101

THE LANCET.

LONDON; SATURDAY, JANUARY 13, 1894.

THE LATE SIR ANDREW CLARK AS A THERAPEUTIST.

THE very characteristic address to students of the London

Hospital on the Treatment of Fibroid Lung Disease (one ofthe series of Instructions in Clinical Medicine given at

that hospital by the late Sir ANDREW CURK), whichwas published in the last issue of THE LANCET, suggestsa brief consideration of the principles upon which he treateddisease and of those qualities which made him so widelyconsulted a physician. He was rather fond of saying thatmedicine is the most unprincipled of arts. Be this as it

may, there are some great general principles underlying SirANDREW CLARK’S treatment of disease which had much to

do both with his own success and that of his treatment, andwhich are stated with his usual felicity and clearness in theaddress. His great fundamental idea of treatment was

that it must have regard to the laws of health. " The first

observation I make to you is a curious but an important one :it is that the laws of health are not suspended because a

person is sick." " He believed that most cases of disease had

their origin in some violation of the laws of health, and ofthese laws he was a constant student ; he reasoned withhis patients as if they studied these laws, too, or were

capable of so doing. It was almost a daily practice withhim to read a portion of some work on physiology, as it wasa daily prescription to each patient that he was to obey thelaws of "physiological righteousness." It would be difficult

to over-estimate the effect his advice and his authority hadin impressing well-to-do people with the conviction that theluxuries they enjoyed were a source of risk and often of dis-ease to them. Few patients left his consulting-room withoutreceiving carefully written instructions regarding diet, andthough these generally allowed three liberal meals a daythey were not immoderate and unlimited ones. He tells

his students that if it were possible to divide patientssuffering from acute diseases into two classes, the

first class consisting of people in circumstances justsufficiently comfortable to live and the other class of

the rich and the great, it would be found that the

mortality amongst the latter class greatly exceeded that ofthe poor and those just sufficiently well-to-do. His teachingabout alcohol, well defined in the address under notice, wasuniform and sound. His remarks had immediate applicationto cases of fibroid phthisis, but they were very much thesame as he used in other cases. If the patient is equallywell without alcohol it is much better that he should not

have it. He was too good a physician not to see that

some cases were greatly benefited by small quantities of

alcohol ; but these must be given at the light time. On this

point he is very explicit, and represents all sound medical

teaching. The right time he defines to be certainly notbetween meals or on an empty stomach. "I entreat

you," he said to his hearers, "to avoid either givingor assenting to the giving of alcohol in sny form under suchcircumstances. (jive the alcohol at dinner or supper, and

at no other time." " It will not be the least service’ SirANDREW CLARK rendered to his generation that with all his

authority he insisted on temperance and did his best to

remove that blind belief that the weakness of disease is to

be overcome by indiscriminate eating and drinking. He

impressed on his patients and on the public audiences thathe addressed that attention to such things has far more todo with health than great things : "It is not so much thebig things of life, it is the little things that make andunmake health."

Another very striking feature of Sir ANDREW CLARK’S

therapeutics was his estimate of the importance of work. In

the last generation one of our great surgeons distinguishedhimself by a work on the surgical advantages of rest; but inthis we have had a physician who has told all his patientsthat to the measure of their ability they are to work. Like

another prophet of this age, he has enjoined and eulogisedwork, not only as a duty and as a pleasure, but as a condi-tion of health. Even patients with fibroid lungs are todo a little work. At the London Hospital the patients weretold to go up and down stairs for the sake of expandingthe contracted lungs, which came to be called the "stair

treatment " ; for even in the case of a delicate organthe fullest regulated discharge of all its functions is the

cardinal condition of its highest life. Some of his friends

thought that he himself did too much work, but he wouldnever admit it, and he was fond of saying that he had neverknown anybody to be the worse for work. In this veryaddress he describes how his contemporaries prognosti-cated his early death because he worked hard and ate

little, and how thirty-eight years afterwards most of his

contemporaries were dead and he himself was one of thefew survivors. On the other hand, he admitted that worryis injurious. "Labour is life, but worry is killing," and

he imposed on his patients, as a duty, that by an effort

of will they should - as he said they could - cultivate

quietness of mind. The fact is that he in his capacity of phy-sician took into consideration the character of his patients,all their conditions and circumstances, and even their

sins and temptations, and on these founded a large part ofhis advice, which enabled the patients as a rule to live longerand where this was not possible to die more easily. As he

said nine years ago,1 in a remarkable account of the case ofa vivacious old gentleman of eighty-two years of age sufferingfrom relapsing pneumonia who recovered after having hadnine or ten rigors, "I first attended to the man and

then to the malady." Every case was unique in his viewand had to be treated on its own merits and according to

special circumstances. This very case showed that he had

his own favourite prescriptions, and that despite his strongteaching on the abuse of purgatives he did not despise the useof colocynth and blue pill in order to prepare the way for

brandy and quinine, and poultices, and an alkaline saline, to beafterwards fortified by the addition of ammonia, and all tobe subordinated to the natural conditions for promotingrecovery. "The food was given in relays, not too liberallyor too frequently "-avoiding a mistake often made with thebest intentions, which loads and narcotises rather than helpsthe patient. He endeavoured to maintain the vigour of thecirculation, to shut out noise and fussiness, and by light and

1 THE LANCET. Dec. 20th. 1884.

102 PSYCHO-PHYSIOLOGY.

flesh air to keep the organism in the best possible state for

recovery. We have said little of Sir ANDREW CLARK’S use

of drugs, but he used them freely and skilfully. We have

the authority of Dr. LAUDER BRUNTON for saying that hewas a master of therapeutics, that he kept himself abreastof the newest remedies, and that he used old ones with

remarkable skill. His instructions on fibroid phthisis includeseveral prescriptions, which he mentions in terms which

show his confidence in them.

We should miss one great secret of Sir ANDREW CLARK’S

power over his patients if we did not recognise two or threeof his other great qualities-viz., the confidence and authoritywith which he spoke, which were based on the soundnessof his general principles of treatment, and the cheerful-

ness with which he regarded even the graver classes of caseswhich came before him. Patients suffering from heart diseaseand lung disease went to him, and received, not prognostica-tions of evil, but materials for hope and comfort. His

paper on Valvular Disease, read at the Brighton meeting ofthe British Medical Association, showed not only how care-

fully he noted the individual cases which came before him,but what an eye he had for the hopeful side of disease.

He had seen 684 patients suffering from valvular disease

without symptoms or suffering, and who had come to himfor other complaints-viz., indigestion (272), rheumatic con-ditions (57), gout (22), nervous complaints (44), eczema

(17), and phthisis (4). Heart lesions in young subjects, hesaid, were considerably improved if development was notcomplete. He found in such patients fit subjects for his

advice about physiological living and sent them away withthe impression that if they obeyed his suggestions theywould live little less happy or less long lives than other men.The physician is bound to regard disease in its most hopefulaspects ; patients go to him, not that he "may cast thefashion of uncertain evils" and accidents, but for sugges-tions of hope and help.

WE announced last week that a course of practical psycho-physiology would be conducted during the Easter term at

University College, London, and mentioned that althoughpsychology, both in America and on the Continent, had beenmade the subject of some precise and experimental treatment,such a course formed a new departure in English scientificeducation. The Leipsic school, with ERNST HEINRICH

WEBER as its mouthpiece, will always be associated with

psycho-physical methods of research, and there can be

no doubt that his practical inquiries into tactile and

muscular sensation form the earliest genuine work in this

direction. The law (the WEBER-FECHNBR law) which

proposed to formulate the due relation between stimulus

and resulting sensation was directly suggested byWEBER’S experiments, though it was afterwards greatlygeneralised by FECHNER, and it remains the best-known

piece of practical work directly dealing with the debatable

province lying between the acknowledged territories of the

physiologist and the psychologist. But these experimentsdate from sixty years ago. And since that time physiologyhas advanced by such enormous strides that to those whctake no heed of beginnings the science may almost seem tc

have been invented during the six decades; while psychology,appearing now as the statistical investigation of the alienist,now as the illuminating lecture of the philosopher, now asthe speculative anatomy of the physician, and now asthe observant guesswork of the novelist, cannot be said tohave been neglected. All this constitutes a double invasion

of the intermediate ground. And although it has not asyet resulted in the discovery of new laws undeniably apper.taining to the region between, rather than to the one scienceor the other, yet it must conduce to such result, if laws

there be which can be made patent to our present under.

standing.Professor BURDON SANDERSON in his learned and sugoles-

tive presidential address on Biology delivered before the

British Association at Birmingham last year pointed out

that "between sensation and the beginning of action thereis an intervening region, which the physiologist has hitherto

willingly resigned to psychology, feeling his incompetenceto use the only weapon by which it can be explored-that of introspection." It will be remembered that Pro-

fessor BURDON SANDERSON then assigned the greaterpart of the debatable ground to physiology by regardingmind (using the word as a collective term for all mental

evolutions and emotions-that is, for the whole of subjectivelife) as a specific energy of the vital organism, the pro-cesses being the special actions normally performed by certaincerebral cells under certain stimuli, and comparable to other

specific energies. Three weeks later Dr. LIONEL BEALE in

his introductory lecture at King’s College on the Nature ofLife found himself standing on the edge of this same terri-tory, and his words showed that, so far from believing thatthere was a great future for the work of the physiologistin a psychical direction, he considered the problem of

the source of life to be beyond the possibilities of human

investigation. *’ We have not advanced," he said, one

step nearer the proof that life is I energy ’-’ immanent,’’specific,’ or ’cosmic’-or due to the properties of matter,or one with cosmic processes, or due to chemical actions,

or to machinery of molecular or other character, or to

the influence of external conditions, or to environment or

tendencies. " 2

By placing these almost simultaneous statements of

opinion from the mouths of two great scientific authoritiesin juxtaposition we are able to see very clearly that there

is a line beyond which, while all find it very hard to go,some believe it is almost wrong to try to go. It would

have been easy to find more controversial expressions utteredfrom either camp, but it has been purposely that we have

; selected the words of men whose sincerity, moderation, andsterling work no one can gainsay, to illustrate the two views

; upon what is colloquially termed ’’ materialism." There are

, some whose delight in the fireworks and acrimony of debatedetracts from the value of their opinions, but when reasonablemen, as well as learned, can see so very distinctly two sidesof a question, the chances are that in the present state of our

knowledge (and theirs) two sides exist. But what we desire

to point out is that such differences of opinion, even upon thefundamental topics of the origin and nature of life, so far from

1 THE LANCET, Sept. 16th, 1893.2 THE LANCET, Oct. 7th, 1893.

102 ATHE LANCET RELIEF FUND.

THE LANCET RELIEF FUND.For Members of the Medical Profession and their Widows

and Orphans when in Distress.

ALMONERS.

THE PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON.

THE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND.

THE PRESIDENT OF THE GENERAL MEDICAL COUNCIL.

THOMAS WAKLEY, F.R.C.S. Eng.

THOMAS WAKLEY, Jun., L.R.C.P. Lond.

HON. AUDITOR.

SIR HENRY PITMAN, M.D. Camb., F.R.C.P.

THIS FUND will be provided year by year in the month of January to the amount of at least £ 300

solely by the Proprietors of THE LANCET, and administered free of cost, for the purpose of affordingimmediate pecuniary assistance to Medical Men, or their Widows and Orphans, in cases of Distress

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Applicants must satisfy the Almoners of the Fund that they are qualified under the followingregulation :-

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;"’has fallen into pressing need of immediate pecuniary relief ; or (b) That they are persons who have been,previously to the date of application, legitimately dependent upon some person holding a registered medicalqualification, and that they have pressing need of immediate pecuniary relief."

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DAVIES, THE LANCET Offices, Strand, London, W.C.

The application should be accompanied by two separate testimonials, one from the Clergyman ofthe Parish or other resident Minister of religion, and one from a registered Medical Practitioner,stating-that the application addressed to the Almoners has been read, how long they have known the

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102 B ’iHE LANCET RELIEF FUND.

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102 CTHE LANCET RELIEF FUND.

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102 D THE LANCET RELIEF FUND.

103THE USE OF ORGANIC EXTRACTS IN THERAPEUTICS.

interfering with future work will be of practical benefit to it.The element of party is introduced, and will prove-as it

always has proved when its operations have been allowed

only moderate scope-a guarantee against loose and facilemethods and over-quick deductions. It cannot really matterto the world at large what the private and prophetic beliefsof the investigator may be as to the general trend of hiswork, provided that he continues to honestly investigate andis protected by equally honest criticism from jumping tohasty conclusions. With the enormously increased facilitiesfor laboratory work on the one hand, and the vast stores oflucid writing on the other that the past twenty years haveplaced at the investigator’s service, it seems to us that

systematic inquiry into borderland problems may very wellresult in valuable discovery-and that without either up-

setting the faith of our forefathers or convicting the sceptical Iof a pernicious atheism. ’

IT is still only recently that the brilliant researches ofMr. VICTOR HoRSLEY on the pathology of myxosdemaconveyed to Dr. GEORGE MURRAY the suggestion that casesof this and kindred diseases might be successfully treatedby the administration, in some form, of the organ, obtainedfrom lower animals, which was supposed to be at fault.

Since Dr. MURRAY made his results known they have

been confirmed by numerous observers, and now it may,without fear of exaggeration, be asserted that the successfultreatment of the conditions alluded to marks one of the

greatest therapeutic advances of the century. It was onlynatural that the method, as applied to other in no waysimilar diseases, should be carried to an extreme, and evento an absurdity. Without any reference to this great dis-

covery, Dr. BROWN-SEQUARD had already introduced a fluid,widely known by his name, which was prepared from thereproductive glands of certain animals and was supposedto have the virtue of endowing tottering senility with theenergy and vigour of manhood. This fluid has been

administered in every conceivable way, but chiefly hypo-dermically ; it has not been found, however, in the hands ofothers, to produce the wonderful results which were claimedfor it by its inventor. And we may say, in passing, that it is amatter for regret that some of those who have had opportuni-ties of observing its utter uselessness for the purposes forwhich it was introduced, as well as for those which were

subsequently claimed for it, should not have recorded in anauthoritative manner the evidence which they have obtainedof its inefficiency. Although the introduction of this sub-stance cannot be ascribed to any imitation of thyroid feed-

ing-indeed, as we have said, Dr. BROWN-S-1QUARD wasfirst in the field-it is significant as a sign of the activesearch for new remedies which has of late years been so

vigorously, and to a certain extent so successfully, prose-

cuted ; but such a step as the introduction of thyroidadministration initiated, was, in the nature of things, boundto be followed by the application of what, at least, were

supposed to be analogous principles in relation to the treat-ment of other diseases.

Among these diseases diabetes may be mentioned. It is

now recognised that, whatever the ultimate pathology of this

condition may be, in certain cases there is undoubtedly awidespread change in the pancreas. According to some thisis merely concomitant, according to others causative ; but itwas at least sufficient to suggest the employment of this

gland in the treatment of the condition. If diabetes were cer-

tainly dependent upon any condition of the pancreas whichabolishes the pancreatic functions it was not unreasonable tosuppose that the administration of a similar substance, or ofone as nearly similar as the lower animals can furnish, mightbe followed by some good effect upon the disease. We are

not aware that such has been the case, although the upholdersof the view that diabetes is a pancreatic disease would

scarcely be prepared to admit that such want of success is

any proof that their theory is incorrect.The condition of pseudo-hypertrophic paralysis, which in

many instances seems to become first manifest at a time at

which the thymus gland is undergoing atrophy, was anotherwhich appealed to the imagination of some therapeutists,being one in which there was a prospect of improvement bythe administration of the gland taken from animals corre-

sponding to the organ supposed to be at fault. In this case

also hopes have so far not been realised, although it will beevident on consideration that they may have been in thefirst instance rashly, if not unreasonably, entertained, and

perhaps also too rashly abandoned. The condition of the

thymus is notoriously a variable one. In some children it

is exceedingly small, while in others of the same age it is

much larger, so that before grounding any hopes of improve-ment in certain states from its administration it would be

at least desirable to have its condition carefully ascer-

tained not only in children suffering from the disease underconsideration, but also in children not so affected. If its

general absence, or even diminution, in this form of paralysiswere an ascertained fact, there would be at least some-

thing to go upon in advocating its employment, and the

hitherto negative results obtained might be due to somedefect in the mode of administration. As is well known,it was at first supposed to be necessary to administer

thyroid extract hypodermically, and although in this case itwas shown-first of aA, we believe, by Dr. HECTOR MAC-

KENZIE-to be unnecessary, it does not follow that it maynot be necessary in the case of other glandular extracts-sothat it will be seen that much careful observation in at

least two directions is still necessary before this idea can

be altogether relegated to oblivion.But with regard to the proposed administration of extracts

from other organs, or of the actual organs themselves, weconfess that we do not in many cases see much justifica-tion even for entertaining a hope that it will be successful.So-called "cerebrin " and "myelin " have been administeredin brain and spinal-cord diseases respectively, but neither inthe pathology of the conditions nor in the composition of theremedies is there any hint of even possible benefit, and nosuch benefit has been obtained. The same may be said of

the use of kidneys in Bright’s disease and of liver in liverdiseases. Such vagaries and irrationalities are, we fear, theinevitable accompaniments of any great step in any science ;more particularly is any great advance in therapeutic sciencelikely to be accompanied by much that is irrelevant anduseless.