Organon of the specific healing art

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Introduction

The highest object of medicine is to remove morbid phenomena, or, in other words, to restore health in the safest, quickest and most pleasant manner. A medical doctrine is of no value except in so far as it fulfils that end.

It is one of the characteristic features of our age to consider the usefulness of things, without paying any regard to the age of an institution, dogma or custom. It is not our purpose here to show that people often go too far in measuring the value of things merely by the material advantages which they procure. However, physicians would exhibit an untimely vanity if they would complain of having their knowledge and talent, and the value of their principles, critically examined, and of being asked, "What certainty have you? What guarantee do you offer that we will not be sacrificed to prejudice, or to the love of system, by confiding in you?" Questions like these have become much more frequent lately. Confidence in medicine has been destroyed by a blind party spirit ; by the intolerance which one physician manifests towards another, and of which Hufeland remarked a few years previous : " Every doctor who loses a patient is accused of having killed him, by those who do not think as he does." In former times medicine enjoyed a higher consideration, and if a reproach was uttered, it was against the wrong application of the principles of the school in isolated cases, or against the boldness of those who had dared leave the beaten track, which was considered the only safe one.

Q ORGANON OF THE SPECIFIC HEALING ART.

But now-a-days, the infallibility of a medical doctrine has become the subject of bitter satire; the contradiction which exists between the different medical doctrines having no longer remained a secret. Physicians who are careful observers, and are not carried away by the spirit of faction, still enjoy the reputation of being intelligent and able men.

I do not mean to say that systems have no value. We ought, to look upon them as creations of a poetic ideality which are sometimes worthy of exciting our astonishment as works of art. Like brilliant stars, their object is to shed light on isolated observations, in order to unite them in one harmonious whole, and to guide us safely through the labyrinth of doubt and hypotheses. Systems should guide us in our practice, and their correctness should be measured by the means which we derive from the true application of their principles.

It is a remarkable fact that the name of the great physician of Cos has remained an object of veneration for thousands of years past, during the period of conservatism as well as of reform in medicine. Even the dogmatists, when at the very climax of their glory, have always spoken of the Hippocratic medicine with respect, and have never dared tarnish the glory of its author. It is not less remarkable that dogmatists, empirics, and eclectics appeal to him as an authority, although his greatest merit consists in teaching us the art of faithfully observing the phenomena of disease. This is his greatest merit. His philosophy is a rational empiricism based upon experience, his rules of practice are derived from experience. Avoiding dogmatism, he has never tried to arrange the results of his experience into a system. In his practice he was an eclectic, and had no other guide in the treatment of disease except his power of observing and individualizing it.

A number of distinguished physicians, both ancient and modern, have taken him as their model in practice, and we may say that the most successful and the most celebrated practitioners have keptaloof from systems, and have been eclectics.

In the course of time, however, the empirical treatment of disease became mor.e and more difficult and uncertain, for the simple reason that the forms of disease are so various that even the oldest man could only become acquainted with very few of them by his own observation. The best memory is not able to hoard all the results of other people's observations, nor is it an easy business to distinguish truth from falsehood in that mass of relations of cures and pretended observations which are offered for sale every day. This is the reason why the most distinguished empirics are frequently greatly embarrassed. In the absence of analogous observations, made either by themselves or by others, they are obliged to resort to an empirical treatment, which is often very doubtful in its results, or else they have to be guided by general rules of their own make. The necessity of analogous principles having been constantly felt, nothing is more natural than that attempts should have been made every now and then to establish the practice of medicine upon a solid foundation.

Justice requires that we should recognize all the importance of the attempts which have been made for upwards of two thousand years to attain that end, and that we should honor with the deepest gratitude the memory of those physicians who have sacrificed fortune, health, life even, to the advancement of medical science. This is not the place to give a detailed account of their devotion, of the services which they have rendered to the collateral sciences, or of the different systems of medicine : our object is to show in what manner we should proceed to reduce the rules of practice to scientific principles.

To appreciate the new doctrine which it is the object of the present work to examine, we have to compare it with the spirit of the old school of medicine ; and, in order to enable our readers to accomplish that purpose, we shall, without entering upon any unnecessary details, furnish an account of the means which have hitherto been resorted to to cure disease.

By merely casting a glance at history, we perceive that medicine has always progressed apace with civilization. We will not inquire whether chance or instinct has first made us acquainted with the medicinal virtues of certain substances in certain diseases. In the first ages of the medical art the knowledge of remedies was evidently very imperfect, and the art of curing consisted merely in administering certain remedies which had been found efficacious in certain cases, whenever similar cases should occur again. This was gross empiricism, based exclusively upon a superficial comparison of the external symptoms of disease, and adapted only to the infancy of humanity. When the human mind had been more developed, man began to reflect on the first causes of the phenomena of nature — on the modifications which they undergo. In medicine, attempts were made to establish a rational mode of treatment, the fundamental principle of which was to remove the cause of the disease, and, in this way, to cure the disease itself.

The principle, " tolle cmisam" has been followed until this day, and has only been objected to by some upon the ground that the cause, being in most cases hidden from our senses, can only be discovered by speculative reasoning. In such a case, it is easy to fall into errors ; every author of a new system has endeavored to guard against errors, and all have succeeded more or less, but none of them entirely.

Inasmuch as at an early age even, the phenomena of disease were considered manifestations of an anormal vital force, this view necessarily led physicians to reflect on the vital force itself, and to ascend to the causes of the perceptible phenomena. Henceforth medicine became subject to the influence of philosophy, as every one may see by looking at the philosophy of Plato.

The philosophy of that age was a daughter of poesy ; and a great portion of it had remained poesy. Hence it was more convenient to imagine than to discover principles, for this additional reason, that the physical sciences were still in their infancy, and therefore unable to furnish to speculative science reliable points of support. In the absence of such points any attempt to discover the first principles of things, must necessarily lead to fanciful speculation. It has been frequently asserted, on this account, that medicine cannot gain any thing from its alliance with philosophy. This assertion is only true, however, if one confounds a principle invented by human ingenuity with a fundamental truth, and adopts such speculalive principles as the highest rules in practice. Philosophers have never succeeded in discovering the first principle of life, and in lifting the veil which covers the mysterious existence and nature of the soul. Pythagoras and Plato have shown a good deal of ingenuity by considering the play of the vital forces as a circular or elliptical movement, or as an oscillation between the two extremities of a line ; but their philosophy has not advanced medicine a single step ; and however beautiful and interesting their speculative reasonings may appear, they have so far been of no sort of avail at the bed-side of the patient.

This is not the place for entering upon a critical examination of the different systems of philosophy, most of which have, in times past, been mere repetitions of the philosophy of Plato and Aristotle, or attempts to conciliate these two thinkers, the former of whom has become the leader of the spiritualists, whereas the latter has devoted his efforts to the defence of materialism. It may be said in general terms, that mere speculative reasoning has had very little influence on the natural sciences and on medicine. Abstract reason is sufficient to establish the general necessity of certain phenomena, but it requires real, positive observations to substantiate speculative doctrines. The idealists neglect too much the slow and laborious process of observing phenomena to investigate their first cause by means of analogy, to derive general laws from facts, and gradually to rise from the lower to the higher.

The analytical method is another system of philosophy, without which there can be no rational medicine, and which is at once more practical and more fertile in results. The object of the analytical method is not to lose itself in speculations about the essence of things, but to observe the changes which take place in the phenomena, and to avail itself of individual observations for the purpose of arriving at a knowledge of the causes by sound logical conclusions.

The gigantic steps which have been made in the natural sciences invite us to arrange the facts obtained under a general law and to trace them to their cause. Analysis and speculation are both busy in accomplishing that work. He who is animated by the desire of attaining a higher degree of knowledge, must be rejoiced to see so many men engaged in cultivating it, It is probable that we shall never arrive at a perfectly satisfactory solution of the problems of nature ; but the better we succeed in accounting for the various manifestations of vitality, the better we shall be able to restore health.

What is more particularly in the way of progress, are the multiplicity of the questions which the study of the unity of all the natural phenomena suggests, and which have so far remained unanswered, and a tendency inherent in our minds to study in one direction only. Even in pursuing the analytical method, we are led to select among (he great mass of natural phenomena some as more particular objects of inquiry, and to establish laws as general, which are not so in reality. Unwilling to give up a favorite idea and obliged, on the other hand, to demonstrate the pretended truth of a theory, the mind plunges into a labyrinth of sophisms based upon premises which are so false that it is sufficient to break down a single one of them, to overthrow the whole structure.

Thus we see how dangerous it is to generalize too soon or too much, whereas by a careful iudividualization, and an impartial examination and observation of isolated phenomena we shall discover their fundamental laws in the surest manner, and at the same time become convinced that general principles, without losing anything of their generality, are frequently obscured by apparent exceptions.

In considering these different methods, we shall be able, without much trouble, to account for the various systems 'of medicine. They all have a common end, which is to remove the known causes of disease ; or, in other words, to apply a rational treatment ; but they differ in regard to the means which the spirit of inquiry has pointed out as the most proper to attain that object. Idealism and empiricism govern in medicine as in philosophy. The former, starting from a preconceived idea of the moving forces of things, inquires particularly into their invisible and occult qualities, and loses itself in fruitless attempts to account by general cosmic principles for the numerous forms of individual life.

Recognizing the difficulty, or rather the impossibility of constructing a practical therapeutic system in accordance with the vast conceptions of the idealists, the partisans of rational empiricism have simply endeavored to elevate medicine to the rank of an experimental science.

Huts and houses have been built, and bridges constructed, long before any one thought of writing a systematic treatise on architecture. In a similar manner the materials of a special therapei'a had first to be collected before it was possible to compare them with one another, to deduce from them the conditions of similar or analogous phenomena, and to establish the principles of a general therapei'a by logical reasoning. This route, however, does not lead to the discovery of a system which is based upon a knowledge of the fundamental principle of life. Our knowledge is, in a great measure, fragmentary. Even those branches of medical science which have been cultivated with the greatest care — osteology and the anatomy of the soft parts — are still imperfect, and are enriched every day with new discoveries. Physiology is still less perfect. We do not yet possess an accurate knowledge of the structure of the organs ; we are still less acquainted with their importance and their functions. The majority of the most important phenomena, nutrition and sanguification, are still mysteries for us, and our knowledge of the sympathetic relation of a great number of organs is still very incomplete.

Pathology is based upon physiology, because we require to know the laws of the vital functions in their normal conditions, before we can obtain a clear notion of their anormal changes. In considering the narrow limits of our physiological knowledge, we will not be astonished at the obscurity of pathology, and the vagueness and uncertainty of our therapeutic principles will at once become manifest. This uncertainty is denied, it is true, by a great number of physicians, particularly by those narrow-minded practitioners who accord an unlimited faith to the text-books and lectures of their teachers, and who, under the cloak of those authorities, think of nothing more sedulously than of obtaining a large practice; or perhaps by those who have too high an opinion of their own wisdom, to admit that the splendor of medicine is darkened by extensive spots. On the other hand, a number of distinguished practitioners and celebrated writers, have complained of the imperfections of our science, and have shown that those who know most, feel them most keenly. The admissions of such men ought to convince us that every thing which has been accomplished hitherto on the field of science, bears the impress of imperfection. Nevertheless, we ought not to despise the efforts which have been made, howsoever unsuccessful, to enrich our knowledge, and we ought to admit that science gains something by all these attempts at establishing order among its phenomena. The zeal of those who cultivate it, will be reanimated by publishing that which is still wanting.

Objective perceptions which constitute, properly speaking, the foundation of our knowledge, have first revealed to us the existence of certain anormal modifications in the material sphere of the sick organism, such as general or topical atrophy or hypertrophy, swellings, boils, nodosities, ulcers, blotches, vesicles, rhagades, exanthemata of every kind, changes in the color of the skin of certain parts of the body, increase or decrease of animal heat, a greater or lesser quantity of sweat than usual, or changes in the character of the sweat, gaseous exhalations, changes in the breath, tears, nasal or buccal mucus, saliva, cerumen, alvine evacuations, urine, semen, mucus of the urethra and vagina ; morbid appearances in the blood, particularly the menstrual blood, in the milk, lochia, etc. Post-mortem examinations have revealed to us more or less general changes of structure, an irregular development and position of certain organs, pseudo-membranes and filaments with unnatural adhesions, interstitial distentions and softenings, complete changes of substances, indurations, concretions, ossifications, obliterations, dilatation of vessels, irregular formation of new vessels, internal swellings and excrescences, polypi, funguses, tubercles, effusions, etc.

By an examination after death, we have even discovered changes in the quality of the blood, bile, pancreatic juice, intestinal mucus, and other fluids.

By means of chemistry we have discovered different proportions in the composition of the tissues, and all these facts have been made use of to explain morbid phenomena. It has been for a long time supposed that disease depended on material changes in the organism. It is undoubtedly true that essential changes in the material tissues which are the substratum of the vital forces, must occasion differences in the manifestations of those forces.

The physicians who incline to materialism, have divided themselves into two classes, the iatro-physical (mechanical) and the chemiatrical (chemical) school. The former school considers simply the structure of the parts representing the bones as the superstructure, the muscles as so many levers, the heart as a sucking pump or a compressing apparatus, the small vessels as sucking tubes or a filtering apparatus, &c. According to the mechanical school, disease is occasioned by derangements in the machine, it leaves the motor force out of all consideration. The influence which that school has had in medicine, has been more sensibly felt in physiology and pathology than in therapeutics ; and even at this moment, when such great improvements have been made in the physical sciences, particularly in the study of electricity, galvanism and magnetism, the modes of the mechanical school are resorted to, to explain in a more or less satisfactory manner any phenomena of vitality. In a most ingenious manner the vertebral column has been compared to the pile of Volta, the nerves to the conductors of the fluid, and the secretions have been considered results of the effects of a closed galvanic chain. This solution of the problem of vitality is, however, too little satisfactory to promise great advantages to the science of curing disease.

The chemical philosophers have only considered the composition of the substances constituting the organism. They are divided into solidists and humoralists, the former of whom consider the solids as the primary sphere of the probable causes of disease, the latter the fluids. The solidists are more nearly related to the mechanical philosophers. Humoral pathology rests upon the supposition that all organized bodies have gradually developed themselves out of liquids by a process of crystallization and condensation, and that the solids of the human body are derived from the fluids. They have simply forgotten, however, that forms, whether they belong to the species, the variety, or the family, are subject to the mysterious action of the vital force which causes the oak to spring from an acorn and not from a coffee-bean, the eagle from an eagle's and not from a goose's egg, or the rhinoceros from his like and not from a goat. They have forgotten that these organized fluids are the products of the activity of the secretory vessels, and, that the deterioration of the fluids must therefore be owing to a more deep-seated cause. The idea, that disease resulted from an alteration of the fluids, had become so fascinating, that a system of pathology and therapeutics was constructed in accordance with it, the only object of which was to expel the vitiated humors, and to correct those which could not be removed, by means of chemical remedies. A glance at the history of this doctrine shows us a heap of hypotheses to which Anaxagoras and Gallierms, Erasistratus and Aetius have contributed. Sylvius de la Boe was the first who attempted to write a systematic treatise of humoral pathology ; he may therefore be considered the founder of that school. Alternately defeated and triumphant, his doctrine has found opponents and partisans, even in our time.

We shall not deny that the humors have some claim to our attention, and that they occasion pathogenetic effects in the organism (unlike Fernelius, for instance, who asserts that the fluids should not be considered as belonging to the organism) ; but to consider them the primary cause of disease, appears to us a sad return to materialism, which has unfortunately found a number of partisans at the present time.

It was reserved to the genius of George Ernest Stahl to found a new school, the dynamic school, which studies principally the motor force in the organism. According to the dynamists, it is this force that produces all the organic and functional changes in the organism. This is not the place to inquire whether Stahl is the only author of that system, or whether the idea has been suggested to him by Van Helmont, Perrault, Descartes, etc. Nor does it matter whether Stahl's idea of the soul being the first cause of all organic activity, is really new, or whether the woquov of Hippocrates, the archaeus of Van Helmont, or vital force or principle, is the same as Stahl's soul.

But he, as weli as a number of his partisans, has made himself liable to the charge of having, like other schools, viewed the matter only from one side. For a long time one had endeavored to account for all physiological and pathological phenomena by arguments drawn from the organic structure and composition of the humors. The school of Stahl did exactly the contrary, and without any more reason ; it viewed the active, moving, modifying force in the organism as an abstraction ; as if that force could act and move in the organism independently of its material forces.

By giving one's self up to the doctrine of the vital forces, it became impossible to avoid falling into a multitude of sophisms and extraordinary hypotheses. It is not our intention to dwell upon them here, contenting ourselves with merely mentioning the purely dynamic system of Brown, the foundations of which had been laid by Louis Roger* more than a century before, who taught that irritability is only a disposition or property by means of which the vital force is enabled to manifest itself, but that irritability is not the only and sufficient cause of those manifestations. This was Brown's explanation of life, who considered instability the internal, and the surrounding world the external factor of the vital force.

This system commended itself by its simplicity to unexperienced physicians and laymen. For a long time it had a number of partisans, and would have lasted much longer, if its nosology had been more conformable to experience, and if a want of success in the treatment of disease, agreeably to Brown's principles, had not made their falsehood evident. According to Brown, every disease resulted from an excess or deficiency of vital action ; hence he arranged all diseases under two general heads.

Brown's system gave rise to that of Broussais, who, starting from a similar principle, considers every disease as one of local irritation. It is from this position that all his therapeutic principles were deduced — those enormous depletions, and that monstrous vampyrism which posterity will look upon as one of the great errors of our age.

Another modification of the theory of irritation is the doctrine of counter-stimulation by Rasori, who, like Brown, admits only of two principal forms of disease opposed to one another : excessive, or deficient activity, representing the ancient striclum and laxurn — contraction and relaxation. The treatment which has been deduced from this principle, consists in administering large doses of remedies supposed to be contrary to the disease. These remedies have been divided into two classes in the most arbitrary manner, and which is by no means justified by experience. In spite of the apparent harmony of this system, it could not be expected that it would acquire any considerable influence ; the poverty of that system was too apparent, and the spirit of our age is totally averse to speculative theories, and requires solid arguments to accept a doctrine.

Brown's system and the theory of irritation to which it had given rise, had given a new impulse to speculation, and had furnished a most favorable opportunity for the construction of a system in accordance with the dictates of the philosophy of nature, which was "based upon the supposition that the general

laws of the universe controlled the existence of every single object, and that we must resort to pure reason, in order to discover the therapeutic method which is harmonious to those laws. This system is dynamic in its character, since its fundamental idea is that of force, by means of which the perceptible phenomena of life are accounted for ; this system is less incomplete than most other similar systems, inasmuch as it does not omit the material sphere of the organism, and recommends particularly the analytical study of the organs ; practical medicine however has not yet derived any advantage from that system.

No one will deny that the pathological alteration of the organs, which we are bound to consider the vehicle of the vital forces, must necessarily modify the manifestations of those forces. But in spite of the light which the physical sciences have shed on the dynamic action of things, a retrogradation to the grossest materialism evidently threatens pathology, since anomalies in the formation and composition of tissues are mistaken for the essential principle and cause of disease ; as though those anomalies could exist independently of the reproductive vital force, and as though they could be any thing else than mere products of an anoraial activity. There are pathologists who are on the point of overlooking the existence of a vital activity, and reject almost every thing which they do not either see or hear. Stethescope, plessimeter, and microscope, are thensurest means of diagnosis, and there are physicians now-a-days who know more about the movements and the covering of the blood-disks, than about the mode in which morbid conditions develope themselves. The great use of pathological anatomy cannot be doubted ; we should guard, however, against attaching too much importance to it.

In the course of a great number of diseases, material modifications take place, which make us indeed acquainted with the course the disease has taken, but do not reveal to us the principle and cause of the disturbance ; hence it is that pathologists are all the time disputing about the fact, whether certain organic anomalies are the result of inflammation, or the product of a primarily disturbed, reproductive activity. Such anomalies are : softenings, relaxations, dilations, strictures, obliterations, hypertrophies, tubercles, indurations, etc. To this class belong likewise the intestinal ulcers, which some believe to be the origin, others the result of typhus abdominalis. Alterations are frequently discovered in bodies, which have taken place after death. I may mention the coagulation of the blood in the heart and the aorta, which has given rise to many errors, the watery effusions in the brain, after a fatal stroke of apoplexy, and the changes of color which are observed in internal parts, the red appearance of which is not always a proof of inflammation, as has been sufficiently shown by the observations of JRapp1 and Yelloly.2 The absence of redness, according to Rapp, is, on the other hand, just as uncertain a proof of the absence of an inflammatory disease, particularly in the intestines, since the discoloration may have been occasioned by certain gases, such as the sulphureted hydrogen gas.

Our knowledge of the modifications which the substance of the organs undergoes in disease, is as yet very imperfect. We know as little of the changes of the blood and humors, and we cannot help being astonished at the boldness with which the imperfect and often contradictory results of the investigations which have been made until this day, and which are mixed with a great number of hypotheses, have been considered by some physicians as proofs that the anomalies in the composition of the humors are the primary causes of disease.

In investigating the causes of the alteration of the humors, the attention of pathologists has first been directed to the blood, inasmuch as it contains the substance which serves to develope the organism ; for no one can deny that the composition of the blood and of the humors is liable to various, sometimes important modifications. For a long time past it has been admitted that the blood of scorbutic and chlorotic patients contains an excess of serous particles, and is deficient in fibrin ; and that the blood of pregnant women contains an excess of coagulable lymph. Wittstock has discovered in the blood of cholera patients a diminution of from one to seven per cent, of fibrin, which was, moreover, less white when washed, than that of the healthy blood. He has, moreover, discovered in the right ventricle a blood resembling tar, and mixed with polypous coagula. According to Jennings, the blood of arthritic patients contains an excess of phosphoric acid and azotic substances. According to Stevens, the blood of yellow fever patients is deprived of its saline particles. According to Andral, the blood becomes more copious in inflammatory fevers ; and, according to Scudamore, it contains three times more fibrin and less saline particles. In a patient affected with pulmonary phthisis, who was bled when the disease had reached