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.