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MASSACHUSETTS MEDICAL SOCIETY.
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WOL. I. — NO. II.
itational QTherapeutics;
A PRIZE ESSAY.
BY WORTHINGTON HOOKER, M.D.,
OF NEW HAVEN.
BOST ON : *
PRINTED BY JOHN WILSON AND SON,
22, ScHool, STREET.

1857.
PRIZE E S S A. Y.
RATIONAL THERAP EUTICS;
OR,
THE COMPARATIVE VALUE OF DIFFERENT CURATIVE MEANS, AND
THE PRINCIPLES OF THEIR, APPLICATION.
“NATURA D U GE.”
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BY WORTHINGTON HOOKER, M.D.
OF NEW HAVEN,
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OF
THE MAss ACHUSETTS MEDICAL SOCIETY.
At a JMeeting of the Councillors, Oct. 3, 1856, -
The Treasurer announced, that, through the liberality of one of its Fellows, the Massachusetts
Medical Society is authorized to offer the sum of One Hundred Dollars to the author of a
Dissertation which may be adjudged worthy of a prize by a Committee appointed by the
Councillors of the Society, on the following subject, viz.: “We would regard every approach
towards the rational and successful prevention and management of disease, without the neces-
sity of drugs, to be an advance in favor of humanity and scientific medicine.”
Jāt a meeting of the Councillors, Oct. 1, 1856, the following gentlemen were appointed the
Prize Committee, viz. : —
Dr. AUGUSTUS A. Gould. Dr. FRANCIS MINOT.
Dr. CHARLES G. PUTNAM. Dr. HENRY W. WILLIAMS.
Dr. ANSON HookER, Sen.
Jāt the Annual JMeeting of the Society, June 3, 1857, −
Dr. GoulD, Chairman of the Prize Committee, reported that six Essays had been received;
that the Committee had unanimously agreed upon the Dissertation considered worthy of the
prize; and handed to the President the envelope bearing the motto of the Dissertation. On
breaking the seal, the author was found to be Dr. WoRTHINGTON HookER, of New Haven, Conn.
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DISSERTATION.
“WE would REGARD EVERY APPROACH TOWARDS THE RATIONAL AND SUC-
CESSFUL PREVENTION AND MANAGEMENT OF DISEASE, WITHOUT THE
NECESSITY OF DRUGS, TO BE AN ADVANCE IN FAVOR OF HUMANITY AND
scIENTIFIC MEDICINE.”
THIS proposition” embodies a grand lesson, which the medi-
cal profession has been learning, especially during the past
half-century; and it is yet far from having come to the end of
the lesson. The recorded medical experience of this period,
which has been so much more busy than any other period in
true rational observation, exhibits, in a great variety of ways,
a marked tendency to a diminution of active medication.
This tendency was but feebly and fitfully manifested during
the first portion of this period, and was, for the most part,
overborne by a contrary tendency: but its struggles became
more and more strong and steady; and, for the past quarter
of a century, it has been predominant in the profession.
And the result is seen, at the present time, in the pre-
vailing disposition to exalt negative means of cure, above
those which are positive ; means that quiet, above those
that disturb ; and simple means, above those whose modus
operandi is occult, and is the subject of theory and dis-
cussion. Drugs, especially those which depress and disturb,
have had greater and greater limitations put upon their
1 It is proper to state, that this proposition is an extract from the excellent
Address of Dr. A. A. Gould, delivered before the Massachusetts Medical Society at
its annual meeting in 1855, p. 43.
152 RATIONAL THERAPEUTICS.
application; while other remedial means, not included under
this term, have more and more engaged the attention of
practitioners. -
Allied to this tendency, and somewhat involved with it,
is another, which is perhaps to have a still greater influ-
ence upon the sanitary welfare of the community. I refer
to the disposition, which has so decidedly increased during
the last twenty-five years in the profession, to seek out the
causes of disease, and to guard against their action. Very
appropriately, therefore, is the prevention of disease coupled
with its treatment in the proposition which is the subject of
this essay. And yet a full consideration of this portion
of the proposition would mar the unity of the plan which
I have marked out for myself; and would, besides, require
more space than can properly be given to it. I shall there-
fore bestow upon it here but a brief notice; and shall after-
wards allude to it only incidentally, as its connection with
the other part of the proposition shall require.
Although much has been said of late years, by physicians
and others, on the subject of hygiene, the community gene-
rally manifest but little interest in the prevention of disease,
while they have an eager and absorbing interest in whatever
relates to its cure. This is seen to be a glaring inconsistency,
when we consider that the chief causes of disease are more
or less under our control, some of them entirely so; and
the ravages of those which are beyond our control, as the
contagions, and some of the causes of epidemics, can be
very much lessened by guarding against the action of the
common causes of disease. It is often the co-operation of
the latter that gives virulency to the former, and occasions
their wide diffusion.
The notion which has been entertained by some ultraists,
that there would be almost no disease if the laws of life were
properly regarded, is extravagant and wild. With all the
control that it is possible for us to exercise over the circum-
stances that surround us, the incidents of our condition must
RATIONAL THERAPEUTICs. 153
render us, to a considerable extent, liable to disease. And yet
that disease may be in a great degree diminished by pre-
ventive measures, is not for a moment to be questioned:
indeed, there is not a doubt that it can be diminished vastly
more by these than by curative measures. -
If it were necessary, statistics might be given bearing
upon this point. The opinions also of physicians, whose
attention has been particularly drawn to this subject, might
be cited. I will content myself with citing but one opinion,
as a specimen, – that of the venerable Dr. James Jackson,
of Boston, who is always careful and deliberate in his state-
ments. The question put to him was this : “How great a
proportion of disease, of suffering, of diminution of physical
capacity, of usefulness, and of abridgment of life, comes
from sheer ignorance ; and which, therefore, we might hope
to see averted, if the community had that degree of know-
ledge which is attainable by all !” His reply was, “I feel
assured that the answer should be, More than one-half.”
When it is brought to mind that the ignorance of parents
is included in the inquiry, the justice of the answer will
probably be admitted by all who are conversant with the
subject. -
What has been said of prevention is especially true of
chronic diseases. Phthisis, that most common and most
destructive of all the maladies of this class, is a striking
example. The causes which predispose to it are such, that
they can, to a great extent, be either avoided or neutralized.
Even the hereditary influence, which acts so largely in the
production of this disease, is far from being inevitable in
its results. I will not go into an extended notice of this
important point, but will barely mention one of the many
facts that demonstrate it. In families that have in succes-
sive generations shown a disposition to phthisis, it is common
to see the female members succumb to it; while the habits
of the male members, tending to make them more robust,
enable them to resist it. And the difference in this respect
154 RATIONAL THERAPEUTICs.
is always lessened when the habits of the male members
of the family are sedentary. All the facts which have been
gathered in relation to the causes of this disease show that
quite a large proportion of its victims might be saved by
preventive means; while curative means succeed in redeem-
ing comparatively few of them. -
It is proper to remark here, that many of the measures
which tend to prevent the occurrence of some chronic mala-
dies are at the same time the principal means of their cure.
This is true of phthisis. Those means which give vigor to
the system are alike preventive and curative; their use being,
of course, modified by the varying circumstances of the indi-
vidual cases. Chronic diseases of a nervous character, and
those which are compounds of local affections and a gene-
rally debilitated and irritable condition, are cured chiefly
by a modified use of the same measures that fortify the
system against such diseases. These are measures which,
however, do not commonly get the credit which they deserve
from the community ; nor even, in all cases, from medical
men. The error committed by John Wesley, who was, as
Dr. Paris says, “more disposed to attribute his cure to a
brown-paper plaster of egg and brimstone than to Dr. Fother-
gill’s salutary prescription of country air, rest, asses’ milk,
and horse-exercise,” has been largely repeated, even up to
the present time ; and all quacks, and many even who are
in the ranks of the profession, are glad to have this error .
perpetuated. . -
What I have said of chronic diseases is true, to a limited
extent, of many of the forms of acute disease. Some of the
curative measures are among the most important of the pre-
ventive measures, – as the free access of pure air, and the
exclusion of all sources of excitement and other deleterious
agents. t - -
To some extent, then, the prevention of disease coincides
with its management; but, for the reasons before stated,
RATIONAL THERAPEUTICS. - 155
I shall chiefly confine my attention in this essay to the
latter. - -
My plan will be to illustrate the proposition under consi-
deration from the history of medicine, especially during the
last half-century; drawing such lessons from the points
brought out, that I may, in conclusion, indicate certain prin-
ciples for the guidance of practitioners in the investigation
of therapeutics, which may secure the full results contem-
plated by the proposition, and thus place therapeutics upon
a more rational basis than it has as yet attained. -
It will be seen that my object is not merely to demonstrate
the truth of the proposition. This would be of compara-
tively little benefit, and might allow of error in a too exten-
sive and indiscriminate abandonment of positive medication.
I propose to go beyond this general view of the subject,
and gather up those facts in the past experience of the pro-
fession which may be of use in discovering the limitations
which should be put upon the application of remedies. I
shall also endeavor to develop the principles which should
guide us in fixing upon these limitations. The tendency of
such an investigation will be, not merely to narrow the limits
of active medication, but to render it much more definite in
its aims, and even to widen the actual range of its efficiency.
It is the true way to relieve medicine, so far as it can be
done, of the uncertainty which is attached to it.
Up to the latter part of the last century, medication was
for the most part of little efficacy. The Materia Medica
was indeed extensive ; but most of the remedies were of
an inert character. Some of the medicines in common use
were made up of these remedies compounded together, some-
times to the number of twenty, fifty, or even a hundred;
and, though many of them were even more inert than our
modern sarsaparilla, great efficacy was attributed to them, the
motions in relation to their mode of action being vague and
fanciful. It was from the prevalence of notions of this cha-
racter that such remedies as frogs’ spawn, powder of crabs’
I56 RATIONAL THERAPEUTICs.
claws, the flesh of vipers, dried toads, &c., were introduced
into the multifarious compounds then in vogue." These
compounds were generally composed of ingredients so various
in their character, that it would be impossible to divine the
purposes which they were to accomplish. The noted Theriac
of Andromachus, or Antidotum Mithridatum, though the
number of its ingredients varied somewhat from time to time,
had in the Codex Medicamentarius of Paris, under the appro-
priate grandiloquent name of Electuarium opiatum polyphar-
nacum, seventy-two ingredients, thus: Acrid substances, 5 ;
astringent, 5 ; bitter, 22; indigenous aromatics, 10; um-
belliferous aromatics, 7 ; balsamic and resinous, 8; fetid, 6 ;
narcotic, 1 ; earthy, 1 ; gummy or amylaceous, 4 ; saccha-
rine, 3. One of these ingredients was the flesh of vipers.
The narcotic substance was opium; which certainly would do
better without such an array of auxiliaries, some of them of
quite a questionable character.
That all the medication of those times was marked by such
polypharmacy, I do not assert. But although there is some
evidence occasionally of a disposition in such minds as Syden-
ham and Boerhaave to discard it, and adopt a more simple
mode of therapeutics, yet they were far from breaking away
fully from the prevalent custom, and farther still from making
any systematic attempt to rid the Materia Medica of its
useless and even disgusting rubbish. Some medicines of a
decided character, such as cathartics, emetics, and opiates,
were, it is true, used, either alone or in connection with the
1. Some of the enemies of the medical profession have cast reproach upon it, on
account of its use of inert and disgusting remedies in olden times. But it is to
be recollected that such follies were far from being confined to medical men in those
days. Wise men of all classes had mingled with their wisdom most strange and ,
ridiculous motions. And it is also to be remarked, that many of the past errors
of the medical profession are now perpetuated in the doctrines and practices of
quackery. Thus that masterpiece of quackery, Homoeopathy, has such inert reme-
dies as oyster-shell, silica, pulsatilla, &c., to which it attributes most marvellous
effects; and, as to disgusting remedies, it surpasses all that can be found in the
darkest times of the medical profession in its infusion of the pediculus capitis, which
Dr. Mure, styled in England “the apostle of Homoeopathy,” proclaims as the grand
remedy for most chronic diseases. - -
RATIONAL THERAPEUTICS. 157
inert articles in such common use ; but they were used
sparingly. So also, from the time of Paracelsus and the
chemists, mercury and antimony were occasionally used; but
their effects were little understood, and the general preju-
dice against them was very strong. So strong was the
prejudice in France against antimony, that this drug was
publicly condemned, and was a long time in gaining the
popular favor. *
No one exerted so much influence as Cullen in disencum-
bering therapeutics of its mass of useless materials, and
in introducing definite ideas of the action of remedies upon
disease. In the preface to his “Practice of Physic,” he
makes some remarks on previous systems of practice, which
show what the state of things was when he came upon the
stage. I cannot forbear making an extract. In speaking
of the influence of the Stahlian system upon the practice of
physicians, he says, “Trusting much to the constant atten-
tion and wisdom of nature, they (Stahl and his followers)
have proposed the art of curing by expectation ; have there-
fore, for the most part, proposed only very inert and frivo-
lous remedies; have zealously opposed the use of some of
the most efficacious, such as opium and the Peruvian bark;
and are extremely reserved in the use of general remedies,
such as bleeding, vomiting, &c.”
“Although these remarks,” he goes on to say, “upon
a system which may now be considered as exploded or
neglected, may seem superfluous, I have been willing to give
these strictures on the Stahlian system, that I might carry
my remarks a little farther, and take this opportunity of
observing, that, in whatever manner we may explain what
have been called the operations of nature, it appears to me
that the general doctrine of Nature curing diseases — the so
much-vaunted Hippocratic method of curing — has often
had a baneful influence on the practice of physic, as either
leading physicians into, or continuing them in, a weak and
feeble practice, and, at the same time, superseding or discour-
- 21
158 RATIONAL THERAPEUTICS.
aging all the attempts of art. Dr. Huxham has properly
observed, that, even in the hands of Sydenham, it had this
effect. Although it may sometimes avoid the mischiefs of
bold and rash practitioners, yet it certainly produces that
caution and timidity which have ever opposed the introduc-
tion of new and efficacious remedies. The opposition to
chemical medicines in the sixteenth and seventeenth centu-
ries, and the noted condemnation of antimony by the medical
faculty of Paris, are to be attributed chiefly to those preju-
dices, which the physicians of France did not entirely get
the better of for near a hundred years after. We may take
notice of the reserve it produced in Boerhaave, with respect
to the use of the Peruvian bark. We have had lately pub-
lished, under the title ‘Constitutiones Epidemicae, notes of
the particular practice of the late Baron van Swieten; upon
which the editor very properly observes, that the use of the
bark in intermitting fevers appears very rarely in that prac-
tice ; and we know very well where Van Swieten learned
that reserve.” --
During the eighteenth century, the influence of those
leading minds — Sydenham, Stahl, Hoffman, and Boerhaave
— was largely but variously manifested in medical practice.
The influence of Boerhaave was continued through Van
Swieten, his illustrious pupil, and other prominent physi-
cians, his admirers. Therefore, when Cullen began the study
of medicine, he says that he “learned only the system of
Boerhaave ; ” and, when he became a professor in the Uni-
versity, he found this system there in full force. Meanwhile,
in France, Lieutaud was the great medical man of the times;
of whom Cullen says that he is “very much upon the old
plan of following nature, and therefore gives often what I
consider as a feeble and inert practice. The humectantia,
diluentia, demulcentia, et temperantia, are with him very
universal remedies, and often those which are alone to be
employed.”
* There was, during the last century, some advance made in
RATIONAL THERAPEUTICS. 159
positive medication ; but it was a hesitating and vacillating
movement. It was reserved for Cullen to usher in the new
era, for which preparation had thus been made by those who
immediately preceded him. He was born in the first part of
the last century, in 1712; but his full influence was not felt
till its close : for, although he was a long time a teacher of
medicine, it was not till 1772 that he published his “Materia
Medica; ” and his “Practice of Physic” he published in
1784, only six years before his death. -
The writings of Cullen gave to medical practice every-
where a more definite and decided character. Especially did
such remedies as calomel and antimony come into more
common use. Dr. James Hamilton, of the University of
Edinburgh, in a very judicious work on the use and abuse
of mercurial medicines, published in 1820, says, that, “for
some ages after mercury became an article of the Materia
Medica, physicians recommended it only on the most urgent
occasions; but, within these few years, British practitioners
seem to have overlooked the necessity for such caution, and
to exhibit that medicine with very little scruple.” He also
says, that “calomel is now in Great Britain almost the
universal opening medicine recommended for infants and
children; and a course of the blue pill (which is one of the
mildest preparations of mercury) is advised, without any
discrimination, for the cure of trifling irregularities of diges-
tion in grown persons.” And the same may be said of its
use in this country at that time.
Other remedies of power were used with the same freedom,
such as bleeding, emetics, purgatives, opiates, &c. An active
medication was generally introduced. “The art of curing by
expectation,” so decidedly denounced by Cullen, was in no
favor. Disease was to be attacked; it was to be overcome;
it was to be broken up. This was the language of the times.
The recuperative energies of nature were to be trusted but
seldom and sparingly. Most practitioners followed the lead
of Cullen, who held this language on the subject: “Although
160 - RATIONAL THERAPEUTICS.
this vis medicatria natura must unavoidably be received as a
fact, yet, wherever it is admitted, it throws an obscurity upon
our system ; and it is only where the importance of our art
is very manifest and considerable that we ought to admit
of it in practice.” Some went even farther than this. This
was true of Dr. Rush, who had such wide and long-continued
influence upon American practice. One of the most distin-
guished physicians in this country recollects hearing him
use, in the lecture-room, this strong language in relation to
nature’s curative efforts: “As to nature, I would treat it in
the sick-chamber as I would a squalling cat, — open the
door, and drive it out.” - -
The reign of active medication, thus established chiefly by
Cullen, reached its culminating point somewhere in the first
quarter of this century. It was not introduced by him in
full, but was fairly begun, and then was consummated in the
course of a few years by those who followed him. This may
be very distinctly seen in relation to the use of mercury.
Cullen, it must be evident to every one that reads his
“Practice of Physic,” had no idea of the extent to which this
remedy was destined to be applied by his successors in the
treatment of inflammations and fevers, much less of the com-
mon and indiscriminate use of it described by Hamilton.
During the past twenty-five or thirty years, the reign of
active medication has been manifestly declining. This de-
cline is to be attributed mostly to the diffusion of more
discriminating views in the profession in relation to the
operation of remedies. Some, however, are inclined to con-
sider it as owing very much to a change which they suppose
to have taken place in the general character of diseases.
But the reality of this change is questioned by many who
are quite as reliable observers as those who assert that it has
occurred ; and their view of the question certainly has some
show of reason, if we consider the agencies which are neces-
sary to the production of so great a change as has been
claimed to have taken place. For observe, that it is not a
RATIONAL THERAPEUTICS. 161
change in the character of any particular diseases, and from
one season to another; but it is a change covering a long
term of years, and in the general diathesis of disease. This,
it is asserted, is much more disposed to be asthenic than it
was in the days of active medication. The fact, so distinctly
observed by Sydenham, that epidemic diseases thus change
from year to year, from modification of some of the concur-
rent causes that produce them, has been well established
by the observation of physicians since his time. But the
change under consideration is altogether different from this :
it is a change which could not be produced, unless a con-
tinuous influence of some considerable power were exerted
during a series of years, alike in healthy and unhealthy
seasons, when epidemics were rife, and when they were mild,
or even absent, modifying the action of the common causes
of disease, so as to alter its general character in all its forms.
And, besides, to effect so great a change as has been asserted,
so abruptly and so thoroughly, some alteration in the very
character of the human system would seem to be required.
It appears clear, then, from these considerations, in addi-
tion to the fact that the reality of the change is matter of
dispute, that there cannot have been an alteration in the gene-
ral diathesis of diseases, sufficient to account for the great
and general change in medical practice that we have witnessed
in the past twenty-five or thirty years.
During the reign of active medication, there were great
strifes in the profession. The most opposite modes of prac-
tice were advocated in the treatment of the same disease,
and physicians were often divided into fiercely opposing
parties. I will refer to but a single example. In the first
quarter of this century, there was in New England a great
contest between two rival parties, in relation to the general
character of diseases and their treatment. Dr. Gallup and
his followers maintained that diseases were almost wholly
sthenic or inflammatory, and therefore depleting remedies
were called for ; and, of these, bleeding was by far the most
162 RATIONAL THERAPEUTICS.
important. Drs. Miner and Tully, on the other hand, con-
tended that the asthenic disposition predominated; and their
remedies were of an opposite character to those of Dr.
Gallup. They made large use of opium and stimulants.
They also used calomel in connection with these. The lan-
guage which these two rival schools held towards each other
was of the most decided character. Thus Dr. Gallup says,
that “it is probable, that, for forty years past, opium and its
preparations have done seven times the injury they have
rendered benefit on the great scale of the world.” And
Dr. Tully says of Dr. Gallup’s mode of practice, “The
lancet is a minute instrument of mighty mischief, -a weapon
which annually slays more than the sword. Antimony alone
does more injury than all the efficient exciting and supporting
agents of the Materia Medica.” And again: “The King
of Great Britain loses every year more subjects by these
means (that is, depleting means) than the battle and cam-
paign of Waterloo cost him, with all their glories.” Dr.
|Miner says of the same means, that they “have been the
scourge and devastation of the human race for more than
two thousand years.”
In this, as well as in all other cases in which such opposite
views of treatment have been held, the appeal to results was
made equally by both the opposing parties; and, from the
statements which were made, it would be impossible to
decide which practice was the most successful, or, rather,
which was the least unsuccessful.
In view of such opposing testimonies in relation to modes
of treatment, some have been inclined to the conclusion, that
medicine is of no avail, and that the sick had better be given
up to the recuperative efforts of nature, the physician only
so managing the diet and regimen as to favor these efforts.
But, while the facts do not forbid such a conclusion, they by
no means fairly lead to it. It is indeed a legitimate conclu-
sion, that the cases treated under the opposing modes would
have done better with no medication ; that is, the gross
RATION AL THERAPEUTICS. 163
results would have been better. But the facts are far from
proving that the absence of all medication would have been
followed by better results than a judicious application of
general principles, – the measures of both modes being
adopted to some extent, and adjusted to the needs of indi-
vidual cases. They do not touch this point at all. This
must be decided by altogether different data.
It will not be deemed unprofitable here to consider briefly
the question, whether positive medication is of real benefit
in the treatment of disease generally. The question, let it
be borne in mind, is, not whether the results of medical
practice, as pursued by the profession at large, are better
than they would be if disease were left to nature and a proper
regimen; but whether this is true of the ordinary practice of
judicious physicians. That it is so, is proved by various
kinds of evidence, which I will very briefly notice.
There is very decisive evidence on this point in the actual,
undoubted effects of remedies. It is often difficult to dis-
tinguish between the favorable effects of medicines and the
results of nature’s efforts ; but there are cases in which
there cannot be the slightest doubt as to the curative influ-
ence of the remedies that we employ. The evidence from
such cases is clear on the simple question, whether medica-
tion is ever useful. To what extent it is applicable is quite
another question, to be decided by other evidence.
We have evidence also from comparisons between cases
subjected to medication and those which are left to nature.
This evidence, however, is limited in amount; because the
belief in the propriety of using some positive means of
treatment in disease is so universal, that such comparisons
are very seldom made. One of the most conclusive which
we have is that reported by M. Grisolle in relation to pneu-
monia. In 1840, he treated eleven patients attacked with
this disease, without using any active remedies. The cases
which he selected for observation were such, that there was
no reason to fear a fatal termination in any of them ; and
164 RATIONAL THERAPEUTICs.
yet they were sufficiently marked to test the question. The
patients were kept quiet in bed, with a light diet; and the
only medicine given to any of them was some mild laxative
to obviate constipation. The result was, that the prominent
symptoms of the disease continued much longer than they
did in other similar cases which were treated in the usual
way. The pain in the side, in some of the cases, continued
so long, that M. Grisolle felt called upon at length to use
cupping and blistering for its removal. This experiment or
observation does not, it is true, touch the question of rate of
mortality directly: but it does indirectly ; for it is proper to
infer, that remedies which relieve and shorten disease when
it is mild, will tend to save from a fatal result when the
disease is severe. e
But we have some evidence furnished to us unwittingly
by Homoeopathy on quite an extended scale. I refer to the
famous returns of the hospital of Fleischmann, near Vienna.
These returns were offered to the public as decisive proofs
of the superiority of the Homoeopathic practice over the
common practice of physicians. If the gross results alone
had been given by Fleischmann, it would have added another
to the many errors that have been palmed upon the world
by bare statistics ; but, fortunately for the truth, though not
so for his interest and for that of Homoeopathy, he entered
into particulars in relation to the number of cases of different
forms of disease, so that we are enabled to make something
like a fair comparison of the results with those of medical
treatment in other hospitals. And such a comparison leads
us inevitably to the conclusion, that the treatment of Fleisch-
mann was much less successful than that which is followed
in hospitals under the care of regular physicians. Now, as
he is a true Homoeopathist, and adheres to the infinitesimal
doses of Hahnemann, we have here a comparison between
the ordinary practice of hospitals and a practice which in
reality leaves every thing to nature, regulating only the
circumstances and the diet of the patients so as to favor
nature’s salutary operations.
RATIONAL THERAPEUTICS. 165
I will notice these returns of Fleischmann very briefly,
in order to show the grounds of this conclusion. . His returns
cover 6,501 cases treated in his hospital during a period of
eight years. The mortality, which was 6.4 per cent, is
claimed by him to be a small percentage of mortality in com-
parison with hospitals managed under the common practice.
While this is true of some hospitals, it is not true of others.
Some have a mortality considerably below that of Fleisch-
mann's hospital. For example: Mr. Thomson states the
mortality of the Dundee hospital to be 5.1 per cent; that
of Aberdeen, 4.6 per cent ; that of Inverness, 4.3 per cent ;
and that of thirty provincial hospitals, taken together, 4.4 per
cent. The average mortality of the English military hospitals
is only § per cent. Those hospitals which have a mortality
above that of Fleischmann’s are in the midst of large cities;
for they are crowded with patients, and from this cause often
reject applications for the admission of mild cases. But
although Fleischmann's hospital was situated out of Vienna,
in the suburbs, and was therefore not liable to be crowded
with bad cases, his mortality is only a little less than that
of the largest hospitals in London, as observed during four
years; this being 8.4 per cent, while his was 6.4 per cent.
And this is not all. On examining Fleischmann’s report
in relation to the diseases of the inmates of his hospital, it
is found that there is an uncommonly large number of cases
of mild and curable diseases; while the number of cases of
severe and incurable diseases is comparatively small. Dr.
Simpson, from whose book on Homoeopathy I glean these
facts, has drawn a comparison in this respect between Fleisch-
mann's hospital and the Edinburgh hospital, which in two
years admitted nearly the same number of patients that
Fleischmann’s did in eight years. This comparison I will
give as concisely as possible.
From an examination of a large number of hospital reports,
Mr. Thomson, as quoted by Dr. Simpson, found that the
percentage of mortality depends chiefly upon the number of
22 -
166 RATIONAL THERAPEUTICS.
cases admitted of the following diseases: 1. Pulmonary con-
sumption ; 2. Organic disease of the heart ; 3. Aneurism
of the large vessels; 4. Organic disease of the kidneys ;
5. Organic disease of the stomach. Of these five forms of
disease, there were only 120 cases admitted into Fleisch-
mann’s hospital; while 548 were admitted into the hospital
at Edinburgh. And, if other forms of disease which are
apt to end fatally be taken into the account, the difference
between the two hospitals will be seen to be still greater than
this, as is represented in the following table : —
No. of cases in No. of cases in
Fleischmann’s Hospital. Edinburgh Hospital.
Consumption . . . . . . . 98 . . . . . 276
Palsies ſº wº g tº • e 5 * wº tº e tº 103
Organic disease of the heart . . . 15 . . . . . . 159
Organic disease of the liver . 33
Bright's disease of the kidney . O 82
Diabetes Mellitus . o O . . 17
Internal Aneurisms . . . 1 . . . . . 18
Caries and Necrosis . . . . . 5 . . . . . 57
O
O
1
Malignant (cancerous) tumors . 55
Other tumors 36
125 836
Besides all this, the difference between the two hospitals,
in regard to cases of severe external injuries, is very great.
In Fleischmann’s hospital, there were only 52 cases of injury;
and, of these, 34 were slight wounds, all of which recovered;
and 18 were cases of burns, of which two died. But, in the
Edinburgh hospital, there were 641 cases of injury; and 150
of them were subjects of the “principal operations,” of
which 32 died.
Again : all cases admitted when moribund are inserted in
the reports of the Edinburgh hospital; while Fleischmann
excludes them. This materially affects the percentage of
mortality. &
Dr. Simpson makes a comparison also between the two
hospitals, in relation to mild and curable cases of disease,
f
RATIONAL THERAPEUTICS. - 167
thus: “While, among the 6,000 Edinburgh-hospital cases,
we have 34 cases of that non-fatal disease, inflamed sore-
throat, or cymanche tonsillaris, among the 6,000 Vienna
Homoeopathic cases, there are no less than 301 cases of this
affection. In the Edinburgh returns there are two cases, and
in the Vienna returns 110 cases, of chicken-pox ; in Edin-
burgh one case of herpes or tetter, in Vienna 20 cases; 48
cases of chlorosis and amenorrhoea at Edinburgh, and 90 at
Vienna; 37 cases of headache at Edinburgh, 61 at Vienna;
52 cases of influenza at Vienna, and none at Edinburgh; and
SO Orl. - t
So unusual a difference as this between these two hospitals,
in regard to the character of their cases, is not to be referred
merely to the fact that one was in the midst of a city, and
the other was in the country. In Fleischmann’s hospital,
there was undoubtedly much management in courting the
admission of favorable cases, and in getting rid of those
which were manifestly incurable ; and, with his large pro-
portion of mild and curable cases thus obtained, the percent-
age of mortality is far from being in favor of his treatment.
Assuming, as we have undoubtedly a right to do, that he
gave his patients infinitesimal doses, we may say that this
comparison between the two hospitals shows, most conclu-
sively, that leaving disease entirely to nature is much less
successful than a judicious positive medication. If this were
not so, Fleischmann ought to have made out a much smaller
percentage of mortality under all the favoring circumstances
which have been mentioned. If any hospital under the
control of “regular medicine * could be managed under
similar circumstances, and with the same manoeuvring in
the admission, exclusion, and discharge of cases, vastly
better results would be realized than those which Fleisch-
mann has so vauntingly spread before the world. Our
hospitals actually do much better than his did, even with
much less favorable circumstances ; as, for example, the
provincial hospitals, whose average mortality is 4.4 per cent;
168 RATIONAL THERAPEUTICS.
while that of Fleischmann’s is 6.4 per cent, — about one-
third more. The mortality of the English military hospitals
is even less than that of the provincial hospitals, — only two
per cent." - -
Having thus definitely settled the question, whether active
medication is of any value, we come to another inquiry of
a much more complex character; viz., Of how much value
is it 7 or, in other words, What are the limits of its applica-
bility ? And another inquiry also is naturally coupled with
this ; viz., What are the principles which should guide us in
fixing on the due limitations of positive medication in indi-
vidual cases of disease ? -
These inquiries are not only complex, but difficult ; and
hence they are not fairly met by the great body of the pro-
fession. The rigid investigation which is requisite for this
is unwelcome to those who are fond of the easy path of
theoretical practice, or, the easier one of routine ; and the
principles which should guide such an investigation have
really been but imperfectly developed, and can for the most
part only be gleaned here and there from the standard works
of the profession. .*
I shall endeavor, in the following pages, to evolve from
the experience of medical men answers to the inquiries which
I have stated. For this purpose, I shall examine some of the
1 Dr. Gairdner, as quoted by Dr. Simpson, remarks of Fleischmann's hospital,
“If I were to give a formula for the management of a hospital designed to exhibit
a low rate of mortality, it would be this: Choose your site well; let it be not in but
near a large city, having already hospital accommodation on a prodigious scale,
well known to the poorest classes of the community, and adapted to their wants;
let the distance from the centre be such (say three miles) as will keep back the
extremely abject and the dangerously diseased, either through want of knowledge
of your institution, or want of power to reach it; let the arrangements be so perfect
as to contrast favorably with the older hospitals, and to attract the valetudinarians,
whose illnesses and means permit them to avail themselves of its superior accom-
modation; and, finally, let some special practice be pursued, in order to enlist the
sympathies of rich or idle dilettanti, who will know how to fill your wards with
the sort of cases suitable for your experiment. THIS IS PRECISELY THE PICTURE
OF THE VIENNA HOMOEOPATHIC HospitaL, which has the amazing effrontery to
call on us to compare its peddling eaſperiments with the great labors of pure benefi-
cence, of which general hospitals of this and other countries furnish examples,”
RATIONAL THERAPEUTICS. 169
changes that have been made in medical practice during
the last twenty-five or thirty years, and, from the limitations
and modifications already made in therapeutics, deduce those
principles which will enable us to make still farther limita-
tions and modifications. I do this with the firm belief, that,
by such an investigation, as before hinted, we shall come at
the principles on which therapeutics may be made much
more definite than it now is, and practical medicine be re-
lieved of much of the uncertainty with which it is supposed
to be unavoidably enveloped. -
I have said that the reign of active medication was at its
height in the first quarter of this century; but it was by no
means an undisputed reign. Many physicians then pursued
a less active treatment than the mass of the profession, and
some publicly protested against the dominant error. For
example: Dr. Falconer, of Bath, as early as 1809, in a paper
in the first volume of the Transactions of the Medical Society
of London, in strong language pointed out the dangerous
effects of the prevalent indiscriminate use of mercury. But
Dr. Hamilton says, about ten years after, that his warning
voice was not regarded, and that “the employment of mer-
curial medicines has for several years become more and more
extensive.” -
So, on the other hand, when the reign of active medica-
tion really began to decline, there was much opposition to
the movement in the profession. Hence it is that Dr. Bige-
low, in his valuable paper on Self-limited Diseases, read
before the Massachusetts Medical Society in 1835, makes
use of such language as this: “In many places, at the present
day, a charm is popularly attached to what is called an active,
bold, or heroic practice ; and a corresponding reproach awaits
the opposite course, which is cautious, palliative, and expec-
tant.” But multitudes of observers had adopted more or less
the same views that Dr. Bigelow developed so clearly in his
paper ; and the decline of positive medication became more
and more general in the profession. The changes which
170 RATIONAL THERAPEUTICS.
have taken place in this movement I propose now to notice,
first in relation to certain remedies, and then in relation to
diseases.
The change which has been made in the use of mercury,
during the past twenty-five or thirty years, presents many
points of interest. Its use for some purposes has been en-
tirely discontinued. It was quite largely used for some length
of time in fever, with the idea, that, if the constitution could
be brought under its influence, the fever would be removed;
a mercurial fever, as it might be called, taking its place,
which the recuperative powers of nature could easily remove.
Although in some cases this mode of practice seemed to
produce the effect intended, it was found, on the whole, so
frequently to fail, and to be attended sometimes with such
disastrous results, that it has been wholly abandoned. Mer-
cury is used, at the present time, very sparingly in fever,
and only so far as it is needed to affect the secretions, or to
combat accompanying inflammation.
Mercury is also discontinued from use in the exanthema-
tous diseases, unless there be some special reasons in the
complications of these diseases for its employment. At one
time, its use was highly lauded by Dr. Armstrong and others
as a remedy in scarlatina ; but, at the present time, there is
mo truth more definitely settled by the experience of the
profession, than the impropriety of its use as a common
remedy in this malady.
Mercury is no longer used as a common cathartic. It has
come to be the settled practice of the profession to avoid its
use, in this respect, in all cases where the distinctive effects
of this drug are not called for. This is in strong contrast
with the incautious and indiscriminate use of this remedy
which was so prevalent, both in and out of the profession,
during the first quarter of this century. -
The same discriminating experience which has discarded
mercury as a general remedy in fever and in the exanthem-
ata has retained it in the treatment of inflammations ; but it
RATIONAL THERAPEUTICS. 171
has been found that it need not be pushed to the extent that
was formerly supposed to be necessary in this class of dis-
eases. In most cases, it is not necessary even to affect the
gums ; and salivation is always to be avoided; although, in
some severe cases, it is proper to run the risk of producing
it.1. -
The combination of calomel, antimony, and opium, which,
in various proportions, is now so much used, is a remedy of
very great value in the treatment of inflammatory diseases.
To Dr. Robert” Hamilton, of Lynn Regis, England, the
credit is commonly given of first drawing the attention of
the profession, in the year 1783, to the efficacy of this com-
bination. He says that its usefulness was first suggested to
him in following out a hint given to him by an army surgeon,
in relation to the use of calomel in the treatment of acute
hepatitis. He added opium to the calomel to relieve the
pain attendant upon inflammation, and then antimony to
relieve the febrile excitement and to produce perspiration;
and, inferring that this combination might be serviceable in
the treatment of the inflammation of other organs as well as
1 A valuable paper has been published recently by Dr. Henry W. Williams, of
Boston, showing that iritis can be treated successfully without the use of mercury
and active antiphlogistic measures. If his results shall be verified by others (and
I see not why they should not be), Dr. Williams will produce as great a change
in the practice of the profession in this disease as Dr. Ware has in its practice in
delirium tremens. Farther investigations are needed, not so much to confirm the
main point in his paper, as to determine how much the different remedies which he
used had to do with effecting the cure. I apprehend that it will be found that the
opium given internally, and the belladonna used locally, were the effective remedies;
while the quinine and the iodide of potassium are of small account. It is to be
regretted that Dr. Williams was not more particular in reporting the amounts of
opium that were taken by the different patients.
2 Too much has been claimed for Dr. Hamilton, by his countrymen, in attribut-
ing to him the first introduction of calomel in the treatment of inflammatory mala-
dies. To an American physician — Dr. Douglass, of Boston—belongs the credit
of this. He introduced it as early as 1736; and, by the middle of the century, it
was quite the common practice among American physicians in pneumonia, pleu-
risy, rheumatism, &c. Dr. Hamilton's observations were made many years after
this; and to him belongs the credit of adding, to what had been established by
Douglass and the American physicians generally, what he discovered in regard
to the combination of other important remedies with the calomel, as stated in the
text. •
172 - RATIONAL THERAPEUTICS.
that of the liver, he proceeded to verify the inference, and
thus inaugurated a practice which has become established
by abundant experience as one of the permanent advances
of the profession in the treatment of a very wide range of
diseases. - --
Mercury is a remedy of great value in the treatment of
many chronic diseases; but, during the reign of active medi-
cation, it was used in them too largely, and often with so
little discrimination, that disastrous results were produced.
Not only is it now used much more cautiously in these
maladies, but, in very many cases in which it would formerly
have been deemed applicable, it is now given up, as calculated
only to add to the sufferings of the patient, without effecting
any good result, or to leave him in a bad condition after the
cure of the particular disease for which it is used is accom-
plished, or even to prevent a cure which might have been
effected if more gentle means had been employed. In Dr.
James Hamilton’s book on the “Use and Abuse of Mercu-
rial Medicines,” there are many interesting facts stated bear-
ing upon these points. -
Emphatically may it be said, in view of the sad results
which have come from the needless use of mercury, that the
great diminution of its use in the treatment of disease is
“an advance in favor of humanity and scientific medicine.”
At the same time, it is to be borne in mind, that it is far
from being a mere general diminution. It is a diminution
which is based upon an extensive range of discriminations ;
so that, while in some cases where it was formerly used it
is now wholly discarded, and in others it is used with much
less freedom, there are some cases in which its introduction
into the system is effected as rapidly as possible ; and
cases occasionally occur in which there is some reason to
think that it is proper to use it in exceedingly large doses.
This last point, however, is as yet subjudice. -
Some of the most valuable acquisitions which the profes-
sion has made in therapeutics during the present century are
§
RATIONAL THERAPEUTICS. 173
the discriminating limitations that it has been able to put
upon the use of this remedy, which is one of the most
efficient of its active means of cure. The advance which
has been effected in this respect step by step in the profes-
sion’s experience is greater than is ordinarily supposed.
Larger additions have in this way been made to our real
means of cure than by any, or even perhaps all, of the new
remedies that have been discovered during the same period
of time.
All disturbing remedies are much less in vogue now than
they were in the first quarter of this century. Physicians
then very commonly used such remedies, especially in the
beginning of attacks of disease, for the purpose of breaking
up the attack, or of lessening its force. Emetics were com-
mon remedies for this object. The practice was applicable
in some cases; but it was far too generally employed. So
common was the plan of thus adding to the turmoil of dis-
ease at the outset, that it was a popular saying, that it
was necessary to make one worse in order to make him
better. And this disturbing and depressing mode of treat-
ment was by no means confined to the beginning of disease ;
but it was customary to continue it to some degree during
the progress of the case. Febrile symptoms, so long as they
lasted, were combated actively; and active remedies were
always addressed to the removal of any local derangements
that might exist, little dependence being placed upon the
recuperative efforts of nature. But now the general charac-
ter of medical practice is vastly different in the points alluded
to. In comparatively few cases, even of acute disease, is the
patient made worse at the beginning, in order to make him
better. Generally he is made better at once, by measures
that relieve the disturbance of disease, instead of adding to
it ; and, during the progress of the case, great caution is
exercised in the use of any remedies that may interfere with
the rest and quiet so essential to the free operation of the
recuperative powers, or that may so depress them that they
23
174. RATIONAL THERAPEUTICs.
cannot act with sufficient energy to effect a recovery. The
truth that the irritation of disease is often the great source of
the exhaustion attending it, and that the physician should
therefore be careful not to add to it by his remedies, is
now quite fully appreciated. Commonly, it is true, some
disturbing treatment is required occasionally during the
progress of a case; but it is managed with caution, and
generally quieting remedies are used in combination, so as
to render the disturbance as slight as possible.
The change of which I have been speaking has done for
medicine what the introduction of the art of healing by
the first intention has done for surgery. The irritation
of the disturbing modes of treatment so prevalent during
the reign of active medication had the same effect upon
internal maladies that the irritating ointments had upon the
wounds into which they were inserted so universally by
surgeons before the time of Ambrose Paré; and the im-
provement in both cases consists in a return to the simplicity
of nature. w
Perhaps there is no remedy in the use of which there has
been so much change as bleeding. It was during the first
quarter of this century, and even for some years farther on,
a common remedy in all febrile and inflammatory diseases.
I have already alluded to the views of Dr. Gallup in regard
to this remedy. Although there were few in this country
whose views were as extreme as his were, bleeding was every-
where a favorite remedy with the profession. In England,
Armstrong and Southwood Smith were the prominent advo-
cates of bleeding. The strong views of the latter — so
earnestly, skilfully, and I may say beautifully, developed in
his book on fever — were very captivating to all enthusiastic
minds; and his book had for a time a wide influence, both
in England and in this country. -
Bleeding was popular with the people as well as with the
profession. In almost all cases of accident, it was practised
as a matter of course. In pregnancy, it was resorted to as
RATIONAL THERAPEUTICS. 175
the established remedy for various inconveniences and com-
plaints, that we now find are easily removed by less for-
midable means, or that commonly had better be borhe than
be removed, if bleeding be the only thing that can remove
them. It was the custom also with many to be bled occasion-
ally, in order to guard against attacks of disease to which
they supposed themselves liable. This was practised espe-
cially in the spring. - - .
This very common resort to bleeding, both as a remedy
and as a preventive, is now abandoned. This remedy has,
with others, been subjected to discriminating limitations;
perhaps, from the influence in part of popular prejudice,
it has been in some quarters too much given up, especially
local bleeding. Whenever inflammation exists in an impor-
tant organ in any marked degree of severity, this remedy is
applicable, – general bleeding when there is sufficient con-
stitutional affection to call for it, and the system is in a
condition to bear the loss of blood; and local bleeding
when the circumstances of the case do not warrant general
bleeding.
Bleeding, it is to be remembered, is a remedy that is calcu-
lated to allay the irritation of disease ; and it never adds to
it when it is really applicable, and is not made use of to an
improper extent. It is therefore, in some cases, really not
as objectionable as certain remedies that are substituted for
it in order to avoid exhaustion. It is often better to reduce
febrile excitement or inflammation by this quiet remedy than
to do it with remedies that may exhaust the vital energies
by a series of impressions which are depressing, and at the
same time irritating. I am persuaded that there is often too
little fear of this result from such impressions on the part of
those who have great fear that bleeding would produce it.
Remedies of the kind alluded to, when pushed too far, may
cause an exhaustion as irremediable as that which is pro-
duced by an inappropriate bleeding.
Having thus noticed the change in practice in relation to
- 176 RATIONAL THERAPEUTICS.
the use of certain remedies, I pass to consider the changes
which have taken place at the same time in the modes of
treatment in some diseases.
I have already alluded to fever in speaking of remedies;
but the change has been so great in the management of this
disease, that it deserves something more than a passing notice.
An active interference, by means of bleeding, mercury, pur-
gatives, emetics, antimonials, &c., was at one time the general
practice; it being supposed that such remedies could shorten,
or even arrest, the disease. There were few that suspected
that the prostration which was so apt to ensue in the progress
of the fever was in part the result of the medicines used in
the beginning. But a great change has taken place in the
treatment of fever. Active measures are, for the most part,
abandoned. Quieting measures predominate ; and great
caution is exercised in avoiding any thing which may ex-
haust the strength by irritation or by direct depression. If
the fever be uncomplicated, the treatment is simple ; and
generally it is its complications only that are attacked with
active remedies; and this is done cautiously.
This change is the result of several concurring causes.
First, the consideration of the character of the disease con-
tributed to this result. So long as it was supposed that fever
was a disease that could be broken up, or be materially short-
ened, by active treatment, this treatment continued in vogue;
but, with the alteration of the views of the profession in
regard to the character of the disease, the treatment became
less active. And most medical men now feel, in regard to
active treatment, as Dr. Pitcairn did, who said, when he
was asked his opinion of some treatise on fever, “I dis-
like fever-curers. A fever can be guided : it cannot be
cured.”
A close observation of the effects of remedies contributed
to this result. Thus, as quoted by Dr. Hale in his investi-
gation of the typhoid fever of New England, Dr. Bright
said in 1827, that he had “almost always found that the
RATIONAL THERAPEUTICS. 177
small doses of antimonial remedies usually administered, as
a part of the diaphoretic plan, do harm where any decided
tendency to irritation of the bowels exists.” Similar observa-
tions were made by others, both in relation to this and other
irritating remedies.
But, thirdly, after a time, pathology brought in its inves-
tigations to confirm the observations made by Bright and
others, in regard to the unfavorable effect of some of the
active remedies. Among the pathological appearances found
the most common is inflammation of Peyer’s glands. This
inflammation must, of course, go through a certain process,
before a recovery can be effected. It is not an inflammation.
of a rapid character ; and so time must be given for the
recovery. We should be exceedingly careful not to aggra-
vate the inflammation by our treatment ; and, although
nothing very direct and decided can be done to lessen it, we
may so alleviate the general irritability, and that of the
intestinal canal, as to make the inflammation go through
its course with ease, without coming to ulceration, or to
insure a successful termination to it even when it is severe
enough to reach this result.
The practice of Broussais, although it was based upon a
false theory, did essential service in bringing about this
change in the treatment of fever. The results of the dis-
placing of irritating remedies by his leeches and gum-water
showed very clearly that such remedies were not required, –
at least, as the ordinary means of treating the disease.
A change very similar to that which has occurred in the
treatment of continued fever has occurred also in the treat-
ment of the exanthematous diseases. This is especially true
of scarlatina. Such remedies as bleeding, calomel, antimo-
nials, purgatives, &c., so common in the treatment of this
disease in the first part of the past fifty years, are now used
but sparingly, and with much caution. During the period
of active medication, various modes of treatment were lauded
by their advocates, each mode having some prominent reme-
178 RATIONAL THERAPEUTICS.
dy, accompanied by some lighter remedies as auxiliaries.
Thus Dr. Fothergill used chiefly stimulants; Dr. Southwood
Smith, bleeding ; Dr. Armstrong, calomel; Dr. Currie, the
affusion of cold water.
The mortality from this malady would undoubtedly have
been less, if it had been left wholly to nature’s recuperative
efforts, instead of being subjected to such active and exclu-
sive modes of treatment. And yet all the remedies of these
modes are applicable to some limited extent; and the true
practice is to use, for the most part, negative measures, and
remedies that quiet irritation, with the occasional employ-
ment of the active remedies alluded to, when the circum-
stances of the case call for them by indications that are clear
and decisive. And this is the view of the treatment of this
disease which is now adopted by the great majority of the
profession.
This malady belongs to that class to which Dr. Bigelow
gave the name of self-limited diseases, which he thus defines:
“By a self-limited disease, I would be understood to express
one which receives limits from its own nature, and not from
foreign influences; one which, after it has obtained foothold
in the system, cannot, in the present state of our knowledge,
be eradicated or abridged by art, but to which there is due
a certain succession of processes, to be completed in a certain
time; which time and processes may vary with the constitu-
tion and condition of the patient, and may tend to death or
to recovery, but are not known to be shortened or greatly
changed by medical treatment.”
This definition applies more strictly to some diseases of
this class than to others; or, in other words, the limits differ
in definiteness in the different diseases which may properly
be said to belong to this class. Thus small-pox and measles
are very definite in the period which each occupies in its
processes; scarlatina is rather less so ; and continued fever
still less. Dr. Watson considers the latter to occupy gene-
RATIONAL THERAPEUTICS. 179
rally about three weeks : * but sometimes it is shorter, and
often is much longer than this ; and, when it is prolonged,
it appears generally to be a continuation of the same disease
essentially, and is not, as is the case with scarlatina when
prolonged, merely a prolongation of results rather than of
the disease itself. It is upon the circumstances that govern
these continuations that medication can sometimes exert a
decided influence; and the more so, the less definite is the
natural period of the disease.
The progress which the profession has made in the thera-
peutics of this class of diseases is much greater than is
commonly supposed. Physicians are hardly aware of the
position of most of the profession some twenty-five years ago,
in regard to their nature and treatment. It was such that
T}r. Bigelow, in his discourse on self-limited diseases in
1835, seemed to have some distrust as to the reception
his ideas would meet with. His language was therefore
cautious. He spoke of the object of his discourse as being
“to endeavor to show the existence of such a class of dis-
eases ; ” and he says, “In proceeding to enumerate more
precisely some of the diseases which appear to me to be
self-limited in their character, I approach the subject with
diffidence. I am aware that the works of medical writers,
and especially of medical compilers, teem with remedies and
modes of treatment for all diseases ; and that, in the morbid
affections of which we speak, remedies are often urged with
zeal and confidence, even though sometimes of an opposite
character.” -
Although there were many at that time holding more or
less the same views with Dr. Bigelow, yet it was quite
common among medical men to speak of his discourse as
showing that he was unduly sceptical in relation to the
powers of medicine. But, at the present time, these views
are those of the profession generally ; and, in carrying
1. As the distinction of continued fever into typhus and typhoid fevers is still a
subject of dispute, I have everywhere in this Essay spoken of it as one thing.
180 RATIONAL THERAPEUTICS.
them out in the treatment of disease, a very great advance
has been achieved in the discriminating limitations which
have been placed upon the use of remedies in this class of
maladies. - -
In that most common of all chronic diseases, phthisis, the
change in treatment, since the reign of active medication has
passed away, has been of the most decided character. Bleed-
ing, emetics, antimonials in small doses, digitalis, &c., were
quite common remedies in the treatment of this malady in
the first quarter of this century. Although, as long ago as
1789, Dr. Thomas Percival developed the true pathology of
phthisis, taking the ground that “inflammation is perhaps
only an occasional concomitant ’’ of the formation and soften-
ing of tubercles, yet the general practice in this disease
continued long after that to be founded upon the idea that
there was inflammation, or at least congestion, to be com-
bated from the very outset. But now this active mode of
treatment is abandoned. It is a general conviction in the
profession, that little comparatively is to be done by medi-
cation; and most of the remedies that are used are such as
are calculated either to give tone to the system, or to quiet
irritation. But perhaps, in avoiding the errors of our prede-
cessors, we have gone too far. Inflammation is, I am
persuaded, too much ignored at the present day as a con-
comitant of the essential pathological process in this disease ;
and local bleeding and counter-irritation are too seldom
employed. There is danger of our having an exclusive
mode of practice in this respect, and thus lessening that
“ advance in favor of humanity and scientific medicine,”
which has certainly been secured in the marked abandonment
of drugs in the treatment of this malady.
Perhaps there is no disease in which there has been so
thorough an abandonment of active medication as in delirium
tremens. For a long time, the doctrine of the profession
was that promulgated by Dr. Sutton, — that the patient must
sleep or die ; and that the grand means of securing sleep
RATIONAL THERAPEUTICS. 181
was opium, which was supposed to be ordinarily needed in
large doses. The profession were right in regard to the first
clause of this doctrine. The excessive agitation of the ner-
vous system would, of course, wear out the patient, unless it
could be brought to an end, and the patient could sleep.
But they were wrong in regard to the necessity of opium to
produce this result. The agitation can be quieted by other
means, as alcohol, for example ; and even negative measures
will often answer the purpose, – the disease coming to an
end from the mere withdrawal, as far as is possible, of all
excitement of body and mind. To Dr. Ware, of Boston,
belongs the honor of having first distinctly announced the
truth on this subject, which he did nearly thirty years ago.
Following up his observations, he became satisfied even that
the sleep in which the disease terminated was much oftener
a spontaneous termination than the result of the operation of
opium. -
Since the investigations of Dr. Ware, various plans of
treatment have been adopted. Dr. Klapp, of Philadelphia,
relied almost entirely upon emetics. He states, that, of
51 cases, opium and alcohol were used in only one case ;
and that only one death occurred, which was caused by
epilepsy. The alcoholic treatment, of which Dr. Gerhard,
of Philadelphia, is a prominent advocate, is represented as
equally successful. He reports, thät, of 162 cases treated
in one year in the Philadelphia hospital, only one died; and
he had been treated with opium previous to his admission,
and died when he had been in the hospital but a few hours.
Dr. Dunglison reports similar success in the treatment of
84 cases in the Women’s Lunatic Asylum ; the treatment
being “entirely eclectic, and in many cases expectant.”
Opiates and stimulants were given in but few of the cases.
Emetics were used in some cases. The patients were shut
up in a darkened room, and kept quiet; easily digested food
was prescribed, when the stomach would retain it ; and the
bowels were kept open by gentle cathartics. This consti-
- 24
182 RATIONAL THERAPEUTICS.
tuted the treatment. Of the 84 cases, all recovered but one.
In this case, the patient had been treated for a week before
admission, and was not seen at all by Dr. Dunglison.
Although these statistics are not extensive enough to
settle many points in regard to treatment, there are some
few points which they do settle very clearly. First, that
opium, so far from being a sine qué non in the treatment of
this disease, is not ordinarily essential to effecting a cure.
Second, that the recuperative power of nature is the chief
agent of cure. Thirdly, that the disease is almost always
recovered from, if it have no other disease complicated with
it. Fourthly, that there is no one plan or mode of cure
which is exclusively applicable.
There are some things which these statistics do not prove,
some of which it is well to notice. They do not prove that
opium is an improper remedy; neither do they show that any
of the other means, which have been made the prominent
measures of the several modes of treatment, are inapplicable;
neither do they indicate the relative value of these different
means, or the circumstances which should govern us in
their application. Mere statistics alone cannot settle such
points; they must be settled by minute and careful obser-
vation of cases; and general statistics can only be auxiliary
to such observation in doing it. It is this observation, that,
under the guidance of established general principles, is
determining, in the experience of multitudes of careful and
scrutinizing practitioners, the relative value of the different
remedies; and, so far as we can get at the verdict of this
observation at present, among the positive means of cure,
opium in moderate doses is the most important. If there
could be an accurate comparison made between the results
of the present discriminating practice in this disease, and
the heroic opium practice of former days, it would un-
doubtedly show that the approach which has here been made
“towards the rational and successful management of disease,
without the necessity of drugs, is an advance in favor of
humanity and scientific medicine.”
RATIONAL THERAPEUTICS. 183
There are some diseases in regard to which there is still a
struggle going on in the profession in relation to modes of
treatment, similar to that which so long prevailed in regard
to some of the diseases which I have noticed. Such are
yellow fever and cholera. There are the same discrepant
testimonies in regard to the modes of treatment in these, as
there have always been about exclusive modes in other
maladies; and probably the result which has commonly been
reached will be reached here. The profession will soon
come to the belief, that medicine has less power over these
diseases than has been supposed; that no one mode of treat-
ment is universally applicable; that nature is to be trusted
quite largely ; and that the curative means must be em-
ployed in obedience to general principles, instead of narrow
theoretical notions.
The movement towards such a result is very strong, of
late, in regard to yellow fever. Bleeding, stimulants, qui-
nine, calomel, the tincture of muriate of iron, &c., have
each had their warm advocates; but active medication of
these various kinds is beginning to be given up. Thus Dr.
Fenner, of New Orleans, in his report on the epidemics of
Louisiana, in the “National Transactions ° of this year,
says, “In respect to treatment, I feel authorized to say, that
the general opinion of the profession in this region now is,
that we have hitherto been giving too much medicine in
yellow fever ; in other words, we have been taking it out
of the hands of nature, and trying too hard to cure it :
whereas all that seems necessary to be done is to assist
nature in her conflict with the febrific cause.” So also Dr.
Cain, of Charleston, says of the profession of that city, that
they have “generally settled down upon the opinion long
since promulged by Pitcairn respecting common continued
fever (typhus and typhoid); viz., that yellow fever cannot
be cured, but may be conducted to a favorable termination.”
There are some diseases, the treatment of which is as
active now as it ever was. Such, for example, are colic and
184 RATIONAL THERAPEUTICS.
intermittent fever. In the latter disease, quinine is often
given much more freely than it formerly was ; and by many
with little regard to those circumstances which, it has been
thought, should limit its use, and in some cases altogether
forbid it. But the limitations, which the varying circum-
stances of the different cases should place upon the admini-
stration of this effective remedy, are not yet ascertained with
sufficient definiteness ; and much is undoubtedly to be
yet learned in regard to its use by careful and extended
observation.
In the inflammations, active medication is much employed
at the present time, but less boldly than formerly, and with
more discrimination in regard to the applicability of the
various means in different degrees to different cases. When
inflammation occurs in connection with other diseases, as
fevers and the exanthemata, it cannot be attacked with
active remedies as freely as when it occurs alone. Espe-
cially is this so when the inflammation forms a part of an
epidemic disease. Good examples of this are found in
yellow fever and dysentery. When dysentery is sporadic, -
that is, when it is an inflammation simply, with the accom-
panying fever for the most part symptomatic, - it is much
more amenable to remedies than when it is an epidemic
dysenteric fever; the inflammation in this latter case bearing
to the existing fever the same relation that the inflammation
in yellow fever does. In both diseases, the inflammation and
the fever are results together of the cause or causes pro-
ducing the disease.
This leads me to remark, that, commonly, active medica-
tion is much less admissible in those acute diseases which
depend in part upon some occult cause, than in those which
result from causes, the operation of which we to some ex-
tent understand. If this fact had been more recognized by
the profession, we should not have had such bold and various
treatment, with all its discrepant testimony, in the epidemics
that have from time to time appeared; and their ravages
would not have been so extensive and severe.
RATIONAL THER, AIPEUTICS. 185
I have thus portrayed to some extent the change which
has taken place in medical practice during the past twenty-
five or thirty years. Just how far this change has been a
real “advance in favor of humanity and scientific medicine,”
it is impossible to estimate; but that the advance has been
a great one is very evident. The deliverance from the suf-
fering that formerly came from fruitless medication is of
itself no small gain. The amount of life saved would be
seen to be very great if we could obtain correct statistics on
this point. But, besides this, there is great gain in many
cases in the actual shortening of the term of sickness, and
in the more clear convalescence which is established; for an
undiscriminating active medication is apt to make long and
bad cases of mild attacks of disease, and to leave patients,
on recovery, with a shattered system and morbid tendencies,
ready to be lighted up into active disease on the application
of any exciting cause. r . . - º
We sometimes have the opportunity of seeing the bad
effects of undiscriminating active medication exhibited in
the most palpable manner. Not only does quackery furnish
us with such opportunities, but we meet with them occa-
sionally within the bounds of the profession. I will give
but a single example. There was at one time much noise
made in various parts of New England about a disease which
was called typhus syncopalis. That such a disease did exist,
I will not deny : but, at the same time, we have the most
abundant and reliable evidence to show, that much of what
was called by this name was the product of the remedies
administered for its relief; in other words, that it was often
in fact a brandy and opium disease. I will not detail the
evidence, but simply state it in the general. 1. In many
cases, the discontinuance of the remedies effected a solution
of the symptoms. 2. A simple and mild treatment relieved
in a very short time cases which had the same symptoms
with those which, under the brandy and opium treatment,
became severe and protracted cases. 3. In some instances,
186 RATIONAL THERAPEUTICs.
all the cases of the so-called typhus syncopalis occurred only
in the practice of those who pursued this mode of treatment,
instead of being distributed among the different physicians
in the same locality. The evidence on the two first points is
abundant and various; and the whole proves beyond a ques-
tion, that a continued use of stimulants and opiates can,
under certain circumstances, produce a morbid condition re-
sembling that which has been described as sinking typhus.
As then we see, in this and in some other cases, an inap-
propriate positive medication almost entirely creating the
disease which it is supposed to cure, we can have some
conception of the extent of its varied influence in different
diseases, more or less modifying and aggravating them.
And the fact that it is not more palpably destructive of life is
owing to the influence of the recuperative powers of nature,
which are ever ready to do their work, and commonly do it
very effectually as soon as art’s busy meddling with her
operations is given over.
In dismissing this topic, I remark, that Homoeopathy has
derived much of its popularity with the people from the
manifestly bad results of rival modes of active medication ;
and that undoubtedly many of those practitioners of this
form of quackery, who were once in the ranks of our pro-
fession, are really less unsuccessful than when they practised
what is called regular medicine, because now they leave to
nature what they once undertook to do by their bungling
over-medication.
I propose now, in pursuance of the plan of this Essay, to
enter somewhat upon a comparative estimate of the value
of the different kinds of curative means, which have been so
variously brought into view in commenting upon the changes
that have taken place in medical practice. This is necessary
as preparatory to the development of those principles which
should guide us in the use of these means.
The most important of all these means is the recuperative
RATIONAL THERAPEUTICS. 187
power of nature. All our means of art have little influence
in comparison with this. Well is it said by Sir Gilbert
Blane, that “the benefit derivable to mankind at large from
artificial remedies is so limited, that, if a spontaneous prin-
ciple of restoration had not existed, the human species
would long ago have been extinct.”
But why do we call this recuperative power our means of
cure ? Because we can use it. We can modify and direct
its efforts; we can remove obstacles out of the way of its
action; we can put the system into a condition to receive
the full benefit of its efforts. A large part of the physician’s
duty is thus to be waiting upon nature; and, even when he
uses active measures, they must commonly coincide with her
efforts, or they will do harm. It is seldom that he is called
upon to go counter to her operations, and then only tempo-
rarily.
This is our means of cure much in the same sense that
the wind is the sailor’s means of bringing his ship safely
into harbor. With his appliances, he so adjusts his vessel
that this natural power shall effect the purpose, as the phy-
sician adjusts the circumstances of his patient so as to let the
natural powers in his system carry him safely into conva-
lescence. The comparison might be followed out, without
bordering in the least upon the fanciful, in other particulars;
but they are so obvious that it need not be done.
Next in importance in the treatment of disease is the class
of quieting and comforting means and measures. Disease
is ordinarily accompanied by turmoil and suffering. These
it is important to allay, in order that the recuperative power
may act easily and effectually. The means of doing this are
widely various. Some of them are negative in their cha-
racter. Rest, which is often so manifestly necessary in the .
practice of the surgeon, is as necessary in the practice of
medicine. There is quite a common failure among practi-
tioners on this point. The neglect of it often counteracts in
part, sometimes wholly, the curative influence of remedies.
188 RATIONAL THERAPEUTICS.
Many a patient dies because the physician has not given him
rest. Especially is this true of mental rest; and, when such
neglect occurs, the dereliction of duty is no less than if the
physician had carelessly allowed the patient to take a poison
that killed him. He has, in fact, allowed him to take a
poison; and, though it be a mental one, it has proved as fatal
as if it were a poison introduced into the stomach.
There are various drugs which are used for the purpose of
securing rest, and relief from suffering. Opium is not only
at the head of this class, but it is the most important of all
drugs that are employed in the treatment of disease. It helps
the physician in giving his patient that rest which is so effect-
ual a means of cure. Its direct influence upon disease consti-
tutes but a small portion of its usefulness. It is in its
indirect influence that it has so wide and varied a curative
agency. By its relief of pain, and its calming of disturbance,
it saves from the exhaustion and aggravation of disease, that
are so certain to result from continued irritation; and enables
the recuperative energies to do their work quietly and effect-
ually. It also, conjoined with other remedies, makes them
act kindly, when they otherwise would occasion so much
irritation that they would do harm rather than good. In
these ways, this remedy is constantly of use in the treatment
of disease. It exerts ordinarily so quiet and gentle a mini-
stration, that we are apt not to be aware of the great amount
of influence that comes from it.
In the reign of active medication, it was common to speak
slightingly of palliative remedies, in distinction from those
which were supposed to be radical in their influence upon
disease. It was not only the popular notion, but it was to
some extent the belief of the profession, that opium never
cures. In those cases where such active remedies as bleed-
ing, mercurials, &c., were used, these were supposed to effect
the cure, while opiates merely relieved the pain and restless-
ness. The fact that in doing this they had much to do with
the cure was but imperfectly recognized. Much less was it
RATIONAL THERAPEUTICS. 189
seen, that, in many cases, nearly all that the physician can
do is to allay disturbance and relieve pain by opiates and
other means, in order that nature may carry on her curative
operations quietly and effectually. And here I cannot for-
bear to remark, that opium is of much more value than many
suppose in quieting the irritation of commencing disease.
Its use is too often deferred till certain impressions, deemed
to be a necessary preparation of the system for the action of
this remedy, are made upon it. It is indeed true, that opium
may be so used as to cover up merely the smouldering fire
of disease; but this is only when other means, which should
be used at the same time, are neglected.
There is no truth better established than that whatever
palliates has, in doing this, a tendency to cure ; and, taking
into view the whole range of disease, quieting and comfort-
ing influences have more to do with effecting recovery than
those which are disturbing. Even the remedies which for
the moment disturb, often do more towards the cure, by the
relief which they at length afford to disturbance or suffering,
than by any direct effect which they have upon diseased
action. This may be said of all remedies that remove sources
of irritation. And the lighter means of contributing to the
relief of the turmoil and distress of sickness are not to be
neglected. Refreshing influences acting upon the morbid
sensibilities, genial mental influences, even so small things
as the smoothing of a pillow, often contribute much to the
recovery, and are sometimes essential to it.
I will not go further in the classification of our means of
cure according to their relative importance. It is sufficient
for my purpose to show that nature’s salutary efforts, and the
quieting means which have so much influence in favoring
these efforts, stand in importance far above all remedies of a
disturbing character.
Before, however, dismissing this subject, I will remark
briefly upon the prominence which should be given to simple
means in the treatment of disease. The judicious application
25
190 RATIONAL THERAPEUTICs.
of these is often neglected, while the physician is busied
with the administration of remedies, the operation of which
is perhaps involved in obscurity. The most successful prac-
titioners are those who take the simplest views of diseases
and their remedies ; practising according to the dictates of a
good common sense, taking that term in its highest meaning.
On the other hand, those who are captivated with recondite
views of the modus operandi of medicines are unsuccessful
practitioners. A young physician once asked an old practi.
tioner," who had acquired by his practical good sense a wide
reputation, not merely with the public, but with all the pro-
fession in his neighborhood, what his principles of practice
were ; expecting to hear from him some very profound
remarks on the subject. But the sagacious old man replied,
“My principles are very simple. If the patient is hot, I
cool him ; if he is cold, I warm him ; if there is pain or
restlessness, I relieve it ; if there are irritating matters, I
evacuate them ; if any secretion is scanty, I try to make it
free. These are some of my most important principles.””
To such a physician, the more simple the means of
cure, the better. Cold water, which can be used so exten-
sively and so variously, is to him often a remedy of greater
value than any drug that can be administered.” He makes
1 The late Dr. Amos Twitchel, of Keene, N.H. This eminent physician used
to relate often an anecdote of himself, and his preceptor, Dr. Nathan Smith, which
is very instructive as to the caution necessary in drawing inferences from single
cases in regard to the efficacy of remedies. “In the earlier part of my practice,”
said Dr. Twitchel, “I made use of a certain preparation of silver, and wrote to
Dr. Smith, saying, ‘I can cure epilepsy; at least, I have done it.' Dr. Smith
wrote in reply, “Do it again.' But,” added Dr. Twitchel, “I never have done it
again to this day.”
* The grand improvement which Sydenham introduced in the treatment of
Small-pox consisted simply in the application of plain principles of common sense.
And I know of no fact which shows more strikingly the prevalent disposition to over-
look these, and to grasp at something beyond them, than the slowness with which
his principles of treatment in this malady obtained a foothold in the profession. .
* Neither the efficacy of this remedy, nor the variety of modes in which it can
be applied, is appreciated generally by the profession; and from want of caution,
and a disregard of the simple principles which should regulate its application, it is
very often used injuriously, especially when its application is left to attendants with
yague and unintelligible directions, as is too often the case.
RATIONAL THERAPEUTICS. 191
much account of such matters as friction, external applications
of various kinds, the regulation of the temperature of the
room, of the amount of clothing, ventilation, cleanliness, &c.
He attends also to the mental influences that are brought to
bear upon the patient. He does not consider himself the
mere doser of the body ; but he regulates the mental doses,
so to speak, that are administered, sometimes considering
these of more importance than the drugs that he gives. He
feels bound to take charge of every thing that can in any
way affect the case, and is satisfied with nothing short of
absolute control of the sick-room.
I pass now to the development of certain principles, by
the guidance of which, in the use of curative means, we
may secure the advance that is contemplated in the proposi-
tion which is the subject of this Essay.
It is a grand axiom of Chomel, that it is the second law
of therapeutics to do good; its first being this, – not to do
harm. This axiom, however, does not go far enough. It
would be better if there were added to it the words, and to
prevent harm from being done. An active interference is de-
manded of the physician to shut out all injurious influences.
His duty in this respect, as I have before said, is as positive
as in the administration of remedies. ..º
But I will go more into particulars. I lay it down as a
rule, fairly deducible from the views which I have presented
in relation to therapeutics, that no active medicine should be
used in any case, unless the evidence is clear that it will effect
good. This is in entire opposition to the old axiom, Melius
anceps remedium quam nullum, - an axiom which, though
time-honored, has been largely destructive of life, and has
hindered greatly the progress of therapeutical science. This
axiom would indeed be applicable if disease were cured only,
or even chiefly, by medicine; but, as the recuperative
power is the chief agent of cure, there is in the use of all
doubtful means great hazard of interfering with its salutary
efforts.
192 RATIONAL THERAPEUTICS.
Substantially, this rule has been adopted by sagacious men
in other matters than medicine. After Lord Chatham had,
upon some occasion, criticized the doings of the ministry, it
being said in their defence that the error charged upon them
arose from a want of information, he said, in reply, that it
had ever been the rule of his life, whenever he did not know
what to do next, to do nothing. Especially applicable is
such a rule in medicine : for besides the fact, that in the
strife of disease there are many and complicated agencies at
work, some of which may be unknown (making, therefore, a
throw at a venture peculiarly hazardous), there is one power-
ful agency — the recuperative power — always working for
good; with which it is exceedingly important that the phy-
sician should not interfere, and to which he had better in-
trust the welfare of his patient, than employ expedients of a
doubtful character.
IBut are there no exceptions to this rule 2 There are
some ; but they are few. Some diseases furnish exceptions:
they are diseases in which, thus far, there has been no cure in
nature, nor any found by art. Hydrophobia is an example.
Bere there is properly room for experiment with remedies.
So, too, there are occasionally cases of disease that is
ordinarily curable, in which it is manifest that the patient
must die, unless some active interference of art can save
him. Here a doubtful remedy, from which there is some
reason to hope, is admissible: . but, to warrant its use, the
case must be a clear one in regard to the prospect of a fatal
termination; and it must be remembered, that cases which
seem to us to have a fatal tendency, almost beyond a doubt,
sometimes recover from causes that we do not understand.
And I may remark in this connection, that the capabilities of
nature are often not sufficiently appreciated in severe disease,
as such cases show us. Cases in which such unexpected
recoveries occur are for the most part rather indefinite in
their character. They are cases in which a physician that
always wishes to have clear reasons for what he does is in
RATIONAL THERAPEUTICS. * 193
doubt what to do ; that is, so far as any remedy that will act
with any directness or efficiency upon the disease is con-
cerned; and so, in obedience to Lord Chatham’s maxim, he
does nothing. He watches the movements of the case,
counteracting, so far as he can, the tendency to death; sus-
tains the exhausted powers; quiets irritation; and awaits the
result. A busy interference in such a case would frustrate
the salutary efforts of nature; unless, as a mere matter of
chance, the physician should strike upon a plan that coin-
cided with these efforts. There are really, then, very few
cases of the kind designated in the beginning of this para-
graph, in which it is proper to disregard the rule laid down.
I would consider as exceptions to the rule some mild cases
of disease, in which it might be proper to try the effect of
doubtful remedies: but, of course, such experiments should
be very infrequent, and should be very carefully made ; and
great caution should be exercised in drawing inferences from
them in regard to the applicability of the remedies to grave
Ca,S62S,
Some would, perhaps, be disposed to exclude from the
operation of the rule cases of chronic disease. I see no rea-
son why they should be excluded. There is as real, though
ordinarily not as great, hazard in indefinite, aimless dosing in
chronic, as there is in acute, disease.
Perhaps it will be thought that so strict a rule will pre-
vent us, in many cases, from doing good, which, without
this rule, we might, perchance, be able to do. This is un-
doubtedly true of some cases; but the number of them will
be very much less than the number of cases in which this
rule will save us from doing harm. -
Venturesome medication is captivating, especially to the
young and enthusiastic practitioner; and the charm is en-
hanced by the occasional brilliant achievements with which it
is attended. Many of these achievements, however, are only
apparent, being erroneously attributed to the remedies, when
they are really the result of nature’s efforts, and have been
194 RATIONAL THERAPEUTICS. *
effected, perhaps, in spite of the agencies to which the credit
is given. While the bold practitioner has this brilliant but
often false show of success, the better results of the practice
of the cautious physician commonly make but little display;
yet, when he does attempt to produce decisive effects by his
remedies, so definite is his aim, that the result may be calcu-
lated upon almost with certainty.
This leads me to say, that the adoption of this rule will
relieve the practice of medicine, to a considerable extent, of
its uncertainty. The practitioner, always having definite
aims, and generally accomplishing clear results, will become
exceedingly exact in his observation; and his recorded ex-
perience will be of great value. With many observers at
work in this way, noting down the results and comparing
their records, the circumstances which should regulate the
use of remedies will be accurately and extensively ascer-
tained; and therapeutics will become immeasurably more
definite than it now is.
Perhaps some will complain, that the rule which I have
laid down hems in the practice of medicine within too nar-
row limits. But if the physician takes the broad view which
I have presented of our means of cure, and attends to the
regulation of them all, both the negative and the positive,
he will find enough to do, even with the strictest application
of the rule; and then the results of his definite observations
under this rule will enable him, as his experience increases,
to widen the range of his active interference in the treatment
of disease.
It will undoubtedly be thought by the advocates of a bold
practice, that the rule which I have stated lowers the dignity
of the physician’s office by restricting so much his active
agency in combating disease; but, so far from this, it is
really enhanced. Great skill is often required to do aright
the little that is to be actively done; for there must be accu-
rate and painstaking discrimination in order to distinguish
between the salutary efforts of nature and the symptoms of
FATIONAL THERAPEUTICS. 195
the disease, and to adjust the agencies which he employs
so that they may coincide with those efforts, instead of
thwarting them. It is a far more complicated, and there-
fore more difficult, plan of practice, if faithfully carried
out, than that which is commonly pursued by those who
are in favor of an active medication. It admits of no
stupid and indolent submission to routine, nor of that mere
show of industry which attends the practice of the theorizing
practitioner. It calls for thorough, patient observation, in
order that all the circumstances of every case may be pro-
perly regulated, and that every opportunity of exerting a
decisive good influence by remedies may be promptly secured.
There is sometimes a necessity for very active medication ;
and the physician is to estimate carefully the degrees of neces-
sity in different cases. A truly rational practice takes so many
points into view, and varies so much its adjustments to the
infinitely varied necessities, of the different cases, that it
affords scope for the exercise of the very highest powers of
mind.
Very dignified is the stand sometimes taken by the dis-
criminating physician, when, after a careful survey of all the
circumstances of a case, he comes to the conclusion that
the patient will have a better chance of recovery if he for the
most part be let alone, than if his case be actively treated.
The disease may be violent in its character, seeming to the
common observer to call for the most active interference of
art, and the importunities of the friends of the patient for
such an interference may be exceedingly urgent; and yet he
remains firm to his purpose, using only such palliatives as
may assist nature in weathering the storm. It is truly a
“masterly inactivity,” of which a frivolous and undiscrimi-
nating mind is wholy incapable. It is in strong contrast
with the fretting and vacillating course which the indefinite
doser is apt to pursue in such a case.
In following the rule which I have laid down, it is not
required of the practitioner that he should know with abso-
196 RATIONAL THER A PEUTICS.
lute certainty that his remedies will produce the effects that
he contemplates. All that is intended is, that he must
have good evidence that they will in all probability do so.
Medicine is not an exact science, but is ranked among the
inexact and conjectural sciences. Some go so far as to say
that a good practitioner is only a good guesser; but this is a
gross libel on the character of medical evidence. The con-
clusions of the rational physician are founded upon a careful
examination of evidence, which is often so complicated that
it requires great skill to unravel it. There is difficulty, it
is true, which leads the superficial and indolent to guess:
but it calls forth the highest powers of observation and rea-
soning in the thinking and industrious; and, with the exer-
cise of proper caution, they arrive at conclusions which are
clear and safe guides for them in their practice.
The inquiry, then, naturally arises here, what the nature
of the evidence is upon which the physician must rely.
There is great mistake often on this point. We see this in
the discrepant opinions which are sometimes given by emi-
nent physicians in regard to the use of active means in the
treatment of the same disease. The relation of the remedies
to the morbid condition fails to be recognized by either
party; else there would not be such opposition of views. If,
for example, stimulating and depressing remedies are both
used under the same circumstances by different physicians,
and both parties make such show of success that it is difficult
to decide between them, both must be in error in regard to
the nature of the evidence to be relied upon in discovering
the relations of remedies to the varying circumstances of
disease; and the error is a radical one. It is a failure in the
very foundation of practical medicine. s
The evidence which we have in regard to the action of
remedies upon disease is twofold. First, there are some re-
medies that have a relation to disease which we do not
understand. We only know that they cure the diseases to
which they have this relation. A very marked instance of
RATIONAL THERAPEUTICS. 197
this kind is the relation of cinchona to intermittent fever.
We may theorize in regard to its modus operandi ; but we
really know nothing about it. We only know that it arrests
the disease. -
But the remedies which have this occult but definite rela-
tion to disease are few in number; and our evidence in this
direction is therefore very limited. Most of our evidence is
in regard to remedies that have altogether a different relation
to disease. They are remedies which are found to produce
certain effects upon the system ; and it is from a knowledge
of these effects that we judge of their applicability in indi-
vidual cases. In other words, we know something of their
modus operand; ; and this knowledge is, or should be, the
foundation of our use of them in the treatment of disease.
Thus, it is what we know of the effects of bleeding upon.
the circulation that guides us in the use of that remedy
for the relief of fever or inflammation. So the effect which
we see calomel produce as a stimulator of the secretions is
chiefly the ground of our use of this drug in many forms of
disease. Examples might be multiplied ; but these are
sufficient. -
The second rule, then, which I would lay down for our
therapeutics, is, that the practice in each case should be based
mostly upon what we know of the modus operandi of remedies.
I say, upon what we know ; for many attempt to go beyond
what is known, and grasp at the occult in the operation of
remedies, making their suppositions in regard to it the basis
in part of their therapeutics. There is no objection to such
suppositions if they are treated as such. They may indeed
lead to some discoveries in relation to the action of remedies;
but when they are considered as established truths, and are
acted upon in practice, they are legitimate sources of error.
Nothing but what is actually known should be the basis of
action. It is only by a strict adherence to this rule that
medicine can be redeemed in any good measure from its
uncertainty. Mere speculation, when it is mingled with our
t 26
198 RATIONAL THERAPEUTICS.
actual knowledge, makes it uncertain and confused; and this
result may always be seen in the practice of the physician
who is captivated with speculative views of the occult opera-
tion of remedies.
Lven in the case of remedies that have a definite and al-
most specific relation to certain diseases, their use is to be
somewhat governed by other known effects of these reme-
dies, and their relations to other morbid conditions; that is,
in order to make their direct relation to disease always avail-
able, their modus operandi, in their indirect influence, must
be well understood. Thus, in giving quinine as an anti-
periodic, we must have some regard to incidental circum-
stances in the case, which, from other relations of this
remedy, may essentially modify, or even prevent, its desired
action.
It is such a knowledge of the modus operandi of medicines
as I have indicated that gives us certain general principles of
practice ; for these principles are but expressions of the
relations of the several remedies, or classes of remedies, to
different morbid states. It is in the application of these
principles to the infinitely varying circumstances of indivi-
dual cases that the rational practitioner exercises his skill;
the only exception being in the case of those few remedies
that act upon disease in a manner to him wholly occult, and
which some would call specific.
Although much is said about general principles, they have
been greatly neglected by many practitioners. This is seen
in the proneness, which has ever been so prevalent in the pro-
fession, to adopt fixed nodes of practice. Obedience to general
principles is inconsistent with the adoption of any exclusive
treatment. It leads to a liberal eclecticism. If medicines
were specifics, either wholly or partially, modes of practice
would be proper; but as nearly all remedies act indirectly
upon disease, and the circumstances which should modify
their application are almost infinitely variant, all the strifes
which the profession has witnessed between opposing parties
RATIONAL THERAPEUTICS. 199
in regard to modes of treatment have not only been useless,
but they have materially impeded the progress of rational
medicine. In most cases of this kind, while both parties
were wrong, neither was wholly so. Very commonly, the
remedies used by both are more or less applicable in the
varied conditions which the different patients present.
I have said that the application of the general principles
of therapeutics is to be greatly varied in individual cases, in
obedience to their varying circumstances. Most of these
circumstances are easily recognized: but some are discovered
with difficulty, at least at the outset; and some are entirely
hidden from view. These secret elements, existing in many
cases, modify essentially the effects of remedies, and some-
times render improper the use of those remedies which the
circumstances that are known in the case, taken by them-
selves, clearly call for. This suggests another rule of thera-
peutics; viz., that we should be governed in our treatment of
disease by the actual effects which we see our remedies produce.
This very important rule is often disregarded. The
physician who is fixed in the notions that he adopts is apt to
disregard it, especially if he be given to theorizing. So,
also, is the physician who, from indolence or lack of discri-
mination, readily falls into a routine of practice. On the
other hand, there may be too great readiness to make changes
in practice from supposed effects of remedies, or from too
little patience in regard to effects which are expected. The
judicious physician avoids both these extremes of fixedness
and variableness.
It would take me into too wide a field to consider to any
extent the causes which vary the ordinary action of reme-
dies; but some of them it will be profitable to notice.
The idiosyncrasies which we occasionally meet with are
such causes. An idiosyncrasy may be such in relation to a
remedy as to call for much larger or much smaller quan-
tities of it than are usually given, or it may be such as to
forbid the use of the remedy altogether.
200 RATIONAL THERAPEUTICS.
A variation of susceptibility under the influence of dis-
ease — a temporary idiosyncrasy, as it may be termed — is a
much more common cause than the one just mentioned.
The susceptibilities are always more or less altered by dis-
ease; and just in proportion to this alteration is that of the
relation of remedies to the diseased condition. We see this
strikingly exemplified in the large doses of opium which
are borne in severe pain, and in the amount of cathartic
medicine sometimes required in a torpid state of the bowels.
These are palpable cases, familiar in the experience of every
one ; but physicians very generally are not aware how ex-
tensively the susceptibilities are changed in disease, and how
wide a range of variation in the doses of medicine is re-
quired to proportion them accurately to the necessities of
each case. It is a very common failure to give either too
much or too little medicine. I am persuaded, that, in chronic
diseases, there is often much harm done by administering
remedies that are really appropriate in quantities that make
too decided impressions upon the system. In many cases,
a succession of gentle impressions from a remedy will do
good, when ordinary doses of it would produce so strong an
effect as to be injurious. Both in acute and chronic diseases,
there is, in the common practice of physicians, altogether
too little variation in the doses of medicine to suit the differ-
ent susceptibilities of patients; and probably the doses are
more often too large than too small. &
There are some occult causes of disease which modify the
action of remedies. This is especially true of epidemic
diseases, as I have remarked in another part of this Essay.
Although our general principles of therapeutics, deduced
from the ordinary relations of remedies to disease, are appli-
cable in such maladies, we cannot act upon them as freely as
we can in diseases that are open and clear in their character.
There is something in the disease beyond what we see,
modifying the effects of remedies often in an unaccountable
manner. We must use the remedies that we deem appro-
RATIONAL THERAPEUTICS. 201
priate, therefore, with great caution, watching their effects,
and depending very much upon what we observe of them
to guide us in the further use of the remedies. We may
find that the unknown substratum so affects the relations of
the apparently appropriate remedies, as to make them mostly,
if not wholly, inappropriate. The symptoms may be such,
for example, as we very properly consider as calling for
bleeding, and examinations after death may show a state
of things that bleeding is ordinarily calculated to relieve ;
and yet that remedy may be really appropriate in but few
cases, perhaps in none.
In yellow fever there is such an unknown substratum,
preventing the physician from obtaining those satisfactory
results which he obtains from active medication in most
diseases; and it is because this fact has not been distinctly
recognized that there has been so much contention in rela-
tion to modes of practice in this malady. Physicians have
been reluctant to acknowledge how little they know of its
nature, and have therefore applied their remedies with a bold
hand; the advocates of each mode persuading themselves
that they have better success than those who practise after
other modes.
" In commenting on the rules which I have laid down for
our guidance in the use of remedies, I have indicated in
incidental remarks what would be the effect of a full adop-
stion of these rules upon therapeutics. One result would be
a great diminution of the amount of medicine administered.
There would be a considerable “approach towards the ra-
tional management of disease without the necessity of drugs.”
It would be an eminently *rational” change, because, so
far from being a mere general diminution, it would be a
diminution by reason of discriminating limitations ; and,
with this diminution, there would be, as the result of the
same discrimination, a more active medication in some cases
than physicians now practise. In short, there would be both
a thorough discrimination in regard to the circumstances
202 RATIONAL THERAPIEUTICS.
calling for medication, and an accurate proportioning of the
quantities of medicines to the necessities of individual cases;
the range of doses being undoubtedly much wider than is
now realized in the general practice of physicians.
But there are circumstances which are so decidedly op-
posed to the adoption of these rules by the profession gene-
rally, that it will be difficult to effect it. There are obstacles
existing both within and without the profession. The com-
munity, for the most part, have great faith in the efficacy of
medicine. This is shown by the demand there is for quack-
medicines ; which is so great, that their sale, with its enor-
mous outlay in advertising and other machinery, constitutes
one of the prominent branches of business in the commu-
nity. It is shown also in the common language of the
people in relation to the efficacy of medicines. They are
inclined to attribute cures to particular remedies which have
been used; and their inquiry continually is, What is good
for this and that complaintº having the idea that remedies
have specific relations to diseases. Many, it is true, talk of
nature’s powers; but they evidently have indefinite notions
on the subject, and suppose medicine to be necessary to the
cure of any disorder which is sufficiently grave to be called
disease. The general disposition is to demand of physicians
an active medication; and those practitioners who are fertile
in expedients are most apt to secure a wide popularity. Ho-
moeopathy is satisfactory to its adherents only upon the
ground that its infinitesimal doses are endowed with a won-
derful power. It thus caters in the most effectual manner
to the prevalent disposition, and secures to itself the credit
which belongs to the recuperative power of nature, — the
grand curer of disease.
In such a state of things, the physician is strongly tempted
to accommodate himself somewhat to the expectations of the
people. It is a work which few are willing to undertake, to
go against the general current of popular sentiment, espe-
cially when it is a sentiment which it is peculiarly difficult
RATIONAL THERAPEUTICs. 203
to correct. For this reason, the great mass of physicians
are induced to administer more medicine than their unin-
fluenced judgment would dictate. The few who manfully
resist the current find themselves obliged to use place-
bos to some extent, as means which are absolutely necessary
to carry out their plans of medication with success. Espe-
cially is this the case with those who have not an established
reputation. - -
But there are obstacles to the adoption of proper limita-
tions of active medication, not only in the popular mind, but
in the profession itself. There are obstacles in the intellect-
ual tendencies of many practitioners. The post hoc propter
hoc mode of reasoning in relation to remedies is not con-
fined to the people; but it is also a common error among
physicians. The general habits of the profession in the
investigation of the effects of remedies are not such as they
should be. This is seen in the prevalent readiness to use to
a large extent at once any new remedies, and in the extrava-
gant notions which, at the outset, many physicians entertain
of their efficacy. There is collected, in regard to every
new remedy, a mass of crude, incautious observations, which
are paraded on the pages of medical journals ; and these
must be sifted thoroughly by a careful and continued
experience, before its efficacy can be properly tested, and
the circumstances which should govern its application can
be ascertained. The result is, that much harm is done
before the profession really become acquainted with the
proper use of the remedy, especially if it be one of consi-
derable power; and, from the fact that it had at the first an
undeserved popularity, it is apt, after a little time, to sink
in the public esteem below its real value. This process,
which is passed through by every new remedy, shows that
there is little appreciation, in the mass of the profession, of
the difficulties of therapeutical observation, and of the ne-
cessity of such rules for our guidance in the use of remedies
as I have laid down in this Essay.
204 RATIONAL THER APEUTICS.
Besides all this, it is for the interest of no inconsiderable
portion of the profession to have the prevalent ideas of the
power of medicine perpetuated. This is true of all followers
of routine, who, in the present state of things, easily satisfy the
expectations of the public. It is especially true of those
who rely much upon the notoriety which they acquire by
particular modes of practice. The adoption by them of the
rules which I have laid down would involve the abandon-
ment of their chief means of success. It is for their interest
to discredit the efficacy of the recuperative powers of nature,
and to have as much credit as possible given to their favorite
means of cure.
But, notwithstanding the existence of these obstacles, I.
believe, that, substantially, the rules which I have stated as
those which should govern our therapeutics are becoming
more and more established in the profession. The tendencies
are decidedly in this direction. Even in the community at
large, there is, among its most intelligent portion, some
movement counter to the general strong tide of public sen-
timent. There is not enough of it, however, to enable a
physician to maintain his stand in giving uniformly suffi-
ciently little medicine, unless he resort somewhat to place-
bos; and, although it is unpleasant to a high-minded man
to do this, yet there is nothing derogatory to his dignity or
honor in doing it occasionally, either to save himself from
the irksome and useless labor of encountering the prejudices
of bystanders, or to save his patient from the injurious
effects of over-medication, which he might otherwise receive
at the hands of another. The necessity of resorting to this
expedient could be soon got rid of entirely, if prominent
physicians of established reputation everywhere would make
known, in their intercourse with their patients, their senti-
ments on this subject. It is time that physicians should, as
we may express it, show their hand to the public more
thoroughly than they have done. Intelligent men should be
disabused by us of their errors in relation to the powers of
RATIONAL THERAPEUTICS, 205
medicine, and should be taught the importance of other
means besides drugs in the treatment of disease.
Medical men have a duty to perform in this respect, both
to themselves and to the community, -— to themselves, in
placing our profession on the elevated ground which it ought
to occupy ; and to the community, in redeeming them from
the injurious and sometimes fatal effects of the over-medica-
tion which is still so prevalent. Until this duty is exten-
sively performed, so as to exert a wide influence upon the
public sentiment, the practice of our profession must con-
tinue to be, in the eyes of the people, more or less on the
same ground with quackery, at least in some of its forms.
It is only by imbuing the public with the views brought out
in this Essay of the comparative value of our different medi-
cal means, and of the discrimination that is needed to apply
these means aright in the wide range of disease, that the
community will be led to bestow that regard upon the pro-
fession which is its due. Só long as a large portion of
medical men yield a real or apparent assent to the popular
notion that drugs are the great means of cure, and reputable
physicians here and there appeal to this notion by giving
undue prominence to particular remedies and to special
modes of practice, the change in therapeutics, which I have
indicated, must take place very slowly.
From what I have said, it is plain that the chief hinder-
ances to this change are in the profession itself. This we
should clearly understand, that we may make proper efforts
for their removal. It is of little use to war against the
quackery without, so long as we harbor in the profession in-
fluences that tend to place it on a level with quackery.
These influences must be exposed, and at least neutralized
by counter-influences, if not directly combated; and the
movement which has been for some time so decidedly mani-
fest in the leading practical minds of the profession, towards
a very strict discrimination in medication, must be in every
Way encouraged.
27
206 RATIONAL THERAPEUTICS.
There is much more to favor this movement now than
there was when it was first set on foot. There were formi-
dable obstacles to it then, which are now removed. The
age of theorizing is past; and practical medicine is thus
relieved of one of the principal hinderances to its advance-
ment. The last general theory of medicine which gained an
extensive hold on the profession was that of Broussais, – a
theory which, quite in contrast with its predecessors, soon
passed away under the advance of a strict and rational obser-
vation, imbittering sadly the last years of this great man’s
life ; and the reign of observation is now so fully established,
that no general theory of medicine can ever again be domi-
nant. The encumbrance of profitless speculation is fairly
thrown off; and the advance of medicine therefore, in strict
investigation, is very rapid. The acquisitions that have been
made in this century, and especially in the second quarter of
it, are vastly greater than were ever made before in the same
length of time. *
The advance has been greater, however, in diagnosis than
in therapeutics. The principal reason of this is obvious.
It is very generally a more difficult achievement to adjust
accurately our remedies to the varying phases of disease,
than it is to make out a clear diagnosis. It is a much more
compound intellectual process. There are more circum-
stances to be considered ; and the relations of these cir-
cumstances are endlessly varied in the different cases.
Therapeutics, therefore, really affords scope for higher men- .
tal powers, and especially for a greater compass of mind,
than diagnosis. The general impression has been otherwise.
This may be seen in the common remark, that, if the diag-
nosis be made out in any case, it is easy to treat it. The
diagnosis, it is true, is the proper basis of treatment; but
the same discrimination that has evolved it is to be exercised
still more carefully and skilfully, in order to secure the
adaptation of the curative means to the morbid condition, as
it varies in its manifestations from day to day. For great suc-
RATIONAL THER APEUTICS. 207
cess, both in diagnosis and in therapeutics, there is required
good sense in the highest meaning of that term, - a quality
which is really both more rare and more valuable than great
learning or brilliant acuteness of mind.
Another reason for the estimation which has been put
upon diagnosis in comparison with therapeutics is to be
found in the brilliant discoveries which have been made in
the diagnosis of disease during the past half-century. To
say nothing of others, Laennec has opened to us a vast and
rich mine in diagnosis. Such discoveries could not but
exert a wonderful influence upon medical men everywhere ;
and this influence has been enhanced by the marked general
bent in the French medical mind towards the researches of
diagnosis in preference to those of therapeutics.
Perhaps, considering the inherent difficulties attending
therapeutical investigations, the advance has been propor-
tionably as great in them as in diagnosis. That there really
has been a great advance during the past quarter of a cen-
tury is manifest from the facts which I have adduced in this
Essay. And these facts show clearly what is the nature of
this advance. It consists not so much in the discovery
of new remedies, as in the discovery, one after another, of
the circumstances that should govern us in the use of reme-
dies which had already long been familiar to the profession.
Though chemistry has made some almost new remedies out
of old ones, by extracting their very essence, there have
been really but few new remedies of any great value dis-
covered. Our means of cure have been little added to in
this respect; but they have been greatly increased by the
discriminations which have been made in regard to their
application. These discriminations have so varied the modes
and degrees of their application as to add materially to the
actual resources of the Materia Medica. While the gross
amount used of most medicines is much lessened, what is
used is generally applied with more clear and definite aim,
and therefore accomplishes more good. At the same time,
208 RATIONAL THERAPEUTICs.
less harm is done. In short, the use of medicines is not as
large as it was, but is more definite and various, and there-
fore more available in meeting the individual variations of
disease. -
The future improvement in therapeutics is probably to be
mostly in the same direction that it has been. Our resources
are to be increased by multiplying their modes of applica-
tion, more than by the discovery of any new resources.
Some have indulged the hope that specifics of different kinds
will be discovered for the cure of disease. Dr. Rush was
wont to talk of the probability that some plant would be
found that would cure consumption; and, even lately, Pro-
fessor Alison, in his “History of Medicine,” indulges in
the anticipation that medicine will hereafter be much ad-
vanced by “the discovery of specifics, which may counteract
the different diseased actions of which the body is suscepti-
ble, as effectually as the cinchona counteracts the intermittent
fever ; citric acid, the scurvy ; or vaccination, the small-
pox.” But, strictly speaking, there are no specific remedies,
though there are a few that approach to this character.
There may be some yet to be discovered: but we have no
reason to expect this from our past experience ; neither have
we reason to anticipate very much in the discovery of new
remedies of any kind. While the search for them should by
no means be discontinued, it is not worth while to expend
labor here which may be more profitably expended in farther
observation of the relations to disease of the valuable reme-
dies already discovered. The improvement in therapeutics
resulting from such observation will probably be very much
greater than it has yet been ; for observation is all the time
becoming more strict and accurate, and will increase greatly
in these qualities if the profession come to be extensively
1 How so acute a mind as Professor Alison's could think of the relation of vac-
cination to the small-pox as being similar to that of citric acid to scurvy, and that
of cinchona to intermittent fever, I am at a loss to divine. The great fact that the
vaccine disease will prevent the small-pox stands entirely alone. There is no other
fact that has the remotest analogy to it.
RATIONAL THERAPEUTICS. 209
governed in their medication by the principles that have been
developed in this Essay.
This advance in therapeutics must be attended with a great
diminution in the range of the Materia Medica. This must
be largely sifted, that we may know what our reliable re-
sources are. A useless polypharmacy has always encumbered
it. Sydenham had some realization of this truth ; for he
speaks of the “immense stock of eminent medicines that we
have long been pestered with,” and seems to deprecate any
addition to their number. Even as late as the beginning of
the present century, the following strong language was used
by Bichat in regard to the Materia Medica: “An incoherent
assemblage of incoherent opinions, it is, perhaps of all the
physiological sciences, that which best shows the caprice of
the human mind. What do I say? It is not a science for a
methodical mind: it is a shapeless assemblage of inaccurate
ideas, of observations often puerile, of deceptive remedies,
and of formulae as fantastically conceived as they are tedi-
ously arranged.” There has been a great improvement in
the Materia Medica since Bichat’s time, but more in the
simplification of formulae than in the diminution of the long
array of medicines which the Materia Medica contains.
Many of these ought to be excluded; and statements which
are made in regard to others ought to be omitted, as not
having yet been ascertained to be true by a careful obser-
vation. Such a sifting, as the strict observation contemplated
in this Essay would give the Materia Medica, would probably
show that many quite current ideas of the efficacy of medi-
cines are mere vague fancies, and that there are compara-
tively few active remedies of real value; and, in relation to
the multitude of new remedies which throng the pages of
our medical journals with flaming representations of their
efficacy, not one of them should be admitted among the real
resources of our art till it has been fairly tested by expe-
rience. -
I have spoken of observation as the means of effecting,
210 * RATIONAL THERAPEUTICS.
under the rules that I have laid down, the improvement in
therapeutics contemplated in the proposition which is the
subject of this Essay. And the inquiry arises here, By what
method or methods of observation is this to be done? It is
claimed by some, that the numerical method of Louis is the
grand means of settling all questions of therapeutics, and
indeed that nothing can properly be considered as definitely
settled till it is verified by the tests of this method. If the-
rapeutical investigations have the complex character that I
have attributed to them, and if the circumstances which
should regulate the application of curative means vary so
much in different cases of the same disease, this method can
throw but little light upon the action of remedies. It can
be at best but an auxiliary in establishing some very general
facts, and cannot aid us at all in adjusting the degrees in
which remedies shall be applied in different cases, much less
in arranging the combinations of remedies as the circum-
stances of each case demand. It fails in the very point in
which it is claimed to be peculiarly serviceable ; viz., in ex-
actness. While it may prove some of the most general
truths in regard to the relations of remedies to disease, it
offers no tests for their exact and minute application under
the various and fluctuating circumstances of individual cases.
For example, it has proved the general truth that bleeding
has commonly a curative influence upon pneumonia; but it
teaches us nothing in regard to the character of the cases of
this disease which call for this remedy, or the circumstances
which should regulate its use; and even the general truth
that it has proved in regard to this remedy was already
abundantly proved by the common every-day observation of
the profession. Indeed, I know of no truth proved by the
numerical method, in regard to the application of remedies,
which was not already established.
It is not my intention to go into an examination of the
defects of the numerical method of observation; but I will
merely remark, that, the greater is the number of remedies
RATIONAL THERAPEUTICS. 211
that are applicable to any disease, the more signal is the
failure of this method, from the great variation which is
required in the different cases in the proportions of these
remedies, and in the relative times of their use.
If therapeutics, then, were shut up to this method of ob-
servation alone, it would be made up of only a few bald
generalities, and would not merit the name of a science.
The industry of Louis, the founder of what is termed the
Numerical School of Observation, is indeed to be admired;
and his minute observation of disease is worthy of imitation:
but his therapeutics, as seen in his great work on fever, is an
entire failure, as might be expected from his adherence to so
narrow a method of investigation. Any physician of ordi-
nary attainments, using the common mode of observation
under the guidance of plain good sense, has a much better
knowledge of the proper application of remedies in cases as
they arise, than Louis has with all his learning and acuteness.
The truth of this remark, I think, would be manifest to any
one who will candidly observe the manner in which he com-
ments, in his work on fever, upon the four remedies, –
bleeding," tonics, blisters, and ice on the head, - on which
1 I cannot see how any one, taking a common-sense view of the matter, can
avoid coming to the conclusion, that, in almost all those cases reported by Louis in
which bleeding was employed, it was not an appropriate remedy. In most of them,
the disease was quite advanced before the bleeding was resorted to; and, in many
of them, the symptoms were such as absolutely to forbid the practice; and, in
Some of them, there is decisive evidence in the record that it did harm. To sustain
what I have said, I subjoin very brief notes of the cases in which bleeding was
used:—
First case. On tenth day, venesection 3 x. No improvement.
Second. On thirteenth day, forty leeches behind ears. No improvement. On
eighteenth day, eighteen leeches to neck.
Fourth. After ailing three weeks, six days in bed; venesection 3 viii.
Sixth. On seventeenth day, venesection [how much not said]; pulse 150; and
face red and flushed before bleeding. After, pulse quicker and smaller, and respi-
ration accelerated. Died at four, A.M., next day.
Seventh. On twenty-second day after first sick, twenty léeches to neck. No
improvement. Prostration.
Eighth. Sick on 21st Oct.; “two venesections” on 26th; leeches to anus before.
Venesection 3 x. on 30th. On 31st, in morning, “face pale, covered with sweat, as
if she were moribund; pulse very small and very feeble; ” twelve leeches to ears.
212 RATIONAL THERAPEUTICs.
he gives us his observations; and the attempt which he
makes, in the conclusion of his work, to apply the numerical
method of observation to the effects of these remedies, is a
specimen of inconclusive and valueless reasonings, which
has seldom had a parallel. &
It is the minute and varied observation, of which the nu-
merical method can take no account, that must be the basis
of the advance in therapeutics contemplated in this Essay.
It is this alone that can furnish the means of detecting all
the limitations which the diversified circumstances of indivi-
dual cases call for in the use of remedies; and it is the
minute and complicated knowledge of the relations of reme-
dies to disease, gained by this mode of observation, that
Ninth. On sixth day, venesection 3 xv. No improvement. Next day, twenty
leeches to ears. Died two days after.
JEleventh. On sixth day, venesection 3 x. Died eighth day.
Fourteenth. On fourteenth day, twenty leeches.
Seventeenth. On ninth day, venesection 3 xii. No call for it in the symptoms,
and no improvement from it.
JEighteenth. On sixteenth day, venesection 3 xvi.; forty leeches, next day, be-
hind ears; venesection next day after, and thirty leeches behind the ears.
Twentieth. On fifth day, eighteen leeches to anus; leeches also two next days.
On tenth day, twenty leeches to jaws; and eleventh, twenty to neck.
Twenty-first. On fifteenth day, venesection 3 xii.; seventeenth, eighteen leeches
to ears.
Twenty-second. On tenth day, venesection.
Twenty-eighth. On third day, venesection. Fourth day, venesection 3 x. Sixth
day, twelve leeches to ears.
Thirtieth. On twenty-fifth day, twenty-five leeches to abdomen; and twenty-
sixth, fifteen leeches. *
Thirty-first. On ninth day, twenty leeches to neck.
Thirty-third. On seventeenth day, venesection 3 x.; next day, fifteen leeches to
anus; and, three days after, twelve leeches to ears.
Thirty-sixth. On third day, venesection 3 xii.; sixth, sixteen leeches to ears.
Thirty-seventh. On sixteenth day, fifteen leeches to anus; and same, two days
after.
Forty-first. On twenty-fifth day, ten leeches, after perforation of intestine.
Forty-sixth. On eighth day, venesection 3 viii.; leeches before.
Forty-eighth. On seventeenth day, venesection 3 x.
Forty-ninth. On tenth day, venesection 3 xii.
Fifty-third. On tenth day, venesection 3 x.; same, next day.
Fifty-fourth. Had been sick about two weeks; venesection 3 xii.
I could give notices of symptoms in more of the cases before and after the
bleeding to verify what I have asserted; but it would make this note too long.
RATIONAL THERAPEUTICS. 213
constitutes true skill in the art of medicine. The numerical
method not only cannot impart this skill, but a strict adhe-
rence to this method is a bar to its attainment.
It has been sometimes asserted, that all conclusions ar-
rived at in therapeutics are really numerical results, as if
physicians were always practising a sort of mental arithmetic
as they gather the results of their daily experience. Nume-
rical estimates, it is claimed, are made continually, although
there may be no consciousness of it; and the usefulness of
a remedy in any disease is determined by such estimates.
So far from this, there is always more of weighing than
of numbering in common, every-day observation; for the
relative value of circumstances in disease is very properly
considered more important than the frequency of their oc-
currence. This is true even of symptoms, but it is more
emphatically true of the effects of remedies; and, farther, it
is by direct observation of the effects of remedies that the
judicious practitioner judges of their applicability more,
much more, than by any gross results that may be expressed
by numerals. Indeed, these gross results, which are so
much relied upon by Louis and his followers, are apt to be
fallacious, unless extreme care be taken to have comparisons
made between cases that are very much alike in their cir-
Cumstances.
The skill or tact which is acquired by common observa-
tion, carefully and thoroughly pursued, is capable of being
much improved by extensive experience. While it must be
in the case of every one, for the most part, the result of his
own experience, yet it may be greatly cultivated by a com-
parison of his experience with that of others. But this
comparison can seldom be made ; for there is really little
experience properly detailed in the records of the profession.
We have an abundance of recorded results of observations;
but these are comparatively of little value when they are not
accompanied to some considerable extent with the observa-
tions themselves, and especially when they are mingled in a
28
214 - RATIONAL THER APEUTICS.
confused mass, as has been too often the case, with theoreti-
cal speculations.
The grand desideratum in therapeutics is recorded minute
impartial observation. We need what Sydenham termed a
natural history of diseases. We want cases of every kind of
disease reported fully, with their treatment. With such
records, we should have the data for making an extensive
examination of the effects of remedies, just as we do in a
limited manner in our own private practice. Touis has set
a noble example in this respect. Let a multitude of ob-
servers make similar minute records of cases of disease as
they arise, and a great advance will be made at once in
therapeutics. I say cases as they arise; for it has been too
much the fashion to report either extraordinary cases, from
which little really can be learned, or cases selected from the
mass because they resulted successfully under some particu-
lar mode of treatment.
If the actual experience of the profession could be exten-
sively gathered in the manner indicated, it would manifestly
tend to give great definiteness to our views of the action of
remedial means, by the acquisition of an extensive knowledge
of the circumstances which modify their action. It would
tend, therefore, to banish that polypharmacy which is the
legitimate result of indefinite views, and to secure the ad-
vance in therapeutics which we have been contemplating.
There is one interesting point upon which I will comment
very briefly before bringing this Essay to a conclusion. It
is the influence which a general resort to preventive means,
or, in other words, an obedience of hygienic rules, would
exert upon the character of disease, and therefore upon its
treatment. This influence would be of such a nature as to
favor materially the deliverance of practical medicine from
its uncertainties. This will appear from the following con-
siderations: The less complicated disease is, the more readily
and clearly do we make out both the diagnosis and the cura-
tive indications. But what is the chief source of the com-
RATIONAL THERAPEUTICs. 215
plications of disease ? Evidently that series of morbid im-
pressions to which the various organs are subjected year after
year, producing successively points of disease that are ready
to be waked up into activity at any time when any general
disturbance is produced in the system. And these impres-
sions are made mostly by causes which are to a great extent
preventible. We see this especially exemplified in chronic
diseases. These, which are always disposed to be compli-
cated, are so generally accumulations of results from a con-
tinued action of the causes referred to, that it has been said,
and with much truth, that chronic maladies are the natural
fruits of our disregard of the laws of health, while acute
diseases are the direct inflictions of Providence. But even
the latter are, to a considerable extent, self-inflictions, though
much less so than the former; for not only are the compli-
cations which so commonly aggravate acute diseases, and
perhaps constitute their chief danger, the results, in part or
wholly, of previous transgression of hygienic principles,
but very often the direct causes of these diseases can be
avoided.
Observe, now, what would be the whole scope of the
effect which a proper attention to hygiene would have upon
therapeutics. It would manifestly give to diseases generally
a much more simple character than they now have. It
would, therefore, simplify the relations of disease to curative
means, and thus favor that simplicity of treatment which
should be our great aim in all attempts for the improvement
of our art; and, more than this, prevention, in delivering
unavoidable disease to a considerable degree from its usual
complications, would diminish its severity. While, there-
fore, the interference of art would be much less needed than
now in aid of the efforts of nature, whenever it should be
called for, it would be directed with a much more definite
aim than is ordinarily possible with the complex character
which the present common neglect of the laws of health so
generally gives to disease. And the fact thus demonstrated,
216 RATIONAL THERAPEUTICS.
that, besides all the direct good effects that come from an
attention to the laws of health, there is an indirect influence
upon therapeutics coinciding with our attempts for its im-
provement, is a consideration of no small importance.
In treating the proposition which is the subject of this
Essay, I have deemed it to be but a small part of my duty
to demonstrate its truth. I have looked far beyond this, and
have endeavored to develop principles, the guidance of
which, in the treatment of disease, would continually ad-
vance our art, relieve it of much of its uncertainty, and
eventually place it upon a satisfactory basis. I have aimed
to mark out the channels into which the energies of the pro-
fession must be directed to accomplish this purpose. I have
considered it very important that physicians should have a
right appreciation of the relative value of the various cura-
tive means which they employ, and especially that they
should be aware of the necessity of great discrimination in
the application of them to various and complicated and fluc-
tuating states of disease. I have endeavored to bring out
fairly the true dignity of the physician’s office, showing the
wide scope which he should give to his investigations and to
his curative means, and the great value of those means
which are neglected, often with ruinous and sometimes fatal
effects, when the world’s idea, that the physician is the mere
doser of the body, rules in the sick-room. But, while I
have shown that drugs are really subordinate means of cure,
I have endeavored to guard very carefully against the danger
of discarding them whenever there is good ground for ex-
pecting curative results from their use. I have endeavored
to inculcate the nicest discrimination on this point, in oppo-
sition to the influence of a mere general vague idea, that
drugs are to be as little used as possible, which produces in
the minds of so many practitioners an indolent and undis-
criminating reliance on nature’s curative powers.
The improvements which I have noticed as having taken
place during the past quarter of a century afford us glimpses
RATIONAL THERAPEUTICS. 217
of the future of our art which are indeed bright with pro-
mise ; for they were accomplished under great difficulties,
such as would of course attend the beginning of a new
movement. And when these shall be to a considerable ex-
tent removed; when the profession, as a whole, shall adopt
right principles in the administration of remedies and in the
observation of their effects; and when a general rational
attention to public and private hygiene shall both greatly
lessen the amount of disease, and render it more simple in its
character, — therapeutics must be placed upon a basis, of
which its present condition affords us no adequate conception.
That the change will be a great one, we know ; but we have
no means of estimating its amount, or of giving any thing
but faint indications of its character.
If the principles which I have developed in this Essay be
correct, the field of investigation offered by therapeutics is a
more inviting one than has commonly been supposed. The
achievements that may be realized here may even vie with
those brilliant results which have of late attended researches
in diagnosis and pathological anatomy. Our art, it is true,
will never cease to be a conjectural one; but it may be re-
deemed from the unnecessary confusion and uncertainty
which false principles of observation have brought upon it,
and be made vastly more definite in its aims than it is at
present. To attain this, severe and patient labor will be
required. Careful observations must be extensively col-
lected by the profession, after the plan which I have indi-
cated; and they must be investigated in the most searching
Iſla III.16]". s ~
This is the great work which is now demanded of the
profession. The time has fully come for it to be done.
The preparatory steps have been taken ; the many changes
that have occurred in medical practice during the past cen-
tury or more have been manifestly preparing for it. Results
have been accumulating which will favor its prosecution ;
and the recent improvements and discoveries in diagnosis
218 R. ATIONAL THERAPEUTICS.
furnish a fitting basis for the full inauguration of this work.
To such a work as this, the eminently practical character of
the American mind is particularly suited. The French excel
us in the researches of pathological anatomy, and perhaps in
diagnosis; the English surpass us in the literature of medi-
cine : but, in therapeutics, we are superior to both, espe-
cially to the French. In the grand movement which I have
described as going on in practical medicine, the American
school (if we can say, that, in our new and forming state, we
have a school) has been thus far in the advance, whether
we regard the general movement itself, or the particular im-
provements which have contributed to it. Tet us, then,
enter heartily upon this work, and do what we can to rid
our art of its encumbrances and defects, and introduce fully
the reign of a truly RATIONAL THERAPEUTICs.
#lassachusetts #1 epital $0 tittg.
SESSION OF 1867.
No. 5.
THE CONTAG I O U S N Ess
OF
CHOLERA,
**-ºs-tºmºsº
By HENRY G. C.L.A. R. K., M. D.,
OF BOSTON,
Read before the Society, June 4, 1867.
THE CONTAGIOUSNESS OF CHOLERA.
MR. PRESIDENT AND GENTLEMEN,--I purpose to consider to-day, as
well as I can in the brief space I feel at liberty to occupy, the
subject of the Contagiousness of Cholera. It is almost unnecessary
to say in this presence, that the doctrine of the contagiousness of
cholera has, of late, found a very considerable number of adherents.
(some of them ardent and able), and that the examples, or the argu-
ments, of these enthusiastic, but as some of us believe mistaken advo-
cates, have been sufficiently influential to give to it such a degree of
credit or currency that, to a certain extent, it may be said to have
become fashionable. It has, at the same time, been, quite distinctly
announced, by some of the advocates of this novel and hurtful doc-
trine of contagion, that all those who, in the absence of what they
deemed to be good and sufficient evidence of its truth, declined to give
it their adhesion and adopt it as their profession of faith, had fallen
behind the progressive and scientific spirit of the age; and that,
standing as they were on the quicksands of a blind unbelief, they,
and their antiquated theories, must soon be swept away by the ad-
vancing tides of a more enlightened literature.
Among these unbelievers, after having, as I think, carefully taken
such observations as have enabled me to estimate “the situation,”
and its difficulties and perils as well as its inherent solidity and
strength, I must confess that I am, for one, quite content to stand.
I do not, of course, on this occasion, intend at all to enter upon a
general discussion—for that is obviously impossible—but simply to
make such suggestions as I hope may induce those who are still in
doubt on so important a subject to examine for themselves the abun- *
dant evidence relating to it which is now accessible to the profes-
246 CONTAGIOUSNESS OF CHOLERA.
sion; and, if possible, to induce those who have adopted a belief which
very many of the best men in this and other countries, most tho-
roughly acquainted with cholera, believe to be an error, and founded
on insufficient reasoning and unproven premises, to revise their
opinions.
In order that there should be no misunderstanding in a case like
the present, it is only right that the terms used should be exactly
and clearly expressed. What, then, is “contagion’’’ It is defined
by one of our best lexicographers” as “the communication of disease
from one person to another by contact, direct or indirect; infection.”
Dunglison says that the terms “contagion and infection are gene-
rally deemed synonymous.” Such, however, I do not understand to be
the generally received opinion in the profession. Contagion is best
defined to be “that quality of disease by which it is capable of
being communicated from one person to another by actual contact, or
which may be caught by a near approach.” Infection is that quality
of disease by which it is capable of being transmitted, by fomites,
or by means of clothing, rags, wool, &c., to long distances from the
bodies of the sick, and which poisonous influences may be retained
in them for a very considerable length of time. In contagion, the
presence of the person is necessary, while in infection it is not.
Some contagious diseases, such as Smallpox, are also infectious ;
others, such as parotitis and pertussis, are not. But infectious dis-
eases, on the other hand, are not always contagious; yellow fever
being a notable example.
The earlier advocates of the contagious properties of cholera did
not hesitate honestly to use the word itself in the sense in which it
is here explained, adding sometimes, also, a credence in its infectious
qualities; but this plainness of speech, for some reason, has more
recently fallen into disuse, and the more flexible words “communi-
cable '' and “communicability " are its substitutes. These were
more generally applicable, and less easily brought within the well-
defined limits assigned to the words “contagion,” “ contagiousness,”
“infection,” &c., and may be made to convey, as might be conveni-
ent, a great variety of meanings; thus, for instance, an epidemic
* Webster, 4to, loc, cit,
CONTAGIOUSNESS OF CHOLERA. 24.7
which prevailed successively in various places on great routes of
travel, was said to have been “communicated,” notwithstanding the
fact that it often happened that the densely populated villages radi-
ating from infected cities, and even intermediate cities, frequently
escaped. By some, the disease was said to be communicable through
the respiration ; by others, through the digestive organs, and each ex-
perimenter—for many experiments were made by injecting the veins,
the air-passages, and the stomachs of dogs by fluids from patients
affected with cholera—proving his own theories, and, at the same
time, effectually disproving the opposite theories of his rivals.
But, in the face of the astounding fact related of “Dr. Foy and
ten others, at Warsaw, who inoculated themselves with the blood of
cholera patients, tasted their dejections, and inhaled their breath,
Without receiving the disease,” we may safely say that the experi-
ments of Drs. Snow and Pettenkofer only prove, what everybody
knew before, that drinking of dirty water and breathing of a foul
air would be the most likely means to produce cholera, in a choleraic
Season, in those who wore thus exposed.
The most remarkable position, however, now taken with pretty
general unanimity is, that in whatever mode the materies morbi
finds its way into the body, the most efficient cause is found in the
choleraic dejections themselves. On this they are agreed; but they
Say, when confronted with all the facts which abound everywhere, of
Constant and continuous exposure, and especially with such as that
related of Dr. Foy, “that the dejections themselves are not poison-
ous until they have become by time and exposure partially decomposed” "
One would imagine—if all these disagreeable conditions must be
complied with in order that cholera should be communicated, and
when coupled with the other aphorism (which some have promulga-
ted) that “no new cases originate unless from Some other case "—
it would spontaneously die out and disappear ! But such facts
fade into insignificance when we consider, as well stated by a
distinguished surgeon of the East India Company, “1, That the
great numbers attacked simultaneously, and who had previously had
no intercourse with the sick, cannot be accounted for except by sup-
posing the disease to be simply epidemic ; and, 2, The general ex-
248 CONTAGIOUSNESS OF CHOLERA,
emption from the disease of medical and other attendants on cholera
cases.”
In the opinion that Asiatic cholera is non-contagious we have the
almost unanimous concurrence of the East India surgeons, who al-
ways see it. We have also the often deliberately expressed judg-
ment of the General Board of Health of Great Britain. In this
connection, the resolution passed by the Westminster Medical So-
ciety (a most competent body) is worth quoting. Dr. Granville
moving, and Dr. James Johnson Seconding the resolution, it was,
after the preamble stating the time, &c., devoted to the considera-
tion of the subject, passed in the following words:—“In the opinion
of the Society, the evidence brought forward to prove the said mala-
dy to be a contagious disease has signally ſailed; and that every
circumstance which has come to the knowledge of the Society shows
the disease to have begun, progressed, and ended in the Ordinary
way of every epidemic disorder.”
This opinion is confirmed and repeated by the experience of the
epidemic of 1854. Dr. Sutherland, one of the Board, says:–“I
look upon the evidence of the non-contagious character of cholera to be
perfectly conclusive.”
The physicians at Moscow and St. Petersburgh generally subscribe
to the same opinion. Of that of the Consulting Physicians of this
city I need not speak, as it is well known.
Dr. Jacob Bigelow, for many years one of the Consulting Board,
and whose opinion will, I know, have with you the great weight
which should be accorded to the wisest of us all, writes as follows,
and the extract contains within itself a whole volume of wisdom:—
“No country, I believe, has succeeded in keeping out cholera by
quarantine, and no country, as far as we know, can produce it artifi-
cially, or retain it after the predisposition has disappeared. In its
own time it moves on thoroughfares where men are travelling, and
spreads in cities where they are stationary, for no better reason known
than that mankind are its necessary food, and that where there are
no people there can be no cholera. But why of two frequented
roads or cities it selects one and avoids the other, investigators have
not yet been able to satisſy us.”
CONTAGIOUSNESS OF CHOLERA. 249
In the uncontradicted statements that cases of cholera have occa-
sionally occurred at the South all winter—in its late fatal loiterings
here the last season—in the Simultaneous announcements to-day of
cases on the Mississippi, in London, and at Paris, we may see the
foreshadowing of the pestilence, which, at these distant outposts of
observation, gives us the necessary timely warning. It seems to be,
then, peculiarly appropriate that we should now turn our attention
to this doctrine, because a belief in the doctrine of contagion will
do much towards retrograding us to the obsolete systems of
quarantine.
When the members of the medical profession, as a body, and with
them most heartily many non-medical sanitarians, have been making
the most strenuous and energetic efforts to mitigate the costliness
and hardships of quarantine, this unnecessary recurrence to the idea
of contagion of course goes far to encourage the restoration of
an evil we have all along been so anxiously striving to be rid of;
and to prevent us from reducing it to the milder forms in which
it would only be likely to exist under the requirements of modern
sanitary law.
By whom has this retrograde movement been inaugurated and pro-
moted 7 As in all the former history of Sanitary Cordons, and of
rigid and useless quarantines, in times past; very much by the preju-
dices of non-professional functionaries—who, only taking counsel of
their fears, or, perhaps, misled by their interests, have used official
power ignorantly or mischievously.
Consular agents and secretaries of State, as Such, know nothing of
sanitary laws; and they take unwarrantable liberties in professional
matters when they undertake to advise for or against quarantines.
To conclude, in the words of the distinguished East India. Sur-
geon whom I have already quoted, “It is by both houses conceded
that if cholera is contagious, the most rigid quarantines that Sagacity
and experience can devise, and firmness enforce, are imperatively
demanded for the protection of populations; and, that if, on the other
hand, it is not contagious, such quarantines are not only useless but
infinitely pernicious, by their tendency to plunge' in extreme misery
the hundreds of families and thousands of individuals who are de-
250 CONTAGIOUSNESS OF CHOLERA.
pendent upon the commerce they suddenly blockade, and the labor
they suddenly discharge; and so to encourage those conditions which
most potently invite the disease, while, at the same time, they fright-
en off the humaner agencies which alone can prevent, conquer, or miti-
gate it; therefore, we prefer to take this question sharply by the
throat, and to declare our positive conclusion, deliberately reached,
through careful examination and comparison of all the evidence
brought forward on both sides, as well as from unusual opportuni-
ties in the very laboratories and hot-beds of this atmospheric poison,
that not a single case—well attested, and clearly, completely demon-
strated—of cholera transmitted by contact alone with the person,
clothing, eaccretions or effluvia of another case, has ever yet been cited ;
and this we say in the full knowledge of all the quasi ‘facts and
proofs' elaborated by the glorious minority of contagionists, whose
doctrine manifestly tends, first, to make victims, and then, to leave
them prostrate and unbefriended—for panic nurses cholera, and THE
DOCTRINE OF CONTAGION PATRONIZES PANIC.”
M O DE R N S U B. G E R Y .
By R. M. HODGES, M.D.
OF BOSTON,
IR E A D J UN E 2, 1868.
33
MODERN SURGERY.
THE celebrated Traité des Maladies Chirurgicales of
Boyer was published in 1814, and the eminent author wrote
at the beginning of his preface, that “Surgery appeared to
have reached, or very nearly so, the highest perfection of
which it seemed capable.”
Fifty years and upward have elapsed since then; yet who
would now dare to assert himself qualified to compose a
perfect and faithful history of Surgery, to delineate with
truth and impartiality the present state of that science;
borrowing from all the centres whence its doctrines are
diffused, in all the countries where it is successfully culti-
Wated ?
Modern Surgical pathology embraces a range of study
beyond any one man's comprehension. Limited but by the
means and method of observation, it obliges the most stu-
dious investigation of details and expects the broadest
philosophic generalization.
In reviewing the actual state of surgical knowledge, it
will be found that its great advancement in our generation
is due to the unlooked-for extension, in these latter years, of
the Sciences to which Pathology naturally turns for assistance.
It is this which has given it a progressive tendency and
stamped its existing condition with at least three character-
istics. These are—1st, Precision of Observation; 2d, Per-
fection of Diagnosis; 3d, Simplification of Treatment and
reluctant resort to Operation.
254 MODERN SURGERY.
Precision of Observation as applied to the methodical
study of Surgical cases and the results of operations, consti-
tutes almost a science in itself. Conducted or facilitated
by the aid of more and more perfect instrumentalities, the
perceptive faculties are distorted by fewer preconceived
ideas; the mind, educated to exactness, discountenances what
is merely traditionary, and rejects that form of argumenta-
tion either in thinking or speaking, which takes for granted
what ought to be proved.
Surgery is not an exact Science. As regards no one
point, therefore, can the need of examination cease, or its
frequent repetition be carried too far. The observation of a
single individual cannot be compared to the experience of
many, and the study of current surgical literature is the only
means by which this experience can be assimilated. A.
knowledge of disease resting on description alone is, however,
of little avail, unless researches already made are con-
firmed afresh by renewed and reiterated investigation;
by the analysis of facts in large numbers a nearer approxi-
mation to truth and better practical conclusions are made
possible. It is more and more a feature of modern Surgical
authorship that its statements are not gathered from Scat-
tered sources, but are the fruit of individual observation.
It is the aim of this observation to see phenomena as they
really are; to analyze these phenomena, compare and classify
them, and from these data to build a theory or reason for
their existence; and so to comprehend the etiology and
control the development of disease, as well as to foresee and
arrest complications which the most skilled hands and in-
genious devices have hitherto been powerless to prevent.
For instance, the ideas prevailing with regard to septae-
mic poisoning and the pathological views emanating there-
from, owe their existence to repeated observation, by
methods increasing in precision, of the consequences which
MODERN SURGERY. 255
follow alterations in the normal condition of the natural
fluids of the body, alterations to a great extent produced by
external causes, more or less amenable to control. The
study of Hygiene is largely occupied with these researches.
They engage the attention of surgeons of our own day more
than any one subject, and have tended in a degree not Suf.
ficiently realized, to modify the aspect of modern surgery.
The practical conclusions arrived at by such observa-
tion have taught us that an injudicious diet, or mode of
dressing wounds, is as pernicious in its influence on the
blood or the secretions as a vitiated atmosphere; that the
fear of traumatic fever need no longer proscribe animal
food or alcohol to the subjects of wounds or operations;
that it is for the interest of the patient as well as to the
advantage of the surgeon, that dressings should be reduced
to their simplest proportions. Indeed, the disuse of cerates
and ointments, of fenestrated lint and charpie with its fan-
tastic shapes, of bandaging and plasters, together with
Setons, issues and the lancet, has robbed minor surgery of
its attractions, and simplified it almost out of date.
Between the two periods of 1836 to 1841, and of 1850
to 1861, the mortality of amputations in the Paris Hospitals
diminished twenty (20) per cent.; though no single cause
can be alleged in explanation, every one recognizes that the
lives thus saved are a consequence of improved Hospital
administration. The unequalled success of Surgery in Our
recent war was confessedly due to the enlightened judgment
which demanded the hygienic surroundings and attention to
executive detail that so generally prevailed in army hospitals
wherever established.
The anxiety to diminish opportunities for the entrance
into the economy of poisonous emanations which distinguishes
Surgical treatment at the present day, has gone So far as to
encourage attempts to supplant cutting instruments by the,
256 MODERN SURGERY.
at least, doubtful expedients of the écraseur and the terrible
osteoclaste, and by the pernicious use of caustics or other
agents which exercise a coagulating influence on the Organic
tissues and fluids. On similar theoretical grounds, acupres-
sure, instead of the ligature of arteries, drainage tubes to
evacuate cavities containing purulent matter, and carbolic
acid as a dressing competent not merely to disinfect wounds
but in fact to avert inflammation, have beenlargely tested by
experiment. Although the merit of neither of these latter
methods has yet been determined, or if determined has
received an unfavorable verdict, the direction of thought
which these suggestions indicate attracts the attention of
surgeons. The restlessness which such endeavors betray,
while it disturbs conservative equanimity, is evidence of a
watchful, though not always judicious activity to promote
safer and surer methods of Surgical treatment.
Perfection of Diagnosis, the second of the three characteris-
tics I have mentioned, is an important aim of modern Sur-
gical inquiry.
Anaesthesia, chemistry, physics, with the microscope, op-
tics, and electricity, experimental physiology, statistical and
historical research, criticism in learned societies, have each
in turn contributed to this end. The basis of all diagnosis,
however, is founded upon exact anatomical knowledge, of
healthy as well as morbid structures.
The habit of comparing what we observe in living
patients and can see in the dead subject, has long per-
mitted Surgeons to recognize the mechanical and physical
influences upon surgical disease which spring from the struc-
tural arrangement of the human body, from the relationship,
density, resistance, permeability and elasticity of the tissues.
Twice Velpeau diagnosticated a peri-anal abscess as having
its starting point at the base of the skull, between the
MODERN SURGERY. 257
pharynx and the articulation of the atlas with the occipital
bone. The route of urinary and purulent infiltrations may
be anticipated by less skilled diagnosticians.
If the limit to which anatomical investigation by the
Scalpel can be carried has been reached, that attainable by
the microscope is far from being approximated. Indeed,
topographical anatomy, less than fifty years old, has lost its
distinctive character; the requisitions of modern surgery
demand, as Something more than a mere accomplishment,
knowledge, not of a few regions or triangles, but of the
whole body even to its elemental structure; and Virchow has
already shown that the fundamental elements control and
modify the characteristic growth and material individuali-
ties of a tumor, in a manner not less than the constituent
parts in the midst of which it is developed influence the
form and contour of the whole mass.
But mere diagnosis of the existing ailment, however pre-
cise, does not satisfy the demands of an observation stimu-
lated by existing means of exploration.
In all our clinical studies there prevails the constant effort
to make out an individual and specific cause for every diag-
nosticated disease. Though this aim is imperfectly realized,
negative results, not without value, have been frequently
reached.
We have learned within the last few years that pyamia,
erysipelas and malignant pustule are something more than
simple inflammations. Certain paralyses and neuralgias are
now known to be excited through reflex action, by lesions
remote from the great nervous centres. Newly recognized
and peculiar features stamp the increasing number of
sequelae which syphilis is found to occasion, as, for example,
the syphilitic teeth and cornea described by Mr. Hutchinson,
and the evidences of this disease in internal organs indicated
by Mr. Wilks, Experimental physiology shows us that the
\
258 MODERN SURGERY.
varying symptoms of different poisons are due to the fact
that toxic influences are probably confined to a single tissue;
that woorara affects the nerves of motion alone, and that
crotaline affects only the blood. Chemistry points out the
relations of diabetes to cataract, carbuncle and gangrene,
and of albuminuria to retinitis. These are but hints of what
may be expected from perfected etiological diagnosis as ap-
plied to a multitude of Surgical diseases.
Rigid clinical observation and exactness in diagnosis dis-
play their beneficial influence in the Simplification of Treat-
ment and the reluctant resort to Operation. This constitutes
the third and last characteristic of modern surgery which I
enumerated at the outset.
It is more and more apparent that the benign or malig-
nant character of new growths, and consequently the pro-
priety or impropriety of removal, is to be determined from
their clinical rather than their anatomical peculiarities. Tu-
mors, therefore, once operated on, certain glandular hypertro-
phies of the breast, for example, are often left to themselves
in the confidence that they are self-limited affections. Others
due to scrofulous or syphilitic disease are made to disappear
by medical aid alone. Electrolysis, judging from what it is
claimed to have accomplished, may prove an efficient agent
for the destruction of certain hyperplastic growths.
An exact appreciation of the bone producing power of the
periosteum has in various ways, especially in operations for
necrosis and excision, enabled results to be obtained with a
minimum of mutilation which but a few years ago were
hardly looked for. The theoretical inferences of Ollier and
the facts asserted by Sédillot, may be exaggerated, but the
practical value of their researches cannot be over-estimated.
Witness the results obtained in the reparation of ununited
fracture by the method of Dr. Bigelow, an operation owing
MODERN SURGERY. 259
its almost unfailing success to investigations characteristic
of modern surgery.
The partial abandonment of the operation of Lithotomy
affords an instance of the readiness with which surgeons
avoid the effusion of blood. Lithotrity was introduced just
as Dupuytren was adding fresh eclat to lithotomy by his
bi-lateral method, but it met with no repelling reception, and
now stands as the exponent of all that is gentle, precise
and bloodless in Surgical manipulation.
The modern treatment of aneurism by compression or
forced flexion affords another illustration. No one point of
operative surgery had reached greater perfection in its details
than the ligature of arteries. No operation was thought to
better display the skill of the operator or excited to greater
expectations the critical spectators of the amphitheatre, yet
it has readily given place to a method of cure which has no
witnesses but the Surgeon and his patient.
The preservation of limbs is attempted where once their
amputation was thought to be inevitable. Plus je veillis,
'moins j'ampute—the older I grow, the less I amputate—said
Welpeau. Between 1847 and 1853, Hutin, Surgeon of the
Hôpital des Invalides, had under his observation sixty-three
old soldiers who had recovered from gunshot fractures of the
femur, but only twenty-one who had survived amputation of
the thigh. Nowhere, however, is this preservative disposi-
tion illustrated on such a scale of success as by the records
of gunshot fractures of the femur, treated by our own sur-
geons during the late rebellion.
The treatment by compression, extension, and immobility,
the substitution of dextrine or starch for cumbersome splints,
have so revolutionized the treatment of diseased joints, that
even excision as a substitute for amputation is decreasing in
frequency of performance.
Reduction of dislocation of the hip by ether and manipula-
34 j
260 MODERN SURGERY.
tion alone, instead of bleeding, tartar emetic and the pulleys,
has been revived with success, only because the principles
on which this simplified practice is founded have been made
plain and precise by modern investigation. The anatomical
points connected with this operation it is well remembered
were admirably elucidated before this Society at its Annual
Meeting in 1865.
The limited application of the trephine at the present day
in fractures of the skull, its use being almost proscribed by
French Surgeons, is in great contrast to the frequent resort
to its aid which prevailed within the recollection of surgeons
still active. Fractures are treated almost without the aid
of apparatus. Chopart's and Pirogoff's amputations, Syme's
operation for stricture, the tying and cutting of varicose
veins, are less and less frequently performed. The illusions
and exaggerations of tenotomy and other subcutaneous sec-
tions, if not in club-foot and staphyloraphy, at least as ap-
plied to the cure of flexed fingers, of stammering and of dis-
torted spines, are looked upon as curiosities of the past, and
yet within the memory of most surgeons these very opera-
tions, from their ingenuity and originality, were deemed in-
dications of the advancement of surgical science.
The disposition to limit the merely mechanical part of
surgery is an increasing one. Though the art of performing
Operations is not likely to cease pre-occupying the minds of
Surgeons, it has evidently lost the préminence which charac-
terized it at the beginning of the present century.
To dethrone the bistoury when surgeons are daily multi-
plying, may seem like inconsistency, but the aspirants of sur-
gical Science no longer find, by the exercise of inventive skill
in the multiplication of manoeuvres, the realization of their
ambition. Ingenious devices are not looked upon as neces-
Sarily improvements, and still less are they deemed disco-
ë
MODERN SURGERY. 261
veries. The scrutiny which operations undergo prior to their
performance does not spring from deference to a public
prejudice which attributes to surgeons an over-anxiety to per-
form them, nor is it due to a sentimental idea that the knife
should be the resource only when everything else has been
tried. Surgery was never bolder than it is now, but its
boldness has no affinity with constitutional coolness, or cold-
blooded audacity; these constitute the traits of a surgeon
who makes operative surgery the chief reliance of his sys-
tem of therapeutics, and who only looks at possibility of per-
formance before undertaking his operations.
True boldness rests on accuracy of diagnosis, which,
based upon a scientific pathology, tells beforehand the or-
ganic condition of parts diseased, teaches how to favor and
facilitate the processes by which nature effects her cures;
Whether danger may be advantageously incurred, and when
neither a steady hand nor adroit manipulation can interrupt
or arrest the inevitable progress of disease.
The genuine surgeon does not operate merely because
there is nothing else to do, nor hesitate to declare the power-
lessness of his skill, rather than compromise the good repute
of his calling. In his eyes Surgery is no longer a mechani-
cal art, northe operator an artist more or less adroit. Ope-
rative dexterity is to him but a secondary acquirement, and
its possession far from marking the great difference in Surgi-
cal reputations, Velpeau shone above others not by his
talent as an operator, which was in no way remarkable, but
by the penetration of his diagnosis and the far-Seeing wis-
dom of his decisions.
If at one time all advancement seemed to come from
across the Atlantic, it can no longer be said that the United
States, New England, or even Massachusetts, are not contri-
buting their full share of improvement in the comprehensive
262 MODERN SURGERY.
studies involved in the principles of Surgery, and their prac-
tical application. The present high standing of the Medical
Profession in this community, largely due to the influences of
your own Organization, and the yearly increasing opportu-
nities which facilitate the acquirement of a medical education,
can Scarcely fail to maintain that progressive professional
advancement, some of the features of which I have attempted
imperfectly to trace.
SOME IMPROVEMENTS IN MIDWIFERY.
By G. W. GARLAND, M.D.
OF LAWRENCE,
R E A D J U NE 2, 1868.
SOME IMPROVEMENTS IN MIDWIFERY.
THE older members of this Society have marked with in-
terest the advancement which has been made from time to
time, during the last thirty years, in many of the departments
of our profession:—in the methods of teaching, in physiology,
pathology, and therapeutics, and in the treatment of many
diseases; in the improvement in Surgical instruments, and
Operations in certain cases.
But it will be admitted, that while in these departments of
medicine much of probability and surmise, much of circum-
locution and complexity, has been removed, the study of Ob-
stetrics is still overloaded with details, and the art with des-
criptions of operations and manoeuvres some of which never
need be performed. And it may not be regarded by this
learned body as presuming, if I ask if this science cannot be
freed from certain trammels which oppose its perfection.
However carefully authors and teachers may point out
minute particulars relating to obstetrics, there are certain
demonstrations needed for which language is inadequate.
Theory leaves our ideas very imperfect—practical knowledge
cannot be acquired from books in any department of medicine,
more especially in obstetrics, where the sense of touch is so
nearly the only guide.
By attending women in labor, the physician acquires bold-
ness, quickness, and experience, which render him able to
operate skilfully in difficult cases; and the practitioners be-
fore me will acknowledge individually that many of the
266 IMPROVEMENTS IN MIDWIFERY.
manoeuvres they adopt in the practice of obstetrics were
suggested to their own minds, not from books, but by cases
which occurred in their practice. , And, gentlemen, the
modifications in the practice of obstetrics which I am about
to present to you, were first suggested to my mind by the
mother of inventions, necessity.
During the first fifteen years of my practice I followed the
books in “turning,” using the right or left hand as the case
or presentation required. My left arm having become dis-
abled by rheumatism, and being called to turn in a case re-
quiring the left hand, I made an attempt to turn with the
right hand. Meeting with difficulty, it occurred to me, while
my hand was in the womb, to rotate the child on its long
axis; accordingly I spread my hand out upon the body of
the child, and during the absence of pain I changed the po-
sition, and turned with ease.
For the last fifteen years, in many of the malpresentations
I have been called to adjust or treat, instead of adopting the
manoeuvre to the presentation, I have placed the child by
Totating in a position to improve, if need be, the presentation,
and to suit my own convenience.
In So doing, I have made, in my judgment, several improve-
ments and discoveries which may not be wholly new to you,
yet were original with myself, and some of which are not re-
ferred to in any of the works which I have read.
It is a settled principle with me, that in order to easily
effect version by the feet, in cases demanding that manoeuvre,
such as delayed malpresentations, placenta praevia, &c., the
hand should be introduced into the womb posteriorly to the
presenting part, and passed along the posterior wall of the
uterus in search of the feet, and the child should be so placed
by rotating, that the feet, foot, or knee can be brought down
along the posterior wall of the womb, for the evident reason
that the abdominal muscles yield, and offer less, much less
IMPROVEMENTS IN MIDWIFERY. 26'ſ
obstruction, than the spine of the mother, to the version of
the child.
When the hand is passed posteriorly to the presenting
part, whether it be the head or shoulder, it is easy to see
that the part will be raised upward, and thrown forward,
enough to give place for the hand, which will relieve its con-
tact with the Superior strait of the pelvis; while if the hand
is passed anteriorly to the presenting part, this does not
readily give place for the hand, as it is opposed by the lum-
bar vertebrae.
Besides this, if the hand is introduced anteriorly to the
presenting part of the child, in bringing down the feet the
pubic arch becomes an unavoidable fulcrum, over which the
arm is compelled to act at a mechanical disadvantage, while
the perinaeum resists the end of the lever to which the power
is applied. It will be remembered, also, that when the
head of the child is posterior to the hand and arm of the
operator, in the first attempt to ascend, it is thrown forward by
the anterior curve of the lumbar vertebræ, in many instances
absolutely preventing version when the hand and arm of the
accoucheur is large, while no such inconvenience will be met
when the hand and arm are posterior.
A moment's reflection will convince any one that rotating
preparatory to turning is advisable in many cases of shoulder
presentation.
In arm and shoulder presentations the rotation should be
made backward, from right to left, or from left- to right, as
the case may require. When the right arm presents, if the
child be rotated from right to left backward, the presenting
arm must of necessity return above the Superior strait of the
pelvis and into the uterus. When the left hand presents,
the child should be rotated from left to right backward, when
the presenting part will also return.
* 35
268 IMPROVEMENTS IN MIDWIFERY.
It will be seen that my practice differs from that recom-
mended by Dr. Simpson, not only in the object of rotating,
but in the manner. *
But, Fellows, great as is the advantage of rotating before
turning in many arm presentations, it is of minor importance
when compared with the superiority of this manoeuvre in all
cases where version by the vertex can be produced, and
delivery effected without turning. This, in my judgment, in-
cludes all malpresentations, such as the forehead, face, chin,
posterior parts of the head, neck, shoulders, back, belly, and
funis.
Rotation and version by the vertex are preferable to turn-
ing in all these malpresentations of the superior parts of the
child, because it is much more easily effected, with less suf.
fering to the mother, and with greater safety to both mother
and child. This is self-evident. In version by the feet, the
head and breech are compelled, per force, to pass each other
in the evolution, subjecting the womb to a distention at a
given point, sufficient to receive two of the largest transverse
diameters of the child, the head and breech; while in rotat-
ing, the womb is but little changed in its form. When the
uterus by its contractions has clasped itself around the body
of the foetus, we should strive to make as little change as
possible in the figure and form of the child.
Version by the vertex can be accomplished after rotating
in all malpresentations, if we except some of the deviated
presentations of the pelvic extremity, as I shall soon attempt
to show.
But, first, what is the best, or most favorable position of
the child in utero, when labor commences? It is when
the vertex lies at the mouth of the uterus, with the chin rest-
ing against the Sternum, the knees flexed upon the abdomen,
the tip of the shoulders on a line with the ears, with arms
resting on the chest. In this position, each contraction of
IMPROVEMENTS IN MIDWIFERY. 269
the womb tends to expel the child, as an attempt to seize the
slimy, tapering eel will illustrate. The harder the fish is
grasped, the greater will be the force with which it escapes
from the hand. In this position the child is conical, taper-
ing like a sugar loaf toward the breech.
In all malpresentations, then, the child should be placed,
if possible, in this the most favorable position, in order to
secure safety to the child and a natural labor and delivery
to the mother.
To explain my method of effecting changes in malpresen-
tations is the object of my remarks. But for me to attempt
at this time to refer to the various malpresentations, and to
give the manoeuvre for each particular case, would extend my
paper to an inconvenient length—I propose, therefore, to
call your attention to a few presentations and their treat-
ment, and leave the principles with you to approve or Con-
demn as your judgment may dictate.
Letºus, then, suppose a case: the second position of the
right shoulder, with protrusion of the arm. In this position
the pelvis of the foetus will be toward the left, and in the up-
per portion of the uterus, while the head is in the right iliac
fossa. Now if the mother has a roomy pelvis, and has had
previous confinements, this presentation need not give anxiety
to the practitioner, for the reason that version by the ſeet
will not necessarily compromise the Safety of the child.
But if it be a first confinement and the accoucheur meets
with difficulty in introducing the hand into the vagina and
womb—and if, after considering the diameter of the pelvis
carefully, he has fears that he may find it difficult to delivor
the head, rotating and version by the vertex should be at-
tempted, for the reason that, if successful, this will afford
greater security to the life of the child, and a natural labor
to the mother. If, after rotating has been effected, the head
cannot, from any cause, be rightly adjusted, the position of
270 IMPROVEMENTS IN MIDWIFERY.
the child will be so much more favorable for turning by the
feet, that the manoeuvre is most emphatically advised.
Before describing the manoeuvre, allow me to ask you to
consider, that when the hand is once in the womb, it becomes
a part and parcel of its contents, and that the hand is held
more or less firmly against the child by uterine action; and
it is worthy of note that this uterine force is at all times just
enough to obviate any necessity of grasping any part of the
child to effect rotation. The concavity of the hand fits the
convexity of the child's body. We see, then, that if the hand,
thus placed and held, is made to traverse the internal cer-
cumference of the womb, the body of the child must follow it,
while the head of the child will be rolled or turned over by
the wrist or arm of the operator.
All the authors I have read, advise the use of the right
hand in right shoulder presentations, and the left hand in left
shoulder presentations, while I recommend the reverse when
version by the vertex is the object. In the case just supposed,
the right shoulder presents and the arm protrudes. In this
case the left hand should be introduced into the vagina in
the usual way and passed along the back of the arm to the
shoulder, and over the shoulder till the heel of the hand, so
to speak, rests upon the neck and shoulders; the hand is then
to be spread out over the back of the child. During the
absence of pain, the child is made to rotate backward from
the right to the left of the mother and child. The right hand
can be used in this presentation, by rotating the hand in the
pelvis, after its introduction, so as to bring the palm of the
hand against the back of the child, and rotate as described
above.
Rotation having been effected, the head is to be adjusted
by bringing the hand down over the head, and seizing the
occiput in the palm, when the vertex can easily be brought
down, and the relative position of the head and shoulders,
chin and sternum accurately ascertained and Secured.
IMPROVEMENTS IN MIDWIFERY. 27]
The hand should then be withdrawn during or at the com-
mencement of a pain, so that the vertex may become fixed in
the superior strait of the pelvis. The case can then be left
to go on as in ordinary labor, and treated as a case of
primary vertex presentation. If from any cause the labor
fails to go forward, the forceps, ergot, &c., can be used with
more safety to the child, than what obtains in podalic version.
As you know, there are other shoulder presentations; but
as I apply the same principle to each one of them, it is un-
necessary to detain you by referring to them.
In all cases of presentation of the face, occiput, forehead,
&c., the hand should be introduced into the womb to effect
adjustment of the head. The reason why complete introduc-
tion of the hand into the uterus is preferable to allowing
the hand to remain in the vagina and pelvis, to effect
version by the vertex, as recommended by authors, is this—
When the hand is introduced so as to grasp the head, the po-
sition of the shoulders is ascertained, and after rotating, and
often without rotating, the head can be seized in the hand, and
placed in its natural relation to the shoulders, sternum, and
pelvic passage. But if we rotate the head with the hand in
the pelvis, we do so at the risk of producing a kink in an
already twisted neck. Besides, adjustment can be much more
speedily effected, with less suffering to the mother. All, or
most of us, have witnessed the tenesmus, and the reflex action
produced on the uterus, diaphragm and pelvic muscles by
the presence of the hand in the vagina. The pains are
greatly augmented by every motion of the hand, at a moment
when absence of the expulsive effort and uterine action are
desirable, while little effect is produced by the arm when the
hand has passed beyond the head.
Let us suppose, for the purpose of illustration, a presenta-
tion of the left side of the head, or neck, in the left occipito-
iliac position; the occiput inclining to the left iliac fossa,
272 IMPROVEMENTS IN MIDWIFERY.
while the face inclines to the right iliac fossa. What is to
be done in such a case ?
In this presentation, as well as all others of the head, it
is important that the position of the shoulders should be
ascertained; accordingly, the left hand should be passed
along the right iliac fossa, and right side of the child's neck,
to the breast, and spread out upon the chest. During the
absence of pain, the child should be made to rotate from left
to right, forward; at the same time pressure should be made
upward. As the child rolls over, it is easy to see that as
the face is carried over from right to left, by the wrist of the
operator, the vertex will naturally slide over the superior
strait of the pelvis. Before withdrawing the hand, the vertex
position can be fixed as already described.
Prolapsion of the umbilical cord is regarded by all authors
and practitioners as a very serious complication of labor;
not that the life of the mother is endangered, but it is ex-
tremely destructive to the child. Dr. Churchill's tables
show that in 722 cases of prolapsion of the funis, 375 were
lost, or more than one half. Any improvement, then, in the
treatment of a prolapsed funis should, to say the least, be
well received by the profession.
I beg leave to call your attention for a few moments to
the effect that rotation of the child in utero will have on a
prolapsed funis, wherever or whatever may be its position.
The circumference of the body of a foetus at the umbilicus,
at the close of the full period of gestation, is from ten to
fifteen inches, and the length of the cord is eighteen or twenty
inches, sometimes more. If the child, then, be turned com-
pletely round on its axis, so as to occupy the same position
it did before rotation was effected, ten to fifteen inches of
the cord will be reeled on to its body, requiring that much
of the prolapsed portion, provided the cord could be wound
about the body directly transverse to its long axis; but as
IMPROVEMENTS IN MIDWIFERY. 273
the cord must of necessity pass obliquely or diagonally,
much more of the cord will be required, and it will be found
that semi-rotation will be quite sufficient, except where the
cord is greatly elongated.
Prolapsion of the funis occurs more frequently in women
who have borne children than in primipara, the uterine walls
having, in the former, in some degree lost their tenacity.
This is favorable to rotating.
In many cases prolapsus occurs in connection with neck,
shoulder, back and abdominal presentations, the treatment
of which by rotation effectually disposes of the funis.
In prolapsion in head presentations, however, the case is
quite different, and the danger to the child much greater. It
is in cases where the prolapsed funis is the only complication,
that rotation is of such great importance and advantage.
What are the steps to be taken, then, when the vertex pre-
sents, with occiput to right, and face to the left of the ob-
lique diameter of the pelvis, with pulsating cord prolapsed
between the arms, over the left side of the neck, and back
of the left ear of the child, with its loop in the pelvis,
while the head is above the superior strait 2 The funis
should be brought to the left of the pubic arch, and held by
the right hand, while the left hand is introduced, and passed
up the right iliac fossa to the shoulders, and back of the
child; then the child should be made to rotate to the right
or left as the pulsations of the cord or other indications de-
mand. The rotation should be made from the placental
end of the cord, the impulse of the foetal heart being the
guide. As the cord recedes, the fingers of the right hand
should follow it till it disappears above the head.
When we realize the ſacility with which this manoeuvre
causes the funis to return into the uterus, we can Scarcely
restrain a smile when we picture the great Ramsbotham
dallying with a prolapsed funis on the end of a bit of
274. IMPROVEMENTS IN MIDWIFERY.
whale-bone; or Dr. Croft, with his hand in the womb, bear-
ing aloft an unwelcome funis, seeking some hook or crook
on which to hang it. The plan of Dr. Thomas, of New
York, is entitled to consideration, if it can be resorted to
before the membranes are ruptured. I have no doubt it is
an effectual method, but not often available.
As the foetal heart may continue to act after its impulse
ceases to be felt in the cord, it should be returned at once
by rotating, unless the accoucheur is assured that the prolap-
sion has existed for a considerable time.
I will call your attention, gentlemen, to one more pre-
sentation requiring manual assistance.
A physician is called to the lying-in room, and is in-
formed that the “waters broke ’’ several hours before his
visit. Contractions of the womb have commenced, and are
increasing. He makes a vaginal examination, and although
the os has scarcely begun to dilate, he finds a head presenta-
tion, and informs the patient and friends that “all is right"
and leaves for a few hours.
On his return he learns that the pains have increased in
vigor. Another examination is made, and the OS found to
be dilated to perhaps twice the size of a crown piece, with
a puffy portion of the scalp slightly protruding at every pain.
The patient is told she is getting on finely. The physician
feels it will not be safe (fee safe) for him to leãve again,
and he concludes to remain and watch the progress of the
case. Frequent examinations are made. Vigorous pains
continue, the os dilates slowly, and the head remains the
Same as at the beginning in its relations to the Superior
Strait.
In a few hours more, the patient becomes flushed in the
face; pulse accelerated; great thirst is complained of; there
is unusual heat in the vagina, and the Doctor is questioned
as to the cause of this delay and suffering. Unfortunately
IMPROVEMENTS IN MIDWIFERY. 275
the medical man in attendance does not comprehend the
difficulty, and the patient is told that “nature must have
time ’’; that she must make the most of her pains.
Time passes. Ergot is injudiciously given. Friends get
anxious; the patient's strength begins to fail. The efforts
of nature are unavailing. The head at length becomes
wedged in the superior strait. The friends and attendants
are no longer to be controlled, and a consultation is de-
manded. The long forceps or craniotomy is the alterna-
tive; either compromising the life of the patient under the
circumstances. If the mother and child are lost, the friends
console themselves that all was done that could have been
done.
Change the Scene, and suppose she has attending her a
physician who perceives, at once, the cause of the delay:
who sees that nature is not able to ſlex the head; that at
every pain the chin is forced from, instead of towards the
Sternum; that the head thereby has become an inclined
plane, and that half the expulsive force of each pain is
thrown transversely or obliquely to the perpendicular axis
of the pelvis. What does he do? He simply produces
flexion of the head, when the labor pains immediately be-
come effective, and the delivery of a living joy into the arms
of a fond mother is the result. Nothing is ever publicly
known of the case; but, gentlemen, there is a silent con-
Sciousness of power in the breast of that physician, worth
more than jewels.
How is flea-ion produced in such a case ? Authors tell us
to adjust the head with the hand in the vagina; while I
recommend that the hand be passed beyond the head, for
the reason that often one of the causes of nature's failure in
this case is a twisted neck. At the moment the waters
eScape, the shoulders may not be on a line with the ears, and
the uterus, contracting upon the body and head of the child
- 36
276 IMPROVEMENTS IN MIDWIFERY.
while thus situated, may hold them in this unnatural relation.
To adjust the position, then, the body may need to be slight-
ly rotated, and before the hand is withdrawn flexion of the
head can be effected much more easily and quickly, and with
less suffering to the mother, than with the hand in the
vagina.
Eor the purpose of version by the feet, in placenta praevia,
&c., authors tell us to introduce the hand into the uterus
without hesitation, but caution and recaution us not to resort
to such a formidable operation under any other circum-
stances. The reason for this, I do not understand.
- Many a practitioner will throw off his coat with a flourish,
and call with great assurance for a supply of oil when he
finds a foetal hand in the vagina, who will sleep in an ad-
joining room in perfect composure while his patient suffers,
for hours, untold agony, on account of some obliquity in the
presentation of the head, which nature is unable to correct,
because, forsooth, he has the books to pillow his head upon.
If he cannot diagnosticate the case, he can repeat “Meddle-
some midwifery,” “Nature must do her own work,” and other
shields to ignorance.
It is my firm conviction, Fellows, that when introduction
of the hand into the womb to ascertain the exact relations
and position of the child in difficult cases, and when rotat-
ing to effect adjustment, shall have come into favor and gen-
eral practice, podalic version will be rarely resorted to, and
the forceps will be used much less frequently than at the
present time.
I beg you will remember, gentlemen, that the remarks I
have just made were prepared to conform to the half hour
allowed me, and for the ears of practitioners, not students.
Hence the want of minor details as to the position of the
patient, the proper time for each manoeuvre, the successive
steps to be taken, &c. &c. I trust, however, I have pre-
IMPROVEMENTS IN MIDWIFERY. 277
#
Sented the leading facts sufficiently clear to give you a guide
to their principles, and that you may have confidence to test
them in your practice, so that they may be brought out to
the public by Some one, in a more elaborate form, and so
embellished as to find that favor with the profession at large
to which they are entitled.
ENUCLEATION OF THE EYEBALL.
By B. JOY JEFFRIES, M.D.
OPHTHALMIG SURGEON MASS. CHARITABLE EYE AND EAR INFIRMARY,
MEMBER OF THE AMERICAN OPTITHALMOLOGICAL SOCIETY.
R. E.A.D J UN E 2, 1868.
37
ENUCLEATION OF THE EYEBALL.
I HAVE found among my patients a perhaps natural horror
in reference to removal of the eyeball, no matter how use-
less this organ may have become as respects sight, and eyen
When it has been the seat of severe or lasting pain; and I
have also found my medical brethren, when bringing their
patients to the specialist, shrinking from advising them to
Submit to the removal of a sightless globe. There seems to
be a sort of vague sensation among the laity, and I have
found it also among physicians, that enucleation of the eye-
ball is a formidable and dangerous operation, only to be re-
Sorted to in malignant disease, and as a dernier resort. The
laity also do not distinguish between the comparatively
trifling operation of enucleation of the globe, and the, at
present, rarely necessary and more formidable one of evacua-
tion of the contents of the orbit. I propose, therefore, to
fully explain the anatomy of the operation, prove its simpli-
city and show its application, and thus, I trust, place before
the members of the Society some of the advances of my
Specialty, which may not have been brought. to their imme-
diate notice.
The foundation of surgery rests, of course, on pure anato-
my, and the instance before us is one of the many where
anatómical points have been forgotten and only recalled
When the requirements of surgery have brought them again
into notice. The capsule of the eyeball, which now bears
the name of Tenon, was known to the students of anatomy
282 ENUCLEATION OF THE EYEBALL.
hundreds of years ago. Galen knew it but imperfectly, for
he says (De usu part., cap. 2), “Sexta quaedam tunica ex-
trinsecus prope accedit, in duram tunicam inserta.” Reald.
Columbus, in his “De re Anatomica ’’ (Venet. 1559, lib. 10),
calls it tunica in nominata. The first correct anatomical
description, however, of this, to us ophthalmologists so im-
portant membrane, was given by Tenon, before the French
Institute in 1804, and the capsule is now known by his name.
Hyrtl" calls it tunica vaginalis bulbi. Richet,” aponeurosis
orbit; ocularis. Budge” and Arnold make some further Sub-
divisions of this fascia, not affecting, however, our present
operation. A most careful subdivision and description is
given by Henle.” I would refer also to Linhart,” Hélie”
and to Richet,” and of course to the various recent compen-
diums on ophthalmology, particularly Pilz.” Mr. Dalrymple,”
of London, described it in 1834 as the cellular capsule of
the eye. Malgaigne has the credit of first pointing out its
surgical importance; he considered it an aponeurosis, and
called it albuginea. In 1840 Mr. Lucas,” of London, and
in 1841 O'Ferrall,” in Dublin, and Bonnet,” of Lyons, re-
described this membrane, each independently of the other,
and therefore naturally individually considered themselves the
discoverer. This was one of those circumstances still too
often occurring, where anatomical and physiological truths
are claimed as novelties, without a previous thorough search
through medical literature, which would often prevent the
critic from the disagreeable necessity of showing that there
is in reality nothing new under the Sun.
I will here give, in order, a brief account from each of
these last three authorities mentioned, because their investi-
gations were made in special reference to the pathology and
treatment of affections of the eye, and lead directly to the
substitution of enucleation of the globe for extirpation of
the contents of the Orbit.
ENUCLEATION OF THE EYEBALL. 283
Mr. Lucas called Tenon's capsule the submuscular fascia,
and thus explains its demonstration:-" The eye and its
appendages, with half an inch of the optic nerve, should be
removed from the Orbit and placed upon a plate, the cornea
being downwards. The masses of fat, together with the
loose cellular tissue and bloodvessels, should be carefully
dissected away, and the muscles be turned forward towards
their insertions, not dissected as if with a view of exposing
their appearance, but merely expanded on the surface of the
plate. If the neurilemma of the optic nerve be now ex-
amined, it will be ſound covered with a fine ſascia, which
can be easily raised with the forceps, and with little difficulty
can be traced off the neurilemma to the sclerotic coat at
the point where the nerve enters. It will now be found to
cover the posterior aspect of the Sclerotica, and to advance
as far as the insertions of all the muscles of the eye; at
these points it turns upon itself, lines the ocular surfaces of
the muscles, and passes backwards along them to where
they surround the optic nerve. This fascia possesses a high
degree of elasticity, and forms rather a membranous sheath
for the Sclerotica than an expansion for the muscles; it
takes the form of the eyeball, and acts the part of a mem.
branous cup for the Organ to move in, separating it from the
bellies of the recti muscles, and covering the ciliary nerves
as they pass onwards to pierce the Sclerotica. In the dead
eye, more or less fluid will be found to exist between this
cup-like membrane and the eyeball, which always enables
the anatomist to separate one from the other with the great-
est facility.”
Dr. O'Ferrall has the merit of a pathological application
of the capsule. Mr. Haynes Walton” gives a print of his
own dissection, and a condensed account from O'Ferrall,
who says, “It is a distinct tunic of a yellowish white color
and fibrous consistence, continuous in front with the posterior.
284. ENUCLEATION OF THE EYEBALL.
margin of the tarsal cartilages, and extending backwards
to the bottom or apex of the orbit, where its consistence
becomes less marked; the sharp end of a probe or a
director will be sufficient to separate it from the eyeball, by
breaking the fine cellular tissue which connects them.
Within, where the eye glides over it, the surface is smooth,
the external or orbital part loose and cellular. The muscu-
lar portions of the recti muscles lie outside of this tunic,
which isolates and protects the eye in the most perfect
manner possible. Half an inch posterior to its anterior
margin are six well defined openings, through which the
tendons of the muscles pass to their insertions in the sclero-
tic coat, and over which they play as through a pulley.”
Bonnet, in his treatise on “Section of tendon and mus-
cles,” says, “When I meet with a case favorable to the ap-
plication I would thus proceed to enucleate the globe. Dis-
tending the lids with suitable instruments which I employ, I
would cut the internal rectus with the same precautions as
for the operation for strabismus. Then sliding the scissors
along the wound I have made, between the Sclerotic on one
side and the Subconjunctival fascia and muscles on the
other, I would cut in turn all the recti muscles near their
ocular insertion. We need then only divide the obliqui as
near as possible to the globe, and afterwards the optic
nerve. The globe will then be removed without my inter-
fering with any vessel or nerve, and without penetrating the
orbital fat.” By not touching vessel or nerve, of course he
means as in the old operation for extirpation of the contents
of the orbit.
Stöber,” of Strasbourg, first performed this operation in
1841.
Here I think it worth while to go back to Tenon's descrip-
tion, which, as it has been so often misquoted, I translate
from his own words:—
ENUCLEATION OF THE EYEBALL. 285
“A little behind the tendon of each of the recti muscles
around the eye, there is formed a tendinous fascia, which
proceeds from the fleshy fibres of each of the recti muscles and
the membranous sheath surrounding and penetrating them.
These tendinous fasciae separate from the tendinous muscles
which they arise from ; they are a continuation of the fleshy
fibres of the muscles, and spring from the membranous
sheath enveloping each of the muscles. The largest and
thickest belongs to the abductor muscle. It springs from the
external side of the muscle, and is attached to the external
angle of the orbit near the lower edge of the lachrymal gland.
It acts as a counter brace on the muscle, and prevents it
While contracting from pressing on the eye. The fascia of
the adductor (rectus internus) is shorter and not so thick as
that of the abductor (rectus externus). It commences at
the point of termination of the fleshy fibres, and is implant-
ed on the inner angle of the orbit at the edge of the nasal
Canal. It acts also as a counter brace. The tendinous
fascia of the elevator of the eye (rectus superior) forms an
aponeurotic band extending from one side of the orbit to
the other, to the depth of the upper lid. The tendinous
fascia of the depressor (rectus inferior) is lost in the lower
lid.” Tenon called it, “the new tunic of the eye.”
For the surgical purposes of our operation we may regard
it as a membranous sac on which the globe rolls, and which
is pierced by the tendons of the muscles, the cutting of which
tendons in front of the capsule at their insertion into the
globe will leave this membranous Sac as a basis or support for
an artificial eye, and the muscles being still attached to this
capsule will therefore move it and the glass eye lying on it
in nearly as great degree as when an artificial eye lies
against a stump of the globe left by disease or surgical
interference.
This so simple operation, recommended by Bonnet, is in
286 ENUCLEATION OF. THE EYEBALL.
such contrast to the former one, really to be dreaded, of ex-
tirpating the whole contents of the orbit, muscles, nerves,
fasciae, gland, &c., that it is a Wonder that ophthalmic Sur-
geons did not sooner practise it, but not more wonderful
than that even to this day, perhaps, unfortunate patients
are undergoing extirpation of their orbital contents, much
as certain bivalves are their contents, and with not very dis-
similar instruments.
I would dwell upon this, because one of the purposes of
this paper, as I have Said, is to prove to you how simple and
little to be dreaded this present operation is, and that it has
no relation with extirpation of the orbital contents, an
operation only applicable to certain tumors in the orbit.
The method of operating for enucleation of the globe,
taught me by Prof. Arlt, in Vienna, is the following:—
Dilating the lids with a speculum and holding in one hand
a pair of toothed forceps and in the other a small pair of
curved scissors, the tendinous insertion of the rectus inter-
nus muscle on the globe is seized and cut through. Retain-
ing the grasp with the forceps the conjunctiva is cut around
the cornea, and the tendons of the other three recti divided at
their insertion. The Scissors are now passed in behind and
the optic nerve severed close to the globe, which will then
start forward, and we have only to cut the tendons of the
two obliqui muscles to free the eye from the orbit and leave.
intact the capsule of Tenon with the muscles attached to it.”
This operation I have done, and it is comparatively easy,
when inflammation has not bound down the conjunctiva or
fastened the globe to the capsule, but under anaesthetics, at
least, I would advise the following:—Raise with forceps a
piece of conjunctiva near the corneal edge, pass in the
curved scissors and separate the conjunctiva all round the
cornea. With strabismus hook lift up and cut all four recti
tendons as carefully as in operating for squint. Steady the
ENUCLEATION OF THE EYEBALL. 287
globe with fingers and thumb, and pass a large pair of curved
Scissors behind it and divide the optic nerve, which releases
the globe from the orbit, and then we can sever the obliqui
attachments. There will be but little bleeding. A piece of
ice in the orbit is all that is required, and filling the latter
with Sponge or charpie and applying pressure is not only
absolutely useless, but apt to be painful. A glass eye may
be inserted, often within a week, and always should be as
Soon as possible to avoid shrinking of the soft parts, which
it certainly does.
Perhaps some one will here say to me, there must be
Something wrong about all this, for I certainly was taught
and learned, that removal of the eye was a severe and dan-
gerous operation. Moreover, I remember the first proceed-
ing was to enlarge the palpebral aperture in order to have
room to work in. My reply is, I desire only to remove the
useless and now offending organ, namely, the eyeball, and
Would as soon think of slitting up the lids, as a dentist
Would of enlarging a man's mouth to extract a molar tooth.
Yet the following is from the American Edition of Erich-
Sen's Surgery, 1866. “Extirpation of the eyeball is also
occasionally called for, when in consequence of injury
or disease one eye has become disorganized and the vision
of the other is sympathetically affected, and can only
be preserved by the removal of the globe that is already
useless. The operation may be performed in the following
way:-The Surgeon standing in front of the patient, makes
an incision through the outer commissure of the lids as far as
the edge of the orbit. The eyelids are then well everted
and held apart with a wire speculum. The surgeon next
passes a double hook into the globe and draws it well for-
ward; then with a curved, broad pair of scissors he divides
the conjunctiva at its upper part, and then proceeds to cut
38
288 ENUCLEATION OF THE EYEBALL.
\
across the several muscles of the orbit, and lastly the optic
nerve.”
The operation of enucleation has been found so simple,
so effective when needed, and so perfectly adapted to its
ends, that we may well wonder at its having been neglected
so many years after Bonnet proposed and Stoeber performed
it. What was called sinking the eye, namely, cutting out a
piece and letting the contents of the globe escape, was for-
merly the operation practised where now enucleation is in
place. Pathology and experience soon taught that in the
operation of sinking the eye, exactly that portion of the
globe was left which was most often the source of trouble,
namely, some part of the ciliary region. Hence soon came
from one and another the improved method of removing the
anterior part of the globe up to the edge of the retina or
ora serrata, leaving the rest to form a stump. Dr. E. Wil-
liams, of Cincinnati, especially, proposed at the Ophthalmic
Congress, at Paris, 1862,” to remove a portion of the an-
terior part of the eye instead of enucleation, for the purpose
of having a better stump for the eye to move on. He cut
through the ciliary body, the only part of his operation I
would object to, as we must remove all of the ciliary region
to avoid sympathetic trouble of the other eye, as time has
since proved. This operation, when done with Stitches
passed behind the portion to be removed, now has Mr.
Critchett's name attached to it, as he introduced it for sta-
phylomata.” Four or five curved needles are passed through
the globe just behind the part to be cut off, and the wound
brought together, an operation which might be in place in
certain cases, rather than enucleation, and we must then
decide between the two. The disadvantages are the long
time consumed in recovery, the probable Subsequent pain,
great swelling during Suppuration, and the possibility that
even then enucleation of the stump must be practised, as I
ENUCLEATION OF THE EYEBALL, 289
have been obliged to do where I have found traumatic or
artificial sinking has occurred. On the other hand, we may
get good union of the Sclerotic and no great pain or swell-
ing. But the stump remains a doubtful source of irritation.
Prof. Knapp,” of Heidelburg, has quite recently proposed.
a modification of this operation which may prove of very
great service. He passes the needles through the conjunc-
tiva alone, above and below, and by drawing it together
closes the sclerotic wound, thus avoiding any chance of sym-
pathetic irritation of the other eye, which the continued
presence of stitches in the Sclerotic may produce.
I will at once answer the question which may arise, by
saying the false eye will move nearly if not quite as well
and sometimes even better, bedded on Tenon's capsule, than
if resting on a stump which it may possibly irritate. I may
say, I have seen the muscles move the capsule sufficiently to
deceive at first glance, even an oculist, as to whether the eye
was false or not. But the point is just here, and it must be
kept steadily in mind. The capsule will move the artificial
eye well enough, and the stump, if composed of any part of
the cornea or ciliary region, is never Safe from the danger
of producing sympathetic irritation.
In the adult, when the features, the bones and soft parts
have reached their fullest development, an objection to enu-
cleation does not apply to the Same extent as in the young.
The objection is this, and I would dwell upon it because
little if anything will be found in regard to it in the ophthal-
mic literature which you will meet. After enucleation of
the globe by the method proposed by Bonnet, the orbital fat
seems to become absorbed, allowing the muscles and Tenon's
capsule to sink in more than natural, and more than when a
stump or portion of the globe remains. When done in youth
before the bones are perfectly formed, or perhaps even after-
wards, the Osseous tissue about the orbit seems also to
290 ENUCLEATION OF THE EYEBALL.
e
shrink, giving a different outline and feature to this compared
with the other side of the face. The expression is peculiar,
making the patient on that side look as if thinner or not in
good health, to which the bright cheek and lips give the denial.
This I have seen so marked, that it always arises to my
mind in deciding whether to enucleate the globe or abscise
the anterior portion of it, and I have in the young chosen
the latter simply on these cosmetic grounds, otherwise emu-
cleation is greatly to be preferred, removing as it does all
source of irritation which has called for the operation.
That the laity may better understand the necessity, sim-
plicity and effectiveness of enucleation, by being taught
through you to no longer dread it as something terrible, to
be avoided till the last, is, as I have said, the purpose of this
paper. It remains, therefore, to show when and why we
ophthalmologists employ it.
Enucleation may be needed simply to get rid of an en-
larged or staphylomatous globe which the lid will not cover,
or which we desire to remove to give place to a false eye;
or, as a prophylactic operation, to Subdue or prevent sympa-
thetic inflammation in the other eye. Years ago (1802)
Beer, and afterwards especially Himly in 1843, noticed and
laid stress upon the fact, that continued irritation or chronic
inflammation of one eye caused its fellow to sympathize.
Graefe,” Arlt,” Bader.” Muller,” and Augustine Prichard*
of Bristol, have since then given us their special studies of
sympathetic irido-choroiditis, so that at present it is as re-
cognized as dreaded by the ophthalmologist. Trouble in
the Sound eye does not commence, as you might suppose, in
the retina or nerve or choroid, but in the uveal tract, and
gradually extends back from there towards the posterior
part of the globe. A patient with an injured or inflamed
eye will have, in the other sound one, intolerance of light,
sensation of fulness, even perhaps perceptible to the touch,
ENUCLEATION OF THE EYEBALL. 291
*
inability to use the eye, fatigue of accommodation and con-
traction of the range of accommodation, long before he may
apply to the Surgeon, who at once recognizes this insidious
Sympathetic irritation from the other eye. I do not propose
here, however, to discuss sympathetic inflammation, except
So far as regards the removal of the injured or inflamed
eye, to control or avoid it.
It is rather curious that the idea of destroying an injured
or inflamed eye to prevent its acting on the other, comes
from veterinary surgery. This in the horse was at first
done by pushing a mail into the globe or putting lime be-
tween the lids; afterwards by Wardrop, in a less cruel man-
ner, by opening the globe. Credit is due the English for first
having proposed destruction of one eye to save the other
from Sympathetic trouble, and formerly the same method was
used as in the horse by Barton,” Crompton and others.
Graefe destroyed the eye by passing a thread through the
Sclerotic and cornea, or through the ciliary body. Walton
and Taylor, as Dr. E. Williams, of Cincinnati, above quoted,
preferred to cut away more of the cornea, to remove iſ
necessary an old cataract, results of exudations, foreign
bodies, &c. Now it is curious to see, that notwithstanding
the knowledge which then existed of Tenon's capsule, its
being repeatedly brought into notice, and even enucleation
within this membrane having been distinctly proposed and
to a small extent practised, yet ophthalmic surgeons did not
commence the employment of this method of removing an
injured or inflamed eye to save its fellow, till Mr. Critchett”
in 1851, probably from seeing how successful enucleation
was when practised for tumors, staphylomata, &c., and how
well the false eye set and moved in the cup of the capsule,
proposed and carried out this operation in preference to
others for sympathetic irritation, and, as Prof. Graefe said in
1857, its practicability and success were at once established.
292 ENUCLEATION OF THE EYEBALL.
&
Again, in 1860, he says, practitioners ought to understand
enucleation better than they do, for they seem to have a sort
of dread of it, as if dangerous to the other eye, and as
though it was a severe and bloody operation. The success
attending Mr. Critchett's operation of course led other En-
glish ophthalmic surgeons to follow him, and enucleation
soon became so frequent in London practice as to astonish
the French and German schools, and naturally excite their
opposition, which was perhaps fortunate, as the whole sub-
ject of enucleation for sympathetic trouble has in conse-
quence been now thoroughly discussed, and the results care-
fully weighed and considered, so that we already have some
definite laws to guide our decision.
The more this operation has been used by surgeons at the
great centres of ophthalmic practice and clinical study and
teaching, the more strongly do they speak of its value, sim-
plicity and necessity. A few quotations from the highest
authorities in the English, French and German ophthalmic
schools will here be directly in place, and probably have their
due weight.
Dr. Bader,” of London, says, “The facility with which
enucleation is performed, its great freedom from risk, and
the adaptability of an artificial eye, ought to make us con-
sider a disorganized eye, which is the seat of pain or annoy-
ance, as a foreign body whose removal the sooner it is ac-
complished the better. If not painful at the time it is a de-
formity, and is liable at any time of ill health to become the
seat of inflammation, and affect sympathetically the opposite
organ. It is not only unwise, but incorrect to bring before
the patient's imagination the idea of ‘taking the eye out,’
and omitting the scientific advantage of excising; medical
men must soon learn to value the operation.”
Mr. Jonathan Hutchinson” says, in regard to enucleation
of the eyeball even during the acute stage of traumatic pan-
ENUCLEATION OF THE EYEBALL. 293
ophthalmitis, “Whenever I am satisfied that an injured globe
is utterly lost, I always advise its excision without loss of
time. By adopting this course the patient's suffering, often
extreme, is at once put an end to, and I think, also, the risk
of sympathetic inflammation of the other eye is avoided. I
have excised globes in all stages of inflammation, and have
never seen the slightest ill consequence, whilst the patients
have invariably been most grateful for the complete relief
afforded.” *
Mr. Critchett, at the Ophthalmic Congress at Heidelburg,
in 1863, says:–1st. That injuries which cause sympathetic
ophthalmia are those which occur in the ciliary region. 2d.
The effects of such inflammations differ in important points
from those dependent on the other forms of iritis. 3d. Lo-
cal or constitutional remedies have as little beneficial effect
on the eye as surgical interference. 4th. Operation must
be suspended till all inflammation is gone by, and even then
a doubtful prognosis must be given. 5th. In view, therefore,
of the uncontrollable inflammation and the dangor of total
blindness, it may be perhaps safer, when injuries have affect-
ed the ciliary region and threaten long irritation, to enucleate
the injured eye before signs of trouble appear in the other.”
From the Franco-German school Wecker” says, “It is
vain to attempt to substitute iridectomy or section of the
optic nerve for enucleation. There is no longer any doubt
of the necessity of removing an eye which is lost, as soon as
it becomes dangerous to the other. The only question aris-
ing is in reference to the case itself and the time when re-
course must be had to enucleation. We are forced to enu-
cleate: 1st. Whenever one eye remaining sound, the other is
sº
the seat of intolerable pain which, not yielding to remedies,
makes us fear for the sound one. 2d. In every case where
a lost eye has given rise to sympathetic irido-choroiditis in
the other, no matter how slight, for this is our only means
2.94. ENUCLEATION OF THE EYEBALL.
of controlling it. 3d. In every case where the eye, till now
Sound, has become in any degree amblyopic, its range of
accommodation rapidly diminished, intolerant of light, or
incapable of prolonged use; these symptoms often being
the precursors of iridó-choroiditis. Enucleation will be all
the more urgent when careful examination cannot find for
these troubles, either in the eye itself or in the general con-
dition, other cause than this sympathetic influence in question.
"Under all circumstances when in doubt, it is better to ope-
- rate too early than too late, for we may find enucleation
useless after sympathetic irido-choroiditis is fully estab-
lished.”
From the various ophthalmic clinics of Germany we also
have concurrent testimony. Graefe’s” and Arlt's* results
and observations I have already quoted. Pagenstecher, at
Wiesbaden, found enucleation necessary from the following,
Cà,U186S —
1st. Traumatic irido-choroiditis occasioned by
(a) Lesion of the iris, resulting from its being nipped
between the edges of the wound.
(b) Lesion of the choroid. e.
(c) Suppurative choroiditis, or suppuration in the
vitreous.
(d) Presence of a foreign body in the eye.
(e) Lesion of the capsule of the lens.
(f) Choroiditis after reclination, or depression of
the lens.
2d. Incipient exudative irido-choroiditis and haemorrhage
from the choroid.
3d. Processes leading to staphyloma (choroiditis serosa).
4th. Extensive separation of the retina.
5th. Tumor developing from the choroid or Sclerotic.
6th. Formation of bone within the choroid.
Let me here add one more testimony from Dr. Mooren's”
ENUCLEATION OF THE EYEBALL. 295
clinical experience for eleven years with 32,000 patients in
Düsseldorf. He says, “The causes of sympathetic disease,
according to my observation, may be divided into three
distinct groups. 1st. Direct injuries of the ciliary region.
2d. Mechanical irritation of the ciliary body, whether by
the action of a foreign body (wearing an artificial eye), or
by the lens turned into a foreign body by displacement, re-
clination, luxation, staphyloma, etc. 3d. Every inflammation
of any part of the uveal tract, when by cyclitis it has
reached its culminating point.” And finally, as do all other
authorities, Dr. Mooren gives, “pain upon pressure in the
ciliary region as the never-failing symptom which pointed
to and proved danger from sympathetic disease. When this
is present, the only possibility of saving the second is by
enucleation of the first affected eye.”
To the above I would add the testimony of my own ex-
perience in ten years of ophthalmic practice in this commu-
nity. In the medical literature of this country you will find
reports of Successful cases of this operation, coming from
the Scientific ophthalmologists of our larger cities, who strive
to avail themselves of the sound sense of the English, the
élan of the French, or the patient industry and scientific
attainments of the German surgeons in this specialty.
I trust, therefore, my efforts have succeeded in proving to
you that enucleation of the eyeball from within the capsule
of Tenon, is un anatomical possibility, a surgical necessity
and a powerful prophylactic remedy.
NoTE. This paper having been intended for a large State Medical Society,
will explain to my brother ophthalmic surgeons why no comparison is made
with simple iridectomy, Section of the optic nerve, or of the ciliary nerves.
39
THE accompanying wood cuts are from photographs of a
diagram and dissection exhibited to the Society when the
paper was read.
Fig. 1. The lids are slit up vertically, and the four flaps turned
back. The conjunctiva dissected off and strings passed under the
tendinous insertion into the sclerotic of the external, internal and infe-
rior recti muscles, just as they would be lifted on the hook to be cut in
operating for squint. A needle is passed under the tendon of the supe-
rior rectus, which is seen to pass to the capsule of Tenon, showing itself
between the upper half of the globe and the upper lid, from both of
which it is freed. In a single wood cut it is of course difficult to give
a more definite view of a minute dissection.
Fig. 2. Represents in diagram a vertical section through the orbit
and eyeball. The heavy dotted line shows the fibrous lining of the
orbit, which at the anterior upper and lower edge passes off to the lids,
and also backwards to the globe which it surrounds to the optic nerve,
thus forming Tenon's capsule. A layer behind runs over the nerve to
form its sheath, and in front a prolongation extends forward to the
conjunctiva. The superior and inferior recti muscles are represented,
and where their tendons pierce Tenon's capsule to become attached to
the globe. It will thus be seen that cutting the tendons of the muscles
at their insertions, and the optic nerve, releases the globe and leaves
Tenon's capsule like a cup for an artificial eye to rest on and be moved
by the muscles.
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BIBLIOGRAPHIC REFERENCES.
_dºah.
www-
Tenon. Mémoires et Observations sur l’Anatomie, la Pathologie
et la Chirurgie, et principalement sur l'Organe de l’OEil. p. 193.
Paris, 1816.
Dalrymple. Anatomy of the Human Eye. London, 1834.
Bonnet. Read at Paris Academy of Sciences, Feb. 1, 1841.
Gazette Méd. de Paris, Feb. 13, 1841. Dublin Med. Press,
March 3, 1841, p. 133. Annales d’Oculistique, t. v. p. 27, and
t. vii. 1842, pp. 141, 237.
O'Ferrall. Dub. Med. Press, March 10, 1841, p. 158. Dub. Jour.
Med. Sci. Wol. 19, p. 336.
Stöber. Annales d’Oculistique. Tome vii. p. 31.
R; Traité pratique d’Anatomie Médico-chirurgicale. Paris,
1857.
Hyrtl. Handbuch der topagraphischen Anatomie. Wien, 1853.
Pudge. Ztschr. für rat. Med. 3 R. vii. p. 273.
Lucas. Practical Treatise on the Cure of Strabismus. London,
1840. American Journal Medical Sciences, Oct. 1841. -
Henle. Handbuch der Anatomie des Meschen. Wol. 2, Prt. 3.
Wºº. Treatise on Operative Ophthalmic Surgery. London,
1853.
Bonnet. Traité des Sections Tendineuses et Musculaires. 1841.
Hélie. Théses de Paris. 1841.
Richet. Anat. Chirurg. Paris. 1860. 2d edit. p. 324.
E. Williams. Congrès Internationale d’Ophthalmologie. Paris,
1862, p. 139.
Critchett. Royal London Ophthalmic Hosp. Reports. Wol. 5.
Part 1. 1863.
Pagenstecher. Klinische Beobachtungen aus der Augen heilanstalt
zu Wiesbaden. 1862. p. 42 et sequitur.
º, Archiv f. Ophth. B. 3. Abth. 2. B. 12. Abth. 2. B. 6.
th. 1.
4% Zeitschrift der Gesellschaft der Aertze zu Wien. 1859.
r. 10.
Bader. Prager Med. Wierteljahrsschrift. 57. Band.
Muller. Archiv. f. O. B. 4. Abth. 1.
Prichard. “Association Journal.” Oct. 6, 1854,
Barton & Crompton. London Medical Gazette, 1837.
I
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300 BIBLIOGRAPHIC REFERENCES. *
Walton & Taylor. Annales d’Oculistique. t. 34, p. 256.
Critchett. Allgemeine Wiener Zeitung. Feb. 14, 1860. Lancet,
1851, p. 368.
Bader. Royal Lond. Opth. Hosp. Reports. No. 1, 1857.
J. Hutchinson. Roy. Lond. Opth. Hosp. Reports. Wol. 5, Part 4.
Wecker. Traité theorique et pratique des Maladies des Yeux.
Blodig. Zeitschirft der Gesellschaft der Aertzte zu Wien. 1860.
Mooren. Opthalmiatrische Beobachtungen. Berlin. 1867.
Pº, Compendium der Operativen Augenheilkunde. Prag. 1860,
p. 3.
Linhart. Würzburger Werhandlungen. Bd. 9. Heft. 2 et 3, 1859.
Lenoir. These sur la Strabisme.
Demarquay. Traité des Tumeurs de l’Orbite. Paris, 1860.
Liebreich. Eine Modification der Schiel Operation. Archiv f. Opth.
12. 2.
Knapp. Staphylomabtragung und Vereinigung der Wunde durch
Bindehautnähte. Archiv. fur Opth. 14. 1.
24
25
26
27
28
29
30
31
32
33
34
35
Hart. London Lancet, Jan. 1863.
Carter. Br. Med. Jour., Nov. 1864.
Wecker. Gazette des Hospitaux, 93. 1864.
Hulke. British Med. Journal, Jan., 1866.
Lawson. London Lancet, Jan., 1863.
Lawson. London Lancet, Aug., 1864.
Wolf. Gazette des Hospitaux, 100. 1864.
Calderini. Jahrbb. 135. p. 356.
36
37
38
39
40
41
42
43
44
E X T R A D I G. IT S.
By BURT G. WILDER, M.D.
READ JUNE 2, 1868.
40
E XT R A D H G IT S.
A CHILD comes into the world with two thumbs instead of
One, or with an extra little finger, or, it may be, with an
additional great or little toe.
The parents, if ignorant and superstitious, are dismayed;
like the ancient physician, “whose pathology was mythology,”
they bewail the deformity as an omen of evil, past, present
or future, rather than as detrimental to the elegance or
usefulness of the afflicted member.
But if they are intelligent and disposed to take the matter
calmly, they console themselves by recalling instances of
Cats and dogs, and even of innocent lambs, which had more
than the usual number of digits, yet whose dispositions and
those of their parents and offspring gave no sign of demo-
niacal influence. Some of their friends, too, have seen or
heard of other children with the like peculiarity, whose
parents, nevertheless, were Christians, who themselves came
to no bad end, and whose descendants, even if they inherited
the deformity, were in no way remarkable, or, at any rate,
not objectionably so.
And so when the physician comes again, and is consulted
in the matter, they are quite prepared to receive his more
accurate information upon other cases, and to follow his
advice with their own. If he be only a practising physician,
with no other object in life than to get his patients into good
condition as soon as possible, he either advises to leave the
306 EXTRA DIGITS.
extra digit alone, since it is not greatly in the way and may
even be useful, or, if this is not the case, proceeds to remove
it after the approved methods: meanwhile recounting to his
hearers the like cases which have come within his knowledge;
some who had seven, eight, nine and even ten fingers or toes;
others, six fingers on each hand and six toes on each foot;
while in other cases, these lesser peculiarities of the limbs
had been associated with such extraordinary malformations
of the body and head, that the astonished parents now con-
gratulate themselves that it was no worse, and that their
child was not born a Cyclops or a Hydrocephalus, instead of
a simple “Sexdigitist.”
But if, on the other hand, our physician is one who while
exerting his utmost skill for his patient, yet allows his mind
to pass from visible effects toward invisible causes, from
isolated facts toward general principles, then will he take
careful note of this case, will make perhaps a sketch and a
dissection of the specimen, and then, as opportunity occurs,
will ponder the whole subject and seek to solve the many
questions which now crowd upon his mind.
What are the causes of such malformations, and how are
they produced ? in which of the two sexes are they more
commonly found 2 on hands or on feet 2 on the right or the
left side 2 on the ulnar or the radial, the tibial or the fibular
border 2 and what is the occasion of the difference if any
exists 2 All these, and many others which readily suggest
themselves, now impart to such anomalies a far deeper
interest than before, and if he looks upon succeeding cases
with something more than a practical eye as to whether
the digit shall be removed or not, and if he now makes
inquiries which seem to have no reference to the physical
well-being of the child or the mental anxiety of the parents,
it is not, as some would have it, because Science has dulled
his heart to sympathy; his former feelings were merely
EXTRA DIGITS. 307
human; they have not now degenerated into what is less,
but have rather been elevated to what is more than human.
But here, let me insist that our hypothetical Doctor, and
every one who takes up this subject, shall get together as
large a number of cases, and as full a history of each, as is
possible, before attempting to draw from them any general
conclusions. For in these days when the scientific world is
flooded with theories as to the nature, the causes and the
significance of the variation of Organized beings; when yet the
normal standards have not been determined; when there is
with some a willingness to ascribe such variations to mere
chance, and with others a disposition to attribute them to phy-
sical laws and condition, acting as if of themselves and inde-
pendently of a Supreme Intelligence; when it is so easy to
speculate, and so tedious to investigate; now, of all times, is
it necessary that we restrain ourselves, and utter no theory
which has not the best foundation in facts, which it is in our
power to gain.
Variation is boundless and infinite. Probably no two
individual things or beings are exactly alike. The cells of
the bee and the webs of the geometrical spider, which have
so long been held up to us as examples of mathematical
exactness, are now found to differ widely among themselves.
No two crystals are identical ; nay, even no two symmetrical
halves of crystal are identical; more marked, though too
often overlooked, are the differences between the two halves
of the bodies of animals and of men; males and females
correspond, but are not the same; parent and child are alike,
yet diverse; even species are by Some supposed to vary and
to change so as to lose their identity.
Merely expressing in passing my total disbelief in the
truth of this last supposition, let me call attention to the
individual variations of the Fingers and the Toes, a group of
308 . EXTRA DIGITS.
cases which appeal to the medical man from nearly every
stand-point of our most comprehensive profession.
For the surgeon they are a not infrequent occasion for
operation. For the anatomist, their own structure and their
connections with adjacent parts afford material for dissection;
and the physiologist is interested in their various degrees of
mobility and usefulness. The embryologist is still in doubt
as to the manner of their formation and especially the means
of their occasional reproduction; and the teratologist may
record and consider their not infrequent association with other
and more serious deformities. To the psychologist, the degree
of influence which the mother's mental condition may exert
upon the production of these and other physical peculiarities
should be a subject of serious consideration, before the ancient
and still popular opinion upon this matter is set aside as
groundless. The statistician may find ample employment
for his industry in recording the prevalence of extra digits
in certain localities, among certain peoples, and more
strikingly in certain families, where they disappear and again
appear after several generations in a most remarkable man-
ner. And finally, to each and every one of the above men-
tioned classes of medical men, these extra digits are too
often a source of regret and disappointment; since it is rarely
the case that the specimen is preserved or drawings made,
or the history recorded to such an extent as to fully answer
the inquiries of any two of them.
All the cases of polydactylism, a synopsis of which I shall
now present, are from the human species: for though cats
and dogs and other animals and birds are known to possess
extra digits, their number is too small and the individual
histories too incomplete for our present purpose; in addition
to which, hardly any two of the common species possess the
same normal number of digits.
I have also confined myself on this occasion to what is
EXTRA DIGITS. * 309
called sexdigitism; the presence of a single Supernumerary
finger or toe; partly on account of the greater number of
such cases and the greater ease of recording and tabulating
them, but chiefly because there are high authorities who
look upon every extra digit as a rudiment of a second indi-
vidual; SO that it is better to confine my statements to these
cases, which, whatever may prove to be the correct view as
to the higher numbers, are, in my own opinion, simply the
result of the undue subdivision of, or an after-growth from,
the primitive limb, and not in any way the indication of a
double monster.”
From various sources, specimens, casts, figures, descrip-
tions, letters, and word of mouth, I have brought together
the principal facts which could be obtained concerning one
hundred and fifty-two individuals who have or have had six
fingers or toes upon one or more of their extremities. The
number may seem large, and it is really more than three
times as great as any one has had before: but I wish before
proceeding farther to express my regret that it is not one
thousand, rather than one hundred and fifty-two; but as these
are all which are now accessible to me, I am induced to offer
them at this time, with three principal objects in view:—
1st. That I may impress upon others the value of each and
every fact relating to these cases, since most of them bear
directly upon questions now under discussion.
* How do the advocates of the view referred to, account for the presence of
extra digits upon more than one of the limbs º do they represent portions of as
many imperfect monsters ? or of one and the same monster, accurately, and as
a general thing, evenly, distributed upon the perfect individual? Neither hy-
pothesis is very reasonable.
+ Lest others may take the pains to record the same cases again, the Writer
has recorded all the cases published by Otto, Monstrorum Sexcentorum Descriptio
Anatomica, 1841; by Simpson, in his Obstetrical Memoirs and Contributions, ii. p.
346; by T. Annandale, of Edinburgh, in the Prize Essay upon Malformations,
Diseases and Injuries of the Fingers and Toes, 1866; by Arthur Mitchell, in a paper
upon Blood Relation in Marriage, Mem. Anthropological Society of London, ii.
402; by Dr. Foltz, Homologie des Membres Pelviens et Thoracique; Journal de
310 EXTRA DIGITS.
2d. To Suggest a general method of recording such cases.
3d. To indicate, so far as these cases go, the direction
which we may expect will be taken by the final results of a
much larger number.
The following table indicates the principal results of this
record and tabulation of cases:
No. Of Region. Side. POrders.
SEXES. Individ- || Affected
uals. Limbs. Ant. POSt. P | R. L. F | U. R. P. T. Fib. ?
Males 86 168 109| 59 81| 78 9| 66 23, 20 12| 16 31
Females 39 81 56|| 25 41. 40 20 18| 18| 3| 8, 14
Doubtful 27 40 30| 10 20|| 17 3 24. 4. 2 6| 3| 1
152 289 195| 94 142||135|| 12110 45 40 21. 27| 46
Ant. Anterior extremity. TJ. Ulnar border.
POSt. Posterior ’’ R. Radial “
R. Right. T. Tibial “
L. Left. B'. Fibular “

No one, so far as I know, has hitherto offered any facts or
expressed any opinion as to the comparative frequency of
extra digits in the two sexes; and in some cases the sex of
Physiologie, vol. vi. p. 49, 1863; by Reaumur, L’Art de Faire Eclose Oiseaux
Domest., 1751, p. 377, quoted incorrectly by Huxley, on the Origin of Species, p.
93; by Darwin, on Animals and Plantsin Domestication, 1868, vol. ii.; by Dr. John
Struthers, Variation in the number of Fingers and Toes and of the Phalanges,
Edinburgh New Phil. Journal, July, 1863; by Dr. J. B. S. Jackson, Catalogue
of Museum of Boston Society for Medical Improvement; by Vrolik, Cyclopedia
of Anatomy and Physiology, iv.–ii. p. 948. He has also had access to all the
specimens in the Warren Anatomical Museum of the Harvard Medical College,
in Prof. Wyman’s Museum in Cambridge, and in the Museum of the Boston
Society for Medical Improvement; and has likewise found a large number of
isolated cases in books, and by inquiring has procured reliable accounts of cases
now living. Several important and interesting cases which were sent by Dr.
George J. Fisher, of Sing-Sing, New York, the only one who has devoted him-
Self especially to these malformations, and who has published a valuable treatise
upon Diplo-teratology (concerning Double Monsters), were unfortunately
received too late for tabulation; but these and all others which can be obtained
the writer hopes, at some future time, to publish both singly and by tabulated
results; the present contribution being intended only as an incentive and help
to others. Probably there is scarcely a neighborhood where one or more cases
may not be discovered,
EXTRA DIGITS. 311
the patient is not even mentioned, although it must have been
known to the recorder.
It is a generally received opinion that not only is the
male the more highly organized, but that he is also more
liable to malformations resulting from an eaccess of develop-
ment, such as double monsters, &c., while the female is
thought to be more commonly subject to arrests of develop-
ment. Now whether extra digits are always so many
primary subdivisions of the rudimentary hand or foot, or
whether they are subsequent outgrowths from the hand or foot
already formed, they are in both cases the result of an excessive
action in one form or another, and so it is interesting to find
that of one hundred and fifty-two individuals affected with
extra digits, eighty-six are males and only thirty-nine females:
the sex of the remaining twenty-Seven is not known.
The one hundred and fifty-two individuals represent six
hundred and eight limbs, of which two hundred and eighty-
nine or nearly one halſ were affected. Of these two hundred
and eighty-nine affected limbs, one hundred and forty-two
were on the right side and one hundred and thirty-five on
the left side. The difference between the two sides is there-
fore very slight; it does not even appear that the two hands
differ any more than the two feet, and while the preponder-
ance of cases is upon that which is generally regarded as
the dynamic side of the body, perhaps it was not to be ex-
pected that parts which vary so slightly in their normal
structure and uses should present any striking differences
in their malformations.
We come now to a most important and interesting division
of the subject: namely, as to the relative frequency of a
sixth digit upon the anterior and posterior extremities, the
hands and the feet.
Here I must admit having been very decidedly predisposed
towards the result which has been reached, for it was this very
question which led me first to take up the subject.
41
312 EXTRA DIGITS.
While studying the various comparisons of the fore and
hind limbs of man and animals which have been instituted
by different anatomists, it appeared to me that far too much
weight had always been attached to the structure and atti-
tude of the fore limbs, on account of their greater functional
importance; so that they were generally unable to see how
nearly the two limbs may be made to correspond in a
symmetrical or antagonistic manner, as do those of the right
and left sides.
The greater functional value of the hand was not to be
questioned; but it occurred to me that if it could be shown
that the hand and the whole arm are more variable than
the foot, in attitude, in proportion of parts and in the number
of digits, then their morphological value would be diminished
to a corresponding degree; and anatomists would be more
ready to accept the posterior limbs as the surer guides in
their comparison of the two. Now it is known to all that
the more various and complicated motions are executed by
the hands; also that among the different species of animals,
the anterior limbs undergo the greater modification of struc-
ture and position to suit the wants of the monkey, the bear,
the bird and the fish; also that when, as in the cat,
the number of digits is not the same upon the two limbs,
the greater number is generally on the hand.
These considerations, anatomical, physiological and zoölo-
gical, as to the variability and consequent less morphological
value of the hand, are now strikingly confirmed by the
statistics of sexdigitism. For of the two hundred and eighty-
mine affected limbs, one hundred and ninety-five, or more
than two thirds, are hands, the remainder being feet.
Here there is a possible disturbing element; for it may
be said that the extra digit would be more often removed from
the feet than from the hand; indeed the additional thumb is
..sometimes thought by the possessor to be a decided advan-
EXTRA DIGITS. 313
tage, either in grasping a pen-handle or in taking anything
from his vest pocket, by opposing the tips of the two
thumbs.”
But I hardly think the consideration above mentioned
will account for the great difference which exists between the
hands and the feet in this respect. The result confirms the
opinion already expressed by Struthers, which, however, was
based upon a much smaller number; while it is directly
opposed to the opinion of Darwin, who in his last work, on
Animals and Plants under Domestication, says that he has
tabulated forty-six cases and finds a slight preponderance in
favor of the feet, there being seventy-five feet and only
seventy-three hands; but this probably includes all varieties
of polydactylism. &
No less striking than the above is the comparative fre-
Quency of the extra digit on the ulnar and radial borders of
the hands, the tibial and fibular borders of the feet; and as
this, too, bears directly upon a part of the question as to
the comparison of the fore and hind limbs, I will dwell
upon it for a moment.
A distinguished French anatomist, who has declared his
belief in the existence of a true symmetrical or polar relation
of the fore and hind limbs, has coupled with it a theory as
to the binary composition of the thumb and great toe; the
desire for this arises from his feeling that both these digits
are too large for a correspondence with the little toe and
little finger, opposite which they come when the hand and foot
are symmetrically placed; but his only facts in its support
* There are also one or two families in Germany whose members pride them-
selves upon the possession of an extra thumb, and there is an Arab Chieftain
whose ancestors have from time immemorial been distinguished by the double
thumb upon the right hand. But in view of the great difficulty of eradicating
the malformation from a family, one is reminded in all these cases of the fable
of the fox who had lost his tail, and ever afterward recommended others to get
rid of theirs.
+ Dr. Foltz.
314 EXTRA DIGITS.
are afew cases of extra or double thumbs and great toes, which
he thus conceives to represent the normal condition of the
parts. But the facts we have to offer indicate that the little
finger and little toe are by far the more often double or
supernumerary: for of the one hundred and ninety-five hands,
one hundred and ten had a Supernumerary little finger, and
only forty-five an additional thumb; while upon the feet there .
are twenty-seven extra little toes and only twenty-one great
toes.
The greater difference in the relative frequency of an extra
digit on the ulnar and radial side of the hand, as compared
with that between the tibial and fibular borders of the feet,
we may associate with the greater functional distinction
between the thumb and the little finger: but the greater
variability of the little toe and little finger does not appear
to be in accordance with the idea already alluded to, that
variation is more frequent in that sex, and in that region of
the body, where the greater development and activity exists.
There is one matter which does not come strictly under
the head of extra digits; but as it is a variation of a similar
nature, and especially as the cases are both rare and ex-
tremely valuable, I will say a few words concerning it.
There are a few instances (of which one specimen is in the
museum of the Boston Society for Medical Improvement)
of a thumb possessing an additional phalanx so as to be long
and finger-like, yet opposable to the other digits. The chief
value of such cases consists in this: that the most serious
objection to symmetry, in the minds of those who still in-
sist upon a comparison of the fore and hind limbs as parallel
parts, and who consequently consider the thumb and great
toe to correspond with each other, is the fact that both these
digits normally consist of only two phalanges, while all the .
others possess three. It is my own opinion that this diffi-
culty is a wholly superficial one, and that the difference in
EXTRA DIGITS. 3.15
the number of phalanges is simply a difference of quantity
like that in the number of digits themselves, and therefore
no basis for a morphological comparison;” but every such
case of a thumb or a great toe having three phalanges is so .
much toward the means of convincing anatomists that they
really correspond, not to each other, but to the little toe and
little finger, respectively.
It may be interesting to know which are the more common
extra digits among these cases. Of one hundred and eighty-
five limbs, being all of which both the sex, side of body, limb,
and border are known, the following is the order of frequency.
There is a slight difference between the two sexes, but the
numbers are too small to prove anything of single digits, and
I give only the totals. The order of frequency is as follows:
Right little fingers, . & g tº 53
Left little fingers, ſº º {º . 52
Right little toes, . e o ſº 18
Right thumbs, . º * tº . 17
Left thumbs, . & e e º 17
Left little toes, . tº • º . 11
Left great toes, & º * e 10
Right great toes, º e o . T
185
So far we have treated of extra digits according to the
separate limbs upon which they occur, and, excepting when the
sexes were mentioned, have dealt with the individual sex-
digitists only in quarters, giving to each limb a distinct place
in our results as well as upon the blanks. Let us now put
together the limbs of each individual, and see how they were
combined. To do this we must first make a division of the
sexdigitists into those which had but one limb affected, those
which had two, those which had three, and those which had
four; these four groups being called Unisexdigitists, Bisex-
* Morphological Value and Relations of the Hand; Silliman’s Am. Journ, of
Science and Art, xliv, July, 1867.
316
EXTRA DIGITS.
digitists, Trisexdigitists, and Quadrisexdigitists.
But a sec-
ond subdivision, the use of which will presently be seen, may
be into Unisexdigitists and Polysexdigitists: of the former
there are seventy-three, and of the latter seventy-five; these
being divided as follows among the three minor groups—
Bisexdigitists thirty-four, Trisexdigitists eleven, Quadrisex-
digitists thirty.
CoMBINATION OF ExTRA DIGITS IN INDIVIDUALS.

No. of
Uniserdigitists. | Individ.
Right thumbs 16
Left & 6 11
P “ 14
41
Left little finger 8
Right “ “ 5
P 6 & 6 & 8
21
62
Right little toe 3 |E
Left & & 6 &
P & & & &
7
Left great “ 2
Right “ 6 & I
? 6 & & 6 1
4
w º 11
Recapitulation. - -
g; Unisexdigitists, 73
# Bisexdigitists 34
# 3 Trisexdigitists 11
# Quadrisexdigitists 30 75
£4
Total 148
Both thumbs and both great toes
No. of
Biseacdigitists. Individ.
Both little fingers 24
& 4 ** toes 2
& 4 great & 4 2
“ thumbs , | 1
“ “ or little fingers 2
“ great or little toes I
Right little finger and little toe 1
& 4 & 6 € $ great or little toe. 1
34
Triseacdigitists.
Both little fingers and right great toe 5
& £ & 4 & 4 6 & & & little & 6 2
“ thumbs and left great toe 1
“ great toes and left thumb I
& & & 4 &c * : « right “ I
6 & & 4 & 4 & 6 ** little fi * I
Ittle ſinger 11
Quadrèsea digitists.
Both little fingers and both little toes | 6
& 4 & 4 & & & 4 “ great “ 1
& 4 & & 6& & 4 & 4 ? & & 6
1
“ fingers or thumbs and both great or little toes 16 30

EXTRA DIGITS. 31'ſ
As will be seen from the foregoing table, the preponder-
ance of hands among the unisexdigitists is very great, being
sixty-two to eleven; an exaggeration of the ratio which we
found by using all the separate limbs: but in our former
results the little fingers have been far more numerous than
the thumbs, whereas taking the unisexdigitists alone, we have
forty-one thumbs to twenty-one little fingers; ſrom which it
appears that if a person has but a single extra digit it is more
than five times as likely to be on a hand as on a foot; and if
on a hand, twice as likely to be a thumb as a little finger.
But how is it now with the multiple group 7 In fifty-four
of the individuals the hands were affected, and in thirty-two
the feet; the trisexdigitists and quadrisexdigitists of course
having one or both of the hands or of the feet affected. But
what is most remarkable is the complete reversion of the
ratio of thumbs and little fingers from what it was with
the unisexdigitists; for here there are forty-seven individuals
in whom one or both the little fingers was double, while in
only five were there extra thumbs; so that if a man has two
or three or four extra digits, he is nine times as likely to
have a little finger as a thumb. The number of posterior
digits is too small for this calculation, but it is evident that
little toes are more common than great toes.
There is another point brought out by this table; namely,
that when there are two extra digits the repetition is far
more likely to be lateral than longitudinal; that is, corres-
ponding digits are doubled on oppositesides of the body rather
than on opposite ends: two little fingers, or two thumbs,
rather than a little finger or thumb and a great or little toe.
Indeed there are but two cases of this latter kind; one being
that of a right little finger and a right little toe, the other
being of a right little finger and either a great or little toe.
There are not yet enough cases to afford any evidence in
either direction upon the question whether the great toe or
the little toe corresponds to the thumb.
‘ſ
3.18 EXTRA DIGITS.
The number of trisexdigitists is too small for this separate
calculation; but the more common combination is of the two
little fingers and the right great toe. The quadrisexdigitists
also are too few to afford any reliable result, but here as
usual the little fingers predominate; in six cases they coexist
with both little toes, and in only one case with the great
toes; while in six cases they coexist with toes of which it is
not known whether they are great or little.
There are many other facts concerning extra digits which
must be passed over here with a brief mention. Nearly all of
them possessed well-formed nails. A few were pedicellated
and not at all under the control of the will: but more often
the attachment was firm and the only motion was between
their own phalanges which generally agreed in number with
those of the adjoining digit. Sometimes there was a sixth
metacarpal or metacarpal bone, and there were all possible
degrees of completeness from this to a single phalanx attached
to the base of the terminal phalanx of the adjoining digit.
Some of the extra digits were amputated in infancy, and they
Seldom re-appeared, though in one case it grew for a second
and a third time. This reproduction of digits, however, is
more common after amputation in utero, when they are some-
times even developed upon the extremity of an arm severed
above the wrist.
A large number of cases have been observed in some
parts of Scotland where intermarriage is common; but
although Some infirmities seem to be the direct result of
this custom, it may be that extra digits are not caused
thereby, but only spread abroad. In one case the defor-
mity is connected with the fact of the mother having
Worked next to a girl with double thumbs, before her
marriage.
As may be expected, the previous extent of extra digits in
the family constitutes by far the most general predisposing
ſº
EXTRA DIGITS. 319
causes; but there must have been some, or at least one, first
and antogenous case. The oldest on record is that of a son
of Goliath of Gath, who had six fingers on each hand and
six toes on each foot; but it is hardly probable that all sex-
digitists are descendants of the Philistine.
The whole great subject of hereditary transmission must
be passed over with a few words: in all cases I have
recorded what was known of the ancestors, the brothers and
sisters and the descendants; with cross references when any
of these constituted others of my cases.
Dr. Struthers, who has published by far the completest
account of original cases of sexdigitism, thinks it necessary
to make a primary subdivision of them into the hereditary
and the non-hereditary cases; , but the second class will also
embrace all those of which nothing is known as to ancestry;
and moreover, though it is certain that there is a very decided
tendency to the perpetuation of the parents' peculiarity in the
offspring, sometimes even, as in one remarkable family,
gathering force as it descends through successive generations,
there being one hand affected in the first generation, two hands
in the Second, two hands and a foot in the third, and all four
limbs in the fourth, yet there are so many cases in which this
seems to fail, or in which the malformation appears only after
One or more generations or not in the direct line of Succession,
that I have thought best not to attempt any generalization, and
have contented myself with recording the facts so far as they
could be ascertained, mentioning not only those relatives who
did, but also the number of those who did not present this
malformation.
Of the total one hundred and fifty-two individuals, thirteen,
Or one in eleven or twelve, had some other deformity beside
the extra digit: two were giants; Anna Boleyn had a super-
numerary mamma and an additional upper tooth. Hydroce-
phalus, or Some deformity of the head, existed in four cases;
42
320 EXTRA DIGITS.
harelip and cleft-palate in five; one individual was a part of
or double monster; varus of one or both feet was present in
four cases; and in four there was an abnormal condition of
the Organs of generation.
In addition to the points already mentioned, it is necessary
to state the date of record, to affix the name or initials, real
or fictitious, of the individual, and his residence or the
museum containing the specimen or the title of the works
where it is figured or described; all this to avoid the
possibility of using the same case a second time.
For convenience of recording these facts I have used a half
sheet blank, on which are figures corresponding to a list of
questions, the answers to which are to be given; additional re-
marks, and a tracing or drawing of the specimen may be put
upon the back. The middle of the front is occupied by a
diagram of the palms and soles of the four limbs, upon which
it is easy to add the extra digits, so as to show at a glance
what the individual possessed.
“It is truly remarkable,” writes the gifted German
anatomist, Oken, “what it costs to solve any one problem
in philosophical anatomy; without knowing the what, the
how, and the why, one may stand, not for hours or days, but
for weeks, before a fish's skull.”
To know the what, the why and the how, is the aim of
every seeker after truth, and that truth is only to be reached
after long and patient work. The great deficiency in the
matter we have considered, is the lack of material; and yet
there is enough to be had ; for in a single small town of
New England there are three distinct families in which one
or more members are sexdigitate. If I have succeeded in
showing that extra digits may be viewed as something more
than curiosities, or as So many pathological specimens, let
me hope that no case will hereafter be allowed to go
unrecorded in its most minute particular, whether of structure
or function, or of history.
EXTRA DIGITS. 321
For if we believe that nothing happens by chance, and
that male and female, right and left, anterior and posterior,
internal and external, are not mere artificial distinctions of
the regions of our bodies, but are truly and fully the out-
ward embodiments of ideas and principles which have a
physical, a spiritual, may a Divine origin and significance,
then the greater frequency of these anomalies in one of the
two sexes, upon one or the other side of the body, upon the
hand or the foot, will be a never-failing subject for thought
and a stimulus to further investigation.
s:
§
Y-
*
s:
:
3.
§
à
se
g
g;
º
:
;
B-
:

QUESTIONS TO BE ANSWERED IN RECORD IN G CASES
OF EXTRA DIGITS.
To be filled out and sent to BURT G. WILDER, M.D., Cornell University, Ithaca, New York,
g from whom copies of this blank may be procured.
.
i
10.
11.
12.
13.
14.
How many digits upon the hand or foot in question?
The date when this record is made.
Name or initials of the person, or the species of the
animal; if the real initials are unknown, fictitious ones
may be used, taking care, of course, not to use the same
ones again on the same day.
How many limbs of this individual have extra digits?”
Age of individual, exact or approximate.
Sex of individual: 3 male ; ? female; ? unknown.
Anterior or posterior extremity. Ant. or Post.
Right or left side.
Ulmar or radial border. The sign + after the answer to
either of these questions indicates that there is an extra
digit on the foot as well as the hand, on the left as well
as the right side, &c.
Is there a nail? -- or 0.
How many joints in addition to the union of the digit.
with the adjoining digit, or with its metacarpal or me-
tatarsal bone?
Degree of mobility and usefulness of the digit.
Coexisting malformations in other parts of the body.
Presence of extra digits in parents or grandparents, in
uncles or aunts, &c.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.’
Presence of extra digits in brothers and sisters, and
cousins.
Presence of extra digits in children; giving in these
three answers a reference to the individuals, and also
mentioning relations which are known to be free from
these malformations.
Predisposing causes: Heredity, Intermarriage, &c.
Exciting causes: Mental Impressions, &c.
Operation for removal, when and by whom performed.
Result of operation.
Name of original observer or recorder.
Reference to original work.
Reference to other works in which it is mentioned.
Race of the sexdigitist.
birth place of sexdigitist.
Present residence of sexdigitist.
Nature of specimen.
Museum or collection containing it.
Name of the present recorder.
Residence of the present recorder.
f
* It is necessary to have this number in order that we may know how many blanks must be filled out in the first place,
and got together afterward when we wish to study all the affected limbs of a single individual. Each of the blanks repre-
sents a limb, and it takes one, or two, or three, or four of them to give the whole individual. It is not necessary to enter
all the statistics of the individual upon each blank, but only upon the first one, which should be that which gives the first
of the affected limbs in the order of the Roman numerals upon the diagram; for instance, if a man has an extra little finger
on the right hand and an extra little toe on each foot, all the questions from 20 to 30 and those relating to ancestry
may be answered only upon the little finger blank.
When, as is sometimes the case, two or more individuals are known to have similar malformations, the same blanks may
answer for them all, provided a large figure be made over the left hand column, so that in all tabulation the number of in-
dividuals so represented may be known.
When it is known which are the extra digits, the Roman numerals corresponding to them are to be surrounded by a
circle; but when a description leaves us in doubt, as between two thumbs, or a thumb or a little finger, each doubtful
one may be indicated by a semicircle. A drawing or tracing of the specimen or the figure may be made on the back of the
blank; and on the diagram itself the extra digits may be added in their proper places, giving simply the outline of the
digit, and indicating the bones by straight lines with interruptions for the joints; only one digit may be shown upon each
blank, but it is also convenient to show them all upon the first blank.
On the back of the diagram may also be made any more extended statements or explanations regarding Some of the
circumstances, especially the ancestry and the supposed causes of the malformation : it is better to put all this upon the
diagram, for in arranging the cases for study and tabulation only that half of the sheet need be retained.