intervals of twenty-four hours. A feeble pulse and great depression do not necessarily forbid bloodletting. The pulse often actually regains fulness, and the patient strength, while the blood is flowing. This was particularly marked in the epidemic of 1815, when the enfeebled powers and the pulse acquired strength even after a fifth or sixth bleeding! It is quite otherwise when the weakness, instead of coming on suddenly at the beginning of the attack, has long preceded it, and when the patient has been exposed to weakening causes. In this truly adynamic pneumonia, bleeding increases the weakness, and we ought to abstain from it, or only employ it watchfully, and as a test (p. 244). It is particularly at the middle period of life that large bleedings are of service. In children, and in the old, they ought to be practised with reserve. Pinel, after a fatal experience, entirely abandoned bloodletting at the Salpêtrière in old women of seventy. Although, in the opinion of Chomel, bloodletting is, as a rule, greatly to be ferred to leeches, yet they often give complete relief when the pain in the side is very acute and superficial. pre We shall see whether the precepts of Chomel tally with his practice by studying the reports of Louis in the Archives' for 1828, and of Grisolle in the 'Journal Hebdomadaire' for 1836, and that in the Gazette Médicale des Hôpitaux' for 1850. Louis gives a résumé of 78 patients treated by Chomel. These were all in perfect health before the attack. He rejected 45 cases in persons previously affected for a certain period with pulmonary catarrh. All the 78 cases were bled: 28 died, or 1 in 211. 41 were bled for the first time during the first four days: 18 died, or 1 in 2; 36 from the fifth to the ninth day: 9 died, or 1 in 4. In the series of 41 bled early, 8 were above the age of sixty, of whom 7 died! In that of 36 bled later, 4 were above sixty, of whom 2 died. Notwithstanding Chomel's wholesome rule as to caution in the use of the lancet in old persons, he bled 12 aged patients, and some of these with unusual severity: 9 died. One patient of seventy-five was actually bled seven times! and another once at the extreme old age of eighty-five! We cannot wonder at the fatal issue in cases thus handled. The same rigid plan of bleeding observed by Louis from 1821 to 1827, was carried out under the eyes of Grisolle from 1832 to 1836. The very old, from sixty to seventy-seven, were still bled, and all died! Those in hopeless depression in the third stage were still bled, and all (6) died. Two of these raised prune-juice sputa. They had all one or more bleedings, tartar emetic, and blisters on the chest and legs! The bleedings appeared to Grisolle to hasten the fatal end, especially in the cases raising prune-juice phlegm. The total amount of blood taken, varied from about one pound to nearly nine pounds, the average loss being between two and three pounds. Chomel, in 1850, according to the reports in the Gazette Médicale des Hôpitaux,' still laid down the same discriminating rules, and still practised bleeding indiscriminately, even in the feeble and the very old. In one case there narrated, an old woman of seventy, who had been subject to catarrh for twenty years, was bled, and, being of course weakened by the bleeding, then blistered. It is clear that the practice of Chomel had not at that time been modified by any real or supposed change in the type of the inflammation. It is, however, too evident that Chomel, however sound his precept, is altogether wanting in discrimination at the bedside. It is painful to see the same fatal errors in practice repeated by him during three successive decades, and that the sad catalogue of fatal cases among the female, the weak, and the aged patients-among those affected with pneumonia of the whole of one, or portions of both lungs-among those already sinking under the disease in the third stage-is again and again and still swollen by a blind and sanguinary routine. It is interesting to watch the career both of Louis and Grisolle, when separated from their master Chomel, they became physicians to the Hôpital de la Pitié. Louis added the results of his own treatment of pneumonia to those of Chomel in his work, Sur les Effets de la Saignée,' where he gives a résumé of 29 cases of pneumonia treated by himself in 1830-33. All these cases were in perfect health before the attack, and they presented every symptom and sign of pneumonia, including the characteristic viscid semi-transparent rusty sputa. These are therefore essentially picked cases, though picked on a rigid system; and they therefore, though comparable with each other, do not represent the actual success or mortality of Louis' practice in pneumonia. Louis, like Chomel, bled all his cases; but in two respects his treatment differed from that of his master. The first bleeding was larger-from thirteen ounces and a half to about twenty-seven, instead of from thirteen to seventeen; and in twenty of the cases he gave tartar emetic in large doses. Of the 29 cases 4 died, or 1 in 74. Tartar emetic, Louis states, caused a marked amelioration of the signs and symptoms. Six to twelve grains were given daily from the fourth to the seventh days of the illness. The convalescence of the cases taking the antimonial was however later by three days than in the other cases. This, as well as the great mortality under its use (3 in 20), Louis accounts for by the fact that it was not given until the repetition of bloodletting was forbidden. Louis is certain that blisters do harm rather than good, at whatever stage they are applied. He remarks that the greater the extent of any inflammation, the greater the probability of some other organ suffering. A blister is an inflammation that does not subtract from the primary inflammation, and is therefore actually added to it. It is certain that blisters increase fever if applied when the skin is hot and dry. These researches are certainly of value, but they omit many points a knowledge of which is necessary if we would compare them with other well-recorded groups of cases. The sex of the patients, and the stage and the extent of the disease, have, with age, the chief influence on the result. Louis enlightens us on none of these points excepting age, and in the résumé of Chomel's cases he does not even tell the age of the fatal cases; which he gives us incidentally in the memoir on his own cases published seven years later. As a specimen of the numerical method, these researches are therefore very defective. This memoir proves also that the numerical method is of little value, unless each case is a separate study, and unless the lifeblood of active thought penetrates the whole group of cases through and through. But though Louis' method is signally at fault in this work, the sagacity of Louis himself shines out. The narrow limits within which bloodletting is of use; the value of tartar emetic; the harm caused by blisters at the time, and afterwards; the causes, irrespectively of bleeding, of the quicker convalescence of cases admitted and bled early; the approach of the natural term of the disease as the cause of the more immediate yielding of the various symptoms and signs after late than early bleedings;-all these points and others, are brought forth by Louis, but not through his méthode numérique. Not one of these points would he have made out by counting: they are the result of the Newtonian method of always thinking towards a foreseen aim. In 1840, Grisolle (p. 460) treated 11 young persons affected with pneumonia of a favourable character with rest, diète, and diluents. He at the same time treated 13 similar cases with one or two bleedings, performed, on an average, on the fourth day. All the patients recovered. In those not bled, the sputa, on an average, ceased to be rusty on the ninth day; in those bled, on the sixth. The pain in the side, in those not bled, was better on the fourth or fifth day, but did not yield until the fifteenth. In 3 it lasted to the twentieth and twenty-fifth. Four of these cases were cupped, owing to the obstinacy of the pain. The pain was invariably relieved in the cases bled, and disappeared in from two to twelve days. Fever went in ten days in those not bled; in seven in those bled. signs in the cases not bled began to yield towards the end of the second week, four or five days after the cessation of fever, and persisted to some degree until the twenty-second or thirtieth day. In those bled, the lung had recovered its permeability in ten or twelve days. The In Italy, Rasori,* in the early part of this century, carried bleeding to an extent * Archives Générales de Médicine, tom. iv. greater than any of the French physicians, including even Sauvages. Rasori bled many of his cases, a pound at a bleeding, night and morning, for days in succession. In the following case (p. 436) he carried his plan to the farthest stretch. A young man, aged nineteen, was admitted on the first day of an attack of pneumonia, which did not seem very formidable at first. In addition to the other symptoms, he bled from the nose, and vomited bile. He was bled that evening, and twelve grains of tartar emetic were given; on the second and third days the vomiting had ceased; he then took half a drachm of the drug. The symptoms increased in severity until the ninth: during that period he was bled night and morning, and took 1 drachm of the antimonial daily. On the twelfth day the fever and cough diminished. From the twelfth to the fifteenth the tartar emetic was replaced by kermes mineral. There were abundant stools on the fourteenth and fifteenth, when the kermes was omitted. The improvement continued, and on the twenty-seventh he left "très bien guéri!" This young man was bled seventeen times, to about 222 ounces, took nearly one ounce and a half of tartar emetic, and two drachms of kermes mineral. This is the largest amount of blood that Rasori had taken from any one patient. The following table shows the character and result of Rasori's practice, as put forth by himself: Rasori gives this table to show the comparative severity of the cases. We give it to show the destructive effects of numerous bleedings. According to Rasori, patients affected with pneumonia tolerate the tartar emetic in enormous doses. As soon, however, as the disease lessens the tolerance ceases, and purging and perhaps vomiting comes on. Rasori's statistics have been discredited from more than one quarter. Archives' for May, Prato gives 80 cases Prato and Strambio, quoted at length in an article in the 1831, give a different account of the successes of Rasori. treated by Rasori, all of whom died but 9. One of them was a robust young girl, three days ill with pneumonia, to whom he gave 270 grains of tartar emetic, and who on the fourth day of the treatment was much purged; she was calm, her cough less violent, and she was in a state of oppression and universal feebleness, the supposed signs of approaching convalescence: she died unexpectedly. Two fatal cases, who had taken respectively three and five ounces of the drug in five and ten days, with tolerance almost complete, presented nevertheless great prostration, indescribable anxiety, and a pulse more and more feeble. Another took daily a drachm of the antimonial for a month, was attacked with aphthous ulcers in the throat, anasarca, and sore back, and died suddenly when apparently recovering. One young man took the tartar emetic, and was bled on the fifth day of the attack; he continued vomiting till the twelfth, still taking one or two drachms daily. On the eleventh, no pain, breathing deep and easy, but so low that he could scarcely speak; pulse irregular; skin cold; tongue dry; thirst intense. Still, still bleeding and antimony! Death on the twelfth. In another, on the eleventh day, extreme depression; pulse feeble; features relaxed; rattle. Tartar emetic 144 grains, bleeding to ten ounces; at the end of the bleeding the sick man fainted and died! Now, these deaths were not from pneumonia. Strambio, Prato, and Macchi testify that very many left Rasori's wards cured of the pneumonia, but with a chronic, incurable, and fatal diarrhoea! Acerbi* gives a summary of 142 cases of pneumonia treated in the hospital of Milan with bleeding, usually night and morning; and tartar emetic, four to eight grains daily. Of the 142 cases, 16 died, or 1 in 9; 4 of those who died had been bled from three to four times, 5 from five to eight times, and 7 from nine to thirteen times. Thirty of the 142 were bled from ten to twenty times, twelve ounces each time, who therefore lost from 120 to 240 ounces! One robust countryman was bled nineteen times in twelve days, and took tartar emetic for ten days, when it was exchanged for kermes mineral. He survived! But when he left the hospital after sixty-nine days he had oedema of the legs, diarrhoea, excessive pallor and weakness. One strong country fellow, who had been cured (!) of pneumonia on the previous January by eighteen bleedings, and who had been sickly during the intermediate four months, was readmitted in May, on the eighth day of a second attack. He was actually bled fifteen times in nine days, and took tartar emetic the while; he died on the twenty-eighth day, after being bled thirty-three times during the two attacks. But they had their successes. One strong high-coloured countryman went out perfectly well on the twenty-sixth day after being bled twelve times; another in thirty-three days, after eight bleedings and twenty-four leeches. A pale sempstress was bled nine times, lingered on in the hospital for fifty-six days, falling into a slow consumptive fever; she was then fortunately transferred to the infirmary for chronic diseases, where she was plentifully fed, and comforted with wine; she left at the end of a month with a slight cough, but with a fine colour, joyous health, and in good flesh! Laennec adopted and modified Rasori's method. He bled usually but once at first, taking from nine to seventeen ounces, and then gave one grain of tartar emetic every two hours for six doses, when a rest of seven or eight hours was allowed, unless the symptoms were urgent. He continued the treatment while tolerance lasted, or crepitation was heard. He thus treated 28 cases of pneumonia in the year 1824, of whom 1 died; and 34 in 1825, of whom 5 died; total mortality, 1 in 103. While he speaks of losing so few on this plan, he however states that he had seen several cases of pneumonia die complicated with severe pleurisy, and others with cancer, phthisis, heart disease, &c. M. Bouillaud, in the 'Dictionnaire de Médecine,' xvii. 398, throws a doubt on the accuracy of Laennec's statistics, on the testimony of Lecouteulx, Aide de Clinique, who states that 9 out of 17 cases of pneumonia admitted in 1825 died, and 3 out of 13 in 1826. The discrepancy can only be explained by the fact that Laennec admitted slight cases into his list; and, as we may infer from what he states, that he excluded complicated cases. Probably M. Lecouteulx knew more about the patients in the deadhouse than the wards. Grisolle treated 44 cases with tartar emetic, and without bleeding. Six died, or 1 in 7; average age of the deaths, above fifty. The pain was never relieved by it. The pulse and breathing were less quick, the sputa were less tinged, and the signs were ameliorated in a considerable proportion at the end of twenty-four hours. Grisolle quotes the practice of the following physicians who employed tartar emetic, some with, some without bleeding:-Bang, of Copenhagen, treated 54 Annotazioni di Medicina Pratica. cases with the antimonial, mostly after a single bleeding; of these 2 died,=1 in 27; only 2 were above the age of sixty. Ruef treated 94 cases with tartar emetic, combined with bleeding; the cases were not complicated; he lost 5,1 in 18. Peschier, of Geneva, treated his cases with antimony, and without bleeding. He states that he lost but one. M. Peschier's memoir seems to be wanting in details; and the author of an article in the Archives' for 1831 treats him and his cases with ridicule. Trousseau treated 52 cases in l'Hôtel Dieu, under the eye of Grisolle, without bleeding, and with tartar emetic. Only 2 died, or 1 in 26. He remarks, that on this plan four days often sufficed to lead the patients to apparent health, though the local signs still remained. Thielmann* treated 110 cases with tartar emetic, six grains daily, without bleeding. If there was diarrhea, he gave opium also. Of the 110 cases, 12 died, =1 in 9. Seventy-seven were males, 9 died,=1 in 85; 36 females, 3 died,= 1 in 12. Fifty-seven of the cases were in the first stage, none died; 32 in the second stage, 3 died, 1 in 103 24 in the third stage, 8 died,=1 in 3. Schmidt treated 37 out of 54 cases with tartar emetic, without bleeding. The mortality of the whole 54 was 12,-1 in 44; that of 37 cases treated with antimony was 4,1 in 94. Fourteen of the cases took opium in some form, of these 6 died,-1 in 2. Skoda has only had occasional recourse to bleeding during the last twelve or thirteen years. Dr. Balfour watched Skoda's treatment during May, June, and July, 1846. He employed no bleeding, but gave extr. graminis in scruple doses, or nitre five to twenty grains, or sublimate a quarter of a grain, with occasionally six grains of Dover's powder, in the course of the day. 45 cases were so treated; only 3 died, 1 in 15. Skoda informed Dr. Balfour that his average mortality during the three preceding years, during which bloodletting had seldom or never been performed, and leeches or cupping glasses had not been applied, was 13.7 per cent. In 1840 he treated 64 females affected with pneumonia with large bleedings and large doses of tartar emetic, and only lost one; yet the deaths amongst the males in the same year made the total deaths amount to 1 in 8. That he conceived to be the general average under all modes of treatment. The great advantage of not bleeding was, he considered, the speedy recovery. Dr. Balfour (loc. cit.) watched the treatment of 19 cases of pneumonia, examined by himself, at the Homœopathic Hospital under Fleischman; of these, 3 died, 1 in 63. The publication by Dietl of his comparatively successful treatment of pneumonia without bleeding, induced many physicians to follow his example. While, however, they refrained from bloodletting, they usually gave medicine of some kind or other. We have already seen that Thielmann and Schmidt, and previously to them Peschier, Trousseau, Bang, and Ruef, trusted to tartar emetic alone, in large doses. = Huss, in 1852, treated 242, of whom 15 died, 1 in 15. The larger proportion were between twenty and forty years of age; 8 were between sixty and seventy. Pneumonia was complicated with delirium tremens in 30, with pleuritic effusion in 27. Besides these 242 cases, 13 were admitted in a dying state. Huss at first gave up venesection, and only cupped; at length he deserted cupping. In a large portion of the cases, bleeding, general or local, had been already performed. The general effect of the treatment without bleeding was quick resolution and rapid convalescence. Huss considers that bleeding is only useful in the congestive stage, which is rare in his wards, and that it is injurious in the second stage unless congestion is still present elsewhere in the same or the opposite lung. Huss considers that what does good to pneumonia at one year or period, does harm at another. Kissel|| never bleeds. He considers that pneumonia lasts thirty-five days when * Canstatt's Jahresbericht, Bd. iii. 231, 1859. |