inflammation, and the latter that of depression and congestion; and while they recognise the condition of excitement as inflammatory, they recognise the opposite condition of depression under the terms asthenic, adynamic, or typhous. (See Wood's Practice, art. 5, Fever, sec. 3, Grade of Fevers.) "Besides the two grades of fever above described, (says Dr. Wood) there are often intermediate or mixed conditions, of which it is difficult to say to which they belong."

And here occurs the hiatus which I have attempted to close, with the classification which I have suggested; for though Dr. Wood has thus acknowledged the existence of intermediate or mixed conditions, he has failed or neglected to tell us what they are. But Dr. Wood further says: "The state of the vital forces on which these different grades depend, may pre-exist, or may be induced by the cause or causes of the fever itself. Whatever tends to increase the powers of the system, predisposes to the inflammatory condition of fever, whatever diminishes these powers, to the typhus." And he goes on to enumerate some of the leading causes which predispose to these conditions, concerning which, and the inflammatory condition, there can be no doubt or disagreement whatever; but his use of the term typhous, to express the opposite condition, creates a difficulty, to obviate which it is necessary that we should have a clear and definite understanding of the import and meaning of the terms. Now, the term typhous, which is synonymous with typhoid, is with us, used to express a condition in which, beside depression, there exists also a depraved and vitiated condition, or a broken constitution of the blood, with a certain hemorrhagic and eruptive tendency, such as petechia, sudamina, &c., and usually delirium and coma. And such is the idea of the condition which Dr. Wood, no doubt, intended to convey by the use of the term typhous: for, he further says, "But it also not unfrequently happens that the exciting cause of the fever is of itself of a depressing nature in relation to some, at least, of the vital functions, and that a typhous (typhoid) condition of the system, as well as the febrile movement, results directly from its operation. Such, beyond all doubt, is the case with the poisonous effluvia which cause the proper typhus fever, and to a certain extent, also, that which produces scarlatina," and to which I would add, yellow fever also. The character of the foregoing extracts shows very plainly that Dr. Wood's typhous condition is the same which

I have arranged under the typhoid condition with which congestion has little or nothing to do.

Having on a former occasion expressed my views with regard to the typhoid condition, which it is unnecessary, and would be irksome for me to repeat, and having from the very outset endeavored to prove the existence of a pathological condition of depression and congestion, as the true physiological, as well as pathological, antagonistic condition of excitement and inflammation, the opinions of Dr. Wood, and others to the contrary, notwithstanding, it remains only for me to say, that though both conditions are characterised by depression, they are altogether of a different character. That the depression of the typhoid condition relates chiefly to the cerebral and animal nervous system, and requires for its production an animal poison or effluvium, and has necessarily for its existence a depraved or vitiated condition of the blood, either as cause or effect, and does not necessarily require a disturbed balance in the circulation. While the congestive coudition implies depression chiefly of the organic nervous system from the influence of atmospheric, meteorologic and malarial or miasmatic causes, and necessarily implies a broken balance in the circulation, and an undue accumulation of blood in the venous cavities, but does not necessarily require that the blood itself should be depraved.

With these views and explanations, with regard to the character of these conditions, and the classification which I have made of them, the necessity of which for practical purposes, I am, upon review, more fully convinced than ever, I shall proceed in conformity therewith, to the examination of the remedy in question, continuing as formerly to use pneumonia for illustration.

As remedies are valuable in proportion to the power which they possess, of increasing or diminishing the vital forces, and regulating and changing the vital actions, the lancet must always hold its rank among the most valuable, as it posesses the power in an eminent degree of diminishing rapidly the vital forces, and of moderating excessive vital action, and such being its power, such must be the necessity for its use. The first important and essential point to determine, then, is whether the general system is in such a condition as to justify or require its use, that is to say, whether there exists in the system such an amount of nervous excitement and vascular action, coupled with and sustained by, such an amount of vigor and tonicity in the general system, as to threat

en vital organs with the invasion of inflammation, or to endanger the vitality of organs already in a state of inflammation, for bloodletting is often as important in such a condition as a prophylactic, as it is a therapeutic remedy. In ascertaining and settling this important and essential point, great nicety and precision of judg ment is often required to determine, whether the excitement is sustained by sufficient vigor to constitute the inflammatory condition, or whether the excitement is a state of irritation only, dependant upon a state of debility, or atonity of the general system. And to aid in arriving at a correct decision upon this point, it is necessary to keep in view, not only the peculiar symptoms present in each case, but to take in review the adventitious influences which are most likely to affect the condition, proximately or remotely, such as age, sex, temperament, habits of life, climate, seasons, epidemic influences, &c., &c., all of which, are not more necessary in determining the condition which requires blood-letting, than in determining the second important point, namely, the extent to which it should be carried, which, of course, must be regulated and controled by the practitioner, in each individual

case.

As the advantages to be derived from blood-letting in local inflammation, which often exists under very different and even opposite conditions of the system, (as I have already shown to be the case with pneumonia, and in like manner, with other diseases) must necessarily be incidental to a general reduction of the vital forces, and of general excitement and vascular action, the only safe rule which can be adopted with respect to this second point is, that in attempting such a reduction by blood-letting, no more blood should be withdrawn, than will be sufficient to bring the general inflammatory condition of the system down to such a point as will enable other adjutory remedies, aided by the recuperative powers of the system to complete the reduction. This object may often be accomplished by the extraction of small quantities of blood, and at other times much larger quantities may be necessary to be drawn, and the operation may even be required to be repeated; but under no circumstances can we venture upon the use of the lancet, in the bold, fearless, and confident manner in which it has been recommended by our northern brethren, for the treatment of rheumatism, pleurisy, pneumonia, and other inflammatory affections; for the reason that the tendency of all these

affections, to the opposite condition of depression and congestion is so strong, as to admonish us, under the most imperative circumstances, to take hold of it with prudence and caution, and sometimes even with "fear and trembling." For fear that it should be suspected that the great prudence and caution which I recommend should be observed in the use of the lancet, is prompted by the working of a tender conscience, from the reminiscence of past misdeeds, it is but truth and justice to myself, to say, that upon the subject of the abuse of the lancet, I have nothing to "disabuse" myself of: for, in the days when the lancet was in the greatest vogue, and the standard of a physician's skill was measured by the number which he carried in his pocket, and his knowledge by the exact number of ounces of blood which his patient was able to lose, and the precise amount of purging which he could stand, without sinking under the operation, which the test of experiment, too often, proved to be fallacious; my voice was then raised, as now, in remonstrance against its reckless use, and consequent abuse, as the following extracts from my manuscripts written many years ago upon the subject, will show, and to which I have now, nothing material to add or take away:

Although I fully appreciate the value and importance of blood-letting, in inflammatory diseases, when regulated by a proper discretion, I must confess that I have never been able to understand the propriety of bleeding for the purpose of preventing or removing congestion-a condition dependent upon a state of debility and depression, which the loss of blood cannot remove, but which, on the contrary, is always accelerated by it; for, besides the loss of the stimulus of the red capsules, and the fibrin of the blood by their extraction from the circulation, as well as the quantity drawn, the blood taken by venesection, comes not from the congested vessels, but from that division of the circulation (the arteries) which are already deficient of their due proportion, blood, which has just passed with difficulty the pulmonary extremity of the circulation, to be hurried too rapidly through the capillary extremity, (for such is the general effect of venesection) thus depriving the brain, heart, &c., of their accustomed and necessary stimulus, inducing syncope and convulsions, increasing the amount of depression and rendering the state of congestion more complete. It is owing to these effects of venesection, and the great tendency which prevails with all our diseases, to assume a congestive char

acter, especially when aided by excessive depletion of any kind, which renders the use of the lancet a matter of so much caution, even in those cases which appear to be more decidedly inflammatory in their general character. The object of bleeding in any disease, is to protect or to relieve important organs from the effects of undue determinations and accumulations of blood, (understood to be arterial) the result of undue excitement in the general system, while the organs affected are the weaker ones. Hence, the extraction of blood is to be made in reference to a reduction of the general excitement, thus giving protection to weak organs, and enabling them to regain their lost tone and activity, and allow them to repair the damage which may already have been done. But in the effort at a reduction of the general excitement, great care must always be taken that it be not done so suddenly, or by such violent means, as to produce the opposite state of depression and congestion. Instead, therefore, of the erect posture, large orifice, and the draft of blood by the pint or quart, for the purpose of cutting off disease, or subduing inflammation by a decisive blow, our patients generally require to be bled, (if they require to be bled at all) when in a recumbent position, from a moderate orifice, and in quantities proportioned to the effects upon the strength and frequency of the pulse, and the general vigor of the system. In judging of the propriety of a resort to the use of the lancet in any case, the existence of pain which usually indicates the seat of inflammation, must be regarded as fallacious on account of the extent and play of the nervous sympathies, especially as this symptom is often more intense, and the ordinary signs of excitement are more manifest when the investing membranes are inflamed or irritated in a slight degree, than when more extensive and serious inflammation exists in the parenchymatous structure of organs. To justify the use of the lancet from these signs, the pulse should always furnish evidences of strength, (the sign of arterial plethora) the pain should be fixed and permanent, whether acute or obtuse, and the evidences of excitement continuous, irrespective of the influence of regular exacerbations and remissions. Nor can we recognise the stage of a disease, as acting either as a warrant or bar to its use, for the reason that it is often contraindicated in the earlier stages of a disease, when during its progress, and even in the latter stages, the necessity for its use may become imperative and absolute."