Chapter 20

But when it comes to substances alien to the healthy system, which never belong to it as normal constituents, the case is very different. There is a presumption against putting lead or arsenic into the human body, as against putting them into plants, because they do not belong there, any more than pounded glass, which, it is said, used to be given as a poison. The same thing is true of mercury and silver. What becomes of these alien substances after they get into the system we cannot always tell. But in the case of silver, from the accident of its changing color under the influence of light, we do know what happens. It is thrown out, in part at least, under the epidermis, and there it remains to the patient's dying day. This is a striking illustration of the difficulty which the system finds in dealing with non-assimilable elements, and justifies in some measure the vulgar prejudice against mineral poisons.

I trust the youngest student on these benches will not commit the childish error of confounding a presumption against a particular class of agents with a condemnation of them. Mercury, for instance, is alien to the system, and eminently disturbing in its influence. Yet its efficacy in certain forms of specific disease is acknowledged by all but the most sceptical theorists. Even the esprit moqueur of Ricord, the Voltaire of pelvic literature, submits to the time-honored constitutional authority of this great panacea in the class of cases to which he has devoted his brilliant intelligence. Still, there is no telling what evils have arisen from the abuse of this mineral. Dr. Armstrong long ago pointed out some of them, and they have become matters of common notoriety. I am pleased, therefore, when I find so able and experienced a practitioner as Dr. Williams of this city proving that iritis is best treated without mercury, and Dr. Vanderpoel showing the same thing to be true for pericarditis.

Whatever elements nature does not introduce into vegetables, the natural food of all animal life,--directly of herbivorous, indirectly of carnivorous animals,--are to be regarded with suspicion. Arsenic-eating may seem to improve the condition of horses for a time,--and even of human beings, if Tschudi's stories can be trusted,--but it soon appears that its alien qualities are at war with the animal organization. So of copper, antimony, and other non-alimentary simple substances; everyone of them is an intruder in the living system, as much as a constable would be, quartered in our household. This does not mean that they may not, any of them, be called in for a special need, as we send for the constable when we have good reason to think we have a thief under our roof; but a man's body is his castle, as well as his house, and the presumption is that we are to keep our alimentary doors bolted against these perturbing agents.

Now the feeling is very apt to be just contrary to this. The habit has been very general with well-taught practitioners, to have recourse to the introduction of these alien elements into the system on the occasion of any slight disturbance. The tongue was a little coated, and mercury must be given; the skin was a little dry, and the patient must take antimony. It was like sending for the constable and the posse comitatus when there is only a carpet to shake or a refuse-barrel to empty. [Dr. James Johnson advises persons not ailing to take five grains of blue pill with one or two of aloes twice a week for three or four months in the year, with half a pint of compound decoction of sarsaparilla every day for the same period, to preserve health and prolong life. Pract. Treatise on Dis. of Liver, etc. p. 272.] The constitution bears slow poisoning a great deal better than might be expected; yet the most intelligent men in the profession have gradually got out of the habit of prescribing these powerful alien substances in the old routine way. Mr. Metcalf will tell you how much more sparingly they are given by our practitioners at the present time, than when he first inaugurated the new era of pharmacy among us. Still, the presumption in favor of poisoning out every spontaneous reaction of outraged nature is not extinct in those who are trusted with the lives of their fellow-citizens. “On examining the file of prescriptions at the hospital, I discovered that they were rudely written, and indicated a treatment, as they consisted chiefly of tartar emetic, ipecacuanha, and epsom salts, hardly favorable to the cure of the prevailing diarrhoea and dysenteries.” In a report of a poisoning case now on trial, where we are told that arsenic enough was found in the stomach to produce death in twenty-four hours, the patient is said to have been treated by arsenic, phosphorus, bryonia, aconite, nux vomica, and muriatic acid,--by a practitioner of what school it may be imagined.

The traditional idea of always poisoning out disease, as we smoke out vermin, is now seeking its last refuge behind the wooden cannon and painted port-holes of that unblushing system of false scientific pretences which I do not care to name in a discourse addressed to an audience devoted to the study of the laws of nature in the light of the laws of evidence. It is extraordinary to observe that the system which, by its reducing medicine to a name and a farce, has accustomed all who have sense enough to see through its thin artifices to the idea that diseases get well without being “cured,” should now be the main support of the tottering poison-cure doctrine. It has unquestionably helped to teach wise people that nature heals most diseases without help from pharmaceutic art, but it continues to persuade fools that art can arrest them all with its specifics.

It is worse than useless to attempt in any way to check the freest expression of opinion as to the efficacy of any or all of the “heroic” means of treatment employed by practitioners of different schools and periods. Medical experience is a great thing, but we must not forget that there is a higher experience, which tries its results in a court of a still larger jurisdiction; that, namely, in which the laws of human belief are summoned to the witness-box, and obliged to testify to the sources of error which beset the medical practitioner. The verdict is as old as the father of medicine, who announces it in the words, “judgment is difficult.” Physicians differed so in his time, that some denied that there was any such thing as an art of medicine.

One man's best remedies were held as mischievous by another. The art of healing was like soothsaying, so the common people said; “the same bird was lucky or unlucky, according as he flew to the right or left.”

The practice of medicine has undergone great changes within the period of my own observation. Venesection, for instance, has so far gone out of fashion, that, as I am told by residents of the New York Bellevue and the Massachusetts General Hospitals, it is almost obsolete in these institutions, at least in medical practice. The old Brunonian stimulating treatment has come into vogue again in the practice of Dr. Todd and his followers. The compounds of mercury have yielded their place as drugs of all work, and specifics for that very frequent subjective complaint, nescio quid faciam,--to compounds of iodine. [Sir Astley Cooper has the boldness,--or honesty,--to speak of medicines which “are given as much to assist the medical man as his patient.” Lectures (London, 1832), p. 14.] Opium is believed in, and quinine, and “rum,” using that expressive monosyllable to mean all alcoholic cordials. If Moliere were writing now, instead of saignare, purgare, and the other, he would be more like to say, Stimulare, opium dare et potassio-iodizare.

I have been in relation successively with the English and American evacuant and alterative practice, in which calomel and antimony figured so largely that, as you may see in Dr. Jackson's last “Letter,” Dr. Holyoke, a good representative of sterling old-fashioned medical art, counted them with opium and Peruvian bark as his chief remedies; with the moderately expectant practice of Louis; the blood-letting “coup sur coup” of Bouillaud; the contra-stimulant method of Rasori and his followers; the anti-irritant system of Broussais, with its leeching and gum-water; I have heard from our own students of the simple opium practice of the renowned German teacher, Oppolzer; and now I find the medical community brought round by the revolving cycle of opinion to that same old plan of treatment which John Brown taught in Edinburgh in the last quarter of the last century, and Miner and Tully fiercely advocated among ourselves in the early years of the present. The worthy physicians last mentioned, and their antagonist Dr. Gallup, used stronger language than we of these degenerate days permit ourselves. “The lancet is a weapon which annually slays more than the sword,” says Dr. Tully. “It is probable that, for forty years past, opium and its preparations have done seven times the injury they have rendered benefit, on the great scale of the world,” says Dr. Gallup.

What is the meaning of these perpetual changes and conflicts of medical opinion and practice, from an early antiquity to our own time? Simply this: all “methods” of treatment end in disappointment of those extravagant expectations which men are wont to entertain of medical art. The bills of mortality are more obviously affected by drainage, than by this or that method of practice. The insurance companies do not commonly charge a different percentage on the lives of the patients of this or that physician. In the course of a generation, more or less, physicians themselves are liable to get tired of a practice which has so little effect upon the average movement of vital decomposition. Then they are ready for a change, even if it were back again to a method which has already been tried, and found wanting.

Our practitioners, or many of them, have got back to the ways of old Dr. Samuel Danforth, who, as it is well known, had strong objections to the use of the lancet. By and by a new reputation will be made by some discontented practitioner, who, tired of seeing patients die with their skins full of whiskey and their brains muddy with opium, returns to a bold antiphlogistic treatment, and has the luck to see a few patients of note get well under it. So of the remedies which have gone out of fashion and been superseded by others. It can hardly be doubted that they will come into vogue again, more or less extensively, under the influence of that irresistible demand for change just referred to.

Then will come the usual talk about a change in the character of disease, which has about as much meaning as that concerning “old-fashioned snow-storms.” “Epidemic constitutions” of disease mean something, no doubt; a great deal as applied to malarious affections; but that the whole type of diseases undergoes such changes that the practice must be reversed from depleting to stimulating, and vice versa, is much less likely than that methods of treatment go out of fashion and come in again. If there is any disease which claims its percentage with reasonable uniformity, it is phthisis. Yet I remember that the reverend and venerable Dr. Prince of Salem told me one Commencement day, as I was jogging along towards Cambridge with him, that he recollected the time when that disease was hardly known; and in confirmation of his statement mentioned a case in which it was told as a great event, that somebody down on “the Cape” had died of “a consumption.” This story does not sound probable to myself, as I repeat it, yet I assure you it is true, and it shows how cautiously we must receive all popular stories of great changes in the habits of disease.

Is there no progress, then, but do we return to the same beliefs and practices which our forefathers wore out and threw away? I trust and believe that there is a real progress. We may, for instance, return in a measure to the Brunonian stimulating system, but it must be in a modified way, for we cannot go back to the simple Brunonian pathology, since we have learned too much of diseased action to accept its convenient dualism. So of other doctrines, each new Avatar strips them of some of their old pretensions, until they take their fitting place at last, if they have any truth in them, or disappear, if they were mere phantasms of the imagination.

In the mean time, while medical theories are coming in and going out, there is a set of sensible men who are never run away with by them, but practise their art sagaciously and faithfully in much the same way from generation to generation. From the time of Hippocrates to that of our own medical patriarch, there has been an apostolic succession of wise and good practitioners. If you will look at the first aphorism of the ancient Master you will see that before all remedies he places the proper conduct of the patient and his attendants, and the fit ordering of all the conditions surrounding him. The class of practitioners I have referred to have always been the most faithful in attending to these points. No doubt they have sometimes prescribed unwisely, in compliance with the prejudices of their time, but they have grown wiser as they have grown older, and learned to trust more in nature and less in their plans of interference. I believe common opinion confirms Sir James Clark's observation to this effect.

The experience of the profession must, I think, run parallel with that of the wisest of its individual members. Each time a plan of treatment or a particular remedy comes up for trial, it is submitted to a sharper scrutiny. When Cullen wrote his Materia Medica, he had seriously to assail the practice of giving burnt toad, which was still countenanced by at least one medical authority of note. I have read recently in some medical journal, that an American practitioner, whose name is known to the country, is prescribing the hoof of a horse for epilepsy. It was doubtless suggested by that old fancy of wearing a portion of elk's hoof hung round the neck or in a ring, for this disease. But it is hard to persuade reasonable people to swallow the abominations of a former period. The evidence which satisfied Fernelius will not serve one of our hospital physicians.

In this way those articles of the Materia Medica which had nothing but loathsomeness to recommend them have been gradually dropped, and are not like to obtain any general favor again with civilized communities. The next culprits to be tried are the poisons. I have never been in the least sceptical as to the utility of some of them, when properly employed. Though I believe that at present, taking the world at large, and leaving out a few powerful agents of such immense value that they rank next to food in importance, the poisons prescribed for disease do more hurt than good, I have no doubt, and never professed to have any, that they do much good in prudent and instructed hands. But I am very willing to confess a great jealousy of many agents, and I could almost wish to see the Materia Medica so classed as to call suspicion upon certain ones among them.

Thus the alien elements, those which do not properly enter into the composition of any living tissue, are the most to be suspected, --mercury, lead, antimony, silver, and the rest, for the reasons I have before mentioned. Even iodine, which, as it is found in certain plants, seems less remote from the animal tissues, gives unequivocal proofs from time to time that it is hostile to some portions of the glandular system.

There is, of course, less prima facie objection to those agents which consist of assimilable elements, such as are found making a part of healthy tissues. These are divisible into three classes,--foods, poisons, and inert, mostly because insoluble, substances. The food of one animal or of one human being is sometimes poison to another, and vice versa; inert substances may act mechanically, so as to produce the effect of poisons; but this division holds exactly enough for our purpose.

Strictly speaking, every poison consisting of assimilable elements may be considered as unwholesome food. It is rejected by the stomach, or it produces diarrhoea, or it causes vertigo or disturbance of the heart's action, or some other symptom for which the subject of it would consult the physician, if it came on from any other cause than taking it under the name of medicine. Yet portions of this unwholesome food which we call medicine, we have reason to believe, are assimilated; thus, castor-oil appears to be partially digested by infants, so that they require large doses to affect them medicinally. Even that deadliest of poisons, hydrocyanic acid, is probably assimilated, and helps to make living tissue, if it do not kill the patient, for the assimilable elements which it contains, given in the separate forms of amygdalin and emulsin, produce no disturbance, unless, as in Bernard's experiments, they are suffered to meet in the digestive organs. A medicine consisting of assimilable substances being then simply unwholesome food, we understand what is meant by those cumulative effects of such remedies often observed, as in the case of digitalis and strychnia. They are precisely similar to the cumulative effects of a salt diet in producing scurvy, or of spurred rye in producing dry gangrene. As the effects of such substances are a violence to the organs, we should exercise the same caution with regard to their use that we would exercise about any other kind of poisonous food,--partridges at certain seasons, for instance. Even where these poisonous kinds of food seem to be useful, we should still regard them with great jealousy. Digitalis lowers the pulse in febrile conditions. Veratrum viride does the same thing. How do we know that a rapid pulse is not a normal adjustment of nature to the condition it accompanies? Digitalis has gone out of favor; how sure are we that Veratrum viride will not be found to do more harm than good in a case of internal inflammation, taking the whole course of the disease into consideration? Think of the change of opinion with regard to the use of opium in delirium tremens (which you remember is sometimes called delirium vigilans), where it seemed so obviously indicated, since the publication of Dr. Ware's admirable essay. I respect the evidence of my contemporaries, but I cannot forget the sayings of the Father of medicine,--Ars longa, judicium difficile.

I am not presuming to express an opinion concerning Veratrum viride, which was little heard of when I was still practising medicine. I am only appealing to that higher court of experience which sits in judgment on all decisions of the lower medical tribunals, and which requires more than one generation for its final verdict.

Once change the habit of mind so long prevalent among practitioners of medicine; once let it be everywhere understood that the presumption is in favor of food, and not of alien substances, of innocuous, and not of unwholesome food, for the sick; that this presumption requires very strong evidence in each particular case to overcome it; but that, when such evidence is afforded, the alien substance or the unwholesome food should be given boldly, in sufficient quantities, in the same spirit as that with which the surgeon lifts his knife against a patient,--that is, with the same reluctance and the same determination,--and I think we shall have and hear much less of charlatanism in and out of the profession. The disgrace of medicine has been that colossal system of self-deception, in obedience to which mines have been emptied of their cankering minerals, the vegetable kingdom robbed of all its noxious growths, the entrails of animals taxed for their impurities, the poison-bags of reptiles drained of their venom, and all the inconceivable abominations thus obtained thrust down the throats of human beings suffering from some fault of organization, nourishment, or vital stimulation.

Much as we have gained, we have not yet thoroughly shaken off the notion that poison is the natural food of disease, as wholesome aliment is the support of health. Cowper's lines, in “The Task,” show the matter-of-course practice of his time:

“He does not scorn it, who has long endured A fever's agonies, and fed on drugs.”

Dr. Kimball of Lowell, who has been in the habit of seeing a great deal more of typhoid fever than most practitioners, and whose surgical exploits show him not to be wanting in boldness or enterprise, can tell you whether he finds it necessary to feed his patients on drugs or not. His experience is, I believe, that of the most enlightened and advanced portion of the profession; yet I think that even in typhoid fever, and certainly in many other complaints, the effects of ancient habits and prejudices may still be seen in the practice of some educated physicians.

To you, young men, it belongs to judge all that has gone before you. You come nearer to the great fathers of modern medicine than some of you imagine. Three of my own instructors attended Dr. Rush's Lectures. The illustrious Haller mentions Rush's inaugural thesis in his “Bibliotheca Anatomica;” and this same Haller, brought so close to us, tells us he remembers Ruysch, then an old man, and used to carry letters between him and Boerhaave. Look through the history of medicine from Boerhaave to this present day. You will see at once that medical doctrine and practice have undergone a long series of changes. You will see that the doctrine and practice of our own time must probably change in their turn, and that, if we can trust at all to the indications of their course, it will be in the direction of an improved hygiene and a simplified treatment. Especially will the old habit of violating the instincts of the sick give place to a judicious study of these same instincts. It will be found that bodily, like mental insanity, is best managed, for the most part, by natural soothing agencies. Two centuries ago there was a prescription for scurvy containing “stercoris taurini et anserini par, quantitas trium magnarum nucum,” of the hell-broth containing which “guoties-cumque sitit oeger, large bibit.” When I have recalled the humane common-sense of Captain Cook in the matter of preventing this disease; when I have heard my friend, Mr. Dana, describing the avidity with which the scurvy-stricken sailors snuffed up the earthy fragrance of fresh raw potatoes, the food which was to supply the elements wanting to their spongy tissues, I have recognized that the perfection of art is often a return to nature, and seen in this single instance the germ of innumerable beneficent future medical reforms.