Excerpted from Medical America in the Nineteenth Century: Readings from the Literature. Edited by Gert H. Brieger, Baltimore and London: The Johns Hopkins University Press, 1972. Pp.98-106.

Editor's Note: JACOB BIGELOW ON SELF-LIMITED DISEASES

Jacob Bigelow (1787-1879) after receiving his medical degree in Philadelphia spent his professional career in Boston. Known as one of America's foremost early botanists, Bigelow was Harvard's first professor of materia medica an played an important role in bringing her medical school and the Massachusetts General Hospital to the forefront of medical education.

Henry Nash Smith has described the American love for oratory as one of the most conspicuous features of American culture in the decades before the Civil War. In medicine this judgment is readily borne out if one looks at the tremendous numbers of printed orations, discourses, and dissertations stemming from medical schools and societies throughout the land. Although their prose is usually florid and their sentiment lofty, these speeches provide a useful source of information for the historian. The selection by Bigelow fits the category of orations. Delivered before the August Massachusetts Medical Society in 1835, when its author was forty-eight years old, it soon became a classic widely referred to. It was Bigelow's central theme, that nature not art should more often be relied upon, and not his words themselves that received the most attention. 

Biibliographical Note: George E. Ellis, Memoir of Jacob Bigelow, MD., L.L.D., Cambridge: Wilson, 1880. 

The death of medical men is an occurrence which eminently demands our attention, for it speaks to us of our science and of ourselves. It reminds us that we, in turn, are to become victims of the incompetency of our own art. It admonishes us that the sphere of our professional exertions is limited, at last, by insurmountable barriers. It brings with it the humiliating conclusion that while other sciences have been carried forward within our own time and almost under our own eyes to a degree of unprecedented advancement, medicine, in regard to some of its professed and most important objects, is still an ineffectual speculation. Observations are multiplied, but the observers disappear and leave their task unfinished. We have seen the maturity of age and the ardent purpose of youth called off from the half-cultivated field of their labors, expectations, and promise. It becomes us to look upon this deeply interesting subject with unprejudiced eyes and to endeavor to elicit useful truth from the great lesson that surrounds us.

In comparing the advances which have been made during the present age in different departments of medical science, we are brought to the conclusion that they have not all been cultivated with equally satisfactory success. Some of them have received new and important illustrations from scientific inquiry, but others are still surrounded with their original difficulties. The structure and functions of the human body, the laws which govern the progress of its diseases, and more especially the diagnosis of its morbid conditions are better understood now than they were at the beginning of the present century. But the science of therapeutics, or the branch of knowledge by the application of which physicians are expected to remove diseases, has not, seemingly, attained to a much more elevated standing than it formerly possessed. The records of mortality attest its frequent failures, and the inability to control the event of diseases, which at times is felt by the most gifted and experienced practitioners, give evidence that in many cases disease is more easily understood than cured.

This deficiency of the healing art is not justly attributable to any want of sagacity or diligence on the part of the medical profession. It belongs rather to the inherent difficulties of the case and is, after abating the effect of errors and accidents, to be ascribed to the apparent fact that certain morbid processes in the human body have a definite and necessary career from which they are not to be diverted by any known agents with which it is in our power to oppose them. To these morbid affections, the duration of which, and frequently the event also, are beyond the control of our present remedial means, I have on the present occasion applied the name of self-limited diseases, and it will be the object of this discourse to endeavor to show the existence of such a class and to inquire how far certain individual diseases may be considered as belonging to it.

By a self-limited disease, I would be understood to express one which receives limits from its own nature and not from foreign influences; one which, after it has obtained foothold in the system, cannot, in the present state of our knowledge, be eradicated or abridged by art, but to which there is due a certain succession of processes to be completed in a certain time; which time and processes may vary with the constitution and condition of the patient, and may tend to death or to recovery, but are not known to be shortened or greatly changed by medical treatment.

These expressions are not intended to apply to the palliation of diseases, for he who turns a pillow or administers a seasonable draught of water to a patient palliates his sufferings, but they apply to the more important consideration of removing diseases themselves through medical means.

The existence of a class of diseases like those under consideration is, to a certain extent, already admitted, both by the profession and the public, and this admission is evinced by the use of certain familiar terms of expression. Thus, when people speak of a "settled disease," or of the time of "the run of a disease," it implies on their part a recognition of the law that certain diseases regulate their own limits and period of continuance.

It is difficult to select a perfectly satisfactory or convincing example of a self- limited disease from among the graver morbid affections, because in these affections the solicitude of the practitioner usually leads him to the employment of remedies, in consequence of which the effect of remedies is mixed up with the phenomena of disease, so that the mind has difficulty in separating them. We must therefore seek for our most striking or decisive examples among those diseases which are sufficiently mild not to be thought to require ordinarily the use of remedies, and in which the natural history of the disease may be observed divested of foreign influences. Such examples are found in the vaccine disease, the chicken pox, and the salivation produced by mercury. These are strictly self-limited diseases, having their own rise, climax, and decline, and I know of no medical practice which is able, were it deemed necessary, to divert them from their appropriate course or hasten their termination.

It may appear to some that the distinction of these diseases from others is the old distinction of acute and chronic. Yet on due inquiry, such an identification is not found to be sustained, for there are some acute diseases which, we have reason to believe, are shortened by the employment of remedies; while, on the other hand, certain chronic cases of disease are known to get well spontaneously after years of continuance.  . . .

As a mode of directing our inquiries toward these diseases, we may suspect those complaints to be self-limited in which it is observed that the unwary and the sceptical, who neglect to resort to remedies, recover their health without them. We may also suspect diseases to be of this character when we find opposite modes of treatment recommended and their success vouched for by practitioners of authority and veracity. We may moreover attach the same suspicion to cases in which the supposed cure takes place under chance applications or inconsiderable remedies; as in the empirical modes of practice, on the one hand, and the minute doses of the homeopathic method on the other. Lastly, we may apprehend that cases are fatally self-limited. . . . In a general sense, however, the last term falls within the second) when enlightened physicians die themselves of the diseases which they had labored to illustrate-as in the case of Corvisart, Laennec, Armstrong, and others.

In proceeding to enumerate more precisely some of the diseases which appear to me to be self-limited in their character, I approach the subject with diffidence. I am aware that the works of medical writers, and especially of medical compilers, teem with remedies and modes of treatment for all diseases; and that in the morbid affections of which we speak, remedies are often urged with zeal and confidence, even though sometimes of an opposite character. Moreover, in many places, at the present day, a charm is popularly attached to what is called an active, bold, or heroic practice; and a corresponding reproach awaits the Opposite course, which is cautious, palliative, and expectant. In regard to the diseases which have been called self-limited, I would not be understood to deny that remedies capable of removing them may exist; I would only assert, that they have not yet been proved to exist.

Under the simple self-limited diseases, we may class whooping cough. This disease has its regular increase, height, and decline, occupying ordinarily from one to six months, but in some mild cases only two or three weeks. During this period, medical treatment is for the most part of no avail. . . .

Most of the class of diseases usually denominated eruptive fevers are self limited. . . . Scarlet fever, a disease of which we have had much and fatal experience during the last three years, is eminently of the same character. The reasons which induce me thus to regard it are the following. The writings of medical observers agree in assigning it a common or average period of duration, and this is confirmed by the observations of practitioners at the present day. . . . The modes of treatment which have had most testimony in their favor are various and opposite. By Dr. Fothergill, stimulants were relied on; by Dr. Currie, cold water; by Dr. Southwood Smith, and others, blood-letting. But it is not satisfactorily shown that either of these modes of practice has been particularly successful, for where the writers have furnished us anything like definite or numerical results, it does not appear that mortality was less in their hands than it is among those who pursue a more expectant practice. The post mortuary appearances, which in many diseases furnish useful lessons for practice, are in scarlet fever extremely various and certain, and sometimes no morbid changes, sufficient to account for death can be discovered in any of the vital organs or great cavities. . . .

But that the usefulness of our profession may extend, our knowledge must go to increase, and the foundation of all knowledge is truth. For truth then we must earnestly seek, even when its developments do not flatter our professional de nor attest the infallibility of our art. To discover truth in science is often extremely difficult; in no science is it more difficult than in medicine. Independently of the common defects of medical evidence, our self-interest, our self-esteem, and sometimes even our feelings of humanity may be arrayed against the truth. . . . Medical books are prompt to point out the cure of diseases. Medical journals are filled with the crude productions of aspirants to the cure of diseases. Medical schools find it incumbent on them to teach the cure of diseases. The young student goes forth into the world believing that if he does not cure diseases it is his own fault. Yet, when a score or two of years have passed over his head, he will come at length to the conviction that some diseases are controlled by nature alone. He will often pause at the end of a long and anxious attendance and ask himself how far the result of the case is different from what it would have been under less officious treatment than that which he has pursued; how many in the accumulated array of remedies which have supplanted each other in the patient's chamber have actually been instrumental in doing him any good. He will also ask himself whether in the course of his life he has not had occasion to change his opinion, perhaps more than once, in regard to the management of the disease in question, and whether he does not, even now, feel the want of additional light.  .  .  .

We are seldom justified in concluding that our remedies have promoted the cure of a disease, until we know that cases exactly similar in time, place, and circumstances have failed to do equally well under the omission of those remedies; and such cases, moreover, must exist in sufficient numbers to justify the admission of a general law on their basis. Nothing can be more illogical than to draw our general conclusions, as we are sometimes too apt to do, from the results of insulated and remarkable cases, for such cases may be found in support of any extravagance in medicine, and if there is any point in which the vulgar differ from the judicious part of the profession it is in drawing premature and sweeping conclusions from scanty premises of this kind. Moreover, it is in many cases not less illogical to attribute the removal of diseases, or even of their troublesome symptoms, to the means which have been most recently employed. It is a common error to infer that things which are consecutive in the order of time have necessarily the relation to cause and effect. It often happens that the last remedy used bears off the credit of having removed an obstruction or cured a disease, whereas in fact the result may have been owing to the first remedy employed, and to the joint effect of all the remedies, or to the act of nature, uninfluenced by any of the remedies. We see this remarkably exemplified in recoveries from amenorrhea and from various irregularities of the alimentary canal.

An inherent difficulty, which every medical man finds to stand in the way of an unbiased and satisfactory judgment, is the heavy responsibility which rests upon the issue of his cases. When a friend or valuable patient is committed to our charge, we cannot stand by as curious spectators to study the natural history is disease. We feel that we are called on to attempt his rescue by vigorous means, so that at least the fault of omission shall not lie upon our charge. We need to put in practice those measures which on the whole have appeared to us to do most good, and if these fail us, we resort to other measures which we read of or heard of. And at the end of our attendance we may be left in uncertainty, whether the duration of sickness has been shortened or lengthened by our practice, and whether the patient is really indebted to us for good or evil. In the study of experimental philosophy, we rarely admit a conclusion to be true until its opposite has been proved to be untrue. But in medicine we are often fed to be content to accept as evidence the results of cases which have been finished under treatment, because we have not the opportunity to know how far these  results would have been different, had the cases been left to themselves. And it too frequently happens that medical books do not relieve our difficulties on this score, for a great deal of our practical literature consists in reports of interesting, extraordinary, and successful results, published by men who have a doctrine to establish or a reputation to build. . . . A prevailing error among writers on therapeutics, proceeds from their professional or personal reluctance to admit that the healing art, as practiced by them, is not, may not be, all sufficient in all cases; so that on this subject they suffer selves, as well as their readers, to be deceived. Hence we have no disease, however intractable or fatal, for which the press has not poured forth its asserted remedies. Even of late, we have seen unfailing cures of cholera successively announced in almost every city in which that pestilence unchecked has completed its work of devastation!

It is only when, in connection with these flattering exhibitions, we have a full and faithful report of the failures of medical practice in similar and in common setting forth not only the truth but the whole truth, that we have a basis sufficiently broad to erect a superstructure in therapeutics on which dependence be placed. Such, it must give the friends of science gratification to observe, part of the rigid method which characterizes the best examples of the modern French school; and such, it is not difficult to foresee, must ultimately be the only species of evidence on this subject to which the medical profession will pay deference.

It appears to me to be one of the most important desiderata in practical medicine to ascertain in regard to each doubtful disease, how far its cases are self-limited and how far they are controllable by any treatment. This question can be satisfactorily settled only by instituting, in a large number of cases which are well identified and nearly similar, a fair experimental comparison of the different active and expectant modes of practice, with their varieties in regard to time, order, and degree. . . . Opportunities for such observations, and especially for monographs of diseases, are found in the practice of most physicians, yet hospitals and other public charities afford the most appropriate field for instituting them upon a large scale. The aggregate of results, successful and unsuccessful, circumstantially and impartially reported by competent observers, will give us a near approximation to truth in regard to the diseases of the time and place in which the experiments are instituted. The numerical method employed by Louis in his extensive pathological researches, and now adopted by his most distinguished contemporaries in France, affords the means of as near an approach to certainty on this head as the subject itself admits. .  .  .

In regard to acknowledged self-limited diseases, the question will naturally arise, whether the practitioner is called on to do nothing for the benefit of his patient; whether he shall fold his hands and look passively on the progress of a disease which he cannot interrupt. To this I would answer by no means. The opportunities of doing good may be as great in these diseases as in any others; for in treating every disease there is a right method and a wrong. In the first place, we may save the patient from much harm, not only by forbearing ourselves to afflict him with unnecessary practice but also by preventing the ill judged activity of others. . . . In the second place, we may do much good by a palliative and preventive course, by alleviating pain, procuring sleep, guarding the diet, regulating the alimentary canal, in fine, by obviating such sufferings as admit of  mitigation and preventing or removing the causes of others which are incidental, but not necessary, to the state of disease. . . . Lastly, by a just prognosis, founded on correct view of the case, we may sustain the patient and his friends during the inevitable course of the disease and may save them from the pangs of disappointed hope on the one side or of unnecessary despondency on the other.  . . .

The importance and usefulness of the medical profession, instead of being diminished will always be elevated exactly in proportion as it understands itself, weighs justly its own powers, and professes simply what it can accomplish. It is no derogation from the importance of our art that we cannot always control the events of life and death, or even of health and sickness. The incompetency which we feel in this respect is shared by almost every man upon whom the great responsibilities of society are devolved. The statesman cannot control the destinies of nations, nor the military commander the event of battles. The most eloquent pleader may fail to convince the judgment of his hearers, and the most skilful pilot may not be able to weather the storm. Yet it is not the less necessary that responsible men should study deeply and understandingly the science of their respective vocations. It is not the less important, for the sake of those whose safety is, and always will be, committed to their charge, that they should look with unbiased judgment upon the necessary results of inevitable causes. And while an earnest and inquiring solicitude should always be kept alive in regard to the improvement of professional knowledge, it should never be forgotten that knowledge has for its only just and lasting foundation a rigid, impartial, and inflexible requisition of the truth.

Med Communications Mass. Med Soc. 5 (1836): 319-58. Reprinted from Nature in Disease (Boston: Ticknor & Fields, 1854), pp. 1-58. This paper was delivered before the Massachusetts Medical Society, May 27, 1835.