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PHYSICIAN AND PATIENT.
PHYSICIAN AND PATIENT;
OR,
A PRACTICAL VIEW
OF THE
MUTUAL DUTIES, RELATIONS AND INTERESTS
OF THE
MEDICAL PROFESSION
AND THE
COMMUNITY.
BY WORTHINGTON HOOKER, M.D.
I here present thee with a hive of bees, laden some with wax, and
some with honey. Fear not to approach. There are no wasps, there are
no hornets here. If some wanton bee should chance to buzz about thine
ears, stand thy ground and hold thy hands; there’s none will sting if
thou strike not first. If any do, she hath honey in her bag will cure
thee too. QUARLES.
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145 NASSAU STREET AND 36 PARK ROW.
1849.
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PREFACE.
A few words may be proper in explanation of the objects for which
this book was written.
The forms which quackery assumes are endless; but the material out
of which they are evolved is essentially the same in all ages and in
all countries. There are certain medical errors which are common to
man everywhere and in every condition. It is these which constitute
the material of quackery, whether it appear among the savage or the
civilized, the rude or the refined, the illiterate or the learned.
One object of this book is to develop these fundamental errors,
and to show the _modus operandi_ by which the genius of imposture
has produced from them the fantastic and ever-changing shapes of
empiricism.[1] I notice particularly some of the specific forms of
quackery which are now prevalent, not because they differ essentially
from those which have preceded them, but because they have a
_present_ interest to the reader.
One of the objects at which I aim is to expose to the public the
fallacy of those sources of evidence, upon which they rely in
estimating the comparative merits of physicians, and to show them
what tests they have at command, which will not prove fallacious.
The proper use of these tests would save the public from mistaking,
as they now often do, the plausible pretensions of the superficial
practitioner, and the charlatan, for the evidences of real skill and
wisdom.
Another object will be to present the claims of the medical
profession to the respect and the confidence of the community. As it
now is, the profession stands in a somewhat false position before the
public. The grounds upon which we ask their regard and trust are not
generally understood. The confidence which is reposed in us is not as
intelligent as it should be. It is unsettled and capricious. It is
overweening at one time, and it is entirely withheld at another, and
for the most frivolous reasons. The inconsistencies of even the well
informed on this subject are surprising. Many, who on some occasions
confide implicitly in nothing but educated science, are found at
other times submitting themselves and their families to the haphazard
administrations of empiricism.
But while I attempt to establish the claims of the medical profession
to the confidence of the people, and to defend it against the
aspersions which are unjustly cast upon it, I endeavor to exhibit
faithfully the abuses which exist in the profession itself. The
quackery which is practised among medical men is a much greater evil
than that which is abroad in the community. I attack it therefore
with an unsparing hand. In so doing I expose many of the tricks and
manœuvres which are employed by those physicians, who, pursuing
medicine as a _trade_ instead of a profession, study the science of
patient-getting to the neglect of the science of patient-curing. When
the rules of an honorable professional intercourse shall come to be
properly understood and appreciated by the public, one of the great
sources of the success of quackery will be removed.
In exposing the errors and faults of the medical profession and of
the public, while I have unflinchingly aimed at the truth I have
endeavored to avoid a censorious spirit, and to give to human frailty
all the tolerance that can properly be demanded. I trust the reader
will therefore find, that, in the language of my motto, “there are
no wasps, there are no hornets here.” That I have escaped all error
myself I do not claim. Some points may be too strongly stated, and
some provisionary and modifying considerations may be omitted. I
ask of the reader a reasonable indulgence, but none which shall be
inconsistent with an honest and candid criticism.
In the practice of medicine there are some points upon which
there should be a common understanding between the physician and
the friends and attendants of the sick. From the want of such
an understanding the purposes and plans of the practitioner are
often interfered with, and sometimes are effectually thwarted.
A considerable portion therefore of this work is devoted to an
elucidation of the points referred to.
In the chapter on the uncertainty of medicine, and in other places,
also, I point out the difficulties which are encountered in the study
and practice of medicine. These difficulties demand of the physician
the exercise of higher and more cultivated powers, than are needed
for the successful prosecution of most other studies and pursuits. I
therefore make it a principal object to urge, by every consideration,
the importance of a well-educated medical profession. Every man
has a personal interest in maintaining the barriers by which the
organizations of the profession undertake to protect the community
from the evils, which they would suffer from ignorance and imposture,
if these barriers were destroyed. It is especially for the advantage
of the _people_, and not, as is commonly supposed, of physicians,
that there should be a proper standard of medical education.
My first chapter, on the uncertainty of medicine, may perhaps be
considered by some as too strictly professional for the common
reader. I ask for it, however, a careful perusal. I have endeavored
to strip the subject of all technicalities, and a full understanding
of the views there presented is necessary to a proper appreciation of
the considerations contained in some of the succeeding chapters.
I write in part for the profession, and in part for the community
at large. I ask both to look candidly at the views which I present
of their ‘_mutual duties, relations, and interests_.’ A reform is
needed in the opinions and practices both of physicians, and of the
people, in regard to medical subjects. This reform is fairly begun
in the profession, and there may be seen, even amid all the present
diversified and flaunting displays of quackery, some indications of
its commencement in the community. The volume which I now offer to
the public is a humble effort to promote this reform.
W. HOOKER.
_Norwich, Conn., June, 1849._
FOOTNOTES:
[1] It will be obvious to the reader that I use this word, wherever
it appears, in its _popular_ sense, and not in its professional one.
I use it as synonymous with quackery.
CONTENTS.
CHAPTER I.
UNCERTAINTY OF MEDICINE, 25
Importance of the subject. Definiteness of results in chemistry.
Only a distant and humble approach to this possible in medicine.
Illustration from chemistry. CAUSES OF THE UNCERTAINTY OF MEDICINE.
1. Sympathy between different organs; 2. Symptoms produced at a
distance from the seat of disease. Disease extended by sympathy.
Transposition of disease from one organ to another. 2. Influence of
unseen or secret causes. Nature of many causes of disease unknown.
Combination of many agencies in producing disease, some of them
having acted a long time. Cases rendered complex by treatment
before physician is applied to. 3. Natural changes in the system
arising from the curative power of nature, and from the principle of
self-limitation in diseases. Illustrations of the operation of the
_vis medicatrix naturæ_—vomiting to remove offending matters from
the stomach—suppuration and discharge of a swelling. Tendency of
diseases to come to a conclusion—more definite and regular in some
complaints than in others. Mistakes from confounding the effects of
remedies with the changes produced by these two tendencies. 4. Mental
influences. Connection of mind with body modifying disease. Effects
produced through the mind often attributed to physical causes and
remedies. Case of the dyspeptic. 5. Individual peculiarities.
CHAPTER II.
SKILL IN MEDICINE, 50
Show in what medical skill consists, in view of the uncertainty of
medicine—_appreciating the condition of the patient in all respects,
and applying remedies in the best manner to relieve this condition_.
Errors impairing skill. Taking limited views of disease. Directing
attention too much to particular organs. Undue attachment to certain
modes of investigation. Difficulties in the way of deciding what
it is best to do. Course of different physicians in view of these
difficulties. Accurate proportioning of means and ends. Value of
experience. Illustration of some of these points in the case of a
sick traveller assisted by his friend in going through a mountain
pass.
CHAPTER III.
POPULAR ERRORS, 63
False estimate of the importance of _positive_ medication. This
error appears in various ways. Healing of wounds—anointed axe.
Attributing effects to agencies just preceding them—_post hoc
propter hoc_ mode of reasoning. Referring the cure of a case to
some _one_ remedy or measure, when commonly the result of many.
Disposition to have something done all the time. Disease considered
often as a palpable thing—a humor—a poison—medicines supposed to
neutralize it. Specifics. Supposed to be many—really few, if any.
Definition. Inadequate ideas of the community of the necessity for
discrimination in medical practice. Propensity to look for some
universal catholicon. Disease supposed by some to be an unit. A sort
of universality of operation attributed to favorite remedies, even
sometimes among physicians. Dr. Beddoes’ gases. Physicians _correct_
their errors by experience—the public only exchange one error for
another in medicine. Changes in popular opinion in regard to quack
remedies.
CHAPTER IV.
QUACKERY, 80
The grand source of quackery the false reference of effects to
causes. The way in which a remedy, whether active or inert, acquires
its reputation. Quack medicines principally of _three_ kinds. 1.
Evacuants. Great similarity in these—made up mostly of articles
in common use. 2. Those which are supposed to act upon the system
in a gradual way, as alternatives. Preparations of sarsaparilla.
Impositions. 3. Those which are supposed to act especially upon the
lungs. Harm done by their indiscriminate use. Quantities of inert
and damaged articles used in preparing quack medicines. Importance
of the _name_ of a medicine in giving it currency. Ridiculousness
of quack advertisements. Certificates. Chiefly of _four_ kinds. 1.
Forgeries. 2. Essentially, sometimes wholly, untrue. How obtained. 3.
Those given by invalids imagining themselves to be relieved. 4. Those
given by invalids who are relieved while taking the medicine—inferred
to be done _by_ the medicine. Certificates of clergymen. Rule of the
medical profession in regard to nostrums. Proposed mode of guarding
against imposition. Quackery as a monstrous business interest.
Press and legislatures trammelled by it. Itinerant quack lecturers.
Lectures especially to the ladies. Animal magnetism. Paracelsus
the “prince of quacks.” St. John Long. Perkins’ tractors. Forms of
Quackery many, but the materials from which they are formed always
the same. No discoveries have ever been made by quackery.
CHAPTER V.
THOMPSONISM, 103
Principles of the system as promulgated by its founder. Bold
confidence of Thompson in his mode of practice. Points in his
theory. Obstructed perspiration. Strife between the heat and the
cold. Simplicity of the system. No need of “learned doctors.”
Thompsonian views of the _modus operandi_ of medicines. Radicalism
of Thompsonism. Prejudice against mineral medicines. No article
injurious simply _because_ it is mineral. The most deadly poisons
in nature vegetable. Effects of vegetable poisons generally as
abiding as those of mineral. Lobelia a poison, sometimes fatal,
though Thompsonians claim it to be perfectly harmless. Definition
of _poison_. Some poisons more rapid than others in their effects.
Poison sometimes used in a relative sense. This word one of the
watch-words of Thompsonians, though they daily use poisons as common
articles of food. Changes in Thompsonian practice since the system
was first promulgated.
CHAPTER VI.
HOMŒOPATHY, 120
Brief notice of the founder of Homœopathy. His exalted ideas of his
“discovery.” Two principles in his theory. 1. _Like cures like._
According to Hahneman there are three modes of practice—allopathic,
antipathic, homœopathic. The last alone truly successful, according
to him. The name allopath wrongly bestowed by Hahneman upon
physicians. 2. _Minute division, with agitation and trituration,
communicates a new power to medicines._ Subdivision very minute, and
extremely particular directions given by Hahneman for effecting it.
Whether such a power is thus communicated to be decided by facts.
“Observations” on which the opinion is founded. Character of them
illustrated from Jahr’s manual. Their extreme minuteness. Mode of
collecting them. Based upon the ridiculous idea that all states of
the body are to be referred to the remedy taken. Notices of some
particular remedies in illustration. Alleged success of Homœopathy.
_Apparent_ success to be attributed to six causes. 1. Mental
influence. 2. A strict regard to diet and regimen. 3. Operation
of the _vis medicatrix naturæ_, or curative power of nature. 4.
Comparisons made between the results of homœopathic practice and
those of over-dosing physicians. 5. An occasional stealthy use of
remedies in ordinary doses. 6. The facility with which people are
deceived in regard to comparative results. Parallel case of a German
clergyman. Empty boasts of homœopathists as to the character of
their physicians. Points of resemblance and of difference between
Thompsonism and Homœopathy.
CHAPTER VII.
NATURAL BONE-SETTERS, 146
Setting of bones wholly mechanical. There cannot be an _innate_ skill
in this, any more than there can be in any other kind of mechanics.
Explanation of bone-setting. Skill obtained in this just as in
anything else. Bone-setter _learns_ all that he actually knows, by
his own observation, and from others. It is not _born_ with him.
Gets some of his knowledge by stealth. _Errors committed by natural
bone-setters._ Supposing a fracture to be a dislocation. Injuries
of joints in which there is neither dislocation nor fracture—harm
sometimes done in such cases by the bone-setter. Failure in the
_medical_ part of the treatment in some cases. Failure in the
management of fractures. Physicians not all good bone-setters.
Mechanical tact requisite. Though so many cases of mal-practice
can be found among the patients of natural bone-setters, generally
supposed by the community to be infallible. Difficulty in getting a
verdict of damages against them. _Reasons why they, in spite of their
errors, acquire a reputation for skill._ Setting sprains. Facility
of the imposition practised. Breaking up old adhesions. Stiff joints
and contracted tendons—efficacy of rubbing. Imagined tenderness and
inability of motion. Sub-luxations—random pulling. False reports of
cases.
CHAPTER VIII.
GOOD AND BAD PRACTICE, 172
Not easy to distinguish between good and bad practice by results. If
it were, would not be such differences of opinion among physicians
and in the community. Examples of these differences. Stimulating and
depleting measures. Homœopathy, Hydropathy, Thompsonism. Quacks aware
of the difficulty in estimating comparative results—act accordingly.
No mode of practice wholly good—none wholly bad. Some good points
in all modes. Exclusive systems. Distinctions between good and bad
practice pointed out. Cases in which the question of life and death
immediately affected by practice. Failure of unskilfulness in such
cases. Interesting case. Seldom is the influence of bad practice so
manifest as in this case. Difficulty of culling out from the mass
cases which are dangerous from the first. Various causes of this.
Difficulty inherent. Cases misrepresented by mistake or wilfully.
Some said to be _very sick_ when not so. Light cases made bad by
treatment—though appear grave, apt to recover. Illustrations.
Comparisons between rival physicians as to results. Public often
mistake in such comparisons. Notice some less direct effects of bad
practice. Unnecessary complications of disease. State of system after
recovery. General state of health in families. Length of sickness.
Summing up of differences in results between good and bad practice.
Two requisites for observing these correctly. 1. Sufficient amount
of evidence. 2. Skill in observation. Community deficient in these.
Confident appeals of quacks to alleged results. Show what the
physician should say in regard to results.
CHAPTER IX.
THEORY AND OBSERVATION, 200
All real knowledge based upon observation, not on theory. Facts
of two kinds—individual and general. General facts ascertained
by observation of many individual or particular facts. No theory
founded on facts—always goes beyond them. No science in which there
has been so much theorizing as in medicine. History of medicine
very much a history of theories. Office of theory—_suggestive_.
Abuse of theory in failing to distinguish between the known and the
supposed. Newton’s carefulness on this point. Circumstances impairing
skill in observation. Mode of reviewing cases. Disposition to form
conclusions from a limited range of facts. Young practitioners.
Dr. Sewall’s plates. Dr. Sutton’s treatment of delirium tremens.
Different theories of fever—Boerhaave, Cullen, Clutterbuck,
Broussais, Cooke, Samuel Thompson. Hobby-riding. Diseases of
the throat and windpipe. Habit of making loose and exaggerated
statements. Credulity and fondness for novelty and change. Changeable
state of medicine. No standard _authorities_ as in law and theology.
Scepticism in medicine. _Easy to theorize—difficult to observe well._
Value of good habits of observation. Medical men had too much to do
with theories and modes and systems. Eclecticism. _Modus operandi_
of medicines. A reform in progress in medicine. Breaking loose from
theory. Promoting rigid observation.
CHAPTER X.
POPULAR ESTIMATES OF PHYSICIANS, 222
No class of men so erroneously estimated as physicians. Object of
this chapter to show how the community can judge of them correctly.
Education of physicians—evidences of it. Medical education
practically despised by a large portion of the public. Standing of
medical man among his brethren criterion of merit. Difficulty in
getting their unbiased opinions. Certain mental qualities essential
to skill in the practice of medicine. How the common observer can
detect and measure these qualities. _Observe them as exhibited
in regard to subjects which he understands in common with the
physician._ Illustration from surgery. Illustrations of same truth
in relation to various characteristics of medical men. Formation
of opinions—credulous—sceptical—hasty and changeable—cautious
and tenacious—strong and ardent. How can test one’s habits of
observation. Asking many questions no sure proof of accurate and
minute observation. Enquiries of different physicians about an
article of curiosity. Same rule for judging of the _measures_ of the
physician, as we have applied to his opinions. A genius in medicine.
Innate skill. Rules which have been pointed out for estimating
comparative merits of physicians not in common use with the public.
A change necessary in this respect. Cannot easily be effected. Many
physicians would be opposed to such a change—would rather false tests
continue to be applied. But the change can be effected.
CHAPTER XI.
MEANS OF REMOVING QUACKERY, 242
The credulous, ignorant, and novelty-seeking, not the only persons
imposed upon by quackery. Many of the judicious and intelligent
also. Efforts to undeceive the public on this subject have been
often faulty. Too much reliance on popular knowledge of anatomy,
physiology, dietetics, &c. This should only be auxiliary to other
means. Relied upon alone, leads to error. Individual influence of
physicians in showing their friends their mistakes in connecting
cause and effect in medicine. This influence to be exerted upon the
intelligent who uphold quackery. Too much sarcasm and ridicule and
invective used against quackery. Credulity of the public takes a
license from that of medical men. Certificates of physicians in favor
of nostrums. Secret medicines put forth by physicians. Spirit of
quackery in the medical profession. Exhibited in various ways. Quite
prevalent, crippling the profession in its warfare with empiricism.
Reform needed. Can be effected. The stable and intelligent can help
in effecting it, by promoting medical education—by sustaining the
organizations of the profession—by renouncing fallacious means of
estimating professional merit—by favoring strict observance of the
rules of intercourse among physicians. Formation of the American
Medical Association, an important movement in the destruction of
quackery.
CHAPTER XII.
INTERCOURSE OF PHYSICIANS, 258
Erroneous views in regard to consultations. “Jury of doctors.”
Dictation not consultation. Giving opinions in relation to the past
treatment. Offices of the _consulting_, and of the _attending_
physician defined. Freedom in consultation necessary. Between
enemies, useless. Should be alone in consultation. Intrigues of
dishonorable practitioners. Supposed want of agreement—favoring the
impression for base purposes. Attributing changes, good or bad, to
some remedy for selfish ends. Failing to defend a medical brother
when circumstances fairly demand it. Making comparisons between
cases. Undue attentions to the patients of others. Conduct of some
when called to see the patient of another in case of unnecessary
alarm. Physicians supposed to be too much attached to etiquette.
Not so usually. Differences and quarrels of physicians—circumstances
giving rise to them. Facility with which deception is practised
in medicine. Peculiar relation of the physician to his employers.
Cliques. Sectarian and other associations. Avoiding quarrels.
Relations of elder physicians to their brethren.
CHAPTER XIII.
INTERFERENCE WITH PHYSICIANS, 275
Confidence which one feels in his physician no reason for
disparaging others. Interference proper in some cases—quackery—gross
ignorance—intemperance. Reckless attacks upon professional character.
The lawyer rebuked. Free canvassing of the merits of physicians not
improper. Interference in the sick room. Destroying confidence.
Recommending medicines. Restricting physicians as to remedies
employed. Frequency of physician’s visits to be mostly left to him.
Anxiety of friends of the sick often embarrasses the physician. Case
of the wife of Napoleon. Harrassing practitioner with inquiries and
criticising his practice distract his attention, and therefore foil
his skill. Same effect produced by the same causes in regard to other
subjects. Criticised clergyman. Watched juggler. Defects in these
analogies.
CHAPTER XIV.
MUTUAL INFLUENCE OF MIND AND BODY IN DISEASE, 288
Inadequate views of this influence prevalent. Importance of
understanding it. Connection of mind and body. No proof that mind
is essentially indestructible. Manifestations of mind connected
with and dependent upon the material organization. Brain in some
sense seat of mind—central organ of the nervous system, with which
mind is connected. Other subordinate nervous centres. Bichat’s idea
of the seat of the moral sentiments. Weakness of mind in sickness.
Slight causes affect it strongly. Importance of quiet in sick
room. Difficult to secure it. Visitors. Conversation. Children as
easily disturbed as adults. Holding up physician as a bugbear to
them. Exciting the mind commonly irritates bodily disease, whether
in the brain, or in some other organ. Death of Hunter caused by a
fit of passion. Duty of physician sometimes to excite the mind in
various ways and degrees. Influence of imagination upon the body.
Use to be made of mental _association_ in the treatment of disease.
_Diversion_ of the mind. Influence of change of scene on the invalid.
Monotony of sick room. Settled gloom with which the sick sometimes
afflicted. How removed. Want of tact in managing whims of the sick.
Notional dislikes. Fretfulness and impatience. Deranged sensations
erroneously supposed to be mere imaginations. Importance of a
faithful study of mental influences to the physician.
CHAPTER XV.
INSANITY, 320
Two classes of causes—those which act upon the mind, and those which
act upon the body. Insanity always, strictly speaking, a disease of
the organization. Too much disposition to look to some one thing
as the cause. Tables of causes in Hospital reports. _Form_ of the
insanity not necessarily indicative of its cause, or of the character
of the patient. CAUSES OF INSANITY. Indulgence of passions. Wrong
views of life. Exclusive and prolonged attention to one subject.
Insanity rare among savages, and those under despotic governments.
Great prevalence in this country. Religious excitement. Debilitated
system predisposing to insanity. Intemperance. Children seldom
insane, though very liable to temporary derangement in sickness.
Foundation of insanity, however, often laid in childhood. _Forms
and signs of insanity._ Cases in which the disease comes on slowly.
Monomania. _Moral_ insanity. Treatment of the insane. Change produced
by Pinel. ADVANTAGES OF RETREATS OR HOSPITALS. 1. Removal of patient
from the _associations_ under which his insanity originated. 2.
Judicious medical treatment. 3. Better mental and moral management
than can have among his friends. Mistakes of friends of the insane
in their management. Reasons why insane apt to dislike their nearest
friends most. Helplessness of insane poor. Duty of the State in
regard to them. Legal relations of insanity. Absurd and inconsistent
opinions and practices of our courts of justice. Professional
evidence in France, and in this country, when prisoner suspected of
insanity. Insane often been executed. Plea of insanity. Importance
of _preventing_ the acts for which the insane are brought before our
courts as criminals. Laws deficient at this point. Necessity of a
commission of lunacy.
CHAPTER XVI.
INFLUENCE OF HOPE IN THE TREATMENT OF DISEASE, 344
Physician’s employment a cheerful one. Contrary opinion quite
prevalent, but erroneous. Cases in which he can neither cure nor
palliate few. Prevailing cast of physician’s mind, therefore,
hopeful. Hope should always be based on intelligent grounds. Hope
in the different stages of a case. Seldom should all hope be given
up—even in apparently desperate cases recovery sometimes occurs.
Interesting case. Hope a cordial—as necessary as the cordial draught,
and as improper to withhold it. Giving false _assurances_ wrong.
Often done by quacks and quackish physicians. Views and feelings
of patients in regard to prospect of death often misunderstood.
Extinction of all hope of recovery not commonly desirable in cases
certain to be fatal. This extinction of hope not essential to perfect
resignation. Influence of collateral circumstances upon the manner in
which death is met. Occasional pauses in the onward progress of fatal
chronic disease. Duty of the physician in regard to the hope awakened
at such times. Supposed salutary moral influence of the certain
expectation of death. Tendency to hope in consumptive patients.
Curability of consumption.
CHAPTER XVII.
TRUTH IN OUR INTERCOURSE WITH THE SICK, 357
Variety of opinion and practice on this subject. Percival’s views
in his Medical Ethics. Advocates falsehood. Object of this chapter
to present the practical considerations bearing on this subject,
illustrating them with cases. 1. Knowledge concealed from the
patient by falsehood it is wrong to assume would certainly do him
harm if communicated to him. 2. Deception as commonly practised
generally fails to be carried out. Case of the deceived child. 3.
The discovery of the deception, when it takes place, has a worse
effect on the patient than a full statement of the truth could
produce. 4. Destruction of confidence occasioned by discovered
deception injurious to the persons deceived. Children. The insane.
Detected deception not only increases insanity, but modifies it. 5.
_General_ effect of deception, extending beyond the individual on
whom it is practised. General distrust of the veracity of physicians.
6. If adopted as a common rule that deception is sometimes proper,
the object of the deception would be defeated. 7. If the door for
deception be once opened there is no limit. Though proper sometimes
to withhold the truth, wrong to put falsehood in its place. Enquiries
of the sick not always to be directly and fully answered. Too
definite opinions often given by physicians.
CHAPTER XVIII.
MORAL INFLUENCE OF PHYSICIANS, 383
Intimate relation of physician to his patients. Mutual confidence.
Abuse of confidence. Guilt of it, especially in case of females.
Sympathy of the physician—active—grows constantly stronger and more
tender. Self-control mistaken for want of feeling. Manifestations
of feeling—surgical operation. Certain nervous effects erroneously
supposed to be evidences of feeling. Sympathy of the physician a
means of influence. Physician at home everywhere. Opportunity of
studying every variety of character. Physicians often fail to exert
the influence which these advantages enable them to do. Influence on
moral questions. Temperance. Acting as a peace-maker. Influence of
daily conduct—little hourly acts. Physician in sick room. Communion
with the spirit in its most momentous hours. Physician’s great
object to cure the patient—nothing should interfere with it. Cordial
influence of hope. Little confidence to be placed in death-bed
repentance and reformation. Opportunities of doing good in lingering
chronic cases. Mode of doing it. Injudicious intercourse with the
sick. In some cases duty clear—in others, doubtful. Conference
between physician, clergyman, and friends. Opportunity of doing
good in convalescence. Moral influence of the physician in his
strictly-professional character.
CHAPTER XIX.
TRIALS AND PLEASURES OF A MEDICAL LIFE, 404
Great mental and bodily toil. Irregularity of life. No command
over time. Exposure to causes of disease. Physicians a short-lived
class. Compensation generally small. Medicine not a money-making
business. Less obligation felt by many to pay physician than to pay
others. Physician often obliged to see the quack and hobby-rider
getting rich by their impostures. Facility with which the people are
imposed upon, a great trial to the honorable practitioner. Especially
so when imposition is practised by his brethren. Valuable lives
sacrificed to ignorance and unskilfulness. Witnessing sad scenes.
Mutual sympathy and confidence add in such cases to physician’s
sorrow. Irreligion and vice at hour of death. Frequency of sad
scenes in times of pestilence. Ingratitude of those on whom the
physician has conferred favors. Services of faithful physician not
to be measured by pecuniary considerations. Dismissing physician
for frivolous or improper reasons. Not so much gratitude in the
world as commonly supposed. Virtuous and vicious poor. Clergymen
generally attended upon gratuitously. What, therefore, is due from
them to our profession. Conduct of some of them. Want of respect
to the medical profession, on the part of the community generally.
Public ingratitude. _Pleasures of a medical life._ Medicine as a
science, full of interest. Its intimate union with other sciences.
Enthusiasm in its pursuit. All discoveries, however small, add to the
capabilities of the medical art in relieving misery and prolonging
life. Pleasure in unraveling the perplexities of medical practice—in
guiding and assisting Nature’s processes when salutary, and in
arresting them when not so. Mental management of the sick. Results
of practice of the judicious physician gratifying. The physician a
hopeful, cheerful man. Gratification of his humanity and benevolence.
His attachments. His social enjoyments. His opportunity for exerting
a good moral influence.
CHAPTER I.
UNCERTAINTY OF MEDICINE.
The uncertainty of medicine is a common topic in all circles; and
yet it is one which is very generally misunderstood, even by the
intelligent and reflecting in the community. They mistake as to the
nature of this uncertainty, its causes, its practical influence in
the treatment of disease, the means which should be resorted to in
order to diminish it, and the best methods of guarding against the
errors into which it is liable to lead us. These errors are, I may
remark, so numerous and so common, and interfere so constantly with
the usefulness of the physician among high and low, educated and
uneducated, almost equally, that the subject is one of vast practical
importance. It is important not only to physicians, but to the
people, and to the people especially, for _they_ are the sufferers
from the multiform and often fatal injuries, which these errors
engender.
It will be profitable then to examine the different points to which
I have alluded, so that it may be seen how far the science of
medicine merits confidence, and by what tests an intelligent and
thinking man may distinguish between that which rests upon good and
substantial evidence, and that which is uncertain and delusive. This
is a distinction which often fails to be made, (as the physician has
occasion every day to lament,) by the shrewd and learned, as well as
the ignorant and unwary; and the deductions of a rational and careful
experience are continually confounded with the false assumptions, and
plausible fallacies of the mere pretender, and the fanciful vagaries
of the enthusiast. So far as my remarks will enable the reader to
make the distinction to which I have referred, just so far will my
object be accomplished.
When the chemist mixes substances together, the composition of which
he knows, he arrives at results which may be strictly denominated
certain and invariable. If he be not able to do this at once, he
can do so ultimately, by a series of experiments, varied to test
each doubtful point. The results which he thus obtains are so exact,
that they can be expressed by numbers and definite proportions. The
physician can imitate the chemist, it is true, in the application
of tests in the investigation of disease; but it is necessarily a
very humble and distant imitation, and no approach to the certainty
and definiteness of chemical analysis and synthesis can be expected
in medical practice. When the chemist mixes substances together, he
knows what they are; and when he sees their effect upon each other,
he has a right to expect the same effect to follow, with absolute
certainty, whenever he shall make the same mixture again. But the
physician cannot infer from the effect of a remedy in one case, that
the same result will certainly occur in another case which appears to
be precisely similar. For he cannot know enough of the circumstances
of the two cases, to determine beyond a doubt that they are exactly
alike. There are often causes, utterly undiscoverable by human
wisdom, which essentially modify the effects of remedies.
If you suppose that the chemist knows the nature of only a part of
the substances which he puts into his retort,—that the retort itself
is made of materials which will act upon these substances, and be
acted upon by them, and that in the midst of his experiment some
other substance is introduced accidentally or by stealth, producing
an entire change in the process; you will then make the chemist to
resemble the physician in the uncertainty of his results. He would
then be obliged, as the physician is, to go through with a great many
observations to establish any one fact; and instead of making, as he
now does, a well-defined line of separation between what is known and
what is not known, he would, like the physician, have a wide middle
ground of probability and supposition.
The causes which make disease complicated, and prevent uniformity in
the effects of remedies, are principally these, viz.:
1. The sympathy which exists between the different organs of the body.
2. The influence of unseen causes or agents.
3. Natural changes, arising from the tendency which exists in the
system to throw off disease, appropriately called the _vis medicatrix
naturæ_, or restoring power of nature; and in connection with this
the tendency to a definite limit manifest in many diseases; for
example, small pox, whooping cough, measles, scarlet fever, &c.
4. Mental influences.
5. Idiosyncrasies, or individual peculiarities.
We will examine in a familiar way each class of these causes
separately.
1. The sympathy which exists between the different organs of the body.
The fact that when one organ is disordered in any way other organs
sympathize, or suffer with it, is familiar to every one. This
sympathy destroys the simplicity of disease, in two ways. In the
first place, it produces many symptoms at a distance from the organ
affected. Pain, for example, is often far away from the disease
which causes it. The pain in the right shoulder from disease of the
liver, in the knee from disease of the hip joint, and in the head
from disordered stomach, are familiar instances. Convulsions, in the
great majority of cases, especially in children, are a mere symptom
developed by the sympathy of the brain and nervous system with
disease in some other organ—for example, a disordered stomach, the
irritation of teething, &c. Now if sympathy renders disease complex,
by developing such marked symptoms as those we have mentioned, at a
distance from the affected organ, much more will it do this by the
numerous less observable, and less definite symptoms, attendant upon
our various bodily maladies.
In the second place, sympathy destroys the simplicity of disease,
not only by exciting symptoms in organs at a distance from the part
affected, but also by creating actual disease in those organs. A
single example will suffice. The child, whose brain sympathizes
with the disease in its stomach, may have inflammation after a time
fastened upon its brain in consequence of this sympathy, the symptoms
at first being obscure, but at length clear and unequivocal.
The influence of sympathy in modifying disease occasions constantly
much perplexity in the mind of the physician. He often finds it
difficult, and sometimes impossible, to decide whether an organ,
which he sees to be affected, is really diseased, or is merely
sympathizing with some other organ.
The simplicity of disease is thus destroyed by sympathy, even
when all the organs, except the one which is attacked, are in a
healthy state at the time of the attack. And when they are already
in an unhealthy, unnatural condition from previous disease, the
complication is rendered still greater. _Chronic_[2] cases especially
are often so complex from this cause, that it requires the most
discriminating acumen to unravel their history, and make out the
starting point of the disease. Often it is impossible to discover
any such starting point; and sometimes there is none, but there
are several different diseases in different organs, all affecting
each other through sympathy, and presenting together a confused and
changing medley of symptoms. In such cases, the manifestations of
diseased action are at one time most prominent in one organ, and at
another time in another. These variations in the phase of the disease
are often so unaccountable, as to seem capricious, and they always
embarrass the physician, as he attempts to determine the effect
of his remedies, and to proportion them to the importance of the
symptoms, as they show themselves in the various organs. It would
sometimes almost seem, that a tricksy little spirit were playing its
pranks among the organs, now here and now there, eluding his search,
and escaping his grasp.
In some cases, disease will leave the organ in which it seems to be
obstinately fixed, and appear in full force in some other organ,
which has been up to that time only sympathetically affected. This
is more apt to occur in children, because the sympathies are more
lively in them than they are in adults. Such changes, taking place
often without any obvious cause, and so suddenly, and sometimes, we
may add, so secretly, you can readily see, must tend to make our
knowledge of disease, and of the effect of remedies, confused and
uncertain.
2. The influence of unseen or secret causes, is another source of
uncertainty in medicine.
The fact, that some causes, whose nature and extent cannot be
appreciated, are at work modifying disease, and the effects of
remedies, constantly forces itself upon the attention of the
practitioner. The causes of disease, and of the changes that occur
during its progress, are much more concealed from our view than is
generally supposed. Patients are fond of fixing upon something to
which they can attribute their sickness; but in the great majority
of cases, the conclusion which they adopt with so much confidence is
a mere supposition, and does not rest upon any substantial proofs.
Even in the case of a common cold, you will find that the reasons
given for believing that this or that cause produced it, often will
not bear a strict examination, according to the acknowledged rules of
evidence. Ordinarily some exposure is looked upon as being without a
doubt the cause, when it may have been only one of the causes, or may
even have had no agency at all in producing the result.
Some of the causes of disease, though, from their definite and
invariable results, we may be perfectly aware of their presence, are
yet of an occult nature, escaping all the tests devised to detect
them. For instance, the miasm, as it is termed, which is the cause of
intermittent fever, has never yet been detected in the atmosphere, by
the application of any chemical test. And yet, no result in the wide
range of disease is more definite and palpable than that which this
miasm produces. And so secretly does it make its impression, that the
disease sometimes lies dormant for a long period, even for weeks and
months—the system all the while showing no signs of its presence. I
once had a case of intermittent fever, which was not developed till a
year had elapsed from the time of the patient’s exposure to the cause.
The nature and mode of operation of the causes of many diseases are
involved in mystery, and are subjects of discussion and dispute among
medical men. The formidable, and often fatal malady, that results
from a wound received in dissection, is attributed by some to a
poison evolved in the decomposition of the body; while others suppose
that it arises from the irritation of the wound simply, circumstances
concurring to increase the irritation in one case, while it is
left to subside in others. It is agreed, on all hands, that the
contingencies on which the disease depends are not ascertained; and
they are so often absent, that the cases in which the malady does
actually occur bear a very small proportion to the whole number of
instances in which such a wound is received.
The same may be substantially said of the causes of typhus fever,
cholera, scarlatina, &c. Some think that these diseases are caused
by subtle poisons, which enter the system in various supposed
ways; while others believe that they arise from causes which make
_impressions_ merely upon the system, and thus awaken trains of
morbid action. Whatever may be our opinion on these disputed points,
the fact that there is so much secrecy in the operation of morbific
influences, must, it is clear, make much of our knowledge of disease
uncertain.
If, then, there be so much ground for difference of opinion in regard
to the nature of the causes of disease, and their mode of operation,
where the results are of so definite a character, as we see in the
disorders to which I have alluded; much more is this the case with
those diseases, which, with their Protean shapes, make up a large
proportion of the maladies that call for the daily attention of the
physician. _These_ do not commonly spring from one cause, but from
many causes concurring together, some of which may be ascertained,
while others are only suspected, or are wholly concealed from the
most scrutinizing investigation. Under these circumstances, the
physician has a difficult task to discover the actual condition of
the patient. It would be a comparatively easy one, if he knew what
all the agents were that had combined to produce the disease, even
though they were numerous and complicated in their operation. He
could then thread out with some success, the trains of morbid action,
and, perhaps, give to each cause its proper place in his estimate of
their agency in causing the disease. But, in some cases, he knows
but little of the nature and mode of action, even of those agents,
whose influence he can perceive: and then, there are some quite as
important, which act in entire secrecy, developing results that
cannot be foreseen, and that cannot be calculated upon after they
have made their appearance. Such developments are often observed
in the progress of disease, and necessarily embarrass us in its
treatment. They sometimes completely alter, either gradually or
suddenly, the whole character of the case; and yet they may be the
consequences of causes, which have been secretly, but surely, doing
their work from the first onset of the disease. In some cases, which
were in the commencement comparatively mild, a group of severe
symptoms all at once start up, exciting astonishment and alarm in
the mind of the practitioner. Sometimes there are precursors of the
full development, half showing themselves, and the watchful physician
may discover in them the coming storm, long before the indications
are manifest to the common observer. Even after convalescence has,
to all appearance, fairly begun, and the symptoms seen during the
progress of the disease are gone, some new symptoms may appear—the
upshot of a train of morbid influences, which had been all the while
imperceptibly advancing to this result; just as I have seen a fire,
supposed to be extinguished, burst forth like a new fire in another
part of the building, to which it had secretly made its way.
It is sometimes impossible to detect the immediate cause of an attack
of sickness, even when the transition from health to disease is
apparently instantaneous. Take, for example, this case. A gentleman,
while quietly sitting in his counting-room, was attacked, as suddenly
as if it were from a blow, with a great sense of oppression in the
region of the heart, almost arresting the action of this organ, and
at once prostrating his strength. No reason could be discovered why
this attack should occur at that time rather than at some other. And
yet there was some hidden cause, or combination of causes, which,
at that moment, did its work; and we know not how long a time a
preparation had been going on for this consummation, and so silently,
too, as to occasion no disturbance.
The physician often finds, on making his first call upon a patient,
that although he may think that his attack is only a thing of to-day,
there is evidence that disease must have been preying upon his system
for some length of time, gradually extending its ravages, till, at
length, it has made a palpable outbreak. The patient may attribute
his sickness to some one cause; but there have been many causes
uniting together, one after another, and swelling the still current
of disease, which has now broken forth as a flood.
And, as a general rule, the longer this preparation has been going
on, the more obstinate does the physician expect the case will be,
and the more difficulty does he find in getting a definite knowledge
of the nature and extent of the malady. And if he could always
trace every train of disease up to all its sources, both original
and tributary, he would often be obliged to go back weeks, months,
and sometimes years. In some cases, such an exploration would lead
him through almost endless labyrinths. As it is, he often finds,
in attempting such a search, that those facts which are the least
material in the eyes of the patient, and which may be overlooked
by him in giving the history of his case, reveal, far back in the
distance, causes which have had more influence than any other
in producing this result. A sort of cross-questioning, and that
sometimes of a rigid character, is often needed, to develop material
facts. The patient’s own story, without such questioning, would
generally give to the physician very erroneous ideas of his case.
The remarks that I have made apply with greater force to chronic than
they do to acute diseases. For in them more especially, as you have
already seen, does the sympathy which exists between the different
organs extend and complicate the morbid condition, and the operation
of unseen causes contributes, sometimes very largely, to this result.
Many chronic cases become exceedingly complex, and therefore
obstinate, from the course which the patient takes with himself,
before he comes under regular and systematic treatment.
Perhaps, first, he goes through with domestic medication,
and then takes patent medicines, recommended to him by kind
neighbors, or blazoned forth in the newspapers. Then he tries
some vaunted system—Thompsonism, or hydropathy, or homœopathy, or
chrono-thermalism, or perhaps all of them in succession. After
going through all this, unless some one of these measures _chance_
to benefit his case, (as _anything_ may _chance_ to do it), he at
last comes to a physician, and puts himself under his care. The case
which was, perhaps, sufficiently complicated in the beginning to
require strict investigation, is now rendered, by all this variety
of practice, very intricate. The difficulty in understanding it
lies in the varied effects which the different agents brought to
bear on it have produced—effects, which, in the retrospect, it is
almost impossible to estimate with any correctness, because the
physician has only the history given him by the patient, and the
appearance of his present symptoms, to guide him in making up his
opinions. If he had himself seen the case in its untouched condition,
and then had witnessed the operation of the different remedies, he
would have been better able to arrive at satisfactory conclusions.
A chronic case, in its best estate, needs to be watched for some
little time, in order to acquire a just and thorough knowledge of
its character. And when it has gone through a series of processes at
_haphazard_, with no intelligent eye to observe it, it is no wonder
that its condition should become a complicated and puzzling one. The
physician, with such a case before him, is situated very much as the
chemist would be, into whose hands should be put a mixture which had
been experimented upon over and over again by different chemists,
and those, too, who were ignorant and bungling. And as you would not
demand of him, that he should arrive at once at definite results in
examining the composition of such a mixture, but would give him time
to apply various tests to it, so it should not be expected of the
physician that he should fully understand at once a case which has
been dabbled with by ignorant experimenters, one after another; but
time must be given him to watch _his_ tests, that he may see them
bring out to view its real character and condition.
It must be obvious to the reader, that those who go through this
round of experimenting, before they put themselves under the care of
an intelligent physician, not only lose valuable time by so doing,
but generally inflict upon themselves positive harm. The remedies
which they have used, if they have had no good effect, have helped
to _fasten_ the disease upon the system, and have increased its
severity. They have done this by irritating the system, and, of
course, the diseased organs, and by extending the complaint far
beyond its original limits. You have seen that, through the sympathy
existing between different organs, disease becomes extended and
complicated. Well-directed treatment has a tendency to prevent this
extension of disease: mere blind experimenting, on the other hand, is
apt to promote it; and if it does not have this effect, the patient
is very fortunate.
3. I pass now to the consideration of the third class of causes which
render medicine an uncertain science, viz., natural changes, arising
from the tendency which exists in the system to throw off disease,
appropriately called the _vis medicatrix naturæ_, or curative power
of nature; and, in connection with this, the tendency to a definite
limit, which is manifest in many diseases, as, for example, small
pox, measles, hooping cough, scarlet fever, &c.
To recur to our chemical illustration. I have said that it would
add vastly to the uncertainty of the results of the chemist’s
experiments, if the retort, into which he puts his substances to
be experimented upon, could itself act upon these substances, and
thus modify their action upon each other. The body of the patient
may be considered as the physician’s retort, and the diseases and
the remedies introduced, as the materials contained in it. Under
this head we are to examine certain principles which reside in this
retort, and which have a constant and important influence upon
diseases and their remedies, modifying, sometimes manifestly, and
sometimes secretly, their action upon each other.
I will speak first of the tendency to throw off disease, the _vis
medicatrix naturæ_. I need not spend time in proving to you the
existence of such a tendency. It requires not the exercise of
any scientific acumen to discover it. It is obvious to the most
superficial observer. And yet the extent to which it operates is far
from being properly appreciated, even by medical men; and much less
is it by those who are out of the profession. The changes which it
produces are constantly confounded with the effects of remedies; and
this is one of the chief sources of the errors which encumber the
annals of medical experience.
The reader will see, as we proceed, that boast as doctors often will
of _their_ cures, as if they were wholly theirs, this _vis medicatrix
naturæ_ is the chief doctor after all; and she, good, kind angel,
hovering over the bed of sickness, without fee, and often without
even any acknowledgment of her services, saves the life of many a
poor patient, who is near being drugged to death by some ignorant
quack, or some over-dosing doctor.
That the reader may be somewhat acquainted with the extent of the
influence which this curative principle exerts, I will cite some
examples of its operation.
If some offending substance be present in the stomach, vomiting is
produced, the substance is evacuated, and this organ, having thus
relieved itself by an effort of nature, as it is commonly expressed,
now goes on with the performance of its usual functions. In this
case, the ordinary action of the organ is entirely reversed, in
obedience to the curative principle. If an attempt be made to allay
the vomiting before the offending substance is thrown off, it is
an injurious interference with a salutary effort. Sometimes the
effort is ineffectual, and needs the assistance of art. It is often
difficult to decide whether vomiting is prompted by this curative
principle, or is caused by irritation, which should be quieted by
medicine. Want of due discrimination, either from lack of knowledge,
or from carelessness, very often leads to errors on this point.
The operation of this principle is beautifully exhibited in the
succession of the processes of inflammation. You see a swelling. It,
after a while, begins to soften. There is matter in it, but it is not
yet very near the surface. But soon, at some point, it comes nearer
and nearer to the surface, the wall of the abscess thus becoming
constantly more thin, till, at length, it opens and discharges. The
discharge continues till the swelling is nearly all gone, and the
remainder is absorbed, and the part is restored to its natural state.
Now, this is quite a series of processes, all contributing to one
result, and it is presided over, or directed, by the _vis medicatrix
naturæ_. The object of this series is a definite one; and each
process does its part in effecting it, and does it commonly at the
right time, and in the right manner. Just look for a moment at the
complicated character of this apparently simple operation. Here
is quite a large deposition of substance which is to be removed;
and this is the object to be effected. Observe how it is done. The
softening of the swelling is not a mere change of solid substance
into a fluid, as if by decay, but it is the result of an active
process, which we call _suppuration_. When this process is properly
performed, good pus is made, or as the old writers in medicine rather
quaintly expressed it, _laudable_ pus. This process of suppuration,
when it is well done, does not go on here and there in the swelling,
making it like a honeycomb with a multitude of little abscesses; but
there is a consent, an agreement of action by the vessels of the
part, as really as if they worked intelligently. It is this consent
of action which not only makes the line of movement in the abscess,
but points it towards the surface, instead of giving it some other
direction, laterally, or inward, upon some of the internal organs.
But it is farther to be observed, that in this agreement of action,
the vessels of the part do not all do one thing. Three different
offices are performed by them in the different quarters of the
abcess. While some of these little workmen are forming the pus,
there are others thinning the wall of the abcess in the direction of
the surface, by absorbing or taking up the substance there; while
there are others still, in the rear, and at the sides of the abcess,
depositing substance, in order to make a barrier to prevent the pus
from being diffused in the surrounding parts. Each class of these
workmen perform their particular work with even more exactness and
harmony than would be expected of any company of intelligent laborers
under the direction of a leader. The absorbents absorb together,
the wall builders build together, and the makers of pus make pus
together, and deposit it in a common reservoir.
But observe farther, and you will soon see an entire change come over
the whole scene of operations. When the absorbents have completed
their passage for the matter through the skin, the pus is gradually
discharged from its reservoir, and the “occupation” of the pus makers
is soon “gone.” The wall builders also cease their work, and while
the vacancy becomes filled up by contraction and deposition, the wall
of defense, so carefully maintained, so long as it was needed, is
now taken up by the absorbents—workmen which seem to know just when,
as well as how, to do their duty, and is emptied into the common
circulation, to be discharged from thence with the general refuse, by
the various outlets of the system.
The object of all this is the restoration of the part to its healthy
condition, and it is effected by a principle existing in the
system—it matters little comparatively by what name you call it.
The name is simply expressive of a great, general fact, as the term
gravitation is, and is not intended, any more than that term is, as
an explanation of the _nature_ of the fact indicated.
This same principle is in operation in all diseases, resisting them,
hemming them in, and as they retreat, following hard upon their
footsteps, repairing their injuries as well as it can. It is true
that its efforts are often ineffectual, that they are sometimes
overpowered by disease, that they are frequently perverted by
injudicious interference, and that they are sometimes stimulated to
a higher degree than is necessary, producing over-action, and thus
making this conservative principle an instrument of injury, perhaps
destruction. It would be interesting and profitable to illustrate
these several points in the operation of this principle, but it is
not essential to our purpose.
We will pass now to the consideration of the principle of
self-limitation,[3] which we find existing in many diseases.
These diseases have a regular rise and decline, including a set of
processes, and a succession of symptoms peculiar to themselves. When
they have once fairly begun, they cannot be abridged; neither are
they prolonged beyond their natural limits, though they may, and
often do, leave results behind them, which are sometimes mistaken
for a continuance of the disease itself. The period of continuance
is more definite and fixed in some of these diseases than in others,
and there is a similar difference also in regard to uniformity of
shape. Thus small pox runs through its course with more regularity
of period, and with a more uniform series of phenomena than scarlet
fever, which, though having a certain general character and average
period, is extremely diversified in its degree of severity, and in
its accompanying circumstances. The more simple and regular and
definite any disease is, the more accurate can our observations be
in regard to it, and the less apt are we to confound the effects of
remedies with the natural changes that take place in its progress.
This principle of self-limitation is found in the movements of
other diseases of a less definite character than those which I have
mentioned, though it does not manifest itself so fully, and with so
much uniformity. You have already seen, that in a common inflammatory
swelling there is a regular set of processes going on to its
termination, in the restoration of the part to its healthy condition.
The tendency of the inflammation ordinarily is to finish itself, just
as is the case with any of the definitely shaped diseases, but its
rate of progress cannot be so well calculated upon. The same can be
said of inflammation of any of the organs of the body, in regard to
this tendency to come to a conclusion of itself; the ways in which
it does this varying much, according to the texture of the part
affected, and other circumstances.
The reader is now prepared to see how it is, that mistakes may be
made, by confounding the effects of remedies with the changes that
arise from the two tendencies, of which I have been speaking. These
mistakes have often been committed, even in those diseases which are
commonly simple and uniform, and definite in their shape and course.
Take, for example, small pox. It was once the custom of physicians
to give much medicine in this disease, with the idea that it was
controlled and lessened by such a course, and the system was thus
enabled to throw it off more easily and effectually. But experience
has corrected this error, and the physician now stands by, and sees
results occur in the progress of this malady without the agency of
medicine, which he used once to consider as produced, in part at
least, by the drugs that he administered. Let me not be understood
to say that no medicine at all should be given in this disease. The
office of the physician is to watch it, and if nature, in going
through the processes necessary to a favorable termination, needs to
be assisted by art, it should be done. But we should be careful not
to ascribe to art what is really effected by nature, for we should be
led by this error to a too officious interference with her efforts.
We may often do much good by medicine—we may moderate the fever,
support the strength when languishing, bring out the eruption when
it recedes, &c. But to attribute the successful termination of small
pox in all cases to the remedies which have been used, would be as
great an error as it would be to maintain that the poultices, and
other applications made to an inflammatory swelling, are of course
the cause of its suppuration and discharge—or, in other words, that
they cured the inflammation. All that can be truly said of them is,
that they assisted nature in the cure. And as these applications
may sometimes be of too stimulating a character to suit the case,
and therefore may increase and extend the inflammation; so the
remedies used in a case of small pox, if they be not actually needed,
may aggravate the disease. And if the patient recover under such
injudicious treatment, it may be supposed that the medicines cured
him, though he actually recovered _in spite of them_, because that
same blessed _vis medicatrix naturæ_ came to the rescue.
If there be so much liability to error in a disease so simple and
uniform as small pox is, it is still greater in those complaints
which are more complicated, from collateral and accidental influences
and affections. Perhaps I cannot adduce a better example for our
purpose than is to be found in scarlet fever. There is no disease,
the history of whose treatment shows so strikingly the uncertainty
of medical knowledge and experience as this does. The most opposite
and various remedies and modes of treatment have been lauded as
successful, in standard medical works, and in medical journals, and
multitudes of _certain_ cures have been proclaimed in the newspapers.
What is praised by one is condemned by another; and it is the
individual experience of every rational and candid practitioner,
that a mode of treatment which at one time is attended with marked
success at another is wholly unsuccessful. It cannot be otherwise
in a disease which varies so much as this does in its degree of
severity, in its real character, and in its attendant circumstances.
A respected medical friend, in reviewing his cases of scarlet fever,
found that he had treated one hundred cases since he had lost a
patient with this complaint. But on the very day on which he made
this review, he was called to a case of scarlet fever which ended
fatally, and out of thirteen cases in the same neighborhood he lost
seven. With such variations in the severity of this disease, it is
very difficult to avoid erroneous inferences as to the comparative
success of modes of treatment. This difficulty is increased by
the fact, which is remarkable in this disease, that the degree of
severity, or amount of danger, is by no means always capable of being
measured by the symptoms which present themselves. In the experience
of every physician, who has seen much of this complaint, many cases
have ended fatally, which, up to within a short period before death,
appeared to be doing better than some others in which recovery took
place. There was much wisdom in the reply that one physician made
to another, who asked him what his mode of treatment was in scarlet
fever. “I have no treatment,” said he. “I manage each case as an
individual case, just as it strikes me at the time.” And to this
conclusion will experience lead every judicious practitioner.
Let me not be understood to mean that experience, so valuable in
the treatment of all other diseases, is nothing worth in this
complaint—that it establishes no facts, and no general principles.
All that I mean is, that this disease is so variable in its character
and tendencies, that extreme caution is necessary in applying these
principles, and that the treatment must be at the very antipodes of
stereotype—as variable as the disease itself.
I trust that it is sufficiently obvious to the reader that great
uncertainty must necessarily rest upon our knowledge of a disease
so varied as this is, and that all our experience of the effects of
remedies upon it must be thoroughly sifted, in order to attain to any
measure of accuracy. It is a disregard of this important truth, that
has made the testimony of medical men so conflicting in regard to
the treatment of this disease.
I need not spend time to show how the same uncertainty must
embarrass us, to a greater or less degree, in our investigation of
all other diseases. The errors resulting from this source may be
avoided, in part, by observing accurately the changes which arise
from the two tendencies that we have been considering, their modes,
periods, signs, and accompanying circumstances. The efficacy of
this precaution against error is, as I have already hinted, in
proportion to the simplicity and uniformity of disease. In disorders
which are complicated, and which vary much in their shape and other
circumstances, it is exceedingly difficult to decide, how much
agency, in bringing about the curative changes, is justly to be
referred to the remedies, and how much to the natural energies of
the system. Too much credit is very commonly given to medicine, and
too little to nature; and sometimes, when some remedy is praised for
its efficacy, and the patient and his friends, and perhaps even the
physician, think that it has saved his life, it had no agency in
promoting his recovery, and perhaps it retarded it.
I pass now to the consideration of the fourth class of the causes of
the uncertainty of medicine—mental influences.
It never should be forgotten in our observation of disease, that we
have not to deal with the body alone, but with the body inhabited
by a mind, which is connected with every particle of that body by
countless nervous filaments, and therefore acting through them upon
it, and affecting to a greater or less degree all its diseased
conditions.
The influence of causes acting through the mind is often concealed
from our view, and even when it can be plainly seen it is difficult
to estimate its amount with correctness. Effects are often produced
through the mind, which are attributed by the patient, and sometimes
by the physician, too, to some remedy that has been administered.
Take a very common case. A dyspeptic, who has contracted his disorder
from mental effort, or from the anxieties of business, applies to
his physician. He prescribes some medicine, and at the same time
recommends him to take a journey, or go to some watering place. He
returns cured, and he perhaps gives the credit for the most part
to the medicine, or to the medicinal waters which he has drank
with scrupulous regularity, either of which may have had little if
anything to do with the cure, and relaxation and diversion of mind
may have been the chief or sole causes of his recovery. This is a
palpable instance of erroneous inference; but we shall have but a
narrow idea of the influence of mind upon disease, if we confine our
view to cases of so decided a character. Its influence is constant
in all diseases; sometimes plain to be seen, as in the case just
mentioned; often entirely concealed from the most careful scrutiny;
and sometimes revealing itself slightly, so that the watchful eye
of the physician catches mere glimpses of it, like passing shadows
gone in a moment. Besides the secret griefs and troubles that often
hinder recovery, there are varying states of mind, some of which the
patient may be hardly conscious of himself, that modify in a thousand
ways the movements of disease, and the action of remedies. For
example, the cordial which is administered is often in part or wholly
neutralized by mental depression, while it is essentially aided in
its effects by the genial and animating influence of hope.
The points to which I have alluded the reader will find fully
illustrated in the chapter on the mutual influence of mind and body
in disease. I will therefore dismiss them for the present, and
will merely recur again for a moment to our chemical illustration.
If the retort of the chemist, besides being composed of substances
which will act upon its contents, should have residing in it some
secret and subtile principle, whose existence is known only by
its effects, and which acts both upon the retort itself and on
whatever it contains, the results of his experiments would be
rendered very uncertain. To follow out the analogy—the human body
being the physician’s retort, the mind is just such a secret and
subtile principle, acting in an unseen way both on the retort and
its contents, modifying therefore the effects of remedial agents, so
as to embarrass the physician in his investigations, and render his
conclusions uncertain.
The fifth class of causes of the uncertainty of medical science
remains to be noticed, viz.: individual peculiarities or
_idiosyncrasies_, as they are termed.
Every individual may, strictly speaking, be said to be peculiar to
some extent, and there is much force in the popular idea of the
benefit resulting from a physician’s being acquainted with his
patient’s constitution. But besides these common differences, some
have very great peculiarities. A few examples will be sufficient.
There are some persons in whom the odor of roses will produce
asthma. Ipecac has the same effect in some individuals. Some persons
are uniformly made sick by eating strawberries even in small
amount. Cases are constantly met with by physicians in which some
medicines have a peculiar effect. The various effects produced by
opium in different individuals furnish many examples. I call to
mind a patient, who though a laboring man of considerable power of
endurance, is extremely prostrated by vomiting, by whatever agent
it is produced. I once gave him an emetic without knowing this
peculiarity. He was so much prostrated, that I supposed that the
apothecary had made a mistake, and that he had taken an overdose. But
a short time after, I witnessed in him the same effect induced by
undigested food, and this revealed the idiosyncrasy in his case.
When idiosyncrasies are known, they can be calculated upon. But
they are not always known. We cannot be aware of them when they
respect the action of remedies which the patient had never taken.
And in relation to remedies which produce no marked and obvious
effect, peculiar susceptibilities may exist without being readily
ascertained. If there be an idiosyncrasy in regard to such a medicine
as an emetic, or an opiate, it is easily discovered. But if it exist
in regard to a remedy that acts silently and slowly, it may not show
itself clearly. The only evidence that we have of its existence may
be the fact, that the medicine after a while is observed to fail in
producing the effects which we ordinarily expect from it in such
cases. And it may be very doubtful whether this failure is to be
attributed to this cause, or to some other.
Let us recur once more to our illustration from chemistry. If the
retorts used by the chemist, (which, I have supposed to carry out
the analogy, to be composed of materials which would act upon their
contents,) were not all made exactly alike, but varied a little
always in their composition, and sometimes considerably, and that
too without the variation always being appreciable, this fact would
obviously still further complicate his experiments, and render
them uncertain in their results. So also the peculiarities in the
different human systems, which are the physician’s retorts into
which he introduces his agents, must have the same effect upon his
investigations.
I have now finished the consideration of the various causes of
uncertainty in medical science. If I have succeeded at all in making
them to be properly appreciated, the reader will agree with me when
I say, that there is no science that requires higher talents for
its successful investigation, and none that is so liable to wrong
influences and conclusions, if the student of it be a careless and
credulous observer. Notwithstanding this liability, imperatively
demanding caution on the part of the physician, there has been much
of careless observation in this science; and the recorded experience
of the medical profession is therefore encumbered with a mass of
errors. In order to get rid of these errors, and to establish the
proper distinctions between the certain and the uncertain, between
the true and the probable, while the merely plausible shall be
entirely rejected, a judicious sifting and testing of evidence must
be resorted to, credulity and skepticism both being equally avoided.
FOOTNOTES:
[2] The terms _chronic_ and _acute_ it may be well to define for the
benefit of some of my non-professional readers. An acute disease is
one which runs its course in a short time. A chronic disease, on the
other hand, is one which has a long duration. For example, pneumonia,
(commonly called lung fever,) is an acute disease of the lungs,
while consumption is a chronic disease of the same organ. The term,
acute, has reference to the violence of the symptoms of the diseases
to which it is applied, rather than to their duration; while its
opposite term, chronic, has reference to duration only. Use, however,
has given them a technical sense which is not liable to be mistaken.
[3] This subject may be found fully illustrated by Dr. Bigelow in the
Annual discourse for 1835, before the Massachusetts Medical Society.