We pity the medical man that is turned adrift to practise his profession, perhaps in military hospitals, on board ship, or in some unhealthy locality, with such a miserable cargo of therapeutic directions; but ten-fold more are their poor patients to be compassionated.

Having thus ascertained the opinions of M. Bouillaud on two forms of typhoid fever, we shall now briefly examine what he has to say on the subject of typhus; which, as has been already stated, is considered by him to be a disease so totally distinct from the former as to be arranged in a class by itself. This class is the IVth, and is devoted to the description of "Miasmatic and Virulent Diseases in general, and Septic Diseases or Typhus in particular." Were we disposed to be very particular, we might, in all simplicity, inquire whether Ague and Remittent fever are not miasmatic diseases, not to mention the purely infectious exanthemata. But, without spending time on controversy, let us proceed to find out what our author has to say about Typhus.

First of all, he finds fault with all such vague terms as typhus, plague, yellow fever, jail-fever, and such like appellations. They have no precise meaning attached to them; it is, therefore, all but impossible to discuss their history. "Hence it comes that we know little or nothing about them; and the only plan to do, if we hope to understand their nature, is to throw overboard all the works that have been hitherto published, and have recourse anew to the book of nature. Ten observations, made with exactitude, on each of the above maladies, would do more to enlighten us than all that has yet been written upon them."

The first position that our author lays down respecting typhus and all other pestilential fevers, whether in Europe, Asia, or America, is, that in all cases, without exception, there is a double morbid element at work— inflammation, and a septic or putrid infection. In some cases, indeed, that latter element predominates over the former from the very outset ; but this is not always the case; for the typhoid condition may not be present at first, and may be only grafted upon the inflammatory, in the manner we have described in a former page, when treating of the history of enteromesenteritis. His second position is, that there are three sorts or species of Typhus-the European, the American or yellow fever, and the Oriental or the plague. These three are not so much different diseases, as varieties of one and the same disease. None of their alleged characteristic features are uniform or constant. Buboes and carbuncles have been witnessed in some cases of typhus; and the black vomit is not invariably peculiar to the yellow fever of the new world.

With respect to the seat or nature of the three species of typhus, our author acknowledges that it must be sought for in the blood. But, in seeking to explain the changes that take place, he is continually falling into the most bewildering errors, in consequence of his mind being ever intent upon mixing up some of his own conjectures with the facts which he describes. For example, he asserts that all miasmatic poisons induce an inflammatory action in the parts with which they come in contact; and then, having settled this point in his own mind, he proceeds to talk very complacently of the invariable co-existence "des états phlegmasiques" with "des états de decomposition septique," in the different forms of typhus or putrid fever. He says that, as yet, we possess no satisfactory

1846.]

TYPHUS, YELLOW FEVER, AND THE PLAGUE.

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information as to the change that takes place in the mass of the blood in this disease. He calls it "a sort of gangrene of this fluid; for it is essentially the same change as that which gives rise to gangrenous decomposition in a case of local septic infection." In confirmation of this statement, he quotes the observations of M. Bonnet of Lyons, to the effect that the blood of typhus patients contains hydro-sulphuret of ammonia-a salt that is well known to exist in putrescent blood. He refers to what he had previously said concerning the state of the blood in typhoid angeiocarditis and entero-mesenteritis, as being applicable to the hæmatology of genuine typhus; and he expresses his astonishment that Pinel, Broussais, and several other writers (whom he afterwards calls exaggerated solidists,) should have been so blind as, " in the midst of symptoms of the most flag. rant septicity," to call in question the existence of an altered state of the blood-ce grand élément pathologique-in patients labouring under typhus or adynamic fever. As he proceeds, he becomes quite a zealous out-andout humoralist ::

"It is not the blood only that exhibits alterations in typhus. As this fluid supplies every part and tissue of the body, and furnishes the materials of all the secretions, it is obvious that every part must be more or less morbidly affected. Among the most frequent alterations, I may mention the vascular injection of different organs, ramollissemens partly inflammatory, partly gangrenous, suppu rations, sanguineous effusions, and extravasations, &c."

With respect to the Etiology of true Typhus, M. Bouillaud agrees with the general opinion; for we find him admitting, that "the essential cause of the disease is a putrid miasm diffused in the atmosphere, and acting on masses of persons crowded together in ill-ventilated situations." He recognizes the contagiousness of the three species of Typhus; but adds that, in his opinion, the influence of this agency has been much exaggerated. His views on the subject of Contagion are evidently the result of a very imperfect examination of details. Indeed, the whole of this section of his work, that professes to treat of miasmatic diseases, is rather an unconnected commentary on the statements of certain authors than any regular exposition of the matter in hand. For example, he denies that any form of true typhus ever exhibits a remittent or intermittent character, and gives the following most convincing reason for his opinion:

"The element, that is common to intermittent and to continued fevers, is the excitation of the sanguiferous system: this element may exist either alone, or combined with a state of miasmatic infection. But in continued fevers, there is present, either in the sanguineous apparatus itself, or in different special organs, à veritable inflammation that keeps the febrile excitement under its dominion, and makes it assume the continued type which necessarily belongs to itself; whereas, in intermittent fevers, on the other hand, the febrile excitement is exempt from all such inflammatory complication: if this were not the case, the intermittent type would be absolutely impossible."

Our author seems to have forgotten all the while that he was treating of typhus, which, he had himself admitted, might exist without any inflammation at all!

The description given of the symptoms and treatment of typhus as seen in Europe, is about as absurd a thing as we have ever encountered.

M.

Bouillaud evidently knows nothing of the matter from his own experience; and at length, after a good deal of most unnecessary verbiage, he is obliged to admit that there is not an atom of difference between typhus and many cases of his entero-mesenteric, or of his angeio-carditic, fever. "The symptoms of the former," says he, "are essentially those which I have described when treating of the septic forms of continued fever (is typhus not a continued fever?-Rev.) and of entero mesenteritis. I will only remark, that there is in the last-named disease phenomena of local septicity and symptoms of general septicity, associated with those of inflammation. Now, if (!) typhus exists without being accompanied with the special inflammation of the mucous follicles of the ileum, it will not exhibit the local phenomena peculiar to this affection. In the contrary case, these phenomena will present themselves in a more or less decided manner."

The account given of the American Typhus or Yellow Fever is, as might be expected, very scanty and imperfect. Pinel, we are told, considered it not as a disease sui generis, but merely as one form of gastro-adynamic or putrid bilious fever; its peculiarities depending upon climate and other accidental causes. Tommassini was of the same opinion. M. Bouillaud flatly denies that the yellow fever (although he never saw a case) ever assumes a remittent, or intermittent type! The leading and most frequent anatomical characters of the disease are inflammation and ulceration of the stomach and small intestines, the presence of a dark sangui. neous fluid in the stomach, engorgement of the lungs, traces of inflammation of the archnoid, &c. M. Louis, in his report of the Gibraltar Epidemic, stated that a yellow discolouration of the liver was the only uniform and characteristic lesion, not observed in other diseases! On the other hand, M. Rufz of Martinique assures us that this is only an occasional appearance. Not even a passing allusion is made by our learned (?) author to the writings of any English physicians, although, we need scarcely say, no men have seen so much or written so ably, on Yellow Fever as our countrymen. But M. Bouillaud knows nothing about them; perhaps he has not even heard their names. He regrets that he has never been able to institute any personal researches on the true nature of the disease; then doubtless all difficulties would have been cleared up. He tells us that the symptoms of Yellow Fever are essentially the same as those of Typhus, and thereupon he sends his reader back to what he had said on this head!

With respect to the question whether the disease be contagious, it ap. pears that the majority of French writers are inclined to return a negative answer; and even those, who adopt the contrary opinion, are all in favour of greatly relaxing the existing quarantine regulations.

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As to treatment, M. Bouillaud very summarily dispatches that subject. Hitherto," says he," nothing precise or rigorously exact has been established. We must look to the labours of writers yet to come, for accuracy; their researches must be conducted in such a spirit of exactness, that no serious objection shall be made against the results which they have ob. tained!"

We shall not follow our author through his equally meagre, and often incorrect, description of Oriental Typhus or the Plague; we shall wait till he has seen it.

1816.]

DOCTRINE OF INTERMITTENT FEVER.

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Even on the more domestic, and therefore better known, subject of Intermittent Fevers, many of his views appear to us crude and most crotchety. We have already mentioned that this important family of febrile diseases, including remittent as well as intermittent fevers, is entirely separated from the genuine Pyrexia on the one hand, and from the different species of Miasmatic and Virulent diseases on the other, and is de scribed as one of the members of the Neuroses. M. B. commences his description of them in these words:

"Like those of a continued type, intermittent and remittent fevers may be either of a miasmatic or of a non-miasmatic origin, simple or compound, i. e., either consisting of the febrile element alone, or of this element, combined with a septic one proceeding from paludal emanations. The intermittent fevers of the first category are pretty generally benignant, whereas those of the second may, if not properly treated from their outset, quickly cause the death of the patient; hence the appellation of pernicious has been applied to them.”

As we proceed in the narrative, we soon discover that our author's opinions are anything but settled on the ætiological history of intermittent. fevers. In some passages, he leaves the impression on the reader's mind that paludal exhalations are the only exciting cause; while, in others, he intimates that a case of genuine ague may be produced by mere alternations of atmospheric temperature. But he will not take upon himself to decide the question; although he does not see in what other manner the not unfrequent occurrence of cases of intermittent fever in Paris is to be accounted for. We should have thought that the exhalations from the filthy Seine, when its waters are low in summer, would have been deemed to have had sufficiently potent influence in this respect.

The proximate cause of intermittent fever is declared to be "an intermittent irritation, a sort of neuralgia of the great sympathetic or ganglionary system of nerves, either with or without paludal infection." Its essential character is a simple nervous excitation of the sanguineous system, whereas that of a continued fever is, as we have already seen, a phlegmasia of this system. M. Bouillaud very adroitly lets go the subject of Remittent Fevers; as it is pretty obvious that their phenomena and course do not tally well with the Procrustean limitations assigned to the other two families of febrile diseases. They are therefore quietly allowed to drop out of consideration, the reader hearing little or nothing about them.

The nervous nature of simple ague is very well shewn by the intimate association and dependence of many truly neuralgic affections on malarious influence, and also by the character of the medicines that are known to be most efficacious in relieving both; for example, quinine, arsenic, &c.

It is amusing to observe how anxious M. Bouillaud is, now-a-days, not to be considered a strict disciple of the physiological school of medicine, which has hitherto been lauded by him as the depositary of all that was safe and sound in our profession. Treating of the administration of quinine in the treatment of Agues, he points out the necessity of often exhibiting it in full doses, "sans craindre le developpement de cette gastrite, tant redoutée de certains médecins sous le règne de la doctrine dite physiologique; mais c'est en pure perte." And to give greater emphasis to this renunciation of out-and-out adherence to the doctrine in question, he tells us in a note that, so far back as 1826, when he published his treatise on

so-called Essential Fevers, he did not partake of the terreur panique which most of the pure disciples of the physiological school entertained on the subject of administering quinine in the early stage of intermittent fever.

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He subsequently informs us that he was the first to propose, and employ, (?) with a truly surprising success, the use of Digitalis as a succedaneum for quinine in the treatment of simple mild intermittent fever. He was led to this happy therapeutic thought by the theory he had formed as to the seat and nature of the inalady. Considering that it essentially consisted in a sort of periodic irritation of that portion of the nervous system which presides over the phenomena of circulation, and proceeded from the calorification in the substance of all the internal organs, I then drew the conclusion that Digitalis, whose fundamental property is to diminish the action of that portion of the nervous systein, and of the heart and arteries, would be well suited to the treatment of ague." The result of his first experiments exceeded his expectations; but latterly, it would seem, he has recourse upon all occasions to the Quinine. Such is the history of too many of the therapeutic proposals of recent times.

M. Bouillaud seems to be afraid lest some of his brethren might suppose that the cases, in which the Digitalis had effected a cure, were not cases of ague at all; and he therefore takes the trouble to assure us that, before exhibiting the medicine, either he or his head clerk had always witnessed one or more of the attacks of the fever after the patient's admission into the hospital!

Before parting with our author for the present on the subject of Fevers, it may be as well to let our readers know what opinion he has formed upon one of the most important topics connected with the history of this ubiquitous class of diseases-we allude to the influence of what has been called the Medical Constitution of different seasons in modifying their characters, nature, and results. M. Bouillaud seems to consider much that has been written upon this theme as the sult rather of meditation in the closet, than of actual experience at the bed-side of the sick. He talks, with an air of almost contemptuous complacency, of anything valuable being discovered at a time when Physics and Chemistry were yet unknown, when Astronomy was not entirely freed from the chimæras of Astrology, and the science of medicine consisted of little more save the most vague data and most shapeless materials. Such is M. Bouillaud's estimate of the age when Sydenham lived and wrote!

"To form," says he, "an idea of the precarious state of the science upon the point which now occupies us, such as it has been treated of by the ancients, the reader may consult the faithful analysis which I have given of the doctrines of Sydenham, of Stoll, and of Pinel, in my Clinique Medicale. I shall content myself with quoting here some passages which refer more especially to our subject.

"According to Sydenham, continued, epidemic or stationary fevers differ so much in themselves, (toto cœlo,) according to the different constitutions of the seasons, that the very same course of treatment, which may have been most successful during the greater part of a year, shall prove useless or positively hurtful towards its decline. Nothing can be plainer or stronger than the assertion of Sydenham; but we shall search in vain for any positive proofs of its truth in the work of this writer.

"There is nothing more celebrated than the doctrine of Stoll upon the im