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ON THE VARIATIONS OF TYPE IN ACUTE
(Concluded from page 22.)
DR. ALISON finds fault with Dr. Bennett for founding his opinion that blood-letting is injurious in pneumoniaupon pathological doctrines or facts. In this Dr. Alison is wrong, for Dr. Bennett does not conclude from these doctrines to the fact that bleeding is injurious; but takes up the fact as clearly and fully established by clinical investigations—and attempts to explain it by the present state of our knowledge of the intimate changes going on in the small vessels and in the cells of the inflamed part. In his mode of reasoning Dr. Bennett is perfectly logical, and in his inferences quite correct. If, as Dr. Alison asserts, "the inference that young men, studying the subject for the first time, will naturally draw from these (Dr. Bennett's) expressions-occurring in a systematic review of pathological improvements recently effected-is that we now possess pathological information sufficiently precise to entitle us to set aside the practical conclusions touching the power of blood-letting over inflammation, which our predecessors had drawn from their observations of disease, and which they have attempted to establish as principles in therapeutics. If young men, studying at Edinburgh, were really to rest satisfied in matters of practice, with inferences drawn from pathological theories, we should have but little to say in favour of the teaching of that school. Yet, if it were so, they would only be carrying out that which we so much object to, in the so-called rational medicine of the present day, which will only tolerate in practice, principles, or rules, which our
reason tells us are the legitimate inferences from our physiological and pathological knowledge. But we do not fear any such result from the teaching of Dr. Bennett; we rather apprehend that his teaching will lead his pupils to investigate the whole matter, taking their physiological and pathological knowledge as their guide and as their safe-guard against the influence of any predilections they may have previously entertained in favour of bloodletting, and that they will carefully and impartially weigh the evidence on either side and judge for themselves on the strength of that evidence alone.
Dr. Alison objects to the pathological views of Dr. Bennett, that "although it is true that the exudation of decolorized lymph into the cells of the lungs is the most characteristic indication of this disease (pneumonia) as we see it in the dead body ..... Yet, in this or any other case of disease threatening organic lesion, but seen during life, it is not merely the mechanical change of position of many particles of the blood, but a strictly vital action-such as we trace up only to principles of physiology and pathology-to which we have to apply a remedy." And a little further on he adds: "Yet I maintain, most confidently, that we have no pathological information which entitles us to doubt that blood-letting, employed in the early stage of the inflammation, when the stagnation, distension of the vessels, change of the blood, and exudation of the decolorized lymph are only beginning, may arrest or greatly shorten those local changes; and most materially diminish both the amount of the local change of structure and the danger of the Dr. Alison also adds general disease that is excited."
"that it is only by careful observation of the symptoms in individual cases before, during, and after, the blood-letting, that we can gather information sufficient to justify the establishment of a principle in therapeutics as to the power of this remedy."
All this is perfectly true, and we are thankful to Dr. Alison for this clear and talented statement of the prinNo. 2, Vol. 1.
ciples which should guide us in the investigation of the truth in this portion of the field of medical practice. It is a thing perfectly possible that blood-letting might arrest the further development of pneumonia when employed at its earliest stage-that is to say, before any change in the blood, stagnating in the capillary vessels, and before any exudation into the pulmonary cells, have taken place. There is, we admit, no pathological reason why it should not be so; but is it really the case? We believe not. Therefore, when Dr. Alison asserts that "there is no principle in medicine better established in this way by experience, or more important than the power of blood-letting over this and other inflammatory diseases," before the pathological changes going on in the part affected have assumed any very great development, we believe he makes a statement quite unsupported by facts.
With all due deference to the experience of so wellpractised and so learned a physician, as Dr. Alison undoubtedly is, we beg leave to dissent from this assertion. His experience has deceived him,-and why? Simply, because he has observed the march of pneumonia and its results when under the influence of blood-letting. But he has neglected the counter-experience—and no scientific investigator should ever neglect the test and the counter-test-he has not seen pneumonia under homœopathic or under dietetic treatment. Hence the error into which he has fallen.
Now, it so happens that this supposed salutary influence of early bleeding in pneumonia is not only not supported by facts but is actually contradicted by them. In the discussion which followed the reading of Dr. Alison's paper, Dr. Simpson stated that the good influence of blood-letting in pneumonia was clearly proved by the army and navy returns. In a paper which appeared in our first number, we proved that Dr. Simpson was mistaken in this opinion, and that, although the army returns exhibited results much more favourable than
those observed in hospitals for civilians,—as we should have expected from the circumstance that men affected with chronic disease are not kept in the ranks,-and hence that the returns do not comprise pneumonic cases complicated with various chronic diseases—yet, that the army returns, for men in the prime and vigour of life, presented less favourable results than did the cases of Dr. Dietl in an hospital for civilians and with patients of all ages, and much less favourable than those presented by all homœopathic hospitals.
If, then, blood-letting is found to be opposed to the dictates of sound pathological science and injurious in the fully-developed stages of pneumonia, it is also found to be injurious in its earliest stage.
The importance attached by Dr. Alison to the careful observation of individual cases, and his contempt of statistics, evidently misled him in his estimation of the value of blood-letting-thus, when speaking of the cases of pneumonia, as he supposes they occurred in the days of Cullen and Gregory, that is to say, with more violent inflammatory fever than he believes is observed at presenthe alludes to the relief given to the breathing, often while the blood is flowing, provided this medication be resorted to within the first three days of the disease, and evidently believes the remedy to be almost infallible. He also mentions his own case, having been affected with pneumonia at the age of fourteen. The relief to all his sufferings being so marked that under the flow of three cupfulls of sizy blood, taken from the arm, his symptoms greatly improved, and on a repetition of the same process the next day, the feeling both of dyspnea and febrile irritation entirely vanished. Yet, it required a few days' blistering, etc., to remove the pain in the side, and, strange to say, it "is to this day easily re-produced, with such indications of imperfect expansion of the side, as to leave no doubt of an inflammatory exudation, at least in the pleura, having taken place!" (Loc. Cit. p. 775.)
If such are the results of the heroic practice of Dr.
Gregory upon a boy of fourteen, at the most favourable age for the treatment of pneumonia, we may well wonder how the favourable impression of the effects of bloodletting should have been retained in the mind of Dr. Alison to the present day! The fact is, that the first bleeding, as bleeding usually does in acute inflammation, acted as a palliative, and that the immediate palliation of the dyspnoea, produced by congestion of a large portion of the lungs, and inflammation of a more limited extent, remained impressed upon his mind. Add to that, the neglect of a proper study of statistics and you will understand how the emeritus professor still holds to his early impression of the effects of blood-letting in spite of the statistics of Dietl and others, which prove it to be injurious.
The remainder of the paper is chiefly taken up with the consideration of the alledged changes of character of pneumonia and other inflammations. We rarely observe now, especially in hospital practice, cases of pneumonia of a type similar to that described by Cullen, and they have a more decided tendency to be accompanied by fever of a typhoid form. Thus, the treatment by full bleeding is more rarely called for. We need not follow the author throughout this part of his paper in order to give an idea how he establishes his position; indeed, it would be difficult to do so without giving long extracts, for which we have not sufficient space. It is sufficient for our purpose to state, that he holds that, in our time, pneumonia is of such a type that it requires bleeding, especially full bleeding, less frequently than formerly, and that the use of stimulants is more frequently called for.
Now, here we find our emeritus professor in a most decided logical difficulty. He states (Loc. Cit., p. 781) that "almost all the cases he can recollect, where bloodletting has been carried further than usual, have been cases terminating favourably; and by far the greatest number of deaths, from inflammatory diseases, have been in cases where the diagnosis was comparatively doubtful, and, therefore, the quantity of blood taken has been com