4th. A tabulated account of the cases treated, showing the care with
which they were observed, and their chief symptoms, including the
time they were under treatment, and the termination in success or
failure.
Doubtless this method of determining the value of any treatment requires
a high degree of medical knowledge, and some trouble; but I would
suggest that it is the only one capable of inspiring confidence and
permanently advancing the interests of the medical art. If it cannot be
carried out during the exigencies of every-day practice, there is
nothing to prevent its prosecution in our public hospitals, where the
patients are under constant observation, and where there are in many of
them a staff of assistants whose business it is to make the necessary
records.
The chief obstacle to obtaining accuracy in result is the general
conviction among medical practitioners that a different treatment is
required, even in fixed morbid conditions, according to the symptoms
which may be present. The progress of diseases is never absolutely
uniform, and no doubt the occurrence of particular phenomena often
require special interference. This secondary treatment of symptoms,
however, should never be allowed to interfere with the primary
management of the morbid condition; and it is the neglect of this rule
which has led to such injurious results in the treatment of many
diseases. If, for example, in order to relieve cough in phthisis we give
opiates and expectorants, how can we maintain the appetite and improve
the tone and digestibility of the stomach, on which the assimilation of
food, cod-liver oil, and nutrition essentially depend?
Since the publication of my papers and treatise on the Restorative
Treatment of Pneumonia I have watched with great interest what has been
published by the profession on this subject. The only published series
of cases that I am acquainted with is given by Dr. T. N. Borland, of the
Boston City Hospital, U.S. He tabulates according to the form I
recommended 90 cases of pneumonia, of which he says twelve died—a
mortality of one in 7½ cases.[1] Of these, four had phthisis; two were
chronic, having been admitted on the eighteenth and twenty-first days of
the disease; one was utterly prostrated on admission, and died the
following day; one was a case of surgical injury, transferred to the
medical wards on the occurrence of fatal pneumonia; and one was a case
of typhoid fever—leaving only three fatal cases of true primary acute
pneumonia. Of these, one died of cerebrospinal meningitis; a second
suddenly, from supposed embolism; and a third, from extensive double
pneumonia, with violent delirium. Details of the post-mortem appearances
are much desired in these fatal cases. A rigid scrutiny into the true
character of these cases therefore shows, instead of a mortality of one
in 7½ cases, as is alleged, a real mortality of only one in 27
cases—that is, three deaths in 82 cases.
Since I published the accounts of 129 cases, on which my statistics were
founded,[2] with four deaths, and a mortality therefore of one in 32¼
cases, I have treated in the clinical wards of the Royal Infirmary 24
other cases, with one death. This increases the mortality to 1 in 30⅗,
in the total of 153 cases. Of these a tabulated account will be
published, without which I venture to say little information can be
obtained with regard to the results of any kind of treatment. Of this
the analysis of the Boston cases offers sufficient proof; for although
Dr. Borland says: “The greater proportion of these cases have been
treated according to the plan set forth by Dr. Bennett, by restoratives
directed to further the natural progress of the disease,” he does not
appear to have remarked that all my cases were those of acute primary
pneumonia, and not consecutive or secondary cases in individuals
weakened by phthisis, broken down by long starvation and surgical
injuries, or such as have become chronic with gangrenous abscesses.
Dr. Popham of Cork[3] tells us that he treated 30 cases of pneumonia by
the restorative plan, and that, with the exception of two who were
admitted in a dying state, all recovered. In 28 cases, therefore,
admitting of treatment, all recovered. It is much to be regretted that
these cases were not tabulated, so that the reader might judge of their
extent, severity, and progress. We are told, however, that six were
cases of double pneumonia; in eight the left lung only was engaged, and
the right lung in fourteen. Dr. Popham also tells us that instances
occurred so grave that he did not consider himself justified in trusting
to restoratives alone. He therefore gave 5 grs. of bicarbonate of potash
in mucilaginous liquid, and also employed epispastics. He is of opinion
that the alkaline salt diminished the viscidity of the sputa, rendered
the cough less harsh and the urine more alkaline. I hope Dr. Popham will
pardon me for believing that these supposed advantages are to a great
extent imaginary, and that his excellent paper can only be regarded as a
valuable contribution, confirming the advantages of the restorative
treatment.
An excellent example of a mild mixed treatment is described in a lecture
by Dr. Sieveking,[4] who, in opposition to the views I have advanced,
and the restorative treatment which has been proved to be so beneficial
in pneumonia, lays down for his students two principles. These are,
first, that pneumonia is not an entity, and second, that pneumonia
differs in type at one and the same time, and therefore demands a
varying treatment. As this last idea still extensively prevails among
medical practitioners, it may be useful to analyse the evidence
furnished by Dr. Sieveking of its correctness. It consists of four
cases, very imperfectly recorded.
_Case I._—A robust man, æt. 26, admitted on the sixth day with pneumonia
of lower half of right lung posteriorly. The treatment was confinement
to bed and low diet. On the thirteenth day there was debility, for which
quinine and ordinary diet was given. On the seventeenth day he was
discharged well.
Now I have little doubt, and the cases I have recorded prove, that if
this robust man had been well supported from the first he would have
recovered much sooner, and that the quinine was altogether unnecessary.
_Case II._—A healthy man, æt. 22, admitted on the seventh day with
double pneumonia at the bases, but to what extent is not stated: had
marked dyspnœa, and other apparently urgent symptoms. He was bled by
venesection to six ounces, and an acetate of ammonia mixture ordered,
containing 1/12 gr. of antim. tart. for a dose, to be taken every three
hours. On the following day there was great relief, and the disease was
“knocked down,” although it is stated that dulness over the bases
continued. He was dismissed cured “a few days” afterwards.
We have here the dyspnœa so commonly present in cases of double
pneumonia on the sixth or seventh day, which readily disappears by
itself, and is relieved by a warm poultice. It is supposed, however,
that a small bleeding of six ounces “knocked down,” or, as some call it,
jugulated or strangled the pneumonia. What really happened, however, was
that the dyspnœa and apparently urgent symptoms disappeared on the
eighth day, which is the usual occurrence. It is distinctly stated that
the lungs remained consolidated, so that no impression was made on the
disease. What is meant by being dismissed “in a few days” it is of
course impossible to tell.
_Case III._—A girl æt. 15, admitted on the eighth day, with double
pneumonia—the left side more affected than the right, but the extent on
neither side stated. She was ordered mist. ammon. acet. with small
quantities (?) of morphia. Two days afterwards articular rheumatism
appeared. On the following day six leeches were applied to the left side
with marked benefit, and a small quantity (?) of antimony was added to
the mixture. Dismissed cured on the thirty-second day.
Here was a case of double pneumonia and acute rheumatism running their
natural course in a weak subject. Is it to be supposed that six leeches
to one side modified the one, or that the “small quantities” of morphia
and other treatment influenced the other? Would not the course of both
have been shortened by a restorative treatment?
_Case IV._—A labourer, æt. 23, admitted on the eighth day, with
pneumonia below the fourth rib, anteriorly on the right side. “Six
leeches with saline mixture, containing 1/12 gr. of antim. tart.,
followed by a blister, appeared (!) to give temporary relief.” On the
twelfth day typhoid fever declared itself, with bronchitis. Brandy,
stimulants, and poultices were then ordered. Dismissed cured on the
thirty-fifth day.
Dr. Sieveking says of this case that probably the patient might have
done equally well without the leeches and tartar emetic. Of this there
can be no doubt. The progress of broncho-pneumonia is always more
tedious than that of simple pneumonia, and the recovery was further
delayed by the complication of typhoid fever. Can the treatment be
defended?
How is it shown in these four cases that the pneumonia in all of them
was not precisely the same, that it varied in type, or required a
different treatment? That it may be complicated with various diseases,
and be associated with strength or weakness of the individual attacked,
is no proof of any specific change in the disease itself. In this
respect it is in no way different at present from what it has ever been.
Then, as to treatment, can it be seriously maintained that the low diet
in the first case, that the loss of six ounces of blood in the second,
or the six leeches and other treatment in the two others, benefited the
pneumonia and hastened its resolution? Of this there is no proof
whatever. Unquestionably they tended to an opposite result, as would at
once be made apparent if Dr. Sieveking, instead of lecturing on four
cases, would tabulate one hundred cases so treated, and let us count
what follows. I submit, therefore, that the principles laid down by Dr.
Sieveking are in no way supported by his own facts; and, as they are
directly opposed to the conclusions derived from more extensive data,
they offer no evidence in favour of that mixed treatment which seems so
reasonable, and is so popular with many members of the profession.[5]
The question of blood-letting as a point of scientific practice has
again been raised by Dr. Richardson,[6] who, appealing to that love of
authority so powerful among medical men, asks—“Is it possible that
twenty centuries were grossly abused by the infliction of what in the
present state of feeling, was, on occasions, akin to crime? I believe
not.” He then proceeds to discuss ten propositions—or, as he calls them,
discoveries made by the ancients; and asks with regard to each of them
how far the application of them is sound and judicious practice. His
conclusion is, that blood-letting is still useful in some stages of
typhus fever; in cases where there is sudden tension of blood, of which
sunstroke is an example; in cases of chronic congestion of brain; in
cases of acute pain from serous membrane; in some classes of spasmodic
pain; in cases of sudden arrest of circulation from concussion; in cases
of congestion of the right heart; and, it may be, in extreme cases of
hæmorrhage. Above all, he says, “I claim for it a first place in the
treatment of simple uræmic coma.”
It is impossible to discuss at length, in this paper, all the important
practical points referred to by Dr. Richardson. But I shall refer to two
great principles in modern as distinguished from ancient medicine, which
I think must vitiate the most of his conclusions.
1. When the authority of the ancients is invoked to determine any
procedure in medical practice, we must remember that their idea of what
constituted disease consisted in the symptoms it manifested. When,
therefore, a symptom was diminished or removed, they regarded the means
they employed as having diminished or removed the disease. That a
blood-letting relieves the pain and dyspnœa in pneumonia is an
unquestionable fact. If employed early, it is true the symptoms
returned, and the remedy had to be repeated; but if carried out on the
fourth up to the eighth day, when, according to the extent of the
disease, these symptoms usually subside, and the exudation commences to
be absorbed, it appeared to act like a charm. It was then said that the
disease was knocked down, or strangulated; and if the patient recovered,
however lingering was his convalescence, the value of the remedy
appeared to be unquestionable. This idea, it seems, still prevails with
some physicians, as we have previously seen that Dr. Sieveking
instructed his pupils that he had “knocked down” a double pneumonia by a
small bleeding, although the condensation of the lungs—that is, the true
disease—still continued.
But modern research has demonstrated that there is no relation whatever
between the symptoms and the morbid state of the lung, which it is the
object of the well-informed physician to remove. It would be easy to
show that there are many cases where all the symptoms of a pneumonia
have been present, but where a post-mortem examination has proved that
there was no inflammation of the lung; and that a still larger number of
instances might be cited where fatal pneumonia has occurred without any
of its symptoms having existed during life. Such was the unacquaintance
of the past race of practitioners with diagnosis and pathology as now
understood, that no confidence whatever can be placed on their
impressions as to what disorders were or were not benefited by bleeding.
That in certain cases a full blood-letting modifies or cuts short
symptoms, I agree with Dr. Richardson in thinking is just as manifest a
truth now, as it was to Galen or Cullen. But I claim for the modern
physician a knowledge and a power far beyond that of alleviating
symptoms: viz., a true knowledge of the lesion which causes the
symptoms, and the power of conducting the disease to a rapid favourable
termination, notwithstanding what appears to the inexperienced or
uninformed the most alarming and fatal phenomena. He is enabled to watch
with accuracy by means of his stethoscope the removal of the
consolidation of the lung, to favour the resolution of the exudation,
and to assist the excretion of the absorbed products from the economy.
These are the aims of the modern practitioner—not so much the
alleviation of symptoms as the removal of the morbid state—not soothing
his patient, but saving his life. That he is capable of doing this by
studying pathology and disregarding the authority of the ancients is no
longer a matter of opinion, but is positively demonstrated, by attending
to the other principle, which also is not referred to by Dr. Richardson.
2. In all the circumstances which Dr. Richardson thinks blood-letting
still useful, we have no solid foundation on which the practitioner can
repose with confidence as a general rule of practice. To refer to the
opinions of the ancients is, as we have seen, useless; and to support
their notions by citing one or two exceptional cases is of no advantage
whatever. Indeed the quotation of successful cases, without also stating
the failures that have been experienced, is the chief cause of the
imperfection of practical medicine. It has been demonstrated that when
the practice of bleeding in acute pneumonia was universal, the result
was one death in three cases. That was what occurred in the carefully
diagnosed and picked cases of M. Louis, as well as what happened in our
best hospitals. In those days practitioners triumphantly pointed to the
two cases out of three that they snatched from what was then considered
a fatal attack of illness. Indeed it might easily be shown that the
worst practice might be defended by what are called successful cases. So
far from two survivors out of three being good practice, we have seen
that the abandonment of blood-letting and the adoption of a restorative
plan of treatment has resulted in diminishing the mortality to one in
twenty-seven or thirty cases.
What I object to in medical literature is that prevalent kind of
writing, which consists of plausibilities supported by successful cases.
What we have at present a right to expect in the way of generalization
or theory is that it should be based on positive researches, and not on
fallacious authority; and as regards practice, we should have a
reasonable number of cases recorded, in which the failures are given as
well as the successes. To say that this or that treatment is good,
because this or that case recovered, is of no advantage to medicine,
unless it stimulate the practitioner to record his cases, tabulate the
result, cease from vague opinion, and demonstrate the exact ratio of his
success. It is satisfactory for the present state of medicine that such
is the kind of inquiry now prosecuted by our most intelligent
physicians.
When, therefore, Dr. Richardson is of opinion that a restoration of
blood-letting is useful in some stages of typhus fever, and other
circumstances previously referred to, I venture to think he should show
how the mortality of that disease would be diminished thereby, when
contrasted with the nutrient system of management introduced by Dr.
Graves of Dublin. The same argument refers to other cases he has
referred to. I believe with him that there are instances of uræmic coma,
in young and vigorous subjects, which may be cured by blood-letting, but
as we have not yet accumulated a sufficient number of such cases it
would be premature to speak confidently of the results.
But with regard to the treatment of acute pneumonia I regard the
following axioms as fully established, viz.:—
1. The great end of medical practice is to remove the consolidation of
the lungs and restore those organs to their natural condition as rapidly
as possible.
2. To this end everything that diminishes vital strength should be
avoided, and nutrients administered as early as possible, to favour the
cell transformation necessary for removing the exudation from the lungs.
3. There is no relation between the violence of the symptoms or force of
the pulse and the fatality of the disease. Young and vigorous subjects
suffer most, but almost always recover soonest.
4. The weak pulse, want of reaction, non-disappearance of the pneumonic
consolidation, or its appearance during the progress of exhaustive
diseases, are the unfavourable signs of pneumonia.
5. Continued exercise or work after the attack; low diet, large
blood-lettings; depressants, such as tartar emetic and sedatives;
expectorants, such as squills and ipecacuanha; mercury and violent
purgatives, are opposed to the restorative treatment of the disease, and
when not fatal, tend to prolong its duration.
6. Small blood-lettings of from six to eight ounces may be used in
extreme cases, more especially of double pneumonia or of
broncho-pneumonia, as a palliative to relieve tension of the
bloodvessels and congestion of the right heart and lungs.