THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW.

JULY, 1858.

PART FIRST.

Analytical and Critical Reviews.

REVIEW I.

1. Reflections on the Results of Experience as to the Symptoms of Internal Inflammations, and the Effects of Bloodletting, during the last Forty Years. By Professor ALISON. (Edinburgh Medical Journal,' March, 1856.)

2. Observations on the Results of an Advanced Diagnosis and Pathology applied to the Management of Internal Inflammations, compared with the Effects of a former Antiphlogistic Treatment, and especially of Bloodletting. By Professor BENNETT. (Ibid., March, 1857.)

3. Reply to Dr. Bennett's Observations. By Professor ALISON. (Ibid., May, 1857.)

4. Note on the Effects of Bloodletting. By THOMAS WATSON, M.D., London. (Ibid., June, 1857.)

5. Remarks on Dr. Bennett's Paper on Bloodletting and Antiphlogistic Treatment. By W. T. GAIRDNER, M.D. (Ibid., September, 1857.)

6. Results of Treatment in Seventy-one Cases of Pneumonia treated in the Glasgow Infirmary. By JOSEPH BELL, M.D. (Glasgow Medical Journal,' July, 1857.)

7. Remarks on the Inflammation and Bloodletting Controversy. By W. O. MARKHAM, M.D. (Lancet,' October to December, 1857.)

"I was trained to bring all BORDEU, who was a man of humour and sense, says: my powers to bear against disease, even in its infancy. Principiis obsta, serò medicina paratur; sola remedia sanant; in extremis extrema; melius est dubium quam nullum,' &c. Such were my axioms. A happy chance cooled my desire to show to the amazed friends and the patient himself an array of bleeding basins. When very young, I was called in as the fourth physician to a patient attacked with fever, pain in the side, and bloody expectoration. I had no advice to give. The first consultant proposed a third bleeding; the second, tartar emetic, followed by a purgative; the third, a blister to the legs. The contest was long, and nobody

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would give way. For my part, I thought they were all in the right. The dispute continued. Various partisans among the friends of the patient sided with the various physicians. Nothing was done. In spite of the terrible predictions of my three masters, the patient, reduced to fever diet, recovered. I watched his case with interest, and alone, for he was deserted by the rest.”

Another anecdote. The Seranes, father and son, were physicians to the hospital at Montpellier. The son was a mere theorist, who knew by heart, and repeated continually, all the formula for inflammation. Serane père had been taught by the great masters. The good man had learned to treat inflammations of the chest with tartarized antimony. He gave it at least every other day, in emetic doses, with or without the addition of two ounces of manna. That was his grand cheval de bataille. I have seen him order it a thousand times-everywhere, and for everybody. The son endeavoured to convert his father, to bring him into the fashion, and to make him dread phlogosis, erethism, and the laceration of the small vessels. The father fell into a singular species of indecision, and knew not what to do. He, notwithstanding, held firm against bleeding; but after looking at the patient, he would mutter to himself, order nothing, and pass on. I have seen him, when restrained from giving tartar emetic, apostrophize his son- Mon fil, m'abès gastat! mon fils, vous m'avez gâté! Never shall I forget this strange scene. I owe him much, and his patients owe him much also. They were cured, almost without being bled, because the elder Serane loved not bleeding; and without tartar emetic, because the younger Serane proved to his father that this remedy increases inflammation. The sick were cured, and I profited by the lesson; and concluded that the bleedings which Serane the son multiplied when left to himself, were at least as useless as the repeated emetics to the use of which Serane the father was so much addicted.”

The elder Serane is the type of some perplexed physicians of the present day, and Bordeu himself of others-thinking men, who, watching disease, do not meddle with Nature unless she herself points out to them what to do.

The almost total abandonment of the lancet of late years has led to the controversy as to the treatment of the internal inflammations, and more especially pneumonia, which has been maintained in Edinburgh during the whole of the past year. Dr. Alison and the disciples of the older but advancing school of medicine account for the change in practice by a change in the type of disease; Dr. Bennett and the men of the "advanced" school attribute the change in practice to the sounder views of pathology now prevailing.

If this controversy were a mere attack upon, or defence of, the practice of former days, it would do harm rather than good; but it will be of real service if it lead to a sounder and more discriminating practice, based on a strict knowledge of the laws of disease, of the powers of recovery, of the tendencies to death, and, above all, on the effect for good or evil of bleeding and other modes of treatment. Although the treatment of inflammation is the avowed object of the controversy, it has practically almost narrowed itself to the treatment of pneumonia by bloodletting.

We shall consequently devote this article to the effect on pneumonia of practising or abstaining from bleeding.

However sanguine we may be as to the power of "an advanced diagnosis and pathology" to regulate treatment, we must submit the proof of that power to the rigid scrutiny of the actual effects in practice of the treatment of pneumonia, with and without bloodletting. We shall now therefore bring together the results arrived at by various observers, and then consider the whole subject.

The controversy itself has been carried on, with earnestness and signal ability on both sides, in the numbers for last year of the 'Edinburgh Medical Journal; we give in a few words the position taken by the more prominent champions of both sides, and shall then proceed to examine the whole question as fully as our oppor tunities will permit.

Dr. Alison is convinced that the change which has taken place in the usual phe

nomena of inflammations, and the usual opinion of medical men as to the effect of bloodletting, is chiefly due to this, that inflammation now very seldom occurs with such symptoms of febrile reaction as Cullen has described as demanding and bearing full bleedings; and further, that very often it is attended with typhoid symp toms. If blood is taken in such cases, it wants the firm buffy coat of former days; faintness is brought on by a smaller loss; and there is no such encouragement to a repetition of the bleeding, from the pulse speedily regaining its strength, or from the local symptoms abating and quickly recurring. We must now, therefore, abstain from strong depletion, and, if needful, commence the use of stimuli. Gangrene is a more frequent result of pneumonia now than it was formerly.

While Dr. Alison thus sustains his original position, that the abandonment of the lancet is owing to a change in the character of inflammation from a sthenic to a low type, Dr. Bennett, in an important paper in reply to that of Dr. Alison, holds his original position, that the change in treatment is the result of an advanced pathology and improved powers of diagnosis.

In this paper, which has been prepared with great care and earnestness of purpose, and in the spirit of truth, Dr. Bennett makes the following series of propositions:

"Proposition 1.-That little reliance can be placed on the experience of those who, like Callen and Gregory, were unacquainted with the nature of, and the mode of detecting, internal inflammations.

"Proposition 2.-That inflammation is the same now as it has ever been, and that the analogy sought to be established between it and the various types of fevers is fallacious.

Proposition 3.-That the principles on which bloodletting and antiphlogistic remedies have hitherto been practised are opposed to a sound pathology.

Proposition 4.-That an inflammation once established cannot be cut short, and that the only end of judicious medical practice is to conduct it to a favourable termination.

Proposition 5.-That all positive knowledge of the experience of the past, as well as the more exact observations of the present day, alike establish the truth of the preceding principles as guides for the future."

Dr. Bennett then gives an analysis of the statistics of the treatment of pneu monia by bleeding, the treatment by diet without bleeding, and his own treatment, directed to further the natural progress of the disease. To these we shall return when we review the whole discussion, and the extensive series of cases that we shall bring to bear upon these questions from various sources.

Dr. Alison and Dr. Bennett sustain their original views with great ability in the May number of the Edinburgh Medical Journal.' The former, at p. 978, gives an interesting anecdote in Dr. Gregory's own words of the extent to which that physician used bloodletting. He bled a young man for pleurisy. The remedy certainly was not spared. It was employed thrice in twenty-four hours, a pound at a time, without the least benefit. He bled him again on the second day to thirty-two ounces, the largest bleeding he had ever ordered. Next day he was worse than ever, so he took twenty ounces from him when sitting erect in bed. This time he bled him into convulsions; one or two pupils took fright and ran out of the room. The doctor himself was uneasy, but not so disconcerted as his pupils. On laying him down the spasms went off, and from that moment he was in a manner cured. The man lost in all ninety-seven ounces of blood. Dr. Alison details two cases from his own practice. One, an old lady of eighty-six, who only the other day suf fered severely from pneumonia. She was blistered, purged, and nauseated; morphia was administered and, after the pain subsided, a little wine. She resumed her usual active habits within a month from the seizure. The second case, a gentleman, aged sixty-seven, was treated, in November, 1841, for severe pneumonia. He was bled six times and cupped twice in five days! He had a second attack, under the care of Mr. Benjamin Bell, in November, 1848, when. no blood was taken, and before the end of the week he was allowed porter several times in the day.

In the course of his paper, Dr. Alison makes the following remark:

"If Dr. Bennett's pathology leads necessarily to the belief, that the principle in Therapeutics which the great body of practitioners, since medicine has been a subject of reflection to mankind, have adopted in regard to the effect of bloodletting in the early stage of inflammatory disease, is false, I confess that I should think that a much better reason for setting aside his pathology than their therapeutics."

Dr. Watson, in a note to his Lecture on Inflammation, in the recent edition of his Lectures (vol. i. p. 231), sides with Dr. Alison in this important discussion. That note is in the hands of our readers, and will be carefully studied by them. Dr. W. T. Gairdner, in an able paper in the September number of the Edinburgh Journal, attacks Dr. Bennett's view that "an advanced diagnosis and pathology" have been the chief causes of the change in the practice of bloodletting. In support of his view, he relates a case of pneumonia treated by Dr. Bennett himself in 1845, with venesection, cupping, antimony, and opium and calomel to ptyalism, and that although there was little pain or fever, and almost no dyspnea.

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Dr. Markham, who gave an important paper bearing upon this subject in the 'Edinburgh Medical Journal' for 1855, has recently published in the Lancet' some well-written and closely-argued papers, on the inflammation and bloodletting controversy.

Bouillaud's plan of bleeding coup sur coup, with the view of "jugulating" inflammation at once and by a 66 coup de grace," "has given him the name of being the most sanguinary physician in Europe. This is his "formule :"

"Bleed in the morning of the first day to sixteen, and in the evening to twelve or sixteen, ounces. In the interval, cup to the same amount, or apply thirty leeches. On the second day bleed again, and if pain still continues, cup or leech. The disease, fortunately, for the most part yields on the third day. If otherwise, don't hesitate, but bleed again. If by a rare chance it should resist to the fourth day, bleed again; but usually it is better to apply a large blister. As a rule you must not give up bleeding until fever, pain, and dyspnoea have almost ceased."*

Bouillaud's treatment in 75 cases is reported by M. Pelletan. The only complication was in a case literally poisoned by tartar emetic. This man was bled once before he was seen by M. Bouillaud. He was too ill for the coup sur coup plan, so he took ten grains of the drug daily for eight days. On the ninth day he died. Ulcers were scattered along the whole track, from the esophagus to the illio-cæcal valve. In no other case was tartar emetic given. Indeed, all the other patients enjoyed the singular advantage of simple treatment, with the addition, however, of blisters in 43 cases.

In his article on Pneumonia in the 'Dictionnaire,' published in 1835, M. Bouillaud informs us that in 102 cases treated by him from 1831 to 1834, the deaths were 12,1 in 84; and he states that Mr. Lacaze treated 42 cases par les saignées à haute dose, and only lost one. Many of the cases were slight, and did not require large bleedings repeated coup sur coup. Notwithstanding this, it is rather amusing to see Bouillaud, with perfect candour, tack these cases on to his own, and so bring out a joint-stock mortality of 1 in 11.

Writing in 1854, M. Bouillaudf informs us that during the preceding twelve years he had the happiness to cure, with some exceptions, which did but confirm the rule, upwards of 400 cases of pneumonia, a good number being over the age of sixty. The rare cases of exception were among those struck with pneumonia affecting nearly the whole of both lungs. In the following page he speaks of aiding by la toute-puissance de l'art between 500 and 600 cases. How are we to reconcile these discrepancies? He asserts at p. 507 that his plan singularly shortens

the duration of the illness, and that the patients recover their strength with remarkable rapidity.

In the work just quoted, M. Bouillaud states that, on an average, he takes away four or five pounds of blood, and that the largest quantity taken was ten pounds, which was abstracted from a patient who recovered. He objects to the plan in the third stage. Dr. Bennett informs us that Bouillaud, when he visited him at La Charité last August, still pursued the coup sur coup treatment in pneumonia. He saw several patients (all young persons) who were then convalescent. On asking him whether he had observed any change in the character of the pulse, or a more typhoid character of the fever in recent times, his answer was, "Certainly not." M. Bouillaud's plan is in some respects a modification of that of M. Sauvages, who prescribed bloodletting to half-a-pound every four hours during the first day, and repeated to ten times, and in an ardent case to eighteen times, with happy effect (feliciter)!*

Louis and Grisolle investigated under Chomel the treatment of pneumonia. Each of them was Chef de Clinique to Chomel at the Hôtel Dieu; each published a résumé of the cases of pneumonia treated by their master; each specially studied the effects of bleeding, tartar emetic, and blistering on the disease; each imbibed certain views in relation thereto from Chomel; each was able to put his views in practice and modify them, by being appointed physician to P'Hôpital de la Pitié. Louis preceded Grisolle, who dedicates his work On Pneumonia to "Mes excellens maîtres, Messieurs Chomel et Louis." Louis' deductions were adopted and worked out by Grisolle, who began his labours when those of Louis were closed. Their researches and those of Chomel are so interwoven, that we shall regard them as one common inquiry.

Chomel says, the earlier, the larger, and the more repeated the bleedings, the more useful are they in pneumonia. One or two very large early bleeedings have sometimes at once arrested the disease, or shortened it to two or three days, whereas it rarely ends before the seventh day, and often much later. But in the great majority of cases it is not so. Since in them, whatever we do, the disease has a period of increase lasting several days, during which the bleedings only cause a short remission, scarcely marked.

Louis gives the following case:-A strong young man, ill twenty-four hours, was admitted with extreme breathlessness, pain, catching expiration, quick pulse, heat of skin, and inability to lie down; the sputa were rusty and viscid; resonance was imperfect behind, where crepitation and partial bronchophony were audible. He was bled to fainting, and lost twenty-seven ounces of blood. He soon felt great relief, and next day the amelioration was such that several medical men thought the disease had been jugulée. Far from it, for the phlegm was still rusty, and dulness on percussion and bronchophony had extended considerably. The disease increased in extent until the fifth day, and convalescence did not set in until the ninth. When the first bleeding is early the disease lasts some days, but when the bleeding is late it very soon yields. The fact is, that the disease then more or less approaches its natural termination; and that the utility of bleeding is really confined within very narrow limits.

Chomel (p. 243) says that bleedings must be regulated in each case by the degree of inflammation and the powers of the patient. The first bleedings in strong adults may be from twelve to seventeen ounces, the later from eight to ten. In general, twelve or twenty-four hours may be allowed to elapse between the first and second bleedings. But you may often resort with advantage to a second bleeding a few hours after the first, and if the powers of the sick are good, a third in the same period after the second. By acting thus with energy early in the disease, you not only shorten the illness, but economize the blood, for two or three early bleedings will produce even more effect than six or eight made at

Nosologie, tom. ii. pp. 496-8.

+ Dictionnaire de Médecine, tom. xvii. p. 242. 1827. Recherches sur les effets de la Saignée, pp. 88-47.