|Oliver Wendell Holmes, Sr. (1809-1894)|
Among the prominent pairs of persons whom posterity remembers by the same name,a the two Oliver Wendell Holmes, father and son, occupy a particularly distinguished place. The junior was a distinguished lawyer who later became a Supreme Court justice. The senior also studied the law but did not like it and instead became a physician, a prominent writer, and a wise medical teacher. Well ahead of his time, he anticipated in his many publications the clinical wisdom and commonsense exhibited a few years later by Sir William Osler.
Remembered nowadays chiefly as a literary man, the senior Holmes was a precocious child, who later wrote that all men are afraid of books if they have not handled them from infancy, and that to appreciate books one has to get used to the smell of old leather at an early age. Growing up in his father’s library he read voraciously, the classics and especially the great poets, composing his first poem at thirteen. Later he wrote many essays – notably the Old Ironside, in which he successfully opposed the dismantling of the USS Constitution battleship. During his long life he published three novels, many articles in the Atlantic Monthly, biographies, travelogues, and addresses to students. He was friends with the great writers of his time, Ralph Waldo Emerson, Henry James, and Alfred Tennyson. He wrote the three famous Breakfast Table series – the Autocrat, the Professor, and the Poet – now classics full of wisdom but somewhat heavy going, bringing to mind John Ruskin’s analogy of the gold miner who must laboriously crush and smelt the rock to extract the precious gold nuggets from the sand and dust.
This difficulty has been compensated for by the frequent publication of quotations from his works: “Beware how you take away hope from another human being;” “Don’t flatter yourself that friendship authorizes you to say disagreeable things to your intimates;” “Speak clearly if you speak at all, carve every word before you let it fall;” “Fame usually comes to those who are thinking about something else;” “Learn the sweet magic of a cheerful face;” “Young people know the rules but old ones the exceptions;” “Man has his will, but woman has her way;” “Everybody likes and respects self-made men. It is a great deal better to be self-made than not to be made at all;” “People do not quit playing because they grow old, but grow old because they quit playing;” and many “die with the music still in them … always getting ready to live … but before they know it, time runs out.” Also “The sound of a kiss is not so loud as that of a cannon, but its echo lasts a great deal longer;” and “It does not matter where we stand as much as the direction into which we are moving.” And for the specialist: ”Little powers, and little narrow streaks of specialized knowledge, are things men are very apt to be conceited about.”
In his writings Holmes has little good to say about “vulgar minds” and ill-bred people, clearly defining himself as a conservative, one could say as an elitist, but it is an elitism of mind and behavior. His Professor favors political equality but social quality. The Autocrat wants great minds to belong to a society of mutual admiration – the right prescription for the successful but not for the mediocre minds, who irritated by their meager achievements are jealous of each other, often envy and hate each other and end up by fighting. Good manners and good breeding, expounds the Professor, consists of always being agreeable and avoiding any subject or expression that might give pain to others. It expresses itself in good dress, quiet ways, lips that can wait, eyes that do not wander. But the ill-bred and the vulgar, always in a hurry and talking mostly of their own ailments and grievances, constantly draw attention to their own shortcomings by apologizing for them, and grossly overstate their own achievements and uniqueness. The Professor finds that good breeding is more likely to be found among the rich, who make more agreeable companions, having benefited from the civilizing influence of ”a fine house, graceful furniture, good libraries, well ordered tables … their whole nature becoming turned into suavity … if they have never become learned they make up for it in grace … so that among the truly elegant people you find more equality and social intercourse than in a country village.”
At twenty-one Holmes enrolled in the faculty of medicine in Boston. After three years he went to Paris to continue his studies and learn from the many distinguished physicians of the cutting edge modern French school of medicine. He was mentored by the great clinician and epidemiologist Pierre Louis, remembered for his studies on tuberculosis, typhoid fever and pneumonia, for his efforts to evaluate the effects of therapy scientifically, and for favoring expectant treatment in preference to harmful methods such bloodletting and toxic drugs.
On returning from Paris, Holmes graduated in 1836 from Harvard Medical School, then taught at Dartmouth and served from 1847 to 1882 as professor of anatomy and physiology at Harvard. For ten years he maintained a medical practice, small and irregular, his interests being more academic. He coined the word “anesthesia” and popularized the use of the stethoscope when it was still rarely used. In 1843 he published a landmark paper showing that puerperal fever was a contagious diseaseb,1; and in two detailed lectures2 exposed the “most fanciful and senseless extravagance” propagated by quacks who claimed to have effected wonderful cures, discussing at great length the royal cure of the King’s Evil or scrofulac; the weapon ointmentd and the sympathetic powdere; the tar waterf; Dr. Perkins’s metallic tractorsg; and the homeopathic doctrines of Hahnemann.h
In contrast to his aversion to quacks and imposters, Holmes was enthusiastic about the advances in science of his time, in chemistry, anatomy, physiology, and neurology. In his introductory lecture to the Harvard medical class of 1861 he discusses catalytic action, isomerization, and the preservation of energy; and how the use of the microscope has led to the discovery of new structures, the ability to examine blood vessels and recognize membranes, pus corpuscles, and white cells. He introduces students to new concepts in anatomy and physiology, the digestive functions, the pancreatic juice, the unknown and puzzling functions of the spleen and thymus, the production of animal heat, the descending and ascending fibers in the spinal cord, reflex activity, and the anatomy of the eye and inner ear. He also emphasizes how so much still remains to be learned, giving as examples that we do not know why iron rusts but gold remains untarnished, why gold amalgamates but iron refuses to do so, why salt crystallizes as cubes but saltpeter as six sided prisms.3
In an address to the Massachusetts Medical Society (1860), he reminds his audience that there is always a changeable element in medicine and that many popular theories and remedies eventually go out of fashion. He strongly suggests that patients are being overdosed by dangerous polypharmacy, pointing out that “no families take as little medicine as those of doctors, except those of apothecaries”, and that “of all practitioners the older are more sparing of active medicines than younger ones” and place less confidence in their effectiveness. He blames the medical profession for “yielding to the tendency to self-delusion which seems inseparable from the practice from the art of healing”; and especially those of its members who have a “singular inability to weigh the value of evidence”, who have “a natural incapacity for sound observation, like a faulty ear in music,” who remember only when a drug worked but not where it failed, leading them to make false inductions from genuine facts of observation, and construct from them fanciful and erroneous theories. Throughout this career he opposed the many harmful procedures still in fashion, blood-letting, blistering, and purging; and indeed stated that “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 he fishes.”4
He also alludes to another undesirable practice, that of doctors making a profit on the medicine they have prescribed. But he acknowledges the immense pressure on the physician to use active treatment, and also blames the public at large, “which insists on being poisoned.” Its members, he points out, have a constituency of millions, the popular belief being “all but universal that sick persons should feed on noxious substances.” Whereas in law a man is presumed innocent unless proven guilty, in medicine a drug should also be presumed to be hurtful unless proven otherwise.4
Writing on medical education well before William Osler, he took the now unfashionable position that the most essential part of a student’s instruction is obtained not in the lecture-room but at the bedside. “It is the bedside that is always the true center of medical teaching”, whereas what many professors teach may be of great interest to themselves but have nothing in them that will ever be of use to the student as a practitioner. “Is it not well to remind the student from time to time that a physician’s business is to avert disease, to heal the sick, to prolong life, and to diminish suffering? … Is it not best to begin by making sure of such knowledge as he will require in his daily walk? … A medical school is not a scientific school, except just so far as medicine itself is a science. … On the natural history side, medicine is a science; on the curative side, chiefly an art.” Teaching a moderate amount of esoteric material is useful, helping to open the student’s mind and allow him later to learn and digest new information; but an excess of learning would be as harmful to doctors as to those called to fix your roof, make new shoes, or repair your plumbing. What is the point of knowing how a drug is synthesized in the body but not remember the dose for its use in an emergency?5 Indeed, there are “many persons who know a great deal about books, but are not sharp-sighted enough to buy a horse or deal with human diseases.”5
Like William Osler, he was a cultured man, who knew the classics and loved books. He was enthusiastic about the opening of a large medical library in Boston, particularly pleased about the development of an effective and convenient index of the medical literature.6 How much more he would have loved to hear about computer driven search engines! He believed that a scholar must have his books and never part with them, using them as if his mind were furnished with drawers. And imagine his delight when “on a rainy day in Lyons, in a dingy bookshop,” he found the classical book he had long been looking for, “for a small pecuniary consideration, though it was marked rare, and was really très rare,” also a copy of the Aphorisms of Hippocrates, edited and with a preface from the hand of Francois Rabelais.6
Yet he warned the practicing doctor not to engage in the arts and literature at the cost of not knowing how to practice his profession, quoting the case of the famous physician who in the seventeenth century was denied appointment at the city hospital because it had become known that he was writing poetry. Do not use long words when short ones will do, he recommended, and do not “ligate” arteries when you can “tie” them. And as advice for the professors teaching medicine to students, “Do not be too learned.”5 Indeed, the essays of Oliver Wendell Homes are well worth reading even today. For highly cultured as he was, he well understood that the doctor’s primary main role should always be, as in the days of Ambroise Par, “to cure sometimes, relieve often, but comfort always.”
- Notably, there were two Catos, two Agrippinas, and several Scipios in Roman history; two Palma Venetian painters, Vecchio and Giovane; two Alexander Dumas, the father of Count of Monte Cristo fame, the son author of La Dame aux Camélias; and two William Pitt chief ministers, as detailed elsewhere in this journal. The comparative influence of genetic versus environmental factors remains to this very day a matter of hot debate among scientists.
- Holmes read his paper in 1843, several years before Ignatz Semmelweiss drew the same conclusions, this at a time when doctors moved freely from the autopsy to the delivery room without washing their hands and or changing their clothes, and when standard texts of obstetrics affirmed that puerperal fever was definitely not contagious. Holmes assembled is evidence by citing the experience of almost twenty doctors, beginning with the work in 1795 of Alexander Gordon of Aberdeen (see also the Summer 2014 issue of this journal), describing how the disease occurred only in women attended by obstetricians or nurses who had previously treated patients affected by the disease. Some doctors were reported as never having had puerperal fever in their practice, while others had so many cases that they stopped delivering babies. Some midwifes had an over 50% mortality, and in some areas all the women afflicted had been delivered by the same midwife. Though initially criticized and ridiculed by the leading obstetricians of their time, Holmes and Semmelweiss were instrumental in convincing the medical establishment that puerperal fever could be prevented by improved hygienic measures.
- Since the Saxon days of Edward the Confessor it was widely believed that kings would cure by the touch scrofula and other ailments, even blindness, some patients being cured immediately, others requiring to be touched a second time. Often the monarch would hang a piece of gold around the neck of each patient, which apparently contributed to the cure. The practice continued well into the beginning of the 18th century, and it was reported that Charles the Second had touched nearly one hundred thousand persons.
- The Weapon Ointment or Unguentum Armarium was used to heal wounds by applying it not to the patient but to the weapon with which the wound had been inflicted. Widely used by barbers but also by some respectable members of the medical profession, it was composed of mummy, human blood, and the moss from the skull of a thief in chains. Even learned authorities such as Francis Bacon gave some credence to this extraordinary remedy, successful perhaps because the wound was cleaned, washed, bandaged and left alone rather than have harmful agents applied to it.
- The Sympathetic Powder, brought from the East to Florence and then to England, had to be applied to the bloodstained governments of the wounded person, even though he were at the greatest distance from this at the time. It had to be prepared in a very careful manner, dissolved, exposed to the sun, then reduced to a fine powder and further treated in several complicated ways. It was used by James and Charles I of England and all their ministers, and found to be effective “in a surprising manner” but consisted of nothing but inert crystals.
- Tar Water was a popular remedy in England for some time, prepared by stirring a gallon of water with a quart of tar and pouring off the clean water. It was claimed to prevent smallpox and cure impurities of the blood, coughs, pleurisy, peripneumony, gout, erysipelas, asthma, indigestion, cachexia, hysterics, dropsy, scurvy, hypochondria, and disease of the teeth and gums. It was particularly recommended to sea-faring, studious, or sedentary persons, but its onset was claimed to be slow, so that its advantages might not have showed themselves for several months.
- The Metallic Tractors, invented by the American Dr. Perkins, became a popular remedy in America as well as Europe at the beginning of the 19th century. They consisted of two pieces of metal, one of iron and one of brass, about 3 inches long, blunt at one and pointed at the other, claimed to be effective against rheumatism, local pains, inflammations, and even tumors. The tractors, which were little bits of brass and iron, the intrinsic value of which might perhaps amounted to a few pennies, were being sold for several Guinness a pair, and at one time were used by many illustrious personages and possibly even by royalty.
- What Holmes called the homeopathic delusion, was based on the theory of fighting likes with likes and by administering various drugs from a specific pharmacopeia, diluted to one or even one million fold drugs. In introducing the subject, Holmes mentioned that kind friends trying to help a person suffering from what he called a tedious complaint might argue that this might be worth trying or any rate could not do any harm. This may indeed be so for the patient himself, argued Holmes, but does great harm to the community by encouraging ignorance, error, or deception in a profession that deals with the life and health of their fellow creatures. Popular with persons ”unacquainted with the fluctuations of disease and the fallacies of observation,” this system was originated by the German physician Samuel Hahnemann, who published his first paper in 1796 and developed a system which he called homeopathy, going so far as to designate the physicians who did not use his methods as practicing allopathic medicine. The homeopathic system became popular and persisted well into the 20th century. It was based on the theory that most chronic diseases were caused by an affliction called Psora, and that the remedy for most of them resided in curing likes with likes, expressed the Latin aphorism “similia similibus curantur.”
- The contagiousness of puerperal fever. New England Quarterly Journal of Medicine and Surgery, 1843
- Homeopathy and its kindred delusions. Two lectures delivered before the Boston Society for the Diffusion of Useful Knowledge. 1842
- Borderlines in some provinces of medical science. An introductory lecture delivered before the medical class of Harvard University, 1861
- Currents and counter currents in medical science. An address delivered before the Massachusetts Medical Society, 1860
- Scholastic and bedside teaching. An introductory lecture delivered before the medical class of Harvard University, 1867
- Medical libraries. Dedicatory address at the opening of the medical library in Boston, 1878
GEORGE DUNEA, MD, Editor-in-Chief