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हकीम गयासुद्दीन साहब दिल्ली में फसद का कम करते है । यह तरीका ऐ इलाज मरीजो के इलाज में काम आता है। फसद में बदन का ख़राब खून हाथ और पाव की नसों के जरिए बहार निकला जाता है , ख़राब खून का जिस्म से निकलना मरीज को फायदा देता है।

फसद और हिजामा दुनिया का सबसे पुराना इलाज का तरीका है। यह इलाज कुदरती है जिसे दुनिया के पैदा करने वाले ने इंसानों को सिखाया है .इंसान को भूख लगने पर ,प्यास और थकान होने पर कुदरत ने उसका इलाज खाना ,पानी और आराम करने में बताया है उसी तरह बीमार होने पर इंसान को यह भी सिखाया है के बीमार होने पर ख़राब खून निकाल कर इंसान मर्ज़ से निजात पा सकता है ।
Full text of "Venesection; a brief summary of the practical value of venesection in disease, for students and practicians of medicine"
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VENESECTION

A BRIEF SUMMARY OF THE PRACTICAL
VALUE OF VENESECTION IN

DISEASE

FOR STUDENTS AND PRACTICIANS
OF MEDICINE

BY

WALTON FOREST BUTTON, M.D.

Fellow American Medical Association; Member Medical Society of the
State of Pennsylvania; Allegheny County Medical Society; Ex-President
Carnegie Academy of Medicine; Pennsylvania Society for Pre-
vention of Social Disease; American Association for the
Advancement of Science; American Academy of
Political and Social Science; International
Congress on Tuberculosis, etc.

PHILADELPHIA

F. A. DAVIS COMPANY, Publishers

English Depot
Stanley Phillips, London 1916 3 COFTRIGHT. 1916 BY
F. A. DAVIS COMPANY Copyright, Great Britain. All Rights Resenred Philadelphia. Pa.. U. 8. A.

Press of F. A. Davis Company

1914-16 Cherry Street

THIS VOLUME
IS DEDICATED TO MY MOTHER,

WHOSE SELF-SACRIFICK HADE IT POSSIBLE FOR
ME TO STUDY MEDICINE, AND TO MY WIFE,
WHOSE FAITHFUL SERVICES HAVE ASSISTED ME IN
FULFILLING THE OBLIGATIONS OF HY PROFESSION.

PREFACE.

Frequent requests from general practitioners for
a book on venesection, especially adapted to their
needs, have prompted the writer to endeavor to meet
these demands.

In preparing this work on venesection, it has been
my purpose to apply to the every-day problems of
the practice of medicine the knowledge with which
the general practician should be familiar. Physicians
and students have long felt the need of such a work.
The author does not claim the book to be a treatise on
disease. The book is meant to give, in a concise and
convenient way, the therapeutic value of an agent
which has been used successfully by some of the most
eminent physicians of past centuries, and will con-
tinue to be used as long as the human body is heir
to disease. The advances in medicine and surgery
require a serious consideration of the greater condi-
tions remaining before us, and upon the medical pro-
fession the laity depend for the alleviation and cure
of disease.

The neglect of scientific venesection, as a thera-
peutic agent, has been recognized by some of the fore-
most medical men of our time, yet it remained for
someone to present the subject logically to the pro-
fession.

I am impressed by the need of such a book which
describes, in detail, the procedure of venesection and
its applications. In the hour when all other thera-
peutic agencies have failed, I have resorted to the
lancet to see the livid hue, which mapped the way to
an early death, give way to the rosy glow and bright
light of health. The opportunity to save a life is
when we have all our armamentarium at hand for
the use of our mental laboratory. If we deny that
venesection is an effective agent in the treatment
of disease, we have to deny, also, the fundamental
principles of physiology and repudiate our medical
teaching.

I wish, therefore, to present, not alone my own
clinical experience, but that of eminent physicians in
the endeavor to give the profession the experience of
those who have secured results. Some authors I have
quoted verbatim, while others I have abstracted, but,
at all times, using the language which seemed to give
the best description of the subject.

It is my desire to place this book on a firm basis
as a work of ready reference. The author would
gladly acknowledge any suggestions as to errors,
corrections, or omissions.

W. F. D.

Tulsa, Okla.

CONTENTS.

PAGE

Venesection, Definition 1

The History of Bloodletting 1

Blood and Lymph 40

Hematology 45

Pathologic Anthropology 54

Indications for Venesection 56

The Technique of Venesection 58

Alcoholism 70

Amenorrhea 73

Angina Pectoris 76

Apoplexy 77

Arteriosclerosis 84

Beriberi 92

Blood-pressure in the Practice of Medicine 93

Blood-pressure and the Composition of the Blood 102

Blood-pressure in Fevers 103

Bronchopneumonia 105

Delirium, Acute 107

Ear Diseases 109

Eclampsia 110

Emphysema * 115

Epilepsy 1 16

Erythremia 121

Eye Diseases 123

Fever, Typhoid 125

Fever, Yellow 128

Gout 129

Heart Diseases 130

Hemorrhage, Treatment 138

Hypertonia Vasorum Cerebri 144

Liver Diseases 162

Lungs, Edema 164

Meningitis, Cerebrospinal 165

Menopause 167

Menopause, Artificial 169

Migrain 170

Myalgia 174

(vii)

viii CONTENTS.

PAGE

Nephritis, Acute 175

Obesity 178

Pleurisy, Acute 180

Pneumonia, Acute Lobar 182-

Pneumothorax 186

Poison, Illuminating Gas ." 186

Pulmonary Hyperemia 188

Rheumatism, Articular 189

Sunstroke, Heatstroke 196

Syphilis 199

Transfusion 200

Uremia 207

Viscosity of the Blood 211

Bibliography 212

Index 215

VENESECTION.

DEFINITION.

The word venesection is from the latin vena, a
vein, and secare, to cut, and means the opening of a
vein for the purpose of letting blood. The term
"Bloodletting" includes all methods of withdrawing
blood from the animal or human body for therapeutic
purposes. The withdrawal of blood from a large vein
or artery, so as to reduce the general mass of blood,
is known as "general bloodletting." The abstraction
of blood from a part or its immediate neighborhood
(i,e,j from the capillaries) by leeching, scarification,
or cupping, is termed "local bloodletting."

Someone has said that when prehistoric man
first hit upon the expedient of picking up a stick or
a stone with which to smite his fellow-man, he had
already made his first step in the direction of civili-
zation. If he drew blood on that momentous occa-
sion, in some degree short of manslaughter, we
should already have an instance of bloodletting. It
was in some such empirical way as this that early
man first chanced upon venesection as a reliable
mode of treatment in the relief of human suffering,
through witnessing the revulsive effects of some ac-
cidental hemorrhage upon bodily ills. The natural
and periodic process of menstruation, no doubt, di-
rected the medical mind to the hygienic and prophy-
lactic advantages of depletion; but we can as little
credit Pliny's fable of how the Egyptians learned to
open a vein from watching the clumsy hippopotamus
wound itself against the reeds as that other bit of
nature-fakery of the old naturalist which asserts that
they assimilated the use of the enema from seeing
the ibis achieve a species of autoclyster by means of
its bill. Bloodletting is one of the oldest and most
common of therapeutic devices and its origin is lost
in antiquity. We know, from Max Bartels and
other writers on primitive medicine, that savages
have used sharp thorns or roots, fishes' teeth, or
sharpened stones for opening abscesses, couching
cataracts, or letting blood; that scarification was re-
sorted to, that cupping was done by means of ani-
mals' horns, and that, in connection with the general
idea of depletion, the North American Indians had
fixed periods, such as the "green-corn feast," for
ritual emesis and purgation, even as our forefathers
used Purgation Calendars and Bloodletting Calen-
dars to determine the proper time and place for these
operations under the signs of the Zodiac, or as those
of only one generation ago went to the old country
doctor every spring to have their veins opened. Of
the ancient Egyptians, Herodotus says, "They purge
themselves every month, three times in succession,
seeking to preserve health by emetics and clysters;
for they suppose that all diseases to which mankind
are subject proceed from the food they use." We
learn from the papyric writings that venesection was
a common practice among the Egyptians, and, on
account of their religious horror of mutilating the
human body, was the only surgical precedure per-
mitted by them, with the exception of circumcision.
Upon the doorposts of a tomb in the cemetery near
Memphis, discovered by Mr. W. Max Miiller,^ we
have the earliest known pictures of surgical opera-
tions represenitng circumcision and two figurations
of operation on the foot and neck, the attitude of the
patients indicating great pain, the hieroglyphics read-
ing "Why do you hurt me thus?" In the light of
the Egyptian restrictions of surgical procedure, it is
not unreasonable to suppose that thesei incisions in
the neck and extremities may have been the earliest
representations of bloodlettitig, of date about B.C.
2500.

The Babylonians, in keeping with the ancient pas-
sion for prediction and prognosis, tried to make
special inferences from the appearance of the blood
drawn in venesection, which reminds us of the com-
mon assumption in early nineteenth-century practice
that "buffing and cupping" of drawn blood was a
sign of inflammation.

1 Described by Dr. James J. Walsh in Journal of the American
Medical Association, xlix, 1593, 1907.

4 VENESECTION.

There are apparently no references to bloodlet-
ting in the Bible, but from the Talmud, the Hebrew
law book, we learn that venesection, cupping, and
leeching were well known among the Jews at the
time of its composition, about the second century,
A.D. ; and it is fair to assume that they were known
before that time. If bloodletting was at all practised
by the ancient Hebrews, it is possible, if not probable,
that it was done with the kind of sharp stone or
primitive knife with which Zipporah, the wife of
Moses, in the second book of Exodus, ^*cut off the
foreskin of her son." The fact that primitive stone
knives were employed by the ancient Egyptians in
embalming and by the Hebrews in ritual circumcis-
ion shows the extreme veneration in which these rude
objects were held, for they go back to the palaeolithic
period of man's development. In the Hall of An-
thropology in the National Museum at Washington
one may see hundreds of specimens of these leaf-
shaped flints, the sign and symbol of prehistoric
man's uplift. In a most important contribution to
American archaeology, Prof. William H. Holmes, ^
of the Bureau of Ethnology, has demonstrated in-
ductively (by working out the initial methods of
chipping and flaking himself) that even among the
recent American Indians of the Piney Branch or
other quarries all over the United States, the process
of shaping and specializing the leaf-shaped celts
from oval or ovoid stones was probably not diflferent
from that employed by palaeolithic man or even
in what seem to be the rude artefacts of eolithic man.
Throughout geological space and time, the leaf-
shaped flint knife has remained the same in shape
and intention whether as weapon, tool, or ceremo-
nial object, but it is the rough-hewn knife, sharpened
as to edge and point by accidental flaking that forms
the true connecting link between prehistoric man
and the evolution of surgery. In the excavations of
the Swiss lake dwellings, which were discovered in
1853, the different cultural objects were found in
separate layers, from the Stone Age up to the Cop-
per and Bronze Ages, and of these, the real begin-
nings of northern European culture are now held to
be the bronze implements and objects found at La
Tene. On the continent of Europe, the phrase "La
Tene" has become a sort of shibboleth among an-
thropologists for the starting point of the north
European culture which followed upon the three Ice
Ages, with their two interglacial periods, and; this,
not because the lake-dwelling finds are necessarily
the earliest bronze objects known, but because they
are the most representative and characteristic. The
La Tene finds, of date about B.C. 300, entirely dis-
tinct from Egyptian, Greek, or Indian culture, in-
clude earrings of Etruscan or West Celtic pattern
and funeral urns containing human remains, show-
ing that cremation was the rule among these people.
Some time later, as, for example, in the Gallo-Roman
finds in France, we trace the evolution of the articu-
lated surgical instruments, like scissors, in which
cutting was done by indirect action.
The interesting point is that primitive North European culture,
up to the La Tene period, was discontinuous, being
interrupted by the three glacial periods, while Greek
culture up to the Age of Pericles, two hundred
years before, was probably a continuous development,
the cutting instruments of metal having been spe-
cialized in this southern country as in Egypt or India,
before the time of Hippocrates. The date of the La
Tene period (b.c. 300) brings us to an interesting
phase of the subject, namely, bloodletting among the
ancient Hindus. It is not positively known whether
the Hindus learned their practical surgery and
medicine from the Greeks at the time of Alexan-
der's Indian expedition (b.c. 327) or whether Greek
travellers, possibly Hippocrates himself, learned
something from them, but this is certain that the
Susriita, the great canon of Indian surgery, reveals
a wonderful knowledge of operative procedure and
an extraordinary specialization in the matter of sur-
gical instruments. Nearly all the major surgical
operations were performed, except the ligation of
arteries, and about 121 different surgical instru-
ments were described, including lancets, scalpels,
saws, scissors, needles, hooks, probes, directors,
sounds, forceps, trocars, catheters, syringes, bougies,
and a rectal speculum. The cutting instruments
were of steel, sharp enough to cut a hair and kept
clean by wrapping in flannel in a box. Now the re-
markable thing about Hindu bloodletting was the
way in which venesection or any other cutting
operation was taught. Having no anesthesia, the
Hindu surgeons recognized that it was necessary to
be swift and sure in incision, and accordingly they
first had the young student go through the motions,
as it were, on plants. To this end, the veins of large
leaves or the hollow stocks of water lilies were punc-
tured and lanced, as also the veins of dead animals.
Gourds, cucumbers, melons, and other soft fruits or
even leather bags filled with water were tapped or
incised, all with the idea of giving a fearless surety
and precision in attack, after which the student
could proceed to the cadavers of animals and the
living subject.^ This method of teaching surgery,
which might well be adopted in our own medical
schools, was actually employed to some extent in
England in the first half of the nineteenth century
and, like hypnotism and the "British army bamboo
splint,'^ was probably imported by the Anglo-Indian
surgeons. Some readers may recall the amusing
example in Captain Marryatt's Japhet in Search of a
Father, in which Mr. Cophagus, the apothecary,
teaches the fatherless Japhet to do venesection by
the Indian method. "He also taught me how to
bleed by making me, in the first instance, puncture
very scientifically all the larger veins of a cabbage-
leaf, until, well satisfied with the delicacy of my
hand and the precision of my eye, he wound up his
instructions, by permitting me to breathe a vein in
his own arm.''

Medicine as a science began among the eager,
imaginative, quick-minded peoples of Ionia and the
islands, and the first textual record of bloodletting in
European practice is to be found in the work of Hip-
pocrates. The Hippocratic writings, as we know, are
not an individualized treatise on medicine and surg-
ery, Hke the works ^f Galen or Celsus, but a scripture
or canon, not unlike the books of the Old Testament,
the work of several writers, some of whom lived be-
fore the Father of Medicine, some after him. The
genuine writings of Hippocrates were all written in
Ionic Greek, and, in the opinion of great scholars like
Littre, the treatises on Regimen in Acute Diseases,
and Ulcers, our principal sources for Hippocratic
bloodletting, are beyond question authentic. Hip-
pocrates was undoubtedly a far-greater surgeon than
Galen, but in clinical medicine his principal business
was the portrayal of the signs and symptoms of im-
portant diseases, and for this reason it is customary
to slur him over as a therapeutist, more especially by
comparison with Galen. The latter, with the experi-
ence of centuries to draw upon, was naturally far
more clever in getting his patients well, but that
Hippocrates was no laggard in the treatment of
disease is evident from the large number of drugs
mentioned in the canon, nearly 200 in all, from his
careful dietetic scheme, and especially from the fact
that his principal service to therapeutics was just
along the lines for which the selective, discrimi-
nating power of Greek intelligence has been justly
famous, namely, in fastening upon what is essential
and in throwing out the superfluous. This is pre-
cisely the object of the treatises on Regimen in
Acute Diseases, and what Hippocrates has to say
about bloodletting goes straight to the point: —

"Bleed^ in the acute affections, if the disease
appears strong, and the patients be in the vigor of
life, and if they have strength. . . . Hypo-
chondria when not due to retention of gas, tension
of the diaphragm, checked respiration, with dry
orthopnea and no formation of pus; more espe-
cially intense pains in the liver, heaviness of the
spleen, and other phlegmasiae and intense pains
above the diaphragm, diseases connected with col-
lections of humors — none of these diseases admit of
resolution if treated at first by medicines, but vene-
section holds the first place in conducting the treat-
ment. . . . When a person suddenly loses his
speech, in connection with obstruction of the veins,
if this happen without warning or any other good
reason, one should open the internal veins of the
right arm and abstract blood more or less according
to the habit and age of the patient. Such cases are
mostly attended with the following symptoms: Red-
ness of the face, eyes fixed, hands distended, grind-
ing of the teeth, palpitations, jaws fixed, coldness of
the extremities, retention of air in the veins [con-
gestion of the brain preceding apoplexy or epi-
lepsy]. ... In epilepsy or apoplexy, the pa-
tients having been first fomented are immediately to
be bled at the start while all the peccant vapors and
humors are buoyant, for then the cases more easily
admit of a cure. In quinsy with convulsive suffoca-
tion, the tongue turning livid and hard, bleed in the

arm and open the sublingual vein and purge with
electuaries and give warm gargles. Peripneumo-
nia and pleuritic affections are thus to be observed:
If the fever be acute with pains on either side or
both, if expiration be painful, if cough be present
and the sputa yellow or livid in color or otherwise
thin, frothy, and florid, let the physician proceed
thus: If the pain pass upward^ to the clavicle, the
breast, or the arm, the inner vein in the arm should
be opened on the affected side and blood abstracted
according to the habit, age, and complexion of the
patient and the season of the year, and that largely
and boldly, if the pain be acute, so as- to bring on
fainting, after which a clyster is to be given. But if
the pain be below the chest and very intense, purge
the bowels gently and during the act of purging give
nothing."

In his treatise on ulcers, Hippocrates shows how
to check accidental hemorrhage after venesection or
cupping; how to relieve the soreness after scarifica-
tion, and points out the most common accident of
venesection, namely, phlebitis. He adds that "Vene-
section is to be practised when the person has dined
or drunk more or less freely and when somewhat
heated and rather in hot weather than in cold" ; also,
"When the cupping instrument is to be applied be-
low the knee, or at the knee, it should be done, if
possible, while the man stands erect. ^ It is a mat-
ter of comment that there is no mention of bloodlet-
ting in the famous surgical treatise on Wounds of
the Head, but one of the aphorisms says, "When a
man has pain in the back part of the head, he will
be benefited by having the straight vein in the fore-
head opened/^ And we know that Ambroise Pare
practised venesection in head injuries on the author-
ity of the Father of Medicine. Such are the Hip-
pocratic rules for bloodletting which became the
basic principles for its practice in aftertime.

Greek medicine was established in Rome by
Asclepiades of Prusa, who opposed the humoral
pathology of Hippocrates and his ideas about the
healing power of Nature. Professor Huxley relates
that he was once talking with an eminent, fashion-
able physician about the vis medicatrix natures,
when the latter replied: "Stuff! ,Nine times out of
ten Nature does not want to cure the man; she
wants to put him in his coffin!" Asclepiades was a
fashionable physician of this kind. He believed in
systematic interference with morbid processes, and,
in a well-worn phrase, referred to the clinical obser-
vations of Hippocrates as "a meditation on death."
Yet his actual therapy, when he came down to
cases, was not very different from that of the Coan
physician, and was limited to such strenuous expe-
dients as diet, massage, hydrotherapy, gymnastics,
and a little wine; in short, what we now call physi-
ological therapeutics. He was opposed to drastic
purgation and emesis, but favored bloodletting, the
principal indication being the relief of pain.

Celsus regarded bloodletting as a principal means
of extracting morbid material from the body, and
he begins his very concise chapter on venesection^
with the following sentence: 'It is not a new prac-
tice to let blood by the incision of a vein, but it is
new to embrace this remedy in almost every dis-
ease/' This statement shows the direction in which
things were moving at the time of Celsus and, hav-
ing made it, he advances at once to the common-
sense standpoint that the true indication; is not the
disease or condition of the patient, but whether the
patient is strong enough to be bled. In all doubtful
cases where there is no time for hesitation, as "in
paralysis, loss of speech, suffocative, angina, or be-
tween two violent febrile paroxysms,'^ it is better
to try a doubtful remedy than none at all, but to
let blood during tjie violence of a fever, in the acme
of its paroxysm, is deliberate homicide. Wait for
a remission, yet, failing this, the last resort is still
not to be omitted. Celsus follows Hippocrates in
recommending that the vein be opened on the same
side as the lesion, but he intimates that the other
method, the so-called derivative bleeding, on the op-
posite side or as far away as possible from the
lesion, was already coming into vogue. This was
to be the special feature of Arabian practice in later
centuries and may have come originally from the
East. Celsus is also at one with Hippocrates in the
idea that bloodletting is good if the drawn blood is
thick and dark — the buffy-coat idea — but, if it is
red and clear, it is a sign that the bleeding should
be stopped immediately. Finally, what Celsus says
about the necessity of proper instruction in blood-
letting shows the wisdom of the ancient Hindus in
practising upon the veins of plants: —

"Although venesection be very easy to a prac-
tised man, yet to the unskillful it is most difficult.
For the vein being joined to the arteries, and the
nerves to these, wherefore if the lancet should touch
the nerve, convulsions ensue, and that cruelly de-
stroys the man. But a wounded artery neither
unites ,nor heals ; sometimes it causes profuse hem-
orrhage. Also if the vein itself happens to be
divided and the extremities by chance compressed,
no blood is emitted. But if the lancet be thrust
timidly, it lacerates the skin without opening the
vein. Also the vein sometimes lies hidden, neither
is it easily discovered. Thus many things concur to
render this a difficult operation to the tyro, which
is very easy to a scientific physician."'^

Galen was a great and resourceful practitioner
noted for the extreme cleverness of his prescrip-
tions and his remarkable originality in treatment,
as where he recommends, for the first time in medi-
cal history, the milk diet and sea voyages for phthi-
sis. As the archcommentator on Hippocrates, it
was natural that he should be very expansive on
the subject of venesection, to which, in fact, he
devoted an elaborate treatise. He was the first
to introduce the quantitative idea in bloodletting,
recommending from seven ounces to one and a half
pounds as a normal quantity to be extracted in the
average case. Like all the Greeks, he was opposed
to derivative bleeding and sometimes even opened
an artery. He carried bloodletting into a great
variety of conditions, among them diseases of the
Hver and spleen, sciatica and coxalgia, insanity and
melancholia, rheumatism, fractures, hemorrhages,
and cerebral irritation, and it was probably upon
Galenical authority that the practice was extended
to almost every ailment in later times.

Rufus of Ephesus, who was the first to describe
bubonic plague, employed bloodletting in his treat-
ment of the disease.

Aretaeus the Cappadocian is usually supposed to
have lived about the same time as Galen, or per-
haps even later, because his descriptions of disease
are the most complete and graphic of all the Greek
writers, and his literary style has that ornate, elabo-
rated character which is usually regarded as the
sign of a period of social decadence. At all events,
he wrote the best treatise on practice of medicine
in antiquity, and his wonderful clinical pictures
bring the Greek period to a splendid close. Are-
taeus, like Galen, recommends bleeding in a long
array of diseases, not only in epilepsy, pleurisy, and
the anginas, but in intestinal obstruction, tetanus,
diseases of the bladder, satyriasis, suppression of
the urine, hemicrania, and hemoptysis; and, with
him, venesection is highly specialized, the blood be-
ing drawn from the frontal vein in headache, epi-
lepsy, and vertigo, from the veins of the tongue in
throat affections, from the nasal veins in hemop-
tysis and headaches, with scarification at the pubes
or venesection of the ankle in cases of hysteria.
This was the beginning of the complex system of
**points of election" which was afterward a special
feature of the bloodletting calendars. Aretaeus, like
Galen, also indicates the quantity of blood to be let,
— about half a pint or more in headaches, for in-
stance.

During the Dark Ages, which for medicine we
call the Byzantine period, the science of physic was
put into very cold storage. As Sir Clifford All-
butt says: 'The chief monuments of learning were
stored in Byzantium until Western Europe was fit
to take care of them.^' The most important writer
who has been preserved in the Byzantine texts was
the great surgeon Antyllus, who gives most careful
directions as to the technique of venesection and
himself sometimes opened the occipital, auricular,
frontal, and temporal arteries. The famous Antyl-
lus operation for aneurism, which consisted in ligat-
ing above and below the sac and then cutting down
and evacuating its contents, was, in reality, a mode
or subvariety of bloodletting.

The Arabians, as devout followers of Galen,
were enthusiastic bloodletters, whether on the bat-
tlefield or at the bedside, but their clinical practice
had the novel feature that venesection was required
to be derivative, on the opposite side from the le-
sion, against the old Hippocratic rule of revulsion.
This opposition between derivative and revulsive
bleeding led, as we shall see, to a controversy of
phenomenal dimensions in the sixteenth century.

Medieval medicine — medicine under the Chris-
tian church — had its origins in the School of Saler-
num, the earliest literary production of which was
the Regimen sanitatis, or Code of Health, a twelfth-
century poem, composed for the benefit of King-
Robert of Normandy, who was cured of a wound
at Salerno in iioi. The Regimen sanitatis consists
of a number of wise laws relating to diet and per-
sonal hygiene, written in Latin hexameter verses
with concealed rhymes (the so-called leonine verse),
each stanza being' detached from and independent of
the others, like so many beads upon a string. This
poem, which passed through some 240 different
editions and was translated into the known lan-
guages, winds up with a special section on blood-
letting, illustrating the Salernitan practice, largely
derived from the Arabic writers. The Latin poem
itself is by no means what the Germans would call
a "right royally pitiful rhyme," for the diction is
elegant. It was translated into English five times
and the subjoined quotation is from the amiable
version of Professor John Ordronaux: —

Of Bleeding and of the Age of Bleeding. Ere seventeen years we scarce need drawing blood ;High spirits fall by tapping life's own flood.

Wine may restore a wanted joyous mood, But loss of blood is late repaired by food. Bleeding the body purges in disguise,

For it excites the nerves, improves the eyes And mind, and gives the bowels exercise. Brings sleep, clear thoughts, and sadness drives away,
And hearing, strength, and voice augments each day.

In what Months it is Proper, and what Improper to Bleed,

Called lunar, are September, April, May,
Because they move beneath the Hydra's sway.
Two days — September first. May thirty-first —
For bleeding and for eating goose are cursed.
When blood abounds in full age or in youth,
May'st bleed in any lunar month, forsooth ;
Yet chiefly in September, April, May,
Bleed freely, if you would prolong life's day.

Of Obstacles to Bleeding.

Cold nature, clime, or when some sharp pain laces ; And after baths that follow love's embraces; In youth, old age, amid disease's traces ;
Or when of food a surfeit overplies

The stomach, and to constant qualms give rise,Then letting blood is truly most unwise.

Circumstances Relating to Bloodletting.

Whatever amount of blood you wish to let. Or great, or small, these rules do not forget : A bath, inunction, cord the arm to bind,
Some wine, a stroll ; lose never these from mind. Of Some Effects of Bloodletting.

Bleeding soothes rage, brings joy unto the sad,And saves all lovesick swains from going mad. Of the Size of the Wound in Bloodletting.

A medium-sized incision always make,Whatever amount of blood you wish to take The copious vapor rising sudden, flees.And thus the blood escapes with greater ease.

Things to be Considered in Bloodletting, When one is bled he should for full six hours Most vigilant maintain his mental powers. Lest fumes of artful slumber too profound Should all his mortal nature sadly wound

For fear that thou some slender nerve shouldst mar,Conduct not the incision deep nor far ;

And being purged through blood, and thus nenewed. Haste not at once to sate thyself with food.

Things to he Avoided After Bleeding,

All things from milk as are in gen'ral made. And draughts of wine, of whatsoever grade. Should every one dismissed, avoided be By recent subjects of phlebotomy.

Cold things are also hurtful to the weak, Nor let them, dauntless, brave damp skies or bleak For vigor only comes once more to these

From sunshine mingled with the passing breeze.

To all rest proves an everlasting gain,

While exercise occasions certain pain.

THE HISTORY OF BLOODLETTING. 19

lOl.

In what Diseases, Ages, and Quantities Bloodletting

Should Occur.

Acute disease, or only so in part,

Demands bloodletting freely from the start.

In middle age, bleed largely without fear,

But treat old age like tender childhood here.

In spring you may bleed doubly at your pleasure —

In other times alone in single measure.

102.

What Parts Are to be Depleted and at What Seasons,

In spring and likewise in the summer tide,
Blood should be drawn alone from the side.
In autumn sere, or on cold winter's day,
Take from the left in corresponding way.
Four parts distinct we must in turn deplete —
The liver, heart, the head, and last the feet.
In spring the heart — liver when heats abound.
The head or feet, when'er their turn comes round.

103.

Of the Benefit of Bleeding from the Salvatella Vein.^

To mortals there will come superior gain.
From tapping off the Salvatella vein ;
It frees the voice, spleen, liver and the chest,
And heart, where'er abnormally distressed.

It is clear from these Salernitan precepts that
bloodletting had already become a prophylactic as

8 In the little finger.

20 VENESECTiOX.

well as therapeutic device, and, as a definite part
of personal hygiene, it became, in due course, im-
mensely popular with the masses. Astrological in-
fluences werd already creeping in and the time for
venesection was soon to be set by the conjunctions
of the planets. But the most interesting feature of
bloodletting in this period was the evolution of an
entirely new figure- in the history of medicine — the
barber -surgeon. There were great surgeons in the
Middle Ages, such as Hugh of Lucca and Theo-
doric; the pioneers of anesthesia and asepsis, Sali-
ceto, Lanfranc, Guy de Chauliac, Mondeville; yet it
cannot be denied that the general practice of surg-
ery, and consequently of internal medicine, fell into
what Allbutt styles "unexampled and even odious
degradation," partly through the medieval schism
between medicine and surgery which had obtained
since Avicenna's time, partly on account of certain
restrictions which the church had to put upon surg-
ical practice by priests and clerics, partly by reason
of the many social and legal restrictions which feu-
dal authority put upon both physician and surgeon,^
partly because the feudal lords of earth were in
position to kill if the surgeon failed to cure, and
largely, no doubt, on account of the almost station-
ary cast of the medieval niind,^ not to mention the
ignorance and incompetence of many of the sur-
geons themselves. Among the Greeks, the surgeon
was held in highest honor. In medieval times.
Church and State were not specially enthusiastic
about him and the medical scholastics, those amazing examples of the "discontinuous mind," affected to look down upon him, although far inferior in first-hand knowledge of their profession. It was a
case of "give a dog a bad name,'' with the result
that the general practice of surgery fell into the
hands of barbers, bath-keepers, sow-gelders, and
the strolling "incisors,'' who, as like as not, put out
an eye in couching for cataract, butchered the vis-
cera in cutting for stone, or in attempting to effect
a radical cure for hernia, often, as Baas puts it, ex-
cised "the radix of humanity itself." No doubt the
self-made, outcast surgeon, not properly bred up
and educated to his calling, must bear his part of
the blame. We find all the leading surgeons of the
period — Lanfranc, Guy de Chauliac, Mondeville —
giving very shrewd and straightforward advice to
their professional brethren as to the necessity of
dignified and straightlaced moral conduct in private
houses. They were not to flirt with the lady of the
house nor to ogle the maidservants, under pain of
losing several cubits from their professional stature
and possibly their practice. Again, the laws of the
Visigoths, the basis of the old Spanish medieval law,
state explicitly that "No physician may undertake to
bleed a woman in the absence of her relatives; that
whoever touched^ the hand, arm, or breast of a
maiden was to be fined; and that if a physician! in-
jured a nobleman in bloodletting, he was to be
fined." It is plain that immorality and incompe-
tence were common enough among the medieval sur-
geons of lower caste.
The deplorable thing about the whole matter was that, for centuries, the rank and file o£ surgeons were under a sort of social ostracism.
An English surgeon once said of John Hunter that "He alone made us gentlemen," and, even in protestant Prussia, up to the time of Fred-
erick the Great, it was the duty of the army surgeon
to shave the officers of the line. In medieval times,
the barber-surgeon attended only to bleeding, cup-
ping, and the dressing of wounds. Medieval sur-
gery was, in fact, merely "wound surgery," and
even in such a slight solution of continuity as blood-
letting it was the practice to give a "wound-drink"
to strengthen the patient. The major operations
were in the hands of specialists, often hereditary in
certain families. Internal medicine was in the
hands of scholastics, whose knowledge of Greek
medicine was derived almost entirely from transla-
tions into Arabic, Hebrew, or other Oriental lan-
guages. Renan, as cited by AUbutt, speaks of a med-
ieval university textbook, an edition of Aristotle,
which consisted of a Latin translation of a Hebrew
translation of an Arab commentary upon an Arab
translation of a Syriac translation of the Greek
text.^" It was under such influences as these that
the medieval physicians began to give up the old
Greek practice of bleeding upon the affected side in
favor of the Arabic method of derivative bleeding
upon the opposite side. All the clinical writers of
the period, the so-called Arabists, Gilbert of Eng-
land, Peter of Abano, Arnold of Villanova, Gentilis

of Foligno, Bernard de Gordon, Valescus of Ta-
ranta, even Savonarola, speak in favor of derivative
bleeding, and, in connection with the University of
Montpellier, which was always under Arabic influ-
ences, the practice became common in France and
was duly approved by the Paris Faculty. How
powerful the Paris Faculty was in the sixteenth cen-
tury, how it made surgeons and barber-surgeons
crawl and knuckle under, how it called down curses
upon heretic physicians which sounded like the
anathemas and excommunications of religion, we all
know. There is always a lingering suspicion that
the general medical profession of these times needed
stirring up with a pole, and they got it in some
measure from Vesalius and the Greek scholars who
poured into Europe, after the destruction of Con-
stantinople in 1453, shortly after the invention of
printing. These men, in the words of Knott, were
literally "sowers of dragons' teeth," and the new
ideas they introduced caused a great fermentation
of medical heresies and the inevitable persecution
of heretics. It is said that there are always three
stages in the introduction of a new idea: First of
all, people say, "It is not true"; second, "It is con-
trary to religion"; finally, "We knew it all before."
And so it happened that in the year 15 14, one
Pierre Brissot, a learned physician of Paris, who
was deeply read in the Hippocratic writings, came
out in defense of the old Greek practice of bleed-
ing on the same side as the lesion, because, from
his own experience, revulsive bleeding did most
good, since it removed the bad blood in a more

direct manner. Immediately upon this pronounce-
ment a storm of controversy broke loose over Bris-
sot's head. The Paris Faculty, as usual, declared
him to be a medical heretic, revulsive bleeding was
forbidden by act of Parliament, and three years
later (1518) Brissot was induced to take a little
journey into Spain and Portugal, ostensibly to
study the strange and rare properties of medici-
nal herbs of the New World, but, in reality, because
it was in his interest to come off with a whole skin.
As in the case of Vesalius, Spain was a genial ciime
for heretics in those early years. The faculty of
Salamanca declared in favor' of Brissot, but in
Paris the controversy raged fiercely long after his
death in 1522, and even the Pope and the Emperor
(Charles V) were dragged into it. Then came the
anticlimax of this teapot tempest. A relative of
the Emperor's, who had been bled by the Arabic
method, during an attack of pleuropneumonia, sud-
denly died. Confusion reigned in the Arabic camp
and the whole edifice of controversy collapsed like a
puffball. The Brissot affair illustrates how purely
theoretical was the practice of medicine in the six-
teenth century, and for sheer absurdity might be
paralleled by an occurrence in the seventeenth cen-
tury which is related by that jovial historian of
medicine, Johann Hermann Baas: —

"In Pleidelburg, about the middle of the cen-
tury, there arose at the bedside of the Margrave of
Baden a difference of opinion between two learned
professors and the ordinary physician — at all events also a medicus punts — whether a plaster for the
illustrious Margravian heart, in order to cover that
organ, should be placed in the middle of the chest,
according to Galen, or upon the left side. The dis-
pute was settled by opening before the.' eyes of the
noble patient — a hog — ^by means of which it was
demonstrated that, as a matter of fact, the heart
of the hog lay on the left side. This evidence so
firmly convinced His Excellency that his own in-
ternal arrangements were quite the same as those
of a hog, that he at once dismissed his private medi-
cal attendant for daring to hold a contrary opinion
as to the position of a nobleman's heart."'

After the fiasco of derivative bloodletting, many
physicians gave up venesection altogether, but in
Italy,^ under the leadership of Botallo, the practice
was pushed to the extraordinary extent of bleeding
in all diseases without exception, and that abun-
dantly and many times in succession. For fully
three centuries the Italians led the world, as it
were, in extensive bloodletting. Costly bleeding
glasses were hereditary in Italian families, and
handed down as heirlooms. ^ ^

A special feature of bloodletting in the northern
countries during the fifteenth and sixteenth centu-
ries was its connection with astrology and the fact
that it had become so popular among the masses
that it was done in the public baths ; in other words.

11 See the interesting essay, "The Old Venetian Bleeding Glass," by
Dr. John Knott in Medical Press and Circular, xlvii, 662-664, London,
1889.

almost as often as a man took a bath. After the
invemion of printing a curious portion of the huge
vernacular literature of the period consisted of the
so-called bloodletting calendars and purgation cal-
endars. In connection with these it is of interest
to note that the first medical publication to be set in
type was the Purgation Calendar {Laxierkalendcr)
of 1457, printed by Gutenburg in the type of his
36-line Bible, and consisting of a single sheet of
paper in the Bibliotheque nationale at Paris; the
second in order of time being the Bloodletting
Calendar (Aderlasskalender) , printed at Mainz in
1462, and now contained in the Fiirstenberg li-
brary at Donaueschingen in the Grand Duchy of
Baden. 1- As in some of the drug-store almanacs
within our own recollection, the writers of these
calendars affected the scientific power of prediction
in regard to wars, famines, epidemic diseases and
other pests that were to befall mankind, and their
efforts were specially characterized by the fact that
the times for purgation and the innumerable points
of election in bloodletting were determined by "ju-
dicial astrology''; that is, by horoscopes drawn
from the ascendancies and conjunctions of the
planets, under the signs of the Zodiac. In the six-
teenth and seventeenth centuries, the doctor was
too frequently an astrologer, and old Fracastorius
declared men to be "slaves to the rabble of the
sky."'^ Doctor Urinal and Doctor Almanac were
standard figures in the plays of the English dram-
atists of the Elizabethan and Jacobean periods;
for example, in Middleton's Inner Temple Masque,
which opens with "Doctor Almanac, coming from
the funeral of December or the Old Year": —

I have seen the Old Year fairly buried ;
Good gentleman he was, but towards his end
Full of diseases : he kept no good diet ;

That was his fault, and many an old year smells on't.

The fifteenth century was, as stated, the great
age of common public baths; the bath-keeper was
usually a barber-surgeon and bloodletter, and to-
ward the beginning of the sixteenth century these
baths came to be frequented by both sexes at one
and the same time. The contemporary pictures of
the artists of» the period reveal the astonishing
spectacle of men and women, absolutely nude, hud-
dled together in a huge common bath-vat or in a
steaming bath-room, some playing upon musical
instruments, some reading books, some guzzling
wine, others eating a set meal from a temporary
board arrangement not unlike that employed in
Pullman cars, all soaking themselves at leisure
and perspiring freely, while, as if to achieve the
height of the ridiculous, a' stream of blood spouts
from the median basilic vein of some patron who is
testing the bath-keeper's skill as a venesector. Pub-
lic establishments of this kind were still common at
Budapest in the first half of the nineteenth century,
and have been described in detail in the Hungarian
travels of Richard Bright (of Bright's disease).

Harvey's quantitative demonstration of the cir-
culation of the blood had no appreciable effect upon
the practice of bloodletting, and it remained for
Magendie to point out what should have been an
immediate inference from Harvey's data, namely,
that the so-called points of election in venesection
are really indifferent points, since the effect of
opening the different veins anywhere is exactly the
same. Like many great experimenters, Harvey
himself was only a passable practitioner and, in the
treatment of disease, he and his contemporaries
were completely overtopped and overshadowed by
the great figure of Thomas Sydenham, who en-
nobled the practice of medicine through those per-
sonal quaHties of piety, good humor, and common
sense which Edmund Burke declared to be the
genius of the English race. All agree that Syden-
ham resembles Hippocrates in his original descrip-
tions of disease, and when he says that he holds
himself answerable to God for the care of his pa-
tients, we recognize the same dignified regard for
human suffering which characterized the Greek
master. It was Sydenham who first threw open the
windows and let the fresh air into the sickroom.
introduced Peruvian bark and paregoric, prescribed
cooling draughts for feverish patients, steel tonics
for love-sick or green-sick maidens, riding in the
open air for consumptives, and divested his pre-
scriptions of all filthy and nauseating ingredients.
In relation to venesection, Sydenham may be classed
among the extensive, as opposed to the intensive,
bloodletters. In almost every disease known to him
he began his treatment by opening a vein, but he
seldom let more than eight to ten ounces of blood
at a time, and, if this did not avail, he pushed the
procedure no further. This was his practice in small-
pox, erysipelas, gout, rheumatism, hysteria, chorea,
insanity, dysentery, renal and biliary colic, hem-
optysis, hematemesis and hematuria, leucorrhea,
metrorrhagia, hemorrhoids, scurvy, epistaxis, con-
vulsive cough in children, and in the condition
known as "going into a decline/' In rheumatism,
gout, renal calculus, and intestinal obstruction blood
was let from the arm of the affected side; in gonor-
rhea he directed that the blood should be drawn
about once or twice when half-way through the
treatment, as also in measles complicated with diar-
rhea or bronchitis. Venesection was interdicted by
him in dropsy, diabetes, cholera morbus, and sup-
pression of lochial discharges. The principal
authority for Sydenham's practice is his little
therapeutic manual (Processus integri) of 1691,
which was the English physician's standby for over
a century, and which a certain Oxford enthusiast of
the day* is said to have committed to memory.
From the details just gleaned from this book it is
evident that, in comparison with contemporary
French practice, Sydenham's bloodletting was sen-
sible, moderate, and temperate. It is said of Guy
Patin, for instance, that he once bled a colleague
thirty-two succeessive times for a continued fever
and showed his own implicit faith in venesection by bleeding himself seven times in succession for simple cold in the head.^"* The abuse o£ blood- letting by the seventeenth-century doctors was, in
fact, a favorite theme for the satire of Moliere and
Le Sage, and the story of Doctor Sangrado, the
"tall, withered, wan executioner of the sisters
three," who reduced the old canon Sedillo "to
death's door in less than two days" by drawing
twelve good porringers of blood at the start, with
repetitions, is a welPknown chapter of Gil Bias.
In the same novel, L^ Sage gives an amusing in-
stance of the use of another means of depletion, the
seton or issue, an adjuvant of treatment which was
first mentioned by the Salernitan surgeons, Roger
and Roland, and was put upon a practical footing
by the directions of Lanfranc. A little girl, Inesilla.
after the communicative habit of the enfant terrible,
betrays the secrets of the housekeeper's toilet to Gil
Bias, which the valet-souled hero proceeds to give
away as follows: "Dame Jacinta. as I have said
before, though a little stricken in years, had still
some bloom. To be sure, she spared no pains to
cherish it: besides daily evacuations, she look
plentiful doses of all-powerful jelly. She got her
sleep in the night too, while I sat up with my mas-
ter. But what perhaps contributed most to the
freshness of this everlasting flower was an issue in
each leg, of which T should never have known, but
for that blab Inesilla."^^

In seventeenth-century Italy, bloodletting was as
popular as ever and was the subject of elaborate
copperplate illustration in the many books on the
subject, of which Malfi's // Barbiere (1618) may be
taken as the type.

The eighteenth century has always been ac-
counted the Gk)lden Age, alike of the successful prac-
titioner and the successful quack, and both found
themselves confirmed and fortified in the practice
of venesection by the ingenious arguments of the
medical theorists who swarmed during this period.
Boerhaave's doctrine of the plethora furnished an
additional excuse for it, and Boerhaave was fol-
lowed by Van Swieten andj the old Vienna school.
Stahl's theory (phlogiston) gave it the well-known
antiphlogistic flavor. Reil favored it on physiologi-
cal. Brown and Friedrich Hoffmann on mechanical
grounds, for the relief of sthenic and asthenic, spas-
modic and atonic conditions. Johann Peter Frank
held that it promoted the resorption of settled
exudates and regulated the excretions. Haller tried
to justify or explain its rationale by experiment, but
got no further than the statement that it hastens
the blood-current. Percival Pott, Pringle, and the
members of the Royal Academy of Surgery of
Paris, bore a hard reputation as intensive blood-
letters. CuUen and Theophile de Bordeu stand out
as physicians who were very moderate in the prac-
tice. In the American colonies, Benjamin Rush, a
follower of John Brown, was a veritable Sangrado
of the New World, but the Anglo-Saxon practi-
tioner of more conservative type was still a follower
of Sydenham.
General Washington, however, lost his life from bloodletting. A well-worn epigram at the expense of John Coakley Lettsom, one of the il-
lustrious line of English Quaker practitioners, noted
for their ability, liberality of spirit, and their large
charities, may still be quoted, although, like most
epigrams, it was perpetrated at the expense of
truth :^

When patients sick to me apply,
I purges, bleeds, and sweats 'em :

If after that they choose to die,
What's that to me? I. Lettsom.

The first half of the nineteenth century is espe-
cially interesting as marking the prow-wave of
extensive and intensive bloodletting, while, at the
same time, by the law of action and reaction, the
general decline of the practice was brought about
in a remarkable way. Many of the leading medical
men of the time had passed through the Napoleonic
wars and, in this rough school, had acquired a hard
brutality, a supercilious indifference toward their
patients which was sharply accentuated when it
came to letting blood. This was particularly the
case with Francois Joseph Victor Broussais (1772-
1838), who had sworn at troops as a sergeant and
had swung a cutlass as a privateersnian during the
Revolution with the same vigor with which he
afterward wielded the lancet as an army surgeon
in Napoleon's campaigns. Broussais, like John
Brown, believed that life depends on external irri-
tation, disease upon local irritation of some
particular organ or viscus, usually the stomach and
intestines. There was no healing power in Nature,
and it was necessary to abort disease by drastic
measures. He therefore initiated an antiphlogistic
or weakening regime which consisted in depriving
the patient of his proper food and leeching him all
over his body. Even in cases of extreme debility,
at least five to eight leeches were prescribed, while
thirty to fifty applied together constituted his usual
treatment. Under the Broussais regime, leeches
became so scarce in France that, in the year 1833
alone, some 41,500,000 were imported, when less
than ten years before 3,000,000 had been suffi-
cient to supply all demands. Broussais was fol-
lowed in this sanguinary practice by Bouillaud,
who abused venesection by bleeding coup sur coup;
by Dupuytren, and by Lisfranc. Of Lisfranc, Dr.
Oliver Wendell Holmes, who was a medical student
in Paris at this time, relates: "I can say little more
of him than that he was, a great drawer of blood
and hewer of members. I remember his ordering
a wholesale bleeding of his patients, right and
left, whatever might be the matter with them, one
morning when a phlebotomizing fit was on him.
I recollect his regretting the splendid guardsmen
of the old Empire, — for what! because they had
such magnificient thighs to amputate."

In England and Germany things were not much
better. The leading English medical journal of the
day, founded in 1823, was called The Lancet. In
Italy, Giovanni Rasori, at his clinic at Milan, be-
came such another vampire for bloodletting as was

Botallo in the sixteenth century. Like John Brown,
Rasori believed that the treatment of disease con-
sists in stimulating depressed conditions and in de-
pressing states of excitement, and that venesection
was not only an arm,' of treatment, but a means of
diagnosis, indicating an excited condition if bene-
ficial or, if injurious, a state of depression. Acting
upon these conventions, he either bled his patients
to death's door or else practically poisoned them
with gigantic doses of saltpeter (i6 to 90 grams
a day), gamboge (i to 4 grams for diarrhea),
aconite (134 grams in a week, death supervening),
digitalis, opium, camphor, etc. Now the effect of
all this pitiless bloodletting and drugging was ex-
actly like what General Grant said about the strict
enforcement of an obnoxious law. It eventually
annihilated itself and in' the most natural way,
through the introduction of a new method of pre-
cision in medicine — medical statistics. Although
the Romans and perhaps the Hebrews took the
census and counted troops, while John Graunt, in
the sixteenth century, studied the meaning of the
birth and death rates, and Siissmilch, in the eight-
eenth, emphasized the moral significance of vital
statistics, yet there were no true medical statistics
before the time of Louis. Louis, like Laennec,
Bichat, and Pinel, was a man of finer mold and
spirit than Broussais or Dupuytren, and touched to
finer issues. Leading the austere life of a scientific
enthusiast, divided about equally between the hos-
pital wards and the post-mortem room, he was the
first to make real medical statistics, in which the
separate items were not merely counted but of
equal weights; and to emphasize the importance of
what he did, it is 'worth while to quote at length
from our principal authority upon French medical
teaching at this time, Oliver Wendell Holmes: —

''You young men who are following the hos-
pitals hardly know how much you are indebted to
Louis. I say nothing of his Researches on Phthisis
or his great work on typhoid fever. But I consider
his modest and brief Essay on Bleeding in Some
Inflammatory Diseases, based on cases carefully
observed and numerically analyzed, one of the most
important contributions to practical medicine, to

•

the treatment of internal disease, of this century, if
not since the days of Sydenham. The lancet was
the magician's wand of the dark ages of medicine.
The old physicians not only believed in its general
efficacy as a wonder worker in disease, but they
believed that each malady could be successfully
attacked from some special part of the body — the
strategic point which commanded the seat of the
morbid affection. On a figure given in the curious
old work of John de Ketam, no less than thirty-
eight separate places are marked as the proper ones
to bleed from in different diseases. Even Louis,
who had not wholly given up venesection, used now
and then to order that a patient suffering from
headache should be bled in the foot, in preference to
any other part. But what Louis did was this: He
showed by a strict analysis of numerous cases that
bleeding did not strangle — jugulate was the word

then used — acute diseases, more> especially pneu-
monia. This was not a reform — it was a revolu-
tion. It was followed up in this country by the
remarkable Discourse upon Self-limited Diseases of
Dr. Jacob Bigelow, which has, I believe, done more
than any other work or essay in our own language
to rescue the practice of medicine from the slavery
to the drugging system which was a part of the
inheritance of the profession. Yes, I say, as I look
back upon the long hours of the many days I spent
in the wards and in the autopsy room of La Pitie,
where Louis was one of the attending physicians —
yes, Louis did a great work for practical medicine.
Modest in the presence of nature, fearless in the
face of authority, unwearying in the pursuit of
truth, he was a man whom any student might be
happy and proud to claim as his teacher and his
friend."

In Vienna, Skoda's therapeutic nihilism soon
made short work of the "antiphlogistic" treatment
of pneumonia by purging and venesection. In Eng-
land, a vigorous assult was made upon the abuse
of bloodletting by two well-known authorities, James
Wardrop, the surgeon, and the physiologist, Mar-
shall Hall; while the manly and straightforward
Charles Reade lent his splendid talents to the ridi-
cule of the practice and landed many a clever cross-
counter, more especially in his enthralling story of
Hard Cash. Charles Dickens has an amusing page
on extensive leeching in The Uncommercial Travel-
ler. Yet, in spite of all this marshalling of genius
and talent against it, bloodletting still held its own
in England until well after the middle of the cent-
ury, when, under the influence of Sir William Jen-
ner and Sir William Gull, it was discarded about
i860. Most of us have or' have had relatives who
went to the old country doctor every spring to have
their veins opened. Even in the latest edition of
Sir Thomas Watson (1870) it is still extensively
indicated, and the buffy coat in the drawn blood was
always looked for as a sign of inflammation. To
be bled was regarded as a sign of a vigorous con-
stitution, and Sir Richard Burton relates that, after
the cholera epidemic of 1831, Englishmen lamented
the disuse of the daily Lady Webster pill as a sign
of decadence. Yet general bloodletting did gradu-
ally and surely decline after the time of Louis, for
even such a rational substitute as the so-called
hemospasia of Junod, a method of producing a
fainting spell by drawing blood from the brain to
the foot, a species of bloodletting without letting
blood, did not make any special impression, al-
though the author asserted he had had most ex-
traordinary success in many different diseases. The
secondary reason for the gradual decline of blood-
letting is probably to be found in the development
of more refined methods of therapeutic procedure,
such as the hypodermic needle, the many alkaloids
introduced by Magendie, the coal-tar products of
the German chemists, good dietetic schemes, begin-
ning with the pioneer work of William Beaumont,
massage, hydrotherapy, electrotherapy, and other
devices which emphasize the principal modern objection to venesection, namely, its extremely disagreeable character, both for the doctor and the patient. The very subject of bloodletting is, in fact,
a disagreeable one. In modern practice, it seems
like the plausible villain in the play, neither entirely
good nor entirely bad. Its true merits have been
ably upheld by such authorities as Paget, Hughes
Bennett, Sir William Broadbent, and Sir Andrew
Clarke, and it would seem to be of special value in
such indications as the sudden dyspnea, coma, and
convulsions of uremic seizures or of puerperal
eclampsia; the severe pain in pleurisy or pneumonia;
threatened asphyxia from cardiac embarrassment,
aneurism, or carbon-dioxide poisoning, and in cere-
bral hemorrhage, actual or threatened.

Haviland and Hall,^^ in a recent study of the
subject, sum up the modern indications for blood-
letting as follows: —

"(i) Cases of an apoplectic nature, especially
when associated with coma and cyanosis. {2) Cases
of high tension and granular kidney in connection
with arteriosclerosis. {3) Cases of convulsions in
the status epilepticus. (4) Cases of uremia. (5)
Cases of sunstroke with asphyxia. (6) Cases of
polycythemia. (7) In hemoptysis, if there be en-
gorgement of the right ventricle of the heart. (8)
In aneurism for relief of pain. (9) In cases of
dilatation of the right ventricle of the heart from
whatever cause arising. (10) In cases of pneu-
monia, for relief of pain and dilatation of the right
ventricle."

Pye-Smith states that its main indication is "cy-
anosis with distention of the right heart." In the
tickHsh matter of arterial hypertension, bloodlet-
ting is usually sneered out of court, on the ground
that "it produced no appreciable fall of blood-pres-
sure till the amount withdrawn by the circulation
has become so great that life is directly endangered
by the operation." On the other hand, Knott argues
that, whatever inferences may be drawn from labo-
ratory protocols, human beings are not necessarily
rabbits, guinea-pigs, or dogs of a larger growth,
since "the effect of a cut head or even a barked
shin or scratched finger on the arterial tension in
the human animal is often very pronounced indeed
and requires neither kymograph nor sphygmograph
to demonstrate it."^*^ The intense thirst and co-
pious water drinking which follow depletion would
seem to make the bloodletting of the past a vague
equivalent of "bloodwashing," in the sense of re-
moving poisons from the system.

The history of therapeutics illustrates Cardinal
Newman's belief that mankind is influenced by
types rather than arguments, and not so much by
ideas and pure reason as by prevailing fashions.
The world has witnessed the rise and fall of many
a drug and has seen bloodletting die hard. In spite
of its long descent, we know little of its reason for
existence beyond the notion that it may relieve
states of tension and plethora or remove peccant
humors. Yet there is hardly a physician with a

good practice who may not suddenly encounter some
circumstance in his experience in which venesection
would turn out to be his sheet anchor and his pa-
tient's salvation. Even as the University of Minne-
sota has adopted the Renaissance idea of a botanic
garden for teaching materia medica, or as experi-
mental surgery is now taught upon animals at Yale
and the Johns Hopkins Hospital, so it would be no
bad plan if our medical schools used the Hindu
method of inducting the student into the ancient
practice of "breathing" a vein.

BLOOD AND LYMPH.

The blood of the body is spoken of as the
medium for the reception and storing of the nu-
tritive elements, after they have been properly
prepared by the digestive organs, and for their
conveyance to all parts of the body. The blood
transports oxygen from the lungs to the tissues and
carries off from the tissues the refuse matter to
those organs whose function it is to separate them
and eliminate them from the body. It is the source
from whence the various tissues take their nutri-
tion. The blood is said to be a digestive as well as
a nutritive fluid, and the digestive processes taking
place are regulated by a linely adjusted mechanism
which at present we do not understand (Vaughan).
The blood is the medium for transmission of cer*
tain internal secretions. It aids in maintaining the
normal temperature and water contents of the
body. The blood, histologically, is composed of an

BLOOD AND LYMPH. 41

almost colorless fluid, the plasma, in which float
numerous microscopic masses, of protoplasm, the
blood-corpuscles. There are three general groups,
or kinds, of corpuscles known, respectively, as the
red, or erythrocytes; the white, or leucocytes; and
the blood-plates.

The normal reaction of the blood is alkaline.
This reaction is attributed to the sodium carbonate
in solution in the plasma. The average specific
gravity of the human blood in the adult male varies
from 1.042 to 1.066. The average specific gravity,
as taken, is about 1.055.

Hammerschlag's method of mixing chloroform
(sp. gr., 1.526) and benzol (sp. gr., 0.889) ^^ such
proportions as to have a specific gravity of 1.055 is
quite simple. A drop of blood is allowed to fall
from the finger into the mixture. If the drop
either rises or sinks, the chloroform, or benzol, is
added to the point that the drop remains . stationary,
thus indicating its specific gravity.

The quantity of blood averages one-half to one-
fourth of the total body weight.

The red blood-corpuscles in man are circular,
biconcave disks without nuclei, from y fi to 8 /m in
diameter, and about 2 fi in thickness. The average
number is given as 5,000,000 per c.mm. for the
adult male. The red color of the corpuscles is due
to the presence of a red coloring matter known as
hemoglobin.

The greater function of the red blood-corpuscles
is to carry oxygen from the lungs to the tissues.
This function is dependent upon the affinity of
hemoglobin for oxygen gas. The study of hemo-
globin in the stroma of the corpuscles has been
somewhat difficult, but it offers a prolific field for
future investigation.

The process of hemolysis, or the discharging of
hemoglobin from the corpuscles so that it becomes
dissolved in the plasma, is caused by hemolytic
agents. Some of the agents which produce hemol-
ysis are as follows: —

Lowered osmotic pressure of the plasma; amyl
alcohol; ether or chloroform; excess of alkali; sap-
onin or sapotoxin; serum of blood of certain ani-
mals; bile or solution of bile salts; various toxins
found in serum of other animals or among the
natural hemolysins or by process of immunization.

The nature and amount of hemoglobin, its com-
pounds with oxygen and other gases, derivative com-
pounds of hemoglobin, variation in number of red
blood-corpuscles, are subjects that should be studied
closely and at length.

The physiology of the blood-leucocytes, or color-
less corpuscles, has been the subject of numerous
investigations, particularly in connection with mor-
bid physiology. In the light of our present knowl-
edge little positive information can be advanced
as to the normal function of these cells in the
body. The colorless corpuscles are not all the
same histologically, and their functions are as di-
verse as their morphology. Formerly various
classifications were made based upon differences in
microscopic structure and reaction to staining
agents, but at present Eriich's system is preferably

used. This classification divides . the white corpus-
cles into two main groups, — ^the lymphocytes and
the leucocytes, — ^and each of these into two or more
subgroups.

The number of leucocytes, under normal condi-
tions, average 5000 to 7000 per c.mm. The num-
ber may vary considerably the same day. They
may be considerably increased (leucocytosis) by a
meal, and diminished (leucopenia) again by fast-
ing. Leucocytosis occurs under various other con-
ditions, such as exercise, cold' baths, pregnancy,
menstruation, and epistaxis.

The functions of the leucocytes are quite inter-
esting and remarkable for the part they play in the
economy of the human body. The most striking
property of the colorless cells is the power of spon-
taneously changing their shape, — ameboid move-
ments. They are termed the "wandering" cells.
This property of the white cells enables them to
migrate through the walls of blood-capillaries into
the surrounding tissue. Among the functions attrib-
uted by physiologists to leucocytes are the .follow-
ing: (i) They assist in protecting the body from
pathogenic bacteria and other foreign organisms.
(2) They aid in the absorption of fats and of pep-
tones from the intestines. (3) They assist in the
process of coagulation. (4) They are an important
factor in the maintenance of normal composition of
the blood-plasma in proteins.

The third variety of corpuscles known as blood-
plates are small, circular, or elliptical bodies of
nearly homogeneous structure, and vary in size
from 0.5 to 5.5 (U. They are smaller than the red
cells.

Not so much is known of their origin, fate, and
functions as in the case of the leucocytes. Wright
claims there is a relationship between the biood-
plates and the giant cells of the marrow (megalo-
karyocytes), and ventures the opinion that the
plates are detached pieces of the cytoplasm of the
giant cells. Deetjen asserts that they are capable
of ameboid movements, and that they possess a dis-
tinct nucleus.

Recent observers using special methods indicate
the average number may be 500,000 per c.mm.
Blood-plates take part in the formation of thrombi
and in the initiation of coagulation.

There may be some question as to the reason
for this brief discussion of the blood and lymph.
Venesection is, at all times, an empiric agent unless
done by one who has a thorough knowledge of
general and morbid physiology. It is, therefore,
positively imperative that one should be possessed
of such learning before scientific venesection is
attempted.

Venesection, in the normal adult, exercises a
mechanical effect upon the circulation and a general
effect upon the system. General bloodletting reduces
amount of body blood, lowers blood-pressure, causes
loss of red blood-cells, lowers specific gravity,
causes leucocytosis. and diminishes activity of va-
rious functions. The heart is quieter, the respira-
tion slower, tissue change less active, and the body
heat is lowered. The depression is temporary, last-
ing from a few minutes to a few hours, depending
upon the amount withdrawn. Then there is re-
newal of blood, with hyperleucocytosis ; tissue
change is accelerated, and the nervous system is
improved by stimulation of the nerve-centers.
Robin claims that after moderate bleeding of 150 to
250 grams there is polyuria and increase in the ex-
cretion of solids, and that a greater amount of air
is taken in with increased consumption of oxygen
by the tissues.

HEMATOLOGY.

Hematology is of intrinsic value in medical and
surgical practice. If one would be a successful
phlebotomist, he must have a thorough working
knowledge of the general physiology and pathology
of the blood. It is, therefore, fitting that hema-
tology be here briefly discussed. As to the specific
diagnosis of a given disease, the results of a blood
examination are often misleading; yet this clinical
evidence is a part of a system that aids in positive
diagnosis.

The detection of the characteristic leucocyte for-
mula in leukemia and of the recognizable megalo-
blastic cell changes in pernicious anemia are signs
of a positive diagnosis. The leucocyte count, hemo-
globin values, coagulation time, bacteremia, iodo-
philia, and cryoscopy are applicable to every-day
practice.

The salient principles of blood histology and
pathology will be briefly referred to as essential
hints to a more extensive reading of hematology.

46

The blood is alkaline in reaction and usually re-
mains so as long as the emunctories act normally.
In severe anemias and cachexias, in uremia, dia-
betes mellitus, cholemia, in many of the dermatoses,
in Asiatic cholera, and after chloroform narcosis,
decreased alkalinity is commonly found. The
specific graz'ity is temporarily increased by cyanosis,
pyrexia, fasting, diarrhea, emesis, sweating, — fac-
tors which tend to inspissate the blood. It is de-
creased by dilution, as after injection of normal salt
solution, anemia, or following the ingestion of a
large volume of liquid.

The fluid constituent of the blood, the plasma,
contains about lo per cent, of solids, chiefly pro-
teids. Sodium chloride is the principal salt of the
blood, and others appear in the form of sulphates;
and the salts of magnesium, calcium, and potas-
sium. The gases of the blood are oxygen, carbon
dioxide, and nitrogen. Some of the extractives of
the blood are sugar, cholesterin, creatin, xanthin,
fats, and urea.

Extravascnlar coagulation is due to the inter-
action of fibrinogen and a calcium salt. Hemato-
pexis, or the coagulation time of the blofid, normally
takes place within from three to six minutes. The
coagulation time is delayed in anemia, jaundice,
anasarca, hemophilia, asphyxia, acute alcoholic poi-
soning, and other toxic conditions. Hematopexis is
accelerated by the administration of small doses of
calcium salts and thyroid extract.

Hyperinosis, or an increase in the amount and
density of fibrin network, occurs in pleural effusion,
croupous pneumonia, abscess, rheumatic fever, peri-
tonitis, variola, erysipelas, and influenza.

Hypinosis is a term used to denote a deficiency
in the quantity of fibrin. It frequently occurs in
primary anemias, malignant disease, tuberculosis,
malaria, purpura, and enteric fever.

The process of estimating the freezing point of
liquids, and applied to the blood and urine, is
termed cryoscopy. It is used with the object of de-
termining the molecular concentration. The freez-
ing point of blood rises in nephritis, pneumonia,
uremia, cyanosis, hemoglobinemia, and high-grade
anemias.

All causes of vascular embarrassment, as hepatic
and cardiovascular diseases, and abdominal neo-
plasms should be excluded before basing a diagnosis
upon the findings of the cryoscope.

Hemoglobin occurs in the stroma of the red
cells as oxyhemoglobin, and is derived chiefly from
the iron ingested from the food. The normal per-
centage of hemoglobin is arbitrarily fixed at lOO.
The term color index means the proportionate
amount of hemoglobin in each erythrocyte, the
normal standard, calculated by dividing the hemo-
globin percentage by that of the erythrocytes, being
I (Da Costa).

The subjects, oligochromemia, hemoglobinemia,
methemoglobinemia, carbon-monoxide hemoglobin,
and the anemias should be studied closely.

Alterations in blood-vohime are of practical in-
terest in the interpretation of the blood report, and
in venesection.

Lipemia is a term used to denote an excess of
fat in the blood. Physiologically, it occurs during
digestion, in obesity, in pregnancy, and in men-
strual suppression. Pathologically, it is present in
diabetes niellitus, gout, acute fevers, and arterio-
sclerosis.

Glycemia means an excessive accumulation of
sugar in the blood. It occurs in acute infections,
diabetes, and carcinoma.

Bacteremia is a term used to denote the pres-
ence of a certain organism in the blood, as the
bacillus of Eberth, pneumococcus, etc.

A knowledge of the pathologic structural
changes of the erythrocytes is quite necessary to a
thoroughly systematized blood work. A great deal
of the present^ discussion, however, will be based
upon leucocytosis : —

Leucocytosis is the term applied to an increase,
above normal, in the number of leucocytes in the
peripheral blood. This increase marks a relative
gain of polynuclear neutrophiles. Leucocytosis
means not simply the total number of cells, but
also the variety — an ordinary leucocytosis, in which
the polymorphonuclear cells are increased in num-
ber, and lymphocytosis, in which the lymphocytes
are decreased in number, and is called leucopenia.
A blood count that shows 40,000 leucocytes per
niiltinieter may mean a leucocytosis or a leukemia,
but if 90 per cent, of this increase are polynuclear
neutrophiles, there is undoubtedly a leucocytosis.

Hyperleucocytosis may be physiologic or patho-
logic. Physiologic leucocytosis occurs under condi-
tions that must be regarded as normal. The con-
centration of the blood and peripheral stasis of
moderate degree and short duration are physiologic
changes when not due to stimulation! of the hema-
topoietic organs. Hyperleucocytosis occurs in the
newborn, digestion, pregnancy, post-partum state,
exercise, massage, baths, and agonal.

Pathologic leucocytosis takes place under posi-
tive abnormal conditions. These abnormal states
may be infections, inflammatory and toxic, causing
an overproduction of cells by the bone-marrow in
order to protect the organism against the attacks
of the disease. It is said that hyperleucocytosis is
preceded by a brief hypoleucocytosis due to the
initial shock of the irritant.

Da Costa finds that in disease the action of the
leucocytes is an index to the intensity of the patho-
logic irritant as well as to the individual resisting
power.

Pathologic hyperleucocytosis may be classified
as follows: (i) posthemorrhagic hyperleucocytosis;
(2) hyperleucocytosis of infection and inflamma-
tion; (3) hyperleucocytosis of intoxication; (4)
hyperleucocytosis of malignant disease; (5) experi-
mental leucocytosis; (6) hyperleucocytosis of leu-
kemia and marasmus.

The leucocytosis of inflammation and infection
has been graphically described and classified by Da
Costa.

The following table serves to illustrate the leu-
cocyte range in relation to the intensity of the irri-
tant and the reaction offered by the individual : —

50

VENESECTION.

Degree of

Intensity of

Resisting

leucocytosis.

irritant.

powers.

Marked,

Marked,

Normal,

Slight,

Moderate,

Normal,

Slight,

Moderate,

Indifferent,

Absent,

Marked,

Feeble,

Absent.

Feeble.

Normal.

The most important factors of true inflam-
matory and infectious leucocytosis are tabulated
herewith : —

Asiatic cholera.
Bubonic plague.
Cerebrospinal fever.
Diphtheria,
Dysentery,
Filariasis,
Glanders, .

I. General Infections.

Malignant jaundice.
Pneumonia,
Relapsing fever.
Rheumatic fever,
Scarlet fever.
Secondary syphilis.
Septicemia & pyemia.

Spotted fever.

Tetanus,

Trichiniasis,

Typhus fever.

Vaccinia^

Varicella,

Variola.

Acute nephritis.

Actinomycosis,

Appendicitis,

Endocarditis,

Enteritis,

Erysipelas,

Gangrene,

Gastritis,

Hanot's cirrhosis.

II. Local Lesions.

Arthritis,
Bronchitis,
Bums,

Hydatid disease.
Infected wounds.
Mastitis,
Meningitis,
Multiple neuritis,
Osteomyelitis,

Cholangitis,

Cholecystitis,

Dermatitis,

Pancreatitis,

Pericarditis,

Peritonitis,

Purulent lesions.

Splenitis.

Within a short time after acute well-marked
hemorrhage the number of leucocytes is greatly
increased, and this lasts for several days. In fatal
cases this increase may not be noted. An ordinary

traumatic hemorrhage, venesection, and post-partum
hemorrhage are exciting causes of this variety of
leucocytosis. Stengel asserts that the lymphocytes
are markedly increased. In chronic hemorrhages,
as in gastric cancer or ulcer, hemoptysis, phthisis,
bleeding hemorrhoids, and oozing uterine fibroids,
leucocytosis is rarely noticeable.

The leucocytosis of intoxication, which occurs in
poisoning from illuminating gas, etherization, qui-
nine, phosphorus, ptomaines, snake-venom, in ure-
mia, cholemia, chloroform narcosis, is explained by
the theories applied to infectious leucocytosis.

The leucocytosis of malignant diseases, such as
carcinoma and sarcoma, is due, no doubt, to the
toxic material liberated in the lymphatic system.

The hyperleucocytosis, accompanying marasmus
and leukemia, is most likely due to a derangement
of the hematopoietic system.

Experimental and therapeutic leucocytosis is
comparatively a new subject and will be the source
of much knowledge, not alone as to hyperleucocy-
tosis, but with regard to the chromaffin system.

Hypoleucocytosis, or leucopenia, indicates a
decrease below normal of the white cells in the
peripheral blood. Lowit asserts that this is due
to leucolysis.

The hypoleucocytosis of infectious diseases is
very important. It is found in measles, paraty-
phoid, influenza, malarial fever, tuberculosis, enteric
fever, and trypanosomiasis. Leucopenia may be in-
duced experimentally by chemic and organic sub-
stances.

Metchnikoff, in his writings on immunity, traces
the history of the theory of phagocytosis, and states
that one of the practical applications is the induc-
tion of artificial leucocytosis to combat the invasion
of bacteria. McDonald has found that injections
of nucleinate of soda produce a considerable leuco-
cytosis without other undesirable effects. He as-
serts that in cases where infections are inevitable
this artificial leucocytosis seems to be efficient in
enabling the system to combat the infection. He
gives, as an illustration, a young girl suffering
from rupture of the intestines after volvulus. The
comparatively uneventful course of the case seemed
to be due to hyperleucocytosis, which had been arti-
ficially induced before operation. The procedure
was found successful in other cases. He gives the
injection of nucleinate of soda twelve hours before
the operation, thus inducing a leuoocytosis a few
hours after operation, when its presence is most
needed.

The secret of Hfe of the human body Hes hid-
den within the borders of its component cells. In
order that life and action be maintained, all cells
must work in harmony. The white blood-cells,
undoubtedly, play the most important role in the
economy of the human organism,

The phagocytic theory of Metchnikoff, Erlich's
side-chain theory in immunity, and the various in-
vestigations of Wright mark the beginning of a
new epoch in medicine and surgery.

The experiments of Vaughan, later confirmed by
Kossel, support the theory that bacteria contain no
cellulose and are particulate, unshielding proteins,
and consequently are more nearly related to the low
forms of the animal kingdom.

It has been proven that most bacteria produce
specific proteolytic ferments. The action of bac-
terial proteoses is delayed by quinine, antipyrin, and
other antifebrile agents. The bacterial proteose is
not capable of digesting' living protein (Vaughan).
Pfeiflfer first demonstrated that normal leucocytes
have a digestive action. Jochmann asserts that leu-
cocytic proteose is supplied from the neutrophile
cells. In resorption from wounds, in cleaning ab-
scesses, and in local infections, leucocytic proteose
plays the principal role. The appearance of foreign
proteins in the body is the signal for the leucocytes
to begin their attack. Some bacteria are destroyed
by intracellular digestion, others by a ferment due
to the disintegration of the leucocytes.

Miiller holds that resolution in pneumonia is due
to the activity of the leucocytic proteose. Accord-
ing to Bittorf, autodigestion of the leucocytes leads
to the production of ammonia, amino-acids, and
nuclein bases. The identity of the bactericidal and
the proteolytic constituents of blood-serum or leuco-
cytic extract is a much mooted question and has
received the attention of eminent investigators.

The production of active proteolytic ferment and
antibodies from the leucocytes in the blood is a
factor of great import in experimental medicine.
Vaughan says that man is immune to most bacteria
not because they do not elaborate poisons in the
tissues of the body, but because they are destroyed

by the proteolytic enzymes before they have time to
multiply.

The observations of Joblin and Bull and others
show that in the infectious diseases the invading
organisms are digested, and among the digestive
products there is one or more highly active poisons.

The study of the relation of the parenteral pro-
tein digestion to immunity and disease has done
much to improve our understanding of the phe-
nomena of infection. There seems to he a very
promising field for advance in medicine and sur-
gery, along some of the most difficult lines of pro-
cedure, in the expedient which has for its basis
theories of phagocytosis, now so generally accepted
as the foundation of immunity and the source of
resistance to bacterial invasion, and the neutraliza-
tion of bacterial and chemic toxins.

PATHOLOGIC ANTHROPOLOGY.

The subject of antliropology has not been ex-
tensively applied to the study of medicine and sur-
gery; yet it is very important and should be con-
sidered in every-day practice. The value of animal
experimentation cannot be denied, but the best
knowledge of the diseases of man is acquired by
the study of man. Every man is a cosmos within
circumscribed limits, no two created exactly alike,
and should be so studied from the cradle to the
grave.

Experience also teaches that one pupil may be
adapted to one kind of exercise and another to

PATHOLOGIC ANTHROPOLOGY. 55

another kind. * 'Accordingly, a really physiologic
system of gymnastics requires that those movements
and those exercises which are least easily per-
formed should be practised, according to special
methods, until they have strengthened the less de-
veloped functions, without causing illness or pro-
ducing harmful reactions'' (De Giovanni).

The final results are an improvement in the
morphologic proportions of the organism, and are
consequently a correction and improvement in the
relative liability to disease.

The other fundamental pathologic type described
by De Giovanni is the hypersthenic (second mor-
phologic combination), corresponding in part to the
sanguine temperment of Greek medicine, and in
part to the bilious temperment. In this type the
total spread of the arms is generally less than the
stature, and the perimeter of the chest notably? ex-
ceeds one-half the stature. Consequently we are
dealing with the brachyscelous type.

This type has a greatly developed thorax, a
large heart, an excessive development of the in-
testines; hence he is a hearty eater, subject to an
overabundance of blood; he is overnourished ; the
ruddy skin reveals an abundant circulation; there
is an excess of adipose tissue and a good develop-
ment of the striped muscles. Such a constitution
accompanies an excitable, impulsive, violent disposi-
tion, and conduces to diseases of the heart. "This
type is characterized in general by robustness and a
liability to disorders of the central circulatory
system" (De Giovanni).

But there are still other forms of disease that
await the individuals of this class, such, for ex-
ample, as disorders affecting the interchange of
organic matter (diabetes, gout, polysarcia) and at-
tacks of apoplectic nature. In the case of acute
illness individuals of this class suffer from excess
of blood and may be relieved by being bled. They
are readily liable to bloody excretions (Montessori).

INDICATIONS FOR VENESECTION.

Venesection is to be governed, in part, by {a)
the intensity of the toxin in the circulation, (b)
the number of leucocytes, (c) condition of the
ennmctories. {d) condition of the heart and arterial
system, (e) the chromaffin system, (f) body weight.

When the emunctories are functionating prop-
erly, and the leucocytes are maintaining" a con-
structive metamorphosis, venesection is not indi-
cated. If there are toxic or bacteremic properties in
excess, inhibited leucocytic action, and emunctories
functionating, small (200 c.c.) venesection is indi-
cated. Intense toxemia, poor elimination, increased
leucocytosis, medium (500 c.c.) is necessary. Poor
elimination, intense toxemia, normal or hyponormal
leucocyte count, large (looo ex.) withdrawal of
blood is imperative. Medium and large with-
drawals of blood must be followed by transfusion of
normal saline or isotonic solution equal to the
amount of the blood withdrawn. It is the best
procedure to give intravenous injection in opposite
!irm simultaneously with the venesection.

Venesection is goveriied by indications much the
same as any other therapeutic agent. Repeated
bloodletting, when indicated, is stimulating and salu-
tary. To use the words of Da Costa: "Venesection
diminishes blood-pressure, increases speed of the
blood-current, thus amends stasis, absorbs exudates,
and washes adherent corpuscles from the vessel-
wall; it decreases amount of fibrin and albumin,
lowers temperature and arrests cell proliferation,
and stops eflfusion," and in so doing produces a re-
sult that no other therapeutic agent can.

When venesection is followed by a normal saline
or other isotonic solution, we have a most excellent
adjunct in the treatment of many diseases. In
acute nephritis, eclampsia, and* various toxic condi-
tions of the blood, most authorities agree as to the
effect of venesection, but not as to the eflfect of
drugs.

The hematopoietic system, emunctories, and lym-
phatic circulation, are influenced in proportion to
the intensity of the toxemia. Slight toxic condition
of the blood will interfere with their functions;
moderate toxemia will cause a partial paralysis, and
intense toxemia may cause partial or complete
paralysis and cessation of function. It is not un-
usual to have congestion of the liver, kidneys,
spleen, and even the lungs and pancreas, in ty-
phoid, eclampsia, lobar pneumonia, and puerperal
septicemia.

The natural sequence of such a condition is an
increase in thej production of toxic material in the
blood. This will continue until relieved by a thera-
peutic agent or death interferes.

Venesection removes toxic material from the
blood in direct ratio to the amount of blood with-
drawn. The bloodletting first affects the blood-
pressure. If the blood-pressure is hypernormal, due
to the irritant producing vasoconstriction, the blood-
pressure is reduced, and if hyponormal, due to the
irritant producing a partial paralysis of vasomotor
centers and ensuing vasodilatation, venesection tends
to bring about a normal blood-pressure. The irri-
tant or toxic factor removed, the hematopoietic sys-
tem is stimulated. New blood is carried into the
circulation. The Ijnnphatiq system takes on re-
newed activity. The congestion of the emunctories
is relieved. The heart and arterial system regain
their equilibrium. The chromaffin and nervous sys-
tems are stimulated, thus bringing about a balance
of functions.

THE TECHNIQUE OF VENESECTION.

Introduction. — The peculiar medical cultures of
the ancients — Egyptians, Babylonians, Jews, Per-
sians, Chinese, and Aztecs — have been buffeted
upon the stormy billows down through the centuries
until there is hardly a vestige that remains. Thou-
sands of scholars have been gathered to the dust
from which they sprung without leaving a heritage
of medical lore. Hundreds mark the pages of his-
tory here and there through the last four thousand
years who have aided in the promotion of future
knowledge.

When we review the works since the time of
Hippocrates, we marvel at how little service has
been rendered to the main object of medicine, the
cure of disease; for, above all, in internal medicine,
which enjoys the most extensive field of activity, we
are, in most part, sadly disappointed.

The history of medicine plainly sets forth the
inadequacy of medical knowledge, and in many
cases the absolute nullity of medical skill in the
struggle with the laws of all-powerful nature.
Medical art from time immemorial has struggled
continually for the prevention, the cure, or at least
the alleviation of the woe and suffering imposed as
an unavoidable heritage, and in a thousand diflferent
forms, upon the human family.

We come now to a department of our theme
which cannot fail to elicit the most profound inter-
est and earnest consideration of every thoughtful
student of medical culture who has followed with
patience the development of the subject to this
point, — ancient Egypt, the home of magnificence and
mystery.

Egypt is undoubtedly one of the oldest of civ-
ilized lands. The extreme antiquity of Egyptian
civilization, from which many of the most ancient
nations (including the Greeks) borrowed a part of
their science and their culture, is evidenced by
records and dynastic registers which are extant.

More than ten thousand years before the dawn-
ing of the Christian era, Egypt was entering upon
the period of its intellectual and spiritual ascend-
ancy. About this time those schooled in the art of medicine, ever watchful for a propitious opportunity to convey their message of scientific knowledge to the world, believed that the hour had
indeed come.
Their teachers in council assembled, after the most thoughtful consideration and candid deliberation, decided to undertake the establiRhnient of a branch school near the center of Egyptian civ-
ilization. To that end Athotis, one of the teachers,
was commissioned to direct this difficult undertak-
ing. Under his persona! supervision the work was
undertaken and inaugurated. A school was estab-
lished. Under the ancient safeguards of secrecy
and the protecting shield of obscurity its work was
conducted in accordance with the laws of the
parent school. For more than four thousand years
its influence was a potent factor in the upbuilding
of Egyptian civilization. Evidences of their art
and science were wrought upon enduring monu-
ments which, even to this day, mark the upward
pathway of E^ptian civilization and bear silent
but eloquent testimony to the wisdom and work of
this school of physicians.

It is not unreasonable to believe that Mesu
(Moses), the great teacher and leader, was edu-
cated in this school. Arabians, Greeks, and many
other nations borrowed much of their knowledge
from the Egyptians.

The tide of Egyptian civilization reached its
height. The material prosperity of a nation or a
people, when it rises to a certain point, seems to
develop a subtle poison whose cumulative effects
will, in due time, manifest themselves physiologic-
ally within the body politic. First comes the spirit
of selfishness, then the desire for power, then strug-
gle for place, then struggle for wealth, then the
practice of dishonesty,, the oppression and suppres-
sion of the weak, then the protest of the injured,
then the internecine strife, then the final struggle
for existence, and in the end spiritual darkness and
national death.

Egypt died of her own poison, Greece perished
by her own hand, and the great Roman empire was
destroyed by her own cancerous disease. A smat-
tering of their arts and sciences has come down to
the present as relics of those crumbled ruins of past
civilizations.

The ancient Egyptians were no less successful
than we in the treatment of internal diseases. The
Greeks and Arabians of that time were well versed
in finer arts of diagnostics. Cleopatra (b.c. 69-30)
prescribed arsenic, elaterium, charcoal, lathyris, and
sulphur for various diseases. Theophrastus of Ere-
sus, in Lesbos (b.c. 372-285), prescribed mercury
in different affections with success. Nicander of
Colophan (b.c. 136), in Lydia, writes of the treat-
ment of the bites of serpents by leeches, cups, and
cautery. He mentions the removal of poisons by
emetics, and the envelopment by drinks of milk, oil,
wine, etc. Physicians of Pharaoh's time practised
venesection and cupping. Praxagoras of Cos
(about B.C. 335) favored bleeding before the fifth
day in inflammations. Venesection and cupping,
especially the former, were used by the ancient In-
dians as a means for exciting and strengthening
the desires and delights of love in both feeble and
strong — a genuine oriental specialty.

Hippocrates II of Cos (b.c. 460-377) — the
greatest and most famous physician of all anti-
quity, a man endowed with the most unique gifts
for his profession — advised venesection after dining
or drinking, and in warm weather instead of cold.
He selected the inner vein of the arm. His pupils
practised first on the veins of plants, until they
were proficient, before they were permitted to oper-
ate upon the human body. The most common acci-
dent was phlebitis. Hippocrates recognized the
importance of the viscosity and specific gravity of
the blood (afterward confirmed by Celsus), for he
bled as long as the blood was "thick and dark"
and stopped when the blood appeared "red and
clear."

Celsus (B.C. 25 to A.D. 45) regarded bleeding
as the principal means of extracting morbid mate-
rial from the blood.

Aretasus the Cappadocian (a.d. 30-90) recom-
mended venesection in epilepsy, pleurisy, vertigo,
etc. He advised venesection from frontal vein in
headaches, epilepsy, vertigo, and hemicrania; veins
of tongue in throat affections; nasal veins in hem-
optysis- and headache: scarification of the pubes or
venesection of the ankle in hysteria, etc.

Ambroise Pare advised bleeding from the
straight vein of the forehead for pain in, the back
of the head.

Galen (a.d. 131-210) was among the first to in-
troduce the quantitative idea. He recommended the
withdrawal of 7 ounces to 1^-2 pounds, according
to the gravity of the disease.

From the time of Galen the art of medicine
gradually declined until most all medical and sur-
gical procedure was in the hands of the barber-
surgeon, bath-keepers, sow-gelders, and the stroll-
ing "incisors/' Thus by prostitution the art of
venesection lost its scientific aspect and efficiency
through incompetency.

It is not unwise to say that the discussion of
the scientific application of venesection brought
about a revolution in the practical branches of
medicine in the sixteenth century. Pierre Brissot,
of Fontenay-le-Comte in Poitou (1478- 1522), who
practised in Paris, came out in the defense of
bleeding on the same side as the lesion (revulsive)
and was declared a medical heretic by the Paris
Faculty. The results of this doctrine bore fruit
and at the end of the century Brissot was recog-
nized as a reformer almost as great as Theophras-
tus von Hohenheim.

Sydenham (1624- 1689), of England, the most
distinguished practitioner of his time, was a scholar
of the Hippocratic type. His additions to diag-
nostics, pathology, and therapeutics were classic
contributions of that period.

Benjamin Rush (1745-1813), of Philadelphia, a
pioneer of American medicine, was a leader in medi-
cine, and a prominent figure in the Revolutionary
War. The favorite remedies of Dr. Rush were
^Venesection and calomel," both of which he em-
ployed freely and with apparent recklessness. There
is no doubt that Dr. Rush went to extremes in his
application of venesection.

It is argued at the present time that venesec-
tion is not indicated, as most infectious diseases
are selMimiting, and, again, that "venesection is
such a disagreeable practice." Then one author
will tell you that George Washington lost his life
from venesection; another will say that S. Weir
Mitchell's life was saved by timely bloodletting. It
is said, "By authorities you may prove anything."
For instance, in the book of Holy Writ it says:
"And Judas went out and hanged himself." In'
another place it says: "Go thou and do likewise."

The therapeutic agents, mercury, sulphur, ar-
senic, elaterium, cinchona, opium, venesection, cup-
ping, massage, hydrotherapy, and cauterization,
have come down to us from antiquity.

I can say. without fear of contradiction, that
outside the ancient remedies, until within the last
twenty-five years, internal medication had made no
progress In two thousand years.

This failure on the part of the medical profes-
sion has caused dissension and unbelief. Thus, a
soil enriched by the slothfulness of the profession
has yielded a rich harvest of pathies, isms, and
systems of healing without number.

Although mercury, arsenic, sulphur, and cin-
chona are among our oldest drugs in the armamen-
tarium of most every practitioner of medicine, how
many physicians can, at first hand, give the physio-
logic action of these drugs? I am skeptical, and
say "very few." Such being the case. I will say,
with all kindness and charity for every practitioner
of medicine, or writer of te-xtbooks. Do not condemn a remedy or method for the alleviation and cure of disease until you have duly and truly prepared yourself and given it strict trial and due
examination.

Where and How Performed.
— The operation of venesection may be performed upon) the median
basilic, median cephalic, external jugular, internal
saphenous where it rests on the tibia above the
malleolus, vein from mastoid foramen, frontal vein,
occipital vein, anterior auricular vein, middle tem-
poral vein, nasal vein, and vein under the tongue,
according to the result to be obtained. If the veins
are obscured in the region of the injury or disease,
leeches may be used to start the flow and then cups
or a vacuum pump used to abstract the desired
amount.

In general bloodletting, the median cephalic,
median basilic, external jugular, or the internal
saphenous may be selected. The median cephalic is
the most common selection, and is preferred to the
median basilic because of the proximity of the
brachial artery, which, if injured, may give rise to
arteriovenous aneurism. The flow is slower from
the median cephalic and enables the operator to get
a better gauge of the pulse. Care should be taken
to avoid division of the branches ofj the cutaneous
nerve, as it may give rise to traumatic neuralgia
(Tillaux).

Thef field of operation is washed thoroughly
with soap and water, benzin applied and allowed
to dry, and then tincture of iodine applied.

Should the median basilic or median cephalic be

selected, a bandage is tied around the arm above
the elbow, just tight enough to prevent venous flow
above and make the veins stand out prominently
below. If the factor of blood-pressure is to be considered, he arm band of the sphygmomanometer can be used instead of the bandage.

The patient is instructed to grasp some object,
as the back of a chair, or clutch the hand tightly.
If the patient is frightened or nervous, a local
anesthetic may be used. All operations are not
performed with the patient in the upright position.
In plethoric individuals the upright or sitting pos-
ture is adhered to; in septic cases the recumbent
position; in asthenic cases, where blood is with-
drawn and saline infusion given, the lower part of
the body is somewhat elevated above the shoulders.

The operator staiids with the back to the patient.
rests the patient's arm against his side and steadies
it, grasping the wrist with the hand. In this man-
ner the patient's arm is, so to speak, in a viceJ It
is expedient for the untrained operator, instead of
holding the wrist, tol steady the vein to be incised
with the thumb and index-finger, so that his in-
cision will be accurate. The vein is transfixed
obliquely with the bistoury (cutting edge up), so
as to include one-half to two-thirds of the diameter.
The blood is allowed to flow into a basin held
underneath the arm. If the flow is retarded the
incision may be held open and the veins massaged
from below upward. When sufiicient blood has
been withdrawn, the incision should be carefully
cleansed, an aseptic gauze pad applied, the bandage

Roller bandage. Catgut half-curved needle.

Microscopic blood trocar.

ALCOHOLISM.

Alcoholism is an intoxication established by the
excessive use of alcohol. Impaired health, unstable
mental power, heredity, the intemperate use of alco-
holic beverages, and unfavorable moral, social, and
personal influences are predisposing causes.

The acute alcoholic condition requires little con-
sideration beyond the prevention of the continued
use of alcohol, elimination, stimulation, and moral
persuasion.

The chronic use of alcohol is a disease of pecu-
liar proportions. The inebriatef who "saturates his
blood and tissues every day for years is much more
apt to suffer from chronic alcoholic poisoning with
its attendant degenerations than one who goes on
a 'spree' once a month for a day or two, and dur-
ing the intervals is free from the toxic influence
of alcohol." Such being the case in its many
phases, alcoholism is a difficult disease to treat.
Alcohol should be gradually withdrawn, patient iso-
lated (preferably in a hospital for inebriates), and
given nutritious, liquid food. Free action of the
skin, kidneys, and bowels should be secured. This
cannot always be done, and a condition of dementia,
deliriumi tremens, and coma ensues. The emunc-
tories fail to respond to internal medication and the
usual therapeutic measures. The administration of
drugs, very often, seem to intensify the toxic
condition.

The most logical procedure is to (a) relieve
the engorged tissues, (b) reduce the mass of toxic
blood, and dilute the blood with some fluid which
will facilitate cellular nutrition and activity; then
(c) administration of indicated remedies.

This is best illustrated by a case reported by
me some years ago: —

Case 90. — D. D., male, aged 30; bartender; had
diseases of childhood, typhoid fever, and syphilis;
came under my service April 5, 1905. Patient had
been on a debauch for four weeks. There was
inability to retain food, insomnia, tremor, intense
excitement, soon followed by the illusions and hallu-
cinations characteristic of delirium tremens. The
bowels were evacuated by warm saHne enemata.
Morphine, gr. ^/4, and atropine, gr. ^/loo. were
administered hypodennically every three hours for
twenty-four hours, without any effect. Chloral hy-
drate was given in the following combination: —

Chloral hydrate 20 gr, ;

Potassium brcmiide 15 gr. ;

Ext. Indian cannabis,

Ext, hyoscyamus aa J^ gr.

The above mixture was given every two hours
for twenty-four hours without any perceptible ef-
fect. The pulse was 95, full and bounding. Eight-
een ounces of blood were withdrawn, repeated in
six hours, and an intravenous infusion of normal
saline solution of sixteen ounces, to which was
added one-half teaspoonful of ammonium chloride
sohition, was used.

The chloral hydrate was then administered in
15-gr. doses every two hours for three doses, and
the patient passed into a quiet sleep which lasted
ten hours. The following day 20 grains of trional
were given and hot liquid diet administered by
mouth. Strychnine nitrate, gr. ^/so, and atropine
sulphate, gr. ^/loo every four hours. April 15, the
patient was able to resume work.

AMENORRHEA.

Amenorrhea is the absence of menstruation. It
may be due to a variety of causes.

ANEURISM. 73

The patient sometimes suffers from attacks of
headache, dizziness, and flushes, recurring at inter-
vals corresponding generally to the expected men-
strual periods. In such cases as these thq discom-
fort can often be relieved by scarifying the cervix
until a few ounces of blood have been removed.
W. L. Burrage has successfully treated cases of
this kind by the application of leeches to the cervix
(Kelly).

Montgomery calls attention to the fact that the
general abstraction of blood is rarely practised.
He is cognizant of the fact that in many 'cases a
good bleeding would cut short a severe illness or
abort an inflammatory attack. The local abstrac-
tion of blood by the use of the scarifier or by punc-
turing the cervix will often be effective in relieving
the pain of engorgement and in promoting absorp-
tion and resolution of inflammatory conditions.

In cases of superinvolution or atrophy of the
uterus, treatment may be followed by favorable re-
sults if the cavity of the organ does not measure
less than two inches and molimen is present. Scari-
fication of the cervix is of benefit in these cases,
and increases the flow of blood to the pelvic
organs. It should be performed twice a week for
an indefinite length of time, and also when the
molimen is present (Ashton).

ANEURISM.

An aneurism is a dilated or ruptured artery
forming a pulsating blood-tumor.

74 VENESECTION.

The object of treatment in aneurism is to lessen
the blood-pressure , so as to diminish the growth of
the tumor and favor coagulation of the blood, by
which the cavity may be eliminated. Aconite is
used to relieve pain and slow the circulation. Cal-
cium chloride, zinc chloride, ergotin, and some
other drugs tend to favor coagulation. Chloroform
relieves dyspnea; morphine with croton chloral for
pain.

A. Robin prescribes a milk and vegetable diet;
also rest and repose for the patient. If the subject
is syphilitic, he begins with the following mixture:

9 Corrosive sublimate gr. iij ;

Potassium iodide,

Distilled water aa 3v;

Syrup of viola tricolor %v;

Simple syrup '$wj.

M. et Sig. : One teaspoonful twice daily before meals.

If the patient is not affected by syphilis, the
following is prescribed: —

]? Potassium iodide Siiss ;

Extract of opium gr. \'};

Chloral hydrate 5j ;

Distilled water 5'''-

M. et Sig.: One teaspoonful twice daily before meals.

Inject every week deep into the tissues of the
buttocks, taking proper antiseptic precautions, lo
drams of the following solution, and increase the
dose each week by 5 drams until about 3 ounces
are taken: —

ANEURISM. 75

Ift Gelatin 5ss ;

Sodium chloride gr. xxj ;

Sterilized water Jv] 5ij.

Make a solution, and sterilize at temperature of 248° F.

In hemoptysis the following is prescribed: —

Ift Calcium chloride 5 j ;

Syrup of opium (Pharmacopee Frangaise) Sj ;

Cinnamon water g^v.

M. et Sig. : One tablespoonful every one or two hours as
needed.

The cough may be alleviated by the following
pill :—

!9 Extract of opium gr. iij ;

Extract of stramonium gr. -M*

Sig. : One pill every three or four hours.

To overcome any dyspnea, give 10 drops of a
50 per cent, solution of oxycamphor in alcohol, on
sugar, three or four times daily; or draw oflf, by
leeches or venesection, about twelve ounces of
blood. To lower arterial tension, Robin gives, ac-
cording to the height of the pressure, 2, 3, 4, and
up to 10 drops of I per cent, solution of nitroglyc-
erin in a tablespoonful of water. Break a pearl of
the nitrite of amyl in a handkerchief and hold it
near the patient's face.

Forchheimer says that in thoracic aneurism
bleeding sometimes gives relief. Pressure on the
veins causing engorgement, particularly of the head
and arms, is sometimes promptly relieved by free
venesection, and at any time during the course of
a thoracic aneurism, if attacks of dyspnea with
lividity supervene, bleeding may be resorted to
with great benefit. It has the advantage also of
promptly checking the pain, for which sjinptom, as
already mentioned, the iodide of potassium often
gives relief (Osier),

The abstraction of blood, by leeches or venesec-
tion, is a valuable method, giving great relief when
there is much venous turgescence or when attacks
of dyspnea are distressing features in a case. It is
scarcely necessary nowadays to inculcate caution in
the use of this therapeutic method ; indeed, it is
probably too infrequently adopted as a means of
relief (Sanson).

ANGINA PECTORIS.

Angina pectoris is a term, applied to a group of
symptoms associated with cardiovascular disease.

The etiologic factors in the disease are: syph-
ilis, arteriosclerosis, excesses in eating, drinking,
smoking, mental and physical labor, and heredity.
It is said that women are rarely attacked. Jews
are particularly prone to the disease.

Syphilitic cases require active treatment — salvar-
san in the subject under 40, mercury and iodide of
potassium in older persons (Osier). The attack
should be relieved by inhalations of nitrite of amyl
(Bninton). Morphine sulphate, gr. V4 to ^/2,
and atropine, gr. ^/loo, should be given at once to
relieve the pain. Nitroglycerin, gr. Vioo, may be
given hypodermically. Balfour urges the use of
chloroform asl a helpful agent. Nitrites of sodium
and potassium are less rapid than amyl in their
action, but have more power to prevent the return
of the symptoms. In angina of mental strain, Mar-
chiafava advocates theobromine gr. xv three times
a day. Lauder Brunton says, "In the case of
angina pectoris, in which I used nitrite of amyl
for the first time, small bleedings of three or four
ounces were the only thing which eased the pain
before the nitrite was employed, and even after its
employment bleeding from the arm benefited the pa-
tient. In engorged conditions of the right side of
the heart, whether due to mitral incompetence or
pulmonary affections, bloodletting not only relieves
the symptoms, but may save the patient's life.

APOPLEXY.

Apoplexy is a term used to denote hemorrhage
into the cerebral tissue, causing pressure and more
or less destruction of function of the brain-sub-
stance ; characterized by sudden unconsciousness ;
noisy, irregular respiration, and muscular relaxation.

Any condition or disease that produces degener-
ation in the arterial walls, as gout, rheumatism,
syphilis, alcoholism, Bright's disease, errors in diet,
is a predisposing cause. A sudden rise in blood-
pressure is the usual exciting cause. It rarely
occurs under 40 years of age, unless due to syphilis
or mineral poison.

Apoplexy may be long postponed, or entirely
prevented, by attention to atheroma and by avoiding all emotions, overeating, alcohol, meats, tobacco,
and other causes of cerebral hyperemia. The treat-
ment of the apoplectic attack depends on the con-
dition present. The indiscriminate bleeder does as
much harm as the timid one who never uses the
lancet.

Goldscheider lays great stress on the necessity
for leaving the patient where he is. not attempting
to remove him. If he has to be taken elsewhere,
the transportation must be done with extreme gen-
tleness, and the distance reduced to minimum. He
should never be allowed to travel, even in the mild-
est cases. The clothing should be removed as if
the patient had been severely wounded — cut off, if
necessary. The aim is to keep him absolutely quiet;
he must not make any movement or speak, but be
placed with the chest and head raised, in a quiet,
cool room. No one should be allowed to tempt him
to speak or induce emotional excitement. An ice-
bag should be placed to the affected side of the
head in case the face is congested and hot. In
case of difficulty in respiration during coma the
mouth and throat should be wiped out repeatedly
and the head bent forward a little to keep the
tongue from falling back, or the jaw and tongue
may have to be drawn forward.

It has been my practice to bleed as soon as
possible after reaching the side of the patient. If
it is indicated by the blood-pressure, repeat the
venesection.

Oppenheim recommends lying on the side. In
case the patient vomits, he must be quietly and
cautiously turned on the side and the vomited
masses wiped away to keep the air-passages free,
supporting the head the while. The nurse in such
cases must be well trained, and if the patient is a
very heavy man a strong male nurse is preferable.
No means are known by which vomiting can be
prevented in these circumstances. Mustard to the
neck and moist heat to the epigastric region or
the calves seem to hasten consciousness. Venesec-
tion generally produces a transient improvement,
and in exceptional cases the improvement may be
permanent. The theoretical objections against ven-
esection are not sustained in practice. Still better
results might follow if it were done earlier. He
advocates it when the cerebral hemorrhage is diag-
nosed beyond question, and the congestion in the
head with full, bounding pulse persists while the
comatose condition continues unmodified or is grow-
ing worse. Small, weak, rapid pulse and pallor
contraindicate venesection^ He withdraws from
200 to 300 c.c. of blood from the arm on the un-
paralyzed side. Collapse, insomnia, headache, con-
vulsions, should be treated symptomatically, not
shrinking from narcotics. Nothnagel's rule is to
bleed when respiratory paralysis is threatened by
cerebral hyperemia. The typical case for bleeding
presents a languid face, distended veins, pulsating
carotids, powerful heart action, tense pulse (normal
or above it), heart slow and regular, respiration
uniform (quiet and snoring), the patient strong
and not too old. Rapid pulse and Cheyne-Stokes
respiration call for bleeding. In other cases it
does harm.

The drawings below diagram in a mechanical
way arteries of the brain most liable to be affected
in cerebral hemorrhage: —

Portions of the cerebral hemispher
middle, and posterior cerebral a

supplied by the anterior,
1. (Redrawn from Dana.)

Waugh says the first indication following the
return of consciousness is to moderate the fever.
This requires rest and quiet, in a cool, dark room,
low diet, and aconitine or veratrine; the bowels
moderately relaxed and the kidneys acting. Re-
tention of the urine should be guarded against.
When the fever has' subsided the resorption of the
clot and infiltration are to be promoted. Diuretics
should be first employed, followed by mercury or
the iodides. No definite directions can be given,
as all depends on the conditions present.

It has been my custom to bleed at once should
prodromal symptoms be in evidence; 200 to 1000
c.c. may be taken, as indicated, without untoward
effects. This should be followed by saline laxative,
aided by an enema. Aconitine may be given to re-
duce blood-pressure. Leeches to the mastoid and
potassium bromide, gr. xl, or fluidextract of ergot,
f3j, may be substituted if the patient is weak. For
the attack, elevate the head and turn to one side,
loosen the clothing, ice-bag to the head, venesection,
a mustard foot-bath, and oleum tiglii, ^ij, placed
on back of tongue, followed later by water.

The amount of blood withdrawn is governed
by the weight, age, circulation, and general condi-
tion. If there is hypertension of the arteries or
fever when consciousness is regained, aconite or
veratrum viride is indicated.

To cause absorption of the effused blood, potas-
sium iodide, gr. v, t. i. d,, gradually increased to
physiologic effect, alternated with: —

6

a VENESECTION.

5 Liq. potassii arseiiit tilv ;

Syr. calcii lactophosph fSij.

After two months a weak galvanic or autocon-
densation current, massage, and baths may be used.

The diagram illustrated below is self-explana-
tory in that it makes plain the fact that blood with-
drawn from the veins at points indicated on the
head andi face in the photographs will relieve con-
gestion of the cerebral vessels: —

The patient should be placed on his back, with
the head high, the neck free, kept absolutely quiet,
and measures taken to reduce the arterial pressure.
Of these the most rapid and satisfactory is vene-
section, which should be practised whenever the
arterial tension is much increased. With a small
pulse of a low tension and signs of cardiac weak-
ness it is contraindicated. The chief difficulty is in
determining whether the apoplexy is really due to
hemorrhage, or to thrombosis or embolism, since
in the latter group of cases bleeding probably does
harm. As a rule, however, in middle-aged men
with arteriosclerosis, an accentuated aortic second
sound, and hypertrophy of the left ventricle, bleed-
ing is indicated.

The treatment of softening from thrombosis or
embolism is very unsatisfactory. Venesection is not
indicated, as it lowers the tension and rather pro-
motes clotting (Osier).

Indirectly the cerebral circulation is affected by
reducing the quantity of blood in the general cir-
culation by bloodletting. When the patient is seen
in the beginning of the attack, the diagnosis being
positive, venesection may be performed, from five
to sixteen ounces of blood being withdrawn, as the
pulse warrants. The contraindication is found in
cases where the blood-pressure is not high, and in
weakened or anemic subjects. In some cases vene-
section seems to be followed by great improvement,
sometimes very temporary; in the massive hemor-
rhages I have rarely found it of service (Forch-
heimer).

ARTERIOSCLEROSIS.

Osier defines arteriosclerosis as a condition of
thickening of the arterial coats, with degeneration,
diffuse or circumscribed. The process leads, in the
larger arteries, to what is known as atheroma and
to endarteritis deformans, and seriously interferes
with the norma! function of various organs.

Josue presents a list of early signs of arterio-
sclerosis which allow its differentiation in its incipi-
ency, while there is still a prospect of arresting its
progress by appropriate measures. The symptoms
are the result of slight and variable disturbances in
the local circulation. The arteries are less elastic,
contracting less readily, and the course of the
blood is not normally regulated. In some cases
these symptoms appear only after eiTort. There
may be general disturbances: the patient tires more
easily, and is weary and depressed, with intolerance
occasionally of alcohol and tobacco. Vasomotor,
nervous, respiratory, ocular or auditory disturb-
ances are also Common, with epistaxis, edema, arterial hypertension or heart and kidney symptoms.
Among the nervous troubles may be lessened aptitude for physical and mental work, disinclination to
commence a new task, transient loss of memory
or a slight transient difficulty in speech. The
patients sometimes display unusual irritability or
somnolency.

Headache is a frequent early sign, especially
morning heaviness and oppression in the head, be-
coming actual headache in the course of the day,
sometimes pulsating. The pain is generally located
high on both sides. The pain sometimes comes
on or is aggravated by mental or physical effort
or ingestion of alcohol. The mere fact of concen-
trating the attention is sometimes enough to arouse
pain. He calls this symptom "the sign of painful
thought." Continuous headache persisting after
correction of refraction errors is probably due to
atheroma or arteriosclerosis. The patients some-
times complain also of a transient tingling or
heaviness in the arms or legs. Intense or persist-
ing neuralgia is noti infrequent, intercostal, trigem-
inal or in the legs, but the pain does not follow
the course of the nerves, and there are occasional
intermissions. Sometimes the pain alternates with
tingling or itching in the limbs; it is not modified
by pressure, and there are no other sensory dis-
turbances in the regions involved. Vertigo is one
of the warning symptoms of arteriosclerosis. Some-
times the patient feels dizzy when he stands up
after reclining, or there may be a vague impres-
sion that the floor is not solid. Sometimes he feels
as if something were moving in his brain. All
other, affections that might induce vertigo must of
course be excluded. The patient generally finds it
impossible to go to sleep, and after tossing rest-
lessly for hours sleeps tardily and briefly, his slum-
ber being restless and interrupted by sub-delirium.

When neurasthenia is observed in a previously
healthy person between 45 and 50 years old, and
no other cause can be assigned for it, incipient
arteriosclerosis should be suspected. This tardy
neurasthenia frequently accompanies cancer, tuber-
culosis, diabetes, and incipient general paralysis, as
well as incipient arteriosclerosis. The neurasthenia
is generally of a mild form, and the arteriosclerotic
lesions are more functional than organic in the
early stage. Another early sign of arteriosclerosis
is the exceptionally slow return to normal after a
traumatism.

Spasmodic phenomena in the arteries of the
retina are also among the signs of incipient arterio-
sclerosis, as also thrombosis of the central artery,
atrophy of the macula and central scotoma or
circumscribed atrophy of the optic nerve. Slight
dyspnea on effort is an important sign, as also
spasmodic severe dyspnea, which generally fol-
lows error in diet. As a rule, such patients have
emphysema.

Epistaxis is another important early sign; it is
best not to check it unless the hemorrhage is ex-
cessive, as it is a valuable safety-valve for high
arterial tension. Slight edema of the legs, espe-
cially toward evening, is another sign. The blood-
pressure is not always high during the early stages
of arteriosclerosis, but when it is, and the high
pressure persists, arteriosclerosis and atheroma
should be surmised, especially when combined with
some of the otlJer signs mentioned above. The
presence of kidney disease does not testify against
arteriosclerosis, and it may even be the cause of the
latter. In one of Josue's cases a young woman had
a mild kidney involvement during an attack of scarlet
fever. There was a slight albuminuria, a little edema
of the eyelids, and a gallop rhythm. These symptoms
lasted only a week, but the radial arteries soon
became hard to the touch and could be rolled
under the finger. There was no other sign of
atheroma, but it was unquestionable that the changes
in the kidney had left their impress on the arterial
system.

Oliver sums up his observations with the fol-
lowing conclusions as to the etiologic factors of
arteriosclerosis : —

1. It is misleading to attempt to refer arterio-
sclerosis to any one cause in all cases.

2. The causes are, as a rule, multiple, though a
certain cause, or more than one cause, may be pre-
dominant in individual cases.

3. The leading causes are: (a) persistent super-
normal arterial pressure, however induced, and (b)
toxins of various kinds, either generated within the
body (endogenetic) or introduced from without
(exogenetic).

4. In addition to these determining causes there
are certain predisposing factors, such as heredity
and trophic proclivities.

The first step in the treatment is to ascertain
the exact condition of the blood, kidneys, metab-
olism and nervous constitution, including" the men-
taHty. Symptoms must be corrected by drugs which
are antagonistic to them and by diet, exercise, and
environriient. The patient must be under treatment
long enough for the correction of the underlying
cause and the completion of a physiologic re-educa-
tion which may overcome the high-tension habit
(Bishop).

Hasebroek assumes that the peripheral vessels
play an active part in the circulation, and describes
the principles by which arteriosclerotics are able to
obtain pronounced benefit from apparatus g}'nmas-
tics. He aims to insure ample exercise without
increasing" the blood-pressure. In an experience of
seventeen years in a Zander institution he has
never witnessed any mishaps from the exercises,
even in cases of severe anatomic sclerosis of the
aorta and coronaries, the patients always feeling
better after the exercises. Climbing stairs is more
dangerous for arteriosclerotics than even the Zan-
der movements. By daily stimulation of the pe-
ripheral circulation with these individualized exer-
cises, the functions of the body in general are
promoted and waste matters eliminated better.

Imperfect circulation and imperfect respiration
tend to produce the products of waste, and we
must look to the elimination of these by the means
of purgatives such asi calomel and compound jalap
powder. Half a dram to a dram of compound
jalap powder every morning, or every other morn-
ing, is a most useful agent in withdrawing water
and waste matter from the body, and thus aiding
the action of the kidneys. Its efficacy is increased
by administering to every dose the following: —

Spirit of juniper mxxx ;

Potassium tartrate gr. xx ;

Decoction of broom-tops q. s. ad 5J«

Or,

Pulveris digitalis,

Pulveris scillae,

Massa hydrargyri,

Extractum hyoscyami aa gr. j.

A great deal of attention should be given to
the diet in all diseases of the heart and arterial
system. A highly nitrogenous diet is absolutely
injurious. The proteids should be kept as low as
they possibly can be consistently with the proper
performance of the bodily functions. The use of
salines, cascara, aloes, rhubarb, along with each
meal, stimulates the action of the stomach and
bowels.

In cases which come under observation for the
first time with dyspnea, slight lividity, and signs
of cardiac insufficiency venesection is indicated. In
some instances, with very high tension, striking re-
lief is aflforded by the abstraction of twenty ounces
of blood (Osier).

Sanson emphasizes the fact that cardiac tonics
are powerless for goods when the right ventricle is
overdistended or when its every systole forces a
considerable back wave into the venous system.
After a bleeding of six or eight ounces from the
arm the distention may be relieved and the cardiac
tonics, which were powerless before, then become
effectual. I have seen many cases in which the
lesson of the value of venesection in these cases
has been taught. One such abstraction of blood
often relieves, but it is usually necessary to repeat
the operation after the lapse of a few days.

In discussing the therapeutics of sclerotic con-
dition of the vessels Lauder Brunton says that the
steady employment of iodides is sometimes most
useful, and that he has found great advantage in a
number of cases of high tension from 20 grains of
nitrite of potash along with ^ to 2 grains of
nitrite of sodium given in a tumbler of water or
aperient water every morning on rising. This
seems to keep the tension from rising too high, and
the treatment may be continued for years.

Where this is insufficient, it may be supple-
mented by 2 or 3 grains of sodium nitrite in water
every four hours, or by nitroerythrol in doses of
^/2 to 2 grains, or ^/loo grain nitroglycerin in
tablets or solution. Ammonium hippurate, as
recommended by Oliver, may be useful.

In very high tension it may be advisable to
bleed from the arm. The efifect of this in relieving
angina was most strikingly shown in the patient
whom I afterward was able to relieve by the use
of nitrite of amyl.

ASPHYXIA.

Asphyxia is a condition in which there is a sus-
pension of all signs of life. It is due to the arrest
of respiration from a deficiency of oxygen in the
blood.

The most common causes are the inhalation of
natural, coal, or carbon-monoxide gas. Chloro-
form, ether, and other gases may cause failure of
respiration.

Artificial respiration and physical measures
should be adopted at once. It is imperative that
500 to 800 c.c. of blood be immediately withdrawn.
After the venesection 1000 c.c. of lOne of the
following physiologic solutions should be given
intravenously : —

Locke's Solution.

Sodium chloride 0.900

Potassium chloride 0.025

Calcium chloride 0.023

Sodium bicarbonate 0.020

Glucose o.ioo

Water 98.932

A , o 100.000

Adler s Solution.

Sodium chloride 0.5900

Potassium chloride 0.0400

Calcium chloride 0.0400

Magnesium chloride 0.0250

Sodium phosphate (NaH2P04) 0.0126

Sodium bicarbonate 0.3510

Glucose 0.1500

Distilled water 98.7914

100.0000

92

In carbon-monoxide intoxications, in which the
tissues are insufficiently supplied with oxygen in
consequence of the formation of carbon-monoxide
hemoglobin, also in intoxications with agents which
form methemoglobin, oxygen therapy, both in tlie
form of inhalations and by rectal administration, is
advisable and theoretically well founded (von
Neusser^.

BERIBERI.

A disorder of metabolism associated with the
defect of certain unknown elements of the food,
and characterized clinically by multiple neuritis,
anasarca, and muscular atrophy (Osier).

The etiology is unknown, but is thought to be
due either to an acute infection or to a disorder
of metabolism. ■

The incubation period of the disease is un-
known. The following forms are recognized: (o)
rudimentary form; (b) atrophic form;; (c) wet or
dropsical form; and (d) acute, pernicious, or
cardiac form.

The disease often sets in with catarrhal symp-
toms; paresthesia, first in the legs, then in other
parts of the body; affections of the heart, atrophy
of muscles, dyspnea, and dropsy. Any set of these
symptoms may grow rapidly worse till death en-
sues. Mortality varies from 2 to 50 per cent.

The treatment consists of nutritious diet, rest
in bed, purgation for dropsy, cardiac stinmlants,
and salicylates for the neuritis. Massage, passive
movements, and electricity, may be used for atro-
phic muscles when edema has subsided.

Bloodletting has a well-recognized field in the
treatment of beriberi, either to prevent or relieve
the cardiac paroxysms. Scheube believes this treat-
ment was first used by Marshall, and has lately
been recommended by Anderson and Balz.

Sodre states that Ithe beneficial and almost
miraculous effects of bloodletting in those cases
in which death is imminent have led some physi-
cians to apply it systematically in all cases of
beriberi. This practice is not to be commended
and can only lead to disastrous results. Balz
draws from 300 to 400 c.c. of blood. Miura ad-
vises against putting off abstracting blood too
long, but to undertake it before cardiac action has
sunk too low and while the impulses of the heart's
beat can still be felt. He reports excellent results
from drawing 100 to 250 c.c. of blood in two or
three sittings by means of cupping glasses or
leeches.

BLOOD-PRESSURE IN THE PRACTICE

OF MEDICINE.

Blood-pressure is the force exerted by the blood
upon the cardiovascular walls. This pressure may
be supernormal, normal, or subnormal. Any aber-
ration of blood-pressure produces a pathologic con-
dition. Therefore, it will be necessary, in taking
up this subject, to consider^ the various phenomena
peculiar to this condition. Dr. Ludolf Krehl, of
Strasburg, has made the following observations:
"Stimulation of the peripheral nerves will normally
cause reflex arterial contraction and rise of blood-
pressure. Nervous impulses from the heart are
able to affect the size of the blood-vessels and in a
measure regulate the work of that organ. The de-
gree of contraction is dependent on the impulses
they receive. As the arteries leading to certain
parts of the body dilate and contract, the blood-
supply to that part is altered." These observations
are confirmed by some authorities and denied by
others; so it leaves one to investigate for himself.

The study of blood-pressure in lower animals
has been very unsatisfactory because of the low
scale of the organism. Experiments on normal
man have produced some good results, but the
only reliable study of blood -pressure 'disease is the
disease itself.

The pathology of abnormal blood-pressure will
be dealt with summarily. Blood-pressure may be,
primarily, the etiologic factor, or, secondarily, the
sequence of pathologic conditions. When blood-
pressure is the causative agent, it produces at first
a hyperemia of the capillaries and arterioles, and
causes a leakage into surrounding tissue. Long-
continued congestion of the capillaries results in
capillary dilatation, capillary ectasis, or capillary
aneurism, as shown in passive congestion of the
lungs. Hyaline degeneration may be observed in
the brain, kidneys, lymph-glands, or tumors. Fatty
changes in capillary epithelium occur frequently in
various conditions. Hemorrhage may result from
diapedesis or rhexis. These conditions also play a
part in thrombosis and embolism. Calcareous infil-
tration occurs frequently, as observed in arterioscle-
rosis and its sequelae. The calcareous infiltration
may be preceded by amyloid degeneration, as found
in the capillaries of the spleen, liver, kidneys, and
in general amyloidosis. The heart and arteries fol-
low in various degenerations. These changes are
fully discussed in ordinary textbooks on pathologic
anatomy, and I need not dwell on them here.

The etiologic factors are: (i) mechanical; (2)
reflex; (3) central — in reference to the central
nervous system.

Mechanical factors, such as inelasticity of the
arteries, increased amount of blood, capillary con-
gestion, impeded venous circulation, forcible action
of the heart, musculer exertion, increased atmos-
pheric pressure, cause increased peripheral resist-
ance or supernormal pressure. A softening or
fatty condition of the arteries, diminished force or
action of the heart, decreased amount of blood,
and decreased atmospheric pressure produce sub-
normal pressure.

Reflex causes, such as stimuli direct to the
vessel-wall or heart-wall and contained ganglia,
produce at once a supernormal or subnormal pres-
sure. The irritant may be adrenalin, nicotine,
alcohol, lead, the nitrites, aconite, digitalis, or caf-
feine. Chemical and biologic irritants are found in
gout, chlorosis (von Noordon), autotoxemia, fevers,
Bright's disease, and syphilis. Intense heat, electricity, and vibration are among other causes that may be classed reflex.

Central causes, or those due to influence on the
central nervous system, such as worry, grief, joy,
fear, produce at once vasoconstriction, or dilatation.
"Stimulation of the central nervous system will
stimulate vasomotor centers and thus produce con-
traction of the splanchnic vessels and great rise of
blood-pressure" (Krehl). "Continuous high pres-
sure may accompany renal disease, arteriosclerosis
of the aorta or of the splanchnic vessels" (Krehl).

The symptoms of aberrated blood-pressure are
varied and complex. They simulate sj-mptoms of
other diseases and may partake of or complicate
other diseases. The brain, because of its large
blood-supply, is generally the part first affected by
the abnormal pressure and gives rise to headache,
vertigo, syncopal attacks, disorders of vision and
hearing, blunted intellect, irritable temper, and per-
haps hallucinations or acute mania. The face and
eyes may be red and congested, and the carotid
pulsating. The sleep is disturbed by dreams and
cramps in the limbs. The patient has usually no
complaints unless he is attacked suddenly by a sen-
sation of falling and may stagger, if standing, and
sink unconscious and completely relaxed to the
ground.

The next to be affected, and perhaps the next
to come to notice, is the heart. Uneasiness and
precordial discomfort are ordinarily the first symp-
toms. Palpitation or pain is seldom complained of
except when there is much increased demand on
the heart. The general symptoms are: flushing of
face, headache, carotid pulsation, and tinnitus au-
rium. In the early stages of high blood-pressure,
the first and second sounds of the heart may be
metallic and accentuated. In the early stages of
atheroma, the cardiac impulse is forcible and the
second sound accentuated. The patient may be
walking along the street, when he feels a peculiar
heavy throb in the chest which is accompanied by
a momentary sensation of choking or smothering.
He feels everything give way under him, loses con-
trol of limbs, staggers, and by chance falls, at other
times recovers before losing his balance. This is a
condition which I shall call artery-block, producing
temporary or transient stoppage of the heart. This
block, caused by spasm of capillaries, arterioles,
arteries, and probably the heart, may be so forcible
as to cause paralysis, rupture, or valvular lesion of
the heart.

Following closely, or simultaneously, the kid-
neys, liver, and lymphatics are affected. When
these organs are affected the blood-pressure is, at.
all times, abnormal unless regulated by treatment.
The lungs are generally the last to be affected,
except in tuberculosis, bronchial asthma^ or ca,rdiac
asthma (Hare).

Diagnosis may be determined early by the char-
acteristic variations of pressure. I have found in
my own cases, using the Riva-Rocci sphygmoma-
nometer, or the Cooke modification, that the physi-
ologic variation of blood-pressure is, when lying at.
rest : —

For children of i to 5 years 80 to 98 mm.

For children over 5 years 98 to 112 mm.

For adult women iio to 130 mm.

For adult men 120 to 140 mm.

I have used the sphygmograph a great deal for
experimental purposes, but find it inconvenient for
practical use, on account of the delicate mechanism.
Otherwise the diagnosis is made only by close
study of symptoms and sequelie.

The prognosis is invariably good if the ab-
normal pressure is recognized early, and when not
produced by degeneration of heart or vessels, or
the presence of unconvertible substance in the
blood. When aberrated pressure is associated with
degenerative processes, the prognosis is fair, pro-
vided a compensatory metabolism exists or can be
produced. In degeneration and non-compensatory
conditions the prognosis is grave, though life may
be prolonged by active and persistent treatment.

The peculiar psychic influence that governs us
in modern society brings about various degenera-
tions in the human organism. It is not the en-
vironment, but the many attributes due to heredity
that influence one individual's thirst for alcohol and
another's desire for tobacco. The gourmand, whose
features and organs are engorged by unassimilable
material, loaded with poisons for the blood, pos-
sesses an organism which is at once abnormal.
To change this order of things brings before us a
most complex problem. Primarily, the individual
must be warned of the dangers before him, and
the necessity of seeking advice. Secondarily, the
part of the clinician should be the early recognition
and treatment of blood-pressure diseases.

The indications for treatment are: if the blood-
pressure is supernormal, reduce to normal; if sub-
normal, raise to normal, and remove the cause of
abnormal pressure whenever possible. Supernormal
blood-pressure is; best met by persistent use of
tincture of veratrum viride, aconite, or their alka-
loids, in small, frequently repeated dosage. The
nitrites, atropine, and iodides, combined with Fow-
ler's solution, may be used with beneficial results,
at the same time keeping the bowels, kidneys, and
skin acting freely. The habits of the patient
should be corrected; The patient should take light
exercise in the fresh air before meals. The diet
should be restricted, avoiding all forms of stimu-
lants, meats, and the ingestion of large quantities
of liquids.

Subnormal blood-pressure is met by adrenalin,
alone or combined with physiologic salt solution,
ergot, suprarenal extract, hydrastinine hydrochlo-
rate, digitalis, ammonia, camphor, alcohol, apocy-
num, strophanthin, caffeine, convallaria, physo-
stigma, and strychnine. These drugs must be
absolutely pure. They may be used alone or com-
bined as indicated.

A. rigid hygienic system should be enforced.
The patient should be given wholesome food, such
as eggs, fresh meat, fish, milk, stewed fruits, vegetables, fats, and carbohydrates. He should have baths, plenty of rest, sunlight, and fresh air; should wear wool or silk and wool in all seasons.

Patients fare better in rural and mountainous districts or at the seashore.

I have presented the treatment by drugs and diet in a cursory way that I might add suggestions which I consider most important in treatment
of blood-pressure diseases.
I have found most diseases affecting normal circulatory equilibrium due
to foreign substances in the blood. These substances so disturb the vessel-walls and nerve-supply, that they not only interfere with anabolism, but produce marked catabolism of the entire organism.
The irritant may be a chemical or an organic agent, such as lead, alcohol, nicotine, arsenic, mercury, phosphorus, the various gases, products of utointoxication, and food poisons. The most pro-
nounced of the biologic irritants are the SpirochcBta
pallida, bacillus of Eberth, diplococcus of cerebro-
spinal meningitis, bacillus of diphtheria, diplococcus
of pneumonia, Plasmodium malarice, bacillus of
Pfeiffer, or their toxins. In uremic poisoning and
eclampsia, the causes of which we do not exactly
know, a regulation of the blood-pressure, blood-
quantity, and blood-quality ameliorates the diseases.

The use of electricity, light, heat, and hydro-
therapy in blood-pressure diseases is to be en-
couraged.

The most valuable adjunct to medical treatment
is venesection. In any hypernormal pressure, when
immediate relief is needed, venesection should be re-
sorted to. This relieves the intracardiac and intra-
vascular pressure. The specific gravity of the blood
is reduced, the amount of toxic or irritant material
is lessened, engorgement of the lymphatics, and ve-
nous stasis, is relieved. The heart and vessels
regain their equilibrium, and cell activity gives new
life to the overworked organs. It may be remarked
that this is a credible clinical picture. I call to mind
a man who came of an apoplectic family. All were
very stout. His brothers died at the average age
of 45 years. Being the youngest brother, he had
opportunity to learn the prodromal symptoms of
the disease. At the age of 40 he began feehng
the same s>-mptoms as the brothers. He consulted
a physician and was depleted of thirty ounces of
blood. This he had repeated whenever he felt any
return of the symptoms, sometimes as often as four
or five times yearly. Today he is living and well
at the age of 75. This man is one of many who
have benefited by this so-called old and effete
practice. In a paper on "Venesection; its Thera-
peutic Value," published in Clinical Medicine for
January, 1907, I have presented the technique and
results in some 600 cases of various diseases. I do
not wish to be misunderstood as heralding venesec-
tion as a panacea. I want to impress you with its
value. There are thousands of deaths every year
from apoplexy, heart, and other diseases, where
medicine is practically inert, that may be prevented
by timely venesection. It bridges the chasm of
empiricism, affects suggestive consciousness of the
patient, and gives time for therapeutic accuracy.

In a conversation on venesection, one of the fore-
most educators and medical authorities in America
said: "I do not know much about the value of

venesection, although I believe it is a good thing."
This seems to be the status of the profession
concerning the scientific application of venesection.
This does not reflect on the individual physician,
but it certainly casts a shadow over the teaching
in our medical schools.

The object to be kept ever in view is the cause of
the disease. This should be searched for carefully
until found, and if not found the disease must be
treated symptomatically.

In the study of abnormal blood-pressure, we
have the underlying cause or sequence of over half
the human ills, which makes it one of the most pro-
found subjects known to the science of medicine.
Much is understood and niuch is misunderstood. I
have proven by my own experiments and observa-
tions that the life of the human organism, whether
through heredity or other causes prone to be aber-
rated blood-pressure, may be prolonged ten to
twenty years. So long as normal blood-pressure
can be maintained, the life of the organism will be
sustained until the natural sequences of decay re-
sult in death.

THE BLOOD-PRESSURE AND THE COMPOSI-

TION OF THE BLOOD.

The data presented by Miinzer show that many
cases of anemia are distinguished by lymphocytosis
and low blood-pressure for which a constitutional
inferiority of the glands with an internal secretion
is unquestionably responsible — the thymic-lymphatic
Status. Persons with lymphocytosis and low blood-
pressure stand general anesthesia badly, while per-
sons with high blood-pressure usually stand it well.
This is easily understood by the connection between
the blood-pressure and the ductless glands, espe-
cially the chromaffin system. The chromaffin sub-
stance is used up during general anesthesia, and
consequently persons with a constitutionally inferior
chromaffin system are liable to suffer most from it.
The discovery of lymphocytosis and a low blood-
pressure thus warns of the need of caution before
attempting operation under general anesthesia.
Persons with high blood-pressure and normal or
subnormal numbers of lymphocytes in the blood
have a sound and vigorous chromaffin system and
are thus able to take the anesthetic without harm,
other things being equal. He adds that the various
diatheses are probably merely the manifestations of
the behavior of the ductless glands.

Schlayer relates considerable research in this
line, the results being constantly negative in respect
to any connection between hypertension in nephritis
and the functioning of the suprarenals.

BLOOD-PRESSURE IN FEVERS.

Davidson points out that a sthenic fever is
physiologically one in which the blood-pressure
keeps high; an asthenic fever one in which it suf-
fers diminution. The fall of pressure is to be
ascribed to relaxation of the peripheral arterioles.
In sthenic fever increased heart-action may more

than counterbalance arterial relaxation or the re-
laxation may be absent; in either event the pressure
remains high. When relaxation is very marked, or
the cardiac muscle is enfeebled by the circulating
toxins, the fall in pressure is progressively more
marked, as the systole is diminished in fever.
Many of the ill effects of fever are in part attrib-
utable to the lowering of blood-pressure. Ordi-
narily , pressure varies directly with the temperature,
but in fevers the two influences, pyrexia and in-
toxication, are at work, and as their effects on
blood-pressure are opposed, and they are not al-
ways proportional to one another, the resultant
effect necessarily varies. Davidson reports the re-
sults of examinations at the Edinburgh City Hos-
pital. Of 37 cases of simple scarlet fever, in all
the blood-pressure curve was very similar to those
of the pulse and the temperature. In severe scarla-
tina cases of the anginose type, the blood-pressure
fell as the toxemia increased. In scarlatinal nephri-
tis in every one of 9 cases the blood-pressure was
raised during the period of albuminuria, often com-
mencing before the trace of albumin had been noted
in the urine. In diphtheria reduction of blood-pres-
sure was found in every case examined, depending
on the degree of toxemia.

It showed a marked rise above the normal dur-
ing severe albuminuria. Practically all patients
with diphtheria were by routine practice put on
strychnine and alcohol, and the fall of blood-pres-
sure was to a large extent annulled. In patients
who did not receive stimulation a fall was always
noted until the treatment was commenced. During
routine administration over long periods the blood-
pressure response to a single dose was apparently
absent or less marked than that of following the
first two doses; but, if the routine was suspended,
the blood-pressure was noticed to fall accordingly.
After the administration of antitoxin in diphtheria,
in most cases there is a rise of temperature of one
or ttvo degrees, coming on four or five hours after
injection. The pulse is accelerated at the same
time, usually out of proportion to the temperature.
The pulse-pressure in almost every case is either
reduced or the same, the fall taking place within a
quarter of an hour, and passing off within an
hour. The effect is evidently one of temporary
depression and permanent stimulation. In typhoid
fever the blood-pressure is akvays considerably
lower, the diminution progressing steadily the longer
the duration of the case. The pressure only rises
again on the establishment of convalescence or the
occurrence of some acute inflammatory complica-
tions. Davidson reports one case of supposed scar-
let fever, with an irregular temperature curve and
a markedly subnormal blood-pressure. This aroused
suspicion of typhoid fever, which was subsequently
confirmed by Widal's test on the first and subse-
quent examinations.

BRONCHOPNEUMONIA.

A term applied to inflammation of the lungs
that, beginning in the bronchi, finally involves the
parenchyma of the lungs. This disease may occur
at either extreme of life. Three varieties »are de-
scribed: (i) a simple, acute form, following a
severe bronchial catarrh; (2) a secondary form,
occurring after the infectious fevers, tuberculosis,
nephritis, cardiac disease, emphysema, and lodge-
ment of foreign particles in the bronchial tubes;
(3) a rare suppurative form, with the formation
of abscesses in the lung. In addition to the bron-
chitis there are scattered areas of consolidation and
collapse throughout the lung.

In children the onset is marked by convulsions,
high temperature (104° F.), violent cough, rapid
respiration (60 a minute), intense dyspnea, rapid
and feeble pulse, cyanosis, and cold extremities.
Localized areas of dullness are present, but usually
not detected. Fine subcrepitant rales are heard
posteriorly at the base of the lungs. Sibilant rales
may also be present. The disease may be mistaken
for lobar pneumonia, but the diagnosis can be made
from the physical signs of the disease.

The treatment is absolute rest in bed and a
nutritious diet; the chest should be enveloped in a
thick cotton jacket. The temperature of the room
should be equable — about 65° or 70° F. If the
bowels are inclined to be constipated,, fractional
doses (}i gr.) of calomel are advisable every hour
until 6 or 7 doses have been taken.

In the earliest stages the tincture of aconite is
of service. Its action should be cautiously watched,
and as soon as the pulse becomes soft, the drug may
be omitted. Usually 6 or 7 doses are sufficient.

DELIRIUM, ACUTE. 107

For a child over 2 years old: —

^ Tincture of aconite "Ix;

Simple elixir Tn.xxxij ;

Sol. of potassium citrate q. s. ad 5j-

M. Sig,: One teaspoonfui every three or four hours.

After the second or third day its action is too
depressing and is not recommended. If the tem-
perature rises above 102.5° F,, it should be reduced
by means of a cold bath. Phenacetin may be given
to control the temperature, but should not be used
routinely. After the third or fourth day a flaxseed
poultice containing mustard may be applied to the
chest and renewed every hour. After the poultice
has remained on the chest about two hours, give the
syrup of ipecacuanha ("txv) every ten minutes until
emesis is produced. Both these procedures should
be repeated on the following day. When the poul-
tice is removed, replace it by a cotton jacket. If
the heart is weak, give cardiac stimulants.

Venesection may do good in bronchopneumonia
following hemoptysis, when the right heart is over-
worked or dilated, blood-pressure high, and pul-
monary edema, cyanosis, and coma imminent or
present. After venesection in bronchopneumonia,
salt solution should be given by hypodermoclysis.

DELIRIUM, ACUTE.

Anders defines acute delirious mania as an
acute maniacal delirium associated with hallucina-
tions, with a febrile course, of limited duration, and
of grave prognosis.
It may be primary or it may be secondary
to infection, intoxication, exhaustion, irritation
(peripheral and central), and senility.

The disease usually commences with certain
indefinite prodromes. These consist of restlessness,
associated either with melancholia, preoccupation,
or anxiety; decreased intelligence, loss of appetite,
constipation, and emaciation. The patient may sud-
denly become violent. The prodromal stage rapidly
passes from that of excitation to collapse. The
tongue is dry, the pulse rapid and weak. The tem-
perature may rise to 105° F. There is rapid emacia-
tion, profound exhaustion, and usually death.

The differential diagnosis is ofttimes difficult.
Typhoid and pneumonia are often confused with
acute delirium.

The medicinal treatment is unsatisfactory. Calo-
mel, in the early stages, should be given in massive
doses. Hyoscyamus land its alkaloids are the best
hypnotics. The temperature should be combated by
baths, and the ice-bag to the head. Solivetti has
obtained excellent results by the administration of
Bonjean's ergotin (hypodermically). In spite of
the progressive exhaustion, blood-letting is recom-
mended (Anders). About 500 c.c. should be with-
drawn and an isotonic solution given intravenously.
Strychnine, alcohol, and the judicious administra-
tion of milk, eggs, broths, etc., by forced feeding are
indispensable.

EAR DISEASES.

Acute catarrhal otitis media is frequently caused
by acute coryza and the infectious fevers.

A moderate spray of Dobell's solution may be
used. If pain is present, dry heat may be applied.
A few drops, warmed, of carbolic acid solution
{1:40), or one of formalin (1:2000), may be in-
stilled into the ear. Bishop has found that leeches
may often give speedy relief. Two Spanish leeches
may be applied in front of the tragus and two be-
hind the auricle for adults. The external canal is
stoppered with cotton so that the leeches cannot
enter it. The skin is pricked until a drop of blood
appears; then the leech in a 2-dram vial, with its
mouth at the opening of the bottle, is placed so that
its mouth covers the drop of blood. The vial is held
in position until the leech takes secure hold. Then
the bottle is removed and the leech allowed to fill
and drop off. This manner of applying leeches is
given because few seem to be conversant with the
subject, and this method removes the common objec-
tion to handling the repulsive animals. Especial
care should be exercised to abstract the blood in
middle-ear inflammation, as much as possible from
the region of the tragus, on account of the intimate
relation of the blood-vessels of this region and the
anterior of the meatus with the vessels of the
tympanic cavity. If enough blood has not been ab-
stracted after the leeches fill and fall off, more can
be drawn by applying napkins wrung out of warm
water. If there should be any difficulty in stopping
the bleeding of the leech-bites, pressure applied to
them will succeed. The artificial leech is also an
excellent device, but occasions more discomfort.

Inflammation of the mastoid cells is evidenced
by deep-seated pain and tenderness over the mastoid
process, more or less fever, swelling, and, if pus has
formed, fluctuation. Leeches and hot fomentations
applied; over the mastoid often give relief. If the
symptoms continue, the Soft tissues over the mas-
toid should be incised. In bad cases it is necessary
to open the mastoid cells.

ECLAMPSIA,

Williams defines eclampsia as "an acute disease
which may occur in the pregnant, parturient, or
puerperal woman, and is characterized by clonic and
tonic convulsions, during which there is loss of
consciousness followed by more or less prolonged
coma." It is said to occur about once in 500 preg-
nancies. It is due to the retention in the system of
toxins that normally should be eliminated.

Dienst explains his grounds for the assumption
that the symptoms of eclampsia are the result of an
overaccumulation of fibrin in /the blood. The fila-
ments of fibrin cause disturbances in the circulation,
thrombosis and consecutive necrosis of the paren-
chyma, especially of the liver. The resulting insuffi-
ciency of the liver leads to imperfect neutralization
of the toxins generated in the metabolism, thus
inaugurating a vicious circle. Retention of salts is
a further indispensable factor in the development of

eclampsia, as the excess of fibrin alone is not suffi-
cient to induce it. Pregnancy nephritis causes
retention of salt and thus proves an indirect factor.
The leucocyte count suggests that dropsy without
albuminuria, "pregnancy kidney," and eclampsia are
links in the same chain.

Graf and Landsteiner relate the results of exten-
sive experimental research which have demonstrated
beyond question the enhanced toxicity of the blood-
serum in eclampsia in comparison to normal serum.
At the same time their research does not indicate
any special eclamptic poison, but merely that the
serum contains an abnormal excess of the toxic sub-
stances naturally in the serum. Waste poisons
seem to be accumulated in abnormal proportions.

The next step is to determine whether or not the
serum acquires this extra toxicity in other patho-
logic processes besides eclampsia.

H. Vaquez calls attention to the fact that ob-
stetricians have for a long time observed during an
attack of eclampsia, and particularly during the
convulsive seizures, that the pulse is hard and tense
and that the heart-sounds are markedly altered, the
second aortic sound taking on a clanging timbre
which is very characteristic.

These observations have given rise to the belief
that during the eclamptic attack, and even before,
there are marked alterations in the cardiovascular
system. He analyzes the historic evidence which
substantiates this view, and reports a number of
studies in blood-pressure which tend to point in the
same direction — that a pronounced vasoconstriction
occurs as an essential feature in the pathogenesis of
the eclamptic state. He does not add any new
hypothesis in his resume, but he holds that the
hypotheses thus far supplied are not sufficient, since
they do not take into recognition the essential symp-
toms of hypertension, which is evidence of vascular
disturbances the pathogenesis of which is still in
an unsatisfactory condition. A definite pathogenic
theory of eclampsia should be able to account for the
hypertensive vascular crises, which is the real
essence of the eclampsia, the convulsive attacks, and
the visceral modifications. Vaquez is under the
impression that the difficulty will be found in dis-
turbances of the thyroid and suprarenal glands,
whose function he assumes is largely to regulate the
arterial tension.

The treatment of the attack consists of the ad-
ministration of chloroform by inhalation, chloral
hydrate (gr. Ix) by enemata, and the fluidextract of
veratrum viride hypodermically (gtt. xx followed
by sufficient dosage to keep the pulse at 70, or below,
beats a minute), to control the convulsions, and free
purgation, free sweating. The induction of labor
should be brought about when it is least likely to
effect the vitality of the patient.

This treatment of eclampsia, Peterson asserts,
has given rise to much discussion. By some it is
regarded as the heroic, but specific treatment of the
attack. Large quantities of blood were formerly
extracted. At present, however, phlebotomy is only
used in plethoric cases, and not more than three
hundred grams of blood are removed.

He emphasizes the fact that blood-letting reduces arterial ten-
sion and likewise diminishes the quantity of toxins
in the circulation. Three hundred grains of blood,
according to Bouchard, will thus secure the elimina-
tion of five grains of toxins. The operation should
be performed upon the median cephalic or other
visible vein upon the anterior surface of the elbow.
After the withdrawal of the blood an equal or
double amount of salt solution (the author would
suggest Adler's or Loeb's solution) at a temperature
of 120° F. would be best injected into the vein. The
solution not only dilutes the toxic blood, but pro-
duces diaphoresis.

In the experience of Lusk, the indications for
treatment during the outbreak are for the most part
the same as laid down for uremic symptoms un-
attended by convulsions, viz., to lower the arterial
tension, to diminish to the fullest extent practicable
the irritation of the vasomotor and convulsive cen-
ters, and to restore to the kidneys their normal func-
tions. Spiegelberg claims that these three indica-
tions are most completely fulfilled by venesection.
Professor Fordyce Barker pleaded for the restora-
tion of the lancet in the management ofi puerperal
convulsions, insisting upon the unmistakeable clin-
ical evidences favorable to its empIovTiient. In my
student days in Paris, at the Hopital des Cliniques.
where the ancient usage was in full favor, I well
remember my first feelings of alarm at the vigor of
the treatment in vogue; but after carefully watching
the cases to the end I was led to conclude that the
claims of bleeding in eclampsia rested upon a sub-
stantial foundation. s

Lusk States that the special advantage of, vene-
section lies in the rapidity of its action; incidentally
it favors absorption and renders the patient more
susceptible to the influence of other remedies. It
forms, therefore, naturally the first step in the treat-
ment of convulsions. The quantity of blood to be
withdrawn varies from eight to sixteen ounces,
according to the vigor and, to some extent, accordr
ing to the size of the individual.

Williams, in his excellent work on obstetrics,
discusses the treatment of eclampsia from a scien-
tific but common-sense way. He gives in detail
the induction of labor. After the birth} of the child
no attempt should be made to hasten the third stage
of labor, as a moderate loss of blood should be
encouraged rather than checked. If the patient
does not show marked signs of improvement shortly
after delivery, from! 300 to 500 c.c. of blood should
be withdrawn. If beneficial results follow, the pro-
cedure may be repeated if necessary. As the
average woman possesses from eight and one-half
to nine pounds of blood, 500 c.c. would represent
from one-eighth to one-ninth of its total bulk.
Accordingly, if that amount of blood is drawn oflF
and replaced by an infusion of an equal quantity of
salt solution, the remainder of blood is so diluted
that, for practical purposes, one-fourth or one-fifth
of the total poison has been removed, and this aid
is often sufficient to tide the patient over sufficiently
long to allow nature to reassert herself.

It is generally stated that bleeding is indicated
only when the pulse is full and bounding.
Williams has bled, with most excellent results, a number of
patients whose pulse was thin and weak. This
experience would certainly show that venesection is
indicated in all cases in which delivery of the child
is not followed by a cessation of the convulsions, no
matter what the condition of the pulse.

EMPHYSEMA.

The name emphysema is given, to the exagger-
ated dilatation of the pulmonary tissue by air.
When emphysema is limited to the alveoli or the
lobules, it is said to be alveolar or intralobular; but ,
when the lobule is ruptured, and the air invades the ]
interstitial .tissue of the lung, the emphysema is
interlobular (Dieulafoy).

The symptoms are a gradual onset, distressing I
cough with expectoration of whitish and very tena-
cious mucus, labored respiration, dyspnea upon
slight exertion, early exhaustion, soft and accel-
erated pulse, and slight cyanosis. The chest is
enlarged in a peculiar manner and gradually be-
comes barrel-shaped. It generally occurs in the
course of asthma, tuberculosis, or chronic bronchitis.

The treatment consists of rest, tonics, and
stimulants. The various symptoms are generally i
met as they develop.

Patients who come into the hospital in a state of
urgent dyspnea and lividity, with great engorge-
ment of the veins, particularly if they are young and
vigorous, should be bled freely. On more than one
occasion I have saved the lives of persons in this
condition by venesection (Osier).

EPILEPSY.

Epilepsy is a condition manifested or character-
ized bv attacks of unconsciousness, with or without
convulsions. According to the severity of the con-
dition it is called petit mal or grand mal. The
convulsions may be tonic or clonic, or may alternate.
A family history of rachitis, malnutrition, nervous
disorders, alcoholism, syphilis, poor physique, ab-
normal and difficult labors, injury to the cranium,
the infectious fevers, intestinal worms, and disorders
of menstruation are some of the causes.

In an article on "Hypertonia Vasorum Cerebri,''
published in 1908, I stated that I had "long held the
hypothesis that epilepsy is the sequel of an angio-
neurotic artericstenosis, or disturbance of the cir-
culation of the convolutions, producing, in accord-
ance with the intensity of the spasm, le petit mal or
le grand mal. The foregoing hypothesis is not
founded upon mere supposition, but upon clinical
evidence presented by 52 cases cured by the regu-
lation of the circulation." To illustrate, one of
these cases became pregnant before menstruating
after the birth of a child. About the end of the fifth
month she began having two and sometimes three
attacks every twelve hours. The bromides, alone
and in their various combinations, were adminis-
tered to no effect. The patient was steadily growing
worse, and at my wits end I decided to induce labor.
When I advised the family what I was going to do,
the mother of the patient, an elderly Italian woman,
advised that I do a venesection, saying that in her
young womanhood venesection had reheved her of
the same condition. Guided by this timely advice,
I withdrew twelve ounces of blood, which was re-
peated in a week. After the first bleeding the
attacks were reduced to one a day. After the
second bleeding the bromides were administered
and the attacks gradually subsided and, at the end
of the fourth week, entirely. The patient was
delivered at term and has never, so far as I can
learn, had a return of the condition.

In the second Goulstonian lecture, 1909, Russell
discusses the correlation between the circulatory
changes postulated as the precipitating factor in
the epileptic fit and the various symptoms of and the
recovery from the attack. Under this head he dis-
cusses the aura, unconsciousness, convulsions, the
physiologic mechanism from recovery underlying
epileptic fits, and the postepileptic phenomena. He
considers vasomotor spasm in the brain as a cause
of epilepsy and discusses petit tiial, infantile convul-
sions, and Jacksonian convulsions. He describes
the symptoms following on prolonged and cerebral
enema as well as similar symptoms resulting from
prolonged chloroform syncope.

Russell describes the results of experimental
study of the restoration of circulation after the
blood-supply of the brain has been cut off. He dis-
cusses the time limit of recovery of the brain from
arrest of the circulation, the post-mortem condition
of the brain, reviews the symptoms, and regards the
diminution in the blood-flow through the brain as
the result of increased intracranial tension. His
observations, clinical and pathologic, lead him to the
conclusion that the fundamental condition under-
lying the status epilepticus is cerebral anemia.

W. Russell, 19 14, discusses a special condition in
which there is spasm constriction of the arterial
channels in localized areas of the brain; the term
"cerebral angiospasm" is given to this condition.
Although the cerebral vessels cannot be seen, the
vessels of the retina can be examined by means of
the ophthalmoscope, and it has been clearly estab-
lished that angiospasm occurs in these vessels.
Various observers have noted that a temporary loss
of vision of one-half of the retina may be associated
with marked diminution in the size of the retinal
vessels corresponding to the blind field, and that
vision returns with the relaxation of the constricted
vessels and the re-establishment of the normal
blood-supply to the part. From these observations
alone Russel believes it is fair to postulate that
corresponding constriction can take place in the
arteries in localized areas of the brain.

In 1908 I described the conditions above referred
to and mentioned that "the occurrence of spasms of
the' arteries caused complete loss of function for a
time. In the retinal picture of arteriospasm, we
have the explanation of visual and sensory disturb-
ances, and other important pathologic conditions.
A distinct homonymous defect may be the first evi-
dence of organic disease." At that time I made my
deductions as to the etiology of epilepsy, and since
that time have known of no reason why I should
change my hypothesis.

A merchant of 41 came under my service April
9, 1915. Family history was good. He showed a
tendency to erythremia. Patient had had diseases
of childhood and enjoyed good health until 17 years
of age. He states that he received a blow from a
rock upon the head posterior to and slightly above
the mastoid. Some months later he began to have
mild convulsions once every six months, at night.
These attacks confined him to bed two or three days.
The attacks began to increase in frequency. At the
age of 23 he had facial paralysis, which lasted for
one month. When the patient came under my
service he was having eight convulsions during the
day and three and four during the night.

Unconsciousness and convulsions were always
of grand mal type. No auras present at any time.
The attack came like a bolt from a clear sky. The
heart and lungs were normal. The blood showed
nothing abnormal, except increased viscosity and
high color index. The urine was high colored,
1025 sp. gr., with an abundance of bile and indican;
no casts were found. Blood-pressure was 145
mm. Hg.

The diagnosis is naturally, on first thought,
epilepsy due to traumatism, The examination of
the site of traumatism did not reveal any depres-
sion, nor was it in that part of the skull where
traumatism would have a tendency to cause epilepsy.
The increased viscosity of the blood, increased blood-
pressure, indican, and specific gravity led me to
infer that the epilepsy was due to circulatory dis-
turbance. From this inference my treatment was
directed toward the vascular crises.

The patient was given 15 gr. potassium iodide
t. i. d. p. c, and gradually increased to physiologic
effect. Glonoin was given in -gr. doses every
three hours. All salty foods and dark meats were
prohibited. The patient was free from the attacks
for one month; then they began to return. The
patient was bled about twenty ounces. He obtained
immediate relief and had no recurrence of attack
for two months. Domestic and financial worries at
this time caused a return of attack. He complained
of intense pain in the head and stated that he felt
as though he was going insane. His eyes were
injected, face congested, and gait unstable. He was
again depleted of twenty ounces of blood. This
gave him immediate relief. August 15, owing to
exposure to heat, the patient had an attack and was
bled about sixteen ounces from the left leg. There
has been no recurrence of the epileptic attacks. The
patient's weight has been reduced from 224 lbs. to
180 lbs. He has improved mentally, physically, and
in general efficiency. I mention this case to show
the good that may be accomplished by persistent
treatment in these apparently hopeless cases.

Some authors claim that venesection has no
place in psychiatry. If there is a place in the whole
system of medicine that venesection is needed as an
adjunct in treatment, it is in the beginning of a
vast number of mental and nervous diseases.

A schoolgirl of 9 came under my service October
26, 191 5. Good family history. Had usual dis-
eases of childhood, and was in apparent good health
until July, 19 14. At this time she began having

convulsions. The attacks gradually increased until
she was having ten a day. She was not able to
walk; had facial paralysis and dribbling of saliva.
Pain in head; mentality much impaired.

A diagnosis of tumor was made and treatment
directed accordingly. The following prescription
of J. C. Wilson was used: —

IJ Hydrarg. chloridi corros gr. j ;

Tinct. ferri chloridi 5ij ;

Liq. arseni chloridi gtt. xlvij ;

Potassii iodidi 3ij ;

Syr. zingiberis 5'ij J

AquiE q. s. ad jvj.

Sig. : A teaspoonful (. i. d. p. c.

The treatment was not efifective until the patient
had a free hemorrhage from the nose. The treat-
ment appeared to take effect almost immediately
after that. The potassium iodide has been increased
from time to time, and the prescription varied to
suit the case.

The patient has improved rapidly. The attacks
have been reduced from ten daily to one or two
weekly. This treatment will, with an occasional
venesection, eventually result in a cure.

ERYTHREMIA.

A disease characterized by a persistent increase
of the red blood-corpuscles, a condition of plethora,
splenomegaly, and at times cyanosis.

The three cardinal features are a change in the
appearance of the patient, enlargement of the spleen,
and hyperglobulism. The superficial blood-vessels,
capillaries, and veins look full, so that the skin is
always congested, in warm weather of a brick-red
color, in cold weather cyanosed. The engorgement
of the face may be extreme, extending to the con-
junctiva, and in the cold the cyanosis of the face and
hands may be as marked as any that is ever seen.
There is often, too, a remarkable vasomotor insta-
bility, e.g., the hand becoming deeply engorged when
held down, and rapidly anemic when held up. The
spleen is usually moderately enlarged, hard, firm,
and painless.

The total bulk of blood is enormously increased,
and the ratio of corpuscles to plasma is high. The
polycythemia ranges from 7 to 12 or even 13
millions of red corpuscles per cmm. Hemoglobin
ranges from 130 to 160 per cent., but the color index
is relatively low.

Headache, flushing, and giddiness are common
symptoms. Constipation and intestinal fermentation
are common, and albuminuria is usually present.
The blood-pressure is high; occasionally there may
be hemorrhages into the skin and from the mucous
membranes. Recurring ascites, probably in asso-
ciation with splenic tumor, may present itself.

Diagnosis may be based upon the triad of fea-
tures above referred to, in absence of congenital
heart disease, emphysema, and forms of cyanosis
associated with poisoning by coal-tar products.

The prognosis is bad for cure, but the condition
may persist for years with reasonably good health.
Cardiac failure, hemorrhage, and recurring ascites
have been the usual modes of death.

The treatment should be directed to the hemato-
poietic system. When there is much fullness of the
head and vertigo, repeated bleedings give relief.
Inhalations of oxygen may be tried when the
cyanosis is extreme. Calomel, gamboge, jalap,
saline purges, and low diet are helpful.

EYE DISEASES.

Fuchs sums up the uses of venesection in treat-
ment of diseases of the eye in the following lan-
guage: "In recent cases of choroiditis with hyper-
emia of the retina the abstraction of blood is recom-
mended, and that by the application of leeches
behind the mastoid process. While blood-letting
has pretty much disappeared from general practice.
in ophthalmology it has remained in use up to the
present time, and rightly, too, since in suitable cases
striking and undeniable advantage is often seen to
accrue from it. The abstraction of blood may be
made with natural leeches or with Heurteloup's
artificial leech. In the former case, six to ten
leeches are applied ; in the employment of the Heur-
teloup, its glass cylinder is filled once or twice with
blood. The point of application is either the temple
or the skin behind the mastoid process. If we are
dealing with inflammations of the conjunctiva, the
iris, or the ciliary body, the temple is selected, be-
cause the vessels of the conjunctiva empty into the
veins of the face, and, moreover, the anterior ciliary
veins communicate freely with the veins of the con-
junctiva. In deep-seated affections, choroiditis,
retinitis, neuritis, or inflammation in the orbit, the
abstraction of blood is performed behind the mas-
toid process, because an emissary vein of Santorini
(passing through the mastoid foramen), which car-
ries off blood from the transverse sinus, empties
here; and the latter is connected with the cavernous
sinus, into which the ophthalmic veins pour their
contents."

FEVER, TYPHOID.

Typhoid fever is a general infection caused by
the Bacillus typhosus, characterized anatomically by
hyperplasia and ulceration of the intestinal lymph-
follicles, swelling of the mesenteric glands and
spleen, and parenchymatous changes in other organs.
There are cases in which the local changes are
slight or absent,'' and there are others with intense
localization in the lungs, spleen, kidneys, or cere-
brospinal system. Clinically the disease is marked
by fever, a rose-colored eruption, diarrhea, abdom-
inal tenderness, tympanites, and enlargement of the
spleen; but these symptoms are extremely incon-
stant, and even the fever varies in character (Osier).

The treatment is largely supportive and prophy-
lactic. Careful nursing, a regulated diet, and the
proper application of hydrotherapy are the essen-
tials in the majority of cases. The patient should
receive aocx) to 3000 calories of food, which may
consist of milk in any form, cream, cocoa, strained
soups, gruels, jellies, coffee and tea with cream,
toast, junket, and eggs, raw or soft boiled, or egg-
lemonade.

There is no specific drug treatment, but it is
advisable to give hexamethylenamine after the first
week, 15 to 20 grains daily. In private practice, I
order hydrochloric acid, dilute, 20 drops, and tinc-
ture nux vomica, 10 drops, every four hours after
nourishment. I very often employ small doses of
quinine and salol. The quinine undoubtedly has a
neutralizing effect upon the action of the toxin.

The special symptoms are treated in relation to
their severity and development. The severe tox-
emia is one condition that taxes our skill and
ingenuity.

The hemorrhage and intoxication are two fac-
tors in typhoid fever that usually give the general
practitioner the most concern. The effect of hemor-
rhage and venesection in typhoid will be noted in
two of a series of cases reported by me in 1907: —

Case i. — W. N., female, aged 34, weight 165.
married, came under my service August 16, 1903.
The patient gave history of usual diseases of child-
hood and simple continued fever in 1902.

Clinical History. — The patient was in the second
week of the disease when I was called. The usual
symptoms indicating typhoid were elicited, which
the diazo-reaction verified. The fever and pulse
were not exaggerated. Nocturnal delirium, stupor,
subsultus tendinum, and carphology were marked.
On the morning of the nineteenth day I was called
about 3 o'clock and found the patient bleeding
profusely from the nares. The hemorrhage was
stopped by plugging the nares with linen. The
patient lost approximately eighteen ounces of blood.
The temperature dropped rapidly to 98° F. Al-
though the temperature arose to 102.5° F. on the
twentieth and the day following to 104° F., the
condition of the patient improved and continued to
improve from day to day. The tenth day after the
hemorrhage, on the twenty-ninth of the disease, the
temperature was normal.

Case 2. — M. M., female, aged 24, gave a his-
tory of the diseases of childhood, and syphilitic
infection at the age of 18.

Clinical History. — Diagnosis from manifest
symptoms was typhoid, and was confirmed by
Widal test and diazo-reaction. Patient was allowed
by mother to use commode and assist herself ad
libitum.

I was called one afternoon in the third week of
the disease and found patient having a hemorrhage
from intestines, nares, and ears. The pulse was
full and bounding. I immediately opened the
median basilic vein and bled the patient of sixteen
ounces. Hemorrhages ceased and condition began
to improve immediately. Patient was convalescent
in twelve days from time of venesection and made
an uneventful recovery.

Rudolph reports his deductions made from a
series of cases at the Toronto General Hospital;
1914:—

In studying* the last 1591 cases of typhoid treated
in the Toronto General Hospital it appears that the
mortality was S.67 per cent, over all, but that the
death rate among those reported as having had one
or more hemorrhages was 37 per cent. This latter
figure is almost the same as occurred in Cusch-
mann's series at Leipsic, which was 38 per cent,,
while in Striimpell's 45 cases of hemorrhage in
typhoid it was 42.2 per cent. In the Toronto series,
excluding the cases that had been bleeding, the
mortality of the remaining 1464 cases was only 6.3
per cent. Rudolph cites 12 cases which show how
the bleeding was followed by a more or less marked
fall not only in the temperature, but also in the pulse
rate. They are said to be the best examples, but
most of the other 115 charts of cases of bleeding
showed more or less of the same thing.

The improvement in the temperature and pulse
curves, while often transient, in some cases lasted
for days and even ushered in convalescence-
Rudolph agrees that it is difficult to explain how
the good effects that may follow a hemorrhage
come about. There is no doubt, however, that it
produces a profound effect on the whole bodily
economy. Thus bleeding has been shown to bring
about an increase in the flow of urine, to greatly
increase the intake of oxygen, with proportionate
raising of tissue-oxidation. It hastens the coagula-
tion time of the blood more than does any other
single agent. It produces a rapid increase in the
antibodies contained in the blood. The agglutinat-
ing power of the blood is enormously raised by the
bleeding. Further, in toxic conditions, such as
uremia and other less-defined states in Tvhich there
is high blood-pressure, bleeding appears in some
way to lessen the toxemia, and possibly in typhoid
it may have some similar effect.

Rudolph agrees with Whitehead, who two years
ago [previous to the writing of this article] sug-
gested the good effects of hemorrhage in typhoid
might be attained and the evil ones (associated with
intestinal hemorrhage) avoided by the timely use of
venesection in those cases which are not doing well
on account of severe infection and toxemia. Vene-
section, he says, appears to be indicated in severe
cases; and if the removal of blood by venesection
be a moderate one, say of six to fourteen ounces, it
can do no harm and may possibly be productive of
great good.

FEVER, YELLOW.

An acute, specific fever of tropic and subtropic
countries, characterized by a toxemia of varying
intensity, with jaundice, albuminuria, and a marked
tendency to hemorrhage, especially from the stom-
ach, causing the "black vomit.'' The specific organ-
ism has not yet been found, but the disease is
capable of being transmitted through the bite of the
mosquito, the Stegomyia fasciata (Osier).

The prophylactic treatment consists largely in
perfect sanitation, with inspection and quarantine
of suspected individuals or goods from infected
ports.

Careful nursing and a symptomatic plan of
treatment probably give the best results. Rest in
bed, cleanliness, ventilation, and disinfection are
necessary measures. Castor oil, calomel, or salines
should be given to empty the bowels. Diaphoresis
by hot packs or mustard foot-baths is essential.
The diet shoulld be liquid and freely given. Hydro-
therapy is used to control the temperature,

Bleeding has long since beeni abandoned. How-
much patients will stand in this disease is illustrated
by Rush's practice, which was of the most heroic
character. He says: "From a newly arrived Eng-
hshman I took 144 ounces, at 12 bleedings, in six
days; 4 in twenty-four hours. I gave within the
course of the same six days inearly 150 grains of
calomel, with the usual proportions of jalap and
gamboge." With the courage of his convictions
this modern Sangrado himself submitted to two
bleedings in one day. and had his infant of 6 weeks
old bled twice (Osier).

GOUT.

A form of perverted nutrition due to a retention
of uric acid and other purin bodies in the system,
characterized clinically by attacks of acute arthritis,
the deposition of sodium-biurate in and about the
joints, and by the occurrence of irregular constitu-
tional symptoms.

The treatment has for its main object elimina-
tion. Laxatives such as calomel and salines are
indicated. Tincture of colchicum seeds, 10 drops,
and veratrine should be given during the attack.
Absolute rest of the parts, local application^ of
ichthyol in lanolin, a select diet, and mineral water
are quite necessary. Between attacks an open-air
life, with plenty of exercise and regular hours, and
properly selected hydrotherapy are advantageous in
bringing about a cure.

Garrod and his associate, Todd, have noted the
interesting fact that after local depletion, with
leeches, joints thus treated remain permanently-
weakened, and may even become completely anky-
losed. Before the days of aseptic surgery there was
also no little danger of erysipelas and other infec-i
tions through cutaneous wounds that were thus
inflicted (Lyman).

When the brain is the seat of retrocedent phe-
nomena, the symptoms of coma are rapidlly de-
veloped. Under such circumstances, if the patient
be plethoric, blood should be taken from the' arm
to the amount of ten to fifteen ounces. Some of
these cases are really due to uremia, and bleeding is
in such as useful as it is in puerperal eclampsia.
Bloodletting should be followed by a drastic purge
with calomel and jalap, or with croton oil if there
be difficulty of deglutition (Lyman).

HEART DISEASES.

The diseases of the heart are varied and com-
plex. In health we are unconscious of the action of
the heart. One of the first indications of debilit)'-
or overwork is the consciousness of the cardiac pul-
sations, which may, however, be perfectly regular
and orderly. Heart disease is either functional or
organic. The discussion will be only briefly touched
Upon, and the space devoted to tlie more prominent
etiologic factors and treatment where venesection
is indicated.

Darhngton states that heart disease among
school-children is greatly on the increase. Of the
defective children in the schools that had been ex-
amined by him, 3500 had heart disease in some form.
During two years 1234 children died from heart
disease, and only 131 of these were under 5 years
of age. With the beginning of school-life the rate
increased 28 at the age of 4 years, 286 at the age
of 15.

Darlington recapulates impressions gained from
a study of heart disease in the United States as
follows : —

1. The mortality rate from heart disease is
steadily increasing.

2. This increase is general throughout the
United States, and is apparently unaffected by
climate conditions, locality or density of population.

3. The correlated condition, chronic Bright's
disease, shows a corresponding increase in mortality.

4. The general death rate is steadily decreasing.

5. No other disease shows a general relative in-
crease in its death rate.

6. The commonly accepted cause of cardiac affec-
tions cannot be held responsible for the increased
death rate without further study of their etiology.

7. The effect produced by high-strung nervous
tension, induced by modern methods of social and
business competition, must be regarded as a causative factor in the production of functional and ultitimately organic cardiac disease.

8. The medical profession has before it an op-
portunity of great moment in teaching the doctrine
of right living, advocating a saner and more whole-
some attitude toward life, and standing as a unit
against false standards of material gain and ad-
vancement obtained by the sacrifice of the normal
healthful and peaceful attributes of calm mental
poise, equable temperament, and physical well-
being.

Functional heart disease is made manifest by
various alterations in the heart-beat, temporary or
habitual; in the volume, force, time, etc. They may
be due to organic brain disease, psychic disturb-
ances, neuroses, reflex influences, as from disturb-
ances of the gastrointestinal tract and kidneys,
toxins, such as tea, coifee, alcohol, tobacco, and
those of the infectious fevers, and various discrasias,
and organic disease of the heart itself.

Heredity, syphilis, tobacco, alcohol, mental
strain, gluttony, and modern methods of preparing
foodstuffs are far the most important factors in the
etiology of cardiac diseases.

In the discussion of prevention of valvular dis-
ease, Caton reminds us that in acute rheumatism the
inflammatory changes in the joint tissues and the
endocardium respectively are alike in kind, but the
essential treatment of rest is not equally possible of
application. The work of the heart varies with
times and circumstances, however, so that within
limits the amount can be regulated, if we take suffi-

cient trouble. Pain and fever can be lessened by
adequate doses of some salicyl compound or other
measures appropriate to the condition. Absolute
rest of mind and body, light, diet, a gentle sedative iri
sleeplessness, fairly full doses of sodium or potas-
sium iodide three or four times daily, to aid absorp-
tion, lessen the volume of the blood and diminish
blood-pressure. These measures slow the heart and
diminish its amount of work. Secondly, through
the first four dorsal nerves, in their distribution
between the clavicle and the nipple, the trophic and
vasomotor nerves of the heart can be stimulated
without exciting the muscle-fibers. This is effected
by small blisters, applied one by one. The rest
treatment is the most important and must continue
for six or eight weeks, or even longer, and it must
begin early, before marked changes occur. This
depends on a capacity to recognize the advanced
stages of valvular disease in the making. The first
sound at the apex consists of two elements: (i) the
less important muscle sound; (2) the crack of the
stretched valve-ducts made taut by the sudden rise
of pressure of the blood-stream under the powerful
squeeze of the ventricle. Thickening and stiffening
of the valve-membrane from inflammatory change,
with subendotheliai effusion, and the formation of
vegetations gradually change the clear sound into a
longer and duller one, eventuating in a whiffing
sound that ultimately develops into a real regurgi-
tant bruit.

When making office tests of heart functionating,
Waldvogel examines the systolic blood-pressure with
the patient horizontal and again as the patient
stands, and summarizes his findings with 130
patients. This simple test of the systolic pressure
as the, patient lies and stands up can never prove
an exertion for the heart, while nervous influences
are almost entirely excluded, and the effort is pro-
portionately the same for all human beings. As
the patient reclines the Recklinghausen cuff is
applied and the Riva-Rocci manometer is applied to
the heart region. The patient holds the manometer
with his free hand and the systolic pressure is noted
twice. Then the patient is told to get up quietly;
as he stands he holds the manometer with his free
hand, on a level with his heart, and again the
systolic pressure is noted twice on the' arm bent at
the elbow, the wrist lightly supported by the ob-
server. Quick work is necessary, as the pressure
soon fluctuates. He tabulates the findings in six
tables, the first showing the cases with the same
pressure in both positions, the other showing a rise
or fall in the pressure, from 5 to 20 mm. or more,
from the change of position. It seems evident that
a drop of 10 or 20 mm. on* standing is an index of
a pathologic condition in heart-action, although a
drop of 10 mm. is still within normal range. The
greatest difference, 35 mm., was observed in a case
of contracted kidney and alcoholism.

Hahn relates a number of cases to show the
excellent effects of venesection when the circulation
of the lungs is interfered with. The circulation in
the lungs provides a regulating reservoir for the
blood, and the effect of venesection is felt here first
and most intensely. Especially in arteriosclerosis,
permanent benefit is derived from venesection, pos-
sibly from reduction of the viscosity of the blood.
Experiments on himself showed that venesection
induced a feeling" of agreeable lassitude, an out-
break of sweat, and somnolency. Among the ex-
periences related was the arrest of incipient edema
of the lungs in severe heart disease in a hard drinker,
and the relief of distress in a patient with emphysema
of the lungs and, secondly, weakness of the right
ventricle.

At any stage in a valvular lesion or in hyper-
trophy and dilatation of the heart from any cause,-
acute cardiac insufficiency may arise associated with
dyspnea, more or less cyanosis, irregular action of
the heart, the gallop rhythm or embryocardia and
a small, rapid pulse. In typical form this is seen in
cases of arteriosclerosis, in hypertrophy and dilata-
tion from overexertion, but it may occur in any
form of valve lesion. It is the one condition in heart
disease in which venesection is advantageous. For
many years now this practice has been carried out
at the Johns Hopkins Hospital with the greatest
benefit. In many hands it is not satisfactory, be-
cause sufficient blood is not taken. Gkjod results are
rarely seen unless as much as 20 ounces is taken.
To "breathe a vein" skillfully is now almost a lost
art. and to get enough blood is sometimes necessary
to bleed from both arms. Hypodermics of ether
in dram doses, strychnine in Yao grain, or digitalin
in V^o grain, or camphor may be administered.
Locally, apply hot mustard leaf (Osier).

The management of the stage of incompetency
consists in rest, resistance exercises, massage, Nau-
heim baths. The selected use of digitaHn, aconitin,
vasodilators, sparteine sulphate, diuretin, laxatives,
morphine, and strychnine may prove efficient for
temporary use. Undoubtedly there are many cases
in which the letting of twenty to thirty ounces of
blood proves a timely measure and starts the patient
on his uphill journey. When arterial tension is so
high and the pulse so bounding as to congest the
head and threaten apoplexy, a vein may be opened
and sixteen to twenty ounces of blood be abstracted
with immense benefit.

The accompanying diagram illustrates beautifully
the graphical outline of the organs that are relieved
by venesection.

Nature sometimes gives a hint in this direction
by the production of severe epistaxis. The nose-
bleed is sometimes hard to arrest and requires plug-
ging of the nares, but afterward the patients are
unquestionably relieved from a condition of hyper-
tension which might prove most dangerous.

In the treatment of pericarditis, if, the dyspnea
is the result of pulmonary congestion and does not
yield to local apphcation to the precordium and to
internal stimulation, recourse should be had to vene-
section. In any condition attended by overstrain
and distention of the right ventricle, venesection,
even if copious, is not dangerous. The more quickly
the blood flows, the greater will be the fall in blood-
pressure in the right ventricle, and therefore the
greater its relief. If the loss of blood is deemed

Diagram showing tile indirect (peripheral) effects of valvu-
lar lesions. This diagram is also of service in iracing the direct
(cardiac) changes due to valvular defects. The indirect results
are catalogued in the sign squares.undesirable, an equal quantity of saline solution may be given subcutaneously to replace the volume of the blood lost.

In cases of dilatation, from whatever cause,
whether in mitral or aortic lesions or distention of
the right ventricle in emphysema, when the signs of
venous engorgement are marked and when there is
orthopnea with cyanosis, the abstraction of from
twenty to thirty ounces of blood is indicated. This
is the occasion in which timely venesection may save
the patient's life. It is a condition in which I have
had most satisfactory results from blood-letting. It
is better done early than late. I have on several
occasions regretted its postponement, particularly in
instances of acute dilatation and cyanosis in connec-
tion with emphysema (Osier),

Forchheimer emphasizes the fact that venesec-
tion is at times of the greatest value. When the
right heart is overfilled and a temporary respite is
necessary, so that it may have a chance to empty
itself, frequently acting in a life-saving way, this
operation should be performed. Local bleeding of
the heart by puncture of the auricle with an aspira-
tor needle should never be resorted to ; it is too
dangerous.

Whittaker believes, in extreme cases of edema
of the lungs or brain where death seems imminent
from suffocation or coma, it may be justifiable to
let blood. In old times blood was let in the quan-
tity of several pints in twenty-four hours in the
relief of these conditions, and there is no doubt of
the value of venesection in these cases. In the
clinic of Liebermeister it was found that in certain
cases of insufficiency and stenosis of the mitral
valve, when the pulse could no longer be felt and
the blood only escaped from the vein in -the arm
drop by drop, the discharge of 240 c.c. from' both
arms rendered the pulse palpable and saved the
patient. Under the use of digitalis, the hydrops,
the cyanosis, and the dyspnea disappeared, so that
in the course of two months compensation was
again restored.

HEMORRHAGE, TREATMENT.

Hemorrhage is arterial, venous, capillary, or
parenchymatous. Arterial blood is bright crimson
or vermilion in color, and issues from the divided
vessel in jets. Venous blood is of a dark-blue tint
and flows in a continuous stream. In capillary
hemorrhage the blood is of a reddish tint and
exudes from the tissues. Parenchymatous hemor-
rhage is characterized by blood of partly venous
and partly arterial origin, as in the spleen. Hemor-
rhage may result in death at once, or S3mcope with
depression of the heart and clot-formation, followed
by reaction, and sometimes with recurrence of the
hemorrhage, and death. In man, death is inevitable
when an adult loses at one time one-half (4 to 6
I)ounds) of the total volume of blood, whereas a
more considerable but gradual loss may be followed
by recovery (Matas). Children are much more
susceptible than adults and may die after very small
hemorrhages, while women will stand the effects of
hemorrhage much better than children or men. In
-the aged or arteriosclerotic the dangers from acute
hemorrhage are still greater.

Observations upon healthy adults have shown
that a loss of about 50 c.c, corresponding to about
250 millions of red corpuscles, is immediately re-
placed without diminution of hemoglobin or ery-
throcytes out of the reserve fund of the vascular
system (Arneth).

Patients recover after the persistence, for weeks
and months, of less than 2,000,000 erythrocytes to
the centimeter. The mere deprivation of the oxygen-
carrying function of the blood usually plays no part
in the causation of death from hemorrhage, and is
shown in pernicious anemia with respiration appar-
ently unaffected (Hayem and W. Hunter).

The immediate source of danger from sudden
loss of blood is the fall of blood-pressure to a point
at which the circulation cannot be maintained.
Pilcher and Sollmann found that hemorrhage pro-
gressively stimulates, depresses, and paralyzes the
vasomotor center. The period of stimulation is
somewhat variable, but usually persists during a
total hemorrhage of about 25 c.c. per kilogram when
the blood-pressure has fallen to about 90 60 100
mm. A period of vasodilatation follows the stimu-
lation; the perfusion flow may remain below the
normal, return to normal, or increase somewhat
above the normal flow. The center becomes para-
lyzed when about 35 to 45 c.c. per kilogram has
been withdrawn and when the blood-pressure has
reached a low level (approximately 30 mm.). Re-
injection of blood or saline solution before the onset
of paralysis may restore the vasomotor tone. The
low blood-pressure (shock) level depends chiefly on
the amount of blood lost and not to an important
degree on the rapidity of the hemorrhage. The
relation of the fall of blood-pressure -to the amount
of blood lost varies in each animal; however, the
median type is approached more or less closely by
each experiment.

The readiest way to meet the threatened failure
of circulation, after severe hemorrhage, is to replace
the lost blood by intravenous infusion of normal
saline. In normal animals, Pilcher and SoUmann
noted that the intravenous infusion of saline solu-
tion (lo to 40 c.c. per kg.) slightly stimulates the
vasomotor center or leaves it unchanged. Occasion-
ally, when the saline causes a maintained rise in
blood-pressure, there may be considerable stimula-
tion of the center. Above a 60 mm. level, the original
blood-pressure seems to have no influence on the
response of the vasomotor center.

The factors that enter into the fall of blood-
pressure and are the essential cause of death in acute
hemorrhage are: The sudden anemia of the bulb,
vasomotor and higher nerve-centers, which are thus
crippled or inhibited, and are unable to regulate the
vasomotor mechanism, and the sudden diminution
in the amount of blood circulating in the blood-
chambers and in the myocardium itself. "Loss of
blood predisposes to shock because shock is due to a
disturbance of the vasomotor mechanism, and the
diminution of the fluid contained in the vessels means

an additional tax brought to bear upon the vaso-
motor center in maintaining a given mean blood-
pressure. Every such stress placed upon the center
diminishes tlie total amount of functional reserve it
may have."

Post-partum Hemorrhage. — Brock points out
that the treatment of serious post-partum hemor-
rhage resolves itself into that of regurgitant venous
hemorrhage, and must be carried out by one of two
methods: (i) The application of direct pressure to
the bleeding sinuses, after the method advocated by
Dr. Herman, of introducing one hand closed into the
vagina, while, with the other, the fundus of the
uterus is pressed down on to it through the abdom-
inal wall; or (2) elevation of the pelvis and com-
pression, not of the aorta, but of the inferior, vena
cava, by precisely the same maneuver. He is of
opinion that the method for arresting post-partum
hemorrhage by compression of the aorta depends
for its success on the compression, not of the aorta,
but of the inferior vena cava, thus stopping the
backwash of blood from the latter vessel.

Hemoptysis. — In 7 cases Broga used amyl nitrite
and the hemorrhage on 15 occasions was arrested as
if by magic; blood ceased to accumulate in the bron-
chial pas.sages, and thus the evil effects of its de-
composition is avoided. Five or six drops of amyl
nitrite on a wad of cotton were inhaled, and' the
hemorrhage ceased at once and did not occur again
in the majority. The inhalations were repeated
several times afterward during the day. It proved
effective, even in cases in which no other treatment
had given relief. Broga augmented the nitrite by.
enemas of gelatin to which calcium chloride had been
added, with fluidextract of hydrastis internally.
Since this method has been adopted no patient has
died from hemoptysis, and whenever it appears it is
controlled at once.

Campani thinks that hemoptysis is the result of
a combination of unusual irritability on the part of
the blood-vessels and increased blood-pressure. The
conditions are approximately the same as in the men-
strual molimen — temporary vascular erethism and
hypertension. He advises amyl of sodium nitrite.
In cases of rupture of a large vessel in the lungs, no
benefit need be expected from the nitrites. In this
case, ice to the chest and small pieces by mouth,
opiates, and the patient placed in a sitting position
proved effective.

Senator thinks lead acetate increases the vis-
cidity and coagulating power of the blood, and occa-
sionally uses it.

Bonney's observations on venesection are most
satisfactory. Ordinarily, any attempt to reduce
arterial pressure in pulmonary circulation by vene-
section is irrational, as the hemorrhage itself has
probably already produced any good to be derived in
this manner. He has found that moderate venesec-
tion does good where the initial hemorrhage has been
slight, and recurs where fever has been persistent
and blood-pressure high. Venesection may do good
in pulmonary tiiberctdosis accompanied by nephritis^
where the abnormally high blood-pressure seems to
provoke and prolong the hemoptysis.

w

HEMORRHAGE, TREATMENT.

In an interesting case reported by me some years
ago, I note the following: —

History. — J. B., Polish, musician, butcher, aged
29, came under my service, August 10, 1903. Fam-
ily history was negative. The patient was married,
had a family of five healthy children. He was
addicted to the use of alcohol, but denied venereal
infection. He played at Polish weddings, which
kept him from sleep often for a period of two days.
The patient's health was good until May, 1903. At
this time a dry, hacking cough, loss of weight and
strength began. On the day the patient came under
my care the patient had had two copious hemor-
rhages. Expectoration was free and showed bacilli
in abundance. Dyspnea on exertion, morning chills,
evening fever, night-sweats, great emaciation, and
weakness were present. The tuberculin reaction was
positive; 2 mg. of tuberculin produced marked rise
in temperature.

Physical examination revealed a marked exag-
geration of signs showing involvement of right apex.
There were no complications.

Treatment. — Morphine, '/i gr., and atropine,
Vi 'to gr., were administered every four hours to
control the cough and sweats. I instructed that the
patient receive plenty of fresh air, sunlight, oleum
morrhu.'e. milk, and raw eggs. When called to the
patient. I found the pulse full and bounding and
dyspnea intense. T immediately depleted the patient
of approximately sixteen ounces of blood and had
the pleasure of seeing the symptoms relieved.

Result. — December 20, 1903, patient was in nor-
mal health; had regained weight and strength.
There was no cough; bacilli were absent from
sputum; tuberculin test of 5 mg. was negative.

Hematemesis. — Hemorrhage from the stomach
may result from traumatism, mechanic obstruction,
cardiac disease, pulmonary disease, vicarious men-
struation, rupture of an aneurism, ulcer of the
stomach, cancer of the stomach, and irritant poisons.

The treatment is rest, rectal alimentation, cold
to the epigastrium, and morphine and atropine
hypodermically. Surgical intervention is ofttimes
necessary.

HYPERTONIA VASORUM CEREBRI.

The etiologic factors bearing exclusively upon
hypertension may be classified, according to Jane-
way, as functional, relatively referred to as (a)
physiologic, pharmacologic, toxic, and ( & ) acute cere-
bral compression and anemia. I would suggest the
addition of the psychologic factor to the above classi-
fication, because of its meaning and importance in
hypertonia.

The factors in essential hypertension are (a)
arteriosclerosis, (&) renal disease, and (c) angio-
sclerosis.

Any transitory cause producing on the vascular
system increased blood-pressure may be spoken of as
functional hypertension. The increase of tension
due to excessive mental activity or physical exertion,
as found in forcible inspiration in normal man, are

physiologic acts which force a large amount of blood
to the heart and brain. Acute gastric and intestinal
pain ma}' cause hypertension (Curschmann). Nico-
tine, alcohol, ergot, adrenalin, hydrastine, hydro-
chlorate, and stypticin are some of the drugs which
cause great increase in blood-pressure. Nicotine is
one of the most destructive agencies to constructive
metabolism, and should be ranked with alcohol.
Toxic factors are found in eclampsia (H. Vaquez),
gout, alimentary intoxication (Finkelstein), and
uremia. Psychic hypertension of great intensity is
seen in fright, sudden joy, and great sorrow.

Extreme high tension may accompany acute com-
pression of the brain in fracture of the base of the
skull, and in apoplexy. Acute cerebral anemia pro-
duces the same symptoms as cerebral compression;
hence, high tension.

Obstruction of the cerebral sinuses and veins may
be due to pressure on the innominate or jugular
veins, by a tumor or aneurism, to suffocation and
strangling, to excessive strain, to tricuspid insuffi-
ciency, to embolism, to thrombosis, to arterial and
venous degeneration, to ulceration, to abscess, and to
hemorrhage. Weinburger observed, in the case of
a gardener of 36, an aneurism and rupture of the
vessels, and the basilar arteries and aorta were
sound. An abscess due to a mycotic embolus may.
result in an aneurism or rupture of the vessel.

The causative factorsi in essential or permanent
hypertension, according to some investigators, are
due to a damaged regulating power of the visceral
circulation. This high level of blood -pressure must
be met by the mechanical complexity of automatic
principles and is so maintained by hypertrophy of
the left ventricle. Some writers ( Hasenf eld, Hirsch,
Janeway) assert that hypertrophy of the left ven-
tricle is due to arteriosclerosis, only when there is
disease of the splanchnic arteries, or in the aorta
above the diaphragm. Thus they exclude all other
parts of the vascular system.

The hypertension of renal disease is a marked
condition, concerning which many theories have
been advanced. Bright, in 1836, first associated
lesions of the kidney with a h)rpertrophied heart.
He thought the causative agent to be irritants in
the blood stimulating the heart abnormally or in-
creasing the resistance of arteries and capillaries.
Schlayer relates observations in this line, stating:
'There is no relation between hypertension of
nephritis and the functionating of the suprarenals."
The hypotheses of Bright and other observers
(Traube, Johnson, Gull and Sutton, Cohnheim) all
have the essence of truth as deducted from clinical
evidence. The cold facts presented to us resolve the
etiology of cardiac hypertrophy and renal disease
into mechanical processes and pathologic sequences.

In a given case of irritation of the vascular
supply of the kidneys, we have, at first, hyperemia;
and such being the case, faulty elimination of waste
products, and a blood overloaded with toxins; then
intensified inflammation of the kidneys, increased
amount of blood through ingestion (as the persistent
imbibing of large quantities of beer) vasomotor
spasm, high arterial tension, chronic inflammation,

sclerosis, heart exertion, and hypertrophy follow.
Janeway claims: "Increased resistance and dimin-
ished splanchnic compensation are essential hypoth-
eses for the comprehension of arterial tension in the
light of present knowledge, whatever the source of
the irritant which provokes them." The splanchnic
circulation may cover a multitude of sins, but, in my
opinion, not that of arterial tension.

The production of nephritic types in the rabbit
and dog by injections of turpentine, phenol, lead,
mercury, or other irritants, or exposure to cold,
elucidates step by step the pathologic alterations in
the kidney structure. I have observed that the
clinical course in the human organism is analogous
to that of the dog and rabbit so closely that I am
forced to believe my hypotheses correct.

I am convinced of the great influence of the
nervous supply upon the vascular system as a whole
or in part. Bishop believes that the cause of hyper-
tonia vasorum is of nervous origin. Sclerosis or
angiosclerosis seems to me to be due to failure of
the vessels to compensate for the increased work in-
duced by etiologic agencies. Thus we should recog-
nize this most important factor in sclerotic arteries,
as well as in other pathologic conditions in any part
of the vascular system.

I shall not confine myself further to the causative
agencies of hypertension of the whole vascular sys-
tem, but to symptoms, and the effects of vascular
hypertension on the brain. The symptoms of irri-
tation are : oppressive headache, which is sometimes
pulsating and aggravated by physical and mental
effort, the sign of painful thought (Josue), vertigo,
irritabiHty, rapid pulse, epistaxis, restlessness, in-
somnia, and nervous phenomena as flashes of light,
hyperacusis, transient tingling or heaviness of arms
or legs, sometimes intense persistent neuralgias, and
convulsive movements. The depressive symptoms
are manifested by the obtunding of the senses. The
anemia of the brain may be sudden, with pallor,
weakness, vertigo, headache, flashes of light, sub-
jective noises, rapid respiration, cool skin, and, in
extreme cases, coma, convulsions, and death. If the
onset is slow, there is somnolence, dullness, apathy,
insomnia, headache, vertigo, tinnitus aurium, and
muscse volitantes. An attack of apoplexy may be
sudden, with unconsciousness, conjugate deviation,
loss of motor power, loss of sensation, and, perhaps,
coma and death. Possibly headache, depression,
choreiform movements, more or less paresthesia,
may precede the attack.

The general symptoms may begin with a feeling
of fullness in the neck and temples due to hyperten-
sion of the cerebral blood-vessels. Tremor is present
in a goodly number of cases.

The temporal and occipital headaches are gen-
erally the result of spasm of locally affected or dis-
eased vessels, and are not of absolute diagnostic
value, but should be carefully noted in their associa-
tion with other factors.

Vertigo is due to disturbed cranial circulation.
Slight or spasmodic dyspnea, following errors of
diet, is an important sign. Flashes of light, restless-
ness, insomnia, convulsive movements, and irritability are the result of the action of the hypertonic vessels on cerebrocellular repose. Depression or obtunding of the senses is due to anemia of the part,
or pressure acting on the convolutions, which, when intensified, produces unconsciousness.

Generally, if the patient has not been under the
care of an observant physician, he is not aware of
any serious condition. He goes about his usual
vocation until he is suddenly attacked, without warn-
ing; but some of the above symptoms may have pre-
ceded the attack. The sequence of the condition may
be cerebral hemorrhage and its results: aneurism,
embolism, thrombosis, encephalitis, anemia from
pressure, edema, hyperemia, artery block, and death,
delayed or sudden.

The course and termination of hypertonia of the
cerebral vessels are inevitably governed by the
gravity of the disease and the accuracy of the
treatment.

To distinguish hypertension of the cerebral ves-
sels from other conditions is, at times, quite difficult.
It differs from acute alcoholism in so far as there are
no pressure symptoms, or organic brain involvement.
Opium poisoning is readily recognized by the pin-
point pupil, slow pulse, and respiration. Uremia is
generally cleared up by the history of the case. Syn-
cope is a symptom of circulatory failure and the
duration of unconsciousness short. Cerebral embo-
lism, apoplexy (a name that is applied to anything
which produces a certain line of symptoms), throm-
bosis, aneurism, and artery block are the sequences
of, or associated with, hypertension of the cerebral
vessels, and confront us with one of the most diffi-
cult and delusive problems found in the diagnostics
of internal medicine. The greatest importance
attaches to correct diagnosis, for without it we are
void of an accurate plan of treatment.

Artery-block, a momentous condition in the study
of hypertonia, may account for the source of a
great deal of error in diagnosis. Many thousand
sudden deaths occur yearly, which are erroneously
imputed to heart, brain, or kidney disease; but, in
fact, are pure and simple cases of artery block. The
post-mortem examination reveals no lesion of the
above-named organs other than the condition of the
vessels as a result of the block.

The block may be due to an active or passive
hypertonic state of the cerebral vessels: —

Active, such as increased cardiac action; exces-
sive ingestion of food or drink; acute alcoholism;
general plethora; sunstroke; prolonged mental exer-
tion; diminished blood-supply to other parts of the
body resulting from ligation of a large artery, or
disturbance of the splanchnic circulation.

Passive, due to dilatation of the right heart, or
pressure on the veins returning the cerebral flow of
blood.

Spasms of the cerebral vessels, which may be
toxic, tonic, or clonic, produce artery block and its
possible sequences : Aneurism, apoplexy, thrombo-
sis, embolism, or capillary hemorrhage, any of
which mav cause death.

I have long held the hypothesis that epilepsy is
the sequel of an angioneurotic artery stenosis, or
disturbance of the circulation of the convolutions,
producing, in accordance iviih the intensify of the
spasm, le petit mat, or le grand mal. The foregoing
h\-pothesis is not founded upon mere supposition, but
upon clinical evidence presented by 52 cases cured
by regulation of the circulation. L. Clark, in The
Lancet, London attributes epileptoid attacks in
tachycardia and bradycardia to withheld nutrition
of the brain, without reference to sudden change in
the blood-pressure in the cerebral vessels. Jn sup-
port of this theory, he cites Langerdorfs experi-
ments in 1878. I think that recent experiments tend
to show plainly the relation of artery block to
epilepsy.

The use of the sphygmomanometer (Riva Rocci
or modification) is of immense practical utility, for
on its use great issues depend. All systolic and
diastolic determinations should be made with the
patient in the recumbent position. The pulse stabil-
ity should be carefully measured. Tactile estima-
tion of blood-pressure should be made of every
.accessible artery. The peripheral and venous cir-
culation should be especially noted. The tympanic
membrane will ofttimes show incipient signs of higli
tension.

The ophthalmoscope should ever be kept in mind,
as the eye frequently presents the first proof of
hypertension of the cerebral vessels. Jackson asserts
that the members of the medical profession at large
do not appreciate the use of the ophthalmoscope in
studying vascular lesions of the retina. With this
statement I heartily agree. Several observers (Ben-
son, Hart ridge, de Schweinitz, Zentmayer) have
reported eases of transient blindness, during which
the retinal artery was temporarily empty, soon re-
filling and becoming normal in appearance.

I have in another part of this work mentioned
the occurrence of spasms of the arteries causing
complete loss of function for a time. In this retinal
picture of arteriospasm, we have the explanation of
visual and sensory disturbances, and other impor-
tant pathologic conditions. A distinct homonymous
defect may be the first evidence of organic disease.
I will state further, by way of delineation, that the
ophthalmic artery coming from the carotid within
the skull, and orbital veins emptying into the caver-
nous sinuses, disease or injury within the cranial
cavity, is often manifest chiefly through disturb-
ances of the circulation within the orbit.

The prognosis in mild cases, uncomplicated with
kidney, heart, or arterial disease, is good. Simon's
case exemplifies that recovery is possible in the case
of red granular kidney when blood-pressure is re-
duced. Severe cases arising from the disease of the
heart, arteries, or kidneys may terminate favorably,
provided proper treatment is instituted early, other-
wise the prognosis is grave.

The treatment of hypertension of the cerebral
vessels includes, in part, the whole vascular system,
but should be governed, mainly, by the etiologic
factors.

The diet is one of the paramount factors in the
treatment of this condition. All meats should be
excluded, — at least, until the disease is greatly
mitigated. A vegetable diet should be adhered to
almost exclusively, allovi'ing moderate amounts of
carbohydrates. The quantity of liquids must be re-
stricted to distilled or mildly alkaline waters, whey,
sour or skimmed milk, or buttermilk. Whey and sour
milk are the most salutary articles of diet which we
have at our command in the treatment of blood-
pressure disease. Tea, coffee, and alcoholics should
be absolutely avoided. The amount of condiments
should be reduced to a minimum. Tobacco in any
form is particularly deleterious in all cases of high
tension.

Whatever the cause of high tension may be,
complete mental and physical rest should be en-
forced, — at least, until there is marked improvement.
Then the periods of absolute rest may vary from two
to three times a week, or until the usual routine may
be again resumed. When allowable, moderate sys-
tematic exercise should be taken before meals.
Massage is beneficial when properly applied; it stim-
ulates peripheral circulation and; promotes waste
elimination. Tepid baths in a warm room, followed
by a brisk rub with a rough towel, aid in stimulating
the peripheral circulation. The Schott method is
admirably adapted to this class of diseases.

Electricity may be used, and in' some cases has
given very good results. Electric light has a salu-
tary effect on the peripheral vessels. Vibration has
a tendency toward vasomotor dilatation, and is espe-
cially active upon the splanchnic circulation.

In my cases, unless there are reasons to suspect
immediate danger, I begin drug treatment by the
administration of calomel 2 gr. at bedtime and a
Seidlitz powder before breakfast. This I continue
for one week, and repeat at such times as I deem
necessary. Potassium iodide 3 gr. is given three
times daily and gradually increased to physiologic
effect, and then reduced to 5 gr. combined with 3
gtt. Fowler's solution, which is given three times a
day after meals. This reduces the viscosity and has
an antidotal effect on certain irritants in the blood.

The potassium element is highly irritant to kid-
ney tissue, and it is not advisable to continue its use
for any great length of time. I have had patients,
however, whose condition improved much better on
potassium iodide than on sodium iodide, which was
no doubt due to a special selection for certain' irri-
tants in the blood. lodipin (10 per cent.) one tea-
spoonful t. i. d. is excellently adapted for sclerotic
conditions. Biniodide of mercury ^0 g^- three
times daily acts well in some cases, especially if there
is a luetic history. Nitroglycerin is a powerful and
a reliable drug in hypertension. It should "be ad-
ministered on the tongue in ^so-gr. doses every
thirty minutes until tension is lowered; then three
or four times daily. Aconite in 4-drop doses three
or four times daily is valuable, but will not admit
of continued use. Sodium nitrate is beneficial. The
theobromine and caffeine group of diuretics can be
efficiently used, or supplemented by digitalis, squills,
potassium citrate, apocynum, and jalap as indicated.

The value of venesection in hypertension has
been fully discussed in my papers on ''Venesection:

Its Therapeutic Value," published January, 1907,^
and "Blood-pressure in the Practice of Medicine,"
published April, 1908.- Kottman has confirmed my
investigations concerning the effect of venesection
on the viscosity of the blood. He states that vene-
section reduces the viscosity of the blood, which re-
duction may last for twenty-one days. In some of
my cases, the attenuated viscosity lasted for forty-
five days. Venesection scientifically appHed is a most
valuable agent in blood-pressure treatment.

I advise all my patients who may be subject to
hypertonia, to carry 3 gtt. pearls of amyl nitrite to
be used in an emergency. Erythrol tetranitrite is a
drug of immense practical value. The dose is Yi to
I gr. The dosage should be small and frequently
repeated.

The establishment of collateral circulation for
the' relief of high tension should not be forgotten.

I have tried to suggest the enormous importance
of these vascular conditions that are so frequently
encountered and that may be so readily studied by
those who use the apparatus for measuring blood-
pressure.

The usual arrangement of the subject-matter
has been somewhat departed from, though I have
given a description of hypertonia with the intention
of providing one complete picture of the condition.
In my opinion, the arrangement facilitates a clearer
comprehension of the subject, since it outlines in full
and avoids repetitions and complications.

It may be the height of folly to deviate from the
beaten path of conservatism in the endeavor to inaug-
urate a new name for a condition that includes a mul-
titude of symptoms which have been heretofore desig-
nated as distinct diseases. The additions to medical
literature are great, and any syndrome calls forth a
new disease and necessarily a large medical name,
until we have nomenclature ad infinitum. When we
look into the condition fairly and squarely, we find a
symptom and not a disease. It may be argued that
it is a difficult matter so to do, but we are aware of
many so-called diseases that may be classified with
their variable phenomena under one head. In so
doing we save time and labor, curtail nomenclature,
and are enabled to concentrate our mind and energy
on the conditions of essential importance. Thus the
physician will be enabled to scientifically treat his
patients, empiricism in blood-pressure disease will
be ancient history, and therapeutic accuracy a cer-
tainty of the present.

It has been seven years since the first publica-
tion of my paper on this subject, "Hypertonia
Vasorum Cerebri." During this time many new
theories have been advanced in regard to the etiology
of diseases of the cerebral arteries. The improve-
ment of methods for the study of arterial disease
has been decidedly marked.

The mortality rate from diseased cerebral ves-
sels is steadily increasing. This increase is general
throughout the United States and is, apparently,
unaffected by climatic conditions, locality, or density
of population. The correlated conditions, heart.
and chronic Bright's disease, show a corresponding
increase in the mortality. The general death rate is.
steadily increasing. It is altogether fitting that I
again discuss the subject in the light of our present
knowledge.

The commonly accepted cause of cerebral affec-
tions cannot be held responsible for the increased
death rate without further study of their etiology.
The etiologic factors encompass ethnologic, bio-
logic, and pathologic problems. These cannot be
treated at length in this work.

The continual evolution in our social life tends
to overtax the systems of men both physically and
mentally. Commercial life is at a higher degree of
development than at any time in the world's history.
The wheels of mighty industries and progressive
governments must be kept turning to maintain this
high standard. The nucleus of all this activity is
the human organism. It labors night and day to
uphold the abstract while the concrete form is grad-
ually sapped of its being.

These conditions slowly evolve biologic, patho-
logic, and ethnologic change. The effect pro-
duced by high-strung nervous tension induced by
modern methods of social and business competition
must be regarded as a causative factor in the pro-
duction of functional and ultimately organic diseases
of the cerebral vessels.

The factors in essential hypertension are (a)
arteriosclerosis, (b) renal disease, and (c) angio-
sclerosis.

Any transitory cause producing on the vascular
system increased blood-pressure may be spoken of
as functional hypertension. The increase of tension
due to excessive mental activity or physical exertion,
as found in forcible inspiration in normal man, are
physiologic acts which force a large amount of
blood to the heart and brain. Increase in the vis-
cosity of the blood impedes the circulation of the
blood through the capillaries (Russell), and hence
high tension. Acute gastric and intestinal pain may
cause hypertension (Curschmann). Nicotine, alco-
hol, ergot, adrenalin, hydrastine hydrochlorate, and
stypticin are among the drugs which cause increase
in blood-pressure. Nicotine and pyridine are two
of the most destructive agencies to constructive
metabolism in the arteries of the brain and should
be ranked with alcohol. Toxic factors are found in
eclampsia (H. Vaquez), gout, alimentary intoxica-
tion, bacteremias, and uremia. Psychic hyperten-
sion of great intensity is seen in fright, anger, sud-
den joy, and great sorrow.

I have long held the hypothesis that epilepsy is
the sequel of an angioneurotic arteriostenosis, or
disturbance of the circulation of the convolutions,
producing, in accordance with the intensity of the
spasm, le petit mal or le grand mal. The foregoing
hypothesis is not founded upon mere supposition, but
upon clinical evidence presented by 184 cases cured
by the regulation of the circulation, L. Clark, in
The Lancet, London, attributes epileptoid attacks
in tachycardia and bradycardia to withheld nutrition
of the brain, without reference to the sudden change
in the blood-pressure in the cerebral vessels.

The medical profession has before it an oppor-
tunity of great vital moment in teaching the doctrine
of right Uving, advocating a saner and more whole-
some attitude toward life and standing as a unit
against false standards of material gain and advance-
ment obtained by the sacrifice of normal, healthful,
and peaceful attributes of calm mental poise, equable
temperament, and physical well-being (Darlington).

Such conditions begin to change the ethnologic
field. The instillation of new blood, or the inter-
mingling of races, is prerequisite to the building up
of a people suffering from physical and mental de-
generacy. The study of structure, life, growth, and
action of the human organism under various condi-
tions gives us an insight to the highest as well as the
lowest possibilities of man.

I believe, were it not for the continual instillation
of domestic and foreign peasant blood into our com-
mercial and professional life, that in one hundred
years our true Americans would become extinct, due
to heart and arterial disease.

Focal anemia, which may be mistaken for a
hemorrhage, calls for the administration of bella-
donna and its alkaloid, atropine, or stramonium, or
valerian. Feeble circulation and a tendency to slight
hypertonic contraction require the administration of
a pill containing iron and digitalis, and a mixture of
spirit of nitrous ether in each dose. When the radials
are slightly hypertonic, pulse feeble, and heart-sounds
faint, liquor strychninse and tincture of squill are
indicated. In a pseudo-hemiplegia with a pulse of
60 to 70, artery somewhat thickened, blood-pressure

160-170 (Oliver), ^ grain of erythrol tetranitrate,
5 minims of digitalis, suitable doses of potassium
iodide, three times daily. After one week stop the
erythrol and continue potassium iodide with 5 minims
liquor strychninae hydrochloridi, three times daily.

Recurring mental or motor phenomena due to
cerebral arterial disease in the aged call for potas-
sium iodide for hypertonia. Paraldehyde and low
diet are also indicated. Insomnia may be treated by
sulphonal, trional, veronal, or phenacetin.

A merchant of 64 came under my service July
19, 191 5. Family history good. He stated that he
had never been sick a day in his life until the present
illness, which began about six months ago. His
condition had been diagnosed "heart disease" and
he was confined to bed the greater part of the day.

Examination of heart and lungs showed them to
be apparently healthy. Arteries slightly hypertonic
and somewhat thickened. The tongue was coated,
but moist; the appetite good; bowels moved daily.
After eating there was flatulence and the patient
became dizzy, unstable, apprehensive, and complained
of a fullness in the head. He had no headache at
any time. He had a rapid, high-tension pulse and a
blood-pressure of 160 mm. Hg. The vision was
good. The urine contained no albumin or sugar.
Bile and indican were present. This, no doubt, was
a case of atonic dyspepsia, which caused a hyper-
tonia because of the irritants in the blood.

It is in these cases that we often get apoplexy
or paralysis, either by complete rupture or aneurism
of a cerebral vessel. There had been an attempt^ on

the part of the attending physician to get rid of the
circulatory irritant by purgatives and diuretics. In
this case, the poison was concentrated in the circula-
tion by such measures. In view of this fact the
patient was bled twenty ounces and lo ounces of
saline given. This was repeated in two weeks, and
milk of magnesia, 2 drams, one hour before meals;
I pint of water directly before meals; 15 gr. char-
coal and sodium bicarbonate, 10 gr., one hour after
meals were administered. This was continued one
month, then alternated with potassium iodide, 15 gr.

November i, 1915, the patient's blood-pressure
was 140 and his general condition very good. Feb.
I, 1916, the patient was actively engaged in business.

A milliner of ;^6 came under my service August
3, 1915. Healthy until 12, when she was injured
on right side. Ovarian and womb trouble at 26. At
34 had hemorrhage of left eye, which necessitated
its removal. Scanty menstruation, intense headache,
extremely nervous, constipation, heart rapid, and
accentuated second sound. Arteries tense, but not
sclerotic. Blood-pressure 145 mm. Hg. ; urine highly
colored, acid in reaction, sp. gr. 1025 ; large amount
of indican. Congestion of right eye and intense
pain.

Patient depleted of sixteen ounces of blood.
Calomel, podophyllin, and soda at bedtime and
Seidlitz powder before breakfast each day for one
week. One week rest, another depletion of twelve
ounces, and KI 15 grains, with 3 drops Fowler's
solution, t. i. d. p. c, and glonoin '/ioo gr- every
three hottrs, were administered. Three months later

dilatation of cervix and the administration of luteum,
5 grains, was followed by rapid recovery.

LIVER DISEASES.

Antiphlogistic measures for inducing a cuta-
neous hyperemia or inflammation, as vesicants,
cauterization, leeches, wet cups, and hot mustard
poultices, in order to compensate for the hyperemic
or inflammatory condition of the liver, are often
prescribed as a matter of routine practice. Punc-
turing of the liver with a small trocar or aspirator
is bad practice.

The most efficacious and absolutely innocuous
methods of lessening hepatic congestion at our dis-
posal are small anal bleeding and intestinal deriva-
tion. The relation which exists between the inferior
hemorrhoidal veins and the portal system permits of
our depleting the latter by applying leeches to the
anal orifice. This procedure meets' with great suc-
cess in many cases of hepatic aflfection, especially
in acute hyperemias. But it is not a form of treat-
ment which can be applied daily, since it would
bring on a condition of anemia, which must be
avoided. We must, therefore, resort to intestinal
derivation by means of saline purgatives, which
have a true dialytic action, and, by producing a
marked serous transudation into the lumen of the
intestines from the small venous radicles, cause a
depletion of the portal system, and thus diminish the
flow of blood to the liver (Semmola and Gioflfredi).

LUNGS, ACUTE CONGESTION.

An increase in, or abnormal fullness of, the
capillaries of the air-cells: active, when the result
of an accelerated circulation; passive, when caused
by an impeded outflow from the capillaries. It may
be due to irritant vapors, exposure to cold atmos-
phere, burns, cerebral lesions, and infectious fevers.

The symptoms are in harmony with the sever-
ity and the extent of the hyperemia. Dyspnea,
cough, pain in the side, ofttimes expectoration
streaked with blood, may exist.

Forchheimer maintains that the question of
phlebotomy is the same as in the treatnient of pneu-
monia; in healthy, strong, full-blooded individuals
it accomplishes much good. When phlebotomy is
not permissible wet cups may be used; these com-
bine the effects of peripheral stimulation with those
of bloodletting.

The treatment of congestion of the lungs is
usually that of the condition with which it is asso-
ciated. In the intense pulmonary engorgement,
which may possibly ocair primarily, and which is
met with in heart disease and emphysema, free
bleeding should be practised. From twenty to
thirty ounces of blood should be taken from the
arm, and if the blood does not flow freely and the
condition of the patient is desperate, aspiration of
the right auricle may be performed (Osier).

LUNGS, EDEMA.

An exudation of serum into the pulmonary-
interstitial tissue and the alveoli of the lungs,
characterized by dyspnea, cough, and a frothy,
blood-streaked expectoration. It may be due to
heart disease, infections, Bright's disease, alcoholic
excesses, pregnancy, and angioneurotic edema.

The onset is sudden, with a feeling of oppres-
sion and pain in the chest and rapid breathing,
which soon becomes dyspneic or orthopneic. Dif-
fused subcrepitant and bubbling rales are heard
over the entire chest; the face is first flushed, later
cyanosed; oppression and anxiety are extreme; and
shallow breathing, feeble pulse, and coma supervene.

The prognosis is grave and the aflfection usually
comes on as a terminal symptom in acute and
chronic diseases.

Dieulafoy insists that the urgent indication in
the treatment of this condition is bleeding. In spite
of the coldness of the patient and the threatened
collapse, which would at first appear as contraindi-
cations, there must be no delay, and, without losing
an instant, ten to fifteen ounces of blood must be
withdrawn. The marvellous results of bleeding
must have been seen to make its importance clear.
He does not exaggerate in saying that it produces
in the patient a visible change. In a case at the
Necker Hospital edema came on with such rapidity
that death would have speedily followed unless
bleeding had been performed at once. The patient,
who had not lost consciousness, told us that he felt

himself dying; and recovering in the space of a few
minutes. In his patient at the Hotel-Dieu blood-
letting had such a marvellous result that imminent
death was arrested, and the rales which filled the
chest from apex to base disappeared as by magic,
leaving only a residue at the bases. Bleeding gave
a similar result in Giraudeau's case.

Of all the methods of bloodletting bleeding is,
without doubt, the most favorable; but, in default
of bleeding, wet cupping over the chest may be made,
or, still better, two dozen leeches may be applied.
Dry cupping of the thorax and of the limbs is also
useful.

Subcutaneous injections of caffeine or ether are
often indicated. We must remember, however, that
the kidneys are inactive, and therefore use caffeine
with caution. We may start with an injection of a
grain, and be ready to repeat it several times dur-
ing the following hours. Oxygen in large doses
may also render service. The patient's strength
must be supported by milk and weak tea, with a
little alcohol.

MENINGITIS, CEREBROSPINAL.

An infectious disease, occurring sporadically
and in epidemics, caused by the Diplococcus iiitra-
cellnlaris, characterized by inflammation of the cere-
brospinal meninges and a clinical course of great
irregidarity.

The onset of cerebrospinal meningitis is gen-
erally sudden and febrile, with or without rigors,
headache, somnolence, spasms of muscles, and feeble
pulse. Usually a purpuric rash develops. There
are many forms and the symptoms vary accordingly.

The treatment of cerebrospinal meningitis is the
more important, in that we are dealing with a dis-
ease which is often curable. It is to be hoped that
we have found a therapeutic means in Flexner's
serum. It should be given as early as possible in the
course and also in doubtful cases. Whenever the
fluid obtained by lumbar puncture is purulent the
serum should be given, but repeated only if the
meningococcus is found. Injections (30 c.c.) should
be given daily as long as the diplococci are found in
the cerebrospinal fluid.

The patient should be kept as quiet as possible,
handled gently, and all cases of irritation removed.
Hot baths to the body and ice to the head. The
bowels should be opened by a calomel and saline
purge, and laxatives and enemata later if necessary.
The diet should be liquid and plentiful. The ad-
ministration of hexamethylenamine, 60 grains a
day, is worth a trial (Osier).

Headache and the delirium must be treated bv
bleeding, leeches behind the ears and on the nape
of the neck, and wet cups to the spine. Intravenous
injections of collar gol may be given. Antispas-
modic remedies, as chloral, sulphonal, and mor-
phine, may be administered.

In discussion of cerebrospinal meningitis, A.
Netter says that bloodletting, narcotics, calomel,
blisters, applications of ice, and quinine have all
been proposed in the treatment of cerebrospinal
meningitis, and each of them has its advocates and
its adversaries.

Bloodletting was naturally frequently employed
at the time when cerebrospinal meningitis first
appeared in France, because at that period the anti-
phlogistic method of treatment was at its apogee.
Faure Villars claimed to have obtained very satisfac-
tory results, and he believed that' when phlebotomy
was resorted to at the beginning of the disease it
would abort it. But in order to obtain this result
it was necessary, he held, to abstract a large quan-
tity of blood, even to the point of inducing syncope.
In addition to the phlebotomy the physicians of that
time resorted to wet cupping and the applications of
leeches to the temples, back of the neck, and along
the spine.

MENOPAUSE.

The menopause is that epoch in the life of the
human female when she ceases to menstruate and
bear children (Ashton). This usually' occurs be-
tween the fortieth and fiftieth years. It is attended
by disturbance of digestion^ flushes of heat, nervous
derangements, and the appearance of presbyopic
symptoms.

The treatment is dietetic, hygienic, and symp-
tomatic. There are two critical epochs — puberty
and menopause — in a woman's life, and with good
reason. The mental disturbances, sexual aberra-
tions, constitutional dyscrasias, the effects of child-
bearing, celibacy, etc., that are apt to appear at this
time require the tenderest care and patience on the
part of the woman's family and the watchful atten-
tion of her medical adviser.

Low diet, saline purgatives, stimulating tonics,
hydrotherapy, and sedatives, in nervous conditions,
are quite necessary. For the; severe headaches,
leeches to the temple, mastoid, and occiput are of
service. For plethora, venesection is valuable, and
more especially if the menstrual flow suddenly
stops.

A housewife of 48, referred to me by Dr. W. A.
Wall, came under my service November 18, 191 5.
Family history good. She had had the diseases of
childhood, including mumps. Had typhoid fever
twenty years ago, malaria eight years ago, and two
years ago had a nervous breakdown.

The present symptoms began two months ago,
after menstruating ten days, and she has not men-
struated since that time. The patient is weak and
nervous, at times bordering on acute mania; com-
plains of an all-gone feeling, faintness, headache,
sharp and shooting pains in temples, palpitation,
and numbness of arms and hands. Is apprehensive,
has insomnia and flatulence, with constipation. The
urine is highly colored, acid in reaction, sp. gr.
1025, bile and indican in large amounts; no albu-
min, sugar, or casts. Blood color-index high,
apparently due to intense toxemia. Blood-pres-
sure 165 mm. Hg.

The diagnosis was hypertonia vasorimi cerebri,
due to sudden cessation of menstruation. In
other words, caused by the accumulation in the
system of toxins that normally should be elimi-
nated by the menstrual flow.

The ordinary measures to remedy this condi-
tion were employed by her family physician, yet
she became gradually worse. Hence, she was
referred to the surgeon and he, thanks to a
proper diagnosis, referred her to me.

The patient was bled thirty-two ounces and
20 ounces of Loeb's solution injected intraven-
ously. The citrate of iron, arsenic, and strych-
nine was given hypodermically. Cascara, senna,
and rhubarb was given for constipation. Meat
was proscribed and a salt-free diet prescribed.
Large amounts of whey, buttermilk, and skimmed
milk were advised, together with the usual pro-
phylactic precautions.

The patient made a good recovery. Blood-
pressure, January 31, 1916, was 135 mm. Hg.
Venesection, in this case, undoubtedly relieved the
patient of the sequelae incident to a stormy
menopause.

MENOPAUSE,
A housewife of 47 came under my service
December 20, 19 15. The family history was
good. The patient had diphtheria, measles, and
whooping-cough in childhood. She menstruated
at II years of age. The menstruation was regu-
lar and painful. She married early and had six
miscarriages. The patient was operated on two
years ago by Dr. X. O. Werder for removal of
uterus and tubes.

The present symptoms began October, 1914.
with persistent pain in both knees, sometimes
sharp and lancinated, with swelling. SHe " com-
plains of persistent pain in temples and nape of
neck. The heart was somewhat enlarged. The
lungs were apparently normal; urine pale, highly
acid, and sp. gr. 1020. Bile and indican were
present. Blood-pressure 140 mm. Hg.

The salicylates were administered internally in
combination with sodium bicarbonate. The diet
was regulated. Local applications of ichthyol,
belladonna, and oil of gaultheria in lanolin were
applied to joints. Later corpus-luteum extract was
given. None of the above was effective. Believing
that venesection would do no harm, the patient was
bled sixteen ounces and 12 ounces of Adler's
solution injected intravenously. Then the above
remedies were given with excellent results. Sub-
sequently the following prescription was given
instead of the above: —

19 Acidi arseniosi gr. %o 5

Ferri sulphatis ex gr. iij ;

Corpus-luteum extract gr. v ;

Phenolthaleini gr. iij.

M. et ft. cap. no. j.

Sig. : One capsule three times daily, p. c.

The patient has much improved, and, I be-
lieve, will make a good recovery.

MIGRAINE.

Hemicrania ; megrim ; sick-headache ; bilious head-
ache; blind headache. A paroxysmal affection
characterized by severe headache, usually unilateral,
and often associated with disorders of vision.
Mobifis claims that heredity plays an important role

in go per cent, of cases. The nature of the disease
is unknown, but toxemia, vasomotor disturhance.
affection of reflex origin, and transient plugging of
the foramen of Monroe have been given as probable
causes.

The unilateral pain in the head is usually accom-
panied by nausea, often vomiting, intolerance of
light and sound, and incapability of mental exertion,
the brain for the time being temporarily prostrated
and disturbed. The affection usually develops be-
fore the age of 25, and is free from danger to life.

The exciting cause should be ascertained and
the treatment should be directed toward it. During
the attack, morphine (gr. 34 hypodermically) with
atropine (gr. Vino), and the fluidextract of cannabis
indica (gtt. 2-3 every half-hour) have been used
with great benefit. Menthol pencils used locally ease
pain. Dieulafoy advocates hydrotherapy and the
bromides as the most efficacious in treatment. Early
free purgation is said to ameliorate the attack
(Hare). The use of nitroerythrol, sodium nitrite,
and amyl nitrite has been recommended (Brunton).

It has been my practice to advise a saline purga-
tive, followed by a hot mustard foot-bath, and a
glass of hot milk, to which is added the following : —

Chloralis hydratis,

Sodii bromidi aa gr. xx ;

Ext. cannabis ind.,

Ext. hyoscyami aa gr. J4-

This will bridge over the attack with twilight
slumber.

The application of leeches to the temple, mas-
toid, and to the nape of the neck, or general blood-
letting have proved very satisfactory in my cases. •

Case 26. — G. P. F. W., male, aged 45, merchant,
had always enjoyed good health except that he "had
the trouble with head since childhood.'' He stated
that mother had same trouble; hence, we may infer
that the trouble was hereditary.

Clinical History. — A few days preceding an
attack the patient complained of a feeling of heavi-
ness over the eyes, indigestion, and mental depres-
sion. The attack was generally ushered in by chilli-
ness, nausea, intolerance of light, ringing in the ears,
vertigo, intense pain extending over left side of
head. Sound greatly irritated patient. There was
at times disturbance of the circulation. The disease
was much aggravated by domestic trouble.

Treatment. — Mentholated pencils, cannabis in-
dica, gelsemium, morphine and atropine, caffeine
citrate, monobromate of camphor, etc., were used,
alone and combined, to no effect. Fourteen ounces
of blood were withdrawn from median basilic and
condition was relieved. Six months afterward the
patient began to have attacks, and sixteen ounces
were abstracted. The patient was under observa-
tion for two years and had no recurrence of the
attack.

I am inclined to the hypothesis of Lauder Brun-
ton, that migraine is an angioneurotic condition in
which there is peripheral contraction and central
dilatation of the arteries. From my own observa-

MIGRAINE.

173

tions, I would infer that the condition is due to
toxemia.

Diagram of the carotid, temporal, and occipital arteries in the

normal state. (After Brunton.)

Diagram of arteries during migraine, showing dilatation of
the carotid and spasmodic contractions of the temporal arteries.
(After Brunton.)

Diagram of arteries during migraine, showing dilatation of
the carotid and temporal arteries, and spasmodic contraction of
an ascending frontal branch of the anterior temporal artery.
(After Brunton.)

MYALGIA.

A painful affection of the voluntary muscles and
of the fascia and periosteum to which they are
attached. It is probable that in many cases the
fibrous tissue is especially affected — a fibrositis. It
is by no means certain that the muscular tissues are
the seat of the disease. Many writers claim in
some cases it is a neuralgia of the sensory nerves
of the muscles. The affection has received various
names, according to its seat, as torticollis, lumbago,
pleurodynia, etc.

The attacks follow cold and exposure, and
trauma is often a factor. It is usually acute, but
may become subacute or even chronic, the last
being more common in later life.

Rest of the affected muscles is of the first im-
portance, and it is well to protect them from cold
by a covering of flannel. Strapping of the side in
pleurodynia, and if the pain is severe a hypodermic
of morphine, gives immediate relief. For lumbago,
ironing, dry-cupping, or acupuncture, in acute cases,
is efficient. The high-frequency current, blisters,
actual cautery, injections of sterile water (Potain
and Dieulafoy), and epidural injections have their
indications. Superheated air and sprays of ethyl
chloride have achieved many successes. The bowels
should be opened freely by calomel and saline purges.
The salicyl compounds, colchicum, and potassium
iodide have been highly recommended. At the out-
set a Turkish bath, w^ith quinine and Dover's powder,
at bedtime may cut short the attack. Bleeding,

leeches, and cupping are useful. Beaumetz obtains
mild revulsion by applications of iodine or by punc-
tate cauterization.

NEPHRITIS, ACUTE.

Acute diffuse nephritis is a condition of the kid-
neys due to the action of cold or of toxic agents.

In all instances changes exist in the epithelial,
vascular, and intertubular tissues, which vary in
intensity in different forms; hence writers have
described a tubular, a glomerular, and an acute
interstitial nephritis. Delafield recognizes acute
exudative and acute productive forms, the latter
characterized by proliferation of the connective-
tissue stroma and of the cells of the Malpighian
tufts (Osier).

The causes of acute nephritis are numerous and
varied. Toxi-infectious diseases, drugs, autointoxi-
cation, pregnancy, and cold are the principal causes.

When the nephritis is severe, the onset is violent.
The patient may have rigors, fever, and lumbar
pains; the urine is scanty, highly colored, and con-
tains blood, albumin, and casts. Edema appears
early. The anasarca commences, as a rule, in the
face, which is pale and swollen, and in a few days
invades the lower limbs and the various regions rich
in loose cellular tissue, such as the eyelids, the
scrotum, the prepuce, and the labia majora. The
edema is soft, white, and pits readily. Ofttimes
edema and dyspnea, wath or without vomiting, are
the only signs of nephritis, and even then the onset
of the disease is not clear. The specific gravity of
the urine is high — 1.025, or even more. The amount
passed may be reduced to only five or six ounces.
The albumin is abundant and urea diminished.

The symptom-complex of uremia may appear in
a few days or a few weeks. Ocular changes should
be looked for at any time during the course of the
disease.

The treatment of acute nephritis consists in rest
in bed, milk diet, plenty of alkaline mineral water,
thin flannel underwear, free evacuation of the
bowels, cupping of the loins, and general blood-
letting in the case of uremic symptoms. Hydro-
therapy in the form of hot bath, wet pack, or the
hot-air bath is often efficient in the treatment of the
dropsy.

Prof. A. Robin recommends, in the treatment of
acute nephritis or edema of the kidney, that blood-
letting be resorted to in the acute stage. Milk and
infusions, he states, only tend to stimulate an organ
which cannot zvork. Instead of stimulating the
function of a diseased gland, the smallest possible
amount of work should be given to it. The patient
should be permitted to drink only as much water as
will relieve his thirst.

Baccelli treats acute nephritis by withdrawing
200 c.c. of blood from a vein in the foot. In a typical
case described in the Policlinic 0, xiv, 18, 1907, the
edema of the lids, fever, blood, albumin and casts in
the urine indicated severe nephritis a few days after
the stormy onset. The trouble in the kidneys causes
lower arterial pressure and increased venous stasis
and thrombosis in the finer ramifications of the veins
with the glomeruH compressed and paralyzed. Vene-
section reheves these conditions as if by magic, and
nature then has a chance to heal. In the severer
cases he follows the venesection with powders con-
taining sodium sulphate, sodium nitrate, and scam-
mony, every five minutes. This stimulates the
emunctories very powerfully, but the venesection
alone generally aborts the nephritis and prevents
its transformation into a chronic phase. In the
severe acute case described, the venesection was
repeated the second day and reco\'er3- was soon
complete.

Dieulafoy advises bloodletting when symptoms
of uremia, epileptiform convulsions, delirium or
coma develop. In this case ten to twenty ounces
of blood must be withdrawn, and the operation re-
peated, if necessary. This measure is most valuable,
and must never be put off. Many cases of acute
nephritis and grave uremia owe their recovery to
free bleeding. Dieulafoy is so convinced of its
efficacy in acute nephritis, that he would advise it in
cases of moderate severity. Bloodletting has not
only an immediate action on the acute symptoms at
the moment, but he believes that it diminishes the
risk of subsequent mischief.

Injections of scrum and all foods containing
salt must be avoided. The milk diet must be strictlv
adhered to for several weeks after the supposed cure.

OBESITY.

A disorder of metabolism characterized by ex-
cessive deposit of fat in the body (Osier).

Obesity is a disease of all ages, more frequent in
adults, and women are more often affected than
men. Primarily it is due to inadequate oxidation of
foods, associated either with excessive absorption of
the materials which produce fat, or with incomplete
combustion. Fat metabolism is directly or in-
directly under the control of the internal secretions.
This fact is made plain at puberty, menopause, after
marriage, after pregnancy, in eunuchs, and in many
other processes where the internal secretions are
concerned. Want of exercise, increase in intake of
liquids, absorption of large quantities of proteid-
sparing foods favor the deposit of fat in the tissues.

The symptoms are manifest mostly in the great
bulk, difficulty in walking, shortness of breath, em-
barrassed cardiac action, and ofttimes arterial
disease.

The treatment consists in regulating the diet,
systematized physical exercise, massage, and hydro-
therapy. The administration of thyroid gland,
iodides in small doses, and alkaline purgative min-
eral waters has been highly recommended.

In obesity associated with erythema, a condi-
tion of plethora, I have used venesection with
excellent results. In cases of obesity, unaccom-
panied by untoward lesions, patients express them-
selves as "feeling fit as a fiddle" for two and three
months after a bleeding; 300 to 500 c.c. of blood is

■II in these cases. It is not an unusual
^^^r patients to tell you that they have had
^^^ ion done oiice or twice yearly for twenty
t ^- years.

[^^-.■lanufacturer of 52 came under my service
^Tjicr I, 1915. Family history was good.
^^^ always been healthy and very active in
5^ " : s affairs. He has been taking on weight
i^t few years. A well-regulated diet and
■atized exercise had failed to reduce the

He is a heavy smoker.
E patient complained of shortness of breath,
wd cardiac action, and difficulty in walk-
(cently he has had intense headache, pain,
numbness in fingers and legs. The
td lungs are apparently normal. Secre-
jbw freely and normally. He is not con-
sleeps well, and has a good appetite,
tte amber, sp. gr. 1020, acid, and shows indi-
Blood-pressure 140 mm. Hg.
^The patient came to me to have me do a
resection. He was bled twenty ounces, which
immediate relief from the headache. He
ffoved much in two weeks. December 2d the
feient was bled twelve ounces and the following
ninistered : —

'^ Extract Phytolacca fruit gr. ij ;

Leptandrin gr. ^ ;

Strychnine sulphate gr. %oo ;

Thyroid gland, desiccated gr. v.

M. et ft. cap. no. j.

Sig. : One three times daily, after meals.

The diet and exercise continued as before.
January 30, 19 16, the patient had lost 25 pounds
in weight. He was improved* in every way, and
bids fair to make a good recovery.

PLEURISY, ACUTE.

•

Inflammation of the pleura. It may be divided,
according to cause, into primary or secondary;
according to extent, into unilateral, bilateral, or
local; according to the exudation, into serofibrinous,
fibrinous, or purulent. Exposure to cold and wet,
traumatism, pneumonia, and pericarditis, cancer,
certain bacteria, and infective and toxemic condi-
tion, such as acute rheumatism, pyemia, typhoid
fever, gout, nephritis, and tuberculosis are etiologic
factors.

The disease may set in abruptly with a chill, fol-
lowed by fever and a severe pain in the side. The
pain, usually referred to the nipple or axillary
region, is lancinating, sharp, and severe, and is
aggravated by cough. Early in the disease a fric-
tion rub can be detected. The temperature rises
(101° to 102° F.); the pulse becomes full, the
respirations increased, and dyspnea develops as
the exudate increases. When the eflfusion has de-
veloped, there will be immobility of the aflfected side,
with bulging of the intercostal spaces and displace-
ment of the apex-beat to the opposite side. Dullness,
which is movable, may be elicited by percussion.
The line of dullness is curved, being higher pos-
teriorly. Above the eflfusion, a hyperresonant note

(Skoda's resonance) may be obtained. Bronchial
breathing may be heard early in the affection, but
later the breath-sounds are sometimes weak and
inaudible. Vocal resonance is usually diminished or
absent, but sometimes bronchophony may be heard.
There is also an increase in the anteroposterior
diameter of the affected side. During the stage of
absorption, the normal physical signs gradually
return.

The treatment consists in rest in bed, light diet,
and the application of flamiel jacket. Pain may be
relieved by the hypodermic injection of morphine in
the region affected, and by strapping the chest with
adhesive. Calomel, jalap, and saline purges may be
given with the view of diminishing the effusion.
Early and, if necessary, repeated aspiration of the
fluid is the most satisfactory method of treatment
(Osier).

The use of the Paquelin cautery, wet cupping;, or
leeches at the beginning of the disease has a salutary
effect. If the effusion remans unabsorbed at the end
of three weeks or causes dyspnea, restricted diet and
potassium iodide, in addition to the above, may be
administered.

Whitney maintains that locally a certain amount
of revulsion is desirable, both because of the relief it
affords and. as some think, in order to diminish
pleural congestion. Some authorities still warmly
defend the local abstraction of blood by wet aips or
leeches (Fraentzel, Bouillaud, Peter); and some go
so far as to recommend venesection. There is no
question, however, that a certain amount of revul-
sion tends to diminish pain and to add greatly to the
patient's comfort.

PNEUMONIA, ACUTE LOBAR.

Pneumonia is called lobar when it invades a lobe,
or part of a lobe, without healthy tissue intervening,
in contradistinction to lobular pneumonia, which
causes isolated or confluent nodules. It is an acute
specific disease, due to the pneumococcus of Fraenkel
and, less frequently, to other micro-organisms, char-
acterized by a fibrinous exudation into the pulmonary
air-cells and bronchioles, and following a course that
is more or less typical, the chief symptoms being
those of toxemia and of interference with the respira-
tory and circulatory functions. Pneumonia usually
occurs in early adult life, during the winter months,
and affects man most often. It may result from
surgical operations, ether narcosis, previous attacks,
infectious fevers, nephritis, alcoholism, heart dis-
ease, gout, cachexias, etc.

The symptoms, diagnosis and prognosis are quite
familiar to all students of medicine. The typical
caSes, when seen early, are not so much to be dreaded.
The atypical cases tax the skill of the most com-
petent. When the correct diagnosis has been made,
the treatment should be heroic and persistent.

The treatment consists in rest in bed, milk diet,
and the administration of calomel and podophyllin,
followed by a saline in the early stage. The nervous
symptoms may be controlled by hydrotherapy. The
heart should be sustained by strychnine and brandy,
atropine, caffeine, nitroglycerin, digitalis, and by
hypodennic injections of camphor oil. When cya-
nosis and dyspnea are extreme, oxygen may be ad-
ministered. In young, vigorous, and plethoric
adults, with hyperpyrexia and a high-tension pulse,
bleeding may be beneficial in the first forty-eight
hours.

The effect of venesection is best illustrated by
one of a series of cases reported by me in 1907 : —

Case 96. — A. S., male, Polish, aged 27, miner;
had had diseases of childhood and varioloid. He had
used alcoholic beverages freely. He came under my
service January 5, 1904.

Clinical History. — Patient had been at a Polish
wedding and had chill on the evening of January 3d.
The patient on the morning of January 5th had a
temperature of 104.5° F"-! pulse was rapid, strong,
and full; sharp pain near right nipple; respirations
45 per minute; a grunting, interrupted speech; rusty
sputum; mahogany blush; herpes; diminished chlo-
rides; pronounced delirium. The two lower right
lobes were solidified. January 6th, in the afternoon,
as the attendant left tlie room, the patient got out of
bed and out of doors and wandered aimlessly around
in the snow, where he was found one-half hour
later. , I was called immediately and found patient
with a temperature of 105.2° F. ; pulse 120, marked
dyspnea, and superficial blood-vessels were standing
out like whip-cords. Tincture of aconite, 4 drops:
tincture of digitalis, 5 drops: and strychnine sul-
phate, Yso grain, were administered, and one-half
hour later sixteen ounces of blood were withdrawn
from the median basilic vein. Six hours after the
venesection the temperature was 103° F. ; pulse 94,
strong and full; dyspnea and pain not marked;
delirium absent. Strychnine, whisky, and quinine,
with an expectorant, were administered. The course
was very favorable. The crisis occurred on the
ninth day of the disease and convalescence was rapid.
Cases 97-100 were of lobar pneumonia; bled in
the first stage of the disease, all within twenty-four
hours after the chill. The heart was always relieved
and dyspnea mild. Venesection always exerted a
favorable influence on general condition of the
patient.

The reproach of Van Helmot, that "a bloody
Moloch presides in the chairs of medicine," cannot
be brought against this generation of physicians.
Before Louis's iconoclastic paper on bleeding in
pneumonia it would have been regarded as almost
criminal to treat a case without venesection. We
employ it nowadays much more than we did a few
years ago, but more often late in the disease than
early. To bleed at the very onset in robust, healthy
individuals, in whom the disease sets in with great
intensity and high fever, is, I believe, a good prac-
tice. I have seen instances in which it is very bene-
ficial in relieving the pain and the dyspnea, reducing
the temperature, and allaying the cerebral symp-
toms (Osier).

Forchheimer believes that venesection has come
into disuse, but in the asthenic form of this disease
there is, in his opinion, one indication — -an embar-
rassment of the right heart, characterized by dila-
tation, great cyanosis, and bad pulse. In these cases
from 150 to 350 c.c. may be drawn. The effect is
rapid, but unfortunately transitory, and this pro-
cedure should be used only in great emergencies,
carefully counting the cost to the patient.

Babcock writes that, during the many centuries
in which pneumonia was conceived to be a local in-
flammatory process, bloodletting, both local and
general, was so universally relied on that he was a
bold man indeed who dared to oppose the method.
When at length venesection was abandoned the pen-
dulum swung to the opposite extreme, and he in turn
became courageous who ventured to resort to this
ancient practice. That the measure did not, how-
ever, deserve to sink into utter oblivion is attested by
the fact that men of recognized judgment and ex-
perience are again advocating the abstraction of
blood under definite indications, as will be seen later
on. Not so, however, with the administration of
tartar emetic and veratrum viride, which, as for-
merly employed, have deservedly fallen into disfavor.
For amelioration of the pain, Babcock recommends
that a sinapism be applied to the side or, as was done
in von Ziemssen's wards at Munich, one may ab-
stract a few ounces of blood by means of wet cups or
by leeches. If venesection is ever justifiable in the
initial stage, it must be when there are signs of
extensive and grave edema. Aufrecht recognizes
this as the only indication for venesection at this
time, and says he has seen it do good under such
circumstances.

In a typical case of lobar pneumonia Thompson
opened the median basilic vein and allowed the pa-
tient to bleed until he complained of faintness. The
effect was immediately noticeable on the pulse, and
general condition of the patient. On the third day
after the initial chill the temperature dropped to
1 00° F., on the fourth day the patient got out of
bed, and on the eighth day he drove six miles to
the doctor's office and was discharged.

In some late cases venesection is also life-saving.
I have used it in the typhoid type accompanied with
extreme toxemia and venous stasis. Convalescence
should be carefully guarded, and tonics, stimulants,
and light foods of high caloric value will be found
useful in this period of the disease.

PNEUMOTHORAX.

Venesection is recommended in proper cases
when there is much venous congestion; I have never
used it, but it seems rational in this stage, where
life hangs on a thread and loss of blood can be easily
compensated for as soon as the patient is relieved
of his critical condition (Forchheimer).

POISON, ILLUMINATING GAS.

Poisoning by illuminating gas may be accidental
or intentional. In severe or fatal cases the symp-
toms are: nausea or vomiting, vertigo, unconscious-
ness, deep coma, and muscular prostration; livid
features, stertorous breathing, and frothing at the

POISON, ILLUMINATING GAS. 187

mouth. Pulse at first accelerated, later intermittent.
Subnormal temperature.

The treatment consists in fresh air, artificial
respiration, inhalations of oxygen, venesection, with
subsequent subcutaneous or intravenous saline in-
fusion (Striimpell).

The management of patients suffering from
intoxication by illuminating gas has been unsatis-
factory, because of the affinity of CO for hemo-
globin, and lack of knowledge of the pathologic
and metabolic processes which the intoxication pro-
duces, observes Glenn I. Jones, in a very thorough
article on the subject, embracing the chemistry,
symptomatology, diagnosis, prognosis, and treat-
ment. Inhalation of oxygen has always been
unjustly esteemed in the treatment. The use of
oxygen by inhalation is of doubtful efficacy, since it
seems improbable that the excess of oxygen over
that in normal atmosphere can become physiologic-
ally combined with the hemoglobin in exchange for
carbon products.

The patient should be taken from the room and
into fresh air. The tongue should be retracted
from the mouth and so retained by means of a
hemostat, improvised gag, or tongue retractor. If
necessary, artificial respiration should be begun at
once. The patient should be removed without de-
lay to an institution or physician's office, where
immediately phlebotomy should he performed.

A pint to a pint and' a half of blood should be
removed, and simultaneously a quart of Nio saline
solution transfused in the median basilic or cephalic
vein of the opposite forearm. Venesection can be
repeated two hours after the first bloodletting, if the
patient be not doing well. Saline solution should
be given subcutaneously every two hours in quanti-
ties of one pint, or by the rectum continuously.
Saline solution diminishes toxemia, lessens the tend-
ency to edema of the lungs, increases the affinity of
the red cells for oxygen, and stimulates the circula-
tory system. At the outset the patient should be
given, by hypodermiq injection: ether, 30 minims;
atropine, ^00 grain, and suprarenalin, 30 minims.
I would suggest the use of Loeb'sj or Adler's
solution instead of the so-called normal salt solution,
as they conform more nearly to the necessary con-
stituents of normal blood.

Should acute dilatation of the right ventricle and
marked signs of stasis in the systemic veins be pres-
ent and the state of the pulse portend danger to life
from paralytic overdistention of the cardiac cham-
bers, recourse should be had to prompt bloodletting.
A vein in the arm may be opened without needless
delay, and twenty to thirty ounces may be allowed
to flow.

Should the stagnation be such that relief is not
afforded, then one may without fear resort to as-
piration of the right auricle. An aspirating needle
may be thrust into this chamber close to the right
border of the sternum, care being exercised to avoid
wounding the internal mammary artery which

passes from one-fourth to one-half inch from the
edg;e of the bone. This procedure is not dang-erous
since the myocardium endures puncture with a fine
needle without subsequent bleeding from the wound.
Since, however, this operation is advisable only in
cases of grave danger to life, the risks of the punc-
ture are not to be weighed against the disastrous
consequences of delay or a too timid treatment
(Babcock).

RHEUMATISM, ARTICULAR.

Rheumatism is a constitutional disease the cause
of which has not yet been determined, and is char-
acterized by high fever, inflammation of the large
joints, acid sweats, and severe blood dyscrasia. It
may be acute or chronic, and is greatly influenced by
heredity, damp climate with sudden changes in the
temperature, exposure to cold and wet, fatigue and
overwork.

The onset of the affection is usually sudden,
although anorexia, sore throat, vague pains, etc..
may precede. The inflammation first attacks the
large joints, and may subside quickly in one joint to
attack another. It is attended by high fever (103°
to 104^ F.), rapid pvilse, and profuse acid sweats.
The urine is scanty, highly colored, and contains an
excess of uric acid and urates. Hyperpyrexia,
organic heart disease, pneumonia, pleurisy, cerebral
symptoms, various cutaneous eruptions, and rheu-
matic nodules may occur as complications. The
prognosis is guardedly favorable.

The treatment consists in rest of the parts, pro-
tection of the body and joints with flannel or soft
wool. Restricted diet is essential. The bowels
should be moved freely by calomel, soda, and
podophyllin, followed by saline purgative. Salicylate
of soda, 60 to 120 grains in twenty- four hours, is of
considerable service. Antipyrin may be adminis-
tered with the salicylate to good advantage. The use
of methyl salicylate in form of an ointment is often
advocated. The patient should drink milk, lemon-
ade, and Vichy water. Subcutaneous injections of
small doses of morphine or pure water in the neigh-
borhood of the diseased joint, twice daily, may
give relief. Hyperpyrexia with threatened cerebral
troubles may be treated by hydrotherapy.

The treatment of chronic articular rheumatism
may thus be summed up: Internally, preparations
of iodine and arsenic; externally, painting with
tincture of iodine over the diseased joints. Hydro -
thermal cures, sulphur, or arsenical baths may be
prescribed.

As a rule, in the treatment of gonorrheal and
puerperal arthritis, we employ the drugs used in
true rheumatism. These affections must be treated
from the onset by energetic local measures, such as
bleeding, leeches, cupping, blisters, and the cautery.
Trousseau's cataplasm has been used with some
success in these cases. Superheated air (125° C.)
is a valuable agent in the treatment of these forms
of arthritis.

During the last century and the first half of
this, rheumatism was regarded as a ''phlegmasia," as

an inflammation dependent, like other inflammatory
affections, on exposure to cold, and differing from
them only in the nature of the textures involved.
The treatment of inflammation was at that time
essentially antiphlogistic, and consisted in the adop-
tion of various means of depletion. The chief of
these was bleeding.

Sydenham wrote, in 1666, that "the cure of
rheumatism is to be sought by bloodletting." His
rule was to take ten ounces of blood as soon as he
saw the patient, to repeat the operation the following
day, to do it again in a day or two, and, for the
fourth and generally the last time, three or four
days later. But he was not satisfied with the results
of this practice; for in 1679, ten years before his
death, he says, in a letter to Dr. Brady: "I, like
yourself, have lamented that rheumatism cannot be
cured without great and repeated losses of blood.
This weakens the patient at the time; and if he have
been previously weak, makes him more liable to other
diseases for some years. Reflecting upon this 1
judged it is likely that diet, simple, cool, and nutri-
tious, might do the work of repeated bleedings, and
save the discomforts arising therefrom. Hence I
give my patients whey instead of bleeding them."
He gives the particulars of a case treated dietetic-
ally, in which the patient "recovered his full strength,
escaping all such discomforts as, ten years before, a
similar attack, which I treated by bleeding, had
entailed upon him."

Cullen, though he regarded bloodletting as "the
chief remedy of acute rheumatism," and taught that
"large and repeated bleedings during the first few
days of the disease seem to be necessary/' was care-
ful to add that "to this some bounds are to be set;
for very profuse bleedings occasion a slow recovery
and, if not absolutely effectual, are ready to produce
a chronic rheumatism."

Though the indiscriminate use of the lancet was
condemned by many able observers, such as Haber-
den. Fowler, Latham, and others, bleeding continued,
till well into this century, to be the sheet anchor in
the treatment of this disease.

In undertaking the treatment of acute or sub-
acute rheumatism, whether we view the inflamma-
tory state of the aponeurotic membranes as primary
and idiopathic, or secondary and symptomatic, it is
necessary in the first instance to adopt the anti-
phlogistic method of treatment, and to carry it on
with some degree of energy, and to a considerable
extent.

"The different branches of the antiphlogistic
regimen requisite in the treatment of rheumatism
are: bloodletting, general and local; the occasional
employment of cathartics, the occasional employment
of emetics, especially tartar emetic, the use of
diaphoretics, and the use of revellants.

''First. — General bloodletting, in order to be
beneficial, ought to be performed early in the dis-
ease, and carried to a considerable extent.
It should be carried at first to twenty or thirty
ounces if possible, and within twenty-four hours to
as much more.

''Second. — The influence of general bloodletting

must be aided by the conjoined operation of various
adjuvants. Full vomiting produced by ipecacuanha
and antimony is, in the majority of cases, requisite;
and complete evacuation of the bowels by eccoprot-
ics and even cathartics is quite indispensable.

"Third. — It is of the utmost importance, in
attempting the thorough removal of rheumatic
pains, to conjoin with bloodletting, or, after its use,
the administration of full doses of tartrate of
antimony.

"Fourth. — It is of great moment, if the bowels
have been previously well opened, to exhibit, after
the first bloodletting, an opiate of 40 or 50 minims
of the solution of the muriate of morphine; or if
the bowels have not been freely moved, to effect this
indication, and take a second bloodletting. After
this to administer the opiate, which may either be
given alone or conjoined with antimony." So wrote
Dr. Craigie in 1S40. In that year appeared also
Bouillaud's "Traite Clinique du Rhumatisme Ar-
ticulaire," in which the treatment by bleeding coup
snr coup was advocated with characteristic ability
and energy.

To Bouillaud, indeed, belongs the credit of having
systematized this mode of treatment. The full
extent of his credit in this respect was not generally
recognized. Previous to his time the practice of
phlebotomy was wanting in method. To take so
many ounces of blood, and to repeat the operation in
one, two, or more days, was all the recommendation.
Bouillaud insisted that there should not be too long
an inter\-al between the bleedings — that the second
should be had recourse to before the effects of the
first had fully passed off, and the third before the
benefit of the second was lost. That is what he
meant by his recommendation to bleed coup sur coup.
It was the frequent repetition of the operation, rather
than the quantity of the blood taken, which formed
the characteristic feature of his mode of treatment.
If the pathologic views which then prevailed were
correct, and if the bleeding were the important
therapeutic agent which it was believed to be, there
can be no doubt that Bouillaud's idea was thera-
peutically sound. No single dose of any remedy
could stop a disease like acute rheumatism.

It would have to be repeated from time to time;
and to get its full beneficial effect the second dose
would have to be given before the first had quite
ceased to act. Bouillaud's merit consists in having
applied this sound therapeutic rule to the practice of
phlebotomy.

About the middle of the century the practice of
phlebotomy and the pathologic views on which it
was founded were vigorously assailed. Facts tended
to show that patients recovered more quickly and
satisfactorily when they were not bled than when
they were. This was noted in acute rheumatism as
in other acute diseases. The rapid accumulation of
such facts produced a marked reaction against the
old mode of treatment, and within twenty years of
the time that Bouillaud's book appeared, the practice
of bleeding in acute rheumatism was all but aban-
doned. Other remedies besides bleeding were used
to allay the inflammation (Maclagan).

In pericarditis especially, local treatment is some-
times of much service. In the early stage of a
severe attack, when pain is a prominent symptom,
when the heart's action is disturbed and tumultuous,
and when there is evidence of serious interference
with the circulation, much good may be got by the
abstraction of a few ounces of blood. This may be
done by opening a vein, or by the application of
leeches or cupping-glasses over the region of the
heart. If the symptoms are urgent, venesection
affords the most speedy relief; but to do good it
must be had recourse to at an early stage. The
cases are few, however, in which the desired effect
may not be got from leeches.

In entertaining the question of bleeding, local or
general, it must be borne in mind that the acute
stage, when got over, is followed by one in which
there is apt to be considerable debility. If bleeding
be had recourse to unnecessarily or too freely, this
stage will be rendered more marked and prolonged.
The mere existence of acute pericarditis is not a
reason for taking blood; such a measure is to be
regarded only as the best means of allaying the
urgent symptoms of the first stage of the acute
attack (Maclagan).

Notwithstanding the arguments against venesec-
tion in acute articular rheumatism, I have noted its
salutary effects in so many cases that I cannot feel
other than that it is indicated in the majority of cases.
The great trouble has been that bleedings have been
used indiscriminately without regard for indica-
tions, and these alone depended upon to cure the

patient. It should always be borne in mind that
venesection is only an adjunct in the treatment of
disease, and not a panacea. A venesection of 300 to
500 c.c, repeated if indicated, at the onset of acute
articular rheumatism, reduces the amount of toxins
in the blood, which incidentally reduces temperature,
quiets the pulse, relieves congestion of the kidneys,
and facilitates the action of drugs.

SUNSTROKE; HEATSTROKE.

A depression of the vital powers the result of
exposure to excessive heat, to the direct rays of
the sun, to artificial heat in confined quarters, or
to diflfused atmospheric heat without proper ven-
tilation. Bodily fatigue, the use of tobacco, over-
crowding, intemperance, and humidity of the at-
mosphere are predisposing causes. The condition
manifests itself as acute meningitis (rare), heat-
exhaustion (common), and true sunstroke.

Heat-exhaustion is characterized by a rapid
feeling of weakness and prostration, cool surface,
pale face, weak voice, rapid and feeble pulse, in-
creased respiration, disordered vision and hearing,
and partial or complete unconsciousness.

Sunstroke is manifested by insensibility, with or
without delirium, convulsions, or paralysis, flushed
and hot surface, injected conjunctivas, rapid and
shallow or labored and stertorous breathing, quick
pulse, axillary temperature from 105° to 110° F.,
and suppression of all glandular action.

The prognosis of heat-exhaustion is favorable if

it is promptly and properly treated. Sunstroke, in
the majority of cases, terminates unfavorably, usu-
ally in from one-half hour to several hours.

Treatment in heat-exhaustion requires the re-
cumbent posture, the external application of heat,
and the use of stimulants. Sunstroke requires re-
duction of temperature by cold baths, cold pack, etc.,
and the hypodermic use of quinine or antipyrin.
Convulsions and restlessness may call for morphine.
Depression will necessitate the administration of
strychnine and other stimulants.

In the cases in which the symptoms are those of
intense asphyxia, and in which death may take place
in a few minutes, free bleeding- should be practised,
a procedure which saved Weir Mitchell when a
young man (Osier).

Occasionally, when the right heart is nmch
dilated, venesection may be valuable, but it should
be used only for this indication ; indiscriminately
used it does harm. Local bloodletting, by leeches or
aipping, is more generally applicable; leeches at the
temple or behind the ear, cups along the spinal
column (Forchheimer).

Flint states that on August 9, 1S62, 8 cases of
coma from sunstroke were admitted into Bellevue
Hospital, of which 7 died. In the last case ad-
mitted, in which the coma was as profound and the
symptoms generally as unfavorable as the others,
the pupils were contracted, breathing stertorous,
skin hot and dry, pulse full and frequent ; bleeding
was resorted to mainly because of the fatal termina-
tion of all others, sixteen ounces being taken from

the arm and the temples being freely leeched, and
on the following day the patient was comfortable,
complaining only of debility. In the summer of
1864, Flint had a similar aggravated case in which
the abstraction of eighteen ounces of blood and the
cold douche constituted the treatment. Conscious-
ness returned in an hour and a half after the vene-
section, and the patient was discharged the following
day quite well. Nevertheless, the practice has few
advocates in our own country, and is generally
condemned by British and East Indian practitioners,
who with equal unanimity depend upon the cold
douche. '*While venesection may do good in some
cases," says Wood, ''in by far the majority of cases
it does absolute harm."

One of the exceptional cases in which it did
undeniable good was that of Dr. S. Weir Mitchell,
who having overheated himself by walking in the
sun and making considerable muscular exertion, all
of a hot August day, became unconscious after
dining and remained so for ten days, being treated
by cold applications, etc., finally recovering con-
sciousness after a prolonged hot mustard foot-bath,
and when able to speak insisted so positively upon
being bled that twenty-five to thirty ounces of blood
were abstracted, with immediate relief and speedy
recovery, when meningitis and permanent mental
derangement might otherwise have been the unfor-
tunate and most regrettable result (Gihon).

SYPHILIS.

A chronic, constitutional, infectious disorder,
transmitted by contact and inheritance, and charac-
terized by an incubation period of from ten to thirty
days, and certain different stages. A complete
delineation of the disease and its various manifesta-
tions will be found in most textbooks on the subject.

The treatment of syphilis in all cases should be
directed toward the general health, and tonics, stim-
ulants, nutritious food, and fresh air should freely
be allowed. The classic and specific remedy, mer-
cury, should never be lost sight of in our enthusiasm
for the newer arsenic preparations. Erlich's 606,
hectine, and the cacodylate of soda are very efficient
when followed by mercurials; otherwise many re-
lapses can be anticipated.

There are many cases that do not respond readily
to treatment because of high blood-pressure, or
high specific gravity and viscosity of the blood. A
case, previously reported by me, was as follows : —

Case 21. — E. B., aged 20, single, miner, came
under my service October 21, 1903. Patient had
usual diseases of childhood. His previous health had
been good. He was a man of exceptional physical
strength.

Clinical History. — Patient stated that the chancre
made its appearance about thirty-five days after
coitus. Rheumatoid pains, headache, neuralgia,
induration and enlargement of lymphatic glands
rapidly followed; cutaneous manifestations were in
evidence early.

the protoiodide of mercury was administered
three times daily; beginning with Ys grain, it was
gradually increased until patient was getting 2 grains
three times daily at the end of two months with-
out noticeable improvement. Mercury bichloride
V5 grain was injected into gluteal muscles once
w^eekly for six weeks without any perceptible im-
pression. February 10, 1904, the median basilic
vein was opened and eighteen ounces of blood with-
drawn. Patient was given enema of 2 quarts of
albumin-water. He did not show any signs of weak-
ness. There was an increase in pulse rate from y2
to 84. On February nth, I began the administra-
tion of the protoiodide of mercury in %-grain doses
three times daily, and increased Vs grain every
second day. At the end of the sixth week after
venesection the patient had gained in weight, mucous
patches and eruptions had disappeared, and the
patient's general condition was much improved.
Treatment was continued for one year. No mani-
festation of syphilis has since appeared.

TRANSFUSION.

The transfer of blood from one person to an-
other; the introduction of blood from the vessels of
another person; also the introduction into the blood-
vessels of any substance, as saline solution. In this
discussion I refer to the direct transfer of blood from
one person to another without exposing it to air.
It is indicated after hemorrhages, in pernicious
anemia, purpura, and various blood dyscrasias.

TRANSFUSION.

A. A. Berg, of New York, says that with the
modern technique transfusion of blood from one
person to another is entirely free from danger. The
blood flows directly from one" blood-vessel to the
other without encountering any foreign body, it
being always in contact with the healthy living in-
tima. The dangers under the old method were
clotting of blood in intermediate tubes, and the car-
riage of the emboli into the vessels of the recipient.
Another danger has been the hemolysis of the blood
from contact with the blood of another. A test can
be easily made to ascertain whether the two samples
of blood will mix without hemolysis. Skill with the
needle will insure success in uniting the two blood-
vessels, the artery of the donor and the vein of the
recipient.

The amount of blood transfused must be regu-
lated by the increase in hemoglobin of the recipient
and the blood-pressure. Berg maintains that the
indications for transfusion are severe acute hemor-
rhage, some cases of shock, and changes in the
blood which favor hemorrhage. In which of these
conditions we may successfully use transfusion is
not yet fully ascertained. It is of value in preparing
feeble and exsanguinated patients for major opera-
tions. It is very useful in poisoning from illuminat-
ing gas.

The transfusion of physiologically unaltered
blood is held by Vogel and McCurdy to be one of
the most promising forms of palliative treatment
available in pernicious anemia. The number of
cases on record in which a remission of notable

degree and considerable duration has followed im-
mediately on a transfusion is so great as to make it
impossible to regard these results merely as coin-
cidences. If proper' precautions are taken to select
a healthy donor, and by the usual tests for isohe-
molysins and isoagglutinins the serum and corpuscles
of donor and recipient are found mutually con-
genial, there is no danger, and the measure should
be employed earlier in the disease instead of waiting
until the patient is in a desperate condition. There
is evidence in favor of the view that greater judg-
ment and accuracy are needed in determining the
amount of blood transferred. It is quite possible
that too large an amount of transferred blood may
be injurious, and that more benefit is to be expected
from small doses introduced at intervals to be de-
termined by the progress of the patient. The
enumeration of the reticulated cells by means of the
method of vital staining affords a useful means of
gauging the hemopoietic activity of the bone-mar-
row, and by watching the patient's progress in this
w^ay the indications for and effects of various thera-
peutic measures can be determined and supervised.

The donor is preferably a healthy young man.
If no near relative is available, recourse can be had
to a convalescent patient. One should be sure in
advance that a number of these are at hand. Tests
of the agglutination and hemolysis do not seem to
be as important as was formerly supposed. The
Wassermann reaction, however, is important and
indispensible, except in absolute urgency.

During the transfusion the two subjects are

placed on tables of the same height, the donor oi
one which can be lowered. The radial region o
the donor and the paramalleolar region of the re
ceptor are bathed with iodine and anesthetized witl
stovaine. " We commence by preparing the "re
ceptor." The internal saphenous vein is exposed a
the lower third of the leg by an incision three ant
one-fifth inches long, the vein has been made pronii
nent by slight compression at the upper part of tht
incision, is freed by dividing and tying all smal

operating hoard for baby used by Dr. V. D. Lespinasse in
"direct transfusion of blood,"

veins holding it in place. This done, the surface o
the wound is covered with liquid vasehn and pro
tected by a compress wet with salt solution, and the
preparation of the donor's arm proceeded with
The radial artery is isolated for two inches; there
are a few collaterals. If these are troublesome, the}
can be tied with fine silk and divided. The artery
well freed, is tied and severed at the lower end o
the wound. A serrefine is placed on the artery a
the upper end of the denudation, and care taken tha
it does not become displaced.

The saphenous is tied^ completely divided at its
lower end, and freed for two inches. The vessels
are now drawn through a cannula of McGrath's

Fig. 1. — Vessels drawn through cannula by means of ends of ligatures.

transfusion forceps,, as shown in Fig. i, by means
of ends of ligatures. Then the vessels are cuffed and
fixed on sharp hooks (Fig. 2) and the lumen washed

Fig. 2. — Vessels cuffed on cannula and fixed on sharp hooks.

TRANSFUSION. 205

out. The forceps are lightly clamped (Fig. 3),
after allowing blood to flow from cannula. The
hemostats on the artery and vein being removed,
the latter becomes swollen and systolic pulsations
are felt in it.

During the whole time of the operation, the vein
is inspected every two minutes to see if the blood is
entering freely, taking care to palpate one-half inch
above the anastomosis to avoid mistaking the propa-

Fig. 3. — Forceps lightly clamped after allowing blood to flow from
cannula, — "a simple instrument for transfusion." (McGrath.)

gation of the arterial pulse for an expansion of the
vein. If great precision is desired, an assistant notes
the exact moment at which blood begins to pass:
another takes the blood-pressure of both subjects.
Finally the assistant tests the hemoglobin strength
every three minutes. As a rule, the donor experi-
ences nothing unusual; rarely there is some thirst.
If he becomes pale, the head is lowered, though
Tuftier has never found it necessary. The receptor
notes a sensation of warmth, sometimes an anxious

206 VENESECTION.

feeling, the lobule of the ear reddens, then the con-
junctivae, also the lips and cheeks.

It is impossible to calculate the time the trans-
fusion should last. The amount passing through
the union is not constant and varies with the con-
traction of the artery above the anastomosis. The
absence of any unfavorable symptom on the part of
the donor, the coloration of the receptor, the normal
strength of the blood in hemoglobin, the duration
of the passage of blood, and the force of the pulsa-
tion in the vein are so many factors enabling one
to estimate the transfusion is sufficient and injurious
to neither subject. If everything is favorable, the
duration varies from fifteen to twenty-five minutes.

The transfusion finished, the artery is tied above
the cannula and, divided between the cannula and
the ligature; the vein is tied below the cannula with
catgut and severed in such a manner that all seg-
ments are removed. Both wounds are filled with
liquid vaselin, the skin united with Michel cHps, and
an antiseptic dressing applied to both donor and re-
ceptor. The choice of the cephalic or saphenous
veins will depend on the receptor; if the latter has
to be moved after transfusion, if there are varicose
veins, or subcutaneous fat is unusually thick, the
cephalic should be chosen. When the receptor is an
infant the femoral may be selected.

After the operation, the urine, blood, and blood-
pressure are examined daily. The urine . remains
normal; the red cells increase greatly, from 1,700,-
000 to 3,600,000, and this increase is kept up for the
following days. The hemoglobin curve is at first

UREMIA. 207

parallel with that of the number of red cells; then
the two diverge, the hemoglobin curve bending, due
to the fact that this represents the new cells
(Murphy).

UREMIA.

A toxemia developing in the course of nephritis
or in conditions associated with anuria. The nature
of the poisons is as yet unknown, whether they are
the retained normal products or the products of an
abnormal metabolism.

The symptoms are especially referable to the
nervous system, and include such premonitory signs
as headache, vertigo, nausea, indistinct vision,
drowsiness, constipation, scanty urine, which may
contain albumin, etc. The uremic seizure may
manifest itself by marked gastrointestinal disturb-
ances, convulsions, or coma, with more or less rise
of temperature, nocturnal dyspnea, Cheyne-Stokes
breathing, vomiting, diarrhea, dry skin, scanty al-
buminous urine with casts, etc. The prognosis is
always grave.

The treatment should be directed toward elimi-
nation of the poisons. Milk diet is of prime impor-
tance in this condition. The milk diet should be
continued for months; if it does not agree well, it
should be replaced by a mixed diet of fresh vege-
tables, farinaceous foods, cakes, fruits, with some
white meat. Tonics and injections of cacodylate of
soda may prove useful at this period (Dieulafoy).

Massage, vapor baths in mild form, and cuta-
neous stimulation with high-frequency current are

208 VENESECTION.

useful. Counterirritation over the kidneys is indi-
cated. Trousseau's wine, digitalis, diuretin, or
theobromine should be employed when the heart is
failing and the edema is persistent. Theobromine,
30 grains daily, is said to produce diuresis and
dechlorination.

Croton oil (gtt. j) and olive oil (5j) should be
administered at once, and later elaterium (gr. ^),
calomel (gr. ij), and compound jalap powder
(gr. XX ) should be prescribed in the acute attack.
Chloral (3j), nitrite of amyl, or chloroform may be
needed to control the convulsions.

In uremia with acute delirium, epileptiform
convulsions or coma, and acute edema of the lungs,
bleeding should be employed up to about ten ounces,
and repeated as may be necessary. Bleeding, if
properly employed, gives excellent results, and often
arrests the convulsions, which are likely to be fatal.
Improvement obtained is due to two causes: first,
bleeding facilitates the absorption of the visceral
edema; and, secondly, it withdraws a considerable
quantity of the uremic poison. In the absence of
bloodletting, leeches may be applied behind the ears
or in the lumbar region.

In uremic dyspnea, which may be most severe,
bleeding usually gives relief. Uremic headache is
relieved by the application of leeches behind the
ears and by antipyrin in doses of 15 to 20 grains
daily (Dieulafoy).

Kottmann extols the advantage of venesection
in uremia. In uremia the venesection removes part
of the toxins and relieves the brain of the almost

UREMIA. 209

invariable local edema while also withdrawing some
of the toxins there accumulated. The brain-cells
in uremia are likely to retain waste products and
salt, and these may in turn attract water, this effect
promoted by nephritic injury of the blood-vessels,
including those in the brain. This explains the
marked and almost instantaneous relief experienced
from venesection in uremia, even when the edema
in the brain is still clinically latent. It also explains
why is it wrong to follow the venesection with in-
fusion of physiologic salt solution, which in its turn
may induce nezv injury to the brain.

Von Reiter has written an interesting little
brochure on "Venesection and Saline Injection in
Uremic Disturbance." He finds that in uremic
disturbances of acute nephroses infusion of saline
solution after venesection is an efficacious treatment
and its employment is unconditionally indicated.
In the uremic disturbances of chronic nephroses the
favorable effect of venesection and infusion will
depend upon the degree of the anatomic lesion of
the kidney.

I am inclined to believe with Kottmann, that
saline solutions are contraindicated in uremic con-
ditions. I advise injections of sterile water, or
water so modified that it will meet the normal
demand of the system. As in all toxic conditions
of the blood, drastic purgatives must not be given
to uremic patients, because the purgative robs the
system of fluid necessary for the secretion of the
urine.

Singer advocates venesection as the most rational

and beneficial measure in scarlatinal uremia. It is
especially indicated in cases showing symptoms
indicating irritation of the brain. When there is
a tendency to coma and depression, venesection can
do no harm, but not much can be hoped from it at
this stage. It is applicable to both robust and
weakly children. If the pulse is filiform, the inter-
nal organs are generally irreparably injured at this
stage and the operation is generally useless. Vene-
section should be done as early as possible, during
the first uremic attack. The amount of blood to be
withdrawn must be decided by the age, strength,
and severity of the attack. Venesection can be re-
peated at need after twenty-four to forty-eight
hours.

Baginsky thinks that from one-fifteenth to one-
twentieth of the total amount of blood can be let
out without danger. In Singer's 17 cases of acute
scarlatinal uremia treated by venesection, all the
patients recovered but two, that is, the mortality
was 12 per cent. In the 9 cases treated without
venesection the mortality was 56 per cent.

Osborne sums up the treatment of uremia as
absolute muscle rest; the withholding of all food,
not even giving milk; administering very little water
by the mouth even if there is no edema, as the
ability of the kidneys to excrete water, even, is often
abolished; frequent colon irrigations of hot water,
leaving some in the colon for absorption if the blood-
pressure is low and there is no edema; the adminis-
tration of thyroid; hot sponging of the skin; vene-
section in most cases, repeated if necessary, as it

has been shown that an ounce of blood will remove
more toxins than eight or nine times that of fluid
feces or than quarts of perspiration; and the ad-
ministration of nitroglycerin if the pulse tension is
high.

VISCOSITY OF THE BLOOD.

Bachmann advises determining the viscosity of
the blood in connection with hemoglobin, the experi-
ences showing that the hemoglobin divided by the
viscosity gives a quotient which is nearly constant
in health, but which varies widely in different dis-
eases. In pneumonia the viscosity is increased; in
typhoid it is reduced, as also in chronic interstitial
nephritis. In thrombosis the viscosity may range
from average to maximal figures. The higher the
viscosity, the graver the prognosis. In epidemic
meningitis the viscosity is always pronounced.

Boveri, of Milan, reported to the Italian Society
of Internal Medicine, that there exists a relation-
ship between the viscosity of the blood and arterial
tension.

In neuroarthritic subjects the viscosity of the
blood is almost always increased, as is also the
arterial tension. He obtained excellent results in
such cases by bleeding, not a large quantity, but in
small amounts (lOO to 120 c.c.) three or four times
a month. Of course in acute cases, as uremia ox
pulmonary congestion, he would draw greater quan-
tities. In these chronic cases, where he bled them
at intervals, he found that the viscosity as well as
the arterial tension remained lowered.

BIBLIOGRAPHY.

1. Vaughan: Parenteral Protein Digestion, Journal American
Medical Association, August 1, 1914.

2. Wright: Boston Med. and Surgical Jour., June 7, 1906.

3. Deetjen: Virchow's Archiv f. path. Anat. u. Physiol, 164, 239,
1901.

4. John C. Da Costa, Jr. : Keen's Surgery, vol. i.

5. Pfeiffer : Wien klin. Wchnschr., 1906, No. 42.

6. JocHMAN : Kolle and Wassermann's Handbuch, ed. 2, ii, 1301.

7. Bittorf : Deutsch. Arch. f. klin. Med., 1913, p. 91.

8. JoBLiN AND Bull : Jour. Exper. Med., 1913, xviii, 453.

9. Montessori: Pedagogical Anthropology.

10. Dutton: Venesection: Its Therapeutic Value, American Jour.
Clinical Medicine, January, 1907.

11. Kelly: Medical Gynecology, p. 145.

12. Montgomery: Textbook of Gynecology, p. 98.

13. AsHTON : Practice of G3mecology, p. 735.

14. OsLER : The Principles and Practice of Medicine, p. 840.

15. Brunton: Therapeutics of the Circulation, p. 189.

16. A. Robin : Bulletin des therapeutiques ; through Jour, de mede-
cine de Paris, December 26, 1908.

17. FoRCHHEiMER : Practice of Medicine, p. 414.

18. Osler: Practice of Medicine, p. 785.

19. Sanson: Twentieth Century Practice of Medicine, vol. iv, p.
514.

20. Waugh : The Treatment of the Sick.

21. Oliver: Atheroma and Arteriosclerosis, Clinical Journal, Lon-
don, Sept. 16, 1908.

22. VoN Neusser : Dyspnea and Cyanosis.

23. Dutton: Blood-pressure in the Practice of Medicine, Medical
Record, New York, April 11, 1908.

24. Davidson: Blood-pressure in Fevers, Lancet, London, October
19, 1907.

25. Williams: Obstetrics.

26. Dienst: Pathogenesis of Eclampsia, Zentralblatt fiir Gynakol-
ogie, Leipsic.

27. H. Vaquez: Puerperal Eclampsia and Arterial Tension, La
Semaine medicale, March 13, 1907.

28. Peterson : Practice of Obstetrics, p. 581.

29. LusK : Science and Art of Midwifery, p. 579, 581.

30. Anders : Practice of Medicine.

31. W. Russell: Lancet, London, 1909.

32. Dutton: Hypertonia Vasorum Cerebri, American Medicine,
July, 1908.

BIBLIOGRAPHY. 213

33. DuANE : Fuch's Textbook of Ophthalmology.

34. Button : American Jour. Clin. Med., Jan., 1907.

35. Rudolph: American Jour, of Medical Sciences, January, 1914,
cxlvii. No. 1, p. 156.

36. Osler: Practice of Medicine, p. 188.

37. Lyman : Twentieth Century Practice of Med. vol. ii, p. 498-499.

38. Osler: Practice of Medicine.

39. Forchheimer: Practice of Medicine.

40. Matas: Keen's Surgery.

41. Brock : The Practitioner, January, 1908.

42. Campani: Sodium Nitrite and Amyl Nitrite in Hemorrhage,
Gazzetta degli Ospedali, Milan, March 8, 1908, xxix. No. 29, pp. 297-312.

43. Semmola and Gioffredi: Twentieth Century Practice of Medi-
cine, vol. ix, p. 513.

44. Dieulafoy: Textbook of Medicine.

45. A. Netter: Twentieth Century Practice of Medicine, vol. xvi,
p. 177.

46. Brunton : Therapeutics of the Circulation.

47. Whitney: Twentieth Century Practice of Medicine, vol. vii,
p. 77.

48. Babcock: Diseases of the Lungs, p. 282, 286.

49. Strumpell : Textbook of Medicine.

50. Maclagan: Twentieth Century Practice of Medicine, vol. ii,
p. 240.

51. GiHON : Twentieth Century Practice of Medicine, vol. iii, p. 281.

52. Berg : Medical Record, March 27, 1909.

53. Murphy : Practical Medical Series, vol. ii, 1913.

54. Kottmann: Correspondenz-Blatt fiir Schweizer Aerzte, Basle,
Dec. 1, 1908, xxxviii. No. 23, pp. 745-784.

55. VoN Reiter: Wien med. Wochenschr., 1908, No. 34.

56. Osborne : Jour. A. M. A., August 21, 1907, vol. xlix. No. 8.

57. BovERi: Viscosity of Blood, Arterial Tension and Bloodletting,
La Semaine medicale, Oct. 25, 1911.

INDEX.

Age, bronze, 5.

copper, 5.

golden, 5.

ice, 5.

stone, 5.
Alcoholism, treatment of, 70.

chronic, 71.
Allbutt, Sir Cliflford, 15, 20.
Amenorrhea, treatment of, 72.
Anesthesia and asepsis, pioneers

of, 20.
Aneurism, 73.

treatment of, 74.

venesection in, 76,
Anders, James M., 107, 108.
Anderson and Balz, 93.
Angina pectoris, 76.
Anthropology, hall of, 4.

pathologic, 54.
Antyllu's, 15.
Apoplexy, treatment of, 77.

venesection in, 81.
Archaeology, American, 4.
Aretaeus the Cappadocian, 14,62.
Arneth, 139.

Arnold of Villanova, 22.
Arabians, venesection by, 15.
Arteriosclerosis, treatment of,
84.

venesection in, 89.
Artery Block, 150.
Asclepiades of Prusa, 11.
Avicenna, 20.
Asphyxia, 91.

venesection in, 91.
Aufrecht, 185.

B

Babcock, Robert H., 185, 189.

Babylonians, 3.

Baccelli, 176.

Bachmann, 211.

Baginsky, 210.

Barker, Professor Fordyce, 113.

Bartels, Max, 2.

Bass, Johann Hermann, 24.

Baths, common public, 25.

Beaumont, William, 37.

Bennett, 38.

Benson, 151.

Berg, A. A., 201.

Beriberi, treatment of, 92.

Bichat, 34.

Bittorf, 53.

Bigelow, Jacob, 36.

Bishop, L. F., 88, 147.

Bloodletting, definition of, 1.

earliest representations of, the
history of, 1.
Blood, alterations in volume of,
47.

-leucocytes, 42.
function of, 41.
number of, 41.

-plates, 43.

coagulation time cf, 46.

color index, 47.

excess of fat in, 47.

extractives of, 46.

freezing point of, 47.

hemoglobin, nature and
amount of, 41, 42.

leucocyte range of, 49.

normal reaction of, 41.

(215)

216

INDEX.

Blood, organisms in, 48.
plasma, 46.

process of hemolysis, 42.
quantity of, 41.
-corpuscles, red, 41.
function of, 41.
number of, 41.
sodium chloride in, 46.
specific gravity of, 41.
sugar in, 48.
viscosity of, 211.
and lymph, 40.

-pressure and composition of
the blood, 102.
in fevers, 103.
in practice of medicine, 93.
venesection in, 100.
Boerhaave, 31.
Bonny, 142.

Bordeu, Theophile de, 31.
Botallo, 25, 34.
Bouchard, 113.
Bouillaud, 33, 181, 193.
Boveri, 211.
Brady, 191.

Bright, Richard, 28, 146.
Brissot, Pierre, 23, 63.
Broadbent, Sir William, 38.
Brock, 141.
Broga, 141.
Bronchopneumonia, 105.

venesection in, 107.
Broussais, Frangois Joseph Vic-
tor, 32.
Brown, John, 31.
Brunton, Sir Lauder, 1^, 171,

172, 173.
Burrage, W. L., 73.
Burton, Sir Richard, 37.

C

Calendar, bloodletting, 2, 26.

purgation, 2, 26.
Campani, A., 142.
Caton, 132.

Celsus, 11, 62.
Chauliac, Guy de, 20.
Clark, L., 151.
Clarke, Sir Andrew, 38.
Cleopatra, 61.
Cohnheim, 146.
Craigie, 193.
Cullen, 31, 191.
Culture, Egyptian, 5, 60.

Greek, 5.

Indian, 5.

North European, 5.
Curschmann, 127, 145.

D

Da Costa, John C, Jr., 47, 49, 57,

Darlington, 131, 159.

Davidson, 103.

Deetjen, 44.

De Giovanni, 55.

De Schweinitz, 152.

Delafield, 175.

Delirium, acute, 107.

Dickens, Charles, 36.

Dienst, A., 110.

Dieulafoy, G., 115, 164, 171, 174,

177, 207.
Dupuytren, 33.

E
Ear diseases, 109.

treatment of, 109.
Eclampsia, 110.

venesection in, 112.
Egyptians, ancient, 2.

venesection in, 120.
Emphysema, 121.

treatment of, 123.
Ethnology, bureau of, 4.
Eye, diseases of, 123.

venesection in, 123.

F
Faculty, of Paris, 23.

of Salamanca, 24.
Fever, scarlet, blood-pressure
in, 104.

INDEX.

217

Fever, typhoid, 124.

venesection in, 125, 127.

yellow, 128.
Finkelstein, 145.
Flexner, 166.
Flint, 197.
Forchheimer, 75, 84, 137, 184,

186, 197.
Fowler, 192.

France, Gallo-Roman finds in, 5.
Fraentzel, 181.
Frank, Johann Peter, 31.
Fuchs, Ernst, 123.

Galen, 8, 13, 62.

Garrison, Fielding H., 1.

Garrod, 130.

Gentilis of Foligno, 22.

Gihon, 198.

Gilbert of England, 22.

Goldscheider, 78.

Gordon, Bernard de, 23.

Gout, 129.

Graf and Landsteiner, 111.

Graunt, 34.

Gull, Sir William, 37, 146.

H

Haberden, 192.
Hahn, 134.
Hall, John, 38.
Hall, Marshall, 36.
Haller, 31.

Hammerschlag, method of, 41.
Hare, Hobart Amory, 97, 171.
Hartridge, 152.
Harvey, 28.
Hasebroek, 88.
Hasenfeld, 146.
Haviland and Hall, 38.
Hayem and W. Hunter, 139.
Health, code of, 15.
Heart, diseases of, 130.
venesection in, 135.

Heatstroke, treatment of, 196,

197.
Hematology, 45.
Hemoptysis, 141.
Hemorrhage, 138.

treatment of, 139.
Herman, 141.
Herodotus, 3.
Hindus, ancient, 6.

bloodletting among, 6.
Hippocrates, 6, 8.

genuine wqtings of, 23.

humoral pathology of, 11.
Hirsch, 146.

Hoffmann, Friedrich, 31.
Holmes, William H., 4.
Holmes, Oliver Wendell, 33, 35.
Hugh of Lucca and Theodoric,

20.
Hughes, 38.
Hunter, John, 22.
Huxley, Professor, 11.
Hypertonia vasorum cerebri,
144.

Indians, North American, 2, 4.

Jackson, 151.

Janeway, Theodore C, 144.

Jenner, Sir William, 37.

Jews, ancient, 4.

Joblin and Bull, 54.

Jochmann, 53.

Johnson, 146.

Jones, Glenn I., 187.

Josue, 84, 148.

Junod, 37.

K
Kelly, 13.

Ketam, John de, 35.
King Robert of Normandy, 16.
Knott, John, 23, 25.
Kottman, 155, 208.

218

INDEX.

Kossel, 52.

Krehl, Ludolf, 93, 96.

Laennec, 34.

Lanfranc, 20.

Langerdorf, 151.

La Tene, 5.

Latham, 192.

Law, old Spanish medieval, 21.

Lespinasse, V. D., 203.

Lettsom, John Coakley, 32.

Liebermerster, 135.

Lisfranc, 33.

Liver, diseases of, 162.

venesection in, 162.
Louis, 34, 184.
Lowit, 51.
Lungs, acute congestion of, 163.

edema of, 164.
Lusk, 113, 114.
Lymen, 130.

M

Maclagen, 194, 195.

Magendie, 28, 37.

Marchiefava, 11.

Margrave of Baden, 24.

Marshall, 93.

Matas, 138.

Method, Hammerschlag's, 41.

McCurdy, 201.

McDonald, 52.

McGrath, Bernard Francis, 204.

Meningitis, cerebrospinal, 165.

Menopause, 167.

venesection in, 169.
Metchnikoff, 52.
Migraine, 170.

treatment of, 171.
Mitchell, S. Weir, 197.
Miura, 93.
Mondeville, 20.
Montessori, 56.
Montgomery, 73.

Moses, 60.

wife of, 4.
Miiller, 53.
Muller, W. Max, 3.
Miinzer, 102.
Murphy, John B., 207,
Myalgia, treatment of, 174.

N

Nephritis, acute, 175.

chronic, 176.

venesection in, 177.
Netter, A., 166.

Neusser, Prof. Edmund von, 92.
Nicander of Colophan, 61.
Noordon, von, 92.
Nothnagel, Id,

O

Obesity, 178.

venesection in, 179.
Oliver, 87, 90, 160.
Oppenheim, IZ.

Ordronaux, Professor John, 16.
Osborne, Oliver T., 210.
Osier, Sir William, It, 82, 84,
89, 92, 115, 137, 197.

P

Paget, 38.

Pare, Ambroise, 11, 62.

Patin, Guy, 29.

Peter, 181.

Peter of Abano, 22.

Peterson, 112.

Period, Byzantine, 15.

La Tene, 6.
Periods, three glacial, 6.
Pericles, age of, 6.
Pfeiflfer, 53.

Pilcher and Sollmann, 139, 140.
Pinel, 34.

Pleurisy, acute, 180.
Pliny, 2.
Pneumonia, acute lobar, 182.

venesection in, 184.

INDEX.

219

Pneumothorax, 186.

Poison, illuminating gas, 186.

treatment of, 187.
Potain, 174.
Pott, Percival, 31.
Praxagoras of Cos, 61.
Pringle, 31.

Pulmonary hyperemia, 188.
Pye-Smith, 39.

R

Rasori, Giovanni, 33.
Reade, Charles, 36.
Reil, 31.
Renan, 22.
Rheumatism, articular, 189.

venesection in, 191.
Robin, A., 45, 74, 176.
Roger and Roland, 30.
Rudolph, R. D., 126.
Rufus of Ephesus, 11.
Rush, Benjamin, 31, 63, 129.
Russell, 2, 117.

Saliceto, 20.

Sangrado, Doctor, 30, 129.

Sanson, 76, 90.

Savonarola, 23.

Scheube, 93.

Schlayer, 103, 146.

School of Salernum, IS.

Senator, 142.

Semmola and GioflFredi, 162.

Simon, 152.

Singer, 210.

Skado, 36.

Sodre, 93.

Solivetti, 108.

Solution, Adler's, 91.

Locke's, 91.
Spiegelberg, 113.
Stahl, 31.
Stengel, 51.
Strumpell, Adolf V., 127, 187.

Sunstroke, 196.

treatment of, 197.
Siissmilch, 34.
Susruta, 6.
Sutton, 146.

Sydenham, Thomas, 28, 63, 191.
Syphilis, 199.

venesection in, 200.

T
Talmud, 4.

Theophrastus of Eresus, 61.
Thompson, V., 186.
Tillaux, 65.
Todd, 130.
Transfusion, 200.
Traube, 146.

U

University of Montpellier, 23.
Uremia, scarlatinal, 210.
treatment of, 207.

V

Valescus of Taranta, 23.
Van Swieten, 31.
Vaughn, 40, 53.
Vaquez, H., Ill, 145.
Vesalius, 23.
Villars, Faure, 167.
VeneseJ:tion, definition, 1.

derivative, 23.

indications for, 56.

Indian method of, 7.

instruments used in, 67, 6S, 69.

revulsive, 23.

the technique of, 58.

where and how performed, 65.
Visigoths, laws of, 21.
Vogel, 201.
Von Reiter, 209.

W
Waldvogel, 133.
Walsh, James J, 3.
Wardrop, James, 36.
Watson, Sir Thomas, 37.

220

INDEX.

Waugh, 81.

Weinburger, 145.

Werder, X. O., 169.

Whitehead, 128.

Whitney, 181.

Whittaker, 137.

Williams, J. Whitridge, 110, 114.

Wood, 198.
Wright, 44.

Z

Ziemssen, von, 152.
Zentmayer, 152.
Zipporah, 4.
Zodiac, signs of, 2.

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