Medical Essays, 1842-1882 Part 14

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 ill.u.s.trate 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 s.e.xton, this five per cent., this certain small injury entering into the chances is clearly the s.e.xton's perquisite for keeping the green table, over which the game is played, and where he h.o.a.rds 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 a.s.sumption.

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 a.s.sumed to be the innocent victim of circ.u.mstances, 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 const.i.tution 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 circ.u.mstances 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 embarra.s.sed 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 Ma.s.sachusetts, 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 pract.i.tioners 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 a.s.sa.s.sinated 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 "coa.r.s.e 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 s.h.i.+ft the presumption about drugs where it belonged, and so at last, just as the sympathetic powder and the Unguentum Armarium came in a superst.i.tious age to kill out the abuses of external over-medication, the solemn farce of h.o.m.oeopathy 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 const.i.tution 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 ant.i.thesis, 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 a.s.sured position of the Profession in our Commonwealth, to the att.i.tude 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 pa.s.sing 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 mult.i.tudinous waves of the ocean on the morrow.

Twenty-five years have pa.s.sed 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 inst.i.tution 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 inst.i.tuted, 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 Cla.s.s of Harvard University, November 6, 1861.

[This Lecture appears as it would have been delivered had the time allowed been less strictly, limited. Pa.s.sages 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 cla.s.s 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 cla.s.s 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 Cla.s.s, new-born babes of science, or l.u.s.tier 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 a.s.sociated 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 n.o.ble 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 cla.s.ses 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 a.s.sistant in the time of need, come back to me with the long sigh of regret for his early loss to our earthly companions.h.i.+p. 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 a.s.sociated companion and friend, Dr. Hodges, whose admirable skill, working through the swiftest and surest fingers that ever held a scalpel among us, has delighted cla.s.s after cla.s.s, 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 s.p.a.ces, 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 ident.i.ty 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 accomplis.h.i.+ng 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-gla.s.ses 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 superst.i.tions 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 alb.u.men.

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 ident.i.ty 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 s.h.i.+ne in the dark nor oxidate in the air. We heat it to 500 F., and it becomes common phosphorus again. We trans.m.u.te 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 trans.m.u.tations 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 a.s.sociation, 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 trans.m.u.tation, 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 gla.s.s vessel, c, we do not expect the gla.s.s to change them, unless a or b or the compound a b has the power of dissolving the gla.s.s. 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 a.n.a.logy 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 a.n.a.logy 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 ident.i.ty of composition and proportions of const.i.tuents with difference of qualities, and of isomorphism, or ident.i.ty of form in crystals which have one element subst.i.tuted 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 const.i.tuted, 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 ill.u.s.trated 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, pa.s.sing 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 diminis.h.i.+ng. 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 pa.s.sing 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 ill.u.s.trious 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 a.s.sociation 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 a.s.sume 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 s.p.a.ces does not, I confess, help my conceptions. I will, and the muscles of my vocal organs shape my speech. G.o.d 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.