Part 17

A third noteworthy feature in modern treatment has been a return to psychical methods of cure, in which _faith in something is suggested_ to the patient. After all, faith is the great lever of life. Without it, man can do nothing; with it, even with a fragment, as a grain of mustard-seed, all things are possible to him. Faith in us, faith in our drugs and methods, is the great stock in trade of the profession. In one pan of the balance, put the pharmacopœias of the world, all the editions from Dioscorides to the last issue of the United States Dispensatory; heap them on the scales as did Euripides his books in the celebrated contest in the “Frogs”; in the other put the simple faith with which from the days of the Pharaohs until now the children of men have swallowed the mixtures these works describe, and the bulky tomes will kick the beam. It is the _aurum potabile_, the touchstone of success in medicine. As Galen says, confidence and hope do more good than physic—“he cures most in whom most are confident.” That strange compound of charlatan and philosopher, Paracelsus, encouraged his patients “to have a good faith, a strong imagination, and they shall find the effects” (Burton). While we often overlook or are ignorant of our own faith-cures, doctors are just a wee bit too sensitive about those performed outside our ranks. They have never had, and cannot expect to have, a monopoly in this panacea, which is open to all, free as the sun, and which may make of every one in certain cases, as was the Lacedemon of Homer’s day, “a good physician out of Nature’s grace.” Faith in the gods or in the saints cures one, faith in little pills another, hypnotic suggestion a third, faith in a plain, common doctor a fourth. In all ages the prayer of faith has healed the sick, and the mental attitude of the suppliant seems to be of more consequence than the powers to which the prayer is addressed. The cures in the temples of Æsculapius, the miracles of the saints, the remarkable cures of those noble men, the Jesuit missionaries, in this country, the modern miracles at Lourdes and at St. Anne de Beaupré in Quebec, and the wonder-workings of the so-called Christian Scientists, are often genuine, and must be considered in discussing the foundations of therapeutics. We physicians use the same power every day. If a poor lass, paralyzed, apparently, helpless, bed-ridden for years, comes to me, having worn out in mind, body, and estate a devoted family; if she in a few weeks or less by faith in me, and faith alone, takes up her bed and walks, the saints of old could not have done more. St. Anne and many others can scarcely to-day do less. We enjoy, I say, no monopoly in the faith business. The faith with which we work, the faith, indeed, which is available to-day in every-day life, has its limitations. It will not raise the dead; it will not put in a new eye in place of a bad one (as it did to an Iroquois Indian boy for one of the Jesuit fathers), nor will it cure cancer or pneumonia, or knit a bone; but, in spite of these nineteenth-century restrictions, such as we find it, faith is a most precious commodity, without which we should be very badly off.

_Hypnotism_, introduced by Mesmer in the eighteenth century, has had several revivals as a method of treatment during the nineteenth century. The first careful study of it was made by Braid, a Manchester surgeon, who introduced the terms hypnotism, hypnotic, and nervous sleep; but at this time no very great measure of success followed its use in practice, except perhaps in the case of an Anglo-Indian surgeon, James Esdaile, who, prior to the introduction of anæsthesia, had performed two hundred and sixty-one surgical operations upon patients in a state of hypnotic unconsciousness. About 1880 the French physicians, particularly Charcot and Bernheim, took up the study, and since that time hypnotism has been extensively practised. It may be defined as a subjective psychical condition, what Braid called nervous sleep, resembling somnambulism, in which, as Shakespeare says, in the description of Lady Macbeth, the person receives at once the benefit of sleep and does the effects or acts of watching or waking. Therapeutically, the important fact is that the individual’s natural susceptibility to suggestion is increased, and this may hold after the condition of hypnosis has passed away. The condition of hypnosis is usually itself induced by suggestion, requesting the subject to close the eyes, to think of sleep, and the operator then repeats two or three times sentences suggesting sleep, and suggesting that the limbs are getting heavy and that he is feeling drowsy. During this state it has been found that the subjects are very susceptible to suggestion. Too much must not be expected of hypnotism, and the claims which have been made for it have been too often grossly exaggerated. It seems, as it has been recently well put, that hypnotism “at best permits of making suggestions more effective for good or bad than can be done upon one in his waking state.” It is found to be of very little use in organic disease. It has been helpful in some cases of hysteria, in certain functional spasmodic affections of the nervous system, in the vicious habits of childhood, and in suggesting to the victims of alcohol and drugs that they should get rid of their inordinate desires. It has been used successfully in certain cases for the relief of labor pains, and in surgical operations; but on the whole, while a valuable agent in a few cases, it has scarcely fulfilled the expectations of its advocates. It is a practice not without serious dangers, and should never be performed except in the presence of a third person, and its indiscriminate practice by ignorant persons should be prevented by law.

One mode of faith-healing in modern days, which passes under the remarkable name of Christian Science, is probably nothing more than mental suggestion under another name. “The patient is told to be calm, and is assured that all will go well; that he must try to aid the healer by believing that what is told him is true. The healer then, quietly but firmly, asserts and reiterates that there is no pain, no suffering, that it is disappearing, that relief will come, that the patient is getting well.” This is precisely the method which Bernheim used to use with such success in his hypnotic patients at Nancy, iterating and reiterating, in a most wearisome way, that the disease would disappear and the patient would feel better. As has been pointed out by a recent writer (Dr. Harry Marshall), the chief basis for the growth of Christian Science is that which underlies every popular fallacy: “Oliver Wendell Holmes outlined very clearly the factors concerned, showing (a) how easily abundant facts can be collected to prove anything whatsoever; (b) how insufficient ‘exalted wisdom, immaculate honesty, and vast general acquirements’ are to prevent an individual from having the most primitive ideas upon subjects out of his line of thought; and, finally, demonstrating ‘the boundless credulity and excitability of mankind upon subjects connected with medicine.’”

WILLIAM OSLER.

SURGERY

The end of the eighteenth century was made notable by one of the most remarkable and beneficent discoveries which has ever blessed the human race, the discovery of the means of preventing small-pox. On May 14, 1796, Dr. Edward Jenner inoculated James Phipps. When we remember that two million persons died in a single year in the Russian Empire from small-pox; that in 1707 in Iceland, out of a population of thirty thousand, sixty per cent., or eighteen thousand, died; that in Jenner’s time “an adult person who had not had small-pox was scarcely met with or heard of in the United Kingdom, and that owing to his discovery small-pox is now one of the rarest diseases,” the strong words I have used seem fully justified. But the eighteenth century was not to witness the end of progress in medicine. The advances in the nineteenth century have been even more startling and more beneficent. What these advances have been in the department of medicine has been related by Professor Osler. It is my province to speak only of surgery.

METHOD OF TEACHING

The first advance which should be mentioned is a fundamental one—namely, methods of medical teaching. At the beginning of the nineteenth century there were only three medical schools in the United States: the Medical Department of the University of Pennsylvania, established in 1765; the Medical Department of Harvard, established in 1783; and the Medical Department of Dartmouth, established in 1797. The last report of the Commissioner of Education gives a list of one hundred and fifty-five medical schools now in existence in this country, many of them still poorly equipped and struggling for existence, but a large number of them standing in the first rank, with excellent modern equipment, both in teachers, laboratories, hospitals, and other facilities. The medical curriculum then extended over only two years or less, and consisted of courses of lectures at the most by seven professors who, year after year, read the same course of lectures, without illustrations and with no practical teaching. The medical schools, even when connected with universities, were practically private corporations, the members of which took all the fees, spent what money they were compelled to spend in the maintenance of what we now should call the semblance of an education, and divided the profits. Until within about twenty years this method prevailed in all our medical schools. But the last two decades of the century have seen a remarkable awakening of the medical profession to the need of a broader and more liberal education, and that, as a prerequisite, the medical schools should be on the same basis as the department of arts in every well-regulated college. To accomplish this the boards of trustees have taken possession of the fees of students, have placed the faculties upon salaries, and have used such portion of the incomes of the institutions as was needed for a constant and yet rapid development along the most liberal lines.

COLLEGE HOSPITALS

The first step has been the establishment in connection with most schools of general hospitals in which the various teachers in the college should be the clinical instructors, and where the students would have the means not only of hearing theoretically what should be done to the sick, but of actually examining the patients under the supervision of their instructors, studying the cases so as to become skilled in reaching a diagnosis and indicating what in their opinion was necessary in the way either of hygiene, medicine, or surgical operation. More than that, in most of the advanced schools to-day the students assist the clinical faculties of the hospitals in the actual performance of operations, so that when they graduate they are skilled to a degree utterly unknown twenty years ago.

ESTABLISHMENT OF LABORATORIES

Another step which was equally important, and in some respects even more so, has been the establishment of laboratories connected with each branch of instruction. A laboratory of anatomy (the dissecting room) every medical school has always had, but all the other laboratories are recent additions. Among these may be named a laboratory of clinical medicine, a laboratory of therapeutics, in which the action of drugs is studied; a laboratory of chemistry, a laboratory of microscopy, a laboratory of pathology for the study of diseased tissues, a laboratory of embryology for the study of the development of the human body and of the embryos of animals, a laboratory of hygiene, a laboratory of bacteriology, a laboratory of pharmacy, a surgical laboratory, in which all the operations of surgery are done on the cadaver by each student, a laboratory of physiology, and in many colleges private rooms in which advanced work may be done for the discovery of new truths.

In all these laboratories, instead of simply hearing about the experiments and observations, each student is required to handle the drugs, the chemicals, the apparatus, to do all the operations, to look through the microscope, etc.; in other words, to do all that which is necessary for the proper understanding of the case in hand. In fact, it may be said that in view of the opportunities and the requirements of modern hospitals, it is undoubtedly true that a hospital patient, the poorest of the poor, often has his case more thoroughly studied and more accurately observed than the wealthy patient who is attended at his home. On the other hand, however, so many laboratories with their expensive apparatus and a large staff of assistants mean an enormous increase in the expense of a medical education, for which the student does not pay anything like an equivalent. Hence the need in all of our best modern medical schools for endowments, in order that such work may be carried on properly, and yet the student not be charged such fees as to be practically prohibitory, excepting for the rich, or at the least the well-to-do. I do not hesitate to say that at the end of the second year many a diligent student of to-day is better fitted to practise medicine than was the graduate of half a century ago.

ANATOMICAL MATERIAL

One of the most important means of the study of medicine, and especially of surgery, is a thorough acquaintance with the anatomy of the human body. No one would think of placing an engineer in charge of a complicated piece of machinery, who had never become intimately acquainted with all the parts of such a machine, so that he could take it to pieces and put it together again with ease and intelligence. Yet, until comparatively recently, this knowledge of anatomy was both required of, and yet at the same time the means of obtaining it was forbidden to, the medical student. If he performed an operation and was guilty of negligence or error, due to his want of anatomical knowledge, he was liable to a suit for malpractice. Yet his only means of becoming acquainted with the anatomy of the human body was by stealing the bodies of the dead. In England, up to 1832, this was equally true. A regular traffic in human bodies existed there as well as here, and, by reason of its perils, the cost of bodies for dissection was very great; but it was only a question of money. In his testimony before the Parliamentary Committee, Sir Astley Cooper made a shiver run down the backs of the noble lords who listened to him when he said that in order to dissect the body of any of them it was only necessary for him to pay enough. The large pecuniary profits of such business, when the supply was very small, led to the horrible atrocities of Burke and Hare in Edinburgh in 1832. They deliberately murdered a considerable number of persons, and sold the bodies to the dissecting rooms in that city. The discovery of their crimes finally led to the passage of the Anatomy Act, which has been in force in Great Britain ever since. Similar violations of graveyards in this country have led to the passage in various States of somewhat similar laws, usually giving for dissection the bodies of those who were so poor in friendship that no one would spend the money necessary for their burial. Even to-day, in a large number of our States, the former anomalous condition of affairs exists. The increase of anatomical material which has resulted from the enactment of wise and salutary laws for this purpose has given a great impetus to the study of anatomy, and has produced a far better educated class of physicians in most parts of the United States within the last few years. The enlightened sense of the community has perceived that to deny the medical schools the means of properly teaching anatomy was a fatal mistake, and resulted in an ignorance of which the community were the victims. As a result, it is possible now, by law, in most States to obtain a reasonable number of cadavers, not only for the study of anatomy, but for the performance of all the usual operations.

MEDICAL LIBRARIES

Along with this there has been throughout this country a marked movement in favor of medical libraries. It is to the credit of the government of the United States that the whole world is debtor to us, not only for the foremost medical library in the world, that of the surgeon-general of the army in Washington, but also for the magnificent index-catalogue, not only of the books, but all the journal articles in every language in the world. No better investment of money was ever made than the establishment of this library, and its allied museum, and the publication of the index-catalogue.

EMBRYOLOGY

As a result of all these means and methods of study, and as a part of the great educational and scientific movement of the century, medical men now take a wholly different view of the normal and abnormal structures of the human body. The study of embryology has shown us that many of the deviations from the normal development of the human body are easily explained by embryology. One of the most important changes in our idea, for example, of tumors is due to the fact that the study of embryology and of the tissues of the embryo have shown us that diseased structures, which lack explanation entirely, when compared with the adult human tissues, readily find their explanation and fall into an unexpected order when compared with the tissues of the embryo. Not only, however, has the study of embryological tissues thrown a flood of light on diseased structures, but we have obtained new views of the relation of man to all creatures, lower in the scale of life. Largely owing to the doctrine of evolution, we now recognize the fact that, so far as his body is concerned, man is kindred to the brutes; that his diseases, within certain limitations, are identical with similar diseases of the lower animals; that his anatomy and physiology are, in essence, the same as the anatomy and physiology of the lower animals, even the very lowest, and that many of his diseases can be best studied in the lower animals, because upon them we can make exact experiments which would be impossible in man. While it is true that each animal has disorders which are peculiar to itself, and that it is not subject to some of the disorders to which man is a victim, and, _per contra_, that man is a victim to some disorders from which animals do not suffer, yet, taking them as a whole, the diseases of man and of animals, and the action of remedies on both, are practically identical. To this I shall have occasion to refer again.

PATHOLOGY

Among the laboratories which I mentioned, one of the most important is that of pathology and morbid anatomy, or the study of diseased tissues and organs. The first work on pathology written in this country was by one of our best-known surgeons, the late Samuel D. Gross, and one of his most important contributions to surgical progress consisted in his persistent advocacy of the need for the study of pathology as a basis for all our means of cure. This is evident, if we consider the illustration I used a moment ago of a steam-engine. Unless he knows precisely the defects of such a machine, the influence of fresh or salt water on a boiler, the influence of rust, the effect of oils, entirely apart from the mere mechanism of the engine, an engineer might make the most serious mistake, resulting in fatal damage, both to the machine and probably to life. So, surgical pathology is the study of the processes of disease, the alterations in the minute structure of tissues and organs, without which no surgeon can be fitted for his task, much less can he be called an accomplished surgeon. All of these laboratories mark the difference between the scientific and the empirical method. The old student of medicine went from case to case, heard many a good maxim, and learned many a useful trick; but, after all, it was only an empirical knowledge which he obtained. It did not go to the foundation of things, it was not scientific, as is the collegiate instruction of to-day.

Having now glanced rapidly at the improvement in medical instruction, let me turn next to a few of the principal discoveries which have made the surgery of to-day so much superior to the surgery of a hundred years ago.

ANÆSTHESIA

After vaccination, the most important medical event of the century is the discovery of anæsthesia. While there were some prior attempts at anæsthesia, practically it dates from October 16, 1846, when Dr. John C. Warren, in the Massachusetts General Hospital, first performed a major surgical operation, without inflicting the slightest pain. I cannot enter into the merits of the various claimants for the credit of first using an anæsthetic, but ether was then for the first time publicly administered by Morton, and the very sponge which was then used is now a precious trophy of the Massachusetts General Hospital. I may, perhaps, quote from an address which I delivered before the Medical and Chirurgical Faculty of the State of Maryland, at their centennial anniversary, in April, 1899, the following in relation to anæsthesia:

“The news went like wildfire, and anæsthesia was soon introduced into every clinic and at almost every operation throughout the civilized world. Prior to that time a surgical operation was attended with horrors which those who live in these days cannot appreciate. He was the best surgeon who could perform any operation in the least possible time. The whole object of new methods of operating was to shorten the period of frightful agony which every patient had to endure. Every second of suffering saved was an incalculable boon. To submit to any operation required then a heroism and an endurance which is almost incomprehensible to us now. All of the more modern, deliberate, careful, painstaking operations, involving minute dissection, amid nerves and blood-vessels, when life or death depends on the accuracy of almost every touch of the knife, were absolutely impossible. It was beyond human endurance quietly to submit one’s self for an hour, for an hour and a half, for two hours, or even longer, to such physical agony.

“It is a striking commentary on the immediate results of anæsthesia to learn that, in five years before the introduction of ether, only one hundred and eighty-four persons were willing to submit themselves to such a dreadful ordeal in the Massachusetts General Hospital—an average of thirty-seven operations per annum, or three per month.... During the last year, in the same hospital—a Mecca for every surgeon the world over—over thirty-seven hundred operations were performed. It is not an uncommon thing at the present day for any one of the more active surgeons of this country to do as many as four or five hundred operations in a year. I have known as many as nineteen operations to be done in the Jefferson Medical College Hospital in a single day—equalling six months’ work in Boston before the introduction of ether.”