rate of mortality in those diseases which tend to destroy life by asthenia, and no one now doubts that the death-rate has been diminished by a much more sparing use of the lancet within late years. So also the pernicious effects of bloodletting are manifest in cases which end in recovery, as well as those which end fatally; these results consisting in a protracted convalescence and subsequent feebleness, presenting a striking contrast with cases which are treated without its use.

It is now generally conceded that it is not an antiphlogistic measure, properly so-called; that although it may exert a powerful immediate effect, as a palliative measure, yet, whatever curative effect it may possess, is exerted indirectly. Its therapeutic action consists solely in lessening the frequency and force of the heart's action, in other words, in diminishing the intensity of symptomatic fever. The same beneficial effects may be generally obtained by other and much more innocuous means, for instance, the mass of blood may be temporarily lessened by saline purgatives and diaphoretic remedies. The force and frequency of the heart's action may be effected by nauseant sedatives, such as tartar-emetic, ipecacuanha, etc., or direct sedatives, such as digitalis, aconite, veratrum viride, etc. I maintain, therefore, since we have these simple medicines in our armament, we are not justified in resorting to a measure which involves in it such great impoverishment of blood; in view too of the well known fact, that most of our prevalent phlegmasia tend to destroy life by asthenia, and by the fact that red corpuscles are not readily reproduced during the progress of an acute disease.

It was my purpose to take up, seriatim, a number of those diseases in which bloodletting was formerly held to be indispensable and show how, in the treatment of each individual disease, the success now-a-days is much more gratifying than formerly, when this heroic remedy was never omitted; but this plan, I perceive, would prolong my paper to an extent much exceeding that which I had intended, or what would be proper. Suffice it then the bare assertion, that a better scientific knowledge, great advancement in animal chemistry and philosophy, together with a close observation of the ill effects of bloodletting as resorted to in the part of the present century, have given the reformed practice an impetus and a precedence which it will probably never lose.

I may now, before closing, call your attention, briefly, to some of the dangers and contraindications which should guard us in the employment of this therapeutic agent. Bloodletting is not admissible when the development of inflammation is not accompanied by high symptomatic fever, nor when the patient was not in good health when attacked, nor when the constitution is feeble, nor when the disease involves danger of death by asthenia. The very young and the old do not well bear the loss of blood, nor, as a general remark, the inhabitants of large cities, nor persons predisposed to phthisis, scrotula, or scurvy. Very fat persons will seldom bear any great loss of blood, fatal syncope having followed the abstraction of even small quantities in those cases. In persons affected with chronic disease of the heart, valves, or large vessels, the abstraction of large quantities of blood has been followed by fatal consequences. We are forbidden to bleed a woman whilst menstruating, as also a woman suffering from hysteria. Bleed very cautiously habitual drinkers or persons resident in a tropical climate. Repeated bloodletting tends to produce disease of the heart and great nervous derangement. Bloodletting, in apparently favorable cases, sometimes produces fatal syncope. It generally produees anæmia in women and persons of debilitated constitutions, whose vital powers. are insufficient to replace the red globules of the blood. It sometimes produces excessive hæmorrhage, occasionally dropsy. It naturally engenders an increased susceptibility of the surface of the body to the influence of cold, and therefore a relapse, or a liability to the excitement of fresh inflammatory disease. Dr. Hope states that he has distinctly observed polypus of the heart as a sequence, when bloodletting has been extensively employed in organic disease of this organ.

I do not wish to be understood as mointaing the proposition that bloodletting is an unmixed unmitigated evil, that it can never under any circumstances, be made to subserve good and useful purposes. On the contrary, I believe, in accordance with the teachings of our most modern and judicious authors, that bloodletting, in well selected cases may be made a remedy of great power for good that in a robust and plethoric habit we may safely, by its aid, reduce the force and frequency of tde heart's aetion and the momentum of the circulation more speedily than by any other one remedy; that by it we may

often afford immediate relief to very urgent symptoms, as in great obstructions of the respiratory and circulatory organs. In fact the measure is probably more applicable to the treatment of inflammations affecting the pulmonary organs than the treatment of any other inflammatory affections, in consequence of the relations of the former to the circulation; the free passage of blood through the pulmonary circuit being promoted and the functional labor which the lungs have to perform being diminished by the abstraction of blood; and were it not for its ulterior effects, it would be invaluable as a palliative measure in pleurisy and other inflammatory affections within the chest. My conclusion then is, that while we cannot deny therapeutic value to bloodletting as a remedy, yet the class of affections in which it is applicable is so small, while the number of restrictions and contra-indications which guard us in its employment is so large that we must confine its use within very narrow limits. Indeed, I think I may say that the range of its usefulness is so small; that the contra-indications to its use are so numerous; that it requires so delicate a discrimination to elect cases in which it may be advantageously resorted to; that so few physicians, comparatively speaking, possess this tact; that its improper employment may be attended with results so disastrous; that we possess so many substitutes for it much less hurtful, and very little if any less efficient, that it becomes a grave question whether it might not be better, on the whole, to dismiss it from our pharmacopoeia altogether. At any rate, I do not hesitate to reaffirm my belief in the proposition with which I set out, viz: That bloodletting, though unfrequently resorted to of late years, is not too much neglected by modern practitioners.

ART. III.-OBSTINATE CASE OF ACUTE AND CHRONIC GONORRHEA TREATED BY INJECTIONS OF GLYCERINE OF TANNIN.*

Perhaps no surgical disease is so frequently observed in hospital (out-patient) practice as gonorrhoea, and the *R. Glycerine iv, Tannin 3j. Rub together and heat. [ED.

treatment which is advocated by surgical authorities cannot, in many instances, be surpassed; occasionally, however, troublesome cases will arise, both in the acute and chronic form of the disorder.

In these cases, previous to the employment of any kind of local or constitutional treatment, whether alone or in combination, Mr. J. D. Hill, who has the care of the Royal Free Hospital, thinks several circumstances have to be considered.

First, it is necessary to determine the occupation, habits and constitutional peculiarities of the patient; or, in other words, what assistance, both from within and without, can be brought to bear upon a purely local affection. Secondly, to overcome local difficulties, which are both physiological and mechanical in character; and these may be briefly said to consist in the mobility of the affected part, its dependent position, and the occasional contact of an irritating fluid-the urine.

The treatment which Mr. Hill tells us he has extensively employed in hospital and private practice, was, he believes, first introduced by Dr. Ringer, of University College, who has kindly favored him with the following remarks: "For some time past I have been making observations with an injection of glycerine of tannin in chronic gonorrhoea and gleets, which I believe may be removed more quickly with the injection than perhaps any other. In the acute stage of the disease a little care is necessary, or great pain is caused. This may be prevented by diluting the glycerine of tannin with equal parts of mucilage. Another point to attend to is that the injection should not be injected too far, or it causes a great and frequent desire to make water."

Mr. Hill is therefore enabled to support the experience of Dr. Ringer, not only by recent cases, but also by observations on the treatment of gonorrhoea by tannin and mucilage injections extending over some years. These injections he first used ie the proportion of ten grains to the ounce, but latterly, as suggested by Dr. Ringer, he found the glycerine of tannin more serviceable, slightly modified, however, as to the diluting agent.

The precaution alluded to as to Injecting is probably a most important one, whatever be the lotion employed; for although in some few instances the fluid may be injected too far, in the larger number it will not be injected far enough. Now in either case the surgeon is blamed

for a fault which in reality rests with the patient; and here it may not be out of place to describe the method which Mr. Hill recommends to all patients using injec

tions:

"The bladder having been first emptied, the bottle containing the lotion is to be well shaken, and about two drachms of it briskly poured into a saucer. This must

be quickly drawn into a glass syringe with a bore in the nozzle equal to a No. 6 catheter. The penis is then to be held in the left hand, with the thumb and little finger respectively placed upou the superior and inferior portions of that organ close to the symphysis pubis, and the fore and middle fingers resting in like manner upon the superior and inferior surfaces of the glans, close to the meatus urinarius. The syringe, with the piston withdrawn, is now to be taken up with the right hand, and the nozzle as far as its shoulder carefully passed into the urethra. Previous to injecting, the thumb and little finger of the left hand must compress the root of the penis, in order that the urethra be closed against the passage of any fluid beyond this point. When a sense of tension is felt, the syringe must be withdrawn; but the front fingers must previously be so applied as to compress the glans, and thus prevent any escape of fluid from the meatus. Next, with the thumb and forefinger of the right hand, the fluid in the urethra is to be set in motion, and so kept for four or five minutes. This will be attended with a gurgling noise, from the mixture of air and fluid. Thus, when the injection has so insinuated itself within the folds and lacunæ of the urethra as to saturate the openings of the follicles and mucous glands, and permeate the whole of the affected structure, it is allowed to escape."

It is conceived that by these means the bladder is protected on the one hand, and on the other there is a certainty of the fluid being applied to the affected surface of the urethra.

Mr. Hill has furnished us with the notes of six cases in which the glycerine of tannin would appear to have been of great service. In several, injections of zinc, lead and alum had been employed without much benefit. The formula employed was the following: Glycerine of tannin, three ounces; olive oil and mucilage, of each one ounce.-Lancet.