Physician and patient

by Worthington Hooker

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.