may be necessary to inject several times before the whole of the wax is washed out.

We would observe that hardened wax frequently escapes the notice of the surgeon and suspicion of the patient. We frequently see persons treated for affections of the head or for inflammatory conditions of the ear, in whom the sole disorder is a collection of cerumen in the meatus. We have always found it useful to have oil dropped into the ear night and morning, for two or three days before and after the syringing. A second syringing is generally necessary.

Dr. Williams enumerates the symptoms of inflammation of the Eustachian tube thus there is great pain in mastication and deglutition; the patient is unable to force air into the tympanum, when the mouth and nostrils are closed there is constant noise in the ear; the tympanum is generally more or less involved; and if the inflammation run high, the external meatus becomes painful upon pressure. The patient is unable to judge of the pitch or tone of his voice, and speaks in an unusual, and generally very loud key. The antiphlogistic treatment, and more particularly emeto-cathartics, are required-gargles should be constantly used-and in some cases it will be advisable, as soon as the more acute inflammation has subsided, to inject warm water into the Eustachian tube, as it frequently happens that this tube becomes filled up with thick mucus, which, if allowed to remain, keeps up irritation, and, in the course of time, permanently obliterates this canal.

Dr. Williams makes the following judicious remarks on the operation of injecting condensed air through the Eustachian tube into the tympanum—an operation which has become but too notorious.

"It has lately been much advocated by some of our own countrymen; and since this thesis was written, has been rendered but too public in consequence of its injudicious application. That the air acts on the tympanum as a very powerful stimulus is at once evident, from the numerous cases of inflammation which have been caused by its injection. It will require the sanction and experience of honest men, before we can admit of contradictory results to those obtained by M. Itard and others, who have not found it of use in a single case." 196.

Here we must close our notice of this fresh contribution to aural surgery. Dr. Williams has expended a good deal of labour and research upon the work, but we cannot compliment him on that lucidus ordo, and strict condensation which compilations should display. Practice will improve him, and we hope that a future edition will be characterised by the absence of what are very remediable defects.

A SYSTEM OF PRACTICAL MEDICINE, COMPRISED IN A SERIES OF ORIGINAL DISSERTATIONS. Arranged and Edited by Alexander Tweedie, M.D. F.R.S. Octavo, pp. 440. Whittaker, April, 1840.

We have some doubt as to the propriety of the term " original dissertations" in the title-page of this work. If dissertations on fever, inflammation, and many other diseases be original, they must necessarily omit nine-tenths of the accumulated experience of the medical world, from the days of Hippocrates to the present time. But the fact is that the work under review is a compilation, and a compilation like that of Copland and its predecessor the Cyclopædia, interlarded with the peculiar views of the individual compiler. This observation implies no censure or discreditquite the contrary. In works of this kind every thing depends on the judg ment and industry of the compiler. Neither judgment nor industry will do alone. They must be combined. They can hardly ever be expected, however, in due proportion in the same individual. A high rate of judgment based on experience, often leads to laziness of research-while incessant researches among books often bewilders even the best judgment.

If the succeeding volumes of the "LIBRARY OF MEDICINE " keep pace in merit with this first one, we predict that the whole will attain a high reputation and an extensive circulation. We are free to confess, indeed, that in these dissertations, or whatever else they may be called, the materials selected from preceding writers are so well worked up, so amalgamated, and so artfully moulded, as to resemble very much Original Essays. The great majority of the writers in this volume stand high in the opinion of their brethren, and though several of them are actively engaged in the exercise of an extensive and fatiguing practice, they do not appear to have spared the midnight oil or the labour of cogitation, in the articles allotted to them. It cannot be expected that we can analyze an elementary work, however artfully cast in the moulds of originality; yet there are more than one or two dissertations in this volume, to which we shall dedicate separate articles, as soon as we can spare space and time.

The

"PATHOLOGICAL INTRODUCTION by Dr. Symonds, comprises in the space of 52 pages, a body of valuable facts and observations which, by a practised writer, might have been spread over three goodly octavos, if well swelled out with long quotations. The object of it is to facilitate the study of diseases by exhibiting a brief view of their more simple or elementary forms. There is no doubt that the student is greatly embarrassed on the very threshold of his studies, by numerous terms which require, each, a dissertation rather than a dictionary for explanation. Thus, what idea can be formed of "congestion," "inflammation," "hypertrophy," hypertrophy," "plethora," &c. without a full explanation of the nature and causes of these states or conditions of the system. One or two extracts will serve as specimens of the manner in which our author has executed this part of the work.

"Revulsion is exemplified in such cases as the following:-congestion of the cerebral capillaries may be removed by congestion in the hæmorrhoidal vessels; subacute inflammation of the bronchial membrane by a cutaneous No. LXV. G

eruption; dropsy of the peritoneum by diarrhoea; a spasm of the bronchial fibres by dysphoria, or fidgets. We have known an inveterate asthma which had existed for years superseded by tic-douloureux. Blisters, issues, and setons, are artificial measures intended to imitate the curative operation of one diseased action upon another. Hence they are called revulsives, or counterirritants. The establishment of a secondary affection to the exclusion of the primary is manifestly the very opposite of sympathy, in which there is a reci. procal maintenance of the diseased conditions. It occurs more frequently in parts of similar anatomical constitution, as when irritation of the skin relieves that of a mucous membrane. We think, also, that the relation is oftener manifested between actions similar in kind: thus a rubefacient is better adapted for the removal of internal congestion than of a suppurative disorder, for which a seton or issue would be more appropriate." 6.

"Metastasis is often confounded with revulsion, but it differs from the latter in the fact, that the second action is not observed until the first has disappeared. The name implies change of place; and, at the time of its introduction, the prevalent belief was, that when a disorder changed its seat, a morbific matter had been transplanted from one part to another. The subsidence of a cutaneous eruption may be followed by inflammation of the bronchial membrane, and a similar relation may be observed between the latter and inflammation of the mucous surface of the intestine. The sudden cessation of hæmorrhois may induce disorder of the brain, such as a transient giddiness, or a fatal apoplexy. Metastasis is observed to occur more frequently in some diseases than in others, as in the instances of gout and rheumatism flying from part to part.

The pathology of these affections is somewhat too complicated to be entered upon at present. We must content ourselves with stating what we consider to be the law of metastasis; namely, that the liability of a disease to metastasis is in an inverse ratio with its dependence upon local causes; whence it may be inferred, that the occurrence implies a fault in the general system. In a plethoric subject, the removal of a determination of blood to a particular part by means which do not reduce the quantity of nutritive fluid, is very easily succeeded by similar disease in some other organ. Congestions dependent upon irritability of the nervous system are likewise migratory. We shall find the principle of very extensive application in pathological inquiries. There are cases, however, in which the cessation of a purely local affection is almost certainly followed by disease elsewhere. We allude to those in which a disease has been so long fixed in an organ as to have become a sort of necessary function to the whole system, or in which other parts have gradually become accommodated to it, so that upon its removal the harmony is again disturbed. Thus an ulcer may have existed so long that either the whole quantity of the blood, or the relative distribution of it to the several organs, has been adjusted to the action on the morbid secreting surface. The healing of the ulcer is, therefore, very likely to cause excessive determination to some internal organ; and that such events often take place in this order is matter of every day's experience." 7.

The author then proceeds to consider "diseases of the capillary system," under the heads of "disordered circulation"-" diseased secretion"-"diseased nutrition"- -"diseases of the blood"-ending with "diseases of nerves and contractile fibres"-all of which important subjects, he handles in a very masterly manner. The language is so terse, and the reasoning so close, that the condensing cylinder of the most practised analytical reviewer would be utterly foiled in any attempt to compress the matter into smaller space. One more specimen is all that we can offer from this very clever introduc

tion. Although the subject of "inflammation" occupies 61 pages of the work itself, and that from the pen of Dr. Alison, yet the following graphic sketch of this foundation of almost all diseases, comprises nearly the whole of what we know respecting its elementary nature.

"Inflammation consists not only in engorgement of the capillary vessels of the part, but also in the arrest and coagulation of the circulating fluid. It occurs under circumstances precisely similar to those which favour or produce congestion; and, in fact, the latter is the incipient stage of inflammation, though it may also exist (as we have seen) as a separate lesion. Inflammation moreover may be divided, like congestion, into active and passive, according to the mode of its production, and to the symptoms which accompany it. Congestion is apt to be converted into inflammation, when its causes act with great intensity, that is, 1. when the blood is attracted in so overpowering a quantity that the ordinary powers of the capillary circulation are unequal to the disposal of it; 2. when the vitality is so low that the motion is not only retarded, but suspended; and, 3. when the venous obstruction is so considerable as to have the same effect. Inflammation is also more likely to occur when the accumulation has not been relieved by the exudation either of blood or of serum, nor by an increase of the normal secretion of the part.

The process of inflammation has been carefully observed by the aid of the microscope; and these are the principal phenomena :-At first, the globules of blood are seen upon the application of the stimulus to move more rapidly, and the currents are somewhat smaller in diameter; but this is soon succeeded by dilatation, and near the point of irritation the motion is slower. In the surrounding parts blood begins to accumulate, and there is a general afflux from the more distant points of the reddened surface to the point of irritation as a centre. At this time the particles may be seen to flow in a direction retrograde to the usual course, and to find channels not previously observed. The next and most important phenomena are the stagnation of the blood in the central part, its coagulation, and the disappearance of the globules in a confused mass. Inflammation is now established; the colour of the part varies, according to the stage of the process, from vivid red to dull crimson or black. The arteries leading to the spot are more distended than usual; and they have been proved by Dr. Alison to lose much of their tonic contractility. The veins leading from the inflamed member yield a larger proportion of blood than those of sound parts. It has been long a warmly disputed question, whether inflammation is to be regarded as increased action. The facts just detailed are obviously quite incompatible with the notion of increased action (i. e. contraction) of vessels. But if increased action refers to the quantity of blood in the tissue, and to the state of the neighbouring parts, it certainly must be predicated of inflammation. The great afflux of blood, the heightened colour, the augmented bulk, the exalted sensibility, the increase of temperature, the throbbing arteries and distended veins, not to mention the subsequent products of serum, fibrin, and pus, present a collection of phenomena which it is difficult to separate from the idea of increased action or commotion; but it is quite certain that there is weakened action of the vessels, with diminished function of the tissue. As inflammation will be treated of more at large in another portion of this work, we have only attempted to say as much as seemed requisite for pointing out the relations of this with other pathological conditions."

18.

The subject of "INFLAMMATION" in all its details, has been assigned to Dr. Alison, and we need hardly say that few men could treat the subject with greater ability. Having exhibited an extract containing an epitome of the theory of inflammation, we are here tempted to introduce another, and a longer one, discusssing the pros and cons respecting our great remedy for the

disease—namely bloodletting. The "cautions" here detailed, are well worthy of attention from old and young practitioners.

"But the principal cautions which it is necessary to keep in mind, as to the use of bloodletting in inflammatory diseases, have reference, not simply to the subsequent effects of the evacuation on the system, but to the alteration to be expected from it on the progress of the existing disease; and in this view we must always carefully attend-1. to the period of the disease at which we are to use the remedy; 2. to the kind of the inflammation; and 3. to the complication which may exist of inflammation with other diseases.

1. When we say that the period of the disease, even in cases of healthy inflammation often decidedly contra-indicates, and still oftener makes us doubtful as to the result of bloodletting, we do not mean merely the number of days from the first decided attack of the disease (although that always demands attention ;) but we must attend particularly to the proofs of effusion or disorganisation consequent on the inflammation, having already made such progress as to indicate that the alteration of structure already effected, rather than the alteration of action which leads to it, demands our chief attention. And in general, as already remarked, this may be apprehended when we see a manifest change in the constitutional or febrile symptoms, attended with continuance or increase of the local symptoms. When the pulse has become slow or irregular, at the same time that the pain of head has passed into delirium or coma, in phrenitis or hydrocephalus; when it has become soft and compressible, or very frequent, or when the fever has taken the form of hectic, in inflammations within the chest, while the cough, or the dyspnoea has continued and increased; when rigors have supervened on hepatitis; when a soft and compressible, or very frequent pulse, and cold sweats have taken place in enteritis, without relief of the bowels or abatement of the tenderness of the abdomen, thoracic respiration, and vomiting; we may always suppose that effusions have taken place to a considerable extent, and that if the inflammation exciting them has not subsided, at least the febrile reaction by which that inflammation had been supported, and on which bloodletting could exert its chief powers, has so far abated, that the time for active depletion is nearly over. If recovery is possible after this period, a long and slow process must be gone through before it can be perfected; and this will require a certain strength of vital action, and may be frustrated by any means which further depress the vital powers; nay it may, in many instances, be obviously promoted by means which excite the system generally, and stimulate and strengthen the circulation.

In many such cases, more definite information is attainable, particularly in the case of inflammation within the chest, whether affecting the bronchiæ, the substance of the lungs, the pleura, the pericardium, or inner membrane of the heart, the indication given by examination of the chest and of the sputa, and by auscultation and percussion, prove the extent of effusion, and the degree in which the play of the lungs or heart is impeded by it; and these, taken along with the state of the pulse, heat of skin, and general strength, may often enable us to speak with much confidence as to the question,-always presenting itself in the advanced stage of these diseases,-whether there is more danger from weakening the circulation by bloodletting, when such impediments to the action of parts within the chest already exist, and can only be remedied by a slow natural process of absorption, or from allowing such inflammation as still exists to go on, unchecked by farther loss of blood.

2. That inflammation may exist, of a nature not to be subdued, even to be aggravated, by bloodletting or other evacuations, is quite certain from such experiments as those of Magendie as to the eye, and of Gendrin as to the stomach; in which the kind of inflammation of mucous membrane formerly mentioned was brought on by inanition, and could only be relieved by fuller nourishment,