- Email: [email protected]
ANIMADVERSIONS ON THE DOCTRINE OF THE METASTASIS OF RHEUMATISM, GOUT, RHEUMATIC GOUT, &c.
755
mentioned shall receive notice, together with or being in the most remote degree depenall other communications respecting the dent upon, a transfer from another of the in-
spleen remaining unpublished in our hands, flammatory action at its maximum of intensity. in a general resumé of the subject now in And in considering diseases in two places course of preparation. exempt from that dependence on each other which
a
metastasis
ing them
ANIMADVERSIONS
to
a
implies, and
in attribut-
contemporaneous inflammation
of the serous membranes, an explanation much less objectionable is offered, and one more consistent with the results of clinical observation, as confirmed by pathological
ON THE DOCTRINE OF THE
METASTASIS OF RHEUMATISM, GOUT, RHEUMATIC GOUT, &c.
anatomy.
If the advocates of the doctrine of metastasis fail in establishing that in those forms WE find that a decided predisposition pre- of disease which have received the names of vails in some constitutions to a simultane- metastatic rheumatism, metastatic gout, rheua sudden diminution of ous attack of inflammation of two or more matic gout, &c., action occurs in the joints upon the Inflammation may origiserous structures. nate in the serous membranes of the thoracic, supervention of the symptoms of inflammaabdominal, or cranial cavities coetaneously, tion in the serous membranes of the thoracic or it may manifest itself in those localities and abdominal cavities; or that this diminuand in the several joints consecutively, with- tion of inflammation in the joints be comout the slightest foundation being afforded mensurate with the amount of inflammatory us for considering the attack of any one to action secondarily developed ; or, if the conhave been dependent on that of the rest, in verse of this proposition be not established, consequence of a metastasis, transfer, or re. namely, as to the equal amount of reflex mevulsion of the inflammatory action from the tastatic action from the cavities to the joints ; serous membrane of one cavity to that of -if the advocates for metastasis do not sucanother. I ceed in proving this satisfactorily, we may In constitutions predisposed thereto, in- I assert with confidence that the truth of the flammation of the fibro-serous membrane has doctrine is legitimately to be doubted, and ’ frequently become manifest ; first, in the that the foundation upon which the fabric right or left side of the chest, and in an in- has been reared being unstable, it must evenconceivably short space of time, almost tually totter to the ground. To many of my professional brethren, I every serous and fibro-serous membrane in the visceral cavities and joints has become doubt not, my notions will appear strange. so seriously involved in the disease that the To a few they may seem to be, in a certain life of the patient has been endangered. degree, just; while by the majority they Conversely, the symptoms and signs of in- may, perhaps, be pronounced an unwarrantflammation of the serous and fibro-serous able innovation, calling into question the aumembranes have originated in the joints of thority of the most celebrated and accurate the superior or inferior extremities ; and, sub- observers of nature. I claim not the slightest sequently, the thoracic or abdominal cavities credit for myself should the views I advance have been attacked by acute inflammation. prove original; for they might have sug. I set out by asserting, without hesita- gested themselves to the minds of many intion, though not without mature deliberation, dustrious and reflecting medical men. To that the doctrine of metastasis, whether of the study of this subject my attention was gout, rheumatism, or any other form of dis- first directed by the collection of a number ease, has occasioned much confusion, set up of observations made in the wards of the many obstacles to our arriving at an accu- General Military Hospital, Phoenix-park, at rate knowledge of these diseases, and tended the time of my residence in that establishto mislead us in our modes of treatment. ment. This doctrine, the principles of which are During the winter of 1840-41, many of the those of a transfer of the diversified forms privates and uon-commissioned officers of of inflammatory action from one part of the the regiments then stationed in garrison, system to another, is not sanctioned, nay, is were sent to this hospital, suffering under rather repudiated, by the results of patholo- different forms of fever. In the majority of gical investigation, as well as by facts eli- these instances it was observed that a decited in our examinations at the patient’s cided predisposition to inflammation of the bedside. When we pay a due attention to serous membranes existed, so that when adthe commencement of the symptoms of in. mitted into the hospital it frequently hapflammation in two or more serous cavities, pened that the symptoms of acme inflammaand observe that they progress in all pai-i tion of the pleura were present, uncomplipassu, that their duration is coequal, and cated with any other form of disease. At their subsidence coetaneous, we are compel- our next examination auscultation rendered led to deny the possibility of the disease in unequivocal the existence of intense inflamone serous cavity having had its origin in, mation of the pericardium ; on the third or
By THOMAS MOORE, M.D.
morbid
I
756 serous membranes, and retrace, step by step, the route of this metastatic rheumatism, gout, &c. ; and let us subject to the test of morbid anatomy the truth or fallacy of the doctrine of metastasis. The disease, generally supposed to originate in, and be transferred from the joints, has now seized upon the fibro-serous membrane of the heart, of the existence of inflammation in which we become convinced by the accompanying symptoms. In a few days the acuteness of the inflammation here (as in the joints, a short time previously) is subdued by proper treatment ; but at a subsequent visit our attention is drawn to the sudden development of symptoms of violent inflammation of the dura mater, or arachnoid membrane, dependent upon a repetition of the metastasis, not from the joints, but from the pericardium. The inflammation of the organ recently attacked being kept in abeyance by antiphlogistic measures, we find, to our dismay, that the (metastatic) rheumatism has not been arrested in its progress, but has been transferred to the serous membranes of the thoreferred. The practitioner who is acquainted with racic or abdominal cavities ; and sometimes the nature and symptoms of rheumatism, and to the joints whence it originally started. whose mind is sufficiently alive to the im- The circuit of the so-called metastasis has portance of a correct diagnosis, soon recog- now been completed ; and to morbid ananises the form of disease which has been de- tomy we must at length appeal, to declare in signated acute metastatic rheumatism. He favour of, or in opposition to, the truth of the makes a close examination of the serous doctrine of metastasis, premising that, on cavities, and the pre-existence, or, at least, according to it a real existence, we cannot the coexistence of acute inflammation of the reasonably expect to find the signs of morbid pleura, pericardium, or peritoneum is de- anatomy in any part of the system except tected. The new disease in the joint is at once that most recently affected. But what is the state of the case ? In the attributed to a metastatic rheumatic diathesis in the patient. But, if this prefatory ex- post-mortem examination what is the actual amination be not instituted prior to an anti- condition of the serous membranes succesphlogistic plan of treatment being adopted, sively attacked by this said metastatic in twenty-four or forty-eight hours the pain rheumatism ? What are the pathological and tension of the joint are removed, the lesions revealed to us by the autopsy ; and tumefaction, in a great measure, subsides, what deductions may be made therefrom rethe sufferings of the patient are relieved, lative to this doctrine? There has invariand the disease is often considered to be sub- ably been observed a striking similarity, an dued. There remains merely a stiffness in almost perfect identity, in the -pathological the joint, with some puffiness, and occasional lesions of the serous membranes contempolancinating pains. The patient’s attention raneously or consecutively attacked by this is no longer rivetted on the joint, as the rheumatic inflammation. In all there has main source of his sufferings, and acalm and been rendered obvious an arrest of secretion composed state may ensue, which is, how- of the serous membrane during the stage of ever, but the harbinger of a storm. For at his irritation, with extreme vascularity and denext visit the medical attendant is terrified tached opacities on its surface; exudations by a catalogue of complaints, which too of plastic lymph and effusions of serum, clearly evince the continuance of an in- sometimes sanguinolent, sometimes gelatitensely inflamed condition of the fibro-serous nous, and at other times purulent; complete membranes of the thorax or abdomen, per- or incomplete organisations of the false memo haps of both. He now deplores the hour in branes, with perfect or imperfect agglutinawhich he had the temerity, by his treatment, tion of the opposed surfaces ; thickening ; to drive the rheumatism from the extremities fibro-cartilaginous induration ; and someto organs of vital importance in the economy, times ossific transformation of the organised and thus to have become accessory to the firmly adherent false membranes, when of fatal termination of the case, by accelerating chronic formation. In each and all of the the transfer of a disease originally metastatic cavities the fibrous structures of the serous in its nature. membranes have been found the seats of Let us reflect for a moment upon the suc- acute, subacute, and chronic inflammation, cessive inflammatory attacks of the fibro- and numerously studded with minute
our attention has been arrested by the altered appearance of the patient ; by his aggravated sufferings, his urgent complaints of excruciating pains in one or more joints, the knee, the ankle, or the wrist. The temperature of the limb has been found elevated ; the surface of the skin glossy and marbled from the prominent distention of the minute ramifications of the venous trunks, but free from inflammatory redness ; the putIiness and tumefaction of the joint have been considerable, with exquisite tenderness on pressure, and sensibility to touch; all which symptoms have been pronounced by experienced regimental surgeons to be the results of acute metastatic rheumatism. Thus, the case has presented new features ; the attention of the patient (and the practitioner also), diverted from the thoracic disease, has been directed altogether to the recently attacked joint, in which all the sufferings of the patient were concentrated, and to which every symptom foreboding an unhappy termination to the case has been
fourth day
757
rounded depositions of lymph, in shape and REFORM
IN
MEDICAL EDUCATION.
size resembling a collection of millet-seeds, or the granular miliary tubercles of phthisis To the Editor of THE LANCET. pulmonalis. Again, these deposits of lymph have been clustered together in such quanSIR,-I read, in THE LANCET for Feb. 4tb, tities as to form extensive and circular page 685, your able article on the false masses, increasing the density of the mem- lights of medical science as obstacles to branes to two or three lines, and in some medical reform, with great interest, and The accu- although you therein make a humiliating cases even beyond six or eight. mulation has been so great in certain cases confession relative to the acquirements and of chronic peritonitis, between the layers of the social position of medical men in general, the omentum, and in several other processes I admit that I read it also with pleasure. of the peritoneum, that in thickness they It is written in a manly, healthy, strain, and have exceeded twelve lines. The free sur. pleads powerfully in favour of such a change faces of the serous membranes of the thorax in the laws relating to the medical profession and abdomen, as well as the membranes of as will have the effect of placing the memthe joints, have been found exempt from bers thereof in a more favourable position disease, smooth, polished, and glistening, than they now occupy in relation to the but presenting a mottled appearance from public generally. I quite agree with you the ramifications of minute vessels, travei-s- that the cause of quackery owes much of I its success to the Act which constituted the ing the yellowish, cream-coloured, or dark exudations of lymph, irregularly in- authorities of Rhubarb Hall nursing mothers of the medical profession. That Act, and terspersed underneath. From the evidence we possess of recent the "old ladies," as you term those who the powers conferred by it, have acute, subacute, and chronic inflammation exercise made pill-mongers-or, as Dr. Sigmond (I in the sevebeing present contemporaneously 11 dealers in draughts" ral serous cavities, supposed on the other think) christened us, the -of great majority of the members of hand to have been successively attacked by metastatic rheumatism; and from the co- what is izominally, and ought ever to have existence of pathological lesions in these been strictly, a profession ; and in order that members of the medical profession may cavities, identical in their origin, identical in the be enabled to render themselves fit hereafter in their phytheir appearance, and identical sical and chemical properties; from our ab- to occupy their proper place in society, and solute inability to discriminate between the take the lead of the public in scientific matit appears to me to be essential that the pathological lesions of the serous membrane ters, whole course of medical education should to be the of results idiopathic be pronounced The fact is, Sir, that pericarditis, and of that denominated rheu. we entirelyatchanged. begin the wrong end, and practice an matic; between those of idiopathic and art before we have learned even its elemenrheumatic arthritis, idiopathic and rheumaThe healing art cannot be tary principles. tic pleuritis, tic. ; in fine, from the subsethe same means as the knowacquired by of the structures of the quent disorganisation of the trade of a butter-merchant, or serous membranes, progressing pari passu, ledge and from the strong similarity these bear to adealer in ribbon and tape. In trades, the each other, we may not hesitate to negative inspection of wares and fabrics and bills of suffices to determine their quality the doctrine of metastasis with all its fallaand value ; not so in the science of medicine, cies and its evil tendencies. the very elements of which consist of various To anticipate the preferment of an accudistinct sciences. Hence, although a long sation of inconsistency on my part, I conbe requisite for learning sider it requisite to amend such passages apprenticeship may a trade, it is to the student of medicine a heretofore appended by me to cases of peri- mere waste of time, which ought to be more carditis, published in THE LANCET, as attri- profitably employed than in capping bottles bute the inflammation of the pericardium and rolling pills. If the system of apprenand pleura to the metastasis of rheumatism is to be continued, I think the pupil from the joints. I acknowledge that at the ticeshipto be thoroughly instructed by his ought time the reports of those cases were pubduring that probationary period, in lished I did acquiesce in the opinions of mccster, the elementary branches of medical knowmany eminent men, promulgated in the dif. viz , in pharmacy, chemistry, botany, ferent works on the practice of medicine. ledge, and materia medica, for which two years But since that time experience has taught would amply suffice, and at the expiration me that many theories, and many doctrines of this period the pupil ought to be subjected which from their appearance, have been pro- to an examination in these elementary nounced to be speculatively true, when sub. branches of medical science, which examinaand to close observation analytical jected tion he having satisfactorily passed, he investigation, may be proved to be practically should apply himself to the study of needifalse. cine itself, or the art of curing disease. Anatomy, physiology, the theory and pracFebruary, 1843.
greyish, I
parcels
mentioned shall receive notice, together with or being in the most remote degree depenall other communications respecting the dent upon, a transfer from another of the in-
spleen remaining unpublished in our hands, flammatory action at its maximum of intensity. in a general resumé of the subject now in And in considering diseases in two places course of preparation. exempt from that dependence on each other which
a
metastasis
ing them
ANIMADVERSIONS
to
a
implies, and
in attribut-
contemporaneous inflammation
of the serous membranes, an explanation much less objectionable is offered, and one more consistent with the results of clinical observation, as confirmed by pathological
ON THE DOCTRINE OF THE
METASTASIS OF RHEUMATISM, GOUT, RHEUMATIC GOUT, &c.
anatomy.
If the advocates of the doctrine of metastasis fail in establishing that in those forms WE find that a decided predisposition pre- of disease which have received the names of vails in some constitutions to a simultane- metastatic rheumatism, metastatic gout, rheua sudden diminution of ous attack of inflammation of two or more matic gout, &c., action occurs in the joints upon the Inflammation may origiserous structures. nate in the serous membranes of the thoracic, supervention of the symptoms of inflammaabdominal, or cranial cavities coetaneously, tion in the serous membranes of the thoracic or it may manifest itself in those localities and abdominal cavities; or that this diminuand in the several joints consecutively, with- tion of inflammation in the joints be comout the slightest foundation being afforded mensurate with the amount of inflammatory us for considering the attack of any one to action secondarily developed ; or, if the conhave been dependent on that of the rest, in verse of this proposition be not established, consequence of a metastasis, transfer, or re. namely, as to the equal amount of reflex mevulsion of the inflammatory action from the tastatic action from the cavities to the joints ; serous membrane of one cavity to that of -if the advocates for metastasis do not sucanother. I ceed in proving this satisfactorily, we may In constitutions predisposed thereto, in- I assert with confidence that the truth of the flammation of the fibro-serous membrane has doctrine is legitimately to be doubted, and ’ frequently become manifest ; first, in the that the foundation upon which the fabric right or left side of the chest, and in an in- has been reared being unstable, it must evenconceivably short space of time, almost tually totter to the ground. To many of my professional brethren, I every serous and fibro-serous membrane in the visceral cavities and joints has become doubt not, my notions will appear strange. so seriously involved in the disease that the To a few they may seem to be, in a certain life of the patient has been endangered. degree, just; while by the majority they Conversely, the symptoms and signs of in- may, perhaps, be pronounced an unwarrantflammation of the serous and fibro-serous able innovation, calling into question the aumembranes have originated in the joints of thority of the most celebrated and accurate the superior or inferior extremities ; and, sub- observers of nature. I claim not the slightest sequently, the thoracic or abdominal cavities credit for myself should the views I advance have been attacked by acute inflammation. prove original; for they might have sug. I set out by asserting, without hesita- gested themselves to the minds of many intion, though not without mature deliberation, dustrious and reflecting medical men. To that the doctrine of metastasis, whether of the study of this subject my attention was gout, rheumatism, or any other form of dis- first directed by the collection of a number ease, has occasioned much confusion, set up of observations made in the wards of the many obstacles to our arriving at an accu- General Military Hospital, Phoenix-park, at rate knowledge of these diseases, and tended the time of my residence in that establishto mislead us in our modes of treatment. ment. This doctrine, the principles of which are During the winter of 1840-41, many of the those of a transfer of the diversified forms privates and uon-commissioned officers of of inflammatory action from one part of the the regiments then stationed in garrison, system to another, is not sanctioned, nay, is were sent to this hospital, suffering under rather repudiated, by the results of patholo- different forms of fever. In the majority of gical investigation, as well as by facts eli- these instances it was observed that a decited in our examinations at the patient’s cided predisposition to inflammation of the bedside. When we pay a due attention to serous membranes existed, so that when adthe commencement of the symptoms of in. mitted into the hospital it frequently hapflammation in two or more serous cavities, pened that the symptoms of acme inflammaand observe that they progress in all pai-i tion of the pleura were present, uncomplipassu, that their duration is coequal, and cated with any other form of disease. At their subsidence coetaneous, we are compel- our next examination auscultation rendered led to deny the possibility of the disease in unequivocal the existence of intense inflamone serous cavity having had its origin in, mation of the pericardium ; on the third or
By THOMAS MOORE, M.D.
morbid
I
756 serous membranes, and retrace, step by step, the route of this metastatic rheumatism, gout, &c. ; and let us subject to the test of morbid anatomy the truth or fallacy of the doctrine of metastasis. The disease, generally supposed to originate in, and be transferred from the joints, has now seized upon the fibro-serous membrane of the heart, of the existence of inflammation in which we become convinced by the accompanying symptoms. In a few days the acuteness of the inflammation here (as in the joints, a short time previously) is subdued by proper treatment ; but at a subsequent visit our attention is drawn to the sudden development of symptoms of violent inflammation of the dura mater, or arachnoid membrane, dependent upon a repetition of the metastasis, not from the joints, but from the pericardium. The inflammation of the organ recently attacked being kept in abeyance by antiphlogistic measures, we find, to our dismay, that the (metastatic) rheumatism has not been arrested in its progress, but has been transferred to the serous membranes of the thoreferred. The practitioner who is acquainted with racic or abdominal cavities ; and sometimes the nature and symptoms of rheumatism, and to the joints whence it originally started. whose mind is sufficiently alive to the im- The circuit of the so-called metastasis has portance of a correct diagnosis, soon recog- now been completed ; and to morbid ananises the form of disease which has been de- tomy we must at length appeal, to declare in signated acute metastatic rheumatism. He favour of, or in opposition to, the truth of the makes a close examination of the serous doctrine of metastasis, premising that, on cavities, and the pre-existence, or, at least, according to it a real existence, we cannot the coexistence of acute inflammation of the reasonably expect to find the signs of morbid pleura, pericardium, or peritoneum is de- anatomy in any part of the system except tected. The new disease in the joint is at once that most recently affected. But what is the state of the case ? In the attributed to a metastatic rheumatic diathesis in the patient. But, if this prefatory ex- post-mortem examination what is the actual amination be not instituted prior to an anti- condition of the serous membranes succesphlogistic plan of treatment being adopted, sively attacked by this said metastatic in twenty-four or forty-eight hours the pain rheumatism ? What are the pathological and tension of the joint are removed, the lesions revealed to us by the autopsy ; and tumefaction, in a great measure, subsides, what deductions may be made therefrom rethe sufferings of the patient are relieved, lative to this doctrine? There has invariand the disease is often considered to be sub- ably been observed a striking similarity, an dued. There remains merely a stiffness in almost perfect identity, in the -pathological the joint, with some puffiness, and occasional lesions of the serous membranes contempolancinating pains. The patient’s attention raneously or consecutively attacked by this is no longer rivetted on the joint, as the rheumatic inflammation. In all there has main source of his sufferings, and acalm and been rendered obvious an arrest of secretion composed state may ensue, which is, how- of the serous membrane during the stage of ever, but the harbinger of a storm. For at his irritation, with extreme vascularity and denext visit the medical attendant is terrified tached opacities on its surface; exudations by a catalogue of complaints, which too of plastic lymph and effusions of serum, clearly evince the continuance of an in- sometimes sanguinolent, sometimes gelatitensely inflamed condition of the fibro-serous nous, and at other times purulent; complete membranes of the thorax or abdomen, per- or incomplete organisations of the false memo haps of both. He now deplores the hour in branes, with perfect or imperfect agglutinawhich he had the temerity, by his treatment, tion of the opposed surfaces ; thickening ; to drive the rheumatism from the extremities fibro-cartilaginous induration ; and someto organs of vital importance in the economy, times ossific transformation of the organised and thus to have become accessory to the firmly adherent false membranes, when of fatal termination of the case, by accelerating chronic formation. In each and all of the the transfer of a disease originally metastatic cavities the fibrous structures of the serous in its nature. membranes have been found the seats of Let us reflect for a moment upon the suc- acute, subacute, and chronic inflammation, cessive inflammatory attacks of the fibro- and numerously studded with minute
our attention has been arrested by the altered appearance of the patient ; by his aggravated sufferings, his urgent complaints of excruciating pains in one or more joints, the knee, the ankle, or the wrist. The temperature of the limb has been found elevated ; the surface of the skin glossy and marbled from the prominent distention of the minute ramifications of the venous trunks, but free from inflammatory redness ; the putIiness and tumefaction of the joint have been considerable, with exquisite tenderness on pressure, and sensibility to touch; all which symptoms have been pronounced by experienced regimental surgeons to be the results of acute metastatic rheumatism. Thus, the case has presented new features ; the attention of the patient (and the practitioner also), diverted from the thoracic disease, has been directed altogether to the recently attacked joint, in which all the sufferings of the patient were concentrated, and to which every symptom foreboding an unhappy termination to the case has been
fourth day
757
rounded depositions of lymph, in shape and REFORM
IN
MEDICAL EDUCATION.
size resembling a collection of millet-seeds, or the granular miliary tubercles of phthisis To the Editor of THE LANCET. pulmonalis. Again, these deposits of lymph have been clustered together in such quanSIR,-I read, in THE LANCET for Feb. 4tb, tities as to form extensive and circular page 685, your able article on the false masses, increasing the density of the mem- lights of medical science as obstacles to branes to two or three lines, and in some medical reform, with great interest, and The accu- although you therein make a humiliating cases even beyond six or eight. mulation has been so great in certain cases confession relative to the acquirements and of chronic peritonitis, between the layers of the social position of medical men in general, the omentum, and in several other processes I admit that I read it also with pleasure. of the peritoneum, that in thickness they It is written in a manly, healthy, strain, and have exceeded twelve lines. The free sur. pleads powerfully in favour of such a change faces of the serous membranes of the thorax in the laws relating to the medical profession and abdomen, as well as the membranes of as will have the effect of placing the memthe joints, have been found exempt from bers thereof in a more favourable position disease, smooth, polished, and glistening, than they now occupy in relation to the but presenting a mottled appearance from public generally. I quite agree with you the ramifications of minute vessels, travei-s- that the cause of quackery owes much of I its success to the Act which constituted the ing the yellowish, cream-coloured, or dark exudations of lymph, irregularly in- authorities of Rhubarb Hall nursing mothers of the medical profession. That Act, and terspersed underneath. From the evidence we possess of recent the "old ladies," as you term those who the powers conferred by it, have acute, subacute, and chronic inflammation exercise made pill-mongers-or, as Dr. Sigmond (I in the sevebeing present contemporaneously 11 dealers in draughts" ral serous cavities, supposed on the other think) christened us, the -of great majority of the members of hand to have been successively attacked by metastatic rheumatism; and from the co- what is izominally, and ought ever to have existence of pathological lesions in these been strictly, a profession ; and in order that members of the medical profession may cavities, identical in their origin, identical in the be enabled to render themselves fit hereafter in their phytheir appearance, and identical sical and chemical properties; from our ab- to occupy their proper place in society, and solute inability to discriminate between the take the lead of the public in scientific matit appears to me to be essential that the pathological lesions of the serous membrane ters, whole course of medical education should to be the of results idiopathic be pronounced The fact is, Sir, that pericarditis, and of that denominated rheu. we entirelyatchanged. begin the wrong end, and practice an matic; between those of idiopathic and art before we have learned even its elemenrheumatic arthritis, idiopathic and rheumaThe healing art cannot be tary principles. tic pleuritis, tic. ; in fine, from the subsethe same means as the knowacquired by of the structures of the quent disorganisation of the trade of a butter-merchant, or serous membranes, progressing pari passu, ledge and from the strong similarity these bear to adealer in ribbon and tape. In trades, the each other, we may not hesitate to negative inspection of wares and fabrics and bills of suffices to determine their quality the doctrine of metastasis with all its fallaand value ; not so in the science of medicine, cies and its evil tendencies. the very elements of which consist of various To anticipate the preferment of an accudistinct sciences. Hence, although a long sation of inconsistency on my part, I conbe requisite for learning sider it requisite to amend such passages apprenticeship may a trade, it is to the student of medicine a heretofore appended by me to cases of peri- mere waste of time, which ought to be more carditis, published in THE LANCET, as attri- profitably employed than in capping bottles bute the inflammation of the pericardium and rolling pills. If the system of apprenand pleura to the metastasis of rheumatism is to be continued, I think the pupil from the joints. I acknowledge that at the ticeshipto be thoroughly instructed by his ought time the reports of those cases were pubduring that probationary period, in lished I did acquiesce in the opinions of mccster, the elementary branches of medical knowmany eminent men, promulgated in the dif. viz , in pharmacy, chemistry, botany, ferent works on the practice of medicine. ledge, and materia medica, for which two years But since that time experience has taught would amply suffice, and at the expiration me that many theories, and many doctrines of this period the pupil ought to be subjected which from their appearance, have been pro- to an examination in these elementary nounced to be speculatively true, when sub. branches of medical science, which examinaand to close observation analytical jected tion he having satisfactorily passed, he investigation, may be proved to be practically should apply himself to the study of needifalse. cine itself, or the art of curing disease. Anatomy, physiology, the theory and pracFebruary, 1843.
greyish, I
parcels