Read Ebook: The Practitioner. May 1869. A Monthly Journal of Therapeutics by Various Anstie Francis Edmund Editor Lawson H Henry Editor

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Editor: Francis E. Anstie Henry Lawson

THE PRACTITIONER.

MAY, 1869.

Original Communications.

ON THE RESTORATIVE TREATMENT OF PNEUMONIA.

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

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--

And

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 7 1/2 cases. 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 7 1/2 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, with four deaths, and a mortality therefore of one in 32 1/4 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 30 3/5 , 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 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, 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.

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.

We have here the dyspnoea 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 dyspnoea 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.

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?

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.

The question of blood-letting as a point of scientific practice has again been raised by Dr. Richardson, 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 haemorrhage. Above all, he says, "I claim for it a first place in the treatment of simple uraemic 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.

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.

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 uraemic 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.:--

NOTES ON THE USE OF POULTICES.

Attention is at present attracted to various applications having for their object the better healing of wounds and sores of different kinds; but I should be sorry if, in the search after new, one at least of the ancient remedies should fall into disfavour. It has been asserted that poultices are often used to conceal defects of treatment, a kind of refuge in ignorance of any more advantageous applications, and that they often do positive harm by inciting profuse, and consequently exhausting, suppuration, and, no doubt, it is true they favour the tendency to suppuration which may exist in particular instances, and that they will increase a suppurating discharge when the latter is already established.

Most remarkable results, however, follow the use of poultices in certain cases--of lupus, for example. A woman attends at my out-patient room with ordinary lupus which, when first seen, had eaten away the middle portion of the upper lip, and had encroached upon the septum of the nose. A bread poultice was applied day and night to the ulcerated surface, and she took iodide of potassium. The sore was soon and completely healed. After six months she returned with the disease worse than ever, but it quickly healed again under treatment, and would, I am sure, remain well if she were ordinarily watchful over it. As the iodide of potassium may have had some influence in this instance, its use was dispensed with in other cases. A woman was taken into Sitwell ward with extensive lupus of the nose. It was with difficulty we persuaded her to submit to such simple treatment as the application of bread poultices continuously to the sore; she craved for physic, which was denied her. Very quickly the sore healed, and she left well. It is needless to record other and similar cases which have been treated in this simple fashion with the same satisfactory results.

Some months ago a man was sent to me from Woolwich with an ulcer on the outer angle of the orbit extending to the conjunctival surfaces of the lids; it was irregularly scabbed over. In my opinion, and in this I was confirmed by several of my colleagues, it was an example of so-called epithelial disease; at all events it had been an open and increasing sore for nearly five years, and before proceeding to remove it I agreed to try the effect of some local caustic. To clean the surface a bread poultice was applied, and it mended so much that this application was continued, when great part of the sore healed rapidly, and the remainder cicatrized after being touched with caustic zinc.

All surgeons are familiar with the good results which follow the application of a poultice to an acutely inflamed surface-part. Quite recently a woman has been under my care with inflammation of the tissues about the internal saphenous vein. She has progressed quite well towards convalescence by keeping the limb at rest, and by having the inflamed vein-track covered with a large poultice of linseed meal; no other treatment has been required. It is a common fault, not so much perhaps in hospital as in private practice, not to give a poultice the chance of curing a local inflammation by limiting its application to the part affected. A poultice to be of any use should widely cover the tissues which surround the seat of inflammation; for example, if the hand is inflamed the poultice should not only completely envelope it, but should extend at least half-way up the fore-arm: and this rule holds good especially when poultices are used for superficial or for subcutaneous diffused inflammation.

A little girl I saw recently in Sitwell ward had a fierce attack of inflammation, after measles, which involved one side of her face and neck. As it threatened to lead to suppuration we made three punctures, carried deeply amongst the tissues, and then applied a succession of large poultices to the entire of the affected side. In twenty-four hours the child, from a condition of great depression, was well enough to leave the hospital--the swelling was much reduced, probably by the draining away of serous fluid, but no suppuration was established. I often direct a bubo to be punctured with a grooved needle, the needle being carried across so as to make a double opening; poultices are then applied, and if the parts are moderately rested, the swelling will usually subside; if the bubo is suppurating the same treatment will suffice to evacuate the pus, and this having discharged the bubo disappears, and no trace even remains of the openings through which the pus has passed out. In cases such as those referred to, some without, some with a surface lesion, the mischief is remedied without any suppurative action being set up by the use of the poultices.

It is desirable, when there is much discharge into a poultice, to dust over the skin about the openings whence the discharge issues some oxide of zinc, or some other drying powder; if this precaution is not taken the matter will irritate and probably enlarge the opening, or will produce vesicles, which break and leave excoriations, or painful papulae on the adjacent integument. It should be remembered also that great heat is not needed with the poultice; it should be comfortably warm to the patient, and should never be allowed to get, by comparison with its condition when applied, so cold as to lessen the temperature of the part.

Ulcers of many kinds will heal rapidly when treated with poultices; and when I use the word "rapidly," I refer to comparative quickness of healing, as ascertained by measuring the chief diameters of the ulcerated surfaces; their progressive over-closing is thus very accurately checked from week to week. This refers more especially to ordinary ulcers, such as result from injuries. A boy now attends in my out-patient room who under this treatment is healing up a sore on the fore-arm, the remains of a bad crushing of the part. Sometimes this healing is hastened by dusting the ulcer twice daily with powder of oxide of zinc before the poultice is at such times applied. In Sitwell ward a woman is just well of a severe phagedaenic sore involving the skin over and below the knee. Mr. Cumberbatch, the dresser of the case, kept the parts at rest by swinging the limb, and applied at first an ordinary linseed poultice, then warm water dressing , and, to expedite the healing of a few remaining sores, some resin ointment. The cure has occupied twenty-six days, a very rapid progress considering the constitutional nature of the affection: no medicine was needed.

I never could understand, seeing it is desirable to keep the parts immediately after an operation warm and quiet, why those objects should not be attained by the use of poultices; nothing I know of is more efficient to lessen the trouble caused by the starting of a limb after amputation, than the weight of and the resistance offered by a large poultice surrounding the stump. But their employment is in disfavour, first from the fear of their provoking recurrent bleeding, although this reckons for little if due care has been taken to have the wound thoroughly dry before closing it, and unless this care is taken there is little chance of its uniting by the first intention; secondly, by the prevailing notion that such union is prevented by the relaxing influence of this kind of dressing. Wishing to put this to the test of experience, the following cases, amongst others, were placed under treatment.

Having occasion to remove the larger portion of the left upper jaw of a female, about forty years of age, I brought together the incised wound of the face with wire sutures, and directed a bread poultice to be at once applied and renewed at intervals. The entire wound united by the first intention. A boy had his hand and fore-arm crushed by machinery, and it was necessary to perform amputation below the elbow. The flaps of integument were carefully adjusted, and the stump was poulticed. On the ulnar side the tissues united without suppuration; on the radial a portion of skin sloughed in consequence of the hurt it had sustained at the time of the accident, and on this side consequently the repair was less quickly completed. I recently amputated at the thigh, on account of strumous disease of the left knee of a boy, and brought the flap surfaces into apposition. The wound was at once covered with a linseed meal poultice. The next day, the stump being swollen, the wire sutures were cut. Bread poultices, and then warm water dressings, were afterwards employed, and the wound healed without any suppuration having been set up by the action of the local remedies. What pus did form was no more than might have been expected from incomplete primary union of portions of the cut surfaces.

I should like to see a more extended trial given to applications which keep a wound warm and moist continuously from the time of the operation. I think their use would give satisfactory results. No doubt they are most serviceable remedies throughout various forms of ulceration, and especially so in cases of lupus.

THE HYPODERMIC INJECTION OF MORPHIA IN MENTAL DISEASE: A CLINICAL NOTE.

BY C. LOCKHART ROBERTSON, M.D. CANTAB., F.R.C.P.

The detail of the hypodermic method of treatment is carefully stated in Dr. Anstie's Paper, and to this I must refer those who desire farther information regarding it. I use a solution of 6 gr. of the acetate of morphia to the drachm; Dr. Anstie's strength is 5 gr. I always commence with ?v of the solution , and in only one case out of many hundred hypodermic injections of morphia has any injurious effects followed the remedy thus used.

Although she could not be prevailed on to take any solid food, she was coaxed at times during the first two days after her admission to take 1/2 gr. of morphia in a little brandy, but she was almost invariably sick after it; moreover, the excitement continued, and she could obtain no sleep.

On the third day the hypodermic injection of 1/2 gr. of morphia was commenced, and continued every four hours except during the middle of the night. On the fifth day she was calm, although incoherent, and had slept during the whole of the previous night, took her food well, and had lost nearly all the typhoidal symptoms. Moreover, the irritability of the stomach was completely allayed.

She has since then recovered without a bad symptom, and she is now convalescent.

This case showed in a very marked manner the advantage of the hypodermic injection of morphia over its administration by the mouth in cases, which so frequently occur, of acute mania with marked asthenia and irritability of the stomach, causing refusal of food.

He was thus treated for some two or three years. He generally suffered from three or four attacks in each year.

In April 1868 he had an unusually severe attack of excitement, combined with much noise and destruction of clothing. The usual medicines having no effect, he was treated with the subcutaneous injection of morphia three or four times in the twenty-four hours, and with marked benefit.

On the recurrence of the next attack subcutaneous injection was had recourse to at once, and the period of excitement was reduced to little over a fortnight.

The next attack passed off in an equally satisfactory manner. In the January of the present year an attack of recurrent mania being evidently imminent, the old treatment of digitalis and opium was tried for fully a fortnight, but without benefit. On February 8th 1/2 gr. of morphia was injected, and the injection continued every six hours, and on February 10th he was decidedly improved and free from excitement and noise.

Not only, therefore, is the duration of the attack of recurrent mania diminished in this case, but during the attack the excitement is much less intense under the hypodermic method of treatment.

In the first place she was treated with stimulants, sedatives, and a nourishing diet, but she remained from May 14th, the day of admission, until May 20th, without any improvement, and was becoming so reduced, from want of sleep and constant worry, that her life was despaired of. On the 20th May, 1868 , "she passed a very restless night, and is much exhausted this morning: injected acetate of morphia gr. j, and she soon fell asleep; took her food well on awaking."

On the 23d, "injected gr. j of morphia twice daily since the last entry, and with decided benefit, and she is much less excited. Sleeps well, and the suicidal tendency seems to have passed away."

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