Physician and patient

by Worthington Hooker

The fifth class of causes of the uncertainty of medical science remains to be noticed, viz.: individual peculiarities or idiosyncrasies, as they are termed.

Every individual may, strictly speaking, be said to be peculiar to some extent, and there is much force in the popular idea of the benefit resulting from a physician’s being acquainted with his patient’s constitution. But besides these common differences, some have very great peculiarities. A few examples will be sufficient. There are some persons in whom the odor of roses will produce asthma. Ipecac has the same effect in some individuals. Some persons are uniformly made sick by eating strawberries even in small amount. Cases are constantly met with by physicians in which some medicines have a peculiar effect. The various effects produced by opium in different individuals furnish many examples. I call to mind a patient, who though a laboring man of considerable power of endurance, is extremely prostrated by vomiting, by whatever agent it is produced. I once gave him an emetic without knowing this peculiarity. He was so much prostrated, that I supposed that the apothecary had made a mistake, and that he had taken an overdose. But a short time after, I witnessed in him the same effect induced by undigested food, and this revealed the idiosyncrasy in his case.

When idiosyncrasies are known, they can be calculated upon. But they are not always known. We cannot be aware of them when they respect the action of remedies which the patient had never taken. And in relation to remedies which produce no marked and obvious effect, peculiar susceptibilities may exist without being readily ascertained. If there be an idiosyncrasy in regard to such a medicine as an emetic, or an opiate, it is easily discovered. But if it exist in regard to a remedy that acts silently and slowly, it may not show itself clearly. The only evidence that we have of its existence may be the fact, that the medicine after a while is observed to fail in producing the effects which we ordinarily expect from it in such cases. And it may be very doubtful whether this failure is to be attributed to this cause, or to some other.

Let us recur once more to our illustration from chemistry. If the retorts used by the chemist, (which, I have supposed to carry out the analogy, to be composed of materials which would act upon their contents,) were not all made exactly alike, but varied a little always in their composition, and sometimes considerably, and that too without the variation always being appreciable, this fact would obviously still further complicate his experiments, and render them uncertain in their results. So also the peculiarities in the different human systems, which are the physician’s retorts into which he introduces his agents, must have the same effect upon his investigations.

I have now finished the consideration of the various causes of uncertainty in medical science. If I have succeeded at all in making them to be properly appreciated, the reader will agree with me when I say, that there is no science that requires higher talents for its successful investigation, and none that is so liable to wrong influences and conclusions, if the student of it be a careless and credulous observer. Notwithstanding this liability, imperatively demanding caution on the part of the physician, there has been much of careless observation in this science; and the recorded experience of the medical profession is therefore encumbered with a mass of errors. In order to get rid of these errors, and to establish the proper distinctions between the certain and the uncertain, between the true and the probable, while the merely plausible shall be entirely rejected, a judicious sifting and testing of evidence must be resorted to, credulity and skepticism both being equally avoided.

FOOTNOTES:

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

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

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.