The Practitioner. E-Book

Various

• Herausgeber: Science & Technology Publishing
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 114

Veröffentlichungsjahr: 2025

Beschreibung

The Practitioner: May, 1869. A Monthly Journal of Therapeutics is a seminal periodical dedicated to the advancement of medical science and the practical application of therapeutic knowledge in the late nineteenth century. This inaugural issue, published in May 1869, offers a comprehensive overview of contemporary medical practices, case studies, and the latest research in therapeutics, making it an invaluable resource for physicians, surgeons, and medical students of the era. The journal features detailed articles on the diagnosis and treatment of various diseases, critical reviews of new medical literature, and insightful commentary on the evolving landscape of medicine. With contributions from leading practitioners and scholars, The Practitioner provides a window into the challenges and innovations of Victorian medicine, emphasizing evidence-based approaches and the importance of continual learning in the medical profession. Rich in historical context and clinical wisdom, this volume not only reflects the medical knowledge of its time but also serves as a testament to the enduring quest for improved patient care and scientific understanding.

Leseprobe

Transcriber’s Note:

The cover image was created by the transcriber and is placed in the public domain.

THE PRACTITIONER. MAY, 1869.

Original Communications.

ON THE RESTORATIVE TREATMENT OF PNEUMONIA.

BY JOHN HUGHES BENNETT, M.D., F.R.S.E.

Professor of the Institutes of Medicine, and Senior Professor of Clinical Medicine in the University of Edinburgh.

I have long formed the opinion that the prevailing method of determining the value of any particular medicine or mode of treatment is essentially faulty. Practitioners, after watching a few cases, form a favourable opinion of this or that mode of procedure; they then publish their views, supporting them with their successful cases, and strongly recommend them to the consideration of their medical brethren. Then follow trials more or less numerous by others, some of whom think the method recommended good, whilst others find it useless or injurious. Such a system is characteristic of an imperfect acquaintance with medicine, and during the progress of many centuries, while it has led to some valuable knowledge, has for the most part only tended to superficiality and the utmost contrariety in medical practice. What seems to be necessary at present for determining the real value of any kind of treatment is—

1st. Rigid accuracy in the diagnosis of the case.

2d. A clear comprehension of the nature of the pathological condition treated.

3d. An acquaintance with the natural progress of the disease.

And

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 112 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 112 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.