Boston in the Time of Cholera
William C. Dowling (Rutgers University)
I want to talk today about a curious clinical episode I came across some years ago when writing a book about Paris medicine in the 1830s. But let me start by distinguishing among three characters whose names might otherwise cause confusion. The first is Dr. James Jackson senior, who was a Professor at Harvard Medical School and founder of the Massachusetts General Hospital. The second is his son James Jackson junior, who belonged to a brilliant group of Boston medical students who went to France to study medicine in the 1830s. I'll refer to him throughout as the young or the younger Jackson.
The third is Oliver Wendell Holmes, who studied medicine in Paris at the same time as the younger Jackson. His son Oliver Wendell Holmes, Jr., went on to became a famous Supreme Court Justice. In what follows, I shall always be speaking about the senior Oliver Wendell Holmes, the Paris-trained physician.
"Boston in the Time of Cholera," talk delivered to the Medical History Society of New Jersey at the Rutgers Club, New Brunswick, NJ, 11 February 2015
"Among the thousands in the profession of this country who . . . sought light and learning in the older lands," Osler wrote, "the group of young men who studied in Paris between 1830 and 1840 had no predecessors and have had no successors. . . . They more than any others gave an impetus, which it still feels, to the scientific study of medicine in the United States." By scientific study Osler meant the systematic correlation of external signs or symptoms with specific lesions in the internal organs of the body.
W.C. Dowling, "Boston in the Time of Cholera"
Its implications for therapeutics were clear: if the bloodletting practiced by physicians on both sides of the Atlantic was frequently harming or even killing patients, might not the same be hypothesized about such remedies as calomelwhich contained mercury, known even then to be poisonous to the bodyor preparations like tartar emetic, based on antimony?
Up to four-fifths of the blood could safely be removed from the body, Rush serenely assured his students. "Tis a very hard matter to bleed a patient to death," he told them, "provided the blood be not drawn from a vital part." Here is Rush's account of his therapeutic rationale. "We will suppose the doctor to have a house containing 100 rooms," he once wrote, "each having a different lock. Of course he must have an equal number of different keys to open themnow I am capable of entering every apartment with the assistance of a single key." The key was bloodletting.
"The disgrace of medicine," Holmes told one group of fellow physicians at midcentury, "has been that colossal system of self-deception in obedience to which mines have been emptied of their cankering minerals, . . . the entrails of animals taxed for their impurities, the poison-bags of reptiles drained of their venom, and all the inconceivable abominations thus obtained thrust down the throats of human beings." A remark Holmes made on another occasion would become instantly famous: "If the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,and all the worse for the fishes."
Even worse, it soon became evident that the expectant method was useless in cases of cholera. Here is the younger James Jackson writing to his father in Boston from the wards of the great Paris hospital the Hôtel Dieu. For this new disease, he reports, there is only "one word;it is death. Truly, at Hôtel Dieu, where I have seen fifty and more in a ward, it is almost like walking through an autopsy room;in many nothing but the act of respiration shows that life still exists. It is truly awful.as for treatment, nothing is yet decided."
Here, it seemed, was heroic intervention, if anything might be called heroic. Yet after careful investigation young Jackson would conclude that this spectacle did not, after all, represent a serious challenge to the expectant method as based on the researches of his teacher Louis. When I first encountered the episode of the saline injections it was the clinical details that puzzled me. We know today that the violent diarrhea caused by the cholera toxin produces an electrolyte imbalance that leads to hypovolemic shock.
When I read Jackson's reports of the injections, what struck me was their uncanny similarity to modern treatments using either oral rehydration salts or, in patients unable to swallow, injections of Ringer's solution. So why had the saline injections survived only as a curious and isolated episode in medical history?
The trouble, I thought, must have lain in the method of injection. The standard method then was by enema. But in cholera the intestinal epithelium is so compromised by the disease that I decided it must have permitted only enough absorption to produce a temporary reaction. But that left an unresolved problem. A few patients treated by saline injection were reported to have survived for somewhat longer periods.
Loring Conant, MD, WCD, Michael Nevins, MD
Latta had indeed begun by trying rectal injections. When they had no effect, he tried inserting a tube into the basilic vein of a terminally ill patient and injecting large amounts of saline fluid. So far as I know, Latta's was the very first use of intravenous therapy. Here is Latta's account of the effect on a female patient: "She had apparently reached the last moments of her earthly existence," he reported . . . "Ounce after ounce was injected, but no visible change was produced. . . . [But then] she began to breathe less laboriously, soon the sharpened features, and sunken eye and fallen jaw . . . began to glow with returning animation; the pulse, which had long ceased, returned to the wrist; . . . and in the short space of half an hour, when six pints had been injected . . . her extremities were warm, and every feature bore the aspect of comfort and health." But such comfort and health turned out to be no more than transitory. Most patients went on to die within a short time.
Only in thinking back over the episode during the years that followed did I begin to see that its real significance could be taken to lie not in the failure of Latta's injections but in the way young Jackson dealt with what he saw. For the circumstances were far more complex than Jackson could possibly have realized. He was, after all, standing on the very cusp of a modern therapeutics in which rehydration would become the standard means of preventing hypovolemic shock, and isotonic fluids would be routinely administered through IV.
Yet, no doubt thinking of the extravagant claims for heroic intervention that still dominated American medicine, young Jackson chose to remain steadfastly skeptical. His ultimate conclusion would be that "the injection undoubtedly produces a temporary excitement, but as yet we have no proof that it arrests the disease. It does not strike at the cause; and how can we suppose that it would? This chemical rage enrages me."
For at the time of young Jackson's death Boston had in fact heard little about the expectant method. The controversy surrounding it would become heated only several decades later. By that point, one has to admit, things had become sufficiently bitter. Today, for instance, everyone remembers Holmes's remark about how deadly the remedies used in heroic treatment would be to the fishes in the ocean. What is seldom remembered is that the medical society to which Holmes delivered his address voted the next day to dissociate itself publicly from his views.
"Have we . . . deduced our results," he asks in one letter, "from all, or from a selection of facts? . . . Do we know how large a proportion of cases would get well without any treatment . . . ? When a disease is destined by nature to be long, do we very often diminish it? . . . What I have seen here of disease and its issues, has rather inclined me to believe that I individually overvalued the utility of certain modes of treatment in America."
But what any serious study of the correspondence between the senior and junior Jacksons demonstrates, I think, that the underlying issue goes far deeper. What was at stake was a belief that is today increasingly accepted as having played an unrecognized but wholly legitimate role in medical practice since the time of Hippocrates and Galen. This is nothing other than the necessary belief of physicians in their own power to heal. A recent study puts it this way: "The physician's belief in the treatment and the patient's faith in the physician exert a mutually reinforcing effect; the result is a powerful remedy that is almost guaranteed to produce an improvement and sometimes a cure."
The starkness of the dilemma is obvious. To repudiate heroic practice would be not simply to give up one's use of the lancet to draw blood, but also to give up one's belief that one had ever actually cured a patient by using such measures.
At the point Holmes made this remark, opponents of the expectant method had taken to denouncing it as the "nature-trusting heresy." Holmes was undismayed. "If there is any state or city which might claim to be the American headquarters of the nature-trusting heresy, provided it be one," he declared with unrepentent pride, "that state is Massachusetts, and that city"by which, of course, he meant Boston"is its capital."
So far as he was inclined to see the injections as simply the latest in a long succession of heroic measures for which false or even dangerous claims had been made, he was no doubt mistaken. Doctor Latta was closer than Jackson could have realized to a genuine breakthrough in therapeutics. But to the degree that Jackson's response withheld assent from claims unsupported by any systematic analysis of clinical results, it seems to me that it must be taken in its own historical moment as an entirely principled therapeutic skepticism.
Among the remedial agents vaunted elsewhere during this second epidemic were assaftida, calomel, camphor oil, castor oil, cod liver oil, oil of turpentine, creosote, opium, mustard cataplasms, sulfate of quinine, sulfate of zinc, hydrocyanic acid, magnesia, decoction of hemlock bark, and bleeding to the amount of 16 to 20 ounces.
But by then, for those who had eyes to see, the days of heroic practice were already drawing to an end. At Harvard Medical School, where Oliver Wendell Holmes was now teaching as Parkman Professor of Anatomy and Physiology, and in the wards of Massachusetts General Hospital, where younger physicians whose reading had included the Memoir of James Jackson, Jr., M.D. were putting the médecine expectante of the great Paris hospital teachers into practice, a future might already have been foreseen in which medicine would in time derive its power to work seemingly miraculous cures by cooperating at the deepest level with nature itself.