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These two cases present to my mind the indications for the judicious resort to venesection. The intercurrent and complicating pneumonia of typhus, enteric, and rheumatic fevers; of rubeola, pertussis, erysipelas, and mania a potu; more rarely of phthisis pulmonalis, diabetes mellitus, and valvular disease of the heart, do not call for the use of the lancet as a remedial measure. This I state as a rule. There is one condition, however, in the course of pulmonary consumption in which blood-letting has proved, in my hands, a most prompt and marked measure of relief. I have often observed that in such patients as suffer from slight but repeated attacks of hæmoptysis, the destructive process is less rapid than in those who never bleed from the lungs. When I meet with a condition of active congestion, simulating the complete stasis described in Case I, marked by acute pain in the side, I use the wet cups, for the immediate relief of the pain, and I verily believe that I sometimes arrest the progress of the disorder.

DR. C. S. WOOD.

Is blood-letting ever indicated in acute lobar pneumonia? Recent authorities say "almost never." Experience says, yes, frequently. The learned propounder of these eight questions admits that it is admissible in certain cases as a palliative, and perhaps to some extent as a curative measure, by reason of the promptness of its action. But I do not propose quoting authors, as their varied views and opinions are well known to all. It is generally admitted, at the present day, that the frequency of venesection, as formerly practiced, is neither called for nor justified, since we now are dealing rather with a specific or local disease than with the effect of such disease as manifested by the general constitutional disturbance.

By far the greater number of cases of pneumonia are found to occur in persons of unsound constitutions, with a vitality lowered by a great variety of causes--e. g., the abuse of alcohol, chronic organic changes, malaria in its protean manifestations, poor food, unhealthy surroundings, overtaxation of either mind or body, or overbathing, etc. In this class, which forms so

large a part of our patients in towns and cities, the abstraction of blood, except perhaps locally, is not to be considered, and is not by the intelligent physician practiced. But a minority, particularly in our cities, may be greatly benefited, provided they be bled early, say within the first twenty-four hours. This is especially true when the pleura on one or both sides is involved, and this is not an infrequent happening. It certainly does relieve the suffering; and do not claim me as an optimist if I say that it may save life. Who of us, having been in practice thirty or more years, has not seen the greatest relief afforded by venesection in the case of a man in the full vigor of life, suddenly attacked, first by a chill, followed or accompanied with a cough, a high fever (temperature 103° to 105°), hurried respiration, severe pain in one side, thirst, anxious expression, and surface of body, more especially of the face and lips, etc., cyanotic? Twenty-four ounces of blood from the arm have been all that was required to change the gloom of relatives into joy, for relief has only antedated recovery.

I shall not now combat the prevalent opinion of its being a general, specific disease, with a local lesion merely, for it does seem to me inexplicable that not alone should the lung tissue be involved, but that in many, and perhaps most of this class of cases, the inflammation extends by continuity to the pleura, and often to the membranes of the heart as well. But admitting for the nonce that it is not sui generis—that it is a specific disease-does that lessen the importance of this mode of treatment, when the principal cause of death is the failure of the heart's action, the right side having been taxed beyond the limits of endurance?

QUESTION VI.

IS ALCOHOL USEFUL IN THE TREATMENT OF CASES OF ACUTE
LOBAR PNEUMONIA, AND, IF SO, WHAT ARE THE
INDICATIONS FOR ITS USE, AND HOW IS ITS
USE TO BE REGULATED AS REGARDS

THE QUANTITY GIVEN, ETC.?

DISCUSSED BY

JOHN SHRADY, M. D., of New York County, and
E. D. FERGUSON, M. D., of Rensselaer County.

DR. JOHN SHRADY.

IN approaching the therapy of this disease, all expect to be beset by difficulties many and various. Being the most obvious of maladies, from the days of Hippocrates down to the present, pneumonia in treatment probably represented the usages of every school which at any and all times swayed professional opinion. Having a typical history, and running its course with rapidity, it furnished opportunities for observation which were improved to the utmost by the medical philosophers of every age. As a curious commentary upon our art, and despite adverse criticisms upon the practices of predecessors, fairly sifted statistics show but little progress in results. We are ever obliged, indeed, to separate numbers from cases. To put it more clearly, the average mortality of the disease (one in three and one in five) has remained at about a fixed point. There have doubtless been much twisting in the way of excuses for this mortality and some exaggeration of the gravity of individual cases, but the fact still remains, even in the widest columns of figures. Every remedy and every mode of treatment has been tested-great names have shed luster upon plausible theories and yet we waver in our faith.

Without discussing the question whether or not the type of the human constitution has really changed, our predecessors appear to have been equally well satisfied with both venesection and nihilism. No one authority has claimed to have cut short the disease by any method, but only to have allowed of a more speedy recovery. Luxury-and I use the term in its most iberal sense as a synonym for increased comforts—while it has weakened the resisting power, has actually gained in "the expectation of life." Hence, the difficulty of discrimination between cures and recoveries meet us at every turn. In all our nosology there is nothing comparable to pneumonia for individuality, and of necessity, therefore, there can be no such thing as a test case. Furthermore, without parallels there can be no mathematics, and without mathematics there can be no criticism of methods. Perfect analogies can not here come into play in the settlement of doubts.

Most writers deprecate all attempts at routine treatment, but from the time of the ancients down to a comparatively late period the reliance of physicians has been mainly vested in expectancy. What has justly been termed nursing, together with the close study of nature, was most in vogue. The "restorative method of Bennett," and "meeting emergencies as they arise," are synonymous expressions of the same ideas of practice. Active interference in the treatment of all acute diseases, notably by large bleedings, sometimes indiscriminate and remorseless, succeeded to the doctrine of "vis medicatrix naturæ," by way of reaction. Even at the present time there may be found survivors of the first semi-centennial of the present century who can show many scars of the lancet, some of whom practiced venesection as a merely prophylactic measure at the beginning of every spring. Venesection, in fact, became a ceremony of purification. Broussais (1816), in the disease under discussion, bled to syncope; so did our own Rush, and such was generally the custom. Laennec, who recognized the connection between lesions and symptoms, opposed copious bleedings (ten to sixteen ounces), but, becoming dissatisfied with his statistics, faltered, and subsequently followed Rasori in giving antimony in rather

full doses. Louis entertained similar views, and in this connection it may not be out of place to quote Watson, who, not without reason, advocated early bleeding as tending to abort the exudative stage. "Both reason and experience," says he, "attest the especial power of bleeding upon acute pneumonia. Very lately one most distinguished French writer, M. Louis, has endeavored to show that venesection has not much control over the progress or event of pneumonia; and I advert to his opinion on this subject merely to caution you against being misled by it, as you otherwise might be, considering his well-merited reputation as an exact and faithful observer."

Trousseau, who condemned the practice of exhausting the disease by exhausting the patient, still held somewhat to the antiphlogistic method, and in particular vaunted the praises of antimony, but in diminished doses. But, judging from the guarded qualification of statements, we may infer that none honestly plumed themselves upon results. Thus far, this short résumé has been given to represent the progress of professional opinion. As there was not much of wholesale condemnation and bitter controversy, the inference is clear that nowhere was there much stubbornness of conviction. All were pretty much left to their own devices.

Dr. Todd,' in 1853, reported eighteen cases of typhus fever, the treatment of which consisted in administering ether every half-hour or every hour, day and night, from half an ounce to an ounce of brandy, with a draught every second hour containing ten minims of chloric ether and five grains of carbonate of ammonia. "Subsequently," adds Stillé, "Dr. Todd and his disciples fell into the error of extending this treatment to all acute diseases." Pneumonia accordingly presented itself as an inviting field, and was soon occupied. Niemeyer, who, along with Magendie, Skoda, Schmidt, and Legendre, represented the Vienna, or expectant, school, protested to the following effect:

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"By giving large doses of camphor, musk, and strong wine, we are often able for about twenty-four or thirty-six hours to support the action of the heart, arrest the progress of the œdema, 1 "Times and Gazette," August, 1853, page 217, quoted by Stillé.

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