Physician and patient

by Worthington Hooker

The abuse of theory consists in the obliteration of the distinction between what is known, and what is merely supposed. So long as this distinction is carefully preserved, no harm is done by theory. No man was ever more thorough, in maintaining this line of separation between the known and the supposed, than was Newton. “I shall not mingle conjectures with certainties,” a passage in a letter announcing his great discovery of the compound nature of light, is a maxim which always governed him, and should govern every searcher after truth in every branch of science.

This maxim has evidently been little regarded by the great majority of theorizers in medicine. They have exalted mere conjectures into the same rank with facts; and so far as they have done this, just so far have they exerted an influence to retard the progress of medical science. If all the energy and talent, which have been expended upon theories, could have been directed to the observation of facts, what a mass of rubbish, which now encumbers the science of medicine, would have remained uncollected, and what an amount of pure unadulterated facts, which as yet are undiscovered, would have been garnered into the storehouse of knowledge!

As observation then is the only source of improvement in medical science, it is important to inquire what influences are adverse to skill in the observer. The influence of an overweening fondness for theory has already been sufficiently pointed out. I will pass therefore to the consideration of some other circumstances which tend to impair skill in observation.

Every physician can add much to his stock of knowledge by a proper review of cases which have come under his care. But a faulty mode of doing this will lead him into error. For example, one physician is so exceedingly fearful that in those cases, in which death has occurred, something which he did or left undone was the cause of the fatal event that he sees nothing clearly, and arrives at no definite and available conclusions; and he ends every review with nothing but unavailing regrets. Another, on the contrary, is too self-confident, scarcely harboring the idea that he could have ever committed any error. This notion of infallibility, though not distinctly avowed, is indulged to a greater or less extent by many physicians. If they do not think that they never err, they at least think that it is very uncommon for them to do so. To such the past is worth nothing as corrective. They add from it nothing to their stock of ascertained facts, though they may add to their medley of true and false inferences. Both of these extremes should be avoided. The physician, in reviewing his cases, should not fear to find errors; for if he investigated them properly at the time with the best lights which he could command, and acted in good faith, he is not to be blamed if he did err. But, on the other hand, he should not pronounce any measure which he has adopted to be an error without substantial evidence.

The disposition to form conclusions from a limited number of facts is a fertile source of error in medical observation. This has already been alluded to in previous chapters.

This disposition is very common among young physicians. A small number of cases is often sufficient to lead them to adopt conclusions, which a larger number of cases would show to be false. The fact that their experience has been limited should teach them to be cautious in their inferences; but very often this caution is never learned, till a larger experience has revealed to them their errors. The disposition under consideration is often increased, and sometimes rendered inveterate, by the practice, so common especially among young aspirants for medical fame, of speaking quite freely in non-professional circles of the results of their experience. This practice is not only disgusting, but it contributes essentially to the establishment of a habit of loose observation and reasoning.

But the disposition to adopt conclusions from a limited observation is by no means confined to young practitioners. It is a very common error in the profession at large; and the annals of medical experience are loaded down with errors, which come from this source. A few illustrations will suffice.

A few years ago a pamphlet appeared from the pen of Dr. Sewall of Washington, on the pathology of drunkenness, with plates exhibiting the state of the drunkard’s stomach in different stages of disease. Among others is a plate representing the appearance of the stomach of a man who died of delirium tremens; and Dr. Sewall says, that it is a true representation of the state of the stomach in all these who die of this malady. This sweeping assertion is based upon nothing but his personal observation, which, it seems from his own account, was very limited. He speaks of having had several opportunities of inspecting the stomach after death in such cases, and says that the appearances on dissection have been extremely uniform. How many he meant by the word ‘several’ I know not; but one thing is certain—that nothing short of many observations could establish the fact, that the plate in question exhibits the true state of the stomach in all cases of death by delirium tremens.

Now what is the truth on this point? This question is not to be answered by what any one man has found in ‘several,’ or even in many cases. It can be properly answered, only by taking the observations of many different physicians, who have had extensive opportunities of making examinations after death in this disease. The uniformity of appearances, spoken of by Dr. Sewall, we find, has not been observed by others; but the stomach has been found in various states in the different cases.

Dr. Sewall infers from the appearances in his cases, that the opinion advocated by some, that delirium tremens has its seat in the stomach is correct. Even if such appearances were competent proof in regard to this point, which is by no means true, it would require a larger number of cases than can properly be included under the term ‘several,’ to establish the correctness of such a conclusion. It is worthy of remark here, that others, taking, like Dr. Sewall, the partial view of facts presented by a limited experience, but having their attention directed to another quarter, have located this disease in some other organ. Thus some have supposed its seat to be in the brain, and have based this opinion, as Dr. Sewall did his, upon what they found in examinations after death. The truth is that all the phenomena of this disease show, that is a peculiar affection of the nervous system, and not a local disease of any one organ. Now in the general disordered condition of the drunkard’s organs, this affection is of course liable to be complicated with various local diseases. And delirium tremens of itself alone is not apt to end fatally; but when death occurs, it is ordinarily the result of some local complaint united with this disease. Wherever this complaint happens to be,—in the stomach, or the liver, or the brain, or some other organ,—there will be found on examination after death the greatest amount of disease. And a partial view of facts has often led physicians to mistake these local complications of delirium tremens for the disease itself.