ARTICLE VI.

CONSERVATIVE METHODS IN MEDICINE.

BY DR. EMORY STANSBURY, OF APPLETON.

The present surpasses every other age in the systematic prosecution and brilliant results of scientific research. Equipped with the marvelous appliances which modern invention supplies, the investigator pushes his way into hitherto unknown and inaccessible fields. No longer satisfied with the mere observation and classification of phenomena, he seeks boldly to grasp the knowledge of causes which have long been involved in impenetrable doubt and obscurity.

Nowhere has this search for the reason of things been more eagerly pursued than in the department of medical science. The mere mention of such names as Pasteur and Koch represents a scientific zeal so ardent as at once to challenge the warmest admiration, combined with wonderful ingenuity and exactness of method, and an almost incredible capacity for pains-taking labor.

Too much stress cannot be laid upon the importance of ætiological discoveries. Only by their aid can the great and beneficent work of the prevention of disease be intelligently prosecuted. Upon them, as a basis, all useful sanitary regulations, whether public or private, must necessarily rest. A thorough comprehension of the causes of disease in the individual patient, must be of incalculable value to the ordinary medical practitioner in the administration of remedies, and the direction of dietetic and hygienic treatment.

Yet, from the very importance of such considerations arises peculiar danger, viz.: that of too hastily assuming the correctness and consequent reliability as bases of treatment, of conclusions, which are, as yet, merely theoretical or speculative. It seems paradoxical, but is nevertheless true, that despite all recent ætiological studies, the profession has really never been more undecided as to

the questions at issue. This is due to the fact that such investigations have necessarily been carried on only by a limited number of persons, and a large proportion of the results obtained are capable of verification only by those especially trained. Many so-called discoveries have not yet been sufficiently tested to remove them unquestionably from the realm of mere theory. Scientific truth, indeed, always progresses in a straight path, but the course of her followers must too often be described as a spiral, intersected by her own immutable right line. The history of discovery is one of alternate advance and retrogression, of false steps taken only to be retraced.

With how much enthusiasm was hailed the promulgation by the German school of medicine, of what we may term the anti-pyretic theory of treatment, which assumed that in a large number of diseases, the danger to the patient was directly proportional to the increase of temperature of the system. While this proposition is in a certain sense true, it has been found that the converse can by no means be so confidently stated. We may reduce the temperature without being able to check the morbid processes already in operation, for, as Farquharson aptly says, "although we may effectually cool down our patient, the progress of the disease may go on quite unchecked." Consequently anti-pyretic ideas are already falling into disfavor with many, and giving place to later theories.

No expenditure of inanimate material, however great, can be considered a waste, which is necessary to the successful study of natural forces. The science of practical medicine, however, is subjected to peculiar limitations and embarrassments by the nature of the interests with which it has to deal. From certain lines of experiment, the conscientious practitioner finds himself often precluded. The maxim, "The greatest good to the greatest number!" cannot be too cautiously acted upon, at the bed-side where an immortal spirit battles with some obscure disease for the possession of its enfeebled

tenement.

In many cases the physician finds the effects of disease already so far advanced, that he has little time to spare for the investigation of causes, whether hidden or apparent. We rescue a drowning man, without stopping to inquire how he fell into the water; we strive to extinguish a conflagration without pausing to learn whether

its source were accidental or incendiary, and if a powerful hydrant is at hand, we shall hardly think the opportunity a favorable one for testing some newly-invented fire-extinguisher.

Twenty-five years ago, the medical world was comparative slow in learning and correspondingly hesitant in accepting any new doctrine or discovery. Now, with our immense system of ocean and land telegraphy, with the daily press at the bidding of every investigator, the physiological experiment or clinical observation of the morning, may be read at evening, throughout the civilized world. A wide-spread craving for something new is thus created in the minds of the laity, which, in turn, reacts upon the profession. Too many physicians, especially in our large cities, yield to the temptation to pander to the whims and morbid tastes of their patients.

A new proposition often charms by its very novelty, or convinces by its boldness. Some new remedy or unusual method of treatment seems far more attractive than the old servants whose faithful and efficient work has been long familiar. Dare I instance as a practical illustration of my meaning, the treatment of acute rheumatism by salicylic acid? The fact that the vast majority of cardiac affections are caused by rheumatism, especially the acute or inflammatory form, has been too well established to be called into question. Garrod tells us that, as early as 1788, Dr. Pitcairn had noticed that persons subject to rheumatism were attacked more frequently than others with symptoms of heart disease. In 1835, Bowillard discovered that rheumatic pericarditis, (a disease at that time generally recognized), was frequently accompanied by inflammation of the lining membrane of the heart, to which he gave the name endo-carditis.

Francis Sibson, in his article on pericarditis in Reynold's System of Medicine, analyses the notes of 326 cases of acute rheumatism treated by him, that were admitted into St. Mary's Hospital during the fifteen years ending in the autumn of 1866. Of these three hundred and twenty-six 54 suffered from endo-carditis accompanied with pericarditis, 9 had simple pericarditis, 108 were attacked with simple endo-carditis, and in 76 endo-carditis, though not established, was either threatened or probable, the signs of that affection being either transient or imperfect. Thus out of his 326 cases of inflammatory rheumatism, 171 were certainly, and 75, probably, complicated with endo-carditis or pericarditis, or both.

The great question, then, in treating this disease is not "How can we give most instant relief?" but "How can we while curing the disease, prevent the supervention of cardiac disorder?" Almost, if not quite every therapeutic remedy known has, at some time, been used in the treatment of rheumatism.

To Dr. Wright belongs the honor of first calling the attention of the profession in 1847 to the value of Alkalies in the treatment of this disease. Among his early followers were Fuller & Garrod. These gentlemen have claimed, and clinical experience has verified, that the Alkaline treatment would lessen the febrile movement, relieve the arthritic inflammation, abridge the duration of the disease, and prevent endo-carditis and pericarditis.

In 1855 Garrod gave to the Medical and Chirurgical Society an account of 51 consecutive cases treated on the alkaline plan, showing the average duration of the disease in 21 males was 11.3 days, the duration under treatment 6.2 days. The average duration of the disease in 31 females was 15.7 days, duration under treatment 7.3 days. "In no case did any heart disease occur after the patient had taken the remedy forty-eight hours." The publication of these facts by so careful and competent an observer as Garrod added many adherents to this method, and the treatment soon came into general favor with the profession, especially in America. Fuller, in a lecture delivered in December, 1862, said among other things "that his experience embraced up to that time one hundred and ninety-four cases and that in no single instance had any heart affection occurred after the patient had been under treatment for twentyfour hours."

In view of the greatly superior results obtained by this treatment over those formerly in vogue, both in subjugating the disease itself and preventing cardiac complications, of the simple and harmless character of the remedies which may be administered almost as freely and fearlessly as water itself, and of the confidence of the profession in its use, which has only been strengthened by the lapse of time since it had been generally employed it might have been supposed that none would abandon it without positive assurance of something better,

However, with the dawn of the germ theory of disease, salicylic acid was proposed as a germicide remedy for rheumatism. Without the sufficient data, which length of time and thorough

clinical observation alone could supply, as to whether or not, this drug would be equally efficacious in preventing cardiac disease, the new remedy was seized upon and employed in spite of the dangers which even its most ardent votaries confess may, at times attend its use. In reference to these dangers, allow me to quote from Longstreth, in his "Treatise on Rheumatism, Gout, etc.," (page 213) he says of Salicylic acid:

"In respect to its toxic effects-the alarming and dangerous symptoms which sometimes supervene in the course of its administration in the doses in which it is recommended have been frequently observed and well recorded by numerous writers."

In reference to the veiled and deceptive character of these dangers which render them all the more formidable, and especially to the not thoroughly experienced practitioner, he says, after noting that the chief result to be feared is the effect of the Salicylic acid upon the circulation:

"They are not evidenced plainly by striking phenomena, as are the nervous symptoms, and are not complained of by the patient, often until an advanced stage of development. They require for their detection, a knowledge of their character, or a familiarity with the physical status of the patient. This depression of the circulation I have seen develop so gradually, the patient meanwhile becoming more comfortable that the condition was easily mistaken for improvement. And it is only by a careful examination of the heart that the weakening of the cardiac action is discovered. In such cases I have not found much alteration of the radial pulse, at least not such changes in its character as would warn one of the coming or existing danger; the softness of the radial pulsations, under these circumstances could be interpreted as an improvement, and is quite compatible with the ease and comfort felt by the patient. I have found that the pulse, by no means in all cases, and not even in many cases, becomes increased in frequency, and neither does it have the feebleness of the failing, frequent pulse of the exhausted patient. In such cases, at the moment we are congratulating ourselves on the relief of the patient, another dose of the remedy may place us on the brink of a serious or fatal depression of the cardiac action, especially if this organ has deformity of its valvular apparatus or fatty changes in its muscular fibre."

Since preparing the present paper, a year ago, I have had the