ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED TOPICS. BY AUSTIN ELINT, M.D., PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, AND OF CLINICAL MEDICINE, IN BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK. PHILADELPHIA: HENRY C. LEA. 1 8 74. Entered according to Act of Congress, in the year 1874, By HENRY C. LEA, In the Office of the Librarian of Congress, at Washington, I). C. ALL RIGHTS RESERVED. PHILADELPHIA *. SHERMAN & CO., PRINTERS. PREFACE. rpHE essays on Conservative Medicine, forming the leading portion of this little volume, appeared some years since, at intervals of time, in different Medi- cal Journals. This republication of them is a tardy compliance with suggestions made repeatedly by those on whose opinion in such a matter, more than on his own, the author would rely. The essays on kindred topics were written for different occasions, without any expectation of their being associated in a volume; and this fact will explain some repetitions which will be ob- served. The concluding essay having been written for a popular audience, its introduction may seem to require an apology. It is introduced under an impression that the study of Deity in disease may have novelty and interest for some medical readers. New York, July, 1874. CONTENTS. PAGE I. Conservative Medicine, 13 II. Conservative Medicine as applied to Thera- peutics, 49 III. Conservative Medicine as applied to Hygiene, 87 IV. Medicine in the Past, the Present, and the Future, 116 V. Alimentation in Disease, 141 VI. Tolerance of Disease, 157 VII. On the Agency of the Mind in Etiology, Pro- phylaxis, and Therapeutics, .... 174 VIII. Divine Design as exemplified in the Natural History of Diseases, 191 MEDICAL ESSAYS. I. Conservative Medicine.1 “ A1 f HAT does the writer mean by Conservative Medi- ’ * cinef’ This will be the mental inquiry of the reader when this expression meets his eye. It is desir- able, first of all, for the writer to explain the subject which he ventures to hope will appear to possess interest enough to lead to a perusal of the pages which are to follow. The meaning of Conservative Surgery is well under- stood. This phrase has been sufficiently common of late years. The conservative surgeon aims to preserve the integrity of the body. He spares diseased or wounded members whenever there are good grounds for believing that by skilful management they may be saved. He resorts to mutilations only when they are clearly necessary. He weighs carefully the dangers of operations, so as not to incur too much risk of shorten- ing life by resorting to the scalpel. By conservative medicine, I mean an analogous line of conduct in the management of maladies which are not surgical. The 1 Published in the North American Medico-Chirurgieal Review. 14 CONSERVATIVE MEDICINE. conservative physician shrinks from employing poten- tial remedies whenever there are good grounds for be- lieving that diseases will pursue a favorable course without active interference. He resorts to therapeutical measures which must be hurtful if not useful, only when they are clearly indicated. He appreciates injurious medication, and hence does not run a risk of shortening life by adding dangers of treatment to those of disease. Such, in brief, is an explanation of the subject of this essay; to give a fuller exposition of the subject is, in part, the purpose of the essay. For the phrase conserv- ative medicine I am indebted to a distinguished friend and colleague, well known as eminently a conservative surgeon.1 During the last quarter of a century a change has taken place in medical sentiment as regards surgical operations. New and grand achievements in surgery seemed formerly to be the leading objects of personal ambition. To borrow a fashionable expression, they were decidedly the rage. Boldness in the use of the knife was the trait in the character of the surgeon which was most highly admired. The history of surgery dur- ing the first third of the present century is characterized by the introduction and frequent performance of numer- ous formidable operations. It was customary to speak of them as brilliant, and the daring surgeon enjoyed somewhat of the eclat which belongs to the hero of the battle-field. This analogy was implied when the greatest of our American surgeons, wishing to distin- guish his most brilliant exploit, styled it his Waterloo operation. The change that has taken place is marked. 1 Prof. F. H. Hamilton. CONSERVATIVE MEDICINE. 15 We hear now comparatively little of terrible operations, and of that sort of heroism which is associated with bloody deeds. What would once have been considered as a degree of courage to be admired, is now stigmatized as rashness. It is an equivocal compliment to say of a practitioner that he is a bold surgeon. The change, it may be said, is in a measure due to the fact that the great number of new operations which have been intro- duced since the beginning of the present century leaves but a limited range for further explorations in that di- rection ; but this explanation will go only a little way. The change is one of sentiment. The desire is to pre- serve the integrity of the body, to avoid mutilations, to incur the dangers of capital operations only when they are imperatively called for—in a word, conservatism has become the ruling principle in surgery. The most important of the more recent improvements in surgery exemplify the influence of this principle on the medical mind. An analogous change, within the same period, has taken place in medical practice. Formerly, boldness was a distinction coveted by the medical, as well as by the surgical, practitioner. “ Heroic practice ” was a favorite expression, consisting in the employment of powerful remedies, or in pushing them to an enormous extent. The physician emulated the surgeon in daring. The change is not less marked in medicine than in sur- gery. We hear now oftener of diseases managed with little or no medication, than of cases illustrating the abuse of remedies. In the treatment of many affections it is not considered necessary to employ measures which, but a few years ago, it would have been considered cul- pable to withhold. The change, too, is here one of sen- 16 CONSERVATIVE MEDICINE. timent. We desire to preserve the vital forces, to avoid the perturbations and damaging effects of potential therapeutic agencies—in short, conservatism has become a leading principle in medicine as well as in surgery. The improved methods of managing a host of affections will be found to illustrate this fact. Before proceeding further, let us inquire how the contrast between medical practice at the present moment and a quarter of a century ago, should affect our estima- tion of medicine. Is medicine disparaged by the changes which have actually taken place? It is not enough to answer this question in the negative. Muta- tions, when they denote progress, are, of course, desira- ble. In as far as the contrast shows improvement, medicine at the present moment is deserving of esteem, the more, as the changes are great. It redounds to the glory of medicine that it admits of illimitable progres- sive changes. In this fact lies the distinctive feature of legitimate medicine as contrasted with illegitimate sys- tems of practice. But, some one may say, is there to be no stability in medicine, no traditional authority, and is reverence for the past to have no influence ? If not, where is our ground of confidence in the practice of the present day ? And is it not probable that at the end of another quarter of a century mutations will have oc- curred quite as great as those which have taken place during the last twenty-five years ? These questions are to be met fairly and squarely; let us endeavor so to meet them. Waiving the consideration of what constitutes per- fectibility in the ars medendi, and whether it be ob- tainable or not, no one will assert that medicine is now, or ever has been, in a condition not to admit of indefi- CONSERVATIVE MEDICINE. 17 nite improvement. Improvement in its practical appli- cations and results is the great end of the labors devoted, now and hitherto, to the different departments of medi- cal knowledge, viz., anatomy, physiology, animal chem- istry, materia medica, pathology, and clinical medicine. We may assume that these labors, thus far, have not been profitless, and, accordingly, that practical medicine has improved. We may assume, also, that there is abundant encouragement to continue these labors, and, hence, that further improvement is to be expected—to what extent it is vain to speculate. It necessarily fol- lows that stability in medicine is not to be counted upon; that the doctrines of to-day have no intrinsic claim to perpetuity; that because they are now in vogue is not a sufficient reason why they should not hereafter be modified or rejected, and that there is, to say the least, no ground to deny the possibility of the changes which are to take place hereafter being a whit less than those which have already taken place. What then ? There are skeptics and scoffers with regard to medicine, and there are many persons who live and thrive by promoting popular distrust of it. It may seem to be giving aid and comfort to the enemies of medicine to concede that its past history abounds in errors, that present errors doubtless abound, leaving am- ple scope for future improvement. Be it so. We have nothing to do with skeptics, scoffers, and charlatans. We are not called upon to repel attacks prompted by ignorance, selfishness, and deceit. Yet it is desirable, with regard not only to the interests of the medical pro- fession, but to the welfare of humanity, that medicine should hold its proper place in popular estimation, What, then, is the attitude to be taken as regards the 18 CONSEKVATIVE MEDICINE. just claims of medicine to public consideration and con- fidence ? A body of men in every generation, from the time of Hippocrates to the present day, in all civilized countries, have conscientiously and industriously labored to acquire knowledge of diseases with reference to the relief of suffering and the prolongation of life. Under a host of difficulties and obstructions, many inherent in the pursuits themselves, and others proceeding from va- rious extrinsic sources, the labors of physicians and their collaborators have continued and still continue. Now, granting that they have advanced slowly and often been led astray, where else can society ever seek for aid in the necessities of illness with a better pros- pect of success ? Granting that they have failed, and still fail, in conferring all the benefit that is to be de- sired, and that, with the purest intentions, their efforts have been sometimes not only without avail, but hurt- ful, should the preponderating good be therefore over- looked, and is there any rational alternative but to ac- cept the good and submit to the limitations and errors incident to existing knowledge? All that society can claim of medicine in any generation is, the capabilities of the medical science in that generation. All that society can claim of physicians is, that these capabilities shall be understood and judiciously applied. But we are open- ing up trains of thought which will lead us a long way from our subject, and we must abruptly return to the consideration of conservative medicine. It is an interesting point of inquiry, whence came the influences leading to conservatism as a principle of medical practice? The answer to this inquiry would not be the same in all countries and sections. It must be admitted that in our country the earliest and fullest CONSERVATIVE MEDICINE. 19 development of the principle was in New England. Our New England brethren are fond of dating a new order of medical ideas from the publication of an address, more than thirty years ago, by Jacob Bigelow, on the self-limited character of certain diseases. Not under- rating the importance of that publication, the spirit of the oral teachings of James Jackson and John Ware has exerted on the medical mind of New England an influ- ence which can only be appreciated by those who have experienced it. To those who have known experimen- tally the value of their teachings, it has been a source of deep regret that the influence of these admirable pro- fessors was not more widely diffused by means of larger contributions to medical literature. British conservatists attribute much to the writings of the late Dr. Forbes. Among the non-medical observers of the change in prac- tice which has taken place, some have been persuaded that it is due to the disciples of Hahnemann, an idea too preposterous to need refutation. The truth is, we are not to look for the causes of the change exclusively in the views emanating from particular persons. It is rather a legitimate result of scientific researches in differ- ent directions. If we were to specify circumstances which have more especially been instrumental in leading to the principle of conservatism, we would mention, first, the abandonment of the attempt to found a system or theory of medicine after the decline and fall of Brunoni- anism and Broussaisism; and second, the study of dis- eases after the numerical method with reference to their natural history and laws. Strange as it appears, the importance of determining by clinical observation the intrinsic tendencies of differ- ent diseases as the basis of therapeutics, seems to have 20 CONSERVATIVE MEDICINE. been heretofore overlooked. Physicians have acted on the presumption that most diseases do not pursue a favorable course without treatment more or less efficient. This has been, to a still greater extent, the popular be- lief. The apparent proof of the success of the Hahne- mannic treatment rests on this belief. What are the facts already ascertained with respect to the intrinsic tendencies of different diseases? We know that diseases in the management of which, but a few years ago, the physician would not dare to omit potent therapeutical measures, almost invariably end in recovery without any active treatment. Take, as examples, pneumonia limited to a single lobe, and acute pleurisy. It is suffi- ciently settled that these diseases involve very little danger in themselves, proving fatal only in consequence of complications. The practitioner, therefore, no longer feels obliged to employ bloodletting, mercurialization, cathartics, blisters, &c., in these diseases, with reference to the saving of life. The only question is, do patients pass through these diseases as well without as with such measures of treatment ? Clinical observation, following up this inquiry, arrives at results which exemplify con- servative medicine. Our acquaintance with the natural history of the great majority of diseases is, as yet, very incomplete. Knowl- edge of the tendencies of diseases allowed to pursue their course without active treatment, is not readily acquired. We cannot conscientiously withhold remedies which we have reason to believe may prove useful. Cases are therefore to be slowly accumulated in which, from cir- cumstances not under our control, diseases have been uninfluenced by therapeutic interference. This knowl- edge, it is evident, is the true point of departure for the CONSERVATIVE MEDICINE. 21 study of the effects of remedies as regards the termina- tion and duration of diseases. The information already obtained has rendered the use of powerful therapeutic agencies far less common than they were but a few years since. It remains to be seen hereafter what will be the further effect on medical practice of continued researches in this direction. Conservative medicine assumes that remedial measures, according to their potency, must either do harm or good; that they can never be neither hurtful nor useful. Prior to the advent of conservatism, this important fact was not duly appreciated. Blows were levelled at diseases, but the patient was not enough considered. It did not enter sufficiently into the calculations of practitioners that if successive blows dealt at a disease were misdi- rected, the effect was not lost, but injury was inflicted in proportion to their force. Hence, it must needs follow that the sick man sometimes encountered, in addition to his malady, nssaults not less real because well meant. In this respect, certainly, we have evidence of progress. We are satisfied that we do not err in saying that the most judicious practitioners of the present day accept the following.maxims of that eminently conservative physi- cian, Choinel: first, that we are not so much to treat diseases, 4s patients affected with disense; and second, that not to do harm, is no less an object of treatment than to do good. Iii defining conservative medicine, we have seen that it expresses 4 characteristic of the improvements in medi- cal practice during the last twenty-five years. Let us now direct our attention to illustrations afforded by some of the different classes of remedial measures. And, first qf all, bloodletting suggests itself. How great the change 22 CONSERVATIVE MEDICINE. as regards this remedy ! Twenty-five years ago it was employed as if it were an innocuous remedy. Prac- titioners thought much more of the risk of not resort- ing to it when it was needed, than of the evils of its being needlessly resorted to. Hence, they often acted on the rule inculcated by a medical writer, namely, when in doubt use the lancet. How different the rule of treatment now! Few practitioners of the present day would resort to this remedy in any case in which its appropriateness seemed to them questionable. Why not? Because it has been ascertained to be a spolia- tive remedy. It causes a disproportionate loss of the corpuscular elements of the blood, which are slowly re- generated. These corpuscular elements are already deficient in many diseases. In short, anaemia and its pathological relations were very imperfectly understood a quarter of a century ago. It is clear now to every one that, if not indicated, bloodletting should never be employed. This simple statement explains, in a great measure, the comparative disuse of bloodletting. The great question now is, whether it is a remedy called for more or less frequently in the management of certain diseases, chiefly the acute inflammations. I do not pro- pose to enter here into a discussion of this question. This much may be said : clinical observation, which is alone competent to settle the question, has shown that it is a remedy not called for so often nor to so great an ex- tent in acute inflammations as was supposed but a few years ago. A single incidental remark with respect to bloodletting, and it is one which will apply to other remedies: In determining its influence for good or evil by means of clinical observation, it is not enough to take into account the ratio of recoveries, and the duration of CONSERVATIVE MEDICINE. 23 cases of disease. Bloodletting may not increase the mortality from a disease, nor protract its continuance, and, yet, prove injurious. The injury may be manifest only in the slowness of convalescence and the impaired condition of the system after recovery. Cathartics were prescribed a quarter of a century ago much more generally and to a much greater extent than at the present time. In fact, purgation was considered as rarely out of place, whatever might be the nature or seat of the disease. This harmonized with the notion that very many diseases originated in, and nearly all were liable to be perpetuated by, causes acting within the alimentary canal. Abernethy’s views of the consti- tutional origin of local diseases were generally received and acted upon, and with him the constitution and the bowels were almost convertible terms, constitutional treatment consisting in the nightly blue pill and the morning black draught. The great Sir Astley Cooper quoted with approbation the quaint saying of an old Scotch doctor, who declared that fear of God and keep- ing the bowels open were the chief requisites of duty for safety in this world and the world to come! The im- portance of purgation became deeply rooted in popular sentiment. Cathartic pills or potions were considered indispensable in every household, and it would hardly express the frequency with which they were used, to say that family devotions were far less common. These were the days when, as Stokes remarks, more truly than chastely, doctors seemed to have always in their minds “a cathartic and a potful of faeces.” In this day, when a change has taken place as respects the employment of purgatives, physicians suffer from the fact that it takes a long time to eradicate a firmly fixed popular notion. CONSERVATIVE MEDICINE. Not only do we find it often embarrassing to reconcile patients to a different practice, but we are expected to inquire into, and carefully examine daily, by sight and smell, the excretions of patients, when we might other- wise consult our comfort (to say nothing of dignity) by dispensing with this exercise of the senses. The objects for cathartics, as now considered, are comparatively few, consisting chiefly in the removal of constipation, and their hydragogue operation in uraemia and dropsy. They are no longer given as a matter of course, without definite indications. As perturbatory and debilitating agents, they cannot but do harm if not required, and their fre- quent repetition conflicts with nutrition, and thereby with sustaining measures of treatment. The change, as respects this class of remedies, thus illustrates the prin- ciple of conservatism. It is needless to remind the reader familiar with the practice current twenty-five years ago, of the frequency with which emetics were employed. Of morbid causes referred to the alimentary canal, a large share were sup- posed to exist in the primcevice—-an expression then often used by writers and in common parlance. The same notion taken up by the public was conveyed by the homely expression “ foulness of the stomach.” Emetics were prescribed by physicians to remove saburral matters, and vomiting was desired by patients as a cleansing operation. Severe and prolonged vomiting by lobelia, in conjunction with the vapor bath, constituted the Thompsonian practice, which, in certain parts of our country, for several years, was considerably patronized. At the present time, emesis, irrespective of cases of pois- oning and over-repletion, is rarely produced, excepting as incidental to the use of remedies not prescribed for CONSERVATIVE MEDICINE. 25 that purpose, such as the nauseant sedatives, colchicum, veratrum viride, etc. What would be thought of a practitioner now who treated cases of phthisis with emetics repeated almost daily ! Yet, within the memo- ries of physicians of twenty-five years’ standing, this practice has been advocated, and, to some extent, adopted. The progress of medical conservatism has led to the aban- donment of emetics, as perturbatory and debilitating agents, excepting in the rare instances in which they sub- serve an explicit purpose. The practice of the present time presents a striking contrast with that twenty-five years ago, as regards the use of counter-irritant applications. The physician whose professional career has already extended over that period, is sometimes reminded of the severe measures then in vogue, by the exhibition of indelible scars on the bodies of his old patients. He is not likely now to con- template these traces of his former vigorous practice with lively gratification. Blisters, sometimes applied succes- sively over the same space, and not diminutive in size, tartar emetic ointment and plasters, issues, the moxa, etc., were considered as among the most efficient of the means of influencing the cure of a host of local affections. How much less frequently are they now used, and, when coun- ter-irritation is deemed advisable, how much milder are the applications chosen! Physicians were strongly im- pressed with the belief that local affections were often removed by revulsion. They accepted the doctrine of Hunter, that two diseases rarely concur, and hence, that an artificial disease is likely to effect a cure by a process of displacement. Not only has this doctrine been dis- proved by pathological researches, but these have shown a large number of the local diseases formerly regarded as 26 CONSERVATIVE MEDICINE. primary, to be the secondary or tertiary effects of morbid conditions then unknown. Bright’s disease had not been discovered, and its pathological consequences were, of course, unintelligible. In those days solidism pre- vailed, and haematology has been since created. Phy- sicians made no account of blood-poisons, and the old humoral notions of coction and fermentation had not been revived under the modern but equally indefinite garb of catalysis. Farr had not invented the name Zymosis, a name expressive of our ignorance rather than conveying any precise knowledge, but, nevertheless, sig- nificant of a wide and most important leap from the doctrine of solidism; or, in other words, of a passage backward, guided by the light of modern science, to humoralism, which, as Rokitansky remarks, is simply a requisition of common sense. This change in pathologi- cal views, in conjunction with clinical observation, has led physicians to distrust, more and more, the value of counter-irritant applications, and, at all events, to con- clude that severe revulsive measures are rarely called for; hence, the change in practice is in conformity to the principle of conservatism. The contrast as regards the use of mercury affords a signal instance of progressive change. The remarkable efficacy of this remedy in certain affections naturally led to the expectation of its utility in many diseases. Mer- curialization being a disease, it accorded with the current belief of the incompatibility of different affections, to suppose that it displaced other diseases. It was con- sidered as par excellence an alterative remedy; and what a latitude for imagined results was afforded by that title! Moreover, its supposed special action on the liver ac- corded with the notion that the secretion of bile had CONSERVATIVE MEDICINE. 27 much to do with morbid phenomena. The relief or pre- vention of portal congestion was incidental to its hepatic effects. It lessened exudations; it promoted the absorp- tion of morbid products; it altered the secretions; it dis- pelled local engorgements, and, by exciting stomatitis, it acted by way of revulsion. Waiving here, as in the other instances, discussion of the actual value of this remedy, the extravagance of the views formerly enter- tained is now sufficiently evident. The statements of those who have made war upon this article of the materia medica, and the popular prejudices thereby produced, are equally, or still more, extravagant; but it is a remedy potent for harm when inappropriate, as it is powerful for good when indicated; and, therefore, the great change that has taken place as regards its use exemplifies con- servatism. These examples are sufficient to show how conserva- tive medicine is illustrated by recent improvements as regards the employment of particular therapeutic meas- ures. They furnish evidence of immense progress in practical medicine. Let not this statement be misunder- stood. The improvements which have been noticed con- sist in the restricted use of bloodletting, cathartics, emetics, counter-irritants, and mercurials. Does the re- stricted use of these measures detract from their real therapeutic value? Not at all. Medicine has, by no means, repudiated them. She employs them with better judgment and discrimination; thus, availing herself of the good they can accomplish, she escapes the evils aris- ing from their injudicious and indiscriminate use.. If we look at the progress of medicine during the last quarter of a century from another point of view, we find additional examples of conservatism. Regarding it 28 CONSERVATIVE MEDICINE. exclusively from the point of view already taken, it ap- pears that, in proportion as the practice of medicine has improved, reliance on certain active or heroic measures of treatment has diminished. This is true, but it is not the whole truth. Some measures are employed with much more freedom now than a few years ago. The use of opium and alcoholic stimulants, in certain diseases, affords the most striking illustrations of this truth. These instances also exemplify the principle of conser- vatism. Opium and alcohol, in excessive doses, occasion immediate disorder, of more or less gravity, and may destroy life. But given so as not to incur any risk of these effects, they do not conflict with conservatism, be- cause their operation is transient, and, unless their use be continued, they do not leave behind them damaging ef- fects. Given in quantities which are comfortably borne, they certainly do not impair the vital forces by pertur- bation, by loss of fluids, by affecting the constitution of the blood, or by inducing local changes, as do the meas- ures previously noticed. This statement, of course, has nothing to do with the ulterior consequences, moral and physical, of intemperance or opium-eating. Here, too, as in other instances, discussion of the modus opercindi of remedies is waived. Most physicians will agree in the statement that, when indicated as remedies, opium and alcohol sustain the vital forces. In this respect they are positively conservative. But a point of distinction is, when not indicated, if given within certain limits, and not continued, they are neither spoliative, exhaust- ing, disturbing, nor disorganizing, as are various other measures, and, therefore, not, like the latter, even then, antagonistical to conservative medicine. The contrast between the practice of medicine now CONSERVATIVE MEDICINE. 29 and twenty-five years ago is not less marked, as regards the use of opium and alcohol, than as regards the re- stricted employment of other measures. Let the prac- titioner, who has seen service for a quarter of a century, consider what a responsibility he would once have taken in treating cases of pneumonia with brandy and opium, to say nothing of the continued fevers. The wonderful tolerance of these remedies in certain cases of disease is a recent discovery. Let the same practitioner consider whether he would once have ventured on a hundred grains or more of opium per diem in a case of peritonitis, or grain doses of the sulphate of morphia hourly, con- tinued for several days, in a case of dysentery. Let him consider whether, at the commencement of his career, with the fulminations of Broussais on incendiary practice resounding in his ears, he ever dreamed of the propriety of giving a quart of spirit daily to fever patients, and of finding the frequency of the pulse diminished, and the mind become more clear under this heavy stimulation! If we turn from remedial measures to dietetics, we find that the improvement which has taken place in prac- tice contributes to the illustration of conservative medi- cine. In fact, conservatism is, perhaps, not less con- spicuous in the contrast as respects the diet of the sick than in any other point of view. In cases of fever, and all acute diseases, twenty-five years ago, it was generally deemed an essential part of the treatment to withhold alimentary supplies. It was a frequent saying to patients who craved food, that to allow it would be to nourish the disease. In chronic affections, too, the diet was usually much restricted. It was believed that a large majority of diseases were attributable, directly, to dietetic imprudences, and that the over-ingestion of food, during 30 CONSERVATIVE MEDICINE. the progress of diseases, was, of all indiscretions, the most prolific of evil. Physicians seemed to lose sight of the plain fact that the vital powers must languish in proportion as the alimentary supplies fall below the wants of the system, and that death may be produced by starvation in disease as well as in health. At the pres- ent time, a nutritious diet is considered as highly import- ant in the management of fevers, as well as in diseases which tend to destroy life by exhaustion, and most phy- sicians appreciate the importance of keeping the body well nourished in chronic affections. Incidentally a point for remark is here suggested. Twenty-five years ago disorders of digestion, grouped under the name dyspepsia, were extremely frequent. Dyspepsia was the popular malady of the day. The number of dyspeptics, of late years, has greatly dimin- ished. The malady is comparatively infrequent. Why is this? I believe it to be explained, in a great measure, by the fact that in the matter of eating, instinct has re- gained its rightful supremacy. We do not hear so much now, as then, of the liabilities to dietetic errors. Phy- sicians are not so ready to attribute diseases to some im- prudence at the table. The subject is not brought to the minds of the people by means of conversation, popular books on diet, public lectures and sermons. The healthy man no longer sits down to dinner with fear and trem- bling, lest he should eat too much, or indulge in improper articles of food. There are fewer patients who hold to the fanatical notion, that moral and physical health re- quires the demand of the system for food in sufficient quantity and variety, as expressed by hunger and appe- tite, to be resisted ; and that the welfare of body and mind is promoted by living on a poor and insufficient CONSERVATIVE MEDICINE. 31 diet. We rarely, nowadays, hear the injunction, which was once impressed upon all who would preserve health, to adopt the habit of always rising from the table hun- gry. Nature and common sense have triumphed over these absurd ideas, and, among other advantages, dys- peptic ailments, which formerly tormented so many per- sons, have wonderfully diminished. Recurring to the definition of conservatism in medicine, it suffices to say that it means the preservation of the vital forces. It is a principle in medical practice, cover- ing everything which prevents impairment of, or tends to develop and sustain, the powers of life. The terms “vital forces” and “powers of life,” although they are not readily explained, have a practical meaning which is well enough understood, and it is unnecessary to enter into an explanation of them. It has been the object, in the foregoing pages, to give an exposition of conservative medicine, and to show that conservatism, in the sense in which the term is now used, is a distinguishing feature of medical practice at the present time, as contrasted with the practice which prevailed twenty-five years ago. The development and adoption of this principle have been seen to be results of the progress of medical knowl- edge, and the circumstances which seem especially to mark the beginning of the changes illustrating the prin- ciple are, abandonment of attempts to reduce the prac- tice of medicine to a system, after the failure of the latest, namely, Broussaisism, and the study of the natural his- tory of diseases, as inaugurated by Louis. It is by no means, however, intended to ignore the fact that the cul- tivation of all the branches of medical knowledge has powerfully co-operated to the same end. The changes which have taken place during the last quarter of a cen- 32 CONSERVATIVE MEDICINE. tury have not been due to a prior recognition of the principle of conservatism, but now that the changes have occurred, we find conservatism to be common alike to all, binding them together, and constituting their most striking characteristic. Having reached the principle thus analytically, are we not bound to recognize it as a fixed principle of medical practice, and one possessing great practical importance ? Assuming it to be such, the remainder of this article will be devoted to its appli- cations in the management of different forms of disease. And, first, let us consider the application of conservatism to the treatment of patients with inflammatory affections. Theoretical views led to the measures called antiphlo- gistic in cases of inflammation. These measures, consist- ing of general and local bloodlettings, cathartics, and rigid or restricted diet, were considered as antagonizing the state of inflammation, not unfrequently arresting its progress, and, when not successful in this end, diminish- ing its severity, limiting its morbid effects, and abridg- ing its duration. As already remarked, the injury which these measures are capable of doing was overlooked, and, on the other hand, all will admit that their efficacy, in effectingtlie objects just stated, was greatly overestimated. Clinical experience has shown that we cannot rely upon these measures to arrest the progress of inflammation. Admitting the possibility or probability of success in a small proportion of cases, we are not justified in exposing patients to the injury produced if these measures do not succeed, when the chances are few that they will prove successful. This statement expresses a rule of conserva- tism applicable to all potent measures employed in any disease as abortive measures of treatment. Measures not impairing the vital forces are allowable, even when CONSERVATIVE MEDICINE. 33 the probability of success is small. Opium, for example, is admissible as an abortive remedy when bloodletting is clearly inadmissible. But measures which, if not suc- cessful, will do harm, are only to be resorted to when the chances of success preponderate over those of failure. Conservatism, therefore, does not justify the employment of the antiphlogistic measures of treatment with a view to the arrest of inflammation, without taking the ground that they invariably fail. Clinical experience has rendered it doubtful whether the antiphlogistic treatment exerts much effect on either the intensity of inflammation, its results, or its duration. Conservatism, therefore, dictates a careful weighing of the evils of the treatment against the chances of its use- fulness as regards these objects. It is not settled by experience that this treatment, carried to a greater or less extent, is always in no measure efficacious. Hence, there is room for difference of opinion, and the practice of different physicians will differ. The discriminating practitioner, who, although satisfied of the evils of the indiscriminate employment of antiphlogistic measures, believes in their utility, if judiciously employed, will be guided in withholding or resorting to them, by the circumstances belonging to in- dividual cases. And here it is that his practical knowl- edge, judgment, and tact are brought to bear on the management of inflammatory affections. Conservatism will dictate to such a practitioner not to employ blood- letting, etc., when the inflammatory affection, from its seat and degree of intensity, involves no danger, and when there is reason to suppose that it may pass through its course favorably, without active interference. Con- servatism will dictate the same policy when all the local CONSERVATIVE MEDICINE. results to be expected from the progress of inflammation have already taken place, and the restorative processes only remain—a condition illustrated by the second stage of pneumonia, when all the exudation that is to occur has occurred, and the recovery involves only the absorp- tion of the morbid deposit. Conservatism will dictate the same line of conduct in all cases of disease in which more danger is to be expected from failure of the powers of life, than from lesions incident to the local affection. The value of therapeutic agencies is, of course, to be determined by experience. Developments in the prog- ress of pathology, however, contribute to our knowledge of therapeutics, not only by giving direction to clinical observation, but by harmonizing with the conclusions drawn from the latter. It is interesting to note the consistency of the practical views now generally held as regards antiphlogistic measures, with late developments respecting the origin of certain inflammations. Inflam- mations not traumatic were formerly considered, and are now often called spontaneous. We may use this term conventionally as distinguishing a local disease not ref- erable to any obvious local cause, but, strictly, it is an absurdity to say that any disease is spontaneous. Every local affection must involve an adequate morbific agency acting on the part affected. It is true that our present knowledge does not enable us generally to appreciate the nature, sources, and the modus agendi of the proximate causes of inflammatory affections, but we have acquired, of late years, some information important in itself as a basis for analogical reasoning. Clinical observation has shown that the accumulation of urea in the blood is apt to lead to inflammation of serous structures. This we CONSERVATIVE MEDICINE. 35 know, and it is a rational supposition that urea (or the products of its decomposition) induces inflammation, by acting directly on these structures. There are suffi- cient grounds for believing that the local inflammations occurring in gout and rheumatism are due to the local action of a materies morbi in the blood, perhaps the uric acid in the former, and the lactic acid in the latter of these diseases. Reasoning by analogy we may expect with considerable confidence that future researches will show the so-called spontaneous inflammations generally to be produced in a similar manner. And with this view of their production, we should rationally expect great results, not so much from the antiphlogistic treat- ment as from measures addressed to the morbid conditions of the blood which underlie the local manifestations of disease. To ascertain these morbid conditions in dif- ferent diseases, to prevent the introduction or accumula- tion of morbific material in the blood, to neutralize the poisonous properties of this material by causing the for- mation of innocuous combinations, to arrest the organieo- chemical changes which its presence induces (catalysis), or to eliminate it through the emanations of the body,— these are the great objects of therapeutics at the present day, harmonizing with the late revelations of path- ology. AVithout stopping to inquire how far these ob- jects have been obtained, it is to be remarked that they are obviously conservative, involving, as they do, pro- tection against internal agencies inimical to life and health. Conservative medicine thus dictates, in inflammatory affections, proper discrimination in the employment of the so-called antiphlogistic measures, which, if failing to exert a controlling influence, are necessarily hurtful, 36 CONSERVATIVE MEDICINE. and, it may be, destructive, by impairing the vital forces. It also dictates the judicious use of remedies addressed to the internal causative conditions pertaining to the blood, so far as our present knowledge extends into these most important provinces of pathology and therapeutics. But this is not all. Conservatism often demands that the vital powers shall be sustained. Sus- taining measures of treatment, practically considered, consist of tonics, alcoholic stimulants, and nutritious diet. We will not inquire as to the rationale of the operation of these measures. Suffice it to say, clinical experience shows abundantly that they lessen the degree to which the vital forces would otherwise be impaired by disease, and may prevent a fatal termination of dis- ease by exhaustion. I have already admitted that the phrase “powers” or “forces of life” is metaphorical. Life is not an entity. But with a fair understanding that this personification of a combination of conditions, as yet but imperfectly understood, is merely for conve- nience, it is unobjectionable. The powers or forces of life enable the system to bear up under disease, to resist it successfully, and recover from it. On the other hand, we may say that disease destroys by overcoming the powers of life, whenever death takes place by asthenia or exhaustion. Every sagacious practitioner knows that certain symptoms, no matter with what disease they are associated, denote failure of the vital powers, or inability to resist disease. He estimates the amount of danger by these symptoms, among which those referable to the circulation are especially important. He often bases his prognosis far more on these symptoms than on the nature and extent of the local affection. Every practi- tioner knows that an inflammation, the same in all re- CONSERVATIVE MEDICINE. 37 spects, so far as the local affection is concerned, in dif- ferent persons, affects the vital forces differently. Take, for example, pneumonia, extending over the same space, and inducing an equal amount of changes, which physi- cal exploration enables us to determine with accuracy: one patient manifests little disturbance of the system, and no symptoms denoting danger, while another pa- tient will succumb to the disease. Every practitioner knows that some persons, who, in health, present no evidence of a lack of vigor, have very little ability to resist severe disease. They are quickly destroyed by affections which other persons readily endure, and en- dure perhaps without much inconvenience. Of course, these facts are explicable, but not with our present knowledge, and, until explained, it answers to refer them to differences as regards the vital powers or forces. They are facts of not a little practical importance. Conservatism dictates sustaining treatment in any in- flammatory affection whenever the symptoms denote failure of the vital powers, whether the period be early or late in the course of the affection. This treatment is to be pursued vigorously in proportion to the rapidity of the failure and the amount already taken place. It is important in all dangerous affections to watch for the first evidence of failure, and to lose no time in resorting to supporting measures. Such is the influence of tradi- tional ideas, that these measures are frequently delayed from a timidity which experience is sure to remove. It is far wiser to enter on the use of tonics, stimulants, and a nutritious diet too early, or when not required, than to incur risk of delay, or their omission when required. In the one case, the liability of harm is small, but in the latter, lost time, which cannot be regained, may 38 CONSERVATIVE MEDICINE. have been of immense importance to the patient. So far from incurring risk of damage from delay, the wise practitioner will anticipate the indications for support, and forestall the failure which he knows would other- wise occur. Physicians, however devoted to the anti- phlogistic treatment of inflammations, have generally recognized the importance of supporting measures to “obviate tendency to When the flame of life is reduced to a glimmer, they would prevent it, if pos- sible, from going out. Does not common sense teach that measures which may prove serviceable under these circumstances, would have proved much more so when the danger was less imminent? Is it not better policy to endeavor to keep the lamp of life burning brightly, than to depend on efforts to restore the flame when nearly extinguished ? In cases involving danger to life, the importance of sustaining treatment is to be measured by these questions : Is the chief danger due to failure of the vital powers, and how great is the danger from this source? In cases not involving danger to life, the im- portance of support has reference to the duration of the disease, the rapidity of convalescence, and the condition of the recovery. The advantages derived from the proper application of conservatism, as regards sustaining treatment, in all inflammations, by no means consist ex- clusively in a reduced rate of mortality, but also in a speedy and rapid convalescence, and in the completeness of the restoration to health. These remarks have had reference more especially to acute inflammations. Chronic inflammation affecting an important part may continue for a greater or less period, and recovery finally be complete; but during its continuance the powers of life are more or less impaired. CONSERVATIVE MEDICINE. It may destroy life by leading to incurable lesions, or by its protracted duration, in either case death usually taking place by slow asthenia. Under all circumstan- ces, the affection is less likely to be prolonged, serious changes of structure are less likely to take place, and a fatal termination is postponed in proportion as the vital powers are preserved. Conservatism, therefore, dictates not measures to reduce, but those which sustain the powers of life in chronic inflammations. It dictates measures to develop appetite, and improve the digestive processes, abundant nutritive supplies, and, in short, the remedies and hygienic means which invigorate and strengthen the body. The “ building up ” treatment, as it is significantly called, has contributed largely to the more successful management of chronic affections since the days of Broussaisism. Some of the most striking examples of the efficacy of this treatment which I have seen have been cases of chronic pleurisy, in which speedy and progressive improvement followed directly the substitution of this treatment for measures opposed to the principle of conservatism. These exam- ples are the more satisfactory because, by means of phys- ical signs,.the improvement within the chest was accu- rately determined at the same time that the local and general symptoms denoted a favorable change. Certain cutaneous inflammations, and cases of ophthalmia, the parts in these affections being open to inspection, also afford examples not less striking. Conservatism has been practically more fully applied to the management of essential fevers than of inflamma- tory affections. Since nearly all pathologists have ad- mitted the essentiality of fever, and since physicians have ceased to agree with Southwood Smith in regard- 40 CONSERVATIVE MEDICINE. ing inflammation as an almost constant concomitant and the chief source of danger in fever, the importance of preserving and sustaining the powers of life has been more and more appreciated, and, at the present moment, with the most intelligent practitioners, these are the leading objects in the treatment. In this remark I refer especially to fevers having a self-limited career, and not arrested by abortive measures. The periodical fevers are controllable by remedies having a special efficacy. These remedies are conservative, acting in an imperceptible manner, and, given within proper limits, producing no destructive or injurious effects even if not indicated. It is a curious fact that the fevers which we are able to arrest with great certainty, i. e., the periodi- cal fevers, continue indefinitely if not arrested, and re- turn, sooner or later, and more or less frequently, in the majority of cases, whereas the fevers which we cannot arrest with any certainty, if at all, i. e., the continued fevers, the eruptive, and yellow fever, have a fixed du- ration, and, as a rule, are experienced only once. It is not without the bounds of a reasonable expectation that the means of arresting the last-named fevers will here- after be discovered. Reasoning by analogy, and from the pathological views now generally entertained, the means for this end must act by neutralizing a morbid material in the blood, or effecting its elimination, acting, therefore, in accordance with the principle of conser- vatism. Tonic remedies, alcoholic stimulants, and nutritious diet are the measures for maintaining the vital forces during the course of the essential fevers. The import- ance of these measures is now so generally admitted as hardly to require argument or advocacy. The only CONSERVATIVE MEDICINE. 41 questions for discussion relate to circumstances indicat- ing their employment, the extent to which they are to be carried, and various details connected with their use. The discussion of these questions does not fall within the scope of this article. I may be indulged, however, in a few remarks on some interesting points connected with the subject. One of these is the wonderful tolerance of alcoholic stimulants in certain cases of fever. Examples have been of late so often repeated, and are so generally familiar, that they need not be cited. How much at variance are the effects of pints of spirit, given daily, with those produced in health! And how fully does this fact, as well as analogous facts relating to the action of opium and other remedies, illustrate the liability to error in judging of the operation of therapeutic measures in disease from experimental observations in healthy persons! How surprised, but a few years ago, would have been the therapeutist if told that the action of alcohol, under certain morbid conditions, is in fact seda- tive ; in other words, that, in certain cases of typhus and typhoid fever, two or three ounces of spirit given hourly may lessen the frequency of the pulse, diminish the heat of skin, and render the mind more clear ! But the past history of medicine shows a tendency to push prevailing ideas to an extreme, against which the prudent physician should endeavor to guard himself. There is danger now of carrying the use of alcohol to an injudi- cious and dangerous extent. The principle of conserva- tism should be the guide. The object is to sustain the vital forces. The tolerance is in proportion to the need of this sustaining agent. If it be used excessively in all cases, without discrimination, it will sometimes do 42 CONSERVATIVE MEDICINE. harm, and life may be destroyed by alcoholic poisoning. We have already seen that, within certain limits, al- cohol is eminently a conservative remedy, because even when not indicated, it is not destructive, and its opera- tion is transient, but beyond certain limits its effects may be poisonous, provided it does not fulfil indica- tions showing that the system is tolerant of quantities which would be dangerous in health. Let the indica- tions, then, in individual cases, be carefully observed, and let the effects be carefully noticed, so as not to vio- late, but conform to the rule of conservatism. Some interesting points are connected with the dietetic management in cases of fever. In perfect health the wants of the system for alimentary supplies are expressed by hunger and appetite. Common observation, however, teaches us that these sensations are not essential as pre- requisites to digestion and nutrition. Almost every one has experienced a state, certainly abnormal but not de- pendent on any well-defined disease, and not interfering with the usual habits of mental and physical activity, in which food is taken habitually for a greater or less period without hunger or appetite, and nevertheless properly assimilated. I ntense mental preoccupation and persisting depressing emotions may involve such a state. During the career of fevers, usually, hunger and appetite are wanting, but it is not to be inferred therefrom that the ability to appropriate nutriment is lost. Some have reasoned that the absence of the desire for food is always evidence of its not being needed, and a comparison has been made between the morbid condition, in this regard, in the essential fevers, and the natural state of hiberna- tion. But the analogy holds good only as respects the disinclination for food. In hibernation, the respirations, CONSERVATIVE MEDICINE. 43 the heart’s action, muscular movements, and the func- tional exercise of all the organs, are reduced to the lowest point compatible with the preservation of life. In fever, the respirations are far oftener increased than diminished in frequency, and more oxygen enters the system than in health; the heart beats with unwonted frequency, muscular action is not wanting, and in the more frequent respiratory movements it is above the healthy standard; the mental faculties are sometimes morbidly active, and, from the absence of sleep, often more continuously so than in health; calorification is increased, and various functions of the body manifest disordered activity. It seems sufficiently clear that no practical inferences are to be drawn from a comparison between the arrest of hunger and appetite in fever, and the suspension of these sensations in hibernation. In hibernation the system has no need for alimentary supplies, and hence, there is no physiological expression of the want of them. In fever the morbid conditions prevent the feeling of this want, although the need of alimentary supplies continues. The correctness of the statement just made rests on clinical observation. Patients with fever, taking food without inclination and even with repugnance, retain it, and no disturbance is produced by its ingestion ; the fecal evacuations may present a normal appearance, and, in some eases in which a nutritious diet has been entered upon after the disease has existed for some time, there is an evident increase of muscular strength, although the career of the fever continues. These are clinical facts. And the conclusion is, digestion and nutrition are not incompatible with the state of fever, although hunger and appetite may be wanting. The faculty of perceiving these sensations is impaired or lost in consequence of the 44 CONSERVATIVE MEDICINE. morbid condition of the nervous system, and hence, they cease for the time to express the demands of the system. The perceptions are often so blunted that the mind takes no cognizance of other wants of the system. The urine is allowed to accumulate in the bladder, and, with the tongue desiccated, the patient manifests no desire for drink. Fatigue from lying continuously in the same position is not complained of. Local complications of the disease are not accompanied by pain. Under these circumstances, it is consistent that the sensations of hun- ger and appetite should not be experienced. The percep- tive faculties, however, sometimes are not so much im- paired as they appear to be. Desires and feelings may not be manifested from an extreme reluctance to make any exertion. Thus, patients not unfrequently drink with avidity when the cup is brought to their lips, who make no complaint of thirst; and in some eases, food, when presented, is also taken with relish. In sustaining the powers of life in fevers, then (and also in certain other diseases), the physician is not to be restrained by the absence of hanger and appetite. He is to act with reference to the wants of the system by endeavoring to secure the ingestion of food, concentrated, containing the necessary variety of alimentary principles, and ample in quantity. Here, too, as with regard to alcoholic stimulants, it is far better to begin earlier than is needed, than run any risk of delay, and to give more aliment than is required than not enough. An appre- ciation of the importance of alimentation in fevers is among the most important of the recent improvements in practice which exemplify the spirit of conservatism. But in all acute diseases, whenever the chief end of treatment is to support the powers of life, a nutritious CONSERVATIVE MEDICINE. 45 diet is essentially important, and the same rules with regard to dietetic management are alike applicable. It will suffice to notice the application of conservatism to those chronic affections collectively which destroy by gradual inroads upon the powers of life. In this class are grouped such affections as carcinoma, tuberculosis, chronic dysentery, cirrhosis, and Bright’s disease. It is sufficiently clear that, with a view to the prolongation of life, when recovery is not expected, the great object is to retard, as much as possible, the failure of the vital forces. If we cannot “ build up,” we may do much to delay the progress of destruction. Evident as this is, it is not suf- ficiently appreciated by all practitioners. Patients affected with incurable diseases are too often abandoned to merely palliative remedies, the fatal issue being considered as merely a question of time, and, therefore, not of much importance. This question of time, however, may be highly important to patients and their friends. To aid in the cure of diseases is, un- doubtedly, the first aim of the physician; and next to this, when a cure is not to be effected, comes the prolon- gation of life, with health more or less impaired. The last of the grand objects of practice are palliation and euthanasia. In the management of any incurable affection, con- servatism dictates the measures which, in general terms, contribute to keep the body in the best possible condi- tion compatible with the continuance or progress of the disease. In this way not only the inroads of the disease on the powers of life but the destructive lesions in the parts affected, are often stayed. It may be assumed to be a rule in pathology that a local affection involving structural changes is less likely to progress with rapidity, 46 CONSERVATIVE MEDICINE. the closer the approximation to health in all other re- spects. The practice which conservatism dictates in such cases is in accordance with this rule. An incurable lesion is sometimes so completely held in abeyance, and the system is rendered so tolerant of its continuance, that life maybe preserved indefinitely, although a vital organ be affected. We meet with cases in which the formations of tubercle and carcinoma remain for a long period non- progressive and nearly innocuous. The conservative practice, moreover, favors those retrogressi ve changes by which even the diseases just named may eventuate in cure. To consider the measures for keeping the body in the best possible condition, would be to enter on a large but immensely important domain of practical medicine. I must content myself with saying that they consist, first, of a nutritious diet; next, of remedies to strengthen and invigorate; and last, of hygienic influences directed to the same end. The hygienic influences comprise exer- cise and everything relating to regimen, change of climate, mental diversion and encouragement—in short, whatever can be brought to bear favorably upon the welfare and vigor of the system. The hygienic is cer- tainly not inferior in importance to the medicinal treat- ment, and here it is that the judgment and tact of the successful practitioner are especially brought into requi- sition. A comparison of cases of pulmonary tuberculosis now and twenty-five years ago, illustrates the importance of the practical views just presented. The management of this disease twenty-five years ago was certainly not in accordance with the principle of conservatism. The measures employed, medicinal and hygienic, were, in- CONSERVATIVE MEDICINE. 47 deed, directly opposed to this principle. The antiphlo- gistic system of treatment was often adopted, under the belief that inflammation was the most important element of the local affection. Bloodletting, cathartics, mercur- ialization, severe counter-irritation, were considered as remedial, and to these were conjoined low diet and con- finement within doors. Now, pulmonary tuberculosis is not cured in the majority of cases, although it is not in- curable, and there is reason to believe that the propor- tion of cures is considerably larger than under the treat- ment just referred to. But, directing attention to the incurable cases, under the plan of treatment generally pursued at the present time, which is eminently conserv- ative, how striking the contrast! Formerly, the in- stances of rapid progress of the disease were more numer- ous, and it almost invariably advanced with a steady march, rarely occupying many months in completing its fatal career. Patients were usually confined to the bed for weeks before death, lingering on the borders of the grave, suffering from extreme debility, bed-sores, aph- thae, and colliquative diarrhoea. It was difficult to con- ceive of a picture more distressing and repulsive than that of an unfortunate being in the last stage of con- sumption. Conservatism has done much toward ame- liorating the condition of consumptives, even when it is hopeless as regards recovery. Cases of so-called gallop- ing consumption are less frequent. Life is not unfre- quently prolonged and made comparatively comfortable for years. It is not uncommon to meet with instances of a considerable tuberculous affection remaining quiescent or progressing very slowly, and the patient able to en- gage in the active occupations and enjoyments of life. Even when the disease is progressing to a fatal termina- 48 CONSERVATIVE MEDICINE tion, the strength is usually so far preserved that a bed- ridden consumptive is now rarely seen, and it is not uncommon for patients to be out of doors almost up to the hour of their death. I appeal to those whose medi- cal experience has extended over a quarter of a century for the truthfulness of this comparison. In concluding these fragmentary remarks, let it be borne in mind that, important as is conservatism in medical practice, it is by no means inconsistent with the employment of efficient therapeutic agencies in the man- agement of diseases. The conservative surgeon does not hesitate to use the knife and dismember the body, when convinced that thereby he may save life. So the con- servative physician resorts without hesitation to his po- tential remedies—not less potent for good or evil than the scalpel—whenever he sees clearly that they will con- tribute to the safety and welfare of the patient. AS APPLIED TO THERAPEUTICS. 49 II. Conservative Medicine as applied to Therapeutics.1 AN explanation of the term Conservative Medicine may be required for many of the readers of this journal. The term should be at once explained, because the reader may suspect a meaning quite different from the sense in which it is to be here employed. It is not intended by this term to refer to a conservatism which adheres to principles and rules of practice on account of antiquity, authority, or usage. The conservatism meant is not an adherence to doctrines which have been or are now held. It is not that kind of conservatism which protests against any changes, and resists all innovations. The definition of the term will be found to involve a signification quite the reverse of all this. In an essay written for another journal, the writer has adopted this term as an analogue of the term Con- servative Surgery. The conservative surgeon, before re- sorting to capital operations, carefully considers the situation of patients, and the danger to life which the operations involve; and he regards the preservation of the integrity of the body as a higher success than the most skilful mutilation. In like manner, the conserva- tive physician considers fully the effects of the potent 1 Published in the American Journal of Medical Sciences. 50 CONSERVATIVE MEDICINE agencies employed as remedies, appreciating the fact that, if not remedial, these agencies are necessarily injurious, and may prove destructive; and in the management of diseases lie always accords due importance to the preser- vation of the powers of life. As the true surgeon is not the mere operator, unmindful of the duty of preserving and restoring parts, who uses the knife without regard- ing the condition of the patient; so the true physician is not the routine practitioner, prescribing, with an un- sparing hand, active therapeutical measures without any clear apprehension of the objects to be fulfilled, making no allowance for the natural tendency of diseases toward recovery, and disregarding the state of the system. In the former essay, the writer attempted to show that the grand improvements in practical medicine which have been steadily going on for the last quarter of a century, are characterized by conservatism as just defined. This conservatism is shown by a greater discrimination in the use of spoliative, perturbatory, and debilitating measures, such as bloodletting, mercurialization, emetics, cathartics, and severe counter-irritation. It is shown by an increased use of remedies which are potent without damaging the organism, such as opium and other seda- tives. It is shown by a reluctance to interfere actively with the course of diseases which have a self-limited career. It is shown by a greater reliance on hygienic measures. It is shown by more attention to alimenta- tion, and by the earlier and more efficient employment of supporting treatment in all affections which tend to destroy life by asthenia. The term conservative medicine thus expresses the great characteristic of medical prac- tice at the present moment ; and it is so, not from the authority of any master mind, or the influence of any AS APPLIED TO THERAPEUTICS. 51 dorp inant theory, but purely because it is incidental to the advancement of our knowledge of pathological con- ditions, of the action of remedies, and of the natural his- tory of diseases. And the term may also be considered as expressing a great principle, which, to a certain ex- tent, should govern the views and conduct of the physi- cian. Regarding it in the latter point of view, I shall present in this essay some considerations connected with the application of the principle of conservatism to thera- peutics. Medicus Natures minister non inagister est. It is in- teresting to note the principle of conservatism as mani- fested by nature in the history of diseases. Waiving all questions concerning the existence and sources of morbid conditions, we see exemplifications of conservatism on every side in pathological laws, and this principle be- comes more and more conspicuous in proportion as we advance in our knowledge of the natural history of dis- eases. The well-established fact with regard to many diseases, that they tend intrinsically to recovery, and not to death, as formerly supposed, shows the conservatism of nature. The recovery, sometimes even without medi- cation, from diseases which are generally destructive, exemplifies the principle. This is certainly true of pul- monary tuberculosis. The principle is exemplified in the situation of the great majority of local affections which are not traumatic, and therefore said to be spon- taneous; the parts oftenest affected being not so closely connected with functions necessary to life as the parts which generally escape. Thus, the great majority of acute inflammations are seated in the skin, mucous structures, and certain of the serous membranes. On the other hand, internal organs, the functional exercise 52 CONSERVATIVE MEDICINE of which is more immediately concerned in vital opera- tions, such as the stomach, small intestines, pancreas, liver, kidneys, are comparatively not often acutely in- flamed. The principle is seen in the spontaneous re- moval of morbid products from different parts of the body, and in the disposal, by elimination or otherwise, of the materies morbi which there is reason to believe give rise to a host of local affections. The study of the events belonging to the natural progress of individual diseases discloses abundant illus- trations of the principle of conservatism. The limita- tion of inflammation to a particular structure furnishes striking examples. For instance, how rare is it that the inflammation in tonsillitis or pharyngitis extends into the larynx! Were it not for this conservative provision, how serious would be these frequent affections of the throat in view of the liability of extensions to the wind- pipe, and the danger attendant on this complication ! Again, what a vast difference is there, in severity of symptoms and danger to life, between ordinary and capil- lary bronchitis; and how rare the latter, notwithstanding the frequency of the former! We can only explain this fact by stating that the inflammation extends from the larger to the smaller bronchial tubes as an exception to a law of the disease. The physician, by attempting to place himself in the false position of the master of na- ture, may thwart her conservative provisions much to the detriment of his patients. A striking illustration of this fact is afforded by the practice heretofore inculcated in cases of hypertrophy of the heart. We have been taught to pursue active measures, and, by some, measures of a very severe character, with a view to prevent and diminish hypertrophy of the heart. Now, it is plain AS APPLIED TO THERAPEUTICS. 53 that this form of enlargement is a most important con- servative provision of nature to obviate evils which would otherwise arise from the valvular lesions pre- ceding the development of cardiac hypertrophy in the vast majority of cases. The physician is the servant of nature when he does not interfere with, if, indeed, he do not endeavor to foster, this abnormal condition. A splendid theme for an essay would be the principle of conservatism as exemplified in the natural history of diseases. I must here content myself with this brief reference to it. Directing attention to conservative medicine as applied to therapeutics, the subject naturally presents itself in a twofold aspect, viz.: First, as regards the therapeutical indications derived from our knowledge of the patho- logical character, condition, etc., of diseases; and, Second, as regards the general object of remedial measures. I shall consider the subject under these two heads; but, before entering upon them, there are certain considera- tions which are suggested by the inquiry, What are some of the general characteristics of conservative medi- cine? Or, to vary the question, What are the more prominent of the traits which distinguish the conserva- tive physician? In answer to this question, I shall offer a series of aphorisms which will lead the way to subse- quent inquiries relating to therapeutical indications and objects. 1. The conservative physician endeavors to protect the system, on the one hand, against disease; and, on the other hand, against injurious medication. He therefore employs potent therapeutical measures only with a view to well-defined objects which are in accordance with clear 54 CONSERVATIVE MEDICINE indications. lie is not represented by the allegory of the blind man with the club; he never strikes at random, but always with a purpose and aim. He regards active remedial agencies as, in themselves, evils which become blessings when they aid in the escape from other and greater evils. To quote the language which some one has used, “lie is content with doing nothing when ignorant how to do good.” 2. The conservative physician does not undertake to control diseases which, with our existing knowledge, are uncontrollable. And if he employ measures for that end tentatively, he is governed by this rule, viz., not to sub- ject the patient to measures which, if they do not prove successful, will diminish materially the chances of his passing through the disease with safety. 3. In the management of all the diseases which our existing knowledge does not enable him to control, the conservative physician always pursues the expectant practice, using this term in its proper sense, viz., as de- noting not necessarily the attitude of a passive spectator of the progress of disease, but the adaptation of thera- peutical measures to circumstances as they arise. In this sense, expectation expresses the proper conduct of the practitioner whenever he is not warranted in resorting to treatment with a view to arresting the progress of disease or abridging its duration. 4. The practice of the conservative physician has ref- erence always, not alone to the disease, but to the condi- tion of the patient. In the language of Chomel, he does not treat diseases, but he treats patients affected with diseases. A forraularized, routine method of treatment for any disease is, therefore, with him impossible. In different cases of the same disease his therapeutical AS APPLIED TO THERAPEUTICS. 55 measures may be quite different, and even directly oppo- site in their character and effects. Of two persons at- tacked with a disease, for instance pneumonia, one may seem to him to claim measures which are commonly known as antiphlogistic, while the other may appear to require tonics and stimulants. 5. The conservative physician directs his attention with special care to the vital powers. He is always ready to support these wherever he sees evidence of their failure, without regard to the name or the stage of the disease. He does not wait for the last flickerings of the lamp of life before resorting to sustaining measures; he endeavors to prevent the flame from falling to so low an ebb, and with sagacious foresight he would forestall the occurrence of failure, resorting to sustaining measures even when not imperatively required, rather than run much risk of deferring them when they might be useful. A full appreciation of the importance of supporting the powers of life (using this metaphorical expression in its common, well-understood, practical sense) is, par excel- lence, a trait of conservative medicine. 6. The conservative physician is by no means a timid practitioner. He carries a lancet, and is ready to use it under certain circumstances, although, it must be con- fessed, the instrument is apt to become rusty from non- use. He does not repudiate any of the potent measures embraced in the materia medica, but he seeks to employ them with a nice discrimination. He is bold in the use of certain remedies which are used with timidity by many practitioners to whom the term conservative is not ap- plicable, viz., such remedies as quinia, opium, and alco- holics. His boldness, however, is quite as much dis- played by resolutely forbearing to resort to potent meas- 56 CONSERVATIVE MEDICINE ures whenever active interference does not seem to him to be called for, as it is by the employment of power- ful therapeutical agencies. 7. Recognizing the fact that medicine should be pro- gressive; that new developments in physiology and pathology, together with the accumulating fruits of ex- perience, should lead to constant improvement in the ars medendi, the conservative physician repudiates all dogmas or systems of practice, whether without or within the pale of the profession, which shackle the mind and stand in the way of progress. In medical faith he is in- dependent of creeds and discipleship. He occupies a middle ground with regard to the extremes of the present day as represented by old fogyism and young physic. 8. The most distinguishing characters of conservative medicine, in a few words, are as follows: Recognizing as a fundamental principle of therapeutics that potent remedies are never neutral, but must do either good or harm in proportion to their potency, it aims to abstain from active measures if uncalled for or of doubtful utility, and it strives to assist the powers of life, by means of remedial and hygienic influences, in enduring and tri- umphing over disease. This enumeration of some of the prominent traits of conservative medicine might be extended, and each might serve as a text for a distinct essay. But I proceed to consider the subject under the first head, viz., “ as re- gards the therapeutical indications derived from our knowledge of the pathological character, causation, etc., of diseases.” And it will serve our present purpose to arrange diseases into the following classes: Inflammatory affections, the essential fevers, degenerations of structure, functional disorders, and a residual class to which we AS APPLIED TO THERAPEUTICS. 57 may apply the term diathetic. The subject covers so wide a field that it is hardly necessary to disclaim the attempt to consider it fully within the limits of a few pages. The considerations presented in this essay must needs be fragmentary and discursive, the object being merely to suggest trains of reflection. Inflammations form the larger share of the affections with which the physician, as well as the surgeon, has to deal. The morbid processes embraced under the name inflammation have accordingly been studied with great interest; and with what success? The series of phenomena which make up the history of inflammation have been unfolded from the first appreciable event, namely, the determination of blood to, and its detention in, the inflamed part, to the various terminations of the inflammatory processes. But the essential pathology underlies that first appreciable event. What is it which occasions the determination of blood to, and its detention in, an inflamed part? The causation involves a knowl- edge of inappreciable conditions antecedent to the devel- opment of the phenomena of inflammation. Reference is here had, of course, to inflammations which are not traumatic. It is as certain that some unknown causa- tive influence exists and acts in, as yet, some unknown manner, to give rise to an inflammation when it is said to be spontaneous, as it is that the local injury produces the inflammation when traumatic. If this be a fair statement of our knowledge of the essential pathology and causation of inflammation, what rational conclu- sion may be drawn therefrom respecting therapeutics? Ought we to expect to be able to suppress an inflamma- tion by diminishing the quantity of blood in the body; 58 CONSERVATIVE MEDICINE or by trying to direct blood elsewhere; or by the pro- duction of an inflammation in another part; or by evacu- ating the stomach and bowels; or by exciting some vio- lent commotion in the system under a vague notion that the local affection may be shaken off? Are the patho- logical and causative conditions seated in the blood or in the nervous system, or in both? This question we may hope to answer when the physiologist has explained more fully the mysteries of the capillary circulation and of nutrition. Until then, we can hardly expect to find rational indications for arresting inflammation. Our knowledge of the means for this end must be empirical; and experience has not yet led to the discovery. Let it not be said that medicine is disparaged by this view of the resources of our art. A conservative prac- tice can do vastly more than simply not do harm by vainly attempting, with the measures just named, to ex- tinguish inflammations. It can do much for the safety of the parts inflamed by measures to palliate local symp- toms, to promote favorable modes of termination, to ob- viate incidental evils, to aid in the removal of morbid products, etc. Conservatism dictates measures for those ends embracing surgical as well as medical interference, as, for example, when paracentesis is resorted to in pleu- risy. Conservative practice can do a vast deal by measures addressed to the system. To obviate the general disturbance occasioned by inflammations, or, in other words, to render the system more tolerant of their existence, by means of opium and other anodyne remedies; to support the vital powers by means of tonics, alcoholics, and nutriment—these are indications which have refer- ence to the safety of the patient, and a speedy triumph over the disease. In fulfilling these indications the Con- AS APPLIED TO THERAPEUTICS. 59 servative physician is often called upon to act boldly, resolutely, and perseveringly. It is to be considered that, exclusive of certain acute inflammations which may destroy life by obstructing the exercise of vital functions, as pericarditis by the pressure of liquid effusion, laryngitis and capillary bron- chitis by preventing the passage of air to and from the pulmonary vesicles, etc., death is generally caused, not by an irremediable injury to the inflamed part, but by the general disorder and failure of the vital powers. Acute peritonitis, for example, is a dangerous disease, not on account of the damage done to the peritoneum or the abdominal viscera, but because the powers of life do not hold out a sufficient time for recovery. Patients may die with this, as with other inflammatory affections, for the simple reason that they do not live long enough for the restorative processes to take place. Is it not, then, an indication not less in accordance with conserva- tism than with common sense, to endeavor to obviate the general disorder, prevent failure of the vital powers, and prolong life sufficiently for restoration? Acute peritonitis has just been cited. How striking an example does this disease afford of an immense im- provement due to bold conservative practice! How fatal was this disease under the treatment until recently in vogue, and for which, alas ! the practitioner still finds authority in some standard works ! Who that has had an opportunity of contrasting the past and present methods of treatment, can doubt that the former want of success was measurably due to overdepletion and cathartics? The comparative success of the present treatment, doubtless, is by no means wholly due to the abandonment of these measures. The free use of opium, 60 CONSERVATIVE MEDICINE and of alcoholics when indicated, has contributed, in no small measure, to this success. This is a reasonable opinion, although here, as with respect to other diseases which have rarely been observed under circumstances in which no medical treatment was employed, it is not easy to determine how much a more successful treatment may depend simply on the displacement of injurious measures. Directing attention to chronic inflammations, to what is their chronicity attributable? Sometimes to an obvi- ous, persisting cause of irritation; sometimes to a palpa- ble, associated morbid condition, as when bronchitis is kept up by pulmonary congestion due to cardiac lesions ; sometimes to lesions which, from the situation of the part affected, are restored with difficulty, as in cases of chronic dysentery. In other instances it is attributable to an inappreciable condition, which, for the sake of dis- tinction, it is customary to call a constitutional cause. Who has not seen chronic venereal ulcers of long stand- ing heal under the use of mercury; or periostitis, from which the patient may have suffered for many months, rapidly disappear under the use of the iodide of potas- sium ? Now, there is reason to believe that certain chronic inflammations are not less dependent on a constitutional causation, although the cause may not be of a specific character like that in syphilis. This is by no means a new idea. It was the leading idea in the teachings of Abernethy, and, as the basis of the so-called alterative treatment, of which mercury was considered as the chief, it has led to not a little injurious medication. In fact, a signal instance of conservatism is the infrequent induc- tion of mercurialization in the treatment of chronic in- flammations, at the present time, as contrasted with the frequent resort to this measure but a few years ago. On AS APPLIED TO THERAPEUTICS. 61 the other hand, the existence of a constitutional causa- tive condition in certain inflammations is often not suf- ficiently considered by practitioners, and hence an over- reliance on topical measures of treatment which are not only inefficacious, but not infrequently contribute to perpetuate the affection. As an illustration of the fact just stated, I will select an affection which of late years has attracted a good deal of attention, both professional and popular, namely, chronic pharyngitis. Exclusive of cases of syphilis, this affection is very common, especially among persons of the male sex engaged in pursuits which overtask the nervous system and involve sedentary habits. For seve- ral years past this affection has been treated very gener- ally by means of topical, cauterizing applications, usu- ally the nitrate of silver, repeated at intervals for a greater or less period. Has this treatment proved suc- cessful? For one, after considerable experience, I am prepared to answer this question in the negative, and this I find to be a conclusion drawn by many from the results of experimental observation. The treatment, I am persuaded, is not only rarely beneficial, but often aggravates the affection. The affection is the local ex- pression of a constitutional state, and will prove rebel- lious to treatment so long as the latter continues. Gene- ral measures, in which hygiene plays an important part, effect the cure. I shall content myself with this illus- tration, although others might be added. Suffice it to say that the same conclusion, I am persuaded, may be drawn with respect to severe topical treatment in diph- theria, and in chronic inflammations seated in other ac- cessible situations, for example, ophthalmia, erysipelas, and certain of the affections of the cervix uteri. 62 CONSERVATIVE MEDICINE Conservatism dictates an appreciation of the depend- ence of local affections on a morbid constitutional state, although our present knowledge may not enable us to understand the primary and essential deviations from health which constitute this state. Conservatism sanc- tions the trial of remedies, under proper restrictions, with a view to the removal of this state. Conservatism is ready to accept remedies for that end, the efficacy of which has been empirically established, without requir- ing an explanation of their modus operandi. The chlo- rate of potassa, in certain affections of the mucous mem- branes, would appear to be a remedy of this description. We may hope that additional remedies of this kind may, from time to time, be discovered. Meanwhile, conservatism enjoins, not only an acquaintance with the resources of our art, but a just appreciation of the limi- tations incident to the present state of knowledge ; and hence, with reference to the affections under considera- tion, conservatism tries to avoid being led into injurious medication by such loose expressions as “ substitution of healthy for diseased action,” and “ alterative treatment,” expressions which have served as a warrant for not a little mischievous practice. Finally, conservatism enjoins as a general indication in chronic inflammations, to place and maintain the body in the best possible condition, by means of tonic remedies, adequate alimentation, and the hygienic influ- ences which conduce to that end. It is consistent alike with experience and good sense, that, other things being equal, the nearer the normal standard the condition commonly known as the general health, the better the prospect of recovery from chronic inflammation, and the better fortified is the system to endure its continuance. AS APPLIED TO THERAPEUTICS. 63 Passing to the essential fevers, we know that each of them has its own morbific agent, that is, a special cause which will produce one particular species of fever, and that species only. The special cause of variola, for ex- ample, will never give rise to rubeola or scarlatina. The special cause known as marsh miasm will not give rise to typhoid or typhus fever. Each of the two last- named species of fever has its own special cause, which will not give rise to the other species. These statements are based on logical inferences from certain facts, not on the demonstrative proof afforded by an analysis and comparison of the different agents which constitute the poisons producing these diseases. Our belief in the ex- istence of these poisons is not derived from our knowl- edge of their nature. What their chemical and physical characters are we know not. We know that an ex- ceedingly small and even an inappreciable amount suffices to produce fever, as when certain of these fevers are produced by inoculation and by contagion; and analogical reasoning has led to the conclusion that they act as ferments, or on the very imperfectly understood principle of catalysis. Hence, we say these diseases be- long to a class distinguished as zymotic. And if they act on the principle of catalysis, their primary action must be in the blood. We, therefore, accept the humoral pathology of fever. The demonstrative part of this pa- thology is confessedly wanting, but it may be considered logically established. Now, the aim of conservative medicine being to afford protection against disease, on the one hand, and, on the other hand, against needless and therefore injurious medication, the first inquiry is, do the present resources of our art enable ns to control these diseases ? As re- 64 CONSERVATIVE MEDICINE gards the purely periodical fevers, this question may be answered affirmatively. We can control these by means of certain special or specific remedies of which quinia is the most efficient. These remedies, for the time being, either neutralize the poison, or, in some way, suspend its morbific action. Conservatism thus manifests its power to protect against disease by its ability to arrest these fevers. And it has also manifested its protection against needless medication by doing away with certain preparatory and adjunctive measures which, until re- cently, were deemed important, experience having abundantly shown their inutility. In fact, the doing away with bleeding, emetics, cathartics, and mercurial i- zation, in the treatment of intermitting and remitting fever, is a striking illustration of conservatism. It is but a few years ago that these measures were in vogue ; it was then thought to be injudicious to enter upon the special remedy at once; this remedy was given timidly in small doses only, never except in the apyrexial period, and not if the fever were complicated with local inflammation. In each of these particulars, the treat- ment has changed, and the change constitutes one of the most important of the late improvements in practical medicine.1 1 The January No. of the American Journal of the Medical Sciences, in 1841, contains an article, by the author of this essay, on the management of inter- mitting fever. In that article the following points were set forth: The safety and propriety of giving quinia in large doses, i. e., from ten to twenty grains; the inutility of preparatory treatment, and of the use of emetics, cathartics, etc., during the progress of the disease; the diminished liability to relapses in pro- portion as the paroxysms are promptly interrupted, and, in cases in which in- flammatory complications exist, the importance of giving the special remedy in doses sufficient to arrest at once the paroxysms. Those views were then at vari- ance with the prevailing modes of practice. The writer is very far from assum- ing to have exerted much agency in producing the change in practice; but he trusts he may be excused for stating that the article referred to advocated, in all respects, the change which has actually taken place. AS APPLIED TO THERAPEUTICS. 65 Protection against the eruptive and continued fevers, like that afforded by quinia and other antiperiodic reme- dies against the periodical fevers, is reserved for the future. We cannot control the former as we can the latter. Yet, with regard to the most formidable of all, namely, small-pox, the glorious discovery of the immortal Jenner, by way of prevention and modification of its severity, affords a protection almost complete, and has deprived the disease of nearly all its terrors. The contagiousness of the eruptive and continued fevers, and the fact that they have a definite, self-limited career, may seem to dis- courage an expectation that means of controlling them will ever be discovered; but how little ground was there to anticipate the fact that the virus of variola, as modi- fied by its production in the body of the cow, would give rise to an affection insignificant except in regard of its power of protecting against the virus received from our own species? How many would have anticipated the wonderful modification of small-pox produced by inocu- lation ! It is not unreasonable to hope that other Jen- ners will hereafter arise, although Providence may have ordained their appearance at remote epochs. Meanwhile, it is a legitimate object of experimental research to dis- cover means of preventing, arresting, and modifying the eruptive and continued fevers. There is ground for the belief that certain measures, which have been already tried, are occasionally successful in suspending and short- ening typhus and typhoid fever. This remark has refer- ence to large doses of opium, and hydropathic measures. But in experiments for these ends the rule of conserva- tism already mentioned is to he observed, namely, not to make trial of measures which, if they do not succeed, will be likely tq prqve in themselves dangerous. The 66 CONSERVATIVE MEDICINE conservatism of present practice is strikingly shown by the relinquishment of potent measures to break up the continued fevers, namely, bleeding, emetics, cathartics, and mercurialization, the inefficacy of which experience has abundantly established. The present prevailing views of the management of the eruptive and continued fevers, irrespective of measures to arrest them, or abridge their duration, are eminently on the side of that conservatism which protects the sys- tem against needless medication. Practitioners now rarely subject patients to loss of blood in order to abate the intensity of febrile excitement and prevent the de- velopment of local congestions or inflammations; they do not produce local complications by blisters and other means of counter-irritation ; they do not subject the sys- tem to the perturbation of cathartics to change the con- dition of the stomach and remove saburral matters ; they do not give cathartic remedies to cleanse the bowels, in- crease the flow of bile, or improve the secretions; they do not resort to powerful measures to produce perspira- tions which they hope may prove critical; they do not attempt to salivate under the vague notion of producing an alterative effect. These anti-conservative measures belong to the past, and the physician is now satisfied, if he cannot arrest or abridge these diseases, to pursue an expectant course; he watches symptoms, and meets indi- cations as they arise in individual cases. He may see nothing which calls for medication during the progress of the disease. Hygienic conditions receive his special attention, the importance of these having come to be more and more appreciated in proportion as remedial agencies have been used with greater discrimination. Pal- liation of symptoms and supporting measures often con- AS APPLIED TO THERAPEUTICS. 67 stitute the sum and substance of his treatment. The latter, if occasion require, he employs boldly and perse- veringly. In certain cases, when his great object is “to obviate the tendency to death,” he supports his patient as he would hold up a drowning man, until, by vigor- ous exertions, at length the shore is reached. No branch of the science of medicine has excited greater interest, of late years, than the study of structural changes. Here the application of the microscope has been of ines- timable service, by unfolding, first, the minute structure of organs in health, and, second, the alterations due to disease. How much light has been shed on our knowl- edge of the various lesions of different organs—the brain, liver, kidneys, heart, &c.! And much more informa- tion is to be expected from continued microscopical re- searches. But, complete as our knowledge of apprecia- ble changes of structure may become, this knowledge is but the scaffolding raising us higher and higher toward the primary conditions of disease; and these are still beyond us when we have reached the highest point of elevation. In other words, structural changes are the effects of prior morbid actions, and the latter must be understood before we can comprehend fully the essential character of diseases. I am far from wishing by this statement to depreciate the results of microscopical re- searches. It is easy to cite illustrations of their great practical value. Thus, our knowledge of the changes which the cerebral arteries undergo from the deposit of fatty granules, enables us to explain the occurrence of apoplexy ; our knowledge of the fatty degeneration of the muscular fibres of the heart, affords an explanation of the weakness of that organ in certain cases and the 68 CONSERVATIVE MEDICINE occasional rupture of its walls; the presence of newly developed fibrous tissue in the interlobular spaces of the liver in cirrhosis, renders the occurrence of ascites in- telligible ; the loss of the secretory cells of the convo- luted tubes of the kidneys in certain affections of the kidneys, accounts for the production of unemia—and numerous additional examples might be cited to show how important in their bearings on practical medicine are the developments for which we are indebted to the microscope. Still, morbid anatomy, in its widest scope, is but a province of the natural history of diseases. It describes appearances; it traces the different steps of morbid alterations, and strives to ascertain their points of departure—and this is vastly important; but the prime source of the lesions which it studies underlies and precedes the earliest of the changes which the senses can discover. Take, for example, Bright’s diseases, and admit the researches of Dr. George Johnson and others to have established that the structural changes incidental to these diseases have their point of departure in the secretory cells of the kidneys, and that the various mor- bid changes of the organs are fully explained by the loss of cells, the presence of fatty and other deposits, etc., we do not reach thefons et origo of the disease. The mor- bid condition on which hangs the first link of the chain of appreciable alterations, is inappreciable, and, as yet, unknown. Commensurate with our progress in the knowledge of structural changes, has been improvement in the means of determining their existence during life. We have learned to investigate certain vital organs with wonder- ful accuracy. The examination of the urine, chemically and microscopically, reveals morbid conditions of the AS APPLIED TO THERAPEUTICS. 69 kidneys; auscultation, together with the other methods of physical examination of the chest, discloses the lesions to which the lungs and heart are liable. Means of in- terrogating in like manner, the liver and other of the abdominal viscera, will, in all probability, be found when their structural changes and their pathological relations have been more fully studied. But it is to be considered that the diagnostician deals with symptoms and signs representing existing changes which have made more or less progress. He determines mischief already done. He has not often the opportunity, and, if he had, he is rarely able to foresee the occurrence of internal lesions. Every clinical observer knows that affections involving irremediable lesions are developed imperceptibly, and are already developed when cases first come under the cog- nizance of the physician. This is true of Bright’s dis- eases, cirrhosis of the liver, pulmonary tuberculosis, car- cinoma in various situations, organic disease of heart, etc. Vastly important as it is to determine the existence of lesions and the amount of damage which they have occasioned, it would be of immense advantage to be able to go still farther and ascertain the existence of those morbid actions which precede and determine the develop- ment of structural changes. Not to dwell too long oil these considerations, let us in- quire into their general bearings on therapeutical indica- tions. What are the dictates of conservatism in view of the foregoing facts ? Suppose an important organ to be the seat of some structural change, and, so far as the organ is already damaged by the change, the affection to be irremediable. Nature, to a certain extent, has pro- vided for such a state of things, by furnishing a surplus amount of structure in important organs. The lungs 70 CONSERVATIVE MEDICINE are so far beyond the actual wants of the economy, that a loss equivalent to the functional capability of one whole lung is not incompatible with robust health. The two kidneys exceed by at least the function of one of these organs, the necessities of the system. The heart may be considerably impaired, and still be sufficient for the circu- lation ; and so with the liver, and, doubtless, the glandu- lar organs contained in the stomach and intestines. Medicus naturae minister est. The physician should en- deavor to aid nature in doing as well as possible under the damage which the affected organ has sustained. How is this object to be attained? In general terms, by pre- venting, if possible, any farther progress of the structural change, and placing the organism in the best possible con- dition compatible with the existence of the lesion. We may lay it down as a rule of general application, that an organic affection is less liable to progress, the functions of the affected organ suffer less, the system is less disturbed, and the local mischief is borne for a longer period, in proportion as, in all other respects, the body approximates to a state of health. Striking results are often obtained in cases of an incurable malady, by effect- ing an improvement in the state of the system. For example, it has occurred to me repeatedly to see patients enter hospitals with renal disease accompanied with such an amount of dropsy, prostration, etc., that the prospect of improvement seemed most unfavorable; but, after a time, the dropsy has disappeared, the strength has improved, and the patients have left the hospital feeling able to return to labor, I do not now refer to cases of acute albuminuria, which may pursue this course and end in recovery, but to chronic cases of an incura- ble affection of the kidnev. The lesion continues in AS APPLIED TO THERAPEUTICS. 71 the cases referred to, the urine remains albuminous, and, sooner or later, grave consequences are developed. Whence the marked improvement and apparent re- covery ? Simply because the system has been improved by rest, by nutritious food, by tonic remedies, and, prob- ably, by an interruption of habits which have contributed greatly to the production of the local affection. Similar examples might be cited of patients with other affections, such as cirrhosis of the liver, cardiac lesions, and pul- monary tuberculosis. Structural changes generally com- mence and increase to a certain extent without giving any obvious manifestations of their existence; the sys- tem tolerates them, provided it has nothing else to bear. But when other circumstances occur to disturb or weaken the economy, an affection, up to this time latent, declares itself. If now the practitioner impute everything to the local affection, he will be much in error. Let him suc- ceed in restoring the system to the state in which it was prior to the manifestations of the affection, and the latter may again become comparatively innocuous. A striking illustration of the influence of associated circumstances in exaggerating the effects of a local af- fection is sometimes afforded by the coexistence of anaemia and cardiac lesions. A patient with this com- bination of affections may present palpitation, dyspnoea, and general dropsy, so that a fatal termination may seem to be near at hand. But, by removing the anaemic state, the effects of the disease of heart disappear, and the patient appears to recover so fully that, were it not for the testimony of physical signs, the existence of the cardiac lesions would not be suspected. Examples of this kind have repeatedly fallen under my observation. Other examples and considerations might be adduced to 72 CONSERVATIVE MEDICINE show how much conservatism can sometimes accomplish by enabling the system to bear up under local affections, the continuance of which is inevitable : but I must hasten to another division of the subject. Disorders occurring independently either of inflam- mation or appreciable lesions, and, therefore, distin- guished as functional, differ as regards their pathologi- cal import. A correct interpretation is necessary to a full understanding of rational indications. Vomiting and purging, for example, in the course of renal dis- eases, have a special meaning which the researches of Bernard and others have enabled us to understand. They show, in that connection, the conservatism of nature, the object being to eliminate vicariously the urea which accumulates in the blood in consequence of its deficient excretion by the kidneys. The con- servative physician thus follows the guidance of na- ture when he endeavors to relieve the system of this exerementitious principle by remedies which act upon the gastro-intestinal mucous membrane; and he would violate conservatism were he to attempt to arrest these symptoms of disorder of the digestive organs. In most instances, however, disorders of functions either have not so definite a significance as this, or our present knowledge does not enable us to interpret them fully; and hence the practitioner must derive his indications from certain general principles. Functional disorders involve, for the most part, morbid conditions of the nervous system. And these, when not produced directly by overexercise or over- excitation, generally involve a prior abnormal state of the blood. This is a capital fact as regards therapeuti- AS APPLIED TO THERAPEUTICS. 73 cal indications. The nervous system, as a generator of force, is powerless, and all its vital functions are speedily lost, without the presence of oxygenated blood. How quickly are the power of willing, the faculty of feeling, and consciousness suspended by the deficient supply of blood to the brain in syncope ! The blood is the medium, on which the nervous system is as dependent for the ca- pacity to perform its functions, as the body on the at- mosphere for the continuance of life. It is not strange, therefore, that deviations from the normal composition of the blood should occasion disturbance of the functions of the nervous system. But the effects of certain poi- sons upon the nervous system, when introduced into the blood in exceedingly minute quantities, are truly won- derful. A fraction of a grain of strychnia acts upon the motor nerves, leaving the mental faculties intact, and gives rise to epileptiform convulsions; a similarly mi- nute quantity of woorara paralyzes the nerves of motion ; a few inhalations of the vapor of chloroform extinguish the faculty of feeling pain ; a few drops of the tincture of the veratrum viride reduces, in a notable degree, the frequency of the heart’s action; an amount of atropia almost inappreciably minute suffices to paralyze the cir- cular fibres of the iris : these are some of the well-known manifestations of an astonishing susceptibility of the nervous system to the action of certain morbific agents contained in the blood in exceedingly small quantities. The facts just stated (of which it is only necessary to remind the reader) are valuable as shedding light on the interpretation of various functional disorders. An impoverished state of the blood stands in a causa- tive relation to various functional disorders. Clinical experience teaches that most of the neuroses, together 74 CONSERVATIVE MEDICINE with various disorders, such as palpitation, dyspepsia, constipation, etc., are often associated with anaemia, and disappear when the blood is restored to its normal con- dition. It is a general principle, then, in the manage- ment of functional disorders, to direct attention to the state of the blood. And here I am led to remark, in passing, that the improvements in practice based on the knowledge and appreciation of anaemia, acquired within the last few years, furnish one of the most striking of the illustrations of conservative medicine. Before this condition of the blood was understood, the affections de- pendent thereon were, of course, not correctly interpreted, and their treatment was inefficacious if not injurious. And the non-recognition of this condition as coincident with a host of affections, involved a want of discrimina- tion in the employment of the antiphlogistic measures, which was the source of not a little unsuccess and injury. The anaemic state is a very important source of indica- tions in the treatment of functional disorders; but there are doubtless other morbid conditions of the blood of which onr present knowledge affords less precise infor- mation. Various functional disorders, as well as in- flammations and structural changes, are probably due to toxaemic conditions which remain to be ascertained. Unknown poisons, received from without and generated within the body, may be the source of diverse affections, the origin of which we are now unable to explain. Reasoning analogically from the effects of the well- known poisons to which reference has been made, we are led to this conclusion. Moreover, we have already acquired knowledge of certain forms of toxaemia, occur- ring as results of morbid actions within the organism. We know that urea accumulating in the blood acts as a AS APPLIED TO THERAPEUTICS. 75 poison on the nervous centres, giving rise to epilepti- form convulsions and fatal coma. We know, too, that serous and other inflammations are incidental to uraemia. The researches of Garrod appear to establish that gout is due to the accumulation of uric acid in the blood ; and the ingenious and striking experiments of Dr. Richard- son go to show that it is lactic acid which gives rise to the articular affection and to endocarditis in acute rheu- matism. May we not expect from researches in this di- rection developments which will shed new light on the production of other affections, and furnish important therapeutical indications? Assuming, for example, that cholesterin is an important excrementitious product pro- duced in the brain and nerve-tissue, and eliminated by the liver, it is probable that a deficient excretion of this substance is the source of a toxsemic condition which has important pathological relations; and we may find that there is a substratum of scientific truth in the vague notions of biliousness with which the professional and popular mind have been so long and strongly imbued. Cholestersemia is one of many analogous conditions of the blood which are yet to be clinically studied. Reasoning from the analogy between the effects of certain poisons and the phenomena of certain functional affections, it is reasonable to attribute the latter to a toxical source. For example, the phenomena of epilepsy bear so much similarity to the effects of strychnia, that the convulsions produced by this poison are said to be epileptiform; and this is true also of the convulsions in- cidental to uraemia. Now, taking into view the clinical history of epilepsy—convulsive paroxysms of brief dura- tion, recurring at variable intervals, the patient often perfectly well just before and immediately after the par- 76 CONSERVATIVE MEDICINE oxysm—how much more probable is it that a poison is generated somewhere in the body, and manifests itself by a powerful transient action on the nervous centres, than that the phenomena are due to any mere disturbance of the circulation or to slight changes in the consistence of the medulla oblongata such as are described by Van der Kolk. What a blessing would be the discovery of the nature and source of the toxsemic condition giving rise to epilepsy and of the means of preventing the pro- duction of the poison! The highest aim of conservative medicine in all affec- tions involving toxaemia from morbid actions within the body is expressed in the foregoing sentence. It is to obviate the production of the poisons. But first of all, the sources of toxaemia must be ascertained and the con- ditions under which its different forms are produced. Here is a field of research from which much is to be hoped for, but from which it is needless to say little has been as yet acquired. The aims of conservatism, next in importance to the one just stated, are, knowing the nature of different poisons, together with the means of their de- struction or expulsion from the body, and recognizing their existence in the blood as early as possible, to effect either their neutralization or elimination. I shall pass by the class of diseases which I have dis- tinguished as diathetic with a very few words. The meaning of the term diathesis, which is used in a varia- ble and often an indefinite sense, 1 would here limit to denote a special state of conformation or of the constitu- tion, which, under requisite causative conditions, deter- mines the occurrence of a particular form of disease; in other words, an intrinsic aptitude of the organism to the AS APPLIED TO THERAPEUTICS. 77 development of certain affections. This diathetic condi- tion may be innate or acquired, and it is often inherited. In this sense scrofula, tuberculosis, asthma, rheumatism, gout, are diathetic affections. In what consists the diathetic state our existing knowledge does not enable us to say. Conservatism would dictate the importance of remov- ing the state if it be practical. But it is evident this is not to be done by medication, for the existence of a dia- thesis is not inconsistent with health; and, moreover, we have not the means of determining with positiveness the existence of a diathesis until it has eventuated in the development of disease. That a diathetic state may be held in permanent abeyance we have every reason to believe. This is accomplished more by hygiene than by therapeutical influences, viz., by climate, habits of life, and avoidance of the causative conditions which render active a latent diathesis. This division of the subject is by no means lacking in interest and importance, but the space already occupied warns me not to enter more fully into it. Besides, the considerations which are suggested under this head relate more especially to hygiene, and the application of conservative medicine to this depart- ment of medical practice does not enter into the scope of the present essay. So far, the subject of this essay has been considered in the first of the two aspects under which it is to be re- garded, viz.: “ The therapeutical indications derived from our knowledge of the pathological character, causation, etc., of diseases.” It remains to notice the second aspect, viz.: “The general objects of remedial measures.” These two divisions of the subject are correlative; therapeutical indications and therapeutical objects are, of course, mu- 78 CONSERVATIVE MEDICINE tually involved, but new considerations arise in looking at the subject from the latter point of view. I shall content myself with endeavoring to classify the objects of remedial measures, and offering a few remarks under the head of each class. The conservative physician places before himself certain general objects in dealing with diseases; what are these objects? They may be em- braced in five classes: 1. The first object is prophylaxis. Diseases may sometimes be prevented. It is not strictly appropriate to call this a therapeutical or remedial object, but in so far as medicinal agents are employed for the prevention of diseases, the object falls within the province of the therapeutist, and the incongruity is merely in the use of terms which imply that disease already exists. Ex- cluding preventive measures which are properly surgi- cal, such as the cauterization of poisoned wounds, etc., known prophylactic remedies are not abundant. In fact, we are limited to a few examples. The protective efficacy of quinia against intermittent fever may be considered as sufficiently established. Alcohol appears to protect the system against certain venoms. The protective power of alcohol against tuberculous disease is a question sub judice, and one may well dread the settlement of the question in the affirmative. The antidotes to poisons in the stomach are preventives of the diseases which they would produce if not neutralized. In like manner, we might hope to discover antidotes to luemic poisons, were we acquainted with their nature, and aware of their ex- istence prior to the production of the affections to which they give rise. Doubtless by judicious management secondary affections may sometimes be prevented. Thus, by favoring the elimination of urea, in anemia, either AS APPLIED TO THERAPEUTICS. 79 through the kidneys or the alimentary canal, we may prevent, for a time at least, inflammations, convulsions, and fatal coma; and by restraining the excretion of albu- men with the urine, we may prevent the occurrence of dropsy. Other instances of this kind of prophylaxis might be cited; but it is evident that what we may ac- complish is, for the most part, only a matter of reasona- ble conjecture, and could not be established by positive proof. It is a curious fact that certain affections appear to be prophylactic as regards others. Asthmatic persons very rarely become tuberculous. The same is true of persons affected with organic lesions of the heart. Tu- berculous patients seem to be insusceptible to the special cause producing typhoid fever. Acute rheumatism and tubercle are not often associated. Other illustrations might be cited. The incompatibility of certain diseases, however, can hardly be made available in practice; and, in short, our expectations from the future, as regards the discovery of prophylactic medicinal agents must needs be small were they to be measured by what has been already discovered. 2. A second object is the arrest of diseases. To arrest diseases in limine, cut them short, or, in the significant language of some French writers, jugulate them, is, ob- viously, an object in desirableness ranking next to pro- phylaxis. But as regards the extent to which this is practicable, how different the popular belief from the present views of the best informed members of the pro- fession ! The notions of the public concerning medical matters generally emanate from the profession, and the reason why patients expect diseases to be arrested is, the ability to do it has been assumed by physicians. It is not long since physicians conscientiously believed that 80 CONSERVATIVE MEDICINE they often strangled diseases which now they are content to allow to run their course. It is only a few years ago that inflammations and most of the essential fevers were considered to be amenable to what have been called abortive measures of treatment. Popular notions are not readily changed, and, with respect to this point, our knowledge is simply in advance of public faith. But why is it that physicians were formerly self-deceived in this regard ? Chiefly because the art of diagnosis had not been brought to such perfection as it has been within the past few years. Patients with an attack of pleuro- dynia or intercostal neuralgia, for example, were often thought to have acute pleurisy or pneumonia. A copi- ous venesection, an active purge, and a blister, appeared to check, at once, the progress of the inflammation. The pain was in fact suspended, and although the recovery from the effects of the remedies may have been slow, the treatment appeared to be signally successful. Neuralgic affections had been comparatively but little studied, and were often confounded with inflammatory affections. Practitioners thought that they contended with inflam- mation of the bowels and brain much oftener than now. Ephemeral fevers were considered to be examples of continued fever broken up. As we have improved in diagnosis, the resources of therapeutics have seemed to be curtailed. Yet, what an improvement is it that the active treatment formerly in vogue to arrest many dis- eases, is no longer resorted to for that end ! Conserva- tive medicine has here gained much in the way of pro- tecting the body against the evils of needless therapeuti- cal measures. On the other hand, conservative medicine has gained much in the wav of abortive treatment in certain affec- AS APPLIED TO THERAPEUTICS. 81 tions. The periodical fevers are arrested with much more promptness and certainty than some years ago. This is true of certain functional disorders, such as colic, cholera morbus, and certain forms of neuralgia, by means of the bolder use of certain remedies, especially quinia and opium. We can count on the arrest of some dis- eases, but it must be confessed, the number is very limited, not embracing those which are the most fre- quent, namely, inflammations and other than the period- ical fevers. Here is ample scope for future discoveries which may enlarge beyond our present powers of calcu- lation the resources of practical medicine. 3. A third object is the cure of diseases. I use the word cure in its conventional sense. From its etymology it should denote simply the care {euro) of the sick. And the latter signification expresses the true function of the physician. His business is to take care of the sick, which means, watching the course of disease, applying the art of diagnosis and of prognosis, bringing to the bedside his knowledge of the natural history and laws of differ- ent affections, regulating hygienic conditions, exercising a proper moral influence, and prescribing remedial agents where these are required. Thanks in behalf of the char- acter of the profession, medical practice bids fair to become something higher in the estimation of the public than the administration of drugs ! The time is coming when the idea of the doctor will be less inseparably as- sociated than heretofore with the lancet and pill-box ! But using the term cure in its conventional sense, it means the exercise of a controlling influence, to a greater or less extent, over diseases. And as an object of thera- peutics, the curative treatment will embrace measures which abridge the duration of diseases, diminish their 82 CONSERVATIVE MEDICINE severity, or which influence favorably their progress in any manner and conduce to a favorable termination. As with the arrest, so with the cure of diseases, the efficiency attributed to therapeutical interference would seem to have decreased in proportion as our knowledge has advanced. Physicians formerly congratulated them- selves on curing diseases which ceased by their own limitations, and which had no tendency to a fatal result. The recovery was considered as proof of a cure having been effected, and that they were not indefinitely pro- longed, was evidence of their duration having been abridged. The study of the natural history of diseases within the last few years has led to the knowledge of the laws of self-limitation, and of the amount of danger which belongs to them intrinsically. The consequence is, the physician is content to assume to be more the servant, and less the master of nature. He undertakes less, and nature has the opportunity of accomplishing more. Here, too, popular belief has not kept pace with the improvement of medicine, and patients are often not satisfied to be taken care of, but expect to be cured. Unquestionably, cases of disease are better managed now than heretofore, and the improvement involves, in part, less reliance on certain therapeutical agents which were formerly considered as curative. I refer more particu- larly to the so-called antiphlogistic measures. We should not hesitate to acknowledge this fact. It is certainly no disparagement to medicine that it has improved, and it must be expected that improvement will consist, measur- ably, in the correction of errors, as well as in newly acquired resources. But the improvement is by no means wholly of this negative character; it consists, measurably, in the employment of more efficient curative AS APPLIED TO THERAPEUTICS. 83 treatment. Of the latter, the free use of opium in acute inflammations, and especially in acute peritonitis, is the most prominent example. The use of large doses of the iodide of potassium in syphilitic periostitis, and in some of the forms of chronic inflammation, and of quinia as a curative remedy in remitting and yellow fever, and in certain cases of neuralgia, may also be cited in the same category. The antiphlogistic measures of treatment were formerly employed too indiscriminately because inflammations were not accurately discriminated from other affections; and too freely because undue reliance was placed on their curative influence. What is the correct estimate of their efficiency? This is a question which every reflect- ing physician cannot but have propounded to himself. Do bleeding, cathartics, antimony and other sedatives, mercurialization, etc., exercise curative influence over acute inflammation ? Do they contribute nothing toward diminishing the intensity of inflammation, shortening its duration, limiting the amount of exudation, and favoring resolution ? If not, these measures always do harm, and should never enter into the treatment of inflammation. There are observing and thinking physicians who adopt the latter view, and there are those who still have great faith in the efficacy of these measures. The truth prob- ably lies between these extremes. For one, I am not pre- pared to ignore entirely the experience of candid, saga- cious observers for many past generations. I believe that these measures may exert a certain amount of curative influence, and that whether they do harm or good de- pends on the discrimination with which they are em- ployed. If resorted to injudiciously, the harm will pre- ponderate over the good ; and if judiciously employed, 84 CONSERVATIVE MEDICINE their use will undoubtedly be much restricted as com- pared with the past. This train of remark has opened up a large topic which I cannot here discuss. I shall leave it after pointing out a highly important practical application of the juste milieu doctrine with regard to antiphlogistic measures. And I am led to make this application because it in- volves, as it seems to me, a nice exemplification of con- servatism. There are certain inflammations, to which reference has been already made, which destroy life, not from their extent or intensity, but from circumstances incidental to their situation. This is true of acute laryn- gitis. The same amount of inflammation situated else- where, would be trifling; here it is fatal by causing ob- struction at the larynx. Capillary bronchitis is an analogous example; the danger is from the obstruction of the small bronchial tubes. Acute meningitis is another example; the danger is chiefly from compression by the products of inflammation. Patients die from these in- flammations by apncea. On the other hand, the source of danger in inflammations situated elsewhere is, generally, in the disturbance of the system and failure of the vital forces. Patients die in most cases by asthenia. Now, in the latter inflammations, the evils of the antiphlogistic measures have reference to the source of danger and the mode of dying; and the problem is, to determine whether the curative influence of these measures, as regards the local affection, will overbalance their effect on the powers of life, or vice versa. In the one case good, and in the other case harm, will preponderate. But in the former inflammations there is not the same need of sparing the powers of life. The danger is not from the giving way of these. Hence, we may consider chiefly, in such cases, AS APPLIED TO THERAPEUTICS. 85 the curative influence of antiphlogistic measures as re- gards the local affection; or, in other words, we have not to balance the probabilities of good or harm as in the previous problem, but simply to secure all the good to be obtained by their judicious employment. This mode of reasoning will be likely to lead to the continued use, to a greater or less extent, of antiphlogistic measures in certain inflammations, albeit their use may be generally abandoned as either unnecessary or as doing more harm than good. 4. The fourth object is palliation. Palliative measures enter largely into the management of diseases. They mainly constitute the treatment in two classes of cases : first, in those in which the disease pursues a favorable course without the need of active interference; and, sec- ond, in those which offer no encouragement for curative treatment. Relief of pain or distress is an important ob- ject of treatment irrespective of the issue of a disease; and it is to be reckoned among the recent improvements in practice not least in importance, that physicians are not now to be restrained, as they have been, in the use of opium and other anodyne remedies, by apprehensions of their unfavorable influence on the progress of various affections. We hear much less nowadays than formerly of the danger of producing cerebral congestion or locking up the secretions by opiates, notions which often deprived patients of the comfort and advantage to be derived from their use. Palliative measures, although addressed to symptoms, and not to the disease per se, may, neverthe- less, be to a greater or less extent curative by diminish- ing the general disturbance and consequent exhaustion incidental to the continuance of suffering. 5. The fifth object is support. Pre-eminent among the 86 CONSERVATIVE MEDICINE characteristics of conservative practice is the employment of supporting measures in all cases of any disease, what- ever be its name, character, or situation, in which danger from failure of the powers of life is to be looked for. Of the importance of this object enough has been already said in the course of the foregoing remarks. Suffice it to add a consideration having reference to the value of support in cases which are unattended with danger to life. In emerging from an acute disease of any kind, a patient who has been judiciously supported by tonics, nutritious food, and, if need be, alcoholics, enters upon convalescence with vigor of body and mind far less im- paired than if this object of treatment had not received appropriate attention, and the complete restoration is more rapid. A comparison of the condition of patients, now and formerly, after the termination of diseases in convalescence and recovery, would perhaps afford a stronger contrast illustrative of improvement in practice, than a comparison of the rates of mortality. This con- trast is, in part, due to differences pertaining to the em- ployment of curative measures of treatment, but, in no small measure, also, to differences of management as re- gards supporting measures. The foregoing classification of therapeutical objects does not embrace, distinctly, a class of measures which hardly ranks inferior to any in its bearing on the man- agement of diseases. I refer to sanitary or hygienic measures, relating to air, temperature, diet, cleanliness, climate, moral influences, etc. The subject of this essay embraces only considerations relating to therapeutics. Conservative medicine as applied to hygiene, is a subject not less fruitful in practical considerations. This sub- ject is reserved for a future essay. AS APPLIED TO HYGIENE. 87 III. Conservative Medicine as applied to Hygiene.1 A S the phrase Conservative Medicine may be miscon- strued, a brief explanation is to be premised. The term Conservatism may be used to express a princi- ple which leads the practitioner, in dealing with diseases, to preserve, develop, and support the vital powers. The unfolding of this principle more and more during the last quarter of a century, has been a result of the progressive increase of the knowledge of the organism in health and disease, together with the accumulating fruits of clinical experience; it is the characteristic of the therapeutics of the present time, as represented by the views of the ablest writers and practitioners, and it is claimed that it should be considered as the governing principle in medical practice. For a fuller exposition, the reader is referred to the previous essays on the sub- ject. The subject of conservative medicine in the articles just referred to, has been considered chiefly as regards its therapeutical relations. The purpose of this article is to consider the subject in its relations to Hygiene. Here, as heretofore, the largeness of the subject is such that the writer can only aim, within the limits of a 1 Published in the American Journal of Medical Sciences. 88 CONSERVATIVE MEDICINE single article, to present a few desultory thoughts which may be suggestive, in the minds of his readers, of trains of reflection leading to important practical con- clusions. Hygiene enters alike into the prevention and man- agement of diseases. The name suggests more especially measures concerned in the preservation of health ; but, in therapeutics, all measures, not medicinal, may be dis- tinguished as hygienic. I shall use the term with this breadth of application. And it will be a natural divi- sion of the subject to direct attention, first, to hygiene in health, and, second, to hygiene in disease. I will adopt this arrangement. Conservatism, as applied to hygiene in health.—There is no need to argue for the validity of the principle of conservatism as applied to the preservation of health. Hygiene, in this application, can, of course, have no object which does not assume to be conservative. To weaken the powers of life, or impair the constitutional strength, is never the design of measures to prevent disease. The violations of the principle which fall within this division of the subject proceed either from ignorance, or false notions as regards the .effects of means supposed to be conservative. A iolations of the principle are less frequent and less marked now than for- merly ; the progress of conservative medicine is shown in its prophylactic, as well as its' therapeutical relations; still, examples of not only past, but present non-conser- vative errors are not wanting. It is not many years since the notion was prevalent, both within and without the profession, that there is such a condition as an overplus of health. And it was the custom to resort to potent measures to reduce the AS APPLIED TO HYGIENE. 89 exuberance of health within safe limits. Bleeding and purging were employed for this end. There are persons now living who were accustomed, in their young days, to get bled from time to time purely as a sanitary meas- ure. Nothing was more common, a quarter of a century ago, than for healthy persons to apply at the offices of physicians for a venesection, which was performed, as a matter of course, on the judgment of the applicants. Such occurrences are very.rare at the present time. Purgation, being practicable without the aid of the doctor, was almost universally employed as a health- preserving duty. Cathartics were regarded as cleansing agents, and not less important for the alimentary canal, than soap for the surface of the body. An occasional internal “ scouring ” was supposed to be even of greater importance than a thorough external scrubbing, for while the latter was enforced chiefly on the score of cleanliness, the former had the additional recommenda- tion of being thought to be essential to the welfare of the system. There are many now in middle life, with whose reminiscences of childhood are associated periodi- cal doses of sulphur and cremor tartar mixed with mo- lasses, given regularly for a series of days, before break- fast, or at bedtime, especially at every recurrence of the vernal season. This was the cleansing mixture for healthy persons of tender age. After this period, the so-called cooling purgatives, such as the Glauber and Epsom salts, had preference. A person with an excess of health was considered to be on the threshold of dis- ease, and the latter was supposed to be warded off by the timely employment of the lowering, cleansing, and cooling measures just referred to. The popular use of C0NSE11VATIVE MEDICINE purgatives or prophylactic agents, is still sufficiently common. Gestation is a physiological, not a pathological, state; and, since it is by no means a modern discovery that all the needful supplies for the development and growth of the foetus are contained in the maternal blood, a common- sense view of the matter, it would seem, should have led to the conclusion heretofore, as now, that pregnant women cannot well afford to lose blood; yet, a few years ago, pregnancy was supposed, as a matter of course, to call for repeated bloodlettings. The physician who de- clined to bleed a healthy person desirous of losing blood simply on the score of pregnancy, had often a task in trying to remove the disappointment which his refusal occasioned. A7enesection, under these circumstances, was deemed an important sanitary measure. How such an ab- surd notion arose I will not stop fully to explain. Briefly, it was a result of theoretical views respecting inflamma- tion, views which led to the conclusion that the great source of danger, as regards the development of disease, was a redundancy of the vital fluid. How different the practical views of the present time, based on the belief that paucity and impoverishment of the blood are con- ditions often giving rise to, and standing in the way of recovery from, a variety of diseases! As another example of the violation of conservatism, may be cited the custom with many surgeons, formerly, to prepare the system for important operations by lower- ing the powers of life. For this end, a course of purga- tives, a system of reduced diet, and sometimes a venesec- tion, were deemed important. This custom does not seem to be entirely exploded at the present time. In like manner, if there were good grounds to expect the speedy AS APPLIED TO HYGIENE. 91 occurrence of any disease, as, after exposure to contagi- ous fevers, during the period of incubation, a similar plan of impairing health, by way of preparation for the disease, was considered to be a prudential measure. Now it may be laid down as a rule of prophylaxis that, other things being equal, disease is less liable to occur in proportion as the health is perfect and the vital powers high in the scale of strength. This rule may not invariably hold good. Some of the special causes of disease, among those styled zymotic, appear sometimes to luxuriate in vigorous organisms; but if there are ex- ceptions, they do not subvert the rule. If this be true, it is a correlative truth that everything which impairs health or depresses the vital powers favors the occurrence of disease. Observation and common sense warrant the adoption of the latter truth as a maxim of conservative medicine. Akin to the foregoing rule is another, viz., the system is prepared to endure and recover from dis- ease in proportion to the previous completeness of health and the degree of constitutional vigor. Without having the statistical data to demonstrate this rule, and without denying the possibility of exceptions, observation and common sense warrant its adoption as a maxim of con- servative medicine. Let us, then, inquire whether among the existing notions or customs having reference to hy- giene in health, there be not some which are inconsistent with the foregoing conservative maxims. I do not mean to inquire concerning those palpable violations of the laws of health, which every reflecting person recognizes as such, and which are common enough. My proposed in- quiry relates to false views respecting the means of pre- serving health or warding off disease; in other words, instances in which persons suppose they are doing right 92 CONSERVATIVE MEDICINE when, in fact, they are doing wrong. It will not be difficult to find examples of this kind. The wear and tear incident to untiring activity in the pursuits of life first suggests itself. In this country the evils springing from false notions and customs, relating to the exercise of the mental and physical faculties, are enormous. A young man enters upon active life with injunctions to push his industry to the utmost limit of his capacity of endurance; he is incited to constant exer- tion by the examples of others; he is stimulated by his ambitious aspirations or a conscientious desire not to be wanting in the discharge of his duties; his position and responsibilities, in the existing state of society, may seem to render excessive and unremitted assiduity imperative. He may, or may not, violate the laws of health in other respects. If he be regular in his habits, temperate and moral, he is encouraged on every side by approving friends; he is held up as a model for imitation; he looks upon himself with self-complacency; and yet, he is ad- vancing steadily onward, perhaps, to the accomplishment of the great objects in life before him, but with greater certainty to a condition of impaired health, with the mind weakened or disordered, and a proclivity to any disease to which there may be a predisposition. All phy- sicians, especially those who practice in cities and large towns, well know that there is a class of patients who suffer from the want of health, without having any dis- ease which has a place in the nosology. The morbid state in these cases has been gradually induced, and many suffer without appreciating the fact that their state is morbid, and, therefore, without making application for medical aid. They feel a deficiency of their accustomed energy and buoyancy, their interest in persons and things AS APPLIED TO HYGIENE. 93 flags, their appetite fails, they lose strength, and they are depressed, without any apparent reason, or by causes which, in a condition of health, would disturb the mind very little. These are the early effects of wear and tear, due to overtasking, not the physical powers alone, but, conjunctively, the mental faculties. Of the cases of chronic diseases, such as tuberculosis, Bright’s disease, diabetes, etc., how large is the proportion in which the previous history shows the existence of wear and tear for a greater or less period prior to the development of the affection! This would be an interesting point for statistical research, but we need not wait for the results of statistics to know that the proportion is large. And, of the cases of acute diseases developed in persons suf- fering from wear and tear, how much of the fatality is due to the diminished power of resistance incident to the antecedent morbid state! How many would probably escape the development of acute disease were it not for this morbid state! These considerations, while they are of vast impor- tance, should not militate against a proper degree of at- tention to the objects in life. They do not show that either physical or mental activity is unfavorable to health. The reverse of this is undoubtedly true. As regards the mind, it is not the intensity of the exercise of the facul- ties which involves wear and tear. It is the long-con- tinued, unrelaxed efforts, accompanied by unceasing anxiety and strain, which tell upon the system. The physician, oppressed by the weight of his professional cares, is well aware that it is not the demand for the operations of the intellect which bears heavily upon him, so much as the pressure of the sense of responsibility inseparable from his duties, It is not the frequency or 94 CONSEKVATIVE MEDICINE force with which the bow is bent, but the constant tension, which destroys its elasticity and renders it worthless. Unremitted exercise of the mental and phys- ical powers, although they are not overtaxed, cannot be indefinitely borne; sooner or later the system will break down. Here is a truth difficult to appreciate in its per- sonal application; but every one recognizes it in its ap- plication to the physical endurance of inferior animals. A horse, never overworked, and in all respects well cared for, after a time must be turned out to grass. The prudent owner sees this clearly enough, and acts accord- ingly, while he fails to see that what is true of his horse is not less true of himself. Many persons pursue a course with respect to themselves which they could not pursue, without remorse, toward a beast of burden. It appears to be a part of the egotism inherent in some persons to think that they are so constituted as to bear an unlimited duration of steady work. Next to this is the folly of supposing that the powers of the system, when they give way, may be restored by medication. And when, at length, they find that they are not exempt from the laws pertaining to all animal, as well as human bodies, they perhaps discover, too late, that the influence of habit has rendered continuance of labor essential to happiness. Fortunate are they who, without sacrificing aught that belongs to a proper degree of assiduity in pursuing the objects of life, have taken care to preserve the capacity for healthful recreation! It is a curious notion, which physicians sometimes inadvertently sanction, that mental and physical exer- tions are compensatory as regards each other. The man who is overworking the brain, seeks to make amends by fatiguing the muscles. It has occurred to me repeatedly AS APPLIED TO HYGIENE. 95 to meet with persons who were devoting too large a number of hours daily to labor of the mind, and who imagined that this may be done with impunity provided a certain amount of muscular exercise be added. A lawyer, for example, who habitually devoted ten or twelve hours a day to intense intellectual occupation, became sensible that he was tasking unduly his mental powers, and, in order to fortify his health, moved out of town, and managed to ride on horseback from ten to twenty miles each day. Under the combined effects of the exercise of mind and body, as might be expected, he was losing ground rapidly. It is clear that exhausting mental labors will be longest borne in proportion as the time not thus occupied is devoted to physical, as well as mental, repose; and, on the other hand, that too much physical labor will be less hurtful in proportion as it is not conjoined with activity of mind. Violations of conservatism, hardly less flagrant, in the hygiene of health, relate to diet. Both the profession and public have been sufficiently alive to the subject of gluttony. The evils of overfeeding, as regards the pro- duction of disease, have undoubtedly been exaggerated. The injurious effects of gormandizing habits are mental and moral, rather than physical. So far as health and prophylaxis are concerned, false notions in an opposite direction have been productive of more harm. A quarter of a century ago, dietetic abstemiousness was considered to be the alpha and omega of hygiene. The world was eating too much ; hence, the ills that flesh is heir to. So believed, not only physicians, but the non-medical health philosophers. The great conditions of health were sup- posed by many to be the minimum quantity of food with which life could be supported, as little variety in 96 CONSERVATIVE MEDICINE the articles of diet as possible, coarseness in quality, and rejection of most of the accessory aliments. Some ad- vised, as a security against errors of quantity, to regu- late each meal by weight. Vegetarianism had not a few apostles and disciples. We have heard a transcendental reformer contend that in assimilating meat the natural characteristics of the animals were necessarily appropriated; that is, pork communicated to man the attributes of swine, and so of beef, mutton, veal, etc. All the refinements of the art of cooking were deprecated as tempting to overindul- gence. The sense of taste was deemed a fallacious guide in the selection of articles of diet, and the appetite was so unsafe as a criterion of sufficiency, that the injunction was always to rise from the table hungry. It was considered a wise course to watch carefully the progress of digestion, so as to ascertain after every meal whether any imprudence had been committed. The subject of dietetics was discussed, not only in medical writings and in intercourse with physicians, but it en- tered largely into popular literature; it not only per- vaded table-talk, but ranked next to the weather in common conversation; public lecturers made no small account of it, and it was not overlooked in the pulpit. In short, the zeal in behalf of abstemiousness in diet amounted to fanaticism. And dyspepsia was the most common of all ailments among the intelligent and cul- tivated classes, while it was rare among those who, without thinking of dietetics or digestion, satisfied the appetite with the food placed before them. There is reason to believe that the fanatical notions just referred to, not only contributed to the prevalence of dyspeptic AS APPLIED TO HYGIENE. 97 disorders, but favored, in no small degree, the develop- ment of other and graver affections, by impairing health and lowering the vital powers. These notions are by no means yet obsolete either within or without the profession. There are many now who fancy they promote the welfare of body and mind by habits of diet which are incompatible with the highest degree of mental and physical vigor. There are physi- cians who sanction such violations of the hygienics of health. It is still considered by not a few to be gross and unrefined to eat heartily. Especially with the other sex, it is deemed a lady-like accomplishment to have a delicate appetite, and abstain from the more substantial articles of food. There are fashionable boarding-schools where, as a part of the educational discipline, girls are placed under dietetic restrictions which, in a measure, explain the imperfect development, the anaemia and fee- bleness of constitution of those who are preparing to become wives and mothers. It is not yet sufficiently appreciated by all, that the mens sana in corpore sano is best secured by nutritious supplies abundant and varied ; that the healthiest, ablest, and best men and women have been good feeders; that an excess of ingesta over the absolute wants of the economy is not necessarily an evil, there being provisions made for the disposition of an overplus, but none against a deficiency of aliment; that generous living, constituting an important part of the management of certain diseases, e.g., pulmonary tu- berculosis, must be also important in preventing their development; that hunger, appetite, and taste were de- signed to govern dietetics, and are adequate to their office; and that personal experience derived from watch- ing the progress of digestion, is extremely fallacious. 98 CONSERVATIVE MEDICINE There is still, therefore, scope for the progress of conser- vatism in this direction, in order to meet the require- ments of existing knowledge and of common sense. With these few remarks on conservatism as applied to hygiene in health, I pass to the second division of the subject. Conservatism as applied to hygiene, in disease.—The importance of the hygienic management of diseases has not been, and is not, adequately estimated, for two rea- sons : First, because hygiene in its relations to health has been imperfectly understood and is not sufficiently appreciated; and, Second, too great reliance has been placed on medicinal measures of treatment. It is only within late years that the profession has begun to be awake to the vast importance of the study of the laws of health. Sanitary science is yet in its infancy, and claims far more interest and attention than it now re- ceives. The main dependence, hitherto, in the manage- ment of diseases, has been on the curative influence of remedies. That many diseases, under favorable hygienic circumstances, intrinsically tend to recovery, is a fact but recently known and still too little considered. The mind of the physician is too often engrossed with the inquiry, “What drugs shall I give to effect a cure?” and, hence, he frequently loses sight of another inquiry, often of far greater consequence, viz., “ What hygienic regulations will contribute to the recovery of the pa- tient?” This division of my subject lias diverse relations. In one aspect it relates to the various hygienic circumstan- ces embraced under the head of diet and regimen; the latter comprehending influences affecting not only the physical but the mental and moral being. In another 99 AS APPLIED TO HYGIENE. point of view, it relates to different diseases, the different stages of disease, and the numerous circumstances which are incidental to disease. I cannot undertake to treat of this more than the former division of the subject with any approach to completeness, or in a systematic manner. I shall only offer a few desultory thoughts, and I will consider first the topic which was last considered in the former division, namely, diet. A striking improvement in the practice of medicine, of late years, relates to diet. Physicians have learned to appreciate, more than formerly, the value of support- ing treatment in fevers and other acute diseases, and to regard alimentation as an essential part of this treatment. They have also learned that it is a great object in various disorders and chronic affections to build up the powers of the system, and that this is to be done by conjoining with other measures nutritious food. Has improvement in this direction reached its limit? Is the extent to which alimentation should enter into the management of diseases, fully appreciated ? Let us see if there be not ground for answering these questions in the negative. Limiting attention to acute diseases, it is now gener- ally understood that they do not stand in the way of dying from starvation. Graves uttered a literal fact wThen he said that patients with continued fever, treated without nourishment, may be starved to death. And this fact is equally applicable to other acute diseases. That a fatal result may take place, and not infrequently has taken place, not from an existing acute disease per se, but from inanition, will not be denied. Now it is only an extension of this fact to say that more or less of the morbid phenomena pertaining to the progress of acute diseases are due to a suspension or impairment of 100 CONSERVATIVE MEDICINE the processes involved in nutrition. If patients affected with acute diseases may die from inanition, the latter must play an important part in the production of the phenomena manifested in connection with the diseases; and this must be true of cases which end in recovery as well as of those which terminate fatally. Deficiency of assimilation originates the symptomatic phenomena, in acute diseases, to a greater or less extent, and here is a source of danger in a greater or less degree. In other words, the symptoms which represent the condition of a patient affected with an acute disease, spring, in part, directly from the disease, and partly from the want of appropriation of fresh supplies for nutrition. Innutri- tion, in a pathogenetic point of view, has not been suffi- ciently considered. There is reason to believe that it forms a constant, and often a very important element of all acute diseases ; and the practical bearing of this fact is of great importance. It is fair to assume that the effects produced in a healthy person by withholding food, may also result from the want of nourishment in disease. If starvation be not less fatal in the latter case than in the former, the morbid phenomena, it may be reasonably supposed, are essentially the same in both cases. In order, therefore, to judge of the extent to which the symptoms of disease are attributable to innutrition, the clinical study of star- vation in health is important. Experimental observa- tions in inferior animals are not altogether satisfactory in consequence of the difficulty of appreciating certain symptoms. Nor are the instances of human beings starved from necessity, as in shipwreck, suited to the purpose, because the effects of the want of food are mixed with the moral influences incident to their situation, and, AS APPLIED TO HYGIENE. 101 moreover, in such instances, generally, there is a depri- vation of water as well as food. Experiments volun- tarily made are to be preferred; and of these the best to which 1 am able to refer are those made by Hammond, to establish the relative nutritive value of albumen, starch, and gum.1 Subjecting himself to the trial of re- stricting his diet to these alimentary principles singly, Hammond found that they were incapable of supplying the wants of the system, and that the two latter were absolutely innutritious. During each experiment certain phenomena were produced. Now, these phenomena, for the most part, certainly were not produced by the ali- mentary principle taken, but resulted from the absence of other alimentary principles, or in other words, from innutrition. These experiments, therefore, may be taken as illustrative of the morbid effects of starvation, effects occurring in disease as well as in health. In this point of view they are not only interesting, but of great value. Deferring the reader to the essay for fuller details, I will simply mention the symptoms entering into the concise descriptions by the experimenter. 1. Under a diet consisting of pure albumen for ten days : Febrile movements, heat and dryness of skin, headache, loss of appetite, nausea, abdominal pains, pro- gressively increasing debility, serous diarrhoea, want of sleep. 2. Under a diet of pure starch for ten days : Debility, disturbed sleep, sense of oppression of chest, palpitation, headache, slight scratches of the skin showing tendency to inflammation and suppuration, febrile movement, abdominal pains. 1 Vide Physiological Memoirs, by ffm. A. Hammond, M.D., Surgeon-General U. S. Army, etc., 1863. 102 CONSERVATIVE MEDICINE 3. Under a diet of gum, which he was able to con- tinue only for four days: Abdominal pains, disturbed sleep, headache, febrile movement, diarrhoea.1 Can it be doubted that these symptoms occur under similar conditions as regards diet, in the course of dis- ease? And, if so, how often are these symptoms, pre- senting themselves in the course of disease, referable, measurably or entirely, to innutrition ? I cannot dwell upon these inquiries. I must leave them, reiterating the belief that, while under erroneous views physicians have been accustomed to regard the ingestion of nutritious food during the course of acute diseases as fraught with evil results, more or less of the morbid phenomena sup- posed to belong directly and exclusively to the existing disease, proceed from defective assimilation. The practical conclusion based on the statement just made is obvious. It is an object in the management of acute diseases not to withhold nutriment, but to promote the assimilation of nutritious supplies. In many dis- eases this is the great object in the management, taking precedence of any known curative remedies. The object always exists, but the extent to which it can be accom- plished varies according to the nature and seat of the disease, together with a host of incidental circumstances. The object is the basis of a principle which may be laid down as applicable to the treatment of all acute diseases, namely, alimentation is important to the fullest practica- ble extent. It is always desirable for a patient affected 1 For a full account of the effects of starvation on the different organs and functions, and for references to the literature of this subject, the reader is re- ferred to the Court de Physiologic., par I*. Berard, tome premier, pages 517 el seq. The following quotation, by this author, from Chossat, embraces a fact which has been to a great extent overlooked: “ L'inanition est une cause de mart qui marche de front el en silence avec loute maladie dans laquelle l’alimentation n'est pas d Vital normal." AS APPLIED TO HYGIENE. 103 with any acute disease to take as much food, embracing a proper variety of alimentary principles, as will be ap- propriated. Inconvenience and evil results may doubt- less follow the ingestion of aliment beyond the powers of digestion and assimilation ; but the risk of injury from this source, with the exercise of a fair amount of pru- dence, is less than the liability of harm if, from an ex- cess of caution, the patient suffer from starvation. The minds of physicians have been too exclusively directed to the harm which may possibly be done by overfeeding in acute diseases, and they have overlooked the greater harm of failing to furnish supplies which may be digested and assimilated notwithstanding the existence of disease. A wide field is opened up by the practical application of this principle. It involves the encouragement of a desire for food instead of the discouragement caused by needless apprehensions. The desire for food may often be developed by judicious contrivances; the appetite may be fostered, on the one hand, or, on the other hand de- stroyed by circumstances connected with the selection, preparation, and administration of articles of diet. Giving medicines too frequently, and the use of nauseous or nau- seating remedies, may do harm by compromising the desire for food and appetite, which their remedial effects will not compensate for. The mental condition may conflict with a disposition to take food, when, if taken, it will be digested and assimilated; this is true of the continued fevers, and other diseases accompanied by a typhoid state. In such cases food is to be given with- out regard to the desire or appetite; the condition of the digestive organs, and the results of experience from day to day, are of course to be considered. These are some of the numerous circumstances affecting alimentation as 104 CONSERVATIVE MEDICINE a measure of management in acute diseases. I must content myself with this allusion to them. But in pass- ing from this topic, a word or two with regard to the diet of hospitals. This is generally determined by the supposed wants of the system, without much reference to the choice or wishes of the patient. How much good might be done by selecting, preparing, and serving food to hospital patients with a view, not alone to the requisite amount and variety of nutritive material, but to develop, encourage, and satisfy desire and appetite ! I have often thought if I had unlimited control of the culinary de- partment of a hospital, I would willingly submit to a proportionate curtailment of the articles pertaining to the dispensary. I cannot find space even to touch upon the various practical points pertaining to the kinds of food suited to the diverse circumstances incident to different diseases; and I will only add, lest some of my readers may imag- ine what I have written on the dietetic management of acute diseases to be purely speculative, that the views now presented are based not only on reasoning believed to be sound, but on considerable experience. This ex- perience would have been larger were it not that tradi- tional ideas fixed in the public mind, as well as still prevailing in the profession, render it difficult often to carry out an efficient plan of alimentation in private practice; and in hospitals this part of the treatment is limited by circumstances which the physician cannot control. Prejudices, professional and popular, against air and water in the management of acute diseases, pre- vailed until within a recent period, and are by no means now obsolete. The antipathy to feeding patients will in AS APPLIED TO HYGIENE 105 time appear as absurd as to deny drink and disregard ventilation. The foregoing remarks have had reference to diet in acute diseases. The importance of ample alimentation in chronic affections is better appreciated, but there is room here for further improvement. I shall content myself here with a maxim of conservative medicine, quoted from my first essay on this subject: “Under all circumstances, a chronic affection is less likely to be pro- longed, serious lesions of structure are less likely to take place, and a fatal termination is postponed in proportion as the vital powers are preserved.” I need not stop to argue that the vital powers are to be preserved by a nu- tritious diet conjoined with other hygienic measures. I have just now alluded to air as an element of hy- giene in disease. Of the various hygienic conditions, perhaps, to none has attention been more directed, of late years, than a sufficiency of breathing-space and ade- quate ventilation. There is room, however, for the in- quiry whether improvement here has reached its limit. Granting the largest estimate of cubic feet, and the best contrivances for the renewal of the air of the ward or sick-room, there is reason to think that additional influ- ences pertaining to the atmosphere may be brought to bear with advantage on the management of diseases. During the civil war in this country it has been re- peatedly observed that the wounded have done better in the open air, exposed to deprivations and vicissitudes of weather, than after having been received into houses or hospitals containing every provision for comfort. Surgeons have found that the most effectual mode of ar- resting hospital gangrene is to transfer patients at once to tents, and the rapidity of improvement in the latter situ- 106 CONSERVATIVE MEDICINE ation is remarkable. Now, the question arises, may not out-of-door exposure, or what is equivalent thereto, be useful in many aeute diseases? Its usefulness in chronic affections is acknowledged. This question is worthy of consideration with a view to experimental observation. It would not be surprising if patients affected with fevers and acute inflammations were found to improve in a notable degree under the freest possible exposure to air. As to the choice between such exposure and insuffici- ency of space and ventilation, there is, of course, no question. There are facts enough bearing on this point. But the question is whether such exposure may not be advantageously added to the observance of the usual sanitary requirements respecting air. Free and daily exposure is important as a means of preserving the vigor of the body in health; may it not be equally important as a means of keeping up the vital powers in disease? Every one accustomed to spend much time in hospi- tal wards, must be aware of the sense of debility felt after remaining there for even two or three hours. How different the feeling after having been in the open air for the same period! How would the strength and energy of mind and body flag, if an active, healthy man were confined for successive days and weeks to an apartment with the air sufficiently renewed to preserve its purity, but kept steadily at a uniform warm temperature ! How refreshing would be cool breezes and alternations of heat and cold after such a confinement! Do not these facts apply to the body and mind in disease as well as in health? As a general rule, the hygienic circumstances required by conservatism in health, are not less impor- tant in disease; and it is at highly probable that, as respects the depressing effects of confinement in heated AS APPLIED TO HYGIENE. 107 rooms on the one hand, and the invigorating effects of free exposure to air on the other hand, sanitary laws are ap- plicable alike to disease and health. As bearing indirectly on this topic, I may refer to in- stances of persons passing safely through fevers and acute inflammations, in situations in which they are necessarily exposed to atmospherical vicissitudes. For example, I have reported a case of pneumonia affecting one entire lung, the patient living entirely alone in a shanty, in the winter season, in Louisiana; the shanty in a swamp, the floor of earth covered with water; his sub- sistence consisting of bread and water with a bottle of whisky, and the evacuations passed in bed. The patient was discovered and removed from this situation to the Charity Hospital of New Orleans already convalescing, and he rapidly recovered. I have known a patient af- fected with pneumonia escape from the ward in a state of delirium during the night in the winter season, wearing only a cotton shirt, and walk a distance of two miles to a house where he had formerly lived. He was brought back to the hospital the next day, free from delirium, and he convalesced rapidly, having received no detriment from this great amount of exposure and exertion. Ex- amples analogous to these occasionally fall under the ob- servation of all practitioners. They show, at least, that prevailing apprehensions of danger from exposure to at- mospheric influences, during the progress of acute dis- eases, are much exaggerated. This remark will apply to early gestation in convalescence from acute diseases. It was formerly supposed that most acute diseases left behind them a liability to relapse, or a condition favora- ble for the development of other affections; and, there- fore, that great care must be taken to avoid all exertion, 108 CONSERVATIVE MEDICINE and especially the morbific agency imputed to cold. A better knowledge of the natural history of diseases has taught us that, as a rule, there is little or no tendency to relapse, and that the sequels of certain diseases pro- ceed from intrinsic tendencies. Of the hygienic circum- stances favoring rapid and complete restoration to health, getting up as soon as the strength will permit, and gentle exercise in the open air, are among the most effi- cient. I could cite illustrations of this fact in abun- dance. As I am writing, a striking instance comes to my mind of a fellow-practitioner who had kept the bed for a long time with chronic pleurisy, accompanied with great debility and emaciation, and, finally, bed-sores were added to his sufferings. At this juncture he was taken out of bed, placed in a carriage, and driven a short distance. The effect on body and mind was such that the experiment was repeated. He continued to ride out daily, and rapidly recovered. This was many years ago; he is now in good health and in active practice. Here is a striking instance among many exemplifying the hy- gienic importance of air and exercise in determining convalescence and promoting recovery. Are the requirements of conservatism fully met by a due appreciation of all that pertains to mental hygiene in disease? This question will lead to a few remarks which will conclude my brief consideration of conserva- tism as applied to hygiene in disease. Physicians are not unmindful of the reciprocal influences of mind and body. It would be trite to assert their existence and importance. They are patent to every medical observer. But it is perhaps true that mental conditions are more largely concerned in either favoring or antagonizing disease than is generally supposed; and hence, that the AS APPLIED TO HYGIENE. 109 therapeutic value of hygienic influences acting prima- rily on the mind, are not sufficiently appreciated. It is obvious that the capacity of resisting and recov- ering from disease varies in different persons. The same disease, having apparently the same intensity, will de- stroy some and not others. And there is a wide differ- ence as regards the duration of life with a similar amount of incurable lesions. Take, for example, pulmonary tuberculosis, how great the diversity in the extent of de- struction of the lungs in cases in which this disease alone has produced death ! Now this intrinsic power of over- coming disease, and of living on with irremediable af- fections which will sooner or later prove fatal, is not altogether vital but in part mental. If the faculties of the mind be not impaired or obscured by disease, the patient is rarely indifferent to its progress or the result; it is accompanied by more or less emotional activity. Much, often very much, depends on the character of the predominant emotions. Hope, confidence in the physi- cian and the means of cure, reliance on the wisdom of Divine Providence, are sentiments which sustain the vital powers and are conservative. On the other hand, discouragement, apprehensions, dissatisfaction, impati- ence, depress the vital powers and are non-conservative. The character of the predominant emotions will, of course, depend in a great measure on mental constitu- tion, education, habits of thought and feeling, etc., with reference to which there is nothing like uniformity in different persons; but judicious management on the part of the physician may determine their character to a greater or less extent. The ability to secure complete confidence, to exert an influence over the minds of 110 CONSERVATIVE MEDICINE patients, enhances, in no small degree, the skill of the physician. As belonging legitimately to the practice of medicine, this is not enough considered. But the skilful exercise of a moral power requires accuracy of diagnosis and knowledge of the laws of disease. If the physician be not able to judge correctly of the situation of a patient, he cannot give the assurances which the nature of the case may warrant; prudence, as regards his own reputa- tion, dictates great reserve, and he depresses his patient by non-committalism. In a dispensary practice limited to affections of the chest, I have been forcibly impressed with the good which may be done in many cases by simply declaring ex cathedra the absence of consumption or an affection of the heart. Poor patients, after having perhaps suffered long from secret apprehension of serious disease, come tremblingly, at length, as if to hear their doom pronounced. Thanks to the invaluble methods of physical diagnosis, the healthy state of the thoracic organs may be positively ascertained. How delightful to witness the transition from despondency to joy, when soundness of the suspected organs is announced and be- lieved! The moral effect is often of more efficacy than any medicinal remedy. It would be easy to cite nu- merous instances of mental suffering with physical dis- order persisting many years for the lack of an authori- tative assurance of the non-existence of a fatal malady. It does not enter into my plan to discuss the various means by which mental influences may be brought to bear on the management of diseases. I wish only to bring forward the fact that here is an important prov- ince of conservative medicine. A topic suggests itself in this connection which I will not pass by, because it relates to a matter concerning which the opinions and AS APPLIED TO HYGIENE. conduct of medical men differ: I refer to the co-opera- tion of the clergy in cases of disease. Some physicians take the position that during the progress of diseases in- volving danger to life, the ministrations of religion are liable to interfere with recovery by producing excite- ment and discouragement. I desire to bear testimony against this position. Divesting the topic of all consid- erations save those which relate to the influence upon the progress of the disease, experience has led me to have no fear of harm from the timely and judicious offices of clergymen and religious friends. On the con- trary, the effect is often manifestly salutary. If the mental faculties remain intact, every patient must think of the probability or possibility of an exist- ing disease ending fatally. There can be no stronger evidence of an imbruted mind than the absence of all thought of danger. And the doubt, uncertainty, and anxiety engendered by the patient’s reflections occasion a more depressing effect than even a definite expectation of a fatal result. Every physician knows how common it is to be entreated by the patient to make known to him his actual condition, to tell him the worst, a painful state of suspense with respect to death, as well as any event involving a deep personal interest, being more difficult to bear than its anticipation. For this reason, although a certain amount of reserve may be allowable, the physician should, as a rule, meet the demands of the patient for explicit information with candor, and he should never violate the truth. The most favorable condition of mind, in a hygienic point of view, is that induced by confidence and hopefulness in union with a cheerful resignation to the will of God. In so far as the services of the minister of religion conduce to the latter, 112 CONSERVATIVE MEDICINE he becomes the coadjutor of the physician. Irrespec- tive of life and health, this topic has relations to mo- mentous interests which would be here out of place, even if the writer were presumptuous enough to consider them. I wish simply to record the opinion, as a phy- sician having had considerable opportunity for observa- tion, that so far from there being any ground for an- tagonism, the minister of religion may effectively co-op- erate with the medical practitioner in behalf of the physical welfare of the sick. Attention to mental hygiene in hospitals often falls short of the requirements of conservatism. The viola- tions of conservatism, in this regard, consist, in the first place, of circumstances which tend to depress the vital powers by their influence on the mind, and, in the second place, in the absence of circumstances influencing the mind in an opposite direction. Obvious sources of a depressing influence are apt to be overlooked. One of these is the necessity of witnessing the distressing manifestations of disease in other cases in the same ward. Cases which, from their character, shock or painfully excite the feelings, should, as far as possible, be isolated. To be confined in the same apartment, or, perhaps, to lie side by side with patients in a state of active delirium, or affected with convulsions, or in stertorous coma, or suffering extreme pain, is to be exposed to a depressing influence which one can best appreciate by imagining himself in such a situation. It is melancholy to think that a brutish insensibility is often the only resource against this influence. It is cruel to compel hospital patients to witness the phenomena of the dying act. How often have I seen the most marked evidence of the unfavorable effect of a prolonged agony in a hospital AS APPLIED TO HYGIENE. 113 ward! If it be true that the patients may become habituated to these scenes, so as to regard them with in- difference, is this a result to be desired ! The propriety of assigning wards to tuberculous cases, or to incurable diseases, is more than doubtful as a measure of mental hygiene. What can be more discouraging to a tubercu- lous patient than to be surrounded with cases presenting all the different phases and gradations of consumption ? For this reason consumptive hospitals are objectionable. The circumstances just referred to may not be under the control of physicians connected with hospitals; but there are circumstances for which medical officers and visitors are exclusively responsible. It is very rarely the case that hospital patients are treated cruelly, roughly, or neglectfully; but the fact of their having the same faculties of thought and the same sensibilities as private patients, is not always sufficiently borne in mind. If this fact were not sometimes forgotten, the nature pf the disease, the prognosis, and the appearances which may be expected to be found after death, would never be discussed without reserve at the bedside of a patient; the chances of recovery or death in the cases under observation, the incidents of the dead house, and other topics of a like character, would not enter into conversations held in the wards. It is but just to say that such breaches of conservatism are by no means common, and that when they do occur they proceed generally from the thoughtlessness incident to youth and preoccupation. There is room for improvement as regards mental hygiene in hospitals, not only by obviating circumstances which exert a depressing influence, but by trying to call into exercise thoughts and feelings which have a salutary 114 CONSERVATIVE MEDICINE effect in disease. It is a great charity to institute for the sick poor places of refuge, furnishing shelter, nour- ishment, nursing, and medical aid; and for many of the miserable candidates for such a charity, a hospital ward offers comforts far beyond those to which they have been accustomed. But supplying these needs does not fulfil all the requirements of relief; sympathy, encour- agement, and religious ministrations may be added with advantage in a sanitary point of view, irrespective of other and higher objects. For this part of the hygienic management the physicians must depend in a great measure on others. And here is a field for philanthropic labor which lacks husbandmen. How few of the many who are earnest to benefit their fellows think of the sick and friendless poor in hospitals, where, by judicious words and offices of kindness, they might reap a harvest of good works, of which least in importance, although important, is the favorable influence on the course of disease! But I am entering on a train of thought which, for the medical reader, offers nothing new and is not called for, and I therefore here rest my remarks on hygiene in disease. With this essay I take leave of the subject of Con- servative Medicine. In my first essay I endeavored to show that the term conservatism expresses the great feature of medicine of the present time, and a governing principle in medical practice. In my second essay I considered the principle of conservatism as applied to therapeutics. In this third essay I have offered a few fragmentary thoughts on the application of this princi- ple to hygiene. With the rise and progress of conser- vatism we see a great, almost a radical change in prac- AS APPLIED TO HYGIENE. 115 tical medicine. This change is a legitimate result of the progress of knowledge. It is not to be expected that medicine is to be stationary; unchangeableness is incom- patible with progress. There must be changes if medi- cine be progressive. Bearing in mind these truths, it is the part of every true physician to try to keep pace with the advancement of the profession. 116 MEDICINE in THE PAST, THE PRESENT, IV. Medicine in the Past, the Present, and the Future.1 TO consider the present in comparison with the past, and in anticipation of the future, is a grand prerog- ative of the human intellect, as contrasted with the mental endowments of the inferior races of created beings. Man alone brings to bear upon the thoughts and acts of individual life the experience of generations which have passed, and man alone undertakes to foresee the events of generations which are to come. Among the highest, the most attractive, and the most useful of studies, are those which consider the different branches of existing knowledge in their retrospective and prospec- tive relations. A just appreciation of the present state of human progress in science, in art, or in social life, is to be based on a comparison of the present with the past, and a rational foresight of developments which are here- after to mark this progress must rest on the same basis. With these truisms I introduce the subject of my dis- course on this occasion. I shall offer some observations concerning medicine in the present, the past, and the fu- ture. In announcing a subject of such wide scope, let me make haste to forestall certain apprehensions which it will be likely to awaken, by saying that, as regards 1 An Anniversary Discourse before the New York Academy of Medicine. AND THE FUTURE. 117 the past, my range will extend only to a period within the memory of those who are not among the younger, nor yet among the oldest, of the living members of the medical profession; and, as regards the future, I shall forego indulgence in elaborate prophetic visions. My observations, moreover, will be confined to medicine proper, that is, to medicine in contradistinction to sur- gery. With these restrictions, a discourse discreetly limited in length can take in but a few of the topics which the subject suggests, and these must be considered in a desultory manner. Let a physician, whose reminiscences extend to the close of the first quarter of the nineteenth century, take this date as a standpoint, and institute a comparison of the present with the past. Human anatomy,-as regards “gross appearances” (a phrase which, had it then been in use, would have had little significance), offers not many striking points in contrast. The descriptions of organs, in the anatomical treatises then in use, would answer well for the medical student of to-day. Up to that date the term anatomy needed no prefixes denoting subdivisions of the study. The names special and descriptive came into use after the creation of general anatomy by Bichat. The stu- dent of anatomy, prior to the date of which I am speak- ing, as compared with the student of the present day, had an easy task. Not only were treatises less porten- tous in bulk, but their authors by no means adhered to dry anatomical details; the functions of organs were treated of, and the student was diverted with excursions into the fields of medical practice and operative surgery. The analytical study of organs, resolving them into their component tissues, was a memorable epoch in 118 MEDICINE IN THE PAST, THE PRESENT, medicine. The voluminous treatise on general anatomy by Bichat has become obsolete ; but it gave an impulse and a direction to researches, not alone in pure normal anatomy, but in morbid changes and processes, and paved the way to the more recent developments, with the aid of the microscope, which have added to general anatomy the extensive and fruitful territory of Histology. Histological researches have carried observation beyond the elementary tissues of Bichat to the “ anatomical ele- ments” into which these tissues are resolvable. So great and important an advance in this direction has been made within the last few years, that one who has lately entered upon anatomical study must find it diffi- cult to appreciate the enthusiasm which, a little more than thirty years ago, led an eminent medical teacher in our country to say that the “ General Anatomy ” of Bichat was a “ revelation in medicine.” But for one whose professional reminiscences extend to the date of the publication of Bichat’s works in our language, it is not easy to forego the desire to linger in admiration of the genius and industry which achieved, at the age of thirty-two, the honor of being styled the “ father of general anatomy.” The present, thus, in medicine, as compared with the past, dating from the labors of Bichat, is characterized by the acquisition of a vast and important territory in anatomy, extending from the boundaries of the unaided vision over a space the limits of which are yet to be de- fined. The importance of this new territory relates by no means exclusively to our knowledge of the normal organization of the body, but also to pathological his- tology and to the bearing of anatomical developments by the microscope on our knowledge of physiological and AND THE FUTURE. 119 pathological processes. The progress thus made in anat- omy required its disseverance from other departments of medical study, and its subdivision into distinct branches, namely: 1. The description of organs, constituting special or descriptive anatomy ; 2. The description of the tissues and of the anatomical elements in health, embracing normal histology ; 3. The gross and microscopical char- acter of disease, or morbid anatomy, embracing patholog- ical histology. Each of these subdivisions now claims in bibliography separate and voluminous treatises. As an illustration of the contrast, in this point of view, between the present and the past, the French translator of Meckel's Anatomy (the American translation of which appeared in 1831) announces in his preface that this work comprises “ all the important facts of general, de- scriptive, and pathological anatomy, and of physiology !” Turning from anatomy to the study of the processes which take place within the body in health and in dis- ease, that is, to physiology and pathology, provinces of medicine conventionally reckoned as distinct, but, in reality, parts of one dominion, and taking the same stand- point, let us briefly notice some contrasts here between the present and the past. At the end of the first quarter of the present century, the great discovery, by Magendie and Bell, of distinct nervous fibres for sensation and motion, was in the pro- cess of adoption, and the discovery of the excito-motor or reflex functions of the nervous system had not been made. Think of the practice of medicine without these discoveries, justly compared, in importance, with the discovery of the circulation of the blood ! Beaumont began his experiments in the case of Alexis St. Martin in 1825, and the results were not given to the profession 120 MEDICINE IN THE PAST, THE PRESENT, until 1833. Physiologists had concluded that the active agent in digestion was a fluid, because food contained in linen bags, and perforated metallic balls, which animals were made to swallow, was found to be digested, and John Hunter had discovered post-mortem digestion of the stomach ; but the physical and chemical properties of the gastric juice had not been ascertained, the digestive power of this secretion when removed from the stomach had not been observed, and the comparative digestibility of different articles of diet had not been brought under direct observation. Magendie had entered upon the vivisections, the results of which entitle him to be called the “ father of modern experimental physiology,” meet- ing with distrust and ridicule, both from within and without the profession, and, on the plea of needless cruelty, with an opposition which certain of the pseudo- humanitarians of this day are not ashamed to continue notwithstanding the use of anaesthetics which were un- known in Magendie’s time; but the withdrawal of the contents of the alimentary canal, and of the products of internal glands, by means of permanent fistulas, was re- served for a later period. Digestion was supposed to be exclusively a function of the stomach ; the digestive power of the intestinal juice, together with the bile and pancreatic secretion, was unknown. The enormous quan- tity of fluids secreted for digestion was not dreamed of. Even now it is difficult to realize the statement that the quantity of digestive fluids secreted per diem exceeds the whole mass of blood, and equals one-seventh of the weight of the body ! Venous absorption was not ac- knowledged. Little was known of osmosis. The prod- ucts of digestion were supposed to be taken up exclu- sively by the laeteals, which, it was imagined, had open 121 AND THE FUTURE. mouths endowed with a kind of intelligent faculty of election. The production of excrementitious substances in the tissues, their presence in the blood, the office of certain glands being for their separation, and not for their formation, are facts, having very important bear- ings on pathology and practice, which have only within late years been demonstrated. Passing to pathology and practical medicine, classical authorities at the date selected for our comparison of the present with the past were, Gregory’s Practice, Thomas’s Practice, and the elaborate “ Study of Medicine,” by John Mason Good. They, whose retrospections extend to the time when the five volumes of Good’s “Study of Medicine” were to be read by the medical student, will not have forgotten how agreeable was the task. The comprehensive scope of the work is set forth in the pref- ace, in which the object is stated to be “to unite the different branches of medical science into a general sys- tem, so that the whole may be contemplated under a single view and pursued under a common study.” “ These branches,” the author continues, “ are the fol- lowing: 1. Physiology, or the doctrine of the natural action of the living principle; 2. Pathology, or the doc- trine of its morbid action; 3. Nosology, or the doctrine of the classification of diseases ; 4. Therapeutics, or the doctrine of their treatment and cure.” The complete- ness of the classification, the classical nomenclature, the “ physiological proems,” the erudition, the interesting episodes and curious incidents together with the attrac- tive style of composition, rendered this work not less charming than instructive. There were “Brunonians” in those days; and soon afterward came Broussais, the founder of another sect, 122 MEDICINE IN THE PAST, THE PRESENT, undertaking, like Brown, to reduce pathology and prac- tice to a simple formula, both starting from substantially the same theory, but reaching systems of practice dia- metrically opposite ; one considering all diseases as as- thenic, and requiring stimulants, the other recognizing in most affections, whether general or local, either in- flammation or over-excitation, and arguing that they are to be combated by depletion and starvation. Standard works on practical medicine may be taken as exponents of current doctrines in pathology and ther- apeutics; and, with successive changes in medical opin- ions, representative works are pretty sure to be forth- coming. Not going beyond British and American medi- cal literature, text-books which supplanted Gregory, Thomas, and Good, were the fascinating and in all re- spects admirable lectures by Watson, the treatises by Eberle, Hosack, Dunglison, Elliotson, and the “ Cyclo- paedia of Practical Medicine.” A quarter of a century is a long life fora text-book in medicine; but “ Watson’s Practice” has reached this longevity, still retaining not a little of the freshness of youth. At the present time, this province of medical bibliography is occupied by several recent works, whose authors aim to represent more fully than those just named, the existing state of pathology and practice; and it is to be hoped that hence- forward the real progress of medical knowledge may render these works more short-lived than their immedi- ate predecessors. Let us now glance at some of the more important of the changes, pathological and practi- cal, which have taken place during the second and third quarter of the present century. In this retrospection auscultation first claims notice. Laennec, it is true, published his great work on mediate AND TIIE FUTURE. 123 auscultation in 1819, and it was translated by Forbes in 1821. Before its publication, a commission, appointed by the Academy of Medicine in Paris (composed of three members whose names are now comparatively unknown), had reported, in substance, that, although this method of exploration was by no means a new discovery, inas- much as many observers, even Hippocrates, had listened to sounds emanating from the chest, yet, the labors of M. Laennec were highly creditable, and might prove of practical value ! The merits of auscultation were not, in fact, appreciated, save to a very limited extent, for several years after the death of Laennec in 1826. It is only within the last few years that there have not been many who were not ashamed to sneer at the stethoscope. In 1836 a writer in a popular magazine said of it, “ The toy is a new toy /n and in the same year the Boylston medical committee of Harvard University offered a question for a prize essay in the following terms : “ How far are the external means of exploring the condition of the internal organs to be considered useful, and impor- tant in medical practice/’ the successful competitor being Oliver Wendell Holmes. Percussion, the elder brother of Auscultation, the difference in their ages being over half a century, had died almost at birth, and was disin- terred by Corvisart in 1808; but it was not really re- suscitated until it became associated with auscultation. Need I ask how unsatisfactory would be the practice of medicine were the profession to be deprived of these methods of direct exploration ? The use of the speculum was among the “ lost arts,” and its revival did not take place for many years after auscultation and percussion Vide Prize Essay, l>y Oliver Wendell Holmes. 124 MEDICINE IN THE PAST, THE PRESENT, had come into vogue. The date of the employment of the thermometer in diagnosis and prognosis, together with the laryngoscope and the endoscope, is so recent that these means of direct exploration are now novelties in medical practice. The labors of Laennec were preliminary to the suc- cessful application of auscultation to the study of cardiac diseases. The disease now known as endocarditis had no place in nosology. Pericarditis was nosologically recognized, but, as regards its diagnosis, Laennec ad- mitted that its existence could only be guessed at; and as to valvular lesions, knowledge of their situation and character was reserved for autopsical disclosures. Thanks to the researches of Bouillaud, Hope, Stokes, Latham, and others, at this moment no diseases are dis- criminated with greater promptness and precision than the various affections of the heart. Let the practitioner reflect upon the hiatus in practical medicine were we to be now deprived of the information relating to these diseases which has been acquired since the days of Thomas, Gregory, and Good. What shall be said of the developments in pathology and practice which had their point of departure in a pub- lication, in 1827, by Richard Bright, under the unassum- ing title, “A Report of Medical Cases?” Bright’s dis- covery came at a time when pathologists explained dropsy by saying that it was owing either to increased action of the exhalant, or to diminished action of the absorbent vessels; and when uraemic coma and convulsions were attributed to “cerebral congestion,” “erethism of the brain,” “ sympathetic irritation,” and “ nervous apo- plexy.” Imagine our present knowledge of the various affections of the kidney, with their pathological rela- AND THE FUTURE. 125 tions, to be obliterated, would it not be like returning to a “dark age” in medicine? and yet, the absence of this knowledge is within the professional recollections of many of the fellows of the Yew York Academy of Medi- cine ! The developments in neuro-pathology are in propor- tion to those relating to the physiology of the nervous system. The practitioners in the beginning of the second quarter of the present century recognized but few of the neuralgic affections as such, considering the visceral neuralgias as inflammatory. They did not undertake to differentiate gastritis, enteritis, and pleuritis, from gastralgia, enteralgia, and pleuralgia. Sciatica and tic douloureux constituted the list of neuralgic affections, the latter being referred, in certain cases, to the portio dura, and this nerve had been sometimes divided as a means of cure. Paralysis, it would seem, could hardly be misinterpreted; yet it is but lately that Duchenne eliminated, from the class of paralytical affections, loco- motor ataxia, and that muscular atrophy has taken the place of “ creeping palsy.” Finally, the most striking of the points of contrast, in this comparison of the present with the past, may be referred to a better knowledge now than formerly of the natural history of diseases. To consider diseases as en- tities was a natural transition from the superstitious doctrine which attributed them to the agency of evil spirits. The ontology against which Broussais battled so truculently came in legitimate succession from a de- moniacal pathology. Even now it is curious to note the extent to which the language used by medical writers implies the personality of diseases. It is common to apply to them various epithets, such as obstinate, per- 126 MEDICINE IN THE PAST, THE PRESENT, sistent, malignant, rebellious, which denote the passions of demons and men. It is said that they yield, that they manifest themselves, that they seize upon, attack, or invade parts, and that they have their local expres- sions, modes of speech thus imputing to them percep- tion and will. This language, now used metaphori- cally, represented formerly ontological ideas. The passions, intentions, and volitions attributed to diseases were, for the most part, in opposition to human life. The morbid entities which perceived, felt, and acted, were the vindictive enemies of the human race. The term “ heroic,” as applied to practitioners and remedies, had its origin, probably, in this imaginary strife for life and death with diseases as if they were intelligent and implacable foes to the existence of man. That the atti- tude of the “doctor” toward disease should be invaria- bly one of antagonism, is a notion which has prevailed up to a recent date; and this notion is still so fixed in the popular mind that the name allopatlust is not con- sidered misapplied even by a majority of those who know the derivation of the word. That pathological laws exemplify often a principle of conservatism; that the beneficent hand of Nature, or, to speak more properly, that Divine design is manifested in pathology, as well as in physiology, the study of the natural history of dis- eases has disclosed in these latter days, and herein is one of the most prominent of the characteristics of the present as compared with the past. Connected with the modern study of the natural his- tory of diseases is the honored name of one whose labors, in themselves of great value, contributed vastly toward the inauguration of a more exact and complete system of observation than had previously been pursued. Need AND THE FUTURE. 127 I say that I refer to Louis, the founder of the so-called “ numerical system ?” This system consists, first, in re- cording, carefully, fully, and honestly, cases of disease, after having acquired, by cultivation and practice, the difficult art of making and noting observations. To comply with the requirements of this part of the system, in addition to opportunities, leisure, and conscientious- ness, the observer must be free from the bias of precon- victions, the pride of opinion, and the prejudices of partisanship. Louis, from the age of thirty-two, devoted seven years to the accumulation of notes of cases, taking no part in the treatment of the cases which he recorded. The notes which for a time he collected he threw aside, considering that, for a certain period, he was learning how to observe. The system, in the second place, em- braces the analysis of a considerable number of recorded cases, properly arranged and classified, and a comparison of them with reference to everything observed in the living and dead body. The fruits of this system, as ap- plied to the study of two important diseases, by Louis, are the great works on Phthisis, and the “ Typhoid Af- fection ”—works which established the history of these diseases on a basis not less valid now than when the works were published, and the validity of which will re- main as long as these diseases and the human constitu- tion are unchanged. Dating from the labors of Louis, the knowledge which has been acquired of the natural history of diseases has affected largely the practice of medicine, in the first place, by developing the fact that many diseases have a definite career, continuing for a certain period, and end- ing after intrinsic laws of limitation. In this connection mention should be made of a striking and well-timed 128 MEDICINE IN THE PAST, THE PRESENT, essay which appeared more than thirty years ago, from the pen of Jacob Bigelow, of Boston, on the self-limited character of certain diseases. This essay did much toward directing the attention of American practitioners to the fact just stated, and the apt name, “ self-limited,” was first applied to diseases by Bigelow. The knowl- edge acquired of the laws of self-limitation has had a powerful influence in leading to a discriminating em- ployment of active therapeutical measures for the arrest and abridgment of diseases. It has led practitioners to direct their efforts less to “heroic” remedies addressed to the disease, and more to the maintenance of the vital powers of the patient; and it often affords encourage- ment, in cases of imminent danger, to persevere in exer- tions to keep the patient alive until the career of the disease is ended. In the second place, the study of the natural history of diseases has developed the fact that in many the in- trinsic tendency is to end in recovery; and that, not in- frequently, certain of the historical events of a disease are conducive to a favorable termination. Take, by way of illustration, pneumonia and typhoid fever: it is certain that these diseases do not destroy life per se, but that, in fatal cases, death is attributable to either com- plications, antecedent affections, or unfavorable influences having no necessary connection with the disease. As an example of an event heretofore considered as highly prejudicial, in its supposed influence on the course of the disease, haemoptysis, in cases of pulmonary tubercu- losis, may be cited, the statistical researches of Ware and others having shown that this event is of favorable omen, constituting a ground of encouragement to look 129 AND THE FUTURE. for either recovery from, or a slow progress of, the tu berculous affection. As practical results of a better knowledge of the in- trinsic tendencies of diseases, it is now considered that herein often is the explanation of the favorable progress and ending attributed heretofore incorrectly to thera- peutical interference; that active measures of treatment, injudiciously employed, may interfere with events by which recovery is brought about; and that, in abundant instances, is illustrated the truth of an old adage, singu- larly incongruous with past prevailing practical notions: Medicus naturae minister non magister est. By means of these results, the influence of a better knowledge now than formerly of the natural history of diseases, on the practice of medicine, has been immense. In the third place, by means of the study of the natural history of diseases, their individuality has been better established; and certain diseases, formerly con- founded, have been shown to be distinct. As an exam- ple of the latter effect, the individuality of the essential fever now called typhoid having been established by the researches of Louis, the fever distinguished as typhus has been shown to be a distinct affection, whereas, until within a late period, the two fevers were by many con- sidered as identical. In the fourth place, in proportion as our knowledge of the natural history of diseases has increased, the rela- tive diagnostic value, generally, of their symptomatic phenomena has been determined; and this, together with new and improved means of exploration, has ren- dered the discrimination of diseases vastly more prompt and precise than heretofore. It is not uncommon for members of the medical profession to speak disparagingly 130 MEDICINE IN THE PAST, THE PRESENT, of diagnostic skill, as absorbing attention which should be devoted to therapeutics. All are familiar with a saying imputed to some one in the French metropolis, namely, that cases of disease, to be truly satisfactory, must end fatally, because autopsies are essential in order to verify the diagnosis! Let it, however, be borne in mind that, although diagnostic skill may not carry with it the skilful management of diseases, yet therapeutical skill requires the practitioner to be a skilful diagnosti- cian. Let it also be borne in mind that a practitioner can acquire true experience in therapeutics only by cor- rectly discriminating the diseases which he treats. And, again, let it be borne in mind that the therapeutical ex- perience embodied in medical literature is not reliable, but delusive, in proportion as it rests on the contribu- tions of those who are not accurate in diagnosis. The memoir by Louis, entitled “ Researches on the Effects of Bloodletting in some Inflammatory Diseases, and on the Influence of Tartarized Antimony and Vesi- cation in Pneumonitis,” which was published first in the Archives Generates de Medecine, in 1828, and after- ward issued as a brochure and republished, with notes by James Jackson, in this country, in 1836, may be considered as a starting-point for the application of statistics to studies in therapeutics. That not a little has been accomplished by the labors of those who have adopted the plan of investigation pursued in that me- moir—that is, the numerical system, as applied to thera- peutics—cannot be doubted. It has been somewhat the fashion to decry statistics here, as in other applications, on the ground that figures may be forced to uphold errors, and to tell untruths. The same objections may be brought against trust in human testimony, and in the AND THE FUTURE. 131 evidence of the senses. Without entering into a dis- cussion of this important topic, which would be here out of place, suffice it to say that while, as must be granted, statistics are liable to be perverted, and in their applica- tion to the effects of remedial agencies they are open to error in various directions, it is difficult to see any other basis of exact therapeutical principles. Notwithstand- ing the many and great difficulties in the way of statis- tical researches, I would express the conviction that therapeutics, on this basis, may be brought, to a certain extent, to the condition of an exact science. But, it is to be added, general principles in therapeutics, however exact, must always, in their applications to the treatment of individual cases of disease, call for the exercise of such a degree of judgment and tact, on the part of the practitioner, as to render the practice of medicine, in the highest sense of the term, a rational art. I must hasten to bring to a close these observations relating to the present and the past. I can only allude, in passing, to points of contrast in medical instruction. There are those here who can go back to the time when, in our medical schools, a winter session of three months was considered sufficiently long; when a teaching faculty consisted of four or five professors, and when a memorable instance occurred, in a New England medi- cal college, of a single professor occupying all the chairs during an entire session; when anatomy and surgery were not infrequently combined in one chair, and when physiology was always an appendage to either anatomy or the practice of medicine. Now, five—and even six— months, for a winter session, are generally considered as inadequate, and summer sessions are coming to be re- garded as a necessity ; a faculty of even fourteen mem- 132 MEDICINE IN THE PAST, THE PRESENT, bers is not found to be too redundant, and not only are anatomy, physiology, and surgery, assigned respectively to separate chairs, but several subdivisions of the medi- cal and surgical departments, or specialties, have their professional representatives in some of the leading col- leges. The practice of medicine, since the date to which our present retrospections extend, has undergone great changes, some of the prominent characteristics of which, briefly stated, are as follows: Active remedies and po- tent therapeutical agencies are employed with much more reserve and discrimination now than formerly. The importance of economizing and sustaining the powers of life, in both acute and chronic affections, or, as I would term it, “ conservative medicine/’ is much more fully appreciated. The physician of the present day is willing to show his heroism by withholding, even in cases of disease involving imminent danger, active treatment, if he do not see clearly the indications for it, acknowledging, as a governing rule, the duty of avoid- ing risk of doing harm by therapeutical interference. He is satisfied to admit that, in most cases, his office is to aid in conducting the course of disease to a favorable termination ; and he is content with being called an u expectant physician,” provided this name be used in its proper signification. The hygienic management, in cases of disease, is much better understood, and its proper rank, as taking precedence, often, over the treat- ment by drugs, is recognized. Erroneous notions in re- lation to diet, which formerly prevailed, are passing away, and the necessity of alimentation in disease is far better understood; medicinal preparations are more con- centrated, and they are far less nauseous, as well as more AND THE FUTURE. 133 efficient; inhalations are employed in the form of anes- thetic vapors, and of medicated spray, and certain remedies are administered by subcutaneous injection. Now, can it be doubted that the changes, of which these examples are among the most obvious, denote im- provement? Will it be denied that the progress of practical medicine, during the present and the preceding quarter of the nineteenth century, has been in propor- tion to the advancement of our knowledge in anatomy, physiology, pathology, and diagnosis? Is not the ratio of recoveries from acute diseases now larger than here- tofore ? Ho not certain chronic affections, for example, phthisis, end oftener in recovery, and, when a cure is not effected, is not their progress slower, and life accord- ingly prolonged? Is not recovery from acute diseases more prompt, and the restoration more complete now, than within the memory of some whom I address? I must content myself with asking these questions, as- suming that a full discussion of them would substantiate affirmative answers; and, in conclusion, let me ask your attention, for a few moments, to some observations in relation to the future. Taking as a standpoint in the past a date within the recollections of the older members of the profession, we have seen how great is the contrast with the present in the different branches of medical knowledge. How will it be at a date equally distant in the future, should an orator of this Academy happen then to select as the subject of his discourse a comparison of that day with this present time? The developments which aje to come can be seen only by the light of past experience, and looking forward by this light we can fancy the 134 MEDICINE IN THE PAST, THE PRESENT, orator of 1893 presenting numerous illustrations of the imperfections of medical knowledge in 1868; noticing the doctrines of this generation which will then have become obsolete; dilating on the great changes in prac- tice, and citing the comparatively short period which at the present time is devoted to medical pupilage. Should such a foreseeing as this make us dissatisfied with the present state of medicine? Certainly not. All that we can do is to avail ourselves of what is known in our day, as far as practicable, making, as far as lies in our power, a good practical use of the knowledge which we acquire. This much we are bound to do; and, also, we are bound, one and all, according to our opportunities and abilities, to aid in the progress of medicine. Is it a just ground of reproach that the history of medicine will be likely to show in the future, as in the past, great changes ? To answer this question affirmatively would be to impugn the wisdom of God. It is in the order of Providence that there should be progressive advance- ment in medicine as in other provinces of science and art; and all that society and individuals can claim of us, as medical practitioners, is the exercise of our art in accordance with the existing state of the science. An appreciation of the limits of our present knowledge of anatomy, physiology, pathology, the natural history of diseases, and therapeutics, will enable us, in some meas- ure, to apprehend the scope which these branches of medicine oifer for further progress. Let us contemplate these several branches of medicine, briefly, in this point of view. It may seem hardly probable, after the study of the body for several years, with the present improved means of microscopical observation, that very important ana- AND THE FUTURE. 135 tomical facts remain to be discovered. Yet, so it seemed at the date in the past which I have selected for a com- parison with the present; the Ultima Thule of anatomi- cal discoveries was supposed to have been reached when Horner claimed to have discovered the tensor tarsi mus- cle in 1824! It is by no means improbable that the range of minute observation may be extended by means which cannot now be foreseen. Who could have guessed, a few years since, that substances composing the sun and stars would be brought within the compass of direct ob- servation ; yet, by means of the spectrum analysis, this wonderful result has been accomplished. It would therefore be unwise to assume that the boundaries of our present knowledge constitute the utmost attainable limits of anatomical research. Physiology, taking advantage of the microscope and of new developments in chemical science, interrogating Nature by means of experimental observations on infe- rior animals, and deriving information from the study of disease, opens to the imagination an illimitable space for future progress. With all that has been acquired within the last half-century, how limited is the extent of our actual knowledge ! The forces which are involved in the circulation of the blood, independently of the heart’s action, are not determined; here is now ample room for discussions and different conjectures. The processes of assimilation, nutrition, secretion, and excre- tion, constitute still a terra incognita. Granting the es- tablishment of the hypothesis which attributes these processes to the action of cells, these are only the agents or organs, the mechanism or rationale remaining to be discovered. The functions of the spleen and the other ductless glands are still undetermined. The purposes 136 MEDICINE IN THE PAST, THE PRESENT, of the various parts composing the encephalon are very imperfectly known, and the physiological actions in- volved in sensation, volition, reflex movements, and mental operations, are beyond our present apprehension. The abolition of consciousness in sleep, and the condi- tions for its existence in waking hours, are mysteries which we cannot begin to comprehend. But it is not necessary to go to the most exalted parts of the organ- ism ; let the physiologist undertake to explain the func- tions of a purely vital organ, for example, the rhyth- mical actions of the heart, and the limits of our knowledge are not less strikingly illustrated. What will be the physiology of the future no one can surmise, but it is certain that in this direction we have but just begun to penetrate the arcana of Nature. Turning to pathology, the mysteries relating to morbid processes must needs correspond to those pertaining to the processes of health. What a flood of light, doubt- less, would illumine the processes involved in inflamma- tion, morbid products, abnormal growths and alterations of structure, were the physiologist able to unfold the secrets of assimilation, circulation, and nutrition! At present, we must be content with the facts and laws which have been determined by observation, canvassing the merits of theories (like the so-called “ cellular pa- thology ”) which aim to extend our vision somewhat beyond the horizon bounding our actual knowledge. Etiology furnishes striking examples of the narrow limits of our present knowledge; and here especially important developments may be looked for in the future. Of certain of the extrinsic special causes of disease, we are entirely ignorant, namely, the miasmas which pro- duce malarious fever, yellow fever, cerebro-spinal men- AND THE FUTURE. 137 ingitis, influenza, epidemic cholera, etc. It has some- times seemed that we were within grasp of new and important truths; and at this moment such is the con- viction of those who believe that organic entities derived from without the body are to be discovered in the blood. One cannot but fervently wish that late efforts to de- monstrate the correctness of the doctrine of the animal- cular or cryptogamic origin of certain diseases may prove successful, so important would be the consequences of such an advance in etiology. On the other hand, if the zymotic theory of certain diseases be substantiated, much is to be hoped for when our chemical brethren have elucidated the phenomena of catalysis—a name which now seems to serve the same purpose as the phrase “ Nature’s abhorrence of a vacuum,” before the pressure of the atmosphere was understood. Whatever be the nature and sources of the external morbific causes which are now unknown, it is highly probable that discoveries in this direction, sooner or later, will effect great changes in pathology and therapeutics. Reference was made in a former part of this discourse to the knowledge of uraemia acquired within late years. We have an inkling already of other intrinsic causes, namely, uricaemia, cho- lesteraemia, lacticsemia (if I may coin such a word), and septicaemia. We may consider it quite certain that, with respect to the presence in the blood of morbific principles, produced within and derived from without the body, information is hereafter to be acquired which will bring into striking contrast medicine in the present and the future. Our present knowledge of the natural history of dis- eases is very far from complete. Mere is ample scope for useful labor. The harvest is abundant, but the 138 MEDICINE IN TIIE PAST, THE PRESENT, laborers are few. It is painful to think of the limited extent to which, in this direction, are utilized the im- mense clinical resources of this metropolis. If a score of the younger members of the profession in this coun- try, whom Providence has blessed with the means of devoting time to the work, were to follow the example of Louis, they would render to medicine an incalculable service, at the same time securing for themselves a measure of attainment and a professional position which should satisfy a reasonable ambition. A sure career of usefulness and honor is here open to any who, properly qualified by education and practice, and having the req- uisite intellectual and moral qualifications, are able and willing to spend a series of years in, first, recording cases of disease, and, second, subjecting the accumulated his- tories to careful analysis and comparison. What shall be said of the therapeutics of the future? How will the practitioners, at the close of the nineteenth century, treat their patients ? What will be the charac- teristics, on the one hand, of.“Young Physic,” and, on the other hand, of “ Old Fogyism,” in that day ? It is too much of a flight of the imagination to try to read the future in these aspects; but, judging prospectively from the past, we may indulge in some reflections. It may be reasonably expected that new remedies will be added to the materia medica, for some of those now con- sidered most valuable (e. g., bromine and the bromide salts, the sulphites, the permanganates, and carbolic acid) are of recent introduction. It is fair to conclude that improvements in the preparation and administration of remedies will continue to be made. Statistical researches will have effected more or less progress in the establish- ment of general principles relating to the management AND THE FUTURE. 139 of different diseases. It is not irrational to suppose that our knowledge of the modus operandi of many remedies will be hereafter much better understood. A logical in- ference from the well-known tendency of the mind to opposite extremes at different periods is, that remedies and therapeutic agencies formerly in vogue, but which are now rarely employed, will hereafter come to be more in use. To my mind, for example, it is not a preposter- ous supposition that our successors, at the end of the present century, will carry lancets ; that venesection will not lapse among the “ lost arts,” but that dexterity in this operation will again resume its former place among the practical accomplishments of the physician. It may be found that injustice to mercury is involved in the in- significant role which it now has, as compared with the important part assigned to it heretofore in the treatment of many diseases. These reflections might be multiplied and extended, but I promised, at the outset, not to indulge in elaborate prophetic visions. Let it not be said that speculations respecting the future are vain and fruitless. Reasonable expectations of continued progress will prevent an undue pertinacity of adherence to doctrines to which the mind is once committed, thus saving us from “ old fogyism,” or from becoming “ monumental physicians ”—that is, from representing in opinions and practice, not the present, but the past. Such expectations conduce to a state of mind desirable with respect to an aptitude for the acknowledgment of new truth of any kind, more especially if it be of importance in its practical bearing; a state admirably expressed by a quotation which will be familiar to some of my hearers, and which I introduce in this connection with becoming reverence, 140 MEDICINE IN THE PAST, THE PRESENT, ETC. namely, “ a happy mean between too much stiffness in refusing, and too much easiness in admitting, variations in things once advisedly established.”1 Finally, the consideration of medicine, in the present, past, and future, leads to the reflection that diseases have been appointed by a Divine Providence, for purposes which human reason can now but imperfectly fathom. At some distant period in the world’s history, or, if not in this world, in another life, the finite understanding may be able to comprehend fully the wisdom and be- neficence which are doubtless exemplified here, not less than in all else affecting human life and happiness. Then it will be seen that the progress made by successive gen- erations, in the science and art of medicine, is in con- formity with a plan which can only be understood by knowing the purposes for which diseases have been ap- pointed. 1 Preface to Book of Common Prayer of the Protestant Episcopal Church of the United States of America. ALIMENTATION in disease. 141 V. Alimentation in Disease.1 CHOMEL, in his admirable treatise on General Pa- thology, defines the art or the practice of medicine to be the application of good sense to the treatment of diseases. He adds that knowledge of diseases is indis- pensable, but good sense ranks first in importance. I give the literal translation of the French term, in preference to the phrase “ common sense ” which is generally used with us, inasmuch as good sense is rather uncommon than common. This definition by Chomel is not less just than striking. The ablest practitioners in the dif- ferent departments of medicine have always been those who, in addition to an abundance of knowledge, pos- sessed in an uncommon degree good sense. This is as true now as hitherto. How often do practitioners, by no means deficient in medical knowledge, fail in practice because they lack good sense ! and, on the other hand, good sense often compensates to a considerable extent for deficiency in medical knowledge. The great improve- ment which has taken place within the last quarter of a century in the practice of medicine, as regards the em- ployment of remedies, and, still more, the hygienic management of diseases, is due not less to the agency of 1 Read before the Medical Society of the County of New York. 142 ALIMENTATION IN DISEASE. good sense than to pathological researches. Good sense restrains the formation or adoption of baseless specula- tions and immature doctrines ; it prevents one-sided and extreme views; it opposes alike presumptuous innova- tions and bigoted conservatism; it keeps within proper bounds reliance upon others and self-reliance, discourag- ing equally blind partisanship and dogmatic egotism ; and, finally, good sense is the true genius of medical ex- perience. With these preliminary remarks I proceed to submit to the good sense of those whom I address some considerations relating to an important subject in practical medicine, namely, Alimentation in Disease. As conducive to a proper appreciation of the impor- tance of alimentation in disease, the natural history of starvation is to be considered. The immediate effects of starvation are, of course, most rapidly produced and most strikingly manifested when all aliment is withheld. The blood is notably diminished and impoverished; emaciation is rapidly progressive, and death, accord- ing to the painful experiments of Chossat on inferior animals, takes place when the body has lost one-fifth or one-fourth of its weight in health. The more ob- vious phenomena attendant on these immediate effects are as follows: Febrile movement frequently occurs, although the temperature of the body is greatly reduced before death; muscular debility is speedily a marked symptom, and is soon followed by great prostration ; the circulation is more and more enfeebled ; there is inabil- ity to sleep; the moral sentiments are perverted, and, after a time, there is delirium which is sometimes active and sometimes passive; diarrhoea often occurs, and the breath becomes intolerably fetid. The average duration of life, the complete deprivation of aliment being under- ALIMENTATION IN DISEASE. 143 stood to include water, varies from five to eight days. The mode of dying is typical of slow asthenia or exhaus- tion. The phenomena are essentially the same, but the duration of life is considerably longer, if water be not withheld. The phenomena of starvation are not confined to cases in which there is complete deprivation of aliment. This is a fact highly important in its bearing upon alimenta- tion in disease. Starvation is produced whenever the aliment is insufficient, either as regards quantity or quality, for repairing the losses which the blood sustains in supplying to the solids materials for nutrition. The phenomena of starvation are essentially the same as vdien all nourishment is withheld'; the only difference being that they are developed more or less slowly, they are consequently less striking, and their connection with defi- cient alimentation is liable to be overlooked. Another fact relating to starvation also has an important bearing on alimentation in disease—certain portions of the body may suffer from the want of materials in the blood proper for their nutrition, while other portions of the body are sufficiently nourished. To quote the language of the author of an able essay on “ Army Alimentation “Starvation is a comparative phrase. We can starve muscle by withholding nitrogen. We can starve the fats of the body, and destroy the animal heat, by withhold- ing carbon. So, too, we can starve the brain by with- holding phosphorus; and starve the blood by failing to supply it with those salts of lime, potash, soda, iron and magnesia, which are essential to its healthy condition/’1 1 Dr. S. B. Hunt, vide Sanitary Memoirs of the War of the Rebellion, voi. i, of the series published by the U. S. Sanitary Commission. 144 ALIMENTATION IN DISEASE. Recognizing the fact that the terra starvation compre- hends all degrees of innutrition between the extreme de- gree produced by the deprivation of all aliment, and the opposite extreme caused by a slight diminution of the alimentary supplies requisite for the wants of the body, and, also, that certain parts may be starved while other parts are amply nourished, I proceed to state another fact, the practical bearing of which on alimentation in dis- ease will be at once apparent. Starvation may be pro- duced in persons affected with different diseases, as well as in healthy persons. There is nothing in disease to prevent starvation or its immediate effects. Starvation is sure to occur in cases of disease, in a degree propor- tionate to the lack of material for nutrition in the blood; in other words, in proportion as the requisite amount of aliment is either not ingested or not assimilated. The immediate effects and the attendant phenomena are the same when starvation occurs in connection with disease, as when it is produced in persons previously in health. Impoverishment of the blood, emaciation, febrile move- ment followed by a reduction of the animal temperature, feebleness of the circulation, vigilance, perversion of the moral sentiments, delirium, diarrhoea, and fetor of the breath—may be attributable, in cases of disease, to star- vation. In connection with all diseases, more or less of the morbid phenomena present arise from starvation, and these phenomena are prominent and grave in pro- portion to the degree in which either alimentation or assimilation is defective. Chossat has enunciated truths in language which enforces their importance, when he says, “ Starvation is a cause of death, marching silently in front with every disease in which alimentation falls below the natural standard. It reaches its natural ter- ALIMENTATION IN DISEASE. mination sometimes sooner and sometimes later than the disease which it covertly accompanies; and it may super- sede the disease of which, at first, it was merely an inci- dental element.” Starvation is often the immediate cause of death, when diseases destroy life by slow asthenia or exhaustion. If a fatal termination be not due to a direct interference with the action of the heart, or with respira- tion, it is correct to say, that patients die because they are starved to death. Certain it is that diseases which do not compromise directly the function of either the heart or lungs, cannot kill so long as the nutrition of the body is maintained at a point compatible with life. Starvation, associated with disease, may be inevitable; that is, the dis- ease may involve an insuperable obstacle to either the in- gestion of aliment, or its assimilation. Then it is that, in the language of Chossat, inanition may reach its termi- nation sooner than the disease. On the other hand— and here is a fact full of practical import—starvation may not be a necessary effect of the existing disease, but may be due to insufficient alimentation. In such cases, inanition may prove a cause of death when the disease need not have destroyed life; the patient, indeed, may die of starvation notwithstanding the progress of the disease per se be favorable. Then, in the language of Chossat, inanition “ reaches its natural termination later than the disease which it covertly accompanies, and it may supersede the disease of which, at first, it was merely an incidental element.” On these facts pertaining to starvation, rest the prac- tical considerations relative to alimentation in disease, which I shall now proceed to submit. A logical inference from these facts is, that to prevent starvation is of fundamental importance in the practice 146 ALIMENTATION IN DISEASE. of medicine. The importance of this object in the treat- ment of individual cases of disease, is to be estimated by the amount of impending danger from starvation as an incidental element. All who hear me are doubtless familiar with the teachings of Graves, with respect to alimentation in the continued fevers. Graves states that he was first led to appreciate the importance of giving nutritious food in cases of fever, by the remark of a shrewd country practitioner, who said that, in his prac- tice, patients generally recovered if he could prevent them from being starved to death. Graves inaugurated a great reform in the treatment of fevers as regards ali- mentation ; and as proof of the strong conviction in the mind of this distinguished clinical teacher of the im- provement in practice which dates from his publications, he is said by his co-worker Stokes to have declared that he could desire no better epitaph than, “ He fed fevers!” Few, if any, practitioners at the present day, are dis- posed to undervalue the importance of alimentation in the essential fevers; but it is not less important to pre- vent, if possible, death from starvation in all other dis- eases. If to die by slow asthenia be often virtually to starve to death, then, no matter what the disease may be, it is an object of fundamental importance to promote, as far as practicable, the assimilation of food. Looking at the object of treatment in another point of view, it is customary to say that the powers of life are to be sup- ported in proportion to the danger of death by asthenia, whatever be the nature or seat of the disease. Now, of supporting measures, alimentation holds the front rank, not depreciating the importance of stimulants, especially alcoholics, which it is foreign to my present purpose to discuss. ALIMENTATION IN DISEASE. 147 Admitting the fundamental importance of alimentation in the treatment of diseases, the inquiry arises, what are its limitations? In answer to this inquiry, it is to be stated, that, if we except the early stage of some acute diseases in which it may be an object to withhold ali- ment with an indirect reference to depletion, there is never any risk of hypernutrition. With the exception just stated, I submit the proposition that it is always desirable, in cases of disease, to supply aliment to the fullest extent of the capacity of the organism for appro- priation. In acute diseases the failure of the vital powers is forestalled in proportion as nutritive supplies are assimilated. This is simply saying that the assimi- lation of nourishment is indispensable for the preserva- tion of the powers of life. And when, in the progress of an acute disease, more or less failure of the vital powers ensues, the more nutrition can be maintained, the more efficient the support. The proposition just submitted embraces not only the acute but the chronic diseases. No matter what may be the seat or the nature of the chronic affection, a diet fully up to the capacity of the organism for nutrition promotes recovery, if recovery be possible, and if recovery be not possible, by increasing the ability of the system to endure the affection, con- tributes to prolong life. The limitations to alimenta- tion, therefore, relate wholly to the physiological pro- cesses which are preliminary to nutrition, namely, digestion and the other processes by which aliment is converted into blood. If more food be ingested than the digestive organs can prepare for assimilation, or if the articles of diet be not suited to the digestive powers, the nutrition will not be in proportion to the alimenta- tion, and disorder of the digestive organs may be pro- 148 ALIMENTATION IN DISEASE. duced. This is, of course, if possible, to be avoided; yet, the harm resulting from over-alimentation is gener- ally exaggerated. Undigested aliment often passes through the alimentary canal without causing any ap- preciable disturbance. The disorder which may be pro- duced is due chiefly to chemical changes in the ingesta, and is manifested by flatulence, pain, and looseness of the bowels. Conservatism is seen here as in other mor- bid effects. As the result, the offending matter is ex- pelled, and the harm is, in general, not more than that caused by a cathartic or laxative. It is quite superfluous to say that to avoid over-alimentation may be highly desirable, but it is sometimes safer to incur risk in that direction, than to limit alimentation below the ability of the digestive powers and the capacity of the organism for nutrition. What rules are to govern the practitioner in so regulating alimentation in disease as to avoid the evils, on the one hand, of starvation, and, on the other hand, of disorder of the digestive organs? To treat of the numerous topics which this question opens up, is impossible within the limits of a brief discourse. In the few moments remaining of the time to which I have re- stricted myself, I can only submit, without discussion, some of the considerations suggested by the question. An unwillingness to presume upon the patience of my auditory must be my apology for offering statements open to criticism on the score of their having the character of aphoristic propositions. As the first in rank of supporting measures in the management of the essential fevers and all acute diseases which endanger life by asthenia, it is often necessary to regulate alimentation without regard to indications af- forded by appetite or taste. In many cases of disease, ALIMENTATION IN DISEASE. 149 owing to bluntness or perversion of the mental percep- tion, the wants of the system as regards nutrition are not indicated by a desire for food, or by choice in its selection and preparation. Patients not infrequently die of starvation without having experienced any sense of hunger. Under such circumstances, the rule is to supply, not only as much aliment as the digestive organs can prepare for assimilation, but food containing, in proper amounts, all the alimentary principles required to repair the waste of the different parts of the organism. Limiting alimentation to an article of food inadequate as regards the different alimentary principles which it contains, will not prevent starvation, no matter how abundantly the article is ingested. For example, pa- tients may be starved to death on the juice or a decoction of beef given without stint and digested. The risk of starvation is much greater if the diet be restricted to substances less nutritious, such as gelatin, albumen, starch, or gum. The valuable experiments of Hammond and others have established the fact that the last three of these alimentary principles, namely, albumen, starch, and gum, singly, are wholly inadequate to nutrition; and the inadequateness of gelatin was long ago settled by the famous Gelatin Commission in Paris. Under the circumstances stated, the diet should not only em- brace the requisite variety of alimentary principles, but food must be given in a concentrated and liquid form. Milk, par excellence, has these recommendations, and is, therefore, of all articles of diet, in fevers and other acute diseases, to be preferred. The alimentation is rendered more effective by the addition to milk of a farinaceous substance, and by alternation with animal broths, or the essence of meat. Eggs, also, form an excellent article 150 ALIMENTATION IN DISEASE. of supporting diet, owing to the fact that they contain the requisite variety of alimentary principles combined by the hand of nature. Whenever alimentation is a measure of support, that is, whenever there is danger, either immediate or remote, from starvation, an impor- tant rule is to allow always, after food has been given, a sufficient period to judge whether or not it produces disorder of the digestive organs. The intervals should be from three to four hours. If food be given every hour or half hour, as is often done, the organs of diges- tion have no period of rest, and it is impossible to form any judgment concerning the digestive powers. More- over, after intervals sufficient to allow of rest, food is more likely to be digested. A grave objection to giving food after very short intervals, is that it involves in- terference with sleep and occasions both physical and mental annoyance. By allowing sufficient intervals the quantity of food may be graduated to the diges- tive powers, and thus disorder from over-alimentation avoided. An important rule of alimentation in fevers and acute diseases, relates to variation in the articles of diet and in the preparation of food. Any article, prepared in a certain mode, and given, without change, day after day, becomes, after a short time, offensive and disgusting. The patient takes it, not merely with indifference or against inclination, but with strong aversion ; and this is an evil, not alone on the score of difficulty and annoy- ance in giving nourishment, but because, under these circumstances, the digestive organs, as well as the palate, rebel against it. Variations may be made by giving, on successive days, the decoction or juice of different kinds of meat; by adding to milk different farinaceous ALIMENTATION IN DISEASE. 151 substances, and by different modes of preparation. This rule, like most other dietetic rules, will not be carried out unless the practitioner be precise and enter into mi- nute details in his directions concerning alimentation. Persons upon whom devolves the nursing of the sick, often attach little importance to the diet; they are apt to imagine that everything depends on remedies. The physician not infrequently meets with opposition to his measures of alimentation, arising from a prejudice against feeding patients. It has been a popular notion that starvation, so far from being the mode in which diseases are apt to kill, is a means of cure. Like other popular notions concerning diseases, this doubtless was derived from the medical profession. It is but a short time since the aura jamis was relied upon in the treatment of most of the acute and many of the chronic diseases. Notions thus derived are often retained in the popular mind long after they have been abandoned by the pro- fession. The introduction by enema of aliment, when it is not retained by the stomach, is often highly impor- tant. Whenever patients desire certain articles of food, as a rule, these are to be allowed. Such a desire, if distinct, represents generally a want of nutrition, more reliable than the judgment of the physician as to the articles best suited to the case. Every one has heard of in- stances in which patients have craved articles of food considered as extremely inappropriate, but the cravings being indulged, perhaps without the sanction of the physician, marked improvement immediately followed. Remarkable instances of this kind are undoubtedly au- thentic, and they are striking illustrations of the sound- ness of the rule just stated. This rule is in conflict 152 ALIMENTATION IN DISEASE. with a popular notion, for the origin of which the pro- fession is doubtless responsible, namely, that in cases of disease the instinctive desires are morbid, and are to be opposed rather than indulged. Alimentation, as a measure of support, is more im- portant in cases of disease affecting the young and the aged, than during the intervening periods of life. This is consistent with the fact that starvation kills children and old persons more quickly than those who have at- tained to full development and who are not in advanced years. Of the 150 persons who, after the wreck of the frigate Medusa, were exposed on a raft for thirteen days, with hardly any food, children, young persons, and the aged, were the first to die from starvation.1 During convalescence from fevers and other acute dis- eases, the ordinary articles of solid food should be al- lowed, as soon as they are desired. Convalescence is protracted by the continuance of a liquid diet, and by an insufficient alimentation. The kinds of food may, in general, be safely left to the choice of the patient, and the quantity is to be graduated by the activity of the digestive powers and of nutrition. The risk of over- alimentation during this period is often exaggerated; and, with reference to alimentation, as well as to other measures, it is to be considered that after many diseases, for examples, the continued fevers and pneumonia, the liability to relapse is exceedingly small. In the management of chronic diseases, measures aside from alimentation, whether medicinal or hygienic, are serviceable in proportion as they contribute to di- gestion and nutrition. Whatever be the nature of the 1 Physiology of Man, by A. Flint, Jr., vol. ii, page 16. ALIMENTATION IN DISEASE. 153 chronic disease, or wherever it be seated, it is always an object of fundamental importance to keep nutrition as near as possible to the standard of health. The rules of alimentation, therefore, in cases of chronic disease re- late to the most efficient means of effecting this object. Medicines not infrequently impair the appetite and interfere with digestion. If not required for a special curative effect, they are then likely to do harm by com- promising, more or less, alimentation and nutrition. Hence in fulfilling therapeutical indications, an impor- tant rule is to select remedies or pharmaceutical prepa- rations which are not offensive either to the palate or the stomach. In prescribing remedies, allowance is always to be made for the wide difference among different per- sons as regards the gustatory and gastric sensitiveness to medicines. The over-drugging which formerly pre- vailed was in no small degree objectionable on account of its effects on appetite and digestion, aside from other effects. In this aspect the use of drugs with far more discrimination and reserve now than formerly, is a great improvement; so, also, is the use of concentrated reme- dies, the preparation of medicines in agreeable forms, and the hypodermic administration of certain articles. Efficient alimentation in cases of chronic disease is often impeded by prevalent popular errors. The notion that starvation is a means of cure, to which allusion has already been made, operates largely against an ana- leptic diet. Another popular notion is that the restric- tion of diet to a very few articles, and to the same arti- cles continuously, is desirable; whereas, nothing is more certain than that a varied diet is most conducive to di- gestion and nutrition. As results of these errors it is not uncommon for persons with some chronic ailment, 154 ALIMENTATION IN DISEASE. and even healthy persons, not only to become feeble and anaemic, but to suffer, more or less, from the blood- changes which are embraced under the name scorbutus. Chronic affections are in this way protracted, the ability of the system to bear them is impaired, and serious ail- ments are thereby superadded. Other absurd popular errors relate to supposed individual peculiarities. Many persons seem to be pleased with the idea that articles of diet which are wholesome for mankind in general, are pernicious to them. Practitioners daily meet with cases illustrating this strange manifestation of egotism. How often do we hear the trite saying that “ what is one man’s meat is another man’s poison,” a maxim which has very little foundation in truth. I suppose every one present has often met with objections to milk arid eggs, which, as representing all the constituents of the organism, may be called the typical foods, on the ground that they are apt to promote biliousness! It will be a great gain, as regards alimentation in chronic diseases, when these and other errors of the same sort are completely eradicated from the popular mind. It is highly important to consider the influence of the mind on appetite and digestion, and thereby on assimi- lation and nutrition. Not a small number of the dis- orders referable to impoverishment of the blood and innutrition are traceable to mental depression, which sustains to various disorders the relation of both cause and effect. Hence, in great part, the advantage, in many cases, of change of scene and new associations, the benefit being derived through the mind. Hence, the greater success of those physicians who take proper cog- nizance of the mental condition, in these cases, as com- pared with those whose professional offices are limited ALIMENTATION IN DISEASE. 155 chiefly to prescribing drugs. Hence, too, the marvel- lous effect often of j udicious encouragement, on the part of the physician, for mental depression in many cases relates to apprehensions which are either groundless or greatly exaggerated. The influence of the mind upon digestion is strikingly shown when, unhappily, patients have fallen into the habit of concentrating the attention upon the sensations which follow the ingestion of differ- ent articles of diet. If food be taken with distrust and anxiety lest it prove hurtful, the chances are it will give more or less trouble; and if taken with a pre-conviction that it will do harm, this result will be pretty sure to follow. Having reached the end of the time which I resolved, on commencing to write, that I would not exceed, I must leave untouched many of the topics which suggest themselves in contemplating the subject of this discourse. The few and somewhat desultory considerations which have been submitted, relate entirely to alimentation when disease exists. A kindred subject is alimentation in health, considered with reference to the prevention of disease, to the development and growth of the organism, and to mental and physical vigor. The latter is a sub- ject large in extent and of vast importance. With re- gard to this subject, as well as to alimentation in dis- ease, notwithstanding the knowledge acquired and the improvements made within late years, there is yet abun- dant scope for further information and progressive prac- tical progress. My remarks have had reference, almost exclusively, to one aspect of the subject, namely, the danger from defective alimentation, or starvation. The evil conse- quences of excessive and improper alimentation, both in 156 ALIMENTATION IN DISEASE. health and disease, enter into another aspect of the sub- ject. Considered in the latter aspect, the subject is one of magnitude and importance. Unquestionably, the evil consequences of excessive and improper alimentation are not always sufficiently appreciated by ail members of the medical profession; and, with the well-known tendency in the doctrines and practice of medicine to opposite extremes, a full apprehension of the danger of defective alimentation is doubtless liable to be followed by error in an opposite direction. Under the necessity, however, of limiting the scope of my remarks, of the two aspects of the subject I have confined myself, for the most part, to the one which, at the present time, as regards the occasion for suggestive considerations, seems to me relatively the more important. TOLERANCE OF DISEASE. 157 VI. Tolerance of Disease.1 THE use of the term tolerance, as applied to parts of the body separately and to the body as a whole, is not novel. The term not infrequently enters into medi- cal writings and conversation. It has the same sense here as in other applications; it means the “power or capacity of enduring.” Strictly the term implies in the subject, or in that which tolerates, consciousness and will; and there is a mental tolerance of disease, the consideration of which belongs to psychology. In the medical sense of the term the mind is only one of a number of elements. When we speak of the tolerance of disease by the body as a whole we regard the organism, which is but an ag- gregation of organs and functions, in the light of an entity; and when we say that such or such a part of the body shows tolerance, or otherwise, we consider this part as having a separate individuality. It has always been the fashion in medicine to use language which implies that an immaterial principle, distinct from the mind or soul, is inherent in the body of man and in all organ- ized bodies; a principle corresponding to the arctueus of Valentine, Paracelsus, and Van Helmont. And so since the time when diseases were considered to be the work 1 Read before the New York County Medical Society. 158 TOLERANCE OF DISEASE. of demons, or evil spirits, it has been the custom to per- sonify them, and to invest them with divers sentiments and passions, such as mildness and malignity, obstinacy, rebelliousness, etc. I will not stop to inquire into the reasons for so doing or to moralize thereon. Suffice it to add that this use of terms is often convenient; and at this day, inasmuch as it is understood they are used figuratively, there is little danger of the understanding being thereby imposed upon. The phrase tolerance of disease therefore is sufficiently sanctioned by propriety and usage. I adopt the name tolerance to express an important principle in medicine. Limiting attention to the body as a whole, or the organism, I shall consider tolerance— the power or capacity of enduring disease—as a prin- ciple which it is convenient and useful to recognize as such, and I shall offer considerations which show its importance in relation to prognosis and therapeutics. To illustrate this principle, let a disease be selected which in itself—that is, irrespective of complications, antecedent or intercurrent affections and accidents—may or may not prove fatal. Let the disease be acute pneu- monia sufficiently extensive to place life in more or less danger. Suppose a series of cases of this disease with the qualifications just stated; the patients of the same age and sex; the conditions of general health and strength of constitution, so far as it is possible to judge, similar; the measures of treatment uniform, and no im- portant diversity in any extrinsic circumstances : clinical observation warrants the assertion that of such a series of cases in some the disease will end in death, and in some recovery will take place. Why is this ? There is in addition to all the apparent points of similitude an TOLERANCE OF DISEASE. 159 agency, a factor, an element, or an unknown quantity, and this is tolerance. In such a series of cases there is a difference in the power or capacity of enduring; and hence while some patients succumb to the disease others triumph over it. I selected pneumonia simply because it was the disease which first came into my mind. What is true of this disease under the view just presented is equally true of other affections. Take as another ex- ample one of the essential fevers. Let it be typhus fever. Under in all respects identical circumstances, intrinsic and extrinsic, so far as we can appreciate them, one patient will die and another patient will recover, because the one has sufficient and the other not enough tolerance to pass through this disease safely. The question at once arises in what the tolerance of disease consists; but, by way of preparing to consider this question, let us first inquire how diseases destroy life. Naturally we are led to apply this inquiry to acute and to chronic diseases separately. Certain acute dis- eases are fatal because they are seated in vital organs, and compromise the functions of these organs sufficiently to destroy life. Examples of this are some rare cases of acute pneumonia and pleurisy, cases of pericarditis and of meningitis when inflammatory changes or prod- ucts affect the portion of the nervous centre which is essential to respiration. The events which are inciden- tal to certain cases of disease may occasion death. Ex- amples are either submucous infiltration or an exudation in laryngitis, and heart-clot in pneumonia and other af- fections. Exclusive of these two explanations of death from acute diseases, they kill because, to quote common expressions, “the powers of life give way,” “the vital forces are exhausted,” “nature can no longer hold out,” 160 TOLERANCE OF DISEASE. etc. There was significance in the report of the cause of death in a certificate from a practitioner in this city to the Board of Health, some years ago, namely, “She died because she could not live!” This, in fact, is the rationale of death in the majority of the fatal cases of acute disease. Patients die because their tolerance is in- adequate to carry them through the course of disease and the processes of restoration. An acute disease which does not involve irremediable lesions of organs essential to life, and which is without incidental events compro- mising fatally vital functions, will end in recovery, pro- vided what we are accustomed to call the “powers of life,” the “vital forces,” or “nature” be sufficient to withstand the disease. In other words, recovery under such circumstances is a question of tolerance. If the patient can tolerate the disease for a sufficient length of time, the ending is in recovery; if tolerance give out, the ending is in death. Chronic diseases, when they destroy life, generally in- volve structural changes which are dangerous in pro- portion to their seat, character, and extent. Seated in vital organs, and incapacitating these for the perfor- mance of their functions, a fatal result is the consequence of this effect. If, however, the parts affected be not immediately essential to life, and if there be no inciden- tal events interfering with vital functions sufficiently to cause death, here, as in acute diseases, a fatal ending is due to want of tolerance. What was said of acute holds true of chronic diseases in all respects, provided the lat- ter admit of recovery; that is, chronic diseases which do not involve incurable lesions, and which do not of necessity compromise the functions of vital organs suf- ficiently to cause death, will end in recovery, provided TOLERANCE OF DISEASE. 161 there be an adequate amount of tolerance; and, on the other hand, they will sooner or later end fatally if there be a deficiency in tolerance. But suppose, what is often true, that there are incurable lesions seated either in vital organs or elsewhere; the reliance is upon tolerance for the continuance of life with such a measure of health as is possible with the existence of the lesions. Here opens up a highly important aspect of my sub- ject. Every one who has had considerable clinical ex- perience must have remarked the wonderful difference in different persons as regards the tolerance of chronic diseases. Take a disease which from its frequency af- fords numerous illustrations, viz., pulmonary phthisis. A patient may die with this disease after a few months, and the amount of local mischief be no greater than that which another patient will tolerate for more than a quarter of a century ! Nothing can be more unreliable than the general condition of the patient; that is, the aspect, weight, muscular strength, etc., as representing the extent to which the lungs are involved in cases of phthisis. The contrast between the so-called rational symptoms and the physical signs is often surprising. This is a matter of common observation, and I need not dwell upon it. Certain cases of organic disease of the heart furnish striking illustrations of tolerance. It is truly astonishing how long and how well valvular le- sions with enormous enlargement of the heart are some- times tolerated. I might in like manner cite in illustra- tion of this aspect of tolerance other chronic incurable diseases, including cancer, seated in any of the organs of the body. I revert now to tlie question, In what does tolerance of disease consist? It is a well-known fact that acute 162 TOLERANCE OF DISEASE. diseases are often not so well tolerated by those who ap- pear to have robust health as by those who seem com- paratively feeble. A man in the prime of life, with strong muscles, and whose aspect is typical of vigor, may succumb to an affection which a weak old woman en- dures with comparative ease. Hence it is that physi- cians have frequent occasions to repeat the familiar adage of the twig, the oak, and the whirlwind. Now, in ex- planation of this fact, one of two things is to be sup- posed : either in the case of the apparently vigorous pa- tient there are occult morbid conditions which render the task of tolerance greater than in the case of the com- paratively weak patient, or there is less power of endur- ance. There are considerations which render the latter the more probable explanation. We notice the same ap- parent incongruity in the ability to endure prolonged muscular exertions, exposure to cold, and other hard- ships in health. The experience of military life is, that, in trials of endurance, soldiers who are slender and deli- cate in appearance are often the most reliable. The pri- vations of long voyages, exploring expeditions, pioneer life, etc., are borne not infrequently as well by those who seem to have tender constitutions as by those of stronger mould; and in shipwrecks women and children have been known to survive hardened seamen. This ability to en- dure in health it is customary to refer to a something which is called stamina. In what this stamina essen- tially consists we cannot say; our knowledge does not enable us to explain it. It is convenient to personify it, and it is therefore spoken of as if there were really such an entity. This physiological principle which we call stamina is the analogue of the pathological principle of tolerance. As we cannot explain the former, so in what TOLERANCE OF DISEASE. 163 the latter essentially consists we cannot say. This com- parison goes to show that when the apparently strong succumb to diseases which the comparatively feeble are able to endure, the fact is due, not to occult morbid con- ditions which are greater in the strong than in the weak, but to a lesser degree of tolerance in the former than in the latter. Admitting that in what the tolerance of disease con- sists is not with our present knowledge fully understood, we know somewhat of its laws and of the circumstances which on the one hand promote and on the other hand impair it. This knowledge is of great importance, and it therefore claims our consideration. The tolerance of certain diseases has laws relating to age. For example, the tolerance of typhus fever is greater between ten and twenty years of age than at other periods of life. While from ten to fifteen per cent, of persons of between ten and twenty affected with this disease die, it kills one- half of those who have it after fifty years of age. Ty- phoid fever is best tolerated between ten and fifteen years of age, and better between five and ten than after the age of fifteen. Small-pox is tolerated badly by children and the aged. The tolerance of acute pneumonia is much less in childhood and in old age than between these extremes of life. I cite these instances as illustra- tions to which many more might be added. The toler- ance of certain diseases has relation to sex. Women, for instance, tolerate typhus fever better than men. The tolerance of certain morbid conditions is greatly affected by habit. A striking instance of this is the ability to bear uraemic poisoning if the accumulation of urea in the blood takes place gradually. A rapid accumulation may occasion sudden coma (apoplexy) and speedy death, 164 TOLERANCE OF DISEASE. the patient perhaps having been conscious of no ailment up to the moment of the apoplectic seizure; whereas, if the accumulation be gradual, coma and convulsions may not take place for a longtime after the manifestations of minor ursemic phenomena. It is probable that the ability to tolerate urea is acquired by habit precisely as the habitual use of narcotic drugs enables persons to take with impunity enormous doses. The exposure to the special causes of various diseases within the limits of that amount of exposure necessary for their development induces, as is well known, an ability to tolerate these causes to any extent. This is the philosophy of what is called acclimation. A native or one who has long re- sided in a yellow-fever zone without ever having had yellow fever, is protected against it by having acquired tolerance of its special cause; in other words, he has become acclimated. Tolerance of the special causes of certain diseases comes with age; thus the contagium of scarlet fever very rarely causes the disease in the middle and advanced periods of life, and after fifty years of age, as a rule, the special cause of typhoid fever is inoperative. In fact, the expression tolerance of the causes of disease embodies all that we know, or rather it is an acknowl- edgment of our ignorance, of the rationale of the wonder- ful fact that certain diseases are experienced but once in a lifetime. Why the eruptive fevers—typhus and ty- phoid and yellow fevers—leave an insusceptibility in the organism to the special causes of these diseases is, with our present knowledge, a marvellous mystery. To say that this insusceptibility is in consequence of an acquired tolerance of the special causes is, of course, only to state the fact in different terms. The laws of the tolerance of disease which have been TOLERANCE OF DISEASE. 165 mentioned are alike incomprehensible and beyond our control; but there are circumstances on the one hand promoting, and on the other hand impairing this toler- ance, which are to a certain extent both comprehensible and controllable. Knowledge of these is especially im- portant. In acute diseases which prove fatal through lack of tolerance this is promoted by those circum- stances which, it is customary to say, tend to maintain the powers of life; and first in rank among these circum- stances is the ability to ingest, to digest, and to assimi- late food. Favorable hygienic conditions promote toler- ance; namely, pure air, proper regulation of tempera- ture, cleanliness, etc. Per contra, circumstances which are the opposite of these—namely, inability to take food or to appropriate it, and unfavorable hygienic conditions —impair tolerance. Moreover, events in the course of disease which are depressing, debilitating, or perturbat- ing, tend to impair tolerance; such as mental apprehen- sion or discouragement, hemorrhages, vomiting, diar- rhoea, etc. This statement respecting acute, holds true equally in chronic, diseases. In the latter, as in the former, the circumstances first in importance as promoting tolerance are those which are conducive to assimilation and nutri- tion. Hygienic influences, mental and physical, which tend to increase constitutional strength and vigor, are important; and the reverse of these, together with de- pressing, debilitating, and perturbating events, impair tolerance. The dependence of tolerance on these cir- cumstances is sufficiently evident in cases of all chronic diseases, but the fact is strikingly exemplified in certain cases of organic disease of the heart. A robust-looking man wishes an insurance on his life, and he comes be- 166 TOLERANCE OF DISEASE. fore a medical examiner writh a proud consciousness of perfect health. He has always been well, excepting an attack of acute articular rheumatism some fifteen or twenty years back. He is between forty and fifty years of age, and in answer to an inquiry he says that of late he has noticed some want of breath on walking fast or mounting stairs; but this he attributes to his having grown somewhat corpulent, and to his sedentary habits. The examiner notices perhaps some irregularity in the pulse, and on auscultating the prsecordia he finds a loud mitral presystolic and a regurgitant murmur. He finds the apex of the heart lowered to the sixth intercostal space, and situated considerably to the left of the linea mammalis. He is obliged to reject him, of course, as a candidate for life insurance, and the man discovers that he is rejected in consequence of disease of the heart. He is astonished, or perhaps indignant; and it may be that he is to be congratulated if, contenting himself with a few expletives, he dismiss the matter from his mind, or if he conclude that his own consciousness is more trust- worthy than the doctor’s stethoscope. This is a sketch of cases which are by no means in- frequent, What is the sequel ? This man had at the time of his application for a life insurance a good appe- tite and a fine digestion. Aside from the organic affec- tion of the heart, all the important organs of the body were sound and their functions were well performed. His habits of life were good, and his spirits were buoy- ant. We will suppose that some months afterward he goes into the country, in the month of July or August, for a little relaxation and rural enjoyment. He gets in- termittent fever, he loses his appetite, and his blood be- comes impoverished. He now suffers from want of TOLERANCE OF DISEASE. 167 breath on slight exercise; soon he is unable to lie down on account of dyspnoea; his extremities became oedemat- ous; hydroperitoneum and some hydrothorax follow. He is relieved by diuretics, digitalis, and tonic remedies. The dropsy disappears, and he resumes his avocations. He is not, however, the man he was before. He can take but little exercise, and he sleeps badly. His diges- tive organs do not recover their wonted functional ca- pacity. He becomes despondent. It is not long before dropsy returns. He is obliged to sit up night after night on account of dyspnoea dependent on imperfect circula- tion, hydrothorax, with perhaps pulmonary oedema. Ju- dicious measures of treatment procure only temporary relief, and he dies after weeks or months of intense suf- fering. Now what is the rationale of such a history? Briefly this: he had had valvular lesions, with enlargement of the heart, for years before it happened to be discovered at the examination for a life insurance; but the lesions had been gradually produced, and progressed slowly. He had become habituated to the comparatively little disturbance of the circulation which they occasioned, and he was conscious of no malady. In other words, under the conditions stated—namely, a good appetite, a fine digestion, and no intercurrent affection—he tolerated perfectly the cardiac lesions. The conditions of toler- ance were changed when he suffered from malaria and defective alimentation. Under these changed conditions as regards tolerance he began to suffer from the effects of the obstructive and regurgitant lesions in conjunction with a weakened heart. The former power of the heart’s action was never regained; but, on the contrary, with diminished appropriation of food and poor blood, the 168 TOLERANCE OF DISEASE. organ became progressively weaker and more yielding to the pressure from the contents of its cavities; hence dropsy, dyspnoea, and at length death from failure of the heart’s action. It would be easy to present hypothetical cases of other chronic diseases in illustration of circumstances which on the one hand promote and on the other hand impair tolerance; but, without dwelling longer on this division of my subject, I pass to some considerations relating to the practical applications of the principle of tolerance to prognosis and therapeutics. Every practicing physician knows that accuracy of diagnosis, although indispensable, is not alone adequate as a basis of positiveness in prognosis. Let us be ever so sure of the nature of a grave acute disease—an essen- tial fever or an inflammation—let the diagnostic evi- dence be as complete as possible in regard to its degree, the extent to which parts are affected, the stage, together with a full knowledge of any existing complications; add to this an acquaintance with all that is known re- specting the intrinsic tendencies of the disease, of its laws, and the results of statistical researches into its rates of mortality; there is still remaining that imponderable element which we call tolerance, on which, in individual cases, hinges the question as to death or recovery. One patient will die because he lacks a sufficient amount of that vital stamina which carries another patient safely through the disease. Hence the proverbial non-commit- talism of those physicians who regard as an unworthy trick an attempt to gain credit for superior acumen by means of a lucky hit at guessing. In like manner, to determine with precision the duration of life in cases of chronic diseases which must sooner or later prove fatal, TOLERANCE OF DISEASE. 169 is beyond the bounds of scientific prescience. In ad- dition, however, to laws and circumstances already adverted to, there are certain considerations which, as ex- perience has taught, are to be taken into account in esti- mating tolerance. Habits of intemperance, for example, aside from the affections directly attributable thereto, di- minish the ability to endure either acute or chronic dis- eases. This is also true of prolonged overtasking of body or mind; in other words, “wear and tear.” Toler- ance is affected in no small degree by the mental tem- perament, in respect of which different persons differ widely. A determined resolution to overcome disease often aids not inconsiderably in effecting recovery, and also promotes tolerance where recovery is impossible. On the other hand, apprehension and despondency have an opposite effect. These, with other considerations which might be added, enter into prognosis as connected with tolerance. They are considerations which bear upon prognosis in advance; that is, in the early stage of diseases. To determine the present condition as regards tolerance in cases of acute or chronic disease is more easy. By means of existing symptoms we can gauge tolerance with considerable positiveness. In acute diseases the circulation, as represented by the pulse, furnishes the symptoms which have the most significance in this aspect. In cases of acute diseases which kill from want of toler- ance the mode of dying is by asthenia or exhaustion. Now, the pulse may be said to be the thermometer of the vital powers. Failure of these—that is, the giving way of tolerance—is denoted by feebleness and frequency of the pulse, assuming that these characters are not de- pendent on heart-lesions. Muscular prostration comes next as denoting impaired tolerance. It might be sup- 170 TOLERANCE OF DISEASE. posed that a high temperature of the body is to be con- sidered as a sign of failing tolerance, but it seems more rational to regard this as causative rather than indicative of ebbing vital powers. In eases of chronic disease, de- fective tolerance is shown by impairment of the forces carrying on the circulation, together with muscular debility and progressive emaciation. Skilful ness as a prognostician in cases of acute and chronic diseases depends on the ability to judge of tolerance by means of these criteria, in conjunction with the laws, circum- stances, and considerations before referred to. The application of the principle of tolerance to thera- peutics is the more important of the practical aspects of the subject. In acute diseases, the danger relating chiefly to asthenia, generally tolerance is the objective point in the management. It is an object, in the first place, to avoid measures which will be likely to impair tolerance. Conservatism in medical practice is, in other words, the protection of tolerance. In the second place, it is an object to promote tolerance. Take, by way of illustration, the potential measure, bloodletting. If the protection of tolerance be an important object, this meas- ure is thereby contraindicated. Assuming that it will procure relief, the ulterior effect will be hurtful in pro- portion to the degree of danger of dying by asthenia. If, on the other hand, whatever danger there may be is not from asthenia, bloodletting is admissible, even if it be only palliative, provided the same palliation is not obtainable by other means which do not impoverish the blood. Governed by this rule, the abstraction of blood is contraindicated, for example, in the essential fevers, in which recovery depends on tolerance; but, in view of its promptness and potency, it may be advisable in acute laryngitis, a disease which kills by apnoea. TOLERANCE OF DISEASE. 171 It is a ready method of forming a judgment concern- ing the propriety of employing any potential remedy or measure of treatment, to propound to one’s self at the bedside, in a case of acute disease, the following ques- tions: If this disease prove fatal, will it kill by asthenia or apnoea? If by asthenia, will the remedy or measure of treatment under advisement impair tolerance? If the answer to the last question be in the affirmative, as a rule the remedy or measure will do harm. It may be sufficient in many cases of acute disease to abstain from treatment which would impair tolerance; but if there be reason to fear that the vital powers are inadequate to carry the patient safely through the disease, then the pro- motion of tolerance becomes an important object of treat- ment. The means for this end are those which consti- tute what is commonly called the sustaining or support- ing treatment. It is a corollary of facts presented already that alimentation holds the first rank among the supporting measures. Tonic remedies have a certain measure of importance as conducive to tolerance. Al- oohol has its place of usefulness here. Without discuss- ing the question whether alcohol be a food or a remedy, and divesting the topic of all moral considerations, that it is an important constituent of the supporting treat- ment must be admitted. Practically, its usefulness as such consists in this: it promotes for a time tolerance; its use is indicated where there is evidence of failure in tolerance; it is often wise to forestall by its use the fail- ure of tolerance; the urgency with which it is indicated is proportionate to the degree of danger from failure in tolerance. The proof of its usefulness is the evidence of increased tolerance without any of the phenomena of alcoholism or excitation. It is superfluous to add 172 TOLERANCE OF DISEASE. that all the favorable hygienic influences, mental or phys- ical, which can be brought to bear upon patients af- fected with acute diseases tending to death by asthenia, are useful by promoting tolerance. Next in importance to the measures which have reference to causative agen- cies, and those which are directly or specially curative, is to be ranked the protection and promotion of tolerance in the management of those acute diseases of which as- thenia is the dangerous element. In the treatment of chronic diseases how few are the known remedies which are directly or specially curative! We have some such remedies. Quinia and arsenic in malarial affections and in certain cases of neuralgia, mer- cury and the iodide of potassium in syphilis, the bro- mides in epilepsy, at once rise in the mind and bear tes- timony to the truth of this assertion. But it would be difficult to extend the list much. In most cases of chronic disease ending in recovery, the result is not due to a direct or specially curative medication. We per- sonify a fictitious entity when we attribute cure to nature or the vis medic,atrix naturae; yet it by no means follows that we are only passive spectators when our patients get well, and we cannot assume to have controlled the dis- ease by drugs. Drugs indeed often do much toward cure, although their action be not directly or specially curative. They procure palliation or relief of suffering, and they may be indirectly of great use by promoting appetite and digestion, supplying important constituents to the blood, favoring the elimination of noxious princi- ples, etc. Operating in these ways, they may be said, in a certain sense, to do good by affecting favorably tol- erance. In so far as tolerance is favorably affected, re- cuperation is facilitated; and here, as in acute diseases, TOLERANCE OF DISEASE. 173 next in importance to curative medication (whenever this is practicable) is to be ranked the protection and promo- tion of tolerance. In the treatment of those chronic diseases which are incurable, tolerance is pre-eminently the objective point. If a cure is not to be effected, the ends of treatment are, first, to prolong as much as possible the duration of life; and second, to render life as comfortable as possible not- withstanding the continuance of disease. These ends are far from being trivial. Shall a patient live for a few months or for many years, is a question the answer to which may depend on the knowledge and skill of the physician. This fact is not perhaps always sufficiently appreciated in medical practice. The recognition of in- curable diseases is of prime importance. Herein diag- nostic ability is essential to a rational management; and a rational management consists on the one hand in the avoidance as far as may be of everything which impairs, and on the other hand in the judicious employment of measures which promote, tolerance. All are familiar with the following maxims of Chomel, which have become classical: The proper aim of the physician is, first, not to do harm; and second, to try to do good. The physician is not to treat diseases, but pa- tients affected with diseases. The former of these max- ims inculcates, in other words, the protection and pro- motion of tolerance as a fundamental rule in the practice of medicine. The latter maxim inculcates this rule with still greater emphasis. In the treatment of patients af- fected with diseases, whether acute or chronic, the prin- ciple of tolerance should always pervade our thoughts and acts. 174 ON THE AGENCY OF THE MIND IN VII. On the Agency of the Mind in Etiology, Prophylaxis, and Therapeutics.1 rpHE reciprocal influences of mind and body offer a wide range for investigation, and certain points of inquiry relating thereto may be said to be of paramount importance as compared with other branches of scientific research. These points relate especially to the influence of body on mind. Here are questions which concern not alone mental pathology, but morality, jurisprudence, social life, the progress of civilization and human hap- piness perhaps in a future life as well as in our present existence. Questions relating to the influence of the mind on the body are more exclusively medical in their character, and I shall confine myself to these in the fol- lowing remarks. With cases illustrating a morbid exaggeration of sub- jective symptoms, and a conviction of the existence of imaginary diseases, all practitioners are familiar. These cases are nosologically disposed of by calling them cases of hysteria, melancholia, pathophobia, and hypochon- driasis. I am tempted to introduce a brief account of two striking examples which have recently fallen under my observation. 1 Bead before the Yonkers Medical Association. ETIOLOGY, PROPHYLAXIS, AND THERAPEUTICS. 175 A married lady, of education and superior intellectual endowments, nearly forty years of age, in easy circum- stances, and without children, unhappily had been led to concentrate her attention on her bodily condition. After a series of fancied ailments, for which she had kept the bed for over three years, she conceived the idea that from a peculiar susceptibility of the brain she was unable to bear the stimulus of light. During several months she insisted that her room should be darkened; and the darkness was made as complete as possible by black cur- tains covering the windows and doors, and by surround- ing her bed with screens, to absorb the few rays of light which entered when a door was opened. In the mean- time repeated examinations of the eyes by an eminent oculist failed to discover any evidence of disease. After much perseverance on the part of physicians and friends, she was at length persuaded to bear a little exercise of vision. Very gradually the darkness was diminished, and she believed herself finally cured of this malady, without admitting that she had suffered from a delusion. She was undoubtedly sincere in her belief in the reality of the fancied malady, and it would have been worse than useless to have attempted to convince her to the contrary. This patient believed that to change her posi- tion in bed by her own efforts would be fraught with evil consequences, and for this purpose the constant at- tendance of a nurse was required; yet it is certain that there was no lack of muscular strength. Her aspect was healthy; there was no impairment of nutrition; she ate an abundance of food, and careful interrogations of the various organs showed no evidences of any disease. A married lady, wealthy, and in a high social posi- tion, about fifty years of age, consulted me for loss of the 176 ON THE AGENCY OF THE MIND IN faculty of speech. She communicated respecting her malady by means of a slate and pencil, which she carried with her for that purpose. She declared her inability to speak even in a whisper. Our conversation was carried on partly in writing and partly by signs which her hus- band interpreted. A thorough examination of the chest was completely negative, and there was no paralysis of the tongue or lips. I refrained from expressing distrust of her inability to speak even in a whispered voice, and after a prolonged interview I dismissed her with a pre- scription. Some time afterward she called again to tell me that she could not take the remedy which I had pre- scribed, and that her malady continued. That she hon- estly believed herself unable to speak I did not doubt. She is a lady of unusual intelligence, and in the second interview the conversation after a time became directed to topics in which she was much interested. Finding at length that the slate and pencil, together with her signs, which were with difficulty interpreted, failed to convey her ideas satisfactorily, she began to speak, and continued the conversation for half an hour in a natural tone of voice. I made no comment thereon, and nothing was said by her respecting the sudden recovery of speech. This was the last consultation. She has not again called upon me. It would be easy to multiply cases illustrative of de- lusions respecting health. The patience and temper of physicians are sorely tried by such cases. Reasoning with the patient is without much avail. Positive assur- ances by the physician are often useless, or their efficacy is but transient. Ridicule only ruptures professional re- lations. There is ample scope for tact and perseverance in the management; and such cases claim more consid- ETIOLOGY, PROPHYLAXIS, AND THERAPEUTICS. 177 eration and persistency of effort in the way of judicious treatment than they are apt to receive. The various delusions respecting imaginary diseases, together with indefinite apprehensions concerning health, and undue attention to the functions of the body, un- doubtedly enter more or less largely into etiology. There is perhaps little ground for the opinion which has been held that devotion to the study of particular affections predisposes to their development ; but it is certain that constant watching of particular functions is almost sure to lead to disorder. If the attention be habitually con- centrated on the digestive organs, indigestion is an almost inevitable consequence. That unfortunate being, a con- firmed dyspeptic, may often indulge his appetite to the fullest extent with impunity, provided the mind be agreeably diverted for some hours afterward. The con- centration of the mind on the digestive processes is, in fact, often the chief cause of chronic dyspeptic ailments. Functional disorder of the heart is frequently kept up by a conviction of the existence of organic disease, and of liability to sudden death. Frequent micturition and polyuria are produced by apprehensions relating to the urine; and temporary impotency is a well-known effect of imagined sexual incompetency. The depressing influ- ence upon the system of fixed delusions and prolonged indefinite apprehensions is by no means inconsiderable. If diseases be not thereby induced, their production is favored by the agency of the mind, which acts either as an auxiliary cause or by rendering the system more sus- ceptible to various morbific influences. The morbid mental conditions to which I have re- ferred, as standing in a causative relation to physical maladies, are themselves often dependent on causes re- 178 ON THE AGENCY OF THE MIND IN lating to the mind. What causes originating in the mind induce these morbid mental conditions? Observa- tion shows that the exercise simply of the intellectual faculties rarely gives rise to mental and thereby to phys- ical disorder. They who are devoted to pursuits involving the active employment of the intellect are not in conse- quence prone to diseases of the mind. Madness is rarely, if ever, an effect of “much learning,” as implied in the exclamation of Festus to Saint Paul. The maladies, mental and physical, which are incident to intellectual pursuits, as a rule, do not depend directly on the latter, but they arise from sedentary habits, or other associated violations of hygienic laws. Observation will, I believe, bear me out in these assertions. “ Wear and tear,” ner- vous asthenia, morbid apprehensions concerning health, melancholia, hypochondriasis, and insanity, together with the ills of the body resulting from these mental condi- tions, are the results of the emotional rather than the in- tellectual activity of the mind. Among those whose work may be distinguished as braincraft, they who suffer from the mental causes of disease are not the close students, the industrious au- thors, and the laborious lawyers, clergymen, and physi- cians, in so large a proportion as men of business, specu- lators, and politicians. It is not the amount of intellec- tual work so much as the constant tension from anxiety and suspense, the alternations of undue exultation and despondency occasioned by the so-called caprices of for- tune, and persistent over-excitement, which constitute morbific agencies of mental origin. I will venture another statement, which, as I believe, observation will verify—namely, the calamities of life which, by way of distinction, we may call providential, ETIOLOGY, PROPHYLAXIS, AND THERAPEUTICS. 179 are far less likely to prove morbific than emotional dis- turbances incident to a disordered imagination, irregu- larities of life, and unrestricted passions. By the term providential calamities I mean those which are in a great measure beyond human control, and therefore appear to occur more especially in the order of Providence; such as the death of relatives and friends, the loss of prop- erty by events which could not be foreseen nor provided against, and deformities or maiming by disease or inju- ries. Both mind and body tolerate such calamities much better than those for which the responsibility rests with man rather than with God. Physicians, sanitarians, and moralists have of late had much to say respecting the evils of over-exertion of the intellect and of mental strain; and there has been much occasion for speaking of these sources of injury to mind and body in our country, especially during the past few years. But there is another aspect of the etiology of morbid mental conditions, concerning which much less has been said—namely, deficient exercise of the intellec- tual powers, or insufficient activity of the mind, as a source of morbific agencies. Observation will, I think, show that evils of both body and mind originate quite as often in a want of the proper action of the intellec- tual and moral faculties as in their over-use or excita- tion. Occupations which employ the intellect are likely to prevent inordinate attention to the bodily functions, and herein their influence is prophylactic. Abundant illustrations of the evils of deficient activity of the mind are to be found among those who, under the delusive ex- pectation of enjoying leisure and rest, have relinquished pursuits which involved an habitual exercise of the men- 180 ON THE AGENCY OF TIIE MIND IN tal faculties. Let me cite two examples from among those which have come under my observation. A highly intelligent, energetic, and able merchant ac- quired a handsome competency at about the age of thirty- five. He then began to be apprehensive concerning his health. Fancying successively the existence of different diseases, he spent most of his time in watching for symp- toms and in the study of medical works. At one time the kidneys were the organs under surveillance, and he became an expert in the chemical and microscopical ex- aminations of the urine, in order to investigate daily this excretion in his own case. For several years he exem- plified the varied phases of pathophobia. At length pe- cuniary reverses came to his relief, and it became neces- sary for him to engage anew in business. He did so, and from that time, for a period now of five or six years, he has been exempt from the delusions which had previ- ously rendered life a burden to him. An astute lawyer, aged about forty, commencing his professional life without means, has been eminently suc- cessful as regards the acquisition of wealth. Some dis- order of the digestive system led him to become ap- prehensive on the score of health. This resulted in confirmed pathophobia. He now devotes most of his time to the study of his bodily functions and to reading medical works. He requires elaborate analyses of the urine and faeces, and is anxious to become a microscopist, in order that he may himself examine his blood. Posi- tive assurances that there is no evidence of disease of any of the organs of the body are unavailing. When told that it is bad policy for him to undertake to inves- tigate his organism, he admits it, but declares that the desire to do so is irresistible. Here is one among many ETIOLOGY, PROPHYLAXIS, AND THERAPEUTICS. 181 instances in which the absence of wealth as regards the mens sana in corj) ore sano would be a positive blessing. It is probable that the employment of the mind to gain a livelihood and a competence would have prevented him from falling into his present truly pitiable mental con- dition. It is a well-known fact that habits of mental activity cannot be given up without risk of impairing the healthy condition of mind and body. Of the members of the professions and men of business who retire to enjoy the fruits of their labors, a large proportion suffer from ennui and depression of spirits. Many become affected with confirmed melancholia and hypochondriasis, and in not a few cases insanity is the result. These morbid mental conditions, acting upon the organism through the nervous system, lower the vital powers, interfere with the processes preparatory to nutrition, and occasion vari- ous functional disturbances. Hence they promote the action of the various causes of disease, they impair the ability to resist disease, and they consequently tend to shorten life. But habits of apparent mental activity, if the different faculties be not adequately engaged, will not protect against morbid conditions of the mind. Let me preface some remarks relating to this statement by a case. A patient, who has hardly reached the middle period of life, by his industry, integrity, and remarkable finan- cial ability has already acquired a large fortune. To this end his energies have been directed, and he has been eminently successful. Now, it may be assumed that any great object of human effort, when accomplished, fails to afford the satisfaction which had been anticipated. The love of riches with this patient is not a ruling passion; yet, from the force of habit, he continues to give his at- 182 ON THE AGENCY OF THE MIND IN tention to business, and doubtless is constantly adding to his wealth. He pursues a prudent course in his busi- ness transactions, and he has become so familiar with his method of money-making that it now requires no great amount of mental effort. His aspirations for success are in a great measure satisfied; but while in the eyes of others he holds a very enviable position as regards worldly prosperity, and while, in addition to wealth, he has everything as regards social and domestic relations to render him happy, he declares, in professional confi- dence, that he is one of the most wretched of men. He finds himself unable to derive enjoyment from the bless- ings which Providence has showered upon him. He is a martyr to melancholia and hypochondriasis. His mor- bid mental state is not dependent on any disease of body. The difficulty is, his mental powers and capacities are not fully and appropriately occupied. The case is a type of a class of unfortunates who are much to be pitied. The practical truth which such cases teach is that the proper exercise of all the faculties of the mind, the sen- timents as well as those belonging to the intellect, is the great requisite for mental health, and consequently for happiness. The habitual activity of those attributes of mind which enter into true philanthropy and practical benevolence would often prove a sure means of prevent- ing and curing morbid mental conditions which embit- ter life. It is safe to assert, without knowledge of the fact, that George Peabody was not a victim of melan- cholia or hypochondriasis; but it is by no means neces- sary to possess the means for munificent generosity to secure the exercise of sentiments underlying the benefi- cent actions which render the name of Peabody illustri- ous. They who are not affluent, and even the poorest, ETIOLOGY, PROPHYLAXIS, AND THERAPEUTICS. 183 may enjoy the sanitary influence (to speak of nothing else) of the exercise of these sentiments. It is one of the traditional sayings of the eccentric Abernethy, that being consulted by a rich patient suffering from mental inac- tivity and the evils of luxurious indulgence of the ap- petite, his advice was to live on a shilling a day, and to earn the shilling. The advice embraces an important practical truth—namely, the need in such cases, in ad- dition to temperance, of mental occupation, with an ade- quate purpose. Of course such advice is superfluous as regards the probability of its being literally followed; but the practical truth which it embraces is not broad enough to meet all cases. It points to the importance of the intellectual faculties only, ignoring those of the moral nature. Some one has said, in substance, that to do something each day which will render others happy is a preventive against ennui and misanthropy. If some of our patients would adopt this as a rule of conduct, it would do far more toward restoring mental and physical health than any drugs which we can prescribe. I have sometimes ventured to propose this rule as a therapeutic measure, but I confess that as yet I have not in any in- stance secured a fair trial of it. I trust that the tenor of the foregoing remarks will not expose me to the charge of having wandered with- out the proper boundaries of practical medicine. Men- tal disorders not amounting to insanity, it seems to me, are not sufficiently considered by medical writers, and their importance is apt to be under-estimated by practi- tioners of medicine. These disorders not infrequently precede and lead to insanity; and there are grounds for the belief that timely attention to the former on the part of the physician would often preyent the latter. 184 ON THE AGENCY OF THE MIND IN It so happened, a few years ago, that I was consulted by the friends of a prominent citizen, holding an office of much responsibility, respecting a state of great men- tal depression, which it was feared denoted danger of in- sanity. From the statements which were made to me I expressed a decided opinion that this danger was immi- nent, and that medical advice should be obtained with- out any delay. This was in the evening, and it was de- cided to defer any action until the following day. Early the next morning the patient committed suicide. I can- not but think that had he been seen on the evening be- fore his death by an intelligent and judicious physician, his valuable life would have been spared. It is true of mental as of many other diseases, that they are easier prevented than cured. In diminishing the prevalence of insanity more is to be expected from prophylaxis than from therapeutics. The treatment of cases of insanity is very properly confided, for the most part, to those who give exclusive or special attention to this branch of medical practice; but it is to be considered that they who treat cases of in- sanity do not, as a rule, see patients until after they have become insane. The treatment of mental maladies which precede and lead to insanity must devolve upon the gen- eral practitioner. Hence the importance of according to affections of the mind a larger share in medical literature than has hitherto been done. It is worthy of note that some of our medical colleges have lately assigned to this class of affections a distinct place in the curriculum of instruction. It should also occupy a fair proportion of space in systematic treatises on the principles and prac- tice of medicine; and a work devoted to morbid men- tal conditions originating from causes pertaining to min4 ETIOLOGY, PROPHYLAXIS, AND THERAPEUTICS. 185 and body, without embracing insanity, would prove, if full justice were done to the subject, most interesting and useful. In conclusion, I shall offer a few thoughts on the pro- phylactic and therapeutic agency of the mind with refer- ence to diseases affecting the physical organism. Are diseases ever prevented by the mental state? It is a common belief with physicians and others that there is a measure of prevention against certain diseases in the absence of fear of them; and, per contra, that fear of a disease sometimes enters largely into its causation. It is not easy to demonstrate the correctness of this belief, but there is reason to consider it as well founded. Dur- ing the prevalence of epidemics it is a matter of obser- vation that the timid and pusillanimous are apt to be attacked, whereas they who are courageous and more thoughtful of others than apprehensive for themselves are likely to be unharmed. There is nothing in this very mysterious or unintelligible. The depressing influence of fear lessens the power of the organism to resist the action of morbific agents. On the other hand, the vital functions go on regularly and actively when the mind is undisturbed, and the attention diverted from self; hence it is more difficult for the causes of disease to take root in the system. I think it may be assumed that the exercise of pure and lofty sentiments is conducive to the health and vigor of body as well as mind. In so far then as bodily health and vigor afford protection against disease, the exercise of these sentiments is prophylactic. If I mistake not, the facts of history show that they who, actuated by motives springing from generosity and nobleness of soul, engage in undertakings requiring long-continued ex- 186 ON THE AGENCY OF THE MIND IN ertions, physical or mental, or both, with perhaps severe hardships and self-denials, are apt to be spared from dis- ease and death until the objects are accomplished. Strik- ing instances of this kind appear to exemplify a direct interposition of Providence. The ends of Providence, however, are effected by means; and it is reasonable to suppose that in these instances there is an agency per- taining to the mind which is conservative as regards the prevention of disease. George Peabody is reported to have said, a few days before his death, “I have prayed daily to God to spare my life to carry out the work I was endeavoring in my feeble way to accomplish, and he has done it.” Is it inconsistent with a belief in the ef- ficacy of prayer to conjecture that the mental condition indicated by this statement may have been positively in- strumental in prolonging the life of this illustrious phil- anthropist? If there be truth in the idea that the ac- tivity of the higher sentiments involves a prophylactic agency, health and length of days are to be added to other and worthier inducements for the cultivation of these sentiments. That mental conditions are more or less operative either in promoting, or otherwise, recovery from diseases, is a truth which all medical observers must admit. While on the one hand a feeling of discouragement and hopelessness as regards recovery are obstacles not infre- quently in the way of cure, on the other hand hope and confidence in the means employed for recovery are often powerful auxiliaries in the successful treatment of dis- eases. The state of the mind of a patient enters in many cases more or less largely into the prognosis. Of course to develop and maintain this, hope and confidence should enter, within proper limits, into the aims of the physi- ETIOLOGY, PROPHYLAXIS, AND THERAPEUTICS. 187 cian. The difference among practitioners as regards suc- cess in the treatment of diseases arises in no small degree from a difference, first, in an appreciation of the impor- tance of exciting a proper measure of influence on the minds of patients in the way of encouragement; and sec- ond, in the knowledge and tact required to exert such an influence. All of us know physicians who are good di- agnosticians, and whose judgment in the employment of remedies is excellent, but who are comparatively unsuc- cessful, both in treating diseases and obtaining practice, chiefly in consequence of a lack of this knowledge and tact. The mental temperament of the practitioner has much to do in this matter. Borne physicians are prone to look always on the dark side of cases. They are con- stantly thinking of the unfavorable events which may happen, and they are unable to conceal their apprehen- sions from patients. They look upon every case in its most serious aspect, and their countenances at the bed- side, if not their words, express gloomy forebodings. No amount of skill in diagnosis and the use of drugs will compensate fully for the baneful effect of this tempera- ment. It were better had those who are thus constituted chosen some other vocation than the practice of medicine. Other physicians are distinguished for always taking the most hopeful view of cases. They look ever on the bright side. Their looks infuse hope, and their words are full of encouragement. The effect is often more powerful than medication. There is, of course, an in- judicious extreme in the latter direction, and between this extreme and the opposite there is a golden mean; but if there must be a deviation from this mean, it is de- sirable that it should incline to hopefulness rather than despondency. 188 ON THE AGENCY OF THE MIND IN We meet sometimes with cases in which recovery from disease seems fairly attributable, in a great measure, to a resolute determination on the part of the patient to re- cover. An unfavorable prognosis is communicated to a patient. He declares that he will not die, and he gets well, when, according to prognostics, which are not thereby invalidated, he ought to have died. Examples of this kind have doubtless fallen under the observation of my readers. It has fallen to my lot to observe a large number of cases of tuberculous disease of the lungs; and I have been struck with the fact that in the compara- tively few which have ended in recovery, the patients have generally been persons of a strong will, who, ap- preciating fully the disease, have resolved, if possible, to overcome it. I cannot but think that the proportion of cases ending in recovery would be larger than it is, were it not that the disease carries with it so often either a delusive expectation of recovery without exertion, or a passive acquiescence in a fatal termination. The management in many cases of disease embraces measures, not to effect a cure, but to secure as fully, and for as long a period as possible, tolerance of the disease. To prolong life, and to render as comfortable as may be life as long as it lasts, are the grand objects of manage- ment when diseases exist which are incurable, and which, sooner or later, will end fatally. Now, mental condi- tions have much to do toward the accomplishment of these objects. Occupations which engage the mind suf- ficiently to prevent undue attention to symptoms, over- anxiety, and apprehensions, are often of great utility. Knowledge of the existence of an incurable disease is sometimes extremely unfortunate for the welfare of the ETIOLOGY, PROPHYLAXIS, AND THERAPEUTICS. 189 patient. I am convinced that the duration of life is sometimes shortened, and comfort during life lessened, by this knowledge. It is perhaps a common belief that the existence of organic diseases of the heart should be known as early as possible, in order to take advantage of precautions re- lating to physical exercise and mental excitement, which are generally deemed of great importance. But even these diseases, as it seems to me, are as a rule better tol- erated when, from either ignorance of their existence or an imperfect appreciation of their gravity, patients con- tinue to pursue avocations which may involve consider- able muscular exertion as well as mental activity. The explanation is simple. Tolerance of these as well as other incurable affections is promoted by keeping the general health and vigor at the highest practicable point. Ample alimentation, active digestion, and good nutrition are means essential for this end. Employment of the faculties of mind and body in the pursuits to which one is accustomed conduce to the end by promoting these means. Certain it is that not infrequently persons with incurable diseases, when they become fully awake to the fact, and make a radical change in their habits of life, begin to show a want of the tolerance which had pre- viously existed, and the resistance diminishes rapidly from that moment. If this be a correct statement, it embodies a truth of great importance in its practical bearing, and it seems to me one which physicians do not always sufficiently consider. It is remarkable how much work has been done, and how much hardship has been endured, by men engaged in large undertakings, with either heart, lungs, kidneys, or other important organs 190 ON THE AGENCY OF THE MIND, ETC. greatly damaged by incurable disease! This valuable lesson is to be learned from these examples: that dis- eases which cannot be cured are best and longest endured when all hygienic influences relating to mind as well as body combine to develop and maintain to the utmost extent the vigor of the organism. divine design as exemplified in disease. 191 VIII. Divine Design as Exemplified in the Natural History of Diseases.1 A N invitation to address the Young Men’s Christian Union ought not perhaps to be accepted by me without some misgivings, if for no other reasons, in con- sequence of the limited range of subjects to which my choice must be restricted. Studies connected with dis- eases have, for several years past, so engrossed my at- tention, that I should be at a loss in looking elsewhere for a theme appropriate to a public lecture. “And what,” I can fancy will be the mental inquiry of those who now hear me, “ can be said of diseases which will have either interest or importance for the majority of those assembled here this evening?” These studies, it will be admitted, have claims on all who are, or who expect to become, curators of the sick; and to the vo- taries of medicine they are, for the most part, cheerfully relinquished by the rest of mankind. A sentiment not uncommon, if I mistake not, would lead many persons to regard the acquisition of scientific knowledge respect- ing diseases with a feeling somewhat akin to that which the prospect of an experimental acquaintance with them is calculated to inspire. I am not aware that in these days of educational enterprises it has ever occurred to 1 Read before the Young Men’s Christian Union in Louisville, Ky. 192 DIVINE DESIGN AS EXEMPLIFIED any one to endeavor to popularize the science of pathol- ogy. Is it possible that this province of knowledge can furnish a subject suited to the taste of the auditory with which I am honored? I should meet this question, I repeat, with misgivings; but in answering it affirma- tively, as I virtually have done by appearing before you, I should do gross injustice to the association, to those present, and also to myself, not to confess the indulgence of a hope that a field of inquiry so forbidding as this may appear on its superficial aspect, may yet be found to supply topics worthy of your attention. It is the unpleasant duty of the physician occasionally to prescribe nauseous medicines. All his remedies, how- ever, are not of that description. Some are even agree- able to the taste. But so closely is the idea of a medi- cated potion associated with an emotion of disgust, that a dose, be it even palatable, is rarely taken without a wry face. Permit me to avail myself of this illustration, so far as it may serve in deprecating a premature judg- ment respecting the subject that I have chosen. I shall ask your attention to some remarks on Divine design as exemplified in the natural history of diseases. To say that the natural history of diseases affords striking exemplifications of Divine design, may seem strange to one who has not given attention to the sub- ject; and still stranger to such a one will be the asser- tion that in pathology, scarcely less than in other of the natural sciences, are to be found evidences, abundant and intelligible, of the wisdom and beneficence of the Cre- ator. I will preface the endeavor to illustrate these po- sitions by a remark which will perhaps excite, for a mo- ment, even greater surprise: The existence of disease, relatively considered, is an inestimable boon vouchsafed by IN THE NATURAL HISTORY OF DISEASES. 193 a hind Providence. I say “ relatively considered.” I refer, in this qualification, especially to the limited du- ration of human life. Man being mortal, his liability to disease is a signal blessing. Extravagant as this as- sertion may at the first blush appear, a little reflection will suffice to make its correctness apparent. Imagine sickness to be abolished, leaving death, as now, an in- evitable destiny ; and consider the effects on the charac- ter, conduct, and happiness of mankind. The termina- tion of life would, of necessity, be invariably without forewarning. The occurrence of that event would always be attributed to the direct fiat of the Almighty; or, quoting the significant expression sometimes employed in cases of inquest, to the “ visitation of God.” How ap- palling to witness the spectacles of instantaneous and un- expected destruction, which would be daily presented in our streets, in places of business, and in public assem- blies! An accident involving the immediate loss of but a single life fills a neighborhood with horror. What if every instance of mortality was of that description, and rendered more shocking by the fact that life was de- stroyed irrespective of any apparent agency! Personally, the liability to sudden death is generally dreaded as a grievous calamity. Both reason and in- stinct lead the mind to prefer that life should be yielded up on the bed of sickness. The litany of the Protestant Episcopal Church, as is well known, teaches the suppli- ant to petition that he may be delivered from so great an evil. Yet, were disease to be abolished, sudden death would be the common lot of all. Were we to trace more deeply the consequences of such u change in the order of nature, we should find that 194 DIVINE DESIGN AS EXEMPLIFIED those already alluded to, although the most obvious, are least in importance. The permanent moral influence on individuals would probably differ according to diversities in mental consti- tution, and other circumstances. In some instances it might lead to a false security in the chances of living; but oftener the result would be a paralyzing sense of the uncertainty of life. In either case there would be a tendency to a spirit of recklessness undermining those motives of action upon which the welfare of society, humanly considered, is founded. We have, then, in the fact that disease exists, an ex- emplification, not only of Divine design, but of the wis- dom and beneficence of the Supreme Ruler of the uni- verse. This conclusion will prepare us to expect illus- trations of these attributes of the Creator in the natural history of diseases. In directing inquiries to pathology—the science of disease—no pains are needed to discover such illustra- tions. They present themselves on every side. The only trouble will be to select points appreciable without previous acquaintance with pathological details, and which can be considered, sufficiently for the present ob- ject, within the limits of a single discourse. The liability to disease pertaining to mankind, more or less, in every situation, and under all circumstances, is designed for important ends in the moral economy of the universe. We are warranted in making this remark by the following interesting facts : 1. The individual in- stances of disease are very numerous. It is needless to say that, in this respect, there are wide differences in dif- ferent places, and at different times. It is true also, that, to a greater or less extent, the frequency with which dis^ IN THE NATURAL HISTORY OF DISEASES. 195 eases occur, is dependent on human conduct. But aside from man’s own agency, voluntarily or involuntarily, and irrespective of causes peculiar to place or time, cases of disease are now, and ever will be, sufficiently numer- ous to show that by Divine appointment they are inci- dent to human experience. And it is worthy of notice that, in this respect, there is a marked contrast between the human family and inferior animals. The diseases affecting the latter are comparatively few, and rare in occurrence. 2. Of the instances of diseases affecting mankind, a fatal issue occurs only in a small proportion. Here again, there is by no means uniformity at different periods and localities, and, it is to be presumed, the ratio of fatality from all diseases, and from some more especially, is affected now, and will be more and more as science advances, by human agency exerted through the healing art. But, independently of these considerations, I think I am justified in assuming that the number of cases of illness would be large in proportion to the number of deaths. In this particular, too, there is a notable dif- ference between the human race and the lower orders of animals. The latter are vastly less subject to diseases, but their diseases are fatal in a vastly greater ratio. Without enlarging on these facts, I have adduced them in proof that the institution of disease is for objects beyond those relating directly to death, to which refer- ence has already been made. The nature of these ob- jects we can, to some extent, understand. Observation and experience teach the utility of sickness in its chas- tening influences on the mind of the sufferer; in the oc- casions which it affords for the cultivation of sentiments of sympathy, affection, and charity; in its admonitions 196 DIVINE DESIGN AS EXEMPLIFIED of mortality, preventing too engrossing an interest in this life, and often inducing a disposition favorable to the re- ception of religious truth. Leaving the illustrations of design which an inquiry in this direction would develop, I wish simply to state, as the point of departure for other illustrations more appropriate to my subject, the princi- ple that the frequent occurrence of diseases not ending fatally, is manifestly an important element in the moral economy of nature. Providence has evidently ordained, not only that, as a general rule, sickness shall be the pre- cursor of death, but that it shall hold an important place among the disciplinary and monitory events of life. Let us now consider briefly some of the points of view in which the laws of disease appear to have been established with express reference to this plan of Divine government. We find exemplifications in facts of pathology per- taining to the seat of diseases. In the great majority of instances diseases occur in situations highly favorable for the preservation of life. The parts of the body most subject to different destructive local affections are not those intimately concerned in the vital operations upon which continued existence is most dependent, but, on the other hand, those which may be damaged, either tempo- rarily or permanently, with the least amount of danger. A form of disease occurring more frequently than any other, and the one occasioning oftener than any other in the various tissues of the body, lesions of structure, is that with the name of which all are familiar—inflamma- tion. Now, of the aggregate of cases of acute inflam- mation, the greater proportion, by far, are seated on the surface of the body, or on internal structures relatively inferior in their vital relations, The organs of the body IN THE NATURAL HISTORY OF DISEASES. 197 which are called par excellence, vital organs, compara- tively speaking, are very rarely inflamed; and this is true especially of those organs in which the processes and re- sults of acute inflammation involve the greatest amount of danger to life; for example, the heart, the stomach, and the brain. Acute inflammation seated in these organs is always a very serious disease, and apt to prove fatal. Were they as liable to become inflamed as other parts less important to life, the present ratio of the num- ber of deaths to the number of instances of disease would be reversed; and assuming the aggregate number of cases of disease of all kinds to be the same as now, the value of life would be immensely depreciated. It is an inter- esting fact that the liability to acute inflammation in the organs severally, which have been just named, is in- versely in proportion to the danger therefrom. Acute inflammation of the heart is attended with the least im- mediate risk, and the heart is more liable to this form of disease than the brain or the stomach.1 Inflammation of the brain is more dangerous than inflammation of the heart, and it is proportionally less frequent. Instances in the adult are rarely met with in medical practice. Acute inflammation of the stomach is one of the most fatal of affections, and it is as infrequent as fatal. The majority of practicing physicians have never witnessed a single case.2 These parts of the body are not all that are distin- guished by exemption from the liability to acute inflam- mation. A group of organs not having the same vital relations, but scarcely less important in their functions, 1 The phrase inflammation of the heart is here, of course, considered as em- bracing endocarditis and pericarditis. 3 The form of disease here referred to is that described by English and Ameri- can authors under the name of acute gastritis, not that called by German writers acute gastric catarrh. 198 DIVINE DESIGN AS EXEMPLIFIED enjoy the same immunity. I refer to organs called glands, which separate from the blood certain of its con- stituents, either for elimination or other useful purposes. The liver, the kidneys, the pancreas, with some others, constitute this group. It is extremely unusual for acute inflammation to attack these organs. What has been stated with respect to inflammation is measurably true of other forms of disease which tend to disorganization of structure. Cancer, for example (which I instance because it is well known to be a fatal form of disease), sometimes is seated in vital parts, but it is oftener found in situations where it may produce extensive rav- ages before life is destroyed; and frequently this, as well as other malignant affections, are confined to portions of the body which may be entirely dispensed with, and are removed by the knife of the surgeon. The malady called by the pathologist tuberculosis,.and popularly known as consumption, may seem to be an ex- ceptional instance of a very fatal form of disease, select- ing, almost uniformly, a very important organ—the lungs. This fact, however, is less exceptional than it at first appears. For reasons which I shall have occasion to notice in another connection—reasons which account for inflammation of the lungs proving fatal in but a small proportion of cases—a tuberculous affection com- promises less the duration of life, and even the chances of recovery, seated in the lungs, than in other vital organs; for example, the brain. Observations prove the correct- ness of this statement. The parts of the body which, from their pre-eminent importance, are called vital, are by no means so exempt from disturbance of their healthy condition, as they are from the liability to disorganizing affections. This fact IN THE NATURAL HISTORY OF DISEASES. 199 gives additional force to the point under illustration. The heart, the brain, and proverbially, the stomach, are extremely prone to disorder. The same is true of the glands that have been mentioned. Their affections, how- ever, are, for the most part, of the kind called functional, and, although more or less distressing, do not involve much, if any, immediate danger. In short, I think I am warranted in assuming it to be a general rule in pathology, that the organs, the integrity of which is necessary to life, are least liable to become affected with local diseases tending to destructive effects in the part affected; and at the same time they are perhaps most susceptible to disorders of function attended with little or no danger. Conversely, it follows that disorganiz- ing processes of disease attack by preference parts of the body in which, relatively considered, the situation must be deemed favorable; and to complete the antithesis it may be added as probably true, that the latter are in a less degree prone to those disturbances which are distin- guished as functional. I cannot leave this branch of the subject without cit- ing a single illustration of the point under considera- tion, whieh will require some reference to anatomical details. In the foregoing remarks I have spoken of the differences in predisposition to diseases inherent in the different structures of the organism. Instances showing the existence of similar differences, not less important as provisions for the preservation of life, are to be found in different portions of the same structure. What are called the air-tubes of the lungs (technically termed the larynx, trachea, and bronchi), are lined by a membrane. This membrane is subject to inflammation, but it is very rarely the case that acute inflammation extends over its 200 DIVINE DESIGN AS EXEMPLIFIED whole extent. The inflammation, in the vast majority of cases, is limited to a portion of the membrane. To what portion it is usually limited, and is it a matter of much consequence what particular portion is affected ? The answers to these questions involve the particular illustration to which I wish to call your attention. Acute inflammation of the summit of the air-tube (the larynx) is a very fatal disease. It is apt to destroy life by in- ducing suffocation in a very short space of time. This was the disease which destroyed our pater patriae—Wash- ington. Agreeably to the pathological rule we have stated, we should expect, what is true, that it is a disease occurring very infrequently. The case of Washington was one of the first recorded as such in the annals of medicine. Acute inflammation seated in the minute ramifications of the bronchi is also a very fatal affection. These tubes are extremely small, and the swelling of the membrane incident to inflammation closes them up; air cannot gain access to the cells of the lungs where the interchange of elements between the blood and air takes place, and the patient dies, as when the windpipe is ob- structed, by suffocation. But this form of bronchitis (capillary bronchitis, as it is called) is a very rare dis- ease. When it does occur it is usually in childhood or old age.1 Inflammation seated between these two is not attended with much suffering, and with very little danger to life. And, thus restricted, inflammation of the mucous membrane of the lungs is one of the most common of the diseases which come under the observation of the practi- tioner of medicine. It is the ordinary form of bronchitis. 1 The moral objects of sickness, so far as the subjects themselves are concerned, it is evident do not extend to diseases of childhood, and in a limited degree only to those incident to old age. It serves to enhance the evidence of design here, and in other instances, to bear this consideration in mind. IN THE NATURAL HISTORY OF DISEASES. 201 We have thus in the laws regulating the seat of dis- ease, clearly exhibited a principle of conservatism (vis conservatrix). Whence is it derived? Is it due to chance ? Certainly it is as unphilosophical not to recog- nize therein Divine design, as it would be to deny that the hand of Providence is displayed in other provinces of nature in which science develops adaptations of means to ends universally attributed to the infinite Intelligence and creative Power of which Nature is the ideal repre- sentative. We educe the evidences of design from the natural history of diseases precisely as when, reasoning from final causes, we “ look thro’ nature up to nature’s God” in the wonders of astronomy, of physiology, or any of the natural sciences. An appreciation of this conservative principle should serve to reconcile us to the comparatively trivial mala- dies which we often thoughtlessly regard with petulant dissatisfaction. Let it be considered, for example, that if the formation of a little matter, deeply seated, at the end of the finger, which, in vulgar parlance, is stigma- tized by the title of a felon, had by an error loci been situated in the brain, a fatal affection would have taken the place of one which is only painful! The small ulceration upon which the impatient man does not bestow his blessings, for the reason that it withdraws him for a few days from his active occupation, had it been seated in the stomach or some other vital organ, instead of a part where it involves not the least danger, would have brought to an end his career of worldly activity. Even the single small intrusive pustule marring for a brief period the beauty of the face, and which, although physi- cally nothing more than a little morbid humor, yet gives rise mentally sometimes to a great deal of ill humor ; this 202 DIVINE DESIGN AS EXEMPLIFIED small pustule transferred elsewhere might constitute an incurable, fatal affection. It is a law of pathology that, in general, a disease seated in one part is limited to that part, not extending to other structures however close their proximity. This law is manifestly designed for protection against an un- limited diffusion of disease. I will content myself with citing one of the number of instances in which the preservation of life is secured by its operation. Every one is familiar with the fact that acute inflammation of the throat proper (the pharynx) is of common occurrence. One of the forms of acute inflammation seated in this part is the painful affection known by the name Quinsy (tonsillitis). This affection, as is well known, although distressing, is not dangerous. Now the larynx, or the summit of the windpipe, opens into the throat, or pharynx, and we have already had occasion to refer to the very great danger which attends acute inflammation seated in that portion of the air-tubes. Were it the case that in quinsy the inflammation often extended into the larynx, it would be one of the most serious of diseases; but although the two parts are in immediate juxtaposi- tion, a free communication existing between them, an ex- tension of the inflammation from the one to the other is so infrequent that it is regarded, when it does occur, as a species of accident. What renders this instance more interesting is the fact that the tissue (the mucous membrane) lining the pharynx and larynx is similar in structure. Illustrations are much more numerous in which diseases are limited to a particular tissue, not extending to other tissues differing in structure, although situated in actual contact. For example, inflammation affecting one of the membranes IN THE NATURAL HISTORY OF DISEASES. 203 investing the brain, so delicate in structure that it is with difficulty separated by the auatomist sufficiently to demon- strate its presence (the arachnoid), never extends to another investing membrane (the dura mater), although the two membranes are in apposition, the one lying beneath and in absolute contact with the other. The quantity of some of the vital organs of the body gives rise to manifestations of design in certain of the diseases to which they are subject. The brain with its nerves, and the lungs, as you are probably aware, con- sist of symmetrical halves, united together, but to a certain extent isolated from, and independent of, each other. Owing to this anatomical arrangement, there may exist an affection of one side, or hemisphere, as it is called, of the brain—for example, effusion of blood— paralyzing one-half of the body laterally, leaving feel- ing and motion in the other half intact, and the intel- lectual faculties not necessarily much, if at all, impaired. Under these circumstances life may be preserved for an indefinite period. The condition of a person thus affect- ed is truly pitiable, yet contrasted with death, which would have been the result but for the peculiarity of con- formation,- we are bound to consider it as exemplifying a principle of conservatism. The lungs afford illustrations of this principle still more conspicuous. Nature has been so bountiful in the amplitude of these organs, that even one-half may be spared without necessarily compromising life. In chronic pleurisy the chest, on one side, becomes filled with liquid effusion, compressing the lung on that side into a small space, and interrupting completely the exer- cise of its functions. In a very large proportion of cases of this description, recovery takes place under 204 DIVINE DESIGN AS EXEMPLIFIED judicious management; and patients with one-half of the chest filled with liquid, the lung contained therein being for the time entirely useless, are not infrequently able to walk about, and even continue occupations re- quiring considerable manual labor. It is evident that were both sides of the chest to be thus affected, the con- dition would be incompatible with life. The liability to this is prevented by a law of pleurisy that, in the vast majority of instances, the disease is confined to one side. Cases of what is called double pleurisy are rare exceptions to the general rule. A similar law obtains with respect to inflammation of the lung-substance, or what is understood by the phrase, “ inflammation of the lungs,” or “ lung fever” (pneumonia). In a great major- ity of cases, this affection is limited to about a fifth part of the whole organ, namely, to one of the several por- tions partially separated from each other, and distin- guished as the lobes of the lung. Two, or even three lobes may be implicated, but it is extremely rare for the lobes on both sides to be simultaneously inflamed. Owing to this law, inflammation of the lungs, in the great ma- jority of cases, ends in recovery. Even the natural history of that most fatal of diseases, pulmonary consumption, is not without striking provis- ions against results which would render it much more rapidly and surely fatal. These are well known to the pathologist, but it would occupy too much of your time to endeavor to explain them on this occasion. Examples betokening a principle of conservatism in pathological laws might be multiplied indefinitely. There is hardly a single malady altogether free from exemplifications of this principle. To exhaust the sub- ject would require a great number of discourses; and, in IN THE NATURAL HISTORY OF DISEASES. 205 fact, to do justice to the extent to which the evidences of divine design are manifested in the natural history of diseases, the subject must be made incidental to the study of all the diseases embraced in the nosological catalogue. A host of striking illustrations are included in the following general statement: Diseases for the most part have an intrinsic tendency to end without destroying life, Observers of the phenomena of disease in all ages have been impressed with the truth of this statement. The father of medicine, as he is called, Hippocrates, en- tertained the belief that the morbid processes underly- ing the appreciable events of disease, were conservative efforts of nature to free the system from noxious agents, either received from without, or generated within the body. The great physician of the 17th century, the English Hippocrates, Sydenham, advocated a similar opinion, and the investigations of modern science have developed, and are constantly developing facts which appear to demonstrate that often, to say the least, this doctrine is not far from the truth. Indeed, to so great an extent is design evinced in the spontaneous evolutions of diseases, that past medical theories emanating from men of learning and genius, have recognized the presence of an immaterial intelligence residing in the organism, distinct from the intellect and soul, whose office it was supposed is to superintend and direct the vital opera- tions both of health and disease. Such were the archceus of Van Helmont, and the anima of Stahl, two distin- guished theorists of the seventeenth century. Nor have these or similar views yet ceased to have an influence on our ideas and language. We now think and speak of the vital 'principle as an intelligent agent, presiding over the 206 DIVINE DESIGN AS EXEMPLIFIED phenomena of life; and the vis medicatrix naturae, the recuperative force of nature, is referred to as the voli- tional activity of a personified entity. Popular notions respecting the self-adjustive and re- storative power inherent in the system, and respecting the extent to which morbid conditions are amenable to medicinal agencies, are often, if not generally, quite erroneous. It appears to be commonly supposed that nearly all diseases have a destructive tendency, which it is the object of the art of medicine to obviate; that each disease has, or should have (were the science of medicine perfect), its peculiar remedy or remedies, the curative efficacy o’f which depends on their opposing obstacles to, or summarily arresting morbid processes. Such is the mode of the operation of certain medicinal agents. These are usually called specific remedies. They are few in number. Much oftener is it the province of the skilful practitioner of medicine to endeavor to remove opposing obstacles, and to promote the natural course of disease, being sure that if this course be unobstructed and facili- tated, the safety of the patient is better secured than by officious interference; and the more the natural history of diseases is studied, the more extensive is found to be the application of this rule of medical practice. Let it not be said that this confession derogates from the dig- nity or usefulness of the science and profession of medi- cine. To know when active interference is injudicious, and consequently injurious, if not destructive, involves not less an amount of knowledge of the laws of disease, not less the exercise of judgment and skill, and much more firmness and moral courage than to decide on the employment of powerful measures. It is by abstaining from potent remedies when not needed, quite as much IN THE NATURAL HISTORY OF DISEASES. 207 by boldly resorting to them under the proper indications, that (to quote an expression for which some have a fond- ness) the physician acquires the claim to the title of the heroic practitioner. To avoid misapprehension in these few remarks on a point which, if time permitted, it might be interesting to consider at greater length, let me say I do not mean to be understood to take the position that all diseases, at all times, exhibit an intrinsic tendency toward re- covery. The rule is by no means without signal excep- tions. Some epidemic affections, cholera for example, are undoubtedly characterized by an opposite tendency. Were we to speculate on the significance of the fatality attending the occasional visitations of cholera and other pestilential diseases, we should find grounds for the belief that they are designed for particular ends—that is, for discipline or punishment, exclusive of the moral ends for which ordinary maladies are instituted. In other words, that they are special dispensations of Providence, ordained for purposes which it would be presumptuous for finite intelligence to attempt to fathom. This view is consistent with the eccentricities which belong to these diseases, and in a scientific point of view, the peculiar mystery which shrouds their origin. In conclusion, ladies and gentlemen, if I may pre- sume a few moments longer on your attention, I will offer some remarks on death, or more properly, the act of dying. The subject of my discourse may properly enough be extended to embrace those circumstances con- nected with the yielding up of life, which fall within the province of pathology—the closing events, in other words, in certain cases of disease. With the current notions on this subject, one would hardly expect to 208 DIVINE DESIGN AS EXEMPLIFIED find in the circumstances attendant on the bed of death, impressive illustrations of Divine design. Yet it is not surprising that providential wisdom and beneficence should be here displayed, especially if we take into view a fact implied in Scripture, according to the views of learned biblical1 commentators, namely, that the means of rendering human existence immortal, on the earth, were denied to our first parents, after the fall, as an act of clemency. It is commonly supposed that the act of dying is attended with exquisite suffering: that the sepa- ration of the soul from the body occasions unutterable distress. “ The last agony,” and “ the pangs of death,” are phrases in daily use. The idea conveyed by such expressions is very far from the truth. On this point I can speak from considerable observation, the practical duties of my profession having led me to witness a large number of deaths. The instances in which much pain or physical anguish is experienced during the last moments of life, are rela- tively few: they are rare exceptions to the general rule. In a large proportion of diseases, death is preceded by what is termed coma—a state of mental insensibility. This condition is induced for hours, and sometimes days, prior to the extinction of life. During the comatose state, and especially during what is called the “ death struggle/’ there are present, it is true, the appearances of great distress. The gasping respiration—the “ death rattle ”—the distorted features, and occasionally even the groans of the dying, are indications, to the spectator, of 1 See Genesis 3: 22. “ And the Lord God said, Behold the man is become as one of us, to know good and evil; and now, lest he put forth his hand and take also of the tree of life, and eat and live forever: therefore the Lord God sent him forth from the garden of Eden,” etc. IN THE NATURAL HISTORY OF DISEASES. 209 intense suffering. These are the automatic efforts of de- parting life, involving neither volition nor consciousness. Under such circumstances, pain cannot exist, for the mental perceptions are already extinct. Persons who fall into a state of coma, and afterward recover, retain no recollection of suffering while in that state, notwith- standing the symptoms may, from the association of ideas, have appeared to denote distress. Physiology gives us an explanation of these facts, by showing that the functions immediately concerned in the maintenance of life, are independent of parts of the nervous system standing in direct relation to the faculties of the mind, and that hence vital death—if the antithesis be allow- able—may be preceded, for a greater or less period, by mental death.1 But even in cases in which the mind is retained until the expiring breath, the moribund state is usually quite free from actual pain or distress. The perceptions be- come blunted, so that the morbid conditions which, up to that time, may have occasioned suffering, cease to pro- duce this effect. It is very common, at the near approach of death, for patients to experience such marked relief that they imagine a favorable change must have taken place. Physicians well know that in the course of dan- gerous diseases, it is of bad omen for the patient to ex- press a consciousness of great improvement. “ I am much better,” is the declaration often accompanying a change which has taken away all ground for the hope of recovery. 1 Not to be misapprehended by this language—which is employed for the sake of antithesis—I wish to say that I would, on no account, be understood to imply an opinion that the mind becomes extinct at death. By the expression mental death, I mean only the change incident to the ending of mortal life. 210 DIVINE DESIGN AS EXEMPLIFIED Ordinarily, in the instances in which coma does not precede death, the patient lapses into a semi-unconscious, dreamy condition, toward the close of existence. In this condition the disconnected ideas which float through the mind usually pertain to the occupation or prominent events of the past life. Thus Napoleon, a few moments before dissolution, fancied himself on the field of battle, as shown by the last words, tete d’armee, which escaped his lips. A venerable schoolmaster—Dr. Adams, of the Edinburgh High School—in his last moments, thought himself in his school-room, and died, shortly after saying, “ It is beginning to grow dark; let the boys be dismissed I”1 Persons in a moribund state, not infrequently, so far as their own sensations are concerned, appear in an agree- able slumber, save when disturbed by efforts made to arouse them, or by injudicious persistence in the admin- istration of remedies. “ I must sleep now l” was the exclamation of Byron, shortly before he breathed his last. Death and sleep personified, have been styled, poetically, twin-sisters. The one sometimes appears at the bed of sickness with attractions scarcely less winning than those which make the visits of the other so accept- able ! The act of dying thus, pathologically or historically, affords evidence of design, inasmuch as therein is exem- plified, in a striking manner, the divine attribute of mercy. The subject, however, interesting as it may be in that aspect, considered abstractly, is rendered still more so from its personal relations. With reference to that experimental knowledge which awaits each one of 1 Prof. Dickson’s Essay on Death. IN THE NATURAL HISTORY OF DISEASES. 211 us, and to the individual experience of those whom we love, the question whether the general views that have now been presented are correct, is one of moment. I have not time to treat of the subject as fully as its impor- tance claims, but I reiterate the opinion that the closing act of mortal life, even exclusive of the instances in which it takes place without consciousness, is very rarely accom- panied by great distress, and is often characterized by marked relief of previous sufferings. Many die without having a suspicion of the approach of that event; and it is difficult, and even impossible sometimes, to convince the dying person that he is in immediate danger, so little do his own feelings foreshadow dissolution. Most interesting is the testimony which several distinguished individuals have left behind them, of the painlessness, and even pleasure, of the act of dying! An eminent physician—Dr. Black—shortly before breathing his last, exclaimed, “Oh that I could hold a pen, I would write how pleasant a thing it is to die !” Prof. Dickson, of Charleston, S. C., in an essay on the subject of death, says, a lady, a patient of his, once exclaimed, “ Is it pos- sible I am dying? I feel as if going into a sweet sleep.”1 I have myself heard similar expressions on such occa- sions. Persons resuscitated after submersion or hanging, have repeatedly declared that the loss of consciousness occurred without pain ; and indeed, there are grounds to believe that, after the shock of arresting respiration in these modes of dying, during the brief period which 1 Prof. D., in the essay referred to—Essays on Life, Sleep, Pain, etc., by Samuel Henry Dickson, M.D.—expresses an opinion the reverse of that entertained by the author of this discourse. I am, however, unable to perceive convincing force in his remarks on this point, 212 DIVINE DESIGN AS EXEMPLIFIED elapses before complete insensibility takes place, the sen- sations are of a pleasurable character.1 In remarking on the suffering incident to dying, I have of necessity had occasion to take into consideration mental conditions so far as concerns sensation, conscious- ness, and volition. I shall now venture a step farther, and state my conclusions, drawn from personal observa- tions, respecting the effect produced on the mind hy the anticipation of impending dissolution. On this point I believe the popular impression to be not less at fault than on that just considered. Much is said from the pulpit, and elsewhere, of the terror and mental agony which belongs to the death-bed of the impenitent; and, if I mistake not, it is generally supposed by those who reflect upon such subjects, that the approach of death is regarded always witli awe and painful apprehensions.2 It has been my lot to observe many cases of disease that have proceeded to a fatal issue; and the fatal cases that have fallen under-my notice have embraced all classes of society : the ignorant, the abandoned, and the skeptic, as well as the educated, the virtuous, and the believer. I have witnessed beautiful, and I would add sublime ex- hibitions of pious faith called forth by the prospect of 1 While engaged in writing this discourse I noticed in the newspapers an ac- count of an execution, by hanging, in which the rope broke, and the poor crimi- nal was resuscitated to be again suspended after an interval of half an hour. He had met his fate with perfect resignation, sustained by religious faith, continu- ing to invoke Divine assistance till the moment of the execution arrived. After the resuscitation he declared he had seen the countenance of the Saviour, and desired to be quickly again suspended that the pleasing image might be repeated. Such, in substance, was the newspaper account. The idea of meeting the Saviour which probably had been uppermost and all-absorbing on the scaffold, during the brief passage to insensibility assumed the character of a vision, leaving on the mind the conviction of its reality. Certainly this was incompatible with suf- fering. 2 Death, personified, is styled the “ King of Terrors.” IN THE NATURAL HISTORY OE DISEASES. 213 dissolution. I rejoice in an opportunity to bear publicly my testimony to the joy and exultation with which the Christian believer is enabled to prepare for the approach of death. But I am bound to say that I have not met with instances in which the fatal issue of disease ap- peared to be contemplated with that fearful anxiety thought by many to be the necessary consequence of the absence of religious sentiments. Many persons, on the bed of sickness, manifest utter apathy as to the result, not asking for information as to the probabilities of re- covery with any earnestness, and frequently making no allusion to the subject. How different would the case be in a suit at law, for example, involving the loss or gain of a few thousand dollars! If the opinion of the physician be asked, and a discouraging answer given, the only emotions excited are those of surprise and dis- appointment. I cannot affirm that I have ever seen a recoiling from the conviction that the hour of death was at hand, with that fright or horror with which, in health, this event as a remote certainty, at times, I suppose, pre- sents itself to the mind of every one. I do not deny that instances as terrific as those which some waiters have described do occur. I only say that with considerable opportunities for observation in hospitals, almshouses and jails, as well as in private practice, such instances have not come within my personal knowledge. It is certain that they are only occasional in their occurrence. I trust that in these remarks no one will do me the injustice to impute to me a desire to depreciate the im- portance of solemn warnings against neglect of prepara- tion for death. I am only constrained to think that these warnings should not be based on the moral, more than the physical, anguish of the dying hour. Truth 214 DIVINE DESIGN AS EXEMPLIFIED IN DISEASE. can never injure the cause of truth. If observation teach us that the mind is usually so modified by severe disease as not to regard the prospect of dissolution with a proper appreciation of its momentous importance, it cannot but subserve the interests of mankind for the fact to be clearly understood. To treat of the bearing of this fact on the danger of deferring proper attention to the subject of death till we are brought into close proximity to the event itself, and other relations of a kindred char- acter, would be inappropriate on an occasion like the present, even if the requisite assurance on my part were not wanting, and I had not already trespassed too much on your patience. CATALOGUE OF BOOKS PUBLISHED BY HENR.T O. I_i3±].A-' (LATE LEA & BLANCHARD.) The books in the annexed list will be sent by mail, post-paid, to any Post Office in the United States, on receipt of the printed prices. No risks of the mail, however, are assumed, either on money or books. 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