Makers of Modern Medicine

by James J. Walsh

With regard to fevers especially Graves' work will count for all time, because he set their treatment on so practical a basis. The trained nurse is quite a modern acquisition, yet seventy-five years ago Dr. Graves insisted that the services of a properly qualified nurse in severe, continued fever are inestimable. He emphasized the necessity for moral management in fever, and friends and relatives are seldom capable of discharging this office. "If they chance to discover from the physician's remarks or questions the weak points of the patient's case they generally contrive to let him know them in some way or another. If the patient is restless, for instance, the ill-judged anxiety of his friends [{172}] will most certainly keep him from sleeping. If he happens to take an opiate and they are aware of the nature of his medicine they will surely inform him of it in some way or another, though it may be only by a hint and his anxiety for sleep conjoined with their disturbing inquiries prevents its due operation."

We are apt to think that the modern aphorism, nursing (meaning trained care) is more important than medicine in the treatment of fever, is the result of observations in our own day. Dr. Graves, however, felt very deeply that the most important element in the treatment is the conservation of the patient's strength with the preservation of his morale, and this can be best accomplished when the patient is constantly under the care of an experienced nurse, noting every symptom and averting every possible source of worry and every form of exhaustion of energy.

With regard to fever treatment, however, Graves' name is immortal in medicine because of his insistence on the doctrine that fever patients must be fed. A century ago the presence of fever was supposed definitely to indicate that the patient should have no food. Any contribution to his nutrition was supposed to feed the fever rather than the patient. Graves pointed out, however, that at the end of a long-continued fever the most serious condition is the emaciation and weakness of the patient. He insisted that, appetite or no appetite, fever patients should be fed regularly. The result was at once noteworthy. Only the very hardy individuals had recovered before this; now even weaker patients had a good chance for life. The mortality from fever fell very strikingly, and in his time Dublin was overrun with typhoid and typhus fever and the saving of life produced by the new method of treatment was very considerable. Graves himself, when he saw how much he had accomplished by his [{173}] new doctrine, said that he wanted no better epitaph on his tombstone than the words, "He fed fevers."

Some of Dr. Graves' very particular hints with regard to treatment of fever show how careful he was in clinical observation. He deprecates the allowance of very much fluid for patients, since their thirst cannot be assuaged in that way, and the amount of liquid taken may be harmful by causing depression. He suggests, therefore, the use of acidulated water made by means of a little currant jelly or raspberry vinegar, given in small portions and at regular intervals. Much better than plain water he considers water to which some light bitter has been added, such as cascarilla. Small quantities of this will appease the morbid thirst of fever more effectually and for a much longer period than large draughts of water.

Even more interesting in these modern times, however, than Graves' attitude toward the treatment of fever is the position he took with regard to the habits of life that were best for the consumptive. At that time tuberculosis of the lungs was considered to be an inflammatory disease requiring the patient to be in the house most of the time, carefully protected from cold, and during any rise of temperature to be kept in warm rooms, without any special encouragement to take food. Graves and Stokes changed all that, and for the time completely revolutionized the principles of treatment for this serious ailment. Alas! their work, notwithstanding the good results shown in a certain number of cases, failed to attract widespread attention, and not until our own time did the principles that they laid down as the rational basis of successful therapeutics for tuberculosis come to be generally adopted.

Graves insisted that his patients when suffering from beginning tuberculosis should not be confined to the house, [{174}] but on the contrary should be out of doors most of the time. He emphasized what he called the taking of exercise, but in such a way that he agrees much more than might be thought with modern ideas on this subject. Now, it is insisted that tuberculous patients must not overtire themselves by taking exercise, though they must be in the open air a large part of the time. Graves explains the exercise that he would like to have them take by saying that they should spend four or five hours every day riding in a carriage, or, as he seems to prefer, in an open jaunting-car. And that they should spend at least as much time sitting outside in quiet.

Besides this the most important element in treatment he considers to be the encouragement of the appetite--as might be expected from the man who first fed fevers. His directions in this matter are very explicit, and he suggests various methods by which patients can be tempted to eat more and more food, and emphasizes the use of cereals and of milk and eggs as likely to be of most service in helping these patients to gain in weight and strength so as to be able to resist the further advance of the disease. This, it may be said in passing, is just the ideal treatment for the consumptive at the present time.

Others of Graves' opinions in regard to tuberculosis are in general surprisingly modern. He insists, for instance, that the main causes of the disease are overcrowding in towns, the long hours of hard work in factories, and abuse of alcohol. He thought that the population of country places, though fed no better as a rule than in the city, do not develop the disease so frequently because of their opportunity for fresh air. He placed very little confidence in the opinion that cold has anything to do with tuberculosis, though he disputed Laennec's dictum that bronchitis was never the beginning of tuberculosis. Graves advises his students not to try to [{175}] protect their throats by means of mufflers, for this will only render them more liable to cold. His advice is rather to harden themselves against cold. For this he suggests the use of water plentifully on the chest and throat, to be employed not too cold during the winter time, unless one is used to it. He also suggests the use of vinegar and alcohol as hardening fluids. They should be applied freely, and in his experience were effective.

Another interesting anticipation of modern methods was with regard to child feeding in summer diarrhoea. It is often thought that only in recent years, with the development of the science of bacteriology, the danger of continuing milk feeding when infants are already ill in the summer has come to be recognized. Milk is now known to be an excellent culture medium for various forms of bacteria, that is, it is a substance on which microbes grow plentifully, and it is often used in the laboratory to raise microbes. Dr. Graves, however, without any knowledge of modern bacteriology, but from clinical observation alone, pointed out that the only way to avoid summer diarrhoea is to stop all milk feeding.

"Let the infant," he says, "abstain from milk in any shape for twenty-four hours, sometimes for the space of two or even three days. It is incredible how small a portion of milk, even in the most diluted state, will keep up this disease, acting like a species of poison on the intestinal mucous surface."