Annual Oration 1887
George J. Townsend, M.D.
In obstetrics, the progress which has been made is well marked, and the change in method, in many respects, is well-nigh radical.
In our student days, we were counselled never to carry a pair of forceps with us to a case of labor; in fact, it was considered better that we should not even own a pair. This was to discourage what is called meddlesome midwifery, as objectionable now as it ever could have been. Yet those of us who have been called, as a last resort, to a patient worn out by days and nights of fruitless effort, and, after a successful delivery with forceps, have seen her succumb, plainly from exhausted vitality, can best realize the danger of a do-nothing policy.
Indiscriminate haste in interference with nature's processes is fraught with evil consequences, often entailing permanent disabilities, while too long delay in affording necessary aid is fatal in its effects.
The happy medium is now inculcated by our teachers, and ably carried out by our Fellows, so that we may reasonably hope that mothers undergo their severest ordeal with a minimum of danger and suffering.
Continued efforts are still made to perfect instruments; but however desirable it may be to have a pair of forceps perfectly adapted to their ends, we should not be allowed to lose sight of the fact that it is of much greater importance that the hand which uses them should be guided by a calm, dispassionate brain, and should be practised and skilled for its work.
In a well directed effort to avert the necessity of a resort to the most repulsive operation in difficult labor, craniotomy, one of our most progressive teachers has most persistently and ably advocated version where forceps have failed. This is a procedure dangerous enough to mother and child, and not lightly to be adopted. Yet it is demonstrable that it often will succeed in safely delivering the mother and saving the life of the child. Should it fail, the dread alternative is still practicable.
In no disease has there greater progress been made, in pathology and treatment, than in that most dread complication of the parturient state, puerperal, now known as septic fever. Less than fifty years ago this disease was accepted as an idiopathic fever, essentially consisting in peritoneal inflammation and not necessarily contagious. The treatment which we were taught in our student days, corresponded with this pathological view, copious blood-letting being the first requisite, the sheet anchor.
Very soon the occurrence of frequent consecutive cases in the practice of one physician after another, attracted attention, and an invaluable paper maintaining its contagiousness was published by a Fellow of this Society; who amongst the flattering homage of the whole literary world, has his crowning glory from our standpoint, in his well-earned reputation as the "faithful teacher." This paper is believed to be the first conclusive argument which had then been published proving the fact, that the disease could be, and had been carried from one patient to another by the attending physician. After its perusal, no one could go from a case of puerperal fever, to attend a case of labor, without an inward consciousness, at least, of criminal carelessness.
It was reserved for more recent investigations, to show upon what this contagion depends, and how the hand which is used to comfort and assist becomes the vehicle of death.
Whether or no the germ origin of disease be yet accepted in its entirety, the results obtained by the systematic and rigid application of antisepsis before, during, and after labor, in abridging the frequency of the disease and diminishing its fatality, are simply astounding, and though in the present state of our knowledge we may not hope to see it entirely stamped out, the fact that we can render its occurrence infrequent and that we can abridge its mortality by means within the reach of every practitioner, will enable us all to breathe a sigh of relief.
The convincing incontrovertible paper prepared with most exhaustive care, the result of most exact observations, just published by the senior attendant of our "Lying-in Hospital," a paper which it would be well were it emblazoned in letters of gold and sowed broadcast throughout the ranks of our profession, leaves no longer room for doubt that the disease is the result of septic infection, introduced from without, that germicidal precautions and treatment will prevent its introduction and will modify its consequences when it has occurred.
In the outlying districts of our Society puerperal septicæmia is a rare disease. The seed to be developed must fall upon good ground. The more robust frames, the purer air, the simpler habits of life obtaining in those districts are all-important factors conducing to this end. But when it does occur, there is nothing in the whole category of disease more appalling, as all of us can realize, who, after leaving a newly-made mother, safely conducted through her dreaded ordeal, happy in the joys of maternity, have been hastily summoned to her bedside, by the onset of that dreaded rigor, too often the precursor of the final chill of death.
It is now but little more than twenty years since antisepsis was first suggested, and it was at once readily adopted, more especially by our surgeons, its methods carefully studied, its details minutely described and faithfully carried out. An able and earnest plea for its general reception has been made from this platform. Its wonderful results speak for themselves, limiting contagious disease to the individual in which it arises, arresting the progress of epidemics, and rendering practicable operations in surgery, previously regarded as formidable, as they were unsatisfactory in their termination.
In abdominal surgery its value is most readily noticeable. Witness the long list of ovariotomies, without a failure, in the practice of our most distinguished specialists, with a host of other triumphs in general, as well as in abdominal surgery.
There has been a difference of opinion as to the manner in which it acts in preventing disease, and it has been maintained by many that it is essentially only that cleanliness which is akin to godliness. Yet in view of recent developments, antisepsis is generally recognized as, not only the prevention of the presence of germs in abraded surfaces, but also the employment of germicides to render them inert should they escape our vigilance.
Its use is now by no means confined to our cities; though the denser the population the more necessary it is to guard against the communication of disease. In the remotest regions it is now habitually employed, and the country physician's satchel is rarely found without a supply of the bichloride, a box of antiseptic unguent, and a nail-brush.
The exclusive use of germicides, in the treatment of all disease, and its triumphant success in arresting morbid processes, is probably a therapeutic Millenium we may never see. For granting that every disease has its specific bacillus the killing of which will arrest the disease, a germicidal agent powerful enough, for that end, would be equally destructive to the organism in which the germ occurs. Yet a growing tendency to the employment of germicidal therapeutics is already noticeable, and the apparent results obtained promise a radical improvement in the treatment of many, especially the zymotic diseases.
We have admitted woman to fellowship in our Society.
Fully realizing the force of the objections urged against this, by many of our most experienced and able Fellows, not believing now, that numerically, she will ever become a large factor in the practice of medicine, we were early confronted with the fact that we had amongst us, conscientious, educated, competent female practitioners, and that they had become such without abating one jot or one tittle of those characteristic, inherent, feminine qualities, which constitute woman's priceless jewels. In the most dignified manner, with the utmost propriety, she asked permission to appear before our censors for examination, that, if found qualified, she might be admitted to our Society, shrinking from no ordeal, however severe, that they might deem necessary to prove her acquirements.
It would seem then that we owed it to our manhood, to our simple sense of justice, to grant her request, and by setting the seal of the Society's approval upon the successful candidates, to enable the public to discriminate between them, and a host of others, amongst whom may be those who are uneducated, unscrupulous, not to say profligate.
There are certain positions which a competent female practitioner, who is also a true woman, is peculiarly adapted to fill and in which her power for good is necessarily greater than that of any man can be. As an evidence of this fact, the good work of the late physician and afterward superintendent of our Female Reformatory Prison, is especially prominent. Her fostering care of the unfortunates committed to her charge and her humanizing influence upon them cannot be overestimated, and we have every reason to believe that the good seed so faithfully sown will bring forth lasting fruits, fraught with good results to the whole community.
But for an accidental circumstance she would probably have become the first female Fellow of our Society, and though now transferred to another more congenial and not less useful sphere, we can but regret her loss to our State.
For similar reasons there is another position which a competent female practitioner is peculiarly adapted to fill, that is, the medical supervision of the female wards of insane asylums, where a large proportion of the cases, as large as one-tenth, if I am rightly informed, are erotic in their type, rendering the very presence of the opposite sex objectionable. The experiment has certainly been tried with success in a neighboring city.
Our good State enjoys the unenviable distinction of being the paradise of empirics. Aroused by the lamentable consequences of malpractice, resulting in one not very remote instance in the death of the victim and a verdict of manslaughter against his slayer, our Society appointed a committee to procure legislation regulating the practice of medicine. Mainly through the efforts of its indefatigable Secretary a bill for that end was framed and introduced into the Legislature, there to be killed by the strenuous efforts of its interested antagonists, aided by able counsel, and well supplied with the sinews of war. This is perhaps well, after all; for though our State is in a small minority, some twenty-six of our neighbors having enacted such a statute, and individuals must still suffer from maltreatment, the true method of overcoming empiricism, is by demonstrating to the public that only treatment by an educated skilled physician can produce the result most to be desired, the speediest possible restoration to health and usefulness. But by making this move we have at least shown our unselfish desire to promote the welfare of suffering humanity. For, had the bill become a law, in no possible sense could we personally have been benefited by it as not seldom our most profitable practice is in undoing the mischief which empirics have caused.
Brethren, the object of this superficial, imperfect sketch, for the half has not been told, is not mutual felicitation. We have sought only to adduce evidence enough to show beyond the possibility of doubt, that, while many of our master minds have originated improvements which constitute eras in medicine and surgery, the Fellows of our Society in general, each one according to his opportunity, have ever been found in the most advanced ranks of medical progress, abreast of its foremost wave.
The relations of our Society to the community in which we practice constitute a subject much misunderstood, yet of vital importance to our patients as well as of interest to ourselves. We have pledged ourselves to unselfishly give them the benefit of the latest researches, the most advanced thought in medical science, considering their welfare of the first, our own interests of secondary importance. We ask of them in return such reasonable compensation as may enable us to gain our daily bread, and we waive even that, in a host of cases where necessity and destitution may require it. This gratuitous practice necessitates more or less self-sacrifice, for though some of our Fellows are blessed with an abundance of this world's goods, if our professional income were divided up there would barely be enough to go round. And while this fact obtains, many an unblushing empiric acquires a large fortune. For as one of our eminent teachers once said to me, "that physician is a fool, who, if he has no principle cannot make money.”
The tendency of many patients to frequently change from one physician to another, is one great obstacle to the systematic and effectual treatment of their cases; an obstacle of more moment to the sufferer than to his physician. For though it is by no means flattering to our self-esteem, after we have carried a case through its gravest phases to have it suddenly taken from us and placed in the hands of some, pretentious pathist, who readily asserts that the patient would have saved much time and suffering if he had only been called sooner, in the long run more patients will come to us under similar circumstances than will leave us.
We value our regular families who for one or two generations perhaps always depend upon us for aid in their hour of need, not because we are sure of their patronage and for the liberal fees which await us when our services are rendered and our attendance ceases; not because of the friendships which, however much the idea may have been depreciated in some quarters will spring up and abide between physician and patient; but because, familiar with their surroundings, their habits of life, their idiosyncrasies, we can render them more intelligent and efficient assistance. No physician, however familiar from long practice with the treatment of disease, can afford to lose sight of the weight of responsibility that rests upon him in the management of every grave case in which the issue of life or death depends upon his fidelity, judgment and ability. Any circumstance that will lighten that burden and make the successful issue more sure is of vast importance and is eagerly sought for by us all.
The causes of this tendency in the community are various. Success being naturally the touchstone, by which a physician's ability is tried, the occurrence of one fatal case after another, in spite of his most able and earnest efforts, often drives relatives to seek any change which promises better results, forgetful of the fact that one such disease awaits us all, no human power availing to ward it off.
Impatience of suffering and delay, a constant search after something new — the characteristic of our nation — misleading statistics, loud pretensions of superior methods, of new means, natural and supernatural, all are factors tending to this result, only to be combatted by a diffusion of the knowledge of the true powers and scope of medicine. There is one cause over which we have some control, and the influence of which we can diminish, and that is the too flippant use of the word cure — a word which, in its sense of restoration to health, it would be well were it eliminated from medical phraseology, and the fact stated that no patient was ever yet cured of any disease or disability by any medication or surgical operation. Medicine arrests pathological changes, abates symptoms, relieves suffering. Surgery removes foreign growths, adjusts displaced and fractured members, and, after all, in many instances, the patient fails to get well. Take any familiar disease, for instance, say diphtheria: many at first uncompromising cases recover, while another, in which the disease seems to have been overcome, the membrane disappears, the appetite returns, fails to do well, and finally succumbs.
So in ovariotomy, a most unpromising case, with extensive adhesions and other grave complications, gets well, while another, in which everything seems favorable for a successful operation, dies.
This, eliminating that general depressing effect of disease and operations, which is termed shock, is from a deficiency of a certain unknown quantity, which we have but limited means of estimating, and over which we have but little control, and which we call constitution, vitality. Whether this be a distinct principle, implanted in the economy with the breath of life, and growing with its growth, or the aggregate of the inherent forces of organized matter, as has been ably maintained for and against, within our Society, is of no moment. The final cause is the same: the strength of that principle, the sum of those forces, determines the issue in every case.
The relations of our Society to other physicians in the community seems to constitute a topic which is to be treated very gingerly, and with great caution, for what reason is not apparent, unless, forsooth, because many of them with good social standing have a greater or less following of people intelligent and educated enough in other matters, but lamentably ignorant of the true scope and powers of medicine.
Under our by-laws, we can simply have no professional relations whatsoever with such practitioners, neither in general, in special, nor in hospital practice. In general practice, the language of our by-laws is explicit enough, and it makes no exceptions for special nor for hospital practice. In fact, the attempt of any Fellow of our Society to treat a special organ, while some pathist manages the rest of the system, would be a manifest absurdity. What, for instance, could an oculist do with the specific forms of iritis, while somebody else dealt with the systemic infection?
If, in hospital practice, the wards are kept distinct, there is nothing in our by-laws which forbids our Fellows taking charge of one part of a hospital, while some other physicians take charge of another part. But if the rules of such a hospital require, at any time, a consultation between the members of the different staffs, medical or surgical, no Fellow of our Society can consent to such a consultation without plainly violating his written assent to our by-laws, and imperiling his affiliation to the Society.
Our by-laws forbid such consultations, for good and sufficient reasons obvious enough to any unbiased inquirer, as it is impossible that any benefit could accrue from them, either to the patient, to medical science, or to the consultants. There can be nothing in common between two physicians, of whom the one, fitted by his experience and studies to cull from the broad domain of medical science all the facts which may throw light upon a given case, bases his diagnosis upon those facts, and shapes his treatment accordingly; while the other, having an exclusive theory to maintain, in all consistency can only accept such facts as accord with his theory, and must reject or ignore all others.
What benefit could the patient derive from such a consultation? No argument is possible between the physicians, and neither of them can conscientiously yield his views. The patient has no new light thrown upon his case which his attendant accepts, no new treatment proposed which he can carry out.
Nothing is gained for medical science; for the more a case is discussed from such opposite standpoints, the wider the difference grows, until the consultants separate with a mutual feeling of dissatisfaction, if not of hostility.
What becomes of our boasted philanthropy when we decline such consultations, and refuse the benefit of our advice to a sufferer? We do not decline to aid any sufferer, as far as our time and strength will allow; but, as the responsibility of life rests upon us, we only ask that we shall meet one who is willing to see the force of our reasoning, and, assenting to it, will faithfully carry out our suggestions.
We have expelled from our Society, Fellows who profess to cure diseases by any exclusive method, any pathy, and a howl of indignation at our uncharitableness and illiberality echoed from one end of the State to the other, which was as unreasonable as it was uncalled for: uncalled for, because we have ample and unquestionable authority to manage our own affairs, to establish our own by-laws and enforce obedience to them without outside interference or criticism; unreasonable, because the main point at issue has been either entirely misunderstood or wilfully ignored. Submission to the will of the majority is the cardinal principle of every organization in a republican government, without which there can be no permanency nor power in it, and our own affords no exception to the rule.
We have adopted a certain standard for ourselves; we are incorporated for certain definite purposes; we have established by-laws to enable us to carry out those purposes; we have provided a way to change those by-laws from time to time as expediency may dictate; we require all Fellows to comply with them, and we allow any Fellow to sever his connection with the Society, at his own will and pleasure, provided only that he has paid his dues and has made a written application giving his reasons therefor. When a Fellow openly and avowedly violates our by-laws with which he has agreed in writing to comply, and he becomes guilty of practices forbidden to Fellows, his conduct viewed by any standard of honor and probity, is unworthy an honorable physician and Fellow of this Society. It is simply giving the lie to his written promise. For this, because they deliberately violated their written word and sought to weaken and subvert an institution which they had promised to sustain, have Fellows been brought to trial, and when found guilty have been expelled from the Society; and not from any personal nor professional hostility to them. No other course was possible consistent with our self-respect and our regard for the permanency and influence of our Society.
Other physicians viewing these objects from a different standpoint, have organized societies professing certain methods of treatment and practising more or less consistently, according to those methods. With these we have no concern. We have no right even if we have the inclination to criticize them, much less to assert that they are dishonorable or unworthy practitioners. Our professional differences are irreconcilable, but there need be no personal nor social antagonism between us, any more than between others who hold opposite opinions upon various subjects.
The relations of our Society to its Fellows comprehend our mutual relations to each other. Our first duty, if we wish to promote the integrity and influence of our Society, is to guard well its portals, to see that none but good men and true enter there. The committee, appointed by our councillors, have with much labor prepared an exhaustive list of medical schools, which have given evidence of honest, faithful work in fitting students for our profession, and this list has been accepted by the council. A diploma from one of these schools, or its equivalent, is a pre-requisite to an examination for fellowship required from every candidate. Yet there are Fellows of our Society to-day by no means necessarily physicians incompetent nor is the date of their admission remote who cannot show such a diploma or its equivalent. This is an evidence of laxity in discharging their duty on the part of the censors who passed them, plainly forbidden by our by-laws. Though our Society thus far may have suffered no detriment from this, a continuance of the practice is clearly an injustice to those candidates who have complied with our requirements, and opens the door to others in the future who may be anything but desirable Fellows.
Once admitted to our Society we cannot sever the affiliation of any Fellow without preferring charges against him, and giving him a fair trial, in which he has an opportunity to explain and refute those charges. It is evident that it would not be an easy matter to convict one of a violation of the by-laws of our Society before he had given his assent to them, and it would necessarily appear that the' fault should be laid at the door of the censors and not of the candidate.
Until quite recently there has been no attempt to secure anything like uniformity in the examinations by the censors of our different districts, and instances are not wanting where candidates rejected in one district have, after the prescribed time has elapsed, applied in another, with the hope of receiving an easier examination. The recent move by the censors to establish a definite system of examination throughout all our districts, is in the right direction, securing a practical, honest test of his acquirements to the candidate, one which every practitioner ought to be able to pass, and excluding only those who are clearly deficient in education and therefore incompetent.
One more topic I fain would not pass over, albeit a delicate one. Our organization is essentially a brotherhood. We are banded together for the public weal. Harmony and unanimity are necessary to the attainment of our ends. In the active competition of professional life, a competition which with many of us means a struggle for daily bread, collisions may occur, always fostered and enjoyed by outside parties ever ready to cavil at our profession, the evil effects of which are only to be averted by mutual concession and forbearance. Sharp criticism, disparaging remarks concerning a brother physician, are often thought to be sweet incense to our ears, whereas a greater insult cannot be offered us or our profession. It is rarely, indeed, the case that we cannot offset such remarks by the mention of some act of unselfish and successful devotion on the part of our abused brother.
We have admitted women to our Society. We all recognize her priceless influence in softening the asperities and promoting the amenities of social life, may we not hope for some of that same influence in our professional relations, so that when we are tauntingly asked, when doctors disagree who shall decide? we may answer, the woman.
Brethren, let us close our ranks, progress shoulder to shoulder, banish all personal animosities, do battle only against the King of Terrors and all his attendant miseries, and, though worsted at last in every encounter, with services often unrequited and even unrecognized, gathering consolation in that we have contributed our mite to diminish the sum of human suffering.
Thus may we expect to see our Society acknowledged as the power for good in the community, which it is; commanding the respect which is its due, because founded upon eternal principles of truth and benevolence.
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