A system of clinical medicine

Front matter

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Preface

THIRD AMERICAN EDITION.

Since the last edition of Dr. Graves's lectures was published in this city, a new one, considerably enlarged, has been published by Dr. Graves, in Europe: from this edition the present one is printed. It contains the whole of the lectures, which make a very large volume ; but some detached papers which were not printed in the former editions, and were first published in the present one, are not reprinted. These essays the publishers will probably issue in a separate form. The demand for a new edition is the best proof of the high character these lectures have gained in the United States, and of the very extended reputation they have justly attained.

The additional lectures, which, at the request of the publishers, were appended to the last edition of the work, have been revised, and some new matter on the subject of Typhus Fever has been added. The lectures were originally delivered as a part of a clinical course, or rather of several clinical courses, at the Philadelphia Hospital, most of them were printed in a medical journal some years since, but they were for the first time published in a collective form in the last edition of Dr. Graves's lectures. The only important subject on which the editor differs from Dr. Graves, is that of typhus fever. This has been, for some years, a contested point between the English and French physicians ; in reality, however, the difference of opinion has arisen from one simple fact. The typhus fever of England and Ireland was unknown in France, at least at Paris, where the continued fever ha 1 been for many years confined to typhoid fever; the same had been the case for many years in this country until in the year 1836. when we had a disease similar to the genuinetyphus fever of the British islands. Since that time we have

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had many cases, imported directly from England, perfectly identical with the same class of fevers. On the other hand, the typhoid fever of France is much less frequent in the British islands than on the continent, and is, to a certain extent, confounded with the much more common form of typhus fever. Such at least seems to me to be the best explanation of the confusion which has existed in the statements of writers, relative to these two allied but not identical diseases.

Philadelphia, >

PREFACE.

Having been, for many years, engaged in giving Clinical Instruction at the Meath and Sir Patrick Dun's Hospitals, I thought it to be my duty occasionally to publish the results of my observations in the form either of detached Essays, or successive series of Lectures ; the former were printed in the Dublin Hospital Reports, and the Dublin Medical Journal, the latter appeared in various English periodicals, but chiefly in that excellent publication, the London Medical Gazette. Many of the detached papers were subsequently translated into French, German, and Italian, and several courses of the Lectures were published by Doctor Robley Dunglison, in a separate volume at Philadelphia. This has encouraged me not only to continue my exertions in the cultivation of practical medicine, but to revise what I had written and compress the whole within the limits of a single volume. It is necessary to mention that the Lectures were all originally delivered extempore, and were printed from notes taken by a short-hand writer. The reader being made aware of this circumstance, will kindly make due allowance for the many imperfections of style, and the redundancy and repetition which occur but too frequently in this work. In revising the whole, I have been at more pains to improve the substance than to polish the surface, and have rigorously excluded every assertion and conclusion which my subsequent experience has not verified.

It should likewise be borne in mind that this volume has no pretensions to the title even of Outlines of the Practice of Physic, for many most important diseases are not mentioned at all, none are fully described, and nowhere is treatment considered in all its bearings ; my object in lecturiug has, in truth, been always strictly clinical, and except where the subject was very tempting, and its discussion seemed to promise some useful and novel result, I have seldom allowed myself to deviate from the legitimate pursuit of that object; on the subject of Fever, perhaps, I may appear to have enlarged far beyond the limits of my prescribed plan, but a very sufficient explanation of this apparent exception may be given, for as the wTards of our Hospitals are never without fever cases, every successive season suggested some new remarks on that disease, and when the task of consolidating these courses of Lectures was undertaken, it became necessary to collect the various scattered observations on Fever, which occurred in almost every Lecture, and consequently (although many insulated cases of Fever, and the remarks they at the time called forth,

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have been omitted), when the materials already printed on that important affection were arranged in a certain connected order, and were elucidated by facts observed since their former publication, the mass of matter thus gradually accumulated was found to be much greater than was expected — still I must beg leave to remind the reader, that these Lectures are not intended to embrace the whole subject, even of Fever, and indeed it will be obvious from a cursory glance that my observations were generally dictated by some case actually under treatment, and were not intended to constitute any thing like a full and complete history of the Symptoms, Pathology, and Treatment of Fever. In attempting to form a continuous and connected series of reasoning on this disease, it became necessary not merely to reprint what I had published at various dates, but to remodel the whole, by adding much, and omitting more, and thus it has happened that the Lectures on Typhus in this work have assumed an entirely new form. For many years, several of the doctrines I promulgated respecting Fever, were opposed to those taught by other Lecturers and generally advocated by authors ; and consequently I was then obliged to dwell on such disputed questions at greater length than perhaps their intrinsic importance would now seem to warrant : formerly I stood almost alone in resisting the inflammatory theory of Fever, as successively brought into fashion by Armstrong, Clutterbuck, and Broussais, and my opinions respecting contagion, the use of mercury, purgatives, of wine, diet, &c, were different from those then generally entertained : and therefore it was that such topics occupied so considerable a space in the original Lectures, and are treated of at some length in the present volume. While engaged in the task of preparing for the press, I have consulted many of my medical friends, both in Dublin, and the Provinces, on various subjects, and by this means having been enabled to avail myself of the experience of others where my own was deficient, much valuable information has been gained, and the courtesy of my professional brethren has produced communications which will no doubt be received by the public with a degree of favour proportioned to the gratitude the Author feels to his friends for their valuable assistance. Some of my readers may perhaps think, that the strictures my Introductory Lecture contains on the Physiological and Pathological Theories, founded on Liebig's chemical researches, are too severe, but a calm reconsideration of the subject convinced me that the Theories in question are calculated to retard the progress of Medical Science, and consequently ought to be energetically opposed.