98

sthenic inflammatory diseases were dying out amongst us, andthat asthenic complaints were taking their place. The cholerawhich visited this country in 1832 was certainly a disease ofdepression, and this was immediately followed by the influenza,a disease of the same depressing class, and, like it, requiring atonic plan of treatment. Since the date referred to, neuralgia,also a disease of depression, had become almost epidemic; car-buncles and carbunoular boils were at present decidedly so;and Bright’s disease, the disease of the supra-renal capsulesgiving rise to the bronzed skin, and the disorders classed underthe head of fatty degeneration, were all much more prevalentthan formerly, even if we do not admit them to be new dis-eases. In fact, it now became a question whether bleedingshould ever be practised at all, and he (Dr. Semple) was ascautious in ordering a patient’to be bled as a surgeon would bein deciding upon the amputation of a limb. Nevertheless,although the cases were met with in practice required in gene-ral the adoption of tonic and stimulating treatment, it was byno means proved that all forms of disease were characterizedby depression; for cases of a sthenic type still presented them-selves, and demanded the application of antiphlogistic measures.The remarks made upon the treatment of inflammatory diseasesin general were particularly applicable to those of the respira-tory organs, which are essential to life, and the inflammationsof which require the most prompt and judicious medication;still it was impossible that any stereotyped rules could be laiddown for the treatment of these affections, which may presentthe most opposite therapeutical indications.The author then related the case of a lady in whom thetreatment by bleeding, calomel, and tartrate of antimony wasadopted for an acute inflammation of the larynx and trachea,- extending to the bronchial tubes, substance of the lungs, andpleurae. This treatment not having at first produced a well-marked effect, the antiphlogistic plan was changed for a stimu-lating one, and carbonate of ammonia and brandy were em-ployed while the acute symptoms still continued. The resultwas, that the patient became decidedly worse, and appearedto be on the point of death by suffocation; but on againchanging the plan, and resorting to bleeding, low diet, andtartrate of antimony, the disease gradually subsided, and thepatient, who is now alive and well, was restored to perfecthealth, without any trace whatever of the previous illness.

Dr. Semple wished that it should be understood that he hadno dogmatic views to offer upon the treatment of the inflam-matory diseases of the respiratory organs. He could not advo-cate indiscriminately large bleedings, profuse mercurialization,and repeated doses of tartar-emetic; nor, on the other hand,- could he approve the universal adoption of the plan of stimu-lating such cases by brandy and carbonate of ammonia; and itwas difficult to determine which would be the greater error ofthe two. He believed that many cases of pure sthenic infl’1m-mation still presented themselves in practice, although theywere by no means so common as they formerly were; and insuch instances the abstraction of blood, and the administrationof mercury, of the alkalies and tartar-emetic, will effect a cure.But there are in the present day a great number of epidemic,contagious, and diathetic forms of disease, which are, it is true,accompanied by inflammation, but of a low or asthenic cha-racter, and these require tonics, alteratives, and stimulants.Undue depletion ought to be avoided in persons who are thesubjects of the gouty, the venereal, or the scrofulous diatheses;and whenever any of these affections co-exist with, or precede,inflammation, the disease ought not to be considered as of asthenic character, and the cure should be sought rather by cor-recting the prevailing morbid taint in the system than in in-discriminate depletion; and some of these constitutionalmaladies, especially scrofula, required cod-liver oil, iodine, iron,meat, wine, and beer.The paper concluded with a sketch of the treatment of pneu-

monia as it presented itself in children, in vigorous adults, inthe inhabitants of towns and cities, in persons labouring underfever, in its typhoid form, and in its complication with tuber-cular phthisis, in each of which cases, although the name ofthe disease was the same, yet the treatment required was verydifferent, owing to the peculiar features which the maladyassumed.

In the discussion which ensued, Dr. ROUTH, Dr. CAMPS,Dr. WEBSTER, Dr. COTTON, Dr. CHOWNE, and Dr. STOCKERtook part. The debate elicited nothing very striking or novel;but it was remarkable that none of the speakers spoke infavour of the stimulating plan of treatment in inflammatorydiseases of the chest.

Dr. SEMPLE, in reply, feared that the nature of his remarkshad been misunderstood by some of the speakers. So far from

advocating the indiscriminate use of bloodletting, his paperhad just the contrary tendency; and he believed that a medicalman was bjund to dispossess himself of all dogmatic opinions,and to treat his patients in such a manner as would mostrapidly restore them to health. This could only be done bystudying the peculiarities of every case, and paying strictattention to all modifying circumstances. However valuablestatistics might be, he thought that they did not throw muchlight upon practice; and as to the number of cases which, itwas said, recovered from pneumonia in the Vienna Hospitalwithout any treatment at all, it was not stated what thepeculiar forms of the disease were, or what were their com-plications, and the results might be quoted to support anydoctrine whatever. He thought that the subject of the moderntreatment of the inflammatory diseases of the respiratoryorgans, and of inflammatory diseases generally, was a veryproper one for debate in medical societies; and as the argu.ments were not yet by any means exhausted, he hoped thatothers would continue the discussion upon some future occa.sion.

HARVEIAN SOCIETY.

JANUARY 7TH, 1858.MR. URE, PRESIDENT, IN THE CHAIR.

Dr. SANDERSON read a paper on

THE NOSOLOGICAL CHARACTERS OF THE YEAR 1857. ’

The author introduced his subject by remarking that fifty yearsago more attention was paid to the modifications which acutediseases undergo from time to time in their general charactersthan at present. This he attributed to the comparative dis.regard to P1"Ogllosi8, or that part of medicine which relates tothe common or variable characters of acute diseases, in favourof diagnosis, or the study of those constant or special cha-racters by which one disease is discriminated from another.Reference was made, in illustration, to the opinion of Dr.Bennett, that disease is invariable, and consequently that thesame diseases have at all times required the same treatment,and to the controversy at present in existence between theEdinburgh professor and those who adhere to the doctrine ofSydenham. The author endeavoured to show, 1st, that sincethe end of the last century diseases have undergone two greatmodifications-that at the beginning of a period of twentyyears, terminating in 1805, the inflammatory and febrile dis-eases exhibited much the same characters as at present, vene-section being usually inj urious, and active antiphlogistics notbeing required, or even tolerated; that towards the end of thatperiod the aspects of disease so completely altered, that thevery men who had before advocated the opposite practice werecompelled to bleed repeatedly, and that not only for internalintiammations, but in continued fever. Since that period, andparticularly since the year 1830, a " constitution" has pre.vailed which is marked by the greater prominence in inflam-matory and febrile diseases of symptoms referable to the nerv.ous system. 2. That in refraining from bleeding in 1800, inagain having recourse to the lancet in 1820, and in graduallylaying it aside since 1830, the profession has acted throughouton the same principles, these not being founded on speculationsas to the nature of inflammation, but derived from observationof the mode of fatal termination of the disease, and of theeffects of the remedy on those constitutional states which werefound by experience to be most dangerous. The year 1857 wasdescribed as favourable to the public health, the mortalityhaving been 6 per cent. below the average. It was shown thatthis diminution was entirely referable to those classes of diseasewhich are supposed to depend on local causes of unhealthiness,the fatality of pulmonary affections having been greater thanusual. The diarrhoea of 1857, which was fatal to 1000 personsin excess of its usual average, was traced in its rise, progress,and decline; and a comparison was drawn between the summerdiseases of the present time and those which prevailed beforethe first advent of cholera. The summer diarrhoea of thisperiod was of a different character from that which now exists;as a cause of death it was so inconsiderable as not to produceany sensible effect on the mortality of London; and althoughsince 1830 it has existed in its present form every summer, itdid not attain more than one-third of its present prevalenceuntil after 1846, the outbreak of that year being 150 per cent.in excess of the previous average, but nearly 40 per cent. beloW

I that of 1857. The rest of the paper was occupied with a. I notice of the epidemic catarrh which prevailed throughout

99

London in November. Reference was made, in conclusion, tothe subject of diphtherite, respecting which interesting com-munications were read from medical men in Devon and Corn-wall descriptive of local epidemics of that disease.Mr. CLEVELAND considered that the large importation of

foreign fruit of late years had contributed to the increase ofdiarrhoea.

Dr. POLLOCK doubted whether the type of disease, hadchanged. We had changed our treatment, but the disease re-mained the same that Sydenham wrote of. The thermometerwould always indicate why diarrhoea increased or diminished.

Dr. QUAIN dwelt upon the importance of the question,whether the constitution was the same now as it was when

bleeding was in vogue ? As an instance of the asthenic natureof disease now, he mentioned the rareness of rusty expectora-tion in the pneumonia of late years; and said that cupperscomplain that they have lost those patients who used sponta-neously to resort to them, which fact showed that the publicfeels its altered constitution.

Dr. CAMPS related the case of a gentleman who was accus-tomed to periodical cupping, and who by its practice was madeparaplegic. Dr. Camps thought that the anxieties attendingour present mode of life, with its fierce competitions, causeddisease to assume a nervous character, and that railway travel-ling had a similar effect. He had seen many country patientswhose lives had been sacrificed by too much bleeding.

Dr. SANDERSON having replied, the Society adjourned.

Correspondence.

THE GENERAL LYING-IN HOSPITAL.[LETTER FROM DR. EDWARD RIGBY.]

"Audi alteram partem."

To the Editor of THE LANCET.

SiR,-Accept my most grateful acknowledgments for thekind and able assistance which you have rendered me on the

subject of the Mortality at the General Lying-in Hospital byyour admirable article of January 16th. When a case of grossmisconduct has been so ably handled by the great organ ofpublic opinion, and also by the two leading medical journals ofthe day, there can be little fear as to the result, although itmay be still somewhat retarded by the obstinacy of consciouserror.

May I be permitted to offer a few remarks on what you term"the drawbacks of Dr. Reid’s system"-viz., "the hermeticalclosure of the windows, the absence of a fire in the grate, thechilliness produced by the entry of the fresh air through thevalves in the wainscoating, and the expense" ?With the ventilation in action, the closure of the windows is

never felt. The air brought in from a high elevation in theroof, enters with a freshness which we should seek in vain withopen windows many feet lower; at every foot that we descendthe air is necessarily more and more charged with surfaceemanations. Hence, therefore, the wards in summer underthis system will be cooler and fresher with closed windows thanthey could possibly be with open windows, admitting air of amuch lower elevation. Hence also it has been a common re-mark with strangers visiting the wards, that they felt as if

they were out of London, and sniffed the pure air with relish.Wherever a chimney is led into the fire shaft, you will readily

understand that the draft must be a good one, and that thefire in the grate will burn well. But the absence of a fire is avery small evil. I am aware it is the usual complaint of theEnglish in the stove-warmed rooms of Germany, but it doesnot hold good in practice; for if the room be thoroughly com-fortable in every part, one thinks as little of a fire in winteras in summer.

Let me assure you there is no chilliness in the air enteringthe perforated zinc plates of the wainscot. Behind these platesare the hot-water pipes, so that the air enters the ward at atemperature considerably above that of the ward itself. It istrue that, amongst other vagaries, the committee allowed theventilation to be renewed in 1855, but refused the warm-waterapparatus. In 1857, they re-established the warm-waterapparatus at some cost; but Mr. Grissell also established the"foramen Grissellii," and cut off the ventilation !

Lastly, as to the expense. There is no doubt but that during

the seven years of ventilation (when we lost only eight patients)the waste of coals was enormous. The matron " would havenothing to do with it," and no supervision was exercised. In1855, the head midwife, Mrs. Fountain, took charge of it forme. I reduced the fire to a fourth of its former size, and, afternumerous trials, satisfied myself that efficient ventilation mightbe kept up at the same cost of coals as one ward fire ; so thatknowing this fact, you will scarcely consider the expense to beone of the drawbacks.

I am, Sir, yours, &c.,EDWARD RIGBY, F.R.C.P.,

January, 1858. Late Senior Physician to the General Lying-in HospitalEDWARD RIGBY, F.R.C.P.,

Late Senior Physician to the General Lying-in Hospital

THE INFLAMMATION AND BLOODLETTINGCONTROVERSY IN 1810-20.

[LETTER FROM DR. J. B. SANDERSON.]

11 large bleediii.-S neither are, nor ever were at any period of man’s history"a fit and proper remedy in internal inflammations."-Dr. Markham, TUELANCET, Nov. 14th, 1857.

" There is but one species of fever-viz., the inflammatory, and consequentlyvenesection is the only anti-febrile remedy. Such is the case in England atpresent, and it must have beettso always, and in every part of the world."-A Writer of the time, (eire. 1820,) quoted by Dr. Graves.

To the Editor of THE LA..""cET.SIR,-I take the liberty of sending you two characteristic-

quotations. The comparison between them is striking. The

writers, while they differ widely in their estimation of blood-letting, agree as remarkably in holding the opinion, each inrespect of the practice of his own time, that what is must everhave been; that if bleeding be right now, it must have beenright always, and the converse.During the first twenty years of the present century, a great

revolution, similar, but in the opposite direction, to that whichhas occurred in more recent times, took place in the prevailingtreatment of fevers and internal inflammations. At the com-mencement of that period, the aspects of the disease seem inmany respects to have resembled those with which we are nowfamiliar. The fever of 1795-1805 required the early use ofstimulants, and venesection, when employed in accordancewith the practice of Cullen, was often followed by fatal results.Even in cases of acute pulmonary inflammation, Dr. Willan:’observed that the use of cupping, blisters, and antimonials wassuccessful, while those patients who had been bled before-coming under observation often died. It is difficult to trace-the successive changes by which the asthenic tendency somanifest in 1810 gave way to the opposite " constitution"which prevailed in 1815. It is not, however, the less certain,that about the period in question all acute diseases underwenta remarkable modification as regards their mode of termination’and the direction in which danger was to be looked for. If wecompare the descriptions given by Dr. Bateman of the internalinflammations of 1804 and 1805 with those which were preva,-lent in London during the intensely cold winter of 1814, alsodescribed by him, it is impossible to resist the conviction, that.if he was right at the earlier period in employing a treatmentanalogous to that which is at present in use, he was also right,in 1814 in again having recourse to the lancet.From 1815 to 1830 bleeding and the antiphlogistic regimen,

constituted the prominent treatment, not only in the pulmonaryinflammations but in fever. The lancet, however, did not gainthe ascendancy without a controversy-a much warmer one,probably, than its counterpart in later times. Just as theolder physicians are now the supporters of venesection, theywere then its opponents; while the younger, the Bennetts ofthat time, guided as they thought by pathology, but in realityby direct observation of the good effects of the new practice,contended for its general adoption. It is a truth common toall periods in the history of medicine, that those who are en-gaged in its practice, believe themselves, and profess to others,to be guided rather by pathology than by individual experi-ence. Thus, the stimulant treatment of fever, which prevailedat the commencement of the century, was supposed at the

, time to be founded upon the Brunonian pathology; whereas,what Brown really did was, to elaborate into an ingenious

system the notions which already existed in the minds of prac-tical men. So also, two years later, bleeding and antiphlo-

gistics were in use long before Broussaism was heard of. Here,again, it was not pathology that taught men to amend their

* Willan, Reports on the Diseases of London, pp. 3, 4. 37. 55. &c.