The Complete PG Works of Oliver Wendell Holmes, Sr.
by
Oliver Wendell Holmes, Sr. (The Physician and Poet)
Part 44 out of 51
"I believe I have answered all your questions. I have been more
particular on some points perhaps than necessary; but I thought you
could form your own opinion better than to take mine. In 1830 I
wrote to Dr. Charming a more particular statement of my cases. If I
have not answered your questions sufficiently, perhaps Dr. C. may
have my letter to him, and you can find your answer there." [In a
letter to myself, this gentleman also stated, "I do not recollect
that there was any erysipelas or any other disease particularly
prevalent at the time."]
"BOSTON, February 3, 1843.
III. "MY DEAR SIR,--I received a note from you last evening,
requesting me to answer certain questions therein proposed, touching
the cases of puerperal fever which came under my observation the past
summer. It gives me pleasure to comply with your request, so far as
it is in my power so to do, but, owing to the hurry in preparing for
a journey, the notes of the cases I had then taken were lost or
mislaid. The principal facts, however, are too vivid upon my
recollection to be soon forgotten. I think, therefore, that I shall
be able to give you all the information you may require.
"All the cases that occurred in my practice took place between the
7th of May and the 17th of June 1842.
"They were not confined to any particular part of the city. The
first two cases were patients residing at the South End, the next was
at the extreme North End, one living in Sea Street and the other in
Roxbury. The following is the order in which they occurred:
"Case 1. Mrs._____ was confined on the 7th of May, at 5 o'clock,
P. M., after a natural labor of six hours. At 12 o'clock at night,
on the 9th (thirty-one hours after confinement), she was taken with
severe chill, previous to which she was as comfortable as women
usually are under the circumstances. She died on the 10th.
"Case 2. Mrs._____ was confined on the 10th of June (four weeks
after Mrs. C.), at 11 A. M., after a natural, but somewhat severe
labor of five hours. At 7 o'clock, on the morning of the 11th, she
had a chill. Died on the 12th.
"Case 3. Mrs._____ , confined on the 14th of June, was comfortable
until the 18th, when symptoms of puerperal fever were manifest. She
died on the 20th.
"Case 4. Mrs._____ , confined June 17th, at 5 o'clock, A. M., was
doing well until the morning of the 19th. She died on the evening of
the 21st.
"Case 5. Mrs._____ was confined with her fifth child on the 17th of
June, at 6 o'clock in the evening. This patient had been attacked
with puerperal fever, at three of her previous confinements, but the
disease yielded to depletion and other remedies without difficulty.
This time, I regret to say, I was not so fortunate. She was not
attacked, as were the other patients, with a chill, but complained of
extreme pain in abdomen, and tenderness on pressure, almost from the
moment of her confinement. In this as in the other cases, the
disease resisted all remedies, and she died in great distress on the
22d of the same month. Owing to the extreme heat of the season, and
my own indisposition, none of the subjects were examined after death.
Dr. Channing, who was in attendance with me on the three last cases,
proposed to have a post-mortem examination of the subject of case No.
5, but from some cause which I do not now recollect it was not
obtained.
"You wish to know whether I wore the same clothes when attending the
different cases. I cannot positively say, but I should think I did
not, as the weather became warmer after the first two cases; I
therefore think it probable that I made a change of at least a part
of my dress. I have had no other case of puerperal fever in my own
practice for three years, save those above related, and I do not
remember to have lost a patient before with this disease. While
absent, last July, I visited two patients sick with puerperal fever,
with a friend of mine in the country. Both of them recovered.
"The cases that I have recorded were not confined to any particular
constitution or temperament, but it seized upon the strong and the
weak, the old and the young,--one being over forty years, and the
youngest under eighteen years of age . . . . If the disease is of
an erysipelatous nature, as many suppose, contagionists may perhaps
find some ground for their belief in the fact, that, for two weeks
previous to my first case of puerperal fever, I had been attending a
severe case of erysipelas, and the infection may have been conveyed
through me to the patient; but, on the other hand, why is not this
the case with other physicians, or with the same physician at all
times, for since my return from the country I have had a more
inveterate case of erysipelas than ever before, and no difficulty
whatever has attended any of my midwifery cases?"
I am assured, on unquestionable authority, that "About three years
since, a gentleman in extensive midwifery business, in a neighboring
State, lost in the course of a few weeks eight patients in child-bed,
seven of them being undoubted cases of puerperal fever. No other
physician of the town lost a single patient of this disease during
the same period." And from what I have heard in conversation with
some of our most experienced practitioners, I am inclined to think
many cases of the kind might be brought to light by extensive
inquiry.
This long catalogue of melancholy histories assumes a still darker
aspect when we remember how kindly nature deals with the parturient
female, when she is not immersed in the virulent atmosphere of an
impure lying-in hospital, or poisoned in her chamber by the
unsuspected breath of contagion. From all causes together, not more
than four deaths in a thousand births and miscarriages happened in
England and Wales during the period embraced by the first "Report of
the Registrar-General." In the second Report the mortality was shown
to be about five in one thousand. In the Dublin Lying-in Hospital,
during the seven years of Dr. Collins's mastership, there was one
case of puerperal fever to 178 deliveries, or less than six to the
thousand, and one death from this disease in 278 cases, or between
three and four to the thousand a yet during this period the disease
was endemic in the hospital, and might have gone on to rival the
horrors of the pestilence of the Maternite, had not the poison been
destroyed by a thorough purification.
In private practice, leaving out of view the cases that are to be
ascribed to the self-acting system of propagation, it would seem that
the disease must be far from common. Mr. White of Manchester says,
"Out of the whole number of lying-in patients whom I have delivered
(and I may safely call it a great one), I have never lost one, nor to
the best of my recollection has one been greatly endangered, by the
puerperal, miliary, low nervous, putrid malignant, or milk fever."
Dr. Joseph Clarke informed Dr. Collins, that in the course of forty-
five years' most extensive practice he lost but four patients from
this disease. One of the most eminent practitioners of Glasgow, who
has been engaged in very extensive practice for upwards of a quarter
of a century, testifies that he never saw more than twelve cases of
real puerperal fever.[Lancet, May 4, 1833]
I have myself been told by two gentlemen practising in this city, and
having for many years a large midwifery business, that they had
neither of them lost a patient from this disease, and by one of them
that he had only seen it in consultation with other physicians. In
five hundred cases of midwifery, of which Dr. Storer has given an
abstract in the first number of this Journal, there was only one
instance of fatal puerperal peritonitis.
In the view of these facts, it does appear a singular coincidence,
that one man or woman should have ten, twenty, thirty, or seventy
cases of this rare disease following his or her footsteps with the
keenness of a beagle, through the streets and lanes of a crowded
city, while the scores that cross the same paths on the same errands
know it only by name. It is a series of similar coincidences which
has led us to consider the dagger, the musket, and certain innocent-
looking white powders as having some little claim to be regarded as
dangerous. It is the practical inattention to similar coincidences
which has given rise to the unpleasant but often necessary documents
called indictments, which has sharpened a form of the cephalotome
sometimes employed in the case of adults, and adjusted that
modification of the fillet which delivers the world of those who
happen to be too much in the way while such striking coincidences are
taking place.
I shall now mention a few instances in which the disease appears to
have been conveyed by the process of direct inoculation.
Dr. Campbell of Edinburgh states that in October, 1821, he assisted
at the post-mortem examination of a patient who died with puerperal
fever. He carried the pelvic viscera in his pocket to the class-
room. The same evening he attended a woman in labor without
previously changing his clothes; this patient died. The next morning
he delivered a woman with the forceps; she died also, and of many
others who were seized with the disease within a few weeks, three
shared the same fate in succession.
In June, 1823, he assisted some of his pupils at the autopsy of a
case of puerperal fever. He was unable to wash his hands with proper
care, for want of the necessary accommodations. On getting home he
found that two patients required his assistance. He went without
further ablution, or changing his clothes; both these patients died
with puerperal fever. This same Dr. Campbell is one of Dr.
Churchill's authorities against contagion.
Mr. Roberton says that in one instance within his knowledge a
practitioner passed the catheter for a patient with puerperal fever
late in the evening; the same night he attended a lady who had the
symptoms of the disease on the second day. In another instance a
surgeon was called while in the act of inspecting the body of a woman
who had died of this fever, to attend a labor; within forty-eight
hours this patient was seized with the fever.'
On the 16th of March, 1831, a medical practitioner examined the body
of a woman who had died a few days after delivery, from puerperal
peritonitis. On the evening of the 17th he delivered a patient, who
was seized with puerperal fever on the 19th, and died on the 24th.
Between this period and the 6th of April, the same practitioner
attended two other patients, both of whom were attacked with the same
disease and died.
In the autumn of 1829 a physician was present at the examination of a
case of puerperal fever, dissected out the organs, and assisted in
sewing up the body. He had scarcely reached home when he was
summoned to attend a young lady in labor. In sixteen hours she was
attacked with the symptoms of puerperal fever, and narrowly escaped
with her life.
In December, 1830, a midwife, who had attended two fatal cases of
puerperal fever at the British Lying-in Hospital, examined a patient
who had just been admitted, to ascertain if labor had commenced.
This patient remained two days in the expectation that labor would
come on, when she returned home and was then suddenly taken in labor
and delivered before she could set out for the hospital. She went on
favorably for two days, and was then taken with puerperal fever and
died in thirty-six hours.
"A young practitioner, contrary to advice, examined the body of a
patient who had died from puerperal fever; there was no epidemic at
the time; the case appeared to be purely sporadic. He delivered
three other women shortly afterwards; they all died with puerperal
fever, the symptoms of which broke out very soon after labor. The
patients of his colleague did well, except one, where he assisted to
remove some coagula from the uterus; she was attacked in the same
manner as those whom he had attended, and died also." The writer in
the "British and Foreign Medical Review," from whom I quote this
statement,--and who is no other than Dr. Rigby, adds, "We trust that
this fact alone will forever silence such doubts, and stamp the well-
merited epithet of 'criminal,' as above quoted, upon such attempts."
[Brit. and For. Medical Review for Jan. 1842, p. 112.]
From the cases given by Mr. Ingleby, I select the following. Two
gentlemen, after having been engaged in conducting the post-mortem
examination of a case of puerperal fever, went in the same dress,
each respectively, to a case of midwifery. "The one patient was
seized with the rigor about thirty hours afterwards. The other
patient was seized with a rigor the third morning after delivery.
One recovered, one died." [Edin. Med. and Surg. Journal, April,
1838.]
One of these same gentlemen attended another woman in the same
clothes two days after the autopsy referred to. "The rigor did not
take place until the evening of the fifth day from the first visit.
Result fatal." These cases belonged to a series of seven, the first
of which was thought to have originated in a case of erysipelas.
"Several cases of a mild character followed the foregoing seven, and
their nature being now most unequivocal, my friend declined visiting
all midwifery cases for a time, and there was no recurrence of the
disease." These cases occurred in 1833. Five of them proved fatal.
Mr. Ingleby gives another series of seven eases which occurred to a
practitioner in 1836, the first of which was also attributed to his
having opened several erysipelatous abscesses a short time
previously.
I need not refer to the case lately read before this Society, in
which a physician went, soon after performing an autopsy of a case of
puerperal fever, to a woman in labor, who was seized with the same
disease and perished. The forfeit of that error has been already
paid.
At a meeting of the Medical and Chirurgical Society before referred
to, Dr. Merriman related an instance occurring in his own practice,
which excites a reasonable suspicion that two lives were sacrificed
to a still less dangerous experiment. He was at the examination of a
case of puerperal fever at two o'clock in the afternoon. He took
care not to touch the body. At nine o'clock the same evening he
attended a woman in labor; she was so nearly delivered that he had
scarcely anything to do. The next morning she had severe rigors, and
in forty-eight hours she was a corpse. Her infant had erysipelas and
died in two days. [Lancet, May 2, 1840.]
In connection with the facts which have been stated, it seems proper
to allude to the dangerous and often fatal effects which have
followed from wounds received in the post-mortem examination of
patients who have died of puerperal fever. The fact that such wounds
are attended with peculiar risk has been long noticed. I find that
Chaussier was in the habit of cautioning his students against the
danger to which they were exposed in these dissections. [Stein, L'Art
d'Accoucher, 1794; Dict. des Sciences Medicales, art. "Puerperal."]
The head pharmacien of the Hotel Dieu, in his analysis of the fluid
effused in puerperal peritonitis, says that practitioners are
convinced of its deleterious qualities, and that it is very dangerous
to apply it to the denuded skin. [Journal de Pharmacie, January,
1836.] Sir Benjamin Brodie speaks of it as being well known that the
inoculation of lymph or pus from the peritoneum of a puerperal
patient is often attended with dangerous and even fatal symptoms.
Three cases in confirmation of this statement, two of them fatal,
have been reported to this Society within a few months.
Of about fifty cases of injuries of this kind, of various degrees of
severity, which I have collected from different sources, at least
twelve were instances of infection from puerperal peritonitis. Some
of the others are so stated as to render it probable that they may
have been of the same nature. Five other cases were of peritoneal
inflammation; three in males. Three were what was called enteritis,
in one instance complicated with erysipelas; but it is well known
that this term has been often used to signify inflammation of the
peritoneum covering the intestines. On the other hand, no case of
typhus or typhoid fever is mentioned as giving rise to dangerous
consequences, with the exception of the single instance of an
undertaker mentioned by Mr. Travers, who seems to have been poisoned
by a fluid which exuded from the body. The other accidents were
produced by dissection, or some other mode of contact with bodies of
patients who had died of various affections. They also differed much
in severity, the cases of puerperal origin being among the most
formidable and fatal. Now a moment's reflection will show that the
number of cases of serious consequences ensuing from the dissection
of the bodies of those who had perished of puerperal fever is so
vastly disproportioned to the relatively small number of autopsies
made in this complaint as compared with typhus or pneumonia (from
which last disease not one case of poisoning happened), and still
more from all diseases put together, that the conclusion is
irresistible that a most fearful morbid poison is often generated in
the course of this disease. Whether or not it is sui generis,
confined to this disease, or produced in some others, as, for
instance, erysipelas, I need, not stop to inquire.
In connection with this may be taken the following statement of Dr.
Rigby. "That the discharges from a patient under puerperal fever are
in the highest degree contagious we have abundant evidence in the
history of lying-in hospitals. The puerperal abscesses are also
contagious, and may be communicated to healthy lying-in women by
washing with the same sponge; this fact has been repeatedly proved in
the Vienna Hospital; but they are equally communicable to women not
pregnant; on more than one occasion the women engaged in washing the
soiled bed-linen of the General Lying-in Hospital have been attacked
with abscess in the fingers or hands, attended with rapidly spreading
inflammation of the cellular tissue."
Now add to all this the undisputed fact, that within the walls of
lying-in hospitals there is often generated a miasm, palpable as the
chlorine used to destroy it, tenacious so as in some cases almost to
defy extirpation, deadly in some institutions as the plague; which
has killed women in a private hospital of London so fast that they
were buried two in one coffin to conceal its horrors; which enabled
Tonnelle to record two hundred and twenty-two autopsies at the
Maternite of Paris; which has led Dr. Lee to express his deliberate
conviction that the loss of life occasioned by these institutions
completely defeats the objects of their founders; and out of this
train of cumulative evidence, the multiplied groups of cases
clustering about individuals, the deadly results of autopsies, the
inoculation by fluids from the living patient, the murderous poison
of hospitals,--does there not result a conclusion that laughs all
sophistry to scorn, and renders all argument an insult?
I have had occasion to mention some instances in which there was an
apparent relation between puerperal fever and erysipelas. The length
to which this paper has extended does not allow me to enter into the
consideration of this most important subject. I will only say, that
the evidence appears to me altogether satisfactory that some most
fatal series of puerperal fever have been produced by an infection
originating in the matter or effluvia of erysipelas. In evidence of
some connection between the two diseases, I need not go back to the
older authors, as Pouteau or Gordon, but will content myself with
giving the following references, with their dates; from which it will
be seen that the testimony has been constantly coming before the
profession for the last few years.
"London Cyclopaedia of Practical Medicine," article Puerperal Fever,
1833.
Mr. Ceeley's Account of the Puerperal Fever at Aylesbury. "Lancet,"
1835.
Dr. Ramsbotham's Lecture. "London Medical Gazette," 1835.
Mr. Yates Ackerly's Letter in the same Journal, 1838.
Mr. Ingleby on Epidemic Puerperal Fever. "Edinburgh Medical and
Surgical Journal," 1838.
Mr. Paley's Letter. "London Medical Gazette," 1839.
Remarks at the Medical and Chirurgical Society. "Lancet," 1840.
Dr. Rigby's "System of Midwifery." 1841.
"Nunneley on Erysipelas,"--a work which contains a large number of
references on the subject. 1841.
"British and Foreign Quarterly Review," 1842.
Dr. S. Jackson of Northumberland, as already quoted from the Summary
of the College of Physicians, 1842.
And lastly, a startling series of cases by Mr. Storrs of Doncaster,
to be, found in the "American Journal of the Medical Sciences" for
January, 1843.
The relation of puerperal fever with other continued fevers would
seem to be remote and rarely obvious. Hey refers to two cases of
synochus occurring in the Royal Infirmary of Edinburgh, in women who
had attended upon puerperal patients. Dr. Collins refers to several
instances in which puerperal fever has appeared to originate from a
continued proximity to patients suffering with typhus.
Such occurrences as those just mentioned, though most important to be
remembered and guarded against, hardly attract our notice in the
midst of the gloomy facts by which they are surrounded. Of these
facts, at the risk of fatiguing repetitions, I have summoned a
sufficient number, as I believe, to convince the most incredulous
that every attempt to disguise the truth which underlies them all is
useless.
It is true that some of the historians of the disease, especially
Hulme, Hull, and Leake, in England; Tonnelle, Duges, and Baudelocque,
in France, profess not to have found puerperal fever contagious. At
the most they give us mere negative facts, worthless against an
extent of evidence which now overlaps the widest range of doubt, and
doubles upon itself in the redundancy of superfluous demonstration.
Examined in detail, this and much of the show of testimony brought up
to stare the daylight of conviction out of countenance, proves to be
in a great measure unmeaning and inapplicable, as might be easily
shown were it necessary. Nor do I feel the necessity of enforcing
the conclusion which arises spontaneously from the facts which have
been enumerated, by formally citing the opinions of those grave
authorities who have for the last half-century been sounding the
unwelcome truth it has cost so many lives to establish.
"It is to the British practitioner," says Dr. Rigby, "that we are
indebted for strongly insisting upon this important and dangerous
character of puerperal fever."
The names of Gordon, John Clarke, Denman, Burns, Young, Hamilton,
Haighton, Good, Waller; Blundell, Gooch, Ramsbotham, Douglas, Lee,
Ingleby, Locock, Abercrombie, Alison; Travers, Rigby, and Watson,
many of whose writings I have already referred to, may have some
influence with those who prefer the weight of authorities to the
simple deductions of their own reason from the facts laid before
them. A few Continental writers have adopted similar conclusions. It
gives me pleasure to remember, that while the doctrine has been
unceremoniously discredited in one of the leading Journals, and made
very light of by teachers in two of the principal Medical Schools, of
this country, Dr. Channing has for many years inculcated, and
enforced by examples, the danger to be apprehended and the
precautions to be taken in the disease under consideration.
I have no wish to express any harsh feeling with regard to the
painful subject which has come before us. If there are any so far
excited by the story of these dreadful events that they ask for some
word of indignant remonstrance to show that science does not turn the
hearts of its followers into ice or stone, let me remind them that
such words have been uttered by those who speak with an authority I
could not claim. It is as a lesson rather than as a reproach that I
call up the memory of these irreparable errors and wrongs. No tongue
can tell the heart-breaking calamity they have caused; they have
closed the eyes just opened upon a new world of love and happiness;
they have bowed the strength of manhood into the dust; they have cast
the helplessness of infancy into the stranger's arms, or bequeathed
it, with less cruelty, the death of its dying parent. There is no
tone deep enough for regret, and no voice loud enough for warning.
The woman about to become a mother, or with her new-born infant upon
her bosom, should be the object of trembling care and sympathy
wherever she bears her tender burden, or stretches her aching limbs.
The very outcast of the streets has pity upon her sister in
degradation, when the seal of promised maternity is impressed upon
her. The remorseless vengeance of the law, brought down upon its
victim by a machinery as sure as destiny, is arrested in its fall at
a word which reveals her transient claim for mercy. The solemn
prayer of the liturgy singles out her sorrows from the multiplied
trials of life, to plead for her in the hour of peril. God forbid
that any member of the profession to which she trusts her life,
doubly precious at that eventful period, should hazard it
negligently, unadvisedly, or selfishly!
There may be some among those whom I address who are disposed to ask
the question, What course are we to follow in relation to this
matter? The facts are before them, and the answer must be left to
their own judgment and conscience. If any should care to know my own
conclusions, they are the following; and in taking the liberty to
state them very freely and broadly, I would ask the inquirer to
examine them as freely in the light of the evidence which has been
laid before him.
1. A physician holding himself in readiness to attend cases of
midwifery should never take any active part in the post-mortem
examination of cases of puerperal fever.
2. If a physician is present at such autopsies, he should use
thorough ablution, change every article of dress, and allow twenty-
four hours or more to elapse before attending to any case of
midwifery. It may be well to extend the same caution to cases of
simple peritonitis.
3. Similar precautions should be taken after the autopsy or surgical
treatment of cases of erysipelas, if the physician is obliged to
unite such offices with his obstetrical duties, which is in the
highest degree inexpedient.
4. On the occurrence of a single case of puerperal fever in his
practice, the physician is bound to consider the next female he
attends in labor, unless some weeks at least have elapsed, as in
danger of being infected by him, and it is his duty to take every
precaution to diminish her risk of disease and death.
5. If within a short period two cases of puerperal fever happen
close to each other, in the practice of the same physician, the
disease not existing or prevailing in the neighborhood, he would do
wisely to relinquish his obstetrical practice for at least one month,
and endeavor to free himself by every available means from any
noxious influence he may carry about with him.
6. The occurrence of three or more closely connected cases, in the
practice of one individual, no others existing in the neighborhood,
and no other sufficient cause being alleged for the coincidence, is
prima facie evidence that he is the vehicle of contagion.
7. It is the duty of the physician to take every precaution that the
disease shall not be introduced by nurses or other assistants, by
making proper inquiries concerning them, and giving timely warning of
every suspected source of danger.
8. Whatever indulgence may be granted to those who have heretofore
been the ignorant causes of so much misery, the time has come when
the existence of a private pestilence in the sphere of a single
physician should be looked upon, not as a misfortune, but a crime;
and in the knowledge of such occurrences the duties of the
practitioner to his profession should give way to his paramount
obligations to society.
ADDITIONAL REFERENCES AND CASES.
Fifth Annual Report of the Registrar-General of England,
1843. Appendix. Letter from William Farr, Esq.--Several new series
of cases are given in the Letter of Mr. Stows, contained in the
Appendix to this Report. Mr. Stows suggests precautions similar to
those I have laid down, and these precautions are strongly enforced
by Mr. Farr, who is, therefore, obnoxious to the same criticisms as
myself.
Hall and Dexter, in Am. Journal of Med. Sc. for January, 1844.-
Cases of puerperal fever seeming to originate in erysipelas.
Elkington, of Birmingham, in Provincial Med. Journal, cited in Am.
Journ. Med. Se. for April, 1844.--Six cases in less than a
fortnight, seeming to originate in a case of erysipelas.
West's Reports, in Brit. and For. Med. Review for October, 1845,
and January, 1847.--Affection of the arm, resembling malignant
pustule, after removing the placenta of a patient who died from
puerperal fever. Reference to cases at Wurzburg, as proving
contagion, and to Keiller's cases in the Monthly Journal for
February, 1846, as showing connection of puerperal fever and
erysipelas.
Kneeland.--Contagiousness of Puerperal Fever. Am. Jour. Med.
Se., January, 1846. Also, Connection between Puerperal Fever and
Epidemic Erysipelas. Ibid., April, 1846.
Robert Storrs.--Contagious Effects of Puerperal Fever on the Male
Subject; or on Persons not Child-bearing. (From Provincial Med. and
Surg. Journal.) Am. Jour. Med. Sc., January, 184,6. Numerous
cases. See also Dr. Reid's case in same Journal for April, 1846.
Routh's paper in Proc. of Royal Med. Chir. Soc., Am. Jour. Med.
Sc., April, 1849, also in B. and F. Med. Chir. Review, April,
1850.
Hill, of Leuchars.--A Series of Cases illustrating the Contagious
Nature of Erysipelas and of Puerperal Fever, and their Intimate
Pathological Connection. (From Monthly Journal of Med. Sc.) Am.
Jour. Med. Se., July, 1850.
Skoda on the Causes of Puerperal Fever. (Peritonitis in rabbits,
from inoculation with different morbid secretions.) Am. Jour. Med.
Se., October, 1850.
Arneth. Paper read before the National Academy of Medicine. Annales
d'Hygiene, Tome LXV. 2e Partie. (Means of Disinfection proposed by
M. "Semmeliveis" (Semmelweiss.) Lotions of chloride of lime and use
of nail-brush before admission to lying-in wards. Alleged sudden and
great decrease of mortality from puerperal fever. Cause of disease
attributed to inoculation with cadaveric matters.) See also Routh's
paper, mentioned above.
Moir. Remarks at a meeting of the Edinburgh Medico-Chirurgical
Society. Refers to cases of Dr. Kellie, of Leith. Sixteen in
succession, all fatal. Also to several instances of individual
pupils having had a succession of cases in various quarters of the
town, while others, practising as extensively in the same localities,
had none. Also to several special cases not mentioned elsewhere.
Am. Jour. Med. Se. for October, 1851. (From New Monthly Journal
of Med. Science.)
Simpson.--Observations at a Meeting of the Edinburgh Obstetrical
Society. (An "eminent gentleman," according to Dr. Meigs, whose
"name is as well known in America as in (his) native land."
Obstetrics. Phil. 1852, pp. 368, 375.) The student is referred to
this paper for a valuable resume of many of the facts, and the
necessary inferences, relating to this subject. Also for another
series of cases, Mr. Sidey's, five or six in rapid succession.
Dr. Simpson attended the dissection of two of Dr. Sidey's cases, and
freely handled the diseased parts. His next four child-bed patients
were affected with puerperal fever, and it was the first time he had
seen it in practice. As Dr. Simpson is a gentleman (Dr. Meigs, as
above), and as "a gentleman's hands are clean" (Dr. Meigs' Sixth
Letter), it follows that a gentleman with clean hands may carry the
disease. Am. Jour. Med. Sc., October, 1851.
Peddle.--The five or six cases of Dr. Sidey, followed by the four of
Dr. Simpson, did not end the series. A practitioner in Leith having
examined in Dr. Simpson's house, a portion of the uterus obtained
from one of the patients, had immediately afterwards three fatal
cases of puerperal fever. Dr. Veddie referred to two distinct
series of consecutive cases in his own practice. He had since taken
precautions, and not met with any such cases. Am. Jour. Med. Sc.,
October, 1851.
Copland. Considers it proved that puerperal fever maybe propagated
by the hands and the clothes, or either, of a third person, the bed-
clothes or body-clothes of a patient. Mentions a new series of
cases, one of which he saw, with the practitioner who had attended
them. She was the sixth he had had within a few days. All died.
Dr. Copland insisted that contagion had caused these cases; advised
precautionary measures, and the practitioner had no other cases for a
considerable time. Considers it criminal, after the evidence
adduced,--which he could have quadrupled,--and the weight of
authority brought forward, for a practitioner to be the medium of
transmitting contagion and death to his patients. Dr. Copland lays
down rules similar to those suggested by myself, and is therefore
entitled to the same epithet for so doing. Medical Dictionary, New
York, 1852. Article, Puerperal States and Diseases.
If there is any appetite for facts so craving as to be yet
unappeased,--Lesotho, necdum satiata,--more can be obtained.
Dr. Hodge remarks that "the frequency and importance of this
singular circumstance (that the disease is occasionally more
prevalent with one practitioner than another) has been exceedingly
overrated." More than thirty strings of cases, more than two hundred
and fifty sufferers from puerperal fever, more than one hundred and
thirty deaths appear as the results of a sparing estimate of such
among the facts I have gleaned as could be numerically valued. These
facts constitute, we may take it for granted, but a small fraction of
those that have actually occurred. The number of them might be
greater, but "'t is enough, 't will serve," in Mercutio's modest
phrase, so far as frequency is concerned. For a just estimate of the
importance of the singular circumstance, it might be proper to
consult the languid survivors, the widowed husbands, and the
motherless children, as well as "the unfortunate accoucheur."
III
CURRENTS AND COUNTER-CURRENTS IN MEDICAL SCIENCE
An Address delivered before the Massachusetts Medical Society, at the
Annual Meeting, May 30, 1860.
"Facultate magis quam violentia."
HIPPOCRATES.
Our Annual Meeting never fails to teach us at least one lesson. The
art whose province it is to heal and to save cannot protect its own
ranks from the inroads of disease and the waste of the Destroyer.
Seventeen of our associates have been taken from us since our last
Anniversary. Most of them followed their calling in the villages or
towns that lie among the hills or along the inland streams. Only
those who have lived the kindly, mutually dependent life of the
country, can tell how near the physician who is the main reliance in
sickness of all the families throughout a thinly settled region comes
to the hearts of the people among whom he labors, how they value him
while living, how they cherish his memory when dead. For these
friends of ours who have gone before, there is now no more toil; they
start from their slumbers no more at the cry of pain; they sally
forth no more into the storms; they ride no longer over the lonely
roads that knew them so well; their wheels are rusting on their axles
or rolling with other burdens; their watchful eyes are closed to all
the sorrows they lived to soothe. Not one of these was famous in the
great world; some were almost unknown beyond their own immediate
circle. But they have left behind them that loving remembrance which
is better than fame, and if their epitaphs are chiselled briefly in
stone, they are written at full length on living tablets in a
thousand homes to which they carried their ever-welcome aid and
sympathy.
One whom we have lost, very widely known and honored, was a leading
practitioner of this city. His image can hardly be dimmed in your
recollection, as he stood before you only three years ago, filling
the same place with which I am now honored. To speak of him at all
worthily, would be to write the history of professional success, won
without special aid at starting, by toil, patience, good sense, pure
character, and pleasing manners; won in a straight uphill ascent,
without one breathing-space until he sat down, not to rest, but to
die. If prayers could have shielded him from the stroke, if love
could have drawn forth the weapon, and skill could have healed the
wound, this passing tribute might have been left to other lips and to
another generation.
Let us hope that our dead have at last found that rest which neither
summer nor winter, nor day nor night, had granted to their unending
earthly labors! And let us remember that our duties to our brethren
do not cease when they become unable to share our toils, or leave
behind them in want and woe those whom their labor had supported. It
is honorable to the Profession that it has organized an Association a
for the relief of its suffering members and their families; it owes
this tribute to the ill-rewarded industry and sacrifices of its less
fortunate brothers who wear out health and life in the service of
humanity. I have great pleasure in referring to this excellent
movement, which gives our liberal profession a chance to show its
liberality, and serves to unite us all, the successful and those whom
fortune has cast down, in the bonds of a true brotherhood.
A medical man, as he goes about his daily business after twenty years
of practice, is apt to suppose that he treats his patients according
to the teachings of his experience. No doubt this is true to some
extent; to what extent depending much on the qualities of the
individual. But it is easy to prove that the prescriptions of even
wise physicians are very commonly founded on something quite
different from experience. Experience must be based on the permanent
facts of nature. But a glance at the prevalent modes of treatment of
any two successive generations will show that there is a changeable
as well as a permanent element in the art of healing; not merely
changeable as diseases vary, or as new remedies are introduced, but
changeable by the going out of fashion of special remedies, by the
decadence of a popular theory from which their fitness was deduced,
or other cause not more significant. There is no reason to suppose
that the present time is essentially different in this respect from
any other. Much, therefore, which is now very commonly considered to
be the result of experience, will be recognized in the next, or in
some succeeding generation, as no such result at all, but as a
foregone conclusion, based on some prevalent belief or fashion of the
time.
There are, of course, in every calling, those who go about the work
of the day before them, doing it according to the rules of their
craft, and asking no questions of the past or of the future, or of
the aim and end to which their special labor is contributing. These
often consider and call themselves practical men. They pull the oars
of society, and have no leisure to watch the currents running this or
that way; let theorists and philosophers attend to them. In the mean
time, however, these currents are carrying the practical men, too,
and all their work may be thrown away, and worse than thrown away, if
they do not take knowledge of them and get out of the wrong ones and
into the right ones as soon as they may. Sir Edward Parry and his
party were going straight towards the pole in one of their arctic
expeditions, travelling at the rate of ten miles a day. But the ice
over which they travelled was drifting straight towards the equator,
at the rate of twelve miles a day, and yet no man among them would
have known that he was travelling two miles a day backward unless he
had lifted his eyes from the track in which he was plodding. It is
not only going backward that the plain practical workman is liable
to, if he will not look up and look around; he may go forward to ends
he little dreams of. It is a simple business for a mason to build up
a niche in a wall; but what if, a hundred years afterwards when the
wall is torn down, the skeleton of a murdered man drop out of the
niche? It was a plain practical piece of carpentry for a Jewish
artisan to fit two pieces of timber together according to the legal
pattern in the time of Pontius Pilate; he asked no questions,
perhaps, but we know what burden the cross bore on the morrow! And
so, with subtler tools than trowels or axes, the statesman who works
in policy without principle, the theologian who works in forms
without a soul, the physician who, calling himself a practical man,
refuses to recognize the larger laws which govern his changing
practice, may all find that they have been building truth into the
wall, and hanging humanity upon the cross.
The truth is, that medicine, professedly founded on observation, is
as sensitive to outside influences, political, religious,
philosophical, imaginative, as is the barometer to the changes of
atmospheric density. Theoretically it ought to go on its own
straightforward inductive path, without regard to changes of
government or to fluctuations of public opinion. But look a moment
while I clash a few facts together, and see if some sparks do not
reveal by their light a closer relation between the Medical Sciences
and the conditions of Society and the general thought of the time,
than would at first be suspected.
Observe the coincidences between certain great political and
intellectual periods and the appearance of illustrious medical
reformers and teachers. It was in the age of Pericles, of Socrates,
of Plato, of Phidias, that Hippocrates gave to medical knowledge the
form which it retained for twenty centuries. With the world-
conquering Alexander, the world-embracing Aristotle, appropriating
anatomy and physiology, among his manifold spoils of study, marched
abreast of his royal pupil to wider conquests. Under the same
Ptolemies who founded the Alexandrian Library and Museum, and ordered
the Septuagint version of the Hebrew Scriptures, the infallible
Herophilus ["Contradicere Herophilo in anatomicis, est contradicere
evangelium," was a saying of Fallopius.] made those six hundred
dissections of which Tertullian accused him, and the sagacious
Erasistratus introduced his mild antiphlogistic treatment in
opposition to the polypharmacy and antidotal practice of his time.
It is significant that the large-minded Galen should have been the
physician and friend of the imperial philosopher Marcus Aurelius.
The Arabs gave laws in various branches of knowledge to those whom
their arms had invaded, or the terror of their spreading dominion had
reached, and the point from which they started was, as Humboldt
acknowledges, "the study of medicine, by which they long ruled the
Christian Schools," and to which they added the department of
chemical pharmacy.
Look at Vesalius, the contemporary of Luther. Who can fail to see
one common spirit in the radical ecclesiastic and the reforming
court-physician? Both still to some extent under the dominion of the
letter: Luther holding to the real presence; Vesalius actually
causing to be drawn and engraved two muscles which he knew were not
found in the human subject, because they had been described by Galen,
from dissections of the lower animals. Both breaking through old
traditions in the search of truth; one, knife in hand, at the risk of
life and reputation, the other at the risk of fire and fagot, with
that mightier weapon which all the devils could not silence, though
they had been thicker than the tiles on the house-tops. How much the
physician of the Catholic Charles V. had in common with the great
religious destructive, may be guessed by the relish with which he
tells the story how certain Pavian students exhumed the body of an
"elegans scortum," or lovely dame of ill repute, the favorite of a
monk of the order of St. Anthony, who does not seem to have resisted
temptation so well as the founder of his order. We have always
ranked the physician Rabelais among the early reformers, but I do not
know that Vesalius has ever been thanked for his hit at the morals of
the religious orders, or for turning to the good of science what was
intended for the "benefit of clergy."
Our unfortunate medical brother, Michael Servetus, the spiritual
patient to whom the theological moxa was applied over the entire
surface for the cure of his heresy, came very near anticipating
Harvey. The same quickened thought of the time which led him to
dispute the dogma of the Church, opened his mind to the facts which
contradicted the dogmas of the Faculty.
Harvey himself was but the posthumous child of the great Elizabethan
period. Bacon was at once his teacher and his patient. The founder
of the new inductive philosophy had only been dead two years when the
treatise on the Circulation, the first-fruit of the Restoration of
Science, was given to the world.
And is it to be looked at as a mere accidental coincidence, that
while Napoleon was modernizing the political world, Bichat was
revolutionizing the science of life and the art that is based upon
it; that while the young general was scaling the Alps, the young
surgeon was climbing the steeper summits of unexplored nature; that
the same year read the announcement of those admirable "Researches on
Life and Death," and the bulletins of the battle of Marengo?
If we come to our own country, who can fail to recognize that
Benjamin Rush, the most conspicuous of American physicians, was the
intellectual offspring of the movement which produced the Revolution?
"The same hand," says one of his biographers," which subscribed the
declaration of the political independence of these States,
accomplished their emancipation from medical systems formed in
foreign countries, and wholly unsuitable to the state of diseases in
America."
Following this general course of remark, I propose to indicate in a
few words the direction of the main intellectual current of the time,
and to point out more particularly some of the eddies which tend to
keep the science and art of medicine from moving with it, or even to
carry them backwards.
The two dominant words of our time are law and average, both pointing
to the uniformity of the order of being in which we live. Statistics
have tabulated everything,--population, growth, wealth, crime,
disease. We have shaded maps showing the geographical distribution
of larceny and suicide. Analysis and classification have been at
work upon all tangible and visible objects. The Positive Philosophy
of Comte has only given expression to the observing and computing
mind of the nineteenth century.
In the mean time, the great stronghold of intellectual conservatism,
traditional belief, has been assailed by facts which would have been
indicted as blasphemy but a few generations ago. Those new tables of
the law, placed in the hands of the geologist by the same living God
who spoke from Sinai to the Israelites of old, have remodelled the
beliefs of half the civilized world. The solemn scepticism of
science has replaced the sneering doubts of witty philosophers. The
more positive knowledge we gain, the more we incline to question all
that has been received without absolute proof.
As a matter of course, this movement has its partial reactions. The
province of faith is claimed as a port free of entry to unsupported
individual convictions. The tendency to question is met by the
unanalyzing instinct of reverence. The old church calls back its
frightened truants. Some who have lost their hereditary religious
belief find a resource in the revelations of Spiritualism. By a
parallel movement, some of those who have become medical infidels
pass over to the mystic band of believers in the fancied miracles of
Homoeopathy.
Under these influences transmitted to, or at least shared by, the
medical profession, the old question between "Nature," so called, and
"Art," or professional tradition, has reappeared with new interest.
I say the old question, for Hippocrates stated the case on the side
of "Nature" more than two thousand years ago. Miss Florence
Nightingale,--and if I name her next to the august Father of the
Healing Art, its noblest daughter well deserves that place of honor,
--Miss Florence Nightingale begins her late volume with a paraphrase
of his statement. But from a very early time to this there has
always been a strong party against "Nature." Themison called the
practice of Hippocrates "a meditation upon death." Dr. Rush says:
"It is impossible to calculate the mischief which Hippocrates, has
done, by first marking Nature with his name and afterwards letting
her loose upon sick people. Millions have perished by her hands in
all ages and countries." Sir John Forbes, whose defence of "Nature"
in disease you all know, and to the testimonial in whose honor four
of your Presidents have contributed, has been recently greeted, on
retiring from the profession, with a wish that his retirement had
been twenty years sooner, and the opinion that no man had done so
much to destroy the confidence of the public in the medical
profession.
In this Society we have had the Hippocratic and the Themisonic side
fairly represented. The treatise of one of your early Presidents on
the Mercurial Treatment is familiar to my older listeners. Others
who have held the same office have been noted for the boldness of
their practice, and even for partiality to the use of complex
medication.
On the side of "Nature" we have had, first of all, that remarkable
discourse on Self-Limited Diseases, [On Self-Limited Diseases. A
Discourse delivered before the Massachusetts Medical Society, at
their Annual Meeting, May 27, 1835. By Jacob Bigelow, M. D.] which
has given the key-note to the prevailing medical tendency of this
neighborhood, at least, for the quarter of a century since it was
delivered. Nor have we forgotten the address delivered at
Springfield twenty years later, [Search out the Secrets, of Nature.
By Augustus A. Gould, M. D. Read at the Annual Meeting, June 27,
1855.] full of good sense and useful suggestions, to one of which
suggestions we owe the learned, impartial, judicious, well-written
Prize Essay of Dr. Worthington Hooker. [Rational Therapeutics. A
Prize Essay. By Worthington Hooker, M. D., of New Haven. Boston.
1857.] We should not omit from the list the important address of
another of our colleagues, [On the Treatment of Compound and
Complicated Fractures. By William J. Walker, M. D. Read at the
Annual Meeting, May 29, 1845.] showing by numerous cases the power of
Nature in healing compound fractures to be much greater than is
frequently supposed,--affording, indeed, more striking illustrations
than can be obtained from the history of visceral disease, of the
supreme wisdom, forethought, and adaptive dexterity of that divine
Architect, as shown in repairing the shattered columns which support
the living temple of the body.
We who are on the side of "Nature" please ourselves with the idea
that we are in the great current in which the true intelligence of
the time is moving. We believe that some who oppose, or fear, or
denounce our movement are themselves caught in various eddies that
set back against the truth. And we do most earnestly desire and most
actively strive, that Medicine, which, it is painful to remember, has
been spoken of as "the withered branch of science" at a meeting of
the British Association, shall be at length brought fully to share,
if not to lead, the great wave of knowledge which rolls with the
tides that circle the globe.
If there is any State or city which might claim to be the American
headquarters of the nature-trusting heresy, provided it be one, that
State is Massachusetts, and that city is its capital. The effect
which these doctrines have upon the confidence reposed in the
profession is a matter of opinion. For myself, I do not believe this
confidence can be impaired by any investigations which tend to limit
the application of troublesome, painful, uncertain, or dangerous
remedies. Nay, I will venture to say this, that if every specific
were to fail utterly, if the cinchona trees all died out, and the
arsenic mines were exhausted, and the sulphur regions were burned up,
if every drug from the vegetable, animal, and mineral kingdom were to
disappear from the market, a body of enlightened men, organized as a
distinct profession, would be required just as much as now, and
respected and trusted as now, whose province should be to guard
against the causes of disease, to eliminate them if possible when
still present, to order all the conditions of the patient so as to
favor the efforts of the system to right itself, and to give those
predictions of the course of disease which only experience can
warrant, and which in so many cases relieve the exaggerated fears of
sufferers and their friends, or warn them in season of impending
danger. Great as the loss would be if certain active remedies could
no longer be obtained, it would leave the medical profession the most
essential part of it's duties, and all, and more than all, its
present share of honors; for it would be the death-blow to
charlatanism, which depends for its success almost entirely on drugs,
or at least on a nomenclature that suggests them.
There is no offence, then, or danger in expressing the opinion, that,
after all which has been said, the community is still overdosed: The
best proof of it is, that "no families take so little medicine as
those of doctors, except those of apothecaries, and that old
practitioners are more sparing of active medicines than younger
ones." [Dr. James Jackson has kindly permitted me to make the
following extract from a letter just received by him from Sir James
Clark, and dated May 26, 1860: "As a physician advances in age, he
generally, I think, places less confidence in the ordinary medical
treatment than he did, not only during his early, but even his middle
period of life."] The conclusion from these facts is one which the
least promising of Dr. Howe's pupils in the mental department could
hardly help drawing.
Part of the blame of over-medication must, I fear, rest with the
profession, for yielding to the tendency to self-delusion, which
seems inseparable from the practice of the art of healing. I need
only touch on the common modes of misunderstanding or misapplying the
evidence of nature.
First, there is the natural incapacity for sound observation, which
is like a faulty ear in music. We see this in many persons who know
a good deal about books, but who are not sharp-sighted enough to buy
a horse or deal with human diseases.
Secondly, there is in some persons a singular inability to weigh the
value of testimony; of which, I think, from a pretty careful
examination of his books, Hahnemann affords the best specimen outside
the walls of Bedlam.
The inveterate logical errors to which physicians have always been
subject are chiefly these:
The mode of inference per enumerationem simplicem, in scholastic
phrase; that is, counting only their favorable cases. This is the
old trick illustrated in Lord Bacon's story of the gifts of the
shipwrecked people, hung up in the temple.--Behold! they vowed these
gifts to the altar, and the gods saved them. Ay, said a doubting
bystander, but how many made vows of gifts and were shipwrecked
notwithstanding? The numerical system is the best corrective of this
and similar errors. The arguments commonly brought against its
application to all matters of medical observation, treatment
included, seem to apply rather to the tabulation of facts ill
observed, or improperly classified, than to the method itself.
The post hoc ergo propter hoc error: he got well after taking my
medicine; therefore in consequence of taking it.
The false induction from genuine facts of observation, leading to the
construction of theories which are then deductively applied in the
face of the results of direct observation. The school of Broussais
has furnished us with a good example of this error.
And lastly, the error which Sir Thomas Browne calls giving "a reason
of the golden tooth;" that is, assuming a falsehood as a fact, and
giving reasons for it, commonly fanciful ones, as is constantly done
by that class of incompetent observers who find their "golden tooth"
in the fabulous effects of the homoeopathie materia medica,--which
consists of sugar of milk and a nomenclature.
Another portion of the blame rests with the public itself, which
insists on being poisoned. Somebody buys all the quack medicines
that build palaces for the mushroom, say rather, the toadstool
millionaires. Who is it? These people have a constituency of
millions. The popular belief is all but universal that sick persons
should feed on noxious substances. One of our members was called not
long since to a man with a terribly sore mouth. On inquiry he found
that the man had picked up a box of unknown pills, in Howard Street,
and had proceeded to take them, on general principles, pills being
good for people. They happened to contain mercury, and hence the
trouble for which he consulted our associate.
The outside pressure, therefore, is immense upon the physician,
tending to force him to active treatment of some kind. Certain old
superstitions, still lingering in the mind of the public, and not yet
utterly expelled from that of the profession, are at the bottom of
this, or contribute to it largely. One of the most ancient is, that
disease is a malignant agency, or entity, to be driven out of the
body by offensive substances, as the smoke of the fish's heart and
liver drove the devil out of Tobit's bridal chamber, according to the
Apochrypha. Epileptics used to suck the blood from the wounds of
dying gladiators. [Plinii Hist. Mundi. lib. xxviii. c. 4.] The
Hon. Robert Boyle's little book was published some twenty or thirty
years before our late President, Dr. Holyoke, was born. [A Collection
of Choice and Safe Remedies. The Fifth Edition, corrected. London,
1712. Dr. Holyoke was born in 1728.] In it he recommends, as
internal medicines, most of the substances commonly used as
fertilizers of the soil. His "Album Graecum" is best left
untranslated, and his "Zebethum Occidentale" is still more
transcendentally unmentionable except in a strange dialect. It
sounds odiously to us to hear him recommend for dysentery a powder
made from "the sole of an old shoe worn by some man that walks much."
Perhaps nobody here ever heard of tying a stocking, which had been
worn during the day, round the neck at night for a sore throat. The
same idea of virtue in unlovely secretions! [The idea is very
ancient. "Sordes hominis" "Sudore et oleo medicinam facientibus."
--Plin. xxviii. 4.]
Even now the Homoeopathists have been introducing the venom of
serpents, under the learned title of Lachesis, and outraging human
nature with infusions of the pediculus capitis; that is, of course,
as we understand their dilutions, the names of these things; for if a
fine-tooth-comb insect were drowned in Lake Superior, we cannot agree
with them in thinking that every drop of its waters would be
impregnated with all the pedicular virtues they so highly value.
They know what they are doing. They are appealing to the detestable
old superstitious presumption in favor of whatever is nauseous and
noxious as being good for the sick.
Again, we all occasionally meet persons stained with nitrate of
silver, given for epilepsy. Read what Dr. Martin says, about the way
in which it came to be used, in his excellent address before the
Norfolk County Medical Society, and the evidence I can show, but have
not time for now, and then say what you think of the practice which
on such presumptions turns a white man as blue as the double-tattooed
King of the Cannibal Islands! [Note A.]
If medical superstitions have fought their way down through all the
rationalism and scepticism of the nineteenth century, of course the
theories of the schools, supported by great names, adopted into the
popular belief and incorporated with the general mass of
misapprehension with reference to disease, must be expected to meet
us at every turn in the shape of bad practice founded on false
doctrine. A French patient complains that his blood heats him, and
expects his doctor to bleed him. An English or American one says he
is bilious, and will not be easy without a dose of calomel. A doctor
looks at a patient's tongue, sees it coated, and says the stomach is
foul; his head full of the old saburral notion which the extreme
inflammation-doctrine of Broussais did so much to root out, but which
still leads, probably, to much needless and injurious wrong of the
stomach and bowels by evacuants, when all they want is to be let
alone. It is so hard to get anything out of the dead hand of medical
tradition! The mortmain of theorists extinct in science clings as
close as that of ecclesiastics defunct in law.
One practical hint may not be out of place here. It seems to be
sometimes forgotten, by those who must know the fact, that the tongue
is very different, anatomically and physiologically, from the
stomach. Its condition does not in the least imply a similar one of
the stomach, which is a very different structure, covered with a
different kind of epithelium, and furnished with entirely different
secretions. A silversmith will, for a dollar, make a small hoe, of
solid silver, which will last for centuries, and will give a patient
more comfort, used for the removal of the accumulated epithelium and
fungous growths which constitute the "fur," than many a prescription
with a split-footed Rx before it, addressed to the parts out of
reach.
I think more of this little implement on account of its agency in
saving the Colony at Plymouth in the year 1623. Edward Winslow heard
that Massasoit was sick and like to die. He found him with a
houseful of people about him, women rubbing his arms and legs, and
friends "making such a hellish noise" as they probably thought would
scare away the devil of sickness. Winslow gave him some conserve,
washed his mouth, scraped his tongue, which was in a horrid state,
got down some drink, made him some broth, dosed him with an infusion
of strawberry leaves and sassafras root, and had the satisfaction of
seeing him rapidly recover. Massasoit, full of gratitude, revealed
the plot which had been formed to destroy the colonists, whereupon
the Governor ordered Captain Miles Standish to see to them; who
thereupon, as everybody remembers, stabbed Pecksuot with his own
knife, broke up the plot, saved the colony, and thus rendered
Massachusetts and the Massachusetts Medical Society a possibility, as
they now are a fact before us. So much for this parenthesis of the
tongue-scraper, which helped to save the young colony from a much
more serious scrape, and may save the Union yet, if a Presidential
candidate should happen to be taken sick as Massasoit was, and his
tongue wanted cleaning,--which process would not hurt a good many
politicians, with or without a typhoid fever.
Again, see how the "bilious" theory works in every-day life here and
now, illustrated by a case from actual life. A youthful
practitioner, whose last molars have not been a great while cut,
meets an experienced and noted physician in consultation. This is
the case. A slender, lymphatic young woman is suckling two lusty
twins, the intervals of suction being occupied on her part with
palpitations, headaches, giddiness, throbbing in the head, and
various nervous symptoms, her cheeks meantime getting bloodless, and
her strength running away in company with her milk. The old
experienced physician, seeing the yellowish waxy look which is common
in anaemic patients, considers it a "bilious" case, and is for giving
a rousing emetic. Of course, he has to be wheedled out of this, a
recipe is written for beefsteaks and porter, the twins are
ignominiously expelled from the anaemic bosom, and forced to take
prematurely to the bottle, and this prolific mother is saved for
future usefulness in the line of maternity.
The practice of making a profit on the medicine ordered has been held
up to reprobation by one at least of the orators who have preceded
me. That the effect of this has been ruinous in English practice I
cannot doubt, and that in this country the standard of practice was
in former generations lowered through the same agency is not
unlikely. I have seen an old account-book in which the physician
charged an extra price for gilding his rich patients' pills. If all
medicine were very costly, and the expense of it always came out of
the physician's fee, it would really be a less objectionable
arrangement than this other most pernicious one. He would naturally
think twice before he gave an emetic or cathartic which evacuated his
own pocket, and be sparing of the cholagogues that emptied the
biliary ducts of his own wallet, unless he were sure they were
needed. If there is any temptation, it should not be in favor of
giving noxious agents, as it clearly must be in the case of English
druggists and "General Practitioners." The complaint against the
other course is a very old one. Pliny, inspired with as truly Roman
horror of quackery as the elder Cato,--who declared that the Greek
doctors had sworn to exterminate all barbarians, including the
Romans, with their drugs, but is said to have physicked his own wife
to death, notwithstanding,--Pliny says, in so many words, that the
cerates and cataplasms, plasters, collyria, and antidotes, so
abundant in his time, as in more recent days, were mere tricks to
make money.
A pretty strong eddy, then, or rather many eddies, setting constantly
back from the current of sober observation of nature, in the
direction of old superstitions and fancies, of exploded theories, of
old ways of making money, which are very slow to pass out of fashion
But there are other special American influences which we are bound to
take cognizance of. If I wished to show a student the difficulties
of getting at truth from medical experience, I would give him the
history of epilepsy to read. If I wished him to understand the
tendencies of the American medical mind, its sanguine enterprise, its
self-confidence, its audacious handling of Nature, its impatience
with her old-fashioned ways of taking time to get a sick man well, I
would make him read the life and writings of Benjamin Rush. Dr. Rush
thought and said that there were twenty times more intellect and a
hundred times more knowledge in the country in 1799 than before the
Revolution. His own mind was in a perpetual state of exaltation
produced by the stirring scenes in which he had taken a part, and the
quickened life of the time in which he lived. It was not the state
to favor sound, calm observation. He was impatient, and Nature is
profoundly imperturbable. We may adjust the beating of our hearts to
her pendulum if we will and can, but we may be very sure that she
will not change the pendulum's rate of going because our hearts are
palpitating. He thought he had mastered yellow-fever. "Thank God,"
he said, "out of one hundred patients whom I have visited or
prescribed for this day, I have lost none." Where was all his legacy
of knowledge when Norfolk was decimated? Where was it when the blue
flies were buzzing over the coffins of the unburied dead piled up in
the cemetery of New Orleans, at the edge of the huge trenches yawning
to receive them?
One such instance will do as well as twenty. Dr. Rush must have been
a charming teacher, as he was an admirable man. He was observing,
rather than a sound observer; eminently observing, curious, even,
about all manner of things. But he could not help feeling as if
Nature had been a good deal shaken by the Declaration of
Independence, and that American art was getting to be rather too much
for her,--especially as illustrated in his own practice. He taught
thousands of American students, he gave a direction to the medical
mind of the country more than any other one man; perhaps he typifies
it better than any other. It has clearly tended to extravagance in
remedies and trust in remedies, as in everything else. How could a
people which has a revolution once in four years, which has contrived
the Bowie-knife and the revolver, which has chewed the juice out of
all the superlatives in the language in Fourth of July orations, and
so used up its epithets in the rhetoric of abuse that it takes two
great quarto dictionaries to supply the demand; which insists in
sending out yachts and horses and boys to out-sail, out-run, out-
fight, and checkmate all the rest of creation; how could such a
people be content with any but "heroic" practice? What wonder that
the stars and stripes wave over doses of ninety grains of sulphate of
quinine, [More strictly, ninety-six grains in two hours. Dunglison's
Practice, 1842, vol. ii. p. 520. Eighty grains in one dose.
Ibid. p. 536. Ninety-six grains of sulphate of quinine are equal
to eight ounces of good bark.--Wood & Bache.] and that the American
eagle screams with delight to see three drachms of calomel given at a
single mouthful?
Add to this the great number of Medical Journals, all useful, we
hope, most of them necessary, we trust, many of them excellently well
conducted, but which must find something to fill their columns, and
so print all the new plans of treatment and new remedies they can get
hold of, as the newspapers, from a similar necessity, print the
shocking catastrophes and terrible murders.
Besides all this, here are we, the great body of teachers in the
numberless medical schools of the Union, some of us lecturing to
crowds who clap and stamp in the cities, some of us wandering over
the country, like other professional fertilizers, to fecundate the
minds of less demonstrative audiences at various scientific stations;
all of us talking habitually to those supposed to know less than
ourselves, and loving to claim as much for our art as we can, not to
say for our own schools, and possibly indirectly for our own
practical skill. Hence that annual crop of introductory lectures;
the useful blossoming into the ornamental, as the cabbage becomes
glorified in the cauliflower; that lecture-room literature of
adjectives, that declamatory exaggeration, that splendid show of
erudition borrowed from D'Israeli, and credited to Lord Bacon and the
rest, which have suggested to our friends of the Medical Journals an
occasional epigram at our expense. Hence the tendency in these
productions, and in medical lectures generally, to overstate the
efficacy of favorite methods of cure, and hence the premium offered
for showy talkers rather than sagacious observers, for the men of
adjectives rather than of nouns substantive in the more ambitious of
these institutions.
Such are some of the eddies in which we are liable to become involved
and carried back out of the broad stream of philosophical, or, in
other words, truth-loving, investigations. The causes of disease, in
the mean time, have been less earnestly studied in the eagerness of
the search for remedies. Speak softly! Women have been borne out
from an old-world hospital, two in one coffin, that the horrors of
their prison-house might not be known, while the very men who were
discussing the treatment of the disease were stupidly conveying the
infection from bed to bed, as rat-killers carry their poisons from
one household to another. Do not some of you remember that I have
had to fight this private-pestilence question against a scepticism
which sneered in the face of a mass of evidence such as the calm
statisticians of the Insurance office could not listen to without
horror and indignation? ["The Contagiousness of Puerperal Fever."--
N. E. Quar. Jour. of Medicine and Surgery, April, 1843. Reprinted,
with Additions. Boston: Ticknor & Fields. 1855.] Have we forgotten
what is told in one of the books published under our own sanction,
that a simple measure of ventilation, proposed by Dr. John Clark, had
saved more than sixteen thousand children's lives in a single
hospital? How long would it have taken small doses of calomel and
rhubarb to save as many children? These may be useful in prudent
hands, but how insignificant compared to the great hygienic
conditions! Causes, causes, and again causes,--more and more we fall
back on these as the chief objects of our attention. The shortest
system of medical practice that I know of is the oldest, but not the
worst. It is older than Hippocrates, older than Chiron the Centaur.
Nature taught it to the first mother when she saw her first-born
child putting some ugly pebble or lurid berry into its mouth. I know
not in what language it was spoken, but I know that in English it
would sound thus: Spit it out!
Art can do something more than say this. It can sometimes reach the
pebble or berry after it has been swallowed. But the great thing is
to keep these things out of children's mouths, and as soon as they
are beyond our reach, to be reasonable and patient with Nature, who
means well, but does not like to hurry, and who took nine calendar
months, more or less, to every mother's son among us, before she
thought he was fit to be shown to the public.
Suffer me now to lay down a few propositions, whether old or new it
matters little, not for your immediate acceptance, nor yet for your
hasty rejection, but for your calm consideration.
But first, there are a number of terms which we are in the habit of
using in a vague though not unintelligible way, and which it is as
well now to define. These terms are the tools with which we are to
work, and the first thing is to sharpen them. It is nothing to us
that they have been sharpened a thousand times before; they always
get dull in the using, and every new workman has a right to carry
them to the grindstone and sharpen them to suit himself.
Nature, in medical language, as opposed to Art, means trust in the
reactions of the living system against, ordinary normal impressions.
Art, in the same language, as opposed to Nature, means an intentional
resort to extraordinary abnormal impressions for the relief of
disease.
The reaction of the living system is the essence of both. Food is
nothing, if there is no digestive act to respond to it. We cannot
raise a blister on a dead man, or hope that a carminative forced
between his lips will produce its ordinary happy effect.
Disease, dis-ease,--disturbed quiet, uncomfortableness,--means
imperfect or abnormal reaction of the living system, and its more or
less permanent results.
Food, in its largest sense, is whatever helps to build up the normal
structures, or to maintain their natural actions.
Medicine, in distinction from food, is every unnatural or noxious
agent applied for the relief of disease.
Physic means properly the Natural art, and Physician is only the
Greek synonyme of Naturalist.
With these few explanations I proceed to unfold the propositions I
have mentioned.
Disease and death, if we may judge by the records of creation, are
inherently and essentially necessary in the present order of things.
A perfect intelligence, trained by a perfect education, could do no
more than keep the laws of the physical and spiritual universe. An
imperfect intelligence, imperfectly taught,--and this is the
condition of our finite humanity,--will certainly fail to keep all
these laws perfectly. Disease is one of the penalties of one of the
forms of such failure. It is prefigured in the perturbations of the
planets, in the disintegration of the elemental masses; it has left
its traces in the fossil organisms of extinct creations. [Professor
Agassiz has kindly handed me the following note: "There are abnormal
structures in animals of all ages anterior to the creation of
mankind. Malformed specimens of Crinoids are known from the Triassic
and Jurassic deposits. Malformed and diseased bones of tertiary
mammalia have been collected in the caverns of Gailenreuth with
traces of healing."]
But it is especially the prerogative, I had almost said privilege, of
educated and domesticated beings, from man down to the potato,
serving to teach them, and such as train them, the laws of life, and
to get rid of those who will not mind or cannot be kept subject to
these laws.
Disease, being always an effect, is always in exact proportion to the
sum of its causes, as much in the case of Spigelius, who dies of a
scratch, as in that of the man who recovers after an iron bar has
been shot through his brain. The one prevalent failing of the
medical art is to neglect the causes and quarrel with the effect.
There are certain general facts which include a good deal of what is
called and treated as disease. Thus, there are two opposite
movements of life to be seen in cities and elsewhere, belonging to
races which, from various persistent causes, are breeding down and
tending to run out, and to races which are breeding up, or
accumulating vital capital,--a descending and an ascending series.
Let me give an example of each; and that I may incidentally remove a
common impression about this country as compared with the Old World,
an impression which got tipsy with conceit and staggered into the
attitude of a formal proposition in the work of Dr. Robert Knox, I
will illustrate the downward movement from English experience, and
the upward movement from a family history belonging to this immediate
neighborhood.
Miss Nightingale speaks of "the fact so often seen of a
great-grandmother, who was a tower of physical vigor, descending into
a grandmother perhaps a little less vigorous, but still sound as a
bell, and healthy to the core, into a mother languid and confined to
her carriage and house; and lastly into a daughter sickly and
confined to her bed." So much for the descending English series; now
for the ascending American series.
Something more than one hundred and thirty years ago there graduated
at Harvard College a delicate youth, who lived an invalid life and
died at the age of about fifty. His two children were both of
moderate physical power, and one of them diminutive in stature. The
next generation rose in physical development, and reached eighty
years of age and more in some of its members. The fourth generation
was of fair average endowment. The fifth generation, great-great-
grandchildren of the slender invalid, are several of, them of
extraordinary bodily and mental power; large in stature, formidable
alike with their brains and their arms, organized on a more extensive
scale than either of their parents.
This brief account illustrates incidentally the fallacy of the
universal-degeneration theory applied to American life; the same on
which one of our countrymen has lately brought some very forcible
facts to bear in a muscular discussion of which we have heard rather
more than is good for us. But the two series, American and English,
ascending and descending, were adduced with the main purpose of
showing the immense difference of vital endowments in different
strains of blood; a difference to which all ordinary medication is in
all probability a matter of comparatively trivial purport. Many
affections which art has to strive against might be easily shown to
be vital to the well-being of society. Hydrocephalus, tabes
mesenterica, and other similar maladies, are natural agencies which
cut off the children of races that are sinking below the decent
minimum which nature has established as the condition of viability,
before they reach the age of reproduction. They are really not so
much diseases, as manifestations of congenital incapacity for life;
the race would be ruined if art could ever learn always to preserve
the individuals subject to them. We must do the best we can for
them, but we ought also to know what these "diseases" mean.
Again, invalidism is the normal state of many organizations. It can
be changed to disease, but never to absolute health by medicinal
appliances. There are many ladies, ancient and recent, who are
perpetually taking remedies for irremediable pains and aches. They
ought to have headaches and back-aches and stomach-aches; they are
not well if they do not have them. To expect them to live without
frequent twinges is like expecting a doctor's old chaise to go
without creaking; if it did, we might be sure the springs were
broken. There is no doubt that the constant demand for medicinal
remedies from patients of this class leads to their over-use; often
in the case of cathartics, sometimes in that of opiates. I have been
told by an intelligent practitioner in a Western town, that the
constant prescription of opiates by certain physicians in his
vicinity has rendered the habitual use of that drug in all that
region very prevalent; more common, I should think, than alcoholic
drunkenness in the most intemperate localities of which I have known
anything. A frightful endemic demoralization betrays itself in the
frequency with which the haggard features and drooping shoulders of
the opium-drunkards are met with in the streets.
The next proposition I would ask you to consider is this:
The presumption always is that every noxious agent, including
medicines proper, which hurts a well man, hurts a sick one.
[ Note B.]
Let me illustrate this proposition before you decide upon it. If it
were known that a prize-fighter were to have a drastic purgative
administered two or three days before a contest, or a large blister
applied to his back, no one will question that it would affect the
betting on his side unfavorably; we will say to the amount of five
per cent. Now the drain upon the resources of the system produced in
such a case must be at its minimum, for the subject is a powerful
man, in the prime of life, and in admirable condition. If the drug
or the blister takes five per cent. from his force of resistance, it
will take at least as large a fraction from any invalid. But this
invalid has to fight a champion who strikes hard but cannot be hit in
return, who will press him sharply for breath, but will never pant
himself while the wind can whistle through his fleshless ribs. The
suffering combatant is liable to want all his stamina, and five per
cent. may lose him the battle.
All noxious agents, all appliances which are not natural food or
stimuli, all medicines proper, cost a patient, on the average, five
per cent. of his vital force, let us say. Twenty times as much waste
of force produced by any of them, that is, would exactly kill him,
nothing less than kill him, and nothing more. If this, or something
like this, is true, then all these medications are, prima facie,
injurious.
In the game of Life-or-Death, Rouge et Noir, as played between the
Doctor and the Sexton, this five per cent., this certain small injury
entering into the chances is clearly the sexton's perquisite for
keeping the green table, over which the game is played, and where he
hoards up his gains. Suppose a blister to diminish a man's pain,
effusion or dyspnoea to the saving of twenty per cent. in vital
force; his profit from it is fifteen, in that case, for it always
hurts him five to begin with, according to our previous assumption.
Presumptions are of vast importance in medicine, as in law. A man is
presumed innocent until he is proved guilty. A medicine--that is, a
noxious agent, like a blister, a seton, an emetic, or a cathartic--
should always be presumed to be hurtful. It always is directly
hurtful; it may sometimes be indirectly beneficial. If this
presumption were established, and disease always assumed to be the
innocent victim of circumstances, and not punishable by medicines,
that is, noxious agents, or poisons, until the contrary was shown, we
should not so frequently hear the remark commonly, perhaps
erroneously, attributed to Sir Astley Cooper, but often repeated by
sensible persons, that, on the whole, more harm than good is done by
medication. Throw out opium, which the Creator himself seems to
prescribe, for we often see the scarlet poppy growing in the
cornfields, as if it were foreseen that wherever there is hunger to
be fed there must also be pain to be soothed; throw out a few
specifics which our art did not discover, and is hardly needed to
apply [ Note C.]; throw out wine, which is a food, and the vapors
which produce the miracle of anaesthesia, and I firmly believe that
if the whole materia medica, as now used, could be sunk to the bottom
of the sea, it would be all the better for mankind,--and all the
worse for the fishes.
But to justify this proposition, I must add that the injuries
inflicted by over-medication are to a great extent masked by disease.
Dr. Hooker believes that the typhus syncopatia of a preceding
generation in New England "was often in fact a brandy and opium
disease." How is a physician to distinguish the irritation produced
by his blister from that caused by the inflammation it was meant to
cure? How can he tell the exhaustion produced by his evacuants from
the collapse belonging to the disease they were meant to remove?
Lastly, medication without insuring favorable hygienic conditions is
like amputation without ligatures. I had a chance to learn this well
of old, when physician to the Broad Street district of the Boston
Dispensary. There, there was no help for the utter want of wholesome
conditions, and if anybody got well under my care, it must have been
in virtue of the rough-and-tumble constitution which emerges from the
struggle for life in the street gutters, rather than by the aid of my
prescriptions.
But if the materia medica were lost overboard, how much more pains
would be taken in ordering all the circumstances surrounding the
patient (as can be done everywhere out of the crowded pauper
districts), than are taken now by too many who think they do their
duty and earn their money when they write a recipe for a patient left
in an atmosphere of domestic malaria, or to the most negligent kind
of nursing! I confess that I should think my chance of recovery from
illness less with Hippocrates for my physician and Mrs. Gamp for my
nurse, than if I were in the hands of Hahnemann himself, with
Florence Nightingale or good Rebecca Taylor to care for me.
If I am right in maintaining that the presumption is always against
the use of noxious agents in disease, and if any whom I might
influence should adopt this as a principle of practice, they will
often find themselves embarrassed by the imperative demand of
patients and their friends for such agents where a case is not made
out against this standing presumption. I must be permitted to say,
that I think the French, a not wholly uncivilized people, are in
advance of the English and ourselves in the art of prescribing for
the sick without hurting them. And I do confess that I think their
varied ptisans and syrups are as much preferable to the mineral
regimen of bug-poison and ratsbane, so long in favor on the other
side of the Channel, as their art of preparing food for the table to
the rude cookery of those hard-feeding and much-dosing islanders.
We want a reorganized cuisine of invalidism perhaps as much as the
culinary, reform, for which our lyceum lecturers, and others who live
much at hotels and taverns, are so urgent. Will you think I am
disrespectful if I ask whether, even in Massachusetts, a dose of
calomel is not sometimes given by a physician on the same principle
as that upon which a landlord occasionally prescribes bacon and
eggs,--because he cannot think of anything else quite so handy? I
leave my suggestion of borrowing a hint from French practice to your
mature consideration.
I may, however, call your attention, briefly, to the singular fact,
that English and American practitioners are apt to accuse French
medical practice of inertness, and French surgical practice of
unnecessary activity. Thus, Dr. Bostock considers French medical
treatment, with certain exceptions, as "decidedly less effective"
than that of his own country. Mr. S. Cooper, again, defends the
simple British practice of procuring union by the first intention
against the attacks of M. Roux and Baron Larrey. [Cooper's Surg.
Diet. art. "Wounds." Yet Mr. John Bell gives the French surgeons
credit for introducing this doctrine of adhesion, and accuses
O'Halloran of "rudeness and ignorance," and "bold, uncivil language,"
in disputing their teaching. Princ. of Surgery, vol. i. p. 42.
Mr. Hunter succeeded at last in naturalizing the doctrine and
practice, but even he had to struggle against the perpetual jealousy
of rivals, and died at length assassinated by an insult.] We have
often heard similar opinions maintained by our own countrymen. While
Anglo-American criticism blows hot or cold on the two departments of
French practice, it is not, I hope, indecent to question whether all
the wisdom is necessarily with us in both cases.
Our art has had two or three lessons which have a deep meaning to
those who are willing to read them honestly. The use of water-
dressings in surgery completed the series of reforms by which was
abolished the "coarse and cruel practice" of the older surgeons, who
with their dressings and acrid balsams, their tents and leaden tubes,
"absolutely delayed the cure." The doctrine of Broussais, transient
as was its empire, reversed the practice of half of Christendom for a
season, and taught its hasty disciples to shun their old favorite
remedies as mortal poisons. This was not enough permanently to shift
the presumption about drugs where it belonged, and so at last, just
as the sympathetic powder and the Unguentum Armarium came in a
superstitious age to kill out the abuses of external over-medication,
the solemn farce of Homoeopathy was enacted in the face of our own
too credulous civilization, that under shelter of its pretences the
"inward bruises" of over-drugged viscera might be allowed to heal by
the first intention. Its lesson we must accept, whether we will or
not; its follies we are tired of talking about. The security of the
medical profession against this and all similar fancies is in the
average constitution of the human. mind with regard to the laws of
evidence.
My friends and brothers in Art! There is nothing to be feared from
the utterance of any seeming heresy to which you may have listened.
I cannot compromise your collective wisdom. If I have strained the
truth one hair's breadth for the sake of an epigram or an antithesis,
you are accustomed to count the normal pulse-beats of sound judgment,
and know full well how to recognize the fever-throbs of conceit and
the nervous palpitations of rhetoric.
The freedom with which each of us speaks his thought in this
presence, belongs in part to the assured position of the Profession
in our Commonwealth, to the attitude of Science, which is always
fearless, and to the genius of the soil on which we stand, from which
Nature withheld the fatal gift of malaria only to fill it with
exhalations that breed the fever of inquiry in our blood and in our
brain. But mainly we owe the large license of speech we enjoy to
those influences and privileges common to us all as self-governing
Americans.
This Republic is the chosen home of minorities, of the less power in
the presence of the greater. It is a common error to speak of our
distinction as consisting in the rule of the majority. Majorities,
the greater material powers, have always ruled before. The history
of most countries has been that of majorities, mounted majorities,
clad in iron, armed with death treading down the tenfold more
numerous minorities. In the old civilizations they root themselves
like oaks in the soil; men must live in their shadow or cut them
down. With us the majority is only the flower of the passing noon,
and the minority is the bud which may open in the next morning's sun.
We must be tolerant, for the thought which stammers on a single
tongue today may organize itself in the growing consciousness of the
time, and come back to us like the voice of the multitudinous waves
of the ocean on the morrow.
Twenty-five years have passed since one of your honored Presidents
spoke to this Society of certain limitations to the power of our Art,
now very generally conceded. Some were troubled, some were almost
angry, thinking the Profession might suffer from such concessions.
It has certainly not suffered here; if, as some affirm, it has lost
respect anywhere, it was probably for other, and no doubt sufficient
reasons.
Since that time the civilization of this planet has changed hands.
Strike out of existence at this moment every person who was breathing
on that day, May 27, 1835, and every institution of society, every
art and every science would remain intact and complete in the living
that would be left. Every idea the world then held has been since
dissolved and recrystallized.
We are repeating the same process. Not to make silver shrines for
our old divinities, even though by this craft we should have our
wealth, was this Society organized and carried on by the good men and
true who went before us. Not for this, but to melt the gold out of
the past, though its dross should fly in dust to all the winds of
heaven, to save all our old treasures of knowledge and mine deeply
for new, to cultivate that mutual respect of which outward courtesy
is the sign, to work together, to feel together, to take counsel
together, and to stand together for the truth, now, always, here,
everywhere; for this our fathers instituted, and we accept, the
offices and duties of this time-honored Society.
BORDER LINES OF KNOWLEDGE IN SOME PROVINCES OF MEDICAL SCIENCE.
An Introductory Lecture delivered before the Medical Class
of Harvard University, November 6, 1861.
[This Lecture appears as it would have been delivered had the time
allowed been less strictly, limited. Passages necessarily omitted
have been restored, and points briefly touched have been more fully
considered. A few notes have been added for the benefit of that
limited class of students who care to track an author through the
highways and by-ways of his reading. I owe my thanks to several of
my professional brethren who have communicated with me on subjects
with which they are familiar; especially to Dr. John Dean, for the
opportunity of profiting by his unpublished labors, and to Dr. Hasket
Derby, for information and references to recent authorities relating
to the anatomy and physiology of the eye.]
The entrance upon a new course of Lectures is always a period of
interest to instructors and pupils. As the birth of a child to a
parent, so is the advent of a new class to a teacher. As the light
of the untried world to the infant, so is the dawning of the light
resting over the unexplored realms of science to the student. In the
name of the Faculty I welcome you, Gentlemen of the Medical Class,
new-born babes of science, or lustier nurslings, to this morning of
your medical life, and to the arms and the bosom of this ancient
University. Fourteen years ago I stood in this place for the first
time to address those who occupied these benches. As I recall these
past seasons of our joint labors, I feel that they have been on the
whole prosperous, and not undeserving of their prosperity.
For it has been my privilege to be associated with a body of true and
faithful workers; I cannot praise them freely to their faces, or I
should be proud to discourse of the harmonious diligence and the
noble spirit in which they have toiled together, not merely to teach
their several branches, but to elevate the whole standard of
teaching.
I may speak with less restraint of those gentlemen who have aided me
in the most laborious part of my daily duties, the Demonstrators, to
whom the successive classes have owed so much of their instruction.
They rise before me, the dead and the living, in the midst of the
most grateful recollections. The fair, manly face and stately figure
of my friend, Dr. Samuel Parkman, himself fit for the highest offices
of teaching, yet willing to be my faithful assistant in the time of
need, come back to me with the long sigh of regret for his early loss
to our earthly companionship. Every year I speak the eulogy of Dr.
Ainsworth's patient toil as I show his elaborate preparations: When I
take down my "American Cyclopaedia" and borrow instruction from the
learned articles of Dr. Kneeland, I cease to regret that his
indefatigable and intelligent industry was turned into a broader
channel. And what can I say too cordial of my long associated
companion and friend, Dr. Hodges, whose admirable skill, working
through the swiftest and surest fingers that ever held a scalpel
among us, has delighted class after class, and filled our Museum with
monuments which will convey his name to unborn generations?
This day belongs, however, not to myself and my recollections, but to
all of us who teach and all of you who listen, whether experts in our
specialties or aliens to their mysteries, or timid neophytes just
entering the portals of the hall of science. Look in with me, then,
while I attempt to throw some rays into its interior, which shall
illuminate a few of its pillars and cornices, and show at the same
time how many niches and alcoves remain in darkness.
SCIENCE is the topography of ignorance. From a few elevated points
we triangulate vast spaces, inclosing infinite unknown details. We
cast the lead, and draw up a little sand from abysses we may never
reach with our dredges.
The best part of our knowledge is that which teaches us where
knowledge leaves off and ignorance begins. Nothing more clearly
separates a vulgar from a superior mind, than the confusion in the
first between the little that it truly knows, on the one hand, and
what it half knows and what it thinks it knows on the other.
That which is true of every subject is especially true of the branch
of knowledge which deals with living beings. Their existence is a
perpetual death and reanimation. Their identity is only an idea, for
we put off our bodies many times during our lives, and dress in new
suits of bones and muscles.
"Thou art not thyself;
For thou exist'st on many a thousand grains
That issue out of dust."
If it is true that we understand ourselves but imperfectly in health,
this truth is more signally manifested in disease, where natural
actions imperfectly understood, disturbed in an obscure way by half-
seen causes, are creeping and winding along in the dark toward their
destined issue, sometimes using our remedies as safe stepping-stones,
occasionally, it may be, stumbling over them as obstacles.
I propose in this lecture to show you some points of contact between
our ignorance and our knowledge in several of the branches upon the
study of which you are entering. I may teach you a very little
directly, but I hope much more from the trains of thought I shall
suggest. Do not expect too much ground to be covered in this rapid
survey. Our task is only that of sending out a few pickets under the
starry flag of science to the edge of that dark domain where the
ensigns of the obstinate rebel, Ignorance, are flying undisputed. We
are not making a reconnoissance in force, still less advancing with
the main column. But here are a few roads along which we have to
march together, and we wish to see clearly how far our lines extend,
and where the enemy's outposts begin.
Before touching the branches of knowledge that deal with organization
and vital functions, let us glance at that science which meets you at
the threshold of your study, and prepares you in some measure to deal
with the more complex problems of the living laboratory.
CHEMISTRY. includes the art of separating and combining the elements
of matter, and the study of the changes produced by these operations.
We can hardly say too much of what it has contributed to our
knowledge of the universe and our power of dealing with its
materials. It has given us a catalogue raisonne of the substances
found upon our planet, and shown how everything living and dead is
put together from them. It is accomplishing wonders before us every
day, such as Arabian story-tellers used to string together in their
fables. It spreads the, sensitive film on the artificial retina
which looks upon us through the optician's lens for a few seconds,
and fixes an image that will outlive its original. It questions the
light of the sun, and detects the vaporized metals floating around
the great luminary,--iron, sodium, lithium, and the rest,--as if the
chemist of our remote planet could fill his bell-glasses from its
fiery atmosphere. It lends the power which flashes our messages in
thrills that leave the lazy chariot of day behind them. It seals up
a few dark grains in iron vases, and lo! at the touch of a single
spark, rises in smoke and flame a mighty Afrit with a voice like
thunder and an arm that shatters like an earthquake. The dreams of
Oriental fancy have become the sober facts of our every-day life, and
the chemist is the magician to whom we owe them.
To return to the colder scientific aspect of chemistry. It has shown
us how bodies stand affected to each other through an almost
boundless range of combinations. It has given us a most ingenious
theory to account for certain fixed relations in these combinations.
It has successfully eliminated a great number of proximate compounds,
more or less stable, from organic structures. It has invented others
which form the basis of long series of well-known composite
substances. In fact, we are perhaps becoming overburdened with our
list of proximate principles, demonstrated and hypothetical.
How much nearer have we come to the secret of force than Lully and
Geber and the whole crew of juggling alchemists? We have learned a
great deal about the how, what have we learned about the why?
Why does iron rust, while gold remains untarnished, and gold
amalgamate, while iron refuses the alliance of mercury?
The alchemists called gold Sol, the sun, and iron Mars, and pleased
themselves with fancied relations between these substances and the
heavenly bodies, by which they pretended to explain the facts they
observed. Some of their superstitions have lingered in practical
medicine to the present day, but chemistry has grown wise enough to
confess the fact of absolute ignorance.
What is it that makes common salt crystallize in the form of cubes,
and saltpetre in the shape of six-sided prisms? We see no reason why
it should not have been just the other way, salt in prisms and
saltpetre in cubes, or why either should take an exact geometrical
outline, any more than coagulating albumen.
But although we had given up attempting to explain the essential
nature of affinities and of crystalline types, we might have supposed
that we had at least fixed the identity of the substances with which
we deal, and determined the laws of their combination. All at once
we find that a simple substance changes face, puts off its
characteristic qualities and resumes them at will;--not merely when
we liquefy or vaporize a solid, or reverse the process; but that a
solid is literally transformed into another solid under our own eyes.
We thought we knew phosphorus. We warm a portion of it sealed in an
empty tube, for about a week. It has become a brown infusible
substance, which does not shine in the dark nor oxidate in the air.
We heat it to 500 F., and it becomes common phosphorus again. We
transmute sulphur in the same singular way. Nature, you know, gives
us carbon in the shape of coal and in that of the diamond. It is
easy to call these changes by the name allotropism, but not the less
do they confound our hasty generalizations.
These facts of allotropism have some corollaries connected with them
rather startling to us of the nineteenth century. There may be other
transmutations possible besides those of phosphorus and sulphur.
When Dr. Prout, in 1840, talked about azote and carbon being "formed"
in the living system, it was looked upon as one of those freaks of
fancy to which philosophers, like other men, are subject. But when
Professor Faraday, in 1851, says, at a meeting of the British
Association, that "his hopes are in the direction of proving that
bodies called simple were really compounds, and may be formed
artificially as soon as we are masters of the laws influencing their
combinations,"--when he comes forward and says that he has tried
experiments at transmutation, and means, if his life is spared, to
try them again,--how can we be surprised at the popular story of
1861, that Louis Napoleon has established a gold-factory and is
glutting the mints of Europe with bullion of his own making?
And so with reference to the law of combinations. The old maxim was,
Corpora non agunt nisi soluta. If two substances, a and b, are
inclosed in a glass vessel, c, we do not expect the glass to change
them, unless a or b or the compound a b has the power of dissolving
the glass. But if for a I take oxygen, for b hydrogen, and for c a
piece of spongy platinum, I find the first two combine with the
common signs of combustion and form water, the third in the mean time
undergoing no perceptible change. It has played the part of the
unwedded priest, who marries a pair without taking a fee or having
any further relation with the parties. We call this catalysis,
catalytic action, the action of presence, or by what learned name we
choose. Give what name to it we will, it is a manifestation of power
which crosses our established laws of combination at a very open
angle of intersection. I think we may find an analogy for it in
electrical induction, the disturbance of the equilibrium of the
electricity of a body by the approach of a charged body to it,
without interchange of electrical conditions between the two bodies.
But an analogy is not an explanation, and why a few drops of yeast
should change a saccharine mixture to carbonic acid and alcohol,--a
little leaven leavening the whole lump,--not by combining with it,
but by setting a movement at work, we not only cannot explain, but
the fact is such an exception to the recognized laws of combination
that Liebig is unwilling to admit the new force at all to which
Berzelius had given the name so generally accepted.
The phenomena of isomerism, or identity of composition and
proportions of constituents with difference of qualities, and of
isomorphism, or identity of form in crystals which have one element
substituted for another, were equally surprises to science; and
although the mechanism by which they are brought about can be to a
certain extent explained by a reference to the hypothetical atoms of
which the elements are constituted, yet this is only turning the
difficulty into a fraction with an infinitesimal denominator and an
infinite numerator.
So far we have studied the working of force and its seeming anomalies
in purely chemical phenomena. But we soon find that chemical force
is developed by various other physical agencies,--by heat, by light,
by electricity, by magnetism, by mechanical agencies; and, vice
versa, that chemical action develops heat, light, electricity,
magnetism, mechanical force, as we see in our matches, galvanic
batteries, and explosive compounds. Proceeding with our experiments,
we find that every kind of force is capable of producing all other
kinds, or, in Mr. Faraday's language, that "the various forms under
which the forces of matter are made manifest have a common origin,
or, in other words, are so directly related and mutually dependent
that they are convertible one into another."
Out of this doctrine naturally springs that of the conservation of
force, so ably illustrated by Mr. Grove, Dr. Carpenter, and Mr.
Faraday. This idea is no novelty, though it seems so at first sight.
It was maintained and disputed among the giants of philosophy.
Des Cartes and Leibnitz denied that any new motion originated in
nature, or that any ever ceased to exist; all motion being in a
circle, passing from one body to another, one losing what the other
gained. Newton, on the other hand, believed that new motions were
generated and existing ones destroyed. On the first supposition,
there is a fixed amount of force always circulating in the universe.
On the second, the total amount may be increasing or diminishing.
You will find in the "Annual of Scientific Discovery" for 1858 a very
interesting lecture by Professor Helmholtz of Bonn, in which it is
maintained that a certain portion of force is lost in every natural
process, being converted into unchangeable heat, so that the universe
will come to a stand-still at last, all force passing into heat, and
all heat into a state of equilibrium.
The doctrines of the convertibility or specific equivalence of the
various forms of force, and of its conservation, which is its logical
consequence, are very generally accepted, as I believe, at the
present time, among physicists. We are naturally led to the
question, What is the nature of force? The three illustrious
philosophers just referred to agree in attributing the general
movements of the universe to the immediate Divine action. The
doctrine of "preestablished harmony" was an especial contrivance of
Leibnitz to remove the Creator from unworthy association with the
less divine acts of living beings. Obsolete as this expression
sounds to our ears, the phrase laws of the universe, which we use so
constantly with a wider application, appears to me essentially
identical with it.
Force does not admit of explanation, nor of proper definition, any
more than the hypothetical substratum of matter. If we assume the
Infinite as omnipresent, omniscient, omnipotent, we cannot suppose
Him excluded from any part of His creation, except from rebellious
souls which voluntarily exclude Him by the exercise of their fatal
prerogative of free-will. Force, then, is the act of immanent
Divinity. I find no meaning in mechanical explanations. Newton's
hypothesis of an ether filling the heavenly spaces does not, I
confess, help my conceptions. I will, and the muscles of my vocal
organs shape my speech. God wills, and the universe articulates His
power, wisdom, and goodness. That is all I know. There is no bridge
my mind can throw from the "immaterial" cause to the "material"
effect.
The problem of force meets us everywhere, and I prefer to encounter
it in the world of physical phenomena before reaching that of living
actions. It is only the name for the incomprehensible cause of
certain changes known to our consciousness, and assumed to be outside
of it. For me it is the Deity Himself in action.
I can therefore see a large significance in the somewhat bold
language of Burdach: "There is for me but one miracle, that of
infinite existence, and but one mystery, the manner in which the
finite proceeds from the infinite. So soon as we recognize this
incomprehensible act as the general and primordial miracle, of which
our reason perceives the necessity, but the manner of which our
intelligence cannot grasp, so soon as we contemplate the nature known
to us by experience in this light, there is for us no other
impenetrable miracle or mystery."
Let us turn to a branch of knowledge which deals with certainties up
to the limit of the senses, and is involved in no speculations beyond
them. In certain points of view, HUMAN ANATOMY may be considered an
almost exhausted science. From time to time some small organ which
had escaped earlier observers has been pointed out,--such parts as
the tensor tarsi, the otic ganglion, or the Pacinian bodies; but some
of our best anatomical works are those which have been classic for
many generations. The plates of the bones in Vesalius, three
centuries old, are still masterpieces of accuracy, as of art. The
magnificent work of Albinus on the muscles, published in 1747, is
still supreme in its department, as the constant references of the
most thorough recent treatise on the subject, that of Theile,
sufficiently show. More has been done in unravelling the mysteries
of the fasciae, but there has been a tendency to overdo this kind of
material analysis. Alexander Thomson split them up into cobwebs, as
you may see in the plates to Velpeau's Surgical Anatomy. I well
remember how he used to shake his head over the coarse work of Scarpa
and Astley Cooper,--as if Denner, who painted the separate hairs of
the beard and pores of the skin in his portraits, had spoken lightly
of the pictures of Rubens and Vandyk.
Not only has little been added to the catalogue of parts, but some
Back to Full Books
|