Physician and patient

by Worthington Hooker

FOOTNOTES:

[22] Some of my readers will require an explanation of these terms. In a case of fracture the broken ends often slip by each other. We draw therefore upon the two portions to bring them into their proper position. The traction exerted upon the portion the farthest from the body is called extension, while that which is exerted upon the other portion is called counter-extension. So when a bone is dislocated the force exerted in drawing the head of it from its position is called extension, while the force by which its fellow bone is drawn in the opposite direction is called counter-extension.

[23] It will be proper for me to state that I had no personal interest in this case, and I became acquainted with the facts in an accidental call upon the family of the patient some time after the accident.

[24] Some of the certificates of the bone-setter, like those of other quacks, are of the most unwarrantable character.

A physician of great eminence was once called to see a clergyman who had sprained his wrist. The sprain was a bad one, and produced considerable inflammation, and therefore gave him great pain. The treatment which my friend pursued relieved the patient, and nothing was wanting but rest to complete the cure. But he very imprudently and in direct disobedience to his physician’s injunctions, drove a spirited horse on quite a long ride with his lame wrist, and of course renewed in some degree the soreness and inflammation. He now put himself under the care of a bone-setter, and after his wrist got well, forgetting the gratuitous as well as successful services of his physician, this clergyman gave the quack a laudatory puff in one of the public papers.

CHAPTER VIII.
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.