CHAPTER I.UNCERTAINTY OF MEDICINE.
The uncertainty of medicine is a common topic in all circles; and yet it is one which is very generally misunderstood, even by the intelligent and reflecting in the community. They mistake as to the nature of this uncertainty, its causes, its practical influence in the treatment of disease, the means which should be resorted to in order to diminish it, and the best methods of guarding against the errors into which it is liable to lead us. These errors are, I may remark, so numerous and so common, and interfere so constantly with the usefulness of the physician among high and low, educated and uneducated, almost equally, that the subject is one of vast practical importance. It is important not only to physicians, but to the people, and to the people especially, fortheyare the sufferers from the multiform and often fatal injuries, which these errors engender.
It will be profitable then to examine the different points to which I have alluded, so that it may be seen how far the science of medicine merits confidence, and by what tests an intelligent and thinking man may distinguish between that which rests upon good and substantial evidence, and that which is uncertain and delusive. This is a distinctionwhich often fails to be made, (as the physician has occasion every day to lament,) by the shrewd and learned, as well as the ignorant and unwary; and the deductions of a rational and careful experience are continually confounded with the false assumptions, and plausible fallacies of the mere pretender, and the fanciful vagaries of the enthusiast. So far as my remarks will enable the reader to make the distinction to which I have referred, just so far will my object be accomplished.
When the chemist mixes substances together, the composition of which he knows, he arrives at results which may be strictly denominated certain and invariable. If he be not able to do this at once, he can do so ultimately, by a series of experiments, varied to test each doubtful point. The results which he thus obtains are so exact, that they can be expressed by numbers and definite proportions. The physician can imitate the chemist, it is true, in the application of tests in the investigation of disease; but it is necessarily a very humble and distant imitation, and no approach to the certainty and definiteness of chemical analysis and synthesis can be expected in medical practice. When the chemist mixes substances together, he knows what they are; and when he sees their effect upon each other, he has a right to expect the same effect to follow, with absolute certainty, whenever he shall make the same mixture again. But the physician cannot infer from the effect of a remedy in one case, that the same result will certainly occur in another case which appears to be precisely similar. For he cannot know enough of the circumstances of the two cases, to determine beyond a doubt that they are exactly alike. There are often causes, utterly undiscoverable by human wisdom, which essentially modify the effects of remedies.
If you suppose that the chemist knows the nature of only a part of the substances which he puts into his retort,—that the retort itself is made of materials which will act upon these substances, and be acted upon by them, and that in the midst of his experiment some other substance is introduced accidentally or by stealth, producing an entire change in the process; you will then make the chemist to resemble the physician in the uncertainty of his results. He would then be obliged, as the physician is, to go through with a great many observations to establish any one fact; and instead of making, as he now does, a well-defined line of separation between what is known and what is not known, he would, like the physician, have a wide middle ground of probability and supposition.
The causes which make disease complicated, and prevent uniformity in the effects of remedies, are principally these, viz.:
1. The sympathy which exists between the different organs of the body.
2. The influence of unseen causes or agents.
3. Natural changes, arising from the tendency which exists in the system to throw off disease, appropriately called thevis medicatrix naturæ, or restoring power of nature; and in connection with this the tendency to a definite limit manifest in many diseases; for example, small pox, whooping cough, measles, scarlet fever, &c.
4. Mental influences.
5. Idiosyncrasies, or individual peculiarities.
We will examine in a familiar way each class of these causes separately.
1. The sympathy which exists between the different organs of the body.
The fact that when one organ is disordered in any wayother organs sympathize, or suffer with it, is familiar to every one. This sympathy destroys the simplicity of disease, in two ways. In the first place, it produces many symptoms at a distance from the organ affected. Pain, for example, is often far away from the disease which causes it. The pain in the right shoulder from disease of the liver, in the knee from disease of the hip joint, and in the head from disordered stomach, are familiar instances. Convulsions, in the great majority of cases, especially in children, are a mere symptom developed by the sympathy of the brain and nervous system with disease in some other organ—for example, a disordered stomach, the irritation of teething, &c. Now if sympathy renders disease complex, by developing such marked symptoms as those we have mentioned, at a distance from the affected organ, much more will it do this by the numerous less observable, and less definite symptoms, attendant upon our various bodily maladies.
In the second place, sympathy destroys the simplicity of disease, not only by exciting symptoms in organs at a distance from the part affected, but also by creating actual disease in those organs. A single example will suffice. The child, whose brain sympathizes with the disease in its stomach, may have inflammation after a time fastened upon its brain in consequence of this sympathy, the symptoms at first being obscure, but at length clear and unequivocal.
The influence of sympathy in modifying disease occasions constantly much perplexity in the mind of the physician. He often finds it difficult, and sometimes impossible, to decide whether an organ, which he sees to be affected, is really diseased, or is merely sympathizing with some other organ.
The simplicity of disease is thus destroyed by sympathy, even when all the organs, except the one which is attacked,are in a healthy state at the time of the attack. And when they are already in an unhealthy, unnatural condition from previous disease, the complication is rendered still greater.Chronic[2]cases especially are often so complex from this cause, that it requires the most discriminating acumen to unravel their history, and make out the starting point of the disease. Often it is impossible to discover any such starting point; and sometimes there is none, but there are several different diseases in different organs, all affecting each other through sympathy, and presenting together a confused and changing medley of symptoms. In such cases, the manifestations of diseased action are at one time most prominent in one organ, and at another time in another. These variations in the phase of the disease are often so unaccountable, as to seem capricious, and they always embarrass the physician, as he attempts to determine the effect of his remedies, and to proportion them to the importance of the symptoms, as they show themselves in the various organs. It would sometimes almost seem, that a tricksy little spirit were playing its pranks among the organs, now here and now there, eluding his search, and escaping his grasp.
In some cases, disease will leave the organ in which it seems to be obstinately fixed, and appear in full force insome other organ, which has been up to that time only sympathetically affected. This is more apt to occur in children, because the sympathies are more lively in them than they are in adults. Such changes, taking place often without any obvious cause, and so suddenly, and sometimes, we may add, so secretly, you can readily see, must tend to make our knowledge of disease, and of the effect of remedies, confused and uncertain.
2. The influence of unseen or secret causes, is another source of uncertainty in medicine.
The fact, that some causes, whose nature and extent cannot be appreciated, are at work modifying disease, and the effects of remedies, constantly forces itself upon the attention of the practitioner. The causes of disease, and of the changes that occur during its progress, are much more concealed from our view than is generally supposed. Patients are fond of fixing upon something to which they can attribute their sickness; but in the great majority of cases, the conclusion which they adopt with so much confidence is a mere supposition, and does not rest upon any substantial proofs. Even in the case of a common cold, you will find that the reasons given for believing that this or that cause produced it, often will not bear a strict examination, according to the acknowledged rules of evidence. Ordinarily some exposure is looked upon as being without a doubt the cause, when it may have been only one of the causes, or may even have had no agency at all in producing the result.
Some of the causes of disease, though, from their definite and invariable results, we may be perfectly aware of their presence, are yet of an occult nature, escaping all the tests devised to detect them. For instance, the miasm, as it is termed, which is the cause of intermittent fever, has never yet been detected in the atmosphere, by theapplication of any chemical test. And yet, no result in the wide range of disease is more definite and palpable than that which this miasm produces. And so secretly does it make its impression, that the disease sometimes lies dormant for a long period, even for weeks and months—the system all the while showing no signs of its presence. I once had a case of intermittent fever, which was not developed till a year had elapsed from the time of the patient’s exposure to the cause.
The nature and mode of operation of the causes of many diseases are involved in mystery, and are subjects of discussion and dispute among medical men. The formidable, and often fatal malady, that results from a wound received in dissection, is attributed by some to a poison evolved in the decomposition of the body; while others suppose that it arises from the irritation of the wound simply, circumstances concurring to increase the irritation in one case, while it is left to subside in others. It is agreed, on all hands, that the contingencies on which the disease depends are not ascertained; and they are so often absent, that the cases in which the malady does actually occur bear a very small proportion to the whole number of instances in which such a wound is received.
The same may be substantially said of the causes of typhus fever, cholera, scarlatina, &c. Some think that these diseases are caused by subtle poisons, which enter the system in various supposed ways; while others believe that they arise from causes which makeimpressionsmerely upon the system, and thus awaken trains of morbid action. Whatever may be our opinion on these disputed points, the fact that there is so much secrecy in the operation of morbific influences, must, it is clear, make much of our knowledge of disease uncertain.
If, then, there be so much ground for difference of opinion in regard to the nature of the causes of disease, and their mode of operation, where the results are of so definite a character, as we see in the disorders to which I have alluded; much more is this the case with those diseases, which, with their Protean shapes, make up a large proportion of the maladies that call for the daily attention of the physician.Thesedo not commonly spring from one cause, but from many causes concurring together, some of which may be ascertained, while others are only suspected, or are wholly concealed from the most scrutinizing investigation. Under these circumstances, the physician has a difficult task to discover the actual condition of the patient. It would be a comparatively easy one, if he knew what all the agents were that had combined to produce the disease, even though they were numerous and complicated in their operation. He could then thread out with some success, the trains of morbid action, and, perhaps, give to each cause its proper place in his estimate of their agency in causing the disease. But, in some cases, he knows but little of the nature and mode of action, even of those agents, whose influence he can perceive: and then, there are some quite as important, which act in entire secrecy, developing results that cannot be foreseen, and that cannot be calculated upon after they have made their appearance. Such developments are often observed in the progress of disease, and necessarily embarrass us in its treatment. They sometimes completely alter, either gradually or suddenly, the whole character of the case; and yet they may be the consequences of causes, which have been secretly, but surely, doing their work from the first onset of the disease. In some cases, which were in the commencement comparatively mild, a group of severesymptoms all at once start up, exciting astonishment and alarm in the mind of the practitioner. Sometimes there are precursors of the full development, half showing themselves, and the watchful physician may discover in them the coming storm, long before the indications are manifest to the common observer. Even after convalescence has, to all appearance, fairly begun, and the symptoms seen during the progress of the disease are gone, some new symptoms may appear—the upshot of a train of morbid influences, which had been all the while imperceptibly advancing to this result; just as I have seen a fire, supposed to be extinguished, burst forth like a new fire in another part of the building, to which it had secretly made its way.
It is sometimes impossible to detect the immediate cause of an attack of sickness, even when the transition from health to disease is apparently instantaneous. Take, for example, this case. A gentleman, while quietly sitting in his counting-room, was attacked, as suddenly as if it were from a blow, with a great sense of oppression in the region of the heart, almost arresting the action of this organ, and at once prostrating his strength. No reason could be discovered why this attack should occur at that time rather than at some other. And yet there was some hidden cause, or combination of causes, which, at that moment, did its work; and we know not how long a time a preparation had been going on for this consummation, and so silently, too, as to occasion no disturbance.
The physician often finds, on making his first call upon a patient, that although he may think that his attack is only a thing of to-day, there is evidence that disease must have been preying upon his system for some length of time, gradually extending its ravages, till, at length, it has made a palpable outbreak. The patient may attribute hissickness to some one cause; but there have been many causes uniting together, one after another, and swelling the still current of disease, which has now broken forth as a flood.
And, as a general rule, the longer this preparation has been going on, the more obstinate does the physician expect the case will be, and the more difficulty does he find in getting a definite knowledge of the nature and extent of the malady. And if he could always trace every train of disease up to all its sources, both original and tributary, he would often be obliged to go back weeks, months, and sometimes years. In some cases, such an exploration would lead him through almost endless labyrinths. As it is, he often finds, in attempting such a search, that those facts which are the least material in the eyes of the patient, and which may be overlooked by him in giving the history of his case, reveal, far back in the distance, causes which have had more influence than any other in producing this result. A sort of cross-questioning, and that sometimes of a rigid character, is often needed, to develop material facts. The patient’s own story, without such questioning, would generally give to the physician very erroneous ideas of his case.
The remarks that I have made apply with greater force to chronic than they do to acute diseases. For in them more especially, as you have already seen, does the sympathy which exists between the different organs extend and complicate the morbid condition, and the operation of unseen causes contributes, sometimes very largely, to this result.
Many chronic cases become exceedingly complex, and therefore obstinate, from the course which the patient takes with himself, before he comes under regular andsystematic treatment. Perhaps, first, he goes through with domestic medication, and then takes patent medicines, recommended to him by kind neighbors, or blazoned forth in the newspapers. Then he tries some vaunted system—Thompsonism, or hydropathy, or homœopathy, or chrono-thermalism, or perhaps all of them in succession. After going through all this, unless some one of these measureschanceto benefit his case, (asanythingmaychanceto do it), he at last comes to a physician, and puts himself under his care. The case which was, perhaps, sufficiently complicated in the beginning to require strict investigation, is now rendered, by all this variety of practice, very intricate. The difficulty in understanding it lies in the varied effects which the different agents brought to bear on it have produced—effects, which, in the retrospect, it is almost impossible to estimate with any correctness, because the physician has only the history given him by the patient, and the appearance of his present symptoms, to guide him in making up his opinions. If he had himself seen the case in its untouched condition, and then had witnessed the operation of the different remedies, he would have been better able to arrive at satisfactory conclusions. A chronic case, in its best estate, needs to be watched for some little time, in order to acquire a just and thorough knowledge of its character. And when it has gone through a series of processes athaphazard, with no intelligent eye to observe it, it is no wonder that its condition should become a complicated and puzzling one. The physician, with such a case before him, is situated very much as the chemist would be, into whose hands should be put a mixture which had been experimented upon over and over again by different chemists, and those, too, who were ignorant and bungling. And as you would not demandof him, that he should arrive at once at definite results in examining the composition of such a mixture, but would give him time to apply various tests to it, so it should not be expected of the physician that he should fully understand at once a case which has been dabbled with by ignorant experimenters, one after another; but time must be given him to watchhistests, that he may see them bring out to view its real character and condition.
It must be obvious to the reader, that those who go through this round of experimenting, before they put themselves under the care of an intelligent physician, not only lose valuable time by so doing, but generally inflict upon themselves positive harm. The remedies which they have used, if they have had no good effect, have helped tofastenthe disease upon the system, and have increased its severity. They have done this by irritating the system, and, of course, the diseased organs, and by extending the complaint far beyond its original limits. You have seen that, through the sympathy existing between different organs, disease becomes extended and complicated. Well-directed treatment has a tendency to prevent this extension of disease: mere blind experimenting, on the other hand, is apt to promote it; and if it does not have this effect, the patient is very fortunate.
3. I pass now to the consideration of the third class of causes which render medicine an uncertain science, viz., natural changes, arising from the tendency which exists in the system to throw off disease, appropriately called thevis medicatrix naturæ, or curative power of nature; and, in connection with this, the tendency to a definite limit, which is manifest in many diseases, as, for example, small pox, measles, hooping cough, scarlet fever, &c.
To recur to our chemical illustration. I have said thatit would add vastly to the uncertainty of the results of the chemist’s experiments, if the retort, into which he puts his substances to be experimented upon, could itself act upon these substances, and thus modify their action upon each other. The body of the patient may be considered as the physician’s retort, and the diseases and the remedies introduced, as the materials contained in it. Under this head we are to examine certain principles which reside in this retort, and which have a constant and important influence upon diseases and their remedies, modifying, sometimes manifestly, and sometimes secretly, their action upon each other.
I will speak first of the tendency to throw off disease, thevis medicatrix naturæ. I need not spend time in proving to you the existence of such a tendency. It requires not the exercise of any scientific acumen to discover it. It is obvious to the most superficial observer. And yet the extent to which it operates is far from being properly appreciated, even by medical men; and much less is it by those who are out of the profession. The changes which it produces are constantly confounded with the effects of remedies; and this is one of the chief sources of the errors which encumber the annals of medical experience.
The reader will see, as we proceed, that boast as doctors often will oftheircures, as if they were wholly theirs, thisvis medicatrix naturæis the chief doctor after all; and she, good, kind angel, hovering over the bed of sickness, without fee, and often without even any acknowledgment of her services, saves the life of many a poor patient, who is near being drugged to death by some ignorant quack, or some over-dosing doctor.
That the reader may be somewhat acquainted with the extent of the influence which this curative principle exerts, I will cite some examples of its operation.
If some offending substance be present in the stomach, vomiting is produced, the substance is evacuated, and this organ, having thus relieved itself by an effort of nature, as it is commonly expressed, now goes on with the performance of its usual functions. In this case, the ordinary action of the organ is entirely reversed, in obedience to the curative principle. If an attempt be made to allay the vomiting before the offending substance is thrown off, it is an injurious interference with a salutary effort. Sometimes the effort is ineffectual, and needs the assistance of art. It is often difficult to decide whether vomiting is prompted by this curative principle, or is caused by irritation, which should be quieted by medicine. Want of due discrimination, either from lack of knowledge, or from carelessness, very often leads to errors on this point.
The operation of this principle is beautifully exhibited in the succession of the processes of inflammation. You see a swelling. It, after a while, begins to soften. There is matter in it, but it is not yet very near the surface. But soon, at some point, it comes nearer and nearer to the surface, the wall of the abscess thus becoming constantly more thin, till, at length, it opens and discharges. The discharge continues till the swelling is nearly all gone, and the remainder is absorbed, and the part is restored to its natural state.
Now, this is quite a series of processes, all contributing to one result, and it is presided over, or directed, by thevis medicatrix naturæ. The object of this series is a definite one; and each process does its part in effecting it, and does it commonly at the right time, and in the right manner. Just look for a moment at the complicated character of this apparently simple operation. Here is quite a large deposition of substance which is to be removed;and this is the object to be effected. Observe how it is done. The softening of the swelling is not a mere change of solid substance into a fluid, as if by decay, but it is the result of an active process, which we callsuppuration. When this process is properly performed, good pus is made, or as the old writers in medicine rather quaintly expressed it,laudablepus. This process of suppuration, when it is well done, does not go on here and there in the swelling, making it like a honeycomb with a multitude of little abscesses; but there is a consent, an agreement of action by the vessels of the part, as really as if they worked intelligently. It is this consent of action which not only makes the line of movement in the abscess, but points it towards the surface, instead of giving it some other direction, laterally, or inward, upon some of the internal organs. But it is farther to be observed, that in this agreement of action, the vessels of the part do not all do one thing. Three different offices are performed by them in the different quarters of the abcess. While some of these little workmen are forming the pus, there are others thinning the wall of the abcess in the direction of the surface, by absorbing or taking up the substance there; while there are others still, in the rear, and at the sides of the abcess, depositing substance, in order to make a barrier to prevent the pus from being diffused in the surrounding parts. Each class of these workmen perform their particular work with even more exactness and harmony than would be expected of any company of intelligent laborers under the direction of a leader. The absorbents absorb together, the wall builders build together, and the makers of pus make pus together, and deposit it in a common reservoir.
But observe farther, and you will soon see an entire change come over the whole scene of operations. Whenthe absorbents have completed their passage for the matter through the skin, the pus is gradually discharged from its reservoir, and the “occupation” of the pus makers is soon “gone.” The wall builders also cease their work, and while the vacancy becomes filled up by contraction and deposition, the wall of defense, so carefully maintained, so long as it was needed, is now taken up by the absorbents—workmen which seem to know just when, as well as how, to do their duty, and is emptied into the common circulation, to be discharged from thence with the general refuse, by the various outlets of the system.
The object of all this is the restoration of the part to its healthy condition, and it is effected by a principle existing in the system—it matters little comparatively by what name you call it. The name is simply expressive of a great, general fact, as the term gravitation is, and is not intended, any more than that term is, as an explanation of thenatureof the fact indicated.
This same principle is in operation in all diseases, resisting them, hemming them in, and as they retreat, following hard upon their footsteps, repairing their injuries as well as it can. It is true that its efforts are often ineffectual, that they are sometimes overpowered by disease, that they are frequently perverted by injudicious interference, and that they are sometimes stimulated to a higher degree than is necessary, producing over-action, and thus making this conservative principle an instrument of injury, perhaps destruction. It would be interesting and profitable to illustrate these several points in the operation of this principle, but it is not essential to our purpose.
We will pass now to the consideration of the principle of self-limitation,[3]which we find existing in many diseases.These diseases have a regular rise and decline, including a set of processes, and a succession of symptoms peculiar to themselves. When they have once fairly begun, they cannot be abridged; neither are they prolonged beyond their natural limits, though they may, and often do, leave results behind them, which are sometimes mistaken for a continuance of the disease itself. The period of continuance is more definite and fixed in some of these diseases than in others, and there is a similar difference also in regard to uniformity of shape. Thus small pox runs through its course with more regularity of period, and with a more uniform series of phenomena than scarlet fever, which, though having a certain general character and average period, is extremely diversified in its degree of severity, and in its accompanying circumstances. The more simple and regular and definite any disease is, the more accurate can our observations be in regard to it, and the less apt are we to confound the effects of remedies with the natural changes that take place in its progress.
This principle of self-limitation is found in the movements of other diseases of a less definite character than those which I have mentioned, though it does not manifest itself so fully, and with so much uniformity. You have already seen, that in a common inflammatory swelling there is a regular set of processes going on to its termination, in the restoration of the part to its healthy condition. The tendency of the inflammation ordinarily is to finish itself, just as is the case with any of the definitely shaped diseases, but its rate of progress cannot be so well calculated upon. The same can be said of inflammation of any of the organs of the body, in regard to this tendency to come to a conclusion of itself; the ways in which it does this varying much,according to the texture of the part affected, and other circumstances.
The reader is now prepared to see how it is, that mistakes may be made, by confounding the effects of remedies with the changes that arise from the two tendencies, of which I have been speaking. These mistakes have often been committed, even in those diseases which are commonly simple and uniform, and definite in their shape and course. Take, for example, small pox. It was once the custom of physicians to give much medicine in this disease, with the idea that it was controlled and lessened by such a course, and the system was thus enabled to throw it off more easily and effectually. But experience has corrected this error, and the physician now stands by, and sees results occur in the progress of this malady without the agency of medicine, which he used once to consider as produced, in part at least, by the drugs that he administered. Let me not be understood to say that no medicine at all should be given in this disease. The office of the physician is to watch it, and if nature, in going through the processes necessary to a favorable termination, needs to be assisted by art, it should be done. But we should be careful not to ascribe to art what is really effected by nature, for we should be led by this error to a too officious interference with her efforts. We may often do much good by medicine—we may moderate the fever, support the strength when languishing, bring out the eruption when it recedes, &c. But to attribute the successful termination of small pox in all cases to the remedies which have been used, would be as great an error as it would be to maintain that the poultices, and other applications made to an inflammatory swelling, are of course the cause of its suppuration and discharge—or, in other words, that they cured the inflammation. All thatcan be truly said of them is, that they assisted nature in the cure. And as these applications may sometimes be of too stimulating a character to suit the case, and therefore may increase and extend the inflammation; so the remedies used in a case of small pox, if they be not actually needed, may aggravate the disease. And if the patient recover under such injudicious treatment, it may be supposed that the medicines cured him, though he actually recoveredin spite of them, because that same blessedvis medicatrix naturæcame to the rescue.
If there be so much liability to error in a disease so simple and uniform as small pox is, it is still greater in those complaints which are more complicated, from collateral and accidental influences and affections. Perhaps I cannot adduce a better example for our purpose than is to be found in scarlet fever. There is no disease, the history of whose treatment shows so strikingly the uncertainty of medical knowledge and experience as this does. The most opposite and various remedies and modes of treatment have been lauded as successful, in standard medical works, and in medical journals, and multitudes ofcertaincures have been proclaimed in the newspapers. What is praised by one is condemned by another; and it is the individual experience of every rational and candid practitioner, that a mode of treatment which at one time is attended with marked success at another is wholly unsuccessful. It cannot be otherwise in a disease which varies so much as this does in its degree of severity, in its real character, and in its attendant circumstances. A respected medical friend, in reviewing his cases of scarlet fever, found that he had treated one hundred cases since he had lost a patient with this complaint. But on the very day on which he made this review, he was called to a case of scarlet fever whichended fatally, and out of thirteen cases in the same neighborhood he lost seven. With such variations in the severity of this disease, it is very difficult to avoid erroneous inferences as to the comparative success of modes of treatment. This difficulty is increased by the fact, which is remarkable in this disease, that the degree of severity, or amount of danger, is by no means always capable of being measured by the symptoms which present themselves. In the experience of every physician, who has seen much of this complaint, many cases have ended fatally, which, up to within a short period before death, appeared to be doing better than some others in which recovery took place. There was much wisdom in the reply that one physician made to another, who asked him what his mode of treatment was in scarlet fever. “I have no treatment,” said he. “I manage each case as an individual case, just as it strikes me at the time.” And to this conclusion will experience lead every judicious practitioner.
Let me not be understood to mean that experience, so valuable in the treatment of all other diseases, is nothing worth in this complaint—that it establishes no facts, and no general principles. All that I mean is, that this disease is so variable in its character and tendencies, that extreme caution is necessary in applying these principles, and that the treatment must be at the very antipodes of stereotype—as variable as the disease itself.
I trust that it is sufficiently obvious to the reader that great uncertainty must necessarily rest upon our knowledge of a disease so varied as this is, and that all our experience of the effects of remedies upon it must be thoroughly sifted, in order to attain to any measure of accuracy. It is a disregard of this important truth, that has made the testimonyof medical men so conflicting in regard to the treatment of this disease.
I need not spend time to show how the same uncertainty must embarrass us, to a greater or less degree, in our investigation of all other diseases. The errors resulting from this source may be avoided, in part, by observing accurately the changes which arise from the two tendencies that we have been considering, their modes, periods, signs, and accompanying circumstances. The efficacy of this precaution against error is, as I have already hinted, in proportion to the simplicity and uniformity of disease. In disorders which are complicated, and which vary much in their shape and other circumstances, it is exceedingly difficult to decide, how much agency, in bringing about the curative changes, is justly to be referred to the remedies, and how much to the natural energies of the system. Too much credit is very commonly given to medicine, and too little to nature; and sometimes, when some remedy is praised for its efficacy, and the patient and his friends, and perhaps even the physician, think that it has saved his life, it had no agency in promoting his recovery, and perhaps it retarded it.
I pass now to the consideration of the fourth class of the causes of the uncertainty of medicine—mental influences.
It never should be forgotten in our observation of disease, that we have not to deal with the body alone, but with the body inhabited by a mind, which is connected with every particle of that body by countless nervous filaments, and therefore acting through them upon it, and affecting to a greater or less degree all its diseased conditions.
The influence of causes acting through the mind is often concealed from our view, and even when it can be plainly seen it is difficult to estimate its amount with correctness.Effects are often produced through the mind, which are attributed by the patient, and sometimes by the physician, too, to some remedy that has been administered. Take a very common case. A dyspeptic, who has contracted his disorder from mental effort, or from the anxieties of business, applies to his physician. He prescribes some medicine, and at the same time recommends him to take a journey, or go to some watering place. He returns cured, and he perhaps gives the credit for the most part to the medicine, or to the medicinal waters which he has drank with scrupulous regularity, either of which may have had little if anything to do with the cure, and relaxation and diversion of mind may have been the chief or sole causes of his recovery. This is a palpable instance of erroneous inference; but we shall have but a narrow idea of the influence of mind upon disease, if we confine our view to cases of so decided a character. Its influence is constant in all diseases; sometimes plain to be seen, as in the case just mentioned; often entirely concealed from the most careful scrutiny; and sometimes revealing itself slightly, so that the watchful eye of the physician catches mere glimpses of it, like passing shadows gone in a moment. Besides the secret griefs and troubles that often hinder recovery, there are varying states of mind, some of which the patient may be hardly conscious of himself, that modify in a thousand ways the movements of disease, and the action of remedies. For example, the cordial which is administered is often in part or wholly neutralized by mental depression, while it is essentially aided in its effects by the genial and animating influence of hope.
The points to which I have alluded the reader will find fully illustrated in the chapter on the mutual influence of mind and body in disease. I will therefore dismiss them forthe present, and will merely recur again for a moment to our chemical illustration. If the retort of the chemist, besides being composed of substances which will act upon its contents, should have residing in it some secret and subtile principle, whose existence is known only by its effects, and which acts both upon the retort itself and on whatever it contains, the results of his experiments would be rendered very uncertain. To follow out the analogy—the human body being the physician’s retort, the mind is just such a secret and subtile principle, acting in an unseen way both on the retort and its contents, modifying therefore the effects of remedial agents, so as to embarrass the physician in his investigations, and render his conclusions uncertain.
The fifth class of causes of the uncertainty of medical science remains to be noticed, viz.: individual peculiarities oridiosyncrasies, as they are termed.
Every individual may, strictly speaking, be said to be peculiar to some extent, and there is much force in the popular idea of the benefit resulting from a physician’s being acquainted with his patient’s constitution. But besides these common differences, some have very great peculiarities. A few examples will be sufficient. There are some persons in whom the odor of roses will produce asthma. Ipecac has the same effect in some individuals. Some persons are uniformly made sick by eating strawberries even in small amount. Cases are constantly met with by physicians in which some medicines have a peculiar effect. The various effects produced by opium in different individuals furnish many examples. I call to mind a patient, who though a laboring man of considerable power of endurance, is extremely prostrated by vomiting, by whatever agent it is produced. I once gave him an emetic without knowing this peculiarity. He was so much prostrated, that I supposedthat the apothecary had made a mistake, and that he had taken an overdose. But a short time after, I witnessed in him the same effect induced by undigested food, and this revealed the idiosyncrasy in his case.
When idiosyncrasies are known, they can be calculated upon. But they are not always known. We cannot be aware of them when they respect the action of remedies which the patient had never taken. And in relation to remedies which produce no marked and obvious effect, peculiar susceptibilities may exist without being readily ascertained. If there be an idiosyncrasy in regard to such a medicine as an emetic, or an opiate, it is easily discovered. But if it exist in regard to a remedy that acts silently and slowly, it may not show itself clearly. The only evidence that we have of its existence may be the fact, that the medicine after a while is observed to fail in producing the effects which we ordinarily expect from it in such cases. And it may be very doubtful whether this failure is to be attributed to this cause, or to some other.
Let us recur once more to our illustration from chemistry. If the retorts used by the chemist, (which, I have supposed to carry out the analogy, to be composed of materials which would act upon their contents,) were not all made exactly alike, but varied a little always in their composition, and sometimes considerably, and that too without the variation always being appreciable, this fact would obviously still further complicate his experiments, and render them uncertain in their results. So also the peculiarities in the different human systems, which are the physician’s retorts into which he introduces his agents, must have the same effect upon his investigations.
I have now finished the consideration of the various causes of uncertainty in medical science. If I have succeededat all in making them to be properly appreciated, the reader will agree with me when I say, that there is no science that requires higher talents for its successful investigation, and none that is so liable to wrong influences and conclusions, if the student of it be a careless and credulous observer. Notwithstanding this liability, imperatively demanding caution on the part of the physician, there has been much of careless observation in this science; and the recorded experience of the medical profession is therefore encumbered with a mass of errors. In order to get rid of these errors, and to establish the proper distinctions between the certain and the uncertain, between the true and the probable, while the merely plausible shall be entirely rejected, a judicious sifting and testing of evidence must be resorted to, credulity and skepticism both being equally avoided.
FOOTNOTES:[2]The termschronicandacuteit may be well to define for the benefit of some of my non-professional readers. An acute disease is one which runs its course in a short time. A chronic disease, on the other hand, is one which has a long duration. For example, pneumonia, (commonly called lung fever,) is an acute disease of the lungs, while consumption is a chronic disease of the same organ. The term, acute, has reference to the violence of the symptoms of the diseases to which it is applied, rather than to their duration; while its opposite term, chronic, has reference to duration only. Use, however, has given them a technical sense which is not liable to be mistaken.[3]This subject may be found fully illustrated by Dr. Bigelow in the Annual discourse for 1835, before the Massachusetts Medical Society.
[2]The termschronicandacuteit may be well to define for the benefit of some of my non-professional readers. An acute disease is one which runs its course in a short time. A chronic disease, on the other hand, is one which has a long duration. For example, pneumonia, (commonly called lung fever,) is an acute disease of the lungs, while consumption is a chronic disease of the same organ. The term, acute, has reference to the violence of the symptoms of the diseases to which it is applied, rather than to their duration; while its opposite term, chronic, has reference to duration only. Use, however, has given them a technical sense which is not liable to be mistaken.
[2]The termschronicandacuteit may be well to define for the benefit of some of my non-professional readers. An acute disease is one which runs its course in a short time. A chronic disease, on the other hand, is one which has a long duration. For example, pneumonia, (commonly called lung fever,) is an acute disease of the lungs, while consumption is a chronic disease of the same organ. The term, acute, has reference to the violence of the symptoms of the diseases to which it is applied, rather than to their duration; while its opposite term, chronic, has reference to duration only. Use, however, has given them a technical sense which is not liable to be mistaken.
[3]This subject may be found fully illustrated by Dr. Bigelow in the Annual discourse for 1835, before the Massachusetts Medical Society.
[3]This subject may be found fully illustrated by Dr. Bigelow in the Annual discourse for 1835, before the Massachusetts Medical Society.