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means by which to remove the poison directly. But there is yet another advantage in blood-letting: by it we relieve congestion of the visceral organs, and specially of the kidneys; hence it usually obtains that, after the removal of blood, secretion takes place readily, and a response is offered to diaphoretic and purgative remedies which did not before present itself.

Practically, again, the evidence of the value of blood-letting in uræmia is well borne out. I have shown at page 143, what happy results follow venesection during uræmic coma and convulsion occurring in the young, as sequences of scarlet fever. I have shown, at page 147, the advantage of the same remedy in a case where the uræmic symptoms occurred on the administration of mercury to an aged man who had been long subject to renal obstruction to these I may add another example which, for special reasons, has always rested on my mind.

An old man, who had suffered from frequent attacks of suppression of urine, was seized, in the year 1847, with symptoms of coma and occasional convulsion. The man was resident at a hamlet of the village of Littlebury, in Essex, and, as he was included in the union district of a practitioner whom I was assisting, I was summoned to take charge of the case. The coma was perfect, the convulsion frequent, and the danger imminent. I then, knowing very little about uræmic coma, but beginning to get impregnated with the notions becoming prevalent respecting the lancet, refused to bleed. I had a

blister placed at the back of the neck; I applied cold to the head, and tried, quite ineffectually, to administer a purgative. Called late at night, I attended the next day, expecting nothing but a fatal termination. On the second morning I received, at the surgery, a message that I need not visit the patient again, as another doctor had been called in. Nevertheless, in passing the house soon afterwards, I did venture to make an inquiry how the old gentleman was progressing, and there I found him, sitting up in bed, quite conscious; and two or three days later I saw him, not sitting up in bed, but leaning on his staff at the door of his cottage, as well as he had been for a period long past.

The history of this man's recovery is remarkable. His friends had formed their opinion that he was suffering from apoplexy, and on that point we were not at variance; but having formed this opinion they jumped at the conclusion that, because there was apoplexy, blood should be drawn. They were, consequently, not satisfied with my treatment; and seeing a neighbouring medical practitioner go by, they summoned his aid. Harassed by no scepticisms about the lancet, my compeer propped the old man in bed, tied up his arm and bled away, and, as he bled, sure enough the cloud of unconsciousness cleared off, the pulse rose, the convulsion subsided, and from that moment the dying man recovered. It may be urged, that the process adopted by my learned brother in this case was not of the highest order of

etiquette, and to say the truth, neither was it of the highest order of science, and I felt both facts thoroughly at the time; but inasmuch as he performed the great feat of prolonging the life of a suffering man, I buried my anger beneath the good that had been done, and took, from the facts, a lesson, never to be forgotten.

In plain truth, when we criticise mercilessly the doings of our predecessors because they bled so frequently, we fall into an error as serious as that which we condemn. Our predecessors, though wanting in our advanced knowledge, were not so devoid of common sense and common feeling as to bleed, and continue to bleed, without seeing any advantages from the practice. They did see advantages: they frequently saw cases, such as we have now discussed, in which results, in these days startling and almost miraculous, were achieved by the abstraction of blood. These results were at once encouraging and misleading,—encouraging in that they promised a remedy universal, on the à priori principle, in its application;-misleading in that, the nature of the symptoms being neglected in the considerations suggested by the practice, the practitioner was led to inquire, not whether the case was suited for bleeding at all (the suitability being always admitted), but whether the method of carrying out the bleeding was suited to the case. Hence, there arose endless controversies as to the amount of blood to be taken, the number of venesections, the vein from which the blood should be drawn, and such like, to end at

last, as by an inevitable tendency, in the conception that the remedy, to be useful, could not be carried too far. Thus it was brought into general discredit by the effort to make it do too much.

In these days we have departed from the principle of studying remedies in detail, to study symptoms and pathology in detail; and this departure is good and safe. But it should do more than it has done: it should lead us rationally to apply every means of cure that may seem suited to every given form of disease, and to classify the specific remedies for our diseases as accurately as we tabulate the signs by which the diseases are known, and the organic devastations by which their course is marked.

Returning to uræmia: when the coma is profound and death is imminent, and the diagnosis is sure, the remedy is blood-letting. The remedy should rarely be applied more than once, but then boldly, until in truth the oppression is relieved and the consciousness shows proofs of return. Let there be no local bleeding or half-measure; that is merely taking away the life-element without object, without, for an instant, setting the body at liberty from the poison; but let a vein be opened by a free incision, and let the blood flow, until not the quantity taken but the effect produced determine the cessation of the current. have had an illustration in point, bearing immediately on this advice. In the case recorded in In the case recorded in pages 142-4, a child was relieved at once by one copious disgorgement of blood; but when this same child, some weeks later, was seized in the same manner, and treated

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this time by local blood-letting; the treatment was followed, not by relief from the symptoms, but by transition to death; the depressing effect of the slow exudation of blood acting probably with the poison.

But while I thus advocate the use of free venesection in extreme cases of uræmia, it is not rational to hold out the belief that the remedy is certain in every case. We may learn, from experiment, an important fact in reference to the remedial value of blood-letting in uræmia. If a dog, in which the function of both kidneys is suppressed, be bled when the uræmic symptoms appear, he will for a time rally from them; he will take food, lose his convulsions, and, in fact, temporarily recover. Again the urea and the water will accumulate; again the symptoms will present themselves, and again they may be relieved by the abstraction of blood. Life can thus be preserved twice, and even three times as long as would be the case were the animal left simply to its fate; but the remedy is not potent to cure, because its frequent repetition is itself a fatal procedure. Thus, in this experiment, the remedy is palliative only. But if another similar animal, in which the function of one kidney is arrested, be bled when the symptoms of uræmic coma and convulsion have appeared, they will disappear on the abstraction of blood; if they reappear, the symptoms may once more be relieved by venesection; and now, if the bleeding be effectually done, the relief will often be permanent. The one remaining kidney, freed from its con

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