toms are dependent upon actual extravasation, bloodletting cannot possibly lessen the pressure of the effused clot, and thus remove the cause. "I reject bloodletting from the treatment of cerebral hemorrhage," says Trousseau, "because experience has taught me that patients do better without it. For when I reflect upon what happens, I do not see how the method can be of any use, since the hæmorrhage is an accomplished fact, when we are called upon to note its symptoms. What influence can be exerted upon a foreign body in the shape of extravasated blood, by letting out blood from a vein of the arm or of the foot, or from the jugular? Reasoning, therefore, agreeing with experience, pronounces the treatment useless against which I raise my voice."

Both classes of cases, therefore, illustrate the position assumed. In cerebral congestion, bloodletting may be useful by removing the physical cause of the symptoms; in cerebral extravasation it will be ineffectual, because incapable by any physical process, of taking off the pressure caused by the clot.

Somewhat allied to the cases just considered, so far as its effects are concerned, is the condition termed uræmia; and the question of the advisability of bloodletting, in this state, is a very interesting one.

Dr. Benj. W. Richardson urgently recommends bloodletting as of supreme importance, in the treatment of uræmia; but if his statements be closely examined, it will be seen that it is mainly against certain conditions which may or may not be superinduced by the uræmia, that he employs venesection; and not simply on account of the presence of the poison in the blood.

"When the coma is fully developed," he remarks, “and the patient is unconscious, and the skin hot and the convulsion strong, there is no remedy so swift, so sure, so useful, as the lancet. * To bleed is to remove tension from the brain."

* *

Now, in cases characterized by the symptoms of cerebral congestion referred to, it is very easy to conceive how the remedy may give relief. But there are other cases of uræmic poisoning in which bloodletting is not found to be so safe and sure a means. In the advanced periods of chronic Bright's disease, in which the elimination of urea may have been failing, and the symptoms of uræmic coma increasing day by day, although the blood be evidently charged with the poison, yet it is not found that benefit results from its abstraction. Upon this point let Dr. Christison speak, than whom few have had larger opportunities for observing the disease:

"In the coma which constitutes the final stage of suppression," he says, "in long continued organic diseases of the kidneys, no remedies are of much avail; bloodletting does no good, and sometimes evidently accelerates death."

There is another condition intimately connected with uræmia, of great pathological and therapeutic interest; and that is puerperal eclampsia.

It seems to be the received doctrine at present, that the convulsions of pregnant and parturient women are very commonly of uræmic origin; and it is certain that the remedy most depended upon until within the last few years, if we accept the statements of systematic writers, was bloodletting.

Now, what is the story of bloodletting in puerperal convulsions, as gathered from the general experience of accoucheurs ? Is it not one of utter failure in a large proportion of cases? "The reports," says Dr. Tyler Smith, "of those who have most pertinaciously followed bloodletting in puerperal convulsions, exhibit the loss of a greater number of patients than those who have been more cautious in this respect."

There are, no doubt, cases of puerperal convulsions in which bloodletting is highly serviceable; and the differ

ent results of the measure in such cases, and in the many in which it fails of doing good, must be ascribed to different pathological conditions in the two classes of cases respectively. Thus, when the convulsions are apoplectiform in character, and connected with active cerebral or spinal congestion, venesection would seem to be indicated. When, on the other hand, they are of an epileptiform character, and dependent probably upon irritation of the nervous centres caused by retained urea, it is very questionable whether bloodletting is capable of giving relief. And it is the latter class of cases that is the most common.

"Is it," says Trousseau, "under circumstances denoting cerebral congestion, that women are ordinarily seized with eclampsia? Ask accouchenrs, and they will tell you that eclampsia manifests itself often before any signs of labour have shown themselves."

For controlling puerperal convulsions dependent upon uræmia, a far better means than venesection is found in the inhalation of chloroform.

Dr. Braun, of Vienna, in his valuable essay upon uræmic convulsions, states that in this condition he has "observed results from the administration of chloroform, which have surpassed all expectations;" and the very general opinion of the profession seems at present to accord with his conclusions.

A consideration of these various conditions makes it probable that bloodletting gives relief in those cases of uræmia to which it is adapted, not so much by simply removing urea along with the abstracted blood, as by relieving the congestion of the nervous centres, that is sometimes, but by no means invariably, connected with the uræmia.

Dr. Richardson seems to ascribe the good effect mainly to the removal of the urea-saturated blood; but it is evi

dent that there is, relatively to the whole quantity of blood, just as great an amount of urea in it subsequently to the bloodletting, as there was before.

Moreover, if this were the mode in which the remedy gives relief, it ought to be found serviceable not only in acute uræmia, to which Dr. Richardson limits its application, but also in the more chronic cases, and in the puerperal conditions which are equally dependent on the presence of urea in the blood. On the whole, therefore, the claims of bloodletting, as a point of scientific practice in uræmia, may be based rather upon its effect in relieving congestion when that has occurred, than upon its power of removing urea from the system.

Another malady that requires consideration in connection with the scientific employment of bleeding, is pneumonia, which constitutes, as is very well known, the principal battle-ground upon which the bloodletting controversy has been fought.

There is full warrant for the assertion that in no disease are the good effects of a remedy more obvious, or more clearly explicable on rational, scientific grounds, than are those of bloodletting in pneumonia, when it is applied to appropriate cases. Certain symptoms sometimes met with in this disease, and due to a change in the physical conditions of the lungs and heart, are relievable by venesection in a manner perfectly intelligible upon physical principles. These are dyspnoea, and oppressed, laboring action of the heart; symptoms which are by no means of constant occurrence in pneumonia, and hence venescction is not applicable to all cases of the disease, as it was once believed to be by the French school of practitioners. But let there be present in pneumonia a certain amount of dyspnoea, and a certain degree of hardness and force in the pulse, and it is as well established as any other fact in medicine that relief to these symp

toms may be obtained, by the abstraction of blood from the arm. About the fact itself there is no room for controversy; and a moment's reflection upon the physical condition of the lung in those cases of pneumonia in which venesection is used with most advantage, will suggest an explanation.of the mode in which the result is accomplished.

A physician is called to a patient whom he finds breathing twenty-five or thirty times in a minute; the muscles of respiration are straining painfully, the percussion sound over the thorax is somewhat dull, and crepitation is audible. The pulse being hard and resisting, he bleeds such a patient from the arm to the amount of twelve or fifteen ounces or more, with the effect of speedily and completely relieving the dyspnoea and tensive pain.

Another case is seen in which dullness of the thoracic wall and fine crepitation are likewise noted, with febrile action; but dyspnoea is very slight, or perhaps not experienced at all. Here the propriety of bloodletting will not be very apt to suggest itself to the medical attendant. Both cases, however, are typical instances of pneumonia; both have, in common, the element of an inflammatory process going on in the lung. But in the former case there is another element not met with in the latter, and that is, the dyspnoea. Hence the inference is very obvious, that in that former case venesection has been beneficial, not so much by a direct influence over the inflammatory process, as by lessening the rush of blood into the incapacitated lung on the one side, and into the over-worked lung on the other side, and by unloading at the same time the engorged right chambers of the heart.

English and American physicians, whatever their views in regard to the effect of bleeding may be, yet as a practical matter do not in general resort to it in pneumonia,