'With, co mp Itments of the, Author. THE EFFICIENCY OF NATURE’S REMEDIAL MEASURES BY EDWARD YON DON HOFF, M. A., M. D. SURGEON TO THE WEST SIDE GERMAN DISPENSARY, NEW YORK MEMBER OF THE NEW YORK COUNTY AND STATE MEDICAL ASSOCIATIONS HONORARY CORRESPONDING MEMBER OF THE SURGICAL SOCIETY OF LOUISVILLE, KY. MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY, ETC. REPRINTED FROM THE NEW YORK MEDICAL JOURNAL FOR AUGUST 12, 1893 NEW YORK D. APPLETON AND COMPANY 1893 THE EFFICIENCY OF NATURE'S REMEDIAL MEASURES EDWARD YON DON HOFF, M. A., M. D. SURGE OK TO THE WEST SIDE GERMAN DISPENSARY, NEW YORK MEMBER OP THE NEW YORK COUNTY AND STATE MEDICAL ASSOCIATIONS HONORARY CORRESPONDING MEMBER OP THE SURGICAL SOCIETY OP LOUISVILLE, KY. MEMBER OP THE MEDICO-CHIRURGICAL SOCIETY, ETC. BY REPRINTED FROM THE NEW YORK MEDICAL JOURNAL FOR AUGUST 12, 1893 NEW YORK D. APPLETON AND COMPANY 1893 Copybight, 1893, By D. Appleton and Company. THE EFFICIENCY OF NATURE’S REMEDIAL MEASURES.* When I accepted an invitation to present to this body some views entertained by myself, in common, I doubt not, with a certain proportion of its members, with regard to this subject, many of the great difficulties in the way of doing so in a thoroughly intelligible and acceptable man- ner, especially as regards the younger contingent of our members, did not occur to me. But, as I have earnestly endeavored to blend the suaviter in modo with the fortiter in re, and avoided as much as possible the semblance of dogmatism, it is hoped that the chiefest obstacle to a pa- tient hearing on their part has been obviated. In order to properly begin a presentation of our subject matter, it seems fitting to recall a few elementary defini- tions. First, What is disease ? To simplify the answer, we may divide the phenomena recognized as evidencing dis- ease into two classes—first, those indicating merely func- tional and temporary disturbances of the body ; and, sec- ond, those indicating organic lesions and suggesting more * Delivered before the New York County Medical Association, June 19, 1893. THE EFFICIENCY OF or less persistent derangement of the bodily functions, based upon pathological changes of tissue. As affording a diametrical contrast to functional or or- ganic diseased conditions, we have the condition recognized as “ physiological equipoise ”—i. e., a status of the physical economy in which every function is regularly performed, and in which there exists no discernible or presumable organic lesion. The next inquiry demands a definition of the relative attitudes of the condition of physiological equipoise to the phenomena of functional or organic disease. Medical phi- losophy adheres to the proposition that the tendency of all pathological phenomena—functional or organic—is to spon- taneous disappearance; or rather to a disappearance as the result of either the increased vicarious functional activity of various organs of the body, or the combined increased activity of all the bodily functions. Given a condition of physiological equipoise at the period of invasion of the body by a diseasing influence, it is presumable that a healthful condition will supervene, unless, indeed, the in- vading element be of so overwhelming a character as to bring about such rapid, baneful modification of physical functions as to necessitate fatal organic changes, which ab- solutely forbid the re-establishment of the physiological activity of the parts so changed. In this event, either chronic diseased conditions result, or exitus. If the condition of the body be such, because of its general lassitude, even without specially marked functional disturbances, a cause of disease attacking it would find, as it were, a suitable soil for accentuating its presence. In such a state of affairs the automatic natural powers are at a disadvantage; but, even in the face of this truth, palpa- ble and oftentimes thoroughly successful efforts to throw off the disease, and even bring about in a given individual NATURE’S REMEDIAL MEASURES. 5 an extraordinary condition of general health, result from the spontaneous activity of such residual functional strength as remained to the individual at the period of attack, and which was successfully fostered by the discreet attendant. It is my purpose to emphasize as much as I may that all therapeutic measures which are of real avail in the management of all manner of clinical emergencies are and must of necessity be derived from an accurate observation of the play of natural forces. Hence it is of pre-eminent importance that a knowledge, or as much of it as is attain- able, of physiology, and the demands of physiological con- ditions, shall be brought to bear on the management of disease and the reconstruction of distorted anatomical con- ditions, and that the only safe or scientific method of pro- cedure is based upon these requisites; and, per contra, that empirical therapeutic adjuvants are only logically ad- missible when they are distinctly suggested by our knowl- edge of physiological processes, and are measurably chosen in harmony with them. It would be an endless task to my- self, and tax your patience too severely, to make of this paper an array of specific details with reference to the management of the sick and sore. I prefer, therefore, to limit myself to a weighing process of the portent of the more modern literature bearing upon this point, since, despite its high source and ostensibly authentic character, it appears to me to propound doctrines which either quite ignore the vis medicatrix naturae, or virtually affect to coun- terpoise it. Foremost in the ranks of these litterateurs are those who consider the destruction of a handful of mi- crobes by means of a germicidal therapeutics as not only necessary but all-sufficient in protecting the victim of dis- ease or injury from threatened or impending dissolution. If I succeed in pointing the fact that, despite their dog- matic assertions wdl-nigh to the contrary, Nature retains 6 THE EFFICIENCY OF for herself the maximum of power of final direction of the results of pathological processes, I shall have quite fully attained my purpose, and with it directed the current of a half-hour’s thought on your part into propitious channels. “ No profound acquaintance with the history of science is needed to produce the conviction that the advancement of natural knowledge has been effected by the successive or concurrent efforts of men whose minds are characterized by tendencies so opposite that they are forced into conflict with one another. The one intellect is imaginative and synthetic; its chief aim is to arrive at a broad and coherent conception of the relations of phenomena; the other is positive, critical, analytic, and sets the highest value upon the exact determination and statement of the phenomena themselves. “ If the man of the critical school takes the pithy aphorism 1 Melius autern est naturam secare quam abstra- here ’ for his motto, the champion of free speculation may retort with another from the same hand, '•Citius enim emer- gite falsitate quam e confusione,’ and each adduce abun- dant historical proof that his method has contributed as much as that of his rival to the progress of knowledge. Every science has been indebted to bold, nay, even to wild hypothesis for the power of ordering and grasping the end- less details of natural fact which they confer from the moral stimulus which arises from the desire to confirm or confute them ; and last, but not least, for the suggestion of paths of fruitful inquiry which, without them, would never have been followed.” “ From the days of Columbus and Kepler to those of Oken, Lamarck, and Boucher de Perthes, Saul, who, seek- ing his father’s asses, found a kingdom, is the prototype of many a renowned discoverer, who has lighted upon verities while following illusions which, had they deluded lesser NATURE’S REMEDIAL MEASURES. men, might possibly have been considered more or less asinine.” “ On the other hand, there is no branch of science which does not owe at least an equal obligation to those cool heads which are not to be seduced into acceptance of sym- metrical formulae and bold generalizations for solid truths because of their brilliancy and grandeur ; to the men who can not overlook those exceptions and insignificant residual phenomena which, when tracked to their causes, are so often the death of brilliant hypotheses; to the men, finally, who, by demonstrating the limits to human knowledge which are set by the very conditions of thought, have warned mankind against fruitless efforts to overstep those limits.” * Yet truths, as such, must often be accepted without be- ing perfectly understood as to their origin, and the con- comitant circumstances that gave rise to, and finally result- ed in, their establishment as accepted expressions of fixed laws of Nature. Thus the mind with facility grasps the attitude of the observer who framed the proverb which is synonymous with the subject of this discourse, as having noted in every animate form an inalienable tendency to con- serve its own existence and prosperity, even at the expense of that of weaker organisms, and that the rejoinder of the lad who, having had pointed out to him by his observant tutor the quick eye and dexterous movement of the crane as it darted its head into the water and caught a passing fish, “ That is well enough for the crane; but how about the fish ? ” is but a homely epitome of the law of existence. So it is in the endless cycle of life: the stronger preys upon the weaker to the end and purpose of the survival of the fittest, and a common progression of the residuum to- ward a higher plane. It is not the province of either philosophy or science to * Huxley. 8 THE EFFICIENCY OF do other than rigidly interpret what they may of natural law as they find it, and to adapt their teachings solely, and freed from hypothetical chimera, to that law, never for- getting that coercion here portends only the exitus of reason. It is distinctly the high prerogative of the physician to interpret with peculiar sincerity natural law, but it would seem that, despite the basic philosophy of his vocation, he is led., by desires which outstrip the pace of indisputable acquisition of knowledge, to indulge an ambition which, however commendable in itself, having ostensibly for its foundation the hope of lessening human suffering, too often launches the votary into turbulent seas of imperfectly ana- lyzed data and irrelevant, though never so beautiful, kaleido- scopic speculations. Nowhere else, as in the field of medicine—within the realm of what should be strictly philosophic teaching, and which does and should plume itself most acceptably when its precepts are based upon axiomatic premises—do there exist such emphasized and withal such insurmountable (?) contradictions in terms. And it does not appear that these fallacies become less obstinate because of the capacity and willingness, on the part of some who do not accept ex cathedra the assertions of their authors, to demonstrate such errors ; and, per contra, offer the safest, being truthful and in keeping with the truth, substitutes for them. The chief difficulty, I take it, in the way of a natural solution of the errors which almost overshadow the, hand- ful of established truths upon which scientific tlierapeusis is based is to be found in the more or less fantastical em- bellishments with which modern teachers and writers are wont to garniture their labors with their disciples. The hot race for distinction and priority, and all the rest of the tinsel and particolored plumage of proclaimed eminence NATURE’S REMEDIAL MEASURES. and pre-eminence, makes even of the should-be staid man of science an exuberant enthusiast; and hence dogmatic as- severation of half-fledged theories, which have grown out of purely impractical speculation, with the slightest sem- blance of or no foundation at all in experience, fill volumes upon volumes, each of which purports to be the “ latest, best, and most undeniable treatise of any yet extant ” upon any one of the host of topics with which the wise (?) men of our era employ themselves. The cheapness of reputa- tion is unfortunately greater than in the day of the Roman philosopher and statesman who wished only that his “ ene- my would write a book.” To write a book in this our day is almost synonymous with creating one’s self an authority (?), provided, indeed, that the writer does not differ too widely from the particular fad of a preceding one on the same subject, or does so dia- metrically, and supports his tenets with such an intermin- able array of arguments, whose matter is made to fit the occasion, that he compels the plaudits of that element in the profession of medicine identical in mental caliber with the mass of groundlings whose voices rend the air in appre- ciation of the loudest-mouthed stump orator. The modest reticence which so charms the layman into profound respect for its possessor, as he contemplates the true votary of the healing art, is born of an inner conscien- tiousness which, were its true cause—paucity of real knowl- edge in the possession of the object of his admiration— known to him, would, perhaps, change this admiration into scoffing unbelief. This characterization of the layman is not unlike the relative attitude of the wonder-dazed embryo medicus, who stares open-mouthed at his wisdom-enshrined (?) modern professor of bacteriology as he isolates with a precision all his own this, that, or the other coccus, and so interposes his 10 THE EFFICIENCY OF skillful dexterity between the life and death of his charge. He, too, might scoff with better reason when he grasps the fact that the dogmatic dicta of his master are hut the would-be-realized vaporizings of a dream, and it is at this point that ever-watchful sophistry and, worse, charlatanry stand guard at the elbow of the false prophet, and over- shadow with impenetrable mysticism the would-be-cunning vision of his inquisitor. There was a time not long past when the “ ’prentice boy ” about to enter the laboratory of his master surgeon received parchments proposing to teach him the “ art and mystery ” of his calling. The art was small; the mystery great, profound, and overwhelming. His art, if true, con- sisted in crudely demonstrating certain oft-met experiences more or less well understood by himself, and proportionately well taught his fledglings. The mysteries consisted in cloaking the not well understood phenomena of disease and injuries with draughts and plasters relatively harmless when the patient’s residual strength was sufficient to pro- tect him from their influence, and all potent for evil when no such good fortune befriended him—he died, despite the good offices of the master. Harvey, the true father of modern physiology, opened what seemed to be the flood-gate of medical philosophy when he discovered the mechanism and office of the little trip-hammer force-pump—the heart—the whole economy subservient to its movements as it pushes on the flow of the red current of life, that conveys in its myriad cells the food to foster it, and in its waters a detergent for its nox- ious enemies. Much as we are disposed to foster with our admiration this great philosopher, as the impetus of modern research, we may not leave off as a part of correct history, as we gather from the study of the papyrus the fact that the Egyptian priests probably knew, as did Harvey, the func- NATURE’S REMEDIAL MEASURES. tions of the heart, as well as those of the vascular systems directly and indirectly connected with it. It would seem that, having attained a certain height in the course of their inductive reasoning, they, as does the modern investigator, reached a point when their reasoning no longer served the purpose of their vaulting ambition to be all wise, and was promptly overshadowed by plausible hypothesis and its equally plausible fruit—empiricism. It may not truth- fully be gainsaid that by means of now better understood and applied laws of physics and chemistry—among the most powerful products of which stand the modern imple- ments of exact information—the store of curious but, for the nonce, measurably practically inapplicable facts has not been largely increased; nor can it be disputed that from this store there have been deducted some laws clearly tributary to the prevention of human ailment. Observe these narrowly ; observe them in their wonderful simplicity, and it would seem that the human intellect that could not grasp with ease their portent and significance and picture with facile exertion the direful result of their absence or inactivity must be puerile indeed. Study them, however, as they appear hidden in the maze of sophistical “ pros and cons ” of the modern bookwriter—I had almost said scripto- maniac—and it does not tax the imagination severely to evoke again the phantom of a century since which taught the “ arts and mysteries ” of its calling. Truth is of unique beauty, sublime in its simplicity, hallowed by its rarity; destined solely for good, it is read- ily grasped by him whcr seeks after it and would become its faithful purveyor and make it to bless the needy and teach the unadvised. The tenets of modern writers who defend with an ex- clusive dogmatism the theory that all disease is due to an invasion of the physical economy by microbic hordes is 12 THE EFFICIENCY OF neither in the particular that they promulgate such doc- trines, nor in the character of their defense of it, new with them. Among the earliest writers similar views were en- tertained and defended in a similar fashion. Perhaps if the Dutch spectacle-maker Jansen, who by accident dis- covered the wonderful powers of a globule of glass which had fallen from a rod of that substance which he was melt- ing, had not been born and had not thus given the initial momentum to the construction of much of the parapherna- lia of the modern laboratory and its myriads of instruments for exact (?) investigation, no one would be answerable now for the ponderous tomes announcing the era-revolutionizing truths (?) promulgated by the modern bibliomaniac and om- niscient microbiologist. Historic lore credits an ancient philosopher who, near the close of a long life, had in his own words “ inflicted the eagerly suffering voluntary student of his works ” with many tomes of his written thoughts and observations with this confession to one whom he loved next himself, and who thus importuned him: “ O beloved master, whence did you glean this marvelous store of wisdom ? ” “ By,” he answered, “ hoping incessantly that mine eyes saw aright, and that at some day in the future some one nearer the gods than myself may succeed in proving to be true a little of that which I have written. For myself, I am as yet conscious only that I know nothing.” From the very nature of the surroundings it would be inadmissible to conjecture that Koch, Pasteur, et al. have written with similar empirical foundation the teachings that set the world agog; and yet, if but the very essence of truth contained in their enunciations were isolated and ar- ranged side by side with a front as impenetrable as that of a Roman phalanx, the phalanx would dwindle into con- temptible insignificance before the pompous magnitude of NATURE’S REMEDIAL MEASURES. the hypothetic possibilities deduced from these little gleam- ing sparks of not yet perfectly pondered truths. Yet the world would not willingly part with these; nor could it if it would; for truth is indestructible; but let the world use it stripped of dangerous confusing and with all plausible conjectures, the benefits growing out of them in their naked simplicity will sufficiently compensate. When Lister, more than a score of years since, directed the attention of the medical profession to the necessity (?) of inveighing therapeutically against certain general influ- ences which he considered responsible for most of the ill- success attendant upon surgical exploits, he at the same time promulgated his teachings with such zest and enthu- siasm and measured the results obtained by him under the new order of things with an eye so exclusively alert to all manner of wondrous possibilities as growing out of the correct technique of his prescribed method, that the whole surgical world wondered, and a large part of it more or less blindly followed his lead. I must not be understood as wishing in the least to de- tract from Sir Joseph’s merited laurels, but those who pa- tiently engaged in the same line of studies as led him to his conclusions, and observed closely the tide and portent of events as time progressed and experience accumulated, witnessed retraction after retraction of their erstwhile ve- hemently asseverated allegations on the part of the antiseptic school until they were forced, first, to yield the distinguish- ing title—antiseptic—which they had chosen, and next to confess the impossibility of preventing the invasion of wounds or the blood by mischievous micro-organisms by those very means which had but lately been adjudged in- fallible. Finally, when other and stronger detergents were brought into use, the great danger to life growing out of their application to wounded surfaces in such strength as 14 THE EFFICIENCY OF had been found necessary to destroy the vitality of the organisms more feared, necessitated a refuge to the simplest and most natural measures known, to which at this mo- ment they concede all desirable efficiency—namely, hot water and chloride of sodium. Meanwhile, as experience grew apace under the new (?) regime, the necessity of an accurate technique with regard to the manner of making surgical wounds, to proper drainage, and to the prevention of even the least haemorrhage after their closure, by suture or otherwise, emphasized itself. Now, add to these well- established principles—all in imitation of the spontaneous phenomena of Nature, occurring under provident circum- stances—the rules of practice requiring the use of clean hands and mechanical implements, and the thorough cleans- ing of the surface which is to be the site of the surgical wound, and we have the sum total of what can be proved to be the sole foundation of surgical success, so far as hu- man precaution can contribute to it. This is asepsis—the condition which Nature demands and which a state of physiological equipoise provides in the individual who has been wisely selected and properly prepared for a surgical ordeal. Again, though the mischievous impression was left by the earlier and more uncompromising and glowing expo- nents of Listerism that many of the most unpromising and extreme conditions of exhaustion attendant upon surgical emergencies might be, with the aid of antiseptic addenda, almost, if not quite, ignored in making up prognostic sum- maries, it is safe to say that no philosophically trained surgeon or physician ever acquiesced in these ridiculous boasts. Yet it is true that such promulgations were and are still responsible for most fallacious and detrimental prac- tices among that somewhat extensive class of physicians who rarely stop to weigh the brilliant statements which are NATURE’S REMEDIAL MEASURES. 15 often made upon exceedingly slender foundation and upon exceedingly tolerant paper. In conclusion, it is not intended to stigmatize those who from sincere conviction adhere to the new doctrines and literally and apparently unquestioningly carry out its pre- scriptions. But every one may rightly claim the preroga- tive of demanding indisputable proof for the faith which he is asked to adopt. As for myself, I repudiate a doctrine which, as I understand it, atfects to ignore in the spirit the necessity of subscribing to the axiom that, especially in medicine, “true science is the handmaid of Nature,” and can only become an adjuvant to her when it is tributary to the increase of natural conservative power by natural means, where such is lacking. And, further, I submit that however efficient as germicides certain chemical agencies may prove to be in the laboratory, the same impracticabil- ity attends them in their adaptation to clinical issues, and renders the effect of their use here either nil or mischiev- ous, as is the case with respect to the effect of many of the so-called chemical preparations, presumably prepared with the nicest precision as supplemental ingesta, intended for the correction of certain qualitatively defective conditions of the blood and tissues. I submit that unless the inherent residual vis resistentice naturalis vouchsafes recovery, no man has yet attained the means of compelling such an issue artificially. REASONS WHY Physicians Should Subscribe FOR The New York Medical Journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 1. BECAUSE: It is the LEADING JOURNAL of America, and contains more reading matter than any other journal of its class. 2. 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