^V^fe^VT:■-'/■■;•.'. :j,>i--: :'■■'■■• v7 v--Vi'4.'.'1---■: VilV.M\V-.- ,-; •■•; ' ■■ <•■•■' #r^-;>:>•■■,'• ,:■'.■•■;. ; V'.''; wJ ■?< v i . J *.:.{. * .:•. i 'irvri-1:. «■■;'.5"... r > ' • ^^:.VM:■:'.Vi^'.^,•■ ■■:M-%$\-;< ■ ':■;■ '■'. ''. ' ^ if-iV/W ' X|.'; •;'■•• Vj v.■,) ^mMMm^B^mm^ ■■■■■>•■ : -,^MwSs^^i \ FIRST PRINCIPLES OF MEDICINE. BY ARCHIBALD BILLING, M.D., A.M., MEMBER OF THE SENATE OF THE ONIVERSITY OF LONDON, FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, ETC.; FORMERLY TROFESSOR Or CLINICAL MEDICINE AND OF THE THEORY AND PRACTICE IN THE SCHOOL OF MEDICINE OF THE LONDON HOSPITAL J PRESIDENT OF THE HDNTERIAN SOCIETY | VICE-PRESIDENT OF THE ROYAL MEDICAL AND CHIRUROICAL SOCIETY, ETC. FIRST AMERICAN, FROM THE FOURTH LONDON EDITION. REVISED AND IMPROVED. PHILADELPHIA : LEA & BLANCHARD. 1842. Y43 1*42- PHILADELPHIA : BARRINGTON AND HASWELL, PRINTERS. THE RIGHT HONOURABLE WILLIAM CAVENDISH, LL.D., F.R.S., EARL, OF BURLINGTON; GRADUATE, WITH THE HIGHEST HONOURS, OF THE UNIVERSITY OF CAMBRIDGE; CHANCELLOR OF THE UNIVERSITY OF LONDON; ETC., ETC., ETC. Ef)is Volume is TjeUfcateU IN TESTIMONY OF THE HIGH RESPECT OF THE AUTHOR. Tu, qui natales antique- sanguine claros Ingenii decoras nobilitate nova, Accipe non magna turgentem mole libellum, Et mea rnansuete quantulacunque lege. Publicus his postquam favor adfuit, acrius audens Spem de se tandem ccepit habere liber; Nee satis esse putat: si Tu dignabere laude, Hoc saltern titulo tutior esse cupit. ADVERTISEMENT TO THE THIRD EDITION. Though it may be thought that the third edition of a book requires no advertisement, I consider it quit necessary to ex- plain some circumstances connected with this work. Feeling that no author has been more indebted to the indulgence of the public press for kind criticism, I have endeavoured to profit by the hints given me in every respect but one. The first edition was sent forth to take its chance in the world without herald of preface or advertisement, unadorned by dedication, and un- accompanied by any table of contents: my original reasons for the last omission remain unshaken; and I have therefore merely given, for the convenience of students, a few pages so prepared that they make an index for their own use, by putting down, as they go through the work, the position in which subjects occur in different parts of it; as I have done with respect to " arterial action," " ulceration," &c, &c. I found that the former editions were more pleasing to fully educated medical men and men of experience than to the tyro. This was not my original intention ; and I have therefore taken 6 ADVERTISEMENT TO pains to render the work more intelligible and useful to the latter, and have added much to suit the taste of both. It does not appear to me that I used too strong an expression formerly in speaking of the confusion which has existed in medicine ; and, as an example, I need only refer to the strik- ing fact noticed in this work, that the two words, inflammation and irritation, which are most frequently in the mouths of medical men, are up to this day perpetually used in a double or equivocal sense. Inflammation is correctly used to imply disease, and incorrectly to signify the process by which the damage done by the disease is repaired (pp. 70-72). Irritation is perpetually incorrectly used to signify a state of disease, as it can only be correctly applied to the process whereby any- thing irritates, annoys, or over-excites a part: the irritant, irri- tating thing, whatever that be, by its operation (irritation) produces in the part morbid sensibility. One great objection to using the term irritation to imply disease, is, that irritation (the act of irritating) produces sometimes inflammation, and sometimes only morbid sensibility ; but, according to the old phraseology, irritation produces irritation and inflammation, and inflammation produces sympathetic irritation and consti- tutional irritation, and sympathetic irritation and constitu- tional irritation arise from local irritation, &c, &c. In order to avoid this equivoque, I determined, in the present edition, to adopt the term morbid sensibility as the name for the diseased state usually implied by irritation, and to use the word irritation only in its proper sense ; and wherever the word irritation oc- curs in other works implying disease, it will be found that morbid sensibility may be substituted for it. In this alteration of a term, I consider that I have done the student good service, rendering my own explanations more clear, and also those of other writers, by giving him an eluci- dation of the word irritation where it occurs as a disease in the THE THIRD EDITION. 7 valuable works of such authors as Sir A. Cooper, Travers, &c, and enabling him at a glance to distinguish whether it be men- tioned as a cause or a symptom. Many of the valuable works of Orfila, Christison, and others, on toxicology, will be more intelligible by referring to the state of morbid sensibility explained in the following pages. Again, I have shown (pp. 89-90) that there is in reality no such thing as a specific; and, on the other hand, I have ex- plained how some medicines become useful in such a variety of diseases as almost to realise the dreams of the ancients and alchymists respecting a 7ra.vctx.1nt., or an elixir vitas ; and thus why one empirical remedy, antimony, held the reins of the " currus triumphalis" until surperseded by the more modern blue-pill.* I may mention a few more of the explanations given. I have shown that tonics are not stimulants; and * I have given my opinions respecting the pathology of the nervous system, as depending on physiology, in the course of this work; but was unwilling at present to introduce a subject so much under dispute as animal magnetism. The principle upon which it acts (and it undoubtedly does act to a certain extent) is, I think, easily explained. The physiology of the nerves shows, not merely in the torpedo, gymnotus electricus, &c, but in simple muscular action, &c, that a change in the electric state, plus or minus, takes place on everv act of volition ; in other words, that there is an electric communica- tion between the brain and the tips of the fingers, whether in playing the pianoforte, or making the passes or actions of animal magnetism; and every one of these actions is a succession of weak electric shocks, not individually perceptible, but by continuation producing an impression or result; as an electric jar may be charged by a weak electric machine, though no sparks be visible. The person who makes the passes produces a succession of trans- missions of electricity, which alters the electric state of the brain of the per- son magnetised, who is in a state of quiescence, and whose nervous system will be more susceptible if out of health or inclined to coma, independent of the very various degrees of susceptibility of the nervous system of persons even in health. 8 ADVERTISEMENT TO why they may be combined advantageously with sedatives, with stimulants, or with narcotics; how stimulants are to- nic ; how sedatives are tonic; how narcotics are tonic; and, though not a homceopathist, how emetics stop vomiting, and purgatives diarrhoea. I have shown how every me- dical man has his hobby to carry him to the same point, which, though he thinks it very different from his neighbour's, is as like it as one four-legged jade is to another; how one man thinks he has made a discovery that he can cure cholera with sugar of lead, and that there is nothing equal to it; whilst tartar-emetic, calomel, Epsom salts, or Glauber salts, or com- mon salt, or mustard, or lemonade, or vinegar and water, &c, &c, will do the same thing ; though none of them more quickly carry off the vomiting and purging than two of these hobbies in double harness — tartar-emetic with some neutral salt, I care little which. An anonymous writer once advanced against this work that I differed from J. Hunter in the theory of inflammation, — as if he were "the law and the gospel." It may be seen that I differ not only from J. Hunter, but from his talented successors, BicMt, Sir A. Cooper, W. Lawrence, and others, in theory, on physiological and pathological principles, though little in therapeutics. On the subject of the division and classification of remedies, on the cause of the sounds of the heart, on the proximate cause of inflammation, on morbid sensibility, &c, I feel confident of obtaining the future suffrages of the profession. On the essential points of practice in the treatment of inflam- mation, I agree of course with men of such experience as Sir A. Cooper and Lawrence. It may be asked, then, what does it signify wherein we differ ? It is, in my opinion, of great consequence to correct erroneous theories, and thereby enable students to arrive sooner at well-founded principles of practice. Although this work consists rather of general pathology than THE THIRD EDITION. 9 what is called the practice of medicine, it will be found to con- tain the essentials of the treatment of disease. The greatest difficulties have arisen from the loose way in which remedies have been arranged and classified: I have endeavoured to re- move these difficulties by the division into stimulants, sedatives, narcotics, and tonics; and by showing how these are to be combined with each other, so as to afford a guide to clinical practice. We sometimes find persons doubting the efficacy of valuable remedies from not knowing how to apply them; for instance, bark, sarsaparilla, dulcamara, logwood, carbonate of iron, arse- nic, conium, digitalis, elaterium, hydrocyanic acid, and blis- ters ; each of these has at one time or other been said to be either inert or injurious, from misapplication, though they are powerful and efficacious remedies. We every day meet with old men who from prejudice have scarcely ever used some one or other of these substances ; though others, placed in an ex- tensive field of practice, such as our hospitals, use them daily with advantage: there are even persons who have been thirty or forty years in tolerably extensive practice who have not made use of a lancet so many times. In going round the wards of an hospital a pupil might re- mark to the physician at one bed, What a small dose, and at the very next, perhaps, What a large dose, you have given ; large and small being both incorrect terms when the force ap- plied is properly adapted to the quantity of disease and state of constitution. In practice there should be no such thing as boldness or timidity : boldness is an ignorance (for we must not suppose a recklessness) of the harm which too strong means may do a fellow-creature ; and timidity is an ignorance of the efficient means which remedies afford of relieving human suf- fering. 2 10 ADVERTISEMENT TO THE THIRD EDITION. In this edition I have added many cases, in illustration of principles laid down, as they are equivalent to diagrams in geo- metry. A person who has studied geometry can understand the proof of a proposition in general terms without a diagram — but not so a beginner; and a beginner in medicine requires a reference to cases, to render some general principles intel- ligible. ADVERTISEMENT TO THE SECOND EDITION. I was originally led to publish this treatise by a recollection of the difficulties I had met with in the study of my profession, and by the hope that I might aid in removing them from the path of others. Upon commencing the study of medicine and surgery, after having become acquainted with the more precise physical sciences in the University, I was appalled to find it a com- plete chaos. Our family physician, really a man of great talent, and one of our professors, disheartened me by his an- swers. I inquired, "What is fever?"—Answer, of course, Cullen's definition. " But what produces it ?" — " Sometimes one thing, sometimes another : excessive cold or heat, or the effluvia from a person who has fever." " But what is the cause of the phenomena in the body?" — "Spasmodic con- traction of the extreme vessels." I could understand that cold might contract the extreme vessels, but I had been taught by the professor of chemistry that caloric expanded everything. And, again, I did not see how effluvia produced spasm, nor how the spasm, even if it were produced, could make the skin extremely hot as well as cold. I was advised to read Cullen, and did so; but without finding the information I sought. Again I asked, " When you give a dose of rhubarb or castor 12 ADVERTISEMENT TO oil to stop a diarrhoea of several days' standing, how does it effect this object ?" — " By clearing away the peccant matter." " But would not the diarrhoea scour away this peccant matter itself ?" — " Not so well." This did not satisfy me. Neither could the surgeon clear up these points: " for his part, he did not pretend to understand physic." I " walked" the hospital at his elbow as dresser, and inquired, " Why do you apply a cold lotion to that inflammation ?" — "To moderate the action of the vessels ?" — " Inflammation, then, is over-action of the vessels ?" —"Yes." "Why do you apply that astringent (goulard or nitrate of silver) to that other inflammation ?" — " To diminish the action of the vessels." Now, the action of the vessels being contraction, my logic did not enable me to comprehend him ; so, after ask- ing why he put a cold lotion or poultice on one inflamed part, and a warm poultice or fomentation on another, and being told that I should find out by experience, I resolved on attempting to find out myself. I accordingly set seriously to work, and endeavoured to draw up a little code of general principles for my own use, as I could find nothing of the kind existing. The so-called sys- tems of Cullen, Brown, Broussais, Rasori, &c, seemed mere individual opinions, totally differing from each other; and which was I to follow ? Each of their originators appeared confident in himself, and despised his adversary ; while their followers almost came to blows, arguing as much for victory as the love of truth. I visited the different schools : the stu- dents of each hinted, if they did not assert, that the other sects killed their patients ; but I found that, provided the physician of each school was a man of talent and experience, the mor- tality was fairly balanced. I therefore concluded that, on in- vestigation, some true general principles would be found to exist by which the apparent inconsistencies of correct practice might be reconciled, and the contest between such systems as were essentially at variance be decided. But, though innu- merable volumes of cases, and interminable heaps of insulated precedents, were to be met with, no treatise upon first princi- ples had appeared. THE SECOND EDITION. 13 After twenty years of intense application to clinical practice, as student, assistant, and professor, I found the same acknow- ledged necessity for reducing the conflicting systems of medi- cine to general principles ; and I therefore ventured to publish the result of my own labours, compressed into 130 pages.* The subject of clinical lectures is closely connected with the attempt to reduce the science to general principles. In medical publications much just censure has been expressed of the ne- glect of clinical instruction, and of the omission on the part of hospital physicians and surgeons to render their experience available to the profession in general, and consequently to the public. In 1822 I had the honour to be elected Physician of the London Hospital,! at which time no clinical lectures were given in London : in the same year, however, I commenced this important branch of medical education, not merely in- structing the pupils in the wards and theatre, but attending and explaining post-mortem examinations. This course I pur- sued, at a great sacrifice of time and some of health, for six or seven years; when the rising members who had been my * The trouble it cost in condensation makes me pleased whenever the term " little" is applied to the work; and I cannot deny myself the satisfac- tion of transcribing the words of Professor Stromeyei", of Hanover: " Dr. Billing's book is a very clever little pathologia generalis; his views cer- tainly go beyond those of most pathologists, by his taking the nervous sys- tem into consideration. Upon the whole, I think it as much adapted for fully educated medical men as for students. Books like this are very rare; almost every writer strives, whatever few original ideas he has, to bury them in a mountain of generally known matter; whilst Dr. B. gives us a very intellectual (geistreAcK) view of his peculiarities." I must acknowledge also that I derived much satisfaction from the favourable notices of the medical reviewers; as their testimony gave me more confidence in the ap- probation expressed by private friends. f The London Hospital, incorporated by royal charter in 1795, besides between nine and ten thousand cases per annum of diseases and injuries treated by the physicians and surgeons as out-patients, contains 320 beds, always filled with fit subjects of clinical study; the surgical accidents average fifty per week. Several foreign hospitals have twice and three times this number of beds; but they include persons disabled by old age, imbecility of mind, malformation, &c, — such as are taken care of in our workhouses and asylums of various denominations. 14 ADVERTISEMENT TO clinical secretaries, — Drs. Macbraire and W. J. Little, (the latter now Professor of Comparative Anatomy, alumnus dig- nissimus of Muller and Grant), Messrs. Hamilton, Adams, Curling, &c, — being able to relieve me, I continued only the lectures, instructions in the wards, and once a week an ana- tomical demonstration, illustrating cases by recently obtained specimens, or by those in the extensive collection of patholo- gical anatomy in the museum. In this mode I persevered up to the present session (1836), when, from being appointed to the University of London, it became impossible for me to con- tinue it. I have of late years had the satisfaction of finding the example very generally followed in the metropolis, besides that of witnessing the success of the school in which it was first regularly established. The medical officers of the London Hospital, I must also observe, were among the first who were mainly instrumental in introducing auscultation ; and I am surprised that it is not yet by any means generally adopted. It is a source of real regret to me that so few medical men have taken the trouble, or known how to avail themselves of this invaluable and indis- pensable method of detecting, so as to combat, the most deadly diseases of the chest. On this score Dr. T. Davies gained a well-earned celebrity; he not merely gave lectures to pupils, but collected the members of the profession at the east end of the town, at his own house, and instructed them in this almost new sense of perception. From the time he became one of the medical officers of the London Hospital, in 1829,1 derived great assistance from him in the clinical department, in the in- struction of those young gentlemen who had the good sense to avail themselves of the opportunities afforded them of learning auscultation and the use of the stethoscope. One cannotbe much surprised that the multitude are slow in adopting what in some instances has been treated with neglect, and in others has met with decided opposition, by men in high reputation and prac- tice. As to the stethoscope, I wish it were understood that it is not absolutely necessary, except from motives of delicacy ; as the apparent difficulty of using it deters some persons from commencing auscultation, and has given occasionally an oppor- THE SECOND EDITION. 15 tunity for opponents to use a tremendous substitute for reason- ing — ridicule ! It is disagreeable to apply the ear to the chest if the patient, as occurs sometimes in charitable institutions, be not clean ; and if the patient be a female, it is objectionable for other reasons: hence the artificial elongation of the meatus auditorius externus, called stethoscope, becomes eligible, though no better than the naked ear to judge by. I am in the habit of using a very simple one, which is merely Laennec's abridged, instead of being complicated, as it has been by other improvers of his instrument: it is rounded and cut away in the middle to make it light and convenient; the flat end being turned to the chest answers the purpose of the obturator ; and it is only four inches long, which is sufficient for the purpose as to stetho- scoper and stethoscoped, and may be obtained from any wood- turner for a few pence. Section of the Stethoscope. f ' One great difficulty in the way of learners of auscultation is their attempting to begin on patients: this is like trying to study morbid anatomy before acquiring a knowledge of healthy structure. If beginners would first learn the sounds of respira- tion and of the heart in healthy persons, which may be done in about ten minutes once for all, they would have little diffi- culty in detecting any unhealthy deviation from the normal state, and would very soon arrive at just diagnosis. I warn medical men that they must soon turn their attention to the subject, or be disgraced. Many affectionate parents are in the habit of feeling the pulse and looking at the tongue of their 16 ADVERTISEMENT TO children when they suspect disease to exist; they will also ere long learn the very simple process of applying their ear to the chest, and thus put the medical attendant to shame if he cannot resort to the same means. But the progress of the schools has been slow enough; it is but now that comparative anatomy, which is the only sure foundation of physiology, is beginning to be taught in London; and it required the energy and talents of a Grant, with a firm footing in a great school, to carry it into effect, and to compel the other schools to follow the example. Professor Macartney, with all his energy and talents (and he does not need my tes- timony to establish his claims to both), fully imbued with its value, could not find support in his laudable attempt to establish it thirty years ago in Bartholomew Hospital; but I consider myself most fortunate in having early met with him and imbibed a taste for physiology. The ingenious and persevering German comparative anatomists with their microscopes are unravelling many a dignus vindice nodus; and I am gratified to find in their recent publications confirmations of opinions advanced in this work seven years since, — as, for instance, my explanation of the cause of a limb being "asleep," benumbed,* by refer- ence to the medullary part of the nerves being in tubes (as asserted by Fontana), which has been demonstrated by Ehren- berg (Darstellung eines merkwiirdigen Baues des Seelenor- ganes, Berlin, &c.); who has proved also that not only are there two sets of nerves (as referred to p. 134) of animal and organic life, but that there is a third set, of the senses, all recognisable by their structure when an isolated piece of either is subjected to the microscope. Remak (Archiv fur Anatomie, Physiologie, &c, von Dr. Johannes Miiller, Jahrgang 1836, Heft 1 und 2) has likewise shown the difference between the motor and sensitive roots of the symmetrical nerves — that the latter pos- sess in addition some organic filaments, and that the glosso- pharyngeal belongs to the same order as the optic, auditory, and olfactory; thereby confirming Panizzi's opinion, that the hypoglossal is the motor, the lingual branch of the fifth the * See p. 105, 4th edition. THE SECOND EDITION. 17 sensitive, and the glosso-pharyngeal the gustatory nerve of the tongue. Schwann (Mailer's Handbuch der Physiologie, Co- blentz, 1833), by experiment on the mesenteric arteries of small living animals, has demonstrated that I was right as to the modus operandi of cold as a remedial agent in inflammation. Schwann and Eulenberg again, have shown that the middle coat of the arteries is not muscular in structure, but elastic, as asserted by me (p. 33), consisting of that distinct tissue con- stituting the ligamentum nuchse of ruminantia, the ligamentum flavum of man, &c. The veterinarians also have contributed in their compara- tive department. Hausmann, by direct experiment, has added fresh proofs to my theory of inflammation (p. 45 et seq.); Sewell, of our own Veterinary College, twenty years ago pub- lished plates showing the muscular coat in the bronchi of the horse; indeed, the muscularity of the bronchi was shown by Morgagni: nevertheless, it has been lately spoken of as a dis- covery, as mentioned in Youat's valuable Journal, March, 1837, in the Report of the Veterinary School of Alfort. Not that I agree that the muscularity of the bronchi can assist in natural expiration, for that is contrary to the physical structure of the chest — it merely helps to get rid of any noxious matter, whe- ther generated there or introduced through the windpipe. Before concluding this Preface, I wish to take the opportu- nity of adverting to one or two matters which will be found in the work. At p. 35, to the note originally published on the heart, I have added, that the sounds depend on, or are pro- duced by, the valves. I would not burden the text with proofs of what I feel assured will shortly be generally received as a fact as well ascertained as the circulation of the blood. But as it is still disputed, not merely by individuals, but by Associations, and committees appointed by them to investigate (he subject, I will here repeat my arguments already published, which have not, to the best of my judgment, been answered; and besides, by referring to their own experiments, I think I can disprove their assertions. In an Essay read at the anni- versary meeting of the Hunterian Society (Feb. 9, 1832, and reported in the "Lancet," May 19, 1832), I first stated pub- 3 18 ADVERTISEMENT TO licly " that the push or beat is caused by the ventricular mus- cles in their systole to expel the blood. The first sound is caused by the tension produced in the shutting of the auriculo- ventricular valves, and the second sound is caused by the tension produced in the shutting of the ventriculo-arterial valves," &c, &c. " This is a simple unsophisticated explana- tion of the causes of the beat and sounds of the heart; and you will find that the morbid signs are all explicable as alter- ations of these." Some exemplification follows, unnecessary to repeat here. Subsequently Rouanet brought forward the same explanation in his thesis, which was noticed in the "Journal Hebdomadaire" (Sept. 1832), and copied into the " Medico-Chirurgical Review" (April, 1833), as well as an ex- tract from my essay ; in which I had advanced, as I thought, sufficient to enable any practised physiologist to confirm my positions by the suggestions of his own mind. Finding, how- ever, from some observations, that this did not appear to be the case, I published the following additional remarks in the " Lancet" (Nov. 30, 1833): " The succession of phenomena of the heart's action is as follows : first, the auricle contracts, then the ventricle ; by the action of which the auriculo-ventri- cular valves are shut by the pressure of the blood against them. Upon the relaxation of the ventricle, the semilunar valves are shut by the backward pressure of the blood in the artery. The first sound takes place exactly synchronous with the impulsion and action of the ventricle ; hence it might be supposed that the action of the muscle (as averred by some) produces the first sound. But the second sound takes place at a time when there is no action of the heart going forward; and this is peculiarly evident when there is an intermitting pulse, as there is then a marked pause after the second sound; so that, in fact, there is nothing but the semilunar valves in operation to produce sound at the instant." I have thus proved that the second sound can be produced by nothing but the valves; and I have therefore shown the tension of the valves to be a sufficient cause for the first sound ; and as nilfrustra naturafacit, according to the laws of reasoning in physics, more causes than are true or sufficient THE SECOND EDITION. 19 are not to be assigned (Newt. Princip. lib. iii. reg. phil. 1), so I discard muscular action as the cause of the first sound. These are my proofs, published between February 1832 and November 1833. Now, as to their experimentum crucis (to show that muscle produced the first sound), of putting the finger into the heart after the valves were destroyed, and their hearing a sound proceeding from the contraction of the heart, with air, carneaa columnar, and bloody moisture in it, without the fingers : doubtless there was a sound produced independent of the valves, but not the sound of the heart. I say, my proof is legitimate —their assertion a sophism of non causa pro causa. It is the tympanic sound of the membranous valves which, with the time of the beats, produces the rhythm; and we judge of the existence of certain states of disease by the degree and manner in which they are out of tune. Looking at the subject physiologically and pathologically, valvular sound is the one we have to depend upon ; for granting, for argument's sake even, that any other exists as a normal accompaniment, it has no more to do with the sound, than the drone of a bag- pipe has to do with the tune. In his last appendix, Dr. Hope began to allow that the first sound may be " possibly partly valvular," but still adheres to the " bruit musculaire." According to the report of the London Committee of the British Association, the subject seemed to be in the position agreeing with the vulgar notion of a "suit in Chancery" ("Med. Gaz.," Dec. 10,1836). With respect to the assertion of a celebrated experimenting physiologist, that the sound is produced by the heart coming pit-a-pat against the parietes of the chest, it is only necessary to refer to Mr. Bryan's beautifully ingenious experiment ("Lancet," Feb. 8, 1834; also Dec. 26, 1835, and Feb. 27, 1836); by which he proved that the heart never quits the anterior, but remains in apposition during both systole and diastole. In giving the above explanation to my class, I was in the habit of exemplifying how the sound was produced, by a strip of paper two or three inches long, and half an inch wide, sud- 20 ADVERTISEMENT TO denly stretched — the sound of which was heard all over the theatre. Dr. Hope subsequently mentioned, in his Appendix, 1835, his having employed a piece of tape for a similar purpose. ******* Mr. Bryan published the same theory ("Lancet," Jan. 1833); but when he became acquainted with my priority, he very candidly wrote an acknowledgment, in a critique on the Report of the Dublin Committee of the British Association ("Lancet," Dec. 26, 1835, and Feb. 27, 1836). -****#* * In our scienee, from insufficiency of data, and being often obliged to found our arguments on analogies, it is difficult to avoid falling into errors of non causa, and reasoning in a circle. I therefore claim indulgence, and entreat some of my highly gifted brethren to improve on my suggestions. The following additional matter on the causes of the sounds of the heart was published by me in the " Medical Gazette,'''' April, 1840. * * * * My object is to prove that the physiological sounds of the heart are caused by the valves, and the valves only. The question is still sub judice; at least, 1 have met with no public acknowledgment of the truth of my proposition, published in 1832, that the normal sounds of the heart are produced by, and depend upon, the tension of the valves. The moment I read Laennec's assertion, that the second sound was caused by the auricles, I perceived that it was erroneous, as being inconsistent with the successive actions of the heart, acknowledged by physiologists from the time of Haller, and fully confirmed by experiments on animals, — viz., that the auricles contract first; then, following continuously without any interval, the ventricles; and that subsequently there is a period of relaxation, or ces- sation of action, in each part during the diastole* between each systole. I was thus satisfied (from the repose of the muscle) of the impossibility of the auricles having anything to do with the second sound, there being no action * During the diastole the muscles are flabby, and yield to the pressure of a probe, whilst during systole they are felt to resist or rather repulse it. The heart being a forcing pump, it is merely necessary to apply one hand over it, and the other to the pulse, to be satisfied that the beat of the heart ("impulsion") depends upon the firm bulging of the muscles in systole. THE SECOND EDITION. 21 of either auricles or ventricles going on at the moment, for it was the time of relaxation of both. Dr. Hope, in his first edition, p. 49, endeavoured to prove that this sound was produced by the " ventricular diastole," and " the blood shooting with instantaneous velocity from the auricles into the ventricles;" although, as he set out with acknowledging that the second sound takes place at the mo- ment that the auricle is relaxed, the blood at that time could be only flowing into the ventricle gently from the veins through the auricles, as it always does at that time; for the ventricles are partly filled in this way, before the auricles (which are never empty) inject the blood into them, so as to stimu- late them. It was evident to me that there was no cause in existence at the moment to produce the sound, except the tympanic tension of the ventriculo-arterial (sigmoid) valves; or, in other words, that the sound was entirely valvular ; and having established that cause as "sufficient" for the second sound, I ven- tured (upon the Newtonian principle) to assert it as the cause of the first sound, and can prove it to be so, the difference in form of the auriculo-ven- trieular valves and surrounding attachments accounting for the slight differ- ence in duration and tone of the sounds. These opinions, which I had discussed with friends and pupils, appeared to me such self-evident propositions, that until I found Dr. Hope and others labouring to establish erroneous explanations, I did not think it necessary to publish mine. At last I made them the subject of a communication to the Hunterian Society, 9th Feb. 1832, together with some practical observations, to show that pathological alterations confirmed my explanation. This was published in the " Lancet," 19th May, 1832, and afterwards in the " Med. Chir. Review." Dr. Hope instituted a number of experiments, as is well known, with the endeavour to support his opinion, that both the first and second sounds were caused by the " motion of the contained fluids;" " the vibratory collision thus occasioned amongst the particles of blood producing sound." This cause, however, he relinquished for the " bruit musculaire;" and at last he was compelled to acknowledge, in his Appendix, 1835, that the cause of the first sound might be "possibly partly valvular." In the new edition of his work, published last year, he still adheres to the opinion of 1835, except that he quite acknowledges that the first sound is not merely "possibly," but actually partly valvular; but he coincides with the opinion of the London Committee of the British Association for the Pro- motion of Science, respecting bruit musculaire. Now I contend that the first sound, as well as the second, is entirely val- vular, and deny that any part depends upon muscular noise (" bruit muscu- laire") ; for when there is simple hypertrophy (increase of muscle and mus- cular action), there is diminution of sound, although more of the condition necessary to bruit musculaire. This contradicts his opinion and confirms 22 ADVERTISEMENT TO mine, inasmuch as it is the valves being encroached upon, and their having less blood to stretch them, which prevents their producing the usual sound. Again, when there is moderate hypertrophy, with proportionate dilatation, there is not appreciable increase of sound; though, if he were right, the quantity of muscle being increased, there ought to be increase of sound. My explanation accounts for the sound here remaining the same, as the valves are in their usual relative condition. Again, when the heart is enormously enlarged by hypertrophy and dilatation, in which case there ought to be enormous first sound (if bruit musculaire were a cause), there is none, or scarcely any, because the openings are so dilated that the valves cannot act: thus we have pathological confirmations of my opinion. In his last edition, 1839, he endeavours to show that he was not ignorant of the valvular theory in 1830. He does not, however, understand it yet; he speaks of the valvularity of the, second sound being confirmed by his ex- periments, as if he had not been labouring to overset it by his experi- ments, and as if I had not published the valvular theory in opposition to him, when he was experimenting to establish the erroneous opinion which he af- terwards relinquished for mine: his successive publications prove the fact. He says (page 13), " that the sound was not attributable to the retrocession of the semilunar valves, I entertained a strong presumption." What was to have prevented him, as well as myself, from having a perfect certainty that it was ? I proved the impossibility that the second sound could proceed from any other cause than the valves, and Dr. Hope had exactly the same data to rea- son upon. In his chapter headed " Erroneous Theories," Dr. H. states that my theory of the first sound was imperfect, because I do not add the bruit mus- culaire. This I deny: the valvular " cause" is " sufficient." I have ac- counted for the difference of sound by the difference of shape of the auriculo- ventricular valves; their attachments are different, they are set in stronger rims, the sigmoid valves are merely attached in a tube, as it were, whereas the auriculo-ventricular have a firmer and different attachment to the parietes of the ventricle, which being in systole at the time of tension, altogether a flatter and longer tone is produced. Again, and above all, there is no sound when there is plenty of muscular action from hypertrophy, because the valves cannot act; hence necessarily it is the valves, not the muscles, which pro- duce sound. Having been the first to publish the valvular explanation of the sounds, I am bound to confute the assertion of Dr. Williams, " that I hold the same opinion as that in print by Dr. Elliott, and of which he says I was a later advocate :"* the fact being, that I proved the second sound to depend on the tension of the valves, produced by the backward pressure of the blood from » " Lectures on the Physiology and Diseasesof the Chest," Sec. &c. By Charles J. B. Williams, THE SECOND EDITION. 23 the arteries; whereas Dr. Elliott asserts, that the second sound depends upon the blood flowing from the auricles, which he even puts in italics; so that my demonstration is, that the sound is caused by the valves in holding the blood on the one side of the heart, whilst the "opinion" of Dr. Elliott, on the contrary, is, that it is caused by the blood floiving in on the opposite side, and he uses the word " verrit" as expressive of the sound produced by sweep- ing or brushing along. Again, so far from attributing the second sound to anything but the rushing of the blood, he (following Dr. Hope) attributes the sudden nature of that sound to the rapid and vehement (as if relaxation could be vehement) diastole of the ventricle; and its abrupt termination (" abruptam''' in italics) to the instantaneous impediment which the sigmoid valves offer to that motion of blood to which alone he refers sound. Thus the only allusion he makes to the valves is, not as producing, but as cutting short the sound; and so far from considering the valves to be the cause of sound, he is evidently puzzled (as we may infer from the expression " faten- dum est") to account for the sound ceasing when it does, " though the blood continues to flow into the ventricles after the sound has stopped," which my explanation of valvular sound renders perfectly clear: the passage shows that he looked only to the flow of the blood, and not the valves, as the cause of the sound. In fact, so far from originating the opinion of the sound de- pending on the valves, he does not advance that as his opinion; and in this thesis there is no originality, but a professional compilation and adoption of the opinion of others — Hope, Williams, &c. The following is the passage from Dr. Elliott's thesis: — " Nobis igitur (me judice) concludendum est, sanguinem a ventriculis agitatum et in arterias immissum, primumsonum cordis efficere: secundumque a sanguine pendere in ventriculos, dum horum fit diastole, ex auriculis influente. Hoc plane confirmatur a phsenomenis quae in vitiis valvularum cordis observantur. Na- turam soni secundi subitam et abruptam oriri credo a diastole ventriculorum tam repente et vehementer inchoata ut sanguis vi magna aucicularum parietes transcurrat: nee non ab impedimento quod in corpore sano fere instanter valvulse praestant sigmoidess sanguini, qui in ventriculos, dum horum fit di- astole, ex arteriis vult refluere. Post sonum secundum quidem fatendum est adhuc plus sanguinis ventriculos inire: hie autem, ut annotat Hope, ven- triculorum parietes (jam multo fluido distentos nee ultra ab illo fricatos) haud verrit, sed cum sanguine jam illic congesto, sese in silentio commiscet nee aliquid interea soni ab auriculis editur, quippe quae sanguinem quern impel- lunt accurate usque sequuntur. Motum igitur sanguinis, tam a diastole quam a systole ventriculorum effectum, sonorum cordis prsecipuam esse causam credendum est: quod ab observationibusquibusdam DoctorumBertin, Williams, et Hope, singulari in modo confirmatur." The London Committee of the British Association (including Dr. C. J. B. Williams), appointed to investigate and report upon the subject, appear to agree with me as to the second sound, but make the unphilosophical addition 24 ADVERTISEMENT TO THE SECOND EDITION. of bruit musculaire to the true cause of the first. (See " Med. Gazette," Dec. 10, 1836, and Dec. 2, 1837.) I say they appear to agree with me, so far as acknowledging the valves to be the cause of sound; but they do not seem to adopt the true principle, which is, that it is the tympanic tension which produces the sound. I judge from the expression in the report, that " it is impossible that the auriculo-ventricular valves should close with a. flap, in the same way as the sigmoid valves." They speak as if the surfaces of the valves flapping together produced the sound, like the click of a solid valve; and, moreover, in conformity with this, in the republication of the same opinion in the Cyclopaedia of Anatomy and Physiology, (article Heart, p. 616,) edited by Dr. Todd, one of the committee, my statement is misre- presented, by saying that the first sound is referred by me to the rapid ap- proximation of the auriculo-ventricular valves; than which nothing is farther from my opinion, which is, that both first and second physiological sounds depend solely on valvular tension. * • • • • » * PRINCIPLES OF MEDICINE. The first step towards treating disease successfully is to ascertain, as far as possible, the nature of the func- tional or structural alteration which has taken place in the tissues of the part affected: in default of this know- ledge, which is sometimes unattainable, we can only depend upon analogies, drawn from what we know to be the fact in other cases, and from physiology, which is a careful observation of the phenomena resulting from the functions of the different parts in health. An accurate knowledge of the functions in their healthy state is the more necessary, because consider- able* deviations from the ordinary routine occur with- out disease ; and as they are frequently much disturbed without any discoverable alteration in the structure of the organs having taken place, morbid anatomy alone will not be sufficient to elucidate all causes of disease ;f * In such instances, an undue interference with nature, by pur- gatives, emenagogues, &c, might do more harm than the irregu- larity. f This is more especially the case in diseases of the nervous sys- tem, and points out the value of remedies which exert an influence on deranged function, without the operation of any agent capable of effecting depletion of the vessels, or of changing structure. 4 26 PRINCIPLES OF MEDICINE. whilst, on the other hand, it is necessary to be aware that a considerably diseased change of structure may exist with little or no interruption of function.* The modes by which students may attain a know- ledge of the nature of disease, after learning physiology, or the nature of healthy functions (which is attainable from lectures), are, accurate observation of the diseases which take place in external parts as they are submit- ted to our senses in clinical surgery, and in the func- tions of internal parts as met with in clinical medicine ; and morbid anatomy, the examination of what is the degree and nature of alteration which has taken place in the structure of the seat of the disease. The object of lectures is to convey to the student, in a condensed manner, that knowledge in abstract which will enable him to understand what he sees at the bed- side, and the observations of the clinical professor; without which clinical instruction, all that the memory may be charged with from books or lectures, is but vanity. Without entering into minute anatomy, it may be necessary, before proceeding any farther, to give a general idea of the apparatus which supports the life of man, consisting of the stomach and intestinal canal, called the prole vle, the absorbent vessels, the heart and blood-vessels, and the nerves. The heart is divided by a partition, each side con- taining a certain quantity of blood, more or less of which is squeezed out at each beat or contraction ; the blood from the left side is sent through the trunk and * This consideration will prevent disease being overlooked in an organ (as the liver, kidney, &c), whose function is, or seems, unimpaired, when indirect symptoms and morbid sympathies exist. principles of medicine. 27 branches of the arteries, to nourish the different parts of the body ; the overplus, and what is spoiled by use, being returned through the veins to the right side, which sends it by arteries into the lungs to be purified (in addition to changes effected by the liver, kidneys, &c), whence it is returned by veins to the left side again, thus constituting what is called the circulation. This is the nature of the circulation with which the individual born begins life, before food has been taken. Subsequently, the process of nutrition is thus car- ried on : the food swallowed is digested by the action of the gastric juice in the stomach; that is, it is con- verted into a grey pulpy mass, called chyme, which. passes on into the intestines, where it is mixed with the bile. The use of the bile is to unite with and separate the feculent parts, as white of egg is used to clear wine. Now, if a pulpy mass be allowed to stand in a vessel, the solid parts will settle to the bottom; but if rolled about in the hands, or in the manner effected by the peristaltic motion of the intestines, the more solid parts are kept in the middle, whilst the surface of the mass is the moistest; and thus a whitish liquid, called chyle, which was disengaged when the bile united with the feculent matter, and which caused the chyme to appear grey, and constitutes the new nourishment, is kept next the coats of the intestines, where it is taken in by the tubes called absorbent vessels; and these absorbents, on account of the white chyle seen through them, are called lacteal (milky). The lacteal absorbents conduct this fresh supply of nourishment to make new blood ; they deliver it first into the veins, near the heart, where it is mixed with the old dark-coloured blood, which has been circulated, 28 principles of medicine. and is on its return to the right side of the heart; from whence this mixture is sent through the lungs, to be purified, where it becomes bright scarlet, and is then returned to the left side of the heart, which sends it through the arteries all over the frame, to supply its demands. All the business of constant support and renewal of parts, and supply of secretions, as the growth or repair of bone, muscle, membrane, and other structures, the formation of bile, saliva, mucus, and other secretions, is carried on by the extreme minute branches of the blood- vessels ; and whilst they preserve their proper size and tone, all goes on well; when their action is deranged, disease commences, often prefaced by pain or other disorder of the nerves. The ultimate minute branches of the arteries, from their fineness, are called capillary (from capillus, a hair). The colour of the blood is caused by red particles diffused through a transparent fluid, liquor sanguinis, composed of serum holding fibrin in solution. When blood is first drawn, the red particles may be seen floating about by the means of a microscope; but when it stands, they settle down to the bottom, in the fibrinous cake or clot (called cruor or crassamentum) which forms by coagulation. . Some capillaries are too small to admit many of the red particles, unless when they are enlarged by inflammation, as in the eye, which, when inflamed, changes from white to red; besides that, even the red capillaries are so minute, that they are not visible individually to the naked eye till enlarged by inflam- mation. The body is nourished by the arteries depositing in appropriate parts the various constituents of the blood PRINCIPLES OF MEDICINE. 29 which is sent through them by the heart. In this way muscles, bones, membranes, &c, grow and are nour- ished ; for the blood contains the constituents of each : fibrin, &c, for instance, to make muscles; lime, &c, for the bones; albuminous and watery fluid for the for- mation of membranes, and to supply the secretions and exhalations which are necessary to lubricate the mu- cous and serous membranes. Though a consideration of the phenomena resulting from these depositions will assist us in our explanation of disease, we cannot exactly ascertain how the deposi- tions themselves are originated. Do arteries build up a bone merely by the addition of homogeneous matter ? And, are the secretions and exhalations modified by the calibre of the minute branches admitting only the vapoury parts to the surface of the serous membranes and of the skin, whilst they permit the transparent fluid parts of the blood to pass to the mucous surfaces, and keep back the red globules ? This mechanical expla- nation might suffice, in part, in the instances adduced; but when we come to the nutrition and renewal of mus- cle, and the formation of peculiar secretions, we must look for some stilluncomprehended agency, which modi- fies the materials conveyed by the arteries whilst they are depositing : even with respect to the deposition of bone, this agency is required to solidify the new particles which are fluid in the blood. This power can be no other than chemical: the processes, when examined, will be found to be chemical precipitations, by which new mat- ter is deposited, and decomposition, by which old matter is separated, and then carried off by absorbents; and thus the support of the frame in health, and the changes of disease, proceed. In this investigation we may ad- vance a considerable way, though we cannot come to 30 PRINCIPLES OF MEDICINE. the knowledge of the ultimate principle on which or- ganic life depends, or we should be able to construct a man. As an instance how far we can go, we can analyse bone, and we may explain how bony matter is deposited from the blood by precipitation; and we know that the shape depends on the periosteum, or membranous mould in which it is cast: but here we stop; we cannot discover how, in the minute embryo in the womb, the membranes were first determined in their shapes; we here arrive at the confines of our knowledge; and must confess an infinitely wise First Cause, who does not permit us to know more than the phenomena by which we can judge how, in many instances, to avail ourselves of the means to regulate the complicated apparatus which He has endowed with life. The deposition of bone is a combination of chemical precipitation and crystallisation, modified by vital ac- tions ; as, for instance, when there is periosteal mem- brane, we see that it keeps up a vital state of bone, whether in the bone of a leg or a tooth ; when there is no membrane attached, as in the enamel of the tooth, crystallisation, with the temporary membrane which forms the mould, decides the form of aggregation; in case of fracture of a bone, the surrounding parts decide the form of the callus which reunites it. Whilst bone is growing (as shown by the common experiment of feeding young animals with madder, so as to produce variegated deposits), there is a change as to disposition of the bony matter going on; but there is no reason to suppose that the substance of a healthy sound bone of an adult is changing, any more than of a tooth, or the wall of a castle, though there are preparations ready to repair a breach, if made. During health the capillary arteries go on with their PRINCIPLES OF MEDICINE. 31 work of nutrition and secretion, the muscles are fed, the mucous surfaces are lubricated just enough to prevent any sensation from the substances which pass along them, the serous surfaces are made sufficiently moist to slide upon each other without sensation, and the skin is kept soft by an insensible vapour. All this time there is another process going forward also, which is the removal of superfluous matter by the absorbents: if it were not for these, there would be inconvenient ac- cumulation of what is deposited by the arteries; the serous cavities, as that of the abdomen, for instance, would become dropsical, if the capillary arteries went on moistening the internal surface, and there were no absorbents to carry off the superfluous moisture. Thus we see that absorbents take up the nourishment from the food to supply the wants of the system ; they also take up the particles which become superfluous, ac- cording as the arteries deposit fresh matter; and these absorbents, like the lacteals, mix their contents with the old blood to be repurified. The deposit, or precipita- tion, of solid matter by the arteries is not difficult to be understood; and we can, by a reference to chemical action, account for the removal also of solids ; for solids become fluid (or gaseous) by what is called spontaneous decomposition, and thus removable by absorbents. Now, whilst bone is healthy, it is protected by its membranes from the action of solvents; but when inflammation surrounds it, there is an extravasation of serous fluid in contact with it, which helps to dissolve it, and when dissolved, the absorbents will carry away the solu- tion. The removal of bone by the pressure of tumours, aneurisms, abscess, &c, as well as the channels left in exostoses for the vessels which traverse them, is effected 32 principles of medicine. by pressure against vessels, not against bone. The pres- sure of a tumour causes death of the part of bone, by compressing its vessels, and so stopping the supply of nourishment; the bone, when dead, becomes decom- posed, and is carried off by absorbents. As to the channel in the growth of an exostosis, or in the natural growth of the bones of an infant's head, it is merely the deposit of bony matter by the side of those vessels which previously existed. Thus so soft a body as the brain of a young person causes the hard skull to grow larger. Arteries are endowed with the power of contracting on their contents, so as to continue full even when a considerable quantity of blood has been lost either by haemorrhage or artificial means. This contraction is the action of arteries, and is distinct from, and opposed to, the contraction and action of the heart. This point it is necessary to understand clearly in speaking of the phenomena of disease. The contraction of the heart is muscular—of the arteries elastic. The heart contracts and relaxes alternately. The arteries keep up a constant contractile pressure on their contents; not, as has been commonly supposed,an alternate contraction and relax- ation, but a continued contractile effort, both longitu- dinally and transversely, which is overcome by the ac- tion of the heart: when there is much blood sent into them, they are distended; and if there be little blood sent into them, as after haemorrhage, their tendency to contract causes them to close, so as to keep always full, and to preserve a continual stream of the blood, even during the temporary relaxation of the heart; and the arteries yielding, and adapting themselves to the pressure of the heart, and recontracting on their con- principles of medicine. 33 tents, whilst the heart is relaxed and filling, is the cause of the equability of* the stream in the veins; nay, the stream even in the arteries is much less in jets than is supposed by those who judge from the mode of its flowing from a wounded artery: for though, when there is a free escape from the wound, the impulse of the heart causes an unequal stream, it must be remembered that in the tube unwounded that force would have been partly expended in stretching the artery, whereas the artery when wounded ceases to be other than as a simple tube, the elasticity not being called into opera- tion, on account of the escape of the blood from the wound. The most simple mechanical illustration, perhaps, is the double bellows of a smith's forge, which keeps up a constant current of air, though the handle works with intermissions; so that the blast into the fire would be in puffs, if it were not for the weight on the upper half of the bellows, which keeps forcing out the air in a continued current, whilst the hand is drawing back to make another impulse. It has been supposed that the circular fibres of the arteries were muscular; that they contracted and re- laxed at each pulse; and that the throb felt was caused by a dilatation of the artery. Those fibres are not muscular, but more approaching to a ligamentous tis- sue,* firm, and, though elastic, not yielding to the force * This has been confirmed by the microscopical investigations of Schwann and Ehrenberg {Be. Tela Elastica, Berolini, 1836); whereby the long-continued controversy concerning the muscularity of the arteries is completely set at rest. They have unequivocally demonstrated that the middle coat of the arteries is composed of that peculiar elastic tissue {tela elastica) which constitutes the ligamentum nucha? of vertebrated animals, the ligamentum flavum of the vertebral 5 34 principles of medicine. of the heart at each beat, but, on the contrary, preserving the calibre of the artery uniform, as may be seen by laying bare an artery in a living animal, or when the artery is exposed in an operation : it is longitudinally that the arteries are stretched at each injection from the heart, by which their capacity is increased; the consequence of which, from their being bound down in various places, is, that there is a serpentine motion in the artery where it is at all loose. The fibres of the middle coat of the artery, being ar- ranged circularly, allow of the separation laterally, and thus accommodate themselves to the elongation of the tube, whilst they resist its dilatation. Now, it may be thought that the motion of the arteries seen at the wrist and in the temples is their dilatation; but it is the ser- pentine movement caused by the alteration of the curve, the artery being elongated at each injection from the heart. Where the artery is perfectly straight, you may lay it bare and scarcely see it move; but the moment you compress it with the finger, or tie a ligature round it, you perceive it pushed at every pulse. To illustrate the deception of the sensation which the pulse gives, as if the artery were dilated at each beat; if a long vein, removed from the body, have a syringe adapted to one end, the other being raised, or arranged with a spring- valve, which yields to the jets so as to keep it full, and fluid be sent through in jets, it will, upon pressure by the finger, give the sensation of dilatation, but the eye perceives none. Again, if any one grasp the leather column of man, &c. No muscular fibres whatever can be detected intermixed with the elastic tissues of arteries, as cellular tissue alone connects the various tunics. principles of medicine. 35 tube of a fire or garden-engine, the sensation given will be that of its expanding in the hand at each stroke of the pump; but the eye contradicts the sensation: it is merely the tendency to resume the cylindrical form from the outward pressure of the fluid, but not ex- pansion. Some writers have attempted to prove that the heart has an active power of dilatation,* by which it helps to refill itself by sucking in the blood, as it were; and one proof is brought forward from the heart of any of the large mammalia, as the horse, ox, or whale, which affords the phenomenon of contracting and expanding after removal from the body : but the expansion is * The impulse of the heart against the side (which takes place just as the auricles have rilled the ventricles, and the latter become rigid, commencing their contraction) is in proportion to its muscular action, and is produced by the heart assuming a form more approaching to the globular, and becoming firm at the same time, giving the hand a sensation similar to what is felt when it is applied to the calf of the leg or to the jaw, and their muscles put in action ; the heart being in an angle between the diaphragm and parietes of the chest, the in- crease of its transverse dimensions has the effect of the driving of a wedge, thus forcing itself against the ribs. Now, these actions may be very strong, but if they be too rapid, there is not time for the heart to receive the usual quantity; so that, only a little being sent into the arteries at each contraction, the pulse may be small when the heart is acting strongly, as in palpitations : and an ignorance of this fact might lead to the administration of stimulants when not required, to say the least, if the pulse alone were consulted: cxteris paribus, " impulsion" is increased by hypertrophy, diminished by dilatation. The ventricles contracting on a small quantity produces the pheno- menon of " impulsion ;" the ratio of thickness of parietes to cavity being altered gives a deceptive sensation, as if there were hypertrophy, which has misled many to predicate hypertrophy where it did not exist, in hysteric and other nervous states. The sounds of the heart are produced by the sudden tension of its valves. (See Preface.) 36 principles of medicine. simple relaxation ; and when a large heart is relaxing, if the hands be pressed on opposite sides of it, they will be sensible of an apparently active expansion from the mere gravitating recovery of position of such a mass of matter; the heart, in fact, not opening actively, but falling open after each contraction. It will be shown now by what means the blood fills the right auricle, which, being flaccid, is easily dis- tended ; but it requires the muscular action of the auri- cle in addition to fill out the more dense ventricle, — this is the use of the auricle : it would be unnecessary if the ventricle had an active power of dilatation, natura (Deus) nihil agitfrustr". It is the constant pressure and equable stream which refills and distends the right auricle of the heart after each contraction; not any suction, to use a vulgar expression, of the heart, or suction of the chest, as has been attempted to be proved; no effect of vacuum and atmospheric pressure. There is no suction,* no atmospheric pressure, during natural respiration; for the glottis is sufficient to admit a free current of air: it is only in croup, or laboured respira- tion of some kind, as of an animal under experiment, that there can be any effect of atmospheric pres- sure. A reference to the hydrostatic principle, of fluid in bent tubes finding its level, will be sufficient to account for the capability of the heart to send the blood, with little effort, all over the frame, and for the refilling of * Sir David Barry endeavoured to demonstrate that a suction, or atmospheric pressure, was produced by the expansion of the chest, exerting an influence in promoting the circulation ; and the Com- mittee appointed by the British Association to investigate the causes of the sounds of the heart have revived (1840) this opinion, which appears to me to be inconsistent with the laws of physics. principles of medicine. 37 the heart after each contraction. The heart sends the blood against the force of gravitation through but a small portion of the system ; for in all the natural posi- tions, upright or horizontal, by far the greatest portion of it is below the level of the heart. Now the blood, being confined in the arterial and venous tubes, will, of course, on hydrostatic principles, return to the same level from which it flows: and as to the capability of the muscular power of the heart to inject the parts that are above its level, when any person compares the force necessary to be used in doing so, with the force which an equal quantity of muscle in the arm is capable of exerting, it appears trifling; besides, whoever applies the hand to an aneurismal tumour may judge of the power of the heart. The blood, then, returning from the parts above the level of the heart, tends to refill it by gravitation, even if not aided by the contractile pressure of the arteries; the blood below the level of the heart, or rather arch of the aorta, returns by the tendency to find its own level; so that the blood is pressed into the right auricle by the weight of the returning blood from all the parts above the level of the heart, added to the pressure caused by the difference of the height of the arch of the aorta above the right auricle of the heart, and, in addition, by whatever remains of the contractile pressure of the arteries. Another con- sideration has generally been omitted in calculating the power and facility with which the influence of the heart is communicated throughout the arterial system, which is, that any retardation which might take place from the friction through the tubes, is more than compen- sated by the sum of the branches being greater than each trunk from which they arise, so that the flow is facilitated; whilst, on the hydrostatic principle of Bra- 38 principles of medicine. mah's press, though the injecting force of the heart is spread over a greater space, it is not weakened, being multiplied, not divided; and in injecting the capillaries, hydraulic friction is compensated by capillary attrac- tion. We must not consider the elastic contractile effort of the arteries as one of the moving powers of the blood, any more than the fly-wheel of a machine, or the weight on a double bellows, which only regulate motion, and are, in fact, a burden on the moving power, though they continue the motion for some time after the moving power had ceased to act. The moving powers are, the contractile force of the heart,* gravitation, and the hydrostatic principle above stated, of the tendency in fluids to return to the same level. By anatomical investigation, then, we ascertain that tubes of various dimensions, called vessels, and which are named arteries, veins, and absorbents, are apparatus of every process in the growth or removal of all parts in health, and in the swelling or wasting of parts in disease. Moreover, we must not forget, — and it is a circum- stance to be recurred to perpetually, both in theory and practice, — that nerves, accompanying the arteries throughout, complete the apparatus. The nerves are whitish threads, which are dis- tributed to every part of the frame, however minute; communicating with the brain, for the purpose of in- forming it of what is going forward in different parts, * Let it not be objected, that some lower animals, which have no heart, have still a circulation : the alimentary canal performs the double function of stomach in making the blood, and heart in sending it en when made ; as, in my opinion, the contraction of the alimen- tary canal of the higher animals sends forward the chyle in the lac- teals. principles of medicine. 39 as when anything touches the hand, tongue, &c.; and for the purpose of conveying the mandates of the will from the head to the muscles of voluntary motion; and again, supplying to all parts nervous influence, which excites action. The nerves communicating with the brain do not blend as they unite into larger and larger trunks, but preserve their individuality, however aggregated, like threads in a skein, or strands in a rope. When we speak of the nerves supplying to all parts nervous influence, which excites action, reference must be had to the spinal cord and sympathetic or ganglionic system, as well as to the brain. We have reason to believe that the nervous influence is generated or secreted, in the more vascular cineritious (grey) Partof the nervous system, and conducted by the medullary (white) part; the medullary part in the spinal cord and brain being an aggregation of nerves from the frame. It is necessary here to state distinctly my opinion respecting action, as depending upon the nerves. I consider that the muscles and capillary arteries, though differing in tissue, have each inherent in their struc- tures a faculty of contracting, organic contractility: this contractility being acted upon by the nervous influence, the result is contraction, the nervous influence being discharged into them from the nerves; and this dis- charge may be produced in a variety of ways, as by the blood in the heart or capillaries, the presence of food in the intestines, the electricity from a charged jar, or in muscle by the will, whether the operation be direct or by " reflexion" — these being known agents of con- traction in the animal. 40 principles of medicine. All organic action is contraction, produced by ner- vous influence. This is termed by Bichat, contraction from "organic contractility," resulting from "organic sensibility," which he distinguishes again from animal sensibility; thereby making it appear that the nerves act upon an ideal inferior sensitiveness in the struc- tures, not confining sensitiveness to the nerves. Now, by his " organic sensibility1' must not be understood sensitiveness, but that liability, or capability, of struc- tures to answer to nervous influence, in the same man- ner that steam or any other agent produces action in a mechanic structure; this is, in fact, organic contrac- tility: so that he divided one property into two. What Bichat calls animal sensibility, is that function of the nervous system alone by which communication is kept up with the sensorium, and by which pleasurable and painful impressions are perceived : his animal con- tractility is merely organic contractility of voluntary muscles called into action by the will; but I would not give organic contractility a new name, merely on account of the different orders of muscles receiving their influence in one instance from voluntary nerves, and in the other from involuntary nerves. Pain is the result of injury done to the nerves, and nerves alone, the union of nerve with other tissues being only to convey sensation, or to effect action : sensibility, there- fore, is in the nerve. When pain takes place from in- jury, in parts which, though not under the control of the will," are still abundantly supplied with (organic) nerves to produce action, as in the heart or intestines, Bichat says this pain is " organic sensibility (action*) * It is impossible to separate them. We know nothing of organic sensibility or organic contractility, except so far as evinced by action taking place. principles of medicine. 41 augmented" until it "becomes* animal sensibility," {Systeme Capill. § vi.); but, on the contrary, it may be seen that " organic sensibility" (action) is diminished in parts where there is pain (in the sensitive nerves) from inflammation. In fine, I prefer the term organic action to organic sensibility, and do not make use of the term " animal" sensibility at all. I use only the terms, organic action, and organic contractility, of the contractile tissues; and sensibility, of the nerves. Bichat, I repeat, makes an ideal inferior sensitiveness in the structures, not confining sensibility to the nerves, as he says, " the nerves are strangers to organic sensi- bility :'' this leads him to become visionary, when he speaks of the lacteals exerting a choice as to what par- ticles they will take up; which is mere chemical or nervous effect on their tissues, making them cease to absorb what is unfit for them, whether that be by the unfit matter causing them to contract and shut against it, or to relax so as to lose power; still no election in them, any more than elective affinity of chemistry. From thus refining too much upon the functions as connected with vitality, he overlooked the more simple explanations which physics afford, and says that " it is ridiculous to attempt the explanation of the pheno- mena of changes in animal functions by mechanical laws and the variations in dimensions of vessels, &c.;" but I think I have shown, that what he calls vital laws, are but these mechanical laws modified by the Deity : we do not know the intimate structure or mechanism by which a muscle or capillary contracts; but doubtless it is as simple as a pair of lazy tongs, and as easily ex- * As they depend on different sets of nerves, one cannot " be- come" the other. 6 42 principles of medicine. cited to action as they are by the hand, or the piston of a high-pressure engine is by the steam. There is no subject more interesting, no pursuit more gratifying, than this investigation of the properties and processes of our animal frame : there is no subject of contempla- tion which gives us so exalted an idea of the omni- science of the Deity, and so humble an opinion of all human inventions, as the excelling utility and efficiency of all its parts. How beautiful, how wonderful, then, must be the Soul, when such infinite wisdom, such exquisite arrangements, are lavished on the structure which it is destined to inhabit for but a short, space of time ! Such perfection in our organisation leads us to believe with Job, that, however disarranged by death and decomposition, it may again be called into re- union, and that " in our flesh we shall see God." The animal heat has been accounted for in different ways by several ingenious physiologists : from the ag- gregate of their opinions and experiments I deduce, that heat is extricated all over the frame ; in the capil- laries, by the action of the nerves during the change of the blood from scarlet arterial to purple venous ; and also whilst it is changing in the lungs from purple to scarlet. There is a perpetual deposition, by the capillary sys- tem, of new matter, and decomposition of the old, all over the frame, influenced by the nerves: in other words, the galvanoid or electroid influence of the nerves, which occasions these depositions and decompositions, keeps up a slow combustion. In this decomposition there is a continual disengagement of carbon, which mixes witli the blood returning to the heart at the time it changes from scarlet to purple; this decomposition principles of medicine. 43 being effected by -the agency of the nerves, produces constant extrication of caloric: again, in the lungs that carbon is thrown off and united with oxygen, during which caloric is again set free; so that we have in the lungs a charcoal fire constantly burning, and in the other parts a wood fire, the one producing carbonic acid gas, the other carbon ; Xhefood supplying, through the circulation, the vegetable or animal fuel from which the charcoal is prepared that is burned in the lungs. It is thus that the animal heat is kept up: on the other hand, the evaporation of perspiration keeps the surface cool ; but in inflammatory fevers, where this is deficient, the body gets too hot; and in low fevers, when the nervous influence is not sufficient to keep up the full fire, the surface gets cooler than the natural standard. This is peculiarly evident in the beginning of eruptive fevers, as scarlatina, where there is strong heat, with the arterial colour of the skin; but if the same becomes malignant and low, with deficient arte- rialization, the temperature sinks, and the diminution of the charcoal combustion in the lungs is evinced by the dusky colour of the skin, showing that the carbon is not thrown off as it ought to be: and the same phe- nomenon takes place in typhoid cases. Whatever nervous influence may be, or however generated, we know that the energy of parts depends upon a something that is communicated to thern by the nerves in conjunction with the ganglia, brain, and spinal cord; that while parts are supplied with this nervous influence, they retain their power of action, and not longer; that arteries become less susceptible of impres- sion from external agents when the nervous energy is low ; that when the vital powers are sunk, the capillary 44 principles of medicine. arteries cease to secrete ; that various phenomena in the healing of inflammation are the effects of healthy action of the heart and arteries. We find likewise when ner- vous energy is deficient, that parts which had advanced to a certain stage of healing become flabby, as in stumps after operation when the patient sinks; and that when the power of the constitution, the nervous energy, fails, nitrate of silver will have no effect upon ulcers, except chemical decomposition — not that astringent effect which is the result of contractility depending on vitality. It is well known, likewise, that a blister not rising from a cantharides plaster is a bad sign, as being an evidence of approaching, or rather commencing, death; this must not be confounded with a want of action in the arterial capillaries — the cause here is a want of in- jecting force in the heart; but no vesication will take place even from boiling water, when the vital powers are sunk, as the heart has not power to effuse serum. This is a more satisfactory example than cantharides, because the effect of the hot water goes so far as to produce the local injury, for the cuticle may be sepa- rated or loosened by the mere chemical effect of the heat; but this takes place equally in a dead body. With respect to the action of the heart, all are agreed that its action is contraction, by which the blood is sent forward in the arteries, and that the power of the heart's action is measured by the pulse when there is no organic alteration, such as ossification of the valves at the beginning of the aorta, aneurism, &c. The action of the arteries also is acknowledged to be contraction, whether considered muscular or not; but there is some difference of opinion as to the degree of action of the arteries in inflamed parts. It is very principles of medicine. 45 common to say, that in inflammation there is an in- crease of arterial action; but a consideration of the phenomena, and of the nature of arterial action, will show that in inflamed parts the capillary arteries are weaker in their action; that there is diminished arterial action, for the action of arteries is contrac- tion : now the arteries in inflamed parts are evidently larger than before — less contracted, that is, acting less. An inflamed part is redder and swelled; where the vessels are visible, as in the eye, we can see that the redness is caused by the minute vessels becoming larger, so as to admit more blood. This enlargement of vessels is not from increased action, but, on the con- trary, from their action being diminished, their giving way and being dilated by the injecting force of the heart. The way to diminish the inflammation is by increasing the action of the arteries, as by cold or astrin- gents, which make the arteries contract, that is, increase their action ; so that, so far from the arteries in an in- flamed part being in a state of increased action, one of the means of diminishing inflammation is by increasing arterial action in the part inflamed. It is common to remark the throbbing of the carotid arteries as increased action; but the more they throb, it shows that they the more yield to the injecting force of the heart. When the eye, or any other part, is injured by heat, or a stream of cold air, a blow, or cantharides plaster applied to the skin, &c, the part becomes redder from the vessels enlarging and admitting a greater proportion of blood than there was before. Now in this first and simplest instance of inflammation the heart does not act more strongly than ordinary, not affecting the pulse; so that the capillary arteries evince debility, having given way 46 principles of medicine. when there is no more force than they bore before with- out distension: from this they sometimes recover of themselves, gradually contracting to their natural size; or if not, the simple application of cold, or an astrin- gent lotion, makes them contract, and the redness dis- appears. It is the opinion of some persons, even at the present day, that the motion of the blood is acceleratedin inflamed parts; though the experiments of Parry and others proved the contrary to be the case, as follows from the capillary arteries being enlarged; inasmuch as when fluid passes through a given space, the current beyond that will be slower in proportion to the wideness of the channel; as in a wide part of a river, where the cur- rent becomes slower : and the same may be observed by passing water, mixed with grains of amber, through a glass tube with a bulbous enlargement in the middle; the current will slacken in the bulb, and resume its velocity beyond it. Some will allow that the capillary arteries, where the blush of inflammation is, are weak, as they visibly have given way; but they still speak of increased arte- rial action, and say that the arteries around or leading to the inflamed part are in increased activity, as a part of the condition, or of what keeps up the inflammation; not considering that an increase in their action would be contraction, and consequently a diminution of the flow of blood to the inflamed part: in fine, an increased action in the arteries both in and leading to the inflamed part, is just what is required to diminish the inflam- mation. But so far from the arteries leading to the inflamed part being in a state of increased activity, we have ob- tained evidence that they also become weak when the principles of medicine. 47 inflammation continues for some time. Hausmann, to whom we are indebted for many valuable experiments on inflammation, has made a series of preparations of the leg of the horse, in which inflammation had existed, showing the participation of the larger arterial trunks in the inflammatory condition of the capillaries, dilata- tion having spread from the minute vessels of the part inflamed to the main arteries of the limb. The in- creased throb which is apparent in these during life confirms my remarks on the subject, that the throb and full feel of the pulsation is an indication of the artery having given way to the injecting force of the heart. Another argument brought forward by the advocates of increased arterial action in inflammation is, that an incision in an inflamed limb, as in phlebotomy or arte- riotomy, will bleed much more freely than the corres- ponding sound one, — to which I would answer, that it simply demonstrates that the arteries contain more blood, in consequence of having become enlarged from diminished action. The more the heart acts, the more of course it forces the arteries of the inflamed part; and the pulse, showing the power of action of the heart, is erroneously by some considered as an evidence of arterial action; the throb- bing of the carotid arteries, for instance. As the heart, therefore, acts against the capillaries, if we cannot cause them to contract strongly enough to resist its force, we are obliged to diminish the force of the circulation, either by taking away blood, which decreases both the quantity of blood sent to the arteries and the action of the heart itself, and in this way we leave less for the arteries of the inflamed part to do; or, we can lower the force of the heart by medicines, such as digitalis, &c. Here, for illustration, the simplest cases of inflam- 48 principles of medicine. mation have been taken, in which the heart is acting naturally, the inflammation being from injury. Sometimes parts are loaded with blood when we cannot find evidence of inflammation, and which state is called congestion. Inflammation or congestion are but varieties of distended vessels, which, if they cannot unload themselves, we assist by applications or medi- cines which make them increase their contractile ac- tion ; or if that alone is not sufficient, by taking off some of the force which injects them, or, as it is called, the vis a tergo. The difference between congestion and inflamma- tion is, that in congestion there is merely distension of the vessels; in inflammation there is, in addition, alter- ation of tissue — actual deterioration, more or less, of the structure of the capillaries. Thus congestion may be produced in a part by a ligature; by the pressure of a tumour; by obstruction to the course of the blood, as by diseased valves of the heart: and vessels thus congested may remain so for a great length of time, and quickly resume their natural state, when relieved from the pressure of obstruction; in fact, the vessels cannot be said to be diseased. But the case is different with inflammation; the fault commences in the tissue. As soon as a want of that harmony between the nerves and capillaries, which is necessary to organisation, takes place, their fine tissue begins to decompose, the parti- cles which were held together by this inscrutable agency begin to be precipitated from one another; and this takes place in every shade and degree, from the slightest scorch of the fire, or blush from the wound of an in- sect, to mortification and putrefaction. When the valves of the heart are diseased, the ob- struction thereby caused to the circulation produces principles of medicine. 49 congestion in the lungs, which is very different from the state of inflammation or peripneumony. Let us see how far we can go in proving that the capillaries depend upon nervous influence for their con- tractile action. Blushing is, perhaps, the most unequi- vocal proof that an alteration in the nerves is the cause of sudden dilatation of the capillaries. It is not the action of the heart alone which causes the partial flush; for, first, the heart often acts stronger without causing blushing, and, next, the blush is partial; whereas, when the mere action of the heart causes increased redness of the skin, as from exercise, it is not partial, as it is in blushing from mental emotion. And this, which is sudden weakness of the capillaries, has been commonly attributed to the "increased arterial action," and "de- termination to the face." I attribute this giving way of the capillaries to derivation of the nervous influence, which, being directed to or expended in the brain more freely by mental emotion, robs, for the moment, the capillaries of the face of their energy. What is called the blush of inflammation may be brought on in a part by reiterated strong electric sparks. It may be said that the effect of the electricity is on the tissue of the capillaries; but the first effect produced is pain, showing that the operation 'of the electricity commences on the nerves, sensitive as well as organic* The same observations are applicable to the blush pro- duced by heat from a fire ; and we have a proof that this is the effect of nervous influence before injury or * An animal may be killed by a strong electric shock, or by light- ning, and not the slightest injury of the vascular tissues be discover- able by dissection ; and as we know that the nervous tissue is the part affected by electricity, its lesion must be inferred to be the cause of death. 7 50 principles of medicine. alteration of the structure of the vessels, by the common experiment of those who have resolution to hold the burned or scalded part to the fire, and remove it gra- dually, which will prevent the disorganisation that would otherwise take place — in common language, prevents blistering. The mischief is caused by ex- haustion of the nervous influence ; the sudden removal of the excitant leaves the capillaries destitute, and they yield immediately to the ordinary injecting force: but if the excitation be renewed, by holding the part to the fire, nervous influence'is supplied from the neighbour- ing parts to the capillaries, with pain certainly, but, by slowly removing from the heat, the nervous influence will be gradually supplied, till the excitant be reduced to a natural standard, relieving the pain and incipient inflammation. On the same principle may be explained a fact pretty generally known, that if melted sealing- wax be dropped on the skin, and be immediately re- moved, the skin will blister, or at least feel scorched, and remain painful for some hours; but if the wax be allowed to cool gradually before removal from the skin, the pain, though severe during the cooling, ceases im- mediately, and no blister arises. These I consider to be proofs that the diminution of nervous influence, rather than alteration of tissue, is the proximate cause of the relaxation of the capillaries; for if it were alter- ation of the tissue, not diminution of tone, the renewal of the heat woukFadd to the previous mischief, instead of affording relief. The progress of inflammation shows the dependence of the capillaries on the nerves. A part may, in certain cases, be observed to become tender before it is red; for it may be observed by experiment that the pleura or peritoneum of an animal is not extra-sensitive im- principles of medicine. 51 mediately on exposure; it first becomes tender, and then red. In inflammation of the conjunctiva of the eye, it is painful, feeling as if there were sand under the lid, some time before its vessels are enlarged. The pain of Erysipelas precedes the redness. The action of cantharides in producing inflammation, is another proof that inflammation begins in the nerve ; for can- tharides have no effect on the tissue of the capillaries, do not corrode or act in any way on their substance after death, when the nerves have no influence; whereas any really corrosive agent would act even more on the dead than on the living capillaries. Without, there- fore, at present seeking for further proofs, I deduce from blushing, and from the effects of electricity, fire, and cantharides, that the capillaries are dependent upon the nervous system for that tone or energy which preserves them from over-distension. The brain, spinal cord, and nerves, again, depend upon the due nutrition afforded by the arteries, which supply them with scarlet blood. . Though Bichat denies the influence of the nerves, or says that it is almost nothing, in secretion, exhala- tion, &c, I consider that the sudden alterations of these from mental emotion prove the contrary; besides the proofs already advanced, that capillaries, which are the agents of these functions, derive energy from the nerves. A cautious application of electricity to an eye red from chronic inflammation will cure it. Spirits, oil of turpentine, squills, even solution of cantharides, &c, applied to a wound, or, through the circulation to a secreting organ, will cause the capillaries to contract; in reality, stimulate them to action (contraction). But the same agents, applied too strong, exhaust the ner- 52 principles of medicine. vous influence, and relaxation (which has been erro- neously called arterial action) takes place. This will account for the use of certain remedial agents to dimi- nish inflammation, which, when pushed a little farther, irritate, and subsequently produce inflammation. It is sometimes remarked, that " local irritation de- tains the blood" in a part, as if by some obstruction or attraction; whereas this phenomenon may be explained by the increased capacity of the vessels causing a slower current, as before stated, thereby allowing the blood to be delayed. Besides the expression detention, and the terms congestion and inflammation, there is another word, determination, used to express an habitual re- ception of more blood than natural in a part; as, " de- termination of blood to the head, with throbbing of the carotids." The throbbing of the carotids has been al- ready explained not to be active, but passive. Now, the word determination, in ordinary language, implies that blood is sent somewhere in particular; but the heart has no power to direct any blood to one part more than another, although, if in any part there be an unusual relaxation of the vessels, they will receive more than ordinary; as, when the water is sent through the main pipe of one of the wrater-works, it cannot be deter- mined to any house in particular, but whichever house has the largest cistern will receive most water.* By * We have an interesting physiological illustration of this principle in the " determination" of blood alternately to the stomach and spleen. A given quantity of blood is constantly sent through one arterial channel, which branches off to the stomach and spleen : when the stomach is empty and collapsed, its arteries being likewise col- lapsed, the blood passes into the spongy texture of the spleen, so constituted and situated as to be ready to receive it; on the contrary, when the stomach is distended with food, its elongated arteries admit principles of medicine. 53 this I wish merely to illustrate, that what is called de- termination is not active, but passive. The term also used by Bichat, of the blood being drawn or invited into an inflamed part, may be explained on the same principles. Irritation, continued excitation of the nerves of a healthy part, as just shown, at last produces inflamma- tion, by exhausting that nervous influence which gives the capillaries power; they thus become weakened, allow of over-distension, and the part is in the state of inflammation or congestion. This effect may be pro- duced by electricity, which acts palpably through the medium of the nerves; so that redness produced in this way is as evidently through the abstraction of ner- vous influence as blushing. Thus, in a part inflamed there is a diminution of organic action, in consequence of which the blood is admitted in excess. As long as the capillaries are sup- plied with nervous influence, as long as they possess perfect organic action, they preserve a due size ; when they lose it, either from the influence not being supplied from the nervous system, or are robbed of it by heat, the blood freely, and consequently the spleen, being then less forci- bly injected, collapses and contains less blood. The spleen thus performs the office of a mill-pond, by receiving the surplus of the stream when not required for the mill, the stomach: and, by this contrivance, the quantity of venous blood sent to the liver from the two organs does not fluctuate. I have never found reason to alter this opinion respecting the use of the spleen, which I advanced in my Thesis. Again, we have an illustration from comparative phy- siology : according as the lungs and thorax become developed in the tadpole, there is an increased development of arteries and capilla- ries, exactly equivalent to what is called determination ; but the increased influx of blood is merely the result of increased vascular capacity. 54 principles of medicine. electricity, cantharides, or other cause, they give way, and admit more blood than before. Taking this view of the proximate cause of the enlargement of capillaries, we can account for all varieties of congestion, from a simple transient blush to the stage with which inflam- mation commences; and it must be impossible to draw a line between congestion and inflammation, one pass- ing into the other by insensible shades. Hence the numerous term used by authors to express the grada- tions of distended capillaries: congestion active and passive, engorgement, hyperemia, erythema passing to erysipelas, &c. When the congestion or inflammation subsides without solution of continuity, or leaving any trace behind, it is called resolution ; and it is very intelligible how cold and astringents promote this de- sirable termination; as does also a means not so com- monly applied, an even bandage with gentle general pressure over an inflamed limb. This leads to an explanation of the diminution of secretion in an organ, at a time when it is, in fact, fuller of that material (the blood) from which it secretes, than ordinary, as the kidneys, the skin, &c.; and enables us to account for the dryness of skin and scanty secretion of the kidneys in fever, &c, without refer- ence to Cullen's doctrine of spasm, by an increase in diameter of the capillaries; not from obstruction, but, on the contrary, from too much room. Secretions are carried on by fine capillaries, which, by their great number and extreme minuteness, envelop, in the form of a vascular membrane, the ultimate or terminal ramifications of the excretory ducts of all glandular organs: for by the researches of Muller, Weber, Rathke, Kiernan, &c, into the intimate struc- ture of the glands of adult animals, and those of Muller, principles of medicine. 55 Von Bur, and others, into the mode of embryonic de- velopment and growth of glands, the correctness of the opinion of Malpighi, Cruikshank, &c, is demonstrated, viz., that the greatest analogy exists between them and the most simple mucous crypt of the intestinal mucous membrane, or cuticular sebaceous follicle; that, in short, a gland is made up of innumerable cryptse, which are ramifications of the excretory duct, each ultimate (and in most organs by aid of the microscope alone visible) branch of the excretory duct terminating by a blind extremity, in the parietes of which are dis- tributed the finest capillaries. These capillaries are many times smaller than the crypt®, follicles, tubuli seminiferi, tubuli uriniferi, &c, as they are called, in different organs, and do not communicate with them by open or terminal extremities, as Ruysch and later anatomists have supposed; on the contrary, the finest capillaries are seen to join with one another, so as to form again larger and larger trunks, then called veins. Secretions, therefore, are vital transudations from the capillaries into the excretory tubes of the glands, by pores invisible to our senses, even when aided by the most perfect optical instruments. We see here the wonderful contrivance by which an enormously large surface is obtained for the purposes of secretion : a gland being strictly comparable to a mucous or serous membrane so convoluted upon itself as to occupy as little space as possible in the economy of animal bodies, having one or more outlets left (the excretory duct or ducts, or sum total of all the excretory tubes), by which the secretion is emptied into its proper receptacle. Not the least interesting point in our present knowledge of the structure of the glands, is the strict analogy shown to exist between all glands and the lungs. Indeed, 56 principles of medicine. owino- to the comparatively large size of the individual parts°constituting the lungs, and, consequently, the facility with which their minute anatomy may be in- vestigated, they may serve to illustrate, by analogy, the structure of the apparently more complicated, be- cause with greater difficulty investigated, glands. The latter, as just stated, consist of an excretory duct or ducts, which subdivide, as if ad infinitum, first into tubes and branches of first, second, third, and fourth orders; and at last into (acini, consisting of) clusters of the finest pouches or follicles, the parietes of which are enveloped in a net-work of capillaries. It is precisely the same with the lungs: composed of an analogue called the trachea, the branches of first, second, third, and fourth orders are the bronchial tubes, which at their ultimate terminations, after the most elaborate branching out, present clusters of minute cells, which represent the acini or clusters of minute cryptee or fol- licles. The air-cells of the lungs have, like the glandu- lar cryptse, their beautiful net-work of capillaries, from which the hydrogen and carbon, or carbonic acid and water, are secreted, without there being any direct communication between them and the capillaries them- selves. The lungs, however, are adapted for some- thing more than a glandular purpose : they convey to the blood the material for aiding its purification, its secretion of carbon, &c.; for whether the atmospheric air carried into the lungs be merely a vehicle for car- rying off, according to Lavoisier, Laplace, and Prout, carbon and hydrogen secreted from the blood; or in order to afford oxygen for absorption by the blood, to be subsequently secreted in the form of carbonic acid and water, as Sir Humphrey Davy and the majority of chemists suppose, — the peculiarity of the lung, be- PRINCIPLES OF MEDICINE. 57 sides its analogy with the glands, remains.* From the free anastomosis between all the capillaries in a secret- ing organ, and their gradually forming larger and larger vessels constituting veins, without any direct commu- nication with the tubes, cryptse, or follicles, into which the secretion takes place, (except by pores necessarily imagined to exist, although unseen,) being proved, so that whatever of the blood is not secreted is returned, — it does not follow, that where there is diminished secretion, there is obstruction; on the contrary, there may be more space for the flow, but then in a slower stream: for, as has been shown, the consequence of enlargement of the capillaries of a part is, that the flow of blood will be slower in them, the supplying arteries remaining the same: the larger the capillaries supplied by these branches, the slower the current will be, as in the skin, kidneys, serous membrane, salivary glands, &c. Hence, to account for the diminished secretion, it is not necessary to suppose either any " spasm," or " error loci of the red particles, getting into the colour- less capillaries :" it is enough to consider, that the fluid finds an easier way, by the enlarged capillaries onwards into the veins, than through the pores in the capillaries into the ramifications or cceca of the excretory tubes, un- * As all secretions are effected by the (galvanoid) agency of the nerves on the blood in a series of capillary tubes, it becomes an in- teresting object of physiological inquiry, how far the mere change of form in each glandular organ — merely by alteration of number and series of capillaries and nerves, as modelled on the ramifications of the excretory duct, the true element of the gland — produces secre- tions apparently so different, but, after all, differing only in the pro- portion of atoms of the four constituents, carbon, hydrogen, nitrogen, and oxygen, which are found in all, with a different proportion of the saline constituents of the blood appropriated to each. 8 58 PRINCIPLES OF MEDICINE. fitted as the capillaries are for secretion, owing to the morbid alteration of their physical condition;* and be- sides, yet more particularly, through the alteration of their dynamic (galvanic or electrical) condition, conse- quent upon the alteration of the supply of nervous energy to the part, the orginal cause of all the disturbance. Lo- cal enlargement of capillaries explains that kind of dimi- nished secretion where the heart is not deficient in inject- ing power; the relaxation of the capillaries, from want of nervous energy, producing a deficiency in the current of the blood ; as in a dry skin when inflamed or feverish, or kidneys inflamed, or their capillaries enlarged by cantharides, so as to diminish secretion, in the manner just explained. In some cases of disease, when the secretions of the skin and kidneys are deficient, we renewT them by bleed- ing, digitalis, antimony, &c, which lower the force of the pulse, thereby diminishing the distension of the capillaries, in conformity with the above statement. On the other hand, in health, stimulants, such as fer- mented liquors, by increasing the nervous energy in the kidneys, &c, and quickening the circulation at the same time, increase secretion; and this takes place in * The pores must become obstructed by the swelling (thickening) of the parietes of the coeca; as a dry cask or a wooden vessel per- forated with small holes will allow fluid to pass through; but if the wood be thickened by soaking in water, the pores become closed up. It is evident that the coeca themselves must be narrowed by that congestion or enlargement of the net-work of capillaries surrounding them, which is produced by inflammatory relaxation, as is well known to take place in hepatitis, nephritis, &c. We can under- stand, too, that the tubes themselves may be thickened, until their calibre is obliterated by the internal swelling of their substance, as takes place in inflammation of the liver, &c. 4 PRINCIPLES OF MEDICINE. 59 a greater degree, if some astringent, such as lemon- juice, be combined, as in the formof punch. Or, medi- cines, such as uva ursi, digitalis, antimony, neutral salts, &c, have also this local astringent effect when circu- lated, besides their influence on the pulse. Stimulants cannot increase secretion by quickening the circula- tion, when the capillaries are in a state of debility and morbid congestion ; and a still farther proof that they are in a state of morbid congestion, is the effect of cold to the loins in such cases in renewing the secretion; and the constringing effect of cold water, even cool air, in promoting the secretion of insensible perspiration, and thereby softening the congested skin, in scarlatina. Increased secretion takes place sometimes with a weak pulse. It will be found that this occurs in cases where, although the circulation is weak, the capillaries are not congested, as in hysteria, in the sweating of hectic, and also in the sweating stage of ague, after the hot, dry, congested stage has passed off, analogous to what was stated above of the effect of cold in scarlatina. In these cases there is a deficiency of nervous influence, which, if the heart were acting strongly, would cause parts to flush; as we see, in fact, in the flushing alter- nations in hysteria, hectic, &c. But when the heart is not acting strongly, and there is a debilitated, ana3- mial, or flaccid state of an organ, the kidney for in- stance, which produces a limpid state of the secretion, this may be counteracted by giving either diffusible stimulus to increase the force of circulation, or local stimulus, such as turpentine, or a combination, as sp. junip. co. &c, which, when circulated to the kidney, by eliciting more nervous influence, will restore the organ to its natural dynamic state, and thus both di- minish the morbid secretion and render it less limpid, 60 PRINCIPLES OF MEDICINE. As soon as the local stimulus of the turpentine becomes excessive, it gives pain in the back, and diminishes the secretion too much; affording an illustration of the cir- cumstance that different doses of medicines produce most opposite effects. The healthy operations of the arteries have been mentioned, as far as their continued and gradual depo- sition of matter in its various modifications from solid bone to gaseous exhalation. Their depositions are very gradual, in proportion to the whole quantity of blood passing through them, a great portion of which returns by the veins unchanged, or at least unconsumed; so that there is always an abundant overplus for the de- mands of the system, and this provides against acci- dental or artificial loss of blood. Whilst the processes described go on, the animal suffers no inconvenience — is in health; but when accidental mechanical injury, or other cause, changes the action of the capillaries, either by a direct impres- sion on themselves, or by primarily injuring their nerves, the derangement of their action is the com- mencement of disease — secretions become altered, checked, or profuse — nutrition is either diminished; so as to produce emaciation, or there is an excessive deposition — vapoury exhalations are diminished to dryness or increased to fluid — bony matter is deposited in wrong places, or albuminous, fatty, and other parti- cles, so as to constitute tumours — the nerves of parts become morbidly sensible, so as to derange the func- tions of those parts — portions, on losing their vitality, undergo spontaneous decomposition, and are removed by the absorbents. To explain this more in detail; every disease is PRINCIPLES OF MEDICINE. 61 some alteration of those actions which, when perfect, constitute the welfare of the animal; and in some in- stances, by a provision of nature, the newly altered action, which is the consequence of the injury, leads to the reparation of the damage, without assistance from art. For instance, the tubes conducting the air through the lungs are, under ordinary circumstances, scarcely moist; but if particles of dust, or insects, be inspired, the resulting irritation causes morbid sensibility, is fol- lowed by the extra-production of mucus, entangle- ment of the foreign substance, and its evacuation by cough. We also see that where a part is cut, the minute arteries conveying coagulable lymph allow the escape of a sufficiency of it to glue and unite the surfaces, if kept quietly in contact — called technically union by the first intention ; and we know that, not merely a part partially severed will reunite, but even a piece wholly cut off, if small, and not depending on vessels of any size, will reunite by the first intention; as the top of a finger or a thumb, including even a bit of the bone, which had been cut off by an artisan with a sharp tool, has been replaced and has reunited. This is analogous to the Hudibrastic version of the Taliacotian operation; but as opportunities of witnessing such circumstances are rare, some knowledge of physiology, and a refer- ence to J. Hunter's experiments, are requisite to enable us to believe the fact. When blood is allowed to stand in a vessel, the upper part of the clot which settles down from the serum, of a yellowish-white colour, affords a specimen of coagu- lable lymph, carried in readiness to repair damages. Now, if the union by the first intention be prevented by disturbance, it becomes necessary that the surfaces 62 principles of medicine. should be reunited by the interposition of a new sub- stance forming a connecting medium ; for this pur- pose small drops of coagulable lymph are exuded, which concrete, remaining at the cut ends of the capillary arterial branches which have yielded them, and in communication with these open ends, so as to become organized and receive nourishment by the ca- pillary growing longer, and continuing itself onwards into the lymph. These little portions of coagulable lymph are called granulations ; and if they are not much disturbed, they adhere to each other, and thus the cementing of the divided part is effected, and even a considerable gap is sometimes filled up by granula- tions springing from granulations. This spongy mass gradually condenses, forming a firm bond of union, generally distinguishable, and is called cicatrix. Wherever solution of continuity of the skin is not healed by the first intention, a visible cicatrix remains, as the newly formed solid has not the same degree of vascularity as the surrounding tissues. In order to protect the new tender granulations, they are covered with pus ; a creamy, thick fluid, which, when of a due consistency, is very properly called healthy pus, for it requires a healthy action of the capillaries to pro- duce it in proper quantity and of due consistency. If pus did not defend the granulations from the air, they would dry and become scabs, instead of uniting and repairing the parts; if the secretion be too thin, so as to become ichor instead of pus, showing a debility in the capillaries, we have, from that same cause, weak, spongy granulations, or even none at all are formed. An ulcer which, whilst healing, appears a large ugly sore to the inexperienced eye, is called by the sur- geon a fine, healthy, granulating surface; and often, to principles of medicine. 63 obtain this healthy process, the exercise of much skill, both in local and constitutional remedies, is required ; as, for instance, to heal an ulcer, a wound, a stump, or other part after operation* This is sufficient example of the necessity of a surgeon being well acquainted with the use of constitutional remedies; and the most dex- terous, after performing an operation, may be glad of a knowledge of medicine to relieve subsequent constitu- tional symptoms. Many persons of great experience practise well em- pirically without much brains or reasoning; but he who begins upon principle, and then profits by expe- rience, must become a much more skilful practitioner. How many persons apply a poultice to an ulcer with a tolerable certainty of improving it, without ever know- ing or caring for the rationale of the effect! By studying the operations of nature we are led to imitate by analogy. Independently of the regulation of temperature, the usual benefit derived from a poul- tice is that of preventing premature scabbing, by the soft moisture assisting the pus to protect the granula- tions. The German water-dressing has much the advantage over the poultice: the piece of lint dipped in water is lighter than the poultice; the oiled silk over all retains the moisture; and the whole does not spoil the sound skin, as the poultice often does. If poultices be too long applied, proud flesh will form, either from a superfluous growth of healthy granulations, or of such as are weak and spongy. Exuberant granulations may be checked, either by applying an astringent, such as vinegar, nitrate of silver, or sulphate of copper, &c, which, by constringing the vessels, gives a firmer, smaller granulation; or by merely laying on a piece of dry lint, to absorb the coagulable lymph as fast as 64 principles of medicine. thrown out, thus stop granulation. This accounts for dry lint preventing the healing of some ulcers, and as- sisting others, according as the granulations require repressing or not; and what *has been here stated af- fords an explanation why in some cases dressings should be changed frequently, in others as seldom as possible. Baynton's strapping unites the advantages of keeping the granulations moist, with support ; but if injudi- ciously applied, injury is done by the pressure. Mr. J. Scott has clearly pointed out the difference, practi- cally, between support and pressure: weakened vessels want support, but cannot bear pressure. I have above used the term premature scabbing, be- cause the crust formed is sometimes of use ; as, in the natural process of healing of an ulcer or abrasion, the crust sets bounds to the granulations, which otherwise might sprout too high. The application of dry lint will be enough, without an astringent, if the proud flesh be merely too great a growth of healthy granulations, caused by keeping on the poultice too long; but if the granulations are also weak, the astringent will be necessary: this weakness may be known by a livid colour, and thin, instead of creamy pus; and if still weaker, the granu- lations will even melt away, and the sore reulcerate. Now, an inexperienced person would suppose that the application of nitrate of silver (lunar caustic) or vinegar would increase the pain; but it is well known that, though they produce momentary smarting, especially if applied undiluted, this soon subsides ; so that a per- son will fall asleep shortly after the application of nitrate of silver to an ulcer, which had banished rest for several days and nights by its morbid sensibility. The beneficial effect may be thus explained, — the PRINCIPLES OF MEDICINE. 65 nerves of the part having become inflamed, and their vessels partaking of the debility of those in the sur- rounding tissues; the astringent diminishes the in- flammation in the nerves, and thus removes their mor- bid sensibility, bringing them to the state of the nerves in a healthy granulating part, in which those below the granulations are sensitive, but not more so than natural. Oil of turpentine applied to a burn acts on the same principle of bringing the nerves to the state of those in a healthy part, not merely by astringency, but also by eliciting more nervous influence in a part whose vital power is depressed (p. 51). This will aptly illustrate the nature of morbid sensi- bility, usually designated by the vague term irrita- tion. It does not occur during the reparatory pro- cess ("healthy inflammation"*), the nerves not being inflamed ; but " morbid" inflammation (as it is called when the reparatory process is interrupted) involves the nerves. A considerable degree of pain may exist during even the healthy reparation of injury, when the healthy nerves are exposed and hurt; but there will be more disturbance and loss of sleep, with perhaps less pain, if, from the nerves themselves becoming in- flamed,! morbid sensibility arises, either locally, or in the nervous centres, in consequence of the lesion of the nerve being communicated to them, whether the lesion be in the sensitive or organic filaments : in the latter case, there can be no evidence of morbid sensibility * Formerly I have sometimes used the term healthy inflammation as synonymous with reparatory process, in compliance with custom ; but it is wrong: inflammation under all circumstances is disease, being, in fact, the injured state which precedes the reparatory process. t I know no other term by which to express their lesion. 9 66 principles OF medicine. until the lesion is propagated to the nervous centre; as in tetanus, arising after a cut has healed almost by the first intention, without pain in the cicatrix; or convul- sions from worms in the intestines, which have caused no pain. By a process analogous to granulation, coagulable lymph, exuded in consequence of inflammation between serous membranes, sometimes becomes organised, and forms adhesions. In mucous membrane the change is very rapid from health to disease: by a slight alteration of the action of the capillary arteries, which secrete a mild fluid to lubricate and protect the surface, it becomes either dry, or a thin saline fluid is poured out, which, so far from protecting the parts, irritates them and others with which it comes in contact. Again; after the mucous membrane has been throwing out the fluid just de- scribed (as in catarrh), the thickening of the discharge, and its becoming bland and opaque, whitish, (in other words approaching to, and in some instances forming actual pus,) is the simple reparatory or restorative pro- cess ; and we know that various mucous membranes, whilst inflamed, — the urethra, for instance,-—throw out an ichorous fluid, which becomes true bland pus as the reparatory process proceeds ; and it is the same with respect to the Schneiderian membrane. Thus, we see, we can have both coagulable lymph and pus, without ulceration. Sometimes coagulable lymph oozes from the capillaries of mucous surfaces, and concretes, forming what are called false mem- branes; as in croup. Similar formations are also some- times passed from the bowels, which have been mis- taken for a separation of the lining membrane. They are of a tubular form, different from the long vermiform evacuations of merely condensed mucus which are some. principles of medicine. 67 times passed from them. Hunter has pointed out the close analogy between the throwing out of coagulable lymph in (I say after) inflammation, and the formation of the first lining membrane of the gravid uterus; and sometimes even a similar false membrane forms in the unimpregnated uterus, as occurs in cases both of dys- menorrhea and menorrhagia, besides those which form in the vagina, of a larger size and different shape. Thus the same coagulable lymph, so useful for the purpose of repairing damage or continuing the species, sometimes kills — as in croup, by blocking up the wind- pipe ; or produces blindness, by rendering the cornea opaque; or glues the intestines to one another, after peritoneal inflammation. And we have not only these false membranes, as they are called, thrown out on serous surfaces, but also pus, without breach of surface. The operations of nature are uniform and simple, — the reparatory process is uniform and simple. The throw- ing out of the coagulable lymph, in these cases, is equi- valent to its being thrown out to effect union by first in- tention, or granulations, though, from the locality (the cornea, windpipe, &c), it becomes inconvenient, or even destructive. If by a blow or other injury, as by caustic, or by any inflammation, the life of a portion be destroyed, it gradually decomposes, and separates from the living part; sometimes in the form of a discoloured slough, the fluid parts running off when the slough is on the sur- face. The separation is effected by decomposition, and not by the absorbents of the living part removing a por- tion of the dead parts, as has been asserted : the part at the line of separation of a slough of the skin, for in- stance, decomposes most rapidly, from the heat and moisture of the surrounding living part; whereas the 68 PRINCIPLES of medicine. centre of the slough often dries up, like a piece of leather. After the separation of a slough on the sur- face of the body, an open wound is left, which, if the reparatory process go on naturally, will be filled up by granulation, as already explained. If a smooth hard substance be laid in the wound (as a pea or bean to keep open an issue), it prevents the formation of granu- lations ; but as the reparatory process or effort never- theless goes on, pus is secreted from the open capil- laries, and as soon as the hard substance is taken away, the formation of granulations will commence. Here, again, we must not confound the reparatory process with inflammation : a properly managed issue is not in a state of inflammation; on the contrary, it is well- known that if it become inflamed, the pea must be taken out for a while to ease it, or the part will become swell- ed, red, and painful; and either proud flesh will form, as before explained, or ulceration take place. Ulceration is the death of successive layers or minute portions of an open wound, of whatever dimen- sions, the solution of continuity having been effected either by spontaneous inflammation and decomposition, or by external injury; and the matter which successively dies in an ulcer is not separated from the living part nor taken away by the absorbents, as has been gene- rally asserted, but decomposes and runs off. Again; an ulcer is not necessarily in a state of inflammation; for, on the contrary, whilst healing, it is in a state of reparation; and any renewal of inflammation causes enlargement —fresh ulceration. There is a little ap- parent contradiction in this statement, from the word ulcer {ulcus) signifying simply an open wound which has been formed by other means, as well as by the pro- cess of ulceration, or ulcerating inflammation; but I PRINCIPLES OF MEDICINE. 69 repeat that, though the process of ulcerating is ulcera- tive inflammation, yet in the resulting wound when once formed there is not necessarily inflammation any longer existing; and it is, on the contrary, by carefully warding off inflammation that the surgeon cures it. An ulcer, therefore, is not necessarily in a state of inflammation ; it is the space left by the destruction of a part by inflammation : but if the constitution be in a natural state, and the ulcer not influenced by any morbid poison, it goes on granulating and healing. If, instead, inflammation be renewed in it, each renewal may cause fresh loss of substance, and the ulcer become what is called phagedenic. When the whole part, killed by inflammation, sepa- rates at once, instead of gradually dissolving away, it is called a slough; and if this slough takes place by spontaneous inflammation, it is called gangrene, spha- celus, and mortification. A slough may be produced by caustic, then called an eschar; or by chemical poisons, as I have seen the whole lining of the oeso- phagus slough away at once in a patient who had swallowed nitric acid. When I say that the absorbents do not effect the separation of a slough, I do not deny that they may, and do, nevertheless, take up some of the decomposed matter; for we know that on the death of a part which is not superficial, and when, as under the skin, the dead matter, being confined, cannot run off, the absorbents will often by degrees convey it all away; but in the case of a caustic eschar, or a gangrenous slough, it is decomposition, not the absorbents, which effects the separation. When any injury, from a blow or inflam- mation, is sufficient to cause death of a portion deeper seated below the skin, the decomposed matter can be 70 principles of medicine. carried off by the absorbents and (venous) capillaries, as we see in the case of an ecchymosis of extravasated blood; but in general, the reparatory process causing the secretion of pus, suppuration, an abscess, takes place. Here, again, I must advert to the incorrectness of language ordinarily used : it is said that, when in- flammation exists, it is of consequence to prevent sup- puration. Now, what is to be prevented is, the death of any portion; if that take place, the suppuration is merely a matter of course, as a part of the reparatory process. After what I have stated, it is scarcely neces- sary to add, that I do not admit of the explanation of pus being formed by the breaking down and liquefying of coagulable lymph, as asserted by Laennec, in speak- ing of empyema; nor the explanations of Dupuytren and others, of part of the sloughs of abscesses dissolving into pus. The cavity is lined more or less with coagulable lymph, analogous to the granulations and false mem- branes and adhesions above spoken of. This lines the cyst, as it is called, of the abscess, which is merely the cellular tissue of the part stretched upon the contained pus, and which does not set bounds to the abscess, but passively depends upon the quantity effused into it. It is the extent of the inflammation which in the first instance decides the size of the abscess; and when the inflammation is diffused or ramifies, we have diffused or ramified abscess, as from diffused cellular inflam- mation. Though it has been stated by high authority, that " inflammation is the means by which local injuries are repaired, and may be considered as the restorative prin- ciple," I contend that it is no such thing ; but a state of disease ; or else, why speak of remedies for it ? And, PRINCIPLES of medicine. 71 indeed, in applying them, it is of great consequence to know when to stop ; for the period of inflammation is , often very short; and unless the practitioner knows when it has ceased, he may do much mischief by inter- fering with the natural reparatory process. The period of inflammation of the pleura or peritoneum is often so brief, that even destruction of tissue of which a patient will inevitably die may have been effected, though the inflammation had not lasted above three or four hours, as we see occasionally in peritonitis and pleurisy, whether idiopathic or from wounds. For example; a youth, after being exposed to severe cold, complained, for a few hours only, of sharp pain in the abdomen, but became feverish, with sickness and constipation. He did not apply for advice for two or three days, at which time he made no complaint of pain in the abdomen even upon moderate pressure, except across the hypochondria, where pressure pro- duced some uneasiness. He died in about a fortnight, though judiciously treated for peritonitis by his medi- cal attendant. On examination, all the intestines were found glued together by coagulable lymph, and some pus was effused in the cavity of the abdomen. The practitioner will do harm if he does not withhold or relax antiphlogistic treatment (not only bleeding, but such medicines as tartar emetic, purgatives, digita- lis, colchicum, &c.) as soon as inflammation is subdued. I have seen a patient in pleurisy, with extensive pleu- ritic effusion in one side, whose life had been saved by active and judicious bleeding, and other antiphlogistic means; but who afterwards nearly sunk in consequence of the medical attendants persevering with purgative and other antiphlogistic medicines after the inflamma- tion was.quite subdued. This they did on account of 72 principles of medicine. that uneasiness in the parts which was only extra sen- sibility (tenderness, as in a bruised part), in consequence of the lesion produced by the severe inflammation, and which uneasiness naturally remained in a certain de- gree even for months afterwards. On the other hand, in many protracted cases of dis- ease, when the patient feels scarcely ill enough to apply for medical advice, we find some latent inflammation, requiring active and decided antiphlogistic treatment, which may surprise the patient, but of which he soon feels the benefit. A distinguished writer on inflammation asserts, that the " adhesive inflammation which precedes the act of ulcerative absorption obliterates the vessels," so that there is no escape of blood. This, as an enumeration of phenomena, is true, but is no more than a mode of enumerating phases : as a rationale of the process, it is incorrect; there is no such thing as adhesive inflamma- tion— the inflammation is that which destroys the life of the part, whereupon the separation of the dead por- tion takes place ; which has been erroneously attributed to the absorbents. The reparatory (adhesive) process, which is intermediate, by its lymph stops the vessels, so as to prevent hsemorrhage, and subsequently pro- duces granulation and suppuration, as before explained. In fact, the succession of events is as follows: inflam- mation, death of part; reparatory {adhesive) process, effusion of lymph closing vessels; then ulceration, de- composition and separation of dead parts. Thus I can account for bone, tendon, cellular tissue, and other parts, dying and gradually coming away dissolved, or in shreds and fragments ; but the explanation of their re- moval by the absorbents, nibbling them across, as it were, is neither intelligible nor credible. Again ; the principles of medicine. 73 term ulceration is used by authors most contradictorily; as, for instance, besides its true meaning of eroding, we have the expression " the process of ulceration, by which the surface is restored:" this anomaly arises from the misuse of the term (healthy) inflammation. It may be asked, how it happens, if the effusion of lymph into the cellular tissue be not a part of inflam- mation, that it occurs as one of the phenomena of ery- sipelas, and also upon inflammation of the cornea or iris, when, instead of deserving to be named a part of the reparatory process, it obstructs their functions. In erysipelas sufficiently severe to cause lymph to be ef- fused, the desquamation is evidence of solution of con- tinuity of the capillaries; hence the necessity for the reparatory process, viz., the effusion of lymph. We may fairly deduce, by analogy, that there is likewise solution of continuity of the capillaries in the cellular substance beneath. The moment this solution of con- tinuity of capillaries — the giving way from the degree of inflammation — takes place, lymph is effused; and its use is evident, viz., to reunite the breach, as even in cases of reparation of an incised wound. When the cornea is wounded, we see that the effusion takes place, to reunite the capillaries; in like manner, when the ca- pillaries give way from inflammation, in one or more of the layers of which the cornea is composed, without breach of surface, lymph is effused for the reparation of damage. Had the inflammation been superficial, the giving way of the capillaries would have been evinced by ulceration. When a part receives a blow of a certain force, there is an extravasation of blood from the capillary arteries, or an effusion of lymph, which causes swelling of the part. In this instance healthy capillaries are compelled 10 74 principles of medicine. by force to allow their contents to escape, which are afterwards gradually removed by the absorbents. In disease the process is similar; in erysipelas, lymph and serum are effused, causing swelling, which are re-ab- sorbed as the patient recovers: in dropsy nearly the same takes place. By savine or cantharides ointment we can produce an inflammation — such a relaxation and debility of the capillaries of a part, that they break away from the adjacent sound parts, by which means warts are thrown off; and this, as regards the mode of separation, is analagous to the rising of the cuticle from a common blister. These phenomena have usually been wrongly attributed to the savine and cantharides producing " a higher degree of action of the vessels than the parts could bear,'' which is altogether irreconcilable with the true physiology of vascular action (see p. 32 et seq.). The cicatrix after a wart, resembling the cicatrix of a pit of small-pox, is sometimes permanently visible, but not always so; as the cicatrix of a small-pox spot is sometimes not a permanent mark, or, in other words, small-pox does not always pit. The reason of this is, that the small-pox vesicle does not always suppurate, though it has incorrectly received the name of pustule : it is naturally only a vesicle filled with serous fluid, which turns whitish and opaque, like pus; but true pus is not formed, except on the surface of membranes, unless the inflammation has been sufficiently great to cause that lesion of the capillaries which requires effu- sion of lymph for their cure, equivalent to granulation and suppuration; but, of course, when this takes place in a mucous membrane, the moisture in general pre- vents the granulating lymph from remaining or form- ing a coating; so that we seldom see false membrane principles of medicine. 75- on mucous surfaces, the pus only being perceived. Fortunately croup is comparatively a rare disease ; but I have known false membrane form even in the urethra — at least small tubes of coagulable lymph, which I judged to be such. Again : we have, after the same degree of lesion, the restorative process sometimes throwing out lymph, equivalent to granulation, or rather to union by the first intention, without pus; as may frequently be seen upon the surface of the rete muco- sum, the lymph immediately drying into cuticle, after a slight abrasion, or a common blister, when the cuti- cle is often restored without suppuration; but some- times the skin is injured, and pus is formed during the necessary process of repair. Sometimes, after a blister, even when the skin is not injured enough to require suppuration, we see a superfluous quantity of the lymph which forms cuticle thrown out with the appearance of The small-pox eruption, as just mentioned, is only a vesicle, though a reticulated one, being an aggregate of minute vesicles formed in succession, precisely like the vaccine. The vaccine always in the end pits, as there is loss of substance of the rete mucosum, owing to the intensity of the inflammation ; but the chicken- pox, which is a more simple vesicle, and of shorter duration, does not always pit. The cause of the pecu- liar depression in the centre of the vaccine and small- pox vesicles is this : each eruption first forms in a point, and that point, having gone through its inflammation before those that follow around it, is elevated on a smaller scale, and its coagulable lymph begins to dry up whilst the circumference is fresh and swollen. I have heard the vaccine central dark spot attributed to the cicatrix of the lancet-puncture, and the variolous 76 principles of medicine. spot to the binding down by a sebaceous duct: but the lancet-puncture heals by first intention, before the specific inflammation begins ; and there are many more than one sebaceous duct in the space of either a vaccine or variolous vesicle. The effect of inflammation, as is evident from its proximate cause (relaxation of capillaries), is to soften the tissue in which it takes place. An inflamed part may feel hard on account of tension; but when cut into, the inflamed tissue will be found softened. Inflammation as hitherto considered is what is called acute, wherein either resolution or destruction of parts soon takes place — cita mors venit, aut victoria lata. Chronic inflammation is that in which the cause of the inflammation remains, producing reiterated lesion, followed by continual efforts of the reparatory process in depositing coagulable lymph, which sometimes be- comes organised and produces actual hardness, as in strumous and other tumours, syphilitic nodes and warts, chronic hepatitis, &c.; sometimes a persisting open ulcer, as a chancre, in which the reparatory process goes on, and by depositing lymph thickens the edges, whilst the continued inflammation keeps the ulcer open by the successive death of minute portions; or, if it be not strong enough to produce death of portions, so as to keep the part in a state of open ulcer, it still renews enough of inflammation to prevent healing — that is, the organisation of the cicatrix, which therefore becomes a scab — sometimes single, constituting a scale, as in the coppery eruption; sometimes in successive layers, as in rupia; sometimes in clusters after pustules, as on the face. It is thus that a morbid poison not only inflicts the injury, but, by adhering in the tissue or constitution, principles of medicine. 77 perpetuates it till expelled by some remedy. This, however, is but an expression or description of pheno- mena : I must indulge my propensity of searching for proximate causes, and would prefer any tolerable ana- logy to none at all. The process of fermentation affords an analogy. A little leaven leaveneth the whole lump: a most minute portion of small-pox virus, on the point of a needle, produces an inflammation similar to that from which it was taken. What is this inflammation but chemical decomposition ? What else is fermentation ? This virus may be absorbed and calculated, as has been hitherto supposed ; or it may produce its effect by some chemical, and consequently electric or galvanic action, positive or negative, on the nervous tissue, constituting a morbid sensibility, which is propagated to the whole system: — this is evinced by racking pains in the spinal cord, brain, &c, producing languor, convulsions, &c, &c, with disturbance of all the functions. All this passes off, we know, in a definite time, as the dough ceases to rise when all the particles inflamed by the leaven have gone through their process of de- composition. So ends small-pox, measles, scarlatina, typhus, plague, synocha petechialis, &c.; the leavens of which are either communicated by contact or car- ried through the air to the lungs, &c. Lues is different; and here I must resort again to analogy. Its destructive decomposition is of a different kind — of a slower, more permanent nature, — as much unknown to us, though we know the phenomena and products, as that of the panary or acetous fermentation. As the acetous fermentation is less violent, though more permanent, than the panary or vinous, so the syphilitic 78 principles of medicine. decomposition (inflammation) is gradual, but steadily pervades the system if unchecked by remedies. I cannot help here hazarding a speculation upon hydrophobia; namely, that it is a leaven which poisons the nervous system, takes a considerable time to fer- ment, and will eventually be remedied by some medi- cine which conquers neuritis — perhaps arsenic — perhaps some narcotic. My own inclination would be to try as much arsenic as the constitution would bear, combined with plenty of opium, which always enables the patient to take more arsenic than he could without it. I have found this to be the case in old cases of ague and dysentery, which I have cured by the com- bination ; indeed it is also proved by the efficacy of opium as an antidote to arsenic* We have not yet obtained a cure for cancer consti- tutionally ; but, aided by the investigations of Kiernan, Miller, Ure, and other pathologists, I think we shall arrive at it {Med Gaz., May and Dec. 1836). We have * It is not very uncommon, on patients being brought to the hos- pital in consequence of having taken poison, to find that, thinking to make assurance doubly sure by taking arsenic and laudanum together, they have saved their lives. In an experience of many years, I have always found these cases do best; and many patients who had taken arsenic (arsenious acid), we have recovered by laudanum and cal- cined magnesia freely administered ; making use, according to cir- cumstances, of the stomach-pump, leeches, and other means not necessary to be enumerated here. If I am not mistaken, a Mr. Hunt was the first to publish this useful plan of treatment. The pain (morbid sensibility), independent of inflammation, would kill, if not relieved by opium, as I have spoken of elsewhere in the instance of gout in the stomach. I must add here, for students, that gout of the stomach is almost wholly neuritis ; but that in poisoning by arsenic there is, besides neuritis, considerable inflammation of the capillaries of the membrane. principles of medicine. 79 also still to seek the remedy for tubercles. Notwith- standing the exertions of Andral, Carswell, Louis, &c, we have not yet arrived at their true pathology; and until that is accomplished, it is only some lucky em- pirical chance that can help us. The treatment of the latter which I have found most useful is that adapted to scrofula. Sometimes tumours are formed in consequence of blows, coagulable lymph being effused, and by the process already described, analogous to granulation, becoming vascular and organised (possessed of vitality), a part of the animal, and not removable by the ab- sorbents, which only take up unorganised, or in other words, dead matter. Some of these tumours remain unaltered; others by their presence keep up an inflam- mation, in consequence of which the capillaries go on depositing more and more by necessarily reiterated re- paratory efforts, and so adding to the tumour, which thereby is increased, until it is removed by remedies or operation, or exhausts the animal and destroys life. Now, as was mentioned in other cases, that which arises here in consequence of accidental injury, some- times also takes place as the effect of disease : tumours form spontaneously, either with or without feverish accompaniment, and sometimes disappear again by what is called resolution, that is, cessation of the inflam- mation, and subsequent re-absorption; sometimes they suppurate, forming abscess; sometimes remain indo- lent ; at other times remain and grow larger, or grow larger and ulcerate at the same time, as in cancerous and other malignant diseases. Tumours are modified by the part they occupy and the constitution of the person: if the substance injured be fat, the arteries there, being depositors of fat, make a fatty tumour; if 80 principles of medicine. it be periosteum, bony : if a highly vascular part, a vas- cular tumour. The tough bands which traverse fatty and other tumours are made by arteries, which in a healthy state would have to support membranous, cel- lular, or ligamentous tissues. A tumour of a lymphatic gland, or other part, in that debilitated, relaxed consti- tution called strumous, or scrofulous, will become so: and in a cancerous constitution tainted by disease, cancerous tumours will form in any and every part, as has been ably demonstrated by Kiernan. The same may be said of tubercular disease, which is totally dis- tinct from common inflammation. The same process which repairs, if induced mor- bidly, produces diseased growths, such as bony tumours from syphilitic or other inflammation of the membranes of the bones. When there is toothache from caries, the injury is in a part which cannot be repaired, as being destitute of membrane; hence the inflammation excited in the sound part produces only a useless de- posit, as we see sometimes evinced by morbid growth at the point of the root, but no repair of the mischief, so that the tooth must be removed altogether. The arteries of the periosteum are always ready to deposit bone; whenever, from accident or disease, its vessels become distended (with or without rupture and extra- vasation), and the part spongy, as in nodes, there is, if not stagnation, a sufficient retardation of the blood to allow of crystallisation of bony matter. The arteries cease to deposit when the spaces made by accident or disease are filled; if there be not enough of bone de- posited to unite a broken limb, or if the consolidation has been prevented by motion of the parts, the surgeon often rubs the broken ends against each other, not for any effect upon the bone, but the real use of this expe- principles of medicine. 81 dient is to produce fresh laceration of the soft parts, so as to allow of renewed deposition of bony matter, and to make fresh spaces for its reception: here though inflammation be excited, as a necessary consequence of the violence resorted to, and it has usually been said that the intention was to produce inflammation, if the space for fresh callus could be made without it, it would be all the better; and, in fact, on the other hand, it is well known that much inflamma- tion in a fractured limb retards the formation of callus, so that leeches and other means are used to moderate it. If the absorbents cannot take up matter which is organised, it may be asked how they remove tumours? The organisation of a tumour is but imperfect, and it is a burden on the previously existing arteries, in addi- tion to their originally allotted task: if these arteries have been enlarged in size (for we know arteries can grow larger) in consequence of the inflammation which gave rise to the tumour, they will go on to support it; at other times, and most frequently, when the inflam- mation subsides, they resume their natural size, and starve the tumour, the constituents of which will, when thus deprived of support, become decomposed, unor- o-anised, and thus amenable to the absorbents : on the other hand, the tumour may have been too well or- ganised to give way, and so continue a comparatively indolent life, after all inflammation has subsided, but producing neither pain nor inconvenience, unless a blow or other cause renew inflammation. Now, if the ef- forts of nature do not remove the tumour, we may diminish it by remedial means. The simplest is pressure on the part, by keeping 11 82 PRINCIPLES OF MEDICINE. nourishment from entering its vessels,* as when a piece of sheet-lead is bound down upon it, &c. Pressure so gentle as not to compress, but merely by affording support to inflamed and distended vessels, at first, to stop the inflammation; after which, stronger pressure may be resorted to without producing pain. Cold will cause vessels to shrink, as cold lotions, &c, constantly applied, where pressure could not be borne on account of its producing pain. Daily, or at least often-repeated, abstraction of blood by leeches, &c, from the part, taking care not to under- mine the constitution by taking too much. Artificial discharge, with counter-irritation, as by is- sues, blisters, the tartar emetic, and iodine ointments, &c. By medicines, such as mercury, iodine, &c, which have an effect on the arteries themselves, directly or through their nerves, so as to make the inflamed capil- laries contract independently of the consideration of the vis a tergo (state of the heart's action), or quantity of circulating fluid; for this may be necessary even when the circulation is very weak; as in some cases, inflam- mation goes on with a most debilitated constitution and weak pulse :f it is only the debility approaching to a * It is by this effect of pressure that a tooth may be made to change its place, as when children's teeth are set straight by a dentist, and which has been asserted to be effected by the absorbents. It is the pressure of the tooth on the vessels in one side of the socket which makes it disorganise ; and then the absorbents may take up the inor- ganic particles, and the vessels on the other side of the socket fill up the space left (see p. 32). f This is by some called passive inflammation, in contradistinc- tion to that which occurs in a strong constitution ; but inflammation is always the same debility of capillaries. Let us call things by their own names, and speak of the active or passive state of the con- stitution as indicating remedies. PRINCIPLES OF MEDICINE. 83 dying state that will prevent a blister from rising, when the poison of cantharides has relaxed the ves- sels : hence it is plain, that it must be an enormous loss of blood which could prevent a blister from rising; which shows that the proximate cause of the inflam- mation is in the vessels of the part, and not in the in- jecting force. This will explain to the pupil, who has seen how much venesection has relieved inflammation from fractured ribs, that he cannot always "knock down"* inflammation by venesection alone; though * I consider the opinion wrong which Dr. M. Hall gives in allu- sion to certain cases of inflammation from accidents which terminated fatally, under the treatment of other practitioners. He says that, had they been real inflammation, they would have borne the deple- tion (see his lecture, Lancet, Nov. 4, 1837, p. 186). Now, I think they would not; for I am convinced that, where cases of inflamma- tion, whether idiopathic or from accident, will not yield to bleeding within rational bounds, assisted by antiphlogistic medicines, they must terminate fatally either by the violence of the disease, or by the unavoidable extent of the depletion. I must also observe, that though he, being experienced, may know when to stop, I should fear his pupils might be led, in * pleurisy, &c, to carry bleeding to dan- gerous lengths : as I was once called to see a medical pupil just be- fore his dissolution, who, after hearing the lecture of a popular teacher on the subject of " knocking down" enteritis by depletion, had made his fellow-student bleed him till he sank never to rise. Dr. Hall says his medical friend (one of the cases he there alludes to — pleu- ritic inflammation produced by fractured ribs) lost about eight pints of blood within four days ; and yet he declares that had it been pleurisy, he might have lost twice as much with impunity and safety. I think, however, no man could lose fifteen or sixteen pints (two gallons) of blood in three or four days with " impunity and safety." This is what he calls establishing a distinction between irritation and inflammation : truly, it is a strongly marked distinction — without a difference ; for it was, in fact, a " mixed case." With respect to the man who died of fractured ribs with wounded lung, in Bartholomew's hospital, quoted by him, I must express an opinion contrary to that of Dr. Hall, who brings forward the case as one of irritation, in which the man died of exhaustion from a degree of bleeding which 84 PRINCIPLES OF MEDICINE. free venesection in the beginning is of the utmost con- sequence. For, on the contrary, though the copious he could have borne had the case been inflammation. I cannot acknowledge the distinction Dr. Hall has here made between inflam- mation and irritation, as I consider inflammation of the pleura or lungs, though produced by broken ribs, still genuine inflammation, and not irritation, or what I call morbid sensibility. By the second ease alluded to at page 71, I have shown when inflammation abates, and irritation (morbid sensibility) predominates. But because the last bleeding in the cases of traumatic pleurisy just noticed accelerated the fatal termination, Dr. Hall seems to doubt the necessity for free venesection in similar ones ; as if they had been cases of " irritation" from the commencement, whereas serious inflammation existed. Indeed, he says {Principles of Theory and Practice, 1837, p. 355), " cases of fractured ribs do not bear the loss of blood like those of inflammation." Of course the mere fractured bones do not require it; but I contend, on the contrary, that pleurisy from broken ribs requires the same antiphlogistic treatment as idiopathic pleurisy ; at the same time making due allowance for inflammation or morbid sensibility being kept up by mechanical irritation, as by fractures elsewhere. I formerly witnessed much surgical practice, and I have seen patients certainly sometimes bled too freely for traumatic pleu- risy ; but I have known the same error committed in medical cases of idiopathic pleurisy. This, however, was not from ignorance of " diagnosis" in either ; it was from want of knowing how much the powers of the constitution could bear ; there was inflammation in all the cases, and "irritation" also. Much as I approve of what he has written on the physiology and pathology of the nervous system, on the " mimoses," " reflex function," &c, I cannot tolerate his per- version of the term " diagnosis," " by blood-letting ;" for, notwith- standing the one sentence in italics placed to meet anticipated objec- tions, that expression is calculated to puzzle, if not mislead, his junior readers. Diagnosis has always been understood to mean the dis- tinction made between diseases for the very necessary purpose of arranging the treatment. In my opinion, before such a decided step as bleeding is adopted, the physician ought to have made up his mind as to what is the nature of the disease. In the previous edi- tions of this work I have adduced examples (which will appear in their proper places) of pure " irritation," that do not bear, or rather are not benefited by, depletion. PRINCIPLES OF MEDICINE. 85 bleedings at first relieve the patient at the time when he can scarcely draw his breath, yet subsequently, pain, and even difficulty of breathing, will return, which cannot be relieved by repetitions of the bleeding, even if that were not inadmissible from the danger of sinking by loss of blood ; and when pain and dyspnoea are urgent, we must try what can be done with anti- mony, ipecacuanha, mercury, opium, digitalis, &c, varied and modified according as there are more or fewer febrile symptoms accompanying. I should say, that it is seldom necessary to abstract to the amount of five or six pints of blood within as many days, if active medicinal treatment be adopted to coincide with the bleeding. We see that solutions of metallic salts, such as nitrate of silver, tartar emetic,* acetate of lead, bichloride of mercury, &c, and some acrid vegetables, such as meze- reon, &c, act on the capillaries as astringents; but each of these, when too strong, produces a contrary effect, viz., inflammation and relaxation. We know that substances applied to the surface of the primse viae, or skin, are ab- sorbed and carried into the circulation; and we judge that in this way these metallic salts, oxydes, &c, are carried to the capillaries of diseased parts, so as to act like astringents, and strengthen and cure. We know too that they are adapted to different cases. Antimony, which produces sickness and lowers the pulse, besides its local effect on the capillaries, when it reaches them through the circulation, is suited to, and resorted to in, acute diseases, such as inflammatory fevers, whether idiopathic or from injuries. Thus, we can account for * A solution of antim. tartar, may be used with great advantage as a lotion to some cutaneous eruptions. 86 PRINCIPLES OF MEDICINE. the efficacy of antimony in such a disease as scarlatina, by its diminishing inflammation in the superficial capillaries of the skin, fauces, &c, which have been relaxed by the morbid poison, and at the same time by reducing the power of the circulation when it is too strong, if administered so as to produce slight sickness or nausea: or if there be a low state of fever not re- quiring reduction of the pulse, the antimony may be given in small repeated doses, so as to circulate to the capillaries without depressing the system. Mercury, which has not this nauseating property, acts less on the pulse than antimony, but perhaps even more upon the capillaries, when circulated to them; hence it is oftener used in chronic cases, both syphilitic and others, be- sides being much employed in acute inflammation, pleurisy, peripneumony, peritonitis, &c. This affords a rationale of these remedies curing inflammations where there is no indication for depletory or common antiphlogistic means; for which mode of cure the vague term, "equalising the circulation," has been adopted; but it is erroneous, as the circulation cannot be unequal: it may be irregular, stronger or weaker, quicker or slower; but in either case the blood must be sent or circulated equally to every part of the body, as it passes at first from the heart through a single canal, the aorta: as stated when speaking of what has been called determination of blood (p. 52). Although chemists cannot detect either mercury or antimony, administered as remedies, in the circulating blood, it alters not my position. It is not fair to con- clude that the metallic compound is not there, because they have been unable to detect a quantity of it which bears so minute a proportion to the whole mass of fluids of the body. PRINCIPLES OF MEDICINE. 87 We are by no means to draw the conclusion, that an affection is not inflammatory, merely because it does not yield to depletion. What degree of depletion would remove a node, or syphilitic iritis, without mercurial or other medicine ? What would venesection do for rheumatic pains, without antimony, colchicum, opium, bark, mercury, and other medicines? Mercury and iodine* remove morbid growths by starving them, which they effect by contracting .the capillaries, and not by increasing absorption, as is a commonly received opinion. It may be said, that the swelling of the gums and fauces from mercury is a contradiction of this; but in many of our medical explanations we appear to " blow hot and cold." Mercury stops inflammation by the same means in one case as it produces it in another, —it contracts the capillaries; so that a healthy part is inflamed and even ulcerated by what contracts its nu- trient capillaries beyond a natural state; an unhealthy ulcer is stopped by what contracts its relaxed capilla- ries to a natural state. Contraction of the vessels, how- ever, does not express the immediate cause of the * Iodine is very similar to mercury in its effects on the animal economy. The hydriodate of potash is a very manageable and good preparation of it. Like mercury, its effects are very variable on different constitutions. Some persons cannot bear much more than one or two grains of the salt three times a day without inconvenience, whilst others can take more than ten times that quantity. The mode in which it mostly disagrees is by irritating the stomach ; it produces a perception of fcetor, and sometimes soreness, in the mouth and fauces, and great languor. I have been called in to two cases where, in imprudent doses, it had produced gastritis, like arsenic, but which was soon relieved by leeches and opiates. The bichloride of mer- cury, or liq. arsenicalis, which are so useful in small doses, would do the same in excess. The abuse of a remedy is no argument against its use. 88 PRINCIPLES OF MEDICINE. sponginess of the gums; there is, in fact, inflammation, relaxation, which is the secondary result of the contrac- tion ; the excessive contraction occasioning the loss of contractility, that is, over-action causing at last a loss of power; as cold, which at first contracts, will at last destroy the power of the capillaries, so that relaxation, amounting to inflammation (chilblain) takes place. The soreness* of the membrane of the mouth in ptya- lism is analogous to chilblain, the cold air, saliva, &c, acting upon a membrane whose vessels are in a state of extra contractility; moderate cold, with extra con- tractility, producing the effect of intense cold with ordi- nary contractility. It is thus that we have, in the rationale of medical phenomena, to refer constantly to the variation of the proportions of the components of a sum — i. e., the two things which contribute to a phe- nomenon. In the foregoing statement, the extra con- tractility depends upon extra sensibility of the nervous part of the apparatus — the organic sensibility of Bi- chat (p. 40) — which is diminished, if not lost, when inflammation takes place, and the augmentation of which is a means of remedying inflammation; as a cold lotion may relieve a chilblain, which is inflamma- tion produced by cold, and as cool air relieves ptyalism. We see, in a variety of instances, that a remedial agent too long or too powerfully applied becomes nox- ious, by exhausting the vitality—in fact, wearing out or straining the machinery of the organ, so that it can no longer answer to the nervous influence, whether the organ be capillary tube or any other structure ; and sometimes it remains for us still to investigate what * There are persons, as is well known, whose mouths are so sus- ceptible to mercury, that they cannot, in the ordinary way, take it long enough to cure the diseased capillaries in other parts. PRINCIPLES OF MEDICINE. 89 part of the machinery has been injured — the contrac- tile or nervous tissue. But, even granting that syphilis or ague might be cured by low diet, abstraction of blood, and other gene- ral means, and supposing itch were curable thus (which it is not), instead of by sulphur; the question is not so much as to possibility, as expedition, and safety to the constitution: what degree of depletion would cure a rheumatism, which gives way to doses of colchicum too small to cause any sensible evacuation ? just as small doses of arsenic will cure cutaneous inflammation, that could not be affected by bleeding or other depletion. It was long before I could account for what are called the specific effects of such remedies as mercury, arsenic, colchicum, &c. We can understand thus far, that the membranes, cellular tissue, skin, and parts which are very vascular, under common inflammation run a rapid course of disease, and are relievable by active antiphlo- gistic means; but when parts are attacked by specific inflammation, which is produced by a morbid poison, and which is slow in its progress, or when the tissue inflamed is one of dense structure with very minute capillaries, depletion, or taking off the vis a tergo, has little or no effect on those capillaries; and we are obliged to resort to what have been called specific medicines, such as mercury, arsenic, &c, which make them con- tract. Here we are supplied with analogies to help us in the prosecution of the cure of diseases with other remedies, in cases when the so-called specific either fails or disagrees : which being ascertained, the specific use of the medicine ceases—it ceases, in fact, to be a specific. For instance, at one time no remedy was known except mercury against the chronic inflamma- tion produced by the syphilitic poison. Now, taking 12 90 PRINCIPLES OF MEDICINE. my view of the proximate cause, we should deduce, a priori, that iodine might cure it, or that rigid diet and such remedies as mezereon would do so, by their effect on the capillaries; which has, in fact, been empirically proved to be the case. But it may be said, I have got no farther than the empiricism ; on the contrary, I have no doubt but that arsenic would answer, but that, again, is not a fair example, as it is already used empirically in India; but iron would answer, only, not being so powerful, it would require the inconvenient adjunct of a rigid diet, as mezereon does. Again, I have no doubt that, on principle, colchicum might be substituted for mezereon; or antimony, silver, or copper, for the other chemical remedies : gold has been tried, and found to succeed. But though it be useful to have other means, when we cannot employ the ordinary one, we need not resort to a hatchet or a penknife to cut bread with, when there is a table-knife at hand; nor have recourse to any- thing in preference to mercury for the cure of syphilis, from an apprehension that it may disagree, because in one in a thousand or a hundred cases it is found to do so. It is better to learn to modify it, by combining opium, &c, with it, to correct any inconvenience when it occurs; and when, of course, it is necessary to be able to bring analogical remedies into play. The specific which puzzled me most and latest was sulphur for itch ; but now the mystery is satisfactorily cleared, and we see why more powerful drugs taken internally could not cure it. Its cause being a para- sitic animalcule, it is easily removed by rubbinc on sulphur, which kills the little animal in his lair; whereas he could not be hurt by the remedies that cure those eruptions which are. a disordered state of the capillaries, and which are easily affected by the reme- PRINCIPLES OF MEDICINE. 91 dies as they circulate through them. Therefore, as i there are other substances which can kill the animal- cule, though perhaps none so conveniently as sulphur (corrosive sublimate, for instance, might salivate before it could cure the itch), one more specific is struck off our list. As for colchicum being a specific for gout or rheumatism, it is no such thing; there are several equally efficacious means of treating either. Again, there is no single specific for tic douloureux: cases have been cured with liq. arsenicalis, in which iron had failed, and vice versa ; and I have cured a case with carbonate of iron, combined with galvanism, which I was told had held out against all the usual modes of treatment.* Tic douloureux may also be sometimes cured better by quinine, or opium with bark or quinine, than by any other medicine; sometimes mercury, &c, &c, are necessary. Bark is no longer a specific for ague; we can cure it with arsenic, and other remedies that cure neuralgia or neuritis, which ague is in fact. In addition to what was formerly stated on the sub- ject, I may here observe, that nervous influence is elicited in producing nervous actions, such as percep- tions or thoughts; organic actions, such as those of capillaries, heart, or intestines; and the combination of nervous and organic action — voluntary motion. If this expenditure exceed the supply, or secretion, by the * Carbonate of iron had, of course, been already employed to a large amount; but the disease was kept up evidently by a torpid state of the liver, which had resisted mercury and other medicines. The cautious repeated application of galvanism to the organ, in about a week produced an abundant secretion of good bile, and improved the digestion ; after which a perseverance with the iron for some time cured the neuralgia. 92 PRINCIPLES OF MEDICINE. cineritious part of the nervous system, exhaustion is evinced in various ways: in health, by sleep; in dis- ease, by delirium, stupor, or death. The heat of fire produces a sensation first of pleasure, then, if increased, of pain : this elicitation of the nervous influence does no harm if the person be in health, because it is kept up by the apparatus of the brain and nervous system which generates it; but if the person be feverish, or the nervous system out of order, sitting close to the fire adds to the exhaustion and debility; nay, even in health, a lazy indulgence over the fire produces languor; and other indulgence of nervous sensation produces debility, " balnea, vinum, venus," &c. To judge by the phenomena, alcohol produces sensa- tion by calling forth nervous influence ; its presence, like that of fire, exciting a quicker extrication of it. Here, again, whilst there is health, so that the nervous influence is renewed, no harm is done; but, according to the constitution, the abuse of wine or spirit produces, sooner or later, an exhaustion, and the result is a feverish or irritable state, analogous to bodily fatigue, which is produced by expenditure of nervous influence in the successive discharge of it into the muscles, to keep up their action in walking or laborious exercise. Sleep is a cessation of that expenditure of nervous influence which takes place in nervous action, such as volition, and other functions of the sensorium, organic action continuing. The expenditure of nervous influ- ence going on, under ordinary circumstances, quicker than the generation of it, a periodical return of sleep is induced. As the nervous influence is supplied to all the nerves in common, from the so-called nervous centres, the ex- penditure of nervous influence in one part usually les- PRINCIPLES OF MEDICINE. 93 sens it in others. Fatigue from labour includes a cer- tain exertion of the brain in the production of volun- tary motion; but if the body and mind be fatigued simultaneously, as when a person has to walk much, the mind at the same time being anxiously occupied, the expenditure of the nervous influence will be more rapid, and the exhaustion greater. Again, the expen- diture of nervous influence in intense study or profes- sional business, especially if anxiety be combined, with- draws so much of it as to diminish the energy of the digestive organs; and in this way the cares of business become the fruitful source of indigestion and gout, par- ticularly if, as in great cities, perpetual feasting add to the labours of the stomach. It is well known that digestion produces drowsiness and chilliness, by diminishing the energy of the brain, and by abstracting the nervous influence of the skin. It is necessary here to notice the distinction between stimulants, sedatives, narcotics, and tonics, a great con- fusion of language and ideas having prevailed on these subjects. For instance, any medicine which made a person better, without evident effect on the bowels, kidneys, &c., was called a tonic; and inasmuch as it restored strength to the system, it undoubtedly had a tonic effect. Now this is the case so often with wine in debilitated habits, that it is no wonder stimulants and tonics became almost synonymous; and the com- mon mode formerly of administering bark in wine in- creased the error, so that bark was thought stimulant. We have a difficulty, too, in distinguishing the quali- ties of medicines, from many of them having two principles combined, as will be presently pointed out; we may, however, get very nearly pure examples of each — stimulant, sedative, narcotic, and tonic. 94 PRINCIPLES OF MEDICINE. A stimulant is that which, through the medium of the nervous system, increases the action of the heart and other organs, by calling forth the nervous influence, or by facilitating the extrication of it in them; for example, wine, brandy, and other spirits, the product of fermentation. A stimulant increases the action of the heart, and consequently for a time, by sending more arterial blood to the brain, besides its own effect on the brain when conveyed thither through the circulation, excites the sensorium to hilarity, if there be no latent disease there ; but in too great a quantity it produces stupor. Brandy produces stupor by excess of stimulus, thereby exhausting nervous influence and perception of the brain; as looking at the sun will take away the power of the optic nerves by excess of stimulus, and as too great noise will cause temporary deafness : though light and sounds in moderation yield pleasurable sensations. The effects of stimulants are referrible to a twofold operation both upon the brain and spinal marrow, and upon the heart. Each of these systems, the nervous and the circulatory, is affected by a local and a general operation of the stimulus upon their respective centres. The stimulant (brandy, for instance), as soon as ab- sorbed and carried into the blood, comes into contact with the internal surface of the heart, upon which organ it acts as an excitant locally or by " reflexion," — besides probably its influence on the heart by sym- pathy, through the branches of the solar plexus passing between the stomach and heart, — and thus excites the heart to increased activity; from thence the spirit, mixed with the arterial blood, is propelled to the brain, which it excites to a more rapid elimination and distribution of the nervous influence. Respiration, or the decarbo- PRINCIPLES OF MEDICINE. 95 nisation of the blood in the lungs, is more perfect; the function of the heart, like that of every other organ, is carried on more energetically as regards frequency and force; the nervous centres receive, therefore, a more copious supply of arterial blood; the sensorium, if the brain be affected by no latent disease, is excited to hilarity: all impressions upon the nerves are perceived by it more acutely; the generation and the flow of ideas are accelerated ; volition is more rapid ; all the glandu- lar organs, as well as the skin and mucous membrane, secrete more actively; through which, and perhaps by arousing even the comparative torpor of the involuntary muscles, as of the alimentary canal, digestion, absorp- tion, and defecation, are accelerated. These are the effects of moderate quantities of stimuli: in excess, phe- nomena the very reverse of many of them succeed: the brain is poisoned by the spirit in contact with it; the nervous principle which it contains is expended, and the generation and disengagement of more is interfered with; so that the capillaries, from the exhaustion of nervous influence, become more distensible ; the imagi- nation is rendered vapid, the perceptions and ideas confused. The brain will be overpowered with arte- rial blood from the increased action of the heart, which the stimulants have occasioned; for although arterial blood is the source from which the capillaries of the brain prepare or secrete the nervous principle, over-in- jection diminishes secretion (as in the kidneys, &c); but mere increased action of the heart is not sufficient to produce the bad effects of over-injection, unless the local effect of the spirit upon the brain, as distensibility of capillaries, &c, takes place simultaneously. The over-injection will lead to febrile excitement, as it is called, the secretions in every part being diminished 96 PRINCIPLES OF MEDICINE. from want of nervous energy (besides the over-injection of the glandular organs themselves); and at length stupor, coma, and even fatal apoplexy, may be the result. Such are the visible effects of stimulants when ad- ministered to persons in health {physiological effects); and similar are those we witness from their agency in disease, although modified by the malady itself under which the patient labours {pathological effects). A sedative is that which diminishes the action of the heart and other organs by repressing the nervous influence ; for example, digitalis and green tea, the last of which, though called a stimulant by some, was long since proved by Dr. E. Perceval to have an effect similar to that of digitalis :* green tea in excess produces a sense of anxiety and oppression of the chest, with in- termitting wreak pulse, nausea, &c. It has been often asserted, that there is no such thing as a direct sedative or allayer of action, but that the sedative effect was only the secondary result of exhaus- tion from stimulus, arguing from the stupid state which comes on in intoxication from fermented liquors, and from opium,f which is observed to be stimulant in small quantities, before enough is taken to produce stupor. It having been thus observed that a state of * The publications of Rush, Rasori, and Tommasini, would, I think, satisfy any person that digitalis is a sedative (" contra-stimu- lant"), though, up to this time, not a year passes in which the pages of periodicals are not loaded with attempts to prove it a stimulant. t It must be recollected in practice, that opium contains two prin- ciples, the narcotic as well as the stimulant. Unluckily, the true narcotic part has received the name of morphia and another part narcotine. , PRINCIPLES OF MEDICINE. 97 exhaustion succeeds intoxication, or any other abuse of stimulus, it became adopted as an axiom by many, that there could be no sedative effect unless secondary, as the result of previous excitement; and I have found many who endeavoured to prove that digitalis at first produces a stimulant effect. The only apparently good argument, in my opinion, that they could bring for- ward is, that digitalis and other sedatives sometimes make the pulse quicker than it was before; but every person who has bled a few patients must have observed that the pulse becomes quicker as the patient grows faint. Mere increased frequency of the pulse is not therefore a proof, as no person will call blood-letting to syncope a stimulant. It may, however, be contended, that in inflammatory complaints the pulse will become not only more frequent but harder, that is, in fact, stronger, during the administration of digitalis: but this effect is not produced by the digitalis; for if, when the patient does not take enough, a few drops only being administered at each dose, or bleeding and other reme- dies being neglected, or the inflammation being uncon- trollable by any means (even in the most skilful hands), the inflammation increase, and the pulse become harder; this is not the effect of the digitalis, any more than of venesection. Every practitioner of experience must have found the pulse become harder after a bleeding which has been insufficient to subdue the inflamma- tion, until another bleeding has softened it: the same occurs with digitalis. Doubtless digitalis, as well as venesection, may raise the pulse when it has been de- pressed below the natural standard by inflammation, as will be hereafter explained; but will any one call venesection stimulant ? We should beware of attribu- 13 98 PRINCIPLES OF MEDICINE. ting to the remedies the changes of pulse which depend on the progress of the disease. A direct sedative diminishes the action of the heart and nervous system; in a large dose, instead of hilarity, producing anxiety, depression, and despondency; nay, more, allaying action in the nervous system, so that it cannot direct the muscles, the patient becoming giddy and staggering, and even the retina being so weakened as not to see distinctly; so that a person may reel or see double without being intoxicated: the same may occur from loss of blood. It is well for the student to be early aware that opposite states may thus produce similar appearances, since the remedy which would cure one would not afford relief to the other: for in- stance, the coma of children which proceeds from inani- tion, and which might be mistaken for a plethoric state of the internal vessels, is relieved by stimulants, as is so well described by Gooch, and the nature of which was previously shown by Dr. Marshal Hall. The disease called delirium tremens has likewise many symptoms in common with those complaints which are cured by venesection and sedatives, but which itself requires stimulants, either alone or combined with narcotics. We see that when nervous influence is expended to the degree that ordinarily induces sleep, or the suspen- sion of sensorial action, this suspension is retarded if any irritation produce a renewal of sensations, as the pain of toothache, or if the extra-excitement of anxiety, in cases where affection or interest is concerned, con- tinue to occasion extrication of nervous influence in the brain: and this power of continuing cerebral action (wakefulness) will be increased by introducing into principles of medicine. 99 the stomach a sedative, such as digitalis, or green tea, which, by diminishing the force of the pulse, and by its influence on the brain, counteracts the plethora which would induce sleep. But, observe, the natural powers are by this means forced; the consequence being, that from the expenditure of nervous influence continuing, with diminution of the power of the heart and primae viae, the brain will become weaker; so that although thoughts may be excited, they will be vague, and false perceptions will arise. This state of morbid sensibility of the system is called being nervous, and is experienced by those who have sat up late watching the sick, or reading, and who, having forcibly kept themselves awake, either with or without tea, coffee, or snuff,* become chilly, start at the slightest noise, and suffer involuntary and unreasonable apprehensions of danger. Persons under these circumstances lying down in a cold bed, will frequently not fall asleep, or if they do, will be harassed by nightmare ;f but a warm bed, by diminishing the sensations transmitted from the skin, and at the same time increasing the circulation, will renew a plethora in the brain favourable to sleep; wine or spirits taken into the stomach will do the same, * The effect of these luxuries, which are in reality often beneficial, has been misunderstood : for instance, tea and coffee — sedatives — counteract the bad effects of wine and other fermented liquors ; as does also tobacco, whether in form of snuff or chewed. On the other hand, we observe persons render themselves debilitated and nervous by too much tea and coffee without fermented liquors, espe- cially females ; and in many instances, excess in snuff or tobacco injures the health by imperceptible degrees. f Nightmare is caused by whatever forces attention on the senso- rium during sleep ; thus, it may be produced either by uneasiness in the stomach from indigestion, by cold of the surface, or by cold feet. 100 principles of medicine. if the brain be not feverish; or even a draught of hot water will have a beneficial effect. One example more of a direct sedative — a common dose of salts makes a person pale, and cooler in body and mind. This is not a simple sedative, being like- wise an evacuant; at any rate, it is not a stimulant. I have heard emetics called stimulants ; but to this I can- not consent until I see a full dose of ipecacuanha or tartar emetic make a person feel warm and cheerful, and his pulse stronger, before or while he is sick. After the cessation of vomiting, by the relief of disease af- forded by the emetic, the morbid sensibility, shivering, and depression, in ague, influenza, or inflammation, are removed ; and from this cause, and not by a direct stimulant operation of the emetic, the patient may be- come warm, and be relieved from chilliness and anxiety of countenance, precisely as by venesection. Sedatives, as opposed to stimulants, diminish the in- jection of the brain, at the same time repressing the nervous influence : so that the proximate cause of de- lirium, stupor, or coma, from sedatives is inanition; whereas the proximate cause of delirium and coma from stimulants is congestion or plethora. One cause of the confusion of terms is hereby ex- plained. Sedatives are sometimes miscalled stimulants, when they relieve the vertigo, stupor, or coma of sti- mulants, or the drowsiness of fatigue or other plethora, because this relief is called arousing, or awakening; as by tobacco-snuff, digitalis, or tea.* On the contrary, * It is sometimes difficult to convince persons, who have been in the habit of resorting to tea or coffee for the purpose of enabling them to apply the mind to any mental occupation, that these are sedatives, and diminish the action of the nervous system : but they operate only by counteracting the plethoric state of the brain induced principles of medicine. 101 a stimulant (wine) given to a person fatigued, produces an inclination to sleep, unless it occasion feverishness. Coffee appears occasionally to produce an effect the reverse of sedative; thus, in some persons it favours sleep; a result attributable to the circumstance, that sleep is often disturbed in consequence of a superabun- dance of blood in the brain, — being a feverish state, the effect of stimulant beverages, such as wine, &c.; or the over-excitement of brain remaining after an evening passed in interesting society, at theatrical exhibitions, or in the arena of debate, when the ordinary status of the capillaries of the brain has been disturbed by ex- citing passions. In other cases, coffee and tea favour sleep by coun- teracting an habitually plethoric condition of the brain, depending on constitutional peculiarity and morbid activity of the heart's function, the tendency of which to cause sleeplessness may be increased by the recum- bent posture. The reader will perceive in the bulk of these obser- vations an illustration of the oft-repeated remark, that opposite causes apparently produce in the animal eco- nomy the same effects. We have here pointed out that sleeplessness may arise from either excessive or insufficient injection of the brain ; that both fermented liquors (stimulants) and tea, coffee, digitalis (sedatives), by the continued stimulation of action, thus merely restoring the brain to its normal state. The same persons do not require tea on rising in the morning, when the brain is in its natural state, to enable them to study ; strong tea or coffee at that time would produce nausea or distraction" of thought. On the other hand, some persons, whose brain is in a plethoric state, do require coffee or tea the first thing in the morning, to enable them to become quite awake. 102 principles of medicine. may, according to circumstances, prove hypnotic or the reverse. By the term sedative is not to be understood that which puts to sleep, this being the operation of a narco- tic, but whatever produces for a time an effect upon the nervous system as if it had been refreshed by sleep, by taking off plethora. But this, of course, has not the restorative effect of sleep ; on the contrary, though the ideas are rendered free at first, exhaustion will at length produce the weakness of thought, the delirium or coma of inanition: as the sedative, besides its interference with the restorative influence of sleep, still further weakens the functions of the sensorium, both by its local effect on the nervous tissue, and by its sedative effect on the heart, diminishing the supply of arterial blood to the brain. The narcotic principle in drugs diminishes the sen- sibility of the nervous system, lessens the perception of external objects, and checks volition, thereby allaying pain and promoting sleep. Narcotics must be distin- guished from stimulants on the one hand, and from sedatives on the other; and the distinction is the more necessary, because in nature the narcotic principle is generally combined with one or other of these, and sometimes also with an acrid irritating matter, which renders it difficult to draw correct inferences from ex- periments made with these substances: hence the con- tradictory and unsatisfactory reports of the value of different narcotic remedies, and the difficulty expe- rienced in their application by those who do not know the reason why opium suits one case, hyoscyamus another. It has been very common to try one of these PRINCIPLES OF MEDICINE. 103 remedies first, and if that did not suit, to resort to the other; but whoever knows that opium in its natural state contains stimulant and narcotic* properties com- bined, will not administer it when the skin is hot and dry, with permanent thirst, delirium, and other evi- dences of symptomatic fever (pyrexia), but will on principle prefer hyoscyamus, which contains the seda- tive combined with the narcotic. Many have arrived at a knowledge of the contrasted use of these substances empirically ; but those who have not experience must be guided by the consideration, that some " sleeping doses" are stimulant, and some sedative; that a patient may be forced by opium into a sleep from which he will awake thirsty, feverish, and unrefreshed, when hyoscyamus would have cooled and refreshed him. Dover's powder is a judicious combination, when a narcotic neither sedative nor stimulant is required : the sulphate of potass and the ipecacuanha being sedative counteract the stimulant part of opium, so that Dover's powder acts nearly as a simple narcotic. There are many cases in which hyoscyamus would be too de- pressing if given in doses sufficient to produce sleepi- ness, and in many cases opium would be too stimu- lating ; so that in fact, when we want narcotic without either stimulant or sedative, we cannot use the natural * That opium contains two principles, the stimulant and narcotic, is not now matter of speculation ; as they have been separated che- mically, and the narcotic part (morphia) can be used to produce sleep without the stimulant. The stupor from opium was said to be the sedative effect subsequently to, or produced by, the exhaustion of the stimulus ; but this is not the case, for the stimulant part being taken away, the morphia produces sleep just as certainly; thus realising the long-sought desideratum of an unstimulating opiate — the vaunted nostrum, from the black drop, down to Battley's liquor. 104 PRINCIPLES OF MEDICINE. drugs uncombined. Hyoscyamus has been known to disappoint the practitioner, by inducing even delirium tremens instead of sleep ; which I attribute to this union of the sedative with the narcotic; and which will also account for its being frequently found useful both in medical and surgical cases, when there is hot skin and hard pulse: this will explain the safety and advantage of using morphia, wfiich is now so much employed empirically, from its possessing no stimulant proper- ties. Battley's preparation, "liquor opii sedativus," is proved by experience to be analogous to Dover's pow- der, but suits many constitutions better; for the sti- mulant part of crude opium contained in Dover's pow- der disagrees more with some constitutions than with others; and the advantage of the preparations of mor- phia may be similarly explained. Digitalis and opium may be advantageously combined; but digitalis and brandy, a direct sedative and a direct stimulant, cannot be expected to produce any combined effect, the one neutralising the other; as strong coffee or green tea tends to counteract the poisonous operation of tincture of opium, and the intoxicating effects of wTine or other fermented liquors. Stimulants promote the extrication of nervous influ- ence, as evinced by increased action; sedatives the reverse. Narcotics do not appear to alter the quantity of nervous influence, but merely to impede its commu- nication : morphia, for instance, merely prevents the perception of pain in a part; produces disinclination to muscular action; does not alter primarily the force of the heart, like wine on the one hand, or digitalis on the other, but soon renders it sluggish by retarding innervation. Narcotics stop the conducting power of PRINCIPLES OF MEDICINE. 105 the nerves, which may be thus illustrated: — if the arm be laid across the back of a chair, or be otherwise compressed in one place, the hand becomes what is called asleep from pressure on.the nerves; sensation and voluntary action are lost, or, if not quite lost, much diminished, " pins and needles," a pricking sensation, being felt. The sensation of a limb being asleep arises from the pressure interrupting the conducting power of the nerves by pushing the medullary matter out of a part of them. If the medullary matter be but slightly separated, the nervous influence is passed like the sparks of electricity, causing the pricking; but if the gap or space be too great, no sensation whatever is transmitted. If the arm be rubbed so as to press back the medullary matter, the " pins and needles" are felt as it begins to meet. I have known the hand remain powerless for many months before the medullary matter could be rubbed into its place, in a person who, having fallen asleep with his head leaning on his fore-arm over the back of a chair, was affected with paralysis of the hand from this cause. This case is precisely analogous to the state of temporary numbness called being asleep, only lasting longer. The cause was clearly mechanical, and independent of any affection of the brain, as the mus- cles which bend the elbow, and all indeed above the point of pressure, were in perfect activity : there was no pain or other symptom of inflammation from which it could be suspected that inflammatory alteration of the nerves had suspended their functions. Narcotics, then, judg- ing by the phenomena described, and others familiar to medical men, appear to interrupt the conducting power of the medullary matter, evinced by their influ- ence over the functions of the brain and spinal cord; 14 106 PRINCIPLES OF MEDICINE. and as there is no mechanical pressure, wTe can account for this only by some chemical action or union with it, altering its (galvanic or electrical) properties. Different narcotics vary as to their effects. A minute quantity, less than a grain, of extract of aconite (a sedative acro-narcotic), dissolved in the mouth and swallowed, produces a pricking sensation, and diminu- tion of power of the muscles of the fauces, so as to render speech and deglutition difficult. Belladonna (a sedative narcotic) produces a similar effect, less a sense of pricking than of dryness. To recur again to the difference between narcotics and stimulants on the one hand, and narcotics and sedatives on the other; sedatives diminish action, but not by interrupting the conducting powrer; for digitalis or green tea tend to render the perceptions more acute, and produce wakefulness instead of sleepiness: it is not until the nervous influence is actually exhausted, so as not to be sufficient in quantity to produce actio^ that there is any defect in the perceptions, and then there is delirium, not sleep. Aconite, belladonna, and tobacco, which contain but little of the true narcotic principle in proportion to the sedative, are never used as hypnotic narcotics, as they produce delirium tre- mens ; whereas hyoscyamus, which contains a sufficient proportion of the narcotic, does not produce delirium tremens, except when misapplied as concerns its seda- tive property; and opium, which is narcotic and stimu- lant, never produces delirium tremens, though it may fail to procure sleep, if misapplied as respects its stimu- lant property. Thus, when administered in cases where feverishness exists, the small proportion of stimu- lus in the opium will often increase the feverish mor- PRINCIPLES OF MEDICINE. 107 bid sensibility, so as to counteract the narcotic influ- ence. These three divisions of remedies may be considered physiologically as well as pathologically; that is, their action may be studied both on the healthy and dis- eased individual. We now come to the fourth division, tonics, which can only be considered pathologically, viz., with reference to their agency in removing a mor- bid state. Tonics are substances which neither immediately nor sensibly call forth actions, like stimulants, nor re- press them, like sedatives, but give power to the ner- vous system to generate or secrete the nervous influence by which the whole frame is strengthened. The action of tonics (which can be traced to their effect on the nervous system) is gradual; if therefore there be any sudden increase in force of the pulse immediately after their administration, it should not be attributed to their tonic nature, as the pulse will vary with the dis- ease, according as it is affected by the use or neglect of other remedies. Thus, either the advance of inflam- mation, or the neglect of other remedies, or the admi- nistration of stimulants with tonics, will occasion that hardness of pulse which has usually hitherto been sup- posed to be the effect of a stimulant property in the tonic. On the contrary, a tonic, when it disagrees with the stomach, depresses the pulse, acting as a sedative by nauseating; and even when it causes a quick pulse, which it sometimes does, with headache, this result is mere dyspeptic morbid sensibility. Even tartar emetic, which is recognised as the reverse of a stimulant, when its sedative operation is too great, or has been too long continued, induces the same state of morbid sensibility, 108 PRINCIPLES OF MEDICINE. which has been sometimes denominated " antimonial fever." We have sufficient proof that the effect of quinine, iron, and arsenic, in neuralgia, &c, is direct on the nerves. There is a palpable analogy between the ac- tion of nitrate of silver, sulphate of copper, arsenic, &c, on sores, and their effect on the constitution when introduced through the circulating fluids. In either case, if used in too great quantity, they will do harm; externally, instead of constringing and healing, they prove caustic; internally, also, too much is poisonqus: but bark or carbonate of iron, which do not produce chemical decomposition, are free from the risk of acting as caustic or poison. Some tonics, then, in excess, as well as stimulants and sedatives, become poisonous. Arsenic produces inflammation, as a poison; but this is not to be referred to when considering the tonic effect of small doses of the mineral; the tonic effect being a modification of vital actions, the caustic or poisonous effect a destruction of the machinery. There is no analogy between the effect of the tonic in proper doses, and the diseased state produced by it when it acts as a caustic poison. Lunar caustic properly applied will heal the skin; improperly, will burn a hole in it. Whoever does not know of what strength to use nitrate of silver, or sulphate of copper, had better confine him- self to oak-bark or alum, which cannot corrode ; or if he does not know how to modify arsenic or croton oil, he had better trust exclusively to Peruvian bark and castor oil, though less efficacious in many difficult cases. Thus, if a man be dexterous, he can perform lithotomy best with Mr. T. Blizard's knife; but if not, he had better use a gorget; as an awkward ploughman will go PRINCIPLES OF MEDICINE. 109 safer with a plough that is guaged by a wheel, than with one that is entirely dependent on the management of skilful hands, but which, when well guided, is the safest and most efficacious, especially in difficult cir- cumstances and rocky ground. Therapeutics and toxicology require very different modes of investigation ; and notwithstanding that ex- periments which have been made with poisons are very interesting and useful for the purpose of finding antidotes, they do not advance us much in reasoning upon the remedial use of these substances. In some cases, by temporarily exciting the nervous system when weak, stimulants give the digestive organs more power for the moment: the new nourishment in- creases the strength of nerve as well as of other parts ; and thus stimulants and generous diet become in reality a part of the tonic plan; and from stimulants being so often administered with tonics, tonics have been thought stimulant. It is of the utmost consequence to know that they are not so, otherwise there may be a fear of using them where they would be very beneficial, com- bined with evacuants and sedatives; for quinine or other tonics may be advantageously used along with digitalis and bleeding on the one hand, or with wine on the other. For instance, it is well known that ague attacks the most opposite constitutions, and that some patients stand in need of support, while others, on the contrary, require sedatives, such as venesection, opening medi- cines, and emetics — still, with the tonics, bark or arse- nic, in both cases — to cure it. Medical men were formerly so strongly imbued with the idea of bark being stimulant, that they prepared the patient, as they called it, by using the antiphlo- gistic treatment before they ventured to begin the tonic ; 110 PRINCIPLES OF MEDICINE. but practical experience has long since disproved the necessity of this precaution, and few now spend time in unnecessary preparation by other medicine, or bleed, except when the state of the pulse, and other symp- toms, indicate its propriety. Tonics, then, being in- trinsically neither stimulant nor sedative, may be use- fully combined with either; for wmether we want to keep down the pulse in inflammation, or to raise it and the appetite, &c, in debility, it must obviously be de- sirable to give tone and strength to the nervous system at the same time; because tone and strength of the nervous system will not increase the action of the heart unless it be called forth by stimulants. We must ob- serve this difference: tonics give strength, stimulants call it forth; a man may be very strong without putting forth his strength. We need not fear any danger from keeping the nervous system in good order by tonics, but we must beware of exciting over-action by stimu- lants, when either inflammation or fever exists. Sti- mulants excite action, but action is not strength; on the contrary, we shall see, when we come to consider fever, that over-action increases exhaustion. A correct understanding of these distinctions will be found of great use. The constitution may sink under the depletion necessary to reduce inflammation, or sub- sequently during tedious reparatory process, if tone cannot be kept up ; but this may be done without sti- mulation. Often is the practitioner foiled by " pouring in the bark and wine:" seeing the inflammation re- lighted, he is obliged to leave off the stimulant; but as he includes the tonic under that head, he leaves that off too, and so loses ground : or else, knowing by expe- rience that if he leave off the tonic, the patient will certainly sink, he continues the two together at all PRINCIPLES OF MEDICINE. Ill hazards, till perhaps the inflammation and stimulus united destroy by fever. It must not be imagined, however, as is too often the case with students, whenever a patient dies, that he might have been saved: they will be convinced by morbid anatomy and experience, that many cases of disease are uncontrollable by human skill and means; but, at the same time, the seeing how much had been effected in ultimately fatal cases, will encourage them in steadily practising on rational principles, and pre- vent their wavering in cases which are curable, though tedious. Tonics, such as bark, then, by imparting healthy energy to the capillary arteries, have a beneficial effect on inflammation (the erysipelatous and rheumatic, for instance), even when bleeding and sedatives may be necessary to keep down the action of the heart; but so long as the action of the heart is not below par, the effect of stimulants would be injurious. Sometimes, even when the acute stage of inflammation has sub- sided or been subdued, the powers of the constitution are so much reduced, that the reparatory process de- generates, so that parts cannot heal; hence the advan- tage of giving tonics to prevent this state as much as possible (even whilst we are keeping down the pulse by bleeding, sedatives, and cathartics), if the constitu- tion seem to require it; but by no means should we administer stimulants in the acute stage. As soon, however, as the acute stage or the inflammation is passed, and the reparatory process, or passive stage of resolution, commences, we must watch for the moment when it may be necessary to administer stimulants to prevent degeneration of the process, the local symptoms of which are lividity, diminution of temperature, &c.; 112 PRINCIPLES OF MEDICINE. the general symptoms, feeble pulse and anorexia. If tonics be not given early, as they act but slowly, there may not be time to introduce them into the system when the acute stage has been subdued; and there may not be sufficient strength for stimulants and food to work upon towards restoration. It is evident that tonics must be considered distinctly from stimulants and sedatives, from the circumstance that we cannot cure an ague or neuralgia, either by stimulants or antiphlogistic treatment, without tonics. We know that many slight cases of either will get well if left to nature; but I allude to those which are severe or obstinate. The term tonic is applicable to all those medicines which cure chronic inflammation without being either stimulant, or directly sedative or depletory. There are various cases in which bleeding, cathartics, emetics, and other sedative or antiphlogistic remedies, have not power to stop inflammation, and yet, together with the disease, are wearing down the constitution: under these circumstances, recourse has been commonly had to mercury. There are also cases in which arsenic, bark, opium, or other medicines, are preferable; but the great nostrum has been mercury : and yet, though so useful in the most ignorant hands, it is difficult to account for or designate its action. It is often called a stimulant, and yet it cures inflammation when all stimulants are carefully withheld, and so coincides in its action with the sedatives, and might as justly be called a sedative. But it also cures inflammation in debilitated habits, when wine and other stimulants are necessarily ad- ministered. I therefore consider mercury neither sti- mulant nor sedative, but tonic; that is, by its specific action on the capillaries, whether directly on their tis- PRINCIPLES OF MEDICINE. 113 sue, or through the medium of their nerves, it causes them to contract, wrhen (though all the injecting force of the heart were taken off by sedative treatment) they would not have had power to close; for when introduced into the system, it circulates to the capillaries, and gives them tone to contract, analogous to the effect of an astringent applied to external sores. Liquor arse- nicalis, nitrate of silver, the sulphates of copper and iron, mezereon, dulcamara, colchicum, &c, have a simi- lar action; some of which are more available than others in particular cases. This is also the rationale of the operation of the so- called alteratives, and of what is called stimulating the secretions of internal organs. When their capillaries are weak, they have their tone restored by mercury, and the secretions are thus renewed ; but it should not be forgotten that mercury, like some other tonics, in excess becomes poisonous, and may cause inflamma- tion in other parts, as it does in the gums, on the prin- ciple adduced before, that one degree of contraction of the capillaries is necessary to reduce inflammation, while a still further degree will stop nutrition, and bring on wasting and disease; as syphilis has been by some starved out at the expense of the constitution. Iodine, arsenic, and sulphate of copper, occasionally produce ptyalism, and are otherwise analogous to mer- cury in their action. Rheumatic inflammation in the fibrous and other tissues, the capillaries of which are very minute, often cannot be cured by common deple- tory antiphlogistic means, as above mentioned; but yield to colchicum, mercury, antimony, bark, &c, in- troduced into the capillaries through the circulation. The tonic property is frequently combined with astringency ; but that they are not identical is evident 15 114 PRINCIPLES OF MEDICINE. from quinine, which contains no tannin, and cinchona bark, which contains very little, being highly tonic; while tannin, oak-bark, and catechu, are very slightly so. Still, however, we are at a loss to conceive any other than an astringent effect produced primarily by the tonic substances. All the metallic salts have, more or less, an astringent effect on the capillaries; and to this influence I attribute the universal efficacy of anti- mony as an antiphlogistic remedy, it being doubly valuable in acute cases, from its sedative effects on the heart and pulse, combined with its locally tonic or astringent effects on the capillaries of inflamed or con- gested parts, as well as on those of all the secreting structures. Hence, too, its efficacy, in small repeated doses, in cases where there is great depression of the system, by its relieving the relaxation of the capillaries by which the depression is caused. Nay, more, we can manage to insure its full antiphlogistic effects without the inconvenience of nausea, by combining it with a little opiate and aromatic. From the analogy of the efficacy of tonic medicine in curing chronic inflammations and neuralgic diseases, we may, I think, infer, that the latter depend on a chronic inflammatory state of the nervous tissue; though, from its capillaries being so fine, it is at present impossible to detect that state. As I set out with observing, it may be seen that tonics must always be considered in reference to dis- ease : thus, different substances which, considered physiologically, or in health, belong to opposite classes, become, in disease, tonics. Even narcotics frequently become, in an indirect manner, most usefully tonic; as, for instance, when rest is prevented by the morbid sensibility of a sore which will not heal, banishing PRINCIPLES OF MEDICINE. 115 " kind nature's sweet restorer, balmy sleep ;" stimu- lants in this case cannot procure repose nor give strength; sedatives are not required, or rather are contra-indi- cated ; sometimes even one dose of a narcotic, by pro- curing a good night's rest, will renew the restorative energy of the system; although a single dose will not, in general, suffice. The value of repeated small doses of opium in chronic periosteal diseases, and what are called irritable sores, as exemplified in Pott's treatment of gangrsena senilis, is well known to surgeons; and also to physicians in chronic affections of the mucous membranes, &c. Its applicability to irritable sores shows that the efficacy lies in the narcotic quality, though it is commonly attributed to a stimulant one even by those surgeons who know how much more they can effect, in such cases, by administering from a quarter of a grain to a grain of opium twice or three times in the twenty-four hours, than by giving wine, spirits, or beer, which are incomparably more stimulant. On the other hand, when the constitutional state is that of debility, rather than irritability (morbid sensibility), as in strumous and certain other cases, fermented liquors are of much more value than opium. There is nothing more efficacious than opium in catarrh ; but, from the idea of its being stimulating, or heating, which it appeared to be chiefly where it confined the bowels, we find that all the experienced practitioners formerly combined it with small quantities of jalap, ipecacuanha, &c, in catarrhal affections. I take this opportunity of pointing out the common error with respect to opium. It will be much better to get a clear notion of the nature of remedies, and to call them by their right names; as, for instance, not to denominate opium either stimulant, sedative, or tonic, 116 PRINCIPLES OF MEDICINE. but to understand its use by its true name of narcotic. Its beneficial effect arises from its narcotic property diminishing that morbid sensibility which prevents sleep, digestion, and other restorative processes: and this is the principle to be followed in the administra- tion of narcotics. The choice of them has already been explained, as to opium, hyoscyamus, morphia, tincture of opium, Dover's powder, &c. Sir Astley Cooper re- commends opium to be given when mercury is em- ployed, which is a judicious precaution, as the latter has a tendency, though primarily a tonic, to produce morbid sensibility secondarily. These few words will serve as a clue to the use and abuse of mercury. Mr. Skey, in a useful little practical work on the treatment of ulcers, has brought forward evidence which supports my opinion of the explanation of the utility of opium; though he seems to think the benefit is owing to a stimulant effect of the opium upon the capillaries. Opium is invaluable to the accoucheur, to allay the morbid sensibility which occurs after parturition. Some use it in the puerperal state as a " cordial," some as a " sedative," some to " bring on'' action, some to " allay" it; as, for instance, to assist labour when it flags; or, on the contrary, to check inordinate uterine contractions. If the midwifery practitioner will re- collect that the object is to allay morbid sensibility, he will be certain in its application; whether he be obliged to use the narcotic with stimulants on the one hand, or with depletion and sedatives on the other. This distinction of stimulants, sedatives, narcotics, and tonics, assists in understanding the operation of remedies in various diseases, it being recollected that the medicines which are used as purgatives and PRINCIPLES of medicine. 117 emetics, such as salts, senna, jalap, tartar emetic, calo- mel, ipecacuanha, &c, are sedative in their operation. The effect of tartar emetic is sometimes intended to be merely local, for the purpose of emptying the stomach, and then it is given in a full dose ; but it w?ill perhaps surprise some to learn that tartar emetic, as a general sedative remedy, will allay sickness. For example, inflammation of the mucous membrane of the intestines is accompanied by nausea and sickness :* these symp- toms may be checked sometimes, even without bleed- ing, by frequently repeated small doses of tartar emetic, called by some febrifuge. We see that the action of medicinal agents becomes most opposite when the proportional quantities are varied, and according to the state of disease which may exist; hence it requires great attention to separate the causes of phenomena, and duly estimate them. The whole practice of the healing art is full of apparent con- tradictions : for instance, opium makes the pulse hard or soft, promotes and takes away appetite; the same means appear in one instance stimulant, in another sedative; venesection sometimes makes the pulse smaller, sometimes fuller. But when we speak of re- medies as stimulant, sedative, narcotic, tonic, and their compounds, we are to consider their moderate action whilst they are working on the natural powers of the organs, and not their exaggerated or poisonous effects when they begin to excite either inflammation or mor- * A patient was admitted into the London Hospital, who had been labouring under diarrhoea and vomiting for two days, for which he had taken chalk-mixture, catechu, opiates, mach and bowels, with which it is continuous. In health it is not of a bright red, but has a pale bloom on its surface, in consequence of the tips of the villi or papillae being less injected with blood than the lower parts ; when the stomach is empty it contains less blood, PRINCIPLES OF MEDICINE. 221 tained the pain to have been at first in the left (p. 157) side ; and, from other hysterical symptoms, felt satisfied that the present state was clavus hystericus of the head, kept up by inanition. She had been allowed the day before a little weak chicken-broth ; but as she became worse, it was supposed she was unable to bear even that, which caused me to be consulted. Wine and animal food immediately and gradually administered, without any medicine except a few drops of vinum ferri, soon calmed all the symptoms of what was called inflammation and determination to the head (p. 201, line 16); and health was restored in a few weeks. These three cases will illustrate several points. We see, 1. Local inflammation, producing morbid sensi- bility and symptomatic fever; hence food and wine its villi are of course paler, and those of the tongue are nearly white: but observe, the tongue is moist; whereas, in the beginning of synocha or pleurisy, or other inflammation, the stomach is empty from anorexia, and the tongue is white ; but it becomes dryer than from a mere empty stomach, and more or less coated, arising from the evaporation of the watery parts of the saliva and mucus of the mouth, which leaves the membrane indued with a more viscid covering than natural. After eating, when the stomach is in a state of healthy activity, the tongue becomes redder ; but still it is not of a bright-red hue, which only takes place when the membrane of the prima? viae is in a congested or inflamed state, as in dysentery, in phthisis when colliquative diarrhoea exists, at the termination of typhoid fever when there has been (in reality) gastro-enteritis or inflammation of the glandulae agminatae, &c. In the progress of severe fever, when the secretions are suspended, the tongue becomes dry, and the mucus which does exist dries, and forms a brownish or blackish crust, and the papillae become so much shrunk down to the level of the rete mucosum, that when the tongue becomes clean, on recovery, it looks glazed and smooth, and some time elapses before the papillae rise up again. In chronic affections, accompanied with a languid and flabby state of the prima? viae, a discoloured state of the mucus occurs, constitut- ing what is called a foul tongue. 222 PRINCIPLES OF MEDICINE. afforded no nourishment, narcotics no rest (as they would have done, had there been only morbid sensibi- lity without symptomatic fever). Cured by a sedative — digitalis. 2. Local inflammation, producing, not fever, but general morbid sensibility, chiefly evinced by loss of sleep; no indications for stimulants, sedatives, or tonics, and no want of strength or appetite. Cured by a nar- cotic,* which, by procuring sleep, gave the nervous system time to regain its natural state, so as subse- quently to give energy to the vessels of the inflamed part. 3. Local affection (chronic hysteritis), having pro- duced, not fever, but constitutional morbid sensibility — hysteria ; debility, arising from depletion and want of nourishment; so that narcotics could procure but temporary relief, as they afford no nourishment, and sedatives aggravated the delirium of inanition. Stimu- lants and food, by giving strength, acted as a tonic, and restored power to the nervous system, and conse- quently to other parts; and, moreover, the stimulant gave almost instant relief, by counteracting the over- sedatived state of the capillaries of the brain. A chronic painful (neuralgic) state of the brain comes on, essentially connected with debility, from a variety of causes — fatigue of body and mind accompanied with indigestion, hysteria, malaria in aguish districts, &c.; this state is often misunderstood, and is some- * We have shown here how a narcotic alone can effect a cure. It is in this way that it cures tetanus, or sometimes with a tonic combined. The narcotic, in some instances, gives only temporary relief, as in tic douloureux, which it is necessary to cure by a tonic; but we may infer that this relief promotes the cure, inasmuch as we have shown that the relief by a narcotic alone, in some instances of morbid sensibility, effects the cure. PRINCIPLES OF MEDICINE. 223 times with difficulty treated, even when understood, on account of the opposition of the patient in most instances to take stimulants, the gradual introduction of which into the system is absolutely necessary. Such patients have a dread of what they call fulness of the head, which is in truth a false sensation depending on morbid sensibility. The temporary uneasiness, or pain pro- duced by stimulants, besides the accompanying dvspep- sia, renders the use of much persuasion necessary to overcome the objection entertained to taking them when prescribed. This state often arises in delicate persons of either sex. A friend of mine came to town for the purpose of consulting me, in consequence of what he and his medical adviser considered determination of blood to the head ; that is, occasional giddiness and headache, with some dyspepsia and depression of spirits, more severe after breakfast (that is, particularly after partak- ing of a sedative, tea) than after dinner. For these symptoms, although a slight person, he had been physicked, kept on restricted diet, and debarred from fermented liquors, entirely with his own concurrence, as he apprehended apoplexy. He is a member of one of the learned professions; and it appeared to me that he was labouring under a neuralgic state from study and over-fatigue. He was convinced of this by my representation ; and in about a couple of months was restored to health, by gradually resuming a generous diet with tonic medicines. Chronic neuralgia of the heart, &c, occurs under similar circumstances, and requires similar treatment. Though keeping the bowels open is useful in chorea, and in a variety of nervous affections, to promote the digestion, constitutional morbid sensibility, hysteria, &c, are always aggravated by debilitating agents, espe- 224 PRINCIPLES OF MEDICINE. cially by abstraction of blood; so that, until food and tonics give strength, no cure can result. Now, some- times in neuroses the patient cannot eat, any more than in fever, though from a different cause: in fever there is anorexia, from a congested state of the mucous mem- brane of the primae viae, and the obtunded state of the nervous system in general, and of the nerves of the stomach in particular; in the neuroses, from morbid delicacy of the senses of taste and smell, or sometimes from morbid sensibility of the primae viae, the first mouthful swallowed produces a sense of repletion; and this nervous anorexia sometimes increases the diffi- culty of distinguishing between fever and constitutional morbid sensibility; and particularly when the primary local affection is in the primae viae, from indigestion simulating inflammation of the mucous membrane (gastro-enteritis). In distinguishing actual (idiopathic) fever from morbid sensibility, which is of so much consequence, we must not confound that languor which arises from nausea and other affections of the primae viae, such as diarrhoea, &c, with the languor of want of power of volition, from the weakened nervous system of fever. Morbid sensibility is an affection of nerve; but nerve, considered in relation to disease, is nothing without capillaries—capillaries nothing without nerves. The isolated consideration of either leads to the error in practice of attempting to relieve the vessels at the expense of the nervous system, or of resorting to ner- vous medicines exclusively, to the prejudice of the vascular system. What I mean by mere nervous medicines is, in the common acceptation, anodynes, which allay sensation for the time, but, having no effect on the vascular sys- PRINCIPLES OF MEDICINE. 225 tem, do not cure the disease; neither will tonics have the effect in many cases, without skilful adjustment of the secretions, digestion, &c. Apoplexy and paralysis depend upon disease of the nervous centres, produced by mechanical injury or spontaneous inflammation, or congestion only; and may either be cured, and the paralysis pass off, or the usual results of inflammation, tumours, abscess, effu- sion, softening, &c, may cause the paralysis to be per- manent. As the nervous centres are hidden from in- spection, we cannot discover the degree of lesion; we ought therefore to persevere in our efforts to cure, which will often at a late period be crowned with success. The principles of treating these injuries of the nervous system, recollecting the importance of the organs in- volved, and the necessity of energy in acting, and care in watching the phases of the disease, are precisely the same as the treatment already laid down for inflamma- tion in other parts of the body, though a mystery was attached to them by the ancients, and a much too de- pletory and lowering treatment was formerly indis- criminately employed, and frequently with an entire neglect of tonics, from the fear of their being stimulant, except mercury, which was not considered a tonic, though I have shown it to be one of the most powerful (p. 112). The principles of treatment, I repeat, have been already laid down: active and decided antiphlogistic and anticongestive, in acute cases and plethoric pa- tients ; in passive inflammatory states, that is, with debility of constitution, just barely enough of local de- pletion of vessels; with tonics, and even stimulants, when the constitution and the stomach require them ; 29 226 PRINCIPLES OF MEDICINE. and a long and steady perseverance in the appropriate remedies, with a careful attention to the ebb and flow of power in the constitution. The point to which I particularly wish to direct the attention of the practitioner is, that there occurs in old people a paralysis from mere debility of the nervous centres, from local congestion, without either inflam- mation, softening, tension, rupture of vessel, or other organic injury, and which will appear sometimes on one side, and afterwards on the other. These cases will recover under gentle and judicious attention to the constitution, by careful non-stimulating support and tonics, including a cautious administration of mercury. I have treated many old persons in this way, adding digitalis when there has been a strong hard pulse, and have effected their recovery from paralysis, which had existed, first of one side, and afterwards of the other, and had depended upon mere temporary local congestion ; which was proved, when they eventually died from some other cause (general dropsical symp- toms, &c.,) as no organic disease of the brain was discoverable. In advanced age this chronic disease of the nervous centres sometimes produces a suffi- ciently evident paralysis, hemiplegia, paraplegia, or partial paralysis, sometimes combined with affection of the sensorium, sometimes not. But the symptoms of affection of the spinal cord are also sometimes ob- scure ; and I have seen the muscles of respiration and circulation attacked periodically, so as to simulate (and be called) spasmodic asthma, the respiration being be- sides permanently though slightly embarrassed. This I have known take place from obscure chronic disease of the nervous centres, and is precisely analogous to those symptoms which arise from the disturbance of the spi- nal cord produced by evident curvatures of the spine, PRINCIPLES OF MEDICINE. 227 which Mr. Hale Thomson has shown such consum- mate skill in treating.* I commenced the pathological part of this work with the consideration of the nature of inflammation, and the principles of its treatment; and having afterwards discussed the nature of the two grand groups of dis- eases which constitute fevers and neuroses, and shown that, although they are both essentially affections of the nervous system, they are widely different from one another, I propose now to add a few observations upon some particular diseases. Although, in discussing their proximate causes, I may be met by doubts on the part of some of my readers, from the novelty of some of the opinions advanced — which it may require farther observation to substantiate, — yet their practi- cal utility, or the principles laid down for their treat- ment, will not be founded on a less solid base than those which concern the. treatment of inflammation, fevers and neuroses in general. There will have been observed nothing of humoralism in the preceding pages; for though I admit the influ- ence of imperfectly assimilated nourishment, and its consequent deterioration of the blood chemically, pro- ducing gravel or scurvy, &c.; I ascribe the effects, whether remedial or noxious, of agents, mineral, vege- table, or animal, taken into, the circulation, to their producing changes of the solids. All diseases, in fact, * This mode of practice was commenced in this country by Mr. Ward, and followed up — I might say improved upon — by Mr. Thomson, one of the surgeons of the Westminster Hospital. It is a union of medical treatment and bodily exercises, directed by inge- nious mechanical contrivances, but which are not worn by the patient, and is similar to the plan so skilfully adopted by Stromeyer of Hano- ver, and in some respects to that of M. Gnerin of Paris, and others. 228 PRINCIPLES OF MEDICINE. commence, as I have already repeatedly said, by dis- turbance of the function of the solid parts of the ma- chine ; and, first of all, of the nervous system. This is solidism, or neuro-pathology. The nervous system, it is superfluous to repeat, regulates and supplies all with energy. There.is no organic sensibility, or organic contractility, independent of the nerves. Every natural impression is received by the nerves; every morbid agent is first felt by, and operates upon, the nerves. Inflammation of cellular tissue, bone, conjunctiva, &c, through mechanical or other violence, result, as we have shown, in consequence of injury to the peripheral nerves and to the capillaries; fever from injury to the centres of the nervous system, which arises either from peripheral injury propagated to them, or through lesion by miasma, which, by the route of the circulation, directly poisons them — most probably by chemical combination and alteration, — instantaneously lowering their power or energy. I have shown throughout, that the immediate effect of the lowering of the power and energy of the nerves or the nervous system is inflam- mation, or congestion of the capillaries, the first degree of inflammation. The diseases of morbid sensibility (neuroses), we have seen, depend also upon a partial or general derangement of the nervous system ; arising, when general, either from the disordered state being propagated to the central organs from a distant region of the body, as from a wound, in traumatic tetanus : a poison, in hydrophobia : from the uterus, in hysteria, &c.; or originating there through the gradual opera- tion of a debilitating cause, as delirium tremens, paralysis agitans, idiopathic tetanus, chorea, &c.; or when general morbid sensibility is suddenly produced by loss of blood or fright; — so that neuroses, as well as fevers, may be produced suddenly or gradually, and PRINCIPLES OF MEDICINE. 229 like them, may be either idiopathic or symptomatic. Fever essentially depends upon a diminution of the power of the nervous system —the nervous influence, whatever that be, is deficient; whereas the diseases of morbid sensibility appear to arise, not from a want of sensitive and motor nervous energy, but from a derange- ment of the machinery of the nervous centre, or a dis- turbance of that connexion of the nervous centres with the nerves, which not only induces, but regulates action. Thus, neither in tetanus nor hysteria is there deficiency of power either in the nerves or muscles — as the morbidly increased sensibility, and the powerful spasms and convulsions show — but a derangement in the direction of it. In fever there is a want of steam, or moving power, to use a mechanical illustration; in the neuroses the machinery is out of order: for in- stance, when fever is fully established, sensibilities of every kind are blunted, both what are called animal and the organic; and there is debility also of the volun- tary and involuntary muscular systems. In the dis- eases of morbid sensibility, epilepsy, tetanus, neuralgia, hysteria, chorea, hydrophobia, &c, either all the sen- sibilities, animal and vegetative, are rendered morbidly acute, or the motor energy is distributed to the mus- cles irregularly, if not too abundantly; as we see in chorea and paralysis agitans, volition would guide the hand to the mouth, but in consequence of the deranged nervous centre, the hand is thrown in other directions, in spite of the will, from the antagonist muscles not being under its direction. Or the derangement of the functions of the perceptions and volition, " incidence and reflexion," is simultaneous, as in hydrophobia, and some cases of hysteria. In fever there is abundant evidence of lesion of the cineritious tissue, interfering with its function, the generation of nervous energy : in 230 PRINCIPLES OF MEDICINE. morbid sensibility we have only an evidence of de- ranged actions in the distribution of it in the medullary white tissue. In morbid sensibility we do not find the faculties of the sensorium seriously interfered with, unless when, in the advanced stages, a degree of fever comes on, and induces the delirium or coma of conges- tion ; or when, on the other hand, inanition produces delirium, as in haemorrhage, delirium tremens, &c. Among the diseases which I intend hereafter briefly to discuss, are, first, ague, cholera, and influenza — allied naturally to fevers, but which I have preferred considering after the diseases of morbid sensibility, in- asmuch as, following what I have said upon these, and concerning the use of sedatives, their treatment will be better understood. Afterwards I shall say a few words upon those affections of the skin and fibrous tissues called erysipelas and rheumatism, upon phthisis, and on those diseased states of the capillaries which produce catarrhs, dropsy, haemorrhages, and chronic cutaneous eruptions. I will not enter here into the description of ague, as I am not writing for those unacquainted with the mean- ing of the term, but for such as have learnt it from lectures, books, or observation ; and under the denomi- nation of ague I include remittent, as well as what are called intermittent fevers. Ague is essentially fever; it forms, however, a con- necting link between fevers and neuroses, as a consider- able degree of morbid sensibility exists in it. Ague is, besides, closely allied to Asiatic cholera and influenza, which are also essentially febrile diseases, as I demon- strated in 1832, when we had daily opportunities of seeing the former epidemic. I consider it of the greatest consequence to investi- PRINCIPLES OF MEDICINE. 231 o-ate these connexions of diseases, which are separated by nosologists. In fact, the very close examination ot them for this purpose increases our intimate knowledge of them, enabling us the more easily to form a diagnosis; as a schoolmaster distinguishes his scholars, or, more surprising still, a shepherd knows the individuals of his flock, though to another person they are «■*»*« *,««».>* **§>»**. By showing points of essential coincidence in diseases which are separated by nosologists wide as the poles, we shall account for those individual diseases, though antipodes, being benefited by the same remedies. Let us just reconsider, what are the essential symptoms of fever, whether, in its course, it assume the form of intermittent or remittent, synocha or typhus — those symptoms which it is of consequence to remove ; and the efficient means of doing so. The urgent symptoms are those of debility of body, or of body and mind together. Let us not have our judgment obscured by the numerous and varied non- essential, though sometimes even epidemic superaddi- tions : as in one case there will be costiveness, in an- other diarrhoea ; in one case full pulse, in another weak; in one case hot skin, in another cool; in some cases accidental inflammation of one part, in others of an- other : all of which non-essential superadditions must, notwithstanding, receive their due share of attention, as aggravating the case. But the patient will recover from the fever, if we can relieve his debility of body and mind : that debility we have shown to be caused by an overloaded state of the nervous centres; and we uniformly see that the only successful means of reliev- ing them consist in diminishing the injecting force when the pulse is strong, and, at the same time, increasing the contracting action of their capillaries by antimony, mercury, salines, bark, &c, &c.; or even when the 232 PRINCIPLES OF MEDICINE. pulse is not too strong, we find bleeding sometimes necessary to diminish the actual quantity of the load, as the constringents alone may not be sufficient to pro- duce contraction; so that, as indicating bleeding, we have much more to consider the state of plethora of the internal vessels than the state of the pulse or vis d tergo. And though emetic substances have an influence simi- lar to that of bleeding, in lowering the vis a tergo, they are, nevertheless, of most essential advantage when the pulse is even almost gone, by their immediate constrin- gent effect on the internal capillaries : hence it is evi- dent that the pulse, which was so long considered as the indication for the use of bleeding or sedative medi- cines, is often alone no guide at all ;* in which cases * There are so many exceptions to the general rules respecting the pulse, that although every one feels the pulse, it requires long ex- perience to avoid being misled by it. I will therefore, in this place, endeavour to lay down some principles for the removal of the dif- ficulties in the way of this source of diagnosis. In the first place, as traced above, increase of frequency and force (hardness) is produced by inflammation ; when the inflammation is in an external part, the pulse is usually strong ; when the inflammation i9 in the internal organs, there is not so much evident force, the pulse is small and hard, sharp, wiry ; and this wiry feel may be very small, yet still evincing a degree of force in the contraction of the heart from its morbid sensibility, though the organ is felt contracting on a small quantity. Now, we must be on our guard that this same, or even a greater degree of internal inflammation may exist, and yet, as shown above, from depression of the vital powers, — as, for instance, when the lungs are gorged in peripneumony, — the pulse may feel quite feeble, from the blood not being arterialised, and therefore not stimulating the heart to contract. In such a case, venesection, by allowing free circulation through the lungs, will increase the stimu- lating properties of the blood, and raise the pulse and vital powers. Here we ascertain the condition of the organs by auscultation, the colour of the lips, and other symptoms, and decide in opposition to the pulse. On the other hand, various neuralgic states produce a frequent and PRINCIPLES OF MEDICINE. 233 the necessary practice by sedatives, from having been hitherto unexplained, has always been called indirect practice. I do dot admit this term, and never practise indirectly: my indications are always founded upon physiology, as I have explained them up to this point. We must again separate clearly in our mind pheno- mena from causes: for instance, rigors, cold shrunken skin — the cause of which was said by Cullen to be spasm of the extreme vessels; the contracted state of the latter is, however, mere effect, not cause: convul- sions, again, are the mere result of morbid sensibility, and have no direct connexion with the fever; on the contrary, they have been considered by experienced men rather favourable in the eruptive fever of variola. strong pulse, which, though ordinarily an evidence of inflammation indicating bloodletting, must be disregarded, as bloodletting would be injurious. In these instances we must be guided much by the pre- vious history of the case ; and be cautious not to be misled by the symptom of pain, if the patient be nervous, and if the various usual accompaniments of the inflammation, which is simulated, do not present themselves. Thus, in hysteria, symptoms sometimes mis- taken for peritonitis arise. In the hysterical affection, less obstinate constipation and less dryness of skin exist; the tongue is generally less dry, though it may assume almost any appearance ; but the pulse in hysteria is less wiry than in peritonitis ; the same may be said of the pulse, skin, and tongue, in the assemblage of hysterical symp- toms resembling pleuritis. In inflammation of the heart, which is so often unfoundedly dreaded by hysterical patients, the pulse is soft, like the pulse of acute rheumatism, as the inflammation renders it weak; so that it allows of distension, and has not power to empty itself. When we find the pulse of natural frequency, full and hard, we must suspect organic disease of the heart; for unless that exist, the pulse is full and soft, or frequent and hard, or frequent and soft. There is a frequent soft weak pulse, with dilatation of the left ventricle; but the practitioner must make himself acquainted with the peculiarities depending on the diseases of the heart itself, as one means to prevent his being misled by the pulse. 30 234 PRINCIPLES OF MEDICINE. What are the steps from the invasion of the poison till the development of the fever ? The first is a debili- tating influence on the nervous centres: the mind is at this time clear, though languid; the pulse is small, the skin cold, and the limbs tremble, or are convulsed, from the morbid sensibility of the nervous centres, evinced also by pain in the head and spine. From the weakness of the circulation, therefore, all the external capillaries contract, not by spasm, but by their natural contractile action — through not being sufficiently injected; the blood is consequently congested in the internal parts of the trunk, producing nausea, and other disturbance of the primae viae, augmented by the morbid sensibility of the sedatived nervous centres, sometimes causing vomiting and diarrhoea. Now, this is the first stage of fever; in which, if the dose of poison has been sufficient, death has been known to occur, and that very suddenly, not only in the " Bombay fever," but, as it has been stated, in the severe yellow and other fevers, attacked with which patients have died at once, without any reaction, or rallying; as, for instance, soldiers have dropped on parade, and died immediately: the heart having been unable to propel the blood to the brain, fatal syncope or asphyxia has ensued.* * From the histories of fevers, and from observation, it appears that the poison of continued fever is generated by animal matter, as in crowded ships, jails, &c. ; the poison of ague and remittent fever by vegetable matter, some cryptogamous species, as those fevers prevail chiefly in situations where these are met with, such as marshes, uncultivated places, &c. For instance, those parts of Rome in which the malaria exists are among deserted buildings, where, in the shade, cryptogamia abound. In London we have many cases of ague arising from malaria, in places inhabited by the poor, where there is warmth, shade, and manure, favourable to fungi, PRINCIPLES OF MEDICINE. 235 This stage of depression may last for minutes, hours, days, or weeks, as evinced in the ephemeral continued fever, regular agues, and those irregular agues vulgarly called "dead" ague, to be described hereafter. The next stage of fever is commonly named the hot stage; but as that designation is totally inapplica- ble to typhous fevers, I prefer the term relaxed, as that implies the actual state of prostration of nerves and capillaries, which is so evident, and which I consider the proximate cause both in " synocha" and " typhus." The severity of this stage will depend entirely upon the dose of poison and state of constitution ; whether, for instance, the individual will return to a state of health immediately, with but a slight degree of lan- gour for a few hours after the chill; or whether the phenomena of a continued fever, or the hot fit of an ague, wTill result, owing to the poison having been suf- ficient to cause the more permanent relaxation of the capillaries of the nervous centres. It has been previously shown how sedative influence ultimately produces relaxation, which state now ensues in the nervous centres ; and it will depend upon how much they are relaxed, whether the fever will be hot or not. If too much relaxed to allow of their secreting nervous influence, as when the fever is typhous, the circulation and respiration will not have power to pro- duce a full pulse and hot skin; if otherwise, we shall have flushed hot skin, as in continued fever and in ague. But in either case the skin will be reinjected ; ete. When marshes are drained and cultivated, the cryptogamia are destroyed, and agues are not generated. The tremendous remittents of hot climates appear chiefly where the ground is at times covered with water, and where, after the rains have subsided, it remains half- wet, abounding in rank and decomposing vegetable matters, es- pecially where there are uncleared woods. 236 PRINCIPLES OF MEDICINE. for even in typhous fever, though the heart be weak, the superficial capillaries, having lost their tone from deficiency of nervous influence, relax, and are refilled even by the weak heart with a dusky blood. And a similar state may be seen in some agues, where, after the chills, there is a typhous state, and a livid colour of skin, with dreadful langour, as may be observed in in- dividuals with ague in the Pontine marshes. Thus, even in ague, the student must not expect to find always the hot stage of the nosologists. These are the only two stages of fever and ague. There is no third stage of ague: the sweat which suc- ceeds the hot stage is nothing but an indication of re- newed secretion by the capillaries, which, after having lost their tone, and been consequently in a relaxed, distended, non-secreting state, renew their secretion on being restored to a normal condition; and, of course, as they are returning from a relaxed state, they will pour out fluid sweat at first, until recontracted sufficiently to secrete insensible perspiration — a mere vapour. It has just been mentioned that the ague exists fre- quently without showing the hot stage; in fact the patient remains in a continued state of depression, with a languid circulation, cold livid skin, and the sensorium more or less oppressed. It is very common for patients in this state to present themselves at the hospital, and, when questioned, not to be able to give any account of their symptoms, as is also the case with them when they apply during the cold stage : in either case the practised physician will see at once that he has before him the subject of ague. Sometimes the patient with irregular ague just described will answer at once, when asked what is the matter with him, that he has the " dead ague," the name given by the peasants to this state of disease, which they know originates amongst PRINCIPLES OF MEDICINE. 237 agues; and which they also know sometimes turns to regular ague, that is with rigors ("shaking") and sweating. In such a case, when I have asked a pa- tient who did not use the term dead ague, " Have you the ague ?" the answer has been, " I wish I had; I should be much better if I could shake out" (outright). It is an interesting subject for a student to watch the effect of a tonic, such as bark or arsenic, on one of these cases, as the uniform evidence of improvement is, that a paroxysm of regular ague is produced as a step to- wards the cure. I became acquainted with this circumstance in the first year of pupilage. A patient was admitted into the hospital with cough, looking very ill and sallow ; he was ordered some calomel and squill mixture, w7ith a blister to the chest. The effect of the calomel, the comfort of the hospital, and change of air, was, that the next morning he felt better, and was soon after attacked with a fit of regular ague. This was an early and useful exemplification of the " larvatae, or masked agues." Plentiful doses of bark (quinine had not then been heard of) cured the ague and cough together.* * A lady consulted me on account of troublesome cough, uncertain as to expectoration, occasionally rather dry, and sometimes pro- ducing toward evening difficulty of breathing, which lasted generally through that night until towards morning, when profuse perspiration came on. She and several of her friends apprehended tubercular consumption, some of her brothers and sisters having died of that disease ; other persons told her it was spasmodic asthma. The tongue was very slightly coated, the pulse above 100, and the skin rather dry ; these were some of the symptoms of consumption ; but the stethoscopic signs of either asthma or tubercles were absent, and I remarked that the colour of the skin was rather muddy and sallow. As she had been my patient before she went abroad, I asked if she had not had " the fever " (ague) in the West Indies, whence she had returned about five months. She said she had, and had not felt quite 238 PRINCIPLES OF MEDICINE. Men of experience, especially in aguish districts, have seen all the modifications of these larvatae, such as aguish apoplexy, aguish paralysis, aguish sore eyes, aguish rheumatism (called intermittent neuralgia,* &c), and which are well described by Macculloch. strong ever since; upon which I decided that she had caught cold (catarrh) upon the dregs of an ague, artd therefore gave her quinine to cure both together, and a little mucilage with squills and syrup of poppies to pacify the cough when troublesome, and allowed her to go into the country. In about a week she returned, saying she felt much better, but had had a regular fit of the ague the day before. I desired her to double the quantity of quinine, and assured her that she would be well in another week. She objected, that a mutual medical friend had told her she must leave off the sulphate of quinine, as it was not safe to take it with such a cough. By following my directions, however, she was quite well in ten days, and has continued so now five years. *In the last note I gave a case of masked intermittent; I may here offer ohe as a caution against confounding inflammation with neuralgia. A gentleman, aged forty-five, caught cold, which was followed by a cough and severe pain in the head, shooting from the right eye to the back of the head, which was aggravated when he coughed or walked, and at those times extended to the top of the head ; pulse generally about 100, hard. When this state of things had existed some weeks, his medical attendant called in a celebrated veteran physician, who prescribed guaiacum for the pains, con- sidering them rheumatic. After this he was cupped on the neck to fourteen ounces, without relief. In about a month he found the sight of the eye weak ; the pains became excruciating, especially pe- riodically from one o'clock a. m. till six, and he got no sleep ; even during the day the pain would not permit him to read or write. Another physician was now called in, who administered anti-neuralgic medicine and laxatives for about three weeks unavailingly. The gentleman's ordinary medical attendant consulted meat this period, and I recommended bleeding, considering that there was chronic inflammation of the membranes of the brain ; but the patient refused to allow it, partly on account of feeling so weak, but principally because he had had an increase of pain after the cupping, though I expressed my opinion that that was merely because the cupping had PRINCIPLES OF MEDICINE. 239 Ague frequently degenerates into continued fever; and I must add a few words upon the nature and variety of the degeneration. When the fever is of the simple continued kind, synochous, with hot skin, the ague is called a remittent; when it is of a typhous character, it assumes the form I have described as dead ague. Ague constitutes the link between fevers and neu- roses ; but in ague, besides the state of morbid sensi- bility of the medullary tissue, we have abundant evi- dence of the plethoric congestion of the cineritious tissue also; so that a compound treatment becomes necessary, — different from that of the neuroses, as well as from that of fevers. The sedative treatment which suits fevers suits agues, and more especially the irre- gular ones; for the irregular dead agues, or remittents, which are deteriorated agues, will be brought to the regular state (if not cured) by sedatives: and this is not been sufficient. My diagnosis was soon confirmed by the occurrence of paralysis of the eyelid and of all the muscles of the eye except the trochlearis (which may be accounted for by the root of its nerve lying about a finger's breadth out of the line of the other nerve, where the inflammation ran); there was also a degree of deafness, besides numbness and pricking in the side of the nose, cheek, lip, and teeth. A consulting surgeon was now called in on account of the eye, who recommended blisters and mercurial medicines, but without success ; as, however, he coincided with me as to the propriety of bleeding, the patient at last gave way to our united entreaties, saying that he thought himself too weak to bear it, but he could not exist under the pain, and therefore consented to lose " a small quantity of blood." We, however, got away about twelve ounces, which relieved him so much, that he did not object to being bled again repeatedly for some weeks, and occasionally for five or six months, until he was quite well, as he has continued now for about seven years. The eye and its muscles have recovered their functions ; but there is still a disagreeable extra sensibility in the skin of that side of the face. 240 PRINCIPLES OF MEDICINE. also the case with influenza and cholera, which are closely allied to the ague. The regular agues, which approach more closely to the neuroses, will be, like them, cured by tonics alone, and, like the neuroses, bear stimulants much better than fevers; remittents, influenza, or cholera, which are curable by sedatives, require sometimes the addition of tonics in convales- cence. In cases of fever, and in all kinds of ague, in- fluenza, and Asiatic cholera, there is an internal con- gestion of the viscera, including the nervous centres, which is relieved by sedatives; though in regular ague and cholera, from peculiarities which may be explained, stimulants are borne with more or less impunity. In regular ague, constitutional morbid sensibility is prominent. There exists, it is true, a great degree of congestion of the nervous system, as well as of the viscera, during the paroxysm, succeeding to a morbid poison; but rarely is real fever produced. There is the pyrexia, equivalent to what occurs in hysteria, but seldom actual fever — not that loss of power in the capillaries of the nervous system which prevents the generation of nervous influence; for in ague, stimulants, unlike the effect they have in fever, do not produce the coma of plethora — the nervous centres being little injured, though debilitated, are relieved by the stimulant nar- cotic tincture of opium; and consequently fresh energy is communicated to the capillaries, even in the hot stage, by which they resist the heart's injecting force. Thus we may explain the apparent inconsistency of using venesection and laudanum simultaneously in ague, which has been recommended by some. The venesection, which we know produces the best effects, is not to relieve inflammation, but congestion; and hence is not often necessary, except, for instance, to relieve some organ, as the brain or lungs, which may PRINCIPLES OF MEDICINE. 241 be evidently suffering during the paroxysm, through its having been previously in a morbid state, as we see in the hemiplegic modifications of ague, which form an exception to the use of laudanum. In the latter the paroxysms are accompanied by coma or hemiplegia, the brain being previously unsound, though the pulse is weak; as in the state of debility after apoplexy and wounds of the head; and as the aguish congestion passes off, the hemiplegia or coma passes off also, until the renewal of the paroxysm. If severe cases of Asiatic cholera be taken in time, they may be cured by acting upon a similar principle, viz., by relieving the internal congestion; unless indeed, as sometimes takes place in continued fevers, the indi- vidual have received so powerful a dose of the epidemic poison as will certainly prove mortal, despite any mode of treatment. If the blood, however, have begun to coagulate, the patient is dead to all intents and pur- poses, even whilst breathing and speaking, and the heart acting; for I have heard the sound of the valves of the heart contracting just before death in cholera, when I am satisfied clots were already formed in the ventricles: at this stage, of course, neither sedatives, stimulants, bleeding, nor anything else, can produce any effect. The slight or middling cases of cholera have a tendency, like ague, to remit of themselves; and hence whatever treatment had been adopted, the prac- titioner used to think he had cured them : and thus I have been repeatedly told by practitioners that they had found the true remedy for cholera. But the next time I met them there was a long face upon mention- ing the specific. Any person, however, who will treat the disease on principle may defeat it by a variety of weapons, only using them with energy, —antimony, all sorts of salines, acetate of lead, sulphate of zinc, 31 242 PRINCIPLES OF MEDICINE. common salt and water, even cold water,* calomel — but the last, if used in the quantity necessary to be sedative, afterwards produces havoc on the mouth. Stimulants in moderation do little good or harm, except the evil of augmenting the, secondary fever, or actually inducing it; as the hot or febrile stage of many cases of cholera would have been scarcely perceptible, if sti- mulants had not been used freely during the collapse, which might have been safely combated by the seda- tive constringents. Considering, then, the constringent effect of the various sedatives, antimony, mercury, lead, neutral salts, alkalies, &c, &c, we can understand how as they ultimately coincide in the indication of cure, they have been adopted by different persons to effect the same purpose; and each, finding some particular substance efficacious in certain cases, has subsequently used that in preference to others. I think, however, I have done something towards reconciling apparent con- tradictions, by pointing out the principles which ought to guide us. Before I had an opportunity of personal observation I was lead, by reading, to make a too-limited estimate of the symptoms of cholera, referring chiefly to the affection of the stomach and bowels (old English cho- lera morbus) as the cause of the collapse. When, how- ever, I encountered the enemy hand to hand, I saw at once that it was like ague ; not merely as regards its epidemic and miasmatic origin, but almost, if not alto- gether, an ague of a fresh type ; and I often thought of what the great Sydenham candidly said of his first en- counters with new epidemics. I inculcated, therefore, * The constant desire for cold water in cholera is an example of natural instinct which is thwarted by man in his wisdom ; while everything hot, both as to caloric and stimulants, is often poured into the patient. PRINCIPLES OF MEDICINE. 243 a treatment in cholera successfully adopted in ague, and borne out by the previous experience of Kennedy, Lefevre, and others, i. e., bleeding, with emetics and neutral salts, but modified and combined with opium and stimulants in some of the stages. Subsequently, both in the cold stage of ague and cholera, I have de- pended much upon antim. tartariz.* with or without * In order to exemplify more definitely the mode of treatment, I will give a couple of cases from my note-book ; taking, first, one with all the marked symptoms of the worst form of the disease from which patients can recover. " March 14th, half-past ten, p. m. Patient aged 40, had been out attending to business, and rode in an open carriage from about 3 till 5 p. m., in good health and spirits, as remarked by his wife. About 6 p. m. attacked with pains in limbs, back, and abdomen, chilliness and coldness of the skin, with frequent vomiting and purging ; sup- posed to have had thirty watery motions up to the present time ; the matter passed like rice-water, with white farinaceous-looking sediment; no urine, thirst, but tongue clean, moist, and cool; pulse 110, very feeble; countenance cadaverous, skin livid (blue-black), hands cold, and the skin shrivelled ; fingers crooked like a bird's elaws ; severe pains from cramps in hands, arms, feet, legs, neck, . and trunk both back and abdomen; voice shrill; complains chiefly of the cramps, cold, and nausea. Ordered antim. tartariz. two grains, magnesia sulph. half an ounce, in half a pint of water, a table-spoonful to be taken every half hour. " 15th, two, a. m. (three hours from last visit.) All the symptoms relieved ; no sickness, only two more motions, of the same appear- ance ; cramps gone from hands and arms, and less in the trunk — still in the legs ; hands less cold, does not now feel chilly ; began to feel warmer along the back after the second dose, i. e., little more than half an hour after commencing the medicine, though the pre- vious efforts of his attendants with hot flannels, bags of hot bran, &c, had not produced the slightest effect, and were laid aside by me on my first arrival. " Eleven, a. m. All the symptoms relieved : pulse full, soft, 76 ; still rather thirsty, and skin warmer than natural, and dry ; tongue clean, rather whitish ; has had refreshing sleep within the last hour—none before; feels only weak, no cramps, but pain in 244 PRINCIPLES OF MEDICINE. neutral salts, and resorted less to bleeding, and with more flattering success. The rationale is explained p. 176 et seq. muscles on motion ; only three motions like the former during the last nine hours, amounting to about two pints ; none for the last three or four hours ; no urine ; slight nausea after the last dose of the medicine. Let him take only half a table-spoonful of the mix* ture every two hours, and five grains of calomel immediately. " Six, p. m. One yellow, foetid, feculent motion, and nearly a quarter of a pint of natural urine. " Eleven, p. m. Has had some sound sleep, feels comfortable, but weak; and muscles feel tired and rather painful after the cramps. " 16th, mid-day. Feels well, but weak ; pulse 84, full, and soft; skin still warmer than natural. Ordered to continue the mix- ture every four hours, with half a grain of sulphate of quinine each time." Having alluded to the very slight cases, I may subjoin one: — " Called at ten, p. m., to a lady. She had been attacked in the morn- ing with a shivering, slight nausea and diarrhoea ; about six watery motions (rice-water and white sediment), unaccompanied by griping, no cramps, but some pain in calves of legs ; the shivering had con- tinued, and she had taken a hot bath without any relief; she then went to bed, and could not get warm until after drinking many cups of mixed tea (a sedative), when profuse perspiration came on, with relief, in which state she was at my visit. There had been a dry heat before the perspiration, but even then a tendency to shivering; and she remarked, that upon stretching out the hand, or even turning the head round, a sense of shivering was produced (morbid sensi- bility, independent of temperature). I recommended her merely to drink more cool tea if thirsty ; and, in case of return of diarrhoea on the following morning, to take a dessert-spoonful of the above saline antimonial every half hour. It did return, with nausea, and the second dose removed it entirely." In these cases will be found an exemplification of the various pecu- liarities above pointed out in treating of cholera. I wish to illustrate the principle of treating the disease, and not to assert a preference of my own remedies; for in the absence of tartar emetic or Epsom salts, I could have treated the case with the sedatives employed by other practitioners, acetate of lead, ipecacuanha, common salt, , by Professor Henry Vethake, is just published. To be had separate, price $2.00 uncut in cloth, or $2.50 bound. East's Reports, edited by G. M. Wharton, in 8 vols., large 8vo., law sheep. Education of Mothers, 1 vol., 12mo., cloth or paper. Electro-Magnetic Telegraph, by Vail, 8vo., sewed, many cuts. Frederic* the Great, by Campbell, 2 vols., 12mo., extra cloth. Fielding's Select Works, in 1 vol. large 8vo., cloth, or in 4 parts paper, price $1.25. 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Cyclopaedia of Practical Medicine, by Forbes, Tweedie, &c, edited by Dunglison, in 4 super royal volumes, 3154 double columned pages. Dunglison's Medical Dictionary, 6th ed., 1 vol. imp. 8vo., 804 large pages, double columns. Hoblyn's Dictionary of Medical Terms, by Hays, 1 vol. large 12mo., 402 pages, double columns. Medical News and Library, monthly at $1 a year. ANATOMY. Anatomical Atlas, by Smith and Horner, large imp. 8vo., 650 figures. Horner's Special Anatomy and Histology, 7th edition, 2 vols. 8vo., many cuts, 1130 pages. Horner's United States Dissector, 1 vol. large royal 12mo., many cuts, 444 pages. Wilson's Human Anatomy, by Goddard, 3d edi- tion, 1 vol. 8vo., 235 wood-cuts, 620 pages. Wilson's Dissector, or Practical and Surgical Anatomy, with cuts, 1 vol. 12mo., 444 pages. PHYSIOLOGY. Carpenter's Principles of Human Physiology, 1 vol. 8vo., 644 pages, many cuts, 2d edition. Carpenter's Elements, or Manual of Physiology, 1 vol. 8vo., 566 pages, many cuts. Connection between Physiology and Intellectual Science, 1 vol. 18mo., paper, price 25 cents. Dunglison's Human Physiology, 6th edition, 2 vols. 8vo., 1350 pages, and 370 wood-cuts. Harrison on the Nerves, 1 vol. 8vo., 292 pages. Miiller's Physiology, by Bell, 1 vol. 8vo., 886 pp. Roget's Outlines of Physiology, 8vo., 516 pages. Todd and Bowman's Physiological Anatomy and Physiology of Man, with numerous wood-cuts. (Publishing in the Medical News.) PATHOLOGY. Andral on the Blood, 1 vol. small 8vo., 120 pages. Abercrombie on the Stomach, new edition, 1 vol. 8vo., 320 pages. Abercrombie on the Brain, new edition, 1 vol. 8vo., 324 pages. Alison's Outlines of Pathology, &c, 1 vol. 8vo., 420 pages. Berzelius on the Kidneys and Urine, 8vo., 180 pp. Bennet on the Uterus, 1 vol. 12mo., 146 pages. Budd on the Liver, 1 vol. 8vo., 392 pages, plates and wood-cuts. Billing's Principles, 1 vol. 8vo., 304 pages. Bird on Urinary Deposits, 8vo., 228 pages, cuts. Hasse's Pathological Anatomy, 8vo., 379 pages. Hope on the Heart, by Pennock, a new edition, with plates, 1 vol. 8vo., 572 pages. Hughes on the Lungs and Heart, 1 vol. 12mo., 270 pages, with a plate. Philip on Protracted Indigestion, 8vo., 240 pp. Philips on Scrofula, 1 vol. 8vo., 350 pages. Prout on the Stomach and Renal Diseases, 1 vol. 8vo., 466 pages, colored plates. Ricord on Venereal, new ed., 1 vol. 8vo., 256 pp. Vogel's Pathological Anatomy of the Human Body, 1 vol. 8vo., 536 pages, col. plates. Walshe on the Lungs, 1 vol. 12mo., 310 pages. Wilson on the Skin, 1 vol. Svo., 370 pages. Williams' Pathology, or Principles of Medicine, 1 vol. 8vo., 384 pages. Williams on the Respiratory Organs, by Clymer, 1 vol. 8vo., 500 pages. PRACTICE OF MEDICINE. Ashwell on the Diseases of Females, by Goddard, 1 vol. 8vo., 520 pages. Benedict's Compendium of Chapman's Lectures, 1 vol. 8vo., 258 pages. Chapman on Thoracic and Abdominal Viscera, &c, 1 vol. 8vo., 384 pages. Chapman on Fevers, Gout, Dropsy, &c. &c, 1 vol. 8vo., 450 pages. Colombat de L'Isere on Females, translated and edited by Meigs, 1 vol. 8vo., 720 pages, cuts. Condie on the Diseases of Children, 2d edition, 1 vol. 8vo., 658 pages. Churchill on the Diseases of Females, by Huston, 4th edition, 1 vol. 8vo., 604 pages. Clymer and others on Fevers, a complete work in 1 vol. 8vo. 600 pages. Dewees on Children, 9th ed., 1 vol. 8vo., 548 pp. Dewees on Females, 8th edition, 1 vol.8vo.,532 pages, with plates. Dunglison's Practice of Medicine, 2d edition, 2 vols. 8vo., 1322 pages. Esquirol on Insanity, by Hunt, 8vo. 496 pages. Thomson on the Sick Room, &c, 1 vol. large 12mo., 360 pages, cuts. Watson's Principles and Practice of Physic, 2d edition by Condie, 1 vol. 8vo.,1060 large pages. SURGERY. Brodie on Urinary Organs, 1 vol. 8vo., 214 pages. Brodie on the Joints, 1 vol. 8vo. 216 pages. Brodie's Lectures on Surgery, 1 vol.8vo.,350 pp. Chelius' System of Surgery, by South and Norris, in 3 large 8vo. vols., near 2000 pages, or in 17 parts at 50 cents each. Cooper on Dislocations, and Fractures, 1 vol. 8vo. 500 pages, many cuts. Cooper on Hernia, 1 vol. imp. 8vo., 428 pp., pl'ts. Cooper on the Testis and Thymus Gland, 1 vol. imperial 8vo. many plates. Cooper on the Anatomy and Diseases ofthe Breast, Surgical Papers, &c. &c, 1 vol. imp. 8vo., pl'ts. Druitt's Principles and Practice of Modern Sur- gery, 3d ed., ] vol. 8vo.,534 pages, many cuts. Durlacher on Corns, Bunions, &c. 12mo., 134 pp. Fergusson's Practical Surgery, 1 vol. 8vo., 2d edition, 640 pages, many cuts. Guthrie on the Bladder, 8vo., 150 pages. Harris on the Maxillary Sinus, 8vo., 166 pp. Jones' (Wharton) Ophthalmic Medicine and Sur- gery, by Hays, 1 vol. royal 12mo.,529 pages, many cuts, and plates plain or colored. Liston's Lectures on Surgery, by Mutter, 1 vol. 8vo., 566 pages, many cuts. Lawrence on the Eye, by Hays, new edition, much improved, 863 pages, many cuts & plates. Lawrence on Ruptures, 1 vol. 8vo. 480 pages. Miller's Principles of Surgery, 1 vol. 8vo., 526 pp. LEA & BLANCHARD'S PUBLICATIONS. 5 Miller's Practice of Surgery, 1 vol. 8vo., 496 pp. Maury's Dental Surgery, 1 vol. 8vo., 286 pages, many plates and cuts. Robertson on the Teeth, 1 vol. 8vo., 230 pp. pts. MATERIA MEDICA AND THERAPEUTICS. Dunglison's Materia Medica and Therapeutics, a new ed., with cuts, 2 vols. 8vo., 986 pages. Dunglison on New Remedies, 5th ed., 1 vol. 8vo. 653 pages. Ellis' Medical Formulary, 8th ed., much improv- ed, 1 vol. 8vo., 272 pages. Griffith's Medical Botany, a new work, 1 large vol. 8vo., with over 350 illustrations. Pereira's Materia Medica and Therapeutics, by Carson, 2d edition, 2 vols. Svo., 1580 very large pages, nearly 300 wood-cuts. Royle's Materia Medica and Therapeutics, by Carson, 1 vol. 8vo., 689 pages, many cuts. OBSTETRICS. Churchill's Theory and Practice of Midwifery, by Huston, 2d ed., 1 vol. 8vo., 520 pp., many cuts. Dewees' System of Midwifery, 11th ed., 1 vol. 8vo. 660 pages, with plates. Rigby's System of Midwifery, 1 vol. 8vo. 492 pp. Ramsbotham on Parturition, with many plates, 1 large vol. imperial 8vo., new and improved edition, 520 pages. CHEMISTRY AND HYGIENE. Brigham on Excitement, &c, 1 vol. 12mo., 204 pp. Dunglison on Human Health, 2d ed.,8vo., 464 pp. Fowne's Elementary Chemistry for Students, 1 vol. royal 12mo., 460 large pages, many cuts. Graham's Elements of Chemistry, 1 vol. 8vo.,750 pages, many cuts. Griffith's Chemistry of the Four Seasons, 1 vol. royal 12mo., 451 pages, many cuts. Practical Organic Chemistry, 18mo., paper, 25 cts. Simon's Chemistry of Man, 8vo., 730 pp., plates. MEDICAL JURISPRUDENCE, EDUCATION, &c. Bartlett's Philosophy of Medicine, 1 vol. 8vo., 312 pages. Dunglison's Medical Student, 2d ed. 12mo.,312 pp. Man's Power over himself to Prevent or Control Insanity, 18mo. paper, price 25 cents. Taylor's Medical Jurisprudence, by Griffith, 1 vol. 8vo., 540 pages. Traill'sMedical Jurisprudence,! vol.8vo. 234pp. NATURAL SCIENCE, &c. Arnott's Elements of Physics, new edition, 1 vol. 8vo., 484 pages, many cuts. Brewster's Treatise on Optics, I vol. 12mo., 423 pages, many cuts. Babbage's " Fragment," 1 vol. 8vo., 250 pages. Buckland's Geology and Mineralogy,2 vols. 8vo., with numerous plates and maps. Bridgewater Treatises, with many plates, cuts, maps, &c, 7 vols. 8vo., 3287 pages. Carpenter's Popular Vegetable Physiology, 1 vol. royal 12mo., many cuts. Hale's Ethnography and Philology of the U. S. Exploring Expedition, in 1 large imp. 4to. vol. Herschell's Treatise on Astronomy, 1 vol. 12mo. 417 pages, numerous plates and cuts. Introduction to Vegetable Physiology, founded on the works of De Candolle, Lindley, &c., 18mo., paper, 25 cents. Kirby on Animals, plates, 1 vol. 8vo., 520 pages. Kirby and Spence's Entomology, from 6th Lon- don ed., 1 vol. 8vo., 600 large pages; plates, plain or colored. Philosophy in Sport made Science in Earnest, 1 vol. royal 18mo., 430 pages, many cuts. Roget's Animal and Vegetable Physiology, with 400 cuts, 2 vols. Svo., 872 pages. Trimmer's Geology and Mineralogy, 1 vol. 8vo., 528 pages, many cuts. VETERINARY MEDICINE. Claterand Skinner's Farrier, 1 vol. 12mo., 220 pp. Youatt's Great Work on the Horse, by Skinner, 1 vol. 8vo., 448 pa^ges, many cuts. Youatt and Clater's Cattle Doctor, 1 vol. 12mo., 282 pages, cuts. Youatt on the Dog, by Lewis, 1 vol. demy 8vo., 403 pages, beautiful plates. NEW MEDICAL AND SCIENTIFIC BOOKS. Lea <$• Blanchard have at press and preparing for publication thefollowing works. Carpenter's Comparative Anatomy and Physiology, revised by the author, with beautiful steel plates. A New Work on the Diseases and Surgery of the Ear, with illustrations. Bird's Natural Philosophy, from a new Lond. ed., in 1 vol. royal 12mo. with wood-cuts. Youatt on the Pig, a new work with beautiful illustrations of all the different varieties. Maunder's Treasury of Natural History, a Popular Dictionary of Animated Nature, with illustrations. Dana on Corals, imp. 4to., with an Atlas of Maps, being vols. 8 and 9 of the U. S. Ex. Expedition. Churchill on the Management and more Important Diseases of Infancy and Childhood, in 1 vol.8vo. Solly on the Human Brain, its Structure, Physiology and Diseases. Spooner on Sheep, with numerous wood-cuts. Malgaigne's Operative Surgery, with numerous wood-cuts. Quain's Elements of Anatomy, by Dr. Sharpey, with many illustrations. De La Beche's new work on Geology, with numerous wood-cuts. Southwood Smith's Philosophy of Health. Kane's Elements of Pharmacy, with additions, in 1 vol. 12mo. The Universal Formulary and Pharmacy, by R. E. Griffith, M. D., in 1 vol. 8vo. An Analytical Compend of the Various Branches of Practical Medicine, Surgery Anatomy, Mid- wifery, Diseases of Women and Children, MateriaMedica and Therapeutics, Physiology, Chemistry and Pharmacy, by John Neill, M. D., and F. Gurney Smith, M. D., with numerous illustrations. Taylor's Manual of Toxicology, in 1 vol. Metcalf on Caloric, in one large 8vo. volume. The History, Diagnosis and Treatment of Typhoid, Typhus, Bilious Remittent, Congestive and Yellow Fever, by Elisha Bartlett, M. D., &c, being a new and extended ed. of his former work. A CyclopjEdia of Anatomy and Physiology, based on the large work of Todd, in 2 vols, large 8vo. Th£ Universal Dispensatory, with many wood-cuts, in 1 large 8vo. volume. A New Work on Bandaging, and other Points of Minor Surgery, in 1 vol. 12mo., with wood-cuts. Elements of General Therapeutics, &c, by Alfred Stille, M.D., in 1 vol. 8vo. Coates' Popular Medicine, a new edition, fully revised and brought up, in 1 vol. large 12mo. Professor Meigs' New Work on Females ; their Diseases and their Remedies, in a Series of Let- ters to his Class, in 1 vol. 8vo. Together with various other works. 6 LEA & BLANCHARD'S PUBLICATIONS. NOW COMPLETE. THE GREAT SURGICAL LIBRARY. A SYSTEM "OF SURGERY. BY J. M. CHELIUS, Doctor in Medicine and Surgery, Public Professor of General and Ophthalmic Surgery, etc. etc. in the Uni- versity of Heidelberg. TRANSLATED FROM THE GERMAN, AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS, BY JOHN F. SOUTH, Surgeon to St. Thomas' Hospital. EDITED, WITH REFERENCE TO AMERICAN AUTHORITIES, BY GEORGE W. NORRIS, M. D. Now complete in three large octavo volumes of over six hundred pages each, or in 17 numbers, at fifty cents. This work has been delayed beyond the time originally promised for its completion, by the very extensive additions of the translator. In answer to numerous inquiries, the publishers now have the pleasure to pre- sent it in a perfect state to the profession, forming three unusually large volumes, bound in the best manner, and sold at a very low price. This excellent work was originally published in Germany, under the unpretending title of "Handbook to the Author's Lectures." In passing, however, through six successive editions, it has gradually increased in exienl and importance, until it now presents a complete view of European Surgery in general, but more especially of English practice, and it is acknowledged to be well fitted to supply the admitted want of a com- plete and extended system of Surgery in all its branches, comprehending both the principles and the prac- tice of this important branch of the healing art. Since Benjamin BelKs great work, first published in 1783, and now almost obsolete, no thorough and extended work has appeared in the English language, occupying the ground which this is so well calculated to cover. The fact of this work being carried to six editions in Germany, and translated into no less than eight lan- guages, is a sufficient evidence of the ability with which the author has carried out his arduous design. This translation has been undertaken with the concurrence and sanction of Professor Chelius. The trans- lator, Mr. John F. South, appears to have devoted himself to it with singular industry and ardor, and to have brought it up almost to the very hour of publication His notes and additions are very numerous, embodying the results and opinions of all the distinguished surgeons of the day, Continental, English and American. The leading opinions of John Hunter, on which Modern English Surgery has been raised, are set forth ; the results of the recent microscopical discoveries, especially in reference to inflammation, will be found here, together with many other practical observations, placing the work on a level with the present stale of Sur- gery, and rendering it peculiarly useful, both to the student and practitioner. The labors of the English translator have been so numerous and important, that there is but little which remains to be supplied by the American editor. Dr. G. W. Norris has consented, however, to superintend the passage of the work( through the press, and supply whatever may have been omitted in*elauon to the Surgical Literature ofthis country The Medical Press and profession, both in England and in this country, have joined in praise of this great work,as being more complete than any other, and as affording a complete library of reference, equally suited to the practitioner and to the student. " We strongly recommend all surgical practitioners and students, who have not yet looked into this work, to provide themselves with it without delay, and study its pages diligently and deliberately."—The Edin- burgh Medical and Surgical Journal. "Judging from a single number only of this work, we have no hesitation in saying that, if the remaining portions correspond at all wilh the first, it will be by far the most complete and scientific System of Surgery in the English language. We have, indeed, seen no work which so nearly comes up to our idea of what such a production sliould be. both as a practical guide and as a work of reference, as this; and the fact that it has passed through six editions in Germany, and been translated into seven languages, is sufficiently.con- vjncing proof of its value. It is methodical and concise, clear and accurate, omitting all minor details and fruitless speculations, it gives us all the information we want in the shortest and simplest form."— The New York Journal of Medicine. '■ Nor do these parts, in any degree, fall short of their predecessors, in the copiousness and value of their details. The work certainly forms an almost unique curiosity in medical literature, in the fact that the notes occupy a larger portion of the volume than the original matter, an arrangement which is constantly appearing to render the text subsidiary to its illustrations Still this singularity of manner does not at all detract from the value of the matter thus disposed."—The London Medical Gazette. '• This work has long been the chief text-book on Surgery in the principal schools of Germany, and the publication of five editions of it in the original and of translations into no less than eight foreign languages, shows the high estimation in which it is held. As a systematic work on Surgery it has merits of a high order. It is methodical and concise—and on the whole clear and accurate. The most necessary information is conveyed in the shortest and simplest form. Minor details and fruitless speculations are avoided. It is in fact, essentially a practical book. This work was first published nearly twenty years ago, and its solid and permanent repuiation has no doubt led Mr. South to undertake the present translation of the latest edition of it, which, we are informed, is still passing through the press in Germany. We should have felt at a loss to select any one better qualified for the task than the translator of Otto's Compendium of Human and Com- parative Pathological Anatomy—a surgeon to a large hospital whose industry and opportunities have enabled him to keep pace wiih the improvements of his time." — The Medico-Chirurgical Review. '• Although Great Britain can boast of some of the most skillful surgeons, both among.her past and her present professors of that branch of medical science.no work professing to be a complete system of Surgery has been published ia the British dominions since that of Benjamin Bell, now more than half a century old. '■This omission in English medical literature is fully and satisfactorily supplied by the translation of Profes- sor Chelius's System of Surgery by agentleman excellently fitted for the task, both by his extensive reading, and the opportunities of practical experience which he has enjoyed for years as surgeon to one of our largest metropolitan hospitals. The fact of Professor Chelius's work having been translated into seven languages is sufficient proof of the estimation in which it is held by our continental brethren, and the English Edition, now in course of publication, loses none of the value of the original from the treatment received at the hands of its translator. The notes and additions of Professor South are numerous, and contain the opinions result- ing from his vast experience, and from that of his colleague."— The Medical Times. "It ably maintains^the character formerly given, of being the most learned and complete systematic treatise now extant The descriptions of surgical diseases, and indeed the whole of the pathological depart- ment, are most valuable."— The Edinburgh Medical and Surgical Journal. (Lj* Persons wishing this work sent to them by mail, in parts, can remit Ten Dollars, for which a set will be sent by the publishers, free of postage, together with a copy of "The J|4edical News and Library" for one year. LEA & BLANCHARD'S PUBLICATIONS. 7 CHELIUS'S SURGERY, CONTINUED. The publishers annex a very condensed summary of the contents of Chelius's Surgery, showing the complete and systematic manner in which the whole subject is divided and treated. I. Division.—Of Inflammation. 1. Of inflammation in general. 2. Of some peculiar kinds of inflammation. a. Of erysipelas ; 6. Of burns ; c. Of frost- bite ; d. Of boils ; e. Of carbuncle. 3. Of inflammation in some special organs. a. Of inflammation of the tonsils ; 6. Of the parotid gland ; c. Of the breasts ; d. Of the urethra ; e. Of the testicle ; /. Of the muscles of the loins; g. Of the nail joints ; h. Of the joints, viz. a. Of the synovial membrane ; b. Of the car- tilages ; c. Of the joint-ends of the bones, viz., aa. in the hip-joint; 66. in the shoulder-joint; cc. in the knee-joint j and so on. n. Division.—Diseases which consist in a dis- turbance of physical connexion. I. Fresh solutions of continuity. a. Wounds ; b. Fractures. II. Old solutions, A. Which do not suppurate, viz. a. False joints; 6. Hare-lip ; c. Cleft in the soft palate ; d. Old rupture of the female perineum. B. Which do suppurate, viz. i. Ulcers. 1. In general. 2. In particular. a. Atonic; 6. Scorbutic ; c. Scrofulous ; d. Gouty ; e. Impetiginous;/. Vene- real ; g. Bony ulcers or caries. ii. Fistulas. a. Salivary fistula ; 6. Biliary fistula; c. Faecal fistula and artificial anus; d. Anal fistula; e. Urinary fistula. in. Solutions of continuity by changed position of 1. Dislocations; 2. Ruptures ; 3. Prolapses; 4. Distortions. IV. Solutions of continuity by unnatural distention. 1. In the arteries, aneurisms ; 2. In the veins, varices; 3. In the capillary-vascular sys- tem, teleangiectasis. III. Division.—Diseases dependent on the unna- tural adhesion of parts. 1. Anchylosis ofthe joint-ends of bones; 2. Grow- ing together and narrowing of the aperture ofthe nostrils ; 3. Unnatural adhesion ofthe tongue; 4. Adhesion of the gums to the cheeks; 5. Narrowing ofthe oesophagus ; 6. Closing and narrowing of the rectum; 7. Growing together and narrowing ofthe pre- puce ; 8. Narrowing and closing of the ure- thra; 9. Closing and narrowing of the vagina and ofthe mouth ofthe womb. IV. Division.—Foreign bodies. 1. Foreign bodies introduced externally into our organism. a. Into the nose ; 6. Into the mouth ; c. Into the gullet and intestinal canal; d. Into the wind-pipe. 2. Foreign bodies formed in our organism by the retention of natural products. A. Retentions in their proper cavities and receptacles. a. Ranula; 6. Retention of urine ; c. Retention ofthe fetus in the womb or in the cavity ofthe belly, (Cesa- rean operation, section ofthe pubic symphysis, section ofthe belly.) B. Extravasation external to the proper cavi- ties or receptacles. a. Blood swellings on the heads of new- born children ; 6. Hematocele ; c. Collections of blood in joints. 3. Foreign bodies resulting from the accumulation of unnatural secreted fluids. a. Lymphatic swellings; 6. Dropsy of joints; c. Dropsy ofthe bursas mucosas ; d. Wa- ter in the head, spina bifida ; e. Water in the chest and empyema;/. Dropsy of the pericardium ; g. Dropsy of the belly; h. Dropsy of the ovary ; i. Hy- drocele. 4. Foreign bodies produced from the concretion of secreted fluids. V. Division.—Diseases which consist in the de- generation of organic parts, or in the produc- tion of new structures. 1. Enlargement of the tongue ; 2. Bronchocele-; 3. Enlarged clitoris; 4. Warts; 5. Bunions; 6. Horny growths; 7. Bony growths ; 8. Fun- gus of the dura mater; 9. Fatty swellings-; 10. Encysted swellings; 11. Cartilaginous bodies in joints; 12. Sarcoma;. 13. Medul- lary fungus ; 14. Polypus; 13. Cancer. VI. Division.—Loss of organic parts. 1. Organic replacement of already lost parts, es- pecially ofthe face, according to the Taglia- cotian and Indian methods. 2. Mechanical replacement: Application of arti- ficial limbs, and so on. VII. Division.—Superfluity of organic parts. VIII. Division.—Display: of the elementary ma- nagement of surgical operations. General surgical operation*: Bleeding, cupping, application of issues,, introduction of setons, amputations, resectians, and so on. DRUITT'S SURGERY. New Edition--Now Ready, 1847, THE PRINCIPLES AND PRACTICE OF MODEBH SURGERY, By ROBERT DRUITT, Surgeon. THIRD AMERICAN FROM THE THIRD LONDON EDITION Illustrated with one hundred and fifty-three wood engravings. WITH NOTES AND COMMENTS, BY JOSHUA B. FLINT, M.D, M. M., S. S., &c. &c. In One very neat Octavo Volume of about Five Hundred and Fifty Cages'. In Dresentin" this work to the American profession for the third time, but little need be said to solicit fiw It a continuation of the favor with which it has been received. The merits which, have procured it this favor its clearness conciseness, and its excellent arrangement, will continue to render it the favorite text- book ofthe student'who wishes in a moderate space a compend ofthe principles and'practice of Surgery. "This work merits our warmest commendations, and we strongly recommend it ta^oung surgeons a? 3ft admirable digest of the principles and practice of modern Surgery .■"-Medical Gazttt*.. 8 LEA &. BLANCHARD'S PUBLICATIONS. WOW READY. ROYLE'S MATERIA MEDICA. MATERIA MEDICA AND THERAPEUTICS; INCLUDING THE PREPARATIONS OF THE PHARMACOPOEIAS OF LONDON, EDINBURGH, DUBLIN, AND OF THE UNITED STATES. WITH MANY NEW MEDICINES. BY J. FORBES ROYLE, M.D., F. R. S., Late of the Medical Staff in the Bengal Army, Professor of Materia Medica and Therapeutics, King's Col- lege, London, &c. &c. EDITED BY JOSEPH CARSON, M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy, &c. &c. WITH NINETY-EIGHT ILLUSTRATIONS. UT1" See Specimen of the Cuts, but not of the Paper or Working; on next Page. In one large octavo volume of about 700 pages. Being one of the most beautiful Medical works published in this Country. The want has been felt and expressed for some time, of a text-book on Materia Medica, which should occupy a place between the encyclopaedic works, such as Pereira, and the smaller treatises which present but a meagre outline of the science. It has been the aim of the author of the present work to fill this vacancy, and by the use of method and condensation, he has been enabled to present a volume to the student, which will be found to contain what is necessary in a complete and thorough text-book of the science, encumbered with few unnecessary details. The editor, Dr. Carson, has added whatever was wanted to adapt it to the Pharmacopoeia ofthe United States, and it is confidently recommended to the student and practitioner of medicine, as one of the best text-books on the subject, now before the profession.—Great care has been taken in its mechanical execution. " Dr. Royle's manual, while it has the convenience of being in a portable form, contains as much matter as would fill two octavo volumes in large type. Our readers will judge, from the remarks which we have already made, that we think highly of this work. The subject is well treated, the matter practical and well arranged, and we do not hesitate to recommend it as a most useful volume to the student and practitioner. It is a good specimen of typography, and the engravings are well executed."—Medical Gazette. In regard to the yet more essential constituent, the literary portion of the work, no one who is acquainted with the former productions of Dr. Royle, will doubt that the author has discharged his duties with the same skill as the artist. The work is, indeed, a most valuable one, and will fill up an important gap that existed between Dr. Pereira's most learned and complete system of materia medica, and the class of productions at the other extreme, which are necessarily imperfect from their small extent. Such a work as this does not admit of analysis and scarcely of detailed critical examination. It would, however, be injustice to the learned author not to state that, in addition to what former works on the subject necessarily contained, the reader will find here not a little that is either original, or introduced for the first time, more especially in the details of botany and natural history, and in what may be termed the archaeology of drugs.—The British and Foreign Medical Review. Ofthe various works that have from time to time appeared on materia medica on the plan ofthe one before us, there is none more deserving of commendation. From the examination which we have given, accuracy and perspicuity seem to characterize it throughout, as a text book of refer- ence to the student of medicine, and especially of pharmacy in its application to medicine, none could he better. We think that every one who can afford it should possess this excellent work, the value of which has been greatly enhanced by the additions of Dr. Carson, than whom no one is more competent to estimate it correctly, and to make such additions as may adapt it for American service.—The Medical Examiner. We have sufficiently extended our notice of the manual of materia medica and therapeutics, to show that, it possesses great merit, which will be a pretty sure guarantee of its acceptableness to the profession. The department of materia medica is now so extended, that the treatises recently issued from the press, partake ofthe nature of cyclopaedias. To the student, whether of pharmacy solely or medicine, an extended manual as the present cannot but be regarded with favor.—The American Journal of Pharmacy. We cannot, however, conclude without expressing our warm approbation of the volume as a whole. It will certainly not detract from the author's high reputation.—The Medico-Chirurgical Review. Fig 85. Fig. 72 Fig. 46. GO H O O i—i w CONIUM MACULATUM. (Hemlock.) DIOSMA CRENATA. (Rue.) MYRISTICA OFFICINALIS. (Nutmeg.) 10 LEA & BLANCHARD'S PUBLICATIONS. CHURCHILL'S MIDWIFERY. ON THE THEORY AND PRACTICE OF MIDWIFERY, BY FLEETWOOD CHURCHILL, M. D., M. R. I. A., Licentiate of the College of Physicians in Ireland; Physician to the Western Lying-in-Hospital; Lecturer on Midwifery, &.c , in the Richmond Hospital Medical School, &c. &.C. WITH NOTES AND ADDITIONS, BY ROBERT HUSTON, M.D., Professor of Materia Medica and General Therapeutics, and formerly of Ohstetrics and the Disease of Wo- men and Children in the Jefferson Medical College of Philadelphia; President of the Philadelphia Medical Society, &c. &c. SECOND AMERICAN EDITION. WITH ONE HUNDRED AND TWENTY-EIGHT ILLUSTRATIONS, Engraved by Gilbert from Drawings by Bagg and others. In one beautiful octavo volume. In this age of books, when much is written in every department of the science of medicine, it is a matter of no small moment to the student, which of the many he shall choose for his study in pupilage, and guide in practice. In no department is the choice more difficult than in that of midwifery ; many excellent and truly valuable treatises in this department of medicine have, within a few years past, been written; of this character are those of Dewees, Velpeau, Meigs and R'gby, with due respect to the authors ofthe works just cited, we are compelled 10 admit, that to Mr. Churchill has been reserved the honorof presenl:ng to the profession one more particularly adapted to the want and use of students, a work rich in statistics—clear in practice—and free iu style—possessing no small claims to our confidence.— The New York Journal of Medicine. WILLIAMS' PATHOLOGY. PRINCIPLES OF ME DICINE, COMPRISING GENERAL PATHOLOGY AND THERAPEUTICS, iSD A GENERAL VIEW OF ETIOLOGY, NOSOLOGY. SEMEIOLOGY, DIAGNOSIS AND PROGNOSIS. BY CHARLES J. B. WILLIAMS, M.D., F.R.S., Fel.ow ofthe Royal College of Physicians, &c. WITH NOTES AND ADDITIONS, BY MEREDITH CLYMER, M. D., &c. In one volume, octavo. PEREIRA'S MATERIA MEDICA. With nearly Three Hundred Engravings on Wood. A NEW EDITION, LATELY PUBLISHED. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS, COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- SITION, EFFECTS AND USES OF MEDICINES. BY JONATHAN PEREIRA, M.D., F.R.S. and L.S. Member of the Society of Pharmacy of Paris; Examiner in Materia Medica and Pharmacy of the University of Loudon; Lecturer on Materia Medica at the London Hospital. &c &c. Second American, from the last London Edition, enlarged and improved. WITH NOTES AND ADDITIONS BY JOSEPH CARSON, M.D. In two volumes octavo, containing Fifteen Hundred very large pages, illustrated by Two Hundred and Seventy-five Wood-cuts This encyclopaedia of materia medica. for such it may justly be entitled, gives the fullest and most ample ex- position of materia imdica and its associate branches of any work hitherto published in ihe English language. It abounds in research and erudition: its statements of facls are clear and methodically arranged, while its therapeutical explanations are philosophical, and in accordance with sound clinical experience. It is eouallv can the standard authority; in the present he has introduced an account of substances thai have recent!v'attracted at- tention by their therapeutic employment, together with the mode of forming the characters and uses of new pharmaceutic preparations, and the details of more elaborate and particular chemical investigation* with respect to the nature of previously known and already described elementary principles—all the important indigenous medicines of the United States heretofore known are also described. The work, however is loo well known to need any further remark. We have no doubt it will have a circulation commensurate wiih its extraordinary merits.— The New York Journal of Medicine. " An Encyclopaedia of knowledge in that department of medica! science— by the common consent ofthe pro- fession the most elaborate and scieni.nc Treatise on Materia Medica in our language."— Western Journal of Medicine and Surgery. J adapted as a text-book for students, or a work of reference for the advanced practitioner and no one < consult its pages without profit. The editor has performed his task with much ability and judgment In first American edition lie adopted the Pharmacopoeia of the United States and the formulae set forth in t LEA & BLANCHARD'S PUBLICATIONS. 11 WILSON'S ANATOMY. New Edition—Now Ready, 1847. A SYSTEM OF HUMAN ANATOMY, GENERAL AND SPECIAL. BY ERASMUS WILSON, M.D., Lecturer on Anatomy, London. THIRD AMERICAN FROM THE LAST LONDON EDITION. EDITED BY P. B. GODDARD, A. M., M.D., Professor of Anatomy in the Franklin Medical College of Philadelphia. WITH TWO HUNDRED AND THIRTY-FIVE ILLUSTRATIONS BY GILBERT. In one beautiful octavo volume of over SIX HUJY&RED Large Pages, Strongly Bound and sold at a low price. Since the publication of the second American edition of this work, the author has issued a new edition in London, in which he has carefully brought up his work to a level with the most advanced science of the day. All the elementary chapters have been re-written, and such alterations made through the body ofthe work, by the introduction of all new facts of interest, illustrated by appro- priate engravings, as much increase its value. The present edition is a careful and exact reprint ofthe English volume, with the addition of such other illustrations as were deemed necessary to a more complete elucidation of the text; and the insertion of such ofthe notes appended to the last American edition as had not been adopted by the author and embodied in his text; together with such additional information as appeared calculated to enhance the value ofthe work. It may also be stated that the utmost care has been taken in the revision of the letter-press, and in obtaining clear and distinct impressions of the accompanying cuts. It will thus be seen, that every effort has been used to render this text-book worthy of a con- tinuance of the great favor with which it has been everywhere received. Professors desirous of adopting it for their classes may rely on being always able to procure editions brought up to the day. This book is well known for the beauty and accuracy of its mechanical execution. The present edition is an improvement over the last, both in the number and clearness of its embellishments ; it is bound in the best manner in strong sheep, and is sold at a price which renders it accessible to all. CONDIE ON CHILDREN.—New Edition, 1847. A practicalTtreatise ON THE DISEASES OF CHILDREN. BY D. FRANCIS CONDIE, M. D, Fellow ofthe College of Physicians, Member ofthe American Philosophical Society, &c. In one large octavo volume. JTT* The publishers would particularly call the attention ofthe profession to an examination of this book. In the preparation of a new edition ofthe present treatise, every part of the work has been subjected to a careful revision; several portions have been entirely rewritten; while, throughout numerous additious have been made comprising all the more important facts in reference to the nature, diagnosis, and treat- ment ofthe diseases of infancy and childhood, that have been developed since the appearance of the firs edinon It is with some confidence that the author presents this edition as embracing a full and connected view of the actual state ofthe pathology and therapeutics of those affections which most usually occur be- ^Thi, w^Vi^beTng Produced, as a text-book, very extensively throughout the Union. CHURCHILL ON FEMALES. New Edition, 1847.—Now Ready. THE DISEASES~OF FEMALES, INCLUDING THOSE OF PREGNANCY AND CHILDBED. BY FLEETWOOD CHURCHILL, M D, Author of "Theory and Practice of Midwifery," &c. &c. FOURTH AMERICAN, FROM THE SECOND LONDON EDITION, WITH ILLUSTRATIONS. EDITED, WITH NOTES, BY ROBERT M. HUSTON, M.D., &c.&c. In one volume, 8vo. The rapid sale of three editions of this.£^£^ ?hrafe^ rfy rybdiefi=ies whIch may have exis,ed in former imprelsio^s, Ind to bring the work fully up to the date of publication. 12 LEA & BLANCHARD'S PUBLICATIONS. LIBRARY OF OPHTHALMIC MEDICINE AND SURGERY. Brought up to 1847. A TREATISE ON THElSEASES OF THE EYE, BY W. LAWRENCE, F.R.S., Surgeon Extraordinary to the Queen, Surgeon to St. Bartholomew's Hospital, &c. &c. A NEW EDITION, With many Modifications and Additions, and the Introduction of nearly two hundred Illustrations. BY ISAAC HAYS, M. D., Surgeon to Wills' Hospital, Physician to the Philadelphia Orphan Asylum, &c. &c. In one very large octavo volume of near 900 pages, with twelve plates and numerous wood-cuts through the text. This is among the largest and most complete works on this interesting and difficult branch of Medica The early call for a new edition of this work, confirms the opinion expressed by the editor of its great value, and has stimulated him to renewed exertions to increase its usefulness to practitioners, by incorporat- ing in it the recent improvements in Ophthalmic Practice. In availing himself, as he lias freely done, of the observations and discoveries of his fellow-laborers in the same field, the editor has endeavored to do so with entire fairness, always awarding to others what justly belongs to them. Among the additions which have been made, may be noticed,—the descriptions of several affections not treated of in the original,—an account ofthe catoptric examination ofthe eye, and of its employment as a means of diagnosis,—one hun- dred and seventy-six illustrations, some of them from original drawings—and a very full index. There have also been introduced in the several chapters on the more important diseases, the results of the editor's ex- perience in regard to their treatment, derived from more than a quarter of a century's devotion to the subject, during all of which period he has been attached to some public institution for the treatmentof diseases ofthe " We think there are few medical works which could be so generally acceptable as this one will be to the profession on this side ofthe Atlantic. The want of a scientific and comprehensive treatise on Diseases of the Eye, has been much deplored. That want is now well supplied. The reputation of Mr. Lawrence as an Oculist has been long since fully established; his gTeat merit consists in the clearness of his style and the very practical tenor of his work. The value of the present beautiful edition is greatly enhanced, by the important additions made by the editor. Dr. Hays has, for nearly a quarter of a century, been con- nected with public institutions for the treatment of Diseases of the Eye. and few men have made better im- provement than he has, of such extensive opportunities of acquiring a thorough knowledge of the subject. 1 The wood-cuts are executed with great accuracy and beauty, and no man, who pretends to treat diseases ofthe eye, should be without this work."—Lancet. JONES ON THE EYE, Now Ready, THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. By T. WHARTON JONES, F.R.S., &c. &c. "WITH ONE HUNDRED AND TEN ILLUSTRATIONS. EDITED BY ISAAC HAYS, M.D., &c. In One very neat Volume, large royal \2mo., with Four Plates, plain or colored, and Ninety' eight well executed Wood-cuts. This volume will be found to occupy a place hitherto unfilled in this department of medical science. The aim of the author has been to produce a work which should, in a moderate compass, be suffi- cient to serve both as a convenient text-book for students and as a book of reference for practitioners, suitable for those who do not desire to possess the larger and encyclopaedic treatises, such as Lawrence's. Thus, by great attention to conciseness of expression, a strict adherence to arrange- ment, and the aid of numerous pictorial illustrations, he has been enabled to embody in it the prin- ciples of ophthalmic medicine, and to point out their practical application more fully than has been done in any other publication of the same size. The execution of the work will be found to correspond with its merit. The illustrations have been engraved and printed with care, and the whole is confidently presented as in every way worthy the attention of the profession. " We are confident that the reader will find, on perusal, that the execution of the work amply fulfils the promise of the preface, and sustains, in every point, the already high reputation ofthe author as an ophthal- mic surgeon, as well as a physiologist and pathologist. The book is evidently the result of much labor and research, and has been written with the greatest care and attention ; it possesses that best quality which a general work, like a system, or manual, can show, viz:—the quality of having all the materials whenceso- ever derived, so thoroughly wrought up, and digested in the author's mind, as to come forth with the freshness and impressiveness of an original production. We regret that we have received the book at so late a period as precludes our giving more than a mere notice of it, as although essentially and necessarily a compilation, it contains many things which we should be glad to reproduce in our pages, whether in the shape of new pathological views, of old errors corrected, or of sound principles of practice in doubtful cases clearly laid down. But we dare say most of our readers will shortly have an opportunity of seeing these in their original locality, as we entertain little doubt that this book will become what iis author hoped it might become, a manual for daily reference and consultation by the student and the general practitioner. The work is marked by that correctness, clearness and precision of style which distinguish all the productions of the learned author."—'The British and Foreign Medical Review. LEA & BLANCHARD'S PUBLICATIONS. 13 NEW AND COMPLETE MEDICAL BOTANY. NOW READY. medicalIiotany, OR, A DESCRIPTION OF ALL THE MORE IMPORTANT PLANTS USED IN MEDICINE, AND OF THEIR PROPERTIES, USES AND MODES OF ADMINISTRATION. BY R. EGLESFELD GRIFFITH, M.D., &c. &c. In one large octavo volume. With about three hundred and fifty Illustrations on Wood. Specimens of the Cuts are annexed, but not so well printed as in the work, nor on as good paper. This work is intended to supply a want long felt in this country, of some treatise present- ing correct systematic descriptions of medicinal plants, accompanied by representations of the most important of them, and furnished at a price so moderate as to render it generally accessible and useful. In the arrangement, the author has treated more fully of those plants which are known to be of the greatest importance; and more especially of such as are of native origin; while others, rarely used, are briefly noticed, or mentioned only by name. In all cases, the technical descriptions are drawn up in accordance with the existing state of botanical knowledge, and in order that these maybe fully appreciated, even by those not proficients in the science, an Introduction has been prepared, containing a concise view of Vegetable Physiology, and the Anatomy and Chemistry of Plants. Besides this, a very copious Glossary of botanical terms has been appended, together with a most complete Index, giving not only the scientific but also the common names of the species noticed in it. It will thus be seen that the work presents a view not only of the properties and medical virtues ofthe various species of the vegetable world, but also of their organization, compo- sition and classification. To the student, who is really anxious to study Botany for those great purposes which ren- der it so necessary for the advancement of Medical Science, and who has been obliged to rest satisfied with such imperfect knowledge as can be obtained from the different treatises on the Materia Medica, the present work will be of great utility as a text-book and guide in his researches, as it presents in a condensed form, all that is at present known respecting those vegetable substances which are employed to alleviate suffering and to minister to the wants of man. It will also be found extremely convenient to practitioners through the country, who are anxious to obtain a knowledge of the medicinal plants occurring in their vicinity, and who are unwilling to procure the scarce and high-priced works which are at present the only ones accessible on this important branch of medical knowledge. Great care has been taken to render the mechanical execution satisfactory. NOW PREPARING, AND TO BE READY BY AUGUST NEXT, AN ANALYTICAL COMPEND OF THE VARIOUS BRANCHES OF PRACTICAL MEDICINE, SURGERY, ANATOMY, MIDWIFERY, DISEASES OF WOMEN AND CHILDREN, Materia JtEedica and Therapeutics, Physiologyr, © HI 31EO© IP IS "2" AS?© JPIHIJV.I&M^.OI'o BY JOHN NEILL, M.D., Demonstrator of Anatomy in the University of Pennsylvania, and F. GURNEY SMITH, M.D., Lecturer on Physiology in the Philadelphia Association for Medical Instruction. To make one large royal Duodecimo volume, with numerous Illustrations on Wood. It is the intention of the publishers to page this work in such a way, that it can be done up in separate divisions, and in paper to go by mail; no one division will cost over 50 cents, thus pre- senting separate MANUALS on the various branches of medicine, and at a very low price. EH O E Ph BQ a ^ ed S •"• Es hr*l §3 eh Fig. 164. I—H Pi! 05 CORNUS FLORIDA. (Dogwood.) ACONITUM NAPELLUS (Wolfsbane.) HELLEBORUS NIGER. (Black Hellebore.) LEA & BLANCHARD'S PUBLICATIONS. 15 THE GREAT MEDICAL LIBRARY. THE CYCLOP/EDIA OF PRACTICAL MEDICINE; COMPRISING TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA AND THERAPEUTICS, DISEASES OF WOMEN AND CHILDREN, MEDICAL JURISPRUDENCE, &c. &c. EDITED BY JOHN FORBES, M. D., F. R. S., ALEXANDER TWEEDIE, M.D., F.R.S., AND JOHN CONOLLY, M.D. REVISED, WITH ADDITIONS, By ROBLEY DUNGLISON, M. D. THIS WORK IS NOW COMPLETE, AND FORMS FOUR LARGE SUPER-ROYAL, OCTAVO VOLUMES. CONTAINING THIRTY-TWO HUNDRED AND FIFTY-FOUR UNUSUALLY LARGE PAGES IN DOUBLE COLUMNS, PRINTED ON GOOD PAPER, WITH A NEW AND CLEAR TYPE. THE WHOLE WELL AND STRONGLY BOUND, WITH RAISED BANDS AND DOUBLE TITLES. Or, to he had in twenty-four parts, at Fifty Cents each. For a list of Articles and Authors, together with opinions of the press, see Supplement to the No- vember number of the Medical News and Library for 1845. This work having been completed and placed before the profession, has been steadily advancing in favor with all classes of physicians. The nu- merous advantages which it combines, beyond those of any other work; the weight which each article carries with it, as being the production of some physician of acknowledged reputation who has devoted himself especially to the subject confided to him; the great diversity of topics treated of; the compendiousness with which everything of importance is digested into a comparatively small space ; the manner in which it has been brought up to the day, everything necessary to the American practitioner having been added by Dr. Dunglison; the neatness of its mechanical execution; and the extremely low price at which it is afforded, combine to render it one of the most attractive works now before the profession. As a book for con- stant and reliable reference, it presents advantages which are shared by no other work of the kind. To country practitioners, especially, it is abso- lutely invaluable, comprising in a moderate space, and trifling cost, the matter for which they would have to accumulate libraries, when .removed from public collections. The steady and increasing demand with which it has been favored since its completion, shows that its merits have been appreciated, and that it is now universally considered as the LIBRARY FOR CONSULTATION AND REFERENCE. A EUAGSJnnCSTffT A2S25 CHEAT WOIUK. SMITH & HORNER'S ANATOMICAL ATLAS. Just Published, Price Five Dollars in Parts. AN ANATOMICAL ATLAS ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. BY HENRY H. SMITH, M.D., Fellow ofthe College of Physicians, 8{c. UNDER THE SUPERVISION OF WILLIAM E. HORNER, M.D., Professor of Anatomy in the University of Pennsylvania, In One large Volume, Imperial Octavo. This work is but just completed, having been delayed over the time intended by the great difficulty in giving to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follow*: Part I. The Bones and Ligaments, with one hundred and thirty engravings. Part II. The Muscular and Dermoid Systems, with ninety-one engravings. Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. Forming altogether a complete Sy6tem of Anatomical Plates, of nearly SIX HUNDRED AND FIFTY FIGURES, executed in the best style of art, and making one iarge imperial octavo volume. Those who do not want it in parts can have the work bound iu extra cloth or sheep at an extra cost. This work possesses novelty both in the design and the execution. It is the first attempt to apply engraving on wood, on a large scale, to the illustration of human anatomy, and the beauty ofthe parts issued induces the publishers to flatter themselves with the hope of the perfect success of their undertaking. The plan of the work is at once novel and convenient. Each page is perfect in iiself, the references being immediately under the figures, so that the eye takes in the whole at a glance, and obviates the necessity of continual reference backwards and forwards. The cuts are selected from the best and most accurate sources; and, where neces- sary, original drawings have been made from the admirable Anatomical Collection ofthe University of Penn sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in the investi- gation of the minute structure of the tissues. In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific and artistical point of view, while, at the same time, its very low price places it within the reach of all. It is particularly adapted to supply the place of skeletons or subjects, as the profession will see by examining the list of plates "These figures are well selected, and present a complete and accurate representation of that wonderful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratulate the student upon the completion of this atlas, as it is the most convenient work of the kind that has yet appeared; and, we must add, the very beautiful manner in which it is • got up' is so creditable to the country as to be flattering to our national pride."—American Medical Journal. "This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomical Atlases, but we will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit. AVe strongly recommend to our friends, boih urban and suburban, the purchase of this excellent work, for which both editor and publisher deserve the thanks of the profession."—Medical Examiner. "We would strongly recommend it, not only to the student, but also to the working practitioner, who, although grown rusty in the toils of his harness still has the desire, and often the necessity, of refreshing his knowledge in this fundamental part of the science of medicine."—New York Journal of Medicine and Surg. " The plan of this Atlas is admirable, and its execution superior to any thing of the kind before published in thi6 country. It is a real labour-saving affair, and we regard its publication as the greatest boon that could be conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy means of recalling the details learned in the dissecting room, and which are soon forgotten."—American Medv- cal Journal. " It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, surgeons and medical students."—Boston Med. and Surg. Journal. '' It has been the aim of the author of the Atlas to comprise in it tne valuable points of all previous works, to embrace the latest microscopical observations on the anatomy of the tissues, and by placing it at a moderate price to enable all to acquire it who may need its assistance in the dissecting or operating^oom, or other field of practice."—Western Journal of Med. and Surgery. •'These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the earlier numbers. We regard all the engravings as possessing an accuracy only equalled by their beauty, and cordially recommend the work to all engaged in the study of anatomy."—New York Journal of Medicine and Surgery. "A more elegant work than the one before us could not easily be placed by a physician upon the table ol his student."—Western Journal of Medicine and Surgery. "We were much pleased with Part I, but the Srcond Part gratifies us still more, both as regards the attract- ive nature of the subject, (The Dermoid and Muscular !Systems.) and the beautiful artistical execution of the .llusiraiions. We have here delineated the most accurate microscopic views of some of the tissues, as, foi instance, the cellular and adipose tissues, the epidermis, rete mucosum and cutis vera, the sebaceous and perspiratory organs of the skin, the perspiratory glands and hairs of the skin, and the hair and nails. Then follows the general anatomy of the muscles, and. lastly, their sepurati* delineations. We would recommend this Anatomical Atlas to our readers iu lite very strongest terms."—New York Journal of Medicine and Sut- fiery. LEA & BLANCHARD'S PUBLICATIONS. 17 NEW EDITION. SPECIAL ANATOMY7 AND HISTOLOGY. BY WILLIAM E. HORNER, M.D., PROFESSOR OF A5ATOMI IN THE UNIVERSITY OF PENNSYLVANIA, &C, &C Seventh edition. With many improvements and additions. In two octavo volumes, with illustrations on wood. This standard work has been so long before the profession, and has been so extensively used, that, in announcing the new edition, it is only necessary to state, that it has under- gone a most careful revision ; the author has introduced many illustrations relating to Mi- croscopical Anatomy, and has added a large amount of text on those various points of investigation that are rapidly advancing and attracting so much attention. This new edition has been arranged to refer conveniently to the illustrations in Smith and Horner's Anato- mical Atlas. "The name of Professor Horner is a sufficient voucher for the fidelity and accuracy of any work on anatomy, but if any further evidence could be required ofthe value ofthe pre- sent publication, it is afforded by the fact of its having reached a seventh edition. It is altogether unnecessary now to inquire into the particular merits of a work which has been so long before the profession, and is so well known as the present one, but in announcing a new edition, it is proper to state that it has undergone several modifications, and has been much extended, so as to place it on a level with the existing advanced state of anatomy.— The histological portion has been remodelled and rewritten since the last edition; numerous wood cuts have been introduced, and specific references are made throughout the work to the beautiful figures in the Anatomical Atlas, by Dr. H. H. Smith."—The American Medical Journal, for January, 1847. HORNER'S_BISSI!CTOE. THE UNITED STATES DISSECTOR, BEING A NEW EDITION, WITH EXTENSIVE MODIFICATIONS, AND ALMOST REWRITTEN, OF "HORJVER'S PRACTICAL, JHYJITOMIW IN ONE VERY NEAT VOLUME, ROYAL 12mo. With many Illustrations on Wood. The numerous alterations and additions which this work has undergone, the improve- ments which have been made in it, and the numerous wood-cuts which have been intro- duced, render it almost a new work. It is the standard work for the Students in the University of Pennsylvania. Some such guide-book as the above is indispensable to the student in the dissecting room, and this, prepared by one of the most accurate of our anatomists, may claim to combine as many advantages as any other extant. It has been so favorably received that the publish- ers have issued the fourth edition, which comes forth embellished by various wood cuts.— The copy for which we are indebted to the publishers, although received by us a fortnight since » ujpluai-TJs of <©ne J^urrtiteti $lafn arrti Colore* Hnflrabfngs. In One neat Octavo Volume. In our last number we gave a pretty full analysis of the original of this very valuable work, to which we must refer the reader. We have only to add here our opinion that the translator has performed his task in an excellent manner, and has enriched the work with many valuable additions.—The British and Foreign Medical IUiTdecidedly the best work on the subject of which it treats in the English language, and Dr. Day, whose translation is well executed, has enhanced its value by a judicious selection ofthe most important figures from the atlas, which are neatly engraved.—The London Medical Gazette. 20 LEA & BLANCHARD'S PUBLICATIONS. A NEW EDITION OF THE GREAT MEDICA L_L E ZI G 0 IT. A Dictionary of MEDICAL SCIENCE, CONTAINING A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS; WITH THE FRENCH AND OTHER SYNONYMES; NOTICES OF CLIMATES AND OF CELE- BRATED MINERAL WATERS; FORMULAE FOR VARIOUS OFFICINAL AND EMPIRICAL PREPARATIONS, &c. BY ROBLEY DUNGLISON, M. D., PROFESSOR OF THE INSTITUTES OF MEDICINE, ETC. IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. Sixth edition, revised and greatly enlarged. In one royal octavo volume of over 800 very large pages, double columns. Strongly bound in the best leather, raised bands. " The most complete medical dictionary in the English language."— Western Lancet. " We think that 'the author's anxious wish to render the work a satisfactory and desirable—if not indispen- sable—Lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science,' has been fully accomplished. Such a work is much needed by all medical students and young physicians, and will doubtless continue in extensive demand. It is a lasting monument ofthe industry and literary attainments ofthe author, who has long occupied the highest rank among the medical teachers of America."—The New Orleans Medical and Surgical Journal. " The simple announcement ofthe fact that Dr. Dunglison's Dictionary has reached a sixth edition, is almost as high praise as could be bestowed upon it by an elaborate notice. It is one of those standard works that have been ' weighed in the balance and (not) been found wanting' It has stood the test of experience, and the fre- quent calls for new editions, prove conclusively that it is held by the profession and by students in the highest estimation. The present edition is not a mere reprint of former ones; the author has for some time been laboriously engaged in revising and making such alterations and additions as are required by the rapid pro- gress of our science, and the introduction of new terms into our vocabulary. In proof of this it is stated ' that the present edition comprises nearly two thousand five hundred subjects and term3 not contained in the last. Many of these had been introduced into medical terminology in consequence of the progress of the science, and others had escaped notice in previous revisions.' We think that the earnest wish of the author has been accomplished ; and that he has succeeded in rendering the work ' a satisfactory and desirable— if not indis- pensable—Lexicon, in which the student may search, without disappointment, for every term that has been legitimated in the nomenclature of the science.' This desideratum he has been enabled to attempt in suc- cessive editions, by reason of the work not being stereotyped; and the present edition certainly offers stronger claims to the attention of the practitioner and student, than any of its predecessors. The work is got up in the usual good taste of the publishers, and we recommend it in full confidence to all who have not yet supplied themselves with so indispensable an addition to their libraries "—The New York Journal of Medicine. A NEW EDITION OF DUNGLISON'S HUMAN PHYSIOLOGY. HUMAN PHYSIOLOGY, WITH THREE HUNDRED AND SEVENTY ILLUSTRATIONS. BY ROBLEY DUNGLISON, M.D., PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, ETC.,ETC. Sixth edition, greatly improved.—In two large octavo volumes, containing nearly 1350 pages. " It is but necessary for the Author to say, that all the cares that were bestowed on the preparation of the fifth edition have been extended to the sixth, and even to a greater amount. Nothing of importance that has been recorded since its publication, has, he believes, escaped his attention. Upwards of seventy illustrations have been added ; and many of the former cuts have been replaced by others. The work, he trusts, will be found entirely on a level with the existing advanced state of physiological science." In mechanical and artistical execution, this edition is far in advance of any former one. The illustrations have been subjected to a thorough revision, many have been rejected and their places supplied with superior ones, while numerous new wood-cuts have been added wherever perspicuity or novelty seemed to require them. , "Those who have been accustomed to consult the former editions of this work, know with how much care and accuracy every fact and opinion of weight, on the various subjects embraced in a treatise on Physiology, are collected and arranged, so as to present the latest and best account of the science To such we need hardly say, that, in this respect, the present edition is not less distinguished than those which have preceded it. In the two years and a half which have elapsed since the last or fifth edition appeared, nothing of consequence that has been recorded seems to have been omitted. Upwards of seventy illustrations have been added, and many of the former cuts have been replaced by others of better execution. These mostly represent the minute structures as seen through the microscope, and are necessary for a proper comprehension of the modern discoveries in this department"—The Medical Examiner. The " Human Physiology" of Professor Dunglison has long since taken rank as one of the medical classics in our language. Edition after edition has been issued, each more perfect than the Ian, till now we have the sixth, with upwards of seventy new illustrations. To say that it is by far the best text-book of physiology ever published in this country, is but echoing the general voice of the profession. It is simple and concise in style, clear in illustration, and altogether on a level with the existing advanced state of physiological science. The additions to the present edition are extremely numerous and valuable; scarcely a fact worth naming which has a bearing upon the subject seems to have been omitted. All the recent writers on physiology, both in the French, German and English languages, have been consulted and freely used, and the facts lately revealed through the agency of organic chemistry and the microscope have received a due share of attention. As it is, we cordially recommend the work as in the highest degree indispensable both to students and practitioners of medicine.—New York Journal of Medicine. The most full and complete system of physiology in our language.— Western Lancet. LEA & BLANCHARD'S PUBLICATIONS. 21 DUNGLISON'S THERAPEUTICS. NEW AND MUCH IMPROVED EDITION. GENERAL THERAPEUTICS AND MATERIA MEDICA. With One Hundred and Twenty Illustrations. ADAPTED FOR A MEDICAL TEXT-BOOK. BY ROBLEY DUNGLISON, M.D., Professor of Institutes of Medicine, &c. in Jefferson Medical College; Late Professor of Materia Medica, &C. in the Universities of Virginia and Maryland, and in Jefferson Medical College. Third Edition, Revised and Improved, in two octavo volumes, well bound. In this edition much improvement will be found over the former ones The author has subjected it to a tho- rough revision, and has endeavored to so modify the work as to make it a more complete and exact exponent ofthe present state of knowledge on the important subjects of which it treats. The favor with which the former editions were received, demanded that the present should be rendered still more worthy of the patronage of the profession, and this alteration will be found not only in the matter of the volumes, but also in the numerous illustrations introduced, and the gnieral improvement in the appearance ofthe work. •'This is a revised and improved edition ofthe author's celebrated book, entitled ' General Therapeutics;' an Recount of the different articles of the Materia Medica having been incorporated with it. The work has, in fact, been entirely remodelled, so that it is now the most complete and satisfactory exponent ofthe existing state of Therapeutical Science, within the moderate limits of a text-book, of any hitherlo published. What gives the work a superior value, in our judgment, is the happy blending of Therapeutics and Materia Medica as they are, or ought to be taught in all our medical schools; going no farther into the nature and commercial history of drugs, than is indispensable for the medical student. This gives to the treatise a clinical and practical charac- ter, calculated to benefit in the highest degree, both students and practitioners. We shall adopt it as a text- book for our classes, while pursuing this branch of medicine, and shall be happy to learn that it has been adopted as such, in all of our medical institutions "—The N Y. Journal of Medicine. "Our junior brethren in America will find in these volumes of Professor Dunglison, a 'Thesatjrus Medica- minum,' more valuable than a large purse of gold."— London Medico-Chirurgical Review. DUNGLISON ON NEW REMEDIES. NEW EDITION, BROUGHT UP TO OCTOBER 1846. NEW REMEDIES. BY ROBLEY DUNGLISON, M.D., &c. &c. Fifth edition, with extensive additions. In one neat octavo volume. The numerous valuable therapeutical agents which have of late years been introduced into the Materia Medica, render it a difficult matter for the practitioner to keep up with the advancement of the science, espe- cially as the descriptions of them are difficult of access, being scattered so widely through transactions of learned societies, journals, monographs, &c. &c. To obviate this difficulty, and to place within reach ofthe profession this important information in a compendious form, is the object ofthe present volume, and the num- ber of editions through which it has passed show that its utility has not been underrated. The author has taken particular care that this edition shall be completely brought up to the present day.— The therapeutical agents added, which may be regarded as newly introduced into the Materia Medica, to- gether with old agents brought forward with novel applications, and which may therefore be esteemed as '•New Remedies," are the following:—Benzoic Acid, Chromic Acid, Gallic Acid. Nitric Acid, Phosphate of Ammonia, Binelli Water, Brocchien Water, Atropia Beerberia, Chloride of Carbon (Chloroform), Digitalia, Electro-Magnetism, Ergotin, Ox-gall, Glycerin, Haemospasy, Haemostasis, Hagenia Abyssinica. Honey Bee, Protochloride Iodide phia and (Naphtha, A^eto"nV)'H^ of Zinc and Strychnia, Double Iodide of Zinc and Morphia, and Valerianate of Zinc. i •" A work like this is obviously not suitable for either critical or analytical review It is, so far as it goes a dispensatory, in which an account is given of the chemical and physical properties of all the articles recently added to the Materia Med ica and their preparations, with a notice of the diseases for which they are prescribed, the doses, mode of administration. &c."— The Medical Examiner. __________ T OR AIDS TO THE STUDY OF MEDICINE. A REVISED AND MODIFIED EDITION. BY ROBLEY DUNGLISON, M.D. In one neat \2mo. volume. 9 HUMAN HEALTH; nn TUF TXFT UFNCE OF ATMOSPHERE AND LOCALITY. CHANGE OF AIR AND CLIMATE, OR, rHVAsONS FOOD CLOTHING, BATHING AND MINERAL SPRINGS, EXERCISE, &£iA& SLEEP CORPOREAL AND INTELLECTUAL PURSUITS, &c. &c, ' ON HEALTHY MAN: CONSTITUTING ELEMENTS OF HYGIENE. BY ROBLEY DUNGLISON, M.D. A New Edition with many Modifications and Additions. In one Volume, 8vo. 22 LEA & BLANCHARD'S PUBLICATIONS. AMERICAN PRACTICE OF MEDICINE. BY PROFESSOR DUNGLISON. SECOND EDITION, MUCH IMPROVED. THE PRACTICE OF MEDICINE; A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. SECOND EDITION. By ROBLEY DUNGLISON, M. D. Professor of the Institutes of Medicine in the Jefferson Medical College; Lecturer on Clinical Medicine, 4"« In Two large Octavo Volumes of over Thirteen Hundred Pages. The Publishers annex a condensed statement of the Contents: Diseases ef the Mouth, Tongue, Teeth, Gums, Velum Palati and Uvula, Pharynx and CEsophagus, Stomach, Intestines, Peritoneum, Morbid Productions in the Peritoneum and Intestines—Diseases of the Larynx and Trachea, Bronchia and Lungs, Pleura, Asphyxia, Morbid Conditions of the Blood, Diseases of the Heart and Membranes, Arteries, Veins, Intermediate or Capillary Vessels.—Spleen, Thyroid Gland, Thymus Gland and Supra Renal Capsules, Mesenteric Glands.—Salivary Glands, Pancreas, Biliary Apparatus, Kidney, Ureter, Urinary Bladder.—Diseases of the Skin, Exanthematous, Vesicular, Bullar, Pustular, Papular, Squamous, Tuberculous, Maculae, Syphilides.—Organic Diseases of the Nervous Centres, Neuroses, Nerves.—Diseases of the Eye, Ear, Nose.—Diseases of the Male and Female Organs of Reproduction.—Fever.—Intermittent, Remittent, Continued, Eruptive, Arthritic, Cachectic, Scrofulous, Scorbutic, Chlorotic, Rhachitic, Hydropic and Cancerous. Notwithstanding the numerous and attractive works which have of late been issued on the Practice of Physic, these volumes keep their place as a standard text-book for the student, and manual of reference for the practitioner. The care with which the author embodies everything of value from all sources, the industry with which all discoveries of interest or importance are summed up in succeeding editions, ihe excellent order and system which is everywhere manifested, and the clear and intelligible style in which his thoughts are presented, render his works universal favorites with the profession. "In the volumes before us, Dr. Dunglison has proved that his acquaintance with the present facts and doctrines, wheresoever originating, is most extensive and intimate, and the judgment, skill, and impartiality with which the materials ofthe work have been collected, weighed, arranged, and exposed, are strikingly manifested in every chapter. Great care is everywhere taken to indicate the source of information, and under the head of treatment, formulae of the most appropriate remedies are everywhere introduced. In con- clusion, we congratulate the students and junior practitioners of America on possessing in the present volumes a work of standard merit, to which they may confidently refer in their doubts and difficulties."— Brit, and For. Med. Rev. " Since the foregoing observations were written, we have received a second edition of Dunglison's work, a sufficient indication ofthe high character it has already attained in America, and justly attained."— Ibid. "In the short space of two years, a second edition of Dr. Dunglison's Treatise on Special Pathology and Therapeutics has been called for. and is now before the public in the neat and tasteful dress in which Lea & Blanchard issue all their valuable publications. We do not notice the fact for the purpose of passing any studied eulogy upon this work, which is now too well known to the profession to need the commendation of the press. "A cursory examination will satisfy any one, that great labor has been bestowed upon these volumes, and on acareful perusal it will be seen that they exhibit the present state of our knowledge relative to special pathology and therapeutics. The work is justly a great favorite with students of medicine, whose exigencies the learned author seems especially to have consulted in its preparation."—Western Jour, of Med. and Surg. '• This is a work which must at once demand a respectful consideration from the profession, emanating as it does from one ofthe most learned and indefatigable physicians of our country. "This arrangement will recommend itself to the favorable consideration of all, for simplicity and com- prehensiveness. We have no space to go into details, and, therefore, conclude by saying, that although isolated defects might be pointed out, yet as a whole, we cheerfully recommend it to the profession, as embracing much important matter which cannot easily be obtained from any other source."— Western Lancet. Hasse's Pathological Anatomy. AN ANATOMICAL DESCRIPTION OF THE DISEASES OF THE ORGANS OF CIRCULATION AMD RESPIRATION. BY CHARLES EWALD HASSE, Professor of Pathology and Clinical Medicine in the University of Zurich, e}c. Translated and edited by VV. E. Swaine, M.D., tec. In one octavo volume. A new work, just ready—October, 1846. LEA & BLANCHARD'S PUBLICATIONS. 23 BRODIE'S SURGICAL WORKS. DELIVERED AT ST. GEORGE'S HOSPITAL By Sir BENJAMIN BRODIE, Bart., V. P. R. S., SERJEANT SURGEON TO THE QUEEN, ETC. ETC. IN ONE NEAT OCTAVO VOLUME. " It would not be easy to find in the same compass more useful matter than is embraced in each of these discourses, or indeed in this volume. We the less regret the limited extracts we have it in our power to make from it, because we feel sure that it will in a short time find its way into all the medical libraries in the country."—The Western Journal of Medicine and Surgery. LECTURES ON THE DISEASES OF THE URINARY ORGANS. SECOND AMERICAN FROM THE THIRD LONDON EDITION. WITH ALTERATIONS 1SD ADDITIONS. In One Small Octavo Volume, Cloth. This work has been entirely revised throughout, some ofthe author's views have been modified, and a considerable proportion of new matter has been added, among which is a lecture on the Operation of Lithotomy. PATHOLOGICAL AND SURGICAL OBSERVATIONS FROM THE FOURTH LONDON EDITION. toitr) trje &tttr)or1s Alterations anb Slbbitions. In One Small Octavo Volume, Cloth. "To both the practical physician and the student, then, this little volume will be one of much service, inas- much as we have here a condensed view of these complicated subjects thoroughly investigated by the aid of the light afforded by modern Pathological Surgery."— N. Y. Journal of Medicine. JKr These three works can be had bound together, forming a large volume ot BRODIE'S SURGICAL WORKS. MILLER'S SURGICAL WORKS. THE PRINCIPLES OF SURGERY. BY JAMES MILLER, F.R.S.E., F.R.C.S.E., Professor of Surgery in the University of Edtnburg, &c. In one neat 'octavo volume, to match the Author's volume on « Practice." « We feel no hesitation in expressing our opinion that it presents the philosophy of the science more fully and clearly than any other work in the language with which we are acqua,nted.»-P/u- ladelphia Medical Examiner.___________________ LATELY PUBLISHED. THE PRACTICE OF SURGERY. BY JAMES MILLER, Professor of Surgery in the University of Edinburg. In one neat octavo volume. This work is printed and bound to match the « Principles of Surgery," by Professor Miller, lately lms worK Prl,ueuisgued by L & B. Either volume may be had separately. . , v „„ ♦v.^mo a nnmnlptp text-book of surgery, and has been under- « This work, with the preceding; one form a =omP[^xJ °°°we are * Je8tly inforrned in the taken by the author at the ^"^"S^ j^on practical surgery which already exist, preface it is not put forth, m nvd y of the excel e^rwork. p^ ^ J^ ^ formidab] we trunk we may tak%«h does not offe/the same attractive illustrations, with which some of rival to most of them Wh e it ^e.9 "^/Vnd while it will not, as indeed is not its design, set our recent text-books have ^een embelIwhed, ™* ^^ th'e fession ■„ jn possession of, aside the more c°mPletn%a"?.^ form, together, a more complete text-book :reX^^^&^b^ron offereU to th* student--ne ^nj°™1 ctf Medicine. 24 LEA & BLANCHARD'S PUBLICATIONS. CARPENTER'S NEW WORK. A MANUAL, OR ELEMENTS OF PHYSIOLOGY, UrCLUDUVG PHYSIOLOGICAL JlJTjlTOJlIir, FOR THE USE OF THE MEDICAL STUDENT. BY WILLIAM B. CARPENTER, M. D., F. R. S , FULLERIAN PROFESSOR OF PHYSIOLOGY IN THE ROYAL INSTITUTION OF GREAT BRITAIN, ETC. Wifhone hundred and eighty illustrations. In one octavo volume of 566 pages. Elegantly printed to match his " Principles of Human Physiology." This work, though but a very short time published, has attracted much attention from all engaged in teach- ing the science of medicine, and has been adopted as a text-book by many schools throughout the country.— The clearness and conciseness with which all the latest investigations are enunciated render it peculiarly well suited for those commencing the study of medicine. It is profusely illustrated with beautiful wood en- gravings, and is confidently presented as among the best elementary text-books on Physiology in the lan- guage. The merits of this work are of so high an order, and its arrangement and discussion of subjects so admi- rably adapted to the wants of students, that we unhesitatingly commend it to their favorable notice. This work studied first, and then followed by the more elaborate treatise of Dunglison. or Muller, or others of similar character, is decidedly the best course for the student of physiology.—The Western Lancet. CARPENTER'S HUMAN PHYSIOLOGY. PRINCIPLES OF HUMAN PHYSIOLOGY, WITH THEIR CHIEF APPLICATIONS TO PATHOLOGY, HYGIENE, AND FORENSIC MEDICINE. BY WILLIAM B. CARPENTER, M. D., F. R. S., &c. Second American, from a New and Revised London Edition, WITH NOTES AND ADDITIONS, BY MEREDITH CLYMER, M. D., &c. Willi Tico Hundred and Sixteen Wood-cuts and other Illustrations. In one octavo volume, of about 650 closely and beautifully printed pages. The very rapid sale of a large impression of the first edition is an evidence of the merits of this valuable work and that it has been duly appreciated by the profession of this couniry The publifhers hope that the present edition will be found still more worthy of approbation, not only from the additions of the author and editor, but also from its superior execution, and the abundance of its illustrations. No less than eiglity-five wood-culs and another lithographic plate will be found to have been added, affoiding the most material assist- ance to the student. " Wehave much satisfaction in declaring our opinion that this work is the best systematic treatise on phy- siology in our own language, and the best adapted for the student existing iu any language."— Medico- Chirurgi- cal Review of London. "The work as it now stands is the only Treatise on Physiology in the English language which exhibits a clear and connected, and comprehensive view of the present condition of that science."— London and Edin- burgh Monthly Journal. SUPPLEMENT TO THE ENCYCLOPEDIA AMERICANA, UP TO THE YEAR 1847. ENCYCLOPEDIA AMERICANA-Supplementary Vol, A POPULAR DICTIONARY OF ARTS, SCIENCES, LITERATURE. HISTORY, POLITICS AND BIOGRAPHY. VOL. XIV. Edited by HENRY VETHAKE, LL. D., Vice-Provost and Professor of Mathematics in the University of Pennsylvania, Author of "A Treatise on Poli- tical Economy." In One large Octavo Volume of over Six Hundred and Fifty double columned pages. The numerous subscribers who have been waiting the completion of this volume can now perfect their sets, and all who want a Register of the Events of the last Fifteen Years, for the Whole World, particularly embracing interesting scientific investigations and discoveries, can obtain this volume separately, price Two Dollars uncut in cloth, or Two Dollars and Fifty Cents in leather, to match the styles in which the publishers have been selling sets. Subscribers in the large cities can be supplied on application at any ofthe principal bookstores ; and persons residing in the country can have their sets matched by sending a volume in charge of friends visiting the city. Complete sets furnished at very low prices in various bindings. "The Conversations Lexicon (Encyclopaedia Americana) has become a household book in all the intelli- gent families in America, and is undoubtedly the best depository of biographical, historical, geographical and political information of that kind which discriminating readers require. There is in the present volume much matter purely scientific, which was all the more acceptable to us that it was unexpected.£—Silliman's Journal. LEA & BLANCHARD'S PUBLICATIONS. 25 FOWNES' CHEMISTRY FOR STUDENTS. ELEMENTARY^ CHEMISTRY. THEORETICAL AND PRACTICAL. * BY GEORGE FOWNES, Ph. D., # Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. With Numerous Illustrations. Edited, with Additions, BY ROBERT BRIDGES, M.D., Professor of General and Pharmaceutical Chemistry in the Philadelphia College of Pharmacy, &c. &c. ln one large duodecimo volume, sheep or extra cloth. Though this work has been so recently published, it has already been adopted as a text-book by many ofthe Medical Institutions throughout the couniry. As a work for the first class student, and as an introduction to the larger systems of Chemistry, such as Graham's, there has been but one opinion expressed concerning it. and it may now be considered as ° ^ THE TEXT-HOOK FOR THE CHEMICAL STUDEJVT. An admirable exposition of the present state of chemical science, simply and clearly written, and display- ing a thorough practical knowledge of Hs details, as well as a profound acquaintance with its principles. The illustrations, and the whole getling-up of the book, merit our highest praise."-British and Foreign Medical Review. or » " Remarkable for its clearness, and the most concise and perspicuous work of the kind we have seen, admi- rably calculated to prepare ihe student for the more elaboraie treatises."—Pharmaceutical Journal. This work of Fownes, while not enlarging on the subject as much as Graham, is far more lucid and expanded, than the usual small introductory works. Persons using it may rely upon its being kept up to the day by fre- quent revisions. GRAHAM'S CHEMISTRY. THE ELEMENTS~~OF CHEMISTRY. INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. With Numerous Illustrations. Br THOMAS GRAHAM, F. R. S. L. and E. D., Professor of Chemistry in University College, London, &c. &c. WITH NOTES AND ADDITIONS, Bt ROBERT BRIDGES, M. D., &c. &c. In one volume octavo. SIMON'S CHEMISTRY OF MAN. A KIM A Si CHBMISTR1T, WITH REFERENCE TO THE PHYSIOLOGY AND PATHOLOGY OF MAN. BY DR. J. FRANZ SIMON. TRANSLATED AND EDITED BY GEORGE E. DAY, M. A. & L. M. Cantab., &c. With plates. In one octavo volume, of over seven hundred pages, sheep, or in two parts, boards. This important work is now complete and may be had in one large octavo volume. Those who obtained the first part can procure the second separate. " No treatise on physiological chemistry approaches, in fulness and accuracy of detail, the work which stands at the head of this article. It is the production of a man of true German assiduity, who has added to his own researches the results of the labors of nearly every other inquirer in this interesting branch of science— The death of such a laborer, which is mentioned in the preface lo the work as having occurred prematurely in 1S42, is indeed a calamity to science. He had hardly reached the middle term of life, and yet had made himself known all over Europe, and in our country, where his name has been familiar for several years as among the most successful of the cultivators of the Chemistry of Man.....It is a vast repository of facts to which the teadher and student may refer with equal satisfaction."—The Western Journal of Medicine and Surgery. " The merits of 1he work are so universally known and acknowledged,»as to need no further commendation at our hands."—iV. Y Journal of Medicine and Surgery. THE CHEMISTRY OF TEE FOUR SEASONS—A NEW WORK. THE CHEMISTRY OF THE FOUR SEASONS, SPRING, SUMMER, AUTUMN AND WINTER. AN ESSAY PRINCIPALLY CONCERNING NATURAL PHENOMENA ADMITTING OF ILLUSTRATION BY CHEMICAL SCIENCE. AND ILLUSTRATING PASSAGES OF SCRIPTURE. BY THOMAS GRIFFITHS, Professor of Chemistry in the Medical College of St. Bartholomew's Hospital, &e. In One very neat Volume, royal 12mo., of Four Hundred and Fifty large Pages, extra cloth, illus- trated with numerous Wood-cuts. " We would especially recommend it to youths commencing the study of medicine, both as an incentive to their natural curiosity and an introduction to several of those branches of science which will necessarily soon occupy their attention We would notice further, and with commendation, that a sound and rational natural theology is spread through the whole work."— The British and Foreign Medical Review. "•This interesting and altractive volume is designed to illustrate by easy and familiar experiments, and in nonular language, many of the phenomena going on in the realm of nature through the ever-varying year, and to exemplify and explain many beautiful scriptural allusions involving the play of chemical and philosophical laws Nor has the gifted author failed in accomplishing his laudable purpose. His agreeable style, the cor- rectness of his philosophical views, and especially the high moral and religious bearing of his work, cannot but secure for him the commendation and patronage of the intelligent and virtuous."— Southern Medical and Surgical Journal. 26 LEA & BLANCHARD'S PUBLICATIONS. LECTURES ON THE OPERATIONS OF SURGERY. AND ON ' DISEASES AND ACCIDENTS REQUIRING OPERATIONS, DELIVERED AT UNIVERSITY COLLEGE, LONDON. BY ROBERT LISTON, Esq., F. R. S., &c. EDITED, WITH NUMEHOUS ALTERATIONS AND ADDITIONS, BY T. D. MUTTER, M. D., Professor of Surgery in the Jefferson Medical College, Philadelphia. In One Large and Beautifully Printed Octavo Volume. WITH TWO HUNDRED AND SIXTEEN ILLUSTRATIONS ON WOOD. More than ene-third of this volume is by Professor Mutter, embodying elaborate treatises on Plastic Operations, Staphyloraphy, Club-Foot, Diseases ofthe Eye, Deformities from Burns, &c. &c. A SYSTEM OP PRACTICAL £TTK,G£ItY. BY WILLIAM FERGUSSON, F. R. S. E. SECOND AMERICAN EDITION, REVISED AND IMPROVED. With Two Hundred and Fifty-two Illustrations from Drawings by Bagg, Engraved by Gilbert, With Notes and Additional Illustrations, BY GEORGE W. NORRIS.M. D.,&c. In one beautiful octavo volume of six hundred and forty large pages. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, IN REFERENCE TO THE PROCESS OF PARTURITION. ILLUSTRATED BY One hundred and forty-eight Large figures on 55 lithographic Plates. BY FRANCIS H. RAMSBOTHAM, M. D., &c. A NEW EDITION, FROM THE ENLARGED AND REVISED LONDON EDITION. In one large imperial octavo volume, well bound. Philadelphia, August 6th, 1845. Messrs. Lea. & Blanchard. Gentlemen :—I have looked over the proofs of Ramsbotham on Human Parturition, with its important im- provements, from the new London edition. This Work needs no commendation from me, receiving, as it does, the unanimous recommendation ofthe British periodical press, as the standard work on Midwifery; "chaste in language, classical in composition, happy in point of arrangement, and abounding in most interesting illustrations." To the American public, therefore, it is most valuable—from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our eountry. There is, however, a portion of Obstetric Science to which sufficient attention, it appears to me, has not been paid. Through you, I have promised to the public a work on this subject, and although the continued occupa- tion of my time and thoughts in the duties of a teacher and practitioner have, as yet prevented the fulfilment of the promise, the day, I trust, is not distant, when, under the hope of being useful, I shall prepare an account of the Mbchanism of Labor, illustrated by suitable engravings, which may be regarded as an addendum to tha standard works of Ramsbotham, and our own Dewees. Very respectfully, yours, HUGH L. HODGE, M.D., Professor of Obstetrics, <$•<:. SfC, in the University of Pennsylvania. PROFESSOR CHAPMAN'S''WORKS ON PRACTICE. A COMPENDIUM OF LECTURES ON THE THEORY AND PRACTICE OF MEDICINE. DELIVERED BY PROFESSOR CHAPMAN IN THE UNIVERSITY OF PENNSYL- VANIA. PREPARED, WITH PERMISSION, FROM DR. CHAPMAN'S MA- NUSCRIPTS, AND PUBLISHED WITH HIS APPROBATION, By N. D. BENEDICT, M. D. In one very neat octavo volume. |3" This work contains the diseases not treated of in the two following. LECTURES ON THE MORE IMPORTANT DISEASES OF THE THORACIC AND ABDOMINAL VISCERA. Delivered in the University of Pennsylvania, by N. Chapman, M. D., Professor of the Theory and Practice of Medicine, &c. In one volume, octavo. LECTURES ON THE MORE IMPORTANT ERUPTIVE FEVERS, HEMORRHAGES AND DROPSIES, AND ON GOUT AND RHEUMATISM, Delivered in the University of Pennsylvania by N. Chapman, M. D., Professor of the Theory and Practice of Medicine, &c. &c. In one neat octavo volume. LEA & BLANCHARD'S PUBLICATIONS. 27 A NEW MEDICAL DICTIONARY. In one Volume, large 12mo,, now ready, at a low price. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES; BY RICHARD D. HOBLYN, A. M., Oxon. FIRST AMERICAN, FROM THE SECOND LONDON EDITION. REVISED, with numerous additions, BY ISAAC HAYS, M D., Editor of the American Journal of the Medical Sciences. A NEW AND COMPLETE WORK ON FEVERS. 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D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, 8[c. S^c. In one large volume, 8vo. TTOV&TT OJY THE DOG. THE~DOC. BY WILLIAM YOUATT. WITH NUMEROUS AND BEAUTIFUL ILLUSTRATIONS. EDITED BY E. J. LEWIS, M. D., &c. &c. In One beautifully printed Volume, Crown Octavo, with Twenty .four Plates, done up in richcrim- son extra cloth. " With this explanation of his connection with the work he leaves it, in the hope that it may prove of value to the sportsman from its immediate relation to his stirring pursuits; to the general reader from the large amount of curious information collected in its pages; and to the MEDICAL STUDENT from the light it sheds on the PATHOLOGY AND DISEASES ofthe dog, by which he will be surprised to learn how many ills that animal shares in common with the human race."— Editor's Preface. LANDRETH'S J0HNS0N'S_GARDENERS' DICTIONARY. JUST READY. A DICTIONARY OF MODERN GARDENING, BY GEORGE WILLIAM JOHNSON, Eso.., Fellow ofthe Horticultural Society of India, &c. &c. With One Hundred and Eighty Wood-Cuts. edited, with numerous additions, BY DAVID LANDRETH, of Philadelphia. In the American edition, many modifications and additions have been made, so as to render the work a com- plete and satisfactory book of reference upon every subject connected with modern gardening in its most ex- tended sense; while great care has been exercised in adapting ittothe practice of every section of thiscountry. Numerous wood-cut illustrations have been added, and the publishers present a beuunful volume of near 650 pages, in a clear but small type, well done up in exira cloth, and at a very low price. Such a work has long been needed by the many persons who cannot afford to purchase the large expensive work of Loudon. Sold by all Booksellers, Nurserymen and Seedsmen in the United States. CONTENTS OF THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, For tfpril, 1847. Memoirs and Cases—Art. I. History of seven cases of Pseudo-membranous Laryngitis, or True Croup. By J. F. Meigs, M. D. II. Poisonous Properties ofthe Sulphate of Quinine. By Wm. O. Baldwin, M. D. III. Removal ofthe Superior Maxilla for a tumour of the antrum; Apparent cure. Return of the disease. Second operation. Sequel. By J. Marion Sims, M. D. [With a wood-cut.] IV. Laceration ofthe Perineum. By John P. Mettauer, M. D. V. Report of Cases treated in Cincinnati Commercial Hospital. By John P. Harrison, M. D. VI. Surgical Cases. By Geo. C. Ulackman, M.D. [Witha wood-cut.] VII. Cases of Paralysis peculiar to the Insane. By Pliny Earle. M. D. VIII. Contributions to Pathology ; being a Report of Fatal Cases taken from the records ofthe U. S. Naval Hospital, New York. By W. S. W. Ruschenber^er, M. D. IX. Case of Hydrops Pericardii suddenly formed, with Remarks. By S. Jackson, M. D. X. Case°of Tuber- cles in the pericardium, vena cava, columnae carneae, pleura, lungs, liver, &c, with Meningitis. By J. D. Trask, M. D. XI. On letting Blood from the Jugular in the Diseases of Children. Bv Charles C. Hildreth. M.D. ' Review.—XII. Lectures on Subjects connected with Clinical Medicine; comprising Diseases of the Heart. By P. M. Latham, M. D. ° Bibliographical Notices.—XIII. Green on Diseases ofthe Air Passages. XIV. Condie on the Diseases of Children. Second edition. XV. Royle's Materia Medica and Therapeutics. Edited by Carson. XVI. Vogel's Pathological Anatomy ofthe Human Body. Translated, with additions, by George E. Day. XVII. Trans- actions of the College of Physicians of Philadelphia. From September to November, 1646 inclusive. XVIII. Wharton Jones on the Principles and Practice of Ophthalmic Medicine and Surgery. ' Edited by Isaac Hays, M.D. XIX. Wood on the Practice of Medicine. XX. Wernher's Manual" of General and Special Surgery. XXI. Baumgarten's Surgical Almanac for the years le<14 and lt45. XXII. Wilson's System of Human Anaiomy, General and Special. Third American from the third London edition. Edited by Paul B Goddard, M. D. XXIII. Von Behr's Handbook of Human Anatomy, General, Special and Topographical. Translated by John Birkett. LEA & BLANCHARD'S PUBLICATIONS. 31 Contents of the Medical Journal Continued. QUARTERLY RETROSPECT, A SUMMARY OF THE IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. Foreign Intelligence—Anatomy and Physiology—1. Quekett on Intimate Structure of Bone. 2. Meckel on Process of Secretion. 3. Blondlot on the Properties of the Bile. 4. Bainbrigge on Supplementary Spleen, death from the patient being placed in the supine position. 5. Robinson on the Nature and Source of the contents ofthe Foetal Stomach. 6. Prof. Bischoff on the Absorption of Narcotic Poisons by the Lymphatics, Materia Medica and Pharmacy.—7. Battley on Syrup of Iodide and Chloride of Iron. 8. Ricord on Bro- mide of Potassium as a substitute for the Iodide. 9. Voillemier on Santonine. 10. Guibourt on the changes of composition which the Tincture of Iodine undergoes in keeping. 11. Melion on the Action of the Acetate of Morphia on Children. Medical Pathology and Therapeutics and Practical Medicine.—12. Bennett on Anormal Nutrition and Diseases of the Blood. 13. Rostan on Acute Spinal Myelitis. 14. Rostan on Curability of Hypertrophy of the Heart. 15. Crisp on Rupture of the left Ventricle of the Heart. 16. Francis on Aneurism of the Basi- lar Artery. 17. Lombard's Observations on Sudden deaths, probably dependent on Diseases of the Heart and large Blood-vessels. IS. Carson on Obliteration of the Vena Cava Descendens. 19. Thompson on Treatment of Chronic Bronchitis and Bronchial Asthma. 20. Muhlbauer's Microscopic Researches on the Absorption of Pus. 21. Briquet on Mercurial Ointment in Variola. 22. Bell on Rupture of Lateral Sinus of Dura Mater. 23. Watts on Tubercles in Bones. 24. Gendrin on Hysterical Affections. 25. Cottereau's Remedy for Toothache. 26. Prof Trousseau on Anatomy of Pneumonia in Infants. 27. Volz on Hooping Cough an Exanthemata. 28. Crisp on Infantile Pleurisy. 29. Youl on Abscess of the Brain in a Child. 30. Trousseau on the Employment of Nux Vomica in the Treatment of St. Vitus' Dance. Surgical Pathology and Therapeutics and Operative Scrgery.—31. Prof. Syme on Amputation at the Shoulder Joint for Axillary Aneurism. 32 Whipple on Amputation at the Hip Joint. 33. Prof. Ehr. mann on Successful Extirpation of a Polypous Tumour of the Larynx. 34. Bellingham on Compression in Aneurism. 35. Orr's Case of Tracheotomy. 36. Holmes Coote on Cancer of the Breast in the Male. 37. Moore on Gunshot wound ofthe Lung, where the ball lodged fifty years. 33. On the Employment of Iodide of Potassium in the Treatment of Syphilis. 39. Application of ice in the treatment of injuries. 40. Lenoir on Ununited Fracture successfully treated by Acupuncturation. 41. Prof. Syme on Amputation of the Thigh. 42. Curling's Case of Fatal Internal Strangulation caused by a cord prolonged from a Diverticulum of the Ileum. 43. Golding Bird and John Hilton on Case of Internal Strangulation of Intestine relieved by Opera- tion. 44. Fergusson on Strangulated Congenital Hernia in an infant seventeen days old, requiring opera- tion. 45. Guersant, Jr., on Surgical Treatment of Croup. 46. Geoghegan on Partial Amputation ofthe Foot. 47. Report of a Committee of the Surgical Society of Ireland, relative to the use and effects of Sulphuric Ophthalmology.—48. Prof. Jacob on Foreign Bodies in the Eye. 49. Dixon's Remarkable Case of Injury ofthe Eye. 50.' Szokalski on Obscurations ofthe Cornea in their Histological relations with reference to the Practice of Ophthalmic Surgery. 51. Berncastle on Amauro sis from Hydatid Cyst in the Brain. Midwifery.—52. Robiquet on Remarkable case of spontaneous rupture of the Uterus during labour—Re- covery. 53. Le Chaptois' Case of Vaginal Entero-hysterocele reduced by taxis, and maintained in place by the introduction of sponges in the Vagina. 54. Kuhne on Rupture of the Uterus—abdominal section— recovery. 55- Czajewski on Wound of the Gravid Uterus—premature delivery—peritonitis—recovery. 56. Bennett on Inflammatory Ulceration of the Cervix Uteri during Pregnancy, and on its Influence as a Cause of Abortion. 57. Caesarian Operation performed by Mr. Skey, at St. Bartholomew's Hospital, the patient being rendered insensible by ether. 58. Pochhammer on Congenital protrusion of the Liver through the umbilical ring. 59. Caesarian Section. 60. Roux on Lacerated Perineum. 61. Depaul on Asphyxia neona- torum. 62. Klencke on Diet in Infancy. Medical Jurisprudence and Toxicology.—63. Taylor on Contested identity determined by the teeth. 64. Blake on Poisons. 65. Delirium Tremens in an Infant. 66. Hamilton on the Echites Suberecta. 67. Dupasquier on Vapours of Phosphorus, Lucifer Matches. 68. Thompson on the mode of testing the presence of minute quantities of Alcohol. 69. Invalidity of a Contract made by a Lunatic. 70. Procuring of Abortion. 71. Lepage's Case of Poisoning by Arsenic relieved by the use of Magnesia. 72. Sale of Poisonous Sub- Medical Education.—73. The Edinburgh Statutes regarding the Degree. 74. Medical Organization in Foreign Correspondence.—Letters to the Editor from London. Sulphuric Ether in Surgical Operations American Intelligence—Original Communications.—Parkman's Anatomical Anomaly. Tyler's Ante- version ofthe Womb with adhesion of Os Uteri to body of 4th Lumbar Vertebra, &c. . Domestic Summary —Beck on Effects of Mercury on the Young Subject. Brainard on Amputation for Scrofulous Diseases of the Joints. Baker on Case of Vicarious Menstruation from an Ulcer on the right Mamma Allen on Singular case of laceration of the Broad Ligaments. WLean on Blindness caused by the use of Sulphate of Quinine. Harrison's Speculations on the Cause of Yellow Fever. Hernck oni Foreign Bodies in the Organs and Tissues of the Body. Swell on Case of Empyema in which the operation for Para- centesis Thoracis failed from a cause not generally noticed. M'Pheeters on Rheumatism, with Hypertrophy of both eve* Draper on the Cause of the Circulation of the Blood. Little on Ischuria Renalis. Hogan on S rvchnine'i'n Chorea. Deaderick on Excision ofthe Inferior Maxillary Bone for Osteo-Sarcoma. Cain on Imperforate Prepuce. Couper on Medical Schools of the United States Warren on Inhalation of Ether Burwell'onT Absence of one Kidney. Brainard on Dislocation of the Elbow Gilmin on Presentation of the sTouWe,--prolapsed Cord-cord not pulsating, yet child born alive. National Medical Convent.on. Dele-ate^Tto National Medical Convention. Arrangements for the Meeting of the National Medical Con- vention. Resignation of Professor Warren. New Medical Books. LEA &. BLANCHARD, Philadelphia. THE TEKMS ARE For the Medical Journal and the Medical News, if paid for in advance, (owing to the time of iLuing this advertisement, this year, amounts remitted before the first of July willbe con- ^ Fof trelo^rnaronlT/when ordered without'funds,'or whe'n paid'for after the first of July, * FWe Dollars. For thl Medical News only, to be paid for free of postage, and always in advance, - One Dollar. ID- I„ „o case: can^News be sent^^ft^^iS. the Journal and the News for 1847 and X^^Vx^X^^^Xvi^ fohm, containing the first 228 pages of Todd and Bow- man's Physiology. Philadelphia, May, 1847 Five Dollars. 32 LEA & BLANCHARD'S PUBLICATIONS. Two Medical Periodicals for Five Dollars a Year. ONE GIVEN GRATIS. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, EDITED BY ISAAC HAYS, M. D., IS PUBLISHED QUARTERLY, ON THE FIRST OF JANUARY, APRIL, JULY AND OCTOBER. The number for January last contained over THREE HUNDRED large octavo pages, with two plates; that for April consisted of two hundred and seventy-two pages. Illustrations on copper, stone, wood, &c. are freely given, wherever required, and the whole is printed on fine white paper, with clear type. ALSO, THE MEDICAL NEWS AND LIBRARY! A MONTHLY PERIODICAL OF THIRTY-TWO LARGE OCTAVO PAGES, WITH NUMEROUS WOOD-CUTS, Is given gratis to subscribers to the Journal, who pay in advance Five Dollars, free of expense to the publishers. It will thus be seen that subscribers obtain about FIFTEEN HUNDRED large sized and solid octavo pages per annum, illustrated with fine engravings on wood, &c, for the love price of Five Dollars a year; rendering these altogether among the CHEAPEST MEDICAL PERIODICALS PUBLISHED. The Medical Journal is now in the twenty-ninth year of its existence, during the whole of which time it has commanded the approbation of the profession at home and abroad. Appearing quarterly, its object is to furnish its readers with a full and accurate resume' of all interesting investigations and discoveries made during the intervals, together with a choice selection of original papers. To this end, its pages are first devoted to ORIGINAL COMMUNICATIONS, from correspondents in all parts ofthe Union, among whom it has numbered a large proportion of the pro- minent members of the profession for many years past; it then furnishes REVIEWS and BIBLIOGRA- PHICAL NOTICES of all new works of interest; and lastly, it presents a very full and extended QUAR- TERLY SUMMARY, consisting of a RETROSPECT AND ABSTRACT OF THE PROGRESS OF THE MEDICAL SCIENCES, CAREFULLY COLLECTED FROM ALL THE FOREIGN AKD DOMESTIC JOURNALS. This department is considered so practically useful, that no exertion is spared to render it as complete as possible, so that both in extent and variety it may compare with any publications of a similar kind. The shorter periods at which this journal appears, enables us to anticipate, by several months, from the original sources, a large portion of the intelligence contained in the semi-annual publications of BRAITHWAITE and RANKING, and the Annual Reports in the BRITISH AND FOREIGN MEDICAL REVIEW, DUB- LIN MEDICAL JOURNAL, &c, and whatever of value is found in them, of which the original accounts have not reached us, is at once taken and laid before our readers; besides much AMERICAN INTELLI- GENCE, which is not likely to find its way across the Atlantic. The arrangements of the publishers for the supply ofthis department, by purchase and exchange, are very extensive, embracing the principal Periodicals of GREAT BRITAIN, FRANCE, GERMANY, DENMARK, ITALY, the EAST INDIES, &c.; besides ALL THE AMERICAN JOURNALS: And especial attention will be given to make it as complete a digest as possible, of all the IMPROVEMENTS AND DISCOVERIES IN MEDICAL SCIENCE. Besides this, subscribers have the advantage of THE IffiONTBLY NEWS, Which furnishes the lighter and floating information, and embraces important books for The Library Department. The work now passing through its columns is TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN, WITH NUMEROUS LARGE AND BEAUTIFUL WOOD-CUTS. Each work in the Library is regularly paged, so as to be bound separately. V ^ ^QflQ^>* A .^ NLM032778100