Physician and patient

by Worthington Hooker

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.