only to allow air to enter a little of the upper part of that organ, and in this condition the man can, at most, live but a few hours. Now, I don't suppose one of you gentlemen (the class consisted of about twenty, half of them practitioners) would, for a moment, think of bleeding in this stage of pneumonia. You would expect the patient to die in the operation, and that you would get the credit of killing him. Nevertheless, I shall bleed him, in a sitting position, freely, with a large stream as you see (just then the lancet was used), and while the man may not recover, it will give him the one, only chance, and will, at least, give him great ease and relief while he does live."

After losing a pint or more of blood, the man was asked: "Now my man, how do you feel?" "A little better, docthur " (the fellow had an Irishman's tongue). Later he was again asked how he felt, and the reply came, "a good deal better, docthur." He was directed to take a long breath. This he was now able, in part, to do, resulting in expectorating freely the bloody sputa of pneumonia. The bleeding was continued to the extent of nearly three pints, when the patient, becoming blanched, he was laid down and the arm dressed. He was now treated with expectorants, anodynes, tonics, alteratives, laxatives and a nourishing, but liquid, diet. Opium, tartrate of antimony and ipecac were given as expectorants. The opium in full doses, allaying all pain and irritation, gave the man needed rest. The antimony, combined with the opium, not only acted as an expectorant, but did much to hold in check the fever and inflammation. These remedies were alternated with powders of calomel and ipecac, aiding expectoration and stimulating the secretions. Following this, in about twelve hours, castor oil was given to clear the intestinal tract. The lecturer continued for some time, a most instructive lecture on pneumonia and its treatment, and especially on the necessity and usefulness of venesection in all severe pneumonias. Hopeless as the condition of this man was, he made a good recovery. This was an object lesson which no student or physician having once seen could well forget. Nor should any phyNor should any phy

sician who has once seen the favorable outcome of a patient in this advanced stage, and almost hopeless condition, lack the courage to make use of this one and only means which gives any hope of recovery.

About a year and a half later, May 25, 1849, I was called to Grand Rapids, Wis., in the night, a distance of twentytwo miles, to visit Moses V., a riverman, a stout chested Frenchman, near forty years of age, six days sick with pneumonia. I found him cyanosed, gasping and struggling for breath, with tumultuous heart action, and seemingly with but an hour or two to live. I had not to tell his friends of the man's almost hopeless condition, but did tell them that blood letting was the only remedy that gave any hope of help. Not waiting to get warm, I made rapid preparation and bled the man nearly three pints, to approaching syncope, when he was laid down and the arm dressed. He was now able to breathe more freely, and to expectorate quite easily. The after treatment was about the same as that of the patient in hospital, treated by Brainard. Two days later I visited the man again, and found him free of pain, expectorating freely and easily, and with little or no fever. To the surprise of all, this man made a rapid and perfect recovery, and is still living, or was a few months ago, about eighty-five years of age. The following winter I visited a man residing about thirty miles north of this place, near Wausau-a Mr. McK., and found him in a very advanced stage of pleuro-pneumonia. Commencing treatment with free venesection, with after treatment much the same as in former cases, the patient made a rapid and perfect recovery. and perfect recovery. A few years later I was called in the evening to visit a patient five miles away-a Mr. C., with the attending physician. I found the patient in the dying stage of pneumonia. I proposed venesection. The answer

was, "the man will die and we will get the credit of killing him." The doctor admitted that the man would die in his present condition. present condition. He admitted that he could only die if bled. I was able to show him that venesection gave him the one and only chance of recovery. The answer came, short and crisp; "Well

you may bleed him. I won't." And I did bleed him. The man was an Englishman, a stout chested blacksmith, and I bled him most freely, till approaching syncope warned me to lay the patient down and dress the arm. I made a few more visits with the Doctor, mostly carrying out the treatment of the former cases, and the patient made a good recovery, moving, a few years later, to Illinois, where he died only a year or two ago, about 84 or 85 years of age.

At this time I recollect bleeding patients in those early years, before bleeding had so nearly become a lost art, patients of some four or five other physicians, in so advanced a stage of pneumonia or pleuro-pneumonia as to make the attending physician fear the effect of so potent a remedy; and generally, if not always, with the best results. It is now but a few years since, visiting a young married woman, some twenty miles away, a patient a week sick, in so advanced a stage of pneumonia that the attending physician hesitated in giving consent to the venesection, but the patient was bled freely, and finally made a good recovery.

So far I have spoken only of a few of the many cases seen during these many years in the very advanced, and almost hopeless stage of pneumonia, and this was all I intended in commencing this article.

I can, however, hardly refrain from suggesting that if such great good, and only good, comes from venesection in this advanced stage, we may well expect good and only good to come from the use of this remedy in the early stage of the disease. I need hardly say that I have made use of this remedy nearly fifty years in all severe pneumonias and and pleuro-pneumonias, and can well say that in no case have I had occasion to regret its use. To get the best results from this remedy the patient should be in a sitting position, and the blood drawn in a large stream and continued to approaching syncope. This sudden with drawal of considerable quantity of blood from the circulation, probably does more than all other remedies to stimulate the absorbents, and thus rapidly to remove the effusion in the lungs, rendering free respiration again possible. And now antipyretics should be used, holding the

temperature nearly to normal. Of these we now have a goodly list to select from. If the coal tar preparations are used, carb. ammonia may be pretty freely given, serving the double purpose of an expectorant and stimulant, counteracting any depression that may arise from the antipyretic. The heart, tired and worn, should be braced up with strychnia and digitalis. In the olden time, the tartrate of antimony was more largely used than at the present time, and a most potent remedy it was, and still is, doing much to control the temperature, and at the same time being one of the best expec torants. It is, however, a potent drug and should be given with the same care as the more active alkaloids are given. Along with the antimony, opium should be given in full doses, to the extent of allaying all pain and irritation, and while the patient, under its influence, will cough far less frequently, he will expectorate freely, and with great ease, and will not be laboring to suppress the cough, by reason of the increase of pain thereby occasioned. And now, having commenced treatment with free venesection, and having followed this with antimony (or other antipyretic), and opium to control all pain and irritation, we have done much to lessen, and at times quite to remove, the inflammation. Calomel should be given, at first as a laxative, followed by castor oil or other suitable aperient, cleaning the intestinal tract, and then continued in small but frequently repeated doses. It has its own peculiar mode of action and does much to aid in cutting short pneumonia and pleurisy. The benefit arising from the early constitutional effect of this drug is, I believe, more marked in pleurisy, and in fact, in inflammations involving any of the serous membranes.

While the armament of the physician is greater than it was fifty years ago, and while mild cases and many of the severe cases of pneumonia may, if seen early, be successfully treated without resorting to the use of the lancet, I know of no physician who has or would propose other remedy with expectation or hope of benefit in the class of cases particularly mentioned in this article. And to prevent patients from drifting into this condition, and to prevent pleuritic adhesions, hepa

tized lung, or other sequelæ in this disease, I know of no remedy that equals venesection. My observation for these many years has been such as to convince me that severe pneumonias, whether seen early or late, are cured with greater certainty, and in shorter time, and with less sequelæ when the treatment is com. menced with free venesection. On my arrival in this field in 1848 there was no physician in this part of the State, altho lumbering operations were being carried on for a distance of seventy-five miles up the river (the Wisconsin) and for a considerable distance in the opposite direction. The lumbering camps generally were small, crowded and overheated. Add to this the early rafting in April and May, the men often working in rain and snow, and sleeping on the rafts, in bunks or without them, and as may be supposed, pneumonia and pleurisy were quite prevalent. While other physicians came from time to time, still, for years, distances were such that the physician often failed to see the sick till in the last stage of the disease. In this way it fell to my lot to see more of these diseases, and to see them in the very late stage, than generally falls to the lot of the young physician.

With these words of explanation I may add that it has not been my intention to go over in detail the full treatment of pneumonia, or to mention the many drugs and means that may be of use in the treatment of the many conditions of different patients afflicted with this disease, but rather to speak of the few remedies, regarded of such prime importance, and relied on with such certainty, by the old time physician for the cure of his patients afflicted with this disease. With all the advance in medicine in the last fifty years, the profession has, in so largely neglecting the use of the lancet in pneumonia, lost sight of the one most

back to the old time treatment and Osler will no longer say: "Pneumonia is a self limited disease and runs its course uninfluenced in any way by medicine. It can neither be aborted nor cut short by any known means at our command." Osler also reports treating twelve cases of pneumonia in this very advanced stage, in which he commenced treatment with venesection, and with but one recovery. Notwithstanding results so unpromising, he still recommends venesection in this stage. It may well be asked, why this mortality? In my own cases in this advanced stage, where the venesection has been most free, to the extent of coming close to the danger line, the benefit has been more decided, the expectoration, and the absorption of the effusion, so largely filling the air cells, has been far greater than when the bleeding has been moderate. The labor of the tired heart is also reduced to the minimum and may now be braced up with tonics and heart stimulants. Anodynes, to produce their best effect, should be given regularly, at intervals not too far apart; not to the extent of narcotizing, but to the extent of keeping all irritation and pain absolutely under control for days, for a week or more, if need be. The antipyretic (I prefer the antimony) should be given continuously to the extent of holding the temperature nearly to normal and the inflammation well in check. In severe pneumonia, and especially of several days' standing, the pleura is likely to be involved, and now the alterative effect of the mercury to the extent of slight ptyalism will do much to cut short the inflammation and to prevent pleuritic adhesions and effusions so likely to occur in inflammation of this membrane.

ady. Osler, in his classical work on medicine, says: "Pneumonia is one of

I hardly need add that there is one class of cases that bear the alcoholic stimulants, in fact, in which it is imperadministered; to inebriates, to tered; to inebriates, to those greatly addicted to the use of alcoholics. Nor does or require anti

tal statistics show that the mortality ranges from 20 to 40 per cent." Again he says: "When an arterial sedative is indicated in a robust, full blooded, healthy individual, I much prefer the lancet." But let the profession come

pyretics to

ease and the
Great of
those free from

this vice. Still if seen late in the disease and the lungs are greatly engorged, I do not hesitate to use the lancet.

JOHN PHILLIPS, M.D.

Stevens Point, Wis.

oz. iv. Mix. Dose, a teaspoonful every hour until the pulse rate comes down to 70 or less.

If there be pleuritic symptoms, evidenced by sharp pains, I add 5 drops of specific bryonia to the above. Should the case be asthenic, with a small, rapid pulse, I substitute specific agonite, drops 15 or 20, for the veratru. case I give the following

R Specific asclepias

Specific ipecac

Water

In either

dr. ss. m xx. oz ij. Mix. Dose a teaspoonful in hot water with a little pure white sug every two hours or more frequently.

If fever runs very high I order frequent spongings with warm water. If much irritation with restlessness, give the diaphoretic powder (ipecac and opium, Amer. Disp.) in 5 to 10 grain doses p. r. n. Bottles of hot water, steaming rocks, or better, ears of boiled corn, wrapped in dry cloths, should be placed around the patient. I usually put two or three ears at the feet, one on either side at the hips and a couple more on the side of the diseased lung. These are frequently changed, so as to keep constantly a little vapor under the bed clothing, and are continued until tolerably free (not profuse) perspiration is induced, which should be continued for a proper length of time, when they should be very gradually removed, and rubber bottles of hot water, one to the feet, the other to the affected side, should be substituted. Care should be taken not to keep the patient too hot, but simply to use enough heat and moisture to cause a moderate but general perspiration. This may appear a somewhat homely treatment, but it cures, and that is the object in view. A greased flannel cloth, covered with a heavy sprinkling of compound powder of

tongue, give one granule, è gr. podophylIf there be constipation with a furred lin every three hours until three are taken, to be followed with a dessertspoonful of effervescent seidlitz salt, repeated every two hours until the bowels move.

The above may usually be followed by strychnia arsen., gr., codeine & gr., cactina or strophanthine, bo gr. One granule of each every two or three hours, as indicated.

The special sedatives are to be discontion ceases. The asclepias and ipecac tinued as soon as the necessity for seda

are continued to the end unless contraindicated. Carbonate of ammonia may be added.

Should expectoration become difficult and the tubes filled with tenacious secretions, especially if attended with difficult respiration as a result, give:

Ꭱ

Specific lobelia ipecac.

Warm water

dr. ij

dr. J

ad. oz. ij

Mix. A teaspoonful in hot water every five or ten minutes until expectoration becomes free, or even to light emesis.

This should be continued at longer i tervals until there are no further indications for its use. This condition will not occur under the above treatment, except thru carelessness in permitting the patient to contract a cold.

In malarial districts, quinine becomes an important factor in the treatment of pneumonia. I have practiced medicine in malarial districts for several years, and I must say that I never have met with a

case of pneumonia of purely malarial origin.

I do not give the above as a routine treatment for all cases of pneumonia, but simply an outline, which, with few changes, will be found applicable in a large number of cases.

There are conditions and special indications that are frequently met, which I will not attempt to point out in this paper. W. B. SQUIRE, M.D. Worthington, Ind.

Pneumonia.

Editor MEDICAL WORLD:-I wish to express my thanks to our eclectic Brother Cooper for his excellent article on Pneumonia in January WORLD.

I am a regular; graduated at Buffalo, N. Y., in 1879, and have been in active practice ever since. Altho not so long in the harness as Brother Cooper, I can also truly say that I have never lost a case of pneumonia. As Brother Cooper so nearly expresses my own views, I will only add in regard to treatment that I consider the carbonate of ammonia of great benefit in a majority of cases, and the only stimulant I have ever used. In a large number of cases I have omitted outward applications entirely. I sometimes use the very one mentioned by Dr. Cooper, but nothing more. Above all, do not overdo the medicine business if you wish good results.

Rockdale, N. Y.

A. E. CROWELL, M.D.

Treatment of Pneumonia in Children.

FELLOW PRACTITIONERS:-I have been asked to give my treatment of pneumonia. Now, my treatment don't differ much from the treatment of a hundred other doctors that I know, and some of the newer text books have described it better than I can. But sometimes a journal or newspaper article impresses the fact more strongly on one's mind, and therefore this may do some one some good. My experience has been chiefly with children. The grown people around my way are wage earners, and they can't afford to get sick; or when sick, can't afford to stay home; and so I hustle them off to the "horspital " where they get what they need. So it

happens that I have to treat only the pneumonias of children.

If the child is seen early it sometimes looks like stomach trouble-constipation, abdominal cramps, coated tongue and fever. If pulse is rapid and respirations frequent, even if nothing is heard in the lungs, I give a guarded diagnosis, especially if the child has been suddenly attacked after exposure on a wet day; or if there is a history of recent occurring measles or whooping cough. The fact that whooping cough brings on pneumonia, or allows pneumonia to develop, many times fatal in its outcome, is not often enough dwelt upon. (In the large cities whooping cough causes more deaths than scarlet fever and measles combined.)

As soon as I detect the lung mischief so that I am certain of the side affected, I order the ice pack-ice in a small rubber bag or bladder, and insist that it should remain over the affected area day and night, with now and then an intermission of a half hour. Internally, I order:

I visit the patient twice daily and take temperature and listen to chest each time, changing the ice pack, if new areas are becoming involved, to the exact location.

The children rest better, breathe easier and temperature runs less high under this form of treatment than any I know of. The whiskey and nux keep the heart in good condition. Of course I watch the bowels, ordering enematas if needed, and give plenty of egg water, meat juice and milk.

I've lost some cases under this form of treatment, but I've saved some that looked pretty desperate. With a mother that is fairly intelligent and plenty of ice on hand, I feel safe in any case, whether single or double pneumonia. I've bathed pneumonia adults in cold water right in a bath tub, but that was in a hospital where everything was handy. My private patients don't have any bath tubs in their shanties (miscalled dwellings), and so I use the next best thing, namely, the ice pack for