Medical Essays

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MEDICAL ESSAYS

By Oliver Wendell Holmes



1842-1882


CONTENTS:

I. HOMEOPATHY AND ITS KINDRED DELUSIONS

II. THE CONTAGIOUSNESS OF PUERPERAL FEVER

III. CURRENTS AND COUNTER-CURRENTS IN MEDICAL SCIENCE

IV. BORDER LINES OF KNOWLEDGE IN SOME PROVINCES OF MEDICAL SCIENCE

V. SCHOLASTIC AND BEDSIDE TEACHING

VI. THE MEDICAL PROFESSION IN MASSACHUSETTS

VII. THE YOUNG PRACTITIONER

VIII. MEDICAL LIBRARIES

IX. SOME OF MY EARLY TEACHERS




PREFACE.

The character of the opposition which some of these papers have met with
suggests the inference that they contain really important, but unwelcome
truths. Negatives multiplied into each other change their sign and
become positives. Hostile criticisms meeting together are often
equivalent to praise, and the square of fault-finding turns out to be the
same thing as eulogy.

But a writer has rarely so many enemies as it pleases him to believe.
Self-love leads us to overrate the numbers of our negative constituency.
The larger portion of my limited circle of readers must be quite
indifferent to, if not ignorant of, the adverse opinions which have been
expressed or recorded concerning any of these Addresses or Essays now
submitted to their own judgment. It is proper, however, to inform them,
that some of the positions maintained in these pages have been
unsparingly attacked, with various degrees of ability, scholarship, and
good-breeding. The tone of criticism naturally changes with local
conditions in different parts of a country extended like our own, so that
it is one of the most convenient gauges of the partial movements in the
direction of civilization. It is satisfactory to add, that the views
assailed have also been unflinchingly defended by unsought champions,
among the ablest of whom it is pleasant to mention, at this moment of
political alienation, the Editor of the Charleston Medical Journal.

"Currents and Counter-Currents" was written and delivered as an Oration,
a florid rhetorical composition, expressly intended to secure the
attention of an audience not easy to hold as listeners. It succeeded in
doing this, and also in being as curiously misunderstood and
misrepresented as if it had been a political harangue. This gave it more
local notoriety than it might otherwise have attained, so that, as I
learn, one ingenious person made use of its title as an advertisement to
a production of his own.

The commonest mode of misrepresentation was this: qualified propositions,
the whole meaning of which depended on the qualifications, were stripped
of these and taken as absolute. Thus, the attempt to establish a
presumption against giving poisons to sick persons was considered as
equivalent to condemning the use of these substances. The only important
inference the writer has been able to draw from the greater number of the
refutations of his opinions which have been kindly sent him, is that the
preliminary education of the Medical Profession is not always what it
ought to be.

One concession he is willing to make, whatever sacrifice of pride it may
involve. The story of Massasoit, which has furnished a coral, as it
were, for some teething critics, when subjected to a powerful logical
analysis, though correct in its essentials, proves to have been told with
exceptionable breadth of statement, and therefore (to resume the
metaphor) has been slightly rounded off at its edges, so as to be
smoother for any who may wish to bite upon it hereafter. In other
respects the Discourse has hardly been touched. It is only an
individual's expression, in his own way, of opinions entertained by
hundreds of the Medical Profession in every civilized country, and has
nothing in it which on revision the writer sees cause to retract or
modify. The superstitions it attacks lie at the very foundation of
Homoeopathy, and of almost every form of medical charlatanism. Still the
mere routinists and unthinking artisans in most callings dislike whatever
shakes the dust out of their traditions, and it may be unreasonable to
expect that Medicine will always prove an exception to the rule. One
half the opposition which the numerical system of Louis has met with, as
applied to the results of treatment, has been owing to the fact that it
showed the movements of disease to be far more independent of the kind of
practice pursued than was agreeable to the pride of those whose
self-confidence it abated.

The statement, that medicines are more sparingly used in physicians'
families than in most others, admits of a very natural explanation,
without putting a harsh construction upon it, which it was not intended
to admit. Outside pressure is less felt in the physician's own
household; that is all. If this does not sometimes influence him to give
medicine, or what seems to be medicine, when among those who have more
confidence in drugging than his own family commonly has, the learned
Professor Dunglison is hereby requested to apologize for his definition
of the word Placebo, or to expunge it from his Medical Dictionary.

One thing is certain. A loud outcry on a slight touch reveals the weak
spot in a profession, as well as in a patient. It is a doubtful policy
to oppose the freest speech in those of our own number who are trying to
show us where they honestly believe our weakness lies. Vast as are the
advances of our Science and Art, may it not possibly prove on examination
that we retain other old barbarisms beside the use of the astrological
sign of Jupiter, with which we endeavor to insure good luck to our
prescriptions? Is it the act of a friend or a foe to try to point them
out to our brethren when asked to address them, and is the speaker to
subdue the constitutional habit of his style to a given standard, under
penalty of giving offence to a grave assembly?

"Homoeopathy and its Kindred Delusions" was published nearly twenty years
ago, and has been long out of print, so that the author tried in vain to
procure a copy until the kindness of a friend supplied him with the only
one he has had for years. A foolish story reached his ears that he was
attempting to buy up stray copies for the sake of suppressing it. This
edition was in the press at that very time.

Many of the arguments contained in the Lectures have lost whatever
novelty they may have possessed. All its predictions have been submitted
to the formidable test of time. They appear to have stood it, so far,
about as well as most uninspired prophecies; indeed, some of them require
much less accommodation than certain grave commentators employ in their
readings of the ancient Prophets.

If some statistics recently published are correct, Homoeopathy has made
very slow progress in Europe.

In all England, as it appears, there are hardly a fifth more Homoeopathic
practitioners than there are students attending Lectures at the
Massachusetts Medical College at the present time. In America it has
undoubtedly proved more popular and lucrative, yet how loose a hold it
has on the public confidence is shown by the fact that, when a specially
valued life, which has been played with by one of its agents, is
seriously threatened, the first thing we expect to hear is that a regular
practitioner is by the patient's bed, and the Homoeopathic counsellor
overruled or discarded. Again, how many of the ardent and capricious
persons who embraced Homoeopathy have run the whole round of pretentious
novelties;--have been boarded at water-cure establishments, closeted with
uterine and other specialists, and finally wandered over seas to put
themselves in charge of foreign celebrities, who dosed them as lustily as
they were ever dosed before they took to globules! It will surprise many
to learn to what a shadow of a shade Homoeopathy has dwindled in the
hands of many of its noted practitioners. The itch-doctrine is treated
with contempt. Infinitesimal doses are replaced by full ones whenever
the fancy-practitioner chooses. Good Homoeopathic reasons can be found
for employing anything that anybody wants to employ. Homoeopathy is now
merely a name, an unproved theory, and a box of pellets pretending to be
specifics, which, as all of us know, fail ignominiously in those cases
where we would thankfully sacrifice all our prejudices and give the world
to have them true to their promises.

Homoeopathy has not died out so rapidly as Tractoration. Perhaps it was
well that it should not, for it has taught us a lesson of the healing
faculty of Nature which was needed, and for which many of us have made
proper acknowledgments. But it probably does more harm than good to
medical science at the present time, by keeping up the delusion of
treating everything by specifics,--the old barbarous notion that sick
people should feed on poisons [Lachesis, arrow-poison, obtained from a
serpent (Pulte). Crotalus horridus, rattlesnake's venom (Neidhard). The
less dangerous Pediculus capitis is the favorite remedy of Dr. Mure, the
English "Apostle of Homoeopathy." These are examples of the retrograde
current setting towards barbarism] against which a part of the Discourse
at the beginning of this volume is directed.

The infinitesimal globules have not become a curiosity as yet, like
Perkins's Tractors. But time is a very elastic element in Geology and
Prophecy. If Daniel's seventy weeks mean four hundred and ninety years,
as the learned Prideaux and others have settled it that they do, the "not
many years" of my prediction may be stretched out a generation or two
beyond our time, if necessary, when the prophecy will no doubt prove
true.

It might be fitting to add a few words with regard to the Essay on the
Contagiousness of Puerperal Fever. But the whole question I consider to
be now transferred from the domain of medical inquiry to the
consideration of Life Insurance agencies and Grand Juries. For the
justification of this somewhat sharply accented language I must refer the
reader to the paper itself for details which I regret to have been forced
to place on permanent record.

BOSTON, January, 1861.




A SECOND PREFACE.

These Lectures and Essays are arranged in the order corresponding to the
date of their delivery or publication. They must, of course, be read
with a constant reference to these dates, by such as care to read them.
I have not attempted to modernize their aspect or character in presenting
them, in this somewhat altered connection, to the public. Several of
them were contained in a former volume which received its name from the
Address called "Currents and Counter-Currents." Some of those contained
in the former volume have been replaced by others. The Essay called
"Mechanism of Vital Actions" has been transferred to a distinct
collection of Miscellaneous essays, forming a separate volume.

I had some intention of including with these papers an Essay on
Intermittent Fever in New England, which received one of the Boylston
prizes in 1837, and was published in the following year. But as this was
upon a subject of local interest, chiefly, and would have taken up a good
deal of room, I thought it best to leave it out, trusting that the stray
copies to be met with in musty book-shops would sufficiently supply the
not very extensive or urgent demand for a paper almost half a century
old.

Some of these papers created a little stir when they first fell from the
press into the pool of public consciousness. They will slide in very
quietly now in this new edition, and find out for themselves whether the
waters are those of Lethe, or whether they are to live for a time as not
wholly unvalued reminiscences.

March 21, 1883.




PREFACE TO THE NEW EDITION.

These Essays are old enough now to go alone without staff or crutch in
the shape of Prefaces. A very few words may be a convenience to the
reader who takes up the book and wishes to know what he is likely to find
in it.

HOMOEOPATHY AND ITS KINDRED DELUSIONS.

Homoeopathy has proved lucrative, and so long as it continues to be so
will surely exist,--as surely as astrology, palmistry, and other methods
of getting a living out of the weakness and credulity of mankind and
womankind. Though it has no pretensions to be considered as belonging
among the sciences, it may be looked upon by a scientific man as a
curious object of study among the vagaries of the human mind. Its
influence for good or the contrary may be made a matter of calm
investigation. I have studied it in the Essay before the reader, under
the aspect of an extravagant and purely imaginative creation of its
founder. Since that first essay was written, nearly half a century ago,
we have all had a chance to witness its practical working. Two opposite
inferences may be drawn from its doctrines and practice. The first is
that which is accepted by its disciples. This is that all diseases are
"cured" by drugs. The opposite conclusion is drawn by a much larger
number of persons. As they see that patients are very commonly getting
well under treatment by infinitesimal drugging, which they consider
equivalent to no medication at all, they come to disbelieve in every form
of drugging and put their whole trust in "nature." Thus experience,

"From seeming evil still educing good,"

has shown that the dealers in this preposterous system of
pseudo-therapeutics have cooperated with the wiser class of practitioners
in breaking up the system of over-dosing and over-drugging which has been
one of the standing reproaches of medical practice. While keeping up
the miserable delusion that diseases were all to be "cured" by drugging,
Homoeopathy has been unintentionally showing that they would very
generally get well without any drugging at all. In the mean time the
newer doctrines of the "mind cure," the "faith cure," and the rest are
encroaching on the territory so long monopolized by that most ingenious
of the pseudo-sciences. It would not be surprising if its whole ground
should be taken possession of by these new claimants with their
flattering appeals to the imaginative class of persons open to such
attacks. Similia similabus may prove fatally true for once, if
Homoeopathy is killed out by its new-born rivals.

It takes a very moderate amount of erudition to unearth a charlatan like
the supposed father of the infinitesimal dosing system. The real
inventor of that specious trickery was an Irishman by the name of Butler.
The whole story is to be found in the "Ortus Medicinm" of Van Helmont. I
have given some account of his chapter "Butler" in different articles,
but I would refer the students of our Homoeopathic educational
institutions to the original, which they will find very interesting and
curious.

CURRENTS AND COUNTER-CURRENTS

My attack on over-drugging brought out some hostile comments and
treatment. Thirty years ago I expressed myself with more vivacity than I
should show if I were writing on the same subjects today. Some of my more
lively remarks called out very sharp animadversion. Thus my illustration
of prevention as often better than treatment in the mother's words to her
child which had got a poisonous berry in its mouth,--"Spit it out!" gave
mortal offence to a well-known New York practitioner and writer, who
advised the Massachusetts Medical Society to spit out the offending
speaker. Worse than this was my statement of my belief that if a
ship-load of miscellaneous drugs, with certain very important
exceptions,--drugs, many of which were then often given needlessly and in
excess, as then used "could be sunk to the bottom of the sea, it would be
all the better for mankind and all the worse for the fishes." This was
too bad. The sentence was misquoted, quoted without its qualifying
conditions, and frightened some of my worthy professional brethren as
much as if I had told them to throw all physic to the dogs. But for the
epigrammatic sting the sentiment would have been unnoticed as a harmless
overstatement at the very worst.

Since this lecture was delivered a great and, as I think, beneficial
change has taken place in the practice of medicine. The habit of the
English "general practitioner" of making his profit out of the pills and
potions he administered was ruinous to professional advancement and the
dignity of the physician. When a half-starving medical man felt that he
must give his patient draught and boluses for which he could charge him,
he was in a pitiable position and too likely to persuade himself that his
drugs were useful to his patient because they were profitable to him.
This practice has prevailed a good deal in America, and was doubtless the
source in some measure of the errors I combated.

THE CONTAGIOUSNESS OF PUERPERAL FEVER.

This Essay was read before a small Association called "The Society for
Medical Improvement," and published in a Medical Journal which lasted but
a single year. It naturally attracted less attention than it would have
done if published in such a periodical as the "American Journal of
Medical Sciences." Still it had its effect, as I have every reason to
believe. I cannot doubt that it has saved the lives of many young
mothers by calling attention to the existence and propagation of
"Puerperal Fever as a Private Pestilence," and laying down rules for
taking the necessary precautions against it. The case has long been
decided in favor of the views I advocated, but, at the time when I wrote
two of the most celebrated professors of Obstetrics in this country
opposed my conclusions with all the weight of their experience and
position.

This paper was written in a great heat and with passionate indignation.
If I touched it at all I might trim its rhetorical exuberance, but I
prefer to leave it all its original strength of expression. I could not,
if I had tried, have disguised the feelings with which I regarded the
attempt to put out of sight the frightful facts which I brought forward
and the necessary conclusions to which they led. Of course the whole
matter has been looked at in a new point of view since the microbe as a
vehicle of contagion has been brought into light, and explained the
mechanism of that which was plain enough as a fact to all who were not
blind or who did not shut their eyes.

O. W. H.

BEVERLY Farms, Mass., August 3, 1891




HOMOEOPATHY AND ITS KINDRED DELUSIONS

[Two lectures delivered before the Boston Society for the Diffusion of
Useful Knowledge. 1842.]

[When a physician attempts to convince a person, who has fallen into the
Homoeopathic delusion, of the emptiness of its pretensions, he is often
answered by a statement of cases in which its practitioners are thought
to have effected wonderful cures. The main object of the first of these
Lectures is to show, by abundant facts, that such statements, made by
persons unacquainted with the fluctuations of disease and the fallacies
of observation, are to be considered in general as of little or no value
in establishing the truth of a medical doctrine or the utility of a
method of practice.

Those kind friends who suggest to a person suffering from a tedious
complaint, that he "Had better try Homoeopathy," are apt to enforce their
suggestion by adding, that "at any rate it can do no harm." This may or
may not be true as regards the individual. But it always does very great
harm to the community to encourage ignorance, error, or deception in a
profession which deals with the life and health of our fellow-creatures.
Whether or not those who countenance Homoeopathy are guilty of this
injustice towards others, the second of these Lectures may afford them
some means of determining.

To deny that good effects may happen from the observance of diet and
regimen when prescribed by Homoeopathists as well as by others, would be
very unfair to them. But to suppose that men with minds so constituted
as to accept such statements and embrace such doctrines as make up the
so-called science of Homoeopathy are more competent than others to
regulate the circumstances which influence the human body in health and
disease, would be judging very harshly the average capacity of ordinary
practitioners.

To deny that some patients may have been actually benefited through the
influence exerted upon their imaginations, would be to refuse to
Homoeopathy what all are willing to concede to every one of those
numerous modes of practice known to all intelligent persons by an
opprobrious title.

So long as the body is affected through the mind, no audacious device,
even of the most manifestly dishonest character, can fail of producing
occasional good to those who yield it an implicit or even a partial
faith. The argument founded on this occasional good would be as
applicable in justifying the counterfeiter and giving circulation to his
base coin, on the ground that a spurious dollar had often relieved a poor
man's necessities.

Homoeopathy has come before our public at a period when the growing
spirit of eclecticism has prepared many ingenious and honest minds to
listen to all new doctrines with a candor liable to degenerate into
weakness. It is not impossible that the pretended evolution of great and
mysterious virtues from infinitely attenuated atoms may have enticed a
few over-refining philosophers, who have slid into a vague belief that
matter subdivided grows less material, and approaches nearer to a
spiritual nature as it requires a more powerful microscope for its
detection.

However this may be, some persons seem disposed to take the ground of
Menzel that the Laity must pass formal judgment between the Physician and
the Homoeopathist, as it once did between Luther and the Romanists. The
practitioner and the scholar must not, therefore, smile at the amount of
time and labor expended in these Lectures upon this shadowy system;
which, in the calm and serious judgment of many of the wisest members of
the medical profession, is not entitled by anything it has ever said or
done to the notoriety of a public rebuke, still less to the honors of
critical martyrdom.]



I

I have selected four topics for this lecture, the first three of which I
shall touch but slightly, the last more fully. They are

1. The Royal cure of the King's Evil, or Scrofula.

2. The Weapon Ointment, and its twin absurdity, the Sympathetic Powder.

3. The Tar-water mania of Bishop Berkeley.

4. The History of the Metallic Tractors, or Perkinism.

The first two illustrate the ease with which numerous facts are
accumulated to prove the most fanciful and senseless extravagances.

The third exhibits the entire insufficiency of exalted wisdom, immaculate
honesty, and vast general acquirements to make a good physician of a
great bishop.

The fourth shows us the intimate machinery of an extinct delusion, which
flourished only forty years ago; drawn in all its details, as being a
rich and comparatively recent illustration of the pretensions, the
arguments, the patronage, by means of which windy errors have long been,
and will long continue to be, swollen into transient consequence. All
display in superfluous abundance the boundless credulity and excitability
of mankind upon subjects connected with medicine.

"From the time of Edward the Confessor to Queen Anne, the monarchs of
England were in the habit of touching those who were brought to them
suffering with the scrofula, for the cure of that distemper. William the
Third had good sense enough to discontinue the practice, but Anne resumed
it, and, among her other patients, performed the royal operation upon a
child, who, in spite of his, disease, grew up at last into Samuel
Johnson. After laying his hand upon the sufferers, it was customary for
the monarch to hang a gold piece around the neck of each patient. Very
strict precautions were adopted to prevent those who thought more of the
golden angel hung round the neck by a white ribbon, than of relief of
their bodily infirmities, from making too many calls, as they sometimes
attempted to do. According to the statement of the advocates and
contemporaries of this remedy, none ever failed of receiving benefit
unless their little faith and credulity starved their merits. Some are
said to have been cured immediately on the very touch, others did not so
easily get rid of their swellings, until they were touched a second time.
Several cases are related, of persons who had been blind for several
weeks, and months, and obliged even to be led to Whitehall, yet recovered
their sight immediately upon being touched, so as to walk away without
any guide." So widely, at one period, was the belief diffused, that, in
the course of twelve years, nearly a hundred thousand persons were
touched by Charles the Second. Catholic divines; in disputes upon the
orthodoxy of their church, did not deny that the power had descended to
protestant princes;--Dr. Harpsfield, in his "Ecclesiastical History of
England," admitted it, and in Wiseman's words, "when Bishop Tooker would
make use of this Argument to prove the Truth of our Church, Smitheus doth
not thereupon go about to deny the Matter of fact; nay, both he and Cope
acknowledge it." "I myself," says Wiseman, the best English surgical
writer of his day,[Edinburgh Medical and Surgical Journal, vol. iii. p.
103.]--"I my self have been a frequent Eye-witness of many hundred of
Cures performed by his Majesties Touch alone, without any assistance of
Chirurgery; and those, many of them such as had tired out the endeavours
of able Chirurgeons before they came hither. It were endless to recite
what I myself have seen, and what I have received acknowledgments of by
Letter, not only from the severall parts of this Nation, but also from
Ireland, Scotland, Jersey, Garnsey. It is needless also to remember what
Miracles of this nature were performed by the very Bloud of his late
Majesty of Blessed memory, after whose decollation by the inhuman
Barbarity of the Regicides, the reliques of that were gathered on Chips
and in Handkerchieffs by the pious Devotes, who could not but think so
great a suffering in so honourable and pious a Cause, would be attended
by an extraordinary assistance of God, and some more then ordinary a
miracle: nor did their Faith deceive them in this there point, being so
many hundred that found the benefit of it." [Severall Chirurgicall
Treatises. London.1676. p. 246.]