Physician and patient

by Worthington Hooker

The same may be substantially said of the causes of typhus fever, cholera, scarlatina, &c. Some think that these diseases are caused by subtle poisons, which enter the system in various supposed ways; while others believe that they arise from causes which make impressions merely upon the system, and thus awaken trains of morbid action. Whatever may be our opinion on these disputed points, the fact that there is so much secrecy in the operation of morbific influences, must, it is clear, make much of our knowledge of disease uncertain.

If, then, there be so much ground for difference of opinion in regard to the nature of the causes of disease, and their mode of operation, where the results are of so definite a character, as we see in the disorders to which I have alluded; much more is this the case with those diseases, which, with their Protean shapes, make up a large proportion of the maladies that call for the daily attention of the physician. These do not commonly spring from one cause, but from many causes concurring together, some of which may be ascertained, while others are only suspected, or are wholly concealed from the most scrutinizing investigation. Under these circumstances, the physician has a difficult task to discover the actual condition of the patient. It would be a comparatively easy one, if he knew what all the agents were that had combined to produce the disease, even though they were numerous and complicated in their operation. He could then thread out with some success, the trains of morbid action, and, perhaps, give to each cause its proper place in his estimate of their agency in causing the disease. But, in some cases, he knows but little of the nature and mode of action, even of those agents, whose influence he can perceive: and then, there are some quite as important, which act in entire secrecy, developing results that cannot be foreseen, and that cannot be calculated upon after they have made their appearance. Such developments are often observed in the progress of disease, and necessarily embarrass us in its treatment. They sometimes completely alter, either gradually or suddenly, the whole character of the case; and yet they may be the consequences of causes, which have been secretly, but surely, doing their work from the first onset of the disease. In some cases, which were in the commencement comparatively mild, a group of severe symptoms all at once start up, exciting astonishment and alarm in the mind of the practitioner. Sometimes there are precursors of the full development, half showing themselves, and the watchful physician may discover in them the coming storm, long before the indications are manifest to the common observer. Even after convalescence has, to all appearance, fairly begun, and the symptoms seen during the progress of the disease are gone, some new symptoms may appear—the upshot of a train of morbid influences, which had been all the while imperceptibly advancing to this result; just as I have seen a fire, supposed to be extinguished, burst forth like a new fire in another part of the building, to which it had secretly made its way.

It is sometimes impossible to detect the immediate cause of an attack of sickness, even when the transition from health to disease is apparently instantaneous. Take, for example, this case. A gentleman, while quietly sitting in his counting-room, was attacked, as suddenly as if it were from a blow, with a great sense of oppression in the region of the heart, almost arresting the action of this organ, and at once prostrating his strength. No reason could be discovered why this attack should occur at that time rather than at some other. And yet there was some hidden cause, or combination of causes, which, at that moment, did its work; and we know not how long a time a preparation had been going on for this consummation, and so silently, too, as to occasion no disturbance.

The physician often finds, on making his first call upon a patient, that although he may think that his attack is only a thing of to-day, there is evidence that disease must have been preying upon his system for some length of time, gradually extending its ravages, till, at length, it has made a palpable outbreak. The patient may attribute his sickness to some one cause; but there have been many causes uniting together, one after another, and swelling the still current of disease, which has now broken forth as a flood.

And, as a general rule, the longer this preparation has been going on, the more obstinate does the physician expect the case will be, and the more difficulty does he find in getting a definite knowledge of the nature and extent of the malady. And if he could always trace every train of disease up to all its sources, both original and tributary, he would often be obliged to go back weeks, months, and sometimes years. In some cases, such an exploration would lead him through almost endless labyrinths. As it is, he often finds, in attempting such a search, that those facts which are the least material in the eyes of the patient, and which may be overlooked by him in giving the history of his case, reveal, far back in the distance, causes which have had more influence than any other in producing this result. A sort of cross-questioning, and that sometimes of a rigid character, is often needed, to develop material facts. The patient’s own story, without such questioning, would generally give to the physician very erroneous ideas of his case.

The remarks that I have made apply with greater force to chronic than they do to acute diseases. For in them more especially, as you have already seen, does the sympathy which exists between the different organs extend and complicate the morbid condition, and the operation of unseen causes contributes, sometimes very largely, to this result.

Many chronic cases become exceedingly complex, and therefore obstinate, from the course which the patient takes with himself, before he comes under regular and systematic treatment. Perhaps, first, he goes through with domestic medication, and then takes patent medicines, recommended to him by kind neighbors, or blazoned forth in the newspapers. Then he tries some vaunted system—Thompsonism, or hydropathy, or homœopathy, or chrono-thermalism, or perhaps all of them in succession. After going through all this, unless some one of these measures chance to benefit his case, (as anything may chance to do it), he at last comes to a physician, and puts himself under his care. The case which was, perhaps, sufficiently complicated in the beginning to require strict investigation, is now rendered, by all this variety of practice, very intricate. The difficulty in understanding it lies in the varied effects which the different agents brought to bear on it have produced—effects, which, in the retrospect, it is almost impossible to estimate with any correctness, because the physician has only the history given him by the patient, and the appearance of his present symptoms, to guide him in making up his opinions. If he had himself seen the case in its untouched condition, and then had witnessed the operation of the different remedies, he would have been better able to arrive at satisfactory conclusions. A chronic case, in its best estate, needs to be watched for some little time, in order to acquire a just and thorough knowledge of its character. And when it has gone through a series of processes at haphazard, with no intelligent eye to observe it, it is no wonder that its condition should become a complicated and puzzling one. The physician, with such a case before him, is situated very much as the chemist would be, into whose hands should be put a mixture which had been experimented upon over and over again by different chemists, and those, too, who were ignorant and bungling. And as you would not demand of him, that he should arrive at once at definite results in examining the composition of such a mixture, but would give him time to apply various tests to it, so it should not be expected of the physician that he should fully understand at once a case which has been dabbled with by ignorant experimenters, one after another; but time must be given him to watch his tests, that he may see them bring out to view its real character and condition.

It must be obvious to the reader, that those who go through this round of experimenting, before they put themselves under the care of an intelligent physician, not only lose valuable time by so doing, but generally inflict upon themselves positive harm. The remedies which they have used, if they have had no good effect, have helped to fasten the disease upon the system, and have increased its severity. They have done this by irritating the system, and, of course, the diseased organs, and by extending the complaint far beyond its original limits. You have seen that, through the sympathy existing between different organs, disease becomes extended and complicated. Well-directed treatment has a tendency to prevent this extension of disease: mere blind experimenting, on the other hand, is apt to promote it; and if it does not have this effect, the patient is very fortunate.

3. I pass now to the consideration of the third class of causes which render medicine an uncertain science, viz., natural changes, arising from the tendency which exists in the system to throw off disease, appropriately called the vis medicatrix naturæ, or curative power of nature; and, in connection with this, the tendency to a definite limit, which is manifest in many diseases, as, for example, small pox, measles, hooping cough, scarlet fever, &c.

To recur to our chemical illustration. I have said that it would add vastly to the uncertainty of the results of the chemist’s experiments, if the retort, into which he puts his substances to be experimented upon, could itself act upon these substances, and thus modify their action upon each other. The body of the patient may be considered as the physician’s retort, and the diseases and the remedies introduced, as the materials contained in it. Under this head we are to examine certain principles which reside in this retort, and which have a constant and important influence upon diseases and their remedies, modifying, sometimes manifestly, and sometimes secretly, their action upon each other.