Popular Science Monthly/Volume 41/May 1892/The Limitatons of the Healing Heart
|THE LIMITATIONS OF THE HEALING ART.|
By Prof. Dr. HERRMANN NOTHNAGEL, of Vienna.
THE fact is very evident that the practical art of healing has made great advances during the past century, especially during the last half of it. The progress of dermatology, the brilliant career of ophthalmology, the new creation of laryngology, the wonderful development of operative surgery and gynæcology, and, in the line of internal curatives, the introduction of a series of effective remedial substances and physical methods of healing, and, further, the greater importance attached to physiological, dietetical, and hygienic factors of the most diversified sorts—have all taken place during this period, and in part in the very presence of our contemporaries. And when we add to Lister's antiseptic process Pasteur's discovery of the antidote for rabies, and Koch's communication of a cure for consumption, which was received a year ago with such unbounded enthusiasm, the question may well force itself upon us, Where are the limits of the healing art? It is indeed humanly proper to hope for a still wider extension of its scope, and it is a duty to try to obtain it. But it is becoming to the scientific man to look without prepossessions only at the facts, and with calm consideration to take account, not of what has been obtained only, but of what is attainable.
"Being ill is life under changed conditions." What, then, is it to heal? To influence pathological processes in the organism in such a way that they shall be brought to a halt, that the deranged tissues and disturbed functions shall be restored to the normal, and the interrupted interchanges between individual tissues and functions and the whole system shall be brought back to healthful relations; that is what we call healing.
Healing, in the sense that the physician's art can control organic processes in full activity, has not been advanced by the practical progress that has been made through antisepsis. For a tumor or an abscess can no more be made to go backward at this time than formerly. The exsection and opening of them are not synonymous with a real cure. And as with superficial lesions and those arising from external causes, so it is with those in the interior organism, out of whatever causes they may have originated. In an ulceration of the bowels, a cure may be speeded by a series of appropriate measures to the extent that further injuries may be prevented, but the restoration of the injured parts will not be accomplished by them. On the bursting of a blood-vessel and the lesion of the brain-substance, it is necessary to apply suitable preventives to limit the congestion of the brain; but no measure of the surgeon hastens the coagulation of the blood or the adhesion of the divided nerve-substance.
Inflammations constitute another class of clinical affections, either acute or chronic, which, appearing in different organs, are grouped under that single designation. As we know from daily experience, the acute forms of inflammation are often cured, the chronic more rarely. There is, however, no internal medicament of demonstrated direct application for acute inflammations. Such remedies can only act indirectly in special cases as, for instance, most means in acute catarrhs as supporting applications.
The therapeutic potentiality of the physician's art is its most ancient possession, grossly overapplied through centuries, then abruptly abandoned in part, and now wavering in uncertainty. Quiet, cold, and local bloodletting are the basis of a treatment which is, under well-defined conditions, very helpful in acute inflammations. But it is sometimes fruitless, sometimes inapplicable. Deep inflammations, skin eruptions, and processes that set in with great activity, are regarded quite apart from specific forms like tuberculosis; and still it is far from being proved that the therapeutic treatment, even when the symptoms have subsided under its application, have had a direct effect on the progress of the inflammation. Although it may appear to be so, it is no way demonstrated. It is the same also with chronic inflammatory processes. The subsidence of single favorably localized forms may perhaps be promoted by such measures as massage, gymnastics, electricity, special baths, etc.; but of them all it can only be said that they promote absorption; but no immediate influence on the organism, no cure of the processes, is worked by them. It may be all the same to the patient whether massage controls the restorative process directly or indirectly, so that it makes him well. In many other instances the application of similar methods in favorable cases may overcome individual symptoms, and remove the products of the disease, without yet having any essential influence upon its progress. The various diseases of the blood, metabolic derangements, and the inexhaustible multitude of disorders of the nervous system, to this time have furnished no more opportunities for a real cure than the soil of Alaska for the successful cultivation of the date palm. Among infectious diseases we admit only that in typhus, scarlet fever, measles, dysentery, cholera, and the long, dangerous host of such contracting diseases, medical art can contribute much to a favorable outcome by counteracting dangerous symptoms, and through general hygienic measures and a judicious direction of nourishment. But in only two, perhaps three, of these diseases can medicine induce a cure by direct influence upon the pathological processes viz., on malaria, syphilis, and acuta rheumatism. Of the last, we only know that the salicylic treatment allays the fever and the joint affection, but is without influence on the dangerous endocarditis, with its following of disordered heartrhythm. And all other infections, when they have become outbroken and developed illness, can not to this day be cured in the sense in which science uses that word. Whichever way one turns he will everywhere strike limits. In fact, a diseased condition is susceptible of cure only so long as it is attacked while still advancing; as soon as it has reached a definite culmination, no more; there then remain deformations, atrophies, hypertrophies, and other resultants of most various kinds. In most cases these are out of the reach of therapeutic influence and restorative process, except occasionally through a mechanical measure or the knife of the surgeon. An acute pleurisy is curable, but not its residues. The metabolic anomalies which lead to the formation of calculus in the kidneys can be influenced in the beginning, but the stone when it is formed can be removed only by the surgeon. The possibility of therapeutic effect is in many cases determined by the locality of the process, and, further, by the circumstance whether the cause of disease accrued suddenly or gradually, or set in with greater or less intensity. A quantity of arsenic which ordinarily would kill at once, is borne by the habitual arsenic-eater. Of two similarly constituted persons, cholera will take one away at once, while another will escape with a light attack. A disease is also incurable when its causes work on without interruption. Malaria induces an incurably chronic condition if the infected person does not leave the impregnated marsh-land of his residence. A bronchial catarrh continues stationary, and at last draws the lungs into sympathy with it, if the person attacked by it remains constantly exposed to a dusty atmosphere. "With like suddenness and energy of the causes of disease, with like continuance of the local processes, the individual's power of resistance, the vigor of his constitution are important factors in determining the outcome. A vigorous thirty-year-old man will overcome an inflammation of the lungs which would be fatal to an old man, to a drinker, or to a man weakened by luxury or a life of dissipation or suffering. Finally, crimen non est artis, sed ægroti—the fault is not of the art, but of the patient—is the phrase that may be applied to those cases in which the most correct measures taken under favorable circumstances fail to accomplish their purpose, because the patient himself does not or can not co-operate with them. No treatment can relieve the smoker from his throat-catarrh, so long as he persists in his habit. This aspect of the case is especially pertinent to the nervous disorders which are one of the growing scourges of our age; incapacity and vacillation, the force of outer influences, or the pressure of business too often intervene to interrupt a cure which was otherwise fairly possible.
Gloomy as are the prospects which we have before us here, we still recognize that all diseases which do not fall under one of these mentioned categories are curable, or that their curability is only a question of time. Strange as it may sound in the present state of medicine, we believe that the possibility of in time curing malignant tumors is not yet closed.
Real healing, the restoration to their normal state of functions and tissues that have been changed by disease, is brought about in its essentials only through the life-processes in the organism. Therefore the answer to the question to what degree the healing art is or may be in a condition to influence these processes will be decisive as to whether it shall enlarge the boundaries of its knowledge. And if it results that this can not be, or can be only within a small compass, then will arise the further question whether the object shall be hopelessly given up, or whether still other possibilities are open for medicine to strive after its high aim. It will never be possible to re-form lost cells or to cause separated ones to grow together again; never immediately to affect the processes which play in hallucinations their wild pranks in the ganglion-cells and associative paths.
We can certainly by the application of certain substances cause changes in particular cells which are expressed, albeit in some unknown way, by physiological effects. Thus many alkaloids, alcohol, ether, chloroform, bromine, curare, digitalis, etc., operate directly on particular cell-groups, and bundles of nerves and muscles; pilocarpine, arsenic, and iodine on certain glands; phosphorus on growth processes in the bones. When the cases at present known are analyzed, it is found that bromine restrains the paroxysms of epilepsy for a short time, but does not remove the processes in the central nervous system from which they originate. Alcohol in moderate doses temporarily excites the brain and heart to activity, but does not cure a single pathological condition the presence of which made the administration of alcohol necessary. Morphine alleviates the pains of neuralgia, but does not effect any fundamental change in the disease. Sometimes effects appear like those of iodine in certain diseases corresponding with a real cure brought about by the means itself; but it is still the last experience of medical art that the restoration from the diseased condition, in the true sense of the word, must come to pass through the organism itself. Whether an order of thoughts like that which Robert Koch developed in his studies of tuberculin will lead to this end must be learned by clinical experiment. It may be that the healing art will make its advance in this way. For the present we must learn, the more impressively as medical knowledge becomes more perfect, that the doctor is only the servant of Nature, not its master.
Although the expectation and the possibility of controlling the fundamentals of pathological processes are so limited, the healing art is nevertheless not doomed to vain contemplation and inactive dallying. While art can not master Nature, it can follow it with diligent observation. The truth of this remark covers a genuine progress, and furnishes the key to the secret of the success of really great physicians. To investigate the exact origin of pathological changes, to ascertain by what methods and under what conditions disturbances of the organism are most easily overcome or counterbalanced, deliberately to support and imitate these methods if possible, and before everything to do no harm, is the way by which the healing art can accomplish something important and good. History proves incontestably that practical efficiency at the sick-bed goes in an exactly parallel line with the cultivation of scientific methods. Medicine to-day, without yet being able directly to cure the pathological condition, reaches, simply by following the principles here laid down, incomparably more favorable results than formerly. It has learned, first of all, not to interfere so as to destroy the course of natural compensations; but seeks by dietetical, hygienic, and climatic influences, here by the removal of excitants, there by methodical stimulation of the matter-changes of the nervous system—to put the organism into a condition to overcome the pathological disturbances. To use such measures, carefully adapted on principles of scientific observation and enlarged knowledge of the course of disease to the most diverse conditions, continually to furnish a closer support to the natural compensations and adaptations that is one of the ways to which the healing art must turn in order to enlarge its scope.
Since we know that already developed pathological processes can be only imperfectly or not at all affected by art, it should be our more inflexible purpose to guard against their beginning, to recognize the causes of disease, and render them harmless. But this purpose must be comprehended in its widest sense; it should not be confined to the prevention of infectious diseases alone, or to mere measures of sanitary policy, but should also include specific means of cure. Thus, the treatment of malarious disease with quinine is to all appearance etiological. The changes that have already taken place in the blood-cells and the spleen are not reversed by quinine, but the plasmodia of malaria are in some way destroyed, and then the disease may be cured.
The hope is not unjustified that in a nearer or further future we shall learn to nullify by specific means the promoters of disease in many other infections. After nullifying the irritating causes, the processes of Nature may be relied upon to complete the cure. It is possible that this advance will be perfected incidentally, as has happened with quinine and malarious disease, and with salicylic acid and rheumatism. There is also good ground here for the hope that methodical research will be rich in results. The fruitful investigations of numerous contemporary laborers permit much to be expected. And though the conflict of opinions sways hither and thither, and although the knowledge that has been gained relates only to diseases of animals, there is no vital reason for supposing that the same results will not also be reached for man.
The efforts of the present are turned in three directions: to cure bacterial diseases that have already become clinically visible; to make infections harmless while in their incubatory stages; and especially to ward off infection. The last-named object is the farthest-reaching one. It can be attained in two ways: by sanitary protective measures against epidemics, and by conferring immunity on the individual organism, of which vaccination for small-pox is a typical example. Securing artificial immunity by inoculation, and its scientific basis, are now in the full flow of investigation. However favorable results may be reached in it, it seems practically clear that preventive immunity, even when we have gained sufficient experience in it, will be conferred only against those infections to which many men are likely to be exposed—such as small-pox, measles, possibly scarlet fever, whooping-cough, inflammation of the lungs, diphtheria, and enteric fever; in the time of approaching epidemics, as cholera, influenza, and typhus and relapsing fever. On the other hand, it is extremely improbable that preventive measures of immunity will be adopted against rabies, anthrax, and tetanus. The problem of warding off and removing the causes evidently exists in the greatest possible comprehensiveness, and in the most diverse other conditions, but its working is not so strikingly manifested in them as it is against bacterial infections.
While art is limited, in the curing of pathological processes, by the impossibility of changing the course of life at pleasure; while it also reaches limitations in warding off disease, yet its function is not exhausted; there still remains to it the extraordinarily important work of treating symptoms. An inconceivable number of pharmaceutical preparations look directly to this purpose. In numerous cases, also, the application of burning and bath-cures, of electricity, and many other therapeutic helps, is made for the same end. The importance of this part of the art is not underrated. It is often indifferent to the patient whether these or those anatomical and functional changes take place; he will have no perception of them, will not be disturbed by them in his capacity or have his life shortened by them. But symptomatic treatment often makes natural cure possible; it bridges over dangerous episodes in the course of the disease. And no person to whom intelligent management by a physician has preserved a dear one will think little of the treatment of symptoms.
In this the healing art is not only capable of extraordinary progress, but is actually advancing in an encouraging degree. Since Griesinger lamented, thirty years ago, that the doctor was helpless in the heat of fever, we can now, by the cold-water treatment and a number of strong antipyretics, keep a typhus patient almost continuously at the normal temperature. Recent years have furnished numerous soporifics and antiseptics, pilocarpine and cocaine and others, and the present is equally fruitful in the introduction of symptomatic methods. Everywhere active life, fresh labors; and, amid all of it, every human existence which comes to a premature end, every person who is hampered in his career by chronic disease, admonishes us that here are the limits of medical art. Some of these barriers it will never raise; at best, it will be able only to push them further on.—Translated for The Popular Science Monthly from the Pharmaceutische Rundschau.
- From an address before the Association of German Naturalists and Physicians at Halle.