Physician and patient

by Worthington Hooker

In regard to this case it is clear, that if the course which this patient pursued for weeks and months before the final attack, was not adequate of itself to cause such an inflammation, it at least was directly calculated to foster it when it was once begun. And yet, because Thompsonism had never absolutely killed any member of his family, he confided in it most fully, though it was hurrying the disease within him on to a fatal termination; and he let go of that confidence, only when it was too late to retrieve his error. And farther than this, the probability is, that if he had put himself under the care of a judicious physician, when the inflammation had but just begun, it might have been overcome, for cases of recovery from this disease, when early put under treatment, are not at all rare in medical experience.

In the case which I have related, the influence of bad practice was palpable; but even here it was not so during all the time it was doing its deadly work, but only after that work was done. And in most cases in which bad treatment has been ruinous in its results, the evidence is not such, even at the conclusion of the case, as will satisfy the public, at least that portion of it which is inclined to quackery. An examination after death is not always obtained; and when it is, it will not always afford us as clear evidence, as was seen in the case above related, for both disease and medicine may destroy life, without leaving any manifest and undisputed traces of their action, to be revealed by the knife of the anatomist.

If a lawyer make a mistake, for example in framing some instrument, it is readily seen to be a mistake, and definite and known results follow, clearly exposing his ignorance. But if a quack, or a physician, through mistake in the treatment of a case, destroy life, or fail to save it, when it could be saved by the use of proper means, we can very seldom have the opportunity of exposing such ignorance, because as you have seen in the chapter on the Uncertainty of Medicine, it is so difficult to connect effects in the human system indisputably with their cause. Suppose the fatal mistake is manifest to physicians, who happen to know the facts in the case; how can they demonstrate it to the satisfaction of the public? The only undoubted proofs of it are often buried with the patient; and if they are not, but are brought to light, even as clearly as in the case which I have described, the community do not adequately appreciate their value, as the honest and high-minded physician is often pained to find, in his conversations on this subject with even intelligent men. Many a popular and fashionable physician, as well as the quack, is saved by the causes to which I have alluded from any effectual exposure of his ignorance and unskillfulness.

I have said that it is by no means easy to cull out from the mass of cases those in which the treatment must necessarily affect the question of life and death. There are inherent difficulties in the way of doing this. Even the skillful and careful observer may mistake in the attempt to do it, from the fact that the first appearance of a case does not always indicate the amount of disease, nor its obstinacy. While some cases, which appear of a grave character at the outset, turn out to be mild ones, when the disturbance of the attack is once over; those, on the other hand, which seem to be mild, are sometimes found to contain in concealment the elements of destruction. And if this difficulty seriously embarrass the physician in making the selection spoken of, much more then would it embarrass the community.

But there is another still more effectual obstacle, which prevents the public from making this selection with any degree of correctness. It is found in the representations, which are made by different physicians and empirics, of the cases under their care. There is great difference in physicians in regard to the degree of hope which they indulge in relation to their patients. One who is apt to be desponding will, from this cause, make such representations of the cases under his care, as will create the impression, that his patients are much more gravely sick, than those that are quite as sick under the care of another physician, who has a strong tendency to hope. And besides this, some make willful misrepresentations for their own selfish ends. A very common artifice, for the purpose of gaining credit, is to make great cases out of small ones. This is easily done. I will suppose a case. A child is taken sick, and the parents are full of anxiety. The physician sees at once that the case is not at present a grave one, and that remedies will probably in a short time give relief. If he be honest he will say so, and remove the undue anxiety of the parents. But if he be disposed, as many are, to make capital out of the anxieties of his employers, he will say that the child is very sick, and perhaps that ‘it is well you have called me so soon,’ or, ‘I wish that you had called me before, but I think on the whole that the little one can be relieved.’ Every physician knows how readily the imagination of a parent may be excited in relation to the symptoms of disease in a darling child. He has seen things believed to be true, under the influence of such an excitement, which have not the slightest foundation. How easy is it then in such a case to practice deception, or at least to leave the parents to deceive themselves with the figments of their own fancy. If the physician manage adroitly, his skill will be proclaimed with all the zeal which gratitude for a restored child can prompt. How dishonest, how cruel is such a course! For the sake of his own reputation, he has given poignancy to the pangs of anxiety in the bosom of fond parents, when it was plainly his duty to quiet their fears, by telling them the true nature of the case.[26]

The physician who practises such deception is indeed occasionally detected; but if he have tact enough to avoid being often detected, and if he have effrontery enough to face down those who see through his arts, such occasional detection is but a small hindrance to success. In the case which I have supposed, the friends of the physician of course would claim for him, that there really was danger, and that he had the sagacity to see what common eyes could not. And the parents of the child would be very slow to believe that all their fear and anxiety were unfounded. Their pride, if nothing else, would prevent them from admitting this to be true.

The risk of a real exposure of the deception being so slight, it is not strange that selfish and cunning physicians should be so fond of this artifice. Some acquire great skill in the use of it, and contrive by this means to make many tongues busy in proclaiming their wonderful cures.

The accounts, which empirics give of the cases under their care, are very commonly misrepresentations. For, from their ignorance of medicine, they are not capable of appreciating in any just manner the character and amount of disease, and the influence of remedies. And besides, they have ordinarily very little regard for truth, the object of most of them being to make the credulity of the public subserve their pecuniary interests. They are accordingly very loose in their ideas of disease, and often represent things to be alike which have no real resemblance to each other. The Thompsonians furnish constant illustrations of this remark. If a man who was in pain has obtained relief under their management, and some one else, who had pain in the same part of the body, or somewhere near it, has died under the care of a physician, they are apt to say without any farther evidence, that the pain was from the same cause in the two cases. So also, when scarlet fever is prevalent, they often represent many as having this disease, who have nothing but a common cold, or a slight fever from disordered stomach, and thus get the credit with some people of cutting short a disease, which, under the care of educated skill, cannot be prevented from going through its natural course.

It is manifest that the misrepresentations, thus made by many physicians, and by all empirics, must add much to the difficulty of judging of the comparative success of different remedies and modes of practice. And this difficulty is much increased by the accretion of falsehood, which is certain to be made to these misrepresentations, as busy rumor passes them about in the community.

Another obstacle to the formation of a just estimate of comparative success in medical practice, is found in the influence of bad treatment upon cases, in which the disease is small in amount and mild in its character. While the judicious physician cures all such cases so readily, that they excite no general interest, the unskillful practitioner and the quack make bad cases of some of them; and yet they are apt to end in recovery, although they appear to be of so grave a character. For a case, which has become bad by improper treatment, is not commonly in as dangerous a condition, as one that has become bad in spite of good treatment. In the latter case you see overpowering disease; while in the former you see little more than the bad influence of inappropriate medicine, which is apt to disappear when the medicine is withheld. The common result of such a case is, that at length the treatment is gradually given up, and the patient, in consequence of its being given up, gets well.