The tube, however, could never be afterwards dispensed with.

The larynx was carefully examined, and it is stated that "there was slight oedema of epiglottis and vocal cords so as almost to close the windpipe." No tumour was then discovered. There was nothing to be felt externally. Iron and potash, iron and mercury, &c., were given him internally, and nitrate of silver, blisters, and scarification, were used locally for some months, and in April the patient was sent to the Convalescent Home prior to having thyrotomy performed. When he returned, however, he was still too weak to undergo any operation, and so was again sent to the country. At a later period he became a patient in the Paisley Infirmary, and there he died.

The hoarseness, dysphagia, pain, and occasional attacks of dyspnoea were marked symptoms throughout, and the oedema continued about the same during the whole of his illness. About a week before his death a small, warty, papillomatouslooking growth was noticed projecting through the rima glottidis. This was the first appearance of a new growth. During the last month all the symptoms became much worse, fluids only could be swallowed, and of these a small quantity passed into the trachea, causing acute dyspnoea and coughing. Everything was done by way of enemata, &c., to sustain the strength; but vomiting came on, and the patient rapidly sank, and died on 25th September, 1882.

Post-mortem examination of the specimen shows that the entire larynx and upper part of trachea are nearly filled with a new growth, which the microscope shows to be epithelioma. The true vocal cords have been destroyed, and the false vocal cords, epiglottis, and ary-epiglottic folds are thickened and infiltrated with the new growth. Thus, the so-called cedema is accounted for. The posterior part of the cricoid has been also destroyed by the ulcerative process, and an opening formed into the oesophagus, while the rest of the mucous membrane is covered with warty vegetation.

I have very little further to say. The disease seems to have begun about the cords or ventricles of Morgagni, and seems to date back to that cold caught in the pit. As a rule, we know very little about the origin of cancer when it appears in any organ, but you know how frequently patients attribute tumours, say of the mamma, to blows and other slight causes. It is possible here that a severe catarrh, together with the debilitating influences of a damp mine, may have been at least the predisposing, if not the actual exciting causes of this disease. may add that in most of the recorded cases the early symp

I

toms are usually those of a simple catarrh, and this leads to great difficulty in the diagnosis. I think I am not wrong in saying that this difficulty was experienced in the present case, and that for a long time the patient was supposed to be suffering from chronic laryngitis with simple ulceration. This opinion would no doubt be supported by the patient's age, which is only 26, a very early age for epithelial cancer to make its appearance. Looking back now over the whole history of the case, the story of catarrh followed by gradually increasing hoarseness, dyspnoea, dysphagia, pain radiating upwards and outwards from the larynx, with foetor of the breath, and cachexia, presents an almost perfect picture of malignant disease of the organ.

ON VENESECTION.

BY JOHN WYLIE, M.B., Stewarton.

DURING the past twelve months I have read with much pleasure several interesting articles in the various medical journals in favour of blood-letting, and as I have paid careful attention to the subject for the last five or six years, I have thought it might not be considered presumptuous in me to record a few cases, in which I have found very great advantage accrue from its adoption.

In an old Encyclopedia of Practical Medicine, published in the year 1833, I find an interesting and instructive article by Marshall Hall, which he introduces by saying that general blood-letting is of all our remedies the most powerful, but that its employment requires the utmost consideration and precaution. The principal circumstances, he says, which require to be attended to, are:

1. The nature and stage of the disease.

2. The velocity and force of the heart's action.

3. The condition of the pulse at the wrist.

4. The appearance of the blood.

5. The effect upon the patient in subduing the disease or inducing syncope.

Now, I venture to think that if we, in this age of progress, with fifty years' more experience, would only carefully and without prejudice consider these circumstances, and use due discrimination in the selection of our cases, we would be compelled to admit that blood-letting is still one of our most powerful remedies. Within the last few years there has been

a gradual reaction in its favour; and now, with our more advanced knowledge of physiology, the indications for resorting to it are much more precisely defined.

I shall never forget my first experience of blood-letting; the circumstances are so indelibly fixed in my memory, that although six years have elapsed I could almost relate them without referring to my notes. M. M., a strong healthy young man, the son of a farmer, had been suffering for three days from a severe attack of capillary bronchitis. I had prescribed the usual remedies-expectorants and emetics, with poultices and turpentine stupes externally, but the symptoms continued to grow more unfavourable, and at last assumed such an alarming aspect that the patient seemed not likely to live many hours. His breathing was 65 per minute, pulse 130, small and feeble. His face had a peculiar blueish, bloated, anxious appearance, and his body and extremities were mottled with blackish smoky coloured spots, and covered at the same time with a cold clammy perspiration.

His father, an old man leaning on his staff, stood by the bed-side, and with tears trickling down his cheeks implored me to bleed him. Although I had then been a graduate for four years, and had spent two years in an English hospital, and two years as assistant in a large city practice, I had to confess that I had never seen the operation performed. However, I thought it might relieve the pressure on the right side of the heart, and give at least a little temporary relief, so with the old man's assistance I bared the arm and opened the vein. The blood at first came with great difficulty, being thick and black, almost like tar; but in a short time it flowed more freely and became less livid. As the blood flowed the patient seemed to rally, his appearance became more natural, his breathing much calmer, his pulse steadier, and when about fifteen ounces had been withdrawn, he expressed himself as feeling almost well. Twenty minutes afterwards his breathing was thirty-four per minute, pulse ninety-eight, and the anxious oppressed look had given place to a pleasant smile. The relief continued for twenty-four hours, but at the end of that time he again became oppressed, and when thirty-six hours had passed the old symptoms had returned to such an extent that I resolved to bleed him again without further delay. By the time twelve ounces had been withdrawn, he declared that he found himself much better. He continued thenceforth steadily to improve, the bad symptoms were never manifested again, and within a week he was able to move freely about his room.

This was the means of turning my attention to the subject,

and I longed and watched for other cases. During the last five years I have bled by the arm over fifty persons, besides practising local depletion by leeches and cupping. These have been almost exclusively farmers and members of their families, or persons employed in agricultural labour. The cases in which I have found most advantage to be derived from its employment are acute cases of pleurisy and pneumonia, peritonitis, hepatitis, and nephritis.

One of my patients was at one time suffering from aneurism of the aorta, and when acute pain and dyspnoea came oncaused by too much exertion, I bled him three times, affording great relief to him by the operation.

On several other occasions, when the right side of the heart was labouring and requiring relief, I resorted to blood-letting, and the same beneficial results invariably ensued. I will very briefly give my notes of a few cases.

W. D., a stout florid-complexioned farmer, had been indulging rather freely in the new year's festivities, and when going home had sat down by the roadside and fallen asleep. When a friend awoke him he was shivering all over, and afterwards complained of a severe darting pain in his left breast. When I saw him two hours after his skin was hot and dry, pulse 96, hard and full, respiration short and hurried; he had also a short harsh cough, which tormented him terribly, and made him cry with pain. Auscultation detected the usual friction sound of pleurisy, at a point just below the nipple, over the sixth intercostal space.

I at once bled him to the amount of sixteen ounces. The pain almost immediately left him, and he stated that he felt himself much better. I then gave him ten grains of Dover's powder, along with ten grains of salicylate of soda, and applied at the same time a warm poultice over the side. Next morn

ing I found him progressing favourably. During the night he had perspired freely, and had felt no pain unless when taking a deep inspiration. In three days he was able to move about the house.

T. S., a ploughman, fell from a cart, and lighted on his shoulders and head. He was stunned, but soon rallied and walked home. Next day he felt stiff and sore about the shoulders, and the following morning he had a rigor. When I saw him about noon his skin was hot and dry, pulse 110, and he was complaining of a severe pain in the head. His face was alternately flushed and pallid, conjunctivæ injected; there was great restlessness, and already, when left alone, his mind wandered, and he talked incoherently. He had also

vomited several times. As the case seemed to me one of acute meningitis, I resolved to bleed him at once, and drew from his arm about fifteen ounces of blood. He seemed relieved, and lay perfectly quiet for about half-an-hour. He then appeared to rally, and to regain consciousness, and expressed himself as feeling very much better.

I applied ice to the head, mustard to the nape of the neck, and administered to him a diaphoretic powder. From this time he continued to improve and to make a good recovery.

N. W., a stout domestic servant, got a severe wetting while menstruating, and neglected to change her clothing. She had a rigor about midnight, and afterwards complained of acute pain in the hypogastric region. This soon spread over the whole abdomen, and was increased by pressure, and attended by high fever.

When I saw her in the morning, the temperature was 103°, pulse 120, small and weak, respiration hurried, and her countenance anxious and expressive of suffering. She lay on her back, with her legs drawn up, and could scarcely bear to be touched. The abdomen felt tense and tympanitic. I at once bled her from the arm, to the amount of twelve ounces. She said she felt very much better, and at the same time her countenance changed and her breathing became quite natural. Half-an-hour afterwards she was lying perfectly quiet, and almost free from pain. I treated her in the ordinary way with opiates, sedative fomentations, ice, and light diet. From that time she continued to improve, and to make a rapid recovery from what undoubtedly threatened to be a serious attack of peritonitis.

With due discrimination in selecting cases, venesection is certainly a safe remedy. I have never seen it do harm, and on every occasion on which I have resorted to it, the patients have spoken in no measured terms of its beneficial results on them. I may mention that it is a remedy in which farmers especially have the greatest faith. I know at least of two cases where the farmers themselves bled each other unknown to the medical attendant, who had refused to do it.

I can well believe that medical men in large cities have fewer opportunities than we in the country have for the practice of venesection. In agricultural districts, where we meet with acute inflammation, in full-blooded over - fed farmers, and their servants, I believe, there is no other remedy that has such a powerful influence in temporarily arresting the progress of the disease, and allowing us an opportunity of applying the ordinary means to keep the disease under control.