with antimony, twenty-eight days when left to itself, and seven or eight days when the "direct treatment" is adopted! Kissel treated 112 cases without bloodletting; 5 died,=1 in 223. He classes his patients into two groups. To one group, in which the urine is alkaline, he gives iron; to the other group, in which the urine is acid, and the crepitation and bronchial breathing are followed by sibilant and mucous rattles, he gives copper. Under this treatment he asserts that the dyspnoea soon lessens, the temperature falls, thirst slackens, the cough is less troublesome, and the sputa become gradually less red. Appetite and strength return on the second day. Kissel states that in the epidemic pneumonia of 1795, observed by Schmiedtman,* the disease was treated without bleeding or nitre. The crisis lasted five to fourteen days. The sick returned to their work in two or three weeks. Of 68 cases, 2 died, 1 in 34. Wittich abjures bleeding. He treated 23 cases, who all recovered, with calomel in three to six grain doses for adults, two to four for children. He pushed it until the gums were tender and the stools green. Cohnt treated 57 cases without bleeding, and with infusion of crocus, antimonial wine, tinct. of opium, and benzoin; 24 died, 1 in 2. The cases, like the treatment, were complicated. Among the complications were old age, debility, drunkenness, meningitis, apoplexy, Bright's disease, bronchitis, and other mala dies. Gandinig treated 25 cases without bleeding, and with calomel and opium. All recovered. Niemeyer only bleeds to relieve threatening suffocation, or to lessen the obstacle to the return of blood from the brain when it is congested. He never bleeds for the inflammation, and he agrees with Dietl that a more early, complete and enduring restoration takes place than by the bleeding plan. He applies cold wet cloths to the chest, repeating them every few minutes, with great relief. To the weak and old he gives iron. = De Bordes treated 90 cases, of whom 19 died, 1 in 41. 17 had double pneumonia, of whom 6 died. Of these, 2 were bled; both recovered. 11 were treated by local bleeding, of whom 2 died, 1 in 5. The local bleeding generally lessened the pain and relieved the anxiety in the chest. It did neither harm nor good to the inflamed part; in one case, however, cupping was followed by a decidedly quick resolution. 77 of the cases were not bled; of these 17 died,=1 in 4. Of the fatal cases, 2 were dying on admission, and some were lowered by ague, albuminuria, and heart disease. The mortality was due more to debility than to the want of bleeding. In 53 the recovery was very quick. De Bordes considers it proved that abstaining from bleeding is useful, since it leads to a quicker convalescence. Chloroform came into use in Germany in the treatment of pneumonia, soon after its discovery as an anesthetic agent. It remained in fashion from 1849 to 1856. Most of the chloroformers in pneumonia were also abstainers from bleeding. Baumgärtner** employed the inhalation of chloroform, not carried to narcotism, in 30 cases of pneumonia, of whom 3 died, 1 in 10. It relieves the pain in the side and oppression, lessens the cough, changes the glutinous into a mucous phlegm, reduces the fever, and lessens the pulse. The objections to it are, that it sometimes causes vertigo, headache, and lowering of the powers of life. As venesection is not mentioned, we may consider that it was not employed in Baumgärtner's cases. The same remark applies to the 90 cases of pneumonia treated by Wucherer in 1848 with the inhalation of ether or chloroform, 14 of them were private patients, 76 were soldiers-only 1 died, 1 in 90! Helbing reports in the same volume (p. 256), 62 cases, who were treated like Wucherer's, with the inhalation == Hufeland's Journal, Band iii. p. 441. Ibid., Band iii. p. 214. 1854. of ether or of chloroform, but who were likewise bled once or twice, and took tartar emetic. Of the 62 cases, 5 died, = 1 in 124. The following table shows the average time at which various symptoms disappeared: Varrentrapp gives, in a detailed and important memoir,* 23 cases of pneumonia treated by the inhalation of chloroform, of whom 1, aged 59, died,=1 in 23. The average age of the patients was thirty-one, oldest sixty-two; 21 were males, 2 females; the pneumonia was double in two; 2 of the cases had bronchitis, 1 jaundice; 1 was bled, 1 cupped, and 2 took calomel. In general, the inhalation while it was proceeding excited very soon a sense of increased warmth, perspiration, lessening of oppression and pain in the chest, diminution of cough, an effectual amelioration in the feelings of the patient, and a corresponding improvement of the fever, expectoration, and physical signs. The relief of pain and oppression lasted about an hour, when they returned nearly with the original severity, but less and less after each time. The pulse and respirations fell considerably under the influence of the treatment. After a few hours, when the symptoms had regained much of their intensity, the inhalation was resumed with the same happy effect. The rusty expectoration came afterwards, mixed with watery secretion. The daily number of inhalations varied from five to ten. On an average, seventyfour inhalations were practised in ten days and a-half; in one case, twenty-seven in five days, and in another, one hundred and sixty-two in fifteen days. One drachm of chloroform was used at each inhalation. The duration of the various signs and symptoms did not differ materially from that observed in Helbing's and Wucherer's cases. In most of the cases the treatment did good. Death was the immediate effect of the chloroform in the single fatal case. Stohamllt treated 30 cases in like manner, with the happiest results. In these cases the effects of each inhalation went off in from four to six hours. Hutava treated 12; Frohnmüller, 12; Theile, 6; and Salawa, 15; in the same manner, with chloroform, and without the loss of any. The two first refrained from bleeding, and Salawa only bled the robust and plethoric. There is a remarkable uniformity in the description given by these various observers of the happy effects of the inhalation on their patients. Although the tide had set so strongly against bleeding in Germany during the last ten years, it has within the last five years been resumed by several physicians with judgment and moderation. = = Wossidlot does not belong to the group of physicians we have just been speaking of; but he, like them, though at an earlier period, employed bleeding with great success in all his cases of pneumonia. Wossidlo employed both local and general bleeding, and gave tartar emetic. He treated 112 cases, of these 4 died, 1 in 28; 34 were children below the age of five, deaths 3, 1 in 11; 76 were between the ages of seventeen and seventy (5 above sixty), 0 died; 2 were above seventy, 1 died, 1 in 2. Wossidlo ridicules the successes of Krüger Hansen, who boasted that he had cured 71 cases without bleeding, and with acetate of lead and opium. Of the 71 cases, 36, Wossidlo states, were treated on the mere report of friends! Burkarts treated 60 cases of pneumonia, in 1854, with bleeding, when the medi cal constitution was decidedly inflammatory. Out of the 60 cases only one death, and in that case there were tubercles! Burkart makes some very sensible remarks as to the treatment of old people affected with pneumonia. They do not bear bleeding in any form. Tartar emetic is less influential on the pneumonia of the aged than of adults, and it often lowers them excessively. Forget gives a résumé of the visitation of pneumonia at Strasburg in the spring of 1855, when the temperature, from being warm, suddenly became very cold. 32 cases were admitted, of whom 7 died, 1 in 44; 2 had double pneumonia. All the fatal cases were complicated. Indeed, complications were the rule. 2 had tuberculosis, 1 followed typhus, 8 were in a typhoid condition, 5 had bronchitis, 3 albuminous urine, 1 meningitis. The illness lasted from one day to forty-eight, average fifteen and a half. General bleeding was practised in 21, local in 20 cases; 24 had tartar emetic, 17 had opiates, 11 were blistered. Petterst gives a summary of 43 cases of pneumonia, 7 of whom died, = 1 in 64; in 2 the pneumonia was double. In 10 of the cases leeches were applied; more than half had no treatment beyond rest and deprival of food. None of them seem to have been bled from the arm. Seützenbergert treated 48 cases of pneumonia in Strasburg during the winter six months of 1854-55; these 48 do not include the typhoid cases. The number of patients rose and fell with the fall and rise of the temperature. Of 48 cases 7 died, 1 in 69. Twelve acute cases recovered; bleeding and mercury were resorted to; 3 acute cases died, 2 admitted in agony: 1 had tartar emetic; 26 less acute cases had tartar emetic combined with acute phlogistic treatment; 25 recovered, 1 died; 2 less acute cases died, who had diffused hepatization, and were not treated; 6 cases of diffused engorgement, treated with acetate of lead and local bleeding, recovered. This enumeration makes 49 cases with 6 deaths. An error must have crept in somewhere. Eighteen of the above cases who, it is stated, were bled, locally or generally, recovered; 5 at least of the fatal cases were not bled. We shall reserve the consideration of Wunderlich's cases to a future part of this article. We have now passed in review a large body of evidence bearing upon the treatment of pneumonia, and more especially upon the treatment of this disease by venesection. We may fairly consider ourselves in a position to arrive at some general conclusions, and, if they are attainable at all in a question of therapeutics, to lay down some guiding principles in spite of the apparent contradiction of authorities. Bloodletting has been the main remedy relied upon for the treatment of pneu monia from the days of Hippocrates down to our own. The father of medicine himself, and such men as Sydenham and Huxham, used the summum remedium with moderation, apportioned it to the severity of the disease and the strength of the constitution, and refrained from it altogether when the patient was weak and the disease assumed a low type. They bled with discrimination. But from time to time reckless bleeders have, by their very excesses, caused others to rush into the opposite extreme, and abstain altogether from bloodletting. Nor need we wonder at these violent oscillations when we read that Heurnius took his four pounds of blood for pleurisy; that Bosquillon, the translater of Cullen, stimulated by that author, his three; and the elder Frank bled an octogenarian nine times; that Sauvages recommended for ardent pneumonia eighteen successive bleedings of eight ounces each, repeated at first every four hours; that Rasori, besides giving tartar emetic, bled one patient seventeen times in nine days; that Dr. Mackintosh says more mischief is done by bleeding too little than too much :-"I am not an advocate for the heroic practice of taking seventy or eighty ounces of blood Canstatt, Band iii. p. 158. 1857. + Prager Vierteljahrsschrift. B. i. p. 190. 1856. + Canstatt, Band iii. p. 158. 1857. at one operation; the largest bleeding that I can boast of was fifty-six ounces ;"— that Dr. Alison, in 1841, ordered an old gentleman of sixty-six, six bleedings and two cuppings in five days; and that Mr. Lawrence, in 1836, amused his class by informing them that he had bled "a slender young girl" to forty-eight ounces for supposed inflammation of the chest! Must we still abandon ourselves to these extreme reactions, or, guided by knowledge, reason, and experience, may we not, standing on the vantage ground of truth, settle and hold fast to certain broad grounds of practice? So far as mere counting is concerned, statistics do not help us, as a glance of the eye at the two rows of figures at the end of this article will prove. Take either side. The cases treated by bleeding show a mortality varying from 1 in 2 to 1 in 60. Examine the other set, in which bleeding was abstained from, and you will find the deaths vary from 1 in 24 to 1 in 90. So startling is the variety, that we are compelled either to discredit the observers, or to admit that, under the common name of pneumonia, . they treated a totally different order of cases as regards severity of disease and tendency to death. The disagreeable assumption, that some, at least, of the observers are not to be trusted, comes upon us with a double force, when we find that Laennec's mortality is put down by himself as 1 in 10, and by Lecouteulx at 1 in 24. That Skoda's mortality in 1846, according to Dr. Balfour, was 1 in 15, while in 1852, according to Dr. Mitchell, it was 1 in 33. The second assumption, that the various physicians treated a totally different order of cases, as regards severity and tendency to death, recommends itself to us instinctively. We shall be able to answer this question if, instead of counting up these observations as so many figures, we study them closely as a body of vital facts. With these objects we shall examine the influence on the result as regards recovery and death; of the age, sex, and constitution of the patient; the season, the climate, the previous destitution of the patient; the early neglect of the disease; the extent, character, and stage of the disease; the complications; the change of type; and the hospital accommodation. Age has a remarkable influence on the mortality of pneumonia. Between six and forty there is a strong tendency to recovery, so that patients during the fever can bear bleeding, tolerate poison, and endure starvation that would destroy a person in health. Many observers give the ages of the patients, very few those of the deaths. In the few instances of great success in which the ages are known, the patients had comparative youth on their side. Deaths are six or seven times more numerous after sixty than before thirty. Skoda's successful cases were chiefly between twenty and thirty; and those of Dr. Bennett, Dr. Bell, and Varrentrapp, were aged on an average from thirty to thirty-one. This implies a small number of very old persons. A large proportion of Dietl's cases were above the age of sixty. We may safely infer that old persons would have a much better chance of recovery if, instead of being bled, starved, and antimonialized, they were fed and kept warm during their illness. The appalling mortality of Chomel's cases, as reported by Louis, proves to demonstration the destructive effect of repeated bleedings in old people. Eight of Louis's own cases were above the age of sixty; the 5 who survived were bled on an average 1'6 times: the number of bleedings practised on the 3 who died is, with the remarkable imperfection pervading Louis's résumé, not given. Twelve of Chomel's cases were above the age of sixty; the 3 who survived were bled on an average 166 times; the 9 who died were actually bled 2.86 times, the bleedings being smaller than in Louis's cases. Several of these 9 patients were bled to death. Bouillaud's 75 cases, reported by Pelletan, when compared with those treated. by Chomel and Louis, appear at first sight to be remarkably successful, seeing that while they lost respectively one-third and one-seventh of their patients, Bouillaud only lost one-eighth of his. But the tables are turned when we apply the test of age, since, while none of his cases were above the fatal age of sixtyand only one-tenth were between fifty and sixty-three-tenths of their cases were fifty years old and upwards, and nearly one-half of those were above sixty. The mortality of pneumonia in the army is numerically very small, seeing that out of nearly 16,000 cases admitted into the military hospitals during the twenty years ending 1836, 621 died, or 1 in 25. It must not be lost sight of, that during one-half the period referred to physical diagnosis was unknown; but the results during the last ten years, when it may be held that the returns approached to accuracy, were nearly as favourable as they were during the whole periodthe proportion of deaths being 1 in 2013. During the ten years ending 1846 the mortality was greater, being 1 in 13. The later returns do not, however, include the tropical stations, in which the mortality is very slight. One great reason for this remarkable success is the comparative youth of the patients, none of whom were over fifty, few above forty years of age. We come down, then, upon these important facts, in relation to the influence of age on the mortality of pneumonia, from the examination of the statistics of bleeding and non-bleeding in that disease,-that to bleed old persons repeatedly, or in some cases at all, is mortal. The day surely never can come round again in medicine when men, with their eyes sealed by false theory and prejudice, shall return to this destructive practice in the aged. That the apparent mortality among younger persons is unduly increased in the statistics of bleeding by the disproportionate number of deaths among the aged caused by that practice. That, whatever be the treatment, the larger the proportion of young patients, the smaller the mortality; and that the extraordinary successes of new plans of treatment-as, for instance, non-bleeding and chloroform inhalation-are often due to the younger patients being selected who are enabled by the disease to bear almost any kind of treatment, especially if it tends to relax the tissues and reduce fever. At first sight the influence of sex on the mortality appears to be great. Grisolle found the proportionate number of female deaths nearly twice as great as that of males during three consecutive years, excepting 1857. The average age of the female deaths was fifty-five, of the male forty-three. It was not so much, therefore, to the sex as to the age that this excessive female mortality was due. Pinel found that pneumonia was almost always mortal in old women of seventy when they were bled, and he therefore discontinued the practice in females of that advanced age. The deaths among females (1 in 2·7) were much greater than among males (1 in 4) in the Vienna Hospital during 1856. But though the age of the deaths is unfortunately not given, the excessive female mortality is manifestly due to the greater proportion of aged patients among the females, the proportion of patients above fifty being 1 in 3 among the females, and 1 in 10 among the males. Briquet's observations as to the greater fatality of the disease among aged women, support those of Grisolle. The proportion of deaths among females was rather less than that of males of the Edinburgh Infirmary, and also in the practice of Thielmann, Schmidt, and Petters. It must not be lost sight of that women, if at all strong, are fitted by their periodic loss to bear bleeding better even than men. Indiscriminate bleeding would undoubtedly have the effect of increasing the mortality among females above the age of fifty; for they being weaker, and suffering from a less intense form of pneumonia than men, do not bear venesection so well. Constitution of the patient. The mortality of pneumonia is much greater in the weak, especially when bled indiscriminately, than in the robust. Thus in the practice of Briquet two-thirds of his deaths were among the feeble, although two-thirds of his patients were among the comparatively strong. He also found that the illness lasted a week longer in the weak than the strong. The Reports of Dr. Morehead and Mr. Stovin on the diseases in the European and native hospitals at Bombay, show in a conclusive manner the remarkable influence of weakness of constitution on the mortality of pneumonia. During the ten years from 1844 to 1853, Mr. Stovin met with but 22 cases of pneumonia out of about 12,000 European patients; 2 only died, or 1 in 11. According to |