"While I attended these women in their fevers, I changed my clothes, and washed my hands in a solution of chloride of lime after each visit. I attended seven women in labor during this period, all of whom recovered without sickness.

"In my practice I have had several single cases of puerperal fever, some of whom have died and some have recovered. Until the year 1830 I had no suspicion that the disease could be communicated from one patient to another by a nurse or midwife; but I now think the foregoing facts strongly favor that idea. I was so much convinced of this fact, that I adopted the plan before related.

"I believe my own health was as good as usual at each of the above periods. I have no recollections to the contrary.

"I believe I have answered all your questions. I have been more particular on some points perhaps than necessary; but I thought you could form your own opinion better than to take mine. In 1830 I wrote to Dr. Charming a more particular statement of my cases. If I have not answered your questions sufficiently, perhaps Dr. C. may have my letter to him, and you can find your answer there." [In a letter to myself, this gentleman also stated, "I do not recollect that there was any erysipelas or any other disease particularly prevalent at the time."]

"BOSTON, February 3, 1843.

III. "MY DEAR SIR,—I received a note from you last evening, requesting me to answer certain questions therein proposed, touching the cases of puerperal fever which came under my observation the past summer. It gives me pleasure to comply with your request, so far as it is in my power so to do, but, owing to the hurry in preparing for a journey, the notes of the cases I had then taken were lost or mislaid. The principal facts, however, are too vivid upon my recollection to be soon forgotten. I think, therefore, that I shall be able to give you all the information you may require.

"All the cases that occurred in my practice took place between the 7th of May and the 17th of June 1842.

"They were not confined to any particular part of the city. The first two cases were patients residing at the South End, the next was at the extreme North End, one living in Sea Street and the other in Roxbury. The following is the order in which they occurred:

"Case 1. Mrs. was confined on the 7th of May, at 5 o'clock, P. M., after a natural labor of six hours. At 12 o'clock at night, on the 9th (thirty-one hours after confinement), she was taken with severe chill, previous to which she was as comfortable as women usually are under the circumstances. She died on the 10th.

"Case 2. Mrs. was confined on the 10th of June (four weeks after Mrs. C.), at 11 A. M., after a natural, but somewhat severe labor of five hours. At 7 o'clock, on the morning of the 11th, she had a chill. Died on the 12th.

"Case 3. Mrs. , confined on the 14th of June, was comfortable until the 18th, when symptoms of puerperal fever were manifest. She died on the 20th.

"Case 4. Mrs. , confined June 17th, at 5 o'clock, A. M., was doing well until the morning of the 19th. She died on the evening of the 21st.

"Case 5. Mrs. was confined with her fifth child on the 17th of June, at 6 o'clock in the evening. This patient had been attacked with puerperal fever, at three of her previous confinements, but the disease yielded to depletion and other remedies without difficulty. This time, I regret to say, I was not so fortunate. She was not attacked, as were the other patients, with a chill, but complained of extreme pain in abdomen, and tenderness on pressure, almost from the moment of her confinement. In this as in the other cases, the disease resisted all remedies, and she died in great distress on the 22d of the same month. Owing to the extreme heat of the season, and my own indisposition, none of the subjects were examined after death. Dr. Channing, who was in attendance with me on the three last cases, proposed to have a post-mortem examination of the subject of case No. 5, but from some cause which I do not now recollect it was not obtained.

"You wish to know whether I wore the same clothes when attending the different cases. I cannot positively say, but I should think I did not, as the weather became warmer after the first two cases; I therefore think it probable that I made a change of at least a part of my dress. I have had no other case of puerperal fever in my own practice for three years, save those above related, and I do not remember to have lost a patient before with this disease. While absent, last July, I visited two patients sick with puerperal fever, with a friend of mine in the country. Both of them recovered.

"The cases that I have recorded were not confined to any particular constitution or temperament, but it seized upon the strong and the weak, the old and the young,—one being over forty years, and the youngest under eighteen years of age . . . . If the disease is of an erysipelatous nature, as many suppose, contagionists may perhaps find some ground for their belief in the fact, that, for two weeks previous to my first case of puerperal fever, I had been attending a severe case of erysipelas, and the infection may have been conveyed through me to the patient; but, on the other hand, why is not this the case with other physicians, or with the same physician at all times, for since my return from the country I have had a more inveterate case of erysipelas than ever before, and no difficulty whatever has attended any of my midwifery cases?"

I am assured, on unquestionable authority, that "About three years since, a gentleman in extensive midwifery business, in a neighboring State, lost in the course of a few weeks eight patients in child-bed, seven of them being undoubted cases of puerperal fever. No other physician of the town lost a single patient of this disease during the same period." And from what I have heard in conversation with some of our most experienced practitioners, I am inclined to think many cases of the kind might be brought to light by extensive inquiry.

This long catalogue of melancholy histories assumes a still darker aspect when we remember how kindly nature deals with the parturient female, when she is not immersed in the virulent atmosphere of an impure lying-in hospital, or poisoned in her chamber by the unsuspected breath of contagion. From all causes together, not more than four deaths in a thousand births and miscarriages happened in England and Wales during the period embraced by the first "Report of the Registrar-General." In the second Report the mortality was shown to be about five in one thousand. In the Dublin Lying-in Hospital, during the seven years of Dr. Collins's mastership, there was one case of puerperal fever to 178 deliveries, or less than six to the thousand, and one death from this disease in 278 cases, or between three and four to the thousand a yet during this period the disease was endemic in the hospital, and might have gone on to rival the horrors of the pestilence of the Maternite, had not the poison been destroyed by a thorough purification.

In private practice, leaving out of view the cases that are to be ascribed to the self-acting system of propagation, it would seem that the disease must be far from common. Mr. White of Manchester says, "Out of the whole number of lying-in patients whom I have delivered (and I may safely call it a great one), I have never lost one, nor to the best of my recollection has one been greatly endangered, by the puerperal, miliary, low nervous, putrid malignant, or milk fever." Dr. Joseph Clarke informed Dr. Collins, that in the course of forty-five years' most extensive practice he lost but four patients from this disease. One of the most eminent practitioners of Glasgow, who has been engaged in very extensive practice for upwards of a quarter of a century, testifies that he never saw more than twelve cases of real puerperal fever.[Lancet, May 4, 1833]

I have myself been told by two gentlemen practising in this city, and having for many years a large midwifery business, that they had neither of them lost a patient from this disease, and by one of them that he had only seen it in consultation with other physicians. In five hundred cases of midwifery, of which Dr. Storer has given an abstract in the first number of this Journal, there was only one instance of fatal puerperal peritonitis.

In the view of these facts, it does appear a singular coincidence, that one man or woman should have ten, twenty, thirty, or seventy cases of this rare disease following his or her footsteps with the keenness of a beagle, through the streets and lanes of a crowded city, while the scores that cross the same paths on the same errands know it only by name. It is a series of similar coincidences which has led us to consider the dagger, the musket, and certain innocent-looking white powders as having some little claim to be regarded as dangerous. It is the practical inattention to similar coincidences which has given rise to the unpleasant but often necessary documents called indictments, which has sharpened a form of the cephalotome sometimes employed in the case of adults, and adjusted that modification of the fillet which delivers the world of those who happen to be too much in the way while such striking coincidences are taking place.

I shall now mention a few instances in which the disease appears to have been conveyed by the process of direct inoculation.

Dr. Campbell of Edinburgh states that in October, 1821, he assisted at the post-mortem examination of a patient who died with puerperal fever. He carried the pelvic viscera in his pocket to the class-room. The same evening he attended a woman in labor without previously changing his clothes; this patient died. The next morning he delivered a woman with the forceps; she died also, and of many others who were seized with the disease within a few weeks, three shared the same fate in succession.

In June, 1823, he assisted some of his pupils at the autopsy of a case of puerperal fever. He was unable to wash his hands with proper care, for want of the necessary accommodations. On getting home he found that two patients required his assistance. He went without further ablution, or changing his clothes; both these patients died with puerperal fever. This same Dr. Campbell is one of Dr. Churchill's authorities against contagion.

Mr. Roberton says that in one instance within his knowledge a practitioner passed the catheter for a patient with puerperal fever late in the evening; the same night he attended a lady who had the symptoms of the disease on the second day. In another instance a surgeon was called while in the act of inspecting the body of a woman who had died of this fever, to attend a labor; within forty-eight hours this patient was seized with the fever.'

On the 16th of March, 1831, a medical practitioner examined the body of a woman who had died a few days after delivery, from puerperal peritonitis. On the evening of the 17th he delivered a patient, who was seized with puerperal fever on the 19th, and died on the 24th. Between this period and the 6th of April, the same practitioner attended two other patients, both of whom were attacked with the same disease and died.

In the autumn of 1829 a physician was present at the examination of a case of puerperal fever, dissected out the organs, and assisted in sewing up the body. He had scarcely reached home when he was summoned to attend a young lady in labor. In sixteen hours she was attacked with the symptoms of puerperal fever, and narrowly escaped with her life.

In December, 1830, a midwife, who had attended two fatal cases of puerperal fever at the British Lying-in Hospital, examined a patient who had just been admitted, to ascertain if labor had commenced. This patient remained two days in the expectation that labor would come on, when she returned home and was then suddenly taken in labor and delivered before she could set out for the hospital. She went on favorably for two days, and was then taken with puerperal fever and died in thirty-six hours.

"A young practitioner, contrary to advice, examined the body of a patient who had died from puerperal fever; there was no epidemic at the time; the case appeared to be purely sporadic. He delivered three other women shortly afterwards; they all died with puerperal fever, the symptoms of which broke out very soon after labor. The patients of his colleague did well, except one, where he assisted to remove some coagula from the uterus; she was attacked in the same manner as those whom he had attended, and died also." The writer in the "British and Foreign Medical Review," from whom I quote this statement,—and who is no other than Dr. Rigby, adds, "We trust that this fact alone will forever silence such doubts, and stamp the well-merited epithet of 'criminal,' as above quoted, upon such attempts." [Brit. and For. Medical Review for Jan. 1842, p. 112.]

From the cases given by Mr. Ingleby, I select the following. Two gentlemen, after having been engaged in conducting the post-mortem examination of a case of puerperal fever, went in the same dress, each respectively, to a case of midwifery. "The one patient was seized with the rigor about thirty hours afterwards. The other patient was seized with a rigor the third morning after delivery. One recovered, one died." [Edin. Med. and Surg. Journal, April, 1838.]

One of these same gentlemen attended another woman in the same clothes two days after the autopsy referred to. "The rigor did not take place until the evening of the fifth day from the first visit. Result fatal." These cases belonged to a series of seven, the first of which was thought to have originated in a case of erysipelas. "Several cases of a mild character followed the foregoing seven, and their nature being now most unequivocal, my friend declined visiting all midwifery cases for a time, and there was no recurrence of the disease." These cases occurred in 1833. Five of them proved fatal. Mr. Ingleby gives another series of seven eases which occurred to a practitioner in 1836, the first of which was also attributed to his having opened several erysipelatous abscesses a short time previously.

I need not refer to the case lately read before this Society, in which a physician went, soon after performing an autopsy of a case of puerperal fever, to a woman in labor, who was seized with the same disease and perished. The forfeit of that error has been already paid.

At a meeting of the Medical and Chirurgical Society before referred to, Dr. Merriman related an instance occurring in his own practice, which excites a reasonable suspicion that two lives were sacrificed to a still less dangerous experiment. He was at the examination of a case of puerperal fever at two o'clock in the afternoon. He took care not to touch the body. At nine o'clock the same evening he attended a woman in labor; she was so nearly delivered that he had scarcely anything to do. The next morning she had severe rigors, and in forty-eight hours she was a corpse. Her infant had erysipelas and died in two days. [Lancet, May 2, 1840.]

In connection with the facts which have been stated, it seems proper to allude to the dangerous and often fatal effects which have followed from wounds received in the post-mortem examination of patients who have died of puerperal fever. The fact that such wounds are attended with peculiar risk has been long noticed. I find that Chaussier was in the habit of cautioning his students against the danger to which they were exposed in these dissections. [Stein, L'Art d'Accoucher, 1794; Dict. des Sciences Medicales, art. "Puerperal."] The head pharmacien of the Hotel Dieu, in his analysis of the fluid effused in puerperal peritonitis, says that practitioners are convinced of its deleterious qualities, and that it is very dangerous to apply it to the denuded skin. [Journal de Pharmacie, January, 1836.] Sir Benjamin Brodie speaks of it as being well known that the inoculation of lymph or pus from the peritoneum of a puerperal patient is often attended with dangerous and even fatal symptoms. Three cases in confirmation of this statement, two of them fatal, have been reported to this Society within a few months.

Of about fifty cases of injuries of this kind, of various degrees of severity, which I have collected from different sources, at least twelve were instances of infection from puerperal peritonitis. Some of the others are so stated as to render it probable that they may have been of the same nature. Five other cases were of peritoneal inflammation; three in males. Three were what was called enteritis, in one instance complicated with erysipelas; but it is well known that this term has been often used to signify inflammation of the peritoneum covering the intestines. On the other hand, no case of typhus or typhoid fever is mentioned as giving rise to dangerous consequences, with the exception of the single instance of an undertaker mentioned by Mr. Travers, who seems to have been poisoned by a fluid which exuded from the body. The other accidents were produced by dissection, or some other mode of contact with bodies of patients who had died of various affections. They also differed much in severity, the cases of puerperal origin being among the most formidable and fatal. Now a moment's reflection will show that the number of cases of serious consequences ensuing from the dissection of the bodies of those who had perished of puerperal fever is so vastly disproportioned to the relatively small number of autopsies made in this complaint as compared with typhus or pneumonia (from which last disease not one case of poisoning happened), and still more from all diseases put together, that the conclusion is irresistible that a most fearful morbid poison is often generated in the course of this disease. Whether or not it is sui generis, confined to this disease, or produced in some others, as, for instance, erysipelas, I need, not stop to inquire.

In connection with this may be taken the following statement of Dr. Rigby. "That the discharges from a patient under puerperal fever are in the highest degree contagious we have abundant evidence in the history of lying-in hospitals. The puerperal abscesses are also contagious, and may be communicated to healthy lying-in women by washing with the same sponge; this fact has been repeatedly proved in the Vienna Hospital; but they are equally communicable to women not pregnant; on more than one occasion the women engaged in washing the soiled bed-linen of the General Lying-in Hospital have been attacked with abscess in the fingers or hands, attended with rapidly spreading inflammation of the cellular tissue."

Now add to all this the undisputed fact, that within the walls of lying-in hospitals there is often generated a miasm, palpable as the chlorine used to destroy it, tenacious so as in some cases almost to defy extirpation, deadly in some institutions as the plague; which has killed women in a private hospital of London so fast that they were buried two in one coffin to conceal its horrors; which enabled Tonnelle to record two hundred and twenty-two autopsies at the Maternite of Paris; which has led Dr. Lee to express his deliberate conviction that the loss of life occasioned by these institutions completely defeats the objects of their founders; and out of this train of cumulative evidence, the multiplied groups of cases clustering about individuals, the deadly results of autopsies, the inoculation by fluids from the living patient, the murderous poison of hospitals,—does there not result a conclusion that laughs all sophistry to scorn, and renders all argument an insult?

I have had occasion to mention some instances in which there was an apparent relation between puerperal fever and erysipelas. The length to which this paper has extended does not allow me to enter into the consideration of this most important subject. I will only say, that the evidence appears to me altogether satisfactory that some most fatal series of puerperal fever have been produced by an infection originating in the matter or effluvia of erysipelas. In evidence of some connection between the two diseases, I need not go back to the older authors, as Pouteau or Gordon, but will content myself with giving the following references, with their dates; from which it will be seen that the testimony has been constantly coming before the profession for the last few years.

"London Cyclopaedia of Practical Medicine," article Puerperal Fever, 1833.

Mr. Ceeley's Account of the Puerperal Fever at Aylesbury. "Lancet," 1835.

Dr. Ramsbotham's Lecture. "London Medical Gazette," 1835.

Mr. Yates Ackerly's Letter in the same Journal, 1838.

Mr. Ingleby on Epidemic Puerperal Fever. "Edinburgh Medical and Surgical Journal," 1838.

Mr. Paley's Letter. "London Medical Gazette," 1839.

Remarks at the Medical and Chirurgical Society. "Lancet," 1840.

Dr. Rigby's "System of Midwifery." 1841.

"Nunneley on Erysipelas,"—a work which contains a large number of references on the subject. 1841.

"British and Foreign Quarterly Review," 1842.

Dr. S. Jackson of Northumberland, as already quoted from the Summary of the College of Physicians, 1842.

And lastly, a startling series of cases by Mr. Storrs of Doncaster, to be, found in the "American Journal of the Medical Sciences" for January, 1843.

The relation of puerperal fever with other continued fevers would seem to be remote and rarely obvious. Hey refers to two cases of synochus occurring in the Royal Infirmary of Edinburgh, in women who had attended upon puerperal patients. Dr. Collins refers to several instances in which puerperal fever has appeared to originate from a continued proximity to patients suffering with typhus.

Such occurrences as those just mentioned, though most important to be remembered and guarded against, hardly attract our notice in the midst of the gloomy facts by which they are surrounded. Of these facts, at the risk of fatiguing repetitions, I have summoned a sufficient number, as I believe, to convince the most incredulous that every attempt to disguise the truth which underlies them all is useless.

It is true that some of the historians of the disease, especially Hulme, Hull, and Leake, in England; Tonnelle, Duges, and Baudelocque, in France, profess not to have found puerperal fever contagious. At the most they give us mere negative facts, worthless against an extent of evidence which now overlaps the widest range of doubt, and doubles upon itself in the redundancy of superfluous demonstration. Examined in detail, this and much of the show of testimony brought up to stare the daylight of conviction out of countenance, proves to be in a great measure unmeaning and inapplicable, as might be easily shown were it necessary. Nor do I feel the necessity of enforcing the conclusion which arises spontaneously from the facts which have been enumerated, by formally citing the opinions of those grave authorities who have for the last half-century been sounding the unwelcome truth it has cost so many lives to establish.

"It is to the British practitioner," says Dr. Rigby, "that we are indebted for strongly insisting upon this important and dangerous character of puerperal fever."

The names of Gordon, John Clarke, Denman, Burns, Young, Hamilton, Haighton, Good, Waller; Blundell, Gooch, Ramsbotham, Douglas, Lee, Ingleby, Locock, Abercrombie, Alison; Travers, Rigby, and Watson, many of whose writings I have already referred to, may have some influence with those who prefer the weight of authorities to the simple deductions of their own reason from the facts laid before them. A few Continental writers have adopted similar conclusions. It gives me pleasure to remember, that while the doctrine has been unceremoniously discredited in one of the leading Journals, and made very light of by teachers in two of the principal Medical Schools, of this country, Dr. Channing has for many years inculcated, and enforced by examples, the danger to be apprehended and the precautions to be taken in the disease under consideration.

I have no wish to express any harsh feeling with regard to the painful subject which has come before us. If there are any so far excited by the story of these dreadful events that they ask for some word of indignant remonstrance to show that science does not turn the hearts of its followers into ice or stone, let me remind them that such words have been uttered by those who speak with an authority I could not claim. It is as a lesson rather than as a reproach that I call up the memory of these irreparable errors and wrongs. No tongue can tell the heart-breaking calamity they have caused; they have closed the eyes just opened upon a new world of love and happiness; they have bowed the strength of manhood into the dust; they have cast the helplessness of infancy into the stranger's arms, or bequeathed it, with less cruelty, the death of its dying parent. There is no tone deep enough for regret, and no voice loud enough for warning. The woman about to become a mother, or with her new-born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden, or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation, when the seal of promised maternity is impressed upon her. The remorseless vengeance of the law, brought down upon its victim by a machinery as sure as destiny, is arrested in its fall at a word which reveals her transient claim for mercy. The solemn prayer of the liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly!

There may be some among those whom I address who are disposed to ask the question, What course are we to follow in relation to this matter? The facts are before them, and the answer must be left to their own judgment and conscience. If any should care to know my own conclusions, they are the following; and in taking the liberty to state them very freely and broadly, I would ask the inquirer to examine them as freely in the light of the evidence which has been laid before him.

1. A physician holding himself in readiness to attend cases of midwifery should never take any active part in the post-mortem examination of cases of puerperal fever.

2. If a physician is present at such autopsies, he should use thorough ablution, change every article of dress, and allow twenty-four hours or more to elapse before attending to any case of midwifery. It may be well to extend the same caution to cases of simple peritonitis.

3. Similar precautions should be taken after the autopsy or surgical treatment of cases of erysipelas, if the physician is obliged to unite such offices with his obstetrical duties, which is in the highest degree inexpedient.

4. On the occurrence of a single case of puerperal fever in his practice, the physician is bound to consider the next female he attends in labor, unless some weeks at least have elapsed, as in danger of being infected by him, and it is his duty to take every precaution to diminish her risk of disease and death.

5. If within a short period two cases of puerperal fever happen close to each other, in the practice of the same physician, the disease not existing or prevailing in the neighborhood, he would do wisely to relinquish his obstetrical practice for at least one month, and endeavor to free himself by every available means from any noxious influence he may carry about with him.

6. The occurrence of three or more closely connected cases, in the practice of one individual, no others existing in the neighborhood, and no other sufficient cause being alleged for the coincidence, is prima facie evidence that he is the vehicle of contagion.

7. It is the duty of the physician to take every precaution that the disease shall not be introduced by nurses or other assistants, by making proper inquiries concerning them, and giving timely warning of every suspected source of danger.

8. Whatever indulgence may be granted to those who have heretofore been the ignorant causes of so much misery, the time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon, not as a misfortune, but a crime; and in the knowledge of such occurrences the duties of the practitioner to his profession should give way to his paramount obligations to society. ADDITIONAL REFERENCES AND CASES.

Fifth Annual Report of the Registrar-General of England.

1843. Appendix. Letter from William Farr, Esq.—Several new series of cases are given in the Letter of Mr. Stows, contained in the Appendix to this Report. Mr. Stows suggests precautions similar to those I have laid down, and these precautions are strongly enforced by Mr. Farr, who is, therefore, obnoxious to the same criticisms as myself.

Hall and Dexter, in Am. Journal of Med. Sc. for January, 1844.—Cases of puerperal fever seeming to originate in erysipelas.

Elkington, of Birmingham, in Provincial Med. Journal, cited in Am. Journ. Med. Se. for April, 1844.—Six cases in less than a fortnight, seeming to originate in a case of erysipelas.

West's Reports, in Brit. and For. Med. Review for October, 1845, and January, 1847.—Affection of the arm, resembling malignant pustule, after removing the placenta of a patient who died from puerperal fever. Reference to cases at Wurzburg, as proving contagion, and to Keiller's cases in the Monthly Journal for February, 1846, as showing connection of puerperal fever and erysipelas.

Kneeland.—Contagiousness of Puerperal Fever. Am. Jour. Med. Se., January, 1846. Also, Connection between Puerperal Fever and Epidemic Erysipelas. Ibid., April, 1846.

Robert Storrs.—Contagious Effects of Puerperal Fever on the Male Subject; or on Persons not Child-bearing. (From Provincial Med. and Surg. Journal.) Am. Jour. Med. Sc., January, 184,6. Numerous cases. See also Dr. Reid's case in same Journal for April, 1846.

Routh's paper in Proc. of Royal Med. Chir. Soc., Am. Jour. Med. Sc., April, 1849, also in B. and F. Med. Chir. Review, April, 1850.

Hill, of Leuchars.—A Series of Cases illustrating the Contagious Nature of Erysipelas and of Puerperal Fever, and their Intimate Pathological Connection. (From Monthly Journal of Med. Sc.) Am. Jour. Med. Se., July, 1850.

Skoda on the Causes of Puerperal Fever. (Peritonitis in rabbits, from inoculation with different morbid secretions.) Am. Jour. Med. Se., October, 1850.

Arneth. Paper read before the National Academy of Medicine. Annales d'Hygiene, Tome LXV. 2e Partie. (Means of Disinfection proposed by M. "Semmeliveis" (Semmelweiss.) Lotions of chloride of lime and use of nail-brush before admission to lying-in wards. Alleged sudden and great decrease of mortality from puerperal fever. Cause of disease attributed to inoculation with cadaveric matters.) See also Routh's paper, mentioned above.

Moir. Remarks at a meeting of the Edinburgh Medico-Chirurgical Society. Refers to cases of Dr. Kellie, of Leith. Sixteen in succession, all fatal. Also to several instances of individual pupils having had a succession of cases in various quarters of the town, while others, practising as extensively in the same localities, had none. Also to several special cases not mentioned elsewhere. Am. Jour. Med. Se. for October, 1851. (From New Monthly Journal of Med. Science.)

Simpson.—Observations at a Meeting of the Edinburgh Obstetrical Society. (An "eminent gentleman," according to Dr. Meigs, whose "name is as well known in America as in (his) native land." Obstetrics. Phil. 1852, pp. 368, 375.) The student is referred to this paper for a valuable resume of many of the facts, and the necessary inferences, relating to this subject. Also for another series of cases, Mr. Sidey's, five or six in rapid succession. Dr. Simpson attended the dissection of two of Dr. Sidey's cases, and freely handled the diseased parts. His next four child-bed patients were affected with puerperal fever, and it was the first time he had seen it in practice. As Dr. Simpson is a gentleman (Dr. Meigs, as above), and as "a gentleman's hands are clean" (Dr. Meigs' Sixth Letter), it follows that a gentleman with clean hands may carry the disease. Am. Jour. Med. Sc., October, 1851.

Peddle.—The five or six cases of Dr. Sidey, followed by the four of Dr. Simpson, did not end the series. A practitioner in Leith having examined in Dr. Simpson's house, a portion of the uterus obtained from one of the patients, had immediately afterwards three fatal cases of puerperal fever. Dr. Veddie referred to two distinct series of consecutive cases in his own practice. He had since taken precautions, and not met with any such cases. Am. Jour. Med. Sc., October, 1851.

Copland. Considers it proved that puerperal fever maybe propagated by the hands and the clothes, or either, of a third person, the bed-clothes or body-clothes of a patient. Mentions a new series of cases, one of which he saw, with the practitioner who had attended them. She was the sixth he had had within a few days. All died. Dr. Copland insisted that contagion had caused these cases; advised precautionary measures, and the practitioner had no other cases for a considerable time. Considers it criminal, after the evidence adduced,—which he could have quadrupled,—and the weight of authority brought forward, for a practitioner to be the medium of transmitting contagion and death to his patients. Dr. Copland lays down rules similar to those suggested by myself, and is therefore entitled to the same epithet for so doing. Medical Dictionary, New York, 1852. Article, Puerperal States and Diseases.

If there is any appetite for facts so craving as to be yet unappeased,—Lesotho, necdum satiata,—more can be obtained. Dr. Hodge remarks that "the frequency and importance of this singular circumstance (that the disease is occasionally more prevalent with one practitioner than another) has been exceedingly overrated." More than thirty strings of cases, more than two hundred and fifty sufferers from puerperal fever, more than one hundred and thirty deaths appear as the results of a sparing estimate of such among the facts I have gleaned as could be numerically valued. These facts constitute, we may take it for granted, but a small fraction of those that have actually occurred. The number of them might be greater, but "'t is enough, 't will serve," in Mercutio's modest phrase, so far as frequency is concerned. For a just estimate of the importance of the singular circumstance, it might be proper to consult the languid survivors, the widowed husbands, and the motherless children, as well as "the unfortunate accoucheur."



III

CURRENTS AND COUNTER-CURRENTS IN MEDICAL SCIENCE

An Address delivered before the Massachusetts Medical Society, at the Annual Meeting, May 30, 1860.

"Facultate magis quam violentia." HIPPOCRATES.

Our Annual Meeting never fails to teach us at least one lesson. The art whose province it is to heal and to save cannot protect its own ranks from the inroads of disease and the waste of the Destroyer.

Seventeen of our associates have been taken from us since our last Anniversary. Most of them followed their calling in the villages or towns that lie among the hills or along the inland streams. Only those who have lived the kindly, mutually dependent life of the country, can tell how near the physician who is the main reliance in sickness of all the families throughout a thinly settled region comes to the hearts of the people among whom he labors, how they value him while living, how they cherish his memory when dead. For these friends of ours who have gone before, there is now no more toil; they start from their slumbers no more at the cry of pain; they sally forth no more into the storms; they ride no longer over the lonely roads that knew them so well; their wheels are rusting on their axles or rolling with other burdens; their watchful eyes are closed to all the sorrows they lived to soothe. Not one of these was famous in the great world; some were almost unknown beyond their own immediate circle. But they have left behind them that loving remembrance which is better than fame, and if their epitaphs are chiselled briefly in stone, they are written at full length on living tablets in a thousand homes to which they carried their ever-welcome aid and sympathy.

One whom we have lost, very widely known and honored, was a leading practitioner of this city. His image can hardly be dimmed in your recollection, as he stood before you only three years ago, filling the same place with which I am now honored. To speak of him at all worthily, would be to write the history of professional success, won without special aid at starting, by toil, patience, good sense, pure character, and pleasing manners; won in a straight uphill ascent, without one breathing-space until he sat down, not to rest, but to die. If prayers could have shielded him from the stroke, if love could have drawn forth the weapon, and skill could have healed the wound, this passing tribute might have been left to other lips and to another generation.

Let us hope that our dead have at last found that rest which neither summer nor winter, nor day nor night, had granted to their unending earthly labors! And let us remember that our duties to our brethren do not cease when they become unable to share our toils, or leave behind them in want and woe those whom their labor had supported. It is honorable to the Profession that it has organized an Association a for the relief of its suffering members and their families; it owes this tribute to the ill-rewarded industry and sacrifices of its less fortunate brothers who wear out health and life in the service of humanity. I have great pleasure in referring to this excellent movement, which gives our liberal profession a chance to show its liberality, and serves to unite us all, the successful and those whom fortune has cast down, in the bonds of a true brotherhood.

A medical man, as he goes about his daily business after twenty years of practice, is apt to suppose that he treats his patients according to the teachings of his experience. No doubt this is true to some extent; to what extent depending much on the qualities of the individual. But it is easy to prove that the prescriptions of even wise physicians are very commonly founded on something quite different from experience. Experience must be based on the permanent facts of nature. But a glance at the prevalent modes of treatment of any two successive generations will show that there is a changeable as well as a permanent element in the art of healing; not merely changeable as diseases vary, or as new remedies are introduced, but changeable by the going out of fashion of special remedies, by the decadence of a popular theory from which their fitness was deduced, or other cause not more significant. There is no reason to suppose that the present time is essentially different in this respect from any other. Much, therefore, which is now very commonly considered to be the result of experience, will be recognized in the next, or in some succeeding generation, as no such result at all, but as a foregone conclusion, based on some prevalent belief or fashion of the time.

There are, of course, in every calling, those who go about the work of the day before them, doing it according to the rules of their craft, and asking no questions of the past or of the future, or of the aim and end to which their special labor is contributing. These often consider and call themselves practical men. They pull the oars of society, and have no leisure to watch the currents running this or that way; let theorists and philosophers attend to them. In the mean time, however, these currents are carrying the practical men, too, and all their work may be thrown away, and worse than thrown away, if they do not take knowledge of them and get out of the wrong ones and into the right ones as soon as they may. Sir Edward Parry and his party were going straight towards the pole in one of their arctic expeditions, travelling at the rate of ten miles a day. But the ice over which they travelled was drifting straight towards the equator, at the rate of twelve miles a day, and yet no man among them would have known that he was travelling two miles a day backward unless he had lifted his eyes from the track in which he was plodding. It is not only going backward that the plain practical workman is liable to, if he will not look up and look around; he may go forward to ends he little dreams of. It is a simple business for a mason to build up a niche in a wall; but what if, a hundred years afterwards when the wall is torn down, the skeleton of a murdered man drop out of the niche? It was a plain practical piece of carpentry for a Jewish artisan to fit two pieces of timber together according to the legal pattern in the time of Pontius Pilate; he asked no questions, perhaps, but we know what burden the cross bore on the morrow! And so, with subtler tools than trowels or axes, the statesman who works in policy without principle, the theologian who works in forms without a soul, the physician who, calling himself a practical man, refuses to recognize the larger laws which govern his changing practice, may all find that they have been building truth into the wall, and hanging humanity upon the cross.

The truth is, that medicine, professedly founded on observation, is as sensitive to outside influences, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density. Theoretically it ought to go on its own straightforward inductive path, without regard to changes of government or to fluctuations of public opinion. But look a moment while I clash a few facts together, and see if some sparks do not reveal by their light a closer relation between the Medical Sciences and the conditions of Society and the general thought of the time, than would at first be suspected.

Observe the coincidences between certain great political and intellectual periods and the appearance of illustrious medical reformers and teachers. It was in the age of Pericles, of Socrates, of Plato, of Phidias, that Hippocrates gave to medical knowledge the form which it retained for twenty centuries. With the world-conquering Alexander, the world-embracing Aristotle, appropriating anatomy and physiology, among his manifold spoils of study, marched abreast of his royal pupil to wider conquests. Under the same Ptolemies who founded the Alexandrian Library and Museum, and ordered the Septuagint version of the Hebrew Scriptures, the infallible Herophilus ["Contradicere Herophilo in anatomicis, est contradicere evangelium," was a saying of Fallopius.] made those six hundred dissections of which Tertullian accused him, and the sagacious Erasistratus introduced his mild antiphlogistic treatment in opposition to the polypharmacy and antidotal practice of his time. It is significant that the large-minded Galen should have been the physician and friend of the imperial philosopher Marcus Aurelius. The Arabs gave laws in various branches of knowledge to those whom their arms had invaded, or the terror of their spreading dominion had reached, and the point from which they started was, as Humboldt acknowledges, "the study of medicine, by which they long ruled the Christian Schools," and to which they added the department of chemical pharmacy.

Look at Vesalius, the contemporary of Luther. Who can fail to see one common spirit in the radical ecclesiastic and the reforming court-physician? Both still to some extent under the dominion of the letter: Luther holding to the real presence; Vesalius actually causing to be drawn and engraved two muscles which he knew were not found in the human subject, because they had been described by Galen, from dissections of the lower animals. Both breaking through old traditions in the search of truth; one, knife in hand, at the risk of life and reputation, the other at the risk of fire and fagot, with that mightier weapon which all the devils could not silence, though they had been thicker than the tiles on the house-tops. How much the physician of the Catholic Charles V. had in common with the great religious destructive, may be guessed by the relish with which he tells the story how certain Pavian students exhumed the body of an "elegans scortum," or lovely dame of ill repute, the favorite of a monk of the order of St. Anthony, who does not seem to have resisted temptation so well as the founder of his order. We have always ranked the physician Rabelais among the early reformers, but I do not know that Vesalius has ever been thanked for his hit at the morals of the religious orders, or for turning to the good of science what was intended for the "benefit of clergy."

Our unfortunate medical brother, Michael Servetus, the spiritual patient to whom the theological moxa was applied over the entire surface for the cure of his heresy, came very near anticipating Harvey. The same quickened thought of the time which led him to dispute the dogma of the Church, opened his mind to the facts which contradicted the dogmas of the Faculty.

Harvey himself was but the posthumous child of the great Elizabethan period. Bacon was at once his teacher and his patient. The founder of the new inductive philosophy had only been dead two years when the treatise on the Circulation, the first-fruit of the Restoration of Science, was given to the world.

And is it to be looked at as a mere accidental coincidence, that while Napoleon was modernizing the political world, Bichat was revolutionizing the science of life and the art that is based upon it; that while the young general was scaling the Alps, the young surgeon was climbing the steeper summits of unexplored nature; that the same year read the announcement of those admirable "Researches on Life and Death," and the bulletins of the battle of Marengo?

If we come to our own country, who can fail to recognize that Benjamin Rush, the most conspicuous of American physicians, was the intellectual offspring of the movement which produced the Revolution? "The same hand," says one of his biographers, "which subscribed the declaration of the political independence of these States, accomplished their emancipation from medical systems formed in foreign countries, and wholly unsuitable to the state of diseases in America."

Following this general course of remark, I propose to indicate in a few words the direction of the main intellectual current of the time, and to point out more particularly some of the eddies which tend to keep the science and art of medicine from moving with it, or even to carry them backwards.

The two dominant words of our time are law and average, both pointing to the uniformity of the order of being in which we live. Statistics have tabulated everything,—population, growth, wealth, crime, disease. We have shaded maps showing the geographical distribution of larceny and suicide. Analysis and classification have been at work upon all tangible and visible objects. The Positive Philosophy of Comte has only given expression to the observing and computing mind of the nineteenth century.

In the mean time, the great stronghold of intellectual conservatism, traditional belief, has been assailed by facts which would have been indicted as blasphemy but a few generations ago. Those new tables of the law, placed in the hands of the geologist by the same living God who spoke from Sinai to the Israelites of old, have remodelled the beliefs of half the civilized world. The solemn scepticism of science has replaced the sneering doubts of witty philosophers. The more positive knowledge we gain, the more we incline to question all that has been received without absolute proof.

As a matter of course, this movement has its partial reactions. The province of faith is claimed as a port free of entry to unsupported individual convictions. The tendency to question is met by the unanalyzing instinct of reverence. The old church calls back its frightened truants. Some who have lost their hereditary religious belief find a resource in the revelations of Spiritualism. By a parallel movement, some of those who have become medical infidels pass over to the mystic band of believers in the fancied miracles of Homoeopathy.

Under these influences transmitted to, or at least shared by, the medical profession, the old question between "Nature," so called, and "Art," or professional tradition, has reappeared with new interest. I say the old question, for Hippocrates stated the case on the side of "Nature" more than two thousand years ago. Miss Florence Nightingale,—and if I name her next to the august Father of the Healing Art, its noblest daughter well deserves that place of honor,—Miss Florence Nightingale begins her late volume with a paraphrase of his statement. But from a very early time to this there has always been a strong party against "Nature." Themison called the practice of Hippocrates "a meditation upon death." Dr. Rush says: "It is impossible to calculate the mischief which Hippocrates, has done, by first marking Nature with his name and afterwards letting her loose upon sick people. Millions have perished by her hands in all ages and countries." Sir John Forbes, whose defence of "Nature" in disease you all know, and to the testimonial in whose honor four of your Presidents have contributed, has been recently greeted, on retiring from the profession, with a wish that his retirement had been twenty years sooner, and the opinion that no man had done so much to destroy the confidence of the public in the medical profession.

In this Society we have had the Hippocratic and the Themisonic side fairly represented. The treatise of one of your early Presidents on the Mercurial Treatment is familiar to my older listeners. Others who have held the same office have been noted for the boldness of their practice, and even for partiality to the use of complex medication.

On the side of "Nature" we have had, first of all, that remarkable discourse on Self-Limited Diseases, [On Self-Limited Diseases. A Discourse delivered before the Massachusetts Medical Society, at their Annual Meeting, May 27, 1835. By Jacob Bigelow, M. D.] which has given the key-note to the prevailing medical tendency of this neighborhood, at least, for the quarter of a century since it was delivered. Nor have we forgotten the address delivered at Springfield twenty years later, [Search out the Secrets, of Nature. By Augustus A. Gould, M. D. Read at the Annual Meeting, June 27, 1855.] full of good sense and useful suggestions, to one of which suggestions we owe the learned, impartial, judicious, well-written Prize Essay of Dr. Worthington Hooker. [Rational Therapeutics. A Prize Essay. By Worthington Hooker, M. D., of New Haven. Boston. 1857.] We should not omit from the list the important address of another of our colleagues, [On the Treatment of Compound and Complicated Fractures. By William J. Walker, M. D. Read at the Annual Meeting, May 29, 1845.] showing by numerous cases the power of Nature in healing compound fractures to be much greater than is frequently supposed,—affording, indeed, more striking illustrations than can be obtained from the history of visceral disease, of the supreme wisdom, forethought, and adaptive dexterity of that divine Architect, as shown in repairing the shattered columns which support the living temple of the body.

We who are on the side of "Nature" please ourselves with the idea that we are in the great current in which the true intelligence of the time is moving. We believe that some who oppose, or fear, or denounce our movement are themselves caught in various eddies that set back against the truth. And we do most earnestly desire and most actively strive, that Medicine, which, it is painful to remember, has been spoken of as "the withered branch of science" at a meeting of the British Association, shall be at length brought fully to share, if not to lead, the great wave of knowledge which rolls with the tides that circle the globe.

If there is any State or city which might claim to be the American headquarters of the nature-trusting heresy, provided it be one, that State is Massachusetts, and that city is its capital. The effect which these doctrines have upon the confidence reposed in the profession is a matter of opinion. For myself, I do not believe this confidence can be impaired by any investigations which tend to limit the application of troublesome, painful, uncertain, or dangerous remedies. Nay, I will venture to say this, that if every specific were to fail utterly, if the cinchona trees all died out, and the arsenic mines were exhausted, and the sulphur regions were burned up, if every drug from the vegetable, animal, and mineral kingdom were to disappear from the market, a body of enlightened men, organized as a distinct profession, would be required just as much as now, and respected and trusted as now, whose province should be to guard against the causes of disease, to eliminate them if possible when still present, to order all the conditions of the patient so as to favor the efforts of the system to right itself, and to give those predictions of the course of disease which only experience can warrant, and which in so many cases relieve the exaggerated fears of sufferers and their friends, or warn them in season of impending danger. Great as the loss would be if certain active remedies could no longer be obtained, it would leave the medical profession the most essential part of it's duties, and all, and more than all, its present share of honors; for it would be the death-blow to charlatanism, which depends for its success almost entirely on drugs, or at least on a nomenclature that suggests them.

There is no offence, then, or danger in expressing the opinion, that, after all which has been said, the community is still overdosed: The best proof of it is, that "no families take so little medicine as those of doctors, except those of apothecaries, and that old practitioners are more sparing of active medicines than younger ones." [Dr. James Jackson has kindly permitted me to make the following extract from a letter just received by him from Sir James Clark, and dated May 26, 1860: "As a physician advances in age, he generally, I think, places less confidence in the ordinary medical treatment than he did, not only during his early, but even his middle period of life."] The conclusion from these facts is one which the least promising of Dr. Howe's pupils in the mental department could hardly help drawing.

Part of the blame of over-medication must, I fear, rest with the profession, for yielding to the tendency to self-delusion, which seems inseparable from the practice of the art of healing. I need only touch on the common modes of misunderstanding or misapplying the evidence of nature.

First, there is the natural incapacity for sound observation, which is like a faulty ear in music. We see this in many persons who know a good deal about books, but who are not sharp-sighted enough to buy a horse or deal with human diseases.

Secondly, there is in some persons a singular inability to weigh the value of testimony; of which, I think, from a pretty careful examination of his books, Hahnemann affords the best specimen outside the walls of Bedlam.

The inveterate logical errors to which physicians have always been subject are chiefly these:

The mode of inference per enumerationem simplicem, in scholastic phrase; that is, counting only their favorable cases. This is the old trick illustrated in Lord Bacon's story of the gifts of the shipwrecked people, hung up in the temple.—Behold! they vowed these gifts to the altar, and the gods saved them. Ay, said a doubting bystander, but how many made vows of gifts and were shipwrecked notwithstanding? The numerical system is the best corrective of this and similar errors. The arguments commonly brought against its application to all matters of medical observation, treatment included, seem to apply rather to the tabulation of facts ill observed, or improperly classified, than to the method itself.

The post hoc ergo propter hoc error: he got well after taking my medicine; therefore in consequence of taking it.

The false induction from genuine facts of observation, leading to the construction of theories which are then deductively applied in the face of the results of direct observation. The school of Broussais has furnished us with a good example of this error.

And lastly, the error which Sir Thomas Browne calls giving "a reason of the golden tooth;" that is, assuming a falsehood as a fact, and giving reasons for it, commonly fanciful ones, as is constantly done by that class of incompetent observers who find their "golden tooth" in the fabulous effects of the homoeopathie materia medica,—which consists of sugar of milk and a nomenclature.

Another portion of the blame rests with the public itself, which insists on being poisoned. Somebody buys all the quack medicines that build palaces for the mushroom, say rather, the toadstool millionaires. Who is it? These people have a constituency of millions. The popular belief is all but universal that sick persons should feed on noxious substances. One of our members was called not long since to a man with a terribly sore mouth. On inquiry he found that the man had picked up a box of unknown pills, in Howard Street, and had proceeded to take them, on general principles, pills being good for people. They happened to contain mercury, and hence the trouble for which he consulted our associate.

The outside pressure, therefore, is immense upon the physician, tending to force him to active treatment of some kind. Certain old superstitions, still lingering in the mind of the public, and not yet utterly expelled from that of the profession, are at the bottom of this, or contribute to it largely. One of the most ancient is, that disease is a malignant agency, or entity, to be driven out of the body by offensive substances, as the smoke of the fish's heart and liver drove the devil out of Tobit's bridal chamber, according to the Apochrypha. Epileptics used to suck the blood from the wounds of dying gladiators. [Plinii Hist. Mundi. lib. xxviii. c. 4.] The Hon. Robert Boyle's little book was published some twenty or thirty years before our late President, Dr. Holyoke, was born. [A Collection of Choice and Safe Remedies. The Fifth Edition, corrected. London, 1712. Dr. Holyoke was born in 1728.] In it he recommends, as internal medicines, most of the substances commonly used as fertilizers of the soil. His "Album Graecum" is best left untranslated, and his "Zebethum Occidentale" is still more transcendentally unmentionable except in a strange dialect. It sounds odiously to us to hear him recommend for dysentery a powder made from "the sole of an old shoe worn by some man that walks much." Perhaps nobody here ever heard of tying a stocking, which had been worn during the day, round the neck at night for a sore throat. The same idea of virtue in unlovely secretions! [The idea is very ancient. "Sordes hominis" "Sudore et oleo medicinam facientibus."—Plin. xxviii. 4.]

Even now the Homoeopathists have been introducing the venom of serpents, under the learned title of Lachesis, and outraging human nature with infusions of the pediculus capitis; that is, of course, as we understand their dilutions, the names of these things; for if a fine-tooth-comb insect were drowned in Lake Superior, we cannot agree with them in thinking that every drop of its waters would be impregnated with all the pedicular virtues they so highly value. They know what they are doing. They are appealing to the detestable old superstitious presumption in favor of whatever is nauseous and noxious as being good for the sick.

Again, we all occasionally meet persons stained with nitrate of silver, given for epilepsy. Read what Dr. Martin says, about the way in which it came to be used, in his excellent address before the Norfolk County Medical Society, and the evidence I can show, but have not time for now, and then say what you think of the practice which on such presumptions turns a white man as blue as the double-tattooed King of the Cannibal Islands! [Note A.]

If medical superstitions have fought their way down through all the rationalism and scepticism of the nineteenth century, of course the theories of the schools, supported by great names, adopted into the popular belief and incorporated with the general mass of misapprehension with reference to disease, must be expected to meet us at every turn in the shape of bad practice founded on false doctrine. A French patient complains that his blood heats him, and expects his doctor to bleed him. An English or American one says he is bilious, and will not be easy without a dose of calomel. A doctor looks at a patient's tongue, sees it coated, and says the stomach is foul; his head full of the old saburral notion which the extreme inflammation-doctrine of Broussais did so much to root out, but which still leads, probably, to much needless and injurious wrong of the stomach and bowels by evacuants, when all they want is to be let alone. It is so hard to get anything out of the dead hand of medical tradition! The mortmain of theorists extinct in science clings as close as that of ecclesiastics defunct in law.

One practical hint may not be out of place here. It seems to be sometimes forgotten, by those who must know the fact, that the tongue is very different, anatomically and physiologically, from the stomach. Its condition does not in the least imply a similar one of the stomach, which is a very different structure, covered with a different kind of epithelium, and furnished with entirely different secretions. A silversmith will, for a dollar, make a small hoe, of solid silver, which will last for centuries, and will give a patient more comfort, used for the removal of the accumulated epithelium and fungous growths which constitute the "fur," than many a prescription with a split-footed Rx before it, addressed to the parts out of reach.

I think more of this little implement on account of its agency in saving the Colony at Plymouth in the year 1623. Edward Winslow heard that Massasoit was sick and like to die. He found him with a houseful of people about him, women rubbing his arms and legs, and friends "making such a hellish noise" as they probably thought would scare away the devil of sickness. Winslow gave him some conserve, washed his mouth, scraped his tongue, which was in a horrid state, got down some drink, made him some broth, dosed him with an infusion of strawberry leaves and sassafras root, and had the satisfaction of seeing him rapidly recover. Massasoit, full of gratitude, revealed the plot which had been formed to destroy the colonists, whereupon the Governor ordered Captain Miles Standish to see to them; who thereupon, as everybody remembers, stabbed Pecksuot with his own knife, broke up the plot, saved the colony, and thus rendered Massachusetts and the Massachusetts Medical Society a possibility, as they now are a fact before us. So much for this parenthesis of the tongue-scraper, which helped to save the young colony from a much more serious scrape, and may save the Union yet, if a Presidential candidate should happen to be taken sick as Massasoit was, and his tongue wanted cleaning,—which process would not hurt a good many politicians, with or without a typhoid fever.

Again, see how the "bilious" theory works in every-day life here and now, illustrated by a case from actual life. A youthful practitioner, whose last molars have not been a great while cut, meets an experienced and noted physician in consultation. This is the case. A slender, lymphatic young woman is suckling two lusty twins, the intervals of suction being occupied on her part with palpitations, headaches, giddiness, throbbing in the head, and various nervous symptoms, her cheeks meantime getting bloodless, and her strength running away in company with her milk. The old experienced physician, seeing the yellowish waxy look which is common in anaemic patients, considers it a "bilious" case, and is for giving a rousing emetic. Of course, he has to be wheedled out of this, a recipe is written for beefsteaks and porter, the twins are ignominiously expelled from the anaemic bosom, and forced to take prematurely to the bottle, and this prolific mother is saved for future usefulness in the line of maternity.

The practice of making a profit on the medicine ordered has been held up to reprobation by one at least of the orators who have preceded me. That the effect of this has been ruinous in English practice I cannot doubt, and that in this country the standard of practice was in former generations lowered through the same agency is not unlikely. I have seen an old account-book in which the physician charged an extra price for gilding his rich patients' pills. If all medicine were very costly, and the expense of it always came out of the physician's fee, it would really be a less objectionable arrangement than this other most pernicious one. He would naturally think twice before he gave an emetic or cathartic which evacuated his own pocket, and be sparing of the cholagogues that emptied the biliary ducts of his own wallet, unless he were sure they were needed. If there is any temptation, it should not be in favor of giving noxious agents, as it clearly must be in the case of English druggists and "General Practitioners." The complaint against the other course is a very old one. Pliny, inspired with as truly Roman horror of quackery as the elder Cato,—who declared that the Greek doctors had sworn to exterminate all barbarians, including the Romans, with their drugs, but is said to have physicked his own wife to death, notwithstanding,—Pliny says, in so many words, that the cerates and cataplasms, plasters, collyria, and antidotes, so abundant in his time, as in more recent days, were mere tricks to make money.

A pretty strong eddy, then, or rather many eddies, setting constantly back from the current of sober observation of nature, in the direction of old superstitions and fancies, of exploded theories, of old ways of making money, which are very slow to pass out of fashion.

But there are other special American influences which we are bound to take cognizance of. If I wished to show a student the difficulties of getting at truth from medical experience, I would give him the history of epilepsy to read. If I wished him to understand the tendencies of the American medical mind, its sanguine enterprise, its self-confidence, its audacious handling of Nature, its impatience with her old-fashioned ways of taking time to get a sick man well, I would make him read the life and writings of Benjamin Rush. Dr. Rush thought and said that there were twenty times more intellect and a hundred times more knowledge in the country in 1799 than before the Revolution. His own mind was in a perpetual state of exaltation produced by the stirring scenes in which he had taken a part, and the quickened life of the time in which he lived. It was not the state to favor sound, calm observation. He was impatient, and Nature is profoundly imperturbable. We may adjust the beating of our hearts to her pendulum if we will and can, but we may be very sure that she will not change the pendulum's rate of going because our hearts are palpitating. He thought he had mastered yellow-fever. "Thank God," he said, "out of one hundred patients whom I have visited or prescribed for this day, I have lost none." Where was all his legacy of knowledge when Norfolk was decimated? Where was it when the blue flies were buzzing over the coffins of the unburied dead piled up in the cemetery of New Orleans, at the edge of the huge trenches yawning to receive them?

One such instance will do as well as twenty. Dr. Rush must have been a charming teacher, as he was an admirable man. He was observing, rather than a sound observer; eminently observing, curious, even, about all manner of things. But he could not help feeling as if Nature had been a good deal shaken by the Declaration of Independence, and that American art was getting to be rather too much for her,—especially as illustrated in his own practice. He taught thousands of American students, he gave a direction to the medical mind of the country more than any other one man; perhaps he typifies it better than any other. It has clearly tended to extravagance in remedies and trust in remedies, as in everything else. How could a people which has a revolution once in four years, which has contrived the Bowie-knife and the revolver, which has chewed the juice out of all the superlatives in the language in Fourth of July orations, and so used up its epithets in the rhetoric of abuse that it takes two great quarto dictionaries to supply the demand; which insists in sending out yachts and horses and boys to out-sail, out-run, out-fight, and checkmate all the rest of creation; how could such a people be content with any but "heroic" practice? What wonder that the stars and stripes wave over doses of ninety grains of sulphate of quinine, [More strictly, ninety-six grains in two hours. Dunglison's Practice, 1842, vol. ii. p. 520. Eighty grains in one dose. Ibid. p. 536. Ninety-six grains of sulphate of quinine are equal to eight ounces of good bark.—Wood & Bache.] and that the American eagle screams with delight to see three drachms of calomel given at a single mouthful?

Add to this the great number of Medical Journals, all useful, we hope, most of them necessary, we trust, many of them excellently well conducted, but which must find something to fill their columns, and so print all the new plans of treatment and new remedies they can get hold of, as the newspapers, from a similar necessity, print the shocking catastrophes and terrible murders.

Besides all this, here are we, the great body of teachers in the numberless medical schools of the Union, some of us lecturing to crowds who clap and stamp in the cities, some of us wandering over the country, like other professional fertilizers, to fecundate the minds of less demonstrative audiences at various scientific stations; all of us talking habitually to those supposed to know less than ourselves, and loving to claim as much for our art as we can, not to say for our own schools, and possibly indirectly for our own practical skill. Hence that annual crop of introductory lectures; the useful blossoming into the ornamental, as the cabbage becomes glorified in the cauliflower; that lecture-room literature of adjectives, that declamatory exaggeration, that splendid show of erudition borrowed from D'Israeli, and credited to Lord Bacon and the rest, which have suggested to our friends of the Medical Journals an occasional epigram at our expense. Hence the tendency in these productions, and in medical lectures generally, to overstate the efficacy of favorite methods of cure, and hence the premium offered for showy talkers rather than sagacious observers, for the men of adjectives rather than of nouns substantive in the more ambitious of these institutions.

Such are some of the eddies in which we are liable to become involved and carried back out of the broad stream of philosophical, or, in other words, truth-loving, investigations. The causes of disease, in the mean time, have been less earnestly studied in the eagerness of the search for remedies. Speak softly! Women have been borne out from an old-world hospital, two in one coffin, that the horrors of their prison-house might not be known, while the very men who were discussing the treatment of the disease were stupidly conveying the infection from bed to bed, as rat-killers carry their poisons from one household to another. Do not some of you remember that I have had to fight this private-pestilence question against a scepticism which sneered in the face of a mass of evidence such as the calm statisticians of the Insurance office could not listen to without horror and indignation? ["The Contagiousness of Puerperal Fever."—N. E. Quar. Jour. of Medicine and Surgery, April, 1843. Reprinted, with Additions. Boston: Ticknor & Fields. 1855.] Have we forgotten what is told in one of the books published under our own sanction, that a simple measure of ventilation, proposed by Dr. John Clark, had saved more than sixteen thousand children's lives in a single hospital? How long would it have taken small doses of calomel and rhubarb to save as many children? These may be useful in prudent hands, but how insignificant compared to the great hygienic conditions! Causes, causes, and again causes,—more and more we fall back on these as the chief objects of our attention. The shortest system of medical practice that I know of is the oldest, but not the worst. It is older than Hippocrates, older than Chiron the Centaur. Nature taught it to the first mother when she saw her first-born child putting some ugly pebble or lurid berry into its mouth. I know not in what language it was spoken, but I know that in English it would sound thus: Spit it out!

Art can do something more than say this. It can sometimes reach the pebble or berry after it has been swallowed. But the great thing is to keep these things out of children's mouths, and as soon as they are beyond our reach, to be reasonable and patient with Nature, who means well, but does not like to hurry, and who took nine calendar months, more or less, to every mother's son among us, before she thought he was fit to be shown to the public.

Suffer me now to lay down a few propositions, whether old or new it matters little, not for your immediate acceptance, nor yet for your hasty rejection, but for your calm consideration.

But first, there are a number of terms which we are in the habit of using in a vague though not unintelligible way, and which it is as well now to define. These terms are the tools with which we are to work, and the first thing is to sharpen them. It is nothing to us that they have been sharpened a thousand times before; they always get dull in the using, and every new workman has a right to carry them to the grindstone and sharpen them to suit himself.

Nature, in medical language, as opposed to Art, means trust in the reactions of the living system against, ordinary normal impressions.

Art, in the same language, as opposed to Nature, means an intentional resort to extraordinary abnormal impressions for the relief of disease.

The reaction of the living system is the essence of both. Food is nothing, if there is no digestive act to respond to it. We cannot raise a blister on a dead man, or hope that a carminative forced between his lips will produce its ordinary happy effect.

Disease, dis-ease,—disturbed quiet, uncomfortableness,—means imperfect or abnormal reaction of the living system, and its more or less permanent results.

Food, in its largest sense, is whatever helps to build up the normal structures, or to maintain their natural actions.

Medicine, in distinction from food, is every unnatural or noxious agent applied for the relief of disease.

Physic means properly the Natural art, and Physician is only the Greek synonyme of Naturalist.

With these few explanations I proceed to unfold the propositions I have mentioned.

Disease and death, if we may judge by the records of creation, are inherently and essentially necessary in the present order of things. A perfect intelligence, trained by a perfect education, could do no more than keep the laws of the physical and spiritual universe. An imperfect intelligence, imperfectly taught,—and this is the condition of our finite humanity,—will certainly fail to keep all these laws perfectly. Disease is one of the penalties of one of the forms of such failure. It is prefigured in the perturbations of the planets, in the disintegration of the elemental masses; it has left its traces in the fossil organisms of extinct creations. [Professor Agassiz has kindly handed me the following note: "There are abnormal structures in animals of all ages anterior to the creation of mankind. Malformed specimens of Crinoids are known from the Triassic and Jurassic deposits. Malformed and diseased bones of tertiary mammalia have been collected in the caverns of Gailenreuth with traces of healing."]

But it is especially the prerogative, I had almost said privilege, of educated and domesticated beings, from man down to the potato, serving to teach them, and such as train them, the laws of life, and to get rid of those who will not mind or cannot be kept subject to these laws.

Disease, being always an effect, is always in exact proportion to the sum of its causes, as much in the case of Spigelius, who dies of a scratch, as in that of the man who recovers after an iron bar has been shot through his brain. The one prevalent failing of the medical art is to neglect the causes and quarrel with the effect.

There are certain general facts which include a good deal of what is called and treated as disease. Thus, there are two opposite movements of life to be seen in cities and elsewhere, belonging to races which, from various persistent causes, are breeding down and tending to run out, and to races which are breeding up, or accumulating vital capital,—a descending and an ascending series. Let me give an example of each; and that I may incidentally remove a common impression about this country as compared with the Old World, an impression which got tipsy with conceit and staggered into the attitude of a formal proposition in the work of Dr. Robert Knox, I will illustrate the downward movement from English experience, and the upward movement from a family history belonging to this immediate neighborhood.

Miss Nightingale speaks of "the fact so often seen of a great-grandmother, who was a tower of physical vigor, descending into a grandmother perhaps a little less vigorous, but still sound as a bell, and healthy to the core, into a mother languid and confined to her carriage and house; and lastly into a daughter sickly and confined to her bed." So much for the descending English series; now for the ascending American series.

Something more than one hundred and thirty years ago there graduated at Harvard College a delicate youth, who lived an invalid life and died at the age of about fifty. His two children were both of moderate physical power, and one of them diminutive in stature. The next generation rose in physical development, and reached eighty years of age and more in some of its members. The fourth generation was of fair average endowment. The fifth generation, great-great-grandchildren of the slender invalid, are several of, them of extraordinary bodily and mental power; large in stature, formidable alike with their brains and their arms, organized on a more extensive scale than either of their parents.

This brief account illustrates incidentally the fallacy of the universal-degeneration theory applied to American life; the same on which one of our countrymen has lately brought some very forcible facts to bear in a muscular discussion of which we have heard rather more than is good for us. But the two series, American and English, ascending and descending, were adduced with the main purpose of showing the immense difference of vital endowments in different strains of blood; a difference to which all ordinary medication is in all probability a matter of comparatively trivial purport. Many affections which art has to strive against might be easily shown to be vital to the well-being of society. Hydrocephalus, tabes mesenterica, and other similar maladies, are natural agencies which cut off the children of races that are sinking below the decent minimum which nature has established as the condition of viability, before they reach the age of reproduction. They are really not so much diseases, as manifestations of congenital incapacity for life; the race would be ruined if art could ever learn always to preserve the individuals subject to them. We must do the best we can for them, but we ought also to know what these "diseases" mean.

Again, invalidism is the normal state of many organizations. It can be changed to disease, but never to absolute health by medicinal appliances. There are many ladies, ancient and recent, who are perpetually taking remedies for irremediable pains and aches. They ought to have headaches and back-aches and stomach-aches; they are not well if they do not have them. To expect them to live without frequent twinges is like expecting a doctor's old chaise to go without creaking; if it did, we might be sure the springs were broken. There is no doubt that the constant demand for medicinal remedies from patients of this class leads to their over-use; often in the case of cathartics, sometimes in that of opiates. I have been told by an intelligent practitioner in a Western town, that the constant prescription of opiates by certain physicians in his vicinity has rendered the habitual use of that drug in all that region very prevalent; more common, I should think, than alcoholic drunkenness in the most intemperate localities of which I have known anything. A frightful endemic demoralization betrays itself in the frequency with which the haggard features and drooping shoulders of the opium-drunkards are met with in the streets.

The next proposition I would ask you to consider is this: The presumption always is that every noxious agent, including medicines proper, which hurts a well man, hurts a sick one. [ Note B.]

Let me illustrate this proposition before you decide upon it. If it were known that a prize-fighter were to have a drastic purgative administered two or three days before a contest, or a large blister applied to his back, no one will question that it would affect the betting on his side unfavorably; we will say to the amount of five per cent. Now the drain upon the resources of the system produced in such a case must be at its minimum, for the subject is a powerful man, in the prime of life, and in admirable condition. If the drug or the blister takes five per cent. from his force of resistance, it will take at least as large a fraction from any invalid. But this invalid has to fight a champion who strikes hard but cannot be hit in return, who will press him sharply for breath, but will never pant himself while the wind can whistle through his fleshless ribs. The suffering combatant is liable to want all his stamina, and five per cent. may lose him the battle.

All noxious agents, all appliances which are not natural food or stimuli, all medicines proper, cost a patient, on the average, five per cent. of his vital force, let us say. Twenty times as much waste of force produced by any of them, that is, would exactly kill him, nothing less than kill him, and nothing more. If this, or something like this, is true, then all these medications are, prima facie, injurious.