Imagens das páginas
PDF
ePub

than any of the internal cutting or divulsing operations. At the present time he has under observation a notable case, in which the stricture had become impermeable. The patient always had dreadful chills after manipulation, and was, in fact, on the verge of the grave. External perineal urethrotomy without guide was performed in January last. He is now going about much improved and constantly improving. He passes a No. 16 E. steel sound as well as a creditable stream of water, and the perineal wound is very nearly healed up.

Report of the Section on Practice.

REFLECTIONS ON PRACTICE,

BY A. B. ARNOLD, M. D.

One of the most cheering signs of the advancement of practical medicine at the present day is the increased attention which is now paid to the study of therapeutics. Experimental investigations are doing for therapeutics that which they have accomplished for other branches of medical science. As much importance is beginning to be attached to the working of the humblest drug as to the contortions of the laboratory frog. Formerly it was asked how a remedy acts, before it was known what it could do. Precision is sought for where it was sorely needed, and this has created the new department of pharmocology. Already the important results of pharmocological studies has raised expectations which are encouraging to the conscientious physician. It is refreshing to meet with the following language from a quarter where skepticism used to be the order of the day. Prof. Rossbach, on the occasion of taking the chair of Practice of Medicine at the University of Jena, says: "I openly declare, with all the force of a strong conviction, that the physician who is furnished with the means which medical science of the present day places at his disposal, no longer engages in a useless fight with, at least, the curable diseases, and that he need not surrender his arms baffled and undeceived."* Lander Brunton,† discussing the same subject, is even tempted to indulge in a flight of rhetoric: "Every

*Address on the present condition of Internal Therapeutics. Berlin, 1883. +Goulstonian Lectures.

day," he says, "is enriching medical science with some discovery; diseases are beginning to be traced more precisely to their origin'; the action of remedies is being more exactly defined and localized. Order is beginning to appear amongst the crowd of new acquisitions to our knowledge, and isolated facts begin to range themselves under general laws. Slow has been the advance of medicine, because she went astray; now the path she follows is right, swift and glorious will be her future." In the meantime the medical profession will have to bear with much adverse criticism, not because of any lack of solid information or for a want of zeal to extend the boundaries of its usefulness, but for reason that medical treatment falls short in its contest with diseases destructive and fatal in their nature. The general public is not aware that under these circumstances impossibilities are expected of the physician, and inevitable failure will therefore cast an unfavora ble reflection on his art. Patients do not ask what we know, but what we can do, though they forget that the apothegm-knowledge is power-is as applicable to medical knowledge as to any other. A more ungenerous sort of disparagement of medicine is now and then encountered. The July number of the British Quarterly contains a trenchant criticism on the claims of modern medical practice in lengthening human life and in having diminished the amount of suffering from disease. The writer ascribes the favorable showing of tables of mortality to other influences than improved methods of treatment. Quite recently a series of articles appeared in the Popular Science Monthly, which bitterly inveigh against the use of drugs in any disease whatever. Strictures of this kind have emanated before this from medical men and should cause no surprize. If the history of medicine be consulted it will be found that two apparently antagonistic tendencies constantly struggled for ascendency in the domain of medical practice. On the one side, it is contended that a rational therapeutics must strictly conform to scientific principles; on the other side it is held that the teaching of experience is the only safe guide. It appears to me not unprofitable to inquire in how far medical practice during the last half century has been influenced by these tendencies, according as the one or the other preponder

ated in the medical world. At the outset it should be remarked that during this period the reign of bold and precarious theories, which had introduced many aberrations into medicine, came to an end. A healthy reaction also set in at the same time against that low species of empiricism, which reflects the Chinese spirit, with its rigid adherence to prescribed modes and traditional formulæ.

The most brilliant epoch in the history of medicine was ushered in by the anatomical labors of Vesalius and Cesalpini. Morgagni followed and laid the foundation of pathological anatomy; then came the grand discovery of Harvey; the important contributions of Haller and Hunter to physiology, and eventually Bichat's memorable classification of the normal animal tissues. The illustrious founder of auscultation introduced a method of physical diagnosis which for precision and practicability left nothing to wish for. Andral and his worthy successors for the first time combined the study of the morbid phenomena presented during life with that of their corresponding pathological changes, and thus created clinical medicine. After this the old nosologies became untenable. The fluxes, the dropsies, the hæmorrhages were remanded to their positions as symptoms. These familiar events are merely mentioned for the purpose of considering their bearing on practice. It may at once be stated that they brought no new accessions to therapeutics. Methods of treatment in the old style were not changed; but conservatism was put to a hard strain, as a better insight into the nature of morbid conditions showed the futility of numerous remedies and modes of treatment which until then had stood in high repute. The conviction daily gained ground that reform in practice was urgently needed. At this stage it was Louis, one of the great masters of the French school, who proposed the numerical method as the only means of placing therapeutics upon a solid basis. That remedy, he main tained, should be selected in a given disease which was found most successful in analogous cases. The numerical method is therefore an empiricism, pure and simple. Independent of every other consideration, the preference in the choice of remedies is to be decided by the results of statistics. There is certainly some

thing exceedingly captivating in a scheme which would invest medical practice with an exactitude that can be expressed in figures. The most serious objection that may be advanced against it is the evident variability in the statistical results according as a large or a small number of cases make up the series of comparative tables. This source of error, as Poisson and Gavarret have shown, is reduced to a minimum when the number of cases is very large. To the charge that the numerical method is at best a calculation of probabilities, it may be justly replied that a high degree of probability is the farthest reach of certainty which the forecast of medical practice can at any rate attain. Admitting all that may be claimed for this method, it cannot be concealed that immense difficulties stand in the way of carrying it out. Diseases identical in type present so many individual peculiarities and are modified by such a great complexity of conditions, that much latitude must be allowed to the idea of "analogous cases.” Besides it savors somewhat of a crude empiricism to conduct treatment on the average principle. Still the numerical method will always constitute the most reliable criterion of the efficacy of a remedy in relation to a well defined symptom. Thus the acknowledged superiority of the bromides in convulsive affections has been ascertained by an implicit compliance with the method of Louis. This method is particularly adapted to determine the rate of mortality under different plans of treatment.

Although the French school was eminently distinguished for original research and solid work, it did not make therapeutics its debtor. In passing on to consider what the Vienna school, of hardly less celebrity than its French neighbor, did for therapeutics, a similar sterility will be noticed. I shall lay the admirable little book of Dr. J. Peterson, which fully treats upon this subject under many contributions.*

Rokitanski's great work on "Pathological Anatomy" appeared in 1846, and was immediately adopted as a text-book in nearly all the universities of Europe. His account of the genesis and development of tissue changes was a step in advance of French pathologists, who were contented with a description and classifi

*Hauptmomente in der Geschichtlichen Entwickelung, etc. 1877.

« AnteriorContinuar »