation, to which the production of the febrile phenomena can be attri- buted; but as this does not appear to be the case, except when we neglect to refer the symptoms to the organs in which they manifest themselves, and to investigate the order of their ap- pearance as well as their dependence, and do not attribute the symptoms to the organic alterations found after death, in similar cases we may conclude that no disease merits this name. Every physician recognises as a symptomatic fever, that in which the irritation of one or more organs is so manifest that no 62 490 PHYSIOLOGICAL PYRETOLOGY. one can deny its existence: now, it has been demonstrated that this is the case in all fevers, and the presumption of Sauvages is converted into certainty.* A primitive fever is only an idiopathic local irritation, which calls the sympathies into play. When the local irritation which excites the sympathies is itself the sympathetic effect of another irritation, it is called secondary fever. An essential fever is said to be complicated with an inflamma- tion, a neurosis or a hemorrhage, when in a fever which is not considered as depending upon a local irritation, unequivocal signs of inflammatory, nervous or hemorrhagic irritation, mani- fest themselves in an organ which has not hitherto appeared to be more affected than any of the others. This appearance of new symptoms, occurs sometimes in the organ, the irritation of which, hitherto unobserved, produces the febrile symptoms, and in this case, the fever denominated essential complicated, is only an irritation attended with febrile symptoms, and which augments in intensity; sometimes in a different organ from that, the irrita- tion of which, produces the febrile symptoms, and in this case, there is a true complication: not in consequence of the super- vention of a hew disease, but owing to the extension of the dis- ease which already existed, to an organ which had not pre- viously been affected, or at least, not to the morbid degree. When a fever manifests itself in the course of any morbid af- fection, whatever the febrile symptoms are, it is the result of a * local irritation which augments or develops itself in an organ, * The division of fevers into essential and symptomatic, is not less erro- neous than that of the Galenists: they call those symptomatic, which are the effect of another disease, and those essential, which are not derived from any other disease. But since, according to the moderns themselves, 1st, fever is caused by an obstruction of the capillaries, or by irritation of the heart, or by derangement of the nerves, and since, by their own avowal, these de- rangements are true diseases, or a vicious state of the solids and fluids, whence arises the lesion of the functions, it follows, from these principles, that all fevers are symptomatic, and that there is no essential fevers: 2ndly, because a cause regarded as cause, is never sensible, the effect as effect, is not more so; the same remark applies to symptom considered as symptom. Sauvages, t. 1. p. 368. t t See my article Fever in the Dictionnaire Abregee des Sciences Medicates, t. vii. p. 380, Pa- ris, 1822. OP SIMPLE, COMPLICATED FEVERS, &C. 491 the seat of this affection, or is the result of an irritation which establishes itself in another organ. In the latter case, the fever is truly secondary, or, if the expression be preferred, sympto- matic. Consequently, every fever is essential, inasmuch as it exists: no fever is essential, if by this we mean that it exists by itself, which signifies nothing when we speak of a disease. It is proper to distinguish primitive from secondary fevers, on account of the modifications which the treatment undergoes from a consideration of the seat. These principles being laid down, let us examine what are the fevers wrhich precede the inflammations of the skin, accom- pany, or succeed them: those which are called exanthematous; fevers which manifest themselves in the course of a phlegmasia, a hemorrhage, or neurosis; fevers which develop themselves af- ter a wound; finally, fevers which are attributed to a vitiated state of the humours. 1st, The fever which precedes for some days the erysipelas, the measles, small pox, and other cutaneous phlegmasiae is al- most always owing to gastro-enteritis: to be convinced of this, it is sufficient to observe the state of the tongue, the derangement of the digestion, and to explore the epigastrium. This fever di- minishes when the inflammation abates or ceases in the gastro- intestinal membrane, and manifests itself on the skin; when the latter is violently irritated, the membrane of the digestive or- gans becomes irritated anew, or the very feeble irritation which in most cases it retains, increases, and the febrile symptoms ac- quire a new intensity. When the irritation of the skin has ceased, reaction no longer exists, provided the gastro-enteritis does not persist or increase. At any period whatever of the cu- taneous phlegmasiae, the gastro-enteritis, and sometimes the sim- ple irritation of the skin in a subject, labouring under a predis- position, may determine a formidable, or even a fatal irritation in the encephalon; derangement of the nervous system is then observed to supervene, with prostration, and if the gastro-ente- ritis arrives at the highest degree of intensity, the phenomena which the ancients attributed to putridity, declare themselves. When the symptoms of gastric, mucous, or bilious fever deve- lop themselves, the sympathetic irritation of the gastro-intesti- nal mucous membrane can no longer be doubted. We have now 492 PHYSIOLOGICAL PYRETOLOGY. sufficiently indicated the nature of gastric, bilious, mucous, atax- ic, and adynamic fevers, which, in the language of the present day, supervene on phlegmasiae of the skin, and the treatment necessary to arrest their progress. The bronchia, and other internal organs, frequently become affected, either conjointly with the digestive organs, or indepen- dently of them. 2dly, A peripneumony, a peritonitis, or a metritis, frequently throws the patient into a profound prostration, or determines symptoms called nervous. For this to occur, it is not necessary that the gastro-intestinal mucous membrane be in a state of in- flammation; but when vomiting, diarrhoea of fetid matters, and an acrid heat of the skin are superadded to prostration, it can no longer be attributed to the inflammation of the lungs, uterus, or peritoneum: there is evidently gastro-enteritis. The same prin- ciples, then, apply to these gastric, adynamic, and ataxic fevers, as to those which complicate phlegmasiae of the skin. When one of these fevers manifests itself in the course of an irritation called nervous, cerebral irritation very readily super- venes, even when there is no gastritis. The remarks which I have made in relation to the fevers which complicate inflammation, apply equally to hemorrhages of the lungs, of the uterus, &c. In speaking of chronic fevers, in the preceding chapters, I have indicated, as far as I could in this work, the points of doc- trine relative to the connexion of chronic diseases with febrile symptoms. 3dly, Traumatic fevers comprehend the synocha, the bilious, adynamic, and ataxic fevers, which manifest themselves after wounds. The first is the direct effect of the irritation, pain, and inflam- mation, inseparable from a solution of continuity, however slight, affecting irritable parts: very often a sympathetic gastro-enteritis supervenes with rapidity, and contributes to the development of the febrile symptoms. The constitution of the patient, and the circumstances to which he is subjected contribute much to the production of these symptoms. The second is always the effect of an intense gastro-enteritis, involving more or less the liver: there are certain wounds, such as those of the head, which determine it more readily than OF SIMPLE, COMPLICATED FEVERS, &C. 493 others. It is far from being in every case, as it has been assert- ed, the effect of a bad regimen. Since a bad regimen had not occasioned it before, it can, at most, only predispose to it, unless the wounded be guilty of excess, or make use of too abundant succulent or gross an alimentation. Traumatic febrile gastro-en- teritis manifests itself more frequently during the heats of sum- mer. When it assumes a high degree of intensity, it gives rise to traumatic adynamic fever. If the irritation of the stomach be transmitted to the encepha- lon, the nervous phenomena are observed which characterize what is called ataxy. But these phenomena are often the direct effect of the traumatic irritation upon the encephalon, as it is pb- served after amputations. It appears from the preceding remarks, that in every fever, essential or primitive, symptomatic or secondary, and in every complicated fever, it is important to know, not only the organs which have suffered lesion, and those which have suffered to the highest degree, but likewise those which have been the first af- fected, and without the irritation of which the others would not have suffered. I think that it may be logically deduced from these facts, that all essential or primitive fevers, and that all symptomatic or se- condary fevers, are not to be attributed to gastro-enteritis; and, therefore, that it is always important to distinguish the cases in which the stomach and intestines are irritated, from those in which they are either not at all, or so slightly affected, that it is not necessary to address the curative measures to them, or, at least, not to them exclusively. If in all generic descriptions of fevers, we find the symptoms of gastro-enfferitis, it is not because the latter occur in all the particular cases which have served as the basis of these descrip- tions: it only proves that this inflammation occurs in many of them; otherwise it would be necessary to say that cerebral irri- tation occurs in all, because the phenomena of this irritation finds a place among the symptoms. It is thus, that in consequence of a faulty method of description, and a mania for groups of symp- toms, that nothing but general diseases, or gastro-enteritis, have been seen in diseases altogether inflammatory and circumscribed in their seat, but invading at different times one or several or- gans. 494 PHYSIOLOGICAL PYRETOLOGY. If these principles are in conformity to truth, and if they are adopted in practice, we shall not so frequently witness the exhi- bition of medicines, in the course of fevers, without the slightest regard to the state of the organs to which they are applied; and this will be the happy result of the theoretic and practical re- searches of M. Broussais on the nature and seat of fevers. Phy- sicians will then less frequently endeavour to stimulate the brain by the internal exhibition of tonics, when the principal seat of the disease is the gastro-intestinal mucous membrane; and, on the other hand, they will be less intent upon combating, in cer- tain ataxic fevers, a gastric irritation, which does not exist, or which no longer exists, or which is only the sympathetic effect of a cerebral irritation. The progress of observation renders the consummation of these hopes every day more probable. Finally, Whence is it that, in the year 1830, we are reduced to the necessity of combating the errors of the middle ages? It is to be ascribed to the nature of the human mind, which ad- vances but slowly in the road of truth, and by many and circu- itous paths, which, returning incessantly to the point of depar- ture, seem to render illusory the progress of science, manners, and institutions. That at a time, when, from the imperfection of anatomical sci- ence, the human body was considered by the most learned phy- cians as a sort of machine containing liquids, in which life and its functions existed, and that when all diseases were attributed to the superabundance, penury, and alteration of these fluids, fe- vers were explained by this absurd theory, and that humoral fevers were then admitted, is not astonishing. A fever was cured after hemorrhage; the blood was then considered as its cause; another ceased after a vomiting of porraceooe matter, and was, therefore, attributed to the bile; another after a mucous ex- pectoration, and consequently the phlegm was its origin; ano- ther proved fatal, notwithstanding copious dejections of black matter: and here the atra-bile had not been evacuated in suffi- cient quantities, and the material cause of the fever not having been eliminated, the patient must necessarily perish. This mode of reasoning justified itself by the maxim, so common among the ignorant, and in the imperfection of knowledge too frequent- ly applied even by the learned, Post hoc, ergo propter hoc. OF SIMPLE, COMPLICATED FEVERS, &C. 495 But it is certainly astonishing, that, at the present day, men, among whom are to be found some of the most intelligent, should be pleased, without any alarm, at the deluge of errors with which the humoral theory had absolutely drowned the sci- ence of diseases, to repeat unnecessarily that there is something true in the ancient humoral pathology, that certain fevers cannot be referred to any organ, and that, therefore, the inference is probable that they affect the humours, and that in this case the fever is general. It is certainly not very consistent with good logic, to say that there is something true in a doctrine, without pointing out what there is in it conformable to observation and reason: we cannot, consistently with correct physiological views, consider the fluids as any thing but what they are made by the organs. When foreign matters are introduced, they are no longer themselves, and this does not occur unless some organ is affect- ed; ignorance of the organic seat of a fever does not authorize us to consider a fever as seated in the humours, in which hitherto no disease, properly so called, has been demonstrated. When it shall have been proved that a humour may undergo a sponta- neous alteration, like cider in a barrel, as it has been said to do, by one who is better entitled to the name of technologist than physiologist, it will still remain to determine what organs re- ceive the febrifacient impression of this humour. It will, be- sides, be necessary to demonstrate that the alteration of a whole humour, of the blood for example, without the alteration of any organ, constitutes a disease of the whole body, as though the or- gans formed no part of the economy. * An abundance of blood, resulting from an energetic alimenta- tion, may sur-excite the heart, lungs, brain, and uterus; the pre- sence of bile may irritate the digestive passages; that of the urine, the bladder: fever may be the result; but what do we know of the effects of the alteration of these liquids, or of the alteration itself? We call upon experimentalists, anatomists, chymists, and prac- titioners to endeavour to penetrate these mysteries, by experi- ments, dissections, chymical analogies, and clinical observations; not by hasty conclusions, unfounded hypotheses, and reveries, which might afford matter of laughter to the public, were they not couched in the unintelligible jargon of pretended science. * Gerdy, Transactions Medicales. 496 PHYSIOLOGICAL PYRETOLOGY. Nothing is more to be suspected than that ardent desire to an- ticipate the progress of knowledge, which frequently betrays the finest intellects into the adoption of errors. In proportion to the progress of pathological anatomy, humo- ral fevers have become organic diseases; and even Pinel wished to banish every Galenical explanation from his theory of fevers. If we are bound to reject no fact, much more are we bound not to advance hypothesis before certain knowledge. No one, at the present day, flatters himself with the idea that he has pene- trated the ultimate secrets of nature, in relation to the state of the solids, either in a pathological or physiological condition; but we at least possess, in relation to these parts, an imposing mass of facts, derived from clinical observation and dissection. Can the same be said of the fluids? Symptoms only lead to suppositions; autopsy has taught us nothing that was not known at the time of Mondini; chymical analysis has shown only simi- larity of composition, and rarely any difference; the slight alter- ations of the blood with which we are acquainted not being discoverable by any certain signs during life, can furnish no principles in pathology, and can be the subject of no indications in therapeutics. They can, therefore, have but little interest for the practitioner, who adopts no theories but those which are indispensable for the classification of facts, and the study of the organs, which permits no fact to be lost, has the farther advan- tage of placing them before the eye in all their nakedness. * * Nosographie Organique, tome iii. Alterations du Sang. OF FEVER. 497 CHAPTER XVII. Of Fever. After having sought in a physiological study of the causes and symptoms of the fevers described by the most celebrated pyre- tologists and in the results of post mortem examinations, positive data in relation to the nature and seat of these diseases, it is pro- per to study fever in general, to determine in what it differs from inflammation, and to establish the most general rules of its treatment. Should it be objected, that fever is only a word, and that in- flammation is a fact, I would answer, that if fevers are only phlegmasiae, the word fever expresses a fact as well as the word inflammation, and that the subject of the present chapter is a comparison of the inflammations which have received the name of fevers, with those to which no one refuses the name of phleg- masiae. Galen and his numerous commentators have defined fevers— a heat contrary to nature, developed in the heart, and which, de- parting from this organ, diffuses itself by the spirits and the blood, by the arteries and veins, through the whole body. This heat is sometimes excessive, and produced by the simple augmenta- tion of the native heat inherent in the animal; and sometimes the product of a putrescent, malignant or pestilential matter, de- veloped in the living body or introduced into it. To constitute fever, it was considered necessary that this heat should be durable and involve the whole body. Its characteristic signs were—a quick, frequent and sometimes unequal pulse, lan- guor, dejection, a sense of acrid heat of the surface, or only an un- pleasant sense of heat internally. Avicenna and Fernel made the important remark, that this heat might arise in other parts besides the heart, although it always involved this organ at last. This theory offers us, on the one hand, all that could be learned in the infancy of medicine from an observation of the symptoms, and, on the other hand, the hypothesis of innate 63 498 PHYSIOLOGICAL PYRETOLOGY. heat and of heterogeneous matters developed spontaneously in the organism or introduced into it, that of the spirits, of putri- dity and of malignity. The sense of heat experienced by the patient, the re-establishment of the health after evacuations, the empty state of the arteries after death, certain-phenomena com- mon to the humours evacuated in inflammation, and to animal matters in a state of putrefaction, the occasional occurrence of death in the midst of symptoms by no means alarming, were the facts upon which were based these hypotheses for so many ages, the inexhaustible source of sterile disputes. But if the Galenists erred in considering fever as a general disease, they at least suspected its true nature, since they attributed it to heat; they were acquainted with the part which the heart performed in this disease; and some of them perceived that this organ was not always the first affected. Galen himself attempted to deter- mine the particular seat of many species of fevers.* More could not have been effected in the infancy of physiology and anatomy, and when pathological anatomy did not even exist. The fundamental ideas of Galen, of the Arabians, and of Fer- nel have, until the present period, been surcharged with innu- merable subtleties rather than modified. Thus when, in the fif- teenth century, Paracelsus attributed fever to the combustion of sulphur and nitre, he only referred to an imaginary cause the heat, which, according to the Galenists, constituted fever. Ga- len had found the rudiments of his theory in certain books of the descendants of Hippocrates; Paracelsus, in attacking him, commenced the monstrous application of chymistry to patholo- gy, which has continued even to the present day. Versed in the writings of Hippocrates, Galen and Paracelsus, Van Helmont made a singular mixture of the doctrines of these celebrated men. Without regard to the structure of the organs, he attributed fever to the terror, the shock, the deranged move- ments of the archaeus, and placed the seat of the disease in the duodenum. They were then better acquainted with the part performed by the stomach and small intestine in the production of fever; but the imagination of physicians, swayed by absurd hypotheses, could not pay much attention to this gleam of truth- Yet in the midst of these humoro-chymical errors, the inflam- * See my Historical Researches on Fevers. Paris, 1822, in 8vo. OF FEVER. 499 matory character of fevers was not entirely unknown, as may be seen in a work, otherwise of little importance, of Henry Screta Schitnor de Zavorziz;* and even in those of Sydenham, who, as remarkable for his powers of observation as he was for the errors of his theory, attributed fever to an effort of nature to ex- pel by fermentation the morbific cause. Borelli attributed this disease to an irritation of the heart, owing to the acridness of the nervous fluid. Bellini to the stag- nation and thickening of the blood in the capillary net-work, the effect of the irregular movements of this liquid. Chirac, an admirer of the chymical and mechanical theories, beheld in fever, -at one and the same time, the effect of the fer- mentation, the stagnation and irregular movement of the blood; but to him belongs the credit of having first positively asserted that we could arrive at a true knowledge of disease only by post mortem examinations.! Stahl demonstrated, that in fever the blood is not in a state of stagnation: he attributed this disease to an excitation of the tonic movement of the solids; he thought that this increased action was provoked with a salutary object by the soul, and he admit- ted no difference between fever and inflammation. Glisson had long since published the fine and pregnant idea of the irritability of the organic tissues, when F. Hoffman attributed fever to a spasm of the periphery, which pushed the blood to the internal parts; he established no other difference between inflammation and fever except the greater extension of the lat- ter. He declared that all the subjects whom he had seen perish in fever, had died in consequence of an inflammation of the sto- mach, the intestines and meninges. Bordeu, although he contributed to the rejection of many lu- minous ideas of Chirac, yet admitted the analogy of fever and inflammation. He was the first to perceive the utility of naming each fever according to the organ most affected. A disciple of Glisson, Hoffman, and Cullen, Brown attributed the intermittent and continued fevers called nervous to astheny, and the synocha to sur-excitation. To these fundamental ideas may be referred all those which have served as the text of the * De Febre Castrensi Maligna seu molliura Corporis Humani partiura In- flammatione dicta. Bale, 1716, p. 26. | Op. cit. tome i. ch. ii. art. 10 et 11. 500 PHYSIOLOGICAL PYRETOLOGY. innumerable works on fever, published from the time of Galen to the commencement of the present age. Among these ideas, those which were most conformable to information obtained the fewest partisans: no one acquainted with the history of pathology can be astonished at the disgust which Pinel manifested to the theories of the schools at the time of the publication of his No- sography. This professor did not, however, think it contrary to the pro- per method of study in natural history to attribute certain fevers to irritation, others to weakness, and others to the irregularity of the functions: it is probable that he would not have blamed those of his predecessors who had written on fever in general, if he could himself have attained to a general idea, which might em- brace the three proximate causes, by the aid of which he ex- plained the production of all fevers. It is at the present day demonstrated, that all fevers are owing to a local irritation of greater or less extent; that if the weakness sometimes precedes this irritation, accompanies it in another or- gan, or follows it, the irritation is the only source of the symp- toms of reaction and the premature source of the symptoms which seem to indicate weakness; finally, that we should never assign the first rank to those symptoms which really denote astheny of an organ, because this weakness either does not constitute the disease, or it is the effect of the irritation which constitutes the latter. I shall not attempt to prove that the acceleration and force of the pulse and heat of the skin are not signs of weakness; the time when such errors prevailed is long passed. But among those physicians who admit that the symptoms of fever, are, if not always, at least most frequently the effect of a local irrita- tion, and especially among those, who, while they acknowledge the extreme frequency of this irritation, still assert that it is ge- neral, there are some who deny its analogy to inflammation. This error would be unimportant, did it not tend to give an un- happy direction to the treatment of fever. It is therefore neces- sary to enter into some details upon this subject. In what does inflammatory differ from febrile irritation? Is it in its causes? But the causes of both are the same, and, were they different, it should be in the modifications undergone by the organs that a proof of their difference should be sought. If we compare the symptoms of fever with those of inflammation OF FEVER. 501 m the first, Second, or third degree of these diseases, we per- ceive that these symptoms are the same; there is but a single point of difference: it is, that the local or direct symptoms are less intense, less manifest, whilst the sympathetic or remote symp- toms are relatively more prominent in the first than in the second. It appears, then, that fever is generally less intense than inflam- mation: but this is only apparently the case. If the sympathetic symptoms are very marked in continued fevers, even when the local symptoms are but slightly so, it is because the irritation then resides in a very excitable organ, of great influence in the economy, or that the organs which feel the influence of the or- gan primitively affected, are very excitable. Nevertheless, there are cases in which the irritation is not very intense, but of great extent, invading many organs important to the maintenance of life. Because the sympathetic symptoms are always greatly de- veloped in fever, let us not conclude that the irritation which constitutes it is of a different nature from inflammation; for we continually see slight though unequivocal inflammations deter- mine sympathetic symptoms of a more marked character than those of a more intense inflammation. If febrile irritation be sometimes less intense than inflamma- tory irritation, let us not be surprised that it leaves in the or- gans traces less profound, and which sometimes even disappear, at the moment when vital action ceases. Let us also remember, that if fever has appeared, during a long series of ages, to leave in the organs fewer traces of inflammation, it is because physicians sought in the mucous and serous membranes, in the arachnoid membrane, for example, disorders as profound, and as evidently inflammatory as those found in the cellular tissue after phlegmon. In vain is the cure of certain fevers, under the influence of to- nics applied even to the irritated organ, brought forward as dis- proving the analogy of fever and inflammation: were these cases as numerous as they are uncommon, they would prove nothing against our opinion. Inflammation is also cured by stimulants applied to the organ in which it is seated. But we know, by a treatment so irrational, we hazard the aggravation of this mor- bid state, and the destruction of the inflamed tissue. This un- doubted fact should not be lost upon the physician, when called upon to treat fever: to the presumption of the ephemeral success of empyricism, let him prefer the satisfactory certainty that he has 502 PHYSIOLOGICAL PYRETOLOGY. only made use of those means which the nature of the disease points out. Would that the innumerable deaths which take place in the course of epidemics, notwithstanding the copious- ness of our materia medica, and which, at least, evince the effi- cacy of tonics; would that the recent progress, of pathological anatomy might correct the error of those physicians, who, while they celebrate the vis medicatriae naturae, act as though they did not believe in its existence, and very frequently do more mis- chief than if they had remained tranquil spectators of the com- bat, in which they believed themselves obliged to take part, at the same time that they protest their attachment to the method of expectation. The intermittent character of fever proves nothing against its analogy to inflammation, since inflammation itself is frequently intermittent. That irritation in intermittent fevers is sometimes less permanent, less profound, of shorter continuance, and of greater mobility than inflammation, may be granted, without de- nying the identical nature of these two morbid conditions, pro- vided we admit that it is at least as acute and not less fatal, al- though more rapid in pernicious intermittent fevers. To the authors who behold in fever only a nervous irritation, it is sufficient to answer that it is nervous when it resides in the nerves or in the brain. As to those who pretend that fever is only a secretory irrita- tion, it is sufficient to refer them to the Galenical theories, which they expect to revive under the garb of modern physiology. As long as the analogy of fever and inflammation has been, if not demonstrated, at least suspected, that is to say, from the time of Galen until the end of the last century, physicians, not- withstanding their humoral, chymical, and mechanical theories, have, for the most part, recognised the utility of blood-letting in the treatment of fever; all would have seen that it was indi- cated in this disease, even when it appeared to be the result of putridity and malignity, had not their minds been preoccupied by these erroneous theories. Some among them did not even fear to avow that blood-letting was one of the most appropriate me- thods of preventing putridity and malignity, and of arresting the progress of these imaginary morbid conditions of the hu- mours. Brown and Pinel limited, to such a degree, the employment OF FEVER. 503 of blood-letting, that there was reason to regret the time when their predecessors, persuaded of the necessity of taking blood, with a view to diminish the plasticity of this fluid, and to faci- litate the circulation, did not fear to resort to this powerful re- medial measure. To complete the history of fevers, profound researches are yet to be made with regard to the complication of encephalic, tho- racic, abdominal and cutaneous inflammations, as well as those of the muscles, the synovial membranes, and fibrous tissues, with irritation of the heart. I have attempted to point out this deficiency, rather than supply it. Broussais has done much towards the overthrow of the ancient pyretological doctrines, but he has only described the gastritis, to which the name of fever has been given. As Pinel neglected to treat of complicated fevers, so has M. Broussais neglected complicated gastritis. It remains to determine the frequency and the diagnosis of the inflammations of each organ, and of every part of the body in fevers. Shall it be said, that it is sufficient to be acquainted with the signs of these different inflammations, to recognise them in every case? This wrould be to elude the difficulty. The signs of simple and intense gastritis were known before the time of M. Broussais, and yet it was not recognised in fevers. The time has arrived, when all practitioners, particularly those who practise in hospitals, and especially in countries often desolated by epidemics, should investigate with care the symp- toms of complicated irritations, which are announced only by symptoms, hitherto grouped under the name of fevers. Many facts are wanting towards the establishment of the treat- ment of these diseases on a solid foundation; these facts cannot be obtained, except through the united efforts of physicians in every country. At the present day, when the nature and seat of fevers are no longer a mystery, and the advantages and disadvantages of blood-letting are positively ascertained, we know in what cases it is indicated, and where the application of leeches is prefera- ble. Hereafter, the efforts of practitioners must be directed, not only to an investigation of the cases in which emetics and tonics may be employed without danger in the treatment of fevers; but, likewise, to the determination of the place in which blood- 504 PHYSIOLOGICAL PYRETOLOGY. letting should be practised, or leeches applied; the quantity of blood which should be taken, the number of bleedings which should be practised, and the number of leeches which should be applied in proportion to the intensity, the seat, and extent of the irritation, the period of the disease, the susceptibility and age of the individual, and the circumstances which have occasioned the disease. They will endeavour to ascertain with greater cer- tainty than has hitherto been attained, the cases in which it is necessary to treat intermittent fever with bark, and with this in view, they will remember that between fever of this type, and intermittent inflammation of an unequivocal character, the only difference is in the seat, and sometimes in the intensity of the dis- ease. And, finally, it will be important to study the powerful in- fluence of an absolute, or, at least, very rigorous diet in the treat- ment of fever, as well as the effect of derivative stimulants applied to the skin, or to the mucous membrane of the great intestines. Important results would doubtless be obtained, if physicians, in- stead of limiting themselves to the observation of symptoms, would carefully engage in post mortem examinations, and submit the facts which they might collect to a physiological analysis, which alone can place the science of medicine on a firm basis. The declamations of certain persons, against the application of physiology to pathology, only proves that they are aware of their incapacity to attain reputation by direct means, and that to attain their ends, they hesitate not to adopt the most indirect methods. - For some time, it has been common to repeat that the physi- ological doctrine has fallen into oblivion, and this at the very time when it is the source of all that is rational in the writings of its detractors, and when every practitioner, professor, and wri- ter, draws largely from it in the exercise of his profession, in teaching and in the investigation of principles. A most singu- lar fact, of a doctrine to make its way against all attempts to ob- struct its progress, and to compel its detractors to borrow its principles, with a view to exhibit an appearance of novelty. THE END, JUST PUBLISHED BY CAREY & LEA. PRIVATE MEMOIRS of NAPOLEON BONAPARTE, from the French of M. Fauvelet de Bourrienne, Private Secre- tary to the Emperor. Second American Edition, complete in one volume. V This edition contains almost a fourth more matter than the previous one, as in order to render it as perfect as possible, extracts have been given from the Memoirs from St. Helena, Official Reports, &c. &c. in all cases where they differ from the statements of M. de Bour- rienne. "This English translation, which has been very faithfully rendered, is still more valuable than the original work, as upon all points where any obliquity from other published recitals oc- curs, the translator has given several accounts, and thus, in the form of notes, we are present- ed with the statements obtained from Napo- leon's own dictation at St. Helena, from the Memoirs of the Duke of Rovigo, of General Rapp, of Constant, from the writings of the Marquis of Londonderry, &c\"—U. Ser. Jour. 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The arrangement is such that particular volumes may be re-edited or rewritten without disturbing the others. The " Cabinet Cyclopaedia " will thus be in a state of continual renovation, keeping pace with the never-ceas- ing improvements in knowledge, drawing within its circle from year to year whatever is new, and casting off whatever is obsolete, so as to form a constantly modern- ized Cyclopaedia. Such are a few of the advantages which the proprietors have to offer to the public, and which they pledge themselves to realize. Treatises on subjects which are technical and profes- sional will be adapted, not so much to those who desire to attain a practical proficiency, as to those who seek that portion of information respecting such matters which is generally expected from well-educated persons. An interest will be imparted to what is abstract by copious illustrations, and the sciences will be rendered attractive, by treating them with reference to the most familiar ob- jects and occurrences. The unwieldly bulk of Encyclopaedias, not less than the abstruse discussions which they contain, has hitherto consigned them to the library, as works of only occasional reference. The present work, from its portable form and popular style, will claim a place in the drawing-room and the boudoir. Forming in itself a Complete Library, af- fording an extensive and infinitely varied store of in- struction and amusement, presenting just so much on every subject as those not professionally engaged in it require, convenient in size, attractive in form, elegant in illustrations, and most moderate in expense, the "Ca-mnet Cyclopedia" will, it is hoped, be found an object of para mount interest in every family. To the heads of schools and all places of public educa- tion the proprietors trust that this work will particularly recommend itself. It seems scarcely necessary to add, that nothing will be admitted into the pages of the " CabinetCyclop.f.di v" which can have the most remote tendency to offend public or private morals. To enforce the cultivation of religion and the practice of virtue should be a principal object with all who undertake to inform the public mind ; but with the views just explained, the conductor of this work feels these considerations more especially pressed upon his attention. Parents ar>d guardians may, therefore, rest assured that they will nevu' find it necessary to place a volume of the "Cabinet" be< ondthe reach of their chil- dren or pupils. Considerable progress having been made in this work^ the publishers wish to direct the attention of the public to the advantages by which it is distin- guished from other similar monthly publications. It is not intended that the Cabinet Cyclopaedia shall form nn interminable series, in which any work of interest which may present itself from time to time can claim a place. Its subjects are classified accord- ing to the usual divisions of literature, science, and art. Each division is distinctly traced out, and will consist of a determinate number of volumes. Al- though the precise extent of the work cannot be fixed with certainty, yet there is a limit which will not be exceeded; and the subscribers may look forward to the possession, within a reasonable time, of a complete library of instruction, amusement, and general refer- ence, in the regular form of a popular Cyclopaedia. The several classes of the work are—1, NATURAL PHILOSOPHY; 2, The USEFUL and FINE ARTS; 3, NATURAL HISTORY; 4, GEOGRAPHY; 5, POLITICS and MORALS; 6, GENERAL LITE- RATURE and CRITICISM; 7, HISTORY; 8, BI- OGRAPHY. In the above abstruse and technical departments of knowledge, an attempt has been made to convey to the reader a general acquaintance with these sub- jects, by the use of plain and familiar language, ap- propriate and well-executed engravings, and copious examples and illustrations, taken from objects and events with which every one is acquainted. The proprietors formerly pledged themselves that no exertion should be spared to obtain the support of the most distinguished talent of the age. They trust that they have redeemed that pledge. Among the volumes already published in the literary department, no less than four have been the production of men who stand in the first rank of literary talent,—Sir James Mackintosh and Sir Walter Scott. In the sci- entific department, a work has been produced from the pen of Mr. Herschel, which has been pronounced by the highest living authority on subjects of general philosophy, to contain "the noblest observations on the value of knowledge which have been made since Bacon," and to be " the finest work of philosophical genius which this age has seen." The following is a selection from the lift of Contributors. The Right Honorable Sir JAMES MACKIN- TOSH, M. P. The Right Rev. The Lord Bishop of Cloyne. Sir WALTER SCOTT, Bart. JOH.N FREDERICK WILLIAM HERSCHEL, THOMAS MOORE, Esq. J. B. BIOT, Member of the French Institute. ROBERT SOUTHEY, Esq. Poet Laureate. The Baron CHARLES DFPIN, Member of the Royal Institute and Chamber of Deputies. THOMAS CAMPBELL, Esq. T. B. MACAULEY, Esq. M. P. DAVID BREWSTER, LL.D. J. C. L. SISMOND1, of Geneva. Capt. HENRY KATER, Vice President of the Royal Society. The ASTRONOMER ROYAL. DA VIES GILBERT, Esq. M. P. S. T. COLERIDGE, Esq. JAMES MONTGOMERY, Esq. The Right Hon. T. P. COURTENAY, M.P. J. J. BERZELIUS, of Stockholm, F. R. S., &c. The Rev. G. R. GLEIG. T. PHILLIPS, Esq. Prof, of Painting, R. A. Rev. C. THIRLWALL, Fellow of Trinity College, Cambridge. ANDREW URE, M. D. F. R.S., &c. &c. &c. DR. lAES^Z^S CABINET CYCltOPiEDIA. VOLUMES PUBLISHED. I. II—HISTORY of SCOTLAND. By Sir Walter Scott. in. VI.—HISTORY of ENGLAND. By Sir James Mackintosh. In 8 Vols. Vols. I. and II. IV.—OUTLINES of HISTORY. V —HISTORY of the NETHERLANDS. By T. C. Grattan, Esq. VII. VIII. XII—HISTORY of FRANCE. By Eyre Evans Crowe. In 3 Vols. IX—MECHANICS. By Capt. Kater and Dr. Lardner. X—A PRELIMINARY DISCOURSE on the OB- JECTS, ADVANTAGES, and PLEASURES of the STUDY of NATURAL PHILOSOPHY. In 1 Vol. By J. F. W. Herschel, Esq. XI—BIOGRAPHY of EMINENT BRITISH STATESMEN. XIII—HYDROSTATICS and PNEUMATICS. By Dr. Lardner. XIV—HISTORY of the PROGRESS and PRE- SENT SITUATION of the SILK MANUFAC- TURE. XV—HISTORY of the ITALIAN REPUBLICS. By J. C. L. Sismondi. XVI. XVII. XVIII—HISTORY of MARITIME and INLAND DISCOVERY. In 3 vols. VOLUMES TO IMMEDIATE PREPARA- TION. HISTORY of ENGLAND. Vol. III. HISTORY of the PROGRESS and PRESENT STATE of the IRON MANUFACTURE. LIVES of EMINENT BRITISH LAWYERS. In 1 Vol. By H. Roscoe, Esq. The HISTORY of the WESTERN WORLD. In 4 Vols. Vol. I. The UNITED STATES of AMER- ICA. Two volumes of this work, nearly ready, will complete the History of the United States to the present time. The two remaining volumes will be devoted to South America and the West India Islands. A HISTORY of IRELAND, to the UNION. In 2 Vols. By T. Moore, Esq. A PRELIMINARY DISCOURSE on the USEFUL ARTS and MANUFACTURES. By the Baron Charles Dupin, Member of the Institute of France and of the Chamber of Deputies. A HISTORY of the MOORS. In 3 Vols. By Rob- ert Southey, Esq. LIVES of the MOST EMINENT LITERARY MEN of ALL NATIONS. In 8 Vols. By Scott, South f.v, Moore, Mackintosh, Montgomery, Cunningham, and all the principal Literary and Scientific Contributors to the Cyclopaedia. A TREATISE on ASTRONOMY. By J. F. W. Hkrschf.l, Esq. GEOGRAPHY. In 4 Vols. By W. Cooley, Esq. auihor of the " History of Maritime Discovery." LIVES of the MOST DISTINGUISHED BRITISH NAVAL COMMANDERS. By R. Southey, Esq. LIVES of the MOST DISTINGUISHED BRITISH MILITARY COMMANDERS. By the Rev. G. R. Gl.EIG. A TREATISE on OPTICS. By David Brew- ster. The HISTORY of GREECE. In 3 Vols. By the Rev. C. Thirl wall. LIVES of EMINENT BRITISH ARTISTS. By W. Y. Otley, Esq. and T. Phillips, R. A. Professor of Painting to the Royal Academy. A TREATISE on ELECTRICITYand MAGNET- ISM. By M. Biot, Member of the French Insti- tute. " books that you may carry to the fire, and hold readily in your hand, are the most useful after all. a man will often look at them, and be tempted to go on, when he would have been frightened at books of a larger size, and of a MORE ERUDITE APPEARANCE."—Dr. Johnson. "We advisedly call the Cabinet Cyclopedia a great undertaking, because we consider, that in its effects on the tone and habits of thought of what is known by the phrase, ' the reading public,' it will be, if carried through in the spirit of its projection and commencement, one of the most invaluable productions of modern literature. * * " But these advantages, eminent as they undoubtedly are, are not the sole nor the chief recommendations of the Cabinet Cyclopaedia. Neither is it on the extreme cheapness of the publication, nor the federal independence —if we may so speak—of its several volumes, that we rest our prediction of its influence on the tone of think- ing of the present, and on the literature of the next gen- eration—but on the promise, amounting almost to a moral certainty, of the great excellence of its execution. A mul- titude of persons eminent in literature and science in the United Kingdom are employed in this undertaking; and, indeed, no others should be employed in it; for it is a truth that the profound and practised writer alone is capable of furnishing a ' popular compendium.' " What parent or guardian that throws his eye over the list of its contributors bat must be rejoiced by meeting the names of those who are in themselves a guarantee of intellectual and moral excellence ?"—Literary Gazette. " The plan of the work appears well adapted to the pur- pose it is proposed to fulfil—that of supplying a series of publications, embracing the whole range of literature and science, in a popular and portable form ; while the excellence of the execution is guarantied by the judgment displayed in the selection of writers. The list of authors employed in this ambitious undertaking comprises some of the most eminent men of the present age."—Atlas. " The Cyclopaedia, when complete, will form a valuable work of reference, as well as a most entertaining and in- structive library. It is an essential principle in every part of it, that it should be clear and easily understood, and that an attempt should everywhere be made to unite accurate information with an agreeable manner of con- veying it. It is an experiment, to try how much science may be taught with little crabbed or technical language, and how far the philosophical and poetical qualities of history may be preserved in its more condensed state. It possesses also the most indispensable of all the qualities of a work intended for general instruction—that of cheap- ness. Whatever the plan might be, it was evident that the grand difficulty of Dr. Lardner was to unite a body of writers in its execution, whose character or works af forded the most probable hope that they were fitted for a task of which the peculiarity, the novelty, and even the prevalent relish for such writings greatly enhance the dif- ficulty. We do not believe, that in the list of contribu- tors, there is one name of which the enlightened part of the public would desire the exclusion. " In science, the list is not less promising. The names of the President, Vice-Presidents, and most distinguished Fellows of the Royal Society, are contained in it. A treatise on astronomy, by Herschel; on optics, by Brews- ter; and on mechanics, by Lardner; need be only recom- mended by the subjects and the writers. An eminent Prelate, of the first rank in science, has undertaken a noble subject which happily combines philosophy with religion. Twelve of the most distinguished naturalists of the age, Fellows of the Linnr James Mackintosh's His- tory ot England, we find enough to warrant the antici- pations of the public, that a calm and luminous philoso- phy will diffuse itself over the long narrative of our Brit- ish History."—Edinburgh Review. " In this volume Sir James Mackintosh fully developes those great powers, for the possession of which the public have long given him credit. The result is the ablest com- mentary that has yet appeared in our language upon some of the most important circumstances of English History.'' —Atlas. b ' " Worthy in the method, style, and reflections, of the author's high reputation. We were particularly pleased with his high vein of philosophical sentiment, and his occasional survey of contemporary annals."—National Gazette " If talents of the highest order, long experience in po- litics, and years of application to the study of history and the collection of information, can command superi- ority in a historian, Sir James Mackintosh may, without reading this work, be said to have produced the best his- tory of this country. A perusal of the work will prove that those who anticipated a superior production, have not reckoned in vain on the high qualifications of the author."—Courier. " Our anticipations of this volume were certainly very highly raised, and unlike such anticipations in general, they have not been disappointed. A philosophical spirit, a nervous style, and a full knowledge of the subject, ac- quired by considerable research into the works of pre- ceding chroniclers and historians, eminently distinguish this popular abridgment, and cannot fail to recommend it to universal approbation. In continuing his work as he has begun, Sir James Mackintosh will confer a great bene- fit on his country."—Land. Lit. Gazette. " Of its general merits, and its permanent value, it is impossible to speak, without the highest commendation, and after a careful and attentive perusal of the two vol umes which have been published, we are enabled to de- clare that, so far, Sir James Mackintosh has performed the duty to which he was assigned, with all the ability that was to be expected from his great previous attain- ments, his laborious industry in investigation, his excel- lent judgment, his superior talents, and his honorable principles "—Inquirer. " We shall probably extract the whole of his view of the reformation, merely to show how that important topic has been handled by so able and philosophical a writer, professing Protestantism.—National Gazette. " The talents of Sir James Mackintosh are so justly and deeply respected, that a strong interest is necessarily ex- cited with regard to any work which such a distinguished writer may thinkfit toundertake. In the present instance, as in all others, our expectations are fully gratified."— Gentleman's Magazine. " The second volume of the History of England, form- ing the sixth of Carey & Lea's Cabinet Cyclopa;dia, has been sent abroad, and entirely sustains the reputation of its predecessors. The various factions and dissensions, the important trials and battles, which render this period «<> conspicuous in the page of history, are all related with great clearness and masterly power."—Boston Traveller. HISTORY OF SCOTLAND. By Sir Walter Scott. In 3 Vols. " The History of Scotland, by Sir Walter Scott, we do not hesitate to declare, will be, if possible, more exten- sively read, than the most popular work of fiction, by the same prolific author, and for this obvious reason: it com- bines much of the brilliant coloring of the Ivanhoe pic- tures of by-gone manners, and all the graceful facility of style and picturesqueness of description of his other charming romances, with a minute fidelity to the facts of history, and a searching scrutiny into their authenti- city and relative value, which might put to the blush Mr. Hume and other professed historians. Such is the magic charm of Sir Walter Scott's pen, it has only to touch the simplest incident of every-day rife, and it starts up invested with all the interest of a scene of romance ; and yet such is his fidelity to the text of nature, that the knights, and serfs, and collared fools with whom his in- ventive genius has peopled so many volumes, are regarded by us as not mere creations of fancy, but as real flesh and blood existences, with all the virtues, feelings and errors of common-place humanity."—Lit. Gazette. BIOGRAPHY OF BRITISH STATESMEN; containing the Iiives of Sir Thomas More, Cardinal Wolscy, Archhishop Cranmer, and IiOrd Burleigh. "A very delightful volume, and on a subject likely to increase in interest a* it proceeds. * * * We cordially commend the work both for its design and execution."— Lon' ri' ««-<■"«• HISTORY OF FRANCE. By Eyre Evans Crowe. In 3 vols. HISTORY OF FRANCE, from the Restora- tion of the Bourbons, to the Revolution of 1830. By T. B. Macaulay, Esq.. M. P. Nearly ready. " The style is concise and clear; and events are sum- med up with much vigor and originality."—Ml. Gazette. " His history of France is worthy to figure with the works of his associates, the best of their day, Scott and Mackintosh."—Monthly Mag " For such a task Mr. Crowe is eminently qualified. At a glance, as it were, his eye takes in the theatre of centuries. His style is neat, clear, and pithy; and his power of condensation enables him to say much, and effectively, in a few words, to present a distinct and perfect picture in a narrowly circumscribed space "—La Belle Assembled. " The style is neat and condensed; the thoughts and conclusions sound and just. The necessary conciseness; of the narrative is unaccompanied by any baldness; on the contrary, it is spirited and engaging."—Bait. Ameri- can. "To compress the history of a great nation, during a period of thirteen hundred years, into three volumes, and to preserve sufficient distinctness as well as interest in the narrative, to enable and induce the reader to possess himself clearly of all the leading incidents, is a task by :,o means easily executed. It has, nevertheless, been well accomplished in this instance."—JV*. Y. American. "Written with spirit and taste."— U- S. Gazette. "Could we but persuade our young friends to give these volumes a careful perusal, we should feel assured of their grateful acknowledgments of profit and pleas- ure."—JV. Y. Mirror. '• At once coucise and entertaining."— Smturday Bul- letin. THE HISTORY OF THE NETHERLANDS, to the Battle of Waterloo. By T. C. Grat- tan. " It is but justice to Mr. Grattan to say that he has executed his laborious task with much industry and pro- portionate effect. I'ndisfigureil by pompous nothingness, and without any of the affectation of philosophical pro- fundity, his style is simple, light, and fresh—perspicuous, smooth, and harmonious.''—La Belle Assemblee. " Never did work appear at a more fortunate- period. The volume before us is a compressed but clear and im- partial narrative "—Lit. Gaz. " A long residence in the country, and a ready access to libraries anil archives, have furnished Mr Grattau with materials which he has arranged with skill, and out of which he has produced a most interesting volume."— Gent. Mng. LARDNER'S CABINET CYCLOPAEDIA. CABINET OF AMERICAN HISTORY. BY T. F. GORDON. Volumes published. ' It is not east to devise a cure for soch a state op things (the declining taste for science;) but THE MOST OBVIOUS REMEDY IS TO PROVIDE THE EDU- I. H. HISTORY OF THE SPANISH DISCOVERIES CATED CLASSES WITH A SERIES OF WORKS ON POPULAR AND PRACTICAL SCIENCE, FREED FROM MATHEMATICAL SYMBOLS AND TECHNICAL TERMS, WRITTEN IN SIMPLE AND PERSPICUOUS LANGUAGE, AND ILLUSTRATED BY FACTS prior to the year 1520. To be succeeded by AND EXPERIMENTS, WHICH ARE LEVEL TO THE CAPACITY III. IV. V. HISTORY OF ANAHUAC, OR MEXICO, OF ordinary minds."—Quarterly Review. from its discovery to the present time. In 3 vols. VI. VII. HISTORY of PERU. In 2 vols. VIII. IX. HISTORY of BRAZIL. In 2 vols. &c.&c. PRELIMINARY DISCOURSE ON THE OB- JECTS, ADVANTAGES, AND PLEAS- URES OF THE STUDY OP NATURAL PHILOSOPHY. By J. T. W. Herschel, A. M. late Fellow of St. John's College, Under this comprehensive title, it is proposed to Cambridge. publish a General History of America, divided into parts making together a continuous whole; yet each, " Without disparaging any other of the many interest- having an integral form, adapted for separate publica- LIS*d7f"uct,vevo/ul»e9ishsuedi"theforrafcah;"et tion. Each portion will be brought down to the and family libraries, it is. perhaps, not too much to place '„■ j , U'T . , ,, . „ 5 , ■,, at the head of the list, for extentand var.etv of condensed Penod ,al vVh,ch U. shalj ^e written, and will contain information, Mr. Herchel's discourse of Natural Philoso- a popular description of the geology, clnnale and pro- phy in Or. Lardners Cyclopedia."— Christian Observer. jductions, and the civil history of the country to which "The finest work of philosophical genius which this "■ relaies. age has seen."—Mackintosh's England. I No work of this general nature has been published " By far the most delightful book to which the existing in the English language. The work of Dr. Robertson competition between literary rivals of great talent and ls rather a philosophical essay on American history, enterprise has given rise."—Monthly Review. than an historical narrative; and though originally " Mr. Herschel's delightful volume. * * * We find 'designed to embrace the whole of the American scattered throush the work instances of vivid and happy continent, it remains unfinished. It is written also, Uustration, where the fancy is usefully called into action, so as sometimes to remind us of the splendid pictures which crowd upon us in the style of Bacon."—Quarterly Review. "It is the most exciting volume of the kind we ever met with."—Monthly Magazine. "One of the most instructive and delightful books we have ever perused.-'—17. S. Journal. A TREATISE ON MECHANICS. By Capt. Rater, and the Rev. Dionysius Lardner. With numerous engravings. " A work which contains an uncommon amount of useful information, exhibited in a plain and very intelli- gible form."'—Olmsted's Nat. Philosophy. "This volume has been lately published in England, as a part of Dr. Lardners Cabinet Cyclopiedia, and has re- ceived the unsolicited approbation of the most eminent men of science, and the most discriminating journals and reviews, in the British metropolis.—It is written in a popular and in'elligible style, entirely free from mathe- matical symbols, and disencumbered as far as possible of technical phrases."—Boston Traveller. " Admirable in development and clear in principles, and _ especially felicitous in illustration from familiar sub- | Brazil and Colombia. Due attention will also be given jects."—Monthly Mag. "Though replete with philosophical information of the highest order in mechanics, adapted to ordinary capaci- ties in a way to render it at once intelligible and popu- lar."— Lit. Gazette. " A work of great merit, full of valuable information, not only to the practical mechanic, hut to the man of sci- ence."—JV. Y. Courier and Enquirer. with a bias unfavorable to America and its produc- tions, is incorrect in many important particulars, and is too much abstracted lor popular use. This void in literature might have been properly filled by the writers of Spain, Portugal, France, or England, but has been supplied for Europe, in a measure, by an Italian, the Cavalier Campagnoni, of whose meritorious labor much use will be made in the proposed enterprise. The volumes herewith presented, may be deemed introductory to the whole work, since they narrate the history of the discovery of the three great portions of America. In the prosecution of the subject, the existing political divisions will be pursued and con- nected with former ones, by proper explanations; and where due regard for unity does not forbid, the chronological order will be preserved. Thus, the next succeeding part of the work, now advanced in preparation, will contain the history of Anahuac, or Mexico: including its ancient annals, an account of lis subjugation, and the policy of its conquerors, of its late revolutions, and of iis present constituent states. In the same manner will be treated Central America, Peru, Chili, Bolivia, the United Provinces of La Plata; A TREATISE ON HYDROSTATICS AND PNEUMATICS. By the Rev. D. Lardner. ■With numerous engravings. " It fullysustains the favorable opinion we have already expressed as to this valuable compendium of modern sci- ence."—Lit. Gazette " Dr. Lardner has made a good use of his acquaintance with the familiar facts which illustrate the principles ol science."—Monthly Magazine. "It is written with a full knowledge of the subject, and in a popular style, abounding iu practical illustra- tions of the abstruse operations of these imporant sci- ences."— U. S. Journal lo the independent Indian nations of South America The history of the remainder of the country will be embraced by the following divisions:—1. Russian; 2. British; 3. Spanish; 4. French ; 5. Danish ; 6. Dutch America; and 7, the Uniied Slates and their depend- encies. In treating the last division, a separate vol- ume will be appropriated to each Stale and Territory, the history of which may require ii, and " The History of the United States" will be confined to the events of the Revolution and the operations of the general gov- ernment. A survey having been thus made of the whole Western Hemisphere, the concluding volume will contain the history of the Indian races, particularly those of the northern part of the continent, with a critical examination of the theories relaiing to the original peopling of America. The general title of the work is sufficiently com- prehensive to include a biography ol distinguished Americans, and oihers connected with American history; and should the public support warrant it, "An American Biography" may also be published uiiuer u, tu a tiraiti/ui«i >.-. CABINET LIBRARY, No. 1.—NARRATIVE OF THE LATE WAR IN GERMANY AND FRANCE. By the Marquess of Londonderry. With a Map. No. 2.—JOURNAL of a NATURALIST, with plates. No. 3.—AUTOBIOGRAPHY of SIR WAL- TER SCOTT. With a portrait. No. 4.—MEMOIRS of SIR WALTER RA- LEGH. By Mrs. A. T. Thomson. With a portrait. No. 5.—LIFE of BELISARIUS. By Lord Mahon. No. 6—MILITARY MEMOIRS of the DUKE of WELLINGTON. By Capt. Moyle Sherer. With a portrait. No. 7.—LETTERS to a YOUNG NATU- RALIST on the STUDY of NATURE and NATURAL THEOLOGY. By J. L. Drummond, M. D. With numerous en- gravings. IX PREPARATION. LIFE of PETRARCH. By Thomas Moore. GLEANINGS in NATURAL HISTORY, being a Companion to the Journal of a Nat- uralist. "The Cabinet Library bids fair to be a series of great value, and is recommended to public and private libraries. to professional men, and miscellaneous readers generally. It is beautifully printed, and furnished at a price which will place it within the reach of all classes of society."— American Traveller. "The series of instructive, and, in their original form, expensive works, which these enterprising publishers are now issuing under the title of the " Cabinet Library." is a fountain of useful, and almost universal knowledge; Hie advantages of which, in forming the opinions, tastes and manners of that portion of society, to which this varied information is yet new, cannot be too highly estimated."—National Journal. "Messrs. Carey and Lea have commenced a series of publications under the above title, which are to appear monthly, and which seem likely, from the specimen before us, to acquire a high degree of popularity, and to afford a mass of various information and rich entertainment, at once eminently useful and strongly attractive. The mechanical execution is fine, the paper and typography excellent."—Nashville Banner. MEMOIRS OP THE LIFE OP SIR WAL- TER RALEGH, with some Account of tlie Period in which he lived. By MRS. A. T. THOMSON. "With a Portrait. "Such is the outline of a life, which, in Mrs. Thom- son's hands, is a mine of interest; from the first page to the last the attention is roused and sustained, and while we approve the manner, we still more applaud the spirit in which it is executed."—Literary Gazette. JOURNAL OF A NATURALIST. With Plates. ,______Plants, trees, and stones we note; Birds, insects, beasts, and rural things. "We again most strongly recommend this little unpre- tending volume to the attention of every lover of nature, and more particularly of our country readers. It will induce them, we are sure, to examine more closely than they have been accustomed to do, into the objects of ani- mated nature, and such examination will prove one of the most innocent, and the most satisfactory sources of gratification and amusement. It is a book that ought to find its way into every rural drawing-room in the kingdom, and one that may safely be placed in every lady's boudoir, be her rank and station in life what they may.'—Quarterly Review, No. LXXVIII. "We think that there are few readers who will not be delighted (we are certain all will be instructed) by the 'Journal of a Naturalist.' "—Monthly Review. "This is a most delightful book on the most delightful of all studies. We are acquainted with no previous work which bears any resemblance to this, except 'White's History of Selborne,' the most fascinating piece of rural writing and sound English philosophy that ever issued from the press."—Athenaum. " The author of the volume now before us, has pro- D duced one of the most charming volumes we remember to have seen for a long time."—New Monthly Magazine, June, 1829. "A delightful volume—perhaps the most so—nor less instructive and amusing—given to Natural History since White's Selborne."—Blackwood's Magazine. " The Journal of a Naturalist, being the second num- ber of Carey and Lea's beautiful edition of the Cabinet Library, is the best treatise on subjects connected with this train of thought, that we have for a long time pe- rused, and we are not at all surprised that it should have received so high and flattering encomiums from the Eng- lish press generally."—Boston Traveller. "Furnishing an interesting and familiar account of the various objects of animated nature, but calculated to afford both instruction and entertainment."—Nash- ville Banner. "One of the most agreeable works of its kind in the language."—Courier de la Louisiane. "It abounds with numerous and curious facts, pleas- ing illustrations of the secret operations and economy of nature, and satisfactory displays of the power, wisdom and goodness, of the great Creator."—Philad Album. THE MARQUESS OF LONDONDERRY'S NARRATIVE OF THE LATE WAR IX GERMANY AND FRANCE. With a Map. " No history of the events to which it relates can be correct without reference to its statements."—Literary Gazette. "The events detailed in this volume cannot fail to excite an intense interest."—Dublin Literary Gazette. "The only connected and well authenticated account we have of the spirit-stirring scenes which preceded the fall of Napoleon. It introduces us into the cabinets and presence of the allied monarchs. We observe the secret policy of eaeh individual: we see the course pursued by the wily Bernadotte, the temporizing Metternirh, and the ambitious Alexander. The work deserves a place in every historical library."— Globe. " We hail with pleasure the appearance of the first volume of the Cabinet Library." " The author had sin- gular facilities for obtaining the materials of his work, and he has introduced us to the movements and measures of cabinets which have hitherto been hidden from the world."—American Traveller. " It may be regarded as the most authentic of all the publications which profess to detail the events of the important campaigns, terminating with that which se- cured the capture of the French metropolis."—Nat. Jour- nal. " It is in fact the only authentic account of the memo- rable events to which it refers:"—Nashville Banner. " The work deserves a place in every library."—Phila- delphia Album. MISCELLANEOUS. A MEMOIR OF SEBASTIAN CABOT, with a Review of the History of Maritime Dis- covery. Illustrated by Documents front the Rolls, now first published. " Put forth in the most unpretending manner, and without a name, this work is of paramount importance to the subjects of which it treats."—Literary Ga.zette. "The author has corrected many grave errors, and in general given us a clearer insight into transactions of considerable national interest."—/*. " Will it not," says the author, with just astonishment, "be deemed almost incredible, that the very instrument in the Records of England, which recites the Great Discovery, and plainly contemplates a scheme of Colonization, should, up to this moment, have been treated by her own writers as that which first gave permission to go forth and explore ?" —lb. " We must return to investigate several collateral matters which we think deserving of more space than we can this week bestow. Meanwhile we recommend the work as one of great value and interest."—lb. " The general reader, as well as the navigator and the curious, will derive pleasure and information from this well-written production."—Courier- "A specimen of honest inquiry. It is quite frightful to think of the number of the inaccuracies it exposes- we shall cease to have confidence in books." " The investi- gation of truth is not the fashion of these times. But every sincere inquirer after historical accuracy ought to purchase the book as a curiosity:'more false assertions and inaccurate statements were never exposed in the same compass. It has given us a lesson we shall never forget, and hope to profit by."—■Spectator. HISTORY OF THE NORTHMEN, OR NOR- MANS AND DANES ; from the earliest times to the Conquest of England by William of Normandy. By Henry Whea- ton, Member of the Scandinavian and Icelandic Literary Societies of Copenha- gen. This work embraces the great leading features of Scan- dinavian history, commencing with the heroic age, and advancing from the earliest dawn of civilization to the introduction of Christianity into the North—its long and bloody strife with Paganism—the discovery and coloniza- tion of Iceland, Greenland, and North America, by the Norwegian navigators, before the time of Columbus—the military and maritime expeditions of the Northmen— their early intercourse of commerce and war with Con- stantinople and the Eastern empire—the establishment of a Norman state in France, under Rollo. and the sub- jugation of England, first by the Danes, under Canute the Great, and subsequently by the Normans, under Duke William, the founder of the English monarchy. It also contains an account of the mythology and litera- ture of the ancient North—the Icelandic language pre- vailing all over the Scandinavian countries until the formation of the present living tongues of Sweden and Denmark—an analysis of the Eddas, Sagas, and various chronicles and songs relating to the Northern deities and heroes, constituting the original materials from which the work has been principally composed. It is intended to illustrate the history of France and England during the middle ages, and at the same time to serve as an introduction to the modern history of Denmark, Norway, and Sweden. LETTERS TO A YOUNG NATURALIST, on the Study of Nature, and Natural The- ology. By JAMES L. DRUMMOND, M. D. &c. "With numerous engravings. "We know of no work, compressed within the same limits, which seems so happily calculated to generate in a young mind, and to renovate in the old, an ardent love of nature in all her forms."—Monthly Review. "We cannot but eulogize, in the warmest manner, the endeavor, and we must say the successful endeavor, of a man of science, like Dr. Drummond, to bring down so exalted a pursuit to the level of youthful faculties, and to cultivate a taste at once so useful, virtuous, and refined." —New Monthly Mag. PRIVATE MEMOIRS of NAPOLEON BO- NAPARTE, from the French of M. Faxjve- let de Bourrienne, Private Secretary to the Emperor. In 2 vols. 8vo. The. peculiar advantages of position in regard to his present subject, solely enjoyed by M. de Bourri- enne, his literary accomplishments and moral quali- fications, have already obtained for these memoirs the first rank in contemporary and authentic history. In France, where they had been for years expected with anxiety, and where, since the revolution, no work connected with, that period or its consequent events has created so great a sensation, the volumes of Bour- rienne have, from the first, been accepted as the only trustworthy exhibition of the private life and political principles of Napoleon. " We know from the best political authority now liv- ing in England, that the writer's accounts are perfectly corroborated by facts."—Lit. Gaz. ANNALS of the PENINSULAR CAM- PAIGNS. By the Author of Cyril Thorn- ton. In 3 vols. 12mo. with plates. The HISTORY OF LOUISIANA, particu- larly of the Cession of that Colony to the United States of North America; with an Introductory Essay on the Constitution and Government of the United States, by M. de Marbois, Peer of France, translated from the French by an American Citizen. In 1 vol. 8vo. The PERSIAN ADVENTURER. By the Author of the Kuzzilbash. In 2 vols. 12mo. "It is full of glowing descriptions of Eastern life."— Courier. MORALS of PLEASURE, Illustrated by Stories designed for Young Persons, in 1 vol. 12mo. " The style of the stories is no less remarkable for its ease and gracefulness, than for the delicacy of its humor, and its beautiful and at times affecting simplicity. A lady must have written it—for it is from the bosom of woman alone, that such tenderness of feeling and such delicacy of sentiment—such sweet lessons of morality— such deep and pure streams of virtue and piety, gush forth to cleanse the juvenile mind from the grosser impu- rities of our nature, and prepare the young for lives of usefulness here, and happiness hereafter."—JV. Y. Com. Advertiser. CLARENCE; a Tale of our own Times. By the Author of Redwood, Hope Leslie, &c. In 2 vols. AMERICAN QUARTERLY REVIEW, pub- lished on the first of March, June, Septem- ber, and December. Price $5 per ann. %* A few complete Sets of the Work are still for sale. CONSIDERATIONS ON THE CURREN- CY AND BANKING SYSTEM OF THE UNITED STATES. By Albert Galla- tin. SONGS of the AFFECTIONS. By Felicia SCOTT, COOPER, AND WASHINGTON IRVING. BY SIR WALTER SCOTT. COUNT ROBERT~oFpARIS, a Tale of the Lower Empire. By the Author of Wa- verley. In 3 vols. ml'Th6 re,ader "1" ?l once Perceive that the subject, the characters and the scenes of action, could not have been better selected for the display of the various and un- equalled powers of the author. All that is glorious in arts and splendid in arms-the glitter of armor, the pomp of war and the splendor of chivalry-the gorgeous scenery of the Bosphorus—the ruins of Byzantium—the magnifi- cence of the Grecian capital, and the richness and volup- tuousness of the imperial court, will rise before the reader in a succession of beautiful and. dazzling images."—Com- mercial Advertiser. AUTOBIOGRAPHY OF SIR WALTER SCOTT. With a Portrait. " This is a delightful volume, which cannot fail to sat- isfy every reader, and of which the contents ought to be known to all those who would be deemed conversant with the literature of our era."—National Gazette. HISTORY OF SCOTLAND. In 2 vols. "The History of Scotland, by Sir Walter Scott, we do not hesitate to declare, will be, if possible, more exten- sively read, than the most popular work of fiction, by the same prolific author.and for this obvious reason: it com- bines much of the brilliant coloring of the Ivanhoe pic- tures of by-gone manners, and all the graceful facility of style and picturesqueness of description of his other charming romances, with a minute fidelity to the facts of history, and "a searching scrutiny into their authenti- city and relative value, which might put to the blush Mr. Hume and other professed historians. Such is the magic charm of Sir Walter Scott's pen, it has only to touch the simplest incident of every-day life, and it starts ap invested with all the interest of a scene of romance; and yet such is his fidelity to the text of nature, that the knights, and serfs, and collared fools with whom his in- ventive genius has peopled so many volumes, are regarded by us as not mere creations of fancy, but as real flesh and blood existences, with all the virtues, feelings and errors of commonplace humanity."—Lit. Gazette. TALES of a GRANDFATHER, being a series from French History. By the Author of Waverley. BY MR. COOPER. THE BRAVO. By the Author of the Spy, Pilot, &lc. In 2 vols. The WATER-WITCH, or the SKIMMER of the SEAS., In 2 vols. ' "We have no hesitation in classing this among the most powerful of the romances of our countryman."— U. Stales Gazette. "We could ont break from the volumes, and may pre- dict that they will excite the same interest in the minds of almost every reader. The concluding chapters produce intense emotion."—National Gazette. New Editions of the following Works by the same Author. LIONEL LINCOLN, or the LEAGUER of BOSTON, 2 vols. The LAST of the MOHICANS, 2 vols. 12mo. The PRAIRIE, 2 vols. 12mo. BY WASHINGTON IRVING. VOYAGES and ADVENTURES of the COMPANIONS of COLUMBUS. By Washington Irving, Author of the Life of Columbus, &c. 1 vol. 8vo. "Of the main work we may repeat that it possesses the value of important history and the magnetism of ro- mantic adventure. It sustains in every respect the repu- tation of Irving." " We may hope that the gifted author will treat in like manner the enterprises and exploits of Pizarro and Cortes; and thus complete a series of elegant recitals, which will contribute to the especial gratifica- tion of Americans, and form an imperishable fund of delightful instruction for all ages and countries."—Nat. Gazette. " As he leads us from one savage tribe to another, as he paints successive scenes of heroism, perseverance and i self-denial, as he wanders among the magnificent scenes of nature, as he relates with scrupulous fidelity the errors, and the crimes, even of those whose lives are for the most part marked with traits to command admira- tion, and perhaps esteem—everywhere we find him the same undeviating, but beautiful moralist, gathering from every incident some lesson to present in striking lan- guage to the reason and the heart."—Am. Quarterly Re- view. | " This is a delightful volume; for the preface truly says that the expeditions narrated and springing out of the voyages of Columbus may be compared with attempts of adventurous knights-errant to achieve the enterprise left unfinished by some illustrious predecessors Washington Irving's name is a pledge how well their stories will be told: and we only regret that we must of necessity defer our extracts for a week."—London Lit. Gazette. A CHRONICLE of the CONQUEST of GRENADA. By Washington Irving, Esq. In 2 vols. "On the whole, this work will sustain the high fame of Washington Irving. It fills a blank in the historical library which ought not to have remained so long a blank. The language throughout is at once chaste and animated ; and the narrative may be said, like Spenser's Fairy Queen, to present one long gallery of splendid pic- tures."—Land. Lit. Gazette. "Collecting his materials from various historians, and adopting in some degree the tone and manner of a monk- ish chronicler, he has embodied them in a narrative which in manner reminds us of the rich and storied pages of Froissart He dwells on the feats of chivalry performed by the Christian Knights, with allthe ardor which might be expected from a priest, who mixed, according to the usage of the times, not only in the palaces of courtly nobles, and their gay festivals, as an honored and wel- come guest, but who was their companion in the camp, and their spiritual and indeed bodily comforter and as- sistant in the field of battle.—Am. Quarterly Review. New Editions of the following Works by the same Author. The SKETCH BOOK, 2 vols. 12m,o. KNICKERBOCKER'S HISTORY of NEW YORK, revised and corrected. 2 vols. BRACEBRIDGE HALL, or the HUMOR- ISTS, 2 vols. 12mo. TALES of a TRAVELLER, 2 vols. 12mo. TRAVELS, ANNUALS, &c. NOTES on ITALY, during the years 1829-30. By Rembrandt Peale. In 1 vol. 8vo. "This artist will gr. tify all reasonable expectation; he is neither ostentations, nor dogmatical, nor iuo mi- nute; lie is not a partisan nor a carper; ha admires'with- out servility, he criticises without malevolence; his frankness and good humor give an !igroi;nblt* coloi" and effect to all his decisions, .:nd the object of Uiem; his book' leaves a useful general idea of the names, works, and de- serts, of the great masters; it is an instructive and enter- taining index."—Nat. Gaz. " We have made a copious extract in preceding columns from this interesting work of our countryman, Rembrandt Peale, recently published. It has received high commen- dation from respectable sources, which is justilied by the portions we have seen extracted.''—CommerciclAdverlise.r. "Mr. Peale must be allowed the credit of candor and entire freedom from affectation in the judgments he has passed. At the same time, we should not omit to notice the variety, extent, and minuteness of his examinations. No church, gallery, or collection, was passed by, and most of the individual pictures are separately and carefully noticed."—Am. Quarterly Review. • A TOUR in AMERICA. By Basil Hall, Capt. R. N. In 2 vols. 12mo. SKETCHES OF CHINA, with Illustrations from Original Drawings. By W. W. Wood. In 1 vol. 12mo. "The residence of the author in China, during the years 3826-7-8 and.9; has enabled him to collect much very curious information relative to this singular people, which he has embodied in his work; nni! will serve to gratify the. curiosity of many whose tiine or disposition? do not allow them to seek, in the voluminous writings ci the Jesuits and early travellers, the information contained in the present work. The recent discussion relative to the renewal of the Ea'it India Company's Charter, has excited much interest; an:! iiui > \x ourselves, the desire to be further acquainted with i'v subjects of'the Celes- tial Empire,' has been consiujiulily augmented." EXPEDITION' to the SOURCES of the MISSISSIPPI, Executed by order of the Government of the United States. By Ma- jor S. H. Long. In 2 vols.8vo. With Plates. HISTORICAL, CHRONOLOGICAL. GEO- GRAPHICAL, and STATISTICAL ATr LAS of NORTH and SOUTH AMERI- CA, and the WEST INDIES, with all their Divisions into States, Kingdoms, &c. on the Plan of Le Sage, and intended as a companion to Lavuisne's Atlas. In 1 vol. folio, containing 54 Maps. Third Edition, improved and enlarged. ATLANTIC SOUVENIR, FOR 1832.. This volume is superbly bound in embossed leather, and ormmonted with numerous plates, executed in the best style, by the firs' artists. I No expense hvs been sp.u ed in the endeavor to render it worthy of the purpose for which it is intended. Embellishments.—1. The Hungarian Prin- cess, engraved by fllrnan and Pillbrow, from a picture by Holmes.—2. The Bower of Paphos, engraved by Ellis, from a picture by Martin.— 3. The Duchess and Suncho, engraved by Du- rand, from a picture by Leslie.—4. Richard and Saladin, engraved by Ellis, from a picture by Cooper.—5. The Rocky Mountains, engraved by Hatch and Smilie, from a picture by Doughty.—6. Lord Byron in Early Youth, engraved by Ell id, from a picture by Saunders. —7. Ti^er Island, engraved by Neagle, from a picture by Stanfield.-—8. The Blacksmith, engraved by Kelly, from a picture by Neagle. —9. The Tight Shoe, engraved by Kelly, from a picture by Richter.—10. Isadore, engraved by Illman and Pillbrow, from a picture by Jackson.—11. The Dutch Maiden, engraved by Neagle, from a picture by Newton.—12. The Mother's Grave, engraved by Neagle, from a picture Ly Schaffer. ATLANTIC SOUVENIR FOR 1831. Embellishments.—1. Frontispiece. The Shipwrecked Family, engraved by Ellis, from a picture by Burnet.—2. Shipwreck off Fort Rouge, Calais, engraved by Ellis, from a pic- ture by Stanfiele.—3. Infancy, engraved by Kelly, from a picture by Sir Thomas Law- rence.—4. Lady Jane Grey, engraved by Kelly, from a picture by Leslie.—5. Three Score and Ten, engraved by Kearny, from a picture by Burnet.—6. The Hour of Rest, engraved by Kelly, from a picture by Burnet.—7. The Min- strel, engraved by Ellis, from a picture by Les- lie.—8. Arcadia, engraved by Kearny, from a picture by Cockerell.—9. The Fisherman's Return, engra/ed by Neagle, from a picture by Collins.—10. The Marchioness of Carmar- then, granddaughter of Charles Carroll of Car- rolltoii,- engraved by Iihnan and Pillbrow, from a picture by Mrs. Mee.—11. Morning among the Hills, engrtved by Hatch, from a picture by Do 1ghty.^l2. Los ■Vlusicos, engraved by Ellis, from a picture by Watteau. A few copies of the ATLANTIC SOUVE- NIR, for 1830, are still for sale. THE BOOK of the SEASONS. By William Howttt. "Since the publication of the Journal of a Naturalist, no work at once so interesting and instructive as the •Volt of the P ■atons has been submitted to the public. Whether in reference to the utilitv of its design, or the grace and beauty of its e.v-cuiion, it will amply mint the popularity it is ceitaiu to obtain. It is, indeed, cheering and refreshing to meet with such a delightful volume, so full of nature and truth-in winch reflection and experi- ence derive ait! from imagination—in which we are taught much ; but in such a manner as to make it doubt- ful whether we hn"e not hecn amusing ourselves all the time we have been reading."— New Monthly Magazine. "The Hook of the Seasons is a delightful book, and Mag- FRAGMENTS of VOYAGES and TRAV- ELS, including ANECDOTES of NAVAL LIF3 ; intended chiefly for the Use of Young Persons. By Basil Hall, Capt. R. N. In 2 vols, royal 18mo'. " His volumes consist of a melange of autobiography, naval am cdotes. and sketches of a somewhat discursive nature; which we have felt much pleasure in perusing." "The title page to these volumes indicates their being chiefly intended for young persons, but we are much mis- taken if the raca of gray-beards will be among the lee.st numerous of the readers of ' midshipmen's pralnks and the 'humors of the green room.' "—Lit. Gazette. '■. LESSONS on THINGS, intended to improve Children in the Practice of Observation, Re- flection and Description, on the System of Pestalozzi, edited by John Frost, A. M. The publishers request the attention of teachers, school committees, and all who are desirous of improving the methods of instruc- tion, to this work, which is on a plan hitherto unattempted by any school-book in this coun- try, and which has been attended with extra- ordinary success in England. The following remarks on the work are ex- tracted from the '; Quarterly Journal of Edu- cation." "This little volume is a 'corrected and re-corrected' edi- tion of lessons actually siven to children, and, therefore, possesses a value to winch no book made in the closet can lay claim, being the. result of actual experiment. The work consists of a number of lessons, divided into rive series; beginning with subjects the uinst easy and elementary, it gradually increases in .difficulty, each suc- cessive step beingadapteri to the mind of the child as it acquires fresh stores of knowledge. " Every part of these lessons is interesting to the child, both on account of the active .operation into which his own mind is necessarily called by the manner in which the lessons are given ; and also by the.attractive nature of many of the materials which form the subject of the lessons. In the first and most elementary series,-the pupil is simply taught to make a right use of his organs of sense, and to exercise his judgment so far only as relates to the objects about him; and accordingly the .matter brought before him at this stage, is such that its obvious properties can be discovered and described by a child who has aequired a tolerable know ledge of his mother tongue." OUTLINES of HISTORY, from the Earliest Records to the Present Time. Prepared for the Use of Schools, witii Questions, by John Frost, A. IV I. "The main object of t!i" work is, by giving a selection of interesting and striking facts from more elaborate his- tories, properly and caref illy arranged, with chronological tables, to render the study of genen.l history less v Mr. Fr.is't. ar- a most valuable auxili- ary for ths teacher.as'well as the pupil. I shall use the "Outlines'" fn my school, and cordially recommend it to parents and teachers. S. C. WALKER." Philadelphia, April 30rA,iKl. " Dear Sir— Ihavejust received a copy of yournlir.ion of the 'Outlines of History.' From a cursory perns.il. i am disposed to zive it a hich rank as a set oo|.book. So well satisfied anf i with the arrangement and execution of the work, that I intend to put it immediately into the hands of a class in myown school. " Verv respectfully, your obedient servant, _-. . 'r.„_'_.' .. ipvi 171 nvupn FRENCH AND SPANISH. BY A, BOLMAK. A COLLECTION of COLLOQUIAL PHRASES on every Topic necessary to main- tain Conversation, arranged under different heads, with numerous remarks on the peculiar pronunciation and use of various words—the whole so disposed as considerably to facilitate tiie acquisition of a correct pronunciation of the French. By A. Lclmak. One vol. 18mo. A SELECTION of ONE • HUNDRED PERRI.VS FABLES, accompanied by a Key, containing the text, a literal and free trans- lation, arranged in such a manner' as to point out the difference between the French and the English idiom, also a figure;! pronunciation of the French, according to the best French works extant on the subject; the whole preceded by a short treatise on the sounds of the French language, compared with, those of the English. Les AVENTURES dk TELEMAQUE par FENELON, accompanied by a Key to the first eight books ; containing like the Fa- bles—the Text—a Literal—and Free Trans- lation ; intended as a Sequel to the Fables. Tnr frj,i-r^„;sa ';";_-.:.'.:;! pr:;:::'.:u iation.' is alove em- ployed to eipress that the teun..- m the Key to the French Fables are sp ;i and nivided as they are pronounced. It is what Walker has t'one. in his Critical Pronouncing Dic- tionary ; for in.-./c-ee. he indicates the pronunciation of the word enough, he J , e/, ,„■ and spelling it thus, e-nnf. In the same ma> .:?■ / n uieu.'c ihe. peer, nidation of the word 'comptatent thus, kon-te. As the understanding of the figured pronunciation if Walker requires the student to be acquainted with the primitive sounds efthe English vow- els, he must likewise, before he can understand the figured pronunciation of the French, make himself arr/uainted with the 20 primitive sounds of the French vowels. This any ilclligent person can get from a 'native, or from anybody WW rt ads Frcnjch well, in a few hours. A COMPLETE TREATISE on the GEN- DERS of FRENCH NOUNS; in a small pamphlet of fourteen pages. This little work, which is the most complete i of the kind, is the fruit of great labor, and will I prove of immense service to every learner. I ALL THE FRENCH VERBS, both REG- ULAR and IRREGULAR, in a small volume. The verbs etre to be, avoir to have, parler to speak, fmir lo finish, recevoir to receive, vendre to sell, se lever to rise, se bten porter to be well, s'en alter to go away, are here all conjugated through—affirmatively —negatively—interr. late Professor of Chemistry,