GOOD AND BAD PRACTICE.
One would suppose at first thought, that the difference between
the results of good, and those of bad practice in medicine, would
be palpable to the most common and superficial observation. But it
is evidently not so. Facts in great abundance show that it is far
otherwise. The history both of medicine, and of quackery, furnishes
many instructive lessons on this subject. If we confine our view to
the medical profession, we see often two directly opposite modes of
practice praised by their adherents, as being successful in the same
complaints. We see the profession and the community both divided on
this point, each party asserting with zeal the claims of its favorite
system of practice to pre-eminence.
I will cite but a single example in illustration of these remarks.
Some years ago there was a warm discussion carried on among quite a
large portion of the medical profession in New England, in regard to
the general character of diseases in this part of the country, and
their proper mode of treatment. One party, at the head of which was
Dr. Gallup, asserted that the diseases of New England had been, since
the beginning of the present century, almost altogether sthenic or
inflammatory, and therefore had required depleting remedies. Another
party, whose chief champions were Doctors Miner and Tully, contended
that diseases had been asthenic, or characterized by debility,
instead of an inflammatory tendency, and that they therefore required
stimulants. While Dr. Gallup denounced the treatment of disease,
pursued by the adherents of Drs. Miner and Tully, as “incendiary
treatment,” and lauded bleeding as the chief remedy for the present
time; Dr. Tully, on the other hand, says that “the lancet is a weapon
which annually slays more than the sword,” and that “the king of
Great Britain, without doubt, loses every year more subjects by these
means”—depleting remedies—“than the battle and campaign of Waterloo
cost him, with all their glories.”
Now if it were easy, by looking at results, to decide in all cases
what is good, and what is bad practice, it is evident that such
diametrically opposite modes of treatment could not be in vogue at
the same time. The proper distinctions would be made, and the good
practice would be approved, both by the profession and by the public;
while that which was seen to be injurious in its results would at
once be rejected.
So also, if it were easy to make this distinction, the truly skillful
physician could always be recognized as such, while the unskillful
and ignorant practitioner would not be able, as he now often is,
to obtain from the public, in spite of his deficiencies and his
blunders, the meed of praise due to real merit and actual success.
The quack, too, would stand forth in his true light, in contrast
with the man of science in the results of his practice, instead of
claiming, with brazen effrontery, and receiving from the multitude,
as he now often does, the credit of being even pre-eminently
successful.
There never was such a variety of systems of quackery before the
community as there is at the present time. To say nothing of minor
claimants, there is Thompsonism, almost parboiling its patients with
steam, and shaking them to shreds with lobelia, and burning them up
with cayenne; and Hydropathy, that wraps up its devotees in the cold,
wet blanket; and then gentle, sweet, refined, sublimated Homœopathy,
that starts with horror at the very idea of such harsh means, and
professes to neutralize all disease with little else than the mere
shadow of medicine. Each one of these systems, so opposite to each
other, asserts its claim to be the only true system of medicine, and
bases this claim upon the success which attends it. The same claim
is also essentially made in behalf of numberless medicines which are
before the public.
Amid all these opposing claims many are bewildered, and ever in doubt
where the truth lies, are never established upon anything, but fly
from one thing to another, as the evidence of success preponderates
in favor of this, or that medicine, or system. Others become the firm
and enthusiastic advocates of some one of them, but after a while
discard this for another, and few adhere to any one thing during a
whole life. And it is amusing to see with what ease some make the
transition from one mode of practice to another, which is totally
different from it, being quite sure that they are right in doing so;
and yet, if they are right, the error from which they have escaped
is a very great one. They do not however always view it in this
light, for they sometimes recur to their former preferences, though
they are as inconsistent with their present ones as they well could
be. If Homœopathy be right, then Thompsonism must be _very_ wrong;
and yet I have known persons, who are disposed to quackery, go from
one to the other, and speak in praise of both as being successful
modes of practice, without seeming to be aware that they are so
entirely opposite to each other. So there are some, who at the same
time manifest confidence both in the common practice of medicine,
and in Homœopathy; though if Homœopathy be right, almost the whole
body of physicians are rank murderers, and if physicians be right,
Homœopathy is as ridiculous an error as ever obtained a foothold in
the community. And then there are some, who appear in the space of
a twelvemonth, at different times, as the advocates of Homœopathy,
Thompsonism, Hydropathy, and perhaps Chrono-thermalism, to say
nothing of various patent medicines from some College of Health, or
some German physician, with a long list of titles, or some Indian
doctor laden with remedies fresh from nature’s rudest and most secret
arcana.
Now it is clear, that if it were an easy thing to decide what is
successful practice and what is not, from an observation of results,
then there would not be such diversity, nor such frequent change
of opinion in the public mind, in regard to modes of treatment so
directly opposed to each other, as those are which I have mentioned.
The advocates of them would not so boldly urge their claims, knowing
the facility with which these claims could be tested. But the
difficulties which actually lie in the way of testing them are such,
that the community are exceedingly liable to be deceived. Practice,
which is really unsuccessful, is often made by its advocates to
appear for a time at least, to be more successful than any other mode
of treatment, and it is often only by long continued observation that
this error is corrected.
This error exists at this time among a large portion of the community
in relation to Homœopathy, and it is to be removed by the same
gradual process, by which all kindred errors have been removed
hitherto. By observation it will be found by its advocates, one after
another, that its reputation for success is founded upon mistake,
and it will thus step by step lose its hold upon the public favor,
to make way for some other system, which in its turn must go through
with the same process.
Those who embrace some form of quackery from mercenary views, are
aware of the facility with which the multitude are deceived in regard
to the comparative results of different modes of practice; and it is
this which makes them so confidently anticipate at least a temporary
success. Homœopathy furnishes many examples of this character.
While there are a few in the medical profession, of a peculiar
cast of mind, who are honest Homœopathists; there are others, of
various degrees of intellectual merit, who have adopted this mode
of practice, simply because they have failed to acquire business in
the ordinary way, or because they saw in the adoption of a system,
just now popular, a fair prospect of so increasing business, as to
secure wealth instead of a mere competence; and others still, who
have dubbed themselves physicians, have gone into the practice of
Homœopathy, as mere adventurers, preferring very wisely to try their
luck on the tide of a popular error, instead of trusting to knowledge
and skill, of which they have little or none. These two last classes
of Homœopathic physicians indulge the hope, that the community will
be deceived, in regard to the success of their system of practice,
a sufficient length of time to enable them to realize their golden
expectations; and then, when this false system shall be supplanted
by some other, they will be ready to adopt that other for the same
_solid_ reasons for which they have adopted this.
I need not dwell longer upon the proofs of the fact, that the
comparative success of different physicians, and different modes of
practice, is not easily discovered by the public, nor even always
by the scientific observer. Before I proceed to show why such a
difficulty exists in regard to this point, it is best that the reader
should understand distinctly what I mean by good and bad practice.
I do not mean by good practice, the use of remedies which are
essentially good, that is, beneficial in all cases; nor by bad
practice, the use of remedies which are essentially bad, that is,
injurious in all cases. There are no such medicines. Thompsonians
claim that there are—that cayenne, lobelia, &c., are always
beneficial, while calomel, opium. &c., are always deleterious. And
this view of the subject is not confined to Thompsonians. There is a
strong tendency to this exclusive notion in regard to remedies and
systems of practice abroad in the community, and it is occasionally
witnessed even in members of the medical profession.
If it were true, that some one system of remedies and doctrines is
wholly good, while all others are bad, it would be very easy for the
community to decide between what is good, and what is bad practice in
medicine. It would only have to watch, and whatever it saw uniformly
doing harm reject, and whatever it saw uniformly doing good retain.
But the subject is not thus simplified. There are some good points
in every system of practice. However bad it may be on the whole, it
will do some good in some cases. For example, the Thompsonian system,
though it is bad as a system, inasmuch as it is injurious, often
destructive in its results as applied indiscriminately to all cases,
yet sometimes does good, and very often in the same case does at
one stage of it good, and at another harm. Thus an attack of fever,
especially if it depend upon a disordered stomach, may be broken up
by an emetic of lobelia. Though commonly some other emetic would do
it better, yet there is no question that in such a case the lobelia
ordinarily does well. Now, after this is done, if the case were
left to itself with rest and a simple diet, the cure would soon be
completed. But the Thompsonian often undoes in part, and sometimes
wholly, the good which he has done. By his heating remedies he
induces a slight fever, with a morbid state of the mucous membrane of
the stomach, indicated by a bad tongue, red, or furred, or both; and
he thus makes a lingering case of one which should have been a short
one, and perhaps creates slow disease, of which the patient may never
get rid by any treatment.
But I will take an example from the practice of physicians, as well
as from quackery. The stimulating practice, of which some have been
so fond as to apply it quite extensively in the treatment of disease,
furnishes a good illustration of my remarks. As a system it is bad,
just as a system on the opposite extreme is bad. And yet either of
these systems is good in some cases, and often both are applicable
to the same case in different stages of it. The truth is, that no
_exclusive_ system of practice can be said to be a good system, for
it is impossible that it should suit all the varying states presented
by disease.[25]
It is now sufficiently obvious to the reader, that I mean by bad
practice, simply that which is inappropriate to the particular
case under treatment. And it is also obvious to him, that a correct
decision upon this point, made from observation of results, is
arrived at with much more difficulty, than it would be, if what is
good in practice were wholly and always good, and what is bad were
wholly and always bad.
I will now proceed to show what are the real points of difference
between the results of good, and those of bad practice, and why it
is that the community are so liable to mistake in their attempts at
comparing these results.
In the chapter on the Uncertainty of Medicine, I treated quite at
large of the _vis medicatrix naturæ_, or the tendency of the system
to throw off disease, and thus cure itself. _In the great majority
of cases of sickness which fall under the care of the physician,
this recuperative power is competent to effect a cure if they are
left to themselves, and in most of them it will do so, even though a
positively bad treatment may be pursued._ Let me not be understood
to say that the kind of treatment which these cases receive makes
no difference with them. It does make a great difference; but this
difference does not ordinarily have any direct and present relation
to the question of life and death, but it lies in circumstances which
may be subjects of dispute, viz., the length of the sickness, the
course which the symptoms take, the injury inflicted upon this or
that organ, or upon the constitution, &c. Of these points I shall
soon speak more particularly.
The cases, in which the difference in results between good and bad
practice is immediate and palpable, are then few in comparison
with the whole number of cases which come under treatment. It is
in these few cases only, that it is of _present_ vital importance
to pursue exactly the right course. And if the community could
select these from the whole mass of cases, separating them both
from those which are mild, and from those which were originally
mild but have been made severe by injudicious treatment, and then
should make these cases the basis of an estimate of the comparative
success of different modes of practice, it might arrive at a just
conclusion. The really skillful would like to be put to such a test,
in comparing him with the ignorant and unskillful, whether they be in
or out of the profession. For it is in such cases that quackery and
unskillfulness most signally fail, and it is only by escaping this
test that they escape the disgrace and neglect which are their due.
At a future stage of my remarks, I shall point out the insuperable
difficulties, which are in the way of making the selection of cases
above alluded to, and forming an opinion upon them.
Before leaving this point I would remark, that the failure, of which
I have just spoken, though not generally obvious to the common
observer, does sometimes at length open the eyes of those, who have
relied upon their own judgment in medicine, or upon the plausible
pretensions of quackery. And unfortunately such persons commonly
have to regret that their eyes are opened too late. For example,
a family may go on for some time, even for years, without asking
for the services of a physician, and, though they may have some
sickness occasionally, they get along apparently very well by their
own domestic management, with now and then the use of some patent
medicine, or the advice of some popular empiric. All the cases of
disease, which occur in this family during this period, are of such
a character, that nature herself could cure them unassisted, or even
when injudiciously meddled with. They all result, therefore, in
recovery, though an impaired constitution is produced in some of the
members of the family by this irregular and bungling management.
At length, one of them is taken sick with a disease of so grave a
character, and in such an amount, that a nicely-adjusted mode of
treatment affords the only chance for safety. Everything now goes
wrong, and, perhaps, after the case has become desperate, a physician
is called in. I know not what is more trying to the feelings of a
humane physician than such a case as this. He sees before him a
fellow-man, perhaps a kind neighbor, or a valued friend, on the brink
of the grave, the victim of error. He cannot rebuke the family for
the course which they have pursued, for they have been honest in it,
and it would do no good now. It is too late, and it would only add
to the anguish which they suffer, in the prospect of losing one so
dear to them. He sees that for a long time they have been drinking
in quackery, and now that they have come at last to the very dregs,
they have called him in to partake with them of its bitterness. There
is a struggle between his feelings and his sense of duty. He would
gladly have nothing to do with a case thus thrown upon his hands
in the hour of its extremity, but he is bound to do all to save a
fellow-being from death that can be done, even to the last; and then
he remembers that recovery has sometimes taken place, when death
seemed inevitable. He therefore addresses himself to his task, but it
is in vain. The patient dies. An examination of the body reveals to
the physician, as clearly as anything can be revealed, the fact, that
the treatment which was pursued, previous to his taking charge of the
case, was inappropriate and destructive.
This is no fancy sketch. Physicians are occasionally obliged to
witness such scenes. I have a vivid recollection of one which
occurred in a case of so interesting a character, that I will briefly
notice it. The patient was one, who, with most of his family, had
pursued such a course as the one I have described. He had himself,
taken Thompsonian remedies for a long time, for what he supposed to
be a ‘bilious trouble.’ He at length was suddenly laid upon his bed
by a most violent attack. Though he had faith enough in Homœopathy
to take some medicine at the hands of a disciple of that school that
very morning, he put himself under the care of a Thompsonian. In a
few hours, being satisfied that his favorite system was not working
well now, though he thought it had done so heretofore, he requested
that I should be sent for. As I expected from the aspect of the
case, though he gained some relief to his sufferings, he died. On
examination after death, we found extensive chronic inflammation of
the stomach and bowels, which had evidently been accumulating for
some time, and which at length, by a sudden aggravation from some
unknown cause, produced the attack which destroyed his life.
In regard to this case it is clear, that if the course which this
patient pursued for weeks and months before the final attack, was
not adequate of itself to cause such an inflammation, it at least
was directly calculated to foster it when it was once begun. And
yet, because Thompsonism had never absolutely killed any member of
his family, he confided in it most fully, though it was hurrying the
disease within him on to a fatal termination; and he let go of that
confidence, only when it was too late to retrieve his error. And
farther than this, the probability is, that if he had put himself
under the care of a judicious physician, when the inflammation had
but just begun, it might have been overcome, for cases of recovery
from this disease, when early put under treatment, are not at all
rare in medical experience.
In the case which I have related, the influence of bad practice was
palpable; but even here it was not so during all the time it was
doing its deadly work, but only after that work was done. And in most
cases in which bad treatment has been ruinous in its results, the
evidence is not such, even at the conclusion of the case, as will
satisfy the public, at least that portion of it which is inclined to
quackery. An examination after death is not always obtained; and when
it is, it will not always afford us as clear evidence, as was seen
in the case above related, for both disease and medicine may destroy
life, without leaving any manifest and undisputed traces of their
action, to be revealed by the knife of the anatomist.
If a lawyer make a mistake, for example in framing some instrument,
it is readily seen to be a mistake, and definite and known results
follow, clearly exposing his ignorance. But if a quack, or a
physician, through mistake in the treatment of a case, destroy life,
or fail to save it, when it could be saved by the use of proper
means, we can very seldom have the opportunity of exposing such
ignorance, because as you have seen in the chapter on the Uncertainty
of Medicine, it is so difficult to connect effects in the human
system indisputably with their cause. Suppose the fatal mistake is
manifest to physicians, who happen to know the facts in the case; how
can they demonstrate it to the satisfaction of the public? The only
undoubted proofs of it are often buried with the patient; and if they
are not, but are brought to light, even as clearly as in the case
which I have described, the community do not adequately appreciate
their value, as the honest and high-minded physician is often pained
to find, in his conversations on this subject with even intelligent
men. Many a popular and fashionable physician, as well as the quack,
is saved by the causes to which I have alluded from any effectual
exposure of his ignorance and unskillfulness.
I have said that it is by no means easy to cull out from the mass
of cases those in which the treatment must necessarily affect the
question of life and death. There are inherent difficulties in the
way of doing this. Even the skillful and careful observer may mistake
in the attempt to do it, from the fact that the first appearance
of a case does not always indicate the amount of disease, nor its
obstinacy. While some cases, which appear of a grave character at
the outset, turn out to be mild ones, when the disturbance of the
attack is once over; those, on the other hand, which seem to be
mild, are sometimes found to contain in concealment the elements of
destruction. And if this difficulty seriously embarrass the physician
in making the selection spoken of, much more then would it embarrass
the community.
But there is another still more effectual obstacle, which prevents
the public from making this selection with any degree of correctness.
It is found in the representations, which are made by different
physicians and empirics, of the cases under their care. There is
great difference in physicians in regard to the degree of hope
which they indulge in relation to their patients. One who is apt to
be desponding will, from this cause, make such representations of
the cases under his care, as will create the impression, that his
patients are much more gravely sick, than those that are quite as
sick under the care of another physician, who has a strong tendency
to hope. And besides this, some make willful misrepresentations for
their own selfish ends. A very common artifice, for the purpose of
gaining credit, is to make great cases out of small ones. This is
easily done. I will suppose a case. A child is taken sick, and the
parents are full of anxiety. The physician sees at once that the case
is not at present a grave one, and that remedies will probably in a
short time give relief. If he be honest he will say so, and remove
the undue anxiety of the parents. But if he be disposed, as many
are, to make capital out of the anxieties of his employers, he will
say that the child _is_ very sick, and perhaps that ‘it is well you
have called me so soon,’ or, ‘I wish that you had called me before,
but I think on the whole that the little one _can_ be relieved.’
Every physician knows how readily the imagination of a parent may be
excited in relation to the symptoms of disease in a darling child. He
has seen things believed to be true, under the influence of such an
excitement, which have not the slightest foundation. How easy is it
then in such a case to practice deception, or at least to leave the
parents to deceive themselves with the figments of their own fancy.
If the physician manage adroitly, his skill will be proclaimed with
all the zeal which gratitude for a restored child can prompt. How
dishonest, how _cruel_ is such a course! For the sake of his own
reputation, he has given poignancy to the pangs of anxiety in the
bosom of fond parents, when it was plainly his duty to quiet their
fears, by telling them the true nature of the case.[26]
The physician who practises such deception is indeed occasionally
detected; but if he have tact enough to avoid being _often_ detected,
and if he have effrontery enough to face down those who see through
his arts, such occasional detection is but a small hindrance to
success. In the case which I have supposed, the friends of the
physician of course would claim for him, that there really was
danger, and that he had the sagacity to see what common eyes could
not. And the parents of the child would be very slow to believe that
all their fear and anxiety were unfounded. Their pride, if nothing
else, would prevent them from admitting this to be true.
The risk of a real exposure of the deception being so slight, it is
not strange that selfish and cunning physicians should be so fond
of this artifice. Some acquire great skill in the use of it, and
contrive by this means to make many tongues busy in proclaiming their
wonderful cures.
The accounts, which empirics give of the cases under their care,
are very commonly misrepresentations. For, from their ignorance of
medicine, they are not capable of appreciating in any just manner
the character and amount of disease, and the influence of remedies.
And besides, they have ordinarily very little regard for truth, the
object of most of them being to make the credulity of the public
subserve their pecuniary interests. They are accordingly very loose
in their ideas of disease, and often represent things to be alike
which have no real resemblance to each other. The Thompsonians
furnish constant illustrations of this remark. If a man who was in
pain has obtained relief under their management, and some one else,
who had pain in the same part of the body, or somewhere near it, has
died under the care of a physician, they are apt to say without any
farther evidence, that the pain was from the same cause in the two
cases. So also, when scarlet fever is prevalent, they often represent
many as having this disease, who have nothing but a common cold, or a
slight fever from disordered stomach, and thus get the credit with
some people of cutting short a disease, which, under the care of
educated skill, cannot be prevented from going through its natural
course.
It is manifest that the misrepresentations, thus made by many
physicians, and by all empirics, must add much to the difficulty of
judging of the comparative success of different remedies and modes of
practice. And this difficulty is much increased by the accretion of
falsehood, which is certain to be made to these misrepresentations,
as busy rumor passes them about in the community.
Another obstacle to the formation of a just estimate of comparative
success in medical practice, is found in the influence of bad
treatment upon cases, in which the disease is small in amount and
mild in its character. While the judicious physician cures all
such cases so readily, that they excite no general interest, the
unskillful practitioner and the quack make bad cases of some of them;
and yet they are apt to end in recovery, although they appear to be
of so grave a character. For a case, which has become bad by improper
treatment, is not commonly in as dangerous a condition, as one that
has become bad in spite of good treatment. In the latter case you
see overpowering disease; while in the former you see little more
than the bad influence of inappropriate medicine, which is apt to
disappear when the medicine is withheld. The common result of such a
case is, that at length the treatment is gradually given up, and the
patient, in consequence of its being given up, gets well.
I will briefly cite two examples in illustration of this point.
A gentleman, who had a friend sick under the care of a physician,
who was strongly in favor of the stimulating mode of practice, was
led to doubt the propriety of the treatment, and as he watched the
case he doubted more and more. He at length ventured to lessen the
amounts of brandy and laudanum, taking care to conceal the fact from
the patient, who was every now and then calling for them, because
he felt a death-like sinking, and he was afraid that his pulse was
failing. He found that in proportion as he lessened them the case
improved, and he very soon discontinued them altogether. There is not
a doubt, that in this case the stimulants, though affording temporary
relief to the patient’s sense of exhaustion, kept the man sick, and
the discontinuance of them was the cause of his recovery. A similar
experience has been detailed to me by others.
Such cases as the one which I have mentioned may appear very badly,
and yet the amount of disease may be slight. Some disordered state
of stomach, which a very little appropriate medicine, with the aid
of rest and a proper diet, would remove, is often the whole of the
disease. I will give here the testimony of one among many physicians
to substantiate this assertion. The physician, to whom I refer, told
me, that when he began to practice, there was an elder physician on
the ground, who used brandy and laudanum largely in a certain class
of cases. They were cases in which there was disordered stomach,
with considerable tendency to a depressed state of the whole system.
The patients were commonly sick from one week to three, or even four
weeks, and though they excited much alarm among their friends, they
all, with but a single exception, finally recovered. He followed
the example of his elder friend for some time in similar cases, but
he soon began to doubt the propriety of such high stimulation. The
result was, that after a while he resorted to a very simple practice
in such cases, which produced entire relief in one or two days;
whereas, under the stimulating treatment, they would have been long
and troublesome.
I might mention many cases from Thompsonian practice, which would
illustrate the same point, but it is not necessary.
Though the community do not generally distinguish between cases which
are necessarily of a grave character, and those which are made so by
bad treatment, there are occasionally individuals, who do to some
good extent make this distinction.
A clergyman, who is blessed with a good share of plain common sense,
in addition to his high talents, and who has uniformly eschewed
quackery in medicine as well as in theology, told me that he was once
conversant with the practice of two physicians of entirely opposite
characters, during the prevalence of an epidemic. The one gave large
amounts of medicine, and much of it was of a stimulating nature. He
had a great many very sick patients, and there was much noise made
about his wonderful cures. The other went about among the sick very
quietly, gave but little medicine, and the number of his cases that
were protracted and severe was comparatively small.
Another instance which I will mention was that of a gentleman,
who employed a large number of men in a factory. A great many of
them were taken sick, one after another, with what was called the
“_sinking typhus_.” He observed that some of them were but slightly
ailing at first, and were able to be about the house, but that after
a while, under the stimulating practice, they were laid upon their
beds. Some died, and many of them were severely sick for some time.
He doubted the propriety of the treatment, and his doubts increased
with every day’s observation. At length he persuaded some who began
to be sick to take some simple medicine, and not send for the
physician. The result was successful, and he recommended the same
course to a large number, none of whom became very sick.
As the community are not apt to make the discrimination which was
made by these two individuals, it is easy to see how the injudicious
physician and the quack often get the credit of success, in their
management of apparently grave cases, when in fact these cases need
never to have been of this character, but they might have been
cured at the onset by a judicious course in a very short time, or
perhaps by the spontaneous efforts of the curative power of nature.
The unskillful and ignorant practitioner often suffers disease to
establish itself, and thus makes a long case, though even ordinary
skill would have succeeded in at once breaking up the attack.
And yet, when the patient at last recovers, he may be applauded
throughout a neighborhood, perhaps a whole community, as having
raised the sick man almost from the dead, when perhaps in the same
neighborhood, in a case of a similar character, the attack was
successfully broken up, and no credit was given to the skill which
did it. This is a point on which undoubtedly the public often give a
wrong verdict in their estimate of comparative success.
In order to show the readiness with which the public commit errors,
on the points to which I have alluded, in their estimate of
comparative success, I will suppose a case which occurs not very
unfrequently. Here are two rival physicians side by side. The one is
really skillful, and, if the results of his practice could be justly
estimated, he would obtain great credit for success. He engages in
medicine, not as a mere trade, but as a noble science. He pursues a
straightforward, honorable, and quiet course, resorting to no tricks
to acquire business. The other, on the contrary, is unskillful,
cares little for medicine as a science, depends upon artifice, rather
than real merit, to obtain business, and, though he may desire to
be successful, he desires more that he may have the reputation of
being so. The issue which is made by these two physicians before the
public is a false one. Though the unskillful one loses more patients
than the other does, in proportion to the whole number who come under
his care; yet he perhaps does not lose as many, in proportion to the
number of those which are considered bad cases by the community. For
he makes many cases to be bad ones which need not to have been so,
and, besides this, represents many as being bad, that are really not
attended with any danger.
Suppose, to make this clear, that, each physician has one hundred
cases of some prevailing epidemic—that each has thirty bad cases—that
the skillful physician loses five of these, the unskillful one eight,
the real balance being therefore much against the latter. But the
latter more than compensates for this difference, by making ten bad
cases out of comparatively mild ones, of which he loses perhaps but
one or two, (such cases having, as I have before shown, a strong
tendency to recovery,) and by representing ten others to be bad
cases which are not so. How then stands the account? The unskillful
physician, has, it is true, lost more patients than the other. But
then, he has _appeared_ to have more cases of the epidemic fall into
his hands; for, while his rival has had but thirty bad cases, he
reckons up fifty of his as having been of this character, and the
community know but little of those cases which are acknowledged to be
mild ones—these make no noise, and are not commonly taken into the
account, in the estimates which the public make on this subject.
I do not mean to be understood, by stating these results in numbers,
that the community generally estimate them in this definite manner.
I only present the subject in this way in order to show, that, while
the real results tell strongly in favor of the skillful physician,
even a numerical estimate might tell against him; that is, as it
would be made out by the community, if they should attempt it. If
then an erroneous conclusion would be so apt to result from any
attempt at a numerical estimate on the part of the community, much
greater is the liability to error in the vague general impressions
which prevail on this subject. Many an unsuccessful practitioner has
obtained a greater reputation for success than his really successful
neighbor, from the noise which is made about his _numerous_ bad cases.
I come now to speak of some other points of difference in the results
of good and bad treatment, in regard to which the community are
commonly even more deceived, than on those of which I have already
treated.
In managing a case, in which disease has become so seated, that it
cannot be broken up, but must be removed gradually, it is evident
that the more judicious are the means which are applied from day
to day to the varying states of the case, the shorter will be the
sickness. It is in the accurate adjustment of remedial means to the
ends to be accomplished, that unskillfulness makes a great failure;
and yet it is a failure, which is for the most part concealed from
the public, because it can be satisfactorily detected only by a
nice comparison of cases. And this comparison cannot be made by the
public, for reasons which will soon be stated.
But the adjustment of remedies to the varying states of disease
has an influence beyond the mere circumstance of the length of
the sickness. The judicious physician saves his patients from
unnecessary complications in their diseases; while the injudicious
physician and the quack are apt, not only to neglect to prevent
or remove such complications, but to excite and foster them. For
example, if there arise in the course of a case of fever some local
inflammation, the judicious physician notices the symptoms of it, as
soon as they appear, and immediately applies remedies to remove it,
and commonly succeeds in so doing. On the other hand, unskilfulness
would be blind to the fact that such an inflammation exists, and
would therefore make no efforts to destroy it, but would perhaps
unwittingly increase it. The same difference between skilful and
unskilful practice could be pointed out in regard to other kinds of
complications—congestions, irritations, and functional derangements
of different organs.
But let us look beyond the results which occur during the progress
of disease, and examine those which appear after recovery has taken
place. When one recovers under injudicious practice, his system is
not apt to be in a good state. His convalescence is not a clear one,
and his recovery is not full and complete. Perhaps his vital energies
are impaired, and his constitution has received unnecessarily an
injury, from which it may never wholly recover. Perhaps some local
chronic ailment is left behind, which, though it may trouble him but
slightly for a long time, may yet be the germ of some future disease.
Such a state of things is not inconsistent with a tolerable condition
of health, even when there may be such disease, as will gradually
accumulate, till it bring him to a bed of sickness, perhaps of death.
These remote consequences of bad practice are the more certain to
occur, if the patient go on, after recovery, to administer medicines
to himself according to his own whims, or those of others. Many
very tedious cases of this kind fall at length under the care of
physicians, from the hands of quacks, who are thus often spared from
witnessing the results of their ignorance and imposture, and from
bearing, in the estimation of the public, any responsibility in
relation to them.
The influence of bad practice upon the health of families, it is
evident from the above facts, must be very great; and yet it is
seldom appreciated at all, and never as fully as it should be. There
is no question of the fact that there is generally a much larger
amount of sickness, from year to year, in families that employ
unskilful physicians or empirics, than there is in those who are
under the care of skilful practitioners. And though the public cannot
discriminate accurately between individual cases in regard to this
point, they can see the evidence of this general fact, especially in
comparing good practice with gross quackery. This evidence will go on
to increase, inasmuch as the evil effects of quackery, continued in a
family from year to year, are constantly accumulating; a result which
is materially aided by the unnecessary dosing, commonly pursued by
them in the intervals of sickness. And from this accumulation we may
infer, that what we now see of the bad consequences of quackery is
but a shadow of what we may see hereafter.
Let us now sum up the points in which the practice of the really
skilful physician differs in its results, from that of the
injudicious practitioner, and the quack.
1. He has a less number of fatal cases in proportion to the whole
number that come under treatment.
2. He has a less number of bad cases, because he avoids converting
light cases into grave ones, and succeeds in arresting disease in
many cases in its very commencement.
3. His patients have commonly a shorter sickness.
4. They are in a better condition after they have recovered—less apt
to have bad results left behind, and less liable to disease in future.
5. He has a less number of patients, and a smaller amount of
sickness, in the same number of families. In order to discover this
difference between skilful and unskilful practice, the observation
must be extended over some length of time, and quite a large number
of families.
That these points of difference between the results of good, and
those of bad practice, may be appreciated with any correctness, two
things are necessary.
First. We must have a sufficient quantity of evidence. A few facts
will not avail in deciding such points—they will only lead to
erroneous conclusions. Comparison is to be made, it is true, between
individual cases, but there must be many of them in order to secure
the avoidance of error.
The second requisite is the capability of observing correctly. I
have altogether failed of obtaining one of my principal objects in
this and the previous chapters, if the reader’s mind is not strongly
impressed with the great liability to error, which attends careless
and unskilful observation in medicine. There is no subject, in the
wide range of human knowledge, the investigation of which requires
more care and skill than this does.
Now it is obvious, that the community in general are very deficient
in these two requisites for a proper appreciation of the comparative
results of practice. Most men have a very narrow range of facts,
upon which they can found such an appreciation. Their observation
of sickness extends little beyond their immediate family circle; for
what they see of disease any where else is not like watching over it,
and what they hear, as you have already seen, is not to be relied
upon. There is much which is styled fact that is not so—it is either
mis-statement, or the result of hasty and superficial observation.
The actual knowledge which any non-professional observer obtains of
disease, by any observation of his own, to which he gives any fair
amount of attention is very narrow. This assertion may be offensive
to many, who are accustomed to utter their opinions, in regard to the
results of medical practice, with almost the authority of an oracle.
But it is nevertheless true.
But, the reader will say, if it be so difficult, and almost
impossible, for me to discriminate between good and bad practice,
by my own observation of their results, what shall I do? How shall
I judge of the different modes of practice, and of the skill of
different physicians? In answer to this enquiry, I remark, that if
the reader is really convinced by what I have said, that it is almost
impossible for him to judge of practice by the results which come
within the compass of his observation, then it is plain that he must
give up, for the most part, this source of evidence as a deceptive
one, and rely upon other means for arriving at correct conclusions on
these points. What these means are I shall point out in the chapter
on Popular Estimates of Physicians.
I think that physicians often err in their readiness to appeal to
results, to show the public the superiority of their practice to
that of the quack. There is no objection to such an appeal, when
a sufficient number of well-observed and authenticated facts can
be produced, bearing upon the point in question. But this cannot
ordinarily be done, when the community are to pass judgment in the
case. The quack likes to join issue with the physician here, for he
knows how easily the public are deceived in relation to facts, and
he makes his appeal before them to results with a bold confidence.
The proprietor of a patent medicine points you to his wonderful
cures, as the facts which must convince every one of its efficacy and
value. The Thompsonian, with his red pepper and lobelia and steam,
claims that he is right and every body else wrong, and appeals to
his successful results as the proof. The Homœopathist comes with his
little globules, and says that, laugh as you may at the tiny doses,
his appeal is to the cures, which he claims they effect as if by
magic. Talk with some physician who has adopted this mode of practice
from purely mercenary views, and who is rather ashamed of it, (for
there are such physicians)—ply him with argument, to show the fallacy
of his doctrines—drive him from one strong hold to another; and at
last you will come to his citadel, in which he feels perfectly secure
from all your shafts. He will tell you, with a cool kind of defiance
that you have not seen in him before, ‘there are the facts—our
medicines cure disease, and the people are beginning to see the
truth.’ The Hydropathist too will point you to narratives of scores
of patients, cured of all sorts of maladies by nothing but a cold
wet blanket, and will say, ‘wonderful as it may seem, there are the
results.’
So it ever has been. The same appeal has been made in behalf of all
the delusions that have ever obtained a currency in any community.
The Indian who performs his strange and uncouth manœuvres, and
utters his howling incantations over his patient, and the Chilian
doctor who blows vehemently about the bed of the sick, both, like
the Thompsonian, and the Homœopath, and the Hydropath, appeal to
their facts, their cures, as the sure proof of the efficacy of
their practice. The royal touch, the weapon ointment, the tar water
of Bishop Berkeley,[27] and the metallic tractors of Dr. Perkins,
were each in their time in the same way proved, to the satisfaction
of the great public, to be wonderfully successful in the cure of
disease. An array of facts appeared in favor of the last mentioned
of these delusions, Perkinism, that surpassed altogether the results
which are now attributed to Homœopathy. But time has shown that the
results were falsely attributed—a fact which should teach the public
a lesson, in regard to the apparent results which are appealed to in
support of the delusions of the present day.
But must the physician say nothing about results to the public?
Certainly he should.
In the first place, he should endeavor to guard those, with whom
he has daily intercourse, against erroneous views of results in
medicine, by showing them the difficulties that lie in the way of
estimating them with correctness. If he succeeds at all in producing
a proper impression upon their minds, and thus induces them to be
modest and careful, instead of being bold and heedless, as too many
are, in expressing their opinions on such subjects, he will exert an
effectual influence, in preventing them from being deluded by the
partial views of facts, and the mis-statements, upon which empiricism
relies for its success.
In the second place, whenever he can make a comparison between the
results of good practice and those of quackery, _which can be fairly
understood_, let him do it. To warrant such a comparison the facts
should be clear, well authenticated, and in sufficient number to
justify the general conclusions drawn from them.
In the third place, whenever he can show, by facts which can be
appreciated by the common observer, that the practice pursued by any
pretender has been entirely inappropriate to any case, especially
if this can be done by evidence discovered in an examination after
death, let him do it, and explain with all clearness the nature of
that evidence to the friends of the patient, and, if necessary, to
the community. At the same time, he should avoid joining in with the
popular disposition to ascribe death to the treatment pursued as a
matter of course, whether the proof be or be not satisfactory.[28]
There is no doubt that death is frequently the consequence of bad
practice, when it cannot be proved to be so; but not even the quack,
murderous as his course certainly is, should be condemned upon faulty
and defective evidence.
FOOTNOTES:
[25] The above remarks may be applied to an exclusive system quite
popular just now—I refer to Hydropathy. Cold water is a valuable
remedial agent, used both internally and externally, as the recorded
experience of medical men abundantly proved long before Priesnitz
appeared on the stage. But the indiscriminate and exclusive use of
it, which is prescribed by his system, is as bad practice as the
indiscriminate and exclusive use of anything else—and _a full and
impartial record of Hydropathic practice would show it to be so_.
[26] When an epidemic is prevalent, such a physician instead of
allaying the undue public excitement, as it is his duty to do,
increases it by his very grave and wise air of conversation, and by
his reports of his cases, of which he is apt to have more than his
neighbors, and to be of course very successful in their treatment.
Even when there are only distant rumors of the epidemic, he has
occasion to report to gossiping circles some cases which at least
come _very near_ to being true cases of it.
[27] Dr. Holmes says of this pre-eminently talented and learned
man—“Berkeley died at the age of about seventy; he might have lived
longer, but his fatal illness was so sudden that there was not time
enough to stir up a quart of his panacea. He was an illustrious man,
but he held two very odd opinions; that tar water was everything, and
that the whole material universe was nothing.”
[28] The bare fact that death results is obviously no proof of the
want of skill, any more than the bare fact that a case has ended in
recovery is proof of the possession of skill. But the disposition to
which I have alluded is quite common, and gives rise to many unjust
conclusions in regard to the merits of physicians. Hence physicians
often manifest, in various ways, a dread of having the charge of
cases, which are sure to end fatally. Some, to avoid the imputation
of “bad luck,” as it is expressed, often manage adroitly to throw
such cases off from their own hands into those of some neighboring
practitioner, or some empiric, before death actually occurs.