"To the testimony of facts we can oppose no equivalent objection; although, considering the very limited powers of art in removing great alterations of structure, it might be reasonably conceived, à priori, that a hepatized lung was not likely to be much under the influence of venesection. This much, at least, I am justified in stating from my own experience, that the vastly inferior power of bleeding in the second and third stage of pneumonia, ought to make us depend principally upon what we can effect in the first stage. And as guiding our practice in this most important particular, I consider the stethoscope as of the utmost consequence; for, without it, who shall say positively that the disease is in its first or its second stage? On this point of practice, the opinion of Lorinser is strongly against bleeding in the latter stages. He says that, after hepatization has taken place, bleeding, by weakening the powers of the system, impedes or altogether prevents the absorption of the effused lymph; and that while one or two venesections in the first stage, often suffice to produce complete resolution, six or even ten, in the latter stage, will not only have no good effect, but will decidedly hasten the fatal event. He adds that he has repeatedly proved the truth of this doctrine in the epidemic pneumonia of cattle, (Lungenseuche der Rinder) in which he invariably found bloodletting if not injurious at least useless, after the disease had reached the stage of hepatization."

M. Laennec observes, that the present practice all over Europe is—" in the beginning of the disease, to bleed to the extent of from eight to sixteen ounces, and to repeat the operation daily, and sometimes even twice a day, if the inflammatory symptoms do not give way, or if, after being subdued for a few hours, they return with fresh violence. After the first five or six days, the bleedings are repeated after longer intervals, and soon cease altogether, except in cases where they are strongly indicated by the renewed strength of the pulse, oppression, and fever."

If this be the practice on the Continent, we maintain that it is wrong. It certainly is not the practice among the more intelligent practitioners of this country-and we have reason to know, that a more active early treatment obtains in many parts of Italy and Germany. From a pretty long and extensive experience in this class of inflammations, we can conscientiously recommend the medical attendant, when called early to acute pneumonia, to abstract blood, in the recumbent position, till a full inspiration can be taken without inconvenience, or exciting cough-or, till syncope take place. When either of these effects is produced, he may bind up the arm, and persevere with the other antiphlogistic measures, presently to be detailed, till the pulse rises, the respiration becomes impeded, and fever and pain increase. Then the vein is to be re-opened, whether at the end of two or twelve hours, and the same objects are again to be obtained, even at the expense of syncope. This mode of procedure should be carried on during the first days of the inflammation, if the inflammation continues for days, especially in subjects whose constitutions are not impaired by age or by other maladies. By this plan, we have repeatedly arrested, and seen arrested, the most intense inflammations of the lungs, with little, and sometimes no succeeding expectoration. In fact, the more active the treatment in the early stage, the less necessity will there be for expectoration, which is the process that Nature employs to remove the effects of the inflammation—namely, the engorgement of the vessels of the lungs. When this process has once commenced, we certainly should be cautious in the employment of the lancet. So much for venesection. It is not a little remarkable that Laennec does not even mention local depletion. Now, one great advantage of auscultation and percussion is to indicate the locality of the inflamed part in order that local depletion and counter-irritation may be employed as near that part as possible. Blood, therefore, should be taken from the chest by leeching. or cupping, simultaneously with, or soon after general bleeding, by which VOL. VIII. No. 16.

40

means, the repetitions of the latter will often be considerably abridged. After one local, and one or two general bleedings, a blister may be applied, but not sooner. Much mischief is often done by the early application of blisters, before the vascular system is considerably emptied.

M. Laennec adverts to the pneumonia which is complicated with typhoid and other fevers, and where depletion cannot, of course, be carried to the same extent as in pure pulmonic inflammation. The remains of our army after the battle of Corunna, and the French prisoners in our pontons, during the late war, presented a wide field for observation in this dreadful complication of idiopathic fever with pneumonia, and if Mr. Lawrence had been on this field, he would have been taught, by dire experience, that neither fever nor inflammation can be "put out" (an expression very aptly used by Mr. Brodie, and very injudiciously ridiculed by Mr. Lawrence) by any system of depletion, however early or however vigorously employed. It was tried by many and by untimid practitioners, at the period alluded to-especially among the prisoners of war; but, for one case where the fever and inflammation were "put out" by such measures, there were ten where the patient's life was "put out" with the disease! These facts must be borne in mind, when we have to treat the pneumonia that arises during idiopathic fever. We repeat it, that it cannot be " put out," by vigorous general depletion. We must trust almost entirely to local depletion and counter-irritation in such cases.

Although the pulse is less fallacious in peripneumony than in most other internal inflammations; yet it is sometimes deceptive, and Laennec has given us a very useful precept on this point. Where there is doubt about the indication afforded by the pulse, the ear or the stethoscope should be applied to the region of the heart. Whenever the pulsations of the heart are proportionally much stronger than those of the arteries, then, he avers, we may bleed without fear. If, on the other hand, the action of the heart, as well as that of the arteries be weak, we should be very cautious how we abstract blood from the general system. This, we hope, will prove a valuable precept in other diseases than peripneumony.

BLISTERS. Laennec seems to have little or no confidence in these derivative auxiliaries. He limits their application to those cases in which resolution proceeds too slowly, after the first stage is over-and to the chronic form of the disease. He thinks that a blister applied to the chest is injurious, by impeding the action of the respiratory muscles. We cannot but think this objection futile, though we acknowledge the bad effects of blisters too early applied.

EXPECTORANTS. Much has been written on this class of medicines, but little is known on the subject. The alkalies have been greatly lauded by Mascagni and others, as having a powerful tendency to promote expectoration. Dr. Farnese, a pupil of Mascagni, was in the habit of giving from a drachm to an ounce of carbonate of potash daily, dissolved in half a pint of water. We doubt whether such doses might not materially injure the stomach and bowels, by too rapidly dissolving the mucus on their internal surface, and exposing their nerves too freely to the action of food, physic, and certain stimulating secretions, as the bile. For our own parts, we have no confidence in any expectorant but antimony, aided and preceded by blood-letting. PURGATIVES. Laennec advises to keep the bowels open in pneumonia, "especially on the approach of convalescence," by glysters and gentle laxatives. Dr. Forbes accords in this rule, and deprecates purgation. Our

own experience leads us to the same conclusions in respect to purgation as to general blood-letting. In the early stage, when inflammation runs high, the bowels may be freely acted on; but in proportion as expectoration comes on, we must be cautious of purging, since hypercatharsis very readily checks the expectoration, and places the patient's life in imminent jeopardy. It is in such cases the carbonate of ammonia has considerable power in renewing expectoration.

TARTAR EMETIC. This remedy, though long in use, both in England and other countries, as an expectorant, in small, but nauseating doses, has lately acquired great celebrity, in pneumonia especially, when exhibited in comparatively large doses. Before making any observations on the mode of administration which we have found most advantageous, we shall lay before our readers the plan of Laennec, who seems to think that this medicine may almost supersede the lancet in pneumonia.

"As soon as I recognize the existence of the pneumonia, if the patient is in a state to bear venesection, I direct from eight to sixteen ounces of blood to be taken from the arm. I very rarely repeat the bleeding, except in the case of patients affected with disease of the heart, or threatened with apoplexy, or some other internal congestion. More than once I have even effected very rapid cures of intense peripneumonies without bleeding at all; but, in common, I do not think it right to deprive myself of a means so powerful as venesection, except in cachectic or debilitated subjects. In this respect M. Rasori does the same. I regard bloodletting as a means of allaying, for a time, the violence of the inflammatory action, and giving time for the emetic tartar to act. Immediately after bleeding I give one grain of the tartar emetic, dissolved in two ounces and a half of cold weak infusion of orange-leaf, sweetened with half an ounce of syrup of marsh-mallows or orange-flowers; and this I repeat every second hour for six times; after which I leave the patient quiet for seven or eight hours, if the symptoms are not urgent, or if he experiences any inclination to sleep. But if the pneumonia has already made progress, or if the oppression is great, or the head affected, or if both lungs or one whole lung is attacked, I continue the medicine uninterruptedly, in the same dose and after the same intervals, until there is an amendment, not only in the symptoms, but indicated also by the stethoscopic signs. Sometimes even, particularly when most of the above-mentioned unfavourable symptoms are combined, I increase the dose of the tartar emetic to a grain and a half, two grains, or even two grains and a half, without increasing the quantity of the vehicle. Many patients bear the medicine without being either vomited or purged. Others, and indeed the greater number, vomit twice or thrice, and have five or six stools, the first day; on the following days they have only slight evacuations, and often indeed have none at all. When once tolerance of the medicine (to use the expression of Rasori) is established, it even very frequently happens that the patients are so much constipated as to require clysters to open the body. When the evacuations are continued to the second day, or when there is reason to fear on the first that the medicine will be borne with difficulty, I add to the six doses, to be taken in twenty-four hours, one or two ounces of the syrup of poppies. This combination is in opposition to the theoretical notions of Rasori and Tommasini, but has been proved to me by experience to be very useful. In general, the effect of tartar emetic is never more rapid or more efficient than when it gives rise to no evacuation; sometimes however, its salutary operation is accompanied by a general perspiration. Although copious purging and frequent vomiting are by no means desirable, on account of the debility and the hurtful irritation of the intestinal canal which they may occasion, I have obtained remarkable cures in cases in which such evacuations had been very copious. I have met with very few cases of pneumonia where the patient could not bear the emetic tartar; and the few I have met with occurred in my earliest trials insomuch that this result now appears to me to be attributable rather to the inexperience and want of confidence of the physician, than to the practice. I now frequently find that a patient who bears only moderately six grains with the syrup of poppies, will bear nine perfectly well on the following day. At the end of twenty-four or forty-eight hours at most, frequently even after two or three hours, we perceive a marked improvement in all the symptoms. And sometimes even, we find patients, who seemed doomed to certain death, out of all danger after the lapse of a few hours only, without having

ever experienced any crisis, any evacuation, or, indeed, any other obvious change but the rapid and progressive amelioration of all the symptoms."

Our readers will perceive that one common effect of this antimonial treatment is vomiting and purging at the beginning; and as the latter evacua-tion is not considered injurious by Laennec, it confirms the observations we made on early purgation, and nullifies the timidity evinced by himself, and also by his translator, in the preceding pages. Having no experience in this mode of administering emetic tartar, we leave it for the consideration of our readers. If it maintains the character drawn by Laennec, it must prove a valuable auxiliary, or even succedaneum to venesection, where it is desirable to husband the vital fluid.

The manner in which we have employed the remedy is as follows:-Immediately after venesection, the bowels are to be opened by a solution of Epsom salts, senna, and tartarized antimony; and, this done, the antimonial wine, in doses of from 30 to 60 minims, with fifteen drops of the vinum colchici, and five drops of tincture of digitalis, is to be exhibited in a common saline draught every four or six hours. If nausea be produced, the doses of the three ingredients are lowered-if no effect seems to result, they are increased. We have found such decided good from this mode of treatment, that we have not, as yet, ventured to change it for the Rasorian method. It must ever be remembered, however, that irritation, or eveninflammation of the gastro-intestinal mucous membrane is frequently complicated with pneumonia. This is to be ascertained by the tongue, by the state of the secretions, and by the increased sensibility of the stomach and bowels to drink and medicine. When such complication exists, it renders the treatment more difficult. The antimonial medicines must be abandoned, and leeches should be applied to the epigastrium. We must trust then almost entirely to general and loeal blood-letting. It is curious that Laennec, a French physician, does not regard this complication as any bar to the administration of large doses of emetic tartar. His decided antipathy to the doctrine and practice of his countryman and rival, M. Broussais, appears to have led our worthy author into a dangerous kind of opposition on this point. Before quitting the subject of treatment, it is proper to notice the plan first introduced by Dr. Hamilton, of Lynn Regis-namely, the administration of calomel and opium till the mouth is affected. His practice was, after bleeding and opening the bowels, to give from one to five grains of calomel, combined with from a quarter to a grain of opium, every six, eight, or twelve hours, according to the urgency of the symptoms, the patient being ordered to drink plentifully of diluent fluids in the mean time. The success attendant on this plan, "was such as to fill him with astonishment." The writings of Armstrong, and many others, have tended to confirm the utility of Dr. Hamilton's practice, with some modifications. When we consider the great influence of calomel and opium in resolving inflammation in the liver, the eye, the heart, and the serous and mucous membranes, we see no reason to doubt its power over inflammation of the, parenchymatous structure of the lungs. The plan, therefore, should not be suffered to go into oblivion from prejudice. From the long established efficacy of this combination in dysentery, where there is unequivocal irritation, as well as inflammation, of the mucous membrane of the bowels, we have every reason to believe that it would be an important remedy in the complication of peripneumony with gastro enteritis-a disease which is equally dangerous and difficult to manage by the common modes of treatment.

There is a state near the conclusion of peripneumony, which embarrasses the young practitioner more than at other periods of the complaint. It is that, in which the expectoration is going on favourably, and the patient is apparently in progress to recovery, but where, from sudden cause, the expectoration suddenly stops, and suffocation is menaced. The practitioner is undecided whether to give stimulants or to abstract blood. In such a state the loss of a few ounces of blood generally seals the patient's fate—and a few doses of carbonate of ammonia, in almond mixture, often restores the expectoration, when life is fast ebbing, and where nothing but this restoration of the process of expuition can save the patient. We have never found any medicine equal to the carbonate of ammonia in such cases; and we have seen many lives saved by its judicious administration. From five to fifteen grains should be given every hour or two till the expectoration recommences, when the dose should be lessened, and the intervals lengthened.

We now bring this article to a close. By means of small type, large page, and patient concentration, we have brought together a vast mass of important information on the subject of peripneumony-the laborious production of various practitioners in different and distant countries. This may serve as a specimen of the advantages which the public derives from the pressand especially from the periodical press. For little more than four-pence sterling, our readers have got the substance of some octavo volumes! We hope to make the remainder of our pages equally pregnant with useful practical matter, as those occupied with our first article, which is necessarily long, as the leading article of this quarter's number. The Review Department in the other l'asciculi will be in opener type, like that in the first page.

II.

On Malingering; or, feigned Diseases. By Dr. CHEYNE.

[Dublin Hospital Reports.]

MAN's journey through life is a perpetual contest between pleasure and pain. He is constantly grasping at the former, and endeavouring to ward off the latter. In the eager pursuit of pleasure, he will frequently undergo a very long course and intense degree of pain--though the former is often transient, or even nugatory, when obtained; while the latter is always real, and not seldom destructive, before the object for which it is encountered can be accomplished. It is difficult to say whether war or peace be the condition designed for mankind by Nature. If we consult history, we shall find that the former has predominated over the latter and if we examine minutely into the constitution of the human mind, and the play of human passions, we shall have little ground for anticipating the promised millennium, under the present dispensation of things! But leaving speculations of this kind to the NATURAL philosopher, who is often imperfectly acquainted with HUMAN NATURE, we may remark that the medical philosopher, whose destinies lead him into naval and military life, comes in contact with no small number of sailors and soldiers who, in battle, will excel the heroic actions of Achilles and Hector; but, when the day of carnage is past, will undergo tortures inconceivable, to get out of the "paths of glory," in order to fall back into the dull and insipid routine of civil life. It is nearly two thousand years since Horace humorously described the FACT of "nemo contentus," but he has not been very happy in ascertaining the true cause. Were we dis