Physician and patient

by Worthington Hooker

FOOTNOTES:

[2] The terms chronic and acute it may be well to define for the benefit of some of my non-professional readers. An acute disease is one which runs its course in a short time. A chronic disease, on the other hand, is one which has a long duration. For example, pneumonia, (commonly called lung fever,) is an acute disease of the lungs, while consumption is a chronic disease of the same organ. The term, acute, has reference to the violence of the symptoms of the diseases to which it is applied, rather than to their duration; while its opposite term, chronic, has reference to duration only. Use, however, has given them a technical sense which is not liable to be mistaken.

[3] This subject may be found fully illustrated by Dr. Bigelow in the Annual discourse for 1835, before the Massachusetts Medical Society.

CHAPTER II.
SKILL IN MEDICINE.

The uncertainty of medicine is often most unjustly made to give a free license to blind experimenting. It should the rather stimulate to the most careful and searching observation of all the doubtful points of the case in hand, so that whatever of experimenting may be necessary, shall be as rational and intelligent as possible. This leads me to remark, that the views, which we have taken of the uncertainty of medicine, show us in what real skill in the practice of the medical art consists. It consists in appreciating the actual state of the patient in all respects, and then applying such remedies, and in such quantities and forms as will do the greatest probable amount of good. This is apparently a very simple proposition. But if we consider it in all its bearings, we shall find that more is included in it than at first sight appears. I will therefore dwell on some of these points in the order in which they are suggested to my mind.

Appreciating the true condition of the patient does not consist merely in finding out the seat, the nature, and the amount of the disease. This is exceedingly important, it is true. But it is by no means all of the case. Sometimes it is but a very partial view of it. For example, suppose that the patient has an inflammation of some organ, and to make the case stronger, let it be a chronic inflammation. In chronic diseases, as you have seen, there are extensive results from sympathy and from the action of concurrent causes in different parts of the system. The physician, in investigating such a case, in order to proportion his curative measures with any accuracy to the ends to be accomplished, must look beyond the main disease, and take into view the whole case, the state of the different organs, and the state of the system as a congeries of organs.

A disregard of this important point is very common, and leads to many errors in practice. Let us look at a few of them.

Many physicians are disposed to consider the morbid state of the system in almost every case as arising from disease in some particular organ. They therefore, in examining the symptoms, search for this disease; and when they think that they have found it, they refer to this, either directly or indirectly, all the phenomena which the case presents. In their treatment of the case, therefore, they direct their remedial means principally to the local disease. They lose sight of the fact, that often there are several organs simultaneously affected, and that the organ which seems to be most diseased is sometimes found to be less so than some other organ, which exhibited no marked signs of its morbid state. They forget too another important fact—that the disease of an organ is often a mere result of a general bad condition of the system. If in such a case the physician considers the local disease the main thing to be attacked by remedies, and directs his efforts to that point, he commits a great error. And this is an error which occurs, I have no doubt, very often in regard to the most common of all chronic complaints—consumption. The local disease is a result, and not a cause, much more often than is generally supposed, even by physicians.

Some physicians acquire exclusive and narrow notions of disease, by having their attention particularly directed to the diseases of certain organs. They get a sort of attachment to some localities in the system, and are disposed always to look to their favorite quarters in their search after the seats of disease. With such an inclination it is no wonder that they often suppose an organ to be the seat of fixed disease, which is merely sympathetically affected.

An undue attachment to certain modes of investigation, to the exclusion of others, is also frequently a source of error. I mention as an example a too implicit and exclusive reliance upon what are called the physical signs of disease. Percussion and auscultation are valuable sources of evidence, but when they are relied upon to the exclusion of other sources, as is often the case, they lead to error. Some who have attained to a high degree of skill in the use of the stethoscope, have on this account sometimes adopted very erroneous conclusions, which might have been avoided by a careful examination of all the sources of evidence in the case.

Having pointed out some of the errors produced by narrow and exclusive views in the investigation of the symptoms of disease, let us now attend to some of the errors which result from this cause, in the application of remedies.

A remedy may be applicable to a disease which the physician finds developed in a given case, but there may be some condition of some organ, which may render it wholly inapplicable to that case. For example, in a case of inflammation of the lungs, the state of the stomach may be such as utterly to forbid the use of some remedies, which would otherwise be proper. If they be administered in spite of this circumstance, they may perhaps produce a beneficial effect upon the inflammation, and yet may do a great injury to the patient, perhaps even a fatal one, by their direct effect upon the diseased stomach. Errors of this kind do often occur in the practice of those who observe inaccurately, or who have fallen into a sort of routine of practice from disinclination to mental effort.

The general condition of the patient sometimes fails to be appreciated by the practitioner. He may be pursuing a course which would be admirably adapted to cure the same disease in a more vigorous patient, and yet in the case in hand it may be ruinous. Though it may relieve and even cure the disease, it yet may destroy the patient. The judicious physician in some cases feels obliged to let morbid processes go on, because the violence which must necessarily be done to the debilitated system by the attempt to arrest them, would put the patient’s life in greater jeopardy, than it would to let them have their course. Questions frequently arise on this point, which tax the physician’s skill and judgment to the utmost. Even when it is proper to moderate the activity of a diseased process, it is often a very delicate point to determine just how far this can be done without doing harm to the patient. Fever is often moderated by means that irritate the system, or prostrate its powers to such an extent, that bad results, sometimes fatal ones, occur; when, if these means had been used less largely, or perhaps even if they had not been used at all, a recovery might have taken place.

Sometimes fearful issues depend upon the decision of the physician. For instance, here is a case which has been going on for some time without giving much occasion for anxiety; but all at once it assumes a new aspect. A new set of formidable symptoms have come on, requiring an entire change in the treatment. A variety of perplexing questions now arise in the mind of the physician,—such as these. If the attempt be made to remove the new symptoms, how much reason is there to fear that that attempt will so affect the debilitated patient as to destroy life? Severe as the symptoms are, is there a probability that, if a mild course be pursued, the patient may weather the storm? Will he certainly die if the symptoms are left to go on without any attempt to arrest them? And if so, what measures will probably arrest them with the least amount of risk to the patient’s life? Such are some of the momentous questions which press upon the physician’s mind; and, though he would like time to give them a patient examination, he cannot have it; for there is necessity for immediate decision and action. The reader can plainly see, that in order to decide such questions under such circumstances properly, great comprehensiveness and concentration of thought, and a cool and clear judgment, are requisite; and that a mind of narrow views, and loose habits of observation and reasoning, must often fail to come to a right decision of them.

Some, in such circumstances, amid all the uncertainty that beclouds this nice balancing of probabilities, will doubt and doubt, till the time in which anything effectual can be done is past by; and the patient dies without having a single intelligent effort put forth to save him. Others, in their confusion of ideas, pursue a vacillating course—at one moment inefficient, at another destructive; and no rational and steady plan is adopted. Others still, without waiting to consider the different questions which I have mentioned, see in the new group of symptoms nothing but a new enemy to be attacked, and plunge, at once, into the fight. A reckless course is entered upon, which must either kill or cure.

The truly judicious physician, in contrast with all these, is neither bewildered nor precipitate. He takes a rapid view of all the circumstances of the case, and looks carefully at the important and perplexing questions which start up one after another in his mind, and then decides intelligently, coolly, and definitely upon his plan of treatment. He may err, it is true; but if he does, it is not his fault, for he has made use of all possible precautions to prevent error. The plan which he fixes upon, he does not pursue obstinately, as being, without a doubt, the best. While it is that which he believes to be the best at the time, he watches its progress, and if he see reason afterward to alter it, he does so. Aware of the uncertainty of his knowledge, while he decides at every step what it is best to do, he is ready to reverse that decision, and change his course, whenever any new development in the case shall call for it.

Sometimes he decides that it is best to wait and watch the movements of the case. Many seem to demand that he shall pursue an active course of treatment all the time, to conquer the disease—that he shall be keeping up a constant cannonade upon it from beginning to end, not reflecting that if he do so, many of his shots must be worse than lost. And some physicians yield to this demand, and pursue this destructive course. The public call them bold practitioners; and they do gain some apparently splendid victories over disease; but if the results of their whole campaign (to carry out the illustration) could be fairly estimated, they would be found not to deserve the reputation for success, which is accorded to them. The prudent and judicious physician, like the prudent and judicious general, fires as few random shots as possible, taking good care, too, that he hit none but enemies—husbands carefully all his resources—rests from his battle with disease whenever it is best to do so, maintaining, for the time, a “masterly inactivity”—retreats when he finds his line of movement is likely to prove disastrous—calculates probabilities as accurately as he can at every step, and endeavors to make every measure tell upon the great result, avoiding, as far as possible, those which will not, and especially those which will hinder or defeat it.

Sometimes the physician finds that he must be satisfied for the present with but a partial view of the case before him. He sees that there are some agencies at work, which are hidden from his view. Under such circumstances, while the careless and adventurous practitioner makes up his theory of the case confidently, and acts upon it, supplying what is not known from his own imagination, and mingling all together in one confused mass; the judicious physician, on the other hand, cautiously distinguishes between what he actually knows and what may be supposed, acts upon this knowledge, and watches for farther developments to clear up what is doubtful. He treats the case according to the indications of the presenting symptoms, carefully scrutinizing the effects of his remedies. Perhaps he succeeds in cutting off at first some of the tributaries of the disease; and, by so doing, patiently and perseveringly, he at length comes at the main disease—the starting point of the whole case.

In pointing out the characteristics of medical skill, allusion was made to the quantities and forms in which remedies are administered. These must, of course, be varied to suit each individual case. Sometimes a very nice adaptation is necessary, especially in regard to quantity. A remedy, which is appropriate to a case, may be given in such a quantity as to be injurious. The use of a medicine may be continued too long. It may have accomplished all the good that it can; and the continuance of it will do harm, perhaps even beyond the undoing of all the good which it has effected. Sometimes a change occurs in the condition of the patient of such a character, that a remedy, which has been up to that time beneficial in its influence, will now produce bad results. Medicine is often continued under such circumstances. Such are some of the errors to which the physician is liable in regard to the quantity of medicine to be given, if he be at all loose in his habits of observation.

Perhaps there is no one thing in medical practice in which failure is so common, as in the accurate proportioning of remedies to the condition of each case. A physician may discover very clearly the nature of the malady, and decide with great correctness upon the appropriate medicines, and yet, may err after all in applying these medicines in the proper amounts, and at the proper intervals. The variations, in these respects, required by different cases, have a wide range—some demanding large doses to produce the needed effects, and others being strongly affected by small ones. In some cases of severe pain, for example, very large doses of opium in some of its forms are necessary to give relief; while, in other cases, in which, perhaps, the pain is by no means slight, quite small doses accomplish the purpose. Similar variations in the quantities of remedies, are required by other circumstances, which are less obvious in their indications on this point, than so palpable a symptom as pain is. The contingencies on which these variations depend, are often, indeed, so uncertain and so secret, that they elude the most watchful and patient investigation, much more that which is hasty and careless.

Experience gives to the shrewd and judicious physician a sort of tact in detecting these contingencies, and in so modifying his practice as to meet with some good degree of fitness the various indications which they present. This tact is to be acquired at the bedside of the sick, by patient watching of the workings of disease, and of the influence of remedies upon it; and though the experience of others is a valuable auxiliary in acquiring it, it is only an auxiliary, and cannot communicate it alone. There are a thousand little things that are observed in watching disease from day to day, which materially influence the physician in the details of his treatment, but which it is impossible to record in the history of the case. It is therefore peculiarly true of the wise and skillful physician, that when he dies much wisdom will die with him. And the student of medicine always finds, when he comes to actual practice, that disease, in the sick chamber, is a very different thing from what he supposed it to be when listening to descriptions of it in the lecture-room. One of the first lessons that he learns is, that the long troup of maladies, arranged in the syllabus of the professor, gives but a faint idea of the various and Protean shapes of disease, as they appear before him, in all their complications, with mingled and confused lineaments, instead of the distinct ones with which they are necessarily described in books and lectures. He sees that the general principles which he has learned, are to be applied with almost endless variations; and that a searching and ever-vigilant observation is needed to apply them aright.

The points which I have endeavored to elucidate, in regard to skill in the management of disease, are very commonly disregarded by the community, and too often even by physicians. To impress them more vividly upon the mind of the reader, I will resort to an illustration, in which some of the same principles are applied to quite a different matter.

Two travellers are wending their way through a mountain-pass to their home. Their path is a perilous one; now lying along on the very brink of a precipice, and now across a succession of points of rock, with an abyss yawning below. Often the foothold of the traveller is but a slight one, and would scarcely suffice were there not some shrub near by that could be caught hold of, or some projecting point of rock on which he could hook his fingers. One of the travellers is weary and sick, and the other is helping him along. The shades of evening have come on, and the flying clouds occasionally obscure the light of the moon that shines upon their path.

It needs a watchful eye, a strong arm, and a firm foot, to go through this pass with safety, even by broad daylight. How fearful, then, are the dangers that threaten the sick traveller? If he were alone, he could not possibly get to the journey’s end. He would fail to reach some foothold, or would let go his grasp upon some shrub, or totter from some giddy height, and be dashed to pieces. His companion sees the difficulties of the task before him, and bidding the poor sick man to be of good cheer, nerves himself for labors that will tax all his strength and all his skill.

See how varied is the assistance which he renders! Now he is before, with outstretched hand raising him up; and now behind, doing the same office, while the feeble man clings to some branch, or to some projecting point of rock. Now you see him gently supporting his tottering steps, as he leads him slowly along a narrow path on the edge of a precipice, where, if he but stumble, he is lost. The effort is now but a slight one; but it requires caution, firmness, and skill. And now there is needed a strong, almost an Herculean effort. He must raise him to the top of a rock just large enough to stand upon, and there let him rest a moment, so that he may step carefully to another rock which offers a secure resting-place. He pauses before making the effort, to calculate with precision the amount of force needed. He sees that if he come short of raising him to the right spot even an inch, his feet may slip, and he is gone. And on the other hand, if he use too much force, he may throw him too far, and then he will plunge over beyond. His courage almost fails him, as he sees the fearful issues—the issues of life and death, that hang on that one effort. But it must be made. Uttering the cheerful words of hope in his companion’s ear, with his whole frame roused to its utmost tension, he makes the attempt. The poor man’s feet just reach a jutting edge of the rock, while he catches with his fingers upon another projection, and there he hangs. His strength is almost exhausted; but he knows that if he lets go he is lost. His friend presses his feet fast to the rock, and tells him to hold on. Then finding some foothold by which he can raise himself a little higher, he lifts his sick companion gently to the summit. There he remains a few moments, trembling, and almost poised upon a point, fearing to move, or even to look down from that giddy height, lest he should slip off. But soon, with the little rest that he gets in this perilous situation, and encouraged by the firm and cheerful voice of his friend, he steps to the next rock, where a broad and sure foothold enables him to pause and recover his little strength, which was well-nigh exhausted by his anxiety and his exertions.

The path is now an easy one for some distance, but soon they are confronted by a high crag, up which they must clamber. It looks gloomy and formidable in the dim and fitful light of the partially-obscured moon. The sick man’s heart almost dies within him, as his companion eyes narrowly the small footholds which are notched up its steep side. Some of them he sees but faintly; but soon the full light of the moon, through the breaking clouds, shows him every notch with distinctness. He calculates their distances in a moment, and as his eye runs upward to the top, he plans out the whole of his ascent. In an instant he seizes his friend; and, again bidding him be of good cheer, tells him to place his foot in the first notch, then raises him gently, but firmly, to the second, and so on to the summit.

It is thus that the sick man, aided and cheered by his friend, after going through with many narrow escapes, at length reaches his home.

The points of resemblance between this journey and the journey of sickness, are sufficiently obvious to suggest themselves at once to the minds of my readers. The journey of sickness has sometimes the same variety of peril, and demands of the physician the same variety of assistance, to suit its various stages and conditions. His efforts, in rendering this assistance, must sometimes be strong and sometimes gentle; sometimes bold and sometimes cautious; always careful and never precipitate. The uncertain and varying light, shining upon the path of the traveller, has its counterpart in the journey of sickness; and sometimes the darkness is so great, that the physician must stop short, and not move at a venture amid such perils. There are times, too, when the light breaks through the clouds of uncertainty that hang over his path, and his eye must be open and ready, as was the traveller’s, to discern all that the light may reveal of that which lies before him.

Often, in most of the journey of sickness, a gentle, but firm support and guidance are needed, on the part of the physician, just as it was in the case of the traveller, when the path lay along the edge of a precipice; and here, in the one journey as well as in the other, an officious and hurrying assistance might prove ruinous. Then there are times (and fearful times they are) when the physician sees, as did the sick man’s companion, that while mighty efforts are required of him, even a slight error in regard to the right proportion in those efforts, may prove fatal. And, as the traveller found occasionally some broad and sure resting-place, where his friend could recruit his wasted energies after a severe effort; so in the journey of sickness there are such resting-places, and the physician must take care to give his patient the benefit of them, and not run the risk of an entire exhaustion of his powers, from too much anxiety to hasten to the journey’s end.

One more point of resemblance, and one which I deem of no small importance, I will barely notice. As the sick man, in all the way through the mountain-pass, was encouraged by his friend, so should the physician cheer his patient with his hopeful voice and manner, amid all the gloom and peril of the journey of sickness; and should hold out to him, in all seasons of despondency, so far as truth will allow him to do so, the hope that he will at length reach the end of that journey in safety.

CHAPTER III.
POPULAR ERRORS.

My intention in this chapter is to notice some of the popular errors, which have resulted from the uncertainty of medicine.

One of the most common of these errors is a false estimate of the importance of positive medication. This error appears in a great variety of forms. I will notice a few of them.

A patient once avowed to me the opinion, that in all cases of recovery from sickness, the recovery is to be attributed to medicine, and that nature never cured anybody of anything that could properly be called disease. Though this error is seldom carried to such a point of ultraism as this, it does exist, to a great extent, even in the medical profession, and it is exceedingly prevalent in the community at large. It therefore exerts a great influence upon the popular modes of the treatment of disease.

One of the most common examples of this false reference of a curative result to the agency of medicine, is to be seen in the prevalent popular notion in regard to the healing of wounds. The cure in this case, is usually attributed to some healing property in the applications made to the wounds. But the truth is, that the union of the divided parts is effected entirely by a natural process; and the only use of any applications, is to put the lips of the wound in apposition, so that this process may be effectual in securing this union. The popular error on this subject, is not as prevalent now, as it once was, and the array of salves and ointments for the healing of wounds, is fast passing away. At a time when this error was in full favor with the people, some one broached the idea, that the medicaments ought to be applied to the instrument that inflicted the wound, instead of being applied to the wound itself. This new mode of practice proved successful in comparison with the old, for the plain reason, that the wounds thus treated were not subjected to applications, which would irritate them, and thus interfere with nature’s process of healing. It acquired a great reputation all over England, and I believe, in other countries also; and the results of the practice were triumphantly referred to as proofs of its success, that were not to be gainsayed. It is related that in one case, in which the wound became very painful, it was suggested that something might have happened to the axe with which the wound was made, and which had therefore been duly anointed with a healing salve; and as the axe happened to be at some distance, a messenger was sent in great haste, who found that it had fallen down from its place, and the dressings were consequently deranged. Here was certainly the cause of all the pain, and accordingly it was ascertained, that at the very time that the messenger re-applied the salve to the axe, and set it up in its place, the patient became perfectly easy![4]

As another very common example of an undue disposition to refer results in the course of disease to positive medication, I would mention the fact, that those who have the care of the sick, often attribute any change that may occur, whether it be favorable or unfavorable, almost as a matter of course, to the remedy that was administered immediately before the change took place. They do this sometimes when the medicine has not had time to produce any effect at all. They do not reflect that some remedies act much more slowly than others, nor that changes are often induced by other agencies than the action of medicine. This error is met with every day, and the cunning and dishonorable physician makes capital out of it whenever he can. A physician of this character was once called to a case of quinsy, in which the abscess in the throat was just ready to break. Perceiving that here was a fair chance for making the “post hoc, propter hoc” mode of reasoning subserve his purpose, he assured the suffering patient that he had some powders, which were “sure to break the quinsy.” While he was preparing some of them in an adjoining room, the nurse came out and told him that they should not need his powders, for the quinsy had broken. The wily doctor could not help remarking in an undertone to a student, whom he was indoctrinating in the arts, as well as in the science of medicine, “I wish that I had been lucky enough to have got down one of my powders before that quinsy broke.”

When one recovers from sickness, it is very common for his neighbors and friends to inquire, what it was that cured him—as if there was some one remedy that effected the cure. It is true, that in some cases, the agency of some one medicine is so prominent, that it may very properly be said to have been the cause of the recovery. But this does not often happen. In the great majority of cases, the cure is to be attributed to the whole course of treatment, including many different remedies and measures.[5] And very often the negative portions of the course are of as much importance as the positive remedies that have been given, perhaps even more so. Thus, in some cases of inflammation of the eye, the exclusion of light is as necessary to the cure as the leeching, the blistering, &c. So also in inflammation of the brain, the exclusion of noise and excitement from the room of the patient, is as essential as any of the positive medication which may be employed.

The undue reliance which is placed upon positive medication is also seen in the disposition, which is so very common, to demand of the physician, that he shall be doing something all the time to overcome the disease. They who make this demand, do not reflect, that in the warfare with disease, as well as in every other warfare, there are times to do, and times also to rest from doing. In some cases, indeed, there are periods when it would be certain death to the patient to employ any positive agencies of any amount, of power. It was the remark of a shrewd old physician, who was often found fault with for giving so little medicine, that it takes as much knowledge to know what not to do, as it does to know what to do? This is an important truth; and I have not a doubt that, in the practice of every physician, who is disposed to give much medicine, sickness often results in death in really curable cases, simply because he did not know what not to do, and therefore did what he ought to have left undone. And yet those who drug their patients freely, are more apt to satisfy the mass of the community, than those who place less reliance upon positive medication. The friends of persons who have died, often remark, as a matter of consolation, that they are sure enough was done, that no means of relief that was suggested was left untried, &c., not seeming to dream that it was possible that too much was done. It appears sometimes to be the idea of the friends of the sick, that one remedy after another must be tried, in order to overcome the disease, until the effectual one is found; and that all the remedies which fail in this trial, simply fail, and do no positive harm. Accordingly, when any grave case occurs, they are disposed to call in many physicians, one after another, with the idea that “one may think of something that another did not.” And they are satisfied with no one who is thus called in, unless he recommend to the attending physician some medicine or measure, that has not yet been tried in the case. If he recommend the lessening of some medicine in quantity, or the discontinuance of it, this does not satisfy such persons, though the change may be of so great importance, that it may be justly considered as an entirely new course of treatment—as really new as it would be, if a new set of remedies were adopted.

It is a very common idea, that medicines have a sort of natural relation to disease. This idea appears in different forms. Some talk about disease as if it were a palpable thing, which is to be attacked, to be hit, to be driven out, or drawn out from its hiding place; and they suppose that there are certain remedies which are calculated to effect these different objects. They therefore speak of the drawing off of “bad matter,” by a blister, and of the “bad blood,” which is taken from one by bleeding, as if the disease itself in palpable shape, was abstracted in these ways from the system.

The most common of these palpable shapes which disease is supposed to assume, is that of “humors,” as they are termed in popular language. The disappearance of a “humor” is the effect quite as often as it is the cause of disease; and yet it is very difficult to make people understand this—they persist in thinking it always to be a cause. So also, if a patient, on recovering from any sickness, has some eruption appear upon the skin, it is taken for granted, that it was this “humor” that has been inside all the time, which has caused all the sickness; and now that it has ceased to play its pranks among the internal organs, and has come out, the patient as a consequence gets well. It never enters their minds, that the eruption may be simply a result of that revival of the energies of the system, which is consequent upon its escape from the depressing influence of disease.

This idea of the palpable shape of disease gives rise to the popular error, which is so prevalent, in regard to the necessity of getting out all the eruption in such diseases, as scarlet fever, measles, &c. The idea is that there is a certain amount in the system, and that this must all be brought out upon the skin, or the patient will suffer some bad consequences from this retention of morbid matter. This notion is entirely erroneous. The eruption in such cases is not the coming out or throwing off of diseased matter contained in the system, but it is merely one of a succession of processes in the natural course of the disease. It is indeed necessary that this process should be well executed, and if the natural energies of the system do not prove adequate, they should be assisted by medicine. But ordinarily they are adequate; and in comparatively very few cases, is there any need of any assistance from art in bringing out the eruption. Most of the dosing so common in scarlet fever and in measles, for this purpose, is worse than useless—it aggravates the symptoms, multiplying and inflaming the eruption beyond the necessities of the case, and it increases the complications which are incidental to it. Death is often the consequence of such officious interference with nature’s regular processes.

Some talk about disease as if it were a poison, whose power can be destroyed by the appropriate agents, very much as an alkali neutralizes an acid. All medicines which do not have this neutralizing influence are, in their view, mere palliatives. It is this idea which lies at the foundation of the opinion, so often expressed, that opium never cures any real disease, but merely gives temporary relief. No opinion can be more erroneous than this. Opium, in its various forms, is one of our chief means of curing disease, as well as of alleviating its sufferings. It is an effectual remedy for many painful affections. For example, it is the great remedy for spasmodic colic. There are auxiliary remedies, which can be used with profit, it is true; but after all opium is the chief remedy. And in the great majority of cases of disease, with which the physician meets in his daily practice, opium materially assists in its cure, by soothing and quieting the irritation of the system, so that the curative power of nature (the vis medicatrix naturæ, of which so much was said in my first chapter), may pursue undisturbed and without hindrance, her processes of restoration.

Another error, to which this idea of the neutralizing influence of medicines gives rise, is this. What is found to be useful in any disease is supposed to be so in all cases of that disease. If a remedy be “good” for a certain malady, fever for example, it is apt to be considered as being “good” in all cases of fever, without regard to circumstances. There is a great proneness to suppose all cases of one disease to be alike, and to require therefore similar remedies. The physician finds it difficult often to make people understand that two cases, in which the disease bears the same name, may require very different, and perhaps almost opposite modes of treatment. The accompanying circumstances of disease vary so much in different cases, that this supposed invariable relation of particular remedies to the cure of particular diseases is impossible. This remark applies even to our most efficient remedies. Colchicum is one of the most effectual remedies which we have for rheumatism; and yet there are many cases of this disease, in which its use is forbidden by the condition of the patient.

The idea, that medicines have a kind of natural relation to disease, assumes sometimes a more definite shape than either of those to which I have alluded. Some suppose that almost all, if not all, diseases have their specific remedies and antidotes. It is often said by those who have this idea, that there are medicines in the plants that grow in any country, which can cure every disease that prevails in that country, if they could only be found. Indians and “Indian doctors” are supposed to know of many of these specifics. The newspapers announce too occasionally the discovery of specifics for the most formidable of diseases, consumption, cancers, hydrophobia, locked jaw, &c., &c. These announcements are accompanied sometimes with statements of cures of the most positive character. No doubt the statements are correct in one respect—the patients recovered. So were the wounds healed when the ointments were applied to the instruments that made them. In some way these specifics after a while lose their reputation. There is a constant succession of them, all equally infallible for the time, but the period of their infallibility is short. Their reputation is built upon the “post hoc, propter hoc” mode of reasoning, and therefore does not stand the test of any continued experience.

In order that this subject may be fairly understood by my readers, they should know what we mean by a specific remedy. A specific remedy for a disease is one which will cure that disease under all ordinary circumstances—that is, when there are no circumstances in the case, apart from the disease, which tend to prevent the cure. Many doubt the existence of any specifics at all. If there be any, they are certainly very few in number. Sulphur and some mercurial preparations, as remedies for Psora (itch), and some other cutaneous diseases, have as strong a claim to be considered specifics as any medicines that can be mentioned. Iodine has been said to be a specific for scrofula, but it by no means holds good its claim. Though tuberculous consumption is a disease of a very definite and specific form, no specific remedy has been as yet discovered for it, and probably none will ever be, though Dr. Rush and others have indulged the pleasing hope that some plant may yet be found that will arrest the ravages of this disease. I would remark in this connection, that there is one specific preventive. I refer to vaccination as a preventive of small-pox. But this fact stands entirely alone—there is no other fact like it.

The physician is continually meeting with evidence, that the community generally have no adequate ideas of the necessity for discrimination in medical practice. He is every day called to patients, who tell him that they have taken some patent pills, or perhaps some pills which they chanced to have in the house, and which they supposed must be “good,” as they express it, though they may not know where they came from, or what they are commonly used for; and this is done by many, without regard to the kind of malady under which they are suffering. All cases must first be dosed by pills, to which they attach this general idea of being “good;” and then, if they do not hit the disease with this random shot, they send for the doctor, not however with the belief, that his shooting will be any less at a venture, but because he may have a greater variety of ammunition.

One of the strongest evidences that the community have a very imperfect conception of the varieties of disease, and of the necessity of accurate discrimination, is the propensity to look for some one grand remedy for all diseases. This propensity is exceedingly common, and exists in every variety of degree. Some, I may say many, have the full belief that there is such a remedy, and try every vaunted medicine that comes along, in their search after the great catholicon, or elixir vitæ. Disease they suppose, in the language of quacks, and we may add of some physicians also, to be an unit, and the remedy for it must therefore be an unit also. Others, (and these form a large portion of the community,) while their ideas are less distinct and exclusive, are still governed in a great measure by this same prevailing notion. They have some favorite remedy, which they use for complaints of almost every kind. The remedy may not always be the same, and commonly is not. The ‘universal cure’ does not ordinarily last a great while, but is at length supplanted by some other, just as universal, which in its turn, is also to be supplanted. Every year, not to say every month, brings to some people a new grand catholicon.

This propensity does not always show itself in relation to some one remedy, but sometimes leads to the adoption of some system or class of remedies. I mention as an example the Thompsonian system. A certain group of remedies was selected by the founder of this system, from the whole kingdom of nature, as the remedies above all others, if not alone, fitted to attack the great unit, disease. The very idea of discrimination was discarded. The unit was to be attacked with these weapons, and the attack kept up till it was destroyed. No fear was indulged that any harm could be done, for Thompson claimed that his remedies had a natural relation to disease, possessed by no other agents, and that therefore, however largely they might be taken, they could not possibly do any injury. How beautifully simple this system of practice is; and, if its claims be just, what a perfect relief it brings to all the uncertainty of medicine! Away then with all care-worn experience, and all study! Keep up a constant fire of lobelia, red pepper, and steam, and you will certainly kill the disease at last—at least if you do not kill the patient. In the infancy of this system, this idea of its simplicity was more distinctly avowed than it is now, and the remedies that were used were much less in number than they now are. The followers of Thompson are certainly departing from the stern principles of his doctrine, and some of them even begin to talk about the necessity of study—a heresy, one would think, glaring enough almost to start Samuel Thompson from his grave!

It is most impudently asserted by Thompsonians, that physicians generally act upon the same exclusive principles that they themselves do—that while Thompsonians give lobelia and cayenne in all cases, we do the same in regard to calomel, antimony, &c. This is undoubtedly true of some physicians, but it is a gross slander when it is applied to the profession in the mass. The real difference in this matter between Thompsonians and physicians is this. While Thompsonians confine themselves to one particular set of remedies for all diseases, physicians use in their daily practice a great variety of remedies, and among them the very medicines used by Thompsonians. We have never claimed, as Thompsonians falsely state that we do, that lobelia and cayenne are not good medicines, but simply that they are not applicable to all cases, any more than is calomel, or any other remedy that may be named.

The quack shows in his advertisements, that he is aware of the prevalence of the propensity of which I have spoken, and here rests his chief hope of success. He begins his advertisement with something of this kind. Disease is an unit; or, All disease is in the blood; therefore the blood must be purified; or, Grand catholicon; or, Grand antidote to disease; or, The real essence of life at last discovered.

This propensity has shown itself in some measure even among physicians. Enthusiasts in our profession have always been disposed to attribute to favorite remedies, a sort of universality in their operation upon disease. Every new medicine that comes up to notice has almost every kind of virtue ascribed to it by such physicians. And it is only by long-continued and well-weighed experience, that the statements made in relation to any remedy can be sifted, and the real truth be discovered in regard to the degree and extent of its efficacy, and the circumstances which should govern us in its use. This process has been gone through with, in the case of every article of the materia medica that has ever had any notoriety. Take for example, digitalis. At one time, this medicine was in common use in many diseases, and especially in consumption; and some enthusiasts, if they did not go so far as to say that it was a certain cure when used sufficiently early, at least extolled it as almost a specific for this disease. The accumulated and compared experience of physicians in regard to it has at length determined pretty nearly its value, and while it is now used far less than it once was, it is used more judiciously from the more definite knowledge of its effects which this experience has gained for us.

The same remarks could be made about other articles.[6] And while the test of experience has corrected our valuation of some remedies, and thus enabled us to use them with more skill; there are others once supposed to be valuable, which, under the application of this test, have gone wholly out of use. I will mention but a single example. Dr. Beddoes, an English physician of some note, but a great enthusiast, thought that some of the gases might be advantageously used in the treatment of disease. The results were said to be astonishing, and the practice of pneumatic medicine, as it was called, became very prevalent. I find in a work, called Medical Extracts, published in 1799, the narrative of sixty-nine cases of various diseases, said to be cured by the respiring of these gases. Among them are certainly some formidable maladies, such as dropsy in the head and chest, consumption, gout, epilepsy, leprosy, scrofula, &c. Some of these cases had been previously under the care of celebrated physicians, and some had even been pronounced by them to be incurable. A description given by one of the patients, a clergyman, of his own case, almost transcends the descriptions given now-a-days by some clergymen of the effects of some patent medicine, or of the infinitesimal doses of homœopathy.

Now, if the respiring of these gases really did produce these results, or any good proportion of them, the same practice would have been in vogue now. But it has not stood the test of experience, and therefore has been rejected. No physician at the present day thinks of setting his patients to breathing these gases.

If it be said that this is the result of change of fashion merely, and that it therefore does not prove that this practice was not successful, I reply that, though fashion in medicine may sometimes temporarily prevent the use of a good remedy, it never effects the entire and continued abandonment of it by medical men. You will find it always true of remedies and modes of practice which are really valuable, that though they may not be as fashionable after a while, as they were when first introduced into notice, and may, from the fact, that they have been estimated too highly, be for a time undervalued, they will never be wholly given up by the profession. Nearly as great stories were told about calomel and digitalis at first, as were told about the gases of Dr. Beddoes. But while experience has shown that calomel and digitalis were over estimated, it has proved that these gases had an entirely false estimate put upon their remedial powers.

It is thus that the medical profession, corrects by experience the errors into which it is led by the uncertainty of medical science. But the community at large pursue a very different course. They never correct their errors, but only supplant one error by introducing another. While physicians reject what is found by experience to be valueless, and retain what is truly valuable, the multitude reject alike the good and the bad, in making their constant changes from remedy to remedy, and from system to system. It is mere caprice, and not a careful discrimination, that leads them to throw aside one favorite medicine or system, and adopt another.

It is amusing to watch the movements of the community in relation to quack medicines. Of these there are a multitude constantly appealing to the credulity of the public. Some of them in some way, acquire a currency above their fellows, and from the extent to which they are used, and from the tales of their wonder-working from all quarters of the land, and from all conditions of life, one would suppose that these remedies would never go out of use until mankind cease to be sick. But look again, only a few years after, and these vaunted medicines have gone out of use, and the flaming advertisements proclaiming their virtues have disappeared, and other remedies have taken their places in the public mind, and on the public tongue, and of course in the public stomach. This process of change in the prominent remedies before the public, has ever been going on. Take a single example. A few years ago, almost every invalid was swallowing the Hygeian pills, from the pauper that purchased them with his begged pittance, up to lords and ladies, and senators, and generals, and clergymen. But in a short time, Brandreth’s effulgent glory burst upon the earth, and the Hygeian orb faded, and glimmered, and sunk to rise no more. And now Brandreth is rapidly on the decline, giving way to others who are rising to take his place.

These successive changes in popular remedies show, that the public have always been egregiously mistaken, whenever they have attributed to them such wonderful efficacy. Else the very high and extensive reputation gained by each could not have been so utterly lost in so short a time. If, for instance, a tithe of the fame of the Hygeian pills was well founded, the thousands of mouths that swallowed them would not have been, as they were almost in a twelvemonth, just as wide open to receive the magic pills of Brandreth. Either a large portion of the community have committed a great error, in ascribing such marvellous efficacy to these remedies; or they have committed a greater one in so soon discarding them. Either the one or the other of these errors has been committed, in regard to each one of the most popular remedies, that have succeeded each other in the favor of the public, from time immemorial—not one that has not had its decline, as well as its rise, and its acme. And what is remarkable is, that when once a remedy has thoroughly passed from the popular favor, no matter how great its fame has been, it never can be revived again, unless it be under an entirely new name, and with new pretensions. Why? Because it has been tried, and its reputation was found to be a splendid bubble that has burst and fallen. And the public, like the child, when a bubble has burst, has done with that one forever, and busies itself at once in raising another, which, in its turn, is succeeded by another, and so on to the end, if end there be, which seems to be hardly a possibility with the bubbles of quackery.