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.