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.