*

spanæmic or hypinotic blood. The earlier the bleeding, the better. M. Louis has shown that pneumonic patients, bled within the first four days, recover, cæteris paribus, four or five days sooner than those bled at a more advanced period; and Dr. Jackson, the enlightened practitioner of Boston, has proved that by bleeding on the first day, the mean duration, in a mass of cases at the Massachusetts Hospital, was lowered from 14.6 to 11 days. No period of the disease is too late for blood-letting, provided the indication be thoroughly and strongly established on general principles. Even the stage of suppuration is by some held not to be a contra-indication, in itself alone, to the use of the lancet; but, although the name of M. Andral appears among those of the supporters of this doctrine, I have the strongest doubts of its correctness. M. Grisolle refers to four patients, bled to ten or twelve ounces, and in whom postmortem examination (the sole positive test) proved the existence of the purulent stage. In all four cases, the fatal issue was obviously hastened (in one almost immediately caused) by the loss of blood. No fixed rule can be laid down for the quantity of blood to be drawn; the mean amount of four pounds five ounces, taken from his patients by M. Bouillaud, has been most satisfactorily proved by M. Grisolle to have produced no more favourable immediate results (and of the ultimate ones what may not be feared?) than the abstraction of a mean quantity of two pounds seven ounces from a mass of patients treated by himself and others. For my own part, I strongly question the

* Appendix to Putnam's translation of Louis on the Effects of Blood-letting. Boston, U. S., 1836.

There is an anatomical fact but little known, which may have some important bearing on the question of bleeding in the first stage. I mean the fact, that sometimes a lung apparently in a state of suppuration is in reality infiltrated with softened fibrinous exudation,-exudation cells alone, and no pus-cells, being found with the microscope. But who shall distinguish, during life, the case of softened exudation from that of suppuration?

Even in our own country, it was at one time thought by many that bleeding could scarcely be pushed far enough: men were systematically bled to convulsions. It was held theoretically sound to take away blood, the source of the existing evil, to the uttermost point; but it was forgotten, or it was not known, that the increased impetus of the circulation during hemorrhagic reaction might make up for the diminished quantity propelled. In those days, too, provided theory were satisfied, facts were held as matters of no importance. "Dr. Gregory, of Edinburgh," reports Dr. Watson, "used to bleed to the verge of convulsion. His colleague, Dr. Rutherford, seldom went beyond three bleedings, and generally accomplished his object by two. His patients recovered quickly; Dr. Gregory's very slowly." Yet Dr. Gregory continued to cling to his practice; for he had theory on his side.

utility of even such amount of depletion as this. Certainly, few cases have presented themselves to me in London practice, where it was necessary to draw blood oftener than twice; sixteen ounces sufficing in the first instance, and some ten or twelve in the second. Slow convalescence is not the worst evil in cases where blood has been too lavishly sacrificed: a form of spanamia is sometimes induced, which it may take months, nay years, to recover from.

Leeching, or rather cupping, over the affected part, should always be employed in addition (in very mild cases it will suffice alone) to general bleeding: local abstraction of blood affects pain much more directly and quickly than venesection. Six or eight ounces may, with propriety, be taken in a case of medium intensity (in addition to the quantity taken from a vein) by cupping: all local pain sometimes instantly disappears after the operation.

Tartarized antimony stands next in importance to blood-letting in the treatment of pneumonia,-were I, indeed, henceforth, in the management of this disease, forced to surrender either, on the one hand, venesection, or on the other, cupping and tartarized antimony, I should not hesitate to relinquish the former. In what manner this important agent produces its beneficial effects on the lung, is matter of the loosest speculation; that it does produce such effects, is the really important. point, and one of which scientific proofs abound. There is not any available evidence to show positively whether the effects of antimony on pneumonia are more marked when the mineral is (as it is technically called) tolerated perfectly or imperfectly, or when it is not tolerated at all. The question could obviously only be decided by numerical comparison; and the number of cases in which complete tolerance is observed (that is, total absence of effects on the stomach and bowels) is relatively very small. Improvement often takes place within eight or ten hours after the medicine has been commenced with, and without any notable effect on the alimentary canal being noticed; whereas recovery also ensues when it acts freely both as an emetic and purgative. Hence it is more as a result of prejudice (for what but prejudices are even plausible à priori theories?) than of logical deduction from experience, that, in imitation of Rasori and Laennec, I prescribe antimony in such manner and combinations as are most likely to prevent its disturbing the stomach. The salt should at first be given in doses of half a grain, com

bined with dilute hydrocyanic acid, paregoric, and tincture of orange-peel, every hour for the first three or four hours,—and the dose then increased, at intervals of two hours, to one grain: in the course of twelve hours the quantity may be raised to two grains,-its repetition made less frequent, say every fourth hour.

The constitutional effect of mercury is by some held to be peculiarly efficacious in the stage of red hepatization. It is even maintained that when that stage has been reached, calomel is a more valuable medicine than antimony. No scientific demonstration of this view exists. If it were correct, the value of antimony in hospital practice, at least, would be singularly small; for the great majority of persons, admitted into hospitals, have some amount of hepatization, when first seen. Mercurials appear to me to be desirable in those cases of pneumonia only, where, for some cause or other, antimony is inadmissible. It seems a point worth submitting, under proper conditions, to the test of experience, whether the free and rapid administration of alkalies might not be useful in pneumonia, attended, as it is, with the maximum amount of hyperinosis observed in any disease.

Blisters are not advisable in the earliest periods of pneumonia: it would appear that they have no effect in shortening the mean duration of the disease, and they certainly increase fever and general irritation at the outset of the attack. At its more advanced periods, when fever has been materially controlled, they certainly relieve pain and dyspnoea, and seem to promote absorption.

The ordinary juvantia of the antiphlogistic regimen must, of course, be carefully put in requisition; the bowels, if necessary, should be opened by medicine; but profuse purgation is, to say the least, absolutely useless.

Complete demonstration of the utility of treatment in pneumonia is found in the fact that the mortality of the disease steadily increases with each succeeding day it has been allowed to run its course uncontrolled. The statistics of M. Grisolle (referring to the treatment by moderate bleeding and tartar emetic) show, that while the mortality among those first seen and treated within the first two days, is only one-thirteenth, it rises among those whose treatment does not commence till the eighth day, from one-third to one-half of the whole number. But, on the other hand, it is important to remember that there

are certain conditions beyond the control of the physician, which exercise a most indubitable influence on the issue of the disease. Of all these, age is the most important: while at the two extremes of life (the new-born infant and the octogenarian) the disease is almost inevitably fatal; the mortality between the ages of six and twelve scarcely exceeds two-and-a-half per cent. Between the ages of fifteen and thirty, the deaths equal about six per cent. of those attacked; suddenly rise to about fourteen per cent. in persons aged between thirty and forty; and thenceforth steadily increases with each succeeding decade. Hence it follows, that in estimating the value of any system of treatment, the age of the pneumonic patients treated is an element of primary importance. There are periods of life at which it is next to impossible to save-there are periods of life at which it is not easy, with common prudence, to lose—a sufferer from idiopathic and sthenic pneumonia.

§ II. Chronic Pneumonia is rare as a sequence of the acute disease; it is rare as a primary disease; it is common as a local attendant on the progress of tubercle, cancer, and other adventitious products in the lung. I mean by chronic pneumonia, that form of disease in which an impermeable tissue is infiltrated with toughly-solid exudation (in the state of induration matter,) and where there is no tendency to a softening process; these are its main characters.

I. When acute pneumonia lapses into the chronic disease, the strength and flesh, instead of returning with more or less rapidity, continue to fail; there is habitual, though moderate, dyspnoea; sensations of discomfort and oppression within the chest are almost constantly present; cough, with insignificant expectoration, and no hæmoptysis, exists; there are thirst and anorexia, with irregular fever, which gradually grows constant, -has its evening-exacerbation, but rarely any notable nightperspirations: with all this, the loss of flesh may, for a time, almost equal that occurring in the same period in phthisis.

II. Physical signs mark the changes in the lung: the surface is more or less extensively depressed, according to the area implicated; the chest movements are impaired, especially the costal ones; the antero-posterior diameter, and the superficial width of the side are diminished; and the percussion-sound is dull (sometimes wooden or tubular,) with marked parietal resistance. The respiration is weak, uneven in quantity, harsh, bronchial, or diffused in the affected parts,-occasionally exag

gerated beyond these. The vocal resonance varies; it may be bronchophonic or null: the vocal fremitus is intensified. Chronic pneumonia has no rhonchus of its own; but there may be subcrepitation from bronchitis or oedema. In all probability, under favourable circumstances, interstitial creaking-sound may be produced by forced inspiration in lung-substance of this kind.

M. Grisolle refers to a case observed by M. Requin, which shows that the physical signs in chronic consolidation may be of a very different kind,-in fact, all of them negative: total absence of all healthy or morbid respiratory murmurs, of rhonchus, and vocal resonance, the percussion-sound at the time being completely dull. In the case referred to, the affection was mistaken for simple pleuritic effusion; but the patient dying in a state of marasmus two or three months after the outset of the affection, the sole morbid condition discovered in the chest was very firm (neither granular nor tuberculous) induration of the lower lobe of the right lung. This is a parallel state of things to that sometimes observed in acute solidification.

III. In cases where the affection principally implicates the upper lobe, and where the contraction of the exudation-matter thrown out into the substance of the lung has been active, flattening of the infra-clavicular region will take place. Under these circumstances, especially if, as often is the fact, among the general symptoms appear emaciation, slow fever, &c., the distinction of the case from tuberculous consolidation is extremely difficult-impossible, indeed, unless by the aid of repeated examinations at certain intervals of time. The comparatively stationary condition of the part in simple consolidation, associated with the progress of the general symptoms, if it do not perfectly explain the nature of the case, will, at least, point to the necessity of a cautious diagnosis. Fortunately difficulties of the class now especially referred to are of singularly

rare occurrence.

IV. The treatment of chronic pneumonia is not essentially different from that of the early stages of tuberculization. If the diagnosis were positively established, the occasional application of a few leeches, or the abstraction of three or four ounces of blood, might be more freely ventured upon, in the absence of all acute symptoms, than in phthisis.

§ III. The varieties of pneumonia are very numerous, and referrible to the seat, course, and primary or secondary character of the disease.