Physician and patient

by Worthington Hooker

The science of medicine, in all its departments, is in a very changeable state. The discoveries, which are made from time to time in anatomy, physiology, and pathology, the theories which are put forth, and the new remedies, and modes of treatment which are continually proposed, keep up a constant excitement in the profession. In this unsettled state of things, with so many novelties to attract the attention, the temptation is so strong to act as a mere gazer, and, setting aside the labor of investigation, to adopt what is asserted upon deficient evidence, that there is the more need of maintaining that cautious observation, which is the only preventive of error.

I cannot forbear to notice here one circumstance, which exerts a great influence in favoring the unsettled state of medicine, and consequently in encouraging the fondness for new things. I refer to the fact, that there are no authorities, properly so called in medicine. The theologian has his standard authors, who are a kind of authority to which he appeals, and above all, he has the Bible as an unerring standard, and every opinion which is advanced he can bring to this test. The lawyer also has his standard works, in which are embodied the principles of law, and they are settled authorities to which he can appeal. In medicine, on the other hand, though there are works which contain the principles of the science, they have none of that fixed and undisputed authority, which standard works on other subjects are apt to have. There is therefore a contempt of authority in matters of opinion in medicine tolerated by the community, and even by the profession, which is not tolerated in regard to any other subject. While the lawyer appeals to ‘the law,’ and the divine to ‘the law and the testimony,’ the doctor often assumes the right of disputing all authorities from Hippocrates down to the present time. If a lawyer should, with bold and thoughtless assurance, call in question a decision of Chief Justice Marshall, he would be treated with contempt by both the bar and the community. But the most ignorant pretender in medicine may even gain credit, and what is of more importance to him, money too, by setting up a bold front against the whole faculty, and declaring, as Hahneman and Thompson each has done, that the medical world was in total darkness till he arose to enlighten it. So in theology, such gross delusions as Mormonism and Millerism are looked upon with mingled pity and contempt by the public, and yet that same public will patronize delusions in medicine which are not a whit less fanciful and ridiculous.[31]

One more cause of inaccurate observation remains to be noticed. It is one, however, which, at the present time at least, is so uncommon, that it cannot have any extensive influence. I refer to scepticism. When it does exist, it not only narrows the limits of knowledge, but actually leads to positive error. The sceptic, in his demand for stern, fixed facts, rejects some facts, which are established by evidence that is sufficient to satisfy any mind possessed of candor and common sense; and the rejection of a well-proved fact, being itself an error, must necessarily lead to other errors. The sceptic too, with all his doubting, is always, to some extent, and on some points, a credulous man. As he doubts on some points against clear evidence, so he will assuredly believe on others against evidence just as clear. His beliefs are no more worthy of confidence than his doubts. The sceptic is therefore disqualified by his scepticism for accurate observation. This is especially true in the practice of medicine, because, as you have seen, there is so much uncertainty in it, and the physician is obliged to base so much of his treatment upon probabilities. Some one has said, that the best guesser is the best practitioner. There is some truth in this remark, though it is of course by no means strictly true. It is well for the physician to guess when facts are wanting, but he must be careful not to esteem his guesses to be facts, as is too often done.

In medicine, as well as in every other science, but little mental effort is required to frame theories. All the hard work which is done—the work by which all knowledge is accumulated—is the work of observation. It therefore needs a higher order of mind to ascertain facts and their relationships, than it does to theorize. “Any man,” says Pott, an eminent English surgeon, “may give an opinion, but it is not every mind that is qualified to collect and arrange important facts.”

It is important that the physician should have at the outset good habits of observation. If he does, every day’s experience will add to his store of facts, and at the same time relieve it from some of the chaff of error which has been brought in unawares. He will be all the time becoming a better practitioner. But, on the other hand, if he start with a loose habit of observation, experience will be to him a source of error. He will have no clean store of facts, but he will garner in a strange mixture of facts, and suppositions, and errors; and every day’s experience will add to the difficulty of separating the good grain from the mass of refuse, with which it is mingled. He will be all the time becoming a poorer practitioner.

The idea then that experience will at any rate confer knowledge is a false idea. It is not true, that the old physician, as a matter of course, knows more than he did when he was young. If he has observed well, he does know more; but if he has not observed well, he not only does not know more, but he knows less. In the latter case, he may indeed have more ideas and opinions than he had when he began his practice, but he does not know as many real ascertained facts, and those which he does know are so encumbered with the long accumulating rubbish of error, that they are of little use to him.

It is easier to adopt a theory with a corresponding system of remedial means, or even to originate one, than it is to encounter the labor of strict daily observation at the bedside of the sick. Many physicians pursue the former course, and go through with a routine of practice from year to year. If they have some tact in managing the capricious credulity of the public, they succeed in attaining the object at which they aim. These followers of a system are generally considered by the community as very rational and scientific men. Some of them, though they live on the opinions advanced, and the facts discovered by others, contrive to get up quite a reputation for originality, by making so much account of these opinions and facts, that the public awards to them, in part at least, the credit of their discovery. It gives them a sort of eclat to stand out from their medical brethren, as the advocates of some peculiarity of doctrine or practice.

The medical profession has had too much to do with theories, and modes, and systems. Every prominent theory can be shown to be unsubstantiated by facts, and is therefore valueless. Every mode, or system of practice, however numerous are the facts which are adduced for its support, can be shown to exclude many facts of a valuable character; and being thus exclusive, it must lead to practical error. All these systems therefore should be discarded. A true eclecticism should be introduced into medicine, and it should have relation not to opinions and theories, but to facts only. Whenever a fact is really ascertained, it should be treasured up in the storehouse, ready for practical use. If it be apparently inconsistent with other facts, this is no reason for rejecting it. If it be really proved, it should be received, and its consistency with other facts may afterward be discovered. Indeed, quite a large proportion of the facts practically applied in medicine, are independent facts, neither explained themselves, nor capable as yet of being used in the explanation of other facts. I have alluded to this point before. A single example here will suffice. No fact in medicine is better established than that arsenic in almost all cases cures hemicrania, or periodical neuralgia on one side of the head. How or why it does this no one knows. The bare fact is known.

In this connexion I will make a remark or two upon a subject which is often the topic of conversation in common as well as professional circles, viz., the modus operandi of medicines, or the mode by which they cure disease. It is a common, but a very erroneous idea, that this subject is easily understood, and much reproach is cast upon physicians for their differences of opinion in relation to it. The modus operandi of many remedies is, as I have already said, wholly unknown, and the knowledge which we have of it in any case is more or less imperfect. And after all, though it may gratify curiosity to know how a medicine cures disease, it is comparatively a matter of little importance. The fact that it does so is the material fact. The knowledge, which it is practically important to obtain in relation to any remedy, is a knowledge of its effects, and of the circumstances which modify them. And physicians, however much they may speculate about the modus operandi of medicines, commonly view this subject in this practical light at the bedside of the sick. The question whether opium is essentially a sedative or a stimulant is forgotten, when a patient suffering the tortures of spasmodic colic is to be relieved. The material fact is, that it can relieve the pain—how it will do it is not just then a subject of consideration.

A reform is now in progress in the medical profession. The struggle to break loose from theory is fairly begun. A deep consciousness, that the science of medicine is cumbered by a mass of rubbish, has awakened a disposition to a more careful and rigid observation. The Materia Medica of the profession is especially burdened in this way. The virtues which are attributed to a large portion of the remedies in use require to be tested in order to strip the statements which are made in regard to them of all that is inaccurate and false. Much of the positive medication of the present day will probably be proved by the tests of a rigid observation to be aimless, but by no means harmless. The over-dosing, which has been so much in vogue both with the community and the profession, is already fast losing its popularity. Heretofore the great object of the physician has been to do positive good to the patient—to overcome disease by a well-directed onset of heroic remedies—and it has been a secondary object altogether to guard against doing him harm. But medical practice is becoming reversed in this respect. It may at the present time be said of quite a large proportion of the profession, that it is the principal object of the physician to avoid doing harm to the patient, and to prevent harm from being done to him by himself and by his friends: and then, after looking well to this object, he is ready to do whatever positive good he sees can be done in the case. Accordingly, cautionary and quieting measures, intended to remove the obstacles which may hinder the operation of the curative power of nature, are getting to predominate in medical treatment over the more active and direct measures for overcoming disease. ‘The golden axiom of Chomel, that it is only the second law of therapeutics to do good, its first law being this—not to do harm—is gradually finding its way into the medical mind, preventing an incalculable amount of positive ill.’ So remarks Dr. Bartlett in a work,[32] which I deem to be one of the best and most effectual efforts, which have been made in promoting the revolution, which is now taking place in the practice of medicine. It is a work which, if I mistake not, is to exert a thorough and extensive influence upon the interests of medical science.