Without giving up the theory in which they had been educated, some physicians began to see that in some epidemics of disease a larger percentage of cases were lost among those where venesection had been used than among those similarly sick who were not bled. The deduction from this was that it would be better to bleed less. But a change was not to be made without a struggle. Reference to the medical literature of the first half of the century shows that there was a deal of warm discussion between the blood-letters and the anti-blood-letters. Out of the observations and discussions made there was cultivated a prejudice, professional to a moderate extent but popular to a large one, against bleeding per se, and without reference to the character of the disease under treatment or to the differing conditions that might exist, which helped to carry the usage from its former abuse at times to the opposite extreme of general abandonment. It is a universal law in nature that the farther the pendulum swings in one direction, the farther will it swing in the opposite on its return. The pendulum of venesection had swung too far forward for the best in the treatment of disease, and the return carried it quite beyond the best in the backward reaction.
Beyond the reasons noted for the present comparative non-use of the lancet, there has been added a pressure of an erroneous and illegitimate nature that has aided to put bleeding under a general ban more unfortunate for the sick than was the former rather indiscriminate use. Somewhat contemporaneously with the warm discussion upon bleeding carried on in the profession, and perhaps partly out of that discussion, there started up in various parts of the country an illegitimate class of practitioners, mostly illiterate and destitute of preliminary culture, interchangeably known as Botanics, Thompsonians, Eclectics, etc., whose chief stock in trade for public acceptance was denunciation, without regard to the conditions that might be met in a case, of leeching, bleeding, blistering, scarification, and other agents for cures. This denunciation found ready public credit. Not only from the mouths of the class named, but in various other ways, the prejudice they sought to create was widely diffused. Outside of the libraries of the profession you seldom see a medical book; anywhere else they have been rarities. But in many sections of the country for the last sixty years a canvass of the families would show an abundance of books, published for family reading, emanating from irregular practitioners, all of them saturated with lying abuse of the methods of treatment of the regular physicians. These books were loaned from one family to another, much as the weekly papers or the cheap novel; and they were read and believed in. The result was that many who read were indoctrinated with the belief that bleeding, no matter what the disease or the conditions, was not only not necessary, but pernicious, and often the cause of death; and there was little printed contradiction offered to disabuse the public mind of this false accusation.
Co-ordinating with this means of false instruction has been and is the public press. As respectable practitioners do not stoop to the quackery of advertising, the pecuniary interest of the press, so far as means and methods for the cure of diseases is concerned, is identical with the pecuniary interests of advertising quacks. The public press sells itself to the broad diffusion of the ways and means of medical quackery in all its forms. The subsidies of impostors and patent medicine men fill up one carotid artery for the support of the press; and the influence of that press, however weak the intellect that bestrides its tripod, is more potent than a hundred of the ablest men in the profession, for the sufficient reason that the voice of the men in the profession seldom strikes the public ear through the same broad and forceful channel.
The result of the false teaching of the class of books alluded to and of the medical advertising, and of the bleating of the tramping lecturers was that a large part of many communities came to believe that blood-letting was a crime against health, and a hindrance to recovery from disease, no matter what might be the conditions. The average intelligence of even well-educated communities goes no further than to accept the plausible teaching that is every day thrust upon its tympanum; it does not stop to criticise the motives nor to analyze the arguments of the advertiser, nor is it cultured in this direction to the capacity of justly weighing them according to their true significance. The average intelligence of even well-educated communities is not up to that grasp of the science of medicine necessary to determine between false and fallacious teaching and that which is rational and correct; it does not differentiate between clap-trap and honesty; it does not separate humbug from truth, and as an ocean of humbug passes the public gullet easier than an ounce of truth, it is not strange that the condition obtaining about bleeding is not so much that the physician has discarded it as improper, or has lost sight of its value in many cases, as that the community will not tolerate him in the abstraction of blood. Public prejudice overrides professional opinion, unless the opinion runs current with the prejudice. To bleed your patient and then have him die is to be damned; if he dies without being bled, no matter whatever else you may do or leave undone, the chances of being cursed are largely lessened. Besides this, very little or nothing is gained against the prejudice by recovery after bleeding, since the popular opinion will be that the patient would have gotten well quicker and better without it—an opinion that can seldom be disproved. Exactly in the same way in any case where venesection has been practiced and the patient does not get well, the opponents of the operation will assert that the bleeding caused the death, and that, in the absence of it, the patient would have got well; which also is difficult to disprove. The average mind proceeds from supposed causes to effects with most unreasonable logic.
As a matter of fact, the whole art of the practice of medicine is involved many times in many uncertainties as to the effects that are to follow the administration of drugs or the institution of any procedure, however simple, that it may puzzle the most sagacious to determine the exact weight of any factor introduced, whether it be for good or for ill. It should not therefore surprise us that to minds quite unacquainted with the therapeutical effects of blood-letting in disease, a death that follows a bleeding, however remote in point of time, should be credited to the operation rather than to the disease for which the operation was performed. An uncertain percentage of cases of many acute inflammations will recover, whether bled or not; an uncertain percentage of them will die, whether bled or not, and no matter how treated; and, while it will sometimes happen that of two cases of the same disease the one that is bled will get well and the one that is not bled will succumb, it will the next week happen that of two other cases of the same trouble the one that is bled will slip off and the one not bled will hold on finely. And it is a notorious fact that in some communities, if a patient is bled and then dies, nine out of every ten persons in the neighborhood will say, and part of them will believe, that the bleeding was an accessory if not the chief cause of the untoward event; and it is usually quite impossible for the doctor to show that the nine are not right in their view of the matter.
Under these circumstances it can hardly surprise us that the use of the lancet has gone out of fashion. It is not so much that we have less faith in its beneficence, rationally employed, as that our patients are opposed to it. Whether in spite of the opposition we should employ it oftener than we do is a question that every one must settle for himself. It might be possible for a bold and determined man to work up that road to confidence with his patients in it, but the path is so beset with difficulties that a hundred will fall by the way where one succeeds. A single death after phlebotomy will do more to impede the success of a young man in the profession than a dozen deaths without it; it is wise therefore to be cautious in the use of so potent a remedy, and to sin less in commission than in omission of opening a vein. It may be said that whether he succeeds or fails it is the duty of the physician to do in all cases what he thinks will be the best for his patient. This position may have its merits but it is a better thing to teach than to act upon. There is no law of right that demands of the practitioner that he shall assume the responsibility of the stupidity and ignorance of all his patients, and, worse still, of all the irrational prejudice they have allowed themselves to imbibe, and which no amount of logical facts will dispossess them of.
The writer, in the nearly fifty years of his practice as student and graduate, has had an average share, perhaps, of his patients die; but he has never had one die of any sort of fever after he had been bled as an aid in subduing that fever. On the other side, he has had patients die of the acute inflammatory diseases when they have not been bled; and, to-night, recalling those cases, he is of the opinion that some of them, if they had been well tapped in the arm at the outset of the sickness, they would have been saved.
Rocky Hill, Conn., December, 1897.
TAKA-DIASTASE IN THE TREATMENT OF AMYLACEOUS DYSPEPSIA.
BY WALTER P. ELLIS, M. D.