medical men in the subject of venesection was made by one so thoroughly competent and so much esteemed as this distinguished gynecologist and professor in the Bellevue Medical College. Indeed, occasionally, there is needed just such a prominent example as that offered by the valuable paper of Dr. Barker to call forth the expression of others on some particular practice, which, from its abuse, has met with great disfavor.

During the Crimean war, and when I was but little out of my "teens," I was a surgeon within the beleaguered city of Sebastopol, and had the good fortune to possess a copy of Dupuytren's Treatise on "blessure par armes de guerre." No part of this surgeon's work on gunshot wounds was read by me with more attention than that which relates to penetrating wounds of the chest. The advice which he has given, that a patient wounded in the chest should be bled as frequently as his strength and the gravity of the symptoms require, is additionally insisted upon in some interesting foot notes (in small type) added by the editors to Dupuytren's work.* These notes allude to some strictures by John Bell on the management of a case of sword wound of the chest reported by Ravaton. "At one time the sense of suffocation and distress was extreme, and the sufferer lost his voice. He was bled five times within three hours, and subsequently venesection was several times repeated. The great loss of blood by venesection brought on a condition of stupor, in which he remained for two days.

"The dyspnoea left him, and he regained strength with the aid of nourishing soups. The cough, fever, and copious perspiration gradually diminished; and on the twenty-second day he was discharged cured-only a little weak and pale." The editors remark: "We ask every impartial reader what was there to blame in Ravaton's management of this case?"

It was not long before an opportunity was presented to test the value of bloodletting in cases of wounds of the chest. At one time there were in my ward, in Fort Nicholas, eleven

* Op. Cit., vol. 2, p. 329. Paris, J. B. Bailliere, 1834.

patients with gunshot wounds of the chest. Each of these patients was bled a number of times, and at each time with more or less marked relief of a very distressing dyspnoea. During the ten or twelve days that these patients were under my care, not more than two of them, so well as I recollect, died, though some of them were in a very critical condition. One night a large number of soldiers, who had just been wounded during a "sortie," were sent to the fort, the casemates of which were used for a hospital. Every available space was occupied by wounded men. On the following morning an order was received to remove all sick and wounded men, previously in the fort at the time of the arrival of the new-comers, to the north side of the harbor of Sebastopol. Consequently I lost sight entirely of most of those cases of gunshot wounds of the chest which so particularly interested me. However, I was quite impressed with at least the temporary advantage of bleeding from the arm to arrest apparently imminent suffocation, which occurs in patients wounded in the chest. I continued occasionally to resort to venesection in such cases, and generally with the temporary benefit which attended my first experiments. After the Crimean war, and during five years that I was at Paris, and was an "eleve des hopitaux," I was frequently ordered to abstract blood for different inflammatory disorders. Besides, Bouillaud, who was well known for his "saignee coup sur coup," was an examiner at two of my examinations for the doctorate, and I felt quite sure to be searchingly questioned about bloodletting. Who, under like circumstances, would not think favorably of venesection?

During our civil war I was a surgeon in the Confederate army, and had opportunities to repeat my Sebastopol bloodletting experiments, but there were then seemingly good reasons to oppose their repetition. Dr. Hughes Bennett's arguments* against bloodletting were fresh in my memory, and the tidal wave of opinion in this country against venesection overtook

*Lectures on Clinical Medicine.

me soon after my return from Paris, and influenced my treatment during our civil war.

I have since been disposed to reconsider the subject of bloodletting. I am inclined to believe that it will regain its place in professional favor, and that the lancet will again ornament in a conspicuous manner the armamentarium of the surgical instrument-maker.

By those who at present use the lancet, I believe that the indications for venesection are better understood than they were formerly.

Those who have no experience with it will not at first readily comprehend its utility, especially in view of the numerous remedies which at the present day take the place of bloodletting. It is not, however, my purpose in this brief article to endeavor to point out the different indications for venesection; but I desire simply to reiterate a fact which has been frequently observed and mentioned by others-i. e., that prompt relief may be given, and I believe life frequently saved, by the sudden abstraction of blood from the arm in cases of dyspnoea caused by penetrating wounds of the chest. The sudden withdrawal of blood as an urgent expedient to stay a threatened attack of apoplexy of the brain or lungs is a practice for which I would hold in reserve the lancet. There are other indications for bloodletting, some of which were well stated by two or three of the gentlemen who took part in the discussion of Dr. Barker's paper; but Dr. Jacobi judiciously expressed by the following questions views that I share with him. He says: "We cannot ask ourselves what will become of the patient next week? How much time will he require to get well? "We should ask, Will the patient live for half an hour if we do not resort to venesection ?"

Such are the considerations which, I think, should determine us to use the lancet, even should it be required to give stimulants immediately after its use.

ART. III.—THE "NASAL DOUCHE" IN THE TREATMENT OF NASO-PHARYNGEAL CATARRH, WITH REPORT OF A CASE OF RUPTURE OF THE DRUM OF THE RIGHT EAR. By WM. H. DOUGHTY, M. D., Prof. Mat., Med. and Therapeutics in Med. College of Georgia, Augusta, Ga.

The addition of this useful invention to the ordinary and hitherto insufficient resources of the profession for the management of chronic disorders of the nasal cavities is justly esteemed a triumph over difficulties. The application of a physical principle so simple at once placed at our disposal an apparatus so easy in its employment, and so thorough in its operation, that until recently its efficiency and safety were never questioned. Whatever restrictions may hereafter be imposed upon its use by professional sentiment, it will not be denied that the management of catarrhal affections of this portion of the respiratory tract has been completely revolutionized, and their incurable element, arising chiefly from the inaccessibility of the interior parts, to a great extent, removed. Those injuries now recognized as incident to it will have the effect of ensuring greater care and caution in the selection of cases to which it may be adapted, but cannot determine the question of its abandonment except for such individual cases alone.

The accidents to which we refer-serious in their nature as endangering the integrity of so important and delicate an organ as the ear-have even prompted the charge of inefficiency in cleansing the nasal passages, based upon the asserted impracticability of discharging a current of water or other fluid, with certainty, through other portions of the nasal cavity than the floor or most inferior part,-the upper and more hidden portion being inaccessible and not traversible by it in the ordinary catarrhal conditions.

However narrow the spaces between the septum in its entire extent and the turbinated bones (the most prominent and projecting objects) situated on the outer walls of the cavities, the practicability of discharging fluid through them in the normal state will scarcely be denied. A simple inspection after

illumination of the region is sufficient to satisfy any inquirer. What obstruction is interposed by catarrh of the mucous membrane to prevent this successful injection or washing out of the entire region? Obviously, it can arise from two causes only-namely, from chronic thickening of the mucous structure, or from the retention of viscid secretions made more difficult of removal by the increased narrowing or diminution of space induced by said catarrh. Chronic catarrhs are characterized by abundant muco-purulent secretions, which, by retention, readily concrete, forming even cylindrical casts of the more pervious portions of the nasal cavity-their retention and decomposition being a fruitful source of the extreme offensiveness of some cases. Even where the lower channels (floor and inferior meatus) are kept clear by voluntary efforts of the subject, the upper regions are occluded by said secretions in smaller quantity, not always removable by even the most powerful sternutatory efforts. That this is the real cause of obstruction to respiration, and not simple alterations in the thickness of the lining membrane, in most cases, we entertain no doubt; for as long as the nares can be kept clear of the discharges, or empty, the subject can blow through either or both nostrils with comparative ease; and to this is to be attributed the immediate and marked change in such cases produced by the nasal douche when properly used. The tenacious secretions are then the chief sources of occlusion, and any crevice or sinuous passage of the part occupied by them can, from the necssity of the case, be occupied or traversed by less viscid fluids upon their removal. The process of nasal irrigation secures their removal by the force of the current employed, and prompts their subsequent collection and retention by frequent occupation of the channels and interspaces. This admitted, the theory of its efficiency as a radical cleanser of these passages is fully sustained.

In the issue of the New York Medical Record of Feb. 1st, 1870, will be found a very interesting article by Dr. Chas. I. Pardee, Clinical assistant at the Manhattan Eye and Ear Hospital, upon the "Danger attending the use of the Nasal Douche,"