THE

BRISTOL

flfcebicosCbiruvGical Journal. 1892.

DECEMBER,

THE TEACHINGS

OF FAILURE.

Ube lpresi&ential Bbfcrcss, bcltvcrcb on ?ctober t2tb. 1892, at the opening of tbc 19tb Session of tbc Bristol /lftci>ico=Cbivurgical Society;.

E.

Markham Lecturer

on

Skerritt, B.A., M.D. Lond., F.R.C.P.;

Medicine in the Medical School of

University College,

Bristol; Senior

Physician

to the Bristol General

Hospital.

My first duty is to thank you sincerely for the honour which you have done me in calling me to the presidential chair of this Society. If I do not proceed to enlarge upon my unfitness for a position of such responsibility, it is not that I am not conscious of it; but you are

already

too familiar with the

expression

of the

sense

of

self-distrust which appears to be inseparable from the assumption of presidential cares, and almost year by year is owned to from this chair. The past session has been one of quiet prosperity to the Society, and of freedom from war's alarms. The 17 Vol. X.

No. 38.

DR.

230

E.

MARKHAM

SKERRITT ON

present year opens under circumstances of It is intended that the

ordinary meetings

shall be held in the Medical

Bristol,

the handsome

Wing

building

good

omen.

of the session

of

University College, by, which, after hope deferred, has at

hard

years of anxious waiting and of length taken so satisfactory material form.

I trust that

it is destined to be the

permanent home of the Bristol Medico-Chirurgical Society. A joint committee from

your committee and the faculty of the Medical School has already been appointed to consider a scheme whereby

library may become your and, of more importance local habitation of the still, your library. So vigorous of the has been the growth latter, under the fostering care of your honorary librarian, that it has already all but expanded to the limits of its present abode; and I look forward with confidence to the time, in the not far distant future, when in the adjacent building there will exist a library which will bear evidence to the vitality of this Society and the activity of medical education in this

the fine hall set apart for a recognised place of meeting,

city, and form a collection of works on medical and allied subjects such as will make it a boon to the members of the profession in this district, and give it undisputed position Medical Reference Library of the West of as the England.1 subject for an present is always a

The choice of

occasion The

as

history

the

a

of the

Society

institutions and medical

again

been recounted

by

address

on

matter of

such

an

difficulty.

and of the life of medical

men

in this

those who

city, are

has far

again more

and com-

1 Since the above was written a scheme has been agreed to by the Medical School and the Society for the amalgamation of the libraries of. the two institutions in the new Medical School building.

THE TEACHINGS OF FAILURE.

petent

to deal with it than

limited

23I

A discourse

myself.

on some

in

practical medicine or in pathology would find a more fitting place in one of the later meetings of the session. No recent great advance in our knowledge of disease, or in our ability to meet it, subject

demands

But if

notice.

look back upon the of the immediate past, two episodes stand out in bold relief?one, the history of tuberculin; our

medical the

we

history

other,

the

onslaught to allay the

of influenza.

alarm which my words may have It is not my purpose to inflict minds. in raised your upon you either an analysis of the results of what is I hasten

known

as

Koch's

The former trust, is

so

is,

I

method, or a disquisition upon influenza. fear, a thing of the past; the latter, I

too, and upon neither

can

we

Koch led

a

as

scientific

away after profession the influenza did with us what it a Will-o'-the-wisp; and the would; contemplation of this has turned my thoughts towards an aspect of our work upon which it is good for our mental discipline that we should at times meditate. This Society is wont to witness the successes look with satisfaction.

of its

members,

regions

us

and their achievements in the various

of medicine and

failures appear before

us

pathology; here

as

even

our

clinical

pathological triumphs.

I ask you to look for a few minutes upon the the picture?to submit yourselves to a short

reverse

of

course

of

fasting

and humiliation for sins of omission and of

mission

; to gaze upon our

remembering that, few

are

more

difficulties and

of all the lessons

our

com-

mistakes;

taught by experience, duly-

valuable than those obtained from

appreciated failure. a

The first part of my text is Koch's announcement of cure for tuberculosis. It may safely be affirmed that no 17

*

E.

DR.

232

MARKHAM

SKERRITT ON

other event of recent years has created so profound a sensation throughout the whole civilised world. Political

disturbances, however grave,

and

wars

rumours

of wars,,

disquieting, have their more or less limited local even a far-reaching scourge such as cholera not at does one grasp lay hold upon all the races of mankind. But here was a thing that was brought home to every people under the sun : not a country but what was however

incidence ;

the home of

tuberculosis, not victims;

had not claimed its

community

a

scientist of the age, a man work had hitherto been above of the bacillus tuberculosis

suspicion,

itself,

came

the discoverer

forward with the

confident assertion that the dread disease "

incurable.

appointment

in which it

and the greatest medical whose reputation for accurate

was no

longer

"

Bitter disPut not your trust in princes ! has followed : the prince among scientists

is fallen from his

high

at confidence in

estate ; and

a

blow has been struck

scientific methods and scientific

which will leave its mark upon

profession

our

men

for

a

generation. Where

the

was

mistake ?

We

as

a

profession?

be it said?trusted too much to

judgment, although he appeared in the novel role of a clinical physician. Probably all recognised the anomaly in Koch's explanation of the phenomena involved, and

against

our

the man,

understand,

found it hard to

surrounding the disease

if tuberculin

destroyed the itself, how the result proved

tissue rather than the active focus And

be eradicated.

was to

that this doubt

was

well founded.

Had the

announce-

ment come from almost any other source it would have

been

differently; but on trial was imperative.

received far

authority

careful

is matter of too recent

history

to

need

such

respected

What followed

recapitulation.

THE TEACHINGS OF FAILURE.

When the usual methods of scientific

233

investigation

were

bear, evidence rapidly accumulated adverse brought to the method, and in its original form it is now practito

cally abandoned. Whether any modification mately be of value remains to be proved. A special regret attaches to the recognition of

own source

reputation

The

error.

fell into

man

unscientific?he based his conclusions upon insufficient observation.

errors

of the and

imperfect

it is of interest to note how any new that is opened up tends to lead to fresh discoveries.

As

path

of Koch's

of world-wide scientific

of the commonest

one

may ulti-

side

a

issue,

The reaction of many tubercular subjects to tuberculin is beyond doubt, and there is much evidence to prove that when tuberculosis does not exist, reaction is comparatively The fluid hence has considerable

rare.

diagnostic value,

to what actual extent is still undecided.

Working product of the bacillus of glanders, which has been called "mallein," has been employed for the diagnosis of glanders and farcy. The result so far

though on

the

same

lines,

a

obtained appears to be met with in tuberculosis. as

with

glanders but

not

curiously

tuberculin

in

and

the reaction is

farcy, absolutely,

all fours with that

on

Observations have shown

tuberculosis,

inasmuch

animals free from the disease.

as

so

generally diagnostic, it

has

But this is

therapeutic history of record of a series of false hopes with disappointments. It is melancholy to the last few years, and see how remedy The modern

that,

with mallein in in

occurred a

digression.

tuberculosis is

a

their consequent look back upon after

remedy

has

been introduced with flourish of trumpets, has failed to stand a wider test, and has fallen into the background. Let

me

remind you of

a

few of the army of

specifics:

DR-

234

E>

MARKHAM

skerritt on

Iodoform, aniline, thymol, tannin, ozone, calomel and corsublimate, homeriana, hydrofluoric acid; antiseptic inhalations of carbolic acid, creasote, iodine, eucalyptol, iodoform, turpentine, sulphurous acid, chlorine, sulphuretted hydrogen (which were to go to the root of the whole matter by attacking the bacillus in its stronghold); rectal rosive

injections

of

intra-tracheal introduced

sulphuretted hydrogen; subcutaneous and injections of drugs that are much better

by

the channels that Nature has of

provided; iodoform, creasote, iodine,

intra-pulmonary injections carbolic acid, iodol, camphor-carbolate, biniodide of mercury, naphthol, boronaphthol, camphor, guaiacol, and (designed to act directly upon the tissues into which they were injected, regardless of the impossibility of absolutely determining the diseased areas by anything short of a post-mortem examination) ; the introduction of the bacterium termo in its legions, to war upon its natural foe, the bacillus tuberculosis; Liebreich's injections of cantharidinate of potash in imitation of Koch; subcutaneous injections of goat's blood and of dog's serum ;?a long array, with Koch's tuberculin at one extreme and the like

Brown-Sequard's Even about

fluid at the other. latest

favourites, creasote and guaiacol, which still hold their ground, we are becoming uncertain. Hitherto it has been generally accepted that it is important to push the dose until large quantities are being taken daily; now we are told, in the last number of this Society's Journal, that large doses have no advantage over small. our

Three years appears to be specific for tuberculosis.

a

a new

announcement of the

discovery, with

proving its value; the second sees with

varying results;

fair average life time for The first year comes the details

a wider

the third year

incontestably

trial of the remedy,

brings

its condemna-

THE TEACHINGS OF FAILURE.

If

tion.

take

we

ment of

phthisis ;

proving

"

in

by

its well

1889

others ;

during

of

spoken we

Weigert's

hot-air treat-

introduced in 1888, backed up by

remarkable

treatment of

the

illustration

as an

235

find in

phthisis

and local

general

by some 1890 the

record that

has met with

nothing

And then it is

past year."

effects ;

good

observers and "

cases "

disparaged the hot-air

but discredit

pointed

out that

nothing else could be expected, inasmuch as both the theory and the practice are wrong: the bacillus tubernecessarily die when the temperature raised, and indeed finds a congenial habitat

culosis does not

of

the

in

body

is

certain animals whose normal temperature ranges from 102.50 to 1080; and further, the inhalation of the hottest air that more

can

than

be borne does not,

trifling

a

the

of

fact, cause temperature of the

as a matter

rise in

lung. Bergeon's method of rectal injections of sulphuretted hydrogen, brought forward in 1886 with not only in incipient but in proof of its great value confirmed cases of phthisis"; well-spoken of by good authorities in 1887; in the following year it is put aside, Then there

was

"

and Forchheimer relates "control" observations to prove that the result is practically the same whether the injection consists of

sulphuretted hydrogen

or

of

simple atmospheric

air. It is of

the

impossible

not to be struck with the

results claimed for each

good

uniformity

and all of the

different modes of treatment on their introduction: diminution of

cough and sputum, of gain weight and strength, physical signs. in

Now these more or

less

are

evidences of

accurately

fever and and often

night-sweats, lessening of

improvement

that

measured ; and there is

no

can

be

doubt

236

DR.

E.

MARKHAM

SKERRITT ON

they have actually occurred under all these varied therapeutic measures. Why then have they not been that

confirmed

by

a

extended

more

experience

?

It would

appear that a case of phthisis when taken in hand and placed under almost any treatment (provided that it is not actively harmful) tends to improve ; and this view is borne out

the

by

culosis has been

experience of hospitals where tuberlargely treated on general rather than

the associated

Doubtless this is in great measure due to improvement in the conditions under which

the

placed.

specific

lines. is

patient

We have

the well-known

with

also, however,

variability

in the

to reckon

course

of the

disease, apart from any special treatment?its tendency to exacerbations and remissions as fresh areas of lung tissue become the seat of active down.

quiet

One

thing

which in its turn may is clear?that the good results

mischief,

not limited to and do not

are

any

line of treatment.

one

uniformly And

we

follow the are

use

of

reluctantly

reminded of Sir Thomas Watson's dictum with regard to acute rheumatism: "You may be sure, when men's

opinions concerning of

common

the treatment of

occurrence

and easy

a

disease which is

recognition

are

thus

you may be sure, first, that no for that disease has yet been discovered, and

unsettled and diverse ;

specific secondly, steadily

that the disease is not very obedient, or not obedient, to any remedial plan." Forty years

after this made it

written, salicin and the salicylates had longer applicable to rheumatic fever; let us hope that the day ma)' come when it will not

was

no

still live in

be true of tuberculosis. If

our

relation

as a

profession

to

tuberculosis

cannot

regarded with any degree of satisfaction, the contemplation of the influenza epidemic is still less calculated to be

THE TEACHINGS OF

flatter

our

self-conceit.

I

mean

be scientific observers and

as

regards

237 our

claim to

therapeutists; for there is no self-sacrificing energy and

be ashamed of the

reason to

endurance with which the foe medical

FAILURE.

encountered

was

by

the

profession.

When influenza first declared its type, when it became evident that, although severe, its paroxysm was very short, and that all the acute

phenomena rapidly disappeared in a large proportion of cases, I ventured to predict that the epidemic would make the fortune of many a specific; the attack would

pass on to its natural termination in recovery, whatever the treatment adopted?always provided that the remedial measures were inasmuch

as

rapidly

What does

not too heroic.

a survey of the voluminous reveal ? A host of authorities,

literature of the

epoch fully convinced of the power of his own remedy, and equally sure that his neighbour's

each of whom is favourite

line of treatment is most

unvarying success with like, and goes on to say:

carbonate of ammonia and the

his

"

geners, most of the deaths

As for in the

to be attributed to their use."

lowed

One writer describes

prejudicial.

antipyrin epidemic

and its

con-

are, I

think, immediately folcases with antipyrin

He is

who treats 400 " I also am combined with salicylate of soda, and says: happy to say that I did not lose a single case, and found no

but

by another,

depressing on

the

other evil effects from the

contrary marked And these two

damages

and

antipyrin, saving of

are

follows: "lam

sequelae; and I used very simplest description."

the

benefit

promptly discounted by a testifies as happy to say that I lose a single patient from the epidemic or its

strength." third, who did not

or

little

medicine, and that of observer, however, scientific position by pro-

The last

his otherwise sound

238

DR.

ceeding on

his

E.

MARKHAM

to hold forth

own

showing

SKERRITT ON

against antipyrin,

he had

a

remedy

which

tried.

never

Aconite, salicin and the salicylates, antipyrin, antifebrin, phenacetin and exalgine, carbonate of ammonia and sal volatile, iron, quinine, ergot, digitalis, camphor (recommended both for its efficacy and for its cheapness), iodide of potassium, vaccination, bromides, morphia,, calomel, halviva, sulphurous acid, pilocarpine, periodate crystals, the Turkish bath, ipecacuanha, belladonna, bicarbonate of

eucalyptus, naphthol, and

potash, electricity,,

host of other remedies?each of them found at

a

least

one

"

believer.

I

convalescence

secured

says one observer, with a most enviable " I find that the disease can be cut ; power an ordinary bronchial attack, by the as easily

hours,"

in

sense

24 of

short, as following combination "?and then comes a prescription containing ether, iron, ipecacuanha, and opium. Another relies upon hot water : drink it freely, gargle the throat with it, keep' the hands in it, syringe the nose with it. Another directs to prevent the poisonous products of the putrethat "

blood,

of food

decomposition

factive

the whole contents of the

discharged

as

water,

warmly

so

soon as

an

doses.

tried

Professor

appleOscar results-

good pain and sometimes My object is to point out

abdominal

Another writes It

by

"

into the should be

not observe any

:

"

the beneficial action of salicin

large

Another

recommended

unpleasant

diarrhoea."

passing alimentary canal

possible."

Liebreich, of Berlin, but did beyond

from

seems to arrest

given frequently the

course

it does that of acute

and in

of this disease

rheumatism, when same manner." Twenty to forty grains of salicin every hour for three to six hours, and then every two hours for a day ; and by that time the fever had.

effectually given in the as

as

THE

TEACHINGS

finished its natural

OF FAILURE.

and the

course

and then, to accentuate his want

239

drug got the credit : of knowledge of the "

type of the disease, he continued the medicine that at wider intervals for were

days,"

some

though it Alcohol, too,,

rheumatic fever that he had to treat.

The writer who recommended aconite

had its advocates.

combined it with alcohol?as well he summed

method

his

up

after

as

by

the

Another

might.

that

statement

he

"

started, kept up, and finished off with stimulants." And an instance is mentioned in which a lady who had been ordered to take

during

daily

her illness did

from

duly

correspondent the French

physicians

brandy

off.

(Jan. 4th, 1890)

relates how

it,

and

of

it up, and The Paris

when last heard of had not of The Lancet

10 to 12 ounces

start

finished

kept

had discovered that those addicted

(a fact, by the way, and Frenchmen), goes on to say: apparently peculiar " The doctors have therefore recommended warm alcoto alcohol did not take the disease to

holic drinks.

prescription

Unfortunately, the

drinks to such

the

have been

public an

on

of this

strength

indulging in these days, including

extent that in three

less than 1500 persons were arrested in the streets of Paris for drunkenness. Of this number,

Christmas at least

Day,

1200

following

no

stated in defence that

the treatment

Prophylactics

Eucalyptus indeed

was

were

of

were

course

in

great

keep

mental

on

"

immunity

washing

boric acid

were

demand.

of the most

persons who had bit of blotting-paper somewhere in the house

perfect

simply

widely patronised, and to be absolutely preventive" ; and a few drops on a handkerchief or on a

was one

said

prescribed

they

for influenza."

from attack.

enjoyed

Those who would

conjunctivae with a solution promised exemption. Quinine was their

of a

E.

MARKHAM

man

took it

DR.

240 favourite

one

:

outbreak of the

SKERRITT ON

and the

epidemic

all

through the first succeeding interval, up

daily

to the time that he succumbed to influenza in its second

And the law when he gave it up as defective. courts have recently been called upon to decide as to the prophylactic value of another infallible safeguard, the

outbreak,

"carbolic smoke ball." Let dictum

me "

:

ment of

a

again of Sir Thomas opinions concerning

remind you When men's

disease

.

are

.

.

Watson's the treat-

thus unsettled and

diverse,

you may be sure, first, that no specific for that disease has yet been discovered, and secondly, that the disease is not very obedient to any remedial plan." No specific for influenza has yet been discovered: the uncomplicated disease runs its own short well-marked ...

practically

uninfluenced

by treatment, as was alone and the result is equally found by those who let it ; good, whether the patient is treated with antipyrin or

course

with

camphor

water.

The truth of this

indeed

was

home to us when influenza assumed its graver when it carried off its victims with almost the

brought form,

uncompromising rapidity

of

specifics then ? Where was of nil, so tractable that a convalescence" ?

secured

itself?whether

benign

or

a

plague.

Where

the disease with man

The

a

were

mortality

could write of

malignant,

"I

it,

true

to

recognised

no

malady it

the

was

specific. We snares success

are

that for

Post Hoc

still far too unscientific in

entrapped us.

our

methods.

are

The

still set with

That old enemy of our profession, the Hoc fallacy, has renewed his youth in

Propter days of therapeutic activity; ready as ever to follow his lead, and these

our

forefathers

and

we

be it in

just influenza, are

as

or

THE TEACHINGS

in

tuberculosis, and

cause

in other

or

effect

Medicine is

an

where

such

no

We

are

24I

too prone to see

relationship and

science,

faulty.

establish

FAILURE.

conditions,

inductive

method is too often

OF

our

exists.

inductive

in too great haste to

general propositions upon give a remedy in a certain particulars. number of instances of a disease, and a certain result follows, which we claim as due to the drug. A wider experience does not bear out our conclusions, and we therefore know that our premisses were wrong?that the particular propositions upon which we generalised were instances, not of cause and effect, but of accidental

generalise too

we

;

We

association.

perience, so

as

our

We

few

we

with

have

should

waited

for

should have made "control"

greater certainty

more

ex-

observations,

to eliminate the element of

chance. And of this I the vis

regular

am sure,

medicatrix natures. medicine

owes

from acute no

disease,

we

I

much to

its infinitesimal doses has

tically

that

do not allow enough for

have

always homoeopathy,

held

that

which with

proved how recovery, especially place under what is prac-

will take

medicinal treatment whatever.

A short time

with my clinical clerks a fairly severe case of acute pneumonia ; and to my query, "What " I should one of them replied, would you do for him ? not give him anything." Upon this prescription the since I

was

discussing

"

patient learnt

made

an

a

recovery. That student lesson?how to let well alone.

perfect

important

had

difficulty of determining the drugs might easily be multiplied?let one suffice. When salicin and the salicylates were first brought forward in the treatment of acute rheumatism, some halfIllustrations

of

the

action of

dozen similar

cases

of the disease

were

under my

care

in

E.

DR.

242

SKERRITT ON

MARKHAM

the Bristol General

Hospital. Half of them were treated an unusually rapid and complete salicin, recovery ; the other half had practically no treatment, and ran an exactly similar course. If all had had the and made

with

remedy,

new

"

but the

it would have "

control

Note, however, that erroneous ; "

not

conclusion from these instances

all that could be said

proven,"

and

was

afforded

by

equally

case

for it

that further observation

practitioner who influenza, which happened to

was

that the

An extreme instance of the

needed. of

a

the value of salicin would have been

against was

gained undeserved credit; prevented this mistake.

observations

a

opposite

was

method

recorded his first be

in

a

case

after

man;

the effects of treatment, he proceeded to generalising draw from his single case the deduction that the disease on

more

often attacked

The

plex

men

than

have to deal

we

fall

Bacon, in his discourse

on

that it is little wonder if

error.

women.

we

problems

with which

Learning, is impressed with the healing art. "This much," he

are so

and

again

com-

again

into

The Advancement

difficulties

of

attending the evidently true,

says, "is that of all substances which nature hath produced, man's

body herbs

is the most and

plants

For

extremely compounded. are

nourished

we

see

earth and water,

by part by herbs and fruits ; man by the flesh of beasts, birds, fishes, herbs, grains, fruits, water, and the manifold alterations, dressings, and preparations of the several bodies, before they come to be his food and beasts for the most

aliment.

Add hereunto that beasts have

a

more

simple

life, and less change of affections to work upon their bodies ; whereas man in his mansion, sleep, exercise passion, hath infinite variations; and it cannot be denied order of

but that the

body

of

man

of all other

things

is of the

THE TEACHINGS

compounded

most

position to

of man's

mass.

OF

.

.

FAILURE.

This variable

.

body

com-

instrument easy did well to conjoin

hath made it

an

and therefore the

distemper;

243

poets Apollo, because the office of tune to but this medicine is curious harp of man's body and reduce it to harmony. So then the subject being so variable hath made the art by consequence more conjectural; and the art being conjectural hath made so For much the more place to be left for imposture. almost all the other arts and sciences are judged by acts, or masterpieces, as I may term them, and not by successes and events. The lawyer is judged by the virtue of his pleading, and not by the issue of the cause; the master of the ship is judged by the directing his course aright, and not by the fortune of the voyage; but the physician medicine in

music and

.

.

.

ability, but

it is

as

particular acts demonstrative of his judged mostly by the event; which is ever taken; for who can tell, if a patient die or

hath but is

recover

no

.

.

whether it be

.

by

art or accident ?

And therefore many times the impostor is prized and the man of virtue taxed. Nay, we see the weakness and

credulity

of

mountebank

men 1

or

is

such,

witch

as

they

before

a

And what followeth ?

sicians an

the

lay

Even this ;

to themselves as Salomon

higher occasion, fools, why should

'

If it befall to

I labour to be

will often learned

prefer a physician. that phy-

it upon befalleth to

expresseth me

more

as

wise ?'

.

.

.

And doubtless upon this ground, that they find that mediocrity and excellency in their art maketh no difference

in

profit

weakness of 1

reputation towards their fortune ; patients, and sweetness of life, and or

for the nature

From montambanco, one who mounts a bench and proclaims the virtue of his remedies?hence a quack doctor.

DR-

244 of

E-

maketh

hope,

MARKHAM

men

SKERR1TT ON

depend

physicians

upon

with all

their defects." Well is it for the in

physician

of all his defects.

spite

that he is still in demand,

For

though

since Bacon's

time medicine has

emerged from mediaeval darkness and science, yet the human mind which has to face its ever-varying problems is the same, and its innate sources of error are unchanged. For," says Bacon, become

a

"

"the mind of

is far from the nature of

man

a

clear and

equal glass, wherein the beams of things should reflect according to their true incidence; nay, it is rather like an enchanted glass, full of superstition and imposture if it be not delivered and reduced. sons

live in the view of

in the

caves

of

minister unto

.

.

.

heaven, yet complexions

our

our own

us

infinite

errors

Although spirits are

our perincluded

and customs, which

and vain

opinions." position. I am not Fortunately for ourselves

I would not have you mistake my a

sceptic

and

adding

as

regards

patients,

our

to,

a

large

treatment.

possess, and armamentary of

we

are

from time to time

drugs

and of remedial

good their claim upon our modern and research into the conditions of confidence; bacterial life has revealed a glimpse of a region of therameasures

that have made

peutics whose limits it is impossible yet to define. But I do regret to see thfe continual series of new remedies that to be thrown aside; I do protest are introduced but against our constant abuse of the inductive method, our want of care in testing the validity of the particular

propositions To

upon which

we

found

experimental therapeutics might

ancient

saying:

"

our

generalisations. applied the

well be

The sinews of wisdom

are

slowness of

belief and distrust." In

no

department

of

our art

are we

free from risk of

THE

error

not been

no

245

Diagnosis, prognosis, treatment?I fear of us who can truly aver that he has

and failure.

that there is

TEACHINGS OF FAILURE.

one

repeatedly

at fault in each

to go into the

of these.

Were I

confessional, shortcomings?the unknown I shrink from picturing?I might well be held to be unworthy of the honourable position that I occupy to-night. And consciousness

myself

to

own

to my many

known

of failure in ourselves should make

us

"

wondrous kind

"

shortcomings of others. Looked at from the standpoint of responsibility, our mistakes fall into one of two categories?the avoidable and the unavoidable ; for undoubtedly no moral responsibility attaches to many of our failures. The degree to towards the

which

error

is unavoidable varies with the individual?

varies with the mould in which the mind is cast, varies with the acuteness of and the

delicacy

vision,

of the

sense

sharpness

of

hearing,

of touch?and

the

no

amount

training can bring all men up to the same level in medicine any more than in other callings. But enough of this personal element.

of

It must be finite

fully recognised that,

knowledge,

with

our

present Diag-

failure is sometimes unavoidable.

nosis affords many instances of this. Granted that there is no special difficulty in the recognition of disease when its type, there is an unfortunate liability for the manifestations of any given malady to become "atypical." And the more marked

it conforms to what

we

regard

as

the variation from type, the greater is the probability that some other morbid condition will be simulated. I

have heard

of world-wide

reputation deliver masterly clinical lecture on presenting all the features of tuberculosis, and point out the certainty of a fatal ending; and I have seen his surprise when the a

physician

a

a

18 Vol. X.

No. 38.

case

246

DR.

did not

patient

that

confusion

E.

SKERRITT ON

MARKHAM

but

die,

arise

may

fever.

and showed forth the

lived,

tuberculosis

between

and

remind you of Langenbuch's typhoid Again, case, in which the symptoms of locomotor ataxy existed, and great good resulted from the stretching of the sciatic nerves;

but

let

on

me

the death of the

locomotor ataxy mention of the

patient

the lesions of

found to be

were

strange protean

absent. The very condition known as

hysteria will recall to everyone moments of great doubt and difficulty, when upon the solution of the problem between hysteria and some grave organic disease turned the question between life and death. And not only does hysteria simulate conditions due to structural change, but it may itself be imitated by them. I well remember in my student days a girl being brought into the casualty in

room

typical hysterical

a

state:

there

was

a

slight

but this did not appear of importance in the face of the other symptoms. The girl was treated by such

squint,

the

of

hospital casualty room and the energy of youth suggested, and was sent home seemingly much better; and a day or two later came a letter announcing her speedy death, and complaining means as

resources

a

of the treatment which she had received.

identical this

case came to

A medical

city.

autopsy

a

on

girl

my

man

knowledge asked

there

me to

who had been

hysterical by several eminent

some

An almost years ago in

be present at

recognised

authorities.

an

purely Here, too, as

slight squint, which did not attract much day the girl had an upset with her friends, the garden in a fit of hysterical crying, and

was a

notice.

One

went into

fell down dead. It is affections

An

important of the

enormous

to

cerebral tumour existed.

recognise

heart

may

that certain functional

simulate

grave

organic

THE TEACHINGS OF FAILURE.

247

A

patient beyond middle age comes with symptoms pointing to fatty degeneration, and the physical signs are in keeping; and the man is warned to put his house in order. The general health improves, and all the symptoms disappear; and the condition is shown to have been one of functional weakness only. My experience has made me very chary of condemning a heart as

disease.

unless the

fatty

has been under observation for

case

a

considerable time. In the

hand, it is

one

be at

fault;

and

less

or

more

simple.

can

on

an

a

double

unknown a

given

source

of

error.

On

upon diagnosis, which may it has to deal with what is

If

quantity.

man

were

a

definite amount of work could be

definite

But

a

dependent the other,

from which

machine,

obtained from be

there is

prognosis

of

supply

fuel,

the

of acute

case

a

problem would endocarditis, who

foretell whether there will remain

murmur

a

and

whether grave distortion of valve will nothing more, result, with rapid failure in compensation, and early or

death ?

country and he

Some years ago I patient with most

a

secondary implication

was

with

pronounced

of heart.

warned to be most

well-known

saw

a

friend in the

valvular disease

When

careful;

20

years old of 40 a

at the age

foretold his death within twelve

authority

months; and he lived to be 60 years of age. The experience of such things tends to undermine

simple

faith with which the young

practitioner

the

emerges

from his student days; and unfortunately for the mental peace, the wider experience becomes, the more do cerAnd in forming tainties give place to probabilities.

opinion possibilities an

it is as

give due weight to to probabilities, and to make unexpected, which happens in

always

well

as

full allowance for the

wise

18

*

to

248

THE TEACHINGS OF FAILURE.

medicine with

even

greater

than in other walks

regularity

of life. "

The man's

philosopher Bacon advises not to self peremptorily in anything, though it

liable to

accident;

but

ever to

have

a

engage seem

window to

fly

a

not out

way to retire. Following the wisdom in the ancient fable of the two frogs, which consulted when

at,

or

their

a

they should go; and the one moved to go down into a pit, because it was not likely the water would dry there; but the other answered,. True ; but if it do, how shall we get out again ?' Avoidable error may be due either to ignorance or to carelessness. In the abstract, all mistakes come from ignorance, inasmuch as there would be no mysteries to perfect knowledge ; but only in so far as any man meets with failure from lack of knowledge which with our present light he might possess, is he responsible. Without doubt, however, carelessness is by far a commoner cause of error than ignorance, especially in diagnosis. My old master, Sir William Jenner, used to preach, in the emphatic way that those who knew him will rememmore mistakes are made from not ber so well, that from not than looking knowing." And often this not from not wilful neglect; but the constant looking" is a certain aspect of a case tends to of watching keep the attention averted from those features which (in Professor Lloyd Morgan's terms) are "peripheral" rather than "focal" to the mental vision. And hence it happens that when another observer comes in, with his eyes not fixed in any one direction, but turned upon each detail of the case in routine succession, he sometimes makes discoveries that would have been just as easy to the plash

was

dry

whither

"

'

"

"

brother whom he is called to meet.

LOCOMOTOR ATAXY WITH

Let

us

DISEASE.

249

consider the conclusion of the whole matter.

We fail from

imperfect knowledge

faulty observation error, we

CHARCOT'S JOINT

must

of individual

one

and

all

of

disease,

cases.

If

study

more

we

and from

would avoid

carefully

the

natural history of every morbid condition, and watch more closely the features of every instance that comes before us.

So shall

of the

we

phenomena

their course;

so

best be able to determine the nature with which shall

we

we meet, and to foretell best discover the real effect of

remedial measures, and escape the fallacy of attributing to treatment what is in truth the outcome of the unIf failure opens our eyes to our deif it makes us more critical, more careful to

touched disease.

ficiencies,

avoid unscientific methods of observation and it leads in

our

us to

work,

research,

greater diligence, thoroughness,

and

then it will not have

in vain.

come to us

if

honesty