AN ADDRESS KEAD BEKOKE THE TENNESSEE MEDICAL SOCIETY, AT ITS TWENTY-THIRD SESSION1, JOHN M. WATSON, M. D., Prof, of Obslretrics and the Diseases of Women and Children, in the Medical Department of the University of Nashville. % NASHVILLE: JOHN T. 8. FALL, BOOK AND JOB PR—BEN FRAMKLIN OFFICB, COLLEGE iTREET. 1853. ADDRESS. Gentlemen:—Both the law and custom of this society make it necessary for me to read an address at this time on some medical subject, consequently I shall proceed without further apology to comply with that requisition, only I will promise not to consume an unreasonable portion of your time; others have to read essays, cases, &c. and our time must be divided accordingly. The subject I have selected may seem a little strange, and the views which I shall offer will be found not to take the 'beaten-track.' I have no pack-horse to drive that cannot turn either to the right or the left—feeling free from all such restraints I shall move in all directions and through all kinds of by-paths. It certainly accords best with the principles and designs of this society not to trudge along the beaten way, over which so many have gone along with almost use- less repetition, but to turn off in all directions whithersoever any thing new or valuable may offer itself, and bring all such materials at once before the society in such a way as to test their value. I will now propose' my subject—The varieties of diseases of the same species. Diversity as well as sim- ilarity is a law of diseases and should receive even para- mount consideration. Whatever scientific advantage may have been gained by a nosological classification of diseases has been more than counterbalanced by the practical evil which it has occasioned; to say the least, practice has gained but little by it, on the contrary, it has in many instances suffered loss. Systematic writers, intent on classifying diseases accord- ing to their outward signs of relationship, have greatly over- 1 looked, or viewed with too little concern, the great field now- presented, the varieties of the same disease—requiring for their production many general and local causes, acting sometimes from without and sometimes from within—engen- dering varieties of the same disease almost as distinct from each other as are diseases of different classes. This is a broad proposition, one to which wordy nosology may object, but which sound practice must ever admit, for diseases of the same species often differ more in a practical point of view than do those of even different classes. Scientific ar- rangements of diseases do not teach us how to cure them, nor indeed in the present state of medical science should it presume to do so. Then allow me to say that as medical science is at fault in that respect, let it be rather content with teaching us how it is that we cure any disease so that we may begin to regard our actually successful practice ra- tionally as well as experimentally. Theoretical researches would then be confided in according to the rationale of known results. This would be a safe way—even false rea- soning and erroneous conclusions would not effect known practical results; and if any errors obtained, they would be errors only of explanation. I would much prefer that the medical philosopher would explain to me the ra- tionale of certain palpable cures, than to presume to teach me how to cure diseases according to a series of reasons assigned apart from practical experience. Unfortunately rational argumentation and practical expe- rience are often found at open variance—a variance by the by detrimental alike to what is termed rational theory and experimental knowledge. Medical gentlemen should then labor to bring these two conflicting elements into agree- ment. Let that be accomplished and we can then fight dis- ease under the banner of science with a reliable watchword, that may be passed by the man of science and received by the practitioner of experience without injury to himself or his patients. But to return more particularly to the subject under con- *ideration:-Iustead of tracing out the similarity of diseases so an to arrange them in particular classes, orders, genera, and species, medical writers should have been more em- ployed in defining the diversities of diseases of the same species, as produced by climate, by sex, by age, by the con- stitution of the atmosphere, by the condition of the sanguif- erous system, by the state of the brain and nervous system, by national and individual habits, and by moral and physical peculiarities. These modifying influences from without and from within, sometimes operative and sometimes inopera- tive; at times in a high degree, and at other times in alow degree; now and then the patient being more amenable to their influence than at other times. How then I ask can any two cases even of the same species be precisely alike, or so much as not to require some difference in treatment? Varie- ties of the same disease must then ensue constantly from the numerous causes just stated; varieties which require more patient investigation, than all the vaunted resemblances of nosologists. Let us allow them, however, all their advan- tages, but, not content with these turn in an opposite direction and study with great care the diversities under con- sideration. Hence, gentlemen, I must digress a little, it is necessary for me to do so; and as digression is the order of the subject, the privilege I hope will be readily granted. I will now ask a question, What is disease?---not for the purpose of cate- chizing, but for illustration. This is a grave question and I claim for my reply one thing at least, that my answer shall be full and embrace the whole subject. The Greeks called disease pathos, and the Latins morbus, but the English word mortality is far better, in one of its significations, a subjection to death. Disease is a morbid action, and is a species of mortality, and mortality itself consists in a morbid action and is a species of disease. Then mortality is disease and disease is mortality! And if so, how shall we distinguish between physiology and pathology? I will reply, just as we do between different degrees of the same power; or as we do between varieties of the same thing. Then pathology is but an exalted physiology! Our mortality involves of ne- I.i cessity a pathological action, a morbid action, all the while. The necessity of dying, and an action constantly responding to that necessity, pervades every physiological movement of the system; every function partakes of it and ceases sooner or later under its influence, just as they do, yet more speedily under the movements denominated pathological. This phy- siology which is so much extolled in the books, called vital powers, phenomena of life &c, is but the carrying out of the sentence, "Thou shalt die." This dreadful sentence is often in that way executed independantly of whatis termed disease. No sooner was mortality impressed upon our nature, than did a morbid action begin—term it physiological, pathologi- cal, or as you may. When man was subjected to death, his physiological powers were constrained to take the way of death, though they remained capable of maintaining life for a definite period. So may we say of disease itself, when the system is subjected to a morbid action, of a higher grade, the vital organs continue to perform their functions for the maintainance of life, though it be for a shorter period. Phy- siology is then a life and death science, and pathology is on- ly an exalted mortality or an increased morbid action Hence we find it very difficult to distinguish, only in de- gree, the death element in physiology, from the same element in pathology. Man must die—it is a law of his nature—Man must die, is no less a law of many diseases. The death element pervades all animated nature, typifying the general and final death of all material things, while the life with which it is associated represents the forth coming of that general and final spiritual life which is to survive all materialism. And what if the materialist should exclaim, i(circu2us aseterni motus." The assertion alike repugnant to reason and revelation would merely indicate atheistical blindness. Man's disjunction from the tree of life has left him without a therapeutic remedy for his mortality. The world has since sought in vain for one; it would now be con- tent to obtain suitable and effectual remedies for that exalted mortality called disease. With this great object in view diseases have been variously classified-remedies likewise. 7 Nosologist have been much engaged in tracing out the simil- itudes of diseases so as to group them together in particular classes; then subdivide them again into orders, genera and species, and last though not least of all, varieties.—The dif- ferences of diseases of one class, are too great to be in- cluded in one order; and those of one order differ too much for one genera &c, but species, genera, order and classes may be all included under the term of the varieties of dis- ease. If the class of diseases denominated Cutanei did not extend their action beyond the skin, such a classification might afford some practical benefit; or if the class Febres con- sisted of an abstract or independent febrile action, it would be of some practical value; or, not to be tedious, if the class Neuroses implicated the nervous system only, something would be gained by such a classification. But there are too many exceptions, and too many differences for practical rules to be deduced from such arrangements of diseases. The Zoologist, Botanist, and Mineralogist have all in their way found great difficulties in classifying the natural mate- rials which constitute the basis of their respective sciences; and if the regular relationships of such materials be hard to classify, I ask what may we expect from attempts, to clas- sify the irregular disorders of a disordered action itself? Even if Nosologists were to succeed in giving us all the points of resemblance between diseases, it would not lessen the necessity of their presenting to us also their great diver- sities. This I again repeat has been too much neglected.— If all morbid action be based upon a general mortality, which, by the by, cannot be denied, we certainly would do well to study its varieties, and find out the great difference between them in a practical point of view, rather than group them together inisuch a way as to mislead us practi- cally. Some of these morbid actions are slow, very slow in- deed, almost as much so as the very mortality on which they are engrafted; others are active and extinguish life at once; some are simple and complicated; others general, and others local; some are curable and some incurable. Successful practitioners generally entertain the varieties which I have Q just mentioned for practical purposes. But my subject re- quires greater precision and further elucidation. I will recapitulate:—We have seen that a subjection of the life-forces to death involved necessarily a morbid ac- tion; and that if physiology be the science of life, it is of a life subjected to death; consequently all physiological action must have its mortal as well as its vital tendencies. How shall we separate or define these? Shall we call one mortal and the other vital, or shall we term them morbo-vital? This is certainly the best term, as one movement is never made independent of the other. The physiological action which sustains life at the same time exhausts to a certain though imperceptible extent the sources of its powers. Though it will be admitted that these two powers are not found always apparently in the same relation to each other. In childhood, youth and manhood the vital powers seem to predominate; but we should be aware that they are sustained in that high degree by an expenditure of the great sources of life, as is evidenced in the consecutive decline of old age. Hence what is gained in one respect is lost in another. Here we have something very analagous to the depression, debility, &c, of the vital organs which follow diseased action in those parts. Our physiological state as well as pathological requires partic- ular management; andthis variety of our mortality is greatly influenced by climate, the mean duration of human life being greater in some countries than in others; by professions, trades, and mode of life. These have a very appreciable in- fluence, with which all medical men are familiar. Here is free scope for that hygiene which has of late been so much neg- lected—the proper treatment for man's chronic mortality.__ This should be treated on principle at least, just as we would any other slow chronic malady, which in relation to the for- mer might be regarded as a kind of more acute mortality, while in relation to other acute diseases it would itself be considered chronic. Such acute diseases affect in a few moments, hours or weeks, as the case may be, what the slow, morbid action of mortality would not accomplish in many instances in a century. 9 So forsooth, one form of our mortality is a physological state, demanding hygienic treatment, and is modified by such treatment. The next variety is that of a patho-phy- siological state—a more acute form of mortality. This may be subdivided into general and local patho-physiological dis- turbances: 1st. Those of particular organs, as of the brain, spinal- marrow, nerves, heart, lungs, stomach, bowels, kidneys, bladder, male and female organs of generation, skin, mucus and serous membranes, muscular system, blood vessels, &c. 2. The influence of a general patho-physiological distur- bance on particular organs, and their reaction again on the general disturbance. Lastly, not to be tedious, the production of a general dis- order of the system by the patho-physiological derangement oi one particular organ—afterwards the reaction of such constitutional recognition on the diseased organ. I am aware that time will not admit of proceeding any fur- ther with this subject. Interesting as it is I must forbear and again take up the main proposition of this address, That diversity as well as similarity is a law of diseases. The fault in Nosology which I have been combating is, that it does not subserve practical purposes. Its main aim seems to be to set forth the points of resemblance in dis- eases which, I admit is commendable and proper; but we must not stop here, but finish that which the nosologist neglects. We must seek out the great differences in diseases of the same class, same order and genera, as well as of mere species. Who will deny the fact that diseases which seem to be very much alike are in point of practice very different; or that their great nosological likeness, in many instances, gives them no practical correspondence. Let us rather learn to distinguish one disease from another as we do one man from another, by the individual peculiarities of each. All men are human beings, and we cannot tell one man from another only by his own peculiar personalities, and every disease even of the same species, has its own individual character. We must not allow the similitude of maladies to obscure, or hinder us from seeing their varieties. n 10 We shall not improve in practice as our means for classi- fying diseases may increase, but on the contrary just as our facilities for studying particular diseases may be improved, so as to enable us to distinguish one variety from another, not only how very different in relation to each other, but in their indications of remedies. The treatment which they may require may be more differ- ent in the varieties of the same complaint than even in dis- orders of different classes. Take for instance the mild and worst form of Eczema—the ring worm and the persisting tetter—the mild yielding forms of scarlatina and its ma- lignant, incurable varieties—the simple catarrh and the peripneumony. There are intermediate grades from each of these extremes to the other, which must be studied in all their individual characters. Can there be two cases so much alike in all respects as to destroy their identity; if so, they would be identically alike, and without some difference any two things would be the same. Here for instance is a case, it has its identity, such an identity as makes it unlike any case that ever occurred before, that now exists, or ever will again, otherwise the law of diversity would fail and iden- tity would be lost! How shall such a case be studied? Not according to its identity with any case seen before by the prac- titioner, for it has none; nor by any read in the annals of med- icine, for it has no identity with such, but it must be studied ac- cording to its own individual identity, and must be treated ac- cording to its own individual indications—its indications be- ing as much its own as its identity.—We may, I admit, bring in as help to our investigations, all the knowledge we have of previous similar cases, and the treatment, or results of the treatment we employed, but we are not to rely im- plicitly on these, but should endeavor to detect the individ- ual peculiarities of every case. This difference in the varie- ties of the same disease which requires such different treat- ment, we should accustom ourselves to trace out with great care. In this way the diseases of the chest and heart have been studied of late according to their individual characters or identities. Percussion and auscultation have 11 enabled us to distinguish varieties in such instances, which were very different from each other as to the remedies indi- cated by each. We have now the means of studying each individual disease of the heart and lungs according to its own inherent identity; and the chief advantage of ausculta- tion and percussion is in ennabling us to study a disease in se, and not as formerly by associating it, in its general as- pect and symptoms, with some other case previously seen and treated. Auscultation and percussion have done far more good by developing the peculiar character of each particular disease of the organs just mentioned, in a practical way, than all the nosological labors of Cullen, Darwin, Good or Hosack have ever accomplished. It may be asked what bad consequences arise from classi- fying diseases? In reply I would state, it seems to favor em- pyricism, as far as the practitioner may attempt to provide a general remedy for a whole class, genus or kind of diseases. We must particularize and not generalize diseases or the re- medies which we employ. In fact the safe practitioner has to undo, in part at least, the very things which the nosolo- gist is at so much pains-taking to effect. It has already been admitted that the classification of diseases has done good, but we should also investigate diseases in an op- posite way. Having treated one case of a particular genus or kind of disease, we must not presume on the next case being precisely like the first in its indication of remedies, but look out for those differences which may cause us to treat the case differently from the first according to its own identical character. If such maladies be seated in the heart or lungs, the difference in them may be learned by percussion and auscultation, with great exactness; but if in the brain, spinal marrow, stomach, bowels, &c, how shall we then study them? Auscultation and percussion will avail but little, and we must turn our attention to other means which, though not so satisfactory, yet when carefully and patiently em- ployed v/ill reveal many dissimilarities in cases, the recogni- tion of which will probably alone enable the practitioner to u treat such dissimilar cases of the same kind of disease suc- cessfully Let us then turn our attention more directly to this subject and endeavor to adopt such means as will reveal to us those very occult differences, which when known modi- fy our treatment so much. Every safe practitioner con- stantly wishes to distinguish one case from another, however greatly they may resemble each other. He feels conscious that there is a difference, and he labors to detect it, that he may vary his treatment accordingly. The Doctor who is in quest of general remedies for the diseases of a genus or kind is in danger of news paper-quackery and the world is in danger of his general nostrums. Quacks, lazy doctors and ignorant pretenders have their vaunted general reme- dies—remedies which merge all the diseases of one class into a perfect unity. Whenever we shall get a test electrometer for the cerebro-spinal pathology, a dynamometer for the muscular system, and a gastro-enteretic test, which will enable us to examine into the patho-physiological state ot these organs, with as much certainty as we now learn that of the heart and lungs, quackery will be despoiled of more power than by any other means whatever. Shall we ever realize these advantages? Who shall confer them?— When the boon comes, most assuredly general remedies will fall! It may be asked where is the consistency in complaining of general remedies, seeing that we have a few which we commonly employ in most cases? Although we may use the same remedy in many cases, yet wre should employ them in degree so that they may produce effects more unlike than even those from different articles. For instance, suppose blood- letting be the means, how very unlike is the indication of the loss of one quart of blood from the arm by venesection, and one ounce by leeching or cups; or if calomel be the remedy, how great the difference between one or two grains as an alterative and twenty or thirty grains as a cathartic—and the same may be affirmed of all other remedies—giving free scope indeed for the many and great modifications which each individual case may require in the judgment of the discrimi- 13 nating physician. I repeat, the practitioner must dis- criminate and not generalize, both in the observation of the peculiarities of his cases, and in his corresponding modi- fications of his remedies. It is with diseases as with men. It is better to know each individual man according to his own identical character, than the particular way in which he may resemble others. We may possess the latter knowl- edge and yet be ignorant of the former. So we may know and recognise the outward signs of the resemblance of one disease from those of another, and yet be ignorant of those inward occult differences which should determine our modi- fications of remedies. Let us suppose for instance that we have three patients with pneumonia. One dies, one lingers and one gets well.— The enquiry should be, were they all treated alike? The indi- cations surely could not have been the same, although all three were cases of what nosologists term pneumonia. How very unlike must these cases have been—one dies, one lin- gers, and one gets well! How great were the differences in the cases, and no less different should have been the treat- ment, while probably all were treated pretty much in the same way. By means of percussion and auscultation and by testing the dynamic powers of the system, the treat- ment of each case might have been so skillfully modified as to have relieved all the cases. Two persons apply to the Dr., both have apparently the same cerebral affection. The lead- ing symptoms in each are pain in, and general fullness of the head, with other corresponding symptoms; both are treated alike; one gets well in a few hours, the other dies of appo- plexy as soon! What a difference in the results! How very different should these cases have been managed; and a very cautious, skillful examination of the two patients might have detected the true character of each case so fully as to have secured to each one a proper modification of the treatment necessary. But the great disinclination on the part of many to a close investigation of individual cases, and the great difficulty in doing so, deter many from adopt- in? this safe though laborious mode of practical procedure. 14 While on the contrary it is so much easier for the man of general remedies to prescribe for the name of a disease than for its peculiar individual indications. In the one case wri- ters' and others will tell him what to do, while in the other he has to find out the proper means in a goodly degree himself. This is difficult, requires much patience, close examination and deliberate consideration, and why trouble ourselves so much about the matter, since others have directed us how to treat all diseases of such and such classes! The name or species of a disease is not likely to have an undue influence on the mind of the safe and successful prac- titioner; but it is the identical malady before him with its pe- culiar characters, which engages his consideration, for these must modify his practice and by such modifications his pa- tient must be relieved, in his judgment, hence in his estima- tion they are of more importance than the name, genus, or kind of disease, in its general character. I ask you, gentlemen, how did Broussias, Leannec, Wil- liams and others investigate diseases? Not, I reply, as did Linneus, Young, Good and other Nosologists. Let us go and imitate their examples; let us study diseases in their individual characters. In conclusion allow me to remark, that the foregoing stric- tures have been brought forward with less order and delibe- ration than I desired; though the object in view has been probably gained, that of calling the attention of the medical gentlemen of this Society to the remarks just read, for their future examination and consideration. / / h,