acquainted with the modern treatment of fistula as if he had been a bat, quietly sleeping for the last quarter of a century under the old eaves of St. Bartholomew's.

But enough, and more than enough, has now been said to show that this book, so far from aiding in the promotion of surgical science, is not even trustworthy as a guide for discharging the routine duties of practice. If the surgery taught here be a specimen of that which the College of Surgeons requires from candidates for its diploma, we should indeed be surprised were the general practitioners of England not to betray some uneasiness under the yoke of Lincoln's-inn-fields monopoly.

Der Aderlass in der Lungenentzündung, Klinisch und Physiologisch erörtet. VON DR JOSEPH DIETL. 8vo. Pp. 128. Wien: 1849. -[Bloodletting in Inflammation of the Lungs, clinically and physiologically considered, &c. Vienna: 1849.]

IN many former Numbers of this Journal, allusion has been made to changes upon the treatment of acute diseases, traceable to the influence of modern pathology. The comparative neglect into which the old-fashioned remedy of venesection has fallen in these days is due, as we think, to many causes,-to the indiscriminate activity with which it has too often been applied in combating all phlogoses,—to the unequivocal mischief which has resulted from such irrational practice, -to the difficulty which undoubtedly attends the discrimination of the precise cases to which it is specially adapted,-to mistakes in diagnosis (still very numerous, notwithstanding the introduction of the stethoscope and plessimetry as aids in our investigations),—to changes in the type of certain diseases, or of the epidemic influences of our seasons, to premature attempts to substitute for the experience of ages the obscure suggestions of theory or of fashionable pathology,-to falsely-styled facts, embodied in rotten statistics, and to erroneous inferences, drawn from what is real and significant. In no part of Europe is the horror of the lancet more conspicuous than in Vienna, where, if report speaks truly, a too exclusive devotion to the study of morbid anatomy, and to the perfection of physical diagnosis, has induced, even among the most eminent professors of the school, a species of medical scepticism, more favourable to the institution of unwarrantable clinical experiments, than to the discovery of a truly rational system of therapeutics. It is a fact not easily accounted for, that the German soil is favourable to the growth of all sorts of quackeries and visionary systems, such as homoeopathy, hydropathy, and mesmerism. These, as if by some mystic charm, impose upon the speculative, under the guise of science, to the exclusion of the results of experience, and suggestions of sober reason; which, if not supported by evidence

almost mathematical, are simply disbelieved and denounced as mischievous fallacy.

These introductory observations will prepare our readers for a brief examination of what is practical in the work of Dr Dietl. In a clinical lecture upon the appropriate practice in cases of pneumonia ("Monthly Journal," New Series, vol. ii., p. 163), Dr Alison, while alluding to the alleged success of the expectant, or, what is quite the same, of the homoeopathic system pursued at Vienna, makes the following remarks upon the only kind of statistical evidence which would satisfy a logical mind as to the comparative expediency of ordinary and expectant practice :

The only perfectly fair way of determining this question by statistics would be, to have a certain number of patients treated from the beginning, in inflammatory diseases, by practitioners accustomed to the use of blood-letting in such diseases, and with the symptoms which they have been accustomed to regard as indicating it, by the expectant practice only; and then an equal number treated by the same practitioners, likewise from the commencement, by the depleting remedies; and farther, we must have perfect confidence, if not in the judgment, at least in the good faith, of the practitioners using (and not abusing) these active remedies. To such a trial I shall only say, that I should not wish myself, nor advise any of my friends, to be a party; and the moral reasons which make me say so must, I think, for ever prevent any such statistical experiment being really tried by any trustworthy practitioner."

The moral scruples here alluded to seem to have had little weight with Dr Dietl, if indeed they ever suggested themselves to him. By education and prejudice favourably disposed towards the use of the lancet in pneumonia, he, during the first years of his practice, bled all the patients who presented serious symptoms of inflammation of the lungs, and sought his assistance. As he makes no mention of any auxiliary measures, of the amount of blood usually abstracted, nor of the indications which guided him in directing repetition of the operation, it is assumed that Dr Dietl, a disciple of Raiman, when first emancipated from the schools, practised phlebotomy with no sparing hand, as the sole and grand cure for all severe cases of pneumonia, without reference to age, sex, stage, or epidemic influence. This inference is strengthened by a perusal of various portions of the work before us; its correctness is, however, in no way essential to the validity of certain statistical objections, fatal, as we shall presently show, to the most important conclusions of the author. In 1831, 1832, and 1833, he so far departed from his usual practice as to commence the treatment of some severe cases on homoeopathic principles; but courage failing him, as he saw the progress of the disease, the experiment was very properly abandoned, and the pupil of Raiman betook himself to his lancets to complete the bungled cure. The history of these homoeopathic experiments must not be lost sight of. It seems to fill what would otherwise be a blank in the author's description of his early practice, and strengthens our belief that he was in the habit of resorting to bloodletting even in advanced cases. (See also "Aphorisms," 76 and 78.)

Dr D. next tried tartar emetic in contra-stimulant doses; and, after he had made the remark that this drug seemed to induce amendment, even when no physiological effect was manifested, came to the conclusion, that the remedy had no power whatever over pneumonia.

"A change came o'er the spirit of his dream,"-bleeding and antimony were alike discarded, and Dr D. coolly determined to go to the fountainhead for information,-to trust all his pneumonic patients in future to the operations of nature and low diet, with some simple ptisan, and to watch the sequel, which could not fail to be highly interesting and instructive. He now presents the profession with the results of a three years' perseverance in this hopeful plan, contrasting them in a variety of ways with the consequences of his earlier practice, and introducing a number of physiological and pathological observations of most startling and untenable novelty, which will hardly pass for current coin in this part of the world. As we should be sorry to do the author the injustice of concealing any part of his doctrine-as the work seems to have been received on the Continent as a valuable contribution to practical science, and as the nature of its contents has not yet been fully exposed in the medical journals of this country-we give the aphorisms, the cream of the whole, unabridged, and accurately translated, so far, at least, as our feeble perception of the author's meaning, when he waxes pathological, will allow :—

Aphorisms.

1. The first stage of pneumonia lasts longer in young strong individuals, attacked with the disease for the first time, than in old weak subjects, who have repeatedly suffered from similar attacks.

2. Venesection may shorten the first stage (literally, premonitory stage). 3. The hyperemia of the lung which precedes inflammation has no essential connection with the dyspnoea of pneumonia.

4. The patient respires with more freedom when hepatisation has taken place than before it.

5. The dyspnoea of pneumonia is not caused by the obliteration of the aircells by plastic exudation.

6. Extensive hepatisations certainly confine the respiratory movements, but do not induce a corresponding amount of sensation of breathlessness.

7. The mechanical obstacles to respiration are neither the sole nor the essential causes of the dyspnoea of pneumonia.

8. The interchange of gaseous elements which takes place in the lung-cells is the fundamental condition on which depend the normal activity of the nervous centres and the movements of respiration which these regulate.

9. The pneumonic process so affects and alters the forces, in virtue of which the interchange of gases is brought about, that it greatly interferes with the usual interchange of the carbonic acid of the blood and the oxygen of the atmosphere.

10. In pneumonia, there exists an increase in the proportion of the fibrin, and a diminution in the corpuscular element of the blood.

11. In consequence of the excessive production of fibrin-an oxide of protein -a considerable amount of oxygen is withdrawn from the blood; and as the blood corpuscles, whose special office it is to convey oxygen, are diminished, the blood is not supplied with oxygen in the same proportion as it is wasted.

12. In pneumonia, less oxygen is abstracted from the atmosphere than is necessary for the oxidation of the venous blood and animation of the nervous centres.

13. The dyspnoea must be greatest while the fibrin is being secreted in the lung-cells; for at this period the consumption of oxygen, and consequently the need of oxygen, is at its height.

14. Dyspnoea must exist even in the premonitory stage, for the blood-changes, at least the diminution of corpuscles, commence at this period.

15. The dyspnoea of pneumonia is more especially due to the altered chemical conditions of the blood.

16. Venesection induces the same conditions of the blood, which the pneumonic process effects; it must, consequently, in a chemical point of view, rather increase than diminish dyspnoea.

17. Venesection acts in relieving the dyspnoea of pneumonia by favouring the continuous flow of the circulation, hence permitting more blood to traverse the capillaries of the lungs in a given time, whereby the process of oxidation is facilitated, and the nervous system animated.

18. No other remedy relieves pneumonic dyspnoea so remarkably as bloodletting.

19. In cases of pneumonia left to nature, the perspirations are never so profuse as when the lancet has been used.

20. Many cases, if left to nature, run their course, and get well without perspiration. In all cases, the cure is the surer and quicker the less the patient sweats.

21. The sweating is a result of weakness, or of venesection, and has no critical significance.

22. When the exudation is completed, the pulse returns suddenly to its normal frequency.

23. The acceleration of the movements of the heart in pneumonia is neither due to mechanical impediments nor to loss of blood.

24. The exudative process, or the particular "crasis" on which it depends, is the special cause of the accelerated pulse.

25. The frequency of the pulse is diminished after venesection, or even while the blood is flowing.

26. The effect of bleeding on the pulse is only transitory.

27. The diminished frequency of the pulse which follows blood-letting is, like the relief of the dyspnoea, caused by the promotion of the regular bloodcurrent, by the animation of the nervous centres, and consequent regulation of the heart's action.

28. Venesection can lower the frequency of the pulse only in individuals who are plethoric enough.

29. Venesection should never be repeated when the pulse becomes quicker instead of slower after the first operation.

30. In the treatment of pneumonia by bloodletting, the frequency of the pulse does not immediately subside when the exudation is completed, but continues to be observed for some time afterwards.

31. Tumultuous action of the heart is not so common when a case of pneumonia is trusted to nature, as when it is treated by venesection.

32. Tumultuous action of the heart is partly caused by venesection.

33. The pulse of pneumonia is dicrotous, but not large, like that of typhoid fever.

34. The compressed pulse of the old pathologists is to be regarded as normal and auspicious; the large dicrotous pulse as abnormal and inauspicious.

35. After one or more bleedings the pulse becomes large and dicrotous; it develops itself and becomes free, as the phrase goes.

36. This change upon the pulse is a sure sign of an increase in the serosity of the blood, and of adynamia.

37. It is a bad sign when the pulse becomes free after the first bleeding.

IN INFLAMMATION OF THE LUNGS.

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38. In the treatment by bloodletting the large dicrotous pulse does not so quickly pass into the small normal pulse, as when dietetic treatment is alone trusted to.

39. There is more thirst observed in the course of the treatment by bloodletting.

40. Venesection relieves, along with the dyspnoea and rapid pulse, the sensation of exhaustion and the muscular weakness; this service is not rendered by the expectant treatment.

41. The yellow tint of the skin subsides remarkably in cases treated by the expectant measures, on the completion of the exudation, and in a very short time passes off completely.

42. The yellow tinge is comparatively rare in cases treated on the expectant plan.

43. The yellow tinge increases after every bleeding.

44. It is in many cases caused by bleeding.

45. In cases subjected to the expectant treatment, the physiognomy of the patient, when exudation is completed, indicates the most perfect comfort.

46. In cases treated by bleeding, the improvement of physiognomy is not so remarkable, for the weakness caused by venesection prevents the patient from enjoying his convalescence.

47. In expectant practice appetite soon follows the completion of the exudation, but seldom reaches the degree of ravenous hunger (Heisshunger).

48. In the treatment by bleeding, appetite does not so soon follow the completion of exudation, but it often reaches the degree of voracity.

49. The short dry cough of pneumonia is due to hyperesthesia of the lung. 50. The most common cause of the cough is bronchitis.

51. There are cases of pneumonia without cough.

52. We have unequivocal evidence that a single bleeding often diminishes or altogether removes the cough of pneumonia.

53. This result is effected by diminishing the pulmonary hyperesthesia and the bronchial secretion; hence the remedy acts as in diminishing the dyspnoea.

54. Expectant practice offers no means of alleviating the cough of pneumonia. 55. The most benign (besten) pneumonias are those in which there is but little expectoration.

56. When, in expectant practice, the completion of the exudation is at once followed by a cessation of the expectoration, it is a favourable sign, indicating the probability of rapid resorption.

57. The expectoration of an albuminous fluid, setting in from the eighth or ninth day, at first liquid, afterwards ropy, and intermixed here and there with puriform streaks, effected by short fits of coughing, and in the course of the expectant treatment of extensive pneumonia, is to be regarded as a normal and favourable variety of sputum.

58. In the treatment by bloodletting the sputa undergo several changes, among which the transition of the tough clear sputa into the so-called sputa cocta, is the most important.

59. Venesection favours the conversion of the pneumonic exudation into pus or into puriform cells.

60. Sputa cocta are very often produced by bleeding.

61. Sputa cocta are neither necessary nor critical evacuations.

62. The most benign pneumonias are those in which no urinary sediment is observed.

63. The less the sediment in the urine, the quicker will be the resorption of the pneumonic exudation.

64. Pneumonias treated on the expectant plan often run their course without urinary sediment; in those treated by bleeding, copious urinary deposits

are common.

NEW SERIES.-NO. XIII. JANUARY 1851.

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