POSITIVE MEDICINE. Br J. R. Uhler, M.D., of Baltimore, Md 
II ad before the Baltimore Academy of Medicine June sth, 1888. 
The subject I have chosen is Positive 
Medicine. What is meant by that term? 
Is there any such thing as Positive Med- 
icine? and if so, what is its scope? These, 
and many other questions, require con- 
sideration; but for the present it will 
only be necessary to say that Positive 
Medicine is that which we are certain 
of, positive about, and that will stand 
the closest scrutiny. It includes all the 
truths imparted during the medical cur- 
riculum, embracing the known facts of 
anatomy, physiology, surgery, obstetrics, 
practice, chemistry, physics, therapeutics, 
and hygiene, so far as they relate to the 
healing art. From feeble beginnings it has 
grown to importance, and now lies scat- 
tered through many tomes and the brains 
of the world. You know a little of it, 
and so do I, but what it needs is some 
“Gradgrind” of the profession, with pa- 
tient industry, to systematize and develop 
it, as he incessantly searches for nothing 
but facts. In this paper I desire to em- 
phasize some of these facts, to make 
the way plain for this coming man, so 
that out of feeble endeavors there may 
come forth some good. “Life is short,” 
and as men become older they get tired 
of screening a mass of chaff for one kernel 
of truth. The medical profession is in 
great need of a compiler and condenser, 
one who will extract the honey for them 
in a few well chosen words. Writers 
could help him, if they would only have 
their new ideas or facts printed in a 
different kind of type from the padding 
or vest of the article, but 1 am afraid 
when they came to look over it for this 
purpose the majority would find so little 
originality, they would cease writing for 
very shame. It is a great thing, when 
writing, to be positive, well provided 
with facts,?iW&to be able to say “/know 
but it is greater to be able to prove these 
facts mathematically for the satisfaction 
of others. In geometry and some other 
branches we have what are called axioms, 
or self-evident truths, things that cannot 
be made plainer by any demonstration. 
So also in medicine there are facts evi- 
dent to all. For instance, we know that 
people all die; that they do not live a 
thousand years; that all sick of a certain 
disease do not perish from that disease, 
and that many drugs have certain effects. 
AH this is a matter of daily observation, 
not of your observation or mine, but one 
of universal experience, where all agree. 
The number of such facts may be great 
or small, but whatever their sum they 
belong to Positive Medicine. Lot us 
examine some of these facts in detail and 
see what will be the outcome and what 
is the degree of certainty in medicine. 
Some say medicine is an art, others a 
science, but we think it both, and if 
there are any laws of health and disease, 
then all must admit it. Practically we 
doso by the formation of boards of health, 
etc.; and so trusting do we become that 
they are given very arbitrary power. 
Whether this is wise or not I do not pro- 
pose at present to discuss, but shall pro- 
ceed to my subject by assuming all the 
assertions of medicine as a whole to be 
an unknown quantity X, which for con- 
venience, (since there are nine branche-) 
we will call 9, or W, and by asking if 
there is anything positive or certain in 
anatomyf You look astonished and say, 
why the whole ot gross anatomy is cer- 
tain,' it is the very groundwork of our 
profession. Then let us put down on the 
blackboard that some thousand or more 
assertions in anatomy are all true, that 
is to say the whole of one branch is posi- 
tive, one part of X ready to be found. 
How about chemistry? Is there any 
truth in chemistry? Why the world 
would not hold together if it were not 
for chemistry and physics, and our bod- 
ies likewise would fall to pieces, They 
are the most positive of all sciences. We 
will, therefore, also put down these two 
branches as certain, and by calculation, 
say f, or 2 more parts of X are ready to 
be found. By this kind of exclusion and 
addition, I or 3 parts of X are made 
certain. But there are other branches 
that are not egual to this I but occupy 
a lower position. How will we find 
them? Take physiology for example! 
How is it with this branch? A glance 
shows it to be partly built up3n 
general chemistry, and that part, of 
course, must be true; so also that which 
is founded on physics. But are we not 
likely to be deceived by phenomena and 
reactions that cannot be seen, and, there- 
fore, but imperfectly understood? We 
certainly are, and on this account, after summing up all the available facts, 
must make allowance, and say that I 
of Physiology is not proven, and, there- 
fore, probably untrue; so for convenience 
we will put down physiology as f true, 
I uncertain, and this I of X by so much 
wanting. But some may ask where do 
you get these figures? Are they im- 
pressions. or the result of study? Both, 
and they may not be absolutely true, 
since “judgment is difficult,” but are 
sufficiently so for our purpose, as they 
come from adding up the generally ad- 
mitted facts in physiology, and compar- 
ing them with the whole number of 
assertions found in the text books of that 
branch. Besides this they are likely to 
be changed and improved by sifting and 
discovery as facts accumulate and time 
goes by, and that is my object in pre- 
senting them for criticism. 
In the practice of medicine we have to 
make such calculations as are possible 
but it is hard to find out the whole num- 
ber of assertions in this a part of X,and 
when found it is still more difficult to 
sift the true from the false. We are 
sure, however, we can combat many 
symptoms, certain we can cure an ague, 
stop a pain, open the bowels, cure syph- 
ilis, conduct some self-limiting diseases 
to their termination; positive we can 
cure the itch, can over-neutralize an acid 
or alkali in the stomach, break up sar- 
cina in vomit, can assist nutrition by 
helping digestion, can cure rheumatism., 
or, at least, modify it and stop the pain, 
cure diarrhoea, check dysentery, but in 
purely medical cases we can do little but 
ameliorate symptoms, and prevent bad 
complications, leaving to nature the cure. 
Take a self-limited disease, typhoid fever 
for example; we may reduce the temper-1 
ature,feed the body, regulate the bowels, 
and perhaps when the abdominal walls 
are thin,kill or modify the germs by the 
internal and external application of 
heat* or antiseptics, and otherwise make 
the patient comfortable, but the disease 
generally lasts many weeks in spite of 
us. Some think we can cure cerebro- 
spinal meningitis, by bin-iodide of mer- 
cury or antipyrin, and we know that we 
can stop> spasmodic croup, but in medi- 
cine proper the number of diseases that 
can be cured is small—how small must 
be determined by statistics. An exami- 
nation of one medium-sized practice of 
medicine shows that there are 155 com- 
mon medical,including the self-limiting 
diseases, and for 56 of these we can do 
something, either in the way of relief or 
cure, that is about Another practice 
gives us 242, with 6S curable, equal to 
/A, rather nearer I than not a very 
flattering exhibit to be sure, and when 
the largest books are considered it will 
probably be I or less, say A, and at this 
figure we will put it down. A more 
positive result can only be reached by 
much labor through the ordinary numer- 
ical method, comparing cases of the same 
kind together, being careful about the 
diagnosis, prognosis and treatment, and 
until this is done for every- disease all 
over the world, one of the factors will be 
by so much deficient. 
Materia medica and therapeutics is 
tnore exact than I anticipated, for after 
an examination of 524 remedies de- 
scribed in our text-books, I find that 218 
are known to frequently work, 
116 are untrustworthy, and about of 
the whole, or 108' are very active, and 
this is probably the correct answer to 
Prof. Partholow’s question of the “De- 
gree of Certainty in Therapeutics.” The 
drugs that may be considered as acting 
with positiveness are chloroform, mor- 
phia, chloral, belladonna, bi-chlo)'ide of 
mercury, etc., and are too well known to 
require repetition. There are probably 
more unsupported assertions in hygiene 
than in most of the other branches, and 
it must ever be so until more is known 
about the causes of disease. One hobby 
that meets with almost universal accept- 
ance is dirt as a cause of disease, and 
for the sake of appearances, as well as 
civilization, it is well for the people to 
believe so, but when we come to abso- 
lutely prove are many difficulties 
in the way. There are some things, 
however, that we do know in hygiene, 
and when they are compared with such 
as are uncertain, the proportion will be 
about Aof the whole. Obstetrics is very 
certain, though 1 cannot agree with 
all that is neglected and done, and there- 
fore will put down its degree of proba- 
bility at ft. Surgery comes nearer to 
perfection than the practice of medicine, 
and taken all together equals obstetrics, 
which might be considered one of its 
*See Sternberg’s work as to the degree at which the 
typhoid bacillus is killed, viz. 132.8 Far. branches. Of late years it has made gi- 
gantic strides, and even within the last 
month the diagnosis and treatment of 
intestinal wounds has been so much im- 
proved that we wonder, with the plumb- 
ers all around, we did not think of it 
before. Senn, of Milwaukee, has been 
arousing the West with his work, and 
already the whole world has heard of it. 
By injecting one or more gallons of hy- 
drogen, under pressure varying from J 
to 2 pounds to the square inch into the 
rectum, he has been enabled to light the 
gas as it escapes trom a tube coming out 
of the mouth or wound, and thus positive- 
ly proves whether the parts be perforated 
or not. It is also applicable when obstruc- 
tion of the bowels is suspected, to find out 
if they be permeable, since the gas can 
.often be heard as it gurgles through 
the intestines, and \ipressure enough be 
used, it can be forced out of the month. 
This, if safe, is an admirable plan, and 
Prof. Senn deserves great credit for 
thinking of and developing it, but it 
seems to me that it is open to the slight 
objection that perfectly pure hydrogen 
must be used if we would avoid it being 
said in medico legal cases, when the pa- 
tient dies, that we have helped to cause 
death by the arsenic in our zinc, or 
sulphuric acid forming arsenide of hy- 
drogen. Besides this it is troublesome 
to seal a tube in a wound to convey hy- 
drogen, and also difficult at times to pre- 
vent the gas from being expelled from, 
the rectum as it is injected, and where 
more than one wound is present, unless 
the gas be escaping in very large quan- 
tity, th" s also must be closed to prevent 
its exit at this place while dealing with 
the other. Moreover, since hydrogen, 
mingled with a certain proportion of 
oxygen, or air, is explosive,risk will be 
run if we are not very careful when it is 
lighted. It appears to me, therefore, 
that it would be less dangerous and more 
simple to dispense entirely with the 
tube in the wound, and to use a wire 
frame with very small meshes, like 
Davy’s safety lamp, a short distance 
above the wound, and light the gas as it 
escapes through this, or perhaps it would 
be better to employ a gas, like carbonic 
acid, with a few drops of peppermint in 
it, that is more readily prepared and not 
open to these objections. As is well 
known to chemists, this gas, (when es- 
caping from the wound) instead of being 
inflammable would put out a light, as I 
have proved in intestinal wounds made 
upon animals. The best way of employ- 
ing it is by steady pressure from & four 
gallon bag, as suggested by Senn for hy- 
drogen, but where the external wound 
is small the gas might be rapidly in- 
jected by a good constantly flowing syr- 
inge, and in an emergency a strong pop 
bottle ox syphon might be used, the power 
of the gas as it is generated creating 
pressure and doing the work. Where 
perfectly pure hydrogen, or the chemi- 
cals to make it, can be readily procured 
1 would prefer it, used with the gauze 
as described above, especially where the 
permeability of the intestines is to be 
proved by its escape from the mouth, 
since the carbonic acid which has gone 
through the intestines might be mistaken 
for that which is supplied by the breath, 
but for abdominal wounds and general 
use, carbonic acid seems to be more 
handy. In the country where nothing 
better can be obtained, atmospheric air, 
impregnated with mint or spices, may 
ho forced into the rectum from a large 
bladder or syringe, and its presence be 
made manifest, either by the odor, by 
holding a light near the wound to see if it 
flares, or by ■placing the cheek and ear 
close to the wound, to both feel it fan and 
hear it as it escapes. There is one other 
fact in this connection that may prove of 
importance. Gas, when blown over a sur- 
face full of bacteria and excrement, like 
the interior of the rectum an d intestines, is 
very apt to widely disseminate poison or 
germs mechanically through the peritoneum 
and make all the difference between re- 
covery and death. Whenever gas, there- 
fore, is employed for the determination 
of intestinal wounds, a very careful toilet 
of the peritoneum will be necessary to pre- 
vent septic peritonitis, and the use of gas 
for the same reason should be for as 
short a time as possible. Before resorting 
to any of these gases or more troublesome 
devices in abdominal wounds, it would be 
well to examine the aperture with a lens, 
and then turn the patient with the ivound 
dowmvard upon a clean white plate, in 
order that blood, or anything extravasated. may run out and he caught upon this, and 
then test it by the microscope or chemical 
means. Thus in stomach wounds, food 
and starch, will sometimes be found in the 
''dish, and can be detected by its appearance 
or the addition of a small quantity of 
tincture of iodine, causing a blue color, 
and where the stomach, when perforated, 
is empty and vomiting absent we can give 
the patient some sugar of lead or tannic 
acid in water, in order that part of the 
solution may run out and be infallibly de- 
tected by appropriate tests, such as iodide 
of potash for the lead and iron for the 
tannic acid. The treatment of abdominal 
affections has also made corresponding ad. 
vances, and I think we are safe in putting 
down the truths of surgery at If. We 
have now examined the various branches 
of medical knowledge, and it is only ne- 
cessary to add up the work to make it 
complete. Reducing the fractions to the 
same denominator, we find that the nine 
branches, instead of being equal to the 
whole of x,or W, as was supposed in the 
beginning, are only equal to Vr, which is 
between f and f of that number, and ac- 
cording to this showing we are less than 
f as certain in the ivhote of medicine as we 
ought to be. If we wish to find out the 
degree of positiveness of diagnosis, prognosis 
and treatment in the three practical 
branches of medicine, surgery and obstet- 
rics, it will only be necessary to divide 
each of these into three parts, making 15 
branches in all, and proceed as we have 
already done. To render diagnosis at the 
bedside positive, the same numerical plan 
may be adopted, remembering, of course, 
that some diseases have pathognomonic 
or characteristic symptoms that enable us 
to decide at once with certainty, while 
others show resemblances that only the 
most skillful can distinguish. Were I 
writing a Practice of Medicine, or Surgery 
I would place at the head of each disease 
the number of symptoms, so that when we 
examinepstients the number would readily 
occur to us. Thus, for instance, when 
-dealing with inflammation I would say G 
symptoms, redness, heat, pain, swelling, 
interference with nutrition and inter- 
ference with function, and at the bedside 
would write them down, using the number 
found present as a numerator, and the 
number that ought to he there, according 
to the book, as a denominator, and in 
this way would become more or less posi- 
tive. If 5 out of the G symptoms of in- 
flammation (provided each had the same 
value) were present, we could he | sure it 
was before us, and so with other more ob- 
scure diseases. The greatest degree of 
diagnostic certainty is probably reached 
in eye diseases, because the eye is 
associated so closely with physics 
and with its lens resembles an optical 
instrument. “ The optic is the only 
nerve” says Loring “that is open to in- 
spection physiologically,” you can see 
its expansion, behold its blood vessels, 
notice their courses, the epithelium that 
shines through, the degenerations of 
nerve or bloodvessel, the injuries to both, 
we can even see the vessels pulsate, all 
this, and more than this, cupping of the 
disc, differences of level, and faults of 
structure does the ophthalmoscope show. 
Even the touch of the eye gives import- 
ant information, for its tension is almost 
diagnostic of a very serious disease. 
Is it any wonder then that so many who 
regard precision, should love the eye, 
and that situated as it is just below the 
dome of thought, looking upward and 
forward, but never backward it should 
become an emblem of progress, so great, 
that when we learn to use it well, care- 
fully as the flower of the body, there 
should bloom forth thoughts to fill the 
world. We have been speaking of facts 
gathered by this organ and I cannot 
leave the subject without soberly asking 
what have we contributed. I do not 
mean, what rehashes have we published 
in Medical Journals or what facts have 
been found and ignored but I do mean, 
what original work have we done, and 
made known, to pile and rub against 
the hard facts of others, that the moun- 
tain of truth may rise and shine. That 
it will shine is evident from the amount 
of certainty already attained, and from 
it many will kindle their torches as 
they “go onward to perfection” and be- 
come great lights in the Medical World. 
661 W. Fayette Street.