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aid in the resolution of inflammatory products. I reason from its clinical use in pelvic inflammatory effusions. We can not expect that of itself it will curtail the inflammatory process, when its curative action as such resides in its products. Its employment by most physicians is throughout the course of a pneumonitis; they explain its action in the light of a hypothetical stimulant. Some of the ammonia salts, like the carbonate, undoubtedly fulfill this purpose, but in the direction in which this exerts its curative effect I deny this action. Entertaining such a view, then, I should give it at the second stage in small and frequent doses, thereby creating a current, as it were, of hydrochlorates through the vessels. Especially is it valuable when the resolution of the exudate is delayed-when the case shows a chronic tendency. I believe that under these circumstances it is very active in aiding absorption. This is the analogue of its use in pelvic effusions, which always become chronic. The absorption of the exudate in lung tissue is much more rapid, and here the salt will exert its full power as a physiological remedy.

QUESTION V.

IS BLOOD-LETTING EVER INDICATED IN THIS DISEASE, AND, IF SO, WHAT ARE THE CIRCUMSTANCES INDICATING AND CONTRADICTING THIS MEASURE OF TREATMENT?

DISCUSSED BY

SIMEON T. CLARK, M. D., of Niagara County, and
CHARLES S. WOOD, M. D., of New York County.

DR. S. T. CLARK.

I WELL remember my preceptor's caution, when leaving for my first course of medical lectures. Said he: "Bleeding has gone out of fashion, and you will be taught in every possible way how to avoid it. Well, that, perhaps, is as it should be, but let no school wrest from you the right of discrimination. He who lacks the judgment when, and the knowledge how, to bleed freely in certain cases of pneumonia and puerperal eclampsia is not qualified to practice medicine. Especially is this the case if he be without the requisite courage." I am not opposed to any theory that may be advanced, believing that all the essential characteristics of true pneumonitis may be developed from a variety of sources, and from very opposite causes, under different circumstances. When from any cause the normal status of an individual has been disturbed, and a pathological condition. has been developed in the parenchyma of the lungs, which, for convenience' sake, is called inflammation, we have pneumonia. I also recognize the fact that in this, as well as in most if not all diseases, there are exciting and predisposing causes; and that on the proper demonstration of this medical proposition rests the superstructure of rational therapeutics. There seems to me nothing incongruous in admitting a plurality of causes for pneumonia, as well as for any other inflammatory disorder, and we have just as good warrant for numerous and diverse modes

of treatment. After reading some of our modern authors, the conviction is brought home that the observer of pneumonia, as met in our eleemosynary institutions, is not a safe exemplar for the country practitioner. As conditions differ, so should customs. In medicine, in particular, there should be no cast-iron rules. Hence, varied and very divergent lines of treatment have been popular from time to time in the profession. A great name has given currency to one doctrine and time-honored tradition to another-the liberty of choice being considerately left to the profession. Happy is he who is full of resources, and equal to any emergency. Lawyer-like he may argue for the lancet, the blister, the cold bath, tonics, sedatives, or what not, and will acquit himself before a jury of his peers; but, what he claims for himself let him yield to others. The banishment of the lancet was never altogether quite complete. Every extreme is followed by its corresponding opposite, from the Sangrado bleeding to its almost criminal neglect. Can we be quite sure that the cups, the leech, and the lancet have not been unjustly prohibited, and that they are not entitled to a re-instatement? The reaction in their favor appears to have begun. Some, like the late Dr. Gross, of Philadelphia, have openly advocated venesection, claiming that it should no longer be among the lost arts. I recognize, at least, two conditions of the disease under discussion indicating the necessity of blood-letting, and these are best presented by the history of the following cases:

CASE I.-W. W. H. P., single, age twenty-three years, weight one hundred and eighty pounds, height five feet ten and a half inches, temperament sanguine, complexion florid, previous health uniformly good. After plowing, during a pronounced thaw, until "dripping in perspiration," without a change of clothing, he jumped into a top-wagon, and after a spirited drive arrived just too late for his train. On his return ride, it being now dark, he was obliged to face the wind, which at this time was blowing a gale, the sleet and frozen rain briskly falling. After proceeding with his companion only about a mile he began to shiver, and so markedly that he found conversation difficult. At the end of the third mile he shook so violently, and was suffering such extreme

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pain in his right side and throat, that he surrendered the reins to his companion, who, throwing the lap-robe over his head and face, made all possible speed. On his arrival at the house, it was with great difficulty that he could get from the vehicle to the door, but, once within, his mother soon resorted to the usual pediluvia, sinapisms, bottles of hot water, and woolen blankets. He passed the night-an exceedingly stormy one-bolstered up in bed, almost in an upright position. His chill did not cease before nine o'clock, having lasted over three hours, but of this he had no recollection. Ilis mother said that from half-past nine until midnight he seemed to sleep, although he groaned at every breath, and every groan ended in a little hacking cough. At 1 A. M., the chill having merged into a fever, he began to throw off the clothes and ask for drink. His thirst was satisfied by a ptisan of mint and pennyroyal, of which he drank copiously. From this time until daylight the fever seemed constantly to increase, and the servant having returned was dispatched for me. After some delay, mainly due to the heavy, muddy roads, I arrived at 8 A. M., when I found him in a condition so closely approaching death that I was exceedingly alarmed. His face was nearly livid, lips were swollen, and eyes suffused; the alæ of the nose kept rhythm with every respiration, the nails were purple, and, to crown all, the radial pulse was almost imperceptible. Nor should I forget to mention that the breathing was bronchial, and the vesicular murmur well-nigh wanting. Need I say that after twelve ounces of blood had been abstracted his muttering moans were heard no more? "Oh, that feels better-my pain in the side is all gone!" he exclaimed, as he recognized me with a sigh of relief. He soon vomited the fluids which he had taken, and thus demonstrated the fact that the stomach had failed to dispose of its contents. Sixteen ounces of blood were allowed as the limit of the venesection.

It is unnecessary to follow the details of this case further than to say that a moderate pneumonia was developed on the right side, with the usual amount of rusty sputa, an average temperature of 103.5°, ending in the establishment of convalescence on the eighth day, dating from the chill. He made a perfect recovery. The subsequent treatment consisted of expectorants, diluents, and local poultices.

Here it may be urged that the blood-letting did not prevent the pneumonia. This I willingly admit, but at the same time. claim that, but for the blood-letting, the patient would never have lived to develop an inflammation.

CASE II.-Mrs. J. B., aged sixty, large and muscular, accustomed to rigorous manual labor, while rowing a boat on Sawyer's Creek, on the morning of the 5th of April, 1875, lost her balance and fell overboard. She was in the water only a few moments, and dry clothing was quickly procured, but the same evening she had a slight chill followed by marked febrile symptoms. On the fourth day Dr. B., her attendant, pronounced her case a mild. pneumonia of the lower lobe of the right lung. For ten days her condition was not much changed, cough troublesome, sputa dark and abundant; she was able to eat a little at each meal-time, slept at intervals, and was not considered in particular peril.

On the evening of the fifteenth day of her illness, Dr. B. was startled on entering her room to find her in great apparent distress for breath, her eyes protruding, pupils contracted to a point, lips and extremities of a cyanotic appearance, skin flabby, and bathed in a profuse, cold perspiration. He learned that she had been gradually growing worse since morning, having at that time without assistance slipped from the bed to a commode, and in an exhausted condition slowly crawled back to her couch.

About 9 P. M. I saw the case in consultation, and found the cardiac and respiratory muscles almost ready to give up. In this case, as in many others, the great labor had fallen on the right ventricle, and a passive congestion was present in the pulmonary circulation. The blood was slowly but surely engorging the veins and capillaries, in consequence of the obstruction to the outflow from the imperfectly emptied heart. Dr. B. informed me that he had been giving stimulants freely since his arrival, two hours before, but without benefit, and that the antecedent treatment had been mainly negative, so far as active medication was concerned. Convinced that a small quantity of blood rapidly taken would immediately lessen the amount of work to be done by the well-near exhausted heart, I abstracted less than eight ounces, which caused the organ to respond instantly to the alcohol that before had been ineffectual.

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