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PHYSICIAN AND PATIENT.




  PHYSICIAN AND PATIENT;

  OR,

  A PRACTICAL VIEW

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  AND THE

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  BY WORTHINGTON HOOKER, M.D.

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PREFACE.


A few words may be proper in explanation of the objects for which
this book was written.

The forms which quackery assumes are endless; but the material out
of which they are evolved is essentially the same in all ages and in
all countries. There are certain medical errors which are common to
man everywhere and in every condition. It is these which constitute
the material of quackery, whether it appear among the savage or the
civilized, the rude or the refined, the illiterate or the learned.
One object of this book is to develop these fundamental errors,
and to show the _modus operandi_ by which the genius of imposture
has produced from them the fantastic and ever-changing shapes of
empiricism.[1] I notice particularly some of the specific forms of
quackery which are now prevalent, not because they differ essentially
from those which have preceded them, but because they have a
_present_ interest to the reader.

One of the objects at which I aim is to expose to the public the
fallacy of those sources of evidence, upon which they rely in
estimating the comparative merits of physicians, and to show them
what tests they have at command, which will not prove fallacious.
The proper use of these tests would save the public from mistaking,
as they now often do, the plausible pretensions of the superficial
practitioner, and the charlatan, for the evidences of real skill and
wisdom.

Another object will be to present the claims of the medical
profession to the respect and the confidence of the community. As it
now is, the profession stands in a somewhat false position before the
public. The grounds upon which we ask their regard and trust are not
generally understood. The confidence which is reposed in us is not as
intelligent as it should be. It is unsettled and capricious. It is
overweening at one time, and it is entirely withheld at another, and
for the most frivolous reasons. The inconsistencies of even the well
informed on this subject are surprising. Many, who on some occasions
confide implicitly in nothing but educated science, are found at
other times submitting themselves and their families to the haphazard
administrations of empiricism.

But while I attempt to establish the claims of the medical profession
to the confidence of the people, and to defend it against the
aspersions which are unjustly cast upon it, I endeavor to exhibit
faithfully the abuses which exist in the profession itself. The
quackery which is practised among medical men is a much greater evil
than that which is abroad in the community. I attack it therefore
with an unsparing hand. In so doing I expose many of the tricks and
manœuvres which are employed by those physicians, who, pursuing
medicine as a _trade_ instead of a profession, study the science of
patient-getting to the neglect of the science of patient-curing. When
the rules of an honorable professional intercourse shall come to be
properly understood and appreciated by the public, one of the great
sources of the success of quackery will be removed.

In exposing the errors and faults of the medical profession and of
the public, while I have unflinchingly aimed at the truth I have
endeavored to avoid a censorious spirit, and to give to human frailty
all the tolerance that can properly be demanded. I trust the reader
will therefore find, that, in the language of my motto, “there are
no wasps, there are no hornets here.” That I have escaped all error
myself I do not claim. Some points may be too strongly stated, and
some provisionary and modifying considerations may be omitted. I
ask of the reader a reasonable indulgence, but none which shall be
inconsistent with an honest and candid criticism.

In the practice of medicine there are some points upon which
there should be a common understanding between the physician and
the friends and attendants of the sick. From the want of such
an understanding the purposes and plans of the practitioner are
often interfered with, and sometimes are effectually thwarted.
A considerable portion therefore of this work is devoted to an
elucidation of the points referred to.

In the chapter on the uncertainty of medicine, and in other places,
also, I point out the difficulties which are encountered in the study
and practice of medicine. These difficulties demand of the physician
the exercise of higher and more cultivated powers, than are needed
for the successful prosecution of most other studies and pursuits. I
therefore make it a principal object to urge, by every consideration,
the importance of a well-educated medical profession. Every man
has a personal interest in maintaining the barriers by which the
organizations of the profession undertake to protect the community
from the evils, which they would suffer from ignorance and imposture,
if these barriers were destroyed. It is especially for the advantage
of the _people_, and not, as is commonly supposed, of physicians,
that there should be a proper standard of medical education.

My first chapter, on the uncertainty of medicine, may perhaps be
considered by some as too strictly professional for the common
reader. I ask for it, however, a careful perusal. I have endeavored
to strip the subject of all technicalities, and a full understanding
of the views there presented is necessary to a proper appreciation of
the considerations contained in some of the succeeding chapters.

I write in part for the profession, and in part for the community
at large. I ask both to look candidly at the views which I present
of their ‘_mutual duties, relations, and interests_.’ A reform is
needed in the opinions and practices both of physicians, and of the
people, in regard to medical subjects. This reform is fairly begun
in the profession, and there may be seen, even amid all the present
diversified and flaunting displays of quackery, some indications of
its commencement in the community. The volume which I now offer to
the public is a humble effort to promote this reform.

  W. HOOKER.

_Norwich, Conn., June, 1849._


FOOTNOTES:

[1] It will be obvious to the reader that I use this word, wherever
it appears, in its _popular_ sense, and not in its professional one.
I use it as synonymous with quackery.




CONTENTS.


  CHAPTER I.

  UNCERTAINTY OF MEDICINE,                                          25

  Importance of the subject. Definiteness of results in chemistry.
  Only a distant and humble approach to this possible in medicine.
  Illustration from chemistry. CAUSES OF THE UNCERTAINTY OF MEDICINE.
  1. Sympathy between different organs; 2. Symptoms produced at a
  distance from the seat of disease. Disease extended by sympathy.
  Transposition of disease from one organ to another. 2. Influence of
  unseen or secret causes. Nature of many causes of disease unknown.
  Combination of many agencies in producing disease, some of them
  having acted a long time. Cases rendered complex by treatment
  before physician is applied to. 3. Natural changes in the system
  arising from the curative power of nature, and from the principle of
  self-limitation in diseases. Illustrations of the operation of the
  _vis medicatrix naturæ_—vomiting to remove offending matters from
  the stomach—suppuration and discharge of a swelling. Tendency of
  diseases to come to a conclusion—more definite and regular in some
  complaints than in others. Mistakes from confounding the effects of
  remedies with the changes produced by these two tendencies. 4. Mental
  influences. Connection of mind with body modifying disease. Effects
  produced through the mind often attributed to physical causes and
  remedies. Case of the dyspeptic. 5. Individual peculiarities.


  CHAPTER II.

  SKILL IN MEDICINE,                                                50

  Show in what medical skill consists, in view of the uncertainty of
  medicine—_appreciating the condition of the patient in all respects,
  and applying remedies in the best manner to relieve this condition_.
  Errors impairing skill. Taking limited views of disease. Directing
  attention too much to particular organs. Undue attachment to certain
  modes of investigation. Difficulties in the way of deciding what
  it is best to do. Course of different physicians in view of these
  difficulties. Accurate proportioning of means and ends. Value of
  experience. Illustration of some of these points in the case of a
  sick traveller assisted by his friend in going through a mountain
  pass.


  CHAPTER III.

  POPULAR ERRORS,                                                   63

  False estimate of the importance of _positive_ medication. This
  error appears in various ways. Healing of wounds—anointed axe.
  Attributing effects to agencies just preceding them—_post hoc
  propter hoc_ mode of reasoning. Referring the cure of a case to
  some _one_ remedy or measure, when commonly the result of many.
  Disposition to have something done all the time. Disease considered
  often as a palpable thing—a humor—a poison—medicines supposed to
  neutralize it. Specifics. Supposed to be many—really few, if any.
  Definition. Inadequate ideas of the community of the necessity for
  discrimination in medical practice. Propensity to look for some
  universal catholicon. Disease supposed by some to be an unit. A sort
  of universality of operation attributed to favorite remedies, even
  sometimes among physicians. Dr. Beddoes’ gases. Physicians _correct_
  their errors by experience—the public only exchange one error for
  another in medicine. Changes in popular opinion in regard to quack
  remedies.


  CHAPTER IV.

  QUACKERY,                                                         80

  The grand source of quackery the false reference of effects to
  causes. The way in which a remedy, whether active or inert, acquires
  its reputation. Quack medicines principally of _three_ kinds. 1.
  Evacuants. Great similarity in these—made up mostly of articles
  in common use. 2. Those which are supposed to act upon the system
  in a gradual way, as alternatives. Preparations of sarsaparilla.
  Impositions. 3. Those which are supposed to act especially upon the
  lungs. Harm done by their indiscriminate use. Quantities of inert
  and damaged articles used in preparing quack medicines. Importance
  of the _name_ of a medicine in giving it currency. Ridiculousness
  of quack advertisements. Certificates. Chiefly of _four_ kinds. 1.
  Forgeries. 2. Essentially, sometimes wholly, untrue. How obtained. 3.
  Those given by invalids imagining themselves to be relieved. 4. Those
  given by invalids who are relieved while taking the medicine—inferred
  to be done _by_ the medicine. Certificates of clergymen. Rule of the
  medical profession in regard to nostrums. Proposed mode of guarding
  against imposition. Quackery as a monstrous business interest.
  Press and legislatures trammelled by it. Itinerant quack lecturers.
  Lectures especially to the ladies. Animal magnetism. Paracelsus
  the “prince of quacks.” St. John Long. Perkins’ tractors. Forms of
  Quackery many, but the materials from which they are formed always
  the same. No discoveries have ever been made by quackery.


  CHAPTER V.

  THOMPSONISM,                                                     103

  Principles of the system as promulgated by its founder. Bold
  confidence of Thompson in his mode of practice. Points in his
  theory. Obstructed perspiration. Strife between the heat and the
  cold. Simplicity of the system. No need of “learned doctors.”
  Thompsonian views of the _modus operandi_ of medicines. Radicalism
  of Thompsonism. Prejudice against mineral medicines. No article
  injurious simply _because_ it is mineral. The most deadly poisons
  in nature vegetable. Effects of vegetable poisons generally as
  abiding as those of mineral. Lobelia a poison, sometimes fatal,
  though Thompsonians claim it to be perfectly harmless. Definition
  of _poison_. Some poisons more rapid than others in their effects.
  Poison sometimes used in a relative sense. This word one of the
  watch-words of Thompsonians, though they daily use poisons as common
  articles of food. Changes in Thompsonian practice since the system
  was first promulgated.


  CHAPTER VI.

  HOMŒOPATHY,                                                      120

  Brief notice of the founder of Homœopathy. His exalted ideas of his
  “discovery.” Two principles in his theory. 1. _Like cures like._
  According to Hahneman there are three modes of practice—allopathic,
  antipathic, homœopathic. The last alone truly successful, according
  to him. The name allopath wrongly bestowed by Hahneman upon
  physicians. 2. _Minute division, with agitation and trituration,
  communicates a new power to medicines._ Subdivision very minute, and
  extremely particular directions given by Hahneman for effecting it.
  Whether such a power is thus communicated to be decided by facts.
  “Observations” on which the opinion is founded. Character of them
  illustrated from Jahr’s manual. Their extreme minuteness. Mode of
  collecting them. Based upon the ridiculous idea that all states of
  the body are to be referred to the remedy taken. Notices of some
  particular remedies in illustration. Alleged success of Homœopathy.
  _Apparent_ success to be attributed to six causes. 1. Mental
  influence. 2. A strict regard to diet and regimen. 3. Operation
  of the _vis medicatrix naturæ_, or curative power of nature. 4.
  Comparisons made between the results of homœopathic practice and
  those of over-dosing physicians. 5. An occasional stealthy use of
  remedies in ordinary doses. 6. The facility with which people are
  deceived in regard to comparative results. Parallel case of a German
  clergyman. Empty boasts of homœopathists as to the character of
  their physicians. Points of resemblance and of difference between
  Thompsonism and Homœopathy.


  CHAPTER VII.

  NATURAL BONE-SETTERS,                                            146

  Setting of bones wholly mechanical. There cannot be an _innate_ skill
  in this, any more than there can be in any other kind of mechanics.
  Explanation of bone-setting. Skill obtained in this just as in
  anything else. Bone-setter _learns_ all that he actually knows, by
  his own observation, and from others. It is not _born_ with him.
  Gets some of his knowledge by stealth. _Errors committed by natural
  bone-setters._ Supposing a fracture to be a dislocation. Injuries
  of joints in which there is neither dislocation nor fracture—harm
  sometimes done in such cases by the bone-setter. Failure in the
  _medical_ part of the treatment in some cases. Failure in the
  management of fractures. Physicians not all good bone-setters.
  Mechanical tact requisite. Though so many cases of mal-practice
  can be found among the patients of natural bone-setters, generally
  supposed by the community to be infallible. Difficulty in getting a
  verdict of damages against them. _Reasons why they, in spite of their
  errors, acquire a reputation for skill._ Setting sprains. Facility
  of the imposition practised. Breaking up old adhesions. Stiff joints
  and contracted tendons—efficacy of rubbing. Imagined tenderness and
  inability of motion. Sub-luxations—random pulling. False reports of
  cases.


  CHAPTER VIII.

  GOOD AND BAD PRACTICE,                                           172

  Not easy to distinguish between good and bad practice by results. If
  it were, would not be such differences of opinion among physicians
  and in the community. Examples of these differences. Stimulating and
  depleting measures. Homœopathy, Hydropathy, Thompsonism. Quacks aware
  of the difficulty in estimating comparative results—act accordingly.
  No mode of practice wholly good—none wholly bad. Some good points
  in all modes. Exclusive systems. Distinctions between good and bad
  practice pointed out. Cases in which the question of life and death
  immediately affected by practice. Failure of unskilfulness in such
  cases. Interesting case. Seldom is the influence of bad practice so
  manifest as in this case. Difficulty of culling out from the mass
  cases which are dangerous from the first. Various causes of this.
  Difficulty inherent. Cases misrepresented by mistake or wilfully.
  Some said to be _very sick_ when not so. Light cases made bad by
  treatment—though appear grave, apt to recover. Illustrations.
  Comparisons between rival physicians as to results. Public often
  mistake in such comparisons. Notice some less direct effects of bad
  practice. Unnecessary complications of disease. State of system after
  recovery. General state of health in families. Length of sickness.
  Summing up of differences in results between good and bad practice.
  Two requisites for observing these correctly. 1. Sufficient amount
  of evidence. 2. Skill in observation. Community deficient in these.
  Confident appeals of quacks to alleged results. Show what the
  physician should say in regard to results.


  CHAPTER IX.

  THEORY AND OBSERVATION,                                          200

  All real knowledge based upon observation, not on theory. Facts
  of two kinds—individual and general. General facts ascertained
  by observation of many individual or particular facts. No theory
  founded on facts—always goes beyond them. No science in which there
  has been so much theorizing as in medicine. History of medicine
  very much a history of theories. Office of theory—_suggestive_.
  Abuse of theory in failing to distinguish between the known and the
  supposed. Newton’s carefulness on this point. Circumstances impairing
  skill in observation. Mode of reviewing cases. Disposition to form
  conclusions from a limited range of facts. Young practitioners.
  Dr. Sewall’s plates. Dr. Sutton’s treatment of delirium tremens.
  Different theories of fever—Boerhaave, Cullen, Clutterbuck,
  Broussais, Cooke, Samuel Thompson. Hobby-riding. Diseases of
  the throat and windpipe. Habit of making loose and exaggerated
  statements. Credulity and fondness for novelty and change. Changeable
  state of medicine. No standard _authorities_ as in law and theology.
  Scepticism in medicine. _Easy to theorize—difficult to observe well._
  Value of good habits of observation. Medical men had too much to do
  with theories and modes and systems. Eclecticism. _Modus operandi_
  of medicines. A reform in progress in medicine. Breaking loose from
  theory. Promoting rigid observation.


  CHAPTER X.

  POPULAR ESTIMATES OF PHYSICIANS,                                 222

  No class of men so erroneously estimated as physicians. Object of
  this chapter to show how the community can judge of them correctly.
  Education of physicians—evidences of it. Medical education
  practically despised by a large portion of the public. Standing of
  medical man among his brethren criterion of merit. Difficulty in
  getting their unbiased opinions. Certain mental qualities essential
  to skill in the practice of medicine. How the common observer can
  detect and measure these qualities. _Observe them as exhibited
  in regard to subjects which he understands in common with the
  physician._ Illustration from surgery. Illustrations of same truth
  in relation to various characteristics of medical men. Formation
  of opinions—credulous—sceptical—hasty and changeable—cautious
  and tenacious—strong and ardent. How can test one’s habits of
  observation. Asking many questions no sure proof of accurate and
  minute observation. Enquiries of different physicians about an
  article of curiosity. Same rule for judging of the _measures_ of the
  physician, as we have applied to his opinions. A genius in medicine.
  Innate skill. Rules which have been pointed out for estimating
  comparative merits of physicians not in common use with the public.
  A change necessary in this respect. Cannot easily be effected. Many
  physicians would be opposed to such a change—would rather false tests
  continue to be applied. But the change can be effected.


  CHAPTER XI.

  MEANS OF REMOVING QUACKERY,                                      242

  The credulous, ignorant, and novelty-seeking, not the only persons
  imposed upon by quackery. Many of the judicious and intelligent
  also. Efforts to undeceive the public on this subject have been
  often faulty. Too much reliance on popular knowledge of anatomy,
  physiology, dietetics, &c. This should only be auxiliary to other
  means. Relied upon alone, leads to error. Individual influence of
  physicians in showing their friends their mistakes in connecting
  cause and effect in medicine. This influence to be exerted upon the
  intelligent who uphold quackery. Too much sarcasm and ridicule and
  invective used against quackery. Credulity of the public takes a
  license from that of medical men. Certificates of physicians in favor
  of nostrums. Secret medicines put forth by physicians. Spirit of
  quackery in the medical profession. Exhibited in various ways. Quite
  prevalent, crippling the profession in its warfare with empiricism.
  Reform needed. Can be effected. The stable and intelligent can help
  in effecting it, by promoting medical education—by sustaining the
  organizations of the profession—by renouncing fallacious means of
  estimating professional merit—by favoring strict observance of the
  rules of intercourse among physicians. Formation of the American
  Medical Association, an important movement in the destruction of
  quackery.


  CHAPTER XII.

  INTERCOURSE OF PHYSICIANS,                                       258

  Erroneous views in regard to consultations. “Jury of doctors.”
  Dictation not consultation. Giving opinions in relation to the past
  treatment. Offices of the _consulting_, and of the _attending_
  physician defined. Freedom in consultation necessary. Between
  enemies, useless. Should be alone in consultation. Intrigues of
  dishonorable practitioners. Supposed want of agreement—favoring the
  impression for base purposes. Attributing changes, good or bad, to
  some remedy for selfish ends. Failing to defend a medical brother
  when circumstances fairly demand it. Making comparisons between
  cases. Undue attentions to the patients of others. Conduct of some
  when called to see the patient of another in case of unnecessary
  alarm. Physicians supposed to be too much attached to etiquette.
  Not so usually. Differences and quarrels of physicians—circumstances
  giving rise to them. Facility with which deception is practised
  in medicine. Peculiar relation of the physician to his employers.
  Cliques. Sectarian and other associations. Avoiding quarrels.
  Relations of elder physicians to their brethren.


  CHAPTER XIII.

  INTERFERENCE WITH PHYSICIANS,                                    275

  Confidence which one feels in his physician no reason for
  disparaging others. Interference proper in some cases—quackery—gross
  ignorance—intemperance. Reckless attacks upon professional character.
  The lawyer rebuked. Free canvassing of the merits of physicians not
  improper. Interference in the sick room. Destroying confidence.
  Recommending medicines. Restricting physicians as to remedies
  employed. Frequency of physician’s visits to be mostly left to him.
  Anxiety of friends of the sick often embarrasses the physician. Case
  of the wife of Napoleon. Harrassing practitioner with inquiries and
  criticising his practice distract his attention, and therefore foil
  his skill. Same effect produced by the same causes in regard to other
  subjects. Criticised clergyman. Watched juggler. Defects in these
  analogies.


  CHAPTER XIV.

  MUTUAL INFLUENCE OF MIND AND BODY IN DISEASE,                    288

  Inadequate views of this influence prevalent. Importance of
  understanding it. Connection of mind and body. No proof that mind
  is essentially indestructible. Manifestations of mind connected
  with and dependent upon the material organization. Brain in some
  sense seat of mind—central organ of the nervous system, with which
  mind is connected. Other subordinate nervous centres. Bichat’s idea
  of the seat of the moral sentiments. Weakness of mind in sickness.
  Slight causes affect it strongly. Importance of quiet in sick
  room. Difficult to secure it. Visitors. Conversation. Children as
  easily disturbed as adults. Holding up physician as a bugbear to
  them. Exciting the mind commonly irritates bodily disease, whether
  in the brain, or in some other organ. Death of Hunter caused by a
  fit of passion. Duty of physician sometimes to excite the mind in
  various ways and degrees. Influence of imagination upon the body.
  Use to be made of mental _association_ in the treatment of disease.
  _Diversion_ of the mind. Influence of change of scene on the invalid.
  Monotony of sick room. Settled gloom with which the sick sometimes
  afflicted. How removed. Want of tact in managing whims of the sick.
  Notional dislikes. Fretfulness and impatience. Deranged sensations
  erroneously supposed to be mere imaginations. Importance of a
  faithful study of mental influences to the physician.


  CHAPTER XV.

  INSANITY,                                                        320

  Two classes of causes—those which act upon the mind, and those which
  act upon the body. Insanity always, strictly speaking, a disease of
  the organization. Too much disposition to look to some one thing
  as the cause. Tables of causes in Hospital reports. _Form_ of the
  insanity not necessarily indicative of its cause, or of the character
  of the patient. CAUSES OF INSANITY. Indulgence of passions. Wrong
  views of life. Exclusive and prolonged attention to one subject.
  Insanity rare among savages, and those under despotic governments.
  Great prevalence in this country. Religious excitement. Debilitated
  system predisposing to insanity. Intemperance. Children seldom
  insane, though very liable to temporary derangement in sickness.
  Foundation of insanity, however, often laid in childhood. _Forms
  and signs of insanity._ Cases in which the disease comes on slowly.
  Monomania. _Moral_ insanity. Treatment of the insane. Change produced
  by Pinel. ADVANTAGES OF RETREATS OR HOSPITALS. 1. Removal of patient
  from the _associations_ under which his insanity originated. 2.
  Judicious medical treatment. 3. Better mental and moral management
  than can have among his friends. Mistakes of friends of the insane
  in their management. Reasons why insane apt to dislike their nearest
  friends most. Helplessness of insane poor. Duty of the State in
  regard to them. Legal relations of insanity. Absurd and inconsistent
  opinions and practices of our courts of justice. Professional
  evidence in France, and in this country, when prisoner suspected of
  insanity. Insane often been executed. Plea of insanity. Importance
  of _preventing_ the acts for which the insane are brought before our
  courts as criminals. Laws deficient at this point. Necessity of a
  commission of lunacy.


  CHAPTER XVI.

  INFLUENCE OF HOPE IN THE TREATMENT OF DISEASE,                   344

  Physician’s employment a cheerful one. Contrary opinion quite
  prevalent, but erroneous. Cases in which he can neither cure nor
  palliate few. Prevailing cast of physician’s mind, therefore,
  hopeful. Hope should always be based on intelligent grounds. Hope
  in the different stages of a case. Seldom should all hope be given
  up—even in apparently desperate cases recovery sometimes occurs.
  Interesting case. Hope a cordial—as necessary as the cordial draught,
  and as improper to withhold it. Giving false _assurances_ wrong.
  Often done by quacks and quackish physicians. Views and feelings
  of patients in regard to prospect of death often misunderstood.
  Extinction of all hope of recovery not commonly desirable in cases
  certain to be fatal. This extinction of hope not essential to perfect
  resignation. Influence of collateral circumstances upon the manner in
  which death is met. Occasional pauses in the onward progress of fatal
  chronic disease. Duty of the physician in regard to the hope awakened
  at such times. Supposed salutary moral influence of the certain
  expectation of death. Tendency to hope in consumptive patients.
  Curability of consumption.


  CHAPTER XVII.

  TRUTH IN OUR INTERCOURSE WITH THE SICK,                          357

  Variety of opinion and practice on this subject. Percival’s views
  in his Medical Ethics. Advocates falsehood. Object of this chapter
  to present the practical considerations bearing on this subject,
  illustrating them with cases. 1. Knowledge concealed from the
  patient by falsehood it is wrong to assume would certainly do him
  harm if communicated to him. 2. Deception as commonly practised
  generally fails to be carried out. Case of the deceived child. 3.
  The discovery of the deception, when it takes place, has a worse
  effect on the patient than a full statement of the truth could
  produce. 4. Destruction of confidence occasioned by discovered
  deception injurious to the persons deceived. Children. The insane.
  Detected deception not only increases insanity, but modifies it. 5.
  _General_ effect of deception, extending beyond the individual on
  whom it is practised. General distrust of the veracity of physicians.
  6. If adopted as a common rule that deception is sometimes proper,
  the object of the deception would be defeated. 7. If the door for
  deception be once opened there is no limit. Though proper sometimes
  to withhold the truth, wrong to put falsehood in its place. Enquiries
  of the sick not always to be directly and fully answered. Too
  definite opinions often given by physicians.


  CHAPTER XVIII.

  MORAL INFLUENCE OF PHYSICIANS,                                   383

  Intimate relation of physician to his patients. Mutual confidence.
  Abuse of confidence. Guilt of it, especially in case of females.
  Sympathy of the physician—active—grows constantly stronger and more
  tender. Self-control mistaken for want of feeling. Manifestations
  of feeling—surgical operation. Certain nervous effects erroneously
  supposed to be evidences of feeling. Sympathy of the physician a
  means of influence. Physician at home everywhere. Opportunity of
  studying every variety of character. Physicians often fail to exert
  the influence which these advantages enable them to do. Influence on
  moral questions. Temperance. Acting as a peace-maker. Influence of
  daily conduct—little hourly acts. Physician in sick room. Communion
  with the spirit in its most momentous hours. Physician’s great
  object to cure the patient—nothing should interfere with it. Cordial
  influence of hope. Little confidence to be placed in death-bed
  repentance and reformation. Opportunities of doing good in lingering
  chronic cases. Mode of doing it. Injudicious intercourse with the
  sick. In some cases duty clear—in others, doubtful. Conference
  between physician, clergyman, and friends. Opportunity of doing
  good in convalescence. Moral influence of the physician in his
  strictly-professional character.


  CHAPTER XIX.

  TRIALS AND PLEASURES OF A MEDICAL LIFE,                          404

  Great mental and bodily toil. Irregularity of life. No command
  over time. Exposure to causes of disease. Physicians a short-lived
  class. Compensation generally small. Medicine not a money-making
  business. Less obligation felt by many to pay physician than to pay
  others. Physician often obliged to see the quack and hobby-rider
  getting rich by their impostures. Facility with which the people are
  imposed upon, a great trial to the honorable practitioner. Especially
  so when imposition is practised by his brethren. Valuable lives
  sacrificed to ignorance and unskilfulness. Witnessing sad scenes.
  Mutual sympathy and confidence add in such cases to physician’s
  sorrow. Irreligion and vice at hour of death. Frequency of sad
  scenes in times of pestilence. Ingratitude of those on whom the
  physician has conferred favors. Services of faithful physician not
  to be measured by pecuniary considerations. Dismissing physician
  for frivolous or improper reasons. Not so much gratitude in the
  world as commonly supposed. Virtuous and vicious poor. Clergymen
  generally attended upon gratuitously. What, therefore, is due from
  them to our profession. Conduct of some of them. Want of respect
  to the medical profession, on the part of the community generally.
  Public ingratitude. _Pleasures of a medical life._ Medicine as a
  science, full of interest. Its intimate union with other sciences.
  Enthusiasm in its pursuit. All discoveries, however small, add to the
  capabilities of the medical art in relieving misery and prolonging
  life. Pleasure in unraveling the perplexities of medical practice—in
  guiding and assisting Nature’s processes when salutary, and in
  arresting them when not so. Mental management of the sick. Results
  of practice of the judicious physician gratifying. The physician a
  hopeful, cheerful man. Gratification of his humanity and benevolence.
  His attachments. His social enjoyments. His opportunity for exerting
  a good moral influence.




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, for _they_ are 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 distinction which 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 the _vis 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 way other 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 in some 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
the application 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 make
_impressions_ merely 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. _These_ do 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 severe
symptoms 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
his sickness 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 and systematic 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 measures _chance_
to benefit his case, (as _anything_ may _chance_ to 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 at
_haphazard_, 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
demand of 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 watch _his_ tests, 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
to _fasten_ the 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 the _vis 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 that it 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, the _vis
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
of _their_ cures, as if they were wholly theirs, this _vis medicatrix
naturæ_ is 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 the _vis 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 call _suppuration_. When this process is properly
performed, good pus is made, or as the old writers in medicine rather
quaintly expressed it, _laudable_ pus. 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. When the 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 the _nature_ of 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 that can 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 recovered _in spite of them_, because that
same blessed _vis medicatrix naturæ_ came 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 of _certain_ cures 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 which ended
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 testimony of 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 for the 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 or
_idiosyncrasies_, 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 supposed that 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 succeeded at 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 terms _chronic_ and _acute_ it 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.




CHAPTER II.

SKILL IN MEDICINE.


The uncertainty of medicine is often most unjustly made to give a
free license to blind experimenting. It should the rather stimulate
to the most careful and searching observation of all the doubtful
points of the case in hand, so that whatever of experimenting may
be necessary, shall be as rational and intelligent as possible.
This leads me to remark, that the views, which we have taken of
the uncertainty of medicine, show us in what real skill in the
practice of the medical art consists. It consists in _appreciating
the actual state of the patient in all respects, and then applying
such remedies, and in such quantities and forms as will do the
greatest probable amount of good_. This is apparently a very simple
proposition. But if we consider it in all its bearings, we shall
find that more is included in it than at first sight appears. I will
therefore dwell on some of these points in the order in which they
are suggested to my mind.

Appreciating the true condition of the patient does not consist
merely in finding out the seat, the nature, and the amount of the
disease. This is exceedingly important, it is true. But it is by no
means all of the case. Sometimes it is but a very partial view of
it. For example, suppose that the patient has an inflammation of
some organ, and to make the case stronger, let it be a _chronic_
inflammation. In chronic diseases, as you have seen, there are
extensive results from sympathy and from the action of concurrent
causes in different parts of the system. The physician, in
investigating such a case, in order to proportion his curative
measures with any accuracy to the ends to be accomplished, must look
beyond the main disease, and take into view the whole case, the state
of the different organs, and the state of the system as a congeries
of organs.

A disregard of this important point is very common, and leads to many
errors in practice. Let us look at a few of them.

Many physicians are disposed to consider the morbid state of
the system in almost every case as arising from disease in some
particular organ. They therefore, in examining the symptoms, search
for this disease; and when they think that they have found it, they
refer to this, either directly or indirectly, all the phenomena
which the case presents. In their treatment of the case, therefore,
they direct their remedial means principally to the local disease.
They lose sight of the fact, that often there are several organs
simultaneously affected, and that the organ which seems to be most
diseased is sometimes found to be less so than some other organ,
which exhibited no marked signs of its morbid state. They forget
too another important fact—that the disease of an organ is often a
mere result of a general bad condition of the system. If in such a
case the physician considers the local disease the main thing to
be attacked by remedies, and directs his efforts to that point, he
commits a great error. And this is an error which occurs, I have
no doubt, very often in regard to the most common of all chronic
complaints—consumption. The local disease is a result, and not a
cause, much more often than is generally supposed, even by physicians.

Some physicians acquire exclusive and narrow notions of disease,
by having their attention particularly directed to the diseases of
certain organs. They get a sort of attachment to some localities
in the system, and are disposed always to look to their favorite
quarters in their search after the seats of disease. With such an
inclination it is no wonder that they often suppose an organ to be
the seat of fixed disease, which is merely sympathetically affected.

An undue attachment to certain modes of investigation, to the
exclusion of others, is also frequently a source of error. I mention
as an example a too implicit and exclusive reliance upon what are
called the physical signs of disease. Percussion and auscultation are
valuable sources of evidence, but when they are relied upon to the
exclusion of other sources, as is often the case, they lead to error.
Some who have attained to a high degree of skill in the use of the
stethoscope, have on this account sometimes adopted very erroneous
conclusions, which might have been avoided by a careful examination
of _all_ the sources of evidence in the case.

Having pointed out some of the errors produced by narrow and
exclusive views in the investigation of the symptoms of disease, let
us now attend to some of the errors which result from this cause, in
the _application of remedies_.

A remedy may be applicable to a disease which the physician finds
developed in a given case, but there may be some condition of some
organ, which may render it wholly inapplicable to that case. For
example, in a case of inflammation of the lungs, the state of the
stomach may be such as utterly to forbid the use of some remedies,
which would otherwise be proper. If they be administered in spite
of this circumstance, they may perhaps produce a beneficial effect
upon the inflammation, and yet may do a great injury to the patient,
perhaps even a fatal one, by their direct effect upon the diseased
stomach. Errors of this kind do often occur in the practice of those
who observe inaccurately, or who have fallen into a sort of routine
of practice from disinclination to mental effort.

The general condition of the patient sometimes fails to be
appreciated by the practitioner. He may be pursuing a course which
would be admirably adapted to cure the same disease in a more
vigorous patient, and yet in the case in hand it may be ruinous.
Though it may relieve and even cure the disease, it yet may destroy
the patient. The judicious physician in some cases feels obliged
to let morbid processes go on, because the violence which must
necessarily be done to the debilitated system by the attempt to
arrest them, would put the patient’s life in greater jeopardy, than
it would to let them have their course. Questions frequently arise
on this point, which tax the physician’s skill and judgment to the
utmost. Even when it is proper to moderate the activity of a diseased
process, it is often a very delicate point to determine just how far
this can be done without doing harm to the patient. Fever is often
moderated by means that irritate the system, or prostrate its powers
to such an extent, that bad results, sometimes fatal ones, occur;
when, if these means had been used less largely, or perhaps even if
they had not been used at all, a recovery might have taken place.

Sometimes fearful issues depend upon the decision of the physician.
For instance, here is a case which has been going on for some
time without giving much occasion for anxiety; but all at once it
assumes a new aspect. A new set of formidable symptoms have come on,
requiring an entire change in the treatment. A variety of perplexing
questions now arise in the mind of the physician,—such as these.
If the attempt be made to remove the new symptoms, how much reason
is there to fear that that attempt will so affect the debilitated
patient as to destroy life? Severe as the symptoms are, is there
a probability that, if a mild course be pursued, the patient may
weather the storm? Will he certainly die if the symptoms are left to
go on without any attempt to arrest them? And if so, what measures
will probably arrest them with the least amount of risk to the
patient’s life? Such are some of the momentous questions which press
upon the physician’s mind; and, though he would like time to give
them a patient examination, he cannot have it; for there is necessity
for immediate decision and action. The reader can plainly see, that
in order to decide such questions under such circumstances properly,
great comprehensiveness and concentration of thought, and a cool and
clear judgment, are requisite; and that a mind of narrow views, and
loose habits of observation and reasoning, must often fail to come to
a right decision of them.

Some, in such circumstances, amid all the uncertainty that beclouds
this nice balancing of probabilities, will doubt and doubt, till the
time in which anything effectual can be done is past by; and the
patient dies without having a single intelligent effort put forth to
save him. Others, in their confusion of ideas, pursue a vacillating
course—at one moment inefficient, at another destructive; and no
rational and steady plan is adopted. Others still, without waiting
to consider the different questions which I have mentioned, see in
the new group of symptoms nothing but a new enemy to be attacked, and
plunge, at once, into the fight. A reckless course is entered upon,
which must either kill or cure.

The truly judicious physician, in contrast with all these, is
neither bewildered nor precipitate. He takes a rapid view of all the
circumstances of the case, and looks carefully at the important and
perplexing questions which start up one after another in his mind,
and then decides intelligently, coolly, and definitely upon his plan
of treatment. He may err, it is true; but if he does, it is not his
fault, for he has made use of all possible precautions to prevent
error. The plan which he fixes upon, he does not pursue obstinately,
as being, without a doubt, the best. While it is that which he
believes to be the best at the time, he watches its progress, and
if he see reason afterward to alter it, he does so. Aware of the
uncertainty of his knowledge, while he decides at every step what it
is best to do, he is ready to reverse that decision, and change his
course, whenever any new development in the case shall call for it.

Sometimes he decides that it is best to wait and watch the movements
of the case. Many seem to demand that he shall pursue an active
course of treatment all the time, to conquer the disease—that he
shall be keeping up a constant cannonade upon it from beginning to
end, not reflecting that if he do so, many of his shots must be worse
than lost. And some physicians yield to this demand, and pursue this
destructive course. The public call them bold practitioners; and
they do gain some apparently splendid victories over disease; but if
the results of their whole campaign (to carry out the illustration)
could be fairly estimated, they would be found not to deserve the
reputation for success, which is accorded to them. The prudent and
judicious physician, like the prudent and judicious general, fires
as few random shots as possible, taking good care, too, that he hit
none but enemies—husbands carefully all his resources—rests from his
battle with disease whenever it is best to do so, maintaining, for
the time, a “masterly inactivity”—retreats when he finds his line
of movement is likely to prove disastrous—calculates probabilities
as accurately as he can at every step, and endeavors to make every
measure tell upon the great result, avoiding, as far as possible,
those which will not, and especially those which will hinder or
defeat it.

Sometimes the physician finds that he must be satisfied for the
present with but a partial view of the case before him. He sees
that there are some agencies at work, which are hidden from his
view. Under such circumstances, while the careless and adventurous
practitioner makes up his theory of the case confidently, and acts
upon it, supplying what is not known from his own imagination, and
mingling all together in one confused mass; the judicious physician,
on the other hand, cautiously distinguishes between what he actually
knows and what may be supposed, acts upon this knowledge, and watches
for farther developments to clear up what is doubtful. He treats
the case according to the indications of the presenting symptoms,
carefully scrutinizing the effects of his remedies. Perhaps he
succeeds in cutting off at first some of the tributaries of the
disease; and, by so doing, patiently and perseveringly, he at length
comes at the main disease—the starting point of the whole case.

In pointing out the characteristics of medical skill, allusion was
made to the quantities and forms in which remedies are administered.
These must, of course, be varied to suit each individual case.
Sometimes a very nice adaptation is necessary, especially in regard
to quantity. A remedy, which is appropriate to a case, may be given
in such a quantity as to be injurious. The use of a medicine may be
continued too long. It may have accomplished all the good that it
can; and the continuance of it will do harm, perhaps even beyond the
undoing of all the good which it has effected. Sometimes a change
occurs in the condition of the patient of such a character, that a
remedy, which has been up to that time beneficial in its influence,
will now produce bad results. Medicine is often continued under such
circumstances. Such are some of the errors to which the physician is
liable in regard to the quantity of medicine to be given, if he be at
all loose in his habits of observation.

Perhaps there is no one thing in medical practice in which failure
is so common, as in the accurate proportioning of remedies to the
condition of each case. A physician may discover very clearly the
nature of the malady, and decide with great correctness upon the
appropriate medicines, and yet, may err after all in applying these
medicines in the proper amounts, and at the proper intervals. The
variations, in these respects, required by different cases, have a
wide range—some demanding large doses to produce the needed effects,
and others being strongly affected by small ones. In some cases of
severe pain, for example, very large doses of opium in some of its
forms are necessary to give relief; while, in other cases, in which,
perhaps, the pain is by no means slight, quite small doses accomplish
the purpose. Similar variations in the quantities of remedies, are
required by other circumstances, which are less obvious in their
indications on this point, than so palpable a symptom as pain is. The
contingencies on which these variations depend, are often, indeed,
so uncertain and so secret, that they elude the most watchful and
patient investigation, much more that which is hasty and careless.

Experience gives to the shrewd and judicious physician a sort of tact
in detecting these contingencies, and in so modifying his practice
as to meet with some good degree of fitness the various indications
which they present. This tact is to be acquired at the bedside of
the sick, by patient watching of the workings of disease, and of the
influence of remedies upon it; and though the experience of others is
a valuable auxiliary in acquiring it, it is only an auxiliary, and
cannot communicate it alone. There are a thousand little things that
are observed in watching disease from day to day, which materially
influence the physician in the details of his treatment, but which it
is impossible to record in the history of the case. It is therefore
peculiarly true of the wise and skillful physician, that when he dies
much wisdom will die with him. And the student of medicine always
finds, when he comes to actual practice, that disease, in the sick
chamber, is a very different thing from what he supposed it to be
when listening to descriptions of it in the lecture-room. One of the
first lessons that he learns is, that the long troup of maladies,
arranged in the syllabus of the professor, gives but a faint idea of
the various and Protean shapes of disease, as they appear before him,
in all their complications, with mingled and confused lineaments,
instead of the distinct ones with which they are necessarily
described in books and lectures. He sees that the general principles
which he has learned, are to be applied with almost endless
variations; and that a searching and ever-vigilant observation is
needed to apply them aright.

The points which I have endeavored to elucidate, in regard to skill
in the management of disease, are very commonly disregarded by
the community, and too often even by physicians. To impress them
more vividly upon the mind of the reader, I will resort to an
illustration, in which some of the same principles are applied to
quite a different matter.

Two travellers are wending their way through a mountain-pass to their
home. Their path is a perilous one; now lying along on the very brink
of a precipice, and now across a succession of points of rock, with
an abyss yawning below. Often the foothold of the traveller is but a
slight one, and would scarcely suffice were there not some shrub near
by that could be caught hold of, or some projecting point of rock on
which he could hook his fingers. One of the travellers is weary and
sick, and the other is helping him along. The shades of evening have
come on, and the flying clouds occasionally obscure the light of the
moon that shines upon their path.

It needs a watchful eye, a strong arm, and a firm foot, to go through
this pass with safety, even by broad daylight. How fearful, then, are
the dangers that threaten the sick traveller? If he were alone, he
could not possibly get to the journey’s end. He would fail to reach
some foothold, or would let go his grasp upon some shrub, or totter
from some giddy height, and be dashed to pieces. His companion sees
the difficulties of the task before him, and bidding the poor sick
man to be of good cheer, nerves himself for labors that will tax all
his strength and all his skill.

See how varied is the assistance which he renders! Now he is before,
with outstretched hand raising him up; and now behind, doing the
same office, while the feeble man clings to some branch, or to some
projecting point of rock. Now you see him gently supporting his
tottering steps, as he leads him slowly along a narrow path on
the edge of a precipice, where, if he but stumble, he is lost. The
effort is now but a slight one; but it requires caution, firmness,
and skill. And now there is needed a strong, almost an Herculean
effort. He must raise him to the top of a rock just large enough to
stand upon, and there let him rest a moment, so that he may step
carefully to another rock which offers a secure resting-place. He
pauses before making the effort, to calculate with precision the
amount of force needed. He sees that if he come short of raising him
to the right spot even an inch, his feet may slip, and he is gone.
And on the other hand, if he use too much force, he may throw him too
far, and then he will plunge over beyond. His courage almost fails
him, as he sees the fearful issues—the issues of life and death, that
hang on that one effort. But it must be made. Uttering the cheerful
words of hope in his companion’s ear, with his whole frame roused
to its utmost tension, he makes the attempt. The poor man’s feet
just reach a jutting edge of the rock, while he catches with his
fingers upon another projection, and there he hangs. His strength is
almost exhausted; but he knows that if he lets go he is lost. His
friend presses his feet fast to the rock, and tells him to hold on.
Then finding some foothold by which he can raise himself a little
higher, he lifts his sick companion gently to the summit. There he
remains a few moments, trembling, and almost poised upon a point,
fearing to move, or even to look down from that giddy height, lest he
should slip off. But soon, with the little rest that he gets in this
perilous situation, and encouraged by the firm and cheerful voice
of his friend, he steps to the next rock, where a broad and sure
foothold enables him to pause and recover his little strength, which
was well-nigh exhausted by his anxiety and his exertions.

The path is now an easy one for some distance, but soon they
are confronted by a high crag, up which they must clamber. It
looks gloomy and formidable in the dim and fitful light of the
partially-obscured moon. The sick man’s heart almost dies within him,
as his companion eyes narrowly the small footholds which are notched
up its steep side. Some of them he sees but faintly; but soon the
full light of the moon, through the breaking clouds, shows him every
notch with distinctness. He calculates their distances in a moment,
and as his eye runs upward to the top, he plans out the whole of his
ascent. In an instant he seizes his friend; and, again bidding him be
of good cheer, tells him to place his foot in the first notch, then
raises him gently, but firmly, to the second, and so on to the summit.

It is thus that the sick man, aided and cheered by his friend, after
going through with many narrow escapes, at length reaches his home.

The points of resemblance between this journey and the journey of
sickness, are sufficiently obvious to suggest themselves at once
to the minds of my readers. The journey of sickness has sometimes
the same variety of peril, and demands of the physician the same
variety of assistance, to suit its various stages and conditions.
His efforts, in rendering this assistance, must sometimes be strong
and sometimes gentle; sometimes bold and sometimes cautious; always
careful and never precipitate. The uncertain and varying light,
shining upon the path of the traveller, has its counterpart in the
journey of sickness; and sometimes the darkness is so great, that
the physician must stop short, and not move at a venture amid such
perils. There are times, too, when the light breaks through the
clouds of uncertainty that hang over his path, and his eye must be
open and ready, as was the traveller’s, to discern all that the light
may reveal of that which lies before him.

Often, in most of the journey of sickness, a gentle, but firm support
and guidance are needed, on the part of the physician, just as it was
in the case of the traveller, when the path lay along the edge of a
precipice; and here, in the one journey as well as in the other, an
officious and hurrying assistance might prove ruinous. Then there are
times (and fearful times they are) when the physician sees, as did
the sick man’s companion, that while mighty efforts are required of
him, even a slight error in regard to the right proportion in those
efforts, may prove fatal. And, as the traveller found occasionally
some broad and sure resting-place, where his friend could recruit his
wasted energies after a severe effort; so in the journey of sickness
there are such resting-places, and the physician must take care to
give his patient the benefit of them, and not run the risk of an
entire exhaustion of his powers, from too much anxiety to hasten to
the journey’s end.

One more point of resemblance, and one which I deem of no small
importance, I will barely notice. As the sick man, in all the way
through the mountain-pass, was encouraged by his friend, so should
the physician cheer his patient with his hopeful voice and manner,
amid all the gloom and peril of the journey of sickness; and should
hold out to him, in all seasons of despondency, so far as truth will
allow him to do so, the hope that he will at length reach the end of
that journey in safety.




CHAPTER III.

POPULAR ERRORS.


My intention in this chapter is to notice some of the popular errors,
which have resulted from the uncertainty of medicine.

One of the most common of these errors is a false estimate of the
importance of _positive_ medication. This error appears in a great
variety of forms. I will notice a few of them.

A patient once avowed to me the opinion, that in all cases of
recovery from sickness, the recovery is to be attributed to medicine,
and that nature never cured anybody of anything that could properly
be called disease. Though this error is seldom carried to such a
point of ultraism as this, it does exist, to a great extent, even
in the medical profession, and it is exceedingly prevalent in the
community at large. It therefore exerts a great influence upon the
popular modes of the treatment of disease.

One of the most common examples of this false reference of a curative
result to the agency of medicine, is to be seen in the prevalent
popular notion in regard to the healing of wounds. The cure in
this case, is usually attributed to some healing property in the
applications made to the wounds. But the truth is, that the union of
the divided parts is effected entirely by a natural process; and
the only use of any applications, is to put the lips of the wound
in apposition, so that this process may be effectual in securing
this union. The popular error on this subject, is not as prevalent
now, as it once was, and the array of salves and ointments for the
healing of wounds, is fast passing away. At a time when this error
was in full favor with the people, some one broached the idea, that
the medicaments ought to be applied to the instrument that inflicted
the wound, instead of being applied to the wound itself. This new
mode of practice proved successful in comparison with the old, for
the plain reason, that the wounds thus treated were not subjected
to applications, which would irritate them, and thus interfere with
nature’s process of healing. It acquired a great reputation all over
England, and I believe, in other countries also; and the results of
the practice were triumphantly referred to as proofs of its success,
that were not to be gainsayed. It is related that in one case, in
which the wound became very painful, it was suggested that something
might have happened to the axe with which the wound was made, and
which had therefore been duly anointed with a healing salve; and as
the axe happened to be at some distance, a messenger was sent in
great haste, who found that it had fallen down from its place, and
the dressings were consequently deranged. Here was certainly the
cause of all the pain, and accordingly it was ascertained, that at
the very time that the messenger re-applied the salve to the axe, and
set it up in its place, the patient became perfectly easy![4]

As another very common example of an undue disposition to refer
results in the course of disease to positive medication, I would
mention the fact, that those who have the care of the sick, often
attribute any change that may occur, whether it be favorable or
unfavorable, almost as a matter of course, to the remedy that was
administered immediately before the change took place. They do this
sometimes when the medicine has not had time to produce any effect at
all. They do not reflect that some remedies act much more slowly than
others, nor that changes are often induced by other agencies than
the action of medicine. This error is met with every day, and the
cunning and dishonorable physician makes capital out of it whenever
he can. A physician of this character was once called to a case of
quinsy, in which the abscess in the throat was just ready to break.
Perceiving that here was a fair chance for making the “_post hoc,
propter hoc_” mode of reasoning subserve his purpose, he assured the
suffering patient that he had some powders, which were “sure to break
the quinsy.” While he was preparing some of them in an adjoining
room, the nurse came out and told him that they should not need his
powders, for the quinsy had broken. The wily doctor could not help
remarking in an undertone to a student, whom he was indoctrinating
in the _arts_, as well as in the science of medicine, “I wish that I
had been lucky enough to have got down one of my powders before that
quinsy broke.”

When one recovers from sickness, it is very common for his neighbors
and friends to inquire, what it was that cured him—as if there was
some one remedy that effected the cure. It is true, that in some
cases, the agency of some one medicine is so prominent, that it may
very properly be said to have been the cause of the recovery. But
this does not often happen. In the great majority of cases, the cure
is to be attributed to the whole course of treatment, including many
different remedies and measures.[5] And very often the negative
portions of the course are of as much importance as the positive
remedies that have been given, perhaps even more so. Thus, in some
cases of inflammation of the eye, the exclusion of light is as
necessary to the cure as the leeching, the blistering, &c. So also
in inflammation of the brain, the exclusion of noise and excitement
from the room of the patient, is as essential as any of the positive
medication which may be employed.

The undue reliance which is placed upon positive medication is also
seen in the disposition, which is so very common, to demand of the
physician, that he shall be doing something all the time to overcome
the disease. They who make this demand, do not reflect, that in the
warfare with disease, as well as in every other warfare, there are
times to do, and _times also to rest from doing_. In some cases,
indeed, there are periods when it would be certain death to the
patient to employ any positive agencies of any amount, of power. It
was the remark of a shrewd old physician, who was often found fault
with for giving so little medicine, that it takes as much knowledge
to know _what not to do_, as it does to know what to do? This is an
important truth; and I have not a doubt that, in the practice of
every physician, who is disposed to give much medicine, sickness
often results in death in really curable cases, simply because he
did not know what _not_ to do, and therefore did what he ought to
have left undone. And yet those who drug their patients freely, are
more apt to satisfy the mass of the community, than those who place
less reliance upon positive medication. The friends of persons who
have died, often remark, as a matter of consolation, that they are
sure enough was done, that no means of relief that was suggested
was left untried, &c., not seeming to dream that it was possible
that too much was done. It appears sometimes to be the idea of the
friends of the sick, that one remedy after another must be tried,
in order to overcome the disease, until the effectual one is found;
and that all the remedies which fail in this trial, simply fail, and
do no positive harm. Accordingly, when any grave case occurs, they
are disposed to call in many physicians, one after another, with
the idea that “one may think of something that another did not.”
And they are satisfied with no one who is thus called in, unless he
recommend to the attending physician some medicine or measure, that
has not yet been tried in the case. If he recommend the lessening
of some medicine in quantity, or the discontinuance of it, this
does not satisfy such persons, though the change may be of so great
importance, that it may be justly considered as an entirely new
course of treatment—as really new as it would be, if a new set of
remedies were adopted.

It is a very common idea, that medicines have a sort of natural
relation to disease. This idea appears in different forms. Some
talk about disease as if it were a palpable thing, which is to be
attacked, to be hit, to be driven out, or drawn out from its hiding
place; and they suppose that there are certain remedies which are
calculated to effect these different objects. They therefore speak
of the drawing off of “bad matter,” by a blister, and of the “bad
blood,” which is taken from one by bleeding, as if the disease itself
in palpable shape, was abstracted in these ways from the system.

The most common of these palpable shapes which disease is supposed to
assume, is that of “humors,” as they are termed in popular language.
The disappearance of a “humor” is the _effect_ quite as often as it
is the cause of disease; and yet it is very difficult to make people
understand this—they persist in thinking it always to be a cause.
So also, if a patient, on recovering from any sickness, has some
eruption appear upon the skin, it is taken for granted, that it was
this “humor” that has been inside all the time, which has caused all
the sickness; and now that it has ceased to play its pranks among the
internal organs, and has come out, the patient as a consequence gets
well. It never enters their minds, that the eruption may be simply
a result of that revival of the energies of the system, which is
consequent upon its escape from the depressing influence of disease.

This idea of the palpable shape of disease gives rise to the popular
error, which is so prevalent, in regard to the necessity of getting
out _all_ the eruption in such diseases, as scarlet fever, measles,
&c. The idea is that there is a certain amount in the system, and
that this must _all_ be brought out upon the skin, or the patient
will suffer some bad consequences from this retention of morbid
matter. This notion is entirely erroneous. The eruption in such
cases is not the coming out or throwing off of diseased matter
contained in the system, but it is merely one of a succession
of processes in the natural course of the disease. It is indeed
necessary that this process should be well executed, and if the
natural energies of the system do not prove adequate, they should
be assisted by medicine. But ordinarily they are adequate; and in
comparatively very few cases, is there any need of any assistance
from art in bringing out the eruption. Most of the dosing so common
in scarlet fever and in measles, for this purpose, is worse than
useless—it aggravates the symptoms, multiplying and inflaming the
eruption beyond the necessities of the case, and it increases
the complications which are incidental to it. Death is often the
consequence of such officious interference with nature’s regular
processes.

Some talk about disease as if it were a poison, whose power
can be destroyed by the appropriate agents, very much as an
alkali neutralizes an acid. All medicines which do not have this
neutralizing influence are, in their view, mere palliatives. It is
this idea which lies at the foundation of the opinion, so often
expressed, that opium never cures any real disease, but merely gives
temporary relief. No opinion can be more erroneous than this. Opium,
in its various forms, is one of our chief means of _curing_ disease,
as well as of alleviating its sufferings. It is an effectual remedy
for many painful affections. For example, it is the great remedy for
spasmodic colic. There are auxiliary remedies, which can be used with
profit, it is true; but after all opium is the chief remedy. And in
the great majority of cases of disease, with which the physician
meets in his daily practice, opium materially assists in its cure,
by soothing and quieting the irritation of the system, so that the
curative power of nature (the vis medicatrix naturæ, of which so much
was said in my first chapter), may pursue undisturbed and without
hindrance, her processes of restoration.

Another error, to which this idea of the neutralizing influence
of medicines gives rise, is this. What is found to be useful in
any disease is supposed to be so in all cases of that disease. If
a remedy be “good” for a certain malady, fever for example, it is
apt to be considered as being “good” in all cases of fever, without
regard to circumstances. There is a great proneness to suppose all
cases of one disease to be alike, and to require therefore similar
remedies. The physician finds it difficult often to make people
understand that two cases, in which the disease bears the same name,
may require very different, and perhaps almost opposite modes of
treatment. The accompanying circumstances of disease vary so much in
different cases, that this supposed invariable relation of particular
remedies to the cure of particular diseases is impossible. This
remark applies even to our most efficient remedies. Colchicum is one
of the most effectual remedies which we have for rheumatism; and yet
there are many cases of this disease, in which its use is forbidden
by the condition of the patient.

The idea, that medicines have a kind of natural relation to disease,
assumes sometimes a more definite shape than either of those to which
I have alluded. Some suppose that almost all, if not all, diseases
have their specific remedies and antidotes. It is often said by those
who have this idea, that there are medicines in the plants that grow
in any country, which can cure every disease that prevails in that
country, if they could only be found. Indians and “Indian doctors”
are supposed to know of many of these specifics. The newspapers
announce too occasionally the discovery of specifics for the most
formidable of diseases, consumption, cancers, hydrophobia, locked
jaw, &c., &c. These announcements are accompanied sometimes with
statements of cures of the most positive character. No doubt the
statements are correct in one respect—the patients recovered. So were
the wounds healed when the ointments were applied to the instruments
that made them. In some way these specifics after a while lose their
reputation. There is a constant succession of them, all equally
infallible for the time, but the period of their infallibility is
short. Their reputation is built upon the “_post hoc, propter hoc_”
mode of reasoning, and therefore does not stand the test of any
continued experience.

In order that this subject may be fairly understood by my readers,
they should know what we mean by a specific remedy. A specific
remedy for a disease is one which will cure that disease under all
ordinary circumstances—that is, when there are no circumstances in
the case, apart from the disease, which tend to prevent the cure.
Many doubt the existence of any specifics at all. If there be any,
they are certainly very few in number. Sulphur and some mercurial
preparations, as remedies for Psora (itch), and some other cutaneous
diseases, have as strong a claim to be considered specifics as
any medicines that can be mentioned. Iodine has been said to be a
specific for scrofula, but it by no means holds good its claim.
Though tuberculous consumption is a disease of a very definite and
specific form, no specific remedy has been as yet discovered for
it, and probably none will ever be, though Dr. Rush and others
have indulged the pleasing hope that some plant may yet be found
that will arrest the ravages of this disease. I would remark in
this connection, that there is one specific preventive. I refer
to vaccination as a preventive of small-pox. But this fact stands
entirely _alone_—there is no other fact like it.

The physician is continually meeting with evidence, that the
community generally have no adequate ideas of the necessity for
discrimination in medical practice. He is every day called to
patients, who tell him that they have taken some patent pills, or
perhaps some pills which they chanced to have in the house, and which
they supposed must be “good,” as they express it, though they may
not know where they came from, or what they are commonly used for;
and this is done by many, without regard to the kind of malady under
which they are suffering. All cases must first be dosed by pills,
to which they attach this general idea of being “good;” and then,
if they do not hit the disease with this random shot, they send for
the doctor, not however with the belief, that his shooting will be
any less at a venture, but because he may have a greater variety of
ammunition.

One of the strongest evidences that the community have a very
imperfect conception of the varieties of disease, and of the
necessity of accurate discrimination, is the propensity to look
for some one grand remedy for all diseases. This propensity is
exceedingly common, and exists in every variety of degree. Some,
I may say many, have the full belief that there is such a remedy,
and try every vaunted medicine that comes along, in their search
after the great catholicon, or elixir vitæ. Disease they suppose, in
the language of quacks, and we may add of some physicians also, to
be an unit, and the remedy for it must therefore be an unit also.
Others, (and these form a large portion of the community,) while
their ideas are less distinct and exclusive, are still governed in
a great measure by this same prevailing notion. They have some
favorite remedy, which they use for complaints of almost every kind.
The remedy may not always be the same, and commonly is not. The
‘universal cure’ does not ordinarily last a great while, but is at
length supplanted by some other, just as universal, which in its
turn, is also to be supplanted. Every year, not to say every month,
brings to some people a new grand catholicon.

This propensity does not always show itself in relation to some
one remedy, but sometimes leads to the adoption of some system or
class of remedies. I mention as an example the Thompsonian system. A
certain group of remedies was selected by the founder of this system,
from the whole kingdom of nature, as the remedies above all others,
if not alone, fitted to attack the great unit, disease. The very
idea of discrimination was discarded. The unit was to be attacked
with these weapons, and the attack kept up till it was destroyed. No
fear was indulged that any harm could be done, for Thompson claimed
that his remedies had a natural relation to disease, possessed by
no other agents, and that therefore, however largely they might
be taken, they could not possibly do any injury. How beautifully
simple this system of practice is; and, if its claims be just, what
a perfect relief it brings to all the uncertainty of medicine! Away
then with all care-worn experience, and all study! Keep up a constant
fire of lobelia, red pepper, and steam, and you will certainly kill
the disease at last—at least if you do not kill the patient. In
the infancy of this system, this idea of its simplicity was more
distinctly avowed than it is now, and the remedies that were used
were much less in number than they now are. The followers of Thompson
are certainly departing from the stern principles of his doctrine,
and some of them even begin to talk about the necessity of study—a
heresy, one would think, glaring enough almost to start Samuel
Thompson from his grave!

It is most impudently asserted by Thompsonians, that physicians
generally act upon the same exclusive principles that they themselves
do—that while Thompsonians give lobelia and cayenne in all cases, we
do the same in regard to calomel, antimony, &c. This is undoubtedly
true of some physicians, but it is a gross slander when it is applied
to the profession in the mass. The real difference in this matter
between Thompsonians and physicians is this. While Thompsonians
confine themselves to one particular set of remedies for all
diseases, physicians use in their daily practice a great variety of
remedies, and among them the very medicines used by Thompsonians. We
have never claimed, as Thompsonians falsely state that we do, that
lobelia and cayenne are not good medicines, but simply that they are
not applicable to all cases, any more than is calomel, or any other
remedy that may be named.

The quack shows in his advertisements, that he is aware of the
prevalence of the propensity of which I have spoken, and here rests
his chief hope of success. He begins his advertisement with something
of this kind. Disease is an unit; or, All disease is in the blood;
therefore the blood must be purified; or, Grand catholicon; or, Grand
antidote to disease; or, The real essence of life at last discovered.

This propensity has shown itself in some measure even among
physicians. Enthusiasts in our profession have always been disposed
to attribute to favorite remedies, a sort of universality in their
operation upon disease. Every new medicine that comes up to notice
has almost every kind of virtue ascribed to it by such physicians.
And it is only by long-continued and well-weighed experience, that
the statements made in relation to any remedy can be sifted, and the
real truth be discovered in regard to the degree and extent of its
efficacy, and the circumstances which should govern us in its use.
This process has been gone through with, in the case of every article
of the materia medica that has ever had any notoriety. Take for
example, digitalis. At one time, this medicine was in common use in
many diseases, and especially in consumption; and some enthusiasts,
if they did not go so far as to say that it was a certain cure
when used sufficiently early, at least extolled it as almost a
specific for this disease. The accumulated and compared experience
of physicians in regard to it has at length determined pretty nearly
its value, and while it is now used far less than it once was, it is
used more judiciously from the more definite knowledge of its effects
which this experience has gained for us.

The same remarks could be made about other articles.[6] And while the
test of experience has corrected our valuation of some remedies, and
thus enabled us to use them with more skill; there are others once
supposed to be valuable, which, under the application of this test,
have gone wholly out of use. I will mention but a single example. Dr.
Beddoes, an English physician of some note, but a great enthusiast,
thought that some of the gases might be advantageously used in the
treatment of disease. The results were said to be astonishing, and
the practice of pneumatic medicine, as it was called, became very
prevalent. I find in a work, called Medical Extracts, published in
1799, the narrative of sixty-nine cases of various diseases, said to
be cured by the respiring of these gases. Among them are certainly
some formidable maladies, such as dropsy in the head and chest,
consumption, gout, epilepsy, leprosy, scrofula, &c. Some of these
cases had been previously under the care of celebrated physicians,
and some had even been pronounced by them to be incurable. A
description given by one of the patients, a clergyman, of his
own case, almost transcends the descriptions given now-a-days by
some clergymen of the effects of some patent medicine, or of the
infinitesimal doses of homœopathy.

Now, if the respiring of these gases really did produce these
results, or any good proportion of them, the same practice would have
been in vogue now. But it has not stood the test of experience, and
therefore has been rejected. No physician at the present day thinks
of setting his patients to breathing these gases.

If it be said that this is the result of change of fashion merely,
and that it therefore does not prove that this practice was not
successful, I reply that, though fashion in medicine may sometimes
temporarily prevent the use of a good remedy, it never effects the
entire and continued abandonment of it by medical men. You will
find it always true of remedies and modes of practice which are
really valuable, that though they may not be as fashionable after a
while, as they were when first introduced into notice, and may, from
the fact, that they have been estimated too highly, be for a time
undervalued, they will never be wholly given up by the profession.
Nearly as great stories were told about calomel and digitalis at
first, as were told about the gases of Dr. Beddoes. But while
experience has shown that calomel and digitalis were over estimated,
it has proved that these gases had an entirely false estimate put
upon their remedial powers.

It is thus that the medical profession, corrects by experience the
errors into which it is led by the uncertainty of medical science.
But the community at large pursue a very different course. They never
correct their errors, but only supplant one error by introducing
another. While physicians reject what is found by experience to be
valueless, and retain what is truly valuable, the multitude reject
alike the good and the bad, in making their constant changes from
remedy to remedy, and from system to system. It is mere caprice, and
not a careful discrimination, that leads them to throw aside one
favorite medicine or system, and adopt another.

It is amusing to watch the movements of the community in relation to
quack medicines. Of these there are a multitude constantly appealing
to the credulity of the public. Some of them in some way, acquire a
currency above their fellows, and from the extent to which they are
used, and from the tales of their wonder-working from all quarters
of the land, and from all conditions of life, one would suppose that
these remedies would never go out of use until mankind cease to be
sick. But look again, only a few years after, and these vaunted
medicines have gone out of use, and the flaming advertisements
proclaiming their virtues have disappeared, and other remedies have
taken their places in the public mind, and on the public tongue,
and of course in the public stomach. This process of change in the
prominent remedies before the public, has ever been going on. Take a
single example. A few years ago, almost every invalid was swallowing
the Hygeian pills, from the pauper that purchased them with his
begged pittance, up to lords and ladies, and senators, and generals,
and clergymen. But in a short time, Brandreth’s effulgent glory burst
upon the earth, and the Hygeian orb faded, and glimmered, and sunk to
rise no more. And now Brandreth is rapidly on the decline, giving way
to others who are rising to take his place.

These successive changes in popular remedies show, that the public
have always been egregiously mistaken, whenever they have attributed
to them such wonderful efficacy. Else the very high and extensive
reputation gained by each could not have been so utterly lost in so
short a time. If, for instance, a tithe of the fame of the Hygeian
pills was well founded, the thousands of mouths that swallowed them
would not have been, as they were almost in a twelvemonth, just as
wide open to receive the magic pills of Brandreth. Either a large
portion of the community have committed a great error, in ascribing
such marvellous efficacy to these remedies; or they have committed a
greater one in so soon discarding them. Either the one or the other
of these errors has been committed, in regard to each one of the most
popular remedies, that have succeeded each other in the favor of the
public, from time immemorial—not one that has not had its _decline_,
as well as its _rise_, and its _acme_. And what is remarkable is,
that when once a remedy has thoroughly passed from the popular favor,
no matter how great its fame has been, it never can be revived again,
unless it be under an entirely new name, and with new pretensions.
Why? Because it has been tried, and its reputation was found to be a
splendid bubble that has burst and fallen. And the public, like the
child, when a bubble has burst, has done with that one forever, and
busies itself at once in raising another, which, in its turn, is
succeeded by another, and so on to the end, if end there be, which
seems to be hardly a possibility with the bubbles of quackery.


FOOTNOTES:

[4] Many varieties of weapon-ointment were used. Some of the articles
in them which were considered most essential were powder of mummy,
human blood, and moss from the skull of a thief hung in chains.

It is a humiliating fact in the history of human wisdom, that Lord
Bacon, the wisest man of his time, could only say of the pretended
efficacy of this ointment, that he, himself, “as yet, is not fully
inclined to believe it.”

[5] The popular disposition to look to some one remedy for a disease,
is seen in the conversations in every circle at the present time,
in regard to the cholera. The inquiry is for some one specific
remedy,—and physicians are constantly asked if something has not yet
been discovered of this character. Though the newspapers are filled
with new and _certain_ cures, no _new_ remedy has been discovered for
this disease since its former visitation in this country. Physicians
do however know better how to treat it, than they did then; but
it is only because experience has taught them better _how_ to use
the appropriate remedies, and not because any very important new
medicines are added to the list of those which are applicable to this
disease.

[6] Ether and chloroform, which are now exciting so much discussion
among medical men, furnish a good illustration. The value of the
discovery which has recently been made in regard to them, great as
it undoubtedly is, cannot as yet be exactly ascertained. But the
profession will be learning more and more in relation to them, and
multiplied and extended observations will at length determine their
precise value, and the circumstances which should govern us in their
use.




CHAPTER IV.

QUACKERY.


The reader is now prepared, by the facts and considerations presented
in the previous chapters, to see in what way quackery, in its various
forms, has obtained such a hold upon the community. If results in
medical treatment could always be traced to their real cause, there
would be no room for the arts of the empiric. But the reader has
seen that, in the progress of every case of disease, there are many
causes acting together in the development of results, and that many
of these act secretly; and that there is, therefore, special need of
caution in our conclusions, in regard to the operation of remedies.
And yet, notwithstanding the manifest necessity for caution, there is
no subject to which the ‘_post hoc propter hoc_’ mode of reasoning
is so frequently, and so incautiously applied. It is the erroneous
reference of effects to causes, consequent upon this mode of
reasoning, which is the great source of quackery.[7]

Let us see how this result is produced.

Take any remedy, no matter what it is, whether it be positive in
its character, or entirely inert, and it can be made to acquire
an extensive reputation for curing disease. Suppose that it is of
a positive character. Let quite a large number of persons in a
community be persuaded to take it. It would be appropriate to a
few out of the whole number of cases, just as a man firing into a
crowd of men at random would be apt to hit some of them. Then there
are some, who, through the recovering power of nature, get well
while using the medicine, perhaps even in spite of it, and falsely
attribute the cure to it. The _many_ that are not benefitted soon,
give up the use of the remedy, and the fact that they have taken it
is known to but few, and is soon forgotten even by them. But the
few that _chance_ to derive benefit from it, or that are cured by
nature while taking it, proclaim everywhere the virtues of the remedy
with the ardent gratitude of restored health, and willingly give
certificates of their cure for the benefit of suffering humanity.
All this helps to get the new remedy in vogue in other places; and
wherever it is introduced, the same result, for the most part, is
realized. The consequence is, that the remedy comes into extensive
use, and continues in the popular favor, till some other remedy, by
the same process, supplants it.

Even if the remedy be not of a positive character, but wholly inert,
enough of the whole number that take it will get better, from the
curative power of nature, and from mental influence, to give it,
for a time, the reputation of curing disease. Many examples might
be given. An amusing instance of the celebrity sometimes gained by
inert remedies, occurred in Paris. A man who had sold to great profit
an eye-water, at length died without communicating to any one the
composition of it. His widow regretted the loss of the profits which
came from the sale of the eye-water. Without telling her trouble to
any one, she filled up the phials from the River Seine, and went
on to sell the eye-water as usual. Cures occurred as before, and
everybody believed that her husband had bequeathed the recipe to her.
On her death-bed her conscience was much disturbed on account of the
deception which she had thus practised upon the community, and she
made confession to the physician who attended upon her. He, however,
quieted her mind by telling her, that he was sure she need give
herself no uneasiness, for her medicine had at least done no harm—a
consolation which most venders of secret medicines could not have.

The variety of both active and inert remedies, which have enjoyed,
in the way that I have indicated, a temporary popularity, is very
great. Even calomel, which now seems to be especially despised by all
empirics and their followers, has had its hey-day of popular favor.
It was one of the chief remedies of Paracelsus, who has been styled
the prince of quacks. And some years ago an empiric, in the staid
city of Boston, acquired a great reputation for wonderful cures, by
giving calomel in very large doses, even by the teaspoonful. His
reputation was, of course, short-lived; for, though he seemed to
make some capital hits, so glaring an abuse of a good remedy could
not but be attended with bad results, occasionally of so palpable a
character, as to undeceive even the credulous public.

The most prominent quack medicines are principally of _three_ kinds.

1. Evacuants. To this class belong the almost numberless varieties of
pills advertised in the newspapers. There is a great similarity in
the composition of these pills, although each kind is ushered into
notice with all the pretensions of an entirely new discovery. Aloes,
gamboge, &c., medicines in common use, form the basis of nearly
all of them. They are simply good cathartic preparations, and have
none of the extraordinary virtues attributed to them. And, as those
who are ailing are commonly benefitted by producing some amount of
cathartic effect, these different pills actually do some good to
quite a large proportion of the cases to which they are applied.
The difficulty with them is, that used indiscriminately, as they so
generally are, they in many cases do injury, and in some to a fatal
extent.

2. The second class of quack medicines are those which are supposed
to act upon the system slowly, producing a change in its general
condition. The general term _alterative_ may be properly applied to
them.

The various preparations of sarsaparilla belong to this class. The
same remark can be made in regard to these that was made in relation
to the great variety of popular pills. They are all very much alike,
although the proprietor of each claims for his preparation that it
is entirely new in its combination, and that it is pre-eminently
successful. A single fact, which came to the knowledge of the author,
will show what kind of imposition some of these discoverers of
_new_ preparations of sarsaparilla practice upon the community.
Twenty years ago, Carpenter’s Fluid Extract of Sarsaparilla had a
high reputation, both with the profession and with the public. No
secret was made of its composition. A student of medicine copied
the formula. A few years ago he furnished an apothecary with this
formula, who forthwith came out before the public with what purported
to be a _new_ preparation of sarsaparilla, which, by the usual
machinery of quackery, obtained extensive popular favor, and made
a fortune for the apothecary. His preparation was not a new one,
but was made according to Carpenter’s formula, with some slight
additions to alter the taste and the appearance of the medicine.
The sale of this once famous preparation of sarsaparilla has, with
that of its rivals, almost, if not wholly gone by; and others are
now the candidates for fame and _money_ with their entirely _new_
preparations.

3. As consumption is the most common of all chronic diseases,
there is a very large class of remedies which are supposed to act
especially upon the lungs. Each one of these is claimed by its
proprietor to be a _certain cure_ for this formidable disease. They
are generally combinations of articles which are in common use among
physicians in affections of the lungs. In the indiscriminate use to
which they are put by the empiric, while they benefit some cases
to which they _happen_ to be appropriate, in the great majority of
instances they undoubtedly do harm; and in the forming stage of
many cases, they fasten the disease irrecoverably, when a judicious
and discriminating treatment might have saved the patient. These
nostrums, therefore, add much to the mortality of consumption in the
community.

It is well understood by any one who proclaims the discovery of
a new medicine for any disease, that his day of prosperity must
necessarily be short. He knows that his medicine, whatever amount of
popular favor it may acquire, will soon be supplanted by some other
_newly_-discovered preparation. He must, therefore, make the most of
his time. Accordingly, as soon as he succeeds in getting his name up
by certificates, advertisements, &c., he throws as large quantities
as possible of his medicine into market, and has but little care for
the quality of the materials of which it is made. Great quantities
of sarsaparilla and other articles which have been damaged, or have
become inert by age, are constantly used up in this way, furnishing
a profitable outlet for the refuse, which accumulates annually in
the shops of the dealers in such articles. Large amounts, too, of
adulterated articles are used in the manufacture of quack remedies.

Another imposition of a kindred character deserves a passing notice.
When any particular article is high in favor with the public, every
empiric incorporates it into the _name_ which he gives to his
medicine, in order to ensure its popularity, though there may be
little, perhaps none, of the article used in its composition. If
the article command a high price, or if there be any difficulty in
obtaining it in sufficient quantity, other substances can supply its
place—the _name_ is all that is essential to secure a profitable
sale of the medicine. Much of the sarsaparilla which is sold, has
little or none of the real Spanish sarsaparilla in it; and as the
Canchalagua of California is now rising into notice, there will,
undoubtedly, be much sold as the genuine article, which will be
composed of substances that Californians never saw.

The fact that the quack’s advertisement is not only ridiculously
pompous and grandiloquent, but palpably false, does not seem to
injure the sale of his medicine, even with quite sensible people. A
medical student in Boston amused himself with writing a burlesque
quack advertisement. An apothecary, to whom he read it, proposed to
buy it of him, and said that he would prepare a medicine, which,
he had no doubt, could be sold in large quantities by the aid of
that advertisement. The young man was astonished that his friend
should suppose that any such use could be made of what he intended
should be so exceedingly ridiculous. But the bargain was struck,
the advertisement was put forth, and the medicine was, for a time,
among the prominent quack remedies. Ridiculous as was this burlesque
advertisement, it has since been surpassed by many of those which
occupy so large a space in the newspapers.

The certificates of cures, which are so important in giving currency
to quack medicines, may be divided into _four_ classes.

1. Some of these certificates are forgeries.

2. Many of them are essentially, sometimes wholly, untrue. Some of
this class are written by the local agents of the proprietor; and
the individuals are persuaded to sign them, because the medicine
had been gratuitously furnished, or for some other reason. I know
many facts which I could adduce in proof of this statement. I will
mention, however, but one case. One who had been an apothecary, and
had sold large amounts of quack medicines, stated, that in one year
he sold three thousand dollars’ worth of one medicine—that he had no
satisfactory proof of its having cured a single case of disease—that
he had obtained, however, many certificates of cure, but not one from
any person who had paid for the medicine.

3. Another class of certificates are obtained in this way. Invalids
are very apt, on taking a new medicine, to imagine themselves for
a little time to be benefitted; but after a while they find that
it is mere imagination. Many certificates are obtained of such
persons at the time when they feel encouraged in regard to their
prospect of recovery. The empiric understands that this is the golden
opportunity for him, and he will have no delay if it can be avoided.
It is astonishing what sensible people are sometimes caught in
this way. A deaf gentleman once asked me my opinion of an empiric,
who pretended to have uncommon skill in the cure of deafness. He
found, among the published certificates, a letter from a gentleman
of his acquaintance, of the highest standing both in character and
intellect, expressing great gratitude for the relief which he had
experienced from the practice of this ear doctor. He wrote to his
friend a letter of inquiry. His friend replied, that when he returned
from his visit to this quack, he thought himself to be somewhat
better, and was so much delighted that he magnified the improvement
in his imagination, and in this condition wrote that certificate;
and that he was now satisfied that he unwittingly made in that
certificate a really false representation of his case.

4. Another class of certificates come from those who are really
relieved while using the medicines, in regard to which they certify.
The inference, according to the ‘_post hoc propter hoc_’ mode of
reasoning is, that the medicines, of course, cured them. I need not
stop to show that this inference can by no means always be a correct
one. I trust that the facts presented in the previous chapters are
sufficient to satisfy the reader on this point.

No class of men have done more harm by giving certificates of
cures by quack medicines, than clergymen. They are so situated in
the discharge of their parochial duties, that they are apt to be
drawn into the signing of such certificates. They hear the glowing
statements recited by patients and their friends. They, of course,
sympathize with the relieved sufferers. They do not sift and examine
the statements, for it seems almost unfeeling to doubt. They often,
therefore, give these statements full credence, and furnish the
empiric with certificates. Certificates from such sources are highly
prized, and are, therefore, eagerly sought for. But clergymen should
consider what they are doing by this course. The facts which I have
stated show, that by such acts they uphold a system of impositions,
and help quackery to destroy the lives of their fellow men.

The feeling which physicians manifest in regard to empiricism, is
very commonly supposed to be prompted by self-interest. This is far
from being true. It would not be at all for the pecuniary interest
of physicians to have quackery suppressed; for it is continually
furnishing them with patients, in whom disease has been created or
aggravated by the use of empirical remedies.

I trust that it is obvious to the reader, from the facts which I
have stated, that the medical profession are right in the ground
which they have for the most part maintained against secret and
patent medicines. The rule which they have adopted, in regard to
themselves, on this point, is thus given in Percival’s Medical
Ethics: “No physician or surgeon should dispense a secret nostrum,
whether it be his invention or exclusive property; for if it be of
real efficacy, the concealment of it is inconsistent with beneficence
and professional liberality. And if mystery alone give it value
and importance, such craft implies either disgraceful ignorance or
fraudulent avarice.”[8]

This rule recognizes a very just distinction between inventions in
medicine and all other inventions. As medicine has to do with such
important interests as health and life, the principles of benevolence
demand, that any invention or discovery in this art, should be
promulgated without any hindrance. And this is the more necessary,
because nearly all of the so-called _new_ medicines, put forth from
time to time, have nothing new in them, and mystery alone gives them
their value and importance in the eyes of the public. The claims
which are set up for the great mass of popular remedies, blazoned
forth in newspaper, pamphlet, almanac, and handbill so profusely,
are gross impositions; and an exposure of the formulas, according to
which these medicines are compounded, would show them to be so.[9]

The only way in which this imposition, so constantly practised upon
the community, can be guarded against effectually, is to oblige every
one who sells a medicine, to make the composition of it known on the
wrapper in which each parcel of the medicine is enclosed. Such a law
is now, I understand, in force in the State of Maine. I hope that the
law will be sustained, and that so just and noble an example will
everywhere be followed.

If it be objected that the inventor in medicine should, like other
inventors, have something more as a reward than the consciousness
of doing good, and the reputation which his invention gives him,
this can be provided for without any difficulty. Let a board be
constituted, whose duty it shall be to examine all medicines offered
to them, rejecting all that have nothing new in material or in the
form of combination, and recommending all that are really valuable.
Let it also be the duty of this board to award to the proprietor of
every medicine, which they approve, as being a real invention or
discovery, a suitable sum to be paid him out of the public treasury.
Such a board, constituted on the most liberal principles that any one
could desire, would find but few among the multitude of remedies now
before the public, of which they could conscientiously approve; and
there would be no ground for fear of any great drain upon the public
treasury, by the awards which they would make to inventors.

Quackery has, at length, come to be so monstrous an evil, that there
will be great difficulty in removing it. The credulity of the public
is so great and so extensive, that the plainest and strongest facts,
brought out even in multitudinous array, are almost powerless before
it. Then, too, the capital invested in this vast system of imposture
is large in amount. It has become one of the great interests in
the community,[10] and is so linked in with other interests in the
relations of business, as to have a strong hold in this way upon
the public. It has even subsidized the press; and it has done it
so thoroughly, that it has not only muzzled it, so far as speaking
out the truth on this subject is concerned, but it has compelled it
to utter freely the falsehoods which it demands for its purposes.
I speak of our secular newspapers. If there are any that are not
guilty, they are exceptions. There may be a few. I know of not one.
Not content with advertising quack medicines, they, for a liberal
fee, admit into their columns, articles which have the appearance
of editorial recommendations; and these are copied as such into
advertisements in other newspapers. And besides all this, respectable
editors have often refused to publish any exposure of the impositions
of quackery. Our legislators, too, are afraid to move in any way
against a system of impostures which has so strong a hold upon the
community. Still, though these formidable obstacles are in the way
of a radical reform on this subject, let the facts continue to be
brought out, and let the truth be told fearlessly; and this evil,
grown now to be so monstrous, will at length yield to our efforts.

I have thus far spoken of only one form of quackery—the sale of
secret medicines. It appears in various other forms. I shall give
some examples of only a few of them.

Many empirics have become itinerant lecturers. They, of course,
always have something to sell—books, medicines, braces,
breathing-tubes, &c. Their lectures are partly, sometimes wholly,
gratuitous, which, certainly, looks like being somewhat benevolent.
The lectures are made up of some very plain truths, borrowed from
some medical works, which, mingled with some popular errors, and
spiced with the prevailing ultraism of the present day, in order to
make them interesting, are urged upon the audience as being both new
and important. A variety of illustrations and analogies, some of
which are true and some merely plausible, are made use of to effect
the lecturer’s purpose; which is, to convince the audience that he
has examined the subject particularly, and is a thorough master of
it. If he succeed in doing this, there is a great rush of invalids to
his rooms in the intervals of his lectures. His remedies are costly,
but his advice is gratuitous; and this is commonly a very successful
bait for the poor invalid. He receives a large amount of money from
his numerous patients for what cost him but very little. For the time
being, he is the great medical lion of the place. But great as he is,
when he is once gone, he is gone never to return to that place again:
his vocation _there_ is ended.

Some of these empirical lecturers have, as a special attraction, one
or two lectures particularly for the ladies, to which no gentleman
can be admitted; and one or two also for gentlemen, from which the
ladies are excluded. I will only say, that in every case in which I
have known this to be done, the character of the lectures has been
such as no virtuous community should tolerate.

Animal magnetism, as applied to medicine, has made quite a figure
in the world of quackery. Miss Martineau, and many other people
reputed to be very sensible, have been entrapped by this delusion.
The magnetized subject, or clairvoyant, who attends the lecturer on
this “science,” in his travels, is said to be able to look into the
sick, and see exactly what is going on there. If this be so, animal
magnetism must be capable of rendering essential aid in investigating
disease—more essential, indeed, than any other means which we have
at our command; and every physician should have his clairvoyant to
attend him in his daily visits. The hits which are sometimes made
by clairvoyants, are said to be astonishing; but they are so for
precisely the same reason that the hits of the fortuneteller are
sometimes truly wonderful. The clairvoyant has ears, and can hear
what may be said aloud or in whisper about different invalids; and
the magnetizer can hear for her.

I will give an example or two, to show what convenient use can be
made of ears by these clairvoyants.

I once heard a lecturer state the case of a young man, who, he
said, had for a long time suffered severe pain, and had applied to
many physicians without obtaining any relief, or any satisfactory
explanation of his case. His clairvoyant at once directed that a
particular tooth be removed, and said that an abscess could then be
opened above it, the discharge of which would relieve the pain. This
was done, and the patient was relieved. Every one supposed, from
his manner of relating the case, that no one had ever hinted at the
real seat of the disease, and that it was a fresh discovery of his
clairvoyant. It was found, however, that physicians had taken this
view of the case, and that it had been talked about in the family.
The clairvoyant, probably, got her knowledge by her ears, before she
was put into the ‘magnetic state.’

A very shrewd lady accompanied a friend on a visit to a clairvoyant,
in Boston, whom she wished to consult in regard to her child, who
had, by a fall, injured his side. She watched the proceedings of
the parties very narrowly. The clairvoyant was for some time quite
in the dark about the case, and used very indefinite language in
regard to it. At length her mind became suddenly clear in its views;
and it _seemed_ to be done by a whisper uttered by one of the party
to another, in relation to the fall. She at once said, “The child
must have had some accident—he fell down, and as he stretched out
his hands, he struck on his chest, _and the bones have shot by each
other_.” The clairvoyant went a little too far. There is no such
thing as the shooting by of any bones in the chest, at least in any
ordinary accident. These clairvoyants, that see right into people,
often have an anatomy of their own.

We sometimes have an opportunity of testing the clearness of the
medical vision of these clairvoyants. One of them, a few years since,
on examining the case of a child, saw in its intestines three kinds
of worms, which she described with great exactness. It was a very
clear and distinct vision. The child died two days after, and I
assisted in its examination after death. The worms, so distinctly
seen, were not to be found. The magnetizer and his clairvoyant
immediately left for another field of labor.

Some names have become quite celebrated in the annals of quackery. I
will give a passing notice to a few of them.

Paracelsus has been called the prince of quacks. He flourished
in the beginning of the sixteenth century. In order to give
himself dignity, he assumed the names of Philippus, Aureolus,
Theophrastes, Paracelsus, Bombastes de Hohenheim. He discarded all
the commonly-received doctrines and modes of practice, and pretended
to have been searching after the truth for many years. He put forth
a pompous proclamation of his travels and researches, and pretended
to have made great acquisitions in medical science. The remedies
which he used were mostly of the _heroic_ kind; and though he killed
many by his rash practice, he stumbled on some great cures, (and
what quack has not?). These were proclaimed in the most bombastic
manner. The result was that his practice was immense in amount and
extent. The magistrates of Basle engaged him, at a large salary, to
fill the chair of medicine in their university. At his first lecture
he burned the works of Galen and Avicenna, and asserted that there
was more knowledge in his _cap_ than in the heads of all physicians,
and that there was more experience in his _beard_ than in all the
universities. “Greeks, Romans, French and Italians,” said he, “you
Avicenna, you Galen, you Rhazes, you Mesne—you doctors of Paris, you
of Montpelier, you of Swabia, you of Prussia, you of Cologne, you of
Vienna—and all you throughout the countries that are washed by the
Danube and the Rhine, and you who inhabit the islands of the sea,
Athenian, Greek, Arab, and Jew: you shall follow and obey me: I am
your king—_the monarchy of physic is mine_!”

Though he did not long retain his professorship, and though he was
grossly intemperate in the last years of his life, he maintained
his reputation for extraordinary cures even to his death. Great and
learned men were among his patients, and even the noted Erasmus
consulted this arrant charlatan.[11]

It is but a few years ago that St. John Long had immense multitudes
of patients in London, though his notions were of the most ridiculous
character, and were attacked with the shafts of reason and ridicule
on every side. His theory was, that all diseases were produced by a
semi-mercurial fluid, and that in order to cure the disease, the seat
of this fluid must be found, and the fluid must in some way be got
out. He had discovered a very summary way of doing this. He used a
liniment, which he applied over the seat of the fluid, and extracted
it at once. Though this liniment had such wonderful power, it would
produce no effect when applied over a part which was not diseased—so
that in any case, in which the seat of the disease was not obvious,
instead of going through with a strict and long investigation after
the vulgar way of regular doctors, St. John Long only had to apply
his liniment here and there, till he found that the disease was
extracted. One would hardly suppose that such nonsense could be
believed in any civilized community; but the theory of this painter,
who had thrown aside his brush and dubbed himself doctor, ridiculous
as it was, found such favor with the public, that the prominent
journals came out with weighty articles against it. Reasoning was
not only in vain, but worse than in vain. The wonder grew—it was not
put down. Quackery never yet was _killed_—it always _dies a natural
death_, and so did the quackery of St. John Long. After running the
gauntlet amidst the heavy blows of wise and powerful enemies, and
coming forth unharmed at every heat, it at length laid itself down,
and died the most quiet death imaginable. It fell asleep; and this is
the end of all quackery.

Who has not heard of Perkins’ Tractors? The inventor, Doctor Elisha
Perkins, was born in the town where the author resides. He was the
son of a physician, who was for forty years in extensive practice,
and was himself, for some time a respectable physician in the town
of Plainfield in this State. He was undoubtedly an honest man.
He duped others, it is true, but he duped himself, too. He was a
deluded enthusiast, and died a victim to his enthusiasm only three
years after he published to the world his grand ‘discovery.’ He had
conceived the idea that a free use of salt as an antiseptic would
cure the yellow fever. He therefore went to New York in the year
1799, when this disease was raging, and, full of confidence in his
mode of practice, offered his services most generously to the poor
as well as the rich. At the end of four weeks he himself caught the
fever, and being exhausted by his labors he survived but four days
after his attack.

The promulgation of Dr. Perkins’ ‘discovery,’ which occurred in 1796,
was preceded, it is said, by a long series of experiments, which were
suggested by the supposition, that metallic substances might remove
disease by some electrical or galvanic power. The Tractors, which
were the final result of these experiments, are two pieces of metal
about three inches long, blunt at one end, and running to a point at
the other. One of them appears to be brass, and the other steel, but
what their real composition is, is not known, as the invention was
patented.

The fame of the Tractors spread with unaccountable rapidity, and
marvelous cures were everywhere reported. Certificates came in
from all quarters, and from all kinds of dignitaries. Not only
captains, and colonels, and generals, and ’squires sounded the
praises of the Tractors, but clergymen and senators and doctors
and professors. And their fame was not confined to this country.
Benjamin Douglass Perkins, a son of the inventor, went to London to
obtain the patronage of the British public for the Tractors. Great
cures were forthwith effected all over the kingdom, of which there
were multitudes of certificates from the wise and good, and, what is
better, from the titled and wealthy. Similar cures were also reported
from other countries in Europe, especially from Denmark.

To prove that imagination had nothing to do with these results, there
were related many instances of cure in infants and in horses. It was
found by some sage observer that, though horses could be cured by the
Tractors, they had no influence at all upon sheep. He supposes that
this is owing to the unctuous matter in the wool, and he remarks that
“even pomatum, it is well ascertained, prevents the Tractors from
relieving pains in that part of the head over which the pomatum is
used.” A lame crow, supposed to have the cramp, was operated upon so
successfully by the Tractors, that though he had not been able to put
his foot to the ground for a week, he walked perfectly well the next
morning after the application.[12]

The multitude of cases which were collected from every quarter were
occasionally published. I have in my possession a volume of nearly
two hundred pages published in London, containing a great number
of these cases. The testimony is of the most decisive character.
Pain was relieved in a trice by a few strokes of the Tractors;
inflammations were drawn out; swellings were dispersed, and, in some
cases, with such rapidity that they were _seen_ to lessen during the
application; rheumatism, which had baffled the best medical skill was
removed; the paralytic was made to walk—such were the reports which
were constantly put forth.

The success of the Tractors was attested not only by multitudes of
wealthy and titled and learned men, but even by many of the medical
profession; and selfish motives were unhesitatingly attributed
to all physicians who were unbelievers. A physician, who was of
sufficient respectability to be a president of a medical society,
said of such unbelievers, that “like _infidels_ to the gospel,
they admit of no mysteries, and refuse to believe what they do not
readily comprehend.” Dr. Haygarth, an eminent physician of Bath, and
some others, drew down a storm of public wrath upon their heads,
because they asserted that a pair of wooden Tractors, painted so as
to resemble the real metallic ones, had produced in their hands as
marked effects as those which were purchased of Mr. Benjamin Douglass
Perkins, at five guineas a pair. So strong was the hold which ‘the
new science of Perkinism,’ as it was called, had obtained upon the
public favor, that the son of the inventor of the Tractors was spoken
of as being most unjustly persecuted by a large proportion of the
medical profession; and his name was often associated with those of
Galileo and Harvey and Jenner, who, it was said, had suffered like
persecution before him, from the stereotyped hatred of everything
that is new.

The efficacy of the Tractors was almost universally acknowledged; and
the only difficulty seemed to be to account for their operation. Many
ingenious electrical and galvanic theories were broached by learned
men in England and in other countries. Perkinism, as it was called by
acclamation, was hailed as one of the greatest of discoveries, and it
was supposed to form a new era in medicine. The Tractors were sold in
abundance at five guineas a pair. That the poor might be benefitted
equally with the rich, the liberality of the British public was
appealed to, and not in vain. A ‘Perkinean Institution’ was formed
under the patronage of the first men in the kingdom. Lord Rivers was
president, and there is a long list of titled vice presidents.

A pamphlet, giving an account of this institution was published,
of which I have a copy. The regulations were evidently based upon
the idea that it was to be a permanent establishment. One of them
prescribes that a donation of ten guineas constitute a governor
for _life_. As many ladies were very enthusiastic patrons of the
Tractors, as they are now of infinitesimal globules, one of the
regulations was, that “ladies have liberty to vote by proxy, given to
any governor of the institution, or by letter to the chairman.”

In this account it is stated that the published cases of cures by
the Tractors up to March, 1802, amounted to about five thousand.
“Supposing,” the author goes on to say, “that not more that one
cure in three hundred, which the Tractors have performed has been
published, and the proportion is probably much greater, it will be
seen that the number, to March, 1802, will have exceeded one million
five hundred thousand. It is believed that no medical remedy ever
yet discovered has been supported by so many well-authenticated and
important cures, performed in so short a time.”

And now, I ask, where is the Perkinean Institution, with its troop
of governors for life, and where is the Perkinean practice, with
its list of five thousand published cures? The institution expired
while the governors for life were almost to a man in the land of the
living; and in less than ten years after the summing up of the five
thousand cures, Perkinism was only thought of as a thing that was
past, and the far-famed Tractors were almost forgotten.

And what became of Benjamin Douglass Perkins, who suffered for the
cause of science and humanity such persecution as Galileo and Harvey
and Jenner suffered before him? He returned to his native land with
ten thousand pounds of John Bull’s money, as a reward of his patient
endurance of persecution, and his active benevolence!

I might extend this notice of names which have been famous in the
history of quackery, but it is not necessary. Those which I have
noticed will answer as illustrations of the mode in which medical
delusions obtain their hold upon the public mind, and of the
facility with which each in its turn is supplanted by some other.
The essential materials of quackery, as I remarked in the Preface,
have been the same in all ages; and its history would be only a
description of the endless forms into which these materials have been
moulded. Great as is the variety in the series of phantasmagoria
with which quackery has excited the wonder of the world, they have
all been produced upon the same canvas, and by the same old magic
lantern.

And busy and multiform as quackery has been, and lofty as have been
its claims, I know not that it has ever made a _single discovery in
medicine_. It may possibly have _stumbled_ upon some discovery, but
I am not aware that it has done even this. On the other hand, all
the discoveries which have been made in the medical art, so far as I
know, have been the results of a truly scientific observation, and
fairly belong to that ‘regular’ profession, which so many consider as
being opposed to everything which is new.


FOOTNOTES:

[7] The following anecdote of an ignoramus, who set himself up as
a doctor, furnishes a good illustration of this erroneous mode of
reasoning. His first case was that of a butcher, who recovered. As
he gave his patient beefsteak and wine quite liberally, he referred
the cure to these articles, and put down in his note-book—beefsteak
and wine will cure a _butcher_. His next case was that of a tailor,
which, under the same treatment, resulted unsuccessfully. He,
therefore, added to the above note—but will kill a _tailor_.

You laugh at the use which this man made of the ‘_post hoc propter
hoc_’ mode of reasoning; but, after all, his inference is no farther
from the truth than many of the inferences of wise dabblers in
physic, promulgated in the newspapers, or even of learned doctors,
gravely recorded in the annals of medicine. The only real difference
is, that among the many preceding circumstances, to which results
might be attributed, he chose one, and they chose some other, a
little more plausible, perhaps, than his, but no nearer the truth.

[8] The whole course of the medical profession, in regard to
discoveries in medicine, has been open and generous, and not secret
and mercenary. Dr. Stevens, in his eloquent address before the New
York State Medical Society, thus speaks on this point: “Was the
introduction of inoculation for the small-pox a speculation? Was
the discovery of the preventive power of vaccination, (the labor of
close, unremitting, and careful research during a period of several
years,)—was that made or conducted with a view to personal emolument?
As a matter of course, Dr. Jenner, as soon as he had completed his
discovery, published it—made it free to all mankind. When quinine
was first discovered, the mode of preparing it was immediately made
known. Recently, when some feeble attempts were made to obtain
a patent for the use of ether, and to conceal the process of
etherization, the indignation of the profession was aroused from one
end of our country to the other. The money changers were driven from
the temple of humanity.”

[9] For example, the famous _Balm of Gilead_, which, in its time, was
said to cure all manner of disease, is nothing but brandy spiced with
cardamoms and other like seeds, and made a little more stimulating
with Spanish flies. The use of this medicine, therefore, was really
only one of the modes of dram drinking.

Louis XV. purchased, for a considerable sum, of Madame Nouffleur,
a nostrum for the cure of tape-worm. The medicine proved to be the
powder of the male fern, which was used for the same complaint
by Galen in the second century, but which, in spite of the
recommendations of this illustrious physician, and the princely
reward paid to Madame Nouffleur for her discovery of it—in, shall I
say, some musty book—it has somehow lost its reputation.

Examples of the same kind might be given almost indefinitely.

[10] A few facts will show the present enormous growth of this
interest. Ten years ago, the revenue of the English government,
from the sale of patent medicines, was only a little short of fifty
thousand pounds sterling. The cost of advertising quack medicines in
the United States, was estimated at that time at 200,000 dollars.
But it is vastly more now. Dr. Stevens, in his recent address
states, that the advertising outlay of some of the most notorious
patent medicine proprietors, is reckoned by its fifty and hundred
thousand dollars per annum. Quack advertisements occupy a large space
in our newspapers. In the twenty columns of a country political
paper published tri-weekly, I once counted eleven filled with such
advertisements, while only nine were devoted to other advertisements,
news, miscellaneous matters, editorials, &c.

[11] After he left his professional chair, he wandered about the
country, generally intoxicated, seldom changing his clothes, or even
going to bed. And though like other quacks who have succeeded him,
he boasted that he had discovered a _panacea_, which would cure
all disease at once, and even prolong life almost indefinitely,
this prince of empirics died after a few hours’ illness, in the
forty-eighth year of his age, at Salzburg in Bavaria, with a bottle
of his panacea in his pocket.

[12] At one time live toads were a popular remedy for hemorrhage,
tied behind the ears, or under the arm pits, or to the soles of the
feet. It was supposed by some that the effect was altogether mental.
But, as in the case of the Tractors, it was contended that this could
not be so, because the same effect was produced upon animals. Michael
Mercatus asserts that “if you hang the toad round a cock’s neck for
a day or so, you may then cut off his head, and _the neck will not
bleed a single drop_.” One cannot help being reminded by this of the
experiments with the _Brocchieri water_ a year or two since upon
animals, which, though reported as perfectly successful, have not
saved this remedy from going to the tomb of the Capulets, to which
all its predecessors have gone before it.




CHAPTER V.

THOMPSONISM.


Thompsonism, or Thomsonianism, as it is more often called, or
written, is a system of quackery, which, though it is evidently
declining in public favor, is still so prominent, that it seems to
merit a separate notice.

The principles of this system shall be stated in the language of its
founder.

“My system of practice is founded upon these few, simple, and I
think, just principles.

1st. That the constitutions of all mankind are essentially alike, and
differ only in the different temper of the same materials of which
they are composed. The materials, of which all men are formed, may
be resolved into the four elements. Earth and water constitute the
solids of the body, which is made active by air and fire. And this
last element in a peculiar manner gives life and motion to the rest;
and when entirely overpowered, from whatever cause, by the other
elements, death ensues.

2d. That the construction and organization of the human frame is in
all men essentially the same. They have similar solids and fluids,
viz., bones, cartilages, tendons, nerves, muscles, veins, arteries,
flesh, blood, and other juices, body and parts, or members.

3d. That all are sustained in a manner as similar as their formation,
from the earth, the common mother of us all. Of the elements man is
made, and by the same elements he is supported.

4th. That a state of perfect health arises from a due balance or
temperature of these elements. But when it is by any means destroyed,
the body is more or less disordered. And when this is the case,
there is always an actual diminution or absence of the element, fire
or heat, and in proportion to this diminution or absence, the body
is affected with its opposite, cold. The former may be denominated
nature itself, the best physician of the body, the latter its enemy;
the first is the health and life of the body; the last its disease
and death.

5th. That all diseases, however various the symptoms, and different
the names by which they are called, arise directly from obstructed
perspiration. The many evils derived from hence, must be obvious,
when it is considered that the discharge from the body thereby is
greater than by all the other evacuations combined. Obstructed
perspiration may be produced from a great variety of effects which
produce the same cause, originating from cold.

Now as all men have similar constitutions, being formed of the
same materials differently tempered; as their construction and
organization essentially agree; as they are all sustained from the
same elements which form their composition; as a just balance or
temperature of these elements produces a state of health, and the
reverse destroys it; as all disease takes its immediate rise from
obstructed perspiration in a greater or less degree; and as this is
an effect universally produced, it is evident that those medicines
which are most agreeable to nature, and efficacious in removing
obstructions, and the evils thereby produced, and restoring the
perfect equilibrium, activity and energy of the system, must be the
best, and universally applicable.

I shall now describe the fuel which continues the _fire_ or _life_
of man. This is contained in two things—_food_ and _medicine_, which
are in harmony with each other, often grow in the same field, and
are created to be used by the same people. People who are capable
of raising their food and preparing the same, may as easily learn
to collect and prepare their own medicine, and administer the same
when it is needed. Our life depends on heat; food is the fuel that
kindles and continues that heat. The digestive powers being correct
causes the food to consume; this continues the warmth of the body, by
continually supporting the fire.

The stomach is the _deposit_ from which the whole body is supported.
The heat is kindled in the stomach by its consuming the food; and all
the body and limbs receive their proportion of nourishment and heat
from that source; as the whole room is warmed by the fire which is
consumed in the fire-place. The greater the quantity of wood consumed
in the fire-place, the greater the heat in the whole room. So in
the body; the more food _well digested_, the more heat and support
through the whole man. But by constantly receiving food into the
stomach, which is sometimes not suitable for the best nourishment,
the stomach becomes foul, so that the food is not well digested. This
causes the body to lose its heat; then the appetite fails; the bones
ache, and the man is sick in every part of the whole frame.

This situation of the body shows the need of _medicine_, and the
_kind_ needed; which is such as will clear the _stomach_ and
_bowels_, and restore the _digestive organs_. When this is done, the
food will raise the heat again and nourish the whole man. All the art
required to do this is to know what _medicine_ will do it, and how
to administer it, as a person knows how to clear a stove and the pipe
when clogged with soot, that the fire may burn free, and the whole
room be warmed as before.

The medicines best calculated to have the desired effect are such
as will raise and retain the vital heat of the system, remove
obstructions, promote perspiration, clear off the canker, and
restore the digestive powers. These can only be found in vegetable
substances; and there can enough be found in all countries to
answer every purpose needed. I have devoted the greatest part of my
life to ascertain those articles that are best to answer the above
purposes; and these may be found in my Book of Practice, properly
classed under the heads of the different numbers, with directions
for preparing and administering them in curing all cases of disease,
which has been secured to me by patent. Family rights will be sold,
and the _necessary information given_ to enable those who purchase to
practice with safety and success, by application to me or any of my
agents duly authorized.”

Such is the statement of the _principles_ of Thompson’s theory. The
_principle_ contained in the last sentence, touching the sale of
family rights, was the favorite one, the _golden_ one in his eyes,
and he fought for it manfully. He made no blunder in putting this
among the _principles_ of his _practice_.

Appended to this ‘statement’ are some ‘Remarks on Fevers,’ which it
is not necessary to copy entire.

“No person,” says Dr. Thompson, “ever yet died of a fever! for as
death approaches, the patient grows cold, until in death the last
spark is extinguished. This the learned doctors cannot deny; and
as this is true, they ought in justice to acknowledge that their
whole train of depletive remedies, such as bleeding, blistering,
physicking, starving, with all their refrigeratives; their opium,
mercury, arsenic, antimony, nitre, &c., are so many deadly engines
combined with the disease, against the constitution and life of the
patient. If cold, which is the commonly received opinion, (and which
is true,) is the cause of fever, to repeatedly bleed the patient, and
administer mercury, opium, nitre, and other refrigerants, to restore
him to health, is, as though a man should, to increase a fire in
his room, throw a part of it out of the house, and to increase the
remainder, put on water, snow and ice!”

And again—“There is no more difference in all cases of fever than
what is caused by the different degrees of cold, or loss of inward
heat, which are two adverse parties in one body contending for power.
If the heat gains the victory, the cold will be disinherited, and
health will be restored; but on the other hand, if cold gains the
ascendancy, heat will be dispossessed of its empire, and death will
follow of course.

“The higher the fever runs, the sooner will the cold be subdued; and
if you contend against the heat, the longer will be the run of the
fever, and when extinguished, death follows.”

When a patient dies of fever, Thompson says, “the question whether
the heat or the cold killed the patient is easily decided, for that
power which bears rule in the body after death, is what killed the
patient, which is cold—as much as that which bears rule when he is
alive, is heat.”

Again he says, “At the commencement of a fever, by direct and proper
application of suitable medicine, it can be easily and speedily
removed. Twenty-four, or forty-eight hours, to the extent, are
sufficient, and often short of that time, the fever may be removed.”

Now see how confident this bold reformer is in the truth of these
assertions. “These declarations,” says he, “are true, and have been
often proved, and can be again, to the satisfaction of every candid
person AT THE HAZARD OF ANY FORFEITURE THE FACULTY MAY CHALLENGE.”

I have but a remark or two to make upon this theory of Dr. Thompson.

It is rather a rude and unscientific theory. There is a trifling
mistake in calling such _compounds_ as earth, air, water and fire
_elements_. Still, as a theory, it is quite as rational as most of
the theories spun from the more refined brains of some of Thompson’s
enemies, the ‘regulars,’ as they are styled by his erudite followers;
and I may say too that it is quite as good a guide in actual
practice. But this point I shall speak of in another place.

Thompson makes great account of ‘obstructed perspiration’ in his
theory. ‘All diseases,’ he says, ‘arise directly’ from it. It is
difficult to conceive what he does in his theory with the cold
_sweat_ of death; with the _sweating_ sickness, as it was called,
once so extensively prevalent and so fatal; with the colliquative
_sweat_, always so bad a symptom in disease, though there may be heat
enough with it to satisfy the most _ardent_ Thompsonian; or with the
_sweat_ of rheumatism, so unapt to bring relief to the disease. In
all these cases, there is certainly _un_obstructed perspiration, and
yet it does not remedy the disease, as it should do, according to the
Thompsonian theory.

While he considers fire or heat as life, he thinks that the
‘obstructed perspiration’ always ‘originates from _cold_,’ which
he seems to personify as a sort of master spirit, producing all
disease—it is the ‘legion,’ which his medicines, and his alone, are
fitted to overcome and dispossess. With him, heat and cold are the
two combatants that fight in the battle of disease. And while the
doctors, he says, ‘assist the cold to kill the patient,’ under his
practice, ‘the heat gains the victory, the cold is disinherited, and
health is restored.’

The fact, that the ‘obstructed perspiration’ is often made free by
cooling medicines, or by the direct application of cold to the skin,
and thus, disease is relieved, (a fact which is as well known to
common observers, as it is to ‘doctors,’ and which is directly in the
face of his theory,) I suppose he flatly denies, as he asserts in
regard to fever, that ‘if you contend against the heat, the longer
will be the run of the fever, and when extinguished, death follows.’

It is rather difficult for the unskilled mind of a ‘regular’ to
reconcile with the ‘simple and plain theory’ of Thompson, these
facts—that persons sometimes die with a great degree of heat upon
them—that heat sometimes remains in the body for a long time after
death—that in the cholera there is occasionally found after death a
great amount of heat, though the patient’s body was very cold for
many hours before death, &c. I once asked a Thompsonian the reason
of this last fact. ‘Why,’ said he, ‘that is plain enough—the disease
was so powerful it kept down the heat, but when the patient died,
the disease let go, and then the heat came out.’ The answer was at
least ingenious. But Thompson says, ‘if the heat gains the victory,
the cold will be disinherited, and health will be restored.’ The warm
corpse of the cholera patient ought, therefore, to have revived.

It is asserted by the followers of Thompson, that there is no need of
‘learned doctors.’ They declare that ‘the whole theory and practice,
is perfectly plain and simple, requiring no study of the dead
languages to comprehend it, thereby enabling any person of common
capacity to practice with a certainty of success, in all ordinary
cases of disease, and this too with but a few hours instruction.’
And, Thompson himself speaks of the art of medicine, as being as
plain and as easy, as the clearing of ‘a stove and the pipe, when
clogged with soot.’

The Thompsonian system dispenses with the services of ‘learned
doctors,’ for another reason also. It claims that, while other
medicines invariably injure the system, the Thompsonian remedies
always benefit it, both in sickness and in health. No matter how much
they are used, nor at what times—they always do good, for they have,
it is claimed, a natural relation to the system. Many Thompsonians
carry this idea still farther than this. A prominent physician of
this class, one sufficiently orthodox and accomplished to be for a
long time an editor of one of their papers, attributed a sort of
selecting power to lobelia. He said, that it would never bring up
anything that it ought not to bring up, and that if a man with a foul
stomach, should eat a good dinner, and then take lobelia, nothing but
the bad matter would be thrown off, and the dinner would stay there
to nourish the system.

Such views as these, being prevalent among Thompsonians, both in
regard to education and to the administration of medicine, it is not
strange that Thompsonian practitioners should be a very ignorant
set of men. In the remarks, which their special hatred for mineral
medicines, leads them to make, they sometimes confound mineral and
vegetable substances together. A Thompsonian of some considerable
note, finding that a patient was applying hot camphor cloths to her
side to relieve pain, said with an air of authority, ‘away with your
camphor—none of your _minerals_ where I am.’—‘What _shall_ we put
on doctor?’ asked a by-stander. ‘A hot bag of salt,’ said he. What
_vegetable_ mine the salt came from I did not learn. So too, a
Thompsonian lecturer told his hearers, that he disapproved of _all_
mineral medicines, such as mercury, _opium_, arsenic, &c.

We occasionally hear some singular reasoning from Thompsonians
in regard to the _modus operandi_ of medicines. Though this is
confessedly a very difficult subject, they claim to know all about
it, and give their opinions in regard to it without any hesitation.
A patient once told me that, among the many physicians of whom she
had suffered many things was a Thompsonian of considerable celebrity.
He assured her that he could effect a cure in a very short time. He
began his treatment with the process of steaming. Some heated bricks
wrapped in wet flannel were placed around her in bed. Presently some
one asked ‘what is it that smells so?’—‘O’ said the doctor, ‘it is
the smell of the disease coming out through the pores—things are
working nicely—this is just as I want to have it. Disease very often
comes out in this way, through the pores, and sometimes I have known
the smell to be so strong, that you could hardly stay in the room.’
As he went on to give his clinical lecture on ‘disease coming out
through the pores,’ the smell grew worse and worse, as if to give
emphasis to his remarks. But at length some one suggested that it
was a little like the smell of burnt flannel, and on examination,
it was found that one of the bricks had scorched the flannel which
was around it. She at once told the doctor, that she had no farther
use for his services, for if he did not know enough to distinguish
between the smell of ‘disease coming out through the pores,’ and the
smell of burnt flannel, he did not know enough to doctor her.

This system of quackery has obtained a large share of its popularity,
by the appeal which it has made to two forms of popular sentiment,
which have been for some time peculiarly prevalent. I refer to the
sentiment of _radicalism_, and to the prejudice against _mineral_
medicines.

As it has been fashionable in the world of business and politics, to
denounce moneyed corporations, as being monopolies, so that system
of institutions, or corporations (as they may be termed,) by which
a well educated medical profession is secured to the community, has
also been denounced and attacked by this same spirit of radicalism.
Thompsonism has been one of the principal channels through which this
attack has been made. The followers of Thompson have always spoken of
the medical faculty as a privileged order, which must be overthrown,
and down with ‘regularism’ has been the chief motto on their banner
of ‘reform.’ All this, however, comes with an ill grace from them,
for the ‘venerated founder’ of their system began his career with as
sheer a monopoly as ever existed—a patent securing to him the power
of selling rights for twenty dollars each, to every family; and the
last days of this ‘reformer’ were embittered by a quarrel on this
point, with some of his agents. And, besides this, his followers have
adopted the very ‘regularism’ for which they have professed to have
so holy an abhorrence. It is Thompsonian ‘regularism’ it is true,
but nevertheless it _is_ ‘regularism.’ Like the ‘regulars,’ against
whom they have waged such an uncompromising war, they have now in
Connecticut, and I suppose in other states also, their State Society,
and their board of Censors for the examination of candidates; and
they put the badge of ‘regularism’ upon these candidates, by giving
them a ‘regular’ diploma. The truth is, that they found that so many
of the class who are too lazy to work were coming from the workshop
and the field, dubbing themselves at once Thompsonian physicians,
that the business was getting to be overdone. Hence the necessity
of some restrictions. And it is _restrictions_ which constitute
the ‘regularism,’ the ‘monopoly,’ against which they have always
declaimed.

Thompsonians have made much use of the popular prejudice against
_mineral_ medicines. This prejudice has arisen in part from the
evils which have been seen to result from the _abuse_ of calomel.
This remedy is so effectual an one in many diseases, that it has
been used more freely, and with less caution, than it should be; and
disastrous effects have sometimes followed this abuse of it. But the
same reasoning which prohibits the cautious use of this article, on
account of the results which come from its incautious use, would
prohibit the use of horses, fire, steam, &c., because, through
carelessness and want of skill, horses run away, conflagrations take
place, and steam boilers burst. Still this groundless reasoning
is applied by a large portion of the community to this remedy.
And this prejudice against calomel has been extended to mineral
medicines generally. So extensive is this prejudice, that the quack
of every name is sure to appeal to it, and he, therefore, puts in
his advertisement, the assurance that his medicine is ‘entirely
vegetable,’ as a necessary passport to public favor. Many physicians,
too, disgracefully yield to the prejudice of the people in this
respect. They pretend to give no calomel, or almost none of it; and
yet, such physicians generally give more of this article, than those
who pursue an open and manly course on this subject.

In the clamor which has been raised against ‘mineral doctors’
Thompsonians have been among the loudest. They uniformly speak of
minerals, as if they were deleterious _because_ they are minerals.
Their chemistry, which, as you have seen, recognizes the existence of
only four elements, has not, I suppose, taught them, that their own
bodies are partly composed of minerals, that there is lime in the
bones, and iron in the blood, that minerals exist in many articles of
food, that their good wives sometimes put a mineral of even deadly
power into the bread which they eat, and that they daily use as a
condiment one of these same luckless minerals. They speak of ‘mineral
doctors’ as the poisoners of the race, while they claim so perfect a
safety in the use of their _vegetable_ remedies, that no carelessness
or want of skill can make them produce any bad results.

There seems to be a quite a general impression abroad in the
community, that there is a _harmlessness_ in vegetable remedies that
does not attach to mineral medicines, and that their effects are of a
_less abiding_ character. Nothing can be more untrue. Let us look for
a moment at these two points.

First, as to the supposed harmlessness of vegetable medicines. The
most active mineral medicines are arsenic and corrosive sublimate.
But arsenic taken in large quantity never produces death in a shorter
time than five to ten hours, and a large dose of corrosive sublimate
destroys life ordinarily in from twenty-four to thirty-six hours. But
among vegetable substances, oxalic acid, found in the common wood
sorrel, has destroyed life in ten minutes, and prussic acid, which is
the bitter principle in wild cherry, bitter almonds, peach blossoms,
&c., in the dose only of a few drops, destroys life instantly.
Comparisons might be made still further, showing that the most deadly
and expeditious poisons are vegetable.

Let us look now at the comparative _duration_ of the results of
vegetable and mineral medicines.

Much is said, especially by Thompsonians, about calomel’s staying
in the system, and all the bodily ills of a life-time are often
attributed to this cause without any hesitation. Whether these
wise ones have ever applied their rude chemistry to the detection
of calomel in such cases I have not learned. But there it is, _for
they say so_. It is in the very bones! Though no intelligent persons
believe in such nonsense as this, yet the general notion that
the effects of mineral, in comparison with vegetable agents, are
peculiarly abiding, is not confined to the ignorant and unthinking.

Leaving out of view the direct corrosive effects upon the living
texture of the concentrated acids, I may remark of poisons, whether
mineral or vegetable, that they produce either morbid _impressions_
upon the system through the nerves with which they come in contact,
or local _irritations_, which may result in inflammation. These
impressions or irritations may abide, or they may be partially or
wholly removed. The fact that they are produced by a mineral is no
more apt to make them abide, than the fact that they are produced by
a vegetable. We should expect this to be true, and experience has
shown that it is. For example the irritation produced by elaterium
(wild cucumber) or croton oil, or any vegetable cathartic of a
drastic nature, is as lasting as if it had been caused by any mineral
poison.

I trust that it is obvious to the reader from the above statements,
that they commit a great error, who suppose that the fact, that a
remedy is composed entirely of vegetable substances, is a sure proof
that it is innocuous, and that it can be used freely without any
discrimination. And yet it is a very prevalent error, to which many
lives are constantly sacrificed, to say nothing of the multitudes of
cases, in which, though death does not occur, injury is inflicted in
various degrees upon the system. A single example will suffice. A
case is detailed in the Boston Medical Magazine of a female, who had
a medicine administered by a botanic empiric, which was composed in
part of elaterium. Her life was destroyed in thirty-six hours by this
_vegetable_ remedy given her by this denouncer of ‘mineral poisons’
and ‘mineral doctors!’

Lobelia, it is claimed by the Thompsonians, is not a poison. I have
often heard them say that there was no danger from it, taken at any
time and in any quantity. Some have so said under oath. The vulgar
name by which this article has always been known, Indian Tobacco,
given to it from the similarity of its effects to those of common
tobacco, show what its character is by general acknowledgment.
Thompsonians however assert that it is not a narcotic; but every
physician, who has had Thompsonian quacks in his neighborhood has
occasionally witnessed effects ordinarily considered narcotic,
produced by this remedy. These effects, it is proper to remark, do
not commonly appear to any great amount, because vomiting occurs
so soon, and the medicine is thrown off with the contents of the
stomach. But when an ineffectual retching occurs instead of free
vomiting, and dose after dose is given, narcosis is certain to
supervene in a considerable degree, and sometimes it proves fatal.
This is especially apt to take place, when the system from any cause
is already in a very depressed state. Several trials have occurred
of Thompsonian practitioners charged with killing their patients
under such circumstances. Two cases are reported in Guy’s Forensic
Medicine, in which the accused were found guilty by the jury, and the
penalty of the law was inflicted.

The idea of Thompsonians and of some others in regard to poisons is
this—that there are some medicines which always do harm, and these
are poisons; while there are some other medicines which always
do good, and these are not poisons. The medicines used by the
‘regulars’ Thompsonians consider as belonging to the first class,
especially their _mineral_ remedies; while the vegetable medicines,
which they use in their practice, they claim to be of the latter
class.

Let us look at the true meaning of the word poison. Webster’s
definition of it is a correct one. He says it is ‘a substance, which,
when taken into the stomach, mixed with the blood, or applied to the
skin or flesh, proves fatal or deleterious.’

This definition has no reference to the time or the quantity required
to produce the effect. There is a wide difference in both these
respects between different poisons. Some are slow, and some rapid in
their operation. Some, as for example opium, arsenic, and prussic
acid, act as poisons in small amounts; while comparatively large
quantities of such articles as lobelia, saltpetre, and salæratus, are
required to produce ‘deleterious,’ and especially ‘fatal’ effects;
and yet lobelia, saltpetre and salæratus are as truly poisons as are
opium, arsenic and prussic acid.

It may be remarked also that this definition has reference only to
the _usual_ effects of substances; and not to any occasional effects
which may be owing to circumstances. If, for example, any substance
produce a bad effect simply from the influence of any constitutional
peculiarity, or some temporary condition of the system, it is not to
be called a poison. The term poison is used often in relation to the
effects of substances in such cases, but it is only in a _relative_
sense. Anything may be a poison in this sense. Anything which is
inappropriate to any case will produce a ‘deleterious’ influence upon
it, and is therefore a poison to it. Food may thus be for the time
being a poison to the sick man, as really as a noxious drug. Indeed
a noxious drug may be to him a cure, while in the same quantity it
would be perhaps even a fatal poison to him if he were well. Thus
a man sick with spasmodic colic is relieved by opium, which is a
noxious drug to a well man; and perhaps, in order to produce the
relief, he requires as much as would kill him if he were in a state
of health.

The word poison carries terror to most minds, and it has therefore
been one of the watchwords of Thompsonians and other quacks, in their
warfare upon the medical profession. And yet, while they are raising
this ridiculous outcry, they themselves, as I have before said,
daily use poisons, even mineral poisons, as common articles of food.
Salæratus, cream of tartar, and even common salt,[13] are poisons,
for when taken in large quantities, they prove ‘deleterious,’ in some
cases ‘fatal,’ and therefore come within the terms of the definition.

I have said thus much of the popular prejudice on the subject of
poisons, and the use which Thompsonians and other quacks have made of
it, because there is so general a misapprehension in regard to these
points abroad in the community.

I cannot conclude this chapter without noticing the changes which
have taken place in the sentiments and practice of Thompsonians
within the last few years. These changes have been quite material. I
have already alluded to some of them.

Thompsonians formerly denied the necessity of education in the
practitioner. But now the candidates for admission to Thompsonian
practice must study, and must submit to an examination before a board
of Censors. And though Thompsonians have from the first denounced
the medical faculty, and their institutions, they have now a medical
faculty of their own, and have organized state societies.

Thompsonians are not now so bold and reckless in their practice
as they once were. In the infancy of this practice every sick
man, whatever might be his disease, or his state at the time, was
subjected to what was called “the operation,”—that is, steaming and
vomiting with lobelia. But so many died during the “operation,” or
immediately after it, that Thompsonian doctors have learned to be
more cautious.

Cathartics used to be utterly discarded by Thompsonians, but now they
are quite extensively used. Indeed they have widened their range of
remedies generally. Once lobelia and steam and red pepper were nearly
all in all. But now they are making out a very considerable materia
medica. At the same time they are dropping the names Thompsonian
Physician and Thompsonian Practice, and adopting instead of them
Botanic Physician and Botanic Practice.

Once no Thompsonian doctor would practice vaccination, because as he
contended, it was better to have even small pox, under the guidance
of Thompsonian treatment, than it was to run the risk of getting
‘humors’ from the vaccine virus. But finding that their employers
would have their children vaccinated, even though they were obliged
to get the ‘mineral doctors’ to do it, some of them have gone into
the business themselves.

Such are some of the changes which have come over Thompsonism, giving
it a very different character from that which it exhibited when it
first came in its stern simplicity from the rude hand of its founder.
Its popularity is already declining, and it will probably soon pass
away, to give place to some other kindred delusion.


FOOTNOTES:

[13] Guy, in his Forensic Medicine, states that common salt taken
in a large quantity has destroyed life, with symptoms of irritant
poisoning.




CHAPTER VI.

HOMŒOPATHY.[14]


Samuel Hahneman, the founder of the system of practice called by this
name, was born at Messein in Saxony in the year 1755. At the age of
twenty he went to Leipsic, to obtain his education, with but twenty
ducats in his pocket. While he was going through with his course
of education, he supported himself chiefly by translating English
works on medicine. He professed to be dissatisfied with the common
modes of medical practice, and after he took his degree, instead of
becoming at once a practitioner of medicine, he preferred to gain
his livelihood by translating books, and by contributing to various
scientific journals in Germany.

It was in the year 1790 that he first broached the idea, which is the
great principle of the Homœopathic system, and which he soon dreamed
was to overturn and dispossess all other medical practice. He viewed
himself as a great reformer, as the founder of a system, and he was
soon ready to proclaim to the world, that his was the ‘great gift of
God to man.’ Discarding all the past experience of ages as useless,
with his mind filled with bright visions of his future greatness, he
was ready to say with Paracelsus, ‘the monarchy of physic is mine.’
In 1796 he published his first paper on the subject of Homœopathy, in
1805 his first work, in 1810 his famous Organon, and the next year
his Materia Medica. He died in Paris at an advanced age, only a few
years since, having lived to see his system adopted very extensively
all over Europe.

It will not be necessary to spread before the reader the principles
of his system in his own language. There is in his statement of them
considerable verbiage, which has quite a learned air, but which would
be unintelligible to the common reader. The essential principles of
his system are but two in number, when the mass of words comes to be
sifted by a little plain common sense.

The great principle, which lies at the foundation of this system, and
which has given it its name, is found in the Latin aphorism, _Similia
similibus curantur_. This is in homely English, Like things are
cured by like. In other words, a disease is cured by remedies which
produce upon a healthy person symptoms similar to those presented
by that disease. Thus vomiting is to be cured by a nauseant,
diarrhœa by a laxative, &c. Hahneman does not pretend that this is
a newly-discovered principle, but says that it has been acted upon
from time immemorial. Of this fact the following examples are given.
Senna has been used for colic; rhubarb for diarrhœa; thorn apple
for insanity; the sweating sickness has been treated by sudorifics,
frozen limbs by rubbing in snow, and burns by putting them to the
fire and by stimulating ointments. So Shakspeare alludes to the same
fact;

    “Tut, man! one fire burns out another’s burning,
    One pain is lessened by another’s anguish;
    Turn giddy and be holp by backward turning;
    One desperate grief cures with another’s languish;
    Take thou some new infection to thine eye,
    And the rank poison of the old will die.”

So also the common proverb ‘cure your bite with the hair of the same
dog’ has reference to the same principle.

All that Hahneman claims is, that he has taken this principle, thus
occasionally recognized, and demonstrated its applicability to the
whole range of disease, and made it the basis of a system of practice.

Hahneman says that there can be but three relations of remedies to
diseases—heterogeneity, opposition, and resemblance; hence severally,
the Allopathic, Antipathic, and Homœopathic systems of practice.

The Allopathic mode—that which treats diseases by creating another
disease—he says, “cannot cure in any case; having no analogy, or
opposing force to the symptoms of the disease, it can never reach
the parts affected: it may suspend the symptoms for a time by
heterogeneous suffering, but it cannot destroy them.”

“Antipathic treatment is merely palliative. When the action produced
by the remedy employed, and which may seem to effect a neutralization
of the symptoms, or even a cure, ceases, the reverse process
immediately takes place—not only shall the primitive malady return,
but come it will with aggravated symptoms, and in proportion to the
doses administered.”

“The Homœopathic is the only one which experience proves to be always
salutary. The pure and specific effects of the remedies employed
being perfectly analogous to the natural symptoms, they go right to
the parts affected; and as two similar diseases cannot exist at the
same time in the same system, the natural symptoms give way, provided
the artificial ones slightly surpass them in intensity.”

The allopathic mode, he claims, is the mode of treating disease in
common vogue, and his followers call physicians generally by the name
of allopaths. Now we have no objection to the name which they assume
to themselves, but we do object to their giving inappropriate names
to their neighbors. The title of Allopath, thus impudently bestowed
upon us by Homœopathists, is not a correct title. The treatment of
disease by physicians of the old school, as they are termed, is not
characterized by any predominance of the allopathic principle. They
do not ordinarily attempt to cure a disease by creating another. They
do sometimes indeed make use of this principle. As good an example of
it as can be given is to be found in the application of a blister to
relieve internal inflammation. Here a new disease is produced, upon
a part which is able to bear it without injury, in order to cure the
disease in the internal organ. And no fact is better established, as
my readers will all allow, than that disease is sometimes thus cured,
although Hahneman says “_Allopathic_ treatment cannot cure in any
case.”

What Hahneman terms the antipathic mode is much used by physicians.
I mention as an example the treatment of spasmodic colic by opium.
This antipathic remedy in almost all cases cures this malady, though
Hahneman says the “antipathic treatment is merely palliative” and
never cures.

In regard to many of the remedies which cure disease, it may be said,
that we know not in what manner they do it. As an example I will
refer to cinchona, and quinine, the essential principle of cinchona,
in curing intermittent fever. The fact that they will cure it in most
cases is as well established as any fact in medicine, but _how_ they
do it no one knows. Many explanations have been ventured, but they
are mere conjectures. Hahneman asserts, that cinchona and quinine
cure intermittent fever on the homœopathic principle, because, as he
declares, he has found, that these articles produce on persons in
health symptoms similar to those of this disease. His experience,
however, does not correspond with that of others, who are more
competent to observe correctly, than one who looks at everything
through the distorting medium of a favorite theory. Cinchona and
quinine have been given to many persons in health, both in large and
in small doses, in order to test the truth of Hahneman’s alleged
experience, and no such results as he describes have followed. They
seem to be singularly confined to Homœopathists.

We see occasionally, but _only occasionally_, effects from agents in
the treatment of disease which seem to have their explanation in the
principle, that one disease is cured by temporarily creating another
similar to it. Hahneman fixed his eye upon these few facts, his mind
became filled with the _one idea_ which he there saw, and he was soon
blind to everything else. Losing thus his mental equilibrium, he
became an errorist precisely in the same way that thousands have done
before him.

The second great principle of Homœopathy is, that a peculiar
power, a ‘dynamic power,’[15] as Hahneman calls it, is communicated
to medicinal substances by minute division, with agitation and
trituration. This Hahneman considers as his grand discovery. This was
wholly an original idea with him, and if it be a really discovered
_fact_ that a peculiar power is thus given to medicines, the credit
belongs to him, and to him alone.

The minuteness of the subdivision prescribed by Hahneman is extreme.
He does not talk of doses so large as the millionth part of a
grain—this would be horribly disastrous. A hundred millionth of a
grain is quite a formidable dose. A decillionth is the common dose,
and this numeral is expressed, after the old method of enumeration,
by an unit with a string of _sixty_ cyphers. If we suppose the
population of the earth to amount to a thousand millions, a grain,
if taken in the dose of a decillionth of a grain, would supply every
inhabitant of the earth with a septillion of doses. And if each
one should take three decillionths of a grain a day, the present
inhabitants of the earth would require very nearly a sextillion of
years to use up the whole grain.

A Dr. Dufresne reports a case in the Bibliotheque Homœopathique, in
which he unfortunately administered an over dose, the _one hundred
millionth_ of a grain of strychnine, a medicine which physicians
ordinarily give in the dose of a fifteenth or tenth part of a grain.
It was a case of neuralgia. He does not say at what time he gave
this over dose of a hundred millionth of a grain. But after taking
it he says, “the patient was seized with a paroxysm of the neuralgia
in the night about an hour earlier than the regular period of its
attack. The usual symptoms were experienced, but it was remarkable
that they occurred in an inverse order, attacking those parts last
that were attacked first before. _The dose was much too strong._
Madame B. was like a mad woman all night; the racking pains seized
her whole head, and her face was swollen and burning hot.” But it
seems that after all, this over dose cured Madame B., for “there was
but one slight accession of the complaint afterwards: the lady has
ever since been perfectly well.” Dr. Dufresne adds that he should
never again be guilty of such over-dosing, but that had he to treat
Madame B’s. malady over again, he should give a decillionth of a drop
of the alcoholic tincture.

Hahneman and his followers do not talk of these exceedingly small
doses in regard to powerful medicines only, but also in regard to
medicines considered almost inert. Nothing is more common with
Homœopathists than to give a decillionth or two of a grain of
charcoal or oystershell, or common salt.

Hahneman thought much of the amount of agitation and trituration,
which were employed in preparing medicines. He gives very particular
directions as to the exact number of minutes to be consumed by
different portions of these processes. In mixing one grain of any
substance with a hundred grains of sugar of milk, he directs that
the mixture shall be made thus—the grain of substance is to be added
first to a third part of the sugar of milk and they are to be rubbed
together six minutes—the mass is then to be scraped from the pestle
and mortar, which is to take four minutes—now it is to be rubbed
again six minutes—then scraped into a heap, which is to take four
minutes—the second third of the sugar of milk is now added—rubbing
six minutes follows—scraping together four minutes—rubbing six
minutes again—another scraping together four minutes is followed by
the addition of the last third of the sugar of milk—then there is
rubbing six minutes, scraping together four minutes, and six minutes
more of rubbing completes the mixture. But this is only the beginning
of the preparation which is required. A long course of processes is
directed to carry the medicine to its proper state of dilution, up
to the billionth, trillionth, quadrillionth, even the decillionth,
degree. For a more full statement of Hahneman’s directions, I refer
the reader to Dr. Holmes’ Lecture on Homœopathy.

Hahneman is very particular as to the number of shakes to which
medicines in solution should be subjected. On this point he says,
“A long experience and multiplied observations upon the sick lead
me within the last few years to prefer giving only two shakes to
medicinal liquids, whereas I formerly used to give ten.” What
particular effect this difference in the amount of shaking has upon
the ‘dynamic power’ of the medicines, he does not see fit to say.
I suppose he means that the more shakes a medicine receives, the
greater is its power. If this be true, what a tremendous ‘dynamic
power’ must be imparted to some of the liquid medicines in the saddle
bags of country doctors, as they jog about from place to place; and
yet, poor unobserving mortals, they never discern any of the effects
of this power though they might be very apparent to the acute vision
of Hahneman and his followers.

The common idea on this subject is, that when any substance, as
tartar emetic, for example, is _fully_ dissolved in water, no amount
of shaking can effect a more intimate union between the tartar
emetic and the water. Nor can it alter the nature of the union, so
as to give the solution any new power, or any increase of power. In
order to alter the nature of the union, you must introduce a third
agent, which shall act _chemically_ upon the tartar emetic and the
water.

This is true so far as we know; and it was universally acknowledged
to be true till Hahneman came out with an opposite opinion. But
to establish what is so opposite to all past experience, and to
overthrow what has been considered by all as an established fact,
the very best of proof is necessary. Hahneman says, that the proof
is to be found in the effects of the solutions, to which agitation
has communicated the ‘dynamic power.’ And if the effects, which
he asserts that he and other Homœopathists have seen, are really
produced, then the proof I allow is competent.

Some loose analogies, which have hardly the shadow of plausibility
are much relied upon by Homœopathists in advocating the efficacy of
their medicines. In relation to the ridicule which has been cast upon
_the little doses_, Dr. Hering says, “suppose _electricity_ had at
its first disclosure been sneeringly called _the little tempest_, how
ridiculous might it have appeared to those persons who were incapable
of comprehending its minuteness or its might.” And the minute
division of matter, as, for example, in the making of gold leaf and
in the diffusion of odors, is often alluded to by Homœopathists, as
illustrating the power of the little doses. When they will prove
that a little electricity will produce a greater effect than a large
amount of it, that a decillionth of a grain of gold will make a
stronger leaf than a whole grain with the same extent of surface, or
that a decillionth of a grain of musk can be made to give out a more
powerful odor than any ‘allopathic’ quantity of it: then I will not
only grant that the analogies are good ones, and that they go to show
that Homœopathy is probably true; but I will also engage to prove,
that a tack-hammer can give a stronger blow than a sledge, that
smallness is always the emblem of might, that a man will be better
nourished by Homœopathic doses of food than by the usual allopathic
ones, and any other ridiculous thing of a kindred character.

Having thus noticed the two great principles of Hahneman’s system,
let us now see on what kind of observation or experience these
principles rest. If the experience be satisfactory in its amount and
character, then, however opposed these principles are to the ideas
and doctrines current among physicians, we must admit them to be
true. It is to _facts_ that I appeal—_numerous_, _well observed_,
_well attested_, _comparable_ _facts_. Nothing else can settle this
question. If the decillionth of a grain of strychnine, or mercury,
or charcoal, or salt, or oystershell, does produce palpable and
measurable effects upon the human system, lasting twenty, thirty,
forty, or fifty days, and does thus cure disease, as Homœopathists
assert, let it be proved by _facts_.

As an example of the character of the observations, which are
relied upon by Homœopathists to establish this point, I will take
Jahr’s Manual of Homœopathic Medicine published in 1838. It was
‘translated from the German by authority of the North American
Academy of the Homœopathic Healing Art.’ This book is high in favor
with all the Homœopathists in this country. It is a closely printed
octavo volume of six hundred pages. Four hundred pages are occupied
with descriptions of the effects of about two hundred remedies,
and the remaining two hundred pages contain a Repertory, as it is
called, in which the symptoms are arranged alphabetically, with the
remedies which produce them opposite. The Repertory is of service
in investigating cases, and, if we understand it, it is to be used
in this way. A list is to be made of the symptoms presenting in any
case, and then the remedies appropriate to the cure of these symptoms
can be found opposite to them in the Repertory.

The descriptions of the effects of remedies are exceedingly minute
and particular. I will give a few examples, taken almost at random
from the descriptions of a few articles. ‘_Drawing_ pain in _hollow_
teeth, extending to the eye-brows—cracked _upper_ lip—stitches in
_hollow_ teeth, _when biting_—pain and pungency in the _elbow_,
which allows one not to stretch or exert the arm—pungency in the
knee and bend of the knee—inflammation and swelling of one _half_
of the nose—torpor and stiffness of one _half_ of the tongue (which
half?)—blood blisters on the _inside_ of the _upper_ lip—loss of
appetite chiefly for bread and tobacco-smoking—phlegm is hawked
out, chiefly in the morning—rending and stinging in the _corns_—red
itching spots on the _shin-bone_—tightening pain in the _joint_
of the elbow—blueish spots on the _fore arm_—tremor of the hands,
when occupied with fine small work—tingling in the _points_ of the
toes—tingling in the arms and _joints_ of the fingers—perspiration
on the hands, and _between_ the fingers—stitches in the ankle _when
stepping out_ (not when stepping in)—a voluptuous tickling on the
_sole_ of the foot, _after scratching a little_, making a _man_
(woman too?) almost mad—ulceration of the _big_ toe, with a pricking
pain—after stooping some time, sense of painful weight about the
head, upon resuming the erect posture—an itching, tickling sensation
at the _outer_ edge of the _palm_ of the _left_ hand, which obliges
the person to scratch.’

With such minuteness of observation as this, the Materia Medica
of Homœopathy must contain a _mass_ of facts, _if they really are
facts_. They are claimed to be such, established by numerous and
careful observations. Let us see how this is done. If an individual
take an article, his condition is watched for some length of time,
according to the duration of the effect of the article. This is
various. The effect of carbonate of lime (common chalk) lasts fifty
days; saltpetre, seven weeks; red pepper, twenty days; salt, fifty
days; &c. If then common salt, for example, be the article, all
bodily conditions, all sensations, all mental states, &c., occurring
within fifty days, are to be set down as the effects of that salt.
A collection of many such histories of cases is used in making up a
complete description of the effects of this article. And so of other
articles. The four hundred pages of descriptions of the effects of
remedies in Jahr’s Manual are, according to the statement of Hering
in his introduction to it, made up precisely in this way.

If all action in the human system were produced only by what is
applied to it from without, and if the system could be so insulated
that only one thing at a time should be permitted to act upon it,
in this case, and in this only, would such kind of observation be
available. But how is it? _Numerous_ agents are constantly acting
upon the system—food of various kinds—air, through the medium of the
skin and the lungs—variations of temperature—varying electrical and
other states—mental influences—processes resulting from previous
impressions—all these exert a constant influence, modifying the
effects of remedies almost infinitely. Some allowance is indeed
made or affected to be made, by Homœopathists, for _some_ of these
influences; but, after all, the remedy administered is considered as
overtopping them all—it has _supreme_ possession of the patient, by
virtue, I suppose, of its _dynamic_ power. All symptoms that can
be observed in him, whatever they may be, are the effects of the
medicine, and Hahneman considers the various influences of which I
have spoken as only modifying these effects, and that to a limited
degree.

Proceeding after the manner which I have described, it is no wonder
that Homœopathists make out such a wide range of symptoms for each
remedy. The symptoms said to be produced by nux vomica, with all
their various conditions, amounted some time ago to about twelve
hundred. How many the recent researches of Homœopathists have added
to them I know not. Even chamomile, a simple mild tonic, as it is
universally considered by our good mothers, has three full pages of
symptoms ascribed to it, beginning in this formidable way—“Rheumatic
drawing, tearing pain, with a disabling numbness in the parts
affected, most aggravated at night, frequently with continued
thirst, heat and redness of _one_ cheek, and hot perspiration on the
head in the hair—vehement pains, almost insupportable, leading to
desperation, aggravated by every movement. Pains mitigated by warm
cataplasms—beating pains as from occult suppuration—cracking in the
joints, particularly in the lower extremities.”

The _mental_ effects of chamomile are thus given. “Hypochondriac
paroxysms of anxiety, as if the heart would break—restlessness, with
anxious groaning and tossing about—irritable readiness to weep, with
whining and howling, frequently on account of _old_ or imaginary
offences—aversion to music, &c.”

If one who knew nothing about chamomile should read over the three
pages of the effects attributed to it, he would be justified in
supposing it to be a fit agent for inquisitorial torture, instead of
being the innocent thing which all nurses and old women think it to
be.

The effects of sodii chloretum (common salt) occupy four and a
half pages. Its _mental_ effects are thus described. “Melancholic
sadness, with searching for many unpleasant things, much weeping, and
increased by consolation—sorrowfulness about futurity—anxiousness,
also during a thunderstorm, chiefly at night—indolence, aversion to
talk, joylessness, and disinclination to labor—hasty impatience and
irritability—easily frightened—hate of _former_ offenders—fretfulness
and disposition to angry violence—inclination to laugh—alternation
of fretfulness and hilarity—great weakness of memory and
forgetfulness—thoughtlessness and mental dissipation—misusing words
in speaking and writing—inability to reflect, and fatigue from mental
exertion—awkwardness.”

The mental effects of sulphur are thus given. “Sadness
and dejection—melancholy, with doubts about his soul’s
welfare—great inclination to weep, frequently alternating with
laughing—inconsolableness, and reproaches of conscience about
every action—attacks of anxiety, in the evening—nocturnal fear of
spectres—fearfulness and liability to be frightened—restlessness
and hastiness—caprice, moroseness, and ill humor—irritability and
fretfulness—disinclination to labor—great weakness of memory—diliria
and carphologia—mistaking one thing for another—philosophical and
religious reveries, and fixed ideas—insanity with imagination, as
if he were in possession of beautiful things and in abundance of
everything.”

The description of _all_ the effects of sulphur occupies _seven_
pages, and if it be a true description, it certainly must be a very
terrible thing to take sulphur.

There is a great show of accurate discrimination on the part of
Homœopathists. Extreme niceness of observation is claimed to be
absolutely requisite for the successful practice of Homœopathy.
The distinctions which are made in regard to symptoms are not only
minute, but sometimes laughably so.

Pain is divided into simple, rending, pressing, tightening, rasping,
rheumatic, stinging, jerking, periodical, contracting, burning,
boring, spasmodic, cutting, bruizing, cramping, drawing, compressing,
constringing, sore, disabling, squeezing, &c. Some of these
distinctions our ‘allopathic’ mind cannot comprehend. Perhaps the
acuteness of a Homœopathic mind may recognize the exact difference
between pressing, compressing, constringing and squeezing pains, but
I confess that I do not.

All these different kinds of pain are produced by different agents,
and different agents cure them. Not only so, but the same pain
requires different remedies, as it appears in different parts. Thus
while one remedy cures a pain in your _whole_ neck, quite another one
cures the same pain in the _nape_ of the neck. Different remedies are
required to relieve the same pain in the shin, the heel, the ball of
the foot, the toes, &c.

I counted up in the Repertory, twenty-four kinds of toothache, in
addition to a great variety of other sensations in the gums, the
teeth and the roots of the teeth. Besides, there are fifty-five
conditions under which toothache appears, resulting from different
agents. Some of these are a little singular. Thus Rhododendron is apt
to produce toothache in a thunderstorm, and therefore, according to
Homœopathic reasoning, is the appropriate remedy for toothache which
is particularly disposed to come on in a thunderstorm—a disposition
of toothache of which I never heard before. The remedy for toothache
which comes on when riding in a vehicle is sepia—no remedy is
mentioned for it when it comes on when riding horseback, or going
on foot. Homœopathic researches have not extended as yet to these
points. Pulsatilla is the remedy for toothache in the _spring_, but
there is no remedy especially for it in summer, autumn, and winter.
Such gaps in Homœopathic experience ought certainly to be filled up.

The varieties of toothache are rendered still more numerous by the
symptoms with which it is connected. I counted eighteen of these.
Among them are coldness of the ears, twitching of the feet and
fingers, and a necessity to run about.

An aversion to different things is produced by different remedies.
Thus colchicum causes an aversion to pork—zinc to veal and
fish—selenium to salt food—hellebore to sour crout—arnica to
broth—assafœtida to beer—sabadilla to wine[16]—belladonna to
vegetables—sulphur to washing one’s self—tartarized antimony
to tobacco smoking—spigelia to tobacco-snuffing, &c. Nothing
is mentioned as causing an aversion to tobacco _chewing_. Some
Homœopathists had better extend the line of discovery in that
direction.

Jahr has some singular grouping of symptoms. Under the effects of
colchicum we have “mental exertion, touch, bright light, smell
of pork, and improper behavior of others, exacerbates the case
excessively.” In relation to the pork, he does not say whether it is
cooked or uncooked—there is certainly a failure in the nicety of his
discrimination here.

These Homœopathists sometimes make wonderful discoveries. In the
notice of the effects of stramonium, I find this. “Air passes out of
the ears.” Does stramonium, I would ask Mr. Jahr, or his translator,
Mr. Hering, set up the manufacture of air in the ears, or does it
punch a hole through the drum of the ear, and thus let the patient
blow air from his mouth through the ears? Our allopathic mind cannot
divine how air can come from the ears except in one or the other of
these two ways.

But enough of this. The reader, I trust, has had a sufficient insight
into Homœopathic observation, to see that it proves nothing. If it
proves what it professes to do, then anything may be made to prove
anything that may be desired. We laugh at the folly of the fly on
the coach, that supposed itself to be the cause of all the dust
made by the prancing horses, and the whirling wheels; but the folly
of the fly is as nothing, compared with his, who considers all
symptoms, bodily and mental, for fifty days as resulting from a few
decillionths of a grain of sulphur, or salt, or oystershell. And
yet it is upon such ridiculous assumptions as these, falsely called
“observations,” that the system of Homœopathy is based. The results
of these observations, we are informed in Dr. Hering’s introduction,
“have, through the zeal of the Homœopathists, already filled more
than _fifteen_ octavo volumes.” The Materia Medica of Hahneman
himself fills six volumes. It is spoken of by his followers as “a
rich arsenal, from which Homœopathy may arm itself against every
known disease; it contains at present nearly 80,000 combinations
of symptoms, with the corresponding substances which shall produce
their counterparts; and it goes on every day to be still farther
enriched, and to such an extent, as to leave it utterly impossible
to assign any limits to the future developments of Homœopathy.”
What a stupendous monument of human folly is this confused mass of
rubbish! It is no wonder that a man who could invent such a system
as Homœopathy is, should at last place as a cap stone upon this
monument the grand discovery, which he says it cost him twelve years
of research to make, viz. that seven eighths of all chronic diseases
come from a _psoric_ virus, of which psora (vulgarly called itch) is
only the simplest development!

But it is said that, laugh as we may at the ridiculousness of
Homœopathy, as a system, it is really successful in practice. If we
are to take the testimony of such observers as Mr. Jahr, and his
brother compilers of the fifteen octavo volumes of “observations” to
this point, I must beg leave to demur. But the doctors who practice
according to these same fifteen octavo volumes, and the multitudes,
especially the _female_ multitudes, who practice in their families
with their little boxes filled with little phials of little globules,
with a little pamphlet of directions, testify, that Homœopathy is
eminently successful. Such _was_ the testimony also in regard to the
success of Perkins’ Tractors, Dr. Beddoes’ Gases, and St. John Long’s
Liniment. That testimony does not avail just now, and I suspect
that some years hence, when some other delusion shall succeed in
supplanting Homœopathy, the present testimony of Homœopathists to its
success will avail as little.

But it is true, I most cheerfully allow, that Homœopathy is more
successful than any _exclusive_ system of practice, which is
characterized by _positive_ medication. It is so, simply because
it leaves the curative power of nature to act freely, undisturbed
by any officious interference. It is also true, that Homœopathy is
more successful than any _over dosing_ practice of any kind. But it
is _not_ true that it is anything like as successful as a cautious
_eclectic_ practice. I mean by this a practice which selects its
remedies from every source where they are to be found, _governing
its choice by the actual effects ascertained by careful observation,
without regard to any theory or any exclusive system of doctrines_.
This is the only proper mode of practice, (if it can be called a
_mode_,) and though it makes no such loud pretensions as are made
by the different exclusive modes of practice, in their strife for
popularity, it is pre-eminently successful. I mean successful in
curing disease. I do not refer at all to success in obtaining the
public favor—that is quite another thing.

The success which Homœopathy has realized, in obtaining its hold
upon the community, results from several causes which I will briefly
notice.

1. Mental influence. This system of practice is especially calculated
to produce a great effect in this way. The very idea, that there is a
peculiar power imparted to the little globules by their preparation,
acts upon the imagination of the patient. It gratifies too the love
of mystery, so common, and so ready to respond to the appeals which
are made to it. The minute examination of symptoms, of which such
display is made by Homœopathic physicians, adds to this influence
upon the mind, by its imposing air of deep and patient research.

2. A strict regard to diet and regimen. This I need not dwell upon.

3. The influence of the curative power of nature, the efforts of
which are not interfered with by Homœopathy. This is the chief cause
of all the cures which Homœopathy claims to itself, as the undoubted
results of its infinitesimal doses. The two influences first named
prepare the system for the operation of this curative power.

4. A comparison between the results of Homœopathic practice and those
of the practice of over-dosing physicians. Such a comparison will
generally tell in favor of Homœopathy, because the plan of giving no
medicine and relying upon a favorable mental influence and a strict
regulation of diet and regimen, is much better than storming a
patient with drugs, as one would a citadel with balls.

5. An occasional use of remedies in the ordinary doses. This is
practised more often than is commonly supposed, and especially by
those who have from mere pecuniary motives left the ranks of the
‘Allopaths’ and adopted the Homœopathic practice. They _know_ that
in acute diseases especially, there is sometimes pressing need of
something more than the tiny doses, and they resort for the moment
to their old mode of practice. And it is easy to do this secretly if
they wish, for calomel, morphine, &c. are not very bulky medicines,
and a good dose of them can easily be put into a very few little
globules. Many a Homœopathic patient is thus saved from death by the
‘old practice,’ while Homœopathy gets all the credit of it.[17] Mr.
Constantine Hering, in his introduction to Jahr’s Manual, complains
that some of his brethren are not strictly orthodox—that they are
guilty of the inconsistency of mixing the practice of the old and of
the new school together. This complaint however comes with an ill
grace from him, for I once knew this prescriber of decillionths of
a grain of such inert things as salt and oystershell, direct for a
patient a nightly dose of half a teaspoonful of red pepper—a dose
quite large enough to suit an ‘Allopath’ or even a Thompsonian.[18]

6. The facility with which people are imposed upon in their attempts
to estimate the comparative merits of modes of practice by their
_results_, is another source of the popularity of Homœopathy. Most
persons, as I take occasion to show in the chapter on Good and Bad
Practice, have an opportunity of witnessing but a _limited_ range of
facts in medical practice—altogether too limited to enable them to
arrive at any just conclusions. And then the flying reports abroad
in the community on this subject are exceedingly vague, and are not
to be relied upon. Yet these limited observations, and these reports
bruited about by the loose tongue of Madame Rumor, are the boasted
facts, by which Homœopathy, like every other delusion, has gained its
popularity.

Such being the sources of the popularity of Homœopathy, I do not
wonder at all that it has acquired so extensive favor with the
public. Neither do I wonder that many very sensible persons have
been captivated with it; for the evidence upon which they base their
preference is so limited and so loose, that it is calculated to
mislead any who rely upon it. And I would not reproach nor ridicule
them for this preference; but I would simply ask them to look
carefully at the nature of the evidence, on which the success of
Homœopathy is so confidently asserted. If they will do this, they
will find that the evidence is insufficient and deceptive.

Before I leave this topic, I wish to present to the reader a
case somewhat parallel to that of Homœopathy, which may serve to
illustrate farther the way in which medical delusions acquire their
hold upon the public mind. A clergyman in a small town in Germany,
interpreting the passage of Scripture, ‘the prayer of faith shall
save the sick,’ as having a literal and an universal application,
some years ago went into the practice of medicine among the people
of his charge upon this idea. He gives no medicine, but merely
visits the sick and prays with them. All kinds of disease, acute
and chronic, are submitted to this treatment. He tells those that
apply to him, that there is no need of doing so, if they will only
themselves repent of their sins, and lift up the prayer of faith.
It is only in default of their penitence and faith that his prayers
are required. He shows great shrewdness in pointing out the sins of
the vicious, to which he attributes their diseases. This adds much
to his reputation, and to the mental influence which he exerts upon
the sick. He is sincere in his views, and takes no compensation for
his services to the sick, which he performs in connexion with his
pastoral labors. His success is so great, that no physician has been
able to get a living in the place where he resides, and invalids come
to him from all the country round, even to the distance of fifty
miles.

In this instance, there are some of the same elements of success
that exist in the case of Homœopathy. His mental influence upon his
patients is very decided. He leaves the curative power of nature
to act undisturbed. And added to these sources of success may be
mentioned, as having a considerable influence, a reformation in the
life of some of those whose vices he faithfully points out to them.
So far as apparent results are concerned, it is quite as proper
to attribute a curative ‘dynamic power’ to the prayers of this
clergyman, as to the infinitesimal doses of Hahneman.

Homœopathists often boast of the inroads which their system has
made upon the ranks of the medical profession. But it is an empty
boast. If the Homœopathic physicians in this country could be
gathered together, it would be an assemblage for the most part of
very common men. No superior order of talent would be found among
them. There would be none who are distinguished for true research;
none who have made any respectable additions to the literature of
medicine, or to its store of experience; and none who have ever had
any commanding influence. There would be some indeed who are reputed
among Homœopathists to be great men; but none, who previous to their
conversion to Homœopathy, were considered great by the medical
profession. A large portion of that assemblage, I am persuaded from
what I have seen, would be made up of men, who have no true faith in
the so-called science of Homœopathy, but have a strong faith in the
deception which can be practised by means of it upon the community,
and its consequent availability in a pecuniary point of view. Those
who have such a strange cast of mind, as to dupe themselves into a
belief of Homœopathic doctrines, after a thorough and scientific
examination of them, I suspect would be in the minority.[19]

Though Homœopathists commonly look down with contempt upon
Thompsonism, as being vulgar and unscientific, there is really
considerable resemblance between Samuel Thompson and Samuel Hahneman.
Let us look at some of these points of resemblance.

Both have a theory on which their practice is based, and nothing is
deemed true that does not correspond with that theory.

Both reject all former theories and observations as worthless. Their
light is the true and only light. “The medical world was in total
darkness till I arose,” said Hahneman; and so said Thompson.[20]

As Hahneman said, “the Allopathic method never really cures—the
Homœopathic method never fails to cure;” so said Thompson, the
“regulars” cure no one—my system always cures curable cases.

Both claim that all who get well under their system are cured by it,
and give no credit to nature; and upon these asserted cures they
build the reputation of their systems.

Both began their career as arrant quacks. Samuel Thompson sold his
patent rights to practice after his theory; and Samuel Hahneman sold
his secret nostrum for the cure and prevention of Scarlet Fever.[21]

Both were exceedingly dogmatical and authoritative, and both
quarrelled with their followers who did not yield to all their
assumptions.

The followers of both have very generally imbibed the spirit of the
“venerated founders” of these systems, and are very sure that they
are right, and everybody else is wholly wrong.

The followers of both look upon physicians as a body as being
wilfully blind to the truth, and unwilling to adopt anything new,
simply because it is new.

There are a few points in which those noted “reformers” _differ_,
which I will very briefly notice.

While Thompson was an illiterate man, Hahneman was an educated man;
and, if the making of many books is a proof of learning, then he was
a learned man. Thompson’s Materia Medica is but a single little
book; but Hahneman’s Materia Medica fills six large octavo volumes.

Thompson’s theory is rude, and has no air of learning. Its philosophy
knows nothing of the modern chemical nomenclature, but reckons earth,
air, water, and fire, as elements. Hahneman’s theory, on the other
hand, has a long name of classic Greek derivation, is more finely
spun, and is learned in its guise.

Hahneman has obtained special favor with the refined and learned and
wealthy; while Thompson has been for the most part the favorite with
those of common minds and limited information.

There is one particular in which the two systems differ very widely.
Though it cannot be said of Thompsonism, that it has never cured
anybody, for it may _chance_ to cure like anything else; yet, in its
general influence upon the medical practice of the community, it has
been an unmitigated evil. Its influence has been to give currency
to the over-dosing, which has been so popular, and so destructive
to health and life. But Homœopathy, on the contrary, is doing a
good work in helping to destroy the undue reliance upon positive
medication, of which I have spoken in the chapter on Popular Errors,
as being quite prevalent in the medical profession, and exceedingly
so in the community at large. And when Homœopathy shall have passed
by, as pass it will, like other delusions before it, I believe it
will be seen, that Hahneman had a vocation to fill, of which he never
dreamed, and that he has unwittingly done more good than harm to the
permanent interests of medical science.


FOOTNOTES:

[14] It may be proper to state at the outset, that the author has
himself suffered no encroachments from Homœopathy, and so has no
personal feelings to gratify in attacking it. It has not seemed to
find, for some reason, a congenial soil among the hills and rocks
of Norwich. Two Homœopathic physicians, (one of them a man of good
education, and with favorable adventitious circumstances) have tried
to get a foothold among us, but have failed. The author has many
friends and acquaintances who are inclined to Homœopathy, some of
whom have their little boxes of medicines, and swallow globules,
and administer them to others. He is, however, on the best possible
terms with them; and Homœopathy is, in his intercourse with them,
more a subject for agreeable pleasantry, than for warm or even grave
discussion.

[15] Dynamic is a word of Greek derivation, meaning simply powerful.
Hahneman’s ‘_dynamic_ power’ then, learned as it sounds to vulgar
ears, in plain English, is powerful power. It reminds me of a
patient, who in her fondness for expletives always spoke of her
weakness as a _debilitated_ weakness.

Hahneman seems to have been fond of words derived from the Greek, and
those, too, of no Homœopathic size. Hence such words as Allopath,
Homœopath, Heterogeneity, Pharmaco-dynamics, &c.

[16] The discoverer of this fact is certainly a great benefactor to
his race—what multitudes may be saved by Sabadilla from a drunkard’s
grave!

[17] The inconsistency of Homœopathists in using medicines in
Allopathic doses is sometimes of the most barefaced character. An
instance of this kind I lately met with in a New York paper. It
seems that the Homœopathic physicians in that city appointed a
committee to draw up some directions, to be given to the citizens
for the prevention and treatment of Cholera. The directions are all
quite consistent till you come to the 12th which reads thus: “If the
diarrhœa should become profuse (with or without pain, and vomiting,)
the discharges being watery and whitish, and the strength rapidly
failing, take five drops of spirits of Camphor every half hour until
it is effectually stopped. Should these symptoms become very severe,
three drops of Camphor may be administered every five minutes.” In
this direction they make a complete leap from Homœopathy over to
Allopathy. In the first eleven directions they adhere most strictly
to the Hahnemanic _attenuations_ and _triturations_. But these, you
will observe, respect those only who are threatened, or imagine
themselves to be threatened, with cholera. It is well enough to amuse
such with the ‘third attenuation’ of Cuprum or Veratrum. But in the
twelfth direction, which is for those who are actually attacked
with the disease, the attenuations and triturations are forgotten;
for it now gets to be a serious business, and the tiny doses will
not do. _Three drops of Spirits of Camphor every five minutes!!!_
If the patient should be dosed at this rate, for twenty-four hours,
he would take nearly _two ounces_ of spirit of Camphor. The whole
Homœopathic committee could not use up this quantity in a twelvemonth
in all their _extensive_ practice, if they should give it strictly on
Hahnemanic principles.

[18] In the Domestic Physician, intended as a guide for families
who practice Homœopathy, this same Dr. Hering, who has adorned the
book with an engraving of himself represented as learnedly poring
over some work, (I presume one of that same 15 octavo volumes,) thus
discourses of physicians, under the head of Effects of Mercury.
“This is the universal elixir of the quacks in all diseases—who,
whilst they pretend to restore their patients to health, destroy
their constitution. They administer it as calomel in powders, or
dissolved as corrosive sublimate, or in pills—those abominable blue
pills.” And then, “that no one may be deceived, at least not those
for whom a physician prescribes,” he goes on to give the different
Latin names of these preparations of mercury, as they are written in
the prescriptions of physicians, or quacks, as he so modestly calls
them: This is a little impudent in one who prescribes as remedies,
and in this very book, two preparations of mercury, and one of them
the most powerful of all, corrosive sublimate, made more powerful
too, according to his theory, by the ‘dynamic power’ imparted to it
by Homœopathic subdivision and trituration.

[19] It is proper to remark here, that some, who at first adopted
Homœopathy from mere pecuniary considerations, may afterwards have
come to a full belief in it. For if, previous to their adoption of
this practice, they were undiscriminating over-dosers, _as most of
those physicians who have turned Homœopathists once were_, they find
themselves actually more successful in the treatment of disease
than they were before their conversion. This is owing only to the
discontinuance of their over-dosing, but they of course refer it to
the “dynamic power” of their globules.

What I have said of the general character of Homœopathic physicians
will probably provoke them to pour out upon me the vials of their
wrath. But as they will undoubtedly administer it in _Allopathic_
doses, and will not stop to give it a “dynamic power” by “dilution”
and “attenuation,” I shall, I think, be able to stand up against it.

[20] So also says Turner, the founder of a new system just rising
into notice, styled Chrono-Thermalism.

[21] This fact, though well authenticated, is carefully omitted in
all notices of him by his followers.




CHAPTER VII.

NATURAL BONE-SETTERS.


The setting of bones is wholly a mechanical operation; and there
cannot be a natural innate skill in this particular kind of
mechanics, any more than there can be in any other kind. It would
be as proper to say that a man is a natural watch maker, steamboat
builder, carpenter, &c., as to say that he is a natural bone-setter.
A man may be born with a taste for mechanics in general, but not with
a taste for any particular kind of mechanics. This innate mechanical
taste shows itself in various ways, as the child grows up into the
man; and it is governed altogether by circumstances, in selecting
the particular branches of mechanics, from which it will seek its
gratification.

Every one applies these plain principles almost instinctively to
every subject but the sciences of medicine and surgery. An exception
is made of these, not only by the ignorant, but often also by the
well-informed and the learned. The healing art seems to be cast out
of the common pale of reason; and learning, as well as ignorance,
often refuses it the plainest and most established principles both of
science and of common sense. There has always been a disposition to
mysticism on this subject, and the idea of a mysterious bestowment
of natural gifts has been an error of all ages, and, I may add, of
all conditions in life.

I have said that bone-setting is a perfectly mechanical operation.
The bones of the body are united together on simple mechanical
principles by ligaments and muscles. When a bone is put out of joint,
it is generally done by the action of the muscles, perhaps we may
say that it always is so, when there is dislocation alone without
any fracture. A man falls from a house—when he comes to the ground
he puts out his hand, and the wrist, or elbow, or shoulder, is
dislocated. If he were dead when he fell, no dislocation would occur,
though there might be fracture; for the muscles would fix none of the
bones upon any point of support, so as to give the head of one bone a
different direction from the head of its neighboring bone. It is for
the same reason that a man, whose muscles are relaxed and powerless
from intoxication, is not apt to have his bones dislocated in a fall,
though they may be fractured.

After a bone is put out of joint, it is the muscles and ligaments
which hold it there. In order to replace it then, the resistance
of these muscles must be overcome by force gradually and steadily
applied, so that the head of the bone which is thrown past the head
of the other may be brought opposite to its proper place. When
brought to this point it is to be pressed into its place, which is
commonly very easily done—sometimes the muscles themselves do it.

The requisites for skill in performing this operation are very
obvious. It is plain that the man who knows the most about the
relations of the parts, will best know how to adjust those parts when
they get out of place; just as one who understands most thoroughly
a machine is the best fitted to repair it when it is out of order.
And there is no such thing as an innate instinctive knowledge of a
machine made of bones, muscles, and ligaments, any more than there
is such a knowledge of a machine made of wood and iron. In both cases
the knowledge is _acquired_ knowledge—acquired by observation and
study. In order that the knowledge which one has, even of the most
common machine, shall be accurate and complete, he must be familiar
with the parts of it when separated, and then with their connection
as a whole. For the same reason, in order that the surgeon may
understand so compound a machine as a human joint, he should become
familiar with the several bones and muscles, and ligaments, and
tendons, of that joint separately, and then with their connection as
they make up the whole machine.

And by familiarity with the machine as a whole, I do not mean merely
that the surgeon should be familiar with the parts of the joint in
their connection, as they are seen when the skin is removed with the
fat and the cellular membrane. In order to perfect his knowledge
of the joint as a whole, he must be familiar with it as it appears
covered with the skin, and observe it in all its various attitudes
and motions. This is quite as important a part of the knowledge of
the joints, as that which is revealed by the dissecting knife. For
the surgeon in his practice has to do with them in this covered
state; and if he be familiar with them only in their uncovered
condition, he will often find himself much puzzled, and may commit
some unfortunate errors. A musician, who had always played upon a
piano with the keys open to the eye, would hardly venture to play a
tune with the keys covered for the first time at a public concert;
but I apprehend that there is many a surgeon who makes his first
real study of a joint as a whole in its covered state, when he is
called upon to determine whether some part of that joint is out of
place. This external geography of the joints, as it may be termed,
is not sufficiently attended to, nor is the importance of studying it
properly urged upon the students of medicine.

The above considerations, I trust, make it clear to the reader,
what are the kind and the extent of the knowledge of the empirical
bone-setter. I am not disposed to say that he has no knowledge at
all. He has power to observe, though his means of observation are
limited, and therefore his knowledge is limited, and of consequence
inaccurate. He acquires all the knowledge which he has by observing
(and that is studying) the external geography of the joints to which
I have alluded. He may perhaps have an accurate eye in such matters,
or, as a phrenologist would express it, he may have the organ of form
well developed. If this be true of him, in many cases of dislocation
he will readily see where the irregularity is. He will see an undue
prominence at one point and a consequent depression at another. The
knowledge thus acquired by the eye guides him in his practice. He
pulls the bones apart, and then applies pressure in such a direction,
as to force in the prominence, and remove the depression. This is the
sum and substance of all that an uneducated bone-setter can know, and
his knowledge all comes from observation, and is not the result of
any mysterious gift.

It is folly to pretend that the empirical bone-setter cannot, by the
study of the internal structure of the joints, add to his knowledge
and skill thus acquired from observation of their external forms. And
yet he assumes, and a large portion of the public believe it, that
not only does his skill, unlike skill in anything else in the wide
world, need no adding to it, but that it would be actually impaired
by anything like scientific study. That his _reputation_ would be
impaired very seriously, if it were publicly known that he in any
measure acknowledged the necessity of study, is certain; for his
skill would then be stripped of the charm, which is given to it by
the idea of its being an innate power. It is for this reason only
that he adheres so pertinaciously to this false and ridiculous notion.

I have thus far gone upon the supposition, that the natural
bone-setter learns all that he knows by his own observation alone,
without any assistance from others. This is far from being true. He
is indebted to physicians themselves for some of his knowledge. For
example, the fact that extension and counter-extension[22] must be
made to enable us to put the dislocated bone into its place, is not
a fact that he discovered. Somebody, (we know not who, but it was
somebody,) discovered it a long time ago, and the knowledge of it has
descended in the medical profession from time immemorial. It is in
this channel that the knowledge of it comes to the bone-setter. He
might as well say that it was an innate idea with him, that knives
and forks are the appropriate instruments to eat with, as that he was
born with the knowledge of the fact, that the expedient which I have
mentioned is necessary in setting dislocated bones.

Perhaps it will be said that the idea of pulling the bones apart is
a very simple idea, and that almost anybody would think of that.
So was the invention of knives and forks a simple idea. But it
was come at rather slowly. The transition from the use of fingers
and teeth, to that of knives and forks in their present state of
perfection, was not a sudden one. Improvement, in this instance, as
well as in every other, had its _march_, step by step—it was not
effected by a leap. So it has been with improvements in the setting
of bones. It is probable that at first many a bone was pushed and
twisted about, and then left in its dislocated state; but at length
it was discovered, either by accident, or by a scientific view of
the subject, that this pushing and twisting could be made to answer
the purpose, by first overcoming the resistance of the muscles by
extension and counter-extension. The man who first knew this fact was
a real discoverer. And further, as the first knives and forks were
made in a very bungling manner, so the setting of bones was at first
done awkwardly and unskillfully. The bones were probably pulled in a
jerking manner, till a second discoverer found out the fact, that it
was best to make the extension very gradually and steadily.

Here then are two very material facts in regard to one part of the
operation of setting bones, which are furnished to the natural
bone-setter from the experience of those who have gone before him;
and I think no one can doubt that he learns them in the same vulgar
way that the educated surgeon does. Though they were new facts once,
they are now familiar to every one who has seen a bone set, or heard
a description of the operation. And I would give no bone-setter the
credit of having been born with these facts in his head, unless he
had been shut up from the world till he was strong enough to set a
bone, and then, on being brought forth had set a dislocated limb,
making the extension and counter-extension in the proper manner. This
would be the only positive proof that he did not learn these facts
from some one else. Many familiar ideas, which we suppose that we
thought of ourselves, unaided by others, if brought to such a test,
would be found to have descended to us from our predecessors.

Bone-setters have not so much confidence in their innate skill, as
to refuse to learn anything from physicians. I suspect that they do
not object to reading a surgical book, or looking upon a skeleton, if
they can do it without its being known. I heard one once utter the
scientific names of bones and their parts, such as humerus, radius,
trochanter, astragalus, &c. He must have got these words from some
of the educated surgeons, whom he professes to despise, or from some
book upon surgery. It is hardly to be supposed, that he was born with
them packed away, in his head, along side of his skill, ready for
use, though perhaps his admirers and patrons may think so.

I have said that the knowledge of the ‘natural’ bone-setter must be
both limited and inaccurate. Hence, though in those cases, in which
the dislocation or fracture is so plain as to be readily seen, he may
perhaps get along without any serious difficulty, he is exceedingly
liable to make mistakes in cases which require nice discrimination.
His mistakes may be arranged chiefly under four classes, which I will
notice separately.

First. A common error is supposing a fracture to be a dislocation.
Generally there is no difficulty in deciding which of these accidents
has taken place. In cases of fracture a crepitus (or grating of the
broken ends of the bone upon each other) can be perceived on moving
the limb in different directions. But sometimes it is difficult to
perceive this, and it can only be done by executing some particular
motions. In such cases the uneducated bone-setter is very liable to
make a mistake and often does. I will relate but three out of many
examples of this error which I have in my possession.

The first case I take from Ticknor’s Medical Philosophy. A young
lad in the city of New York received an injury of the elbow joint,
which, under the most judicious surgical treatment, terminated in
permanent stiffness. The parents of the lad took him soon after
to a bone-setter who had acquired considerable celebrity. He at
once pronounced the elbow to be out of joint, and attempted to set
it. After repeated attempts, he at length by an extreme degree of
violence, which was attended with excruciating pain, succeeded in
straightening the limb. The bone-setter triumphed in the achievement,
and the parents were delighted with the result. But the force
employed to reduce the pretended dislocation did such violence
to tendons, ligaments, and nerves, that the child’s life was in
jeopardy, and was saved only by the timely amputation of the arm.

The second case which I shall mention occurred in the practice of
Professor Hooker in New Haven. A man fell from a canal bridge and
fractured the neck of the scapula, the bone which is commonly called
the shoulder-blade. There was depression of the arm similar to that
which occurs in common dislocation of the shoulder; but the crepitus
and other symptoms obviously distinguished the case from simple
dislocation. Professor H. dressed the shoulder in such a way as to
secure a perfect apposition of the two surfaces of the fracture;
and, if the man had continued under his care, a complete union would
undoubtedly have taken place, and he would have had a good shoulder.
But at the end of a week Professor H. found the apparatus removed
and the arm simply supported in a sling. The patient had been to
see a natural bone-setter, who convinced him that the Professor
had mistaken the case—that there was no fracture, but a simple
dislocation. He accordingly ‘set’ the shoulder. The patient was much
easier than he was with the confinement of Professor H.’s apparatus,
and he was gratified with the bone-setter’s assurance that the
shoulder would soon be well. He continued to have confidence in the
opinion of the bone-setter for about six weeks. Then, as the shoulder
was no better, he went again to Professor H. It was now of course too
late to remedy the fracture, and the poor man has a crippled shoulder
for life, as the result of his foolish reliance upon the ‘natural’
skill of a bone-setter.

The third case was related to me by Dr. Mercer, of New London in this
State. It was a case of oblique fracture of the thigh. The evidence
that it was a fracture was of the most palpable character; and yet
the most famous ‘natural’ bone-setter in this part of the country,
who has imparted his ‘gift’ to his descendants, and even to those
who are connected with them by marriage, stripped off the dressings
of Dr. M., pronounced the case a dislocation, and proceeded to ‘set’
it. The patient supposed that all was right, for the bone-setter was
considered infallible. But many of the inhabitants of New London well
remember the poor old man Bolton, who for so many years with his
crooked thigh, which was pronounced so confidently by the bone-setter
to be ‘set,’ literally crawled about the streets.

Secondly. The uneducated bone-setter is very liable to make a mistake
in those cases in which, though there may be much tumefaction and
pain, and the motion of the joint may be much impeded, there is
neither dislocation nor fracture. Of all the cases of injury of
the joints a very large proportion are of this character. There
is simply a sprain or a bruise, or both together. Such cases the
bone-setter almost invariably treats as dislocations. I will not
at present dwell upon this class of cases, as I shall speak of them
more particularly in another connexion. I will only remark here, that
if the bone-setter does but little in such cases, no real harm may
be done; but he may use so much violence, in reducing the supposed
dislocation, as to inflict a serious injury upon the joint.

Thirdly. Another class of mistakes, to which the uneducated
bone-setter is liable, have relation not to the mechanical
principles of bone setting, but to what may be called the _medical_
in distinction from the _surgical_, or operative part of the
treatment. The mere operator, however skillful he may be, is not a
finished surgeon. Very far from it. In order to be able to do his
_whole_ duty to his patients, the surgeon must in addition to his
skill in operating, understand well the principles of inflammation
and irritation, and must be in fact familiar with the whole range
of disease. The bone-setter is entirely destitute of any such
qualification for his department of surgery. He looks upon every case
as a mere mechanical matter, and operates upon it without any regard
to the state of the patient’s health, or to any of the circumstances
of the case. He therefore operates upon many cases that ought not
to be operated upon, and does to them a serious injury, sometimes
a fatal one. In some cases he neglects to do what is necessary for
the relief of the patient, and prevents any one else from doing it.
It may be that inflammation needs to be guarded against, or to be
overcome. This he neglects to do; and not only so, but perhaps, by
the violence which he does to the affected part, he aggravates, or
creates inflammation. The same may also be said of his neglecting the
prevention and cure of spasmodic affections.

I will cite but a few cases illustrative of the above remarks.

A man had a bad fracture of the wrist, which was taken care of by
a regular physician. After the fracture united, the joint he said
continued to be very weak, but it did not prevent him from getting a
livelihood by doing light work in a factory. More than a year after
the accident, the wrist became quite sore. Rest and some appropriate
applications would probably have restored it to its usual condition
in a short time. But he was persuaded to show it to a famous
bone-setter, who lived a few miles distant. The bone-setter said at
once that it was not set right in the beginning, and that it must be
broken over again, in order to set it as it should be done. The great
violence he did to the joint produced a severe inflammation. It was
in this state that I first saw it. Abscesses formed in consequence of
the inflammation, and the final result was that the arm was rendered
useless for life. If this man had been thus treated by an educated
surgeon, instead of an _infallible_ bone-setter, he could undoubtedly
have recovered large damages for such mal-practice.

The second case which I shall relate is that of a young man who had a
chronic disease of the shoulder, which came on gradually, without any
evidence that the joint had ever received any injury. A bone-setter,
whom he accidentally met, assured him that he could remove the
difficulty, and give him a good arm. He told him that the bone of
the arm had ‘dropped down out of the socket,’ that there was ‘callus
in the socket,’ and talked about ‘squeezing it out.’ This opinion he
gave without any examination of the shoulder. He did not even remove
a thick overcoat which the young man had on. He directed a liniment,
which was to be used for some time previous to the operation of
setting the shoulder. After using the liniment for six weeks, he
went to the bone-setter’s residence to be operated upon. Three stout
assistants held the patient, while the bone-setter _squeezed out the
callus_, and set the joint. The pain produced by this operation was
so severe that the young man fainted. The bone-setter, thinking that
the joint was not yet quite right, repeated the operation the next
day. The consequence of all this violence was an increase of the
inflammation. There was much soreness and pain, and at length several
abscesses appeared in succession, which discharged abundantly, and
the arm became exceedingly weak, very limited in its motions, and
much emaciated.

Cases of hip-disease, as it is commonly called, are often supposed
by bone-setters to be cases of dislocation, and sometimes are
unfortunately treated as such. I might relate many instances of
this kind, but I will detain the reader with but one, which I take
from Ticknor’s Medical Philosophy. In this case “the complaint had
existed for some time and produced a great degree of emaciation of
the affected limb, which gave to the joints an unusual prominence;
and, as is common in this disease, the limb was in a flexed position.
This patient had been attended by a respectable practitioner, who
understood the disease, and who had done all that the art can do in
this much dreaded complaint. But the natural bone-setter was sent
for. He pronounced _the hip, the knee, and the ankle dislocated_; and
straightway commenced furiously pulling at all these joints to get
them in place. The boy shrieked, and entreated him to desist. The
diseased parts being exceedingly tender and painful on the slightest
motion, the complaints of the boy only made his tormentor the more
confirmed in his opinion and the more persevering in his efforts to
‘set the bones.’ He did persevere till the child repeatedly fainted;
and being fearful that he had _cured the patient to death_, or
killed him outright, at length concluded his manipulations, by saying
that he had _got the bones all in their places_. The disease was so
aggravated by this cruelty, that in a few days the child’s sufferings
were at an end.”

The last case which I shall relate under this head, is a case of
tetanus or locked-jaw. The patient had his foot crushed. He was for
four days under the care of a regular surgeon. During this time such
a course was pursued as was calculated to prevent the occurrence of
tetanus, and the patient was in a very promising condition. But the
bone-setter was sent for. He discontinued the remedies which had been
used, and simply dressed the foot with a salve, which was of course
of an _all-healing_ character. The foot soon became very offensive,
and symptoms of locked-jaw came on, and in a few days the patient
died. The bone-setter within twelve hours of his death assured him
that he would get well.

Fourthly. Uneducated bone-setters fail most signally in their
treatment of _fractures_. In the case of a _dislocation_, when the
bone is once put into joint it is generally done with. The joints
are so aptly and closely fitted, that the reduced bone is not liable
to slip out of joint again from any slight cause. But in the case
of a _fracture_ on the other hand, after the bones are put into
place, some care and skill are required to keep them so. The pressure
which is brought to bear upon different points of the limb is to
be skillfully regulated, and motion of the two parts of the broken
bone is to be carefully prevented, in order that they may grow
together without irregularity, and with as little amount of callus
as possible. The bone-setter for obvious reasons, fails in these
particulars, and there may, therefore, be found among his patients a
great many crooked and shortened limbs, with a large and irregular
callus. One of the most deformed limbs that I ever saw was an arm
which had been under the care of one of the most famous bone-setters
in the country. The case was a simple fracture of the two bones of
the fore-arm, about midway between the wrist and the elbow. Any
ordinary surgical care would have secured to the patient a sound arm
without any deformity. But when she showed me her arm, after the
bone-setter had dismissed it from his care as _cured_, I found that
one bone had its two parts united at quite an angle, with a large
callus; and in the case of the other bone no union at all had taken
place, but the ends of the fracture could be still made to rub upon
each other by executing certain motions of the arm. Such mal-practice
as this, in the case of a young woman, who is dependent upon her
labor for a livelihood, ought to be punished with exemplary damages.

The remarks which I have made refer to ordinary fractures merely. But
there are some cases of fracture which require a peculiar and nice
application of mechanical principles in their treatment. In these the
bone-setter generally makes an utter failure. For example, there are
some fractures of the elbow-joint that require a particular position
of the arm, and a nice adjustment of the apparatus applied to it;
and, in order to prevent stiffness of the joint it is necessary that
the surgeon should, as soon as it will answer, begin to execute the
motions of the limb, gradually extending their range, till the joint
become entirely free. Such cases under the care of a bone-setter have
always resulted, so far as my observation has extended, in permanent
stiffness of the joint.

In the remarks that I have made upon the mistakes of uneducated
bone-setters, I wish not to be understood to claim that educated
surgeons never make any mistakes in their treatment of fractured
and dislocated limbs. They are not infallible, and some of them, I
am free to say, know very little about bone-setting, and have very
little skill in it. There is a mechanical tact which is necessary to
make a physician a good bone-setter, and some are so destitute of
this tact, that they are not even able to extract a tooth decently
well. But I do claim, that educated medical men, generally, do have
vastly more skill in this department of surgery, than the herd of
uneducated bone-setters.

If the claims of natural bone-setters be just—if it be true, as
they say it is, that surgeons are constantly making mistakes, which
_their_ innate skill is as constantly taxed to correct, then we
should expect, that in those parts of the country, which are not
blessed with bone-setters, there would be cripples in abundance, the
victims of educated unskillfulness. But I have never heard that it is
so. There has been no complaint that it is. And I have not a doubt
that in the neighborhood of every natural bone-setter, there can be
found more deformed and crippled limbs, than can be found in any
similar neighborhood, where educated surgeons are not so fortunate as
to have infallible possessors of the gift of bone-setting standing
ready to correct their errors.

If the bad cases which occur in the practice of natural bone-setters
could be found in the practice of regular physicians, they would
be frequently prosecuted for mal-practice, and damages would be
recovered of them by the sufferers. But I doubt very much whether
anything would be gained by prosecuting a bone-setter for the
grossest mal-practice. People are generally more willing to make
allowances for the uneducated bone-setter, than for an educated
surgeon; though, at the same time, inconsistent as it may appear,
they may claim that by virtue of a divine gift he is infallible.
One would suppose that cases resulting badly would lead them to
doubt his boasted infallibility. But no. They infer that these cases
were beyond the reach of the highest skill in the world, and that
it was impossible that they should have come to any better result.
They seem to regard it almost as a sin to express the least doubt
to the contrary. With this state of feeling, existing to such an
extent as it does in some parts of the country, no jury could be
found sufficiently unprejudiced to inflict any just penalty upon a
bone-setter for mal-practice; though they would inflict it to the
full, if the same facts were proved to them in regard to any educated
surgeon.

The testimony of physicians in such cases would be very apt to be
disregarded, however rational and clear it might be, unless it could
be brought to confront the testimony of the bone-setter himself.
Whenever this is done, educated skill always comes off victorious
over quackery. Nothing so exposes and demolishes quackery, as a
well-directed examination of the quack himself. It dispels from
the minds of the jury the false notion of a natural gift that
needs no teaching; a notion, which, so long as it remains in the
mind, effectually prevents any candid examination of the facts.
They are made to see by such a course, that the joints of the body
are constructed upon mechanical principles, and that they are to
be understood just like any other machine; and the ignorance and
consequent want of skill of the bone-setter become even ridiculously
palpable. Some few years ago a physician in Springfield, Mass., was
prosecuted by a patient for mal-practice. The case had fallen from
his hands into those of a celebrated bone-setter, who appeared as a
witness at the trial. The physician was triumphantly acquitted, and
the exposed ignorance of the bone-setter had more influence with the
jury, than all the display of surgical knowledge on the part of the
faculty, drawn out by the learned counsel.

It now remains for me to show why it is that natural bone-setters,
in spite of all their ignorance and their mistakes, acquire such a
reputation for success, as they often do. I deem it a very easy task
to do this to the satisfaction of any reasonable person.

I have already alluded to those cases in which the bone is not
dislocated, but the patient supposes, and the bone-setter supposes,
or, as is more often the case, _pretends_, that there is a
dislocation. These are the cases which are the principal source of
the bone-setter’s reputation. He pulls upon the affected limb and
performs various manœuvres with it, and then thinks, or pretends,
that he has ‘set’ the bone. In time the limb of course in most
instances gets well, and thus in a case of mere sprain he gains the
credit of having performed a wonderful operation. Especially is this
so, when the patient has been first examined by a regular physician.
_Probably more than half of the reputed cases of dislocation which
come under the care of bone-setters are nothing but sprains._

It is easy to see how the credulity of the patient can be imposed
upon in such cases. He supposes that there must be something out
of place, and is not satisfied with being told that there is not.
Rest, the principal remedy in such a case, seems to him to be a
very ineffectual remedy at least, and he gets out of patience. His
imagination, with the aid of friends, and neighbors, at length
conjures up before him the idea of a limb forever crippled. The
bone-setter is now consulted, and he says, of course, that there _is_
something wrong. No bone-setter was ever known to say otherwise under
such circumstances. After executing certain manœuvres, he pronounces
all now to be right. The patient is now satisfied, although the limb
improves no faster than it did before, perhaps not so fast. He is
satisfied, because he feels now that _something has been done_. If
the surgeon who first saw the case had gone through with the same
pretended setting of the joint, the patient probably would have been
equally well satisfied. A surgeon of some note once remarked, that he
pulled nearly all the sprained joints that came under his care and
pretended to set something right; ‘for,’ said he, ‘if I did not do
this, such patients would go to a bone-setter to have it done, and he
would do them some harm, which I am careful not to do.’

But it may be said, that in many cases the testimony of the patients
in regard to the setting of the bone is of the most positive
character, and even that decided relief is at once experienced. That
it is often imagined, I know. I have seen many cases of this kind,
in which there was the most undoubted evidence that the relief was
wholly imaginary.

As the deception of the bone-setter in such cases is so common, and
so successful, even with persons of shrewdness and discernment, I
will mention two cases in illustration.

A stout Irish girl had an inflammation of the ankle, which had come
on gradually. She in some way imbibed the idea that the ankle was
out of joint, though she did not remember to have hurt it in any
way. I told her that it was not possible to put the ankle out of
joint without knowing when it was done. But she chose to send for the
bone-setter. He came and pretended to set the ankle, and she declared
that he relieved her at once. The inflammation however was still
there, and was gradually dissipated by appropriate remedies.

A gentleman, esteemed to be very shrewd by all his friends, received
an injury of the first joint of his forefinger, which resulted in
inflammation. After commencing medical treatment, he was persuaded to
consult a bone-setter. He returned with a poor idea of the knowledge
of regular physicians, because ‘_they could not even set a dislocated
finger_,’ and loudly praised the skill of the bone-setter. He soon
found, however, that the finger was no better, and, openly declaring
that he had been deceived, submitted the finger to proper treatment,
which in a little time removed the inflammation.

These two cases, taken from the two extremes of rank and intelligence
in society, are fair examples of the imposition which is so
frequently practised by the bone-setter upon all classes of his
patients.

In this connexion I will notice another class of cases not so
numerous, in which the bone-setter either imagines or pretends there
is fracture, when there is nothing but a sprain, or an injury of the
nerves of the limb, producing inability of motion. Such cases, at
least in old persons, recover slowly. If the bone-setter puts on his
splints, he commits a great error, but it is an error that may not
be detected. The splints are taken off in due time, and the limb has
recovered through the influence of rest alone.

There is another small class of cases from which bone-setters get
much credit, and in which their bold practice, I will candidly allow,
sometimes really does good. In the recovery of injured joints there
sometimes form adhesions, which seriously impair their power of
motion. I have said that the bone-setter operates on almost every
case that presents, and he takes hold of these cases with a strong
hand. He breaks up the adhesions, and sets the joint free. A regular
surgeon would hesitate to do it, from the fear of inflicting an
injury upon his patient greater than he would suffer if the joint
were to remain with its limited power of motion. The bone-setter
fearlessly runs this risk, for he has no very delicate sense of
responsibility to prevent him from doing it; and if he does harm,
he knows that a large portion of the community have so high an idea
of his ‘gift,’ that they will absolve him from all blame. He may do
great violence at times, and make some very bad cases; but there is
little said about these, while the cases in which he has the good
fortune to be successful are in everybody’s mouth.

The bone-setter sometimes acquires considerable reputation from some
cases of stiff joints and contracted tendons, which are benefitted by
a persevering course of friction, fomentation, &c. Physicians often
prescribe such a course in such cases, but they do not, like the
bone-setter, make the applications themselves, nor perhaps see that
they are made. In the one case the course is faithfully pursued, and
in the other it is not. A gentleman who had a stiff knee cured by a
quack principally by friction, detailed the treatment to a medical
friend. ‘I often prescribe just such a course for similar cases,’
said the physician. ‘Yes,’ replied the gentleman, ‘but you do not
take hold and rub yourself. If I came to you with an aching tooth you
would pull it, and not tell me or my friends to do it.’ There was
much truth in this reply. Physicians often give directions of this
kind, but do not see that they are followed up by the patient. I do
not mean to say that they should do all the rubbing themselves. But
they should show others how it is done, and then see that they do it.
All the credit which bone-setters get from neglect of duty on the
part of physicians, they have a perfect right to.

Another class of cases may properly be noticed here, of which I
will cite but two examples. A lady sprained her ankle. Instead of
the gradual recovery usual in such cases, the joint continued for
a long time to be excessively tender—she could not bear to have
it moved or touched without the most extreme care. The celebrated
Professor Smith, of New Haven, on being called in to see the patient,
recommended that all this caution in moving and touching the joint
be discontinued, and that it at once be put to use. The prescription
seemed to the patient to be a cruel one; but it was obeyed, and the
recovery was rapid and perfect. The extreme sensitiveness of the
joint in such cases is dependent upon two causes, the imagination and
nervous irritability—sometimes almost wholly upon the former. If this
case had chanced, like the one about to be mentioned, to pass into
the hands of a natural bone-setter, his rubbing and other manœuvres
would have accomplished the same object, and a great cure would have
been proclaimed.

The other case was that of a lady, who had been long confined to
her bed with a spinal disease. She supposed, and her friends did
also, that it was not possible for her to move her back at all.
A physician, to whom one of her friends described the case, said
that he had no doubt that the disease had all been removed by the
treatment which had been pursued, and that the patient could move
about, and ought in some way to be made to do so. He saw that, as in
the case just related, the sensitiveness and inability of motion were
chiefly or wholly imaginary. And he predicted, that if she should be
put under the care of a bone-setter, as her friends had contemplated,
he would get her up and rub her back with his medicated applications,
and she would be able to walk about in a very short time. She was
carried to the bone-setter, the prediction was verified, and her
father, a distinguished clergyman, gave the quack a certificate of
the wonderful cure.

I remark upon these two cases—that, while Dr. Smith prescribed
intelligently, the bone-setter only _chanced_ to hit right—that
while the discrimination of Dr. S. saved him from applying a similar
treatment to cases to which it would be inapplicable, the bone-setter
does much, sometimes fatal, harm to many cases by his lack of this
discrimination, (cases which somehow fail to be reported)—and lastly,
that while Dr. S. had no public testimony paid to the success of
his discriminating skill, the _lucky hit_ of the quack has been
proclaimed, by the certificate of the clergyman, as the result of
pre-eminent skill, throughout the length and breadth of the land.

There is still another class of cases to be noticed. Sometimes the
motions of a joint are impeded, while there is no obvious deformity;
and yet the case may be something more than a mere sprain, and often
turns out to be so, when the subsidence of the swelling reveals the
true nature of the case. It is a sub-luxation. That is, the bone is
_partially_ thrown out of place, but is not fairly out of joint. In
such cases merely pulling upon the joint is commonly enough to set
it. As soon as the bones are sufficiently separated to allow of it,
the dislocated one slips into its place, or rather is drawn into it
by the muscles. I have no doubt that many such cases, pronounced by
physicians to be sprains, are remedied by the bone-setter, not from
any superior skill on his part, but from the fact that he makes it a
practice to pull the joint in every case.

One great source of the reputation of bone-setters is to be found
in the flaming reports of their cases, made by themselves and their
friends, _most of which are either partly or wholly false_. These
reports are got up precisely in the same way that the reports of the
great cures of other quacks are, and they have the same influence.

I will give two cases in illustration. These cases appeared in a
letter in a newspaper correspondence, in which a self-styled reformer
of some note undertakes to abuse the regular clergy, and regular
doctors, and laud Thompsonism, and natural bone-setting.

One of these cases is that of a boy who was born with a club foot.
He states in regard to him, that, after the best surgical skill of
Philadelphia and New York had been tried upon him in vain, he was
brought to the bone-setter, and in the course of a few weeks the boy
(then six years old), was perfectly cured. This statement I know to
be false. The bone-setter, so far from curing the boy, did him no
good. And further, the deformity of the foot has since been relieved,
so far as it can be, by the skill of one of those regular surgeons,
of whom the bone-setter so modestly said to our wise reformer, “that
during a constant practice of more than thirty years he has scarcely
found one who understood his business,” while he himself had “not in
a single instance,” among all his cases, committed any error.

The other case was that of a man of whom it is said that he
“was caught by one of his arms by the belt of the picker, and
carried over the drum [shaft?] upwards of one hundred times.” The
bone-setter “found that his shoulders, ribs and breast, were all
badly lacerated—his left arm broken near the shoulder—his right
arm broken in three places between the shoulder and elbow, much
hemorrhage having taken place—his right knee broken in pieces, and
partially dislocated—two of the bones of the toes of his right foot
loose in his stockings—a compound fracture of the left leg—one of the
condyles of the pelvis, near the back knocked off—his skull fractured
above his left eye—his scalp cut to the skull, and rolled up some
distance—and his whole body covered with bruises and lacerations.” It
is also stated that “the physicians who were summoned, said he could
not live an hour, and declined attempting to relieve him.” Perhaps
they would have taken this view of the case if the facts had been
as our reporter has stated them. But they were not. _Nearly all_ of
this statement is false. That the man was carried over that shaft
“upwards of one hundred times,” none but a stark-mad reformer is
foolish enough to believe—the man’s shoulders, ribs and breast were
_not_ “badly lacerated”—his right arm was _not_ “broken in three
places,” but only in one, and that not badly—there was _not_ “much
hemorrhage,” but almost none—his right knee was _not_ “broken in
pieces,” and was _not_ “partially dislocated,” but there was merely
a small abrasion of the knee-pan—there were _not_ “two bones in his
stockings,” but one small piece of bone in one stocking—there was
_not_ “a compound fracture of the left leg,” but a simple one—“one
of the _condyles_ of the pelvis near the back” was _not_ “knocked
off,” for there is no such thing in the body, and besides, the man
himself says that there was no injury of the back, and so says his
wife who took care of him—his skull was _not_ “fractured above the
left eye,” nor anywhere else—his scalp, instead of being “cut to
the skull and rolled up some distance,” was not enough injured to
leave any scar—“his whole body” was _not_ “covered with bruises and
lacerations”—and finally, the physicians did _not_ say that “he
could not live an hour,” for they saw no _mortal_ injury in three
simple fractures. But not only is this statement false in almost
every particular, but there are some facts in regard to this case
which are omitted. Under the care of the bone-setter the right arm
united in bad shape, though the fracture was simple and perfectly
manageable; and the leg, before it became firmly united, was broken
again by the bone-setter in an attempt to ‘stretch down the cords,’
as he expressed it, and finally came under the care of one of those
regular ‘scientific’ physicians, of whom our reformer says that
“probably not one in a hundred knows how to manage such cases.” If it
had been under his care from the beginning, the leg would undoubtedly
have healed in good shape, but now there is a large irregular callus,
which was produced by the violence done to it by the ignorant
bone-setter in ‘stretching down the cords.’[23]

No wonder that such a collector of facts as this reformer has proved
himself to be, should make the sweeping remark, that “there is
incomparably more of quackery in the schools of law, physic, and
divinity, than there is out of them.” The other cases, which he gives
in his letter, are probably about as worthy of belief as the two
which I have extracted. And these two are a fair sample of the degree
of truth in the wonderful stories which are told in relation to the
feats of bone-setters.[24]

I flatter myself that I have made it clear to the reader, that it
is no difficult matter for the natural bone-setter, in spite of
his ignorance of the structure of the joints, and his consequent
mistakes in managing injuries of them, to acquire a reputation for
skill, especially if he have some mechanical tact, a good share of
shrewdness, a plausible way of _embellishing_ his narratives of
cases, and impudence withal. I have said that a very large proportion
(probably more than half) of his reputed cases of dislocations are
mere sprains. All these he gets the credit of setting, and many of
them after they have been seen by some physician. Add to these his
occasional lucky hits in breaking up old adhesions, and in setting by
his random pulling some sub-luxations, and here is material enough,
with a loose veracity, to make up a reputation in this credulous and
marvel-loving world.


FOOTNOTES:

[22] Some of my readers will require an explanation of these terms.
In a case of fracture the broken ends often slip by each other. We
draw therefore upon the two portions to bring them into their proper
position. The traction exerted upon the portion the farthest from the
body is called extension, while that which is exerted upon the other
portion is called counter-extension. So when a bone is dislocated the
force exerted in drawing the head of it from its position is called
extension, while the force by which its fellow bone is drawn in the
opposite direction is called counter-extension.

[23] It will be proper for me to state that I had no personal
interest in this case, and I became acquainted with the facts in an
accidental call upon the family of the patient some time after the
accident.

[24] Some of the certificates of the bone-setter, like those of other
quacks, are of the most unwarrantable character.

A physician of great eminence was once called to see a clergyman
who had sprained his wrist. The sprain was a bad one, and produced
considerable inflammation, and therefore gave him great pain. The
treatment which my friend pursued relieved the patient, and nothing
was wanting but rest to complete the cure. But he very imprudently
and in direct disobedience to his physician’s injunctions, drove
a spirited horse on quite a long ride with his lame wrist, and of
course renewed in some degree the soreness and inflammation. He now
put himself under the care of a bone-setter, and after his wrist got
well, forgetting the _gratuitous_ as well as successful services of
his physician, this clergyman gave the quack a laudatory puff in one
of the public papers.




CHAPTER VIII.

GOOD AND BAD PRACTICE.


One would suppose at first thought, that the difference between
the results of good, and those of bad practice in medicine, would
be palpable to the most common and superficial observation. But it
is evidently not so. Facts in great abundance show that it is far
otherwise. The history both of medicine, and of quackery, furnishes
many instructive lessons on this subject. If we confine our view to
the medical profession, we see often two directly opposite modes of
practice praised by their adherents, as being successful in the same
complaints. We see the profession and the community both divided on
this point, each party asserting with zeal the claims of its favorite
system of practice to pre-eminence.

I will cite but a single example in illustration of these remarks.
Some years ago there was a warm discussion carried on among quite a
large portion of the medical profession in New England, in regard to
the general character of diseases in this part of the country, and
their proper mode of treatment. One party, at the head of which was
Dr. Gallup, asserted that the diseases of New England had been, since
the beginning of the present century, almost altogether sthenic or
inflammatory, and therefore had required depleting remedies. Another
party, whose chief champions were Doctors Miner and Tully, contended
that diseases had been asthenic, or characterized by debility,
instead of an inflammatory tendency, and that they therefore required
stimulants. While Dr. Gallup denounced the treatment of disease,
pursued by the adherents of Drs. Miner and Tully, as “incendiary
treatment,” and lauded bleeding as the chief remedy for the present
time; Dr. Tully, on the other hand, says that “the lancet is a weapon
which annually slays more than the sword,” and that “the king of
Great Britain, without doubt, loses every year more subjects by these
means”—depleting remedies—“than the battle and campaign of Waterloo
cost him, with all their glories.”

Now if it were easy, by looking at results, to decide in all cases
what is good, and what is bad practice, it is evident that such
diametrically opposite modes of treatment could not be in vogue at
the same time. The proper distinctions would be made, and the good
practice would be approved, both by the profession and by the public;
while that which was seen to be injurious in its results would at
once be rejected.

So also, if it were easy to make this distinction, the truly skillful
physician could always be recognized as such, while the unskillful
and ignorant practitioner would not be able, as he now often is,
to obtain from the public, in spite of his deficiencies and his
blunders, the meed of praise due to real merit and actual success.
The quack, too, would stand forth in his true light, in contrast
with the man of science in the results of his practice, instead of
claiming, with brazen effrontery, and receiving from the multitude,
as he now often does, the credit of being even pre-eminently
successful.

There never was such a variety of systems of quackery before the
community as there is at the present time. To say nothing of minor
claimants, there is Thompsonism, almost parboiling its patients with
steam, and shaking them to shreds with lobelia, and burning them up
with cayenne; and Hydropathy, that wraps up its devotees in the cold,
wet blanket; and then gentle, sweet, refined, sublimated Homœopathy,
that starts with horror at the very idea of such harsh means, and
professes to neutralize all disease with little else than the mere
shadow of medicine. Each one of these systems, so opposite to each
other, asserts its claim to be the only true system of medicine, and
bases this claim upon the success which attends it. The same claim
is also essentially made in behalf of numberless medicines which are
before the public.

Amid all these opposing claims many are bewildered, and ever in doubt
where the truth lies, are never established upon anything, but fly
from one thing to another, as the evidence of success preponderates
in favor of this, or that medicine, or system. Others become the firm
and enthusiastic advocates of some one of them, but after a while
discard this for another, and few adhere to any one thing during a
whole life. And it is amusing to see with what ease some make the
transition from one mode of practice to another, which is totally
different from it, being quite sure that they are right in doing so;
and yet, if they are right, the error from which they have escaped
is a very great one. They do not however always view it in this
light, for they sometimes recur to their former preferences, though
they are as inconsistent with their present ones as they well could
be. If Homœopathy be right, then Thompsonism must be _very_ wrong;
and yet I have known persons, who are disposed to quackery, go from
one to the other, and speak in praise of both as being successful
modes of practice, without seeming to be aware that they are so
entirely opposite to each other. So there are some, who at the same
time manifest confidence both in the common practice of medicine,
and in Homœopathy; though if Homœopathy be right, almost the whole
body of physicians are rank murderers, and if physicians be right,
Homœopathy is as ridiculous an error as ever obtained a foothold in
the community. And then there are some, who appear in the space of
a twelvemonth, at different times, as the advocates of Homœopathy,
Thompsonism, Hydropathy, and perhaps Chrono-thermalism, to say
nothing of various patent medicines from some College of Health, or
some German physician, with a long list of titles, or some Indian
doctor laden with remedies fresh from nature’s rudest and most secret
arcana.

Now it is clear, that if it were an easy thing to decide what is
successful practice and what is not, from an observation of results,
then there would not be such diversity, nor such frequent change
of opinion in the public mind, in regard to modes of treatment so
directly opposed to each other, as those are which I have mentioned.
The advocates of them would not so boldly urge their claims, knowing
the facility with which these claims could be tested. But the
difficulties which actually lie in the way of testing them are such,
that the community are exceedingly liable to be deceived. Practice,
which is really unsuccessful, is often made by its advocates to
appear for a time at least, to be more successful than any other mode
of treatment, and it is often only by long continued observation that
this error is corrected.

This error exists at this time among a large portion of the community
in relation to Homœopathy, and it is to be removed by the same
gradual process, by which all kindred errors have been removed
hitherto. By observation it will be found by its advocates, one after
another, that its reputation for success is founded upon mistake,
and it will thus step by step lose its hold upon the public favor,
to make way for some other system, which in its turn must go through
with the same process.

Those who embrace some form of quackery from mercenary views, are
aware of the facility with which the multitude are deceived in regard
to the comparative results of different modes of practice; and it is
this which makes them so confidently anticipate at least a temporary
success. Homœopathy furnishes many examples of this character.
While there are a few in the medical profession, of a peculiar
cast of mind, who are honest Homœopathists; there are others, of
various degrees of intellectual merit, who have adopted this mode
of practice, simply because they have failed to acquire business in
the ordinary way, or because they saw in the adoption of a system,
just now popular, a fair prospect of so increasing business, as to
secure wealth instead of a mere competence; and others still, who
have dubbed themselves physicians, have gone into the practice of
Homœopathy, as mere adventurers, preferring very wisely to try their
luck on the tide of a popular error, instead of trusting to knowledge
and skill, of which they have little or none. These two last classes
of Homœopathic physicians indulge the hope, that the community will
be deceived, in regard to the success of their system of practice,
a sufficient length of time to enable them to realize their golden
expectations; and then, when this false system shall be supplanted
by some other, they will be ready to adopt that other for the same
_solid_ reasons for which they have adopted this.

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.

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.

I will briefly cite two examples in illustration of this point.

A gentleman, who had a friend sick under the care of a physician,
who was strongly in favor of the stimulating mode of practice, was
led to doubt the propriety of the treatment, and as he watched the
case he doubted more and more. He at length ventured to lessen the
amounts of brandy and laudanum, taking care to conceal the fact from
the patient, who was every now and then calling for them, because
he felt a death-like sinking, and he was afraid that his pulse was
failing. He found that in proportion as he lessened them the case
improved, and he very soon discontinued them altogether. There is not
a doubt, that in this case the stimulants, though affording temporary
relief to the patient’s sense of exhaustion, kept the man sick, and
the discontinuance of them was the cause of his recovery. A similar
experience has been detailed to me by others.

Such cases as the one which I have mentioned may appear very badly,
and yet the amount of disease may be slight. Some disordered state
of stomach, which a very little appropriate medicine, with the aid
of rest and a proper diet, would remove, is often the whole of the
disease. I will give here the testimony of one among many physicians
to substantiate this assertion. The physician, to whom I refer, told
me, that when he began to practice, there was an elder physician on
the ground, who used brandy and laudanum largely in a certain class
of cases. They were cases in which there was disordered stomach,
with considerable tendency to a depressed state of the whole system.
The patients were commonly sick from one week to three, or even four
weeks, and though they excited much alarm among their friends, they
all, with but a single exception, finally recovered. He followed
the example of his elder friend for some time in similar cases, but
he soon began to doubt the propriety of such high stimulation. The
result was, that after a while he resorted to a very simple practice
in such cases, which produced entire relief in one or two days;
whereas, under the stimulating treatment, they would have been long
and troublesome.

I might mention many cases from Thompsonian practice, which would
illustrate the same point, but it is not necessary.

Though the community do not generally distinguish between cases which
are necessarily of a grave character, and those which are made so by
bad treatment, there are occasionally individuals, who do to some
good extent make this distinction.

A clergyman, who is blessed with a good share of plain common sense,
in addition to his high talents, and who has uniformly eschewed
quackery in medicine as well as in theology, told me that he was once
conversant with the practice of two physicians of entirely opposite
characters, during the prevalence of an epidemic. The one gave large
amounts of medicine, and much of it was of a stimulating nature. He
had a great many very sick patients, and there was much noise made
about his wonderful cures. The other went about among the sick very
quietly, gave but little medicine, and the number of his cases that
were protracted and severe was comparatively small.

Another instance which I will mention was that of a gentleman,
who employed a large number of men in a factory. A great many of
them were taken sick, one after another, with what was called the
“_sinking typhus_.” He observed that some of them were but slightly
ailing at first, and were able to be about the house, but that after
a while, under the stimulating practice, they were laid upon their
beds. Some died, and many of them were severely sick for some time.
He doubted the propriety of the treatment, and his doubts increased
with every day’s observation. At length he persuaded some who began
to be sick to take some simple medicine, and not send for the
physician. The result was successful, and he recommended the same
course to a large number, none of whom became very sick.

As the community are not apt to make the discrimination which was
made by these two individuals, it is easy to see how the injudicious
physician and the quack often get the credit of success, in their
management of apparently grave cases, when in fact these cases need
never to have been of this character, but they might have been
cured at the onset by a judicious course in a very short time, or
perhaps by the spontaneous efforts of the curative power of nature.
The unskillful and ignorant practitioner often suffers disease to
establish itself, and thus makes a long case, though even ordinary
skill would have succeeded in at once breaking up the attack.
And yet, when the patient at last recovers, he may be applauded
throughout a neighborhood, perhaps a whole community, as having
raised the sick man almost from the dead, when perhaps in the same
neighborhood, in a case of a similar character, the attack was
successfully broken up, and no credit was given to the skill which
did it. This is a point on which undoubtedly the public often give a
wrong verdict in their estimate of comparative success.

In order to show the readiness with which the public commit errors,
on the points to which I have alluded, in their estimate of
comparative success, I will suppose a case which occurs not very
unfrequently. Here are two rival physicians side by side. The one is
really skillful, and, if the results of his practice could be justly
estimated, he would obtain great credit for success. He engages in
medicine, not as a mere trade, but as a noble science. He pursues a
straightforward, honorable, and quiet course, resorting to no tricks
to acquire business. The other, on the contrary, is unskillful,
cares little for medicine as a science, depends upon artifice, rather
than real merit, to obtain business, and, though he may desire to
be successful, he desires more that he may have the reputation of
being so. The issue which is made by these two physicians before the
public is a false one. Though the unskillful one loses more patients
than the other does, in proportion to the whole number who come under
his care; yet he perhaps does not lose as many, in proportion to the
number of those which are considered bad cases by the community. For
he makes many cases to be bad ones which need not to have been so,
and, besides this, represents many as being bad, that are really not
attended with any danger.

Suppose, to make this clear, that, each physician has one hundred
cases of some prevailing epidemic—that each has thirty bad cases—that
the skillful physician loses five of these, the unskillful one eight,
the real balance being therefore much against the latter. But the
latter more than compensates for this difference, by making ten bad
cases out of comparatively mild ones, of which he loses perhaps but
one or two, (such cases having, as I have before shown, a strong
tendency to recovery,) and by representing ten others to be bad
cases which are not so. How then stands the account? The unskillful
physician, has, it is true, lost more patients than the other. But
then, he has _appeared_ to have more cases of the epidemic fall into
his hands; for, while his rival has had but thirty bad cases, he
reckons up fifty of his as having been of this character, and the
community know but little of those cases which are acknowledged to be
mild ones—these make no noise, and are not commonly taken into the
account, in the estimates which the public make on this subject.

I do not mean to be understood, by stating these results in numbers,
that the community generally estimate them in this definite manner.
I only present the subject in this way in order to show, that, while
the real results tell strongly in favor of the skillful physician,
even a numerical estimate might tell against him; that is, as it
would be made out by the community, if they should attempt it. If
then an erroneous conclusion would be so apt to result from any
attempt at a numerical estimate on the part of the community, much
greater is the liability to error in the vague general impressions
which prevail on this subject. Many an unsuccessful practitioner has
obtained a greater reputation for success than his really successful
neighbor, from the noise which is made about his _numerous_ bad cases.

I come now to speak of some other points of difference in the results
of good and bad treatment, in regard to which the community are
commonly even more deceived, than on those of which I have already
treated.

In managing a case, in which disease has become so seated, that it
cannot be broken up, but must be removed gradually, it is evident
that the more judicious are the means which are applied from day
to day to the varying states of the case, the shorter will be the
sickness. It is in the accurate adjustment of remedial means to the
ends to be accomplished, that unskillfulness makes a great failure;
and yet it is a failure, which is for the most part concealed from
the public, because it can be satisfactorily detected only by a
nice comparison of cases. And this comparison cannot be made by the
public, for reasons which will soon be stated.

But the adjustment of remedies to the varying states of disease
has an influence beyond the mere circumstance of the length of
the sickness. The judicious physician saves his patients from
unnecessary complications in their diseases; while the injudicious
physician and the quack are apt, not only to neglect to prevent
or remove such complications, but to excite and foster them. For
example, if there arise in the course of a case of fever some local
inflammation, the judicious physician notices the symptoms of it, as
soon as they appear, and immediately applies remedies to remove it,
and commonly succeeds in so doing. On the other hand, unskilfulness
would be blind to the fact that such an inflammation exists, and
would therefore make no efforts to destroy it, but would perhaps
unwittingly increase it. The same difference between skilful and
unskilful practice could be pointed out in regard to other kinds of
complications—congestions, irritations, and functional derangements
of different organs.

But let us look beyond the results which occur during the progress
of disease, and examine those which appear after recovery has taken
place. When one recovers under injudicious practice, his system is
not apt to be in a good state. His convalescence is not a clear one,
and his recovery is not full and complete. Perhaps his vital energies
are impaired, and his constitution has received unnecessarily an
injury, from which it may never wholly recover. Perhaps some local
chronic ailment is left behind, which, though it may trouble him but
slightly for a long time, may yet be the germ of some future disease.
Such a state of things is not inconsistent with a tolerable condition
of health, even when there may be such disease, as will gradually
accumulate, till it bring him to a bed of sickness, perhaps of death.

These remote consequences of bad practice are the more certain to
occur, if the patient go on, after recovery, to administer medicines
to himself according to his own whims, or those of others. Many
very tedious cases of this kind fall at length under the care of
physicians, from the hands of quacks, who are thus often spared from
witnessing the results of their ignorance and imposture, and from
bearing, in the estimation of the public, any responsibility in
relation to them.

The influence of bad practice upon the health of families, it is
evident from the above facts, must be very great; and yet it is
seldom appreciated at all, and never as fully as it should be. There
is no question of the fact that there is generally a much larger
amount of sickness, from year to year, in families that employ
unskilful physicians or empirics, than there is in those who are
under the care of skilful practitioners. And though the public cannot
discriminate accurately between individual cases in regard to this
point, they can see the evidence of this general fact, especially in
comparing good practice with gross quackery. This evidence will go on
to increase, inasmuch as the evil effects of quackery, continued in a
family from year to year, are constantly accumulating; a result which
is materially aided by the unnecessary dosing, commonly pursued by
them in the intervals of sickness. And from this accumulation we may
infer, that what we now see of the bad consequences of quackery is
but a shadow of what we may see hereafter.

Let us now sum up the points in which the practice of the really
skilful physician differs in its results, from that of the
injudicious practitioner, and the quack.

1. He has a less number of fatal cases in proportion to the whole
number that come under treatment.

2. He has a less number of bad cases, because he avoids converting
light cases into grave ones, and succeeds in arresting disease in
many cases in its very commencement.

3. His patients have commonly a shorter sickness.

4. They are in a better condition after they have recovered—less apt
to have bad results left behind, and less liable to disease in future.

5. He has a less number of patients, and a smaller amount of
sickness, in the same number of families. In order to discover this
difference between skilful and unskilful practice, the observation
must be extended over some length of time, and quite a large number
of families.

That these points of difference between the results of good, and
those of bad practice, may be appreciated with any correctness, two
things are necessary.

First. We must have a sufficient quantity of evidence. A few facts
will not avail in deciding such points—they will only lead to
erroneous conclusions. Comparison is to be made, it is true, between
individual cases, but there must be many of them in order to secure
the avoidance of error.

The second requisite is the capability of observing correctly. I
have altogether failed of obtaining one of my principal objects in
this and the previous chapters, if the reader’s mind is not strongly
impressed with the great liability to error, which attends careless
and unskilful observation in medicine. There is no subject, in the
wide range of human knowledge, the investigation of which requires
more care and skill than this does.

Now it is obvious, that the community in general are very deficient
in these two requisites for a proper appreciation of the comparative
results of practice. Most men have a very narrow range of facts,
upon which they can found such an appreciation. Their observation
of sickness extends little beyond their immediate family circle; for
what they see of disease any where else is not like watching over it,
and what they hear, as you have already seen, is not to be relied
upon. There is much which is styled fact that is not so—it is either
mis-statement, or the result of hasty and superficial observation.
The actual knowledge which any non-professional observer obtains of
disease, by any observation of his own, to which he gives any fair
amount of attention is very narrow. This assertion may be offensive
to many, who are accustomed to utter their opinions, in regard to the
results of medical practice, with almost the authority of an oracle.
But it is nevertheless true.

But, the reader will say, if it be so difficult, and almost
impossible, for me to discriminate between good and bad practice,
by my own observation of their results, what shall I do? How shall
I judge of the different modes of practice, and of the skill of
different physicians? In answer to this enquiry, I remark, that if
the reader is really convinced by what I have said, that it is almost
impossible for him to judge of practice by the results which come
within the compass of his observation, then it is plain that he must
give up, for the most part, this source of evidence as a deceptive
one, and rely upon other means for arriving at correct conclusions on
these points. What these means are I shall point out in the chapter
on Popular Estimates of Physicians.

I think that physicians often err in their readiness to appeal to
results, to show the public the superiority of their practice to
that of the quack. There is no objection to such an appeal, when
a sufficient number of well-observed and authenticated facts can
be produced, bearing upon the point in question. But this cannot
ordinarily be done, when the community are to pass judgment in the
case. The quack likes to join issue with the physician here, for he
knows how easily the public are deceived in relation to facts, and
he makes his appeal before them to results with a bold confidence.
The proprietor of a patent medicine points you to his wonderful
cures, as the facts which must convince every one of its efficacy and
value. The Thompsonian, with his red pepper and lobelia and steam,
claims that he is right and every body else wrong, and appeals to
his successful results as the proof. The Homœopathist comes with his
little globules, and says that, laugh as you may at the tiny doses,
his appeal is to the cures, which he claims they effect as if by
magic. Talk with some physician who has adopted this mode of practice
from purely mercenary views, and who is rather ashamed of it, (for
there are such physicians)—ply him with argument, to show the fallacy
of his doctrines—drive him from one strong hold to another; and at
last you will come to his citadel, in which he feels perfectly secure
from all your shafts. He will tell you, with a cool kind of defiance
that you have not seen in him before, ‘there are the facts—our
medicines cure disease, and the people are beginning to see the
truth.’ The Hydropathist too will point you to narratives of scores
of patients, cured of all sorts of maladies by nothing but a cold
wet blanket, and will say, ‘wonderful as it may seem, there are the
results.’

So it ever has been. The same appeal has been made in behalf of all
the delusions that have ever obtained a currency in any community.
The Indian who performs his strange and uncouth manœuvres, and
utters his howling incantations over his patient, and the Chilian
doctor who blows vehemently about the bed of the sick, both, like
the Thompsonian, and the Homœopath, and the Hydropath, appeal to
their facts, their cures, as the sure proof of the efficacy of
their practice. The royal touch, the weapon ointment, the tar water
of Bishop Berkeley,[27] and the metallic tractors of Dr. Perkins,
were each in their time in the same way proved, to the satisfaction
of the great public, to be wonderfully successful in the cure of
disease. An array of facts appeared in favor of the last mentioned
of these delusions, Perkinism, that surpassed altogether the results
which are now attributed to Homœopathy. But time has shown that the
results were falsely attributed—a fact which should teach the public
a lesson, in regard to the apparent results which are appealed to in
support of the delusions of the present day.

But must the physician say nothing about results to the public?
Certainly he should.

In the first place, he should endeavor to guard those, with whom
he has daily intercourse, against erroneous views of results in
medicine, by showing them the difficulties that lie in the way of
estimating them with correctness. If he succeeds at all in producing
a proper impression upon their minds, and thus induces them to be
modest and careful, instead of being bold and heedless, as too many
are, in expressing their opinions on such subjects, he will exert an
effectual influence, in preventing them from being deluded by the
partial views of facts, and the mis-statements, upon which empiricism
relies for its success.

In the second place, whenever he can make a comparison between the
results of good practice and those of quackery, _which can be fairly
understood_, let him do it. To warrant such a comparison the facts
should be clear, well authenticated, and in sufficient number to
justify the general conclusions drawn from them.

In the third place, whenever he can show, by facts which can be
appreciated by the common observer, that the practice pursued by any
pretender has been entirely inappropriate to any case, especially
if this can be done by evidence discovered in an examination after
death, let him do it, and explain with all clearness the nature of
that evidence to the friends of the patient, and, if necessary, to
the community. At the same time, he should avoid joining in with the
popular disposition to ascribe death to the treatment pursued as a
matter of course, whether the proof be or be not satisfactory.[28]
There is no doubt that death is frequently the consequence of bad
practice, when it cannot be proved to be so; but not even the quack,
murderous as his course certainly is, should be condemned upon faulty
and defective evidence.


FOOTNOTES:

[25] The above remarks may be applied to an exclusive system quite
popular just now—I refer to Hydropathy. Cold water is a valuable
remedial agent, used both internally and externally, as the recorded
experience of medical men abundantly proved long before Priesnitz
appeared on the stage. But the indiscriminate and exclusive use of
it, which is prescribed by his system, is as bad practice as the
indiscriminate and exclusive use of anything else—and _a full and
impartial record of Hydropathic practice would show it to be so_.

[26] When an epidemic is prevalent, such a physician instead of
allaying the undue public excitement, as it is his duty to do,
increases it by his very grave and wise air of conversation, and by
his reports of his cases, of which he is apt to have more than his
neighbors, and to be of course very successful in their treatment.
Even when there are only distant rumors of the epidemic, he has
occasion to report to gossiping circles some cases which at least
come _very near_ to being true cases of it.

[27] Dr. Holmes says of this pre-eminently talented and learned
man—“Berkeley died at the age of about seventy; he might have lived
longer, but his fatal illness was so sudden that there was not time
enough to stir up a quart of his panacea. He was an illustrious man,
but he held two very odd opinions; that tar water was everything, and
that the whole material universe was nothing.”

[28] The bare fact that death results is obviously no proof of the
want of skill, any more than the bare fact that a case has ended in
recovery is proof of the possession of skill. But the disposition to
which I have alluded is quite common, and gives rise to many unjust
conclusions in regard to the merits of physicians. Hence physicians
often manifest, in various ways, a dread of having the charge of
cases, which are sure to end fatally. Some, to avoid the imputation
of “bad luck,” as it is expressed, often manage adroitly to throw
such cases off from their own hands into those of some neighboring
practitioner, or some empiric, before death actually occurs.




CHAPTER IX.

THEORY AND OBSERVATION.


All real knowledge is based upon observation; and it is the facts
discovered by observation, which, accumulating from age to age,
constitute the _store_ of human knowledge. Not a single grain has
ever been added to this store, in all the ages of the world, through
the instrumentality of theory alone. Theory, or hypothesis, has often
suggested the existence of facts, and has directed in the pursuit
after them, but observation after all is the only agent that has
discovered them.

Facts are of two kinds—particular and general. General facts are
discovered by a careful observation of a great number of particular
facts. Thus Newton, by observing many particular or individual facts,
established the general fact, which is called gravitation, viz., that
all bodies are attracted towards each other, or have a tendency to
come together. So in medical science, by an observation of many facts
in individual cases, it has been discovered, that there is a tendency
in the human system to restoration to health, whenever it is attacked
with disease—a tendency, existing as a general fact, to which has
been given the name, _vis medicatrix naturæ_.

These general facts are sometimes termed principles or laws, and
are sometimes spoken of as the relationships of facts. A theory, or
hypothesis, consists in a supposition of relationships which have
not yet been ascertained. Thus Newton, after discovering the great
general fact of gravitation, supposed that there might be a sort of
ether connecting bodies together, and acting as the medium of their
attraction. This supposition of a relationship, or general fact, not
yet ascertained, is a theory or hypothesis. So when Stahl supposed
the principle called the _vis medicatrix naturæ_ to be in the soul,
and when Cullen supposed that it exists in the nerves and produces
in fever a spasm of the extreme vessels, they both put forth a mere
theory. Cullen speaks of Stahl’s theory as being fanciful. It is so.
But Cullen’s is just as fanciful, if by this word it is meant that it
is unsubstantiated by fact. Cullen’s supposition is more plausible,
it is true, than Stahl’s; but it is no nearer being a proved fact.

There is often much indefiniteness in the use of the word _theory_.
Thus the doctrine, or law of gravitation, as discovered by Newton is
sometimes spoken of as his _theory_ of gravitation. It was _once_
his theory; that is, when it was a mere supposition in his mind. But
when, by a series of observations it came to be a proved fact, it
was no longer a theory. So the laws of the circulation of the blood,
as discovered by Harvey, are sometimes erroneously spoken of as his
theory of the circulation.

Some theories are said to be founded on facts, while others are
deemed to be very fanciful. But theory can never be said, strictly
speaking, to be founded on facts. It has relation to facts, it is
true, but in the attempt to explain their nature, it goes _beyond_
them over into the domain of conjecture.

Every one who puts forth a theory, is apt to think that all previous
theories are false, while his is proved to be conformable to facts.
Dr. Cullen, in announcing his theory, or doctrine (as he styles
it) of fever, which is from beginning to end a series of unproved
assertions, says, “I flatter myself that I have avoided hypothesis,
and what have been called theories.” So Dr. Rush, after framing a
theory even more palpably fanciful, says, that he conceives the
doctrine of fever that he has aimed to establish rests upon facts
only.

There is no science, in which there has been so much theorizing, as
there has been in that of medicine. Its history seems to be almost
altogether a history of untenable theories. These theories are at
least the prominent objects that present themselves to view. Every
period has had its favorite theory, which has exerted its influence
upon the general medical mind. Almost every great name in medical
history is associated with some celebrated hypothesis. And it would
seem that sometimes the attention of the whole profession has been
almost exclusively directed to the strife between the advocates of
opposing theories. This overweening attachment to theories has been
a very great obstacle to the advancement of medicine as a science.
It has turned the medical mind away from the legitimate pathway of
discovery, and the strict observation of facts has been neglected in
the contemplation of mere fancies.

It is true of medicine, as it is of every other science, that every
advance which has been made has been effected by observation,
and by observation alone. It is the good observer, and not the
mere ingenious theorizer, who has made these advances. And if the
theorizer has added anything to the store of knowledge, it is only
when he has come down from his airy flight of fancy to the drudgery
of humble common observation. He has for the time forgotten
his favorite theory, and has subjected hypothesis to its proper
subserviency to observation, in suggesting the points to which that
observation may be directed. It is in this way, and in this alone,
that many of the authors of theories, escaping occasionally from
the domination of a theorizing spirit, have added rich treasures
to the storehouse of medical science. Even before the discovery of
the circulation of the blood, though medical theories necessarily
contained many absurdities, yet many of their advocates were acute
and accurate observers; and their facts are valuable, though the
theories, which they framed to account for these facts, may appear to
us even ridiculous. They collected a great amount of good materials;
but instead of erecting with them a structure full of beauty and
symmetry, capable of resisting the commotions of ages, they reared
a motley pile which easily tumbled into ruins. They were men of the
most persevering industry. They seemed to forget entirely that “of
making many books there is no end; and much study is a weariness of
the flesh.” Quartos and folios were produced in abundance, full of
mixtures of wisdom and folly, as incongruous as were some of the
old prescriptions with their hundred or more ingredients. And as
some of the articles, which composed these hundred-headed enemies
of disease, are now among our most valuable remedies, so there are
portions of those strange compounds of fact and speculation, which
will always stand as monuments of genius and industry. They are among
the principles which form the basis of medicine. The student, as he
now reads the older works in medical science, regards but as matters
of curiosity the theories of lentor and viscosity, acrimony, &c.; and
picks out from the mass of rubbish the pearls and precious stones,
which are almost concealed beneath it.

The reader cannot fail to have seen, in the course of my remarks,
what I deem to be the province of theory, or hypothesis. It is simply
suggestive. This is its true vocation. It _establishes_ no fact, and
no principle. It should be the mere handmaid of observation, and
should be kept in perfect subjection to her control. It never should
be a rival, much less should it have supremacy, as it has too often
done, in the domains of science.

Thus restricted to its proper sphere, theory is of essential service
in extending the boundaries of science. It often suggests the line
of discovery. It constantly reaches beyond present knowledge. We
theorize, that is, we suppose; then by observation we discover. If
we find our hypothesis or supposition to be correct, we discover a
positive fact. If we find it not to be, we discover a negative fact,
and not valueless because negative—some of our negative facts are
worth quite as much as positive ones.

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.

Another error, of a more directly practical character, which existed
for a long time in relation to this same disease, will serve as
another illustration of the influence of a partial view of facts, in
leading to wrong conclusions. Dr. Sutton, one of the early authors
on delirium tremens, asserted as the result of his observation, that
the patient must sleep or die, and that opium in _large_ doses was
the proper remedy to produce the sleep. This opinion was for a long
time almost universally adopted, and practised upon. But the compared
experience of _many_ observers has demonstrated this practice to be
erroneous, and it is now very commonly given up by the profession.

In examining disease, whether in a single case, or in groups of
cases, it is essential to the formation of correct conclusions, that
_all_ the symptoms be observed, and that their relative importance be
duly estimated. Much error has arisen from a disregard of this plain
truth. Take for example the observations of different individuals in
regard to fever. Boerhaave, looking mainly at one class of symptoms,
taught that fever was caused by a bad state of the blood; Cullen
looking at another class of symptoms, considered fever to be an
affection of the nervous system; Clutterbuck, fixing his eye upon
another class of facts, was very sure that the cause of fever is
always to be found in the brain; Broussais, directing his attention
to the symptoms developed in another quarter of the system, asserted,
that all fever arises from an inflammation of the mucous membrane of
the stomach and of the upper portion of the intestines; Dr. Cooke of
this country, narrowing his vision down to a certain set of symptoms,
proclaimed that the primary cause of fever is a weakened action of
the heart, producing an accumulation of blood in the venous system;
and Samuel Thompson, following in his rude way the example of all
previous theorizers on this subject, in taking into view but a part
of the facts in the case, declared that fever is a battle between the
cold and the heat, and that, if the cold conquer, the patient dies,
and if the heat gain the victory, the patient lives.[29]

It is thus that a disposition to form conclusions from a limited
experience, and to take partial views of facts, leads to errors of
opinion, and consequently errors of practice. I might multiply
illustrations on this point, but it is not necessary.

Allied to the influence just mentioned is another, to which I
will give a passing notice. I refer to the hobby-riding which is
so common in the medical profession. Every good thing seems to be
destined to this use till it loses its novelty; and therefore its
real value can never be accurately ascertained, till it has passed
what may be called the _hobby-period_ of its existence. No careful
discriminations are made to any extent until this period is finished.
Even the experience, which is recorded in journals of medicine during
its continuance, needs to be thoroughly sifted by after observation.
The influence of this hobby-riding is therefore a great hindrance to
the progress of medical science. And this influence is not confined
to the particular subjects to which it is applied. It does not merely
throw obstacles in the way of _their_ investigation. It is not thus
limited and evanescent, for it is counter to the true _spirit of
observation_, and impairs its hold upon the profession as a whole.

The riding of hobbies is very much regulated by fashion. For there
is a fashion in medicine as well as in everything else; and it not
only bears rule in the community at large, but it exercises no
inconsiderable authority in the medical profession itself. Some
particular diseases and modes of treatment, are ever, sometimes one,
and sometimes another, uppermost in the popular mind.

When anything new comes up in regard to disease or its treatment,
which attracts considerable attention, there is a strong temptation
to make a hobby of it. Multitudes suppose that they have the
disease, and need the treatment. This may be really true of but
few of them, but such is their belief. There is no time for
accurate discrimination if the object be to make fame and money.
If a physician honestly undertakes to decide what cases need the
treatment, and what do not, he will not be as successful in gaining
eclat, and in getting the people’s money, as his neighbor will be,
who catches the popular breeze with all his sails, knowing that it is
not wont to blow in one direction for any length of time.

A few years ago dyspepsia was very fashionable; but now it is so
old-fashioned, that we hear but little about it, and no hobby-rider
thinks at the present day of setting up any pretensions to great
skill in the treatment of this complaint. Diseases of the throat have
taken its place in the public mind, and multitudes are running to
those, who are reputed to have peculiar skill in clipping off tonsils
and palates, and swabbing out windpipes. The new treatment, as it is
called, is good practice in some cases; but the almost indiscriminate
application which some hobby-doctors make of it is ridiculous and
contemptible. The confirmed consumptive, who has his palate clipped,
or his throat or windpipe swabbed, and because he fancies that he
feels better, revives for a time the delusive hope of recovery, and
cheerfully pays the doctor his fee, has a most unjustifiable cheat
practised upon him. And such fees! From five to twenty dollars,
according to the circumstances of the patient, is asked by some of
these doctors for clipping the palate, one of the most trifling
operations in surgery.[30]

When this fashion shall have passed by, as pass it will, like all
other fashions before it, and this hobby shall have ceased to be
ridden, how little will be the actual knowledge of diseases of the
throat and windpipe, which will be found to be added to the stock
of information in the possession of the profession by those, who
have now the reputation in the community of being very skilful in
the treatment of these complaints! Some, who have had less eclat,
and have therefore reaped less pecuniary benefit, will have made the
proper discriminations; and to them will the profession be indebted
for all that has been really discovered in relation to the nature and
treatment of these diseases.

A habit of making loose and exaggerated statements has become
so common in the medical profession, that it is really no small
obstacle in the way of the accumulation of accurate observations in
medicine. The credulity of the public tempts to an indulgence in such
statements, in the common intercourse of physicians with those who
are around them, and to whom they relate their cases, and state the
results of their experience. If they yield to the temptation, the
habit grows, and it inevitably begets and fosters another habit—that
of loose observation. The statements of such physicians are not to
be relied upon, even when they appear on the pages of some medical
journal. Much of the recorded experience of the profession is
undoubtedly from this cause worse than valueless.

I mention as another very common cause of inaccurate observation
in medicine, an easy credulity, and a consequent fondness for
novelty and change. It is a very prevalent opinion that the medical
profession is opposed, as a general thing, to anything which is
new, and that it really thus stands in the way of the march of
improvement. This may have been true once, when the authority of
antiquity held an almost undisputed supremacy over all the votaries
of learning and science. But it is far from being true now. One of
the prominent faults of the medical profession in the nineteenth
century is, on the other hand, that it is as a body too fond of
new things, and too much disposed to receive them upon doubtful
evidence. There is a great disposition to hail every new remedy with
enthusiasm. The annals of medicine are therefore burdened with false
statements in regard to the effects of remedies. Though the public
think that there have been of late many discoveries of new medicines
of great value, there really have been but few. There have been many
improvements in the _forms_ of medicines. I mention as examples,
quinine and morphine, the active principles of bark and opium. But
there have been but few absolutely new medicines introduced which are
of any importance. Many have been announced with much flourish, and
have been extensively used for a time, but the confidence which has
been put in them has in most cases been found to be misplaced. And
it may be remarked, that physicians, who try all the new remedies
recommended from time to time in medical journals, do not add so much
to their stock of available experience, as those do who are more
cautious, and less ready to adopt everything which is new.

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.

I cannot conclude this chapter without paying a passing tribute
to the memory of one, my preceptor and friend, who stood among
the foremost in the work of reform now going on in the medical
profession. I refer to the late Dr. Hale,[33] of Boston. He was
eminently a man of accurate observation. His enquiry always was
after the _facts_. He asked not what a man _supposed_, but what he
had _observed_—not what he _thought_, but what he had _found to be
true_. His valuable contributions to the recorded experience, and
the literature of the profession, bear him witness on this point.
His labors, so deservedly prized by his brethren, are ended, but we
have reason to rejoice, that he has left behind him so many of a like
spirit, who are endeavoring to redeem our science from the dominion
of fanciful theory and loose reasoning, and to place it under the
control of a true and rigid OBSERVATION.


FOOTNOTES:

[29] Hunter in one of his lectures thus speaks playfully, but most
truthfully of the various _theories_ of digestion, which have arisen
from exclusive views of different sets of facts. “Some physiologists
will have it that the stomach is a mill;—others, that it is a
fermenting vat;—others again, that it is a stew-pan; but in my
view of the matter, it is neither a mill, a fermenting vat, nor a
stew-pan—but a _Stomach_, gentleman, a _stomach_.”

[30] If this be a suitable charge for this operation, it would be
proper to ask at least an hundred dollars for extracting a tooth, if
the prices of operations are to be regulated by their magnitude, or
by the amount of skill required in performing them.

[31] ‘Have you ever looked into Homœopathy,—have you ever read
Hahneman’s Organon?’ said an eminent divine to an equally eminent
physician. ‘No,’ replied the physician, ‘and let me ask you, in
return, if you have read the Mormon Bible?’ The clergyman of course
answered in the negative, and his medical friend said to him very
properly, ‘when you take the trouble to examine Joe Smith’s Bible, I
will take the trouble to examine Hahneman’s Organon.’

[32] An Essay on the Philosophy of Medical Science.

[33] The reader will permit the author to gratify his own feelings of
regard for Dr. Hale as a _man_, as well as a physician, by inserting
here the following extract from the memoir of him, from the pen of
Dr. Channing. “Dr. Hale was an honest man. He was honest in sentiment
and in purpose. He had little or no tolerance for what he thought
unfair; and any believed misuse or abuse of trusts he resolutely
opposed, however active or however strong was the agency by which the
wrong was attempted to be consummated. These were not the elements
of popularity. You could hardly make a very popular man out of such.
But for the honor and exceeding praise of humanity, there are men
who have found something better worth living for than the present
fame—men who are happy and satisfied to do that which may live after
them, and the memory and the use of which can only be for good. Dr.
Hale enjoyed life—the best thank-offering for living. He was social
and hospitable, for he would contribute to the pleasure of others,
as well as his own. He was always cheerful, because he was truly
hopeful. He looked on the bright side of disease in himself and
in others; and if he labored so well for their recovery, he never
questioned his own.

Dr. Hale was a religious man. In the development of the religious
sentiment was his power. It was kept active by habitual, daily
devotion. It influenced his whole life, making him an earnest student
and a faithful practitioner—giving him strong interest in all wise
effort to extend Christianity in distant lands, and by his example
recommending to others the religious life. In his religion was his
benevolence, which with very narrow fortune led him to attempt and to
accomplish most important objects. In this was his cheerfulness in
suffering and all trial; and out of his religion came the peace and
the hope of his death hour.”




CHAPTER X.

POPULAR ESTIMATES OF PHYSICIANS.


There is no class of men whose talents and attainments are so
erroneously estimated by the public as are those of physicians. Some
of the causes of this erroneous estimate have been brought to view
in the chapters on the Uncertainty of Medicine, and on Good and Bad
Practice. I propose in this chapter to treat of this subject more
distinctly, to point out some other causes operating with those which
I have already mentioned, to show the results of this false estimate
of medical character and attainments, and to develope some plain
principles, on which a correct estimate may for the most part be
secured.

I presume it is sufficiently clear to the reader, from the views
which I have before presented, that the community cannot judge
with any degree of correctness _directly_, of the practice of
physicians,—either of the truth of the principles on which it is
based, or of its actual results.

How then shall the community judge of physicians? This question I
will endeavor to answer.

The view which I gave, in the first chapter, of the uncertainty of
medicine, I trust, made it obvious to the reader, that a thorough
education is pre-eminently necessary to the proper practice of the
medical art. In endeavoring therefore to form an estimate of the
qualifications of any physician, let the evidence of his having
obtained such an education be well considered.

But what is this evidence? Is it to be found in the bare fact
that he has a diploma, obtained from some respectable medical
institution? While a diploma is worth something as evidence, as
there must be some improvement of the means of education, in
order to pass the examination requisite to obtain it; yet it must
necessarily be defective evidence. That the truth may be more fully
ascertained, let the inquiry be made, how far the physician has
improved the advantages he has had; for it must be remembered, that
it is especially true of medicine, that a diligent and wise use of
limited opportunities will impart more knowledge and skill, than
can be acquired by a careless and unwise use of the most extensive
advantages afforded by the profession.

I will allow that there are difficulties in the way of arriving at
the truth in this inquiry, and the public are often most grossly
deceived by the parade which is made by some physicians, in regard to
the opportunities which they have enjoyed. Still, I apprehend, that
the erroneous judgment of the public in regard to such cases, arises
from a too ready confidence in mere pretensions, and that it can be
avoided for the most part by a little more pains-taking in making the
inquiry, and by applying tests of another character, to which I shall
soon allude.

But education in the science of medicine is practically despised by
quite a large portion of the community. Though this sentiment is not
often distinctly avowed, yet it exists to a greater extent than is
generally supposed. It shows itself in an indifference to the true
evidences of a physician’s qualifications, and in a readiness to put
the quack on a level with the thoroughly-educated physician, or even
above him. These indications of the prevalence of this sentiment, are
not confined to the ignorant; but they often appear among the well
informed, and even the learned.

Sometimes this sentiment is boldly avowed in language like the
following: ‘I care little about the evidence of a physician’s having
had an education. The fact that he is successful in treating disease
is worth vastly more than a piece of parchment. Many a man has risen
to eminence in other professions by his own exertions, without any
great amount of education; and why should not this be the case in
the practice of medicine? There was Franklin, who rose by his own
efforts to a post of honor and usefulness far above multitudes of
his cotemporaries, who had a most finished education; and why should
there not be Franklins in medicine, as well as in other departments
of knowledge?’

The assertion, that success in curing disease is worth more than a
piece of parchment, is strictly true. But the evidences, on which a
correct estimate of success can be formed, are not ordinarily, as the
reader has seen in the chapter on Good and Bad Practice, within the
reach of the community; and the attempts which it makes to form an
estimate from the defective evidence at its command, often result in
the bestowment of the praise due to success upon those who are really
unsuccessful.

As to the use which is made of so great a name as that of Franklin
to justify a disregard of education in medicine, I remark, that
those who hold such language forget three very plain truths. 1st.
That self-education is, after all that can be said, education. It
is education acquired in spite of difficulties, and without the
aids which men usually have. 2d. That education thus obtained
indicates the possession of _uncommon_ power of mind. There are but
few Franklins in any profession. It is not common for men to rise to
eminence with the small means which he enjoyed, and in face of the
difficulties which he encountered. 3d. That Franklin, and all those
men who have thus risen to eminence, so far from despising education,
made most diligent use of all the means of education which they could
command, aspiring all the time to higher and higher advantages; and
while they lamented the deficiencies of their own early training,
they labored most assiduously to give to others the most extensive
means of acquiring knowledge. Very different from this, I cannot
avoid remarking in this connexion, is the spirit of those pretenders
in medicine, who affect to despise education, and who claim that they
have an innate skill, which education can neither impart nor improve.

I shall in another chapter maintain, that it is both the duty and
the interest of the community, to demand that there shall be a
respectable standard of education in the medical profession, and will
therefore dismiss this topic for the present.

The second source of evidence, in regard to the qualifications of a
physician, is to be found in the unbiassed opinion of his medical
brethren. I allow that there are difficulties in the way of obtaining
such an opinion. There is, on the one hand, the prejudice of rivalry,
and, on the other, the partiality arising from mutual interest.
Sometimes these influences extend beyond the individual, and arrange
medical men in small parties, or cliques; and these often render it
exceedingly difficult to discover the standing which any physician
has among his brethren. Yet it is true, that every physician has a
general estimate put upon him by the profession, _and it is commonly
a correct one_. And this estimate can ordinarily be ascertained by
any one, who makes due allowance for the influences to which I have
alluded.

While this strictly professional reputation, which is awarded
to every physician by his brethren, is commonly very nearly
correspondent with his true merits, that which the public awards
to him may be far otherwise. It is often the case, that, while a
physician, of whom his brethren have an exalted opinion, meets with
but little favor from the community; another, who is a very ordinary
practitioner, and who is so considered by the profession at large,
has an extensive practice, and a high popular reputation. Such a
physician may be treated with much outward deference by his medical
brethren, on account of the position in which the public favor
has placed him; and this is often very erroneously considered as
evidence, that he is held in great estimation by the members of the
profession generally.

I pass now to the consideration of a means of estimating the
qualifications of physicians, which is of a more practical character,
and more certain in its results, than those which I have already
mentioned. And yet it is one which has been very generally neglected,
for reasons which I shall give in a future stage of my remarks.

There are certain mental qualities, which are essential to the
possession of skill in the practice of medicine. Whoever is found to
possess these qualities, you may be sure, will with proper education
make a good physician. And if they are wanting in any one, no
education, nor experience can supply the deficiency. He never can be
truly skilful as a physician; and if such an one acquire a reputation
for skill, which is no uncommon thing, all that we can say is, that
the public are deceived in their estimate of his qualifications.

How then can an intelligent man discover, whether a physician has
these requisite mental qualities, and to what extent he has them?
What tests can he apply to bring them out, so that he can see them
distinctly, and measure them with any good degree of accuracy?

The science of medicine is so much a mystery to the common observer,
that he cannot, as you have already seen, apply his tests to a direct
examination of the physician’s knowledge. He is not competent to make
the estimate in this way; and if he is not aware of this, he will
certainly be deceived. If he wishes effectually to avoid error, he
must apply a touchstone which he himself understands, and not one of
which he is profoundly ignorant. What is this touchstone? Plainly
this. _Let him observe the mental qualities of the physician, as they
are exhibited in regard to any subject, with which he is himself
familiar in common with the physician_; and he has here a test upon
which he may rely with absolute certainty. He discovers in this way
the character of the physician’s mind; and it is just to infer that
the mental qualities thus laid open to view, stamp their impress upon
the practice of his profession, and give to it its character. No
change comes over his mind when he passes from other subjects to that
of medicine. The same mental powers are there, and he will observe,
think reason, and act, just as you have seen him do in regard to
common subjects.

Take an illustration from surgery. You see a surgeon set a fractured
limb. You cannot judge whether he does it skilfully, because you
do not understand how it should be done, so as to bring the broken
ends accurately together, and keep them so. But if that surgeon,
in passing your house, by some accident breaks the thill of his
carriage, you can watch him as he splices the thill, and you can
judge, for you are competent to do so, whether he exhibits mechanical
talent in the operation. If he does, you can safely infer that the
same mechanical talent will be brought into exercise in setting a
bone, and that he will set it as skilfully as he spliced the thill.
Other talents in a medical man can be tested in a similar manner.

The truth, of which I have given this single illustration, is so
obvious when plainly stated that it hardly needs to be dwelt upon at
all; and yet, it is so often disregarded by the community, in the
estimates which are made of physicians, that it may be profitable to
illustrate it somewhat at large. In doing this we shall accomplish
another important purpose—we shall obtain a clear view of those
qualities which are most necessary in the particular calling of a
physician.

Let us then cursorily notice some prominent characteristics, as they
are seen in physicians in your daily intercourse with them on common
subjects, and apply the criterion which we have under consideration.

Look at the mode in which physicians form their opinions.

You discover in your conversations with a physician upon politics,
religion, or the occurrences of the day, that he is very credulous.
Have you a doubt that the same credulity follows him into a sick
room, and mars the accuracy of his observations of disease and of the
influence of remedies? And so, on the other hand, the physician who
shows a sceptical cast of mind on other subjects, will assuredly be a
doubter on a subject clothed with so much uncertainty as medicine is,
and his treatment of disease will be marked by hesitation and lack of
energy and firmness.

You see a physician apt to form his opinions on ordinary subjects
hastily. Slight evidence satisfies him, and he makes up his mind at
once. It may be that he does it with so much shrewdness that he is
very apt to be right in his conclusions; but sometimes he is entirely
wrong, because he has in his haste overlooked some apparently slight
circumstances which are really of vital importance. There is quite a
large class of such minds in the medical profession. They are better
fitted to practice in acute forms of disease than in chronic cases.
These latter require patient investigation to thread out all their
intricate complications.

I once knew two physicians of considerable eminence, who had directly
opposite casts of mind, in regard to the qualities to which I have
just alluded. They lived and practised in the same neighborhood
through a long life. The one would spend perhaps an hour in ferreting
out all the hidden labyrinths of a chronic case, and I have often
been delighted, as he would clearly and in choicest language unfold
his views, after he had concluded his examination. The other never
wanted more than a few minutes to learn all he wished to know
of a case, and he was prepared to act. Possessed of much native
shrewdness, it was astonishing to see how he would avoid error in
forming his hasty opinions. He seemed to be aware in what his forte
lay. He had an abhorrence of all long and intricate cases, and turned
them over, so far as he could, to his brethren; and he took peculiar
pleasure in managing acute cases, in which the changes were rapid,
and the end either for good or ill came soon.

You discover in your conversations with one physician on common
subjects, that he is very slow and cautious in adopting opinions, and
when he has once adopted them he adheres to them with great tenacity;
while another, on the contrary, is exceedingly changeable in his
opinions. These opposite qualities, exhibited as they are abroad in
society, go with them to the sick chamber, and they exert their full
influence. The one will fix upon a course of practice in a given case
with all due consideration, and when he has once fixed upon it, he
will pursue it most faithfully, even though the progress of the case
may furnish conclusive evidence that he is wrong. He will be blind to
that evidence, because he believes most assuredly that he is right in
his views of the case. The other will not pursue a course long enough
to determine whether it be right, but will see continual reasons
for change; and his course from the beginning to the end of a case
will often present a medley of variations, from which no intelligent
conclusions can be drawn. The one will have a few favorite remedies,
which he reckons as old and tried friends, and he adds but few to the
little group from year to year. The other will make frequent changes
in the remedies which he employs, and will try in rapid succession
the new medicines, which every fresh periodical bring to his notice.

Some men take strong views of everything which they see. They must
always have an opinion, whether the evidence upon which it is based
be sufficient or not; and that opinion fills the mind, and actuates
all the conduct. They are apt to have very partial and exclusive
views, overlooking in their ardor points, which, though they may
have little apparent prominence, may, if properly examined, lead to
discoveries of great importance. Such men in the medical profession
always make a decided impression upon the public mind, and have many
strong and ardent friends; and if they possess considerable talent,
they generally acquire a dazzling reputation. It is true that they
commit frequent and often great errors. But when their bold opinions
turn out to be correct, it adds wonderfully to their reputation for
acuteness and wisdom, while their errors are mostly concealed,
and the whisper that tells of those errors that chance to be
discovered, is effectually drowned in the noisy commendation of their
enthusiastic adherents.

If I at all succeeded in my object in the chapter on the Uncertainty
of Medicine, the reader was convinced that there is no pursuit in
which a habit of accurate observation is more needed than in the
practice of the medical art.

How then can a common observer test a physician in regard to this
talent? If the observer were himself a physician, he could do this
by watching him in his examinations of cases of disease. But as he
is not, and is therefore ignorant of the subjects to be examined,
he will fail in any attempt of this kind. He will be apt to commit,
for example, this error. He sees that a physician makes a great
many inquiries of his patients in regard to their complaints, and
he may for this reason alone conclude that he is a nice observer.
This minuteness of examination often gives a physician very unjustly
this reputation; and in fact it is one of the most common tricks of
the trade. There is often a great parade of questioning with very
little true observation. A physician who is a skilful observer will
learn more of a patient’s condition, by watching him as he lies in
bed, and making a few inquiries, than another will by a multitude
of questions; just as one man, who scarcely appears to look at
anything as he passes through a street, may really observe and
know more about the various objects in that street, than another
man, who appears with eyes wide open to look at everything. A mere
glance will sometimes reveal to the skilful observer the true nature
of the case, when the unskilful have not been able to discover it
with the most diligent examination of the symptoms. I will mention
a single example. A man who was severely sick was attended by two
physicians, who were somewhat at a loss in regard to the nature of
his disease. Another physician, who was called in, before asking a
single question, suspected from the posture of the patient that he
had a hernia, in common language a rupture; and on examination this
was found to be the case.

I might mention some other errors, to which the inquirer would be
liable, if he attempted to judge directly of the physician’s mode of
examining disease, but it is not necessary.

How then, the question recurs, shall he test the physician on the
point under consideration?

Let him see how the physician observes in regard to some subject,
with which he himself is acquainted. He will discover in this way
what his habits of observation are; and he may be sure, that these
same habits mark his investigations of disease in the chamber of
the sick. No man has different habits of observation for different
subjects.

Suppose that you have a curious article in your possession, and you
have become acquainted with all the facts in regard to it. If you
show it to several physicians, and observe the inquiries which they
make in relation to it, you can discover the different characters
of their minds, and may thus know how they observe and investigate
disease.

One of them asks perhaps but few questions, and some of those are
irrelevant. He discovers but little in regard to the article, and
you may be sure that he will never discover but little in regard to
disease.

Another, after making a few inquiries, starts some supposition or
theory, and this directs all his future inquiries. He of course
obtains a very partial knowledge of the facts, and this is mingled
with errors. And so it is with him in his investigation of medical
subjects. He is a theorizing practitioner.

Another makes many inquiries, but they are of a rambling character.
He finds out many of the facts in regard to the article, but
by no means all of them. His observation is active, but it is
without method and incomplete. Though he will be diligent in the
investigation of disease, and will appear to most persons to be an
acute and skilful observer, he never will obtain a thorough and
complete knowledge of any case.

Another, by a natural succession of inquiries, discovers one fact
after another, till he knows the whole. He does not ask a single
irrelevant question. The answer to every question either developes a
new fact, or confirms one already discovered. He separates accurately
the probable from the true, wholly rejecting the merely plausible.
He frames no theory. His search is only for facts. You may be sure
that he will be a skilful observer in the sick room, and that in the
investigation of disease he will be constantly adding to his store of
valuable and well-arranged facts.

Do you wish to ascertain what characterizes a physician’s _measures_
in the treatment of disease? Instead of watching his practice, of
which, as you have seen, you cannot judge with any good degree of
correctness, observe what measures he proposes when acting, not in
the capacity of a physician, but in that of a citizen, a neighbor,
a member of an association, and what reasons he gives for these
measures. If you find that he advocates measures which show common
sense, shrewdness, and good judgment, and which accomplish the
purpose aimed at; you may safely conclude that the same common sense,
shrewdness and good judgment mark his treatment of his patients, and
that he is a skilful and successful practitioner of medicine.

A very little thing will sometimes develope some characteristic of
a physician’s measures. A physician, as he starts his horse to
leave you after a pleasant chat, finds the rein caught under some
part of the harness. He pulls it up to disengage it; but, as he does
not succeed, he gives it a twitch in which he succeeds no better.
His face reddens, and he twitches again and again, each time more
violently, and finally, by tearing out a loop in his harness, he
disengages the rein. You may safely infer that that physician will
be apt to have just such twitching measures in his treatment of the
sick, and will in this way mar some things which are of some more
importance than the loops in his harness.

It is quite a prevalent idea in the community, that a man may be an
ignoramus in regard to other subjects, and yet may have great skill
in medicine. It is supposed that there is in the healing art a sort
of mysterious tact or skill, innate in the man, and not acquired
like other knowledge. It is this idea which gives such a reputation,
for infallibility almost, to the natural bone-setter. We find here,
also, the reason that intemperance in a physician so little impairs
the confidence of his employers. It must be obvious that in no
employment is a steady and clear state of mind more needed; and the
obscurity of mind and recklessness, which intoxication, even when
existing only in a slight degree, invariably produces, must unfit the
physician for the proper performance of his duties. And yet how many
sensible people, who would fear to trust an intemperate stage-driver
or engineer, will unhesitatingly commit their health and life to the
care of an intemperate physician, because they suppose that he has
a peculiar skill, of which even intoxication cannot deprive him.
His drunkenness seems to act as a dark background, making his skill
appear the brighter by contrast.[34]

In confirmation of this idea of the possession of innate skill, it
is said that a man may be a fool on one subject, and yet may be a
genius on another. A man may be, for instance, a great arithmetician,
or a very ingenious mechanic, and may yet exhibit folly on most
other subjects. This may be true in some few instances, but it is
not at all common; and rare cases never can establish a general
rule or principle. And besides, a genius in medicine, if he be a
mere genius, in the popular sense of the term, makes but a poor
practitioner. For true skill in the practice of medicine requires
the possession of a wide range of talents, and among these sound
judgment, or, (as it is familiarly called when used in reference
to ordinary subjects,) common sense, is pre-eminent. This is a
_sine qua non_ in the physician. The most brilliant talents cannot
make one a good practitioner without this qualification. They may
make him an interesting lecturer, or writer, and may give him a
high reputation in the community. But his lack of this practical
talent must render him unsuccessful in the treatment of disease,
and the lectures which he may give will be deficient in practical
instruction, and the books which he may write will add nothing to
that storehouse of facts, which come only from observation, guided by
a discriminating judgment, and plain common sense. He may construct
beautiful theories, and explain and defend them with ingenuity, but
he never can be a reliable source of instruction and information to
his medical brethren.

The reader has seen that there are then _five_ ways of judging of
the skill and the attainments of a physician. 1st. By examining his
opinions on medical subjects, and the reasons upon which they are
based. 2d. By observing his practice, and comparing its results
with those of the practice of others. 3d. By inquiring into the
evidences of his education. 4th. By observing the unbiassed opinions
entertained of him by his medical brethren. 5th. By observing his
mental qualities as they are exhibited in relation to those subjects
which the observer himself understands.

If the inquirer be a physician, he can very properly make use of the
two first-named means of arriving at the estimate. But if he be a
non-professional observer, he must for the most part give up these
means, as being liable to lead him into error, and resort to the
remaining ones. That he should _entirely_ give up the two first means
I do not claim. All that I claim is, that he should place very little
reliance upon them, while his chief reliance should be upon the three
last.

If intelligent men would adopt the course which I have indicated, in
their attempt to estimate the professional merits of physicians, they
would for the most part avoid the errors which they now so frequently
commit. But, as it now is, they very generally form their judgment
from a direct observation of medical practice, and from the reports
which their friends and acquaintances give of their observations;
and they make but slight use of those means of judging, which I have
shown to be the least liable to error. And I fear that they will be
slow to change in this respect, for the simple reason, that they will
be slow to admit their incompetence to sit in judgment on modes of
treating disease. Dr. Beddoes, an eminent English physician, once
remarked, that “there are three things which almost every person
gives himself credit for understanding, whether he has taken any
pains to make himself master of them or not, These are: 1. The art
of mending a dull fire: 2. Politics: and 3. PHYSIC.” And this is
especially true of the last of these. Both the well informed and the
ignorant seem to think, that they are perfectly competent to decide
whether a physician is treating a case properly; and watch the effect
of remedies in order to do this, and hesitate not to express their
opinions on this point in the most positive manner. So common and
inveterate is this habit in the community, that it will be difficult
to eradicate it. And yet I think it can in some good degree be done.
Intelligent men can be made to see, by a candid exposition of the
peculiar liability there is in medical experience to mistake in
regard to the relation between cause and effect, that it requires an
extensive knowledge of medicine to make accurate observations of the
influence of remedies; and that therefore one who has never studied
this science, and who has had but limited means of observation, must
be but a poor critic on the practice of physicians. They can see
that, though such an one may cope with others in the art of mending
a dull fire, or on the subject of politics, yet on so abstruse
a subject as medicine is, he ought to be somewhat modest in his
opinions, and not put them forth, as is now so often done, with all
the authority of an oracle.

Why then, let me ask, have not intelligent men been made to look upon
this subject in this light? This question I will endeavor to answer.

There is, in the first place, a large class in the medical
profession, who desire no change in the views of the community, but
prefer to maintain their present false position. Their success, like
that of the quack, actually depends on practising upon the credulity
of the public. They would dread being scrutinized in the way which I
have pointed out, by tests which the observer himself understands.
They would prefer that people should continue to judge of them as
they have done, by tests of which they are ignorant, because they can
in this way continue to deceive them. The number of such men in our
profession, I am sorry to say, is very large; and many of them have
an extensive practice, and stand high in the public favor, and for
this reason are quite indifferent both to their own standing with
their brethren, and to the general standing of the profession itself.
Though they do nothing perhaps which is sufficient to endanger their
loss of caste among physicians, their influence is detrimental to the
interests of the profession, and favors in the worst possible way the
hold of quackery upon the community.

There is another large class of medical men, who really desire to
be honorable in their course, but who have felt themselves obliged
to use to some extent the same arts with which the dishonorable
impose upon their patients. They feel that they cannot reform
public sentiment, but must take it as it is, and do the best they
can with it. They find whims and caprices and false ideas among the
intelligent, as well as the ignorant; and instead of taking any
pains to correct the evil, they succumb to it, and set themselves to
work to make capital out of it. They thus place themselves on common
ground with the quack and the pretender, and subject themselves to
be estimated by the same false rules which are applied to them. They
thus have almost insensibly contracted habits of low cunning and
shallow pretension; and these are habits which are not easily given
up. Of course this class of medical men will be inclined to look with
distrust upon any efforts to reform the profession, and the public,
in the particulars to which I have alluded; and, though they may not
actually oppose such efforts, or may from selfish motives even make a
show of favoring them in certain quarters, they cannot be expected to
give them any active support.

There is, however, one result of the course which this class of
medical men have pursued, which seems to be opening the eyes of the
most honorable among them, and which promises to bring them out from
their false and degrading position. They find that their cunning
subservience to the false opinions of the people, has increased the
hold of those opinions upon the public mind; and, as a wide door has
thus been opened for quackery, they find that the same arts, in using
which they have been so successful, are now used quite as dexterously
by the whole herd of ignorant quacks and showy pretenders. They find
that the Homœpathist is stealing away some of their best, and, as
they thought, their most reliable patients. The Thompsonian, the
Chrono-thermalist, &c., are committing similar depredations. And of
all this they have no right to complain, because these pretenders
obtain these patients by the same artful and deceptive means, by
which these physicians at first acquired them, and by which they have
so long retained them among their patrons.

The result which I have pointed out is an accumulated result. The
community are running wild now after various systems and modes of
practice, and the public mind is all afloat, carried about by every
wind of doctrine in medicine. It is now the hey-dey of quackery of
all kinds and degrees. The causes of the great prevalence of this
evil are not temporary and recent, but they have been acting for a
long time, and we now see the accumulated result. Among the chief of
these causes is the course which has been pursued by a large portion
of the medical profession. The profession itself has given birth to
much of the quackery of the present day.

The evil of this comes upon the profession generally, but more
particularly and grievously upon the class of physicians of which I
have just been speaking. The first class which I mentioned are not
as much affected, because, being less scrupulous, they have a wider
range of arts to be used; and the mortifications to which they are
subjected in their competition with quacks are more easily borne,
because they have less of honor and conscience to trouble them in
relation to their course. While this class will be utterly opposed
to any attempts at reform, the second class of which I have spoken,
seeing their false position, and beginning to suffer some of its
vexatious results, will probably experience a sifting process,
whenever efforts at reform shall be thoroughly entered upon. The
least honorable, and those whose habits of imposition (for such they
must be termed), have become fixed, will join the first class, giving
up all scruple, and adopting in full the measures of the quack and
charlatan. But I am persuaded, that the largest portion of this class
of practitioners have so much of honor and conscience, that, whenever
a general effort shall be made to redeem the profession from its
false position before the community, they will be ready to unite in
that effort.

But this effort is not to begin in this class. There is still another
class of physicians who are to originate it. They are the men in our
profession who have always pursued an honorable course, and have
never yielded to the temptations to use the arts of empiricism,
however strong they may have been—who, though they have often seen
their brethren use such arts successfully in their competition with
them without injuring their standing in the community, have never
allowed such mortifications to induce them to swerve from the path
of honor and duty. Efforts, it is true, have been made by such
physicians to enlighten the public mind in relation to its false
estimates of professional merit; but they have been for the most part
isolated and individual efforts, and they have soon been given up for
reasons to which I have before alluded. A general and united effort
is needed, and I have no doubt that it would be successful.


FOOTNOTES:

[34] We had some years ago, says Dr. Rush in one of his lectures,
a physician in this city of sprightly talents, who was an habitual
drunkard. Soon after his death, I was called to attend a gentleman
who had been one of his constant patients. He submitted with
reluctance to my prescriptions, because they were contrary to the
modes of practice of his former physician, to whom he was so much
attached, that he declared he would rather be prescribed for by him
when drunk, than by any sober physician in the city.




CHAPTER XI.

MEANS OF REMOVING QUACKERY.


It must be obvious to any one who observes the wide influence which
quackery maintains in its various forms in the community, amid all
the efforts which are made to overthrow it, that there has as yet
been discovered no adequate remedy for this evil. It is common for
physicians to say that there is no remedy—that there is, and always
will be, a class of persons who must, from the very character of
their minds, be addicted to quackery; and that it is of no avail to
attempt to deliver them from their errors, but they must be left to
go from one delusion to another, as they choose, all their lives. If
quackery were confined to such persons, it would, I allow, be idle
to talk of any remedy. But it is not so confined. We every day see
men, who are intelligent and judicious on other subjects, perfectly
deceived and captivated with the false pretensions of empiricism. If
these individuals were ignorant, and were easily influenced by merely
plausible reasoning, or were enthusiastic, or over fond of novelty
and change, then 1 should despair of making any impression upon them.
But as this is not the case, I am led to the conclusion, that there
must be some defects in the _mode_ in which truth on the subject of
medicine has been presented to their minds; and that the sources of
error have not been so plainly revealed to their view in this, as
they have been in other fields of enquiry.

Efforts, it is true, have been made by the medical profession
to correct the tendency to empiricism, which is so rife in the
community. But I believe that it can be satisfactorily shown that
these efforts have, to a great extent, been made with wrong means,
and in a wrong direction; and that for this reason they have failed
to strike at the root of the evil.

Much reliance has been placed upon giving to the people a knowledge
of anatomy, physiology, dietetics, &c. For this purpose books have
been published, journals of health have been issued, and lectures
have been delivered. All this is very well. Valuable information
has thus been communicated. Still, it leaves the great sources of
empiricism nearly, if not quite, untouched. These are pouring forth
their destructive streams more abundantly than ever, notwithstanding
the great increase of late of popular knowledge on medical subjects.

And this is as we should expect it would be from the nature of the
case. For the knowledge, which one obtains from popular books and
lectures, of the human system as a piece of mechanism, can have but
little influence upon his notions in regard to the operation of
remedies, on that system; for the operation of remedies, for the most
part, lies beyond the mere mechanical principles of the organization,
and therefore cannot be materially elucidated by a knowledge of those
principles. For example, the knowledge, which the dyspeptic gains,
from popular instruction, of the situation and the shape of the
stomach, of the number of its coats, and of the process of digestion,
cannot enlighten him in regard to the treatment of his disease, and
will therefore not guard him against delusion on this subject. He
will be just as ready, as he was before he acquired this knowledge,
to take some patent medicine, or to resort to some boasting empiric.

None of the common popular errors can be removed by the knowledge
referred to. If a man should adopt the notion, that the blood is the
seat of all disease, and therefore that remedies relieve disease by
purifying the blood, would it be possible to dislodge that error,
simply by showing him the heart, and describing to him minutely
the circulation? The mechanical contrivances of this beautiful
and wonderful piece of machinery have manifestly no reference to
the state of the blood contained in it. How can he know, from an
examination of the heart and the arteries and the veins, whether
he is right in attributing all disease to a corrupt state of the
life-giving fluid? Or what light will this examination give him in
relation to the remedies which he supposes enter the circulation and
rectify the blood, by neutralizing whatever it contains which is bad?

I will even take a case in which one would suppose that a knowledge
of the mechanical structure of the body would be of essential
service, as an antidote to quackery. I refer to a belief in the skill
of the natural bone-setter. How often does the knowledge referred to
entirely fail to dislodge this error. You may show the believer in it
the structure of the joints, and demonstrate to him by a clearness
of proof which would satisfy him on any other subject, that it is
as necessary to understand this structure, as it is any other piece
of mechanism, in order to be skilful in detecting the nature of the
injuries which it receives, and in repairing them. And yet, he will
reply, ‘all this looks right, to be sure; but still here is the fact
that the bone-setter does set bones some how or other.’ You will
have to do something more, to convince him that his confidence is
misplaced. You must show him, how it is that the ignorant bone-setter
acquires a reputation, in spite of his ignorance, and his consequent
blunders. And this can be done by facts. In commenting on these
facts you can make use of the knowledge, which your friend may have
of anatomy, as an auxiliary in pressing your point; and it may thus
prove of great service, though it is wholly unavailing when appealed
to alone. For a full view of this subject I refer the reader to the
chapter on Natural Bone-Setters.

While a popular knowledge of anatomy and physiology has but little
influence in restraining quackery, it sometimes evidently increases
it, by giving its possessor an exalted idea of his medical acumen.
He upon whom it has had this effect is much disposed to adopt
opinions and theories on slight and plausible grounds, and in this
way is constantly led into error. The physician meets persons of
this character every day. They are always ready to talk with him,
and they seem to feel quite at home on medical subjects, and some of
them have really acquired considerable information on these subjects;
but they have built upon it a superstructure of untenable theories
and notions, and they are commonly carried about by every wind of
doctrine in medicine.

The quack aware of the prevalence of this superficial knowledge of
medicine, gathered from popular books and lectures, often makes
provision for the taste thus engendered. He hires some one, perhaps
a medical student, to prepare for him a disquisition on some of the
principles of medical science, which is to accompany the certificates
setting forth the virtues of his nostrums. This disquisition may
all be correct, though it is more commonly a mixture of truth and
fallacy, so combined, that the superficial reader does not separate
the one from the other. It answers the purpose for which it is
intended. It convinces most people who read it, that the author (whom
they suppose to be the proprietor of the medicines) really has a
great knowledge of medical science, and that, therefore, though other
patent medicines may be impositions, his cannot be. There is often in
these disquisitions page after page of physiological discussions, in
learned guise, which have no sort of bearing upon the nature of the
medicines recommended, though they do have most manifestly upon their
_sale_, as the result shows.

Let me not be understood to mean, that none but physicians ought
to know anything about the human system; nor that the knowledge of
it, which is obtained from popular books and lectures, can be of no
advantage in the warfare with empiricism. Though, when it is relied
upon as the chief, almost the only, weapon in this warfare, it is,
as you have seen, of little avail, and is often even turned against
the cause of truth and science; yet, as an _adjuvant_ to other means
in removing quackery, it may prove very valuable. What then, let us
enquire, are those other means?

I have shown in another chapter, that the principal popular errors
in medicine arise from partial views of the operations of disease
and the effects of remedies, and are false conclusions in regard to
the relation of cause and effect. These false conclusions are, as
you have seen, the basis of quackery; and therefore one of the chief
means of removing quackery is to be found in the exposure of the
fallacy of these conclusions.

But it will perhaps be said, that this has often been attempted, and
with so slight success, that there is very little encouragement for
repeating such attempts; and that it is best on the whole to let
the community find out their errors by their own experience, sad
as it sometimes is. Those who take this ground assume, that the
efforts which have been made for this object have been of a proper
character. I think it to be clear that they have ordinarily not been
so. There has been too much of ridicule and sarcasm. These are means
which are appropriate to a certain extent, as auxiliaries to sober
argument; but they never should be relied upon, as the only, or the
chief, instruments in combatting error. There has also been too much
of denunciation, and calling of hard names. There has not been, on
the other hand, enough of calm, candid and patient discussion on the
part of physicians with the well-informed, as they meet them from
day to day. To the medical man quackery appears so nonsensical, that
he has commonly no patience with those who embrace it. He does not
remember that many of his own profession have, in their reasonings
about cause and effect, committed some of the very same errors which
have engendered that quackery. Perhaps, if he looks back upon his
own course, he may find that he himself has at some time fallen
into an error, which might have led him into empiricism, if he had
been out of the profession, but which was prevented from producing
this effect upon him by that sense of dignity, which characterizes
the man of science, and by that disposition to careful scrutiny,
which the pursuit of medical science is peculiarly apt to impart.
He should therefore avoid being betrayed, by the ridiculousness of
quackery, into the utterance of harsh expressions, or into too free
an use of sarcasm. He should, on the contrary, endeavor to show any
intelligent friend, who has chanced in some way to be deluded by
empiricism, that he has been deceived, and point out to him just how
it has been done. He should show him what the mistakes are which he
has made, in relation to the connexion between cause and effect; and
should endeavor to impress upon his mind the truth, that there is
more necessity for cautious discrimination, in forming conclusions
on this, than on any other subject in the wide range of science. He
should show him how common it is in medicine, to attribute results
to causes, which have had no agency in producing them; and that if
physicians themselves are apt to commit this error, much more must
they be, who are ignorant of medical subjects, and who have but
limited means of observation.

It is this individual influence, which may thus be exerted by the
profession, that must be relied upon as one of the principal means
of ridding the public of the evils of quackery. It is not a mere
occasional effort—some address, some short article in a public
journal, some fling of biting sarcasm, or some sally of wit—that will
do it. Men of strong sense and good judgment, when they are led into
error, as such men often are on the subject of medicine, are not
to be delivered from that error by such means. Remedies of a more
searching character, and a treatment more patient, thorough, and
persevering, are required to reach their case.

It is very desirable that this individual influence be exerted by
medical men, because the class of persons to whom I have alluded,
and who may be successfully reached by it, are the chief pillars
of empiricism. It is true, I will allow, that the ignorant, the
enthusiastic, and the novelty-seeking, make up the great mass of the
patrons of quackery; but they are kept in countenance by those men
of acknowledged good sense, who are found in considerable numbers
in every community, supporting empiricism in some of its many forms
by the weight of their example. The plain unlettered man who takes
some patent medicine, is encouraged to do so by the example of some
neighbor of general repute for shrewdness and wisdom, or perhaps of
commanding talents and influence, and by the array of great names
which he sometimes sees appended to certificates. A sort of general
license is thus given to empiricism by this occasional endorsement by
men of this character.

Some other reasons, besides those already mentioned, for the want
of success in efforts for the overthrow of quackery, remain to be
noticed.

The credulity in the public mind, that gives rise to the errors
on which quackery is based, is encouraged by a similar credulity
existing, to a considerable extent, in the medical profession itself.
If the physician is seen to believe upon mere plausible evidence
one thing, his friends will feel justified in believing some other
thing resting on similar evidence. If he is not careful in sifting
evidence, he cannot expect that others around him will be. If he,
for example, give full credence to all the juggleries of animal
magnetism, and all the extravagancies of phrenology, as they are
put forth by travelling lecturers, how can he hope to dissuade an
undiscriminating public from exercising a like credulity, in regard
to the pretensions of quackery, which are not a whit more extravagant
and fallacious?

The influence of the example of physicians in sustaining empiricism
shows itself occasionally in a still more objectionable mode, than
the one just mentioned. The profession sometimes gives its sanction
to the credulity of the public, not only by indulging a similar
credulity, but by giving currency to some of the measures with which
the quack deceives a credulous community. Many physicians, and some
of them of high standing, have for various reasons given certificates
in regard to patent medicines. Some too, from the love of money, have
even ministered to the empirical tastes of the community, by getting
up some secret nostrums of their own. Such physicians either boldly
bid defiance to an indignant profession, or save themselves from
merited disgrace and expulsion, by announcing, that they are willing
to make known, to any physician who asks it, the composition of their
medicines. By this miserable artifice they comply with the letter
of our regulations, while they go directly counter to their spirit.
For, after all, the successful sale of their medicines requires the
employment of the same measures, to act upon the credulity of the
public, which are made use of by the whole herd of ignorant quacks,
and they commonly have little scruple in resorting to them.

But there is a greater evil still, beyond all this, that exists in
the medical profession, hindering it from waging successful war with
empiricism. It is the _spirit_ of quackery, actuating quite a large
proportion of the profession. It is not always manifested in palpable
shape, and in acts which can be exposed to the contempt of all
honorable men, but it exerts a concealed and yet a constant influence
upon the habits of intercourse, prompting to the use of cunning arts
in order to deceive the community, exciting an overweening desire
for reputation, with an indifference to the grounds upon which it
is based, and producing a competition among physicians that rests,
to a great extent, if not wholly, upon false issues. Where such a
spirit exists, the object is not so much to seek after truth, as it
is to make out a good case in the eyes of the public. No effort is
therefore made to correct the credulity of that public, but this is
looked upon as one of the instruments to be used for the attainment
of their selfish ends. They follow medicine as a trade, and this is
an essential part of their capital.

I need not spend time to show, that this subserviency of medical men
to the credulity of the public, is one of the worst obstacles to
the eradication of the quackery which results from this credulity.
And this mode of self-aggrandizement is an evil, which prevails in
the profession to a greater extent than is commonly supposed. It is
so covert and sly in the case of many physicians, that it is called
by their friends worldly wisdom, or perhaps even good judgment. And
the physician who adopts it, if he have much conscience, quiets it
with the consideration, that the world cannot be reformed, but we
must take it as it is; and he looks upon the honest votary of medical
science, that pursues his investigations in obedience to a love of
the truth, independent of the whims of a credulous world, as a man
who has not sense enough to look out for his own interests.

It must be obvious to my readers, that a reform is needed in the
ranks of the medical profession, to enable it to exert any commanding
influence in the removal of empiricism. Not only is its dignity
impaired, but its energies are crippled, in all its honest endeavors
for this object, by the extent to which that spirit, which I have
described, prevails among its members. It is not confined to a few
of the ignorant and grossly unprincipled, who have stolen into our
ranks; but it is seen to a greater or less degree even in some who
occupy stations of power and influence, and in quite a large portion
of the common mass of practitioners. This may be considered by some
as too strong a charge to bring against so noble a profession; but my
own observation, and that of other physicians from different parts of
our country, prove it to be a true charge.

Let then the profession be purged. Let the true spirit of
investigation animate all the members of it, instead of only a
portion of them. Let that short-sighted policy, which relies upon
the credulity of the community for success, instead of attempting
to correct it, be given up. Let all false issues be avoided. Let
reputation be sought after on true grounds, and let competition be
honorable, and therefore such as will further the cause of truth, and
promote the interests of the profession, and not sacrifice them to
mere temporary self-aggrandizement, as is now so often done.

If such could be the prevailing spirit of the profession, and if
each member of it should undertake to exert his individual influence
in the way that I have pointed out, there is no doubt that a most
effectual blow would be given at once to the domination of quackery.
The whole profession then, instead of being dispirited by the errors
and inconsistencies of a large portion of its members, as it now is,
conscious of the strength which self-respect always inspires, would
present a bold, unbroken front in its warfare with empiricism. The
community then would not, as they do now, take a license for their
own credulity and quackery from that of medical men; but the uniform
example of the profession, in its search after truth, would always
rebuke the spirit of empiricism, and prevent, in a great measure
at least, the sensible and well informed from coming under its
influence. That such a change can be produced, to a great extent at
least, I have not a doubt. But in order to accomplish it, all the
honorable and the true votaries of medical science must be aroused
to the effort, and must make common cause both against the abuses
that exist in our own ranks, and the abounding and multiform quackery
of the public. And because some of the occasional efforts which
have been put forth by individuals for this object have effected
but little, we should not therefore despair as to the success of a
general and united effort.

We would call upon the stable and well-informed in the community to
co-operate with us in effecting this change. They can render us very
material assistance. In what ways they can do this I will endeavor
very briefly to point out.

One of the most effectual means of eradicating quackery is the
promotion of a thorough education of the medical profession. The
lower the standard of education is among medical men, the greater
will be the number of ignorant pretenders who will gain admission
into their ranks, and consequently the greater will be the prevalence
of quackery in the profession, and of course in the community. This
result is the more certain to follow, because deception and imposture
are practised upon the public so much more easily in medicine,
than in regard to other subjects. And it is for this reason that
it is for the interest of the community to have a proper standard
of medical education maintained _much more even than it is for the
interest of the profession itself_. For so little are they qualified
to judge on medical subjects, and so much are they obliged to take
medical practice upon trust, that it is important for them, that
they should have all the benefit of the safeguards the requisitions
of our professional organizations throw around them. And this leads
me to say, that it is only through these organizations that a proper
education of the profession can be secured. Imperfect as they are,
and much as they fall short of accomplishing fully the object, if
they were done away, as some self-styled reformers, who hate all
‘regularism,’ desire, empiricism would abound vastly more than it
does even now, for the door then would be opened widely for the
impostures which it so easily practises upon the people.

The community are much at fault in their opinions and practices on
this subject. These organizations are lightly esteemed, and sometimes
even treated with contempt. Even those who are shrewd and judicious
in all other matters, often put the quack of a day on a level
with the accredited physician, laden with the carefully gathered
experience of years, or perhaps even above him, and welcome with
open arms the advocate of some new system for the moment high in
favor, with scarcely any regard to the inquiry, whether he has been
educated in any proper manner for the responsible post into which he
has thrust himself. Many a man of fair address, and a good share of
cunning, with but a mere smattering of medical knowledge, has dubbed
himself a physician, and, adopting Homœopathy, or some other system
just then in fashion, has imposed not only upon the ignorant, but the
intelligent and learned.

This ought not so to be. The public should, one and all, feel that
they are personally interested in upholding a well-educated medical
profession. Here is a science which is confessedly difficult above
all others, and in which, as you have seen, careless observation
is peculiarly liable to error. How important then, that those who
take charge of your health, your life, should be careful and skilful
observers. And education is obviously as much needed to form good
habits of observation in this, as it is in other sciences. But let me
say, that whenever you give countenance to quackery, whether it be in
the shape of a secret nostrum, or a fashionable system, you strike a
blow at the standard of medical education. You in effect say to the
physician, observe, watch, study as much as you will, we esteem all
your labor and experience vain. When men of wisdom and influence do
thus, as I am sorry to say they often do, it certainly casts contempt
upon education, and therefore tends to lower its standard in the
profession. For if physicians see, that they can acquire the esteem
of the public without study and labor, many will be disposed to give
them up, and take the easier path to success, into which they are
thus invited. And this is the grand reason, why so many pretenders
are found in the ranks of the medical profession.

Before I leave this topic let me correct one error, which is quite
prevalent in regard to the basis of our organizations. We are charged
with being proscriptive in regard to opinions. We are called in
vulgar cant _regulars_, and we are supposed to have ‘regular’ systems
of doctrine and practice, and to maintain a deadly hostility to
any opinion which is opposed to these systems. This may be true of
individuals, but it is not true of the great body of the profession.
We allow of the utmost latitude of belief. We have no creed, nor sets
of creeds. We thrust none out of our medical societies for opinion’s
sake. Any member may adopt any doctrine or system he pleases, however
much opposed to the opinions of the great majority—Homœopathy,
Hydropathy, or even Thompsonism. Education is the qualification
for admission to our ranks; and nothing but a gross and obstinate
infraction of our rules of intercourse, which are based upon truth
and honor and benevolence, can be made the ground of expulsion.

Another way in which the stable-minded and well-informed can
assist the medical profession, in the eradication of quackery, is
by renouncing all fallacious means of judging of the merits of
physicians, and relying upon those which I have shown to be so apt to
lead to correct conclusions. For an extended view of this subject I
refer the reader to the chapter on Popular Estimates of Physicians.
And I will only remark here, that, while the honorable practitioner
desires from his employers an _intelligent_ confidence, the quack and
the quackish physician are very willing, that the community should
continue to judge of medical men by the same false rules, which have
been so long in vogue, because they subserve so well their narrow
and selfish purposes.[35]

The sensible and influential in the community can render effectual
aid in the overthrow of quackery, by promoting the strict observance
of the rules of medical intercourse. These rules are not sufficiently
understood and appreciated by the public. If they were, those who
have influence in society would frown down the base arts of a cunning
competition, instead of encouraging them, as they now often do; and
would give no countenance to the false issues, upon which empirics
and dishonorable physicians so much depend for their success. For a
full view of this subject I refer my readers to the chapter on the
Intercourse of Physicians.

A recent movement of the medical profession in this country, if I
mistake not, is destined to exert a great and a permanent agency
in the overthrow of empiricism. I refer to the formation of the
“American Medical Association” in 1847. Although the meeting in
Boston in May last was only the _second_ annual meeting of the
Association, so fully did the profession throughout the country
respond to the call, that the number of the delegates amounted to
about four hundred and fifty. The measures which have already been
entered upon, and the spirit which has been manifested, clearly
indicate, that the great object for which the Association was formed,
“the elevation and advancement of our common calling” will be
rigorously and steadily prosecuted. The recurrence of this _festival_
of the profession from year to year, I fully believe, will be marked
by real advances in all the interests of medical science.

And now, I ask, is it too much to expect of the stable and
well-informed in the community, that they will give their countenance
to the objects at which we aim? While we are thus struggling together
to elevate the standard of medical education, and to rid our noble
profession of the abuses which impair its honor and its usefulness,
we have a right to demand of the community, which is to be especially
benefitted by these efforts, a cheerful and active support. Whether
this shall be given us, will depend upon the men of influence in
every profession and occupation in our land. It is to them that we
make our appeal, and we believe that it will not be made in vain.


FOOTNOTES:

[35] There is nothing by which the quackish practitioner is more
plainly distinguished from the honorable one, than by the mode of
competition in which he engages, and the kind of reputation at which
he aims. He resorts to tricks, and raises false issues. He boasts of
success; and, if he do it skilfully, he does not much endanger his
reputation for a proper degree of modesty. He is always finding out
something wonderful in his cases—something which it is supposed other
physicians have not acuteness enough to discern. He loves to see the
credulous, whether learned or unlearned, gaze at his wonders, and
to hear the loose tongues of gossipers busy in his praise. He aims
at a reputation for performing great cures in cases in which others
have been said to fail—_a reputation which no honorable physician
ever has, however eminent he may be, because he does not seek after
it_. Every quack seeks for it, and acquires it to a greater or less
extent. The physician can have it if he will make it his aim, but in
doing this he puts himself on a level with the quack in the common
field of empiricism.




CHAPTER XII.

INTERCOURSE OF PHYSICIANS.[36]


The object of this chapter is to notice some points in relation
to the intercourse of physicians, which the community ought to
understand, and to correct some prevalent errors, which tend to
destroy the harmony of the profession, and to impair its usefulness.

Mistaken notions are very prevalent, even among thinking and
judicious men, both in regard to the object of consultations, and the
principles by which they should be regulated. These notions sometimes
exert a very injurious influence, and the patient is deprived of the
benefit to which he has a right, from the combined wisdom of those
who consult upon his case.

What then is the main object of a consultation, is an important
inquiry.

It seems to be considered by many as the chief object of a
consultation to decide the question, whether the patient will die
or recover. We hear ignorant people talk about a ‘jury of doctors,’
and they ask ‘what they gave in,’ as if a sort of verdict was to be
pronounced of a decisive, almost a binding, character, in regard to
the result of the case. The same erroneous ideas are, to some extent,
to be found among sensible and well informed people, though they are
expressed in a different way. Let me not be understood to say, that
the question, whether the patient will probably recover, should not
come up for consideration at all. But it is certainly a gross error
to suppose, that the decision of this question is a principal object
of the consultation. It is in fact a merely incidental object, and it
is profitable only as it may have some bearing upon the treatment,
as it sometimes does, though much less often, and to a less extent,
than is commonly supposed. Sometimes, I may say often, nothing like a
decision of this question can be arrived at. Farther developments in
the progress of the case must be waited for before this can be done.

Neither is it the object of a consultation to have the physician
who is called in prescribe to the attending physician what he shall
do; though this is often considered to be the object, especially
when the consulting physician is much older than the one who is in
attendance upon the case. _Dictation_ is certainly very far from
being consultation.

Again. It should not be among the objects of the friends of the sick,
in calling a consultation, to obtain the opinion of the physician who
is called in upon the course of treatment which has been pursued.
He has nothing to do with the past, except so far as it will aid
him in discovering the true nature of the case, and in fixing upon
the course to be adopted at the present time. He steps out of his
province altogether, if he says anything to the friends in regard
to what _has_ been done. This general rule applies not only to
criticisms upon practice, but to all expressions of approbation
also. The patronizing air, with which some physicians utter their
commendations of the course, which has been pursued by the attending
practitioner, is a most flagrant insult. It generally involves an
unwarrantable and ridiculous assumption of superiority. It is a
common trick resorted to by the dishonorable, to impress upon the
by-standers an idea of their greatness.

The friends of the sick often put the consulting physician in an
awkward position, by the inquiries which they make of him in regard
to the measures which have been pursued. If he really approves of
them all, of course there is no difficulty. But suppose that he does
not—that he cannot say with truth, that if he had been called to the
case at the first he should have adopted precisely the same course.
What answer shall he make then to the inquiries put to him? Shall he
reply to them fully and frankly? By no means. It would be cruel both
to the friends of the patient and to the physician to do so. He has
no right to take such a course, unless there be gross and palpable
mal-practice, which the good of the patient and of the community
requires should be exposed. This is the only case which can justify
such a measure. Where there exists merely that difference of opinion,
which results from the various individual notions and preferences and
doctrines of physicians, all such inquiries of the friends of the
sick should not be replied to.

There are also some exceptions to the rule in its application
to expressions of approbation. If for example an older and
well-established physician, on being called in to the patient of
a junior member of the profession, sees that the propriety of the
course, which has been pursued, has been called in question by some
of the friends or by busy bodies, it is his duty to volunteer in
the defence of that course if he can conscientiously do it. Older
physicians often have such opportunities of doing essential service
to meritorious young men.

It is only such cases as I have mentioned, which form the exceptions
to the rule laid down. The general practice of remarking upon what
has been done cannot be too severely reprobated, as opening a wide
door for cunning intrigue and ungenerous insinuation. The honorable
physician desires no such privilege, but the dishonorable prize it
highly, as one of the means of inflicting their base wounds upon the
reputation of their competitors. Such physicians are ever ready to
answer the inquiries of friends and neighbors, about the previous
treatment, in every case to which they are called. They commonly
prefer to do this in a corner, rather than openly. Whenever they
see that a stab can be given to the professional character of any
competitor they do it, and often so stealthily, that it is not seen.
A word, a look, a mere movement of the head may do it, and perhaps
oftener does it than any tangible expression of opinion. An open show
of the weapon that inflicts the wound the cunning and dishonorable
physician most studiously avoids.

In this connexion I may remark, that the bandying about of the
opinions of this and that physician, in regard to different cases,
by their partizans, is one of the chief causes of the jealousies
and quarrels among the members of our profession. If the friends
of the sick would ask simply for the result of the consultation,
instead of endeavoring to obtain the opinions of each physician in
regard to the various points of the case, it would manifestly shut
out all opportunity for intrigue at such times. And it is to this
result alone that they have any right under ordinary circumstances.
When a consultation is held, it is expected that some definite
conclusion is to be arrived at, in relation to the nature of the
case, and the treatment of it. It is the result of a _deliberative_
body, no matter of how few, or how many it consists. The individual
opinions expressed in the deliberations leading to this result are
wholly confidential; and whoever reveals them without the consent
of the parties is guilty of a breach of confidence. So long as the
attending physician is alone in the case, he acts as an individual;
but when a consultation is called individual action ceases, and he is
now to act in obedience to the result of the consultation—his duty
is simply to carry out that result. He is the _executive_ of the
acts of the deliberative body. He alone is to give the directions
in the management of the case. If the consulting physician gives
any directions either voluntarily, or in answer to the inquiries of
the friends, he usurps authority which does not belong to him. His
business is simply counsel, deliberation, and not action; unless, as
in some surgical cases, he is called in for both purposes.

The chief object of consultation, which is to fix upon the best
course to be pursued in the treatment of the patient, is to be
secured by thorough and free investigation and discussion of the
different points of the case. Anything which interferes with this
mode of attaining the object has a tendency to defeat it. If, for
example, jealousy exist—if one physician feels that the other is
disposed to take advantage of anything that may occur, which can
possibly be turned to his own benefit, there can be none of that
frankness which is so essential to the accomplishment of the object
proposed. A consultation between enemies is generally a failure,
though the friends of the patient may not always know it. At the
same time, let it be remembered, that the mere fact that physicians
are competitors does not necessarily make them enemies. If the
competition be an honorable one, and neither is disposed to treat the
other in an ungentlemanly manner, there is nothing to hinder their
consultation from being free and unembarrassed.

Physicians should always be alone in a consultation.

The presence of others would prevent that freedom of discussion,
which in some cases is so necessary. For each physician, knowing that
his individual opinions will be reported by those who are present,
would be very cautious in expressing them, and there would therefore
be none of that freeness of suggestion and discussion, which is so
desirable in a consultation. And farther than this, while the honest
and high-minded physician would be simply embarrassed under such
circumstances, the selfish and unprincipled physician would, on the
other hand, express his opinions with a view to their effect upon his
own standing with those who are present, while the welfare of the
patient would be altogether a secondary object. His main object would
not be consultation based upon a rigid investigation of the case,
but an exhibition of his skill and knowledge to the non-professional
listeners.

The reasons which I have thus briefly given, are, I trust, sufficient
to show the reader the reasonableness of the rule, which excludes the
friends of the sick from the consultations of the physicians. But it
is sometimes spoken of as unreasonable, and a strict adherence to it
is considered by some as implying a want of frankness and candor.
Tattlers and busy-bodies are ready to attribute some sinister design
to this bar which is put upon their curiosity; and some physicians,
especially in the country, where there is apt to be less regard to
strict rules in medical intercourse, than in our cities, sometimes
flatter this prejudice, and assuming an air of frankness in the
expression of their opinions, adroitly throw the responsibility of
the exclusion upon some of their brethren.

The intrigues, which are practised by the cunning and dishonorable in
connexion with consultations, are very numerous. I will notice a few
of them.

Sometimes, when there is perfect agreement between physicians in
a consultation, the friends of the patient in some way get the
impression that their views of the case are really different. They
therefore sound the consulting physician on the subject. If he be
an honorable man, he will at once say that they have agreed upon
the course to be pursued, that he approves of it entirely, and that
the attending physician will carry it into effect. But if he be
unprincipled and intriguing, he will increase the impression, or even
create it if it do not already exist, that there is disagreement;
and he will do it so adroitly, that, while he will say nothing that
is tangible, he will yet excite curiosity to know his views more
fully, and feed the desire, which perhaps some partizan of his has
awakened by his representations, that he shall take charge of the
patient. If he thus gets possession of the case, as is often done, he
will perhaps adopt the very course agreed upon in consultation with
his brother physician, from whom he has filched it, and will alter
only the _form_ of the medicines, so as to give the appearance of an
actual change in the treatment.

If after a consultation the patient improves, and the change is
attributed by his friends to some particular remedy, credit is
sometimes acquired by the dishonorable physician, by producing the
impression that the remedy was suggested by himself. He makes perhaps
no distinct assertion to that effect, especially if there be no
ground for it, but in his conversations with the patient and his
friends, he throws out such hints, and manifests so much interest
and delight in speaking of the effects of the remedy, that the
desired impression is made.

When, on the other hand, a case terminates fatally, and, as often
happens, the friends of the patient are disposed to find fault,
and fix upon some remedy, or measure, as the chief cause of death,
the intriguing practitioner seeks to make capital for himself by
fastening the blame upon the physician who had the management of the
case. He does this, not by any direct and open attack upon him, for
then he would be exposed, but by slyly ministering to prejudices
which he finds awakened against him, or by exciting such prejudices
by insinuations, and remarks of so indefinite a character, that he is
effectually screened from detection.

Physicians who are called in consultation often have opportunities
of defending the reputation of the attending physician from unjust
attacks. And if they fail to make the defence when truth demands it,
they may be quite as guilty as they would be if they volunteered the
attack themselves, for they give to it their sanction; and yet, by
doing no positive act, they shield themselves from blame. Lending a
listening ear to aspersions upon the reputation of a medical brother,
negative as the act is, is under some circumstances more base, and
does more harm, than any open and bold attack.

An artifice, which is not unfrequently employed by the dishonorable
physician after being called in consultation, is this. On meeting
some friend of the patient he inquires very particularly about the
case, asks whether this or that medicine or measure has been tried,
expresses by word, or perhaps only by his manner, some surprise
at being answered in the negative, though he really has no reason
for doing so, and says that he will see the attending physician in
relation to the matter. He does not see him—he has no intention
to do so. His only object is to create dissatisfaction, or, if the
patient dies, to produce the impression, that the measures which he
alluded to were agreed upon, and ought to have been followed, and if
they had been, they perhaps would have saved the patient.

The selfish and cunning physician is apt to make comparisons between
the cases to which he is called in consultation, and some of his
own cases of the same complaint, which he speaks of as having been
very severe, though they terminated successfully. His object is to
set forth his own skill, and in doing this he commonly very much
over-estimates the severity of the disease in his own cases.

Some physicians _manifest_ a deep interest in the patients of their
brethren, and make many inquiries of their friends, in regard
to the nature of the disease, and the mode of treatment. And if
their services are requested in consultation, they are exceedingly
attentive at the time, and make some very friendly calls afterwards.
This undue attention, assuming the guise of great kindness and a
lively interest in the welfare of the patient, though a burdensome
and pains-taking trick, is nevertheless a very common one.

Sometimes a physician is called in consultation in a case which is
not of a grave character, because the friends of the patient think
that the attending physician places too low an estimate upon the
severity of the disease. If he be an honorable man, he will under
such circumstances have no hesitation as to his duty, but will at
once say, that the attending physician is right in his views of
the case, and that they are unnecessarily alarmed. The cunning and
dishonorable practitioner pursues a different course. He makes a
great show of examining the case thoroughly, asking many utterly
needless questions; and, though he may sooth the anxieties of the
family of the patient, and express the belief that he will recover,
he does it in such a way as to favor the impression, that the
attending physician was not really aware of the magnitude of the
case, but that _he_ on the other hand, has estimated it aright, and
has looked into it as it should be done.

The dishonorable physician often makes difficulty, by attempting to
hold on to the patient of another, when he has been called in a case
of emergency. His plain duty under such circumstances is to give up
the patient to the family physician when he arrives, or to request
that, for this purpose, he should be sent for, if it has not already
been done. And in all cases, in which the physician is doubtful,
whether he has been called accidentally or from choice, he should
take measures to remove the doubt. Some, in their eagerness to get
practice, make no effort to settle this question, but disregard all
the evidence which may appear against their claim to the patient;
and, taking it for granted that the case is theirs, proceed at once
to its treatment, and hang on to it till they are actually driven
from the ground. And if they have a good share of assurance, they
manage by this dishonorable course to keep possession of many cases
which rightfully belong to their more modest neighbors. For many
persons, from the fear of giving offence, are reluctant to tell
them frankly that their services are needed only for the present
emergency, and the physician of the family feels that it would be at
least awkward for him to assert his rights under such circumstances.

Sometimes a second physician is sent for to see a patient without the
knowledge of the one in attendance. This may be done from the whim of
the moment, or from the earnest recommendation of some meddler, or
from a desire to obtain the opinions of another practitioner, which,
it is perhaps thought, will be more candid and unbiassed, without
a formal consultation. A strictly honorable man, when thus called
in, declines giving any opinion at all, for he considers that he has
no right to have anything to do with the case, unless he meets the
attending physician in consultation, or the case is fully and openly
transferred to his care. Not so with the dishonorable and intriguing
physician. Such calls furnish him with opportunities for exercising
his cunning, which are too good to be lost.

It is a very common idea, that physicians are generally attached, to
a foolish degree, to the rules of etiquette in their intercourse.
Many talk as if the welfare of the sick, and sometimes even life, is
sacrificed to it. The physician is often entreated to lay it aside,
as being an obstacle in the way of his usefulness. When, for example,
he is sent for to visit the patient of another physician without his
knowledge, it is perhaps said to him, ‘we wish you to give up all
etiquette—if you can do any good to this poor sufferer, do it.’

The impression which is so common in regard to this subject is an
erroneous one. The rules of intercourse which govern the medical
profession abridge no man’s liberty. A strict adherence to them
favors freedom of intercourse, by maintaining mutual confidence;
while a disregard of them destroys this freedom, by engendering
mutual distrust. The truly honorable physician is therefore always
scrupulous in obeying them, while the dishonorable physician
prefers a lax observance, because it furnishes him with occasional
opportunities of obtaining by his manœuvres advantages over his
medical brethren.

I have thus noticed, as briefly as I could, some of the dishonorable
practices which are common among physicians, impairing the harmony
of their intercourse, and therefore limiting the usefulness of the
profession. I have done so, principally because the community do
not appreciate in any just degree the evil of these practices,
and therefore those who are guilty of them generally escape with
impunity, especially in the country, where there is no medical public
opinion to control them, as there is in the cities and larger towns.
It is well that the ‘tricks of the trade’ should be understood; and
that the public should be able to discriminate, better than it now
does, between those who are honorable practitioners, and those who
are not.

The differences, the jealousies, and the quarrels of medical men have
become proverbial. ‘Who shall decide when doctors disagree,’ is often
uttered as a reproach upon the profession, not only in regard to its
opinions but its practices also. It is manifest to every one, that a
jealous and quarrelsome spirit is more prevalent among physicians,
than it is in the other professions. The reasons for this I will
briefly notice.

These reasons are to be found in the peculiar circumstances which
attend the relations of physicians to each other, and the community.

As the reader has already seen, the public have, for the most part
at least, no _direct_ means of judging of the correctness of a
physician’s practice, for the whole science of medicine is to them a
mystery. He can commit the most gross and fatal errors, even while
his patients and their friends may be reposing the most unlimited
confidence in his skill and wisdom. His professional intercourse with
them is indeed wholly a matter of confidence. The positions advanced
by the lawyer can commonly be correctly appreciated by ordinary
intelligence; the doctrines proclaimed by the clergyman it is the
privilege and the duty of every man to examine by the light of the
Bible; but the prescriptions of the physician must for the most part
be taken upon trust. There is great room therefore for imposition;
and the more, because with all this ignorance of medicine, most
people are apt to think that they have no inconsiderable amount of
knowledge on this subject.

It is in this facility with which deception can be practiced upon the
community, that we find the principal circumstance that fosters the
jealousies, the disagreements, and the bickerings which disgrace the
medical profession. For it is this facility which tempts to the use
of all those arts and manœuvres, that are so common among physicians.
If the practice of these were confined to empirics, and to physicians
who have an established character as dishonorable and intriguing
men, the evil would by no means be as great as it now is. But it is
not thus confined. The facility for deception is so great, and the
temptations to turn it to profit are so many and constant, that many
physicians, who are in the main honorable, occasionally yield to the
temptation. This of course begets to some extent a general distrust,
and then circumstances from time to time produce jealousy, perhaps
disagreement and strife.

This state of things is promoted by the peculiar relations which
the physician sustains to his employers. They are generally his
warm friends, and are ready to act with zeal in his favor, and to
recommend him earnestly to those upon whom they have any influence.
The attachment of families to their physician is somewhat peculiar,
differing essentially from the preferences which are felt in regard
to other professional men. The result is, that each physician has
a party in the community composed of all classes and ages, and a
large portion of that party are active in urging his claims. This
of itself so affects the competition in which he is engaged with
his brethren, that it is apt to awaken distrust and jealousy. And
besides, interferences are sometimes practised which aggravate the
difficulty. Some attribute most of the strifes of physicians to these
interferences; and assert that if their friends would let them alone,
there would generally be no want of harmony among them. Though there
is some truth in this remark, yet it is certain that physicians are
often the prompters of these interferences. Some physicians always
have a troop of busy-bodies trumpeting their fame. They have a tact
in drawing such persons into their train, and they do it by precisely
the same means by which the quack accomplishes the same object. The
quack and the quackish physician are alike in this respect. The
prompting influence, thus exerted, may not always be obvious, and
sometimes is least so when it is the most effectual. The old adage,
that the highest evidence of art is in the concealment of art, is
applicable here.

The disposition to jealousy and strife in the medical profession
is also promoted by the associations which are sometimes formed by
physicians with each other, or with the community, for the sake
of furthering their own selfish ends. Professional cliques on the
one hand, and alliances with various societies, social, moral or
religious, on the other, when relied upon as means of advancing one’s
professional interests, are always inimical to the harmony of medical
men. They render competition unfair and dishonorable and therefore
contentious. The physician who calls to his aid the influence of a
sect, or a party, or an association of any sort, in so doing not
only places himself in an attitude to awaken distrust, but subjects
himself in maintaining the alliance to a necessity for employing
means of self-aggrandisement, which will conflict with the rights of
others, and will therefore involve himself in either a secret, or an
open warfare with his brethren.

It is peculiarly true of the physician, that he will always find
it for his interest and especially for his comfort, to obey the
injunction of the Apostle, ‘If it be possible, as much as lieth in
you live peaceably with all men.’ Sometimes it is hardly ‘possible’
even for the strictly honest and honorable to do so. It is sometimes
difficult to restrain the outburst of an honest indignation provoked
by the base tricks of physicians, who, in spite of such tricks, hold
an honorable position before the community. But it is best to do
it, if ‘possible.’ For even if the act complained of be clearly and
palpably a disgraceful one, the public, with their present ideas
of the rules of medical intercourse, will not generally appreciate
the true merits of the case. The friends of the physician who has
committed the act will be disposed to think him right; and those
who feel indifferent to the matter, will turn it off with the old
remark, ‘two of a trade cannot agree,’ as if that settled it. If one
who has been injured by a competitor manifest any sensitiveness,
and is earnest in denouncing the act, he will generally make the
matter worse for himself. And if his opponent keep still, and utter
the little which he does say very slily, he will be sure to gain an
advantage over his more honest, but less cunning, neighbor. It is
especially true of the medical profession, that one gives dignity to
a dishonorable opponent by stooping to quarrel with him. The artful
often endeavor to provoke the honorable to strife, managing at the
same time to produce the impression upon the public mind, that they
themselves have no disposition to quarrel. The best course therefore,
commonly is, to avoid as much as possible, and in a very quiet
way, having any intercourse with the artful and intriguing in the
profession.

I have spoken of the interferences of the friends of physicians as
occasioning jealousy and contention in the profession. It is proper
to remark that such interferences ought to produce no ill feeling,
unless they are prompted or justified by physicians themselves.
No physician should be held responsible for all the injudicious
or mischievous acts, which may be done by over-zealous patrons
in his behalf. I would also remark in this connection, that the
representations which are made by the friends of physicians in regard
to the acts or sayings of their competitors, which are so apt to
excite ill feeling, and foment so many quarrels, are very often to
be received with many grains of allowance, and sometimes are wholly
false.

When the medical man has arrived at that period of life, when, from
the amount of his experience through a long practice, he will be
called upon often by younger physicians in consultation, he may
stand in a very enviable position. He _may_, I say, for it depends
altogether upon those habits of intercourse which he has cultivated
from the beginning. If he has been governed by wrong principles
in his competition with his brethren, and has treated them in an
ungentlemanly manner, mutual distrust and jealousy will mark the
intercourse between him and younger physicians, and his situation
will be far from being a desirable one. His standing with the
community may give him the power of extracting from them the show of
respect, and some of them may be attached to him as partizans, from
mere motives of policy, but he cannot obtain from them a true respect
and attachment. It is melancholy sometimes to see the intriguing
practitioner, tottering on the brink of the grave, as busy as ever
with his petty arts in filching whatever he can get of credit, or
respect, or advantage, in his competition with his medical brethren.

If, on the other hand, the physician has been governed by honorable
principles in his intercourse, when he acquires the eminence which
the fact of having had a long and thorough experience gives him, the
respect of his younger brethren is cheerfully accorded to him, and
his declining years are made happy, being free from the strifes and
jealousies which so often disgrace our profession.

In concluding this chapter I remark, that neither controversy
in regard to opinions, nor competition in practice, necessarily
implies contention. Though the controversy may be earnest, and the
competition active, so long as the former is honest and candid, and
the latter is honorable, they will not impair the harmony of the
profession, and they will greatly promote the cause of truth, and the
interests of medical science.


FOOTNOTES:

[36] I have placed in the Appendix the Code of Medical Ethics adopted
by the American Medical Association, in which the reader will find
concisely stated the rules and principles, which I have endeavored to
illustrate in this and in some of the other chapters of this work.




CHAPTER XIII.

INTERFERENCE WITH PHYSICIANS.


Great latitude is allowed by the community in interfering with the
practice of physicians. It is the object of this chapter to point out
some of the ways in which this interference is exercised, and some of
the injurious consequences which result from it.

Sometimes the confidence which one feels in his own physician leads
him to put a low estimate upon the merits of other physicians and
to attempt to destroy the hold which they have upon the confidence
of their employers. Though this is very common, it is a most
unjustifiable interference. While it is right that every one should
be attached to the physician who has done well for him and his
family in their sickness, this furnishes no ground for disparaging
the physician to whom another is attached, perhaps for just as good
reasons. He may sincerely believe that his friend has misplaced
his confidence. But let him ask himself, am I sure—do I _know_,
that it is so? Have I the data on which I can properly base such an
opinion? Am I competent to judge of the comparative merits of the
two physicians from observing their practice? If every one, who is
tempted by a mere preference, or by pride of opinion to practice the
interference referred to, should put to himself such questions as
these, he would at least be less positive in his opinions, and less
zealous in his efforts to unsettle the confidence of others in the
physicians whom they employ.

Let me not be understood to mean that interference is proper in no
case whatever. There are cases, in which it is not only allowable,
but it is even an imperative duty. If you see a friend confiding in
a quack, or an unskilful and ignorant practitioner, it is your duty
to persuade him to relinquish such a misplaced confidence. But you
must remember that the evidence upon which you act should be clear
and satisfactory, and that no mere preference can justify such an
interference, however strong that preference may be. So also, if you
have a friend, who trusts his own life and that of his family in the
hands of an intemperate practitioner, it is a case which calls loudly
for the warnings of friendship. But in this case, you must have
better evidence of the fact, upon which your advice is based, than
mere suspicion, or vague reports.

Some of those, who are fond of practising the interference under
consideration, hesitate not to make the most severe and reckless
attacks upon the professional reputation of physicians. Indeed, such
attacks are quite common in all circles. Though the non-professional
observer, as you have seen, is not capable of estimating correctly
the results of medical practice, many are in the habit of expressing
their opinions upon this subject freely, and sometimes very harshly,
especially when any case comes to a fatal issue. In such a case the
busy partizans of other physicians are ready to cast blame upon the
practitioner who has attended upon it, though all they may know in
relation to it may be the idle rumors which come from gossiping
tongues. The interests of the physician are often seriously injured
by the reckless opinions thus expressed by men, who, though wholly
incompetent to judge in such matters, from their wealth and standing
have considerable influence.

The professional reputation of medical men seems to be considered by
common consent as fair game for the shafts of all, whether high or
low, learned or unlearned. Although the charge of mal-practice is
a serious charge, especially when it has relation to the death of
a patient, it is exceedingly common to hear this charge put forth
without any hesitation, and in the most positive manner. So common is
it, that it awakens but little feeling; and, though it be a shameful
enormity, it seldom meets with any rebuke. A very severe rebuke
was once administered by a judge in Massachusetts to a lawyer, for
hinting at the charge of mal-practice against a physician, who was
one of the parties in a case before the Court. The insinuation was
intended as a sort of make-weight for the advantage of his client.
The judge at once inquired of the lawyer, if he intended to make
that a point, giving him to understand, that if he did, he would be
expected to produce evidence bearing upon it. The lawyer said that he
did not. ‘You will withdraw that point then,’ said the judge, ‘and
indulge in no farther remarks upon it.’ Very soon, however, he made
the same insinuation again. The judge interrupted him, and remarked,
that, as a professional man’s reputation was of the highest value to
him, and was even the means of his livelihood, he would not suffer
it to be wantonly attacked in any case; and he told the lawyer,
that, as he had twice brought the charge of mal-practice against
this physician, he should not permit him to go on with his plea,
till he had withdrawn it in _writing_. It would be well if the same
regard for the value of professional reputation were felt by all our
judges, and by all the wise and influential in the community.

Let me not be understood to claim, that the merits of physicians
should not be canvassed at all by the community. There should be
freedom of opinion upon this subject; and, when it will accomplish
any good purpose, there should be freedom also in expressing that
opinion. But the opinions of those who are ignorant of the subjects
to which they relate, and who are not in possession of the facts
in the case, ought at least to be uttered with some degree of
modesty, and a mere blind preference is no justification of the bold
opinionating, and the busy interference, which are so common with the
train of zealous partizans, which some physicians draw after them.

Some in their zeal carry their interference even into the chamber
of the sick, and disturb its quiet with debates in regard to the
propriety of the practice which is pursued. To say nothing of the
evil resulting from the excitement thus produced, the influence of
the physician over the mind of the patient, which, as you will see in
another chapter, is sometimes of great importance, is often destroyed
in this way. Hope is as real a cordial to the sick as any restorative
medicine that can be given. And the meddler, who attempts to destroy
the confidence of a patient in his physician, and thus take from him
the hope that he will be relieved by his skill, does as cruel an act
as if he entered the sick room and snatched from the very lips of the
enfeebled, languishing, and perhaps dying man, the cordial draught
which was to revive him.

Some are zealous in their recommendation of medicines to the sick,
and perhaps even urge the patient to take them without the knowledge
of the attending physician. Such meddlers have no scruples in
regard to this interference with the physician’s course, so long
as the responsibility of the case remains upon his hands; but the
moment that it is proposed to them to take the responsibility upon
themselves, they shrink from it, notwithstanding the confidence and
earnestness with which they urge the use of their favorite remedies.

It is amusing to see what various, and even opposite measures are
recommended by different persons in the same case. The friends of a
patient, who are anxious that everything should be done to save a
life so valuable and dear to them, are often perplexed and troubled
by the great variety of remedies urged upon them, and the plausible
reasons, and the asserted cures, upon which these recommendations
are based. And not a little firmness is required to resist the
importunity of these meddlers, especially as it is often prompted
by undoubted kindness. But the welfare of the patient demands it,
and no fear of giving offence should hinder from pursuing the proper
course. The adequate remedy in such circumstances is to thank such
meddlers for their kindness, and tell them that the measures which
they recommend shall be mentioned to the physician, and, if he thinks
proper, they shall be used.

Some are disposed to restrict physicians in regard to the medicines
which they shall give. While the practitioner should avoid a useless
war with the notions and caprices of his employers, and should
sometimes even yield to them in unessential matters, it is ordinarily
not only compromising his own dignity and independence, but is
doing an absolute injury to the patient, to make any concessions on
this point. The omission of some remedy or measure, in obedience
to prejudice, may prove very injurious, and even in some cases
fatal. As a general rule, therefore, the physician should claim
his right to pursue his own course, independent and untrammeled.
He, and he alone, is responsible for the proper management of the
case before him, and his rights are certainly commensurate with his
responsibility, and should not be interfered with. But those who make
medicine a trade, and who care more for popularity and patronage
than they do for the interests of science, or the welfare of the
sick, often submit, as a matter of policy, to this interference with
their rights. They will do anything to satisfy their employers. They
will, for example, pursue the homœopathic mode of practice, if it be
desired, and stoop to the farce of infinitesimal globules. They must
despise themselves for so doing, and deserve to be despised by others.

The frequency of a physician’s visits[37] should for the most part
be left to his own judgment; for if he is not to be trusted in
relation to this matter, he had better be dismissed, and another
employed in his place. The conscientious physician is often much
embarrassed by the complaints of his patients on this point. Some
complain that his visits are too frequent, and others that they
are not enough so. The attendance of the physician is sometimes
discontinued too soon for the welfare of the patient, from motives of
delicacy, where this fault-finding is practised. And, on the other
hand, the extreme frequency of visits, which is sometimes required
of the practitioner, especially by the wealthy, is in many cases
injurious. For example, it may impair the mental influence, which it
is important that the physician should maintain over his patient, or
it may impose upon him almost a necessity to use too much medication,
or to make too frequent changes in his course of practice in the case.

I trust that it is now clear to the reader, that all interferences
with the practice of the physician are inconsistent with the best
management of the sick. They repress that freedom of thought and
action, which is an essential element of success in the treatment of
disease, as well as in everything else. Even when no interference is
intended, the anxiety of friends is sometimes the cause of so much
embarrassment to the physician, as to be detrimental to the welfare
of the patient. And there is no doubt, that, in spite of all the care
that is lavished by numerous friends upon the sick in the higher
walks of life, they are often, from the cause above alluded to,
treated with less skill and judgment than the miserably attended sick
in the cheerless habitations of the poor. This may appear at first
though rather paradoxical to the reader; but let us examine this
point, and you will easily see the reasonableness of the assertion.

I will suppose a case. A lady is sick under the care of her
physician. Her husband and friends are exceedingly anxious in regard
to the result of the case. They have many inquiries to make of the
physician about her symptoms, his fears and hopes, the operation
of medicines, &c. They ask him, perhaps, if he is not afraid that
such a remedy will produce such an effect, and such an one such an
effect; and they may even go so far as to attribute some unfavorable
symptom to some medicine that has been administered. There are
few physicians who are so independent, that they will not feel
themselves embarrassed under such circumstances. The responsibility
of an important case in itself occasions sufficient embarrassment,
without adding to it by such a course. Napoleon, that shrewd observer
of men, saw this in the case of his wife, and governed himself
accordingly. He saw that there was danger, and that the physician was
in a measure paralyzed by his sense of his responsibility. Instead of
talking with him about the difficulties of the case, and expressing
his apprehensions, he immediately said to him, “she is but a woman:
forget that she is an empress, and treat her as you would the wife
of a citizen of the Rue St. Denis.” This restored confidence to the
physician; and his treatment of his royal patient was successful,
when perhaps a timid course would have been fatal to her.

Let me not be understood, that I would have the friends of a patient
make no inquiries at all of the physician in relation to the case.
His intercourse with them should be candid and free, and the
intelligent and honorable physician wishes it to be so. All that
I claim is, that the practitioner should not be _harrassed_ with
inquiries, and especially with such scrutiny, and such expressions of
doubt as to the effect of remedies, as shall indicate their lack of
confidence in the treatment, and therefore tend to destroy his own
confidence in it. The physician knows, and for the most part should
be left to judge, how much ought to be communicated to the friends of
a patient in relation to his case.

Neither let me be understood to mean, that physicians are afraid
to have their practice watched and scanned. Every honorable and
intelligent practitioner is willing that his treatment of any case
be scanned most thoroughly, but he would prefer that it should be
done by _skilful_ eyes. The friends of the patient should always
remember, that they have not sufficient knowledge of the human
system, and of the effects of agents upon it, to appreciate properly
the workings of disease, and the operation of remedies; and they
should therefore be careful not to put themselves in the attitude of
_clinical_ critics—a station for which none but a physician is really
fitted. The physician himself is in constant danger of making wrong
inferences, on account of the complicated character of the system,
and the various circumstances which therefore modify the operation
of agents brought to bear upon it—even he, prepared as he is by
study and well-weighed experience to observe accurately, is obliged
to sift well the evidence in regard to the effects of remedies, in
order to avoid mistake in his conclusions. How much more then should
_they_ be cautious in the inferences which they draw, who have never
studied the human frame, and who have had but little experience of
the treatment of disease. And yet many make no scruple in forming the
most decided opinions of the practice of physicians, in every case of
which they have any knowledge, however limited, and in proclaiming
those opinions with all the authority of an oracle. The practitioner
is sometimes so much harrassed by these meddlers that he is in danger
of mixing up with the measures of his practice expedients to satisfy
or foil their officiousness—a compound which brings no benefit to
the patient. The attention and the skill of the physician should
be _concentrated_ upon one object—the proper treatment of the case
before him. And the expenditure of his ingenuity, in using feints
and practising concealments, to avoid a collision with the whims and
prejudices of by-standers, impairs this concentration to the injury
of the patient, and that sometimes a _fatal_ injury.

The influence of scrutiny in impairing the skilfulness of action is
seen on other subjects, as well as in the practice of medicine. The
eloquent clergyman, who would ordinarily carry his audience along
with him, while he is aiming with clear mind and zealous heart to
attain the _one_ great object of his preaching, the impression of the
truth upon the conscience would fail to produce the same effect upon
an audience of _critics_. For, to say nothing of the embarrassment
which the very idea of criticism occasions, his attention would be
distracted by supposed criticisms, which would suggest themselves
to his mind while he is speaking; and that concentration of mental
and moral energies upon one object, which is essential to true
eloquence, would be wanting. To be eloquent before such an audience,
he must either disarm their criticism, or he must forget that they
are critics, and look upon them only as men whose minds are to be
impressed and whose feelings are to be moved by the truth.

Take another illustration of quite a different character. A noted
juggler perceived, at the commencement of his performance, that
he was very narrowly watched by a gentleman whom he knew at once
to be a very acute observer. He was embarrassed, as I have seen a
practicer of the juggleries of animal magnetism embarrassed by a
similar cause, and he felt that he could not practice his deceptions
with so free and easy a hand, as he could if he were not watched by
so an intelligent an eye. The consciousness of being thus watched
distracted his mind, and prevented him from concentrating its
energies upon one object. The juggler immediately gave this gentleman
a piece of money, telling him that he must look out or he would get
it away from him in the course of the evening. At the conclusion of
the exhibition the gentleman said to the juggler, ‘well, sir, here
is your money—you see that I have kept it safely.’ ‘Yes,’ replied
he, ‘and I meant that you should, for I chose that you should have
something else to watch besides me.’

The case of the physician, whose practice is scrutinized by
by-standers, is worse even than that of the criticized clergyman, or
the watched juggler. For the criticism to which he is subjected is
not skilful, and is therefore not capable of appreciating the merit
of the measures which he employs. In the case of the clergyman, the
analogy would be more correct if his audience were illiterate, and
his subject were one of an abstruse and metaphysical character. Their
criticism would then bear a strong resemblance to that to which the
practice of the physician is often made to submit. If the physician
investigate the case before him, thoroughly and scientifically, the
reasonings upon which his treatment is based are often as much beyond
the knowledge of those who have not been instructed in the science
of medicine, as a strictly metaphysical argument is beyond the
knowledge, and therefore the criticism, of a plain unlearned audience.

A similar defect can be pointed out in the analogy of the case of
the juggler. However much he felt embarrassed by the keen eye which
he was conscious was watching him, he knew that if the way in which
his feats were performed was discovered, his skill would nevertheless
be appreciated and admired. The physician, as you have seen, has no
consolation of this kind. He knows that those who watch him have
generally so little knowledge of disease, and of its treatment, that
they cannot estimate with any correctness the skill with which he
meets the various phases presented by disease, with its numerous and
changing complications; and yet they are quite confident that they
are exactly right in their judgment on such points. He is watched by
ignorance, and ignorance, too, believing itself to be wise.

And farther, as the clergyman, if he be one, who, instead of
possessing true eloquence, is skilled in the mere tricks of oratory,
would prefer an ignorant and indiscriminating audience, and fears
one of an opposite character; and as a bungling juggler had rather
be watched by unskilful than skilful eyes; so the ignorant and
dishonorable physician is more at home, when the eyes of the
multitude are fixed upon him, than when he is under the scrutiny of
his medical brethren. And as many, who are incapable of being real
orators, study most faithfully the tricks of oratory, and so far
succeed as to deceive the superficial and the ignorant, so there is
many a physician, who, instead of bestowing all his energies upon
the management of disease, wastes them in learning the tricks of the
charlatan, which will enable him, like the mock orator, to make a
show of skill and acquire the reputation of possessing it with the
multitude. This he can do with more certainty than the pretender
in oratory, because he deals with subjects on which most men are
profoundly ignorant, and yet think themselves to be very wise. It is
for this reason, that the quackish physician, in common with the open
quack, addresses all his appeals to the multitude, and brings all
his arts to bear upon the one point of making such false displays as
will impress upon their minds the idea that he has uncommon knowledge
and skill. He therefore loves their credulous gaze, while he hates
the intelligent scrutiny of his brethren. There is no one thing, in
which the difference between the empirical and dishonorable physician
and the high-minded and truly skilful practitioner is more strongly
marked than in this.

The practice, then, of interfering with physicians in the
performance of their duties, which is so common in every community,
impairs their usefulness, not only directly, by embarrassing them
in their treatment of the sick, but also indirectly, by encouraging
the intrigues and manœuvres of the dishonorable in our profession.
We have no hope of persuading busy-bodies to abandon a practice of
which they are so fond; but we have a right to expect, that the wise
and good, who are so often betrayed into it by zeal for some favorite
physician, or remedy, or by a generous kindness, or an urgent anxiety
for the patient, will, upon seeing their error, renounce it, and
pursue in future such a course as will secure to the sick the best
efforts of the physician in their behalf.


FOOTNOTES:

[37] Though the plan of charging so much a visit, so universally
adopted by the profession, is on the whole the best general plan
of regulating the prices of the physician’s services, it is liable
to some abuses. Some variations from it must of course be allowed;
and in making these a door is opened for manœuvering on the part of
dishonorable practitioners. It is a very common ‘trick of the trade’
to make more visits than are necessary, perhaps quite short ones, and
then charge less per visit than is usually charged by medical men in
the same neighborhood. In this way the credit of being both a very
cheap and a very attentive physician is most unjustly obtained.




CHAPTER XIV.

THE MUTUAL INFLUENCE OF MIND AND BODY IN DISEASE.[38]


Many seem to think that when the body is sick, it is simply a
sickness of the body alone, and the mind has nothing to do with it.
They do indeed allow that when actual mental derangement occurs in
connection with any disease the mind is affected with the body; but
they are prone to lose sight of the fact in all ordinary cases of
disease, and yet it exists in these as really, though not to the same
degree. The influence of disease upon the mind is obvious to the
most careless and superficial observer, when he sees the delirium
produced by inflammation of the brain; but such cases seem to him
to stand out as glaring exceptions to what he considers the great
general fact—that the mind is independent of the ailments of the
body. Physicians themselves too often overlook the influence of mind
in their treatment of disease, and the community generally have very
inadequate views of its extent and universality. There can not be
any sickness of the body, however slight, that does not produce some
effect upon the mind, and which is not influenced either for good or
for ill through mental impressions.

It is important in the management of the sick, not only that this
fact should be kept clearly and steadily in view by the physician;
but that it should be understood by the community, so that the
efforts of the physician may not be thwarted, as they often are, by
the attendants and friends of the sick, when he aims to act upon
bodily disease by impressions made on the mind. And I refer not in
this remark merely to impressions of this kind where the attempt to
produce them is so palpable that the most careless observer would
perceive it, but to all those influences which the physician is
exerting upon the minds of the sick, in his daily intercourse with
them. In truth, everything that he says and does in the sick room, is
to be regarded as really a medicine, and producing as real if not as
manifest effects upon the state of the patient, as any of the drugs
that he administers.

It will be profitable, then, to the general reader, as well as to the
medical man, to examine the influences which the mind and the body
exert upon each other in sickness, the use which can be made of such
influences in the cure of disease, and the abuse to which they are
liable from the mismanagement of those who have the care of the sick.

Before doing this, however, it may be both interesting and profitable
to look at the connection which exists between the body and the mind.
There are various figures used to illustrate this connection. The
most common one is that in which the mind is spoken of as dwelling
in the body as a habitation. In a certain sense this is true. This
tabernacle of flesh, as the Bible aptly terms it, is, in its present
state a habitation, which the mind is to leave in a short time, to
return to it, however, at length, rebuilt and refitted in a more
glorious, an incorruptible form, to dwell in it then forever. But
this illustration of the mysterious connection of the mind with
the body is but a _partial_ one—it does not express the extent nor
the intimacy of that connection. The mind is not a mere dweller put
into this habitation. Its union with it is not thus loose and easily
severed. It is bound to its every nerve and fibre, so that the least
touch of the body at any point affects the mind. Instead of being
put into the body, it has, being thus interlaced, as we may say,
fibre with fibre, grown with its growth, and strengthened with its
strength. In the feebleness of infancy the mind is just as feeble as
the body, and they both grow together up to the vigor and firmness
of manhood, and both decline together in old age. So close is their
union through all the stages of life, and so equally is each affected
by the joys and sufferings of the other, that we might justly
conclude that at death, when the tabernacle crumbles into dust, the
mind falls with it never to rise again, had not a divine revelation
told us that, indissoluble as this connection appears during life,
almighty power will dissever it and release the soul from the
thousand ties that bind it to its habitation at the very moment of
its destruction. Were it not for this assurance of our immortality,
we could look forward in the uncertain future to nothing but blank,
drear annihilation, as awaiting our minds, just as it does the minds
of the brutes that perish.

In our carefulness to avoid materialism, we are too apt to look upon
the mind and the body as two separate and independent things. At
death they do indeed become so, but who of us knows that they would,
were it not for the fiat of the Almighty? Who knows that there is not
a necessity for the putting forth of his power in each individual
case at the time of death, to prevent the mind of man from dying
with his body, just as the mind of the brute does with his? The very
prevalent notion that the mind is _essentially_ indestructible,
and that it is put into the body as a separate thing, having the
power _of itself_ to leave the body whenever it dies, rests on no
substantial proof. That it is _destined_ thus to leave the body is
quite another thing.

Materialists, of whom we are pained to say there are many among
believers in phrenology, though they flatly deny it,[39] seem to
think that the brain produces thought pretty much as the liver
makes bile or the stomach gastric juice. This doctrine would be
_gratuitous_, a mere supposition, even if there were no Christian
revelation to contradict it. But while we discard all such
anti-Christian and absurd fantasies, we must not run to the other
extreme, as some good men have done. It must be admitted, that in
this life all the _manifestations_ of mind are not only connected
with, but are _dependent_ upon, a material organization. The nature
of this connection and dependence is of course a mystery, but of its
existence there is no doubt. So far as injury is done to the brain
and nervous system, just so far are the manifestations or actions
of the mind impaired. And, on the other hand, moral causes, acting
_directly_ upon the mind, affect through it the organization. And
when insanity results from moral causes thus acting, it is not a
direct effect, but an _indirect_ one—the organization affected by
the mind is thrown into a diseased state, and reacts upon the mind,
influencing its manifestations. If the mind thus acted upon were
a spirit, separated from the body, the result would be merely the
feelings, which the motives applied would _naturally_ produce, and
not the unnatural feelings of insanity. It is not strictly proper
then to speak of a ‘mind diseased.’

Let me not be understood to mean that mental derangement in every
case is to be attributed to disease that leaves such palpable traces
that the dissecting knife would reveal it if death were to take
place. There are diseased operations in the body, that are hidden
from our view—so hidden, that they not only leave no traces, but
often develop no characteristic bodily symptoms.

Although the principles above stated are often overlooked, and
sometimes doubted, or even denied, there are some cases in which they
stand out so plainly, that everybody acknowledges for the time their
truth. For example, if a man, by a blow on his head, has a piece
of his skull pressed inward upon his brain, he becomes senseless,
and, if he arouse at all from his stupor, his mind is obviously in
an unnatural state. The surgeon raises the depressed bone, and thus
taking off the pressure from the brain, restores the mind of the man
to activity and sanity. In this case it is plain to every one, that
the mental manifestations were suspended by a cause acting directly
upon the material organization, and that they were revived again by
the removal of this cause.

Take another example. A man of strong and clear mind becomes
deranged, and at length arrives at perfect idiocy. He goes down to
the grave in this condition. No one supposes that in such a case the
mind is affected independently of the body, but the mental state is
of course attributed to bodily disease; and affection fondly, and we
may say rationally, cherishes the expectation, that when the mind
shall be freed from this tabernacle of flesh, it will emerge from
its long night of darkness, and possess again its faculties in full,
just as the man who lies senseless from pressure upon the brain, is
restored to mental activity when that pressure is taken off by the
trephine and elevator of the surgeon.

Now what is true of the cases that we have cited is true in every
case—all mental aberration, however slight it may be, results from
the connection of the mind with the body, and would not occur without
this connection. It is the product of some impression made upon
the material organization, either directly, or indirectly through
the mind. This impression may be momentary and evanescent, or it
may produce a real change of structure. It would be interesting to
enlarge upon these points, but it is not necessary for our purpose.

We speak of the brain as the seat of the mind, or soul. If we mean
by this simply, that this is the great central organ of that system
in the body (the nervous system) through which the mind acts upon
external things, and is acted upon by them, it is correct so to
speak. But if we mean to localize the mind, as sitting there, and
especially if we fix upon some one part of the brain, as Descartes
did upon the pineal gland (a body smaller than a pea) as the seat,
the throne of the mind, the illustration is an erroneous one. The
mind acts upon the whole body, through all the parts of the nervous
system, and each portion of that system has its own peculiar offices
to perform in obedience to the mind. This is as true of the brain as
it is of the rest of the nervous system. This organ is a complex one,
and the different parts have their different offices. This we know
in regard to some of these parts, and we can justly presume it in
regard to others. And we do this without adopting the fanciful ideas
of phrenologists in locating the different faculties of the mind.

While the brain is the great central organ of the nervous system,
by which the mind imparts and receives impressions, there are other
parts of that same system which seem to bear some other relation
to the mind than that by which they transmit these impressions to
and from the mind through the brain, as the nerves ordinarily do.
They seem to have a connection with the mind independent of the
direct agency of the brain, and for aught we know they have such
a connection. When the mind is affected by any passion, either of
the cheerful or the depressing kind, its sensible effects upon the
body are not observable chiefly in the brain, but in the region of
the heart and the other organs adjacent to it. The thrill of joy is
felt there, and grief produces there its sensation of oppression,
prompting the occasional sigh to relieve it.

Such facts as these led an eminent French physiologist, Bichat, to
adopt the theory, that while the intellectual functions have their
seat in the brain, the moral sentiments have theirs in the ganglionic
system of nerves, (as it is called,) which has certain great nervous
centres in the region of the heart, stomach, &c.

I will not stop to expose the fallacy of this plausible theory. It
is sufficient for my purpose simply to advert to the fact, that the
moral sentiments of the mind or soul are manifested more in that part
of the body than in the brain. The very language of the affections,
and the gestures which accompany the utterance of that language,
or supply its place when feeling is too big for utterance, are in
consonance with this fact. We speak of the heart, and we place the
hand upon the heart when the moral sentiments are in lively action.
And when feeling is so great as to be overpowering, or when the
attempt is made to suppress it, there is with the load which is felt
at the heart, a sensation of choking, (no word expresses it so well
as this homely one,) preventing utterance; and then when it finds
vent, it seems as if there was a gushing forth from the heart, not
merely figuratively, but from the material heart that is throbbing in
our bosoms.

The fact which I have been illustrating shows the force of such
expressions in the Bible as ‘bowels of compassion,’ ‘bowels did
yearn,’ &c. It throws some light also on the influence of grief
upon the stomach, and on the depression of spirits which so sorely
afflicts the dyspeptic.

It gives but a faint idea, then, of the all-pervading connection
of the mind with the body, to suppose the mind to be locked up in
some chamber of the brain, there receiving by the nerves messages
from every quarter, and sending forth messages in return by the same
media. There is no evidence of the existence of one great central
point of attachment for the mind, but the ties of its connection
with the body are multiplied and diffused. It is not merely,
therefore, positive disease existing in the brain that affects the
mind. Disorder of mind is infinitely modified by the different seats
and modes of disease in different portions of the nervous system,
as well as in different parts of the brain itself. I speak not now
of palpable insanity alone, but of all the various states of mind
occurring in sickness.

One of the most common and prominent characteristics of the state of
mind in sickness, is weakness. The weakness of body caused by disease
is generally accompanied by a corresponding debility of mind. When
Cassius speaks of Cæsar, as asking, ‘give me some drink, Titinius,
as a sick girl,’ you see something more than weakness of muscle—the
giant _mind_ of the mighty Cæsar is prostrated to effeminacy.

And as weakness of muscle is attended with unsteady, irregular, and
sometimes even spasmodic action of its fibres, so it is with weakness
of mind. Its efforts are fitful, and it is easily thrown off from
its balance. A feeble man tottering along, occasionally resting upon
his staff, or taking hold of a post or a fence, is thrown down by
the gentlest touch, or by stumbling over even a slight obstacle,
that he chances not to see so as to avoid or guard against it. And
in the tedious journey of sickness, mind and body totter along in
their feebleness together, and either is exceedingly liable to fall.
And if the one fall, the other is pulled down with it. The guide,
therefore, of these two travellers in this journey, must see to it,
that all obstacles in the way of either be removed or avoided, that
no rude hand be permitted to touch them, and that all those supports
be supplied on the way which either can best use.

The mental weakness which disease occasions, is often exhibited to
the physician under affecting circumstances. Minds that have been
able to grasp the most difficult and abstruse subjects return, in
the debility of sickness, to the simplest ideas—those which are both
common and precious to the child, the man, the angel, and to God
himself. The ‘strong meat’ is turned from, for the ‘milk of babes.’
I remember one of lofty intellect, fading away with consumption, who
well exemplified this remark. Her aged father was reading to her
a chapter in one of the epistles of Paul. ‘It is good,’ said she,
‘but I cannot understand it now. It bewilders me. Something more
simple—something from the Apostle John is better for my poor feeble
mind.’

The mind, weakened by disease, is easily disturbed and agitated,
except in those cases in which disease blunts the sensibilities.
Derangement of mind is often the product of mere weakness, under
increase of excitement, without any fresh accession of local disease.
A familiar illustration of this you may see in fever. Very often
there is mental derangement only during the paroxysm of fever, the
mind being quite clear in the remissions. Especially is this the case
with children, whose sensibilities and sympathies are in so much more
lively a state than those of the adult.

Slight causes, therefore, which would produce little or no effect
upon the mind of one in firm health, may affect strongly the mind of
a sick man. A single example will suffice. The patient was sick with
typhus fever. He had been very much deranged, and great care had been
taken to guard against any excitement, which might act injuriously
upon him. He was now getting better, and his mind had become calm
and clear, though still, like his body, it was very weak. A friend
came in one morning as usual to inquire about him. He knew that all
visitors had been prohibited from going into the sick room, but he
wished very much to see his friend, and, as he had an opportunity, he
looked in through the door, as it chanced to be a little open. The
dull eye of the sick man saw him dimly, and he at once became as much
affected as if he had seen a dreadful vision. His distempered fancy
conjured up ideas of a painful character, which remained upon his
mind for a week, and endangered as well as delayed his convalescence.

This incident leads me to remark that physicians find great
difficulty in securing a due degree of quietness in the sick room.
I use the word quietness in its widest sense. I do not mean the
avoidance of noise merely, but of all improper excitement. Visiting
is generally a nuisance in the chamber of sickness. Multitudes of
lives are continually sacrificed to curiosity and mistaken kindness.
The tattling circles that gather round the fireside of the sick
room, and retail their mixtures of medical lore, and slander, and
hair-breadth escapes, and wonderful cures, often inflict torture upon
the shattered nerves of the poor patient, and that torture sometimes,
I have not a doubt, ends in death, when a recovery might otherwise
have taken place.

No one should enter the sick room from curiosity or from a mere vague
desire to do good. Nothing but the actual prospect of doing good
should prompt him to go there. Indeed, everything which interferes
with the proper quiet of the sick should be most scrupulously
avoided. It should always be remembered, that in many cases of
disease, mental excitement may do as much harm as the excitement
produced by stimulating medicines. And it is as much the business
of the physician to direct in the management of this matter, as in
the administration of remedies; for it has as real, if not as great
a bearing on the recovery of the patient. Indeed, sometimes it is
vastly more important than all the medicine that is given in the
case. I call to mind a case which illustrates this last remark so
strikingly, that I will state it as briefly as possible. A patient
was taken sick, with some important business pressing upon his
attention at the time of the attack. He was persuaded to dismiss it
entirely from his thoughts for the time. He was soon relieved by the
remedies that were used, and he was in a fair way for a recovery.
He was, however, in such a state, that it was very important that
he should be kept from all excitement, and as I saw that he was
disposed to do the business now with some friend, whom he wished to
have called in for the purpose, I told him and his family in plain
terms the risk which he would run if he should pursue this course. He
however disregarded my injunctions, and the consequence was that in
the evening of the same day he was very sick, and in a few days died
from disease in the brain, which was clearly induced by the mental
excitement. If he had followed my directions as scrupulously in
regard to this point as he did in regard to the medicines which were
given, recovery instead of death would probably have been the result.

Some in their anxiety to secure the quiet of the sick, go to an
extreme, and give almost the silence of the grave to every sick room.
They institute a sort of prison discipline, and shut out both the
light of heaven and all cheerfulness of intercourse. The very means
which they take to produce quietness, the stealthy step and the
whisper, are apt to disturb the patient more than noise or excitement
would do. Discretion should be exercised by the physician, and the
friends of the patient should rely on him to direct this part of the
management of the case, as well as that which is strictly medical.
He must judge as to the degree and kind of excitement appropriate to
the case, and direct in its application, for the same reason that he
should, in a case of disease of the eye, direct as to the amount of
light which should be admitted to it.

It is often very difficult to carry out these principles, especially
in families that have but a small number of apartments. The fear of
giving offense, too, very often opens the door wide for visitors,
against the most positive injunctions of the physician. To obviate
this difficulty, I have in some few cases put upon the door a card,
forbidding this kind of intrusion—an expedient which I have found
to be very successful. One case was that of a clergyman’s family.
So many were sick, that the house was a perfect hospital. A large
portion of the parish poured in of course, to offer their sympathy
and their services. Most of these persons did more harm than good.
I attempted to remedy the evil by directions to the nurses, and by
conversation with individuals, but in vain. At length I put up a card
on the door of the house, to this effect: ‘Visitors are requested to
go directly into the parlor. No one is to enter the sick rooms but
those who have the care of the sick. No talking in the entry.’ This
effected the desired change at once. I introduce this case simply
to show the difficulties which exist on this point, especially in
country towns, and the very plain remedy which can be applied. There
is no reason why a universal rule should not be adopted in every case
in which it is deemed necessary by the physician.

The attendants on the sick often make a great mistake in supposing
the patient to be so fast asleep, or so stupid, as to receive no
impressions from their conversation. Often, from this cause, he
is obliged to hear what may do him great harm. Amid the confused
thoughts of his dreary bewildered state of mind, the idea of his own
death is conjured up by some remark, to trouble and affright him.
Instead of getting the rest which his wearied body and mind so much
need, his nerves are disturbed by the hum of conversation, and his
mind is harrassed by a succession of dread thoughts and visions,
suggested by remarks, of which it is supposed that he takes no
cognizance.

Some, who are very cautious on these points in regard to adults,
never think of their application to children. Often, for example,
does the physician find, on entering the sick room, those whom
kindness and curiosity have assembled there, talking loudly, while
the mother is trying in vain to soothe the troubled child by rocking
the cradle as if for a wager. Much, too, is often said in presence
of sick children that ought not to be, on the false supposition that
they do not understand what is said. Many a child is frightened by
horrid stories, and by gloomy comments upon his own case. Visitors
stand over him, and besides fretting him by their staring, they say
something, perhaps, of this sort. ‘Poor thing! how sick he looks! I
don’t believe he can get well.’ And then they go on to tell about
some little child, perhaps his playmate, that had died recently, and
whom, perhaps, he saw laid in his grave, and utter in his hearing,
with all due solemnity and sorrowfulness, the opinion that he is
affected much like him, and will probably die in the same way;
adding, by way of consolation to the poor mother, that then they
will be in heaven together. Children have sensibilities and hopes
and fears, like adults, and they understand, even at a very tender
age, enough about death to be affected, and often very strongly, by
this holding up of its grim visage directly before them. The mind,
and the nervous system, by which the mind is connected with the body,
are as excitable in the child as in the adult, and the avoidance of
unnecessary alarm and excitement is as important in the sickness of
the one as in that of the other.

I cannot forbear here to notice one thing, which often exerts a
bad influence upon the mind of the child in sickness. It is the
habit which many people have of threatening their children, when
in health, with sending for the doctor to bleed them, or to give
them some bitter medicine, as a punishment for their misdeeds. The
inevitable tendency of this is to increase the mental depression and
agitation which disease produces, by the gloomy associations which
are thus necessarily attached to sickness in the mind of the child.
The physician should never be held up as a bugbear to children, but
should uniformly be spoken of in their presence in such terms, that
when he visits them in sickness they may rejoice to see him, both as
a friend and as one who is to bring them relief. There is no doubt
that many a child is seized with an ill-defined terror, when the
physician is called in, and thinks of him only as some dreadful
monster that cuts off children’s ears, and gashes their flesh almost
for sport. The effect of such a feeling on the weakened and agitated
nerves is always injurious and undoubtedly is sometimes fatally so.
One may get some adequate idea of the feelings of children under
such circumstances, by imagining himself, in a state of weakness and
disease, to be visited by an incarnate demon, who has both the power
and the disposition to torment him.

I am anxious to impress most faithfully the mind of the reader with
the importance of giving rest to the mind in sickness. I have already
remarked on the extent and the intimacy of the union between the mind
and the body. It is never to be forgotten in the chamber of sickness,
that the mind not only is not by itself, alone and independent, but
that it is not connected with sound nerves, but acts upon a deranged
body, and is acted upon by it, through the multitude of nervous
filaments, which, scattered everywhere, are receiving impressions
at every point, and transmitting them to the mind. If, therefore,
the mind, thus disturbed by disease, be at the same time troubled by
causes applied directly to it, the result must be a reaction from
the mind through the nerves upon the disease itself. The mental and
the bodily irritations must increase each other. It is then just as
important to withhold all irritating causes from the mind, as from
the diseased organ. For example, if the brain be inflamed, that
inflammation may be aggravated as certainly by exciting the mind, as
it would be by the administration of any stimulant to the body. In
either case the same result occurs—the brain is stimulated—the only
difference is in the channel through which it comes. And it is the
duty of the physician to shut out the irritation from one channel,
as much as from the other. When the eye is inflamed, one part of
the curative means is to exclude the light, because the light, by
exciting the nerve of sight, would increase the inflammation. But the
action of the mind is as really connected with the brain and nervous
system, as the act of vision is with the eye; and therefore it must
be guarded against, in inflammation of the brain, as vision is in
inflammation of the eye. The same may be said, to some extent, at
least, of every other part as well as the brain, for every organ is
supplied with nerves connecting it with the mind.

As an illustration of these remarks, I will introduce a case, showing
the influence of the irritation of passion upon a diseased body. I
refer to the death of John Hunter, who has been often called the
greatest anatomist and physiologist of his age. “On October 16,
1793,” says his biographer, “when in his usual state of health, he
went to St. George’s hospital, and, unexpectedly meeting with some
things that ruffled his temper, he allowed himself to give way to
passion; the heart became overloaded with blood, the ossified aorta,
not yielding to the effort of the heart, the countenance became
dark, angina pectoris immediately ensued, and turning round to Dr.
Robertson, one of the physicians of the hospital, he was incapable of
utterance, and died.”

This, it is true, is an extraordinary case; but the result of mental
irritation in common cases of disease, though not as great and as
palpable as in this case, is nevertheless as real. While it caused
in the case of John Hunter a sudden and final suspension of the
heart’s action, it would, in a man suffering from some inflammation,
aggravate that disease, by driving the blood too forcibly into the
inflamed part, and by making its irritable nerves partake of the
general excitement of the system. The effect might not be at any
moment very powerful, but if the irritation be repeated or continued,
although it may be vastly less in amount than it was in the case of
Hunter, the accumulative effect of the excitement upon the disease
would at length become very great, perhaps destructive. And in
certain low states of disease, when, in the midst of great weakness,
the nervous system is in an extremely agitated condition—a condition,
in which little causes may produce powerful effects—a comparatively
slight irritation induced in the mind, connected as it is with every
trembling filament of that nervous system, may overwhelm the very
powers of life as certainly, if not as suddenly, as did the strong
passion of Hunter, in overloading his diseased heart, and thus
stopping its action.

But withholding irritation, and securing rest and quiet, do not
comprise all the physician’s duty in relation to the mind, any more
than they do in relation to the body of the patient. He is sometimes
to excite the mind to positive action, for the same reasons that
exciting medicines are sometimes administered to the body; and he
may thus often exert, through the mind, a very happy influence upon
disease. This remedy, as I have already hinted, is to be applied
with discretion, according to the nature of each case, and so
as not to interfere with that rest, which I have shown to be so
necessary to the mind in the treatment of disease. The excitement
must, with some few exceptions, be agreeable in character, in order
that it may produce a genial influence upon the nervous system.
The mode, the time and the degree of its application require the
exercise of discrimination, as much as the dose, and form, and time
of any stimulant or other medicine that is given to the patient.
The judgment and tact of the physician are never more needed than
upon such points as these. Tissot, a French physician, relates an
amusing case, showing the utility of discrimination in regard to
the kind of mental stimulation to be applied. A lady was affected
with a lethargy, and many applications were used to rouse her, but
to no purpose. At length a person, who knew that the love of money
was the ruling passion of her soul, put some French crowns into her
hand. After a few minutes she opened her eyes, and was soon entirely
aroused from her stupor.

The influence of the imagination upon the body is familiar to every
one. I will mention a few cases to show its power.

Beddoes, an English physician of great enthusiasm, had imbibed, among
other new ideas, the notion that palsy could be cured by inhaling
nitrous oxide gas. He requested that eminent chemist, Sir Humphrey
Davy, to administer the gas to one of his patients, and sent him to
him for that purpose. Sir Humphrey put the bulb of a thermometer
under the tongue of the paralytic, to ascertain the temperature of
the body, so that he might see whether it would be at all affected
by the inhalation of the gas. The sick man, filled with faith from
the assurances of the ardent Dr. Beddoes, and supposing that the
thermometer was the remedy, declared at once that he felt better.
Davy, desirous of seeing how much imagination would do in such a
case, then told him that enough had been done for that time, and
directed him to come the next day. The application of the thermometer
was made from day to day in the same way, and in a fortnight the man
was cured.

When Perkins’ tractors were in vogue, Dr. Haygarth of Bath, as I
have stated in another chapter, had a pair of wooden ones made
of precisely the same shape with the orthodox metallic ones, and
contrived to color them so that the deception should not be
discovered. He then applied them to quite a number of patients, with
the same results that followed the use of the genuine tractors,
which cost five guineas a pair. Pain was relieved as if by magic,
and the lame were made to walk. Their operation in these cases is of
course to be accounted for in the same way with the operation of the
thermometer in the case just related.

Some medical students determined to try the influence of imagination
upon a countryman who was going into town to market. They met him one
after the other, each telling him how pale and sick he looked. At
first, as he felt perfectly well, he paid no regard to it, but after
two or three had thus accosted him, he began to think there must be
something the matter with him. By the influence of imagination he
soon began to feel badly, and to look really pale. And as he still
continued to meet persons, who declared themselves struck with his
peculiarly sickly and ghastly appearance, he grew worse, and the
result was that he sickened and died.

I could cite numerous cases illustrative of the influence of the
imagination upon the condition of the body, but these will suffice.

The physician has constant opportunities for making use of the
influence of mental _association_ to much advantage in the management
of the sick. He does this almost insensibly in his daily intercourse
with his patients, exciting trains of agreeable associations in their
minds, varied to suit the mental and moral character of each, thus
aiding materially the operation of his remedies.

Dr. Rush gives a striking instance of the influence of association,
which I will relate in his own words: “During the time,” says he,
“that I passed in a country school in Cecil county, in Maryland, I
often went on a holiday with my schoolmates to see an eagle’s nest,
upon the summit of a dead tree in the neighborhood of the school,
during the time of the incubation of that bird. The daughter of
the farmer in whose field this tree stood, and with whom I became
acquainted, married and settled in this city about forty years ago.
In our occasional interviews, we now and then spoke of the innocent
haunts and rural pleasures of our youth, and, among other things, of
the eagle’s nest in her father’s field. A few years ago I was called
to visit this woman, in consultation with a young physician, in the
lowest stage of a typhus fever. Upon entering the room I caught her
eye, and with a cheerful tone of voice said only, _the eagle’s nest_.
She seized my hand without being able to speak, and discovered strong
emotions of pleasure in her countenance, probably from a sudden
association of all her early domestic connections and enjoyments with
the words I had uttered. From that time she began to recover. She is
now living, and seldom fails, when we meet, to salute me with the
echo of _the eagle’s nest_.”

It is important in the treatment of disease, to remove all causes
which awaken disagreeable associations in the minds of the sick, for
they often retard, and sometimes prevent the recovery of the patient.
It is as clearly the duty of the physician to detect the causes of
such associations, and to remove them if possible, as it is to detect
and remove the material causes of any irritation or inflammation.

Dr. Rush mentions a case that came under his observation, in which
the influence of disagreeable associations hindered the recovery
of the patient. “A gentleman in this city,” he says, “contracted a
violent and dangerous fever by gunning. After being cured of it, he
did not get well. His gun stood in the corner of his room, and being
constantly in sight, kept up in his mind the distressing remembrance
of his sickness and danger. Upon removing it out of his room he soon
recovered.”

Some are much more readily affected by mental associations than
others. A gentleman in a stage coach was observed to keep his cloak
lying by his side, while he was shivering with the cold. He was asked
by one of his fellow travellers why he did not put it on. He replied,
‘I have just returned from a voyage, in which I was very sea-sick,
and while so I lay with that cloak wrapped around me. Foolish as it
may seem, I cannot put it on without renewing the nausea.’

The various degrees and modes in which mental associations appear
in the sick room, require of course the exercise of discretion and
tact, in managing them to good purpose. There is often much injury
done by failure in this respect. If, for example, the patient have
great irritability of stomach, and if some medicine which has been
doing him good, at length become exceedingly offensive to him, the
continuance of that medicine might do him essential harm, by the mere
influence of mental association; though, aside from this, it may be
still an exceedingly appropriate remedy for his disease. Under such
circumstances a change must be made, or the patient will be injured,
it may be fatally. It will not do to call the patient whimsical, and
to go right on with the course. The mental association connected with
the medicine is practically one of the _ingredients_ in it, and as
such has so modified its nature as to render it inappropriate to the
case.

The physician can often do much in curing disease by _diverting_ the
mind of his patient. Disease is frequently broken up by producing a
new action in the system. This is a principle in medical practice
which is familiar to others, as well as to the physician. And
this change may sometimes be brought about in the system, by a
corresponding change effected in the mind, especially in those
cases where the state of the mind is particularly influenced by the
disease. The husband of a poor woman, who in a feeble state of health
had fallen into a settled melancholy, broke his thigh. The whole
current of her thoughts and feelings was now diverted into another
channel, from her own sorrows to the care of him and the relief of
his pains, and she recovered her sanity, and with it, for the most
part, her health, long before the fracture was united. The misfortune
of her husband was a severe remedy, but an effectual one.

A physician of my acquaintance some years since became thoroughly
impressed with the idea, that some symptoms which he had, indicated
the existence of an organic disease which was certain to end fatally.
At his request I made a full examination of his case, and found
the symptoms to be purely of a nervous character. The expression
of my opinion relieved him for the time of his anxiety. But as he
brooded over his feelings when alone, the same idea returned again.
I examined him repeatedly with the same result, but the comfort
which he received from me was only temporary. Knowing that he was
paying his addresses to a lady who was not only cheerful herself,
but who had the power of making every body else cheerful about her,
I recommended to him to be married at once, and told him that if
he would be, we never should hear any more about his aneurism. My
prescription was followed, and was entirely successful. The idea,
which had so long haunted him like an evil spirit, was cast out never
to return.

Every one is familiar with the fact, to which I have already alluded,
that dyspepsia has a depressing influence upon the mind. And as the
mental depression reacting upon the disease aggravates it, anything
which tends to remove this depression assists materially in curing
the disease. Diversion of the mind from its habitual gloomy ideas
to cheerful thoughts and efforts, often exerts a great influence in
such cases. I will mention a single case illustrative of this remark.
A gentleman of high intellectual character, who was sadly afflicted
with the dyspepsia, visited his friend Dr. Ives of New Haven, and
placed himself under his care. The Doctor saw at once that medicines
would do but little good in his case, so long as his mind remained
in the same condition, and occupied with the same thoughts; and that
a change there would go far to effect a corresponding one in his
bodily condition. He determined to produce this change without the
patient’s being aware of his intention, as it in this way would be
more effectually accomplished. In one of his rides with him they
alighted to pick some wild flowers. He adroitly excited his friend’s
curiosity in regard to the structure and growth of the flowers, and
leading his mind on step by step, he did not stop till he had fairly
made him a student of botany without his knowing it. The result was
that he engaged in the study with great enthusiasm, and followed it
up for some time. He was changed at once from a gloomy self-tormentor
into an ardent and cheerful seeker after knowledge in one of its
richest and fairest fields, and this change made his recovery a rapid
and easy one.

But it is not only in those cases in which the mind is obviously
affected, that the physician is to apply the principle of which we
have just been speaking. He can make use of it with much profit in
ordinary cases of disease, in his intercourse with his patients from
day to day. The sick are prone to brood over their own complaints,
and to watch their sensations, and they need to have the mind
diverted to other subjects.

In this connection I will notice very briefly the influence of change
of scene upon the invalid. When the same objects are seen by him from
day to day, and he has the same subjects of thought and conversation,
these all act as so many fastenings, or points of attachment, tending
to hold the disease in the same unvarying condition. But take him
away from them all, and set him free from this discouraging and
burdensome sameness, and let his thoughts and feelings flow into
other channels, and the change of course favors the introduction of a
new state of things, bodily as well as mentally. The new objects that
he sees not only take off his attention from his diseased sensations,
but the new excitement that he feels, as he sees them one after
another, diffuses a refreshing and invigorating influence throughout
his system. And imagination lends her aid in producing this effect.
It seems to him that everything is better than it was where he was so
lately shut up with the feeling almost of a prisoner—that the air is
more pure, the grass more green, the foliage of the trees more dense
and rich, and even the sun more cheerfully bright. Something, it is
true, is to be attributed to change of air under such circumstances,
but much less commonly than to the influence of change of scene upon
the mind.

The sick room, as every physician has frequent occasion to witness,
acquires after a time a monotony that is dreary and painful to the
confined invalid. Day after day he sees the same furniture and same
walls, every irregularity of whose surface he becomes acquainted
with, and he is forced to seek for some variety even in the most
trivial circumstances. “There, Doctor,” said an invalid playfully,
“I have made a little change, to-day. I have had the rocking-chair
put the other side of the fire-place, and the bureau moved to that
corner, and those phials on the shelf, you see, have changed their
places. My friends, Cologne and Camphor, have gone to the other side
of that vase, and those drops (which, by the way, Doctor, I think
that I have taken so long that some _change_ would be well) have
their station now quite at the other end of the shelf. And my good
grandmother, you see, looks down upon me from the other side of the
room. Variety is pleasing, Doctor, even within a few yards square,
when one can not get any farther.”

Even when the invalid is not confined to the sick chamber, but has
his rides and his walks, the monotony of every day’s routine becomes
a weariness. And no wonder that an escape from this is so often so
manifestly beneficial to him.

But it is not merely the diversion of mind, attendant upon change of
scene, that benefits the invalid, but his release from those mental
associations, that have so tenaciously connected themselves with his
sickness, has an important influence. The place where he has spent
wearisome days and nights of pain and restlessness and languor, must
necessarily have unpleasant associations connected with it. These
hinder, and in some cases even prevent convalescence; and when he
casts them off, he feels that he has rid himself of a great burden,
and as he goes on his course with a light heart, a fresh impulse is
given to the vital powers of his body, making him to feel, as he says
that he does, like a new man.

The mind of the sick man sometimes gets into a fixed, unvaried state,
with one settled cast to its ideas. The tendency of this is to make
the diseased condition of body to remain fixed also. It is important,
therefore, to alter this mental state—to break up this unvarying
train of thought and feeling. There are different ways of doing this
in the different cases that present, and the physician must judge as
to the most proper mode of effecting the object in each case. I will
give a few cases as illustrations.

A patient who had been very sick, but who had recovered from the
severity of her attack, and who was in a fair way for getting
well, remained precisely in the same condition for some time. Her
mind was in a fixed state of gloom, marked by a perfectly unvaried
expression of countenance. Her friends had tried in every way to
make her cheerful, but it was in vain, for the simple reason that
all their attempts to do so were obvious. I knew that she had
naturally a lively sense of the ludicrous, and therefore, after
getting her somewhat off her guard by some incidental conversation,
I then, with an air of perfect carelessness, uttered something
which I thought would be very apt to hit her mirthfulness, as the
phrenologists term it. It did so, and a smile kindled up at once upon
her sad countenance. The spell was now fairly broken. She speedily
regained her wonted cheerfulness, and the load being cast off, she
went straight on in the bright road of convalescence. In this case
it was but a small thing, after all, that turned the current of
thought and feeling, and the means which had already been used, most
persons would suppose, were much better calculated to do it. All
direct and palpable efforts to make the gloomy invalid cheerful, are
almost always unsuccessful; and yet it is such efforts that are most
commonly made use of by the friends of the sick.

The course which was pursued in another case, was quite a different
one. The patient was a clergyman, who had the impression strongly
fastened upon his mind that he should certainly die, and could not
be made to admit by the force of any reasoning, the possibility even
of his recovery. It was not an opinion founded upon evidence, but it
was a fixed state of mind, which was the product of the disease. It
was important to remove, if possible, this all-absorbing thought,
for it was reacting unfavorably upon the disease itself. It could
not be done by argument, nor by speaking to him the words of hope;
for it was not a conviction of truth arrived at by any reasoning,
but an impression unaccountable, but strong and vivid. He did not
_think_ that he should die, but he _felt_ that he _knew_ it. Some
remedy, then, different from either of these, was necessary. As he
was a man of stern, decided religious principle, I determined to make
a bold onset in that quarter. I told him that God alone knew whether
he would die or recover, and that he was doing wrong—absolutely
committing high-handed sin, in setting himself up as knowing what
God only knows. This was the substance of what I said to him, and it
produced the desired effect. The impression was dislodged from his
mind, and though he occasionally talked discouragingly of the result
of his sickness, he never said after that, that he _knew_ that he
should die.

One other case I will relate, in which the course taken to destroy
the diseased mental impression was of still a different character.
A patient, a gentleman of superior mental and moral qualities, sent
for me to inform me that he had received a revelation, in which God
had forbidden him to eat or drink or sleep. The confidence which he
manifested in me by sending for me determined in my mind at once the
course to be pursued. I told him that I had also had a revelation,
which was quite as good as his, perhaps better. ‘And,’ said I,
assuming the air of calm authority that expects submission as a
matter of course, ‘you must obey it.’ ‘What is your revelation,’ he
inquired. ‘My revelation,’ said I, ‘embraces all that is necessary
in your case. And in obedience to it you must continue to follow
my directions, and you must eat and drink and sleep as you have
done.’ I left him with my revelation fastened in his mind, it having
supplanted his altogether, and he immediately ate and drank, and that
night slept as well as he usually did.

In chronic cases especially, the sick are often prevented from
recovering by the influence of unpleasant circumstances in their
situation, or in their relation to others around them. The friends
of the sick often get out of patience with them in the tediousness
of a long confinement. Sometimes there is unkindness, and this to
the weakened mind and depressed spirits of the invalid, is often a
burden that cannot be borne. Some secret grief often neutralizes the
influence of medicine.

There is often great want of tact in managing the whims and caprices
of the sick. Many expect them to be as reasonable in their notions
and desires and feelings as if they were well. It is unwarrantable
and unjust to demand this of a weakened and beclouded mind, and
agitated nerves. Trifles light as air affect the sick strongly. The
very grasshopper is a burden to them. It is with the mind of a sick
man as it is with his senses. Noise troubles him—even the motion of
a rocking-chair, perhaps, or the swinging of a foot, disturbs his
sight, and through that sense disturbs his mind. The darling child,
whom he delights, when he is well, to see running about playing his
little pranks, must be taken out of the room, because he makes his
father’s head to whirl and to ache. Thus easily is he disturbed
through the senses. Just so is it with his mind—it is as easily
disturbed, and circumstances, which would scarcely excite a passing
thought in health, now agitate and depress him. Disappointments,
that ordinarily would be felt but for a moment and slightly, he can
hardly brook now. Every mother has often seen how easily her child is
grieved by little things, when mind as well as body is prostrated
by sickness. And she does not commonly get out of patience with it
for its seemingly unreasonable griefs, but soothes and quiets them.
It would be well if the attendants and friends of the sick had more
of that patience and forbearance, which are prompted by a mother’s
tenderness.

The sick often contract a strong feeling of dislike towards some
things, and sometimes towards individuals. They may regret it, and
see that it is unfounded and foolish, and yet not be able to get
rid of it. Some make the sick dislike them by their very kindness,
because it is so officious and pains-taking. There is a tact in the
good and judicious nurse which dictates just what to do and how much,
and many of the attendants on the sick are sadly deficient in this.

The fretfulness and impatience of contradiction, which are so often
the product of the nervousness of disease, are generally not to be
combatted, but to be borne with. The considerations which I have
already presented clearly show the propriety of this maxim; and yet
it is a maxim which is very commonly neglected. Many a dispute about
the most trivial things is held between the patient and the attendant
or friend, when a little tact might have diverted the weakened mind
from the subject, without yielding in the least anything, which
pride of opinion or firmness would prompt to hold fast to. I once
heard a mother, a woman of intelligence too, dispute with her sick
daughter about the number of crackers she had eaten during the day,
each maintaining her side of the question with as much zeal and
pertinacity, as if it were a matter of vital importance. The result
was that the patient was injuriously agitated by this rencontre
about nothing, and ended it by bursting into tears, and the mother
triumphed, as was her wont to do, by having the last word. And this
was a fair specimen of the moral management of that patient during a
long sickness. It added vastly to her nervousness, and clouded a mind
filled with lofty, and refined, and tender sentiment, and made that
chamber a scene of painful exhibition of thought and feeling, when a
different management might have soothed her agitated nerves, and left
the sensitive chords of her soul to respond clearly and harmoniously
to the gentle touch of friendship and love.

The patient often feels, and takes comfort in feeling, that his
temporary outbursts of fretfulness and impatience are understood
by his friends, as having no consonance with the real feelings of
his heart. A much respected patient, of whose sickness I have many
pleasant recollections, was one day speaking to me of his sister in
the highest terms of eulogy. “Yet,” said he, “I scold at her, but I
have no business to do it. However, she understands it. She knows
that I am nervous, and that I am sometimes hardly myself and she
forgives it all.”

Let me not be understood to mean that all the notions and caprices
of the sick are to be yielded to as a matter of course. I only
object to an useless and injudicious warfare with them. There should
always be firmness exercised in the management of the sick, but
there should be no struggle with them from mere pride of opinion, or
a desire for authority, or from want of a proper charity for their
mental weakness. They should never be directly opposed, except it be
distinctly and manifestly for their good.

One very common mistake in the mental management of some chronic
cases remains to be noticed. I refer to those cases in which the
nervous system is so deranged, as to produce a variety of sensations
of a deceptive character. Such patients are generally laughed at as
hypochondriacs, and they are told by their friends, and sometimes
even by physicians, that these sensations are wholly imaginary. This
is not so. Some of their notions about them are mere imaginations,
it is true; but the sensations themselves are, to some extent at
least, real. Imagination may magnify them, but it does not ordinarily
create them. The wrong ground which is so often taken in regard to
such patients, sometimes essentially retards their recovery. They
feel that they are trifled with, and they have but little confidence
in the judgment of those who deny that their sensations are real,
and therefore have but little if any in the remedies which they
administer to them. Besides, the mind of the patient is disturbed
continually by the disputes and consequent ill feeling which such
differences of opinion necessarily engender, and this of course has a
tendency to aggravate the diseased condition.

As an illustration of these remarks, I will mention a single case.
The patient, who had long been an invalid, had, among a great variety
of sensations, a burning, twinging, sometimes a pulling sensation,
in the region of the stomach. Her notion about it was that there was
a cancer there, that really pulled, and burned, and twinged. She had
been assured again and again that there was no cancer there, but so
little credit had been given to her account of her sensations by
those who had told her so, that she had on her part given little
credit to their knowledge of her case. I immediately told her that
I had no doubt that the nerves in that part of the body were the
seat of the sensations she described, but that she was wrong in the
disease which she fancied to be the cause of those sensations. By
taking this plain and obviously proper ground with her as to the
nature of her case, making the true distinction between what was real
and what was imagined, she was induced to give up the imaginary
notion that was weighing down her spirits. This view of her case,
so consonant with the faithful report of her own sensations from
day to day, commended itself to her common sense, and by inspiring
confidence and hope, did quite as much for her recovery as any other
remedial means that were used.

Among the great variety of topics which have suggested themselves in
connection with the subject of this chapter I have selected those,
the discussion and illustration of which would most interest and
profit the general reader. There are two topics, however, of this
character which require so extended a notice, that I shall devote
to each of them a separate chapter. I refer to insanity, and the
influence of hope in the treatment of disease.

In concluding this chapter I remark, that the subject of it demands
of medical men a more distinct and thorough attention than it
commonly receives. The physician should be something more than a
_mere doser of the body_. Mental influences are among the most
important of our appliances in the cure of disease. The physician,
therefore, in fulfilling his high vocation, should not only have a
full knowledge of mental philosophy, but he should aim to acquire a
practical skill in applying its principles to all the ever varying
phases, which the mind presents in its connection with disease. The
possession of this skill is one of the most valuable endowments of
the medical art.


FOOTNOTES:

[38] This chapter, and the chapter on _Truth in our Intercourse with
the Sick_, appeared some years since in the New Englander.

[39] It is often difficult to determine definitely what are the real
sentiments of phrenologists on this subject. But that some of them,
if not actually and fully materialists, are very near it, there is
no sort of doubt, if language is to be understood as used by them
in the same way that it ordinarily is. They not only strip man of
all the elements of moral character, and consider him, as one of
them expresses it, as ‘a bundle of instincts,’ thus making him but
a brute of a higher order; but the material organization is exalted
in their view above all those spiritual qualities or powers, which
they seem to consider either as attached to it, or resulting from it,
or at least as being in no sense independent of it. If this be not
materialism, it comes very near to it.




CHAPTER XV.

INSANITY.


It is not the object of this chapter to treat at large of insanity.
It is my intention to speak, as briefly as possible, of some points
in regard to its causes and its treatment, which ought to be
understood by the community.

The causes of insanity may be divided into two classes—those which
act upon the mind, and those which act upon the body.

The mental causes of insanity do not produce the disease directly
through their influence upon the mind. But this influence extends to
the organization with which the mind is connected; and the insane
manifestations or symptoms are entirely the result of the reaction
of the affected organization upon the mind. As this point has been
somewhat fully elucidated in the chapter on _the Mutual Influence of
Mind and Body in Disease_, it is not necessary to dwell upon it here.

The physical causes of insanity may be subdivided into three classes;
those which act upon the great central organ of the mind, the brain;
those which produce disease in other organs, affecting the brain
sympathetically; and those which have a more general influence upon
the system as a whole, or as a congeries of organs. In an individual
predisposed to insanity by the peculiar cast of his nervous system,
this malady may be induced by some local disease of some of the
organs, or by an impaired state of the general health.

There is commonly too much disposition to look to some one thing,
as the cause of the insanity in each individual case. And this
disposition is encouraged by the tables of causes, which appear in
some of the reports which are issued from our Insane Hospitals.
These tables cannot be made up with any degree of correctness. They
are therefore of little, if any, use; and they are even calculated
to lead to error, if any great reliance be placed upon them. In the
great majority of cases of insanity, the disease is the result of a
concurrence of causes, and not of one cause alone. Perhaps it will
be said, that in constructing these tables the _predominant_ cause
is sought for in each case. If it be, it is by no means always easy
to find it. In very many cases there must be much doubt in regard
to it; and in no small proportion of them candor would lead to the
confession, that we are entirely in the dark on this question. In the
classification of causes, the class of _doubtful_ or _unknown_ should
be much more numerous than it usually is in the annual reports of
Institutions for the Insane.

One of the mistakes which are committed by the community, and
sometimes even by physicians, in regard to the causes of insanity,
deserves a passing notice. The _form_ of the derangement is often
considered as indicative of the nature of its cause. It is by
no means necessarily so. For example, an individual, who in his
derangement talks mostly on the subject of religion, cannot as a
matter of course be considered as having become insane through
religious excitement. It may have been so, but the bare fact, that
religion furnishes the subjects of his insane ideas and feelings, is
no absolute proof that it is so. As well might it be said, that a
patient who thinks that he has no stomach, of course became insane
through abuse of that organ. A very common cause of insanity of a
religious character is an impaired state of the general health; and
the insane ideas run in that particular channel very often from the
influence of merely collateral, or adventitious circumstances.

Neither can the form of the derangement furnish any conclusive
evidence as to the character of the patient. Persons of the purest
minds, and of the deepest reverence for the Deity, are sometimes in
their insanity exceedingly profane and obscene.

It is important that the public should be informed in relation to
the _causes_ of insanity, in order that these causes may as far as
possible, be avoided. I will therefore notice some of them very
briefly.

One of the causes of insanity is an indulgence of the passions.
I take as an example the passion of pride. When this passion
has obtained a monstrous growth from long indulgence, a severe
mortification of it, especially if it be repeated or continued,
will produce insanity in those who are predisposed to this disease,
and sometimes in those who have no marked predisposition of this
character. Many cases of this kind may be found in our Retreats.

In this connection I mention, as another source of insanity,
the wrong views of life, the false principles, and the sickly
sentimentalism, which are infused insensibly into the mind by a very
large proportion of the fictitious literature of the world. This
influence is a more prolific source of insanity than is commonly
supposed. Not only is it exerted upon the reader as an individual,
but it affects through the multitude of readers the general tone
of thought and feeling, and thus acts widely, not merely as a
particular, but as a general cause of insanity.

Anything which causes an undue excitement in the mind has a tendency
to produce insanity. A too exclusive and prolonged attention to one
subject has this effect. It is in this way in part that ultraism
acts as a cause of this disease. The brain becomes wearied out and
weakened by one kind of effort, just as the muscles of the school
boy’s arm are tired out, when, as a punishment, he is compelled to
hold with outstretched arm any heavy article for some considerable
length of time. A wearied and weakened brain, when the infliction
which produces this result, is frequent and long continued, is apt
to become diseased; and one of the diseases to which it is thus made
liable is insanity.

It is said that insanity is hardly known among the savage and
uncivilized. There are two reasons for this. They are the
intellectual torpor, and the physical vigor, which result from the
habits of the savage. Wild passion, it is true, sometimes lashes his
mind into fury, but it easily subsides into its usual repose, and the
firm fibres of the brain and nerves suffer no injury from the shock.
So also in countries which are ruled by despotic governments, the
mental torpor which prevails makes insanity a rare disease.

As the intellectual torpor and the physical vigor of savage life
prevent the occurrence of insanity; so on the other hand, the
intellectual activity and the physical debility of civilized life
conduce to its existence. Mental excitement combined with luxury and
effeminacy is a prolific source of this disease. In this age, and
especially in this nation, the mental activities in every department
of effort are so lively, and have so little intervals of relaxation,
that the wear and tear of brain in all this conflict produce an
unusual amount of insanity, greater as is shown by statistics, than
in any other country in the world.

It is not strange that the excitement which is created in the mind by
the stirring motives presented by religion, should sometimes occasion
mental derangement. The struggle which it often awakens against
the passions, and propensities, and errors, which have accumulated
in amount and force by long indulgence in sin, must render persons
of considerable nervous susceptibility liable to this disease. But
in such cases religion acts only as the exciting cause, while the
predisposing causes have been exerting their influence through a long
series of years. And it is to be remembered, that though, even when
it is properly taught and enforced, it may occasionally act as the
exciting cause of insanity, its general influence tends to remove
the predisposing causes to which I have alluded, and its universal
prevalence would be attended by their entire removal. It is also to
be remembered, that of all those cases which are charged to religion
by an indiscriminating public, and by the enemies of Christianity, in
very few of them is the insanity produced by the proper presentation
of religious truth, while in the great majority of them it owes its
origin to the wild vagaries and the rash measures of the errorist,
the ultraist, and the fanatic.

A fruitful source of insanity is to be found in a general debilitated
condition of the system, which may be induced by a great variety
of causes. Such a condition is commonly characterized by a morbid
nervous irritability, which, with the aid of concurring causes, often
produces mental derangement. A very large proportion of the inmates
of our Insane Retreats present this condition of system. Their
physical and mental energies have both been exhausted by incessant
toil, and care, and anxiety from year to year, and long continued
ill-health has at length resulted in insanity. I may remark that we
see, in the loss of physical vigor as a cause of insanity, the chief
reason why there are more females than males among the insane.

As intemperance combines so many of the agencies which tend to
produce insanity, it is justly considered as one of the most prolific
sources of this disease. Strong drink exerts its destructive
influence upon the whole man, mental, moral, and physical. It
dethrones the reason, and inflaming the passions, gives them the
supremacy. It creates a morbid excitement throughout the whole
nervous system, and especially in the brain, the great central organ
of this system, and the instrument of the mind. It affects other
organs also, and particularly the stomach, which sympathizes so
readily with the brain, that its disorders, as is known to every one,
have a great influence upon that organ. Strong drink, therefore,
acting in these different ways upon the system, not only expends the
vital power rapidly, bringing on premature old age, but it makes its
deposites of disease here and there in the various organs, which
seriously embarrass them in the performance of their functions. With
such an impaired and diseased state of the system, and with the
constant excitement to which both body and mind are subjected, it is
no wonder that the intemperate are peculiarly liable to insanity.

In looking at the causes of insanity we readily discover the reason
why children are so seldom insane, though, from the liveliness of
their sympathies, they are much more apt to be _temporarily_ deranged
by disease than adults are, as we see in the paroxysms of fever. The
brain and nervous system require a long series of influences to bring
them into such a state, as renders them liable to that class of
diseases, which we include under the name of insanity. This state is
an accumulated result of the action of predisposing causes, continued
for some length of time, perhaps during all the previous life of the
patient. But the derangement of the child ceases with the temporary
disease which causes it. Its organs, not being incumbered with any
accumulations of disease, return readily to the performance of their
healthy functions; and its nervous system not having been shattered
with repeated attacks of sickness, and not having experienced the
wear and tear of trouble and toil, resumes at once its usual free and
easy and buoyant condition.

But, though insanity is not a common disease in the early years of
life, the foundations are often laid for it in this forming period.
The intellectual is often cultivated at the expense of the physical,
thus inducing that debilitated, and at the same time irritable
state of system, which you have seen is one of the prominent causes
of insanity. The passions, instead of being curbed by reasonable
restraints, are left to run riot. False views of life are permitted,
with all the bewitching fascinations which genius and fancy and wit
can furnish, to stamp their impress upon the mind, and through it
upon the brain during the impressible period of its growth. Luxury
too pampers the appetites, and gives to them a supremacy, which
debases and impairs alike the physical and the mental powers. When
the child therefore becomes the man, it is not strange that the
predisposition, thus formed within him by this moral and physical
training, should become more and more developed amid the stirring and
troublous scenes of active life, till at length, through the agency
of some exciting cause, insanity appears as the accumulated result
of all these evil influences. Education then, using the word in its
widest sense, has much to do with the production of insanity when it
is directed by wrong principles; and, on the other hand, it can be
made under proper management, to exert a powerful influence in the
prevention of this disease.

Let me now call the attention of the reader to a few considerations
in regard to the forms and the signs of insanity.

In some cases the symptoms of this disease are from the first of so
marked a character that no one can mistake the nature of the malady.
But in other cases its signs are for a long time indistinct, and no
period can be accurately fixed upon as marking the commencement of
the disease. Such cases are apt to be very obstinate, and the longer
they continue without proper treatment, the more difficult is it
to effect a cure. And delay is so common on the part of friends in
relation to such cases, that many of them, in which an early adoption
of the proper course would have resulted in an entire restoration
to health, become incurable before anything effectual is done. In
order that cases of this character should not be thus neglected, the
community need to be enlightened in regard to them.

The conversation and the conduct of such patients often exhibit no
signs of aberration of mind, which would strike the common observer,
even when the disease has existed for some length of time. And when
physicians assert that they are insane, some of their friends are
apt to doubt in regard to it, and sometimes they even controvert the
assertion. Of many cases of this character which have come under my
observation, I will allude to but two. One of them is the case of a
lady, whose insanity, which had taken the form of religious ultraism,
had been coming on very gradually for a long time. Though it was
of so deep a character as to be absolutely incurable, many even
very sensible persons among her acquaintances expressed their doubt
of the necessity of taking her to an Insane Hospital, and probably
would have cast blame upon me for so doing, had she not at one time
summoned her friends around her, and after giving some singular
directions and parting counsels, retired to her chamber and laid
herself down to die. Such palpable acts as this, are often the first
evidence that convinces the friends of a patient of the reality of
his insanity. Though it may have existed for weeks or months, they
perhaps have thought him to be nervous and ‘in a strange way,’ as it
is expressed, but they have not really supposed him to be insane.

The other case which I will mention is one which was brought to
the consideration of the civil authority of the town. I was called
upon to testify in relation to it. The proofs of this gentleman’s
insanity, which I adduced, were even made the subject of ridicule
by a portion of that wise body of men, and yet his insanity very
soon became so decided that he might be seen from day to day in our
streets picking up rags and strings and bits of wood and coal.

The delusions of some patients are confined to some particular
subjects. Upon these their insanity will appear in their
conversation, while upon all other subjects they are perfectly
rational. A man, who conversed with the utmost propriety on all
other topics, on being asked if he believed in Jesus Christ, said at
once, ‘I am Jesus Christ.’ A lady, who had very ambitious desires in
relation to her husband’s standing in society, became insane upon
this point alone, and while she was as rational as ever on all other
subjects, she constantly poured a storm of reproach and abuse upon
him, because he was not as great a man as she wished and expected
he would be. A lady, who had been much fatigued in preparing for
house-keeping, upon going into her new abode contracted a feeling in
regard to the house, which was something more than a mere dislike—it
was a horror. She could not bear to be in it, especially if she were
alone. She had an impression, ill-defined but unconquerable and ever
present, that something dreadful would happen to her if she remained
there. She said that she had rather live anywhere else, even in the
poorest shanty. Her friends thought that it was a foolish notion,
which she could overcome if she would make the effort. But they were
mistaken. She was really insane on that one point. I recommended that
she should be permitted to stay away from her house so long as she
desired it, and that her mind should be diverted by journeying and
visiting. A few weeks sufficed to remove the delusion. I once knew
a similar case in which the patient was not removed, and her misery
finally drove her to the commission of suicide.

It may be remarked of these cases of monomania, as it is termed,
that they do not ordinarily retain the same definite and exclusive
character which they at first have. If the insanity continue for some
length of time, other delusions are apt to be added to the original
one.

_Moral_ insanity is a form of the disease which is scarcely believed
to exist by the community at large, and our courts of justice are
very reluctant to recognise it, and will not do so without the most
indisputable and abundant evidence. And yet this form of insanity
is by no means rare. Many cases of it are found in our Retreats;
and the outrages, which such patients commit, are occasionally
made the subject of investigation before our legal tribunals. It
is an insanity of the moral sense, affecting the intellect little
if at all. Dr. Bell in speaking of it says, “There is insanity of
_conduct_, but not of _conversation_; the persons afflicted are
capable of reasoning with correctness and energy upon premises not
only false, but which they know to be false, and frequently display
the greatest ingenuity in giving reasons for and explaining away
their eccentric and unjustifiable conduct, and accounting for the
change which, they will admit, has occurred in the whole tone and
temper of their dispositions and propensities.

“It is a form of disease in which, perhaps more than in any other,
acts which, in a rational and responsible being would be crimes, are
committed. It occurs, at times, as the sequel of violent attacks of
mania,—it passes into decided mania or demency,—it alternates with
intellectual derangements; all which circumstances afford an adequate
presumption of its being a genuine form of insanity.”[40]

“Sometimes” says Professor Smith of New York, in a very excellent
description of this form of insanity, “it shows itself in the
abandonment of ordinary habits and pursuits; in carelessness of
one’s own affairs with random indulgence in follies and gross
sensualities. Sometimes it is seen in the form of ardent devotion
to a succession of projects, each suddenly conceived and embraced,
with, it is believed the certain prospect of rapidly amassing wealth,
or advancing in honor and happiness—and each as suddenly given up
in disgust. In some cases there is an uncontrollable disposition to
merriment, boisterous hilarity, and sportive and mischievous conduct
towards others. Occasionally the more striking phenomena are inflated
pride, exquisite vanity, and contempt of ordinary things. Frequently
it assumes the character of melancholy or deep gloom, attended with
fondness for solitude, and forebodings of evil when all around and
in prospect is inviting and joyous. A form not uncommon displays
itself in an unaccountable partiality for particular persons, and
a dislike of the nearest and dearest friends, with a disposition
to revile and injure them. The more serious varieties are those in
which there is a suicidal propensity, or a feeling of necessity
to commit some dreadful crime—for example, to destroy a certain
individual, perhaps a relative, as a tender and beloved child—an
act, the execution of which, the reasoning power strongly opposes,
and the conscience prevents by awakening the feeling of horror.
These restraining forces, however, are not always sufficient to curb
the strong propensity. Sometimes, as if urged irresistibly by some
demoniac influence, the fatal deed is perpetrated; and instant relief
from the burning passion is obtained; the homicide feels that a part
of his destiny is fulfilled, and hence an emotion of satisfaction
spreads over his mind. But such relief is not always durable; regret
and remorse may succeed, and rankle long and deep in the soul.”[41]

I will pass on now to a few remarks upon the _treatment_ of insanity.

The past history of the treatment of this disease is to a great
extent a history of tyranny and cruelty. The errors and abuses which
have generally marked the management of the insane, till within a few
years, are numerous and truly horrible. But these errors and abuses
are fast passing away. Ever since the wise and humane physician,
Pinel, entered in 1792 the Bedlam of France, in whose cells three
hundred maniacs were chained, and in the short space of a few days
knocked off the chains from fifty-three of them with none but happy
results, the management of the insane has been becoming steadily
more wise and merciful from year to year.[42] In producing this
change throughout the community, the public institutions for the
insane have had a great agency. I will therefore pass at once to the
consideration of the usefulness of these institutions, as the best
mode which I can adopt for developing the principles to be observed
in the treatment of insanity.

The advantages of Retreats, or Hospitals for the Insane, may be
summed up under three heads, which I will notice separately.

1. In sending a patient to a Retreat you take him away from all
those mental associations under which his insanity originated. These
associations are so many _points of attachment_, by which his malady
is fastened upon him; and it is therefore almost a _sine qua non_
in the cure to release him from their influence. The power of these
associations is most strikingly shown in the renewal of the insanity,
in those who are returned to their homes before their restoration
is fairly confirmed. Change of scene, as is known to every one, has
a good effect upon invalids generally; but it is especially true
of those invalids whose disease is insanity. Accordingly a very
important part of the treatment of the insane in a Retreat, consists
in such a management of their occupations and amusements, as will
best divert their minds from those channels of thought and feeling,
in which they have previously run.

2. The insane are ordinarily subjected to a more judicious _medical_
treatment in a Hospital than they are among their friends. It is
the testimony of all who have had charge of the insane, that their
restoration depends mostly upon regimen, or the regulation of their
occupations and amusements, bodily and mental, and very little
indeed upon medicine. It is undoubtedly true, that the deranged are
very often injured by too much positive medication prior to their
admission to a Retreat. They are first dosed by their friends, and
the physician who is called in, having had perhaps but a limited
experience in insanity, places too high an estimate on the curative
power of remedies in this malady, and gives the patient altogether
too much medicine. It was once very common to bleed the insane. But
it is now settled by the accumulated experience of the profession,
that very few of them require this measure, and that most of them
would certainly be injured by a reducing practice.

3. In sending a patient to a Retreat, you place him under a better
moral and mental management than he can have among his friends.
There is a peculiar tact requisite for the proper management of the
insane, which some seem to possess naturally, and which is much
improved by actual practice. In the selection of attendants in our
Retreats special regard is of course had to the possession of this
qualification. The attendants are therefore skilful in managing the
insane mind. They are free from those errors which are so common in
the community in relation to the treatment of insanity, and which
often do so much harm to the insane while they continue under the
care of their friends at their homes. Some of these errors it will be
profitable to notice briefly in this connection.

It is very common for the friends of the insane to attempt to
_reason_ them out of their delusions. If the derangement be of a
religious type, the clergyman, or some excellent friend, endeavors
by argument to convince the patient of his error. This is in vain,
and worse than in vain. _It uniformly does harm._ It does nothing but
strengthen the patient’s confidence in his notions, and make him more
earnest and obstinate in their defence.

It is quite common still, though not so much so as it once was, to
practice deception upon the insane. This ruinous error I comment upon
in the chapter on _Veracity in our Intercourse with the Sick_, to
which I refer the reader.

Another error which is frequently committed, is to pursue a timid
course at one time and a violent one at another, instead of one which
is both mild and firm throughout. This error has been the cause of
the practice of much unnecessary cruelty in the domestic treatment of
the insane.

These and other errors are for the most part avoided by the
attendants in our Hospitals. They have no needless collisions
with the patients in regard to their notions and delusions. They
practice no deception upon them, but win their confidence by an open
and candid intercourse. Their conduct towards them is marked with
mildness, and they make use of no more restraint than is absolutely
necessary, and that with calm firmness, instead of impetuous and
noisy violence.

It is a common observation that the deranged are apt to look upon
their most intimate friends as their enemies; while, on the other
hand, they are ordinarily much attached to their attendants and
physicians. The reasons of this I will briefly notice. In every
family, however warm may be its attachments, and however strong may
be the control of principle in its members, there must be differences
of taste and feeling and opinion, and a mutual yielding on these
points is absolutely essential to the maintenance of harmony and
peace. Now if one of the members of that family become deranged,
his self-restraint is gone, and he no longer does his part of the
yielding. He becomes unreasonable, obstinate, opinionative. There is
no more agreeing to differ on his part. All the points of difference
between him and his friends become now to him so many battle
grounds; and those whom he fights he is apt to hate. The injudicious
discussions and disputes, which friends are disposed to hold with
the insane, add to the difficulty. Then too the deceptions, which
most persons feel themselves authorized to practice in such cases are
certain to confirm the enmity, by destroying the confidence of the
insane in their candor and honesty. I need not stop to show, that
there is an absence of all these circumstances in the intercourse
between the insane and their attendants in a Retreat.

The reader cannot have failed to see in the course of my remarks,
that it is very important that the insane should early come under
proper treatment. The first indications of insanity should be
noticed, and measures should at once be taken to convey the patient
to some Retreat. The delay which is so apt to occur in relation to
those, in whom the malady comes on slowly and imperceptibly, is one
great reason why so many of them are incurable. If these could all in
the very beginning be removed away from the influences, which have
produced and are maturing their insanity and be placed under proper
treatment, many more of them would undoubtedly recover than now do.

Among the most helpless and pitiable of the miserable in this world
are the insane poor. Ordinary sickness requires only ordinary care.
But insanity is a malady, which not only often requires more care
than other sickness, but a care which is, as you have seen, of a
peculiar character—such as the comfortless home, the want, and the
ignorance of the poor are unfit to supply. It is the duty of society
therefore to make systematic and ample provision for the proper care
of this class of the insane. In many of the states some provision
has been made for them, but it is very inadequate. The provision
in Connecticut is an annual appropriation placed in the hands of
the Governor to be dispensed by him to applicants till the whole
sum is expended. In this way a large number of the insane poor have
secured to them a residence for a suitable period in the Retreat at
Hartford. This is well so far as it goes, but it is not sufficient.
_All_ the insane poor in the State should be provided for. And
the expense need not be very great if a proper plan be adopted. A
portion of the expense, one third or one half, should be defrayed
in each case by the town where the patient resides. In this way any
improper use of the public benefaction would be guarded against,
for the local authorities would, in behalf of the towns, secure a
suitable examination of the pecuniary circumstances of the patients.
Such a plan would be a truly economical one. For many, who, with the
scanty and irregular provision which is now made, are left to become
hopelessly insane, and to be therefore lasting burdens to the towns
in which they reside, would under a better plan be restored and
become able to support themselves.

This chapter is already so long, that I must devote less space than
I originally intended to the _legal relations_ of insanity. A few
points only can be briefly noticed.

The legal relations of insanity are very imperfectly understood, even
by those who are concerned in the administration of justice. The
lawyer at the bar, and the judge on the bench, often exhibit great
ignorance on this subject. The history of the legal definitions of
insanity, given by learned judges, is almost from beginning to end
a history of profound blunders. And yet these definitions have been
the guide in trials in which insanity has been alleged, except when
they have been set aside by the plain common sense of the jury, as
has sometimes very fortunately been the case. In speaking of the
inconsistencies and absurdities of the English law in relation to
insanity, Dr. Bell, in his valuable report to which I have before
had occasion to refer, remarks, that “from the test of Judge Tracey,
that to exempt from criminal responsibility, the patient should
know absolutely nothing, to that of a later tribunal, where ability
to repeat the multiplication table was gravely considered as the
exact point in a civil case, the doctrines and decisions have
been amusingly strange and inconsistent. Even cunning, foresight,
calculation, all possessed occasionally in a wonderful degree by the
most insane patients of every hospital, have been regularly decided
by the highest English tribunals, to contraindicate the existence of
that degree of alienation which implies criminal irresponsibility!”

The course which is adopted by our courts, to decide whether a man
accused of any crime is insane and therefore irresponsible, is a very
objectionable one. In France they are far in advance of us on this
subject. The course there is to place the accused, if suspected of
insanity, under the examination of a commission composed of men who
are practically qualified to decide such a question. “Upon them,”
says Dr. Bell, “rests the awful responsibility of determining the
state of the mind of the accused, as to the one fact of insanity;
they approach him at all times, they watch his actions in his
presence and without his knowledge; his habits, his sleeping and
waking hours, his physical condition, everything in fact which
can throw light upon the momentous question, passes under slow,
persevering, scientific investigation. Under the responsibility
of reputations as precious to them as those of the highest court,
and under the sanction of an oath, they arrive at conclusions, and
present their reasons for such conclusions, which form one, not the
exclusive, element for a court and jury to arrive at a just judgment.

How are the facts, elucidating the state of a prisoner’s mind after a
doubtful act, ascertained with us? The functions devolved in France
upon the bright professional luminaries such as I have named, here
fall upon the gaoler, the constables, and the turnkeys. _Experts_
may on the day of final trial be summoned in, to give their opinions
on testimony, derived from such sources as this! No provision exists
for any investigation beyond the _volunteer_ aid, which such an
ungracious task will rarely secure. The moment for investigating
the perhaps fleeting manifestations and evidences of disease
passes, before the law makes the least advances for the prisoner’s
protection. I have even known the instance of a professional man
whose life was spent among the insane, and who, moved solely by
humane feeling, had visited in prison a friendless wretch whose
homicidal act was feared from circumstances to be the result of
insanity, being held up and vilified to a jury by a government
functionary, for his _officious_ intermeddling in matters in which he
had no concern!”

Such having been the opinions and practices of our courts of justice,
it is not strange that the rights of the insane have often been
trampled upon and that _even life has been sometimes sacrificed
under all the solemn formalities of law, for acts committed in the
irresponsible condition of insanity_. I could cite _many_ sad cases
in illustration, but I will merely advert to one of a recent date,
which the efforts of one individual prevented from being added to the
long list of cases, in which the robe of justice has been stained
by the blood of irresponsible maniacs. I refer to the trial of the
poor negro Freeman, who killed the Van Nest family, consisting of
four persons. In this case a verdict of guilty was given, and the
community who came near resorting to Lynch law before the trial,
were eager to have the sentence executed. Governor Seward, who, to
his praise be it spoken, as a volunteer nobly stemmed the raging
torrent of popular excitement, defended the prisoner. He succeeded in
obtaining a grant for a new trial. This trial never took place. The
judge, before whom he was to be tried, visited the prisoner in his
cell, and becoming satisfied of his insanity, refused to try him. In
a few short months the prisoner died, leaving no doubt upon the mind
of any one acquainted with the case that he was truly insane.

It is true that the plea of insanity, just like any other plea, is
often set up when there is very little ground for it. But there
is good reason to believe, that it is very seldom established and
made the basis of an acquittal, when it ought not to be. Dr. Bell
remarked upon this point in 1844, that “it may be a consolation and
an encouragement to juries, in faithfully following out their own
sincere convictions upon the law and evidence in such cases, to
know, that in a pretty diligent inquiry as to the event of every
case of homicide in New England, where the accused has had the
defence of insanity ‘set up’ for him, and been acquitted on that
ground, it has been found that _not a single instance has occurred,
where the progress of time has not abundantly verified the soundness
of the defence_.” And he has recently informed me that this assertion
holds true up to the present time.

While it is important that justice should be secured to the insane,
when placed under trial for acts which they have committed, it is
of still greater importance that such acts should, if possible, be
prevented. If, when a man in an irresponsible condition destroys the
life of a fellow-man, we prevent his innocent blood from being shed,
we do well: but if we recognise the existence of that condition, and
the danger to others which attends it, sufficiently early, to take
measures to prevent his destroying the life of his fellow-man, _we do
better_.

This point of prevention should be made an especial object of
legislation. But in this country the laws which aim at this object
are exceedingly defective. In Connecticut it is the duty of the civil
authority and select men to order “any lunatic, who is dangerous
and unfit to be without restraint to be confined in some suitable
place.” If they fail to attend to the complaint, in three days it
may be brought before any justice of the peace, and he can issue
such an order. In Massachusetts the judges of Probate may commit to
the hospital any lunatic “who in their opinion is so furiously mad,
as to render it manifestly dangerous to the peace and safety of the
community, that he should be at large.” The objectionable points in
these provisions are two. 1. Those are made the judges of the fact of
insanity, and of the danger to the peace and safety of the community
attendant upon it, who are not competent to pass such judgment. When
we say that judges of probate, selectmen, and justices of the peace
are not thus competent, we say nothing to their discredit. Insanity
is a subject which they have no opportunity of understanding with any
definiteness or to any extent. 2. The terms in which these provisions
are couched show, that only great and manifest danger is contemplated
by them. Some outrage or attempt at outrage is commonly therefore
to be proved, in order to authorize in the view of the law the
confinement of the person complained of.

With such defects in the provisions of the law, it is no wonder that
the community is occasionally shocked with outrageous, even fatal
acts by insane persons, who through neglect have been permitted to
go at large. Indeed, in some cases there has been no apprehension
of danger up to the time of the commission of such acts; and yet if
these cases had been submitted to the examination of those who have
knowledge and skill on the subject of insanity, the danger would,
generally, at least, have been foreseen, and the acts would therefore
have been prevented. To secure such an examination a standing
commission of lunacy should be appointed, composed of physicians
who are properly qualified to decide the important questions which
would come before them. Every case of suspected insanity should
be subjected to their examination, and it should be their duty to
prescribe what measures shall be adopted in regard to each case.
Such a commission would not only prevent the peace and safety of the
community in many cases from being violated, and save many valuable
lives, but it would also secure a recovery in many cases of insanity
in which now neglect renders such a result impossible.

Many other points in regard to the legal relations of insanity might
be noticed with profit and interest to the general reader, but this
chapter is already sufficiently long. In conclusion I cannot but
express the hope that our lawyers and judges will give more attention
to this part of medical jurisprudence; and that the abuses which
exist may be speedily removed, so that the pretender to insanity may
be sure to be detected and punished, and the truly insane may as
surely be secured in their rights.


FOOTNOTES:

[40] Annual Report of the McLean Asylum, 1843.

[41] A Discourse on the Influence of Diseases on the Intellectual and
Moral Powers, by Joseph M. Smith, M. D., Professor of the Theory and
Practice of Physic, and Clinical Medicine.

[42] The following very interesting account of this experiment is
taken from an article on the treatment of lunatics, in the London
Quarterly.

It was during the reign of terror, and while all France labored under
a new form of insanity, that the idea was first conceived of setting
loose madmen from their bonds. The good and wise physician, Pinel,
seems to have been struck with the injustice of keeping the patients
chained in the dungeons of Bicetre, while so many hundreds of his
countrymen, more mischievously distracted than many of them, were at
large to work the bloody frolics of the revolutionary frenzy. There
were at that time upwards of 300 maniacs chained in the loathsome
cells of the horrible Bedlam of France. Pinel formed the resolution
of setting them free from their strict restraint, and he entreated
permission of the Commune to that effect. Struck with the novelty
of the enterprise, at that time a sufficient recommendation before
any assembly in France, the Commune listened to the proposal, and
deputed one of their body, the notorious Couthon, to accompany the
physician to the spot, and judge of the propriety of carrying his
undertaking into effect. They were received by a confused noise—the
yells and vociferations of some hundreds of madmen, mixed with
the sounds of their clanking chains, echoing through the damp and
dreary vaults of the prison. Couthon turned away with horror, but he
permitted Pinel to pursue his enterprise. The philanthropist resolved
speedily to liberate fifty of the number by way of experiment, and
began by unchaining twelve of the most violent. The account of his
proceeding has been recorded by his nephew, Sclyion Pinel, in a
lively narrative, which was read before the Academy of Sciences. The
first man set at liberty was an English captain. He had been forty
years in chains, and his history was forgotten by himself and all
the world. His keepers approached him with dread; he had killed one
of their comrades by a blow with his manacles. Pinel entered his
cell unattended, and accosted him in a kind and confiding manner,
and told him that it was designed to give him the liberty of walking
abroad, on condition that he would put on a waistcoat that might
confine his arms. The madman appeared to disbelieve; but he obeyed.
His chains were removed, and the door of the cell was left open.
Many times he raised himself and fell back; his limbs gave way; they
had been ironed forty years. At length he was able to stand and to
stalk to the door of his dark cell, and to gaze, with exclamations
of wonder and delight, at the beautiful sky. He spent the day in
the enjoyment of his newly-acquired privilege; he was no more in
bonds; and during the two years of his farther detention at Bicetre,
assisted in managing the house. The next man liberated was a soldier,
a private in the French guards, who had been ten years in chains,
and was an object of general fear. His case had been one of acute
mania, occasioned by intemperance—a disorder which often subsides in
a short time under abstinence from intoxicating drinks unless kept
up, as in this case, by improper treatment. When set at liberty, this
man willingly assisted Pinel in breaking the chains of his fellow
prisoners; he became immediately calm, and even kind and attentive,
and was ever afterwards the devoted friend of his deliverer. In an
adjoining cell there were three Prussian soldiers, who had been many
years in chains and darkness; through grief and despair they had sunk
into a state of stupor and fatuity, the frequent result of similar
treatment; they refused to be removed. Near to them was an old
priest, harmless and patient, who fancied himself to be the Savior of
the world. When taunted by the keepers, who used to tell him that, if
he was Christ, he could break the heavy chains that loaded his hands,
he replied with solemn dignity, _Frustra tentaris Dominum tuum_.
After his release he got rid of his illusion, and recovered the
soundness of his mind. Within a few days Pinel liberated fifty-three
maniacs from their imprisonment. The result was beyond his hopes.
Tranquility and harmony succeeded to tumult and disorder, and even
the most ferocious madmen became more tractable. This took place
in 1792; and the example of Pinel was followed in various parts of
France.




CHAPTER XVI.

INFLUENCE OF HOPE IN THE TREATMENT OF DISEASE.


I remember well that Dr. Jackson of Boston used to remark to the
students, that the medical profession is, from the nature of its
duties, a _cheerful_ profession. The physician has so much to do
with suffering, disease, and death, that this assertion would at
first view seem to be erroneous. But when it is considered that
in the great majority of cases he is able to effect a cure, that
in those which terminate in death he can generally give relief to
suffering from time to time, and thus at least smooth the passage to
the tomb, and that the number of sick whose diseases he can neither
palliate nor cure is exceedingly small, we can see why it is that the
physician is ordinarily so cheerful a man in his daily intercourse.
The impressions of most persons on this subject are wrong, and for
very obvious reasons. Out of their own immediate circle of relations
and friends, they hear only of the severe cases of disease, and often
only of those in which death is the result, and know but little,
perhaps nothing, of the multitude of cases, here and there in every
part of the community, which end in recovery.

Sometimes, it is true, sad cases occur which cast a gloom over the
path of the physician; but then the gloom is soon dissipated by the
successful issue of other cases which he had reason to fear would
have a fatal termination. Sometimes, too, unfortunate cases come in
clusters, and the physician is for the time obliged to see so much
of suffering and death, and the sorrows of bereavement, that in his
sadness he is ready to regret that he ever adopted such a profession.
But this happens only occasionally. It is a mere coincidence, and
it is but momentary. Events soon take their ordinary current, and
he has his usual amount of success, and resumes his wonted air of
cheerfulness and hope.

The results of the skilful and judicious practice of medicine are
such then as to make hope, and not despondency, to characterize
the prevailing cast of the physician’s mind. And so it should be.
For hope stimulates to action—steady, clear-minded action—while
despondency is prone to inaction, and leads to no efforts except
those which are hurried, fitful and confused. I do not mean that
the physician should in any case blind himself to the dangers
which it presents, and let a vain hope lull him into security.
This error should be as carefully avoided as the opposite one,
committed by those who see difficulty and danger in almost every
case, magnifying every bad symptom, and imagining some which have no
existence. The hope of the physician should be an intelligent hope.
It should be based upon just and definite conclusions. It should be
discriminating, and should be varied in its degree according to the
character of each individual case.

Every medicine that is given should be administered by the hand of
hope. The prospect, at least of relief, and generally of recovery,
should be held up to the mind of the patient. Remedies should be
given to effect some definite object, and the physician should hope
to a greater or less degree that they will do so. Hope may thus be
indulged in relation to the different stages of a case, without
regard to the final event of it, which may be so distant and so
clouded in doubt that no calculations can be made in regard to it.
And the physician may direct the attention of the patient to these
same points, and thus give variety to the hope which he excites in
his mind. This in many cases is much better than to come to him
every day with the simple expression of the hope that he will at
length recover. In the tedium of his confinement, if it be a long
one, he soon tires of looking far ahead to the bright fields of
convalescence, but finds relief in the little spots lighted up of
hope by the way—the oases thus made in the desert of sickness.

Even in those cases in which the physician feels it to be almost
certain that the final issue will be a fatal one, it is not proper
to give up wholly the idea of recovery, in his conversations with
the patient or with his friends. This remark must not be understood
to apply to those cases in which the evidence of approaching death
is not to be mistaken, and so far as human wisdom can see it is
absolutely certain that the patient will die. At the same time it is
to be remembered that there are occasionally recoveries when death
was confidently expected, and we must avoid being too ready to decide
that there is no ground of hope, especially in cases of an acute
disease.

I will relate a case in point. A physician was called in great haste
to a patient upon whom he had been attending with deep anxiety.
He found the family and the friends assembled around the bed of
the patient weeping over him as a dying man. The physician himself
thought from his appearance that he was really dying. Still he did
not _know_ that he was, and as he might possibly be in a condition
from which he could be revived, he prepared a cordial at once, and
with the look of hope and uttering the words of hope, he administered
it. The patient not only revived but recovered. In his convalescence
he told the physician that as he lay there dimly seeing with his
glazed eyes the sad countenances of his friends, and feeling the
oppressive languor of death, as he supposed, upon him, and panting
for some cordial and for the pure air of heaven, and yet unable to
speak or even to raise the hand, no words could express the relief
which he at once felt, spreading a genial glow over his benumbed
body, when he heard his cheerful voice speak of hope, and it seemed
to him that this had more influence in reviving him than the cordial
which he administered.

Strong as this case is, similar cases are in the recollection of
every physician who has been in practice for any considerable length
of time. And they cannot be distinguished from some other cases in
which attempts to revive the sinking powers fail, and the patient
dies. Now it will not be claimed that the physician does wrong in
uttering the language of hope in the case of those who recover; and
he certainly should not be reproached for uttering the same language
in the case of those who appear just as likely to recover, but
for some reason hidden from human wisdom do not. Just as he would
administer the cordial to all of them, so also should he apply to all
of them the cordial influence of hope. The same rule is applicable to
both the mental and the physical remedy.

It is often said that if the physician, on the whole, taking into
view all the circumstances of the case, thinks that a patient is
going to die, he ought frankly to tell him so. The considerations
which I have presented are, I trust, sufficient to convince the
reader that this is by no means true. Shall the physician, I ask,
add to all the depressing agencies which are bearing down the patient
the appalling idea of death, and thus lessen, perhaps destroy, the
possibility of his recovery? Shall he, in the struggle between life
and death, give his influence in any way on the side of death? When
the powers of life are sinking, and the life-giving fluid circulates
but feebly in the extremities of the system, and is accumulating in
the larger blood vessels and in the heart itself, threatening every
moment to stop its faint throbbings, shall he, while he administers
the cordial, defeat its effect, by holding up to the eye of his
patient the grim visage of death, to oppress the vital forces and
curdle the blood in its channels? Shall he not rather pour into the
mind the cheering influence of hope, and thus aid the cordial in
reviving the expiring energies of the system, and in stimulating the
heart and the whole circulation into a freer action?

Let me be fully understood on this point. Far be it from me to
justify the wide departure from truth, of which some are guilty at
such times. Giving utterly false assurances to the patient is a very
different thing from merely exciting the hope in his mind to such
a degree as the case may allow, that the remedies will produce the
desired relief. The latter can be consistently done by the upright
and high-minded practitioner, but the former is to be expected only
in the ignorant pretender, and the dishonorable and unprincipled
physician. The quack always gives assurances of a cure to those whom
he undertakes to dupe; for, besides being incompetent to estimate the
degree of danger in any case, he is unable to inspire confidence in
his measures except by a strong appeal to the hopes of the patient.
And some physicians imitate the quack in this particular. They
are in the habit of exciting unwarrantably the hopes of the sick
for their own selfish ends. By so doing they occasionally retain
under their care patients who would otherwise pass into the hands
of some one else; and they also get possession of some cases, in
relation to which their more honest and honorable brethren have not
found themselves warranted in giving any positive encouragement.
But, though occasional advantage may result from this course to the
physician, and sometimes even to the sick themselves, yet on the
whole the honest course is truly the politic one.

It is important, as I shall show more particularly in the next
chapter, that the physician maintain his character for veracity
and candor in his intercourse with his patients; else, when he can
consistently utter the language of hope, it may prove no cordial,
because his lips have so often uttered that language so falsely.
There are cases in which death may seem to the patient and to his
friends to be staring him in the face, and yet the physician may see
a sure and speedy relief coming to all the alarming symptoms. Now
when he gives an assurance to this effect, in order to quell the
anxieties and fears of the sick man and his friends, if he has been
known to be in the habit of giving similar assurances without any
ground for them, he cannot expect to be believed.

The views and feelings of patients, in regard to the expectation
of a recovery, are often misunderstood by their friends. They are
sometimes supposed to be wholly blind to their danger, when they are
really fully aware of it. They perhaps speak occasionally of what
they will do if they get well, and allude to the expected effect of
remedies, as if they supposed that they would overcome the disease,
and dwell, in their conversation with their friends and with the
physician, upon the favorable symptoms that may appear. All this may,
and often does, occur in cases in which death is almost certain to be
the result; and yet it is entirely consistent with the existence in
the mind of the patient of a rational view of his danger. I remember
well a respected friend, who talked of hope and relief now and then
almost to the last; and yet, from day to day, he was making such
preparations, even to the framing of his will, as showed that, on the
whole, he believed this to be his last sickness.

We are not to confound these occasional expressions of hope, these
fitful and momentary states of mind, with the settled conviction of
the understanding often existing behind all this. The promptings of
the natural desire for life are ordinarily not utterly destroyed
by the sure prospect of death. There will be moments when this
instinctive love of life, and of whatever in life has ministered to
the happiness of the sufferer, will turn off his thoughts from the
contemplation of death, and call up by association a thousand objects
of endearment.

    “For who, to dumb forgetfulness a prey,
      This pleasing, anxious being e’er resigned,
    Left the warm precincts of the cheerful day,
      Nor cast one longing, ling’ring look behind?”

It is well that the hope of recovery should occasionally light up in
cases which are certain to end fatally, especially when the patient
is the subject of protracted chronic disease. It breaks in upon
that painful monotony of mind, which is otherwise apt to exist. It
is not commonly well for any one, in any point of view, to have the
certain expectation of death fastened in the mind week after week
and month after month, even if he have all the while a clear view
with the eye of faith of a glorious immortality beyond. This one
unvaried state of thought and feeling, though commonly spoken of as
exceedingly to be desired, is ordinarily neither so profitable nor
so happy, as that condition of mind, in which the expectation of
death is not so constantly present, but occasionally gives way to
thoughts and emotions of quite a different character. The keeping
the mind strained up to a certain state, and fixed upon one set of
thoughts, is never either in sickness or in health profitable to the
individual himself, or to others. And aside from this consideration,
though the calm and fixed contemplation of approaching death has
something noble in it, and challenges our admiration, still the
triumph over death may be as signal, when there is occasionally an
indulgence of the natural desire of life, and a shrinking back from
the encounter with the king of terrors. The destruction of this love
of life, and the utter extinction of the hope of a recovery, are by
no means essential to perfect resignation. Indeed the highest degree
of resignation may exist when the desire to live is so strong as to
prompt the sufferer to catch with eagerness at the slightest grounds
of hope even to the last. Incidental circumstances have much to do
with the manner in which death is met. A cool temperament, the long
continued cultivation of a stoical indifference in the midst of
change and calamity, a morbid misanthropy, an habitual disposition to
fatalism, the breaking up one after another of all the attachments
to this world, the benumbing influence of disease or of medicine,
long familiarity with suffering, and the consequent capability of
enduring it, which is sometimes truly wonderful—some of these various
circumstances may conspire to render submission to the necessity of
the case easy, and give to the death-hour a calmness that is often
erroneously supposed to arise from a true Christian resignation. The
calmness thus induced is often an incidental adjunct to resignation,
and is sometimes auxiliary to it, imparting to it firmness and
steadiness in its manifestations. But it is in no wise essential to
it, nor one of its elements.

In chronic cases, which are going on gradually to a fatal
termination, there sometimes occurs either a temporary pause in the
onward course of the disease, or an alleviation of the symptoms of so
decided a character, that the patient and the physician cannot avoid
indulging for the moment the hope of a recovery. At such times the
bosom of the physician is the seat of conflicting hopes and fears. He
hardly dares to hope, when he calmly surveys the whole case from the
beginning. And yet he has known, he has himself _seen_ some strange
recoveries, perhaps even more strange than such a result would be
in the case before him. What now is his duty to his patient? Shall
he tell him the worst, as it is expressed, and thus extinguish his
rising hopes? Shall he say to him, “This very probably is only a
truce for a little while, and then your now dormant disease will
renew its attack, and perhaps with more vehemence; and, even at
this time, it may be secretly carrying on the work of destruction,
while the remedies are merely administering to your comfort, and
smoothing your passage to the tomb?” To say nothing of the evil of
such a course, if the case be susceptible of a cure, it cannot be an
advisable one, if the prolongation of life and the alleviation of
suffering be objects worthy of the aim of the physician; for such
a course would in most cases have a strong tendency to defeat the
attainment of these objects. If the friends of the patient deem it
important that such a view of his case should be presented to his
mind, let them take the responsibility of doing it themselves, and
not call upon the physician to do it. Ask not him to come to his
patient with the look and language of despair, and utterly dissever
the idea of hope from the efforts which he makes and the remedies
which he administers. Put no such unnatural, and cheerless, and, I
may add, profitless office upon him.

I remember once being strongly urged to such a course by the friends
of a patient. Whilst apparently going steadily down to the grave,
his symptoms at length became much relieved, and he took some
encouragement from the state of his case. In reply to the inquiry of
his friends, whether I had any hope of his recovery, I frankly said
that I had not, and that from all I could see I supposed that the
relief which he experienced was to last but a short time, and that he
must die very soon. They urged me to tell him so, but I declined, for
the reasons that I have stated above. The condition of comfort and
relief lasted in this case, contrary to my expectation, for several
weeks; and they were weeks of delightful intercourse, of affectionate
counsel, and of triumphant faith and joy. And I have not a doubt that
his life was thus happily prolonged in part by the cordial influence
of the hope, that the remedies which relieved his distress might
effect a cure.

It seems to be the idea of some, that there is something very
salutary in a spiritual point of view in the knowledge of the
fact, that death is certain and near. That it is more alarming and
awakens more emotion than the mere idea of danger, I allow; but
that it is more apt to produce right views and feelings is by no
means satisfactorily proved. Even if it be true, that the certainty
of death is more likely to secure decisive action in regard to the
interests of eternity, a decision under such circumstances is by
no means so worthy of confidence as one which is arrived at when
the hope of recovery is not wholly extinguished. To test this, take
as an example the feeling of resignation. When death is seen to be
absolutely certain, its very certainty is apt to induce a sort of
calm semi-fatalism, which has the appearance of true submission,
and is often mistaken for it through the charity and fondness of
friendship. But when the result is seen to be uncertain, if there
be amid all the balancing of the mind between hope and fear a
willingness to acquiesce in the supreme will, there is good reason to
believe that the patient has a true Christian resignation. There was
much force in the remark of a patient, who had for some days had the
certain expectation of death, but who had at length experienced so
much relief, that there was some ground for hope. “I am glad,” said
she, “that this relief has occurred, even if I do not recover; for
now I can fairly test the reality of my submission. I can put life
and death together, and examine my wishes and desires in regard to
them.”

There is one disease in which the disposition to hope is so
marked, that Dr. Good enumerates it among its symptoms. I refer
to consumption. In some cases, it is true, this symptom does not
appear, but despondency for the most part prevails. But this arises
either from a morbid sensitiveness of the nervous system, or from a
diseased condition of the digestive organs. When neither of these
circumstances exists, and the disease is uncomplicated with other
maladies, the tendency to hope is so strong as often to resist the
force of the most decisive evidence. Nothing is more common than to
hear a consumptive patient say, “Doctor, if you will only cure this
cough, I shall be well,” as if the cough were only a slight matter,
and its continuance was rather provoking than dangerous. I once saw
a physician deceiving himself to the last week of his life with the
idea, that his disease was in the stomach and liver, when there was
the most palpable evidence that the lungs, and the lungs only, were
diseased.

This tendency to hope is beautifully alluded to in a poetical sketch
of consumption by an anonymous author:

    “Then came Consumption with her languid moods,
    Her soothing whispers, and her dreams that seek
    To muse themselves in silent solitudes:
    She came with hectic glow, and wasted cheek,
    And still the maiden pined more wan and weak,
    Pale like the second bow: _yet would she speak
    The words of Hope, even while she passed away,
    Amid the closing clouds, and faded ray by ray_.”

Shall this hope, delusive as it so commonly is, be demolished by
the physician? Clearly it, in most cases at least, should not be.
For in very many cases it manifestly prolongs life, and adds to its
comfort and its usefulness, and in some cases it proves not to be as
delusive as perhaps even the physician is disposed to consider it.
Recovery does now and then occur in cases of true consumption, and
even in some which are quite advanced. The changes observed by means
of the stethoscope in the progress of some cases which have ended in
recovery, and the examinations of the lungs of those who have died of
some other malady, show conclusively that tubercular consumption is
not necessarily a fatal disease. Every physician who has seen much of
this disease has occasionally witnessed facts confirmatory of this
statement.[43]

In concluding this chapter I remark, that the obvious rule in regard
to the use to be made of hope as a curative agent is this—that
its cordial influence should always be employed, so far as it can
be done consistently with truth, and no farther. And the bare fact
that a case has ended fatally, when the physician has encouraged in
the patient the hope of a recovery, should by no means, as is often
done, be considered as proof that he has dealt falsely. He may have
encouraged the patient in good faith. For the physician, however wise
and skilful he may be, is not able to foresee with any certainty the
final event of sickness so frequently as is commonly supposed, and in
all doubtful cases he is bound to give the patient the benefit of all
the hope of which the symptoms will admit.


FOOTNOTES:

[43] The mortality of consumption has been undoubtedly increased by
the very prevalent, but erroneous, opinion, that when this disease
has only fairly begun it is never arrested, but sooner or later
ends in death. The definite opinions, too, sometimes given to the
patient as to the supposed hopelessness of the case, founded upon the
revelations of the stethoscope to the exclusion of other evidence,
have produced the same effect.




CHAPTER XVII.

TRUTH IN OUR INTERCOURSE WITH THE SICK.


On the question, whether strict veracity should be adhered to, in
every case and under all circumstances, in our intercourse with
the sick, there is very great difference of opinion, as well among
medical men, as in the community at large. Some are most scrupulously
strict in their regard to truth; others, while they are generally so,
make some few occasional exceptions in cases of great emergency and
necessity; while others still (and I regret to say that they are very
numerous) give themselves great latitude in their practice, if they
do not in their avowed opinions.

In examining this subject, it is not so much my intention to
discuss the abstract question, as to present the many practical
considerations that present themselves, illustrating them, so far as
is necessary, by facts and cases.

In order to introduce the subject, I will here quote a passage from
Percival’s Medical Ethics, which presents the views of those who are
in favor of an occasional departure from truth, where the necessity
of the case seems to demand it.

“Every practitioner must find himself occasionally in circumstances
of very delicate embarrassment, with respect to the contending
obligations of veracity and professional duty; and when such trials
occur, it will behoove him to act on fixed principles of rectitude,
derived from previous information and serious reflection. Perhaps
the following brief considerations, by which I have conscientiously
endeavored to govern my own conduct, may afford some aid to his
decision. Moral truth, in a professional view, has two references;
one to the party to whom it is delivered, and another to the
individual by whom it is uttered. In the first it is a _relative
duty_, constituting a branch of justice, and may properly be
regulated by the divine rule of equity prescribed by our Saviour,
_to do unto others as we would_, all circumstances duly weighed,
_they should do unto us_. In the second it is a relative duty,
regarding solely the sincerity, the purity and the probity of the
physician himself. To a patient, therefore, perhaps the father of a
numerous family, or one whose life is of the highest importance to
the community, who makes inquiries, which, if faithfully answered,
might prove fatal to him, it would be a gross and unfeeling wrong to
reveal the truth. His right to it is suspended, and even annihilated;
because its beneficial nature being reversed, it would be deeply
injurious to himself, to his family, and to the public. And he
has the strongest claim, from the trust reposed in his physician,
as well as from the common principle of humanity, to be guarded
against whatever would be detrimental to him. In such a situation,
therefore, the only point at issue is, whether the practitioner shall
sacrifice that delicate sense of veracity, which is so ornamental
to, and indeed forms a characteristic excellence of the virtuous
man, to this claim of professional justice and social duty. Under
such a painful conflict of obligations, a wise and good man must be
governed by those which are the most imperious, and will, therefore,
generously relinquish any consideration referable only to himself.
Let him be careful, however, not to do this but in cases of real
emergency, which, happily, seldom occur, and to guard his mind
sedulously against the injury it may sustain by such violations of
the native love of truth. I shall conclude this long note with the
two following very interesting biographical facts. The husband of the
celebrated Arria, Cæcinna Pactus, was very dangerously ill. Her son
was also sick at the same time, and died. He was a youth of uncommon
accomplishments, and fondly beloved by his parents. Arria prepared
and conducted his funeral, in such a manner, that her husband
remained entirely ignorant of the mournful event which occasioned
that solemnity. Pactus often inquired with anxiety about his son,
to whom she cheerfully replied, that he had slept well, and was
better. But if her tears, too long restrained, were bursting forth,
she instantly retired, to give vent to her grief, and when again
composed, returned to Pactus with dry eyes and a placid countenance,
quitting, as it were, all the tender feelings of the mother at
the threshold of her husband’s chamber. Lady Russell’s only son,
Wriothesley, Duke of Bedford, died of the small-pox, in May, 1711, in
the 31st year of his age. To this affliction succeeded, in November,
1711, the loss of her daughter, the Duchess of Rutland. Lady Russell,
after seeing her in the coffin, went to her other daughter, married
to the Duke of Devonshire, from whom it was necessary to conceal her
grief, she being at that time in childbed likewise; therefore she
assumed a cheerful air, and, with astonishing resolution, agreeable
to truth, answered her anxious daughter’s inquiries with these words,
‘I have seen your sister out of bed to-day.’”

The falsehood in the two cases related by the author is of the most
egregious character, and yet they are fair representations of that
kind of deception which many feel authorized to use in the sick room.
The equivocation which is practised, it is true, is not always as
gross and as labored, but it is as real. And whatever be the degree
or kind of deception, the same principles will apply to every case.

The question that presents itself is not, let it be understood,
whether the truth shall in any case be _withheld_, but whether, in
doing this, real falsehood is justifiable, in any form, whether
direct or indirect, whether palpable or in the shape of equivocation.

And we may also remark, that the question is not, whether those
who practice deception upon the sick are guilty of a criminal act.
This depends altogether on the motive which prompts it, and it is
certainly often done from the best and kindest motives. The question
is stripped of all considerations of this nature, and comes before
us as a simple practical question—whether there are any cases in
which, for the sake of benefitting our fellow men, perhaps even to
the saving of life, it is proper to make an exception to the great
general law of truth.

The considerations which will bring us to a clear and undoubted
decision of this question, are not all to be drawn from the
preciousness of the principle of truth, as an unbroken, invariable,
and ever-present principle, the soul of all order, and confidence,
and happiness, in the wide universe. But the principle of expediency
also furnishes us with some considerations that are valuable in
confirming our decision, if not in leading us to it. In truth,
expediency and right always correspond, and would be seen to do so,
if we could always see the end from the beginning.

I will remark upon each of the considerations as I present them.

First. It is erroneously assumed by those who advocate deception,
that the knowledge to be concealed from the patient would, if
communicated, be essentially injurious to him. Puffendorf remarks in
relation to this point, that “when a man is desirous, and it is his
duty, to do a piece of service, he is not bound to take measures that
will _certainly_ render his attempts unsuccessful.” The certainty
of the result, thus taken for granted, is far from being warranted
by facts. Even in some cases where there was a strong probability
(and this is all we can have in any case) that the effect would
be hurtful, it has been found not to be so. I might here narrate
some cases to prove the truth of this assertion, but it is not
necessary. Suffice it to say, that it is confirmed by the experience
of every physician who has pursued a frank and candid course in his
intercourse with the sick.

Secondly. It is also erroneously assumed that concealment can
always or generally be effectually carried out. There are so many
ways by which the truth can be betrayed, even where concerted plans
are laid, guarded at every point, that failure is much more common
than success, so far as my observation has extended. Some unguarded
expression or act, even on the part of those who are practising
the concealment, or some information communicated by those who are
not in the secret, perhaps by children, or some evidence casually
seen, very often either reveals the truth, or awakens suspicion and
prompts inquiry which the most skilful equivocation may not be able
to elude. The very air that is assumed in carrying on the deception
often defeats the object. In one instance where this was the case,
the suspecting patient said very significantly, ‘How strangely you
all seem—you act as if something dreadful had happened that you mean
to keep from me.’ Even the little child often exhibits a most correct
discrimination in detecting deception in the manner, the modes of
expression, and even the very tone of the voice. And sometimes, nay
very often, people so far undervalue the good sense and shrewdness
of children, that their deception is even ridiculously bungling, and
justly excites an honest indignation in the bosom of the deceived
child.

I give the following scene as an illustration of the above remark.

‘Come, take this,’ said a mother to her child, ‘it’s something good.’

The child was evidently a little suspicious that he was not dealt
with candidly; but after a great many assurances from her on whom a
child ought to be able to rely, if upon any body in the wide world,
he was at length persuaded to take the spoon into his mouth. The
medicine, which was really very bitter, was at once spit out, and the
little fellow burst forth in reproaches upon his mother for telling
him such a lie.

‘No, my dear,’ said she, ‘I have told you no lie. The medicine _is_
good—it is good to cure you. That is what I meant.’

‘Good to cure me!’ cried he, with a look and an air of the most
perfect contempt. ‘You cheated me. You _know_ you did.’

The contempt which this child manifested towards such barefaced
equivocation was most justly merited, and yet this is a fair example
of the deceptions which physicians are almost every day obliged to
witness, and which, (may I not say?) some of them encourage both by
precept and example.

Thirdly. If the deception be discovered or suspected, the effect upon
the patient is much worse than a frank and full statement of the
truth can produce. If disagreeable news, for example, be concealed
from him, there is very great danger that it will in some way be
revealed to him so abruptly and unexpectedly, as to give him a severe
shock, which can for the most part be avoided when the communication
is made voluntarily. And then, too, the very fact that the truth has
been withheld, increases, for obvious reasons, this shock. I will
relate a case as an example. It occurred during the prevalence of an
epidemic. A lady was taken sick and died. The fact of her death was
studiously concealed from another lady of her acquaintance, who was
liable to be attacked by the same disease. She was supposed by her
to be doing well, until one day a child from a neighboring family
accidentally alluded to the death of her friend in her presence.
The shock which the sad news thus communicated produced upon her
was almost overwhelming, and it was of course rendered more intense
by the reflection, that her friends thought her to be exceedingly
in danger of dying of the prevailing disease, and therefore had
practised this concealment in order to quiet her apprehensions. She
soon followed her friend, and it is not an improbable supposition,
that the strong impression thus made upon her mind had some agency in
causing her death.

In another case of a similar character, the first intimation which
a lady had of the death of a friend was from seeing the husband
of this friend pass in the street with a badge of mourning. She
was immediately prostrated upon her bed, and was a long time in
recovering from the shock.

In both of these cases the concealment of the truth was prompted by
the best of motives—pure kindness; and yet nothing is more plain
than that it was a _mistaken_ kindness. Whatever may be true in
other instances, the result showed this to be the fact in these two
cases. And if it be true, as I think all experience will prove, that
success, and not failure, in the attempt at concealment, is the
exception to the general fact, it clearly follows that deception is
impolitic as a measure of kindness, and therefore, aside from any
other consideration, it should be wholly discarded in our intercourse
with the sick.

I have a case in mind, which exhibits in contrast the influence of
frankness and of deception.

A little girl, the daughter of a farmer, had her arm torn to pieces
up to the elbow in a threshing machine constructed very much like a
picker. As her mother was confined to her bed with severe sickness,
the child was carried into the house of a neighbor. When I arrived,
I was told that her mother was in great distress, and fears were
expressed that the accident would have a very bad influence upon her
case. I asked if she knew what had happened. ‘No,’ said her husband,
‘not exactly. She found out by the children that Mary was hurt, and
then sent for me, and asked me what was the matter. I told her at
first that she had got her finger hurt. She said she knew that was
not all, and I at length, after she had begged and begged me to tell
all, told her that her hand was hurt badly. And now she is crying
most piteously, and says that we are deceiving her, and that she
knows that Mary is almost killed.’

I immediately went in to see the mother, and found her indeed almost
distracted with the great variety of dread visions that had suggested
themselves to her fancy in regard to her darling child. As I entered
the room she cried out, ‘Oh, she’s dead, doctor, or dying—torn to
pieces—in agony—Oh, isn’t it so? tell me, tell me the truth!’ ‘Be
quiet,’ said I, ‘and I _will_ tell you all the truth. I will not
deceive you.’ I assured her that she need give herself no anxiety
about the _life_ of her child—that was safe. This announcement
quieted her in a good measure, and I went on to tell her that the
arm was badly torn, and that I must amputate it above the elbow.
I told her that this would take but a minute or two, and then the
child would be essentially well. It was necessary to go into these
particulars in answer to her inquiries, (which were the more minute
from the fact that she had been deceived,) or else I should forfeit
her confidence, and thus commit the same error that had already been
committed. She thanked me for being so frank with her, and said, that
though it was hard to think of the operation, she could bear that,
if the child’s life was only spared. She grieved still, it is true;
but there was none of that overwhelming distraction that results from
vague apprehension.

Fourthly. The destruction of confidence, resulting from discovered
deception, is productive of injurious consequences to the persons
deceived. The moment that you are detected in deceiving the sick, you
at once impair or even destroy their confidence in your veracity and
frankness. Everything that you do afterward is suspected, and a full
and unshrinking trust is not accorded to you even when you deserve
it, though you may try to obtain it by the most positive and solemn
assurances. If, for example, you wish to encourage a patient, and you
tell him that though the bow of hope is dim to his eye, it is bright
to your own: ‘Ah!’ he will think, if he does not say, ‘how do I know
but that it is as dim to him as it looks to me—he has deceived me
once, and perhaps he does now.’

Every physician has seen the injurious influence of deception upon
children. Sometimes it is of a most disastrous character, and
occasionally, I have not a doubt, it proves fatal. Deception is more
frequently practiced upon children than upon adults, and many seem to
think that they have not the same right to candor and honesty in our
intercourse with them. But a child can appreciate fair and honest
treatment as well as an adult can, and he has as good a right to
receive it at our hands. He sometimes claims this right in terms, and
by acts not to be mistaken. And when it is taken from him, he shows
his sense of the wrong by remonstrances and retaliatory language, and
by a system of rebellion to an authority which he despises, as well
as fears, for its falsehood.

Suppose a mother succeeds in giving a dose of medicine by stratagem,
the administration of every dose after it is accompanied with a
fearful struggle. The strife which results from the spirit of
resistance thus engendered, perhaps in the beginning of a long
sickness, and which might in most cases have been avoided by frank
and candid treatment, continues through the whole course of the
disease to the last hour of life if the case prove fatal, the little
creature feebly but obstinately resisting its mother, till the
exhaustion of coming death puts an end to its struggles; and, though
she plies every art that fondness can devise to win back the lost
confidence of her darling child, it is all in vain.

If the reader have any adequate idea of the importance of quietness
in the management of the sick, I need not spend time to prove, that
this resistance of the sick child has an injurious effect upon
the disease, and that in those cases where life has but a feeble
trembling hold, where the silver cord is worn down almost to its last
thread, such a struggle may break that thread by its violence. I have
not a doubt that many a child has died under such circumstances, that
might otherwise have recovered.

Let me not be understood to imply that the resistance made by
children to the administration of medicine is invariably the
result of deception practised upon them, though this is the cause
undoubtedly in quite a large proportion of the cases, and those
too of the worst and most unconquerable character. And it may be
remarked, that in many cases this may be the cause of the difficulty
where it is little suspected. For it is so common a habit to deceive
children in this matter, that it is often done unconsciously. But
though the parent may not remember it, the child does, and the cruel
oppressive act (for so it may be properly called) locked up in the
memory of the child, wakes up rebellion in his heart that is not
easily quelled. Many a parent has thus in a moment, for the sake of a
slight temporary advantage, sown the wind to reap the whirlwind.

Deception has very often been made use of in the management of the
insane, though recently not to the same extent that it once was.
The consideration which I have been illustrating and enforcing lies
against the practice of it in our intercourse with this unfortunate
class of patients, with the greater force, because in their case the
mind is diseased, and any bad mental influence has therefore a worse
effect than it would have upon a case of mere bodily disease. The
reason is obvious—it acts directly upon the seat of the disease in
the former case, but indirectly in the latter.

Besides, let the insane man once see that you have deceived him, and
you lose the principal, perhaps we may say the only, moral means that
you have for curing his malady. Confidence is essential to any good
moral influence that you may exert upon him. I might cite many facts
to prove this, but will advert to only one. The wife of an insane man
was the only person among all his friends that had any control over
him, and she could manage him with perfect ease. After his recovery
she asked him the reason of this fact, and his reply was, ‘You was
the only one that uniformly told me the truth?

The bad influence of deception upon the insane man is rendered
the more certain and effectual from the fact that his insanity
incapacitates him for appreciating the kind motives which may have
prompted the deception. You cannot convince him as you can the sane
sick man, that you have deceived him for his own good. His suspicious
eye sees nothing but a sinister purpose in the cheat which you have
practised upon him.

One of the most vivid recollections of my childhood is that of a
scene which illustrates these remarks. A poor crazy man who wandered
about the streets was thought to have become dangerous, and it was
proposed to confine him in the common jail. A plan was laid to do it
by stratagem. He fancied himself to own some large possessions, and
talked much about going to Boston to see his friend the governor,
and attend to his business there. A neighbor offered to go with him,
and he accepted the offer. As they passed by the jail, his friend
proposed to visit it. As they entered one of the cells he adroitly
slipped out, and the door was closed upon the insane man. His dream
of earthly happiness and wealth was in a moment at an end, and he
beheld himself the victim of base treachery in the narrow cell of
a prison. Never shall I forget how eloquently he pleaded for his
release, how he asked what crime could be charged to his account,
how he denounced those who had thus without cause shut him up like
a felon, and especially with what sorrowful but burning indignation
he spoke of the man, ‘who under the guise of friendship, had decoyed
him into this snare of his enemies.’ Though a mere boy, I pitied him.
I sympathised with him. I had known him only as a pleasant old man,
who used to amuse us as we met him in the streets with stories of
his immense wealth and of the splendid plans of building on which he
loved to speculate. I felt that it was wrong to confine him among
vile criminals, and wondered not that the keen sense of such injury
prompted to the utterance of curses on those who inflicted it. But
these natural feelings gave way in my bosom, as they did in older
ones, to what was then supposed to be the necessity of the case—a
necessity which, I rejoice to say, has since that been found not to
exist in similar cases. A very great improvement has been effected
in this as well as in other respects, in the management of the
insane. Most of those whom it was once thought necessary to confine
with bolts and bars, and perhaps chains, and upon whom deception was
continually and systematically practised, thus adding poignancy to
the pangs of the oppressed spirit, are now permitted to have so much
liberty, that they are cheerful and happy, reposing entire confidence
in their attendants, who are careful never to deceive them. And
those whom it is thought necessary to confine, are not doomed to the
cheerlessness and disgrace of the cell of the felon, but they are
placed in as agreeable circumstances as is consistent with safety.
And it has come to be an established rule with those who have the
care of the insane, that force is always preferable to deception.
But still, erroneous views are very prevalent in the community on
this subject. It is common to this day, even among the excellent and
well informed, to propose to send their insane friends to a Retreat
by stratagem, and this has often been done even by the advice of
physicians. So far as I recollect, in all the cases of insanity that
have gone to Retreats from under my care, this mode of management has
been spoken of by some, and generally by many, as the only proper
mode. The public need to be instructed and reformed on this point.

It is a common observation that the insane are apt to look upon
their best and most intimate friends as their enemies. Why is this?
It is clear, that it is in part to be ascribed to the influence of
deception, waking up, as might be expected, feelings of resentment
and enmity in the bosom of the insane, which would not otherwise be
there. This point I have commented upon in the Chapter on Insanity,
and I need not dwell upon it here.

The extent to which deception is practised upon the insane cannot be
fully appreciated, except by those whose attention has been specially
called to this subject. As I have already remarked in regard to
children, so also it is with the insane—deception is so common, that
people often make use of it almost unconsciously. The whole course
of management on the part of their friends, is often characterized
throughout by an absence of candor and veracity.

The tendency of such a course is invariably to increase insanity,
making it more intense and obstinate. And not only so, but it
modifies to a greater or less degree its character. Deception prompts
the insane man to exercise his ingenuity in forming plans to foil and
circumvent his deceivers, whom he supposes very naturally to be his
enemies. Of course, new feelings and thoughts are thus excited in his
bosom, giving in some measure a new cast to his insanity.

I will here relate a case that illustrates these remarks.

The friends of an insane gentleman determined to send him to a
Retreat by stratagem. For this purpose, he was induced by one of
them to go a journey with him. On, their way, his friend proposed to
him to visit an Insane Retreat as a matter of curiosity. When they
arrived there, he was given to understand that he was to remain as
an inmate. Great was his rage at being so grossly deceived. After
the first burst of indignation was passed, he saw that it was of no
use to say anything or to make any resistance. He was a shrewd man,
and therefore, as a matter of policy, he submitted with apparent
cheerfulness to his new situation. He did not forget, as the insane
sometimes fortunately do, the wrong which his friends had done him,
and as he was decoyed there by stratagem, it is no wonder that he at
length made his escape by stratagem also. He came out, as might have
been expected, with his insanity more thoroughly fixed than it was
when he went in, and he added to it a deep hatred of Retreats, and of
course of the man who had betrayed him into one.

Another attempt was made to carry him to the same Retreat, which
from mismanagement utterly failed. The insane man was victorious,
and he felt himself to be so, over his friends, who he supposed
were bent upon cheating and oppressing him. All this not only made
him more crazy, but it gave a new shape to his insane ideas. In a
conversation which I chanced to have with him, he said to me, ‘It is
perfectly evident, doctor, that these Insane Retreats are joint-stock
institutions, and the stockholders are chiefly lawyers and doctors
and ministers. And it’s good stock too. Just see how much they charge
for board—full double at least of the actual expenses. I need not
tell you anything about it, however, for you own some of this stock,
and you know how profitable it is to you.’

‘Oh no,’ said I, ‘this is all new to me.’ He looked at me as if
he would look me through. He had been deceived so much, that he
believed, he trusted no one. Although I gave him the most positive
assurance that I owned no such stock, still, in spite of the
confidence which he ordinarily reposed in me, he showed that he did
after all suspect me on this point, so firmly was this notion about
Retreats fastened in his mind. He went on to give his reasons for his
opinion.

‘I can look back,’ said he, ‘to my very childhood, and see that from
that time to the present, there has been a series of efforts on the
part of these stockholders to make me a crazy man; and they at length
succeeded, and then contrived the mean plan of tricking me into one
of their Retreats. The minister that I lived with when I was ten
years old began this scheme, and all the ministers and lawyers and
doctors, that I have had anything to do with since that time, have
had a hand in it—have exerted their influence on me, all in relation
to this one object. It’s a regular money-making business. Of course
the stockholders all want to see these Retreats well filled up. Just
see how they have treated me lately. They have combined to cross my
purposes, break up my plans, defeat my projects, ruin my business,
and all this to irritate and disappoint me, and thus craze me. And
then, to cap the whole, they lied to me and betrayed me into their
prison to die a slow death, paying them all the time about twelve
dollars a week. Good stock, doctor, but a cruel business,’ said he,
with a most unearthly grin, and a shudder that shook his whole frame.
‘But thank heaven,’ cried he, ‘I’ve escaped their clutches. Though
they have ruined me, they shall not have their twelve dollars a week
out of me. No, I’ll die first. Such systematic, cheating, lying
oppression, I’ll resist to the death.’

It is evident that the treatment which this man received at the
hands of his friends, tended to aggravate, instead of lessening his
insanity. And I may remark, too, that the notion which he derived
from this treatment, in relation to Retreats, false as it was, was
founded on more plausible reasons as they were presented to his mind,
than are some of the opinions that are adopted by some sane men in
the community.

Fifthly. The _general_ effect of deception, aside from the
individual which it is supposed it will benefit, is injurious.
The considerations on which I have already remarked, have had
regard entirely to the person that is deceived, and I think that I
have shown most clearly, that even taking this narrow view of the
influence of deception, it is in almost all cases a bad influence:
and therefore as we cannot tell in what cases this influence will
be good, it is impolitic, and should be entirely discarded. Let
us now go farther, and looking beyond the individuals who are the
subjects of the deception, we shall see its influence extending
all around from these individuals, as so many radiating points of
influence, leavening the whole mass of society with a most poisonous
leaven. It is not an influence that can be shut up in the case of
any individual, in that one breast, or within that one chamber of
sickness.

That confidence, which should always exist in the intercourse of
the sick with their physicians and friends, and which may be made
the channel of great and essential benefits to them, is materially
impaired, often even destroyed by such deception. And this effect
is unfortunately not confined to those who practice it, but the
imputation rests upon others. The distrust thus produced often exerts
a depressing influence in those cases, where the cordial influence
of hope is most urgently needed, and where it can be administered in
consonance with the most scrupulous veracity. It is well if, under
such circumstances, the physician can appeal to the patient’s own
experience of his frankness in all his previous intercourse with him.

I call to mind an instance in which I was able to make this appeal
with the most marked good effect. The patient was a lady who was
in a great state of alarm in regard to the probable result of her
sickness. She was indeed very sick, but there was good reason to hope
that remedies would relieve her. At the same time I feared that the
depressing effect of this state of alarm, if it should continue,
would prove a serious obstacle to her recovery. But as I expressed
to her the confident hope that she would get well, she said to me,
‘Physicians always talk in this way, and you do not really mean
as you say. I shall die, I know that I shall die.’ I had been the
physician of the family for many years, during which time they had
gone through some trying scenes of sickness. Alluding to all this, I
asked her if she could look back and call to mind a single instance
in which I had not dealt candidly and frankly with her. She allowed
that she could not. ‘Well,’ said I, ‘believe me _now_; I _am_ in
earnest; I do believe, and confidently, too, that you will recover.’
The tears were at once wiped away. Cheerfulness, the cheerfulness of
hope, lighted up her countenance and the case went on to a speedy and
full recovery.

Every day we see evidence of the fact that so large a proportion
of the medical profession practice deception upon the sick, that
the profession, as a whole, has to a greater or less degree the
imputation fastened upon it. Indeed patients often, as a matter of
course, make the distinction between the obligations to professional
veracity, and those of the man, as a man, in his ordinary
intercourse; and the physician, who has an established reputation for
the strictest veracity everywhere else but in the sick chamber, has
there the suspicion of deception put upon him; and it is supposed to
be no imputation of which he should complain, because deception is
allowed here almost by general permission. For this reason, whatever
of frankness and honesty there may be in our intercourse with the
sick, often fails to produce the effect intended, in part at least if
not wholly. And this result follows just in proportion to the extent
to which deception is made use of in the profession.

The indirect and collateral effects of deception are often manifest
in a family of children. Its influence extends beyond the mind and
character of the deceived child. If the other children witness the
deception, what hinders them from believing that their parents can
deceive them also whenever it suits their convenience? And if they
do not witness it, the sick child will remember it when he recovers,
and the rebellion which he has, in consequence, in his bosom towards
an authority that rules by deceit, and is therefore deemed with good
reason oppressive, is of course communicated to the other bosoms
of the little flock. Many a parent, who supposed that he was doing
nothing that would last beyond the present moment, has thus sown the
seeds of rebellion among the little band of subjects, over whom God
has placed him; and who can tell what the fruits will be, or to what
extent or length of time they will grow!

I need barely say in concluding my remarks on this consideration,
that the momentary good which occasionally results to _individual_
cases from deception, is not to be put in comparison, for one moment,
with the vast and permanent evils of a _general_ character, that
almost uniformly proceed from a breach of the great law of truth.
And there is no warrant to be found for shutting our eyes to these
general and remote results, in our earnestness to secure a particular
and present good, however precious that good may be—a plain
principle, and yet how often it is disregarded.

Sixthly. If it be adopted by the community as a common rule, that
the truth may be sacrificed in urgent cases, the very object of the
deception will be defeated. For why is it that deception succeeds
in any case? It is because the patient supposes that all who have
intercourse with him deal with him truthfully—that no such common
rule has been adopted. There is even now, while the policy on this
subject is unsettled and matter of dispute, enough distrust produced
to occasion trouble. And if it should become a settled policy under
an acknowledged common rule, the result would be _general_ distrust,
of course defeating deception at every point. And yet if it be
proper to deceive, then most clearly is it proper to proclaim it as
an adopted principle of action. Else we are driven to the absurd
proposition, that while it is right to practice deception, it is
wrong to say to the world that it is right.

It is in vain to say that the evil result which would attend this
adoption of occasional deception, as the settled policy of the
medical profession, would find a correction in the very terms of the
rule which should be adopted, viz. that the case must be an urgent
one to warrant deception, and there must be a fair prospect that it
can be carried through without discovery. For every patient, that was
aware of the adoption of such a rule, might and often probably would
suspect that his own case is considered as coming within the terms of
the rule.

Seventhly. Once open the door for deception, and you can prescribe
for it no definite limits. Every one is to be left to judge for
himself. And as present good is the object for which the truth is to
be sacrificed, the amount of good, for which it is proper to do it,
can not be fixed upon with any exactness. Each one is left to make
his own estimate, and the limit is in each one’s private judgment, in
each one’s individual case as it arises. And the limit, which is at
first perhaps quite narrow, is apt to grow wider, till the deception
may get to be of the very worst and most injurious character. I will
give a single illustration of this remark, which though not taken
from the practice of medicine, is appropriate to my purpose. It
has always been allowed in the laws of war, to deceive the enemy
by stratagems, false lights, &c. At one time some English ships in
two or three instances decoyed the enemy by counterfeiting signals
of distress. The deception in this case is productive indirectly
of the very worst consequences, for it manifestly tends to prevent
relief from being afforded to those, who are actually in a distressed
condition. Our feelings of humanity instinctively condemn such a
stratagem and yet it is only a mere extension of that deception,
which has been by common consent allowed in war. It involves no
different principles, and is only more objectionable, because it
produces worse indirect results. It differs in degree only and not in
kind.

So it is with deception always. Its indirect effects are always bad
to some extent, and to what extent they will prove so we know not in
each individual case. You can never know at the time how great is the
sacrifice which you are making for a present good. While you may be
thinking that you are only sacrificing your own veracity, and that
the influence of the act will not extend beyond the passing moment,
you may be producing disastrous results upon the interests of others,
and those results may be both lasting and accumulative. A man who was
captured by some Indians, was asked by them if there were any white
men in the neighborhood. He told them that there were, and directed
them to a spot where he was very certain that there were none. They
immediately started in pursuit, leaving him bound and in the charge
of one of their number. When they were gone, he contrived to make his
escape. Almost every one would say, that this was a strong case, and
that they could not blame him for telling a falsehood to Indians,
in order to escape from their cruelty. Here was a great good to be
obtained, the saving himself from torture, perhaps from death, and
deceiving savages for such a purpose, it will be said, is not to be
condemned. But mark the result of that deception. Five white men were
found on the spot to which he directed them, and were captured.

In order to make out a justification of deception, on the ground
of expediency in any case, all the possible results, direct and
indirect, must be taken into the account. But this is impossible
except to omniscience itself. Even in those cases which appear
the most clear to us, there may be consequences of the most grave
character utterly hidden from our view. In the instance just related,
the captive was very certain, from some circumstances, that he
directed his captors to a spot where there were no white men.

The uncertainty of our knowledge of the circumstances of each case
prevents then our defining any limits, within which deception shall
be bounded. We can make no accurate distinctions, which will enable
us to say, that it can be beneficially employed in one case, while in
another it will be inexpedient.

I have now finished the examination of the various considerations
which have been suggested to my mind in relation to this subject.
And I think that they settle the question as to the expediency of
deception beyond all doubt. I think it perfectly evident, that the
good, which may be done by deception in a _few_ cases, is almost as
nothing, compared with the evil which it does in _many_ cases, when
the prospect of its doing good was just as promising as it was in
those in which it succeeded. And when we add to this the evil which
would result from a _general_ adoption of a system of deception, the
importance of a strict adherence to truth in our intercourse with
the sick, even on the ground of expediency, becomes incalculably
great.

In the passage, which I quoted in the beginning of this article
from Percival’s Medical Ethics, the writer makes, I conceive, a
false issue on the question under consideration. He assumes that the
injury, which results from a sacrifice of the truth for the good of
the sick, comes upon him who practices the deception, and that in
doing it, “he generously relinquishes every consideration referable
only to himself.” But the considerations that I have presented show,
that the injury is very far from being thus confined. Often the
very person intended to be benefited is injured, perhaps deeply, in
some cases even fatally. And then the indirect effects can not be
estimated.

There are many illustrations, used by those who advocate deception,
which are plausible but fallacious. I will cite a single example.
Dr. Hutcheson of Glasgow, as quoted by Dr. Percival, in remarking
on the maxim, that we must not do evil that good may come, says,
“Must one do nothing for a good purpose, which would have been evil
without this reference? It is evil to hazard life without a view
of some good; but when it is necessary for a public interest, it
is very lovely and honorable. It is criminal to expose a good man
to danger for nothing; but it is just even to force him into the
greatest dangers for his country. It is criminal to occasion any pain
to innocent persons, without a view to some good; but for restoring
of health we reward chirurgeons for scarifyings, burnings, and
amputations.”

I would remark on this that the infliction of pain is not in itself
a moral act, but the purpose for which it is done gives it all the
moral character that it has. Aside from this, it affects no moral
principle, as the infliction of an injury upon truth certainly does,
independent of the object for which it is done. The infliction of
pain then for a good purpose can not be said to be doing evil that
good may come—it is doing good.

The sacrifice of life which the writer speaks of, is the sacrifice of
a less good for a greater one simply, and not the sacrifice of any
principle. But when the truth is sacrificed for what is deemed to be
a greater good, it is in fact the sacrifice of a greater good, for
not only a less, but an uncertain good—a sacrifice of the eternal
principle, which binds together the moral universe in harmony, for a
mere temporary good, which after all may prove to be a shadow instead
of a reality.

I can not leave this subject without making some explanations of a
few points, in order to guard against some erroneous inferences to
which the sentiments that I have advanced might otherwise be liable.

I wish not to be understood as saying that we should never take pains
to withhold knowledge from the sick, which we fear might be injurious
to them. There are cases in which this should be done. All that I
claim is this—that in withholding the truth no deception should be
practised, and that if sacrifice of the truth be the necessary price
for obtaining the object, no such sacrifice should be made. In the
passage which I have quoted from Dr. Percival, he states a case in
which he very properly says, that the patient’s right to the truth is
suspended; but I do not agree with him, that in withholding the truth
we have the right to _put absolute falsehood in its place_.

It is always a question of expediency simply, whether the truth ought
to be withheld. And it is a question that depends, for its proper
decision, upon a variety of considerations in each individual case.
It is very often decided injudiciously. There is generally too
great a readiness to adopt an affirmative decision. It is too easily
taken for granted, that the knowledge in question will do harm to
the patient if it be communicated to him. The obvious rule on this
subject is this—that the truth should not be withheld unless there be
a reasonable prospect of effectually preventing a discovery of it,
and that too by fair and honest means.

It has often been said that the physician has no right to excite too
much hope in the mind of a patient by directing his attention, as is
often done, to any favorable symptoms that may appear in his case.
But I ask, how is it known that in the case in relation to which this
remark is made, too much hope is excited? The physician is fallible,
and is by no means answerable for putting just the right degree of
hope into the patient’s bosom. It is not to be expected of him that
he shall always tell each patient just how his case stands. His own
mind is often filled with conflicting hopes and fears, and he cannot
decide clearly what the probabilities are in many cases. And if he
thinks that he can do so, he may be very much mistaken. Estimates are
often made most unwarrantably. An exactness is often aimed at which
is impracticable. The patient in many cases has no right to such an
estimate, for while it may be a mere guess, he may look upon it as
a well-founded estimate, made upon a real knowledge of his case. He
will therefore draw false inferences from it, and this the physician
is bound to prevent, and in so doing he actually prevents deception.

The physician should always remember that though he may be aware
himself of his liability to err in making any such estimate, the
patient may have such confidence in his judgment, that he will
consider the opinion which he may express to be of course a correct
one—almost beyond the possibility of a mistake. So that however
guarded he may be in expressing an unfavorable opinion of the
probable issue of any case, that opinion may have too much weight in
the patient’s mind.

It is by no means true that all direct questions on the part of the
sick must be directly and fully answered. For example, suppose the
patient asks the physician, “Do you think on the whole that I shall
recover”—a question that is sometimes asked under very embarrassing
circumstances. If the physician thinks that he will probably not
recover, he has no right to say to him that he will, for this would
be falsehood. But he has a right, and it is his duty if he thinks
it for the good of the patient, to withhold his opinion from him,
if he can do it without falsehood or equivocation. He may say to
him something like this: “It is difficult to decide that question.
Perhaps it is not proper for me at this stage of your case to attempt
to do it. You are very sick, and the issue of your sickness is
known only to God. I hope that remedies will do so and so (pointing
out somewhat the effects ordinarily to be expected) but I cannot
tell.” Something of this kind, varied according to the nature of
each case, especially in the amount of hope communicated, it is
perfectly consistent with truth and good faith to say; and very often
when more is said, even in very dangerous cases, the physician goes
beyond the limits which infinite wisdom has thought best to set to
his knowledge. It is very common, as the reader has already seen in
the preceding chapter, for persons to recover, particularly in cases
of acute disease, when the physician had supposed that they would
die. This fact should make him somewhat cautious in giving definite
opinions to the sick in relation to the probable final result of
their sickness.




CHAPTER XVIII.

MORAL INFLUENCE OF PHYSICIANS.


The relation which the physician sustains to the community is a
peculiar one. No other man has so free access to so many families
among all classes of society. He is admitted into the very bosom
of the families upon which he attends, even of those that receive
other visitors with a distant formality. So much is this the case,
that most persons have the feeling that their physician is a sort of
confidant, and on that ground they are willing that he should see and
hear, in his daily intercourse with them, what would be improper to
be seen and heard without the confidence of intimate friendship. And
when that confidence is abused, as it sometimes is by the tattling
and the unprincipled physician, how gross the abuse, and how keenly
is it felt by those who have, as a matter of necessity, reposed the
confidence! I say as a matter of necessity, for the very nature of
the intercourse of the physician with his patients is such as to make
this confidence necessary. And the necessity is recognised by both
parties. The physician knows that it is expected of him, that he will
pay the most scrupulous regard to the principles of honor which have
relation to this necessity, and that any discovered infraction of
them on his part will materially injure his professional character.
He feels this instinctively; and it is this feeling which is
generally an effectual safeguard against abuse of confidence, when
the patient chances to be under the care of a physician who is devoid
of moral principle.

In the above remarks, I do not refer merely to the secrets which,
either from choice, or necessity, are so often entrusted to the
physician by his patients. But I refer to the confidential character
which marks his _whole_ intercourse with them, extending to all the
little nameless acts which makeup that intercourse. He enters the
dwelling of the sick as if he were one of the family, and the very
office that he is to perform disarms all formality, and pre-supposes
intercourse of the most familiar character. The patient is to speak
to him not of a foreign subject, nor of some one else, but of
himself, of his own body, of its pains and ailments, and that too
with sufficient minuteness to communicate an adequate knowledge of
his case. In doing so, he calls into exercise not only the scientific
acumen of the _physician_, but, mingled with this, the sympathy of
the confidential _friend_. If he has been the physician of the family
for any length of time, and has been with them in many scenes of
suffering, ready to relieve, so far as in him lay the power to do it,
this feeling of affectionate reliance is deep and ardent; so much
so, that it is a severe trial to the sensitive mind to be obliged
to consult a stranger, even though there be nothing in the case to
disturb the most refined and scrupulous delicacy. Especially is this
so when the patient is a female. In her case the confidence reposed
is of the most sacred character. And shame be to the physician who
dares to trifle with it—who dares to offend in any way the delicacy
of a patient, whom necessity has placed in such near relationship to
him. It is principally this relationship, which the physician holds
to the mothers and daughters of the families upon which he attends,
that introduces him, if he be a man of honor and principle, as the
esteemed and loved friend into the very _bosom_ of those families.

One circumstance, that makes the intercourse of the physician with
his patients familiar and intimate, which I have as yet barely hinted
at, merits a more particular notice. I refer to the sympathy which
he has felt with them in their seasons of suffering, anxiety, and
affliction. It has sometimes been said, that the physician, from his
familiarity with scenes of distress, becomes unfeeling, and incapable
of sympathizing with others. This may be true of him, if he from the
first look at the sufferings of his fellow-men only as a source of
emolument to himself. If at the onset he enthrones this perfectly
selfish and therefore hardening principle in his bosom, he will of
course become devoid of sympathy and benevolence. But if he does
not this strange violence to his natural sympathies, but lets them
flow out, as he goes forth on his daily errands of relief and mercy
to high and low, to rich and poor, and especially if he be faithful
to the poor who can give him nothing but their blessing and their
prayers, his sympathy and kindness will be so often drawn out, and
under such a variety of circumstances, that they will become more
tender and active, instead of being blunted and repressed. True, he
will not have that mawkish sensibility which vents itself in tears,
and sighs, and expressions of pity, but stops short of action, or,
if it ever reaches forth its hand, does it but fitfully, and with
none of that steadiness so essential in giving relief and support
to soul or body in its feebleness and suffering. If he ever had any
of such romantic and unpractical sensibility, he has cast it off
in his actual service in the fields of benevolence, into which his
profession has necessarily led him. He has learned over and over,
the lesson of _active_ sympathy. He has learned it often under
circumstances of discouragement, and sometimes without even the show
of gratitude being offered to him. He has learned it, I am glad to
say, (and I say it with some tender recollections,) with signs of
gratitude in his patients, which are not to be mistaken—with the
blessing of those who were ready to perish, but who were saved by
his timely and persevering exertions. He may appear to the casual
observer to have merged the feelings of the man in those of the
physician—to have surrendered his humanity to the cold and stern
demands of science. He may seem to be devoid of sympathy, as he goes
to work midst scenes of suffering, without a tear, or even a sigh,
performing his duties with an unblanched face, a cool and collected
air, and a steady hand, while all around are full of fear, and
trembling, and pity. Yet there _is_ sympathy in his bosom, but it
is _active_. It vents itself in the right way—in doing. There _is_
feeling there. It is not destroyed, but its manifestations are _under
control_. It is from this power of control which he has acquired,
that the physician or surgeon may appear to others to be utterly
without feeling, even when a tide of emotion may be pressing his
heart almost to bursting, because he knows that a valuable life is
hanging upon those very exertions, which he is making with all the
seeming coolness of indifference.

I have said that the feeling of the physician vents itself in action.
Before that action begins, his emotions are often oppressive, more
so than those of the by-standers; for he knows all the difficulties
and dangers of the case, and sees the very points which should
excite anxiety. Watch him while preparing for a serious operation.
Though he may appear to the careless observer perfectly cool and
undisturbed, you may see in his unguarded moments a betrayal of
the strong under-current of feeling, which he endeavors to conceal.
The occasional sigh, followed perhaps by an incidental remark to a
by-stander, as a diversion to his feelings, just as the boy whistles
to destroy his fear, the compressed lips, the slightly trembling
hand, as he busies himself in making his preparations, thus finding
relief to the pressure of the excitement within by external acts,
some of them perhaps needless—these and other signs show it. And
these signs may appear up to the last moment of delay. But the
instant he begins the operation, they are gone. The hand may tremble
till the knife touches the flesh, and the blood begins to gush; and
then it is firm, for his feelings have now found relief in _action_.

Perhaps it will be said that there is conclusive evidence, that the
tendency of the practice of medicine and surgery is to harden and
destroy feeling, in the fact itself, that, when the physician comes
to act, his natural sensibilities give place to the mere excitement
attending the different steps of that action. In reply to this I say,
that it is an error to suppose, that because feeling is relieved
for the moment by diversion of the mind into another channel, it is
of course hardened, or destroyed. Feeling may and does resume its
hold when the action ceases; and, if the action ends in relief, it
manifests itself in a different form—in a joyful and triumphant, in
place of a sad and anxious sympathy. And this change in the character
of the sympathy has a tendency to strengthen rather than lessen
the natural sensibilities of the heart. He who has year after year
sympathized with his patients in their sufferings, and then has
rejoiced with them in their deliverance—a deliverance of which he has
himself been instrumental—must be possessed both of a more deep, and
a more active sympathy, than when he began his career of usefulness.
This result is in consonance with the laws of our nature. While the
mere sight of suffering, without any attempt to relieve it, often
repeated, manifestly blunts the sensibilities, and hardens the heart;
it is, on the other hand, the invariable effect of the effort to
remove the distresses of our fellow men, to make our sensibilities
more deep and more tender. Our interest in the effort, our joy in its
success, our lamentation over its failure, the common cause which we
make with the poor sufferer, tend to produce this effect.

In this connection I will notice an error which is very common.
Persons who are not accustomed to look at wounds, or witness scenes
of sufferings, are apt when they do so to have certain effects
produced upon the physical system, which are so well known, that I
need not describe them. The error consists in supposing them to be
evidences of feeling and sympathy, and the process of overcoming them
to be necessarily a hardening process. They are effects produced in
the nervous system, and have a mere incidental, and not an essential
connection with the moral sensibilities. It is well known that all
are not equally susceptible of these effects, and the degree of
susceptibility is far from being an index of the degree of sympathy
in each individual. I have known many men, who had little of true
tenderness and kindness of feeling, faint away at the sight of blood,
while others with hearts overflowing with tenderness, and a hand
ever extended in active sympathy to the needy and suffering, under
the same circumstances were entirely unaffected. The possession of
this susceptibility has therefore no necessary relation, to the
moral character. They who exhibit it are commonly spoken of as being
‘tender-hearted,’ and yet there is nothing in this quality which is
inconsistent with the most wanton cruelty, or the most abandoned
vice. Neither has this susceptibility any necessary relation to
physical courage; much less to moral courage. Many, who possess it
to a great degree, have nevertheless uncommon physical courage, so
that though they would turn pale at the sight of a cut finger, they
would face the cannon’s mouth without fear, and in the excitement of
battle, the flow of blood and the groans of the wounded, would be
unheeded. While on the contrary, there are many, who are unaffected
by the sight of blood and suffering, in whom the idea of personal
danger would at once blanch the face and make the knees to tremble.

It is the conquest which the physician obtains over this nervous
susceptibility, of which I have been speaking, that has given rise to
the erroneous impression, that the practice of medicine and surgery
necessarily subjects the heart to a hardening process. But you have
seen, that while he is acquiring this self-control, his sympathy
with suffering is becoming all the time deeper and livelier, by the
exercise of that active benevolence to which his profession calls
him. It is only the physician who refuses to yield to this call, and
pursues his profession as a mere trade for self-aggrandizement, that
blunts his sensibilities, and hardens his heart.

Sustaining then, as the physician does, so intimate a relationship
to his patients, and sympathizing so deeply, as they feel that he
does, with them in their trials, and sufferings, and joys, his
opportunities for influencing those around him for good or for ill
must be greater than fall to the lot of most of those who occupy
commanding stations in society. He cannot avoid exerting a wide and
an effectual influence. It can be said emphatically of him, that
every act which he does, every word that he drops, is seed which will
surely produce fruit, and it is seed which he sows with a broad
cast. The advice which he gives, the opinions which he expresses, and
the example which he sets, have a double force from the fact, that
the intimacy and sympathy which exist between him and his patients
unlock the heart, and his influence finds no repulse in entering
there.

Every man has more influence in his own little community at home by
his own fireside, than he has abroad in the great community around
him. Familiarity, mutual confidence, and sympathy, are the obvious
causes of this. But the physician may in a measure, as you have
seen, be said to be at home everywhere, by everybody’s fireside,
in the mansion and in the cottage, in the garnished chamber of the
wealthy, and in the humble and comfortless garret of the poor. It
is a matter of every day’s occurrence, that he should be at home in
all these varied scenes, and he acquires a tact in accommodating
himself to them, and to the endless diversity of character which they
present. Wherever he goes he enters the family circle, as I have
before said, without that formality which attends the reception of
other visitors. He is received ordinarily without any preparation,
and at any hour when necessity calls for it. He sees his patients,
too, in every variety of situation, and in just those circumstances
which are calculated to develope and exhibit character. He sees
them in their unguarded moments, and when sufferings and trials of
every variety, from the great calamity down to the most trivial
disappointment, are acting upon them as tests, searching and sure.
He sees much that glitters before the world become the merest dross
in the sick chamber; and he sees too the gold shining bright in the
crucible of affliction. He sees human passion in every form and
condition; implacable hatred and love stronger than death; fallen
virtue, and virtue tried and proved; mental and moral strength
inconceivable, and childish imbecility in the once mighty and great;
hope beaming bright with heavenly lustre, and ghastly fear and black
despair; unbounded power of endurance, and the crushing of the once
buoyant spirit by even light calamities—every feeling, or passion,
or quality, or condition, that can be imagined, in every possible
variety of phase and degree, is displayed to his view.

No one then has better and more various opportunities for studying
human character than the physician: and he adds every day from this
source to the storehouse of his experience. I need not spend time to
prove, that this knowledge of character thus acquired confers upon
him a means of influence which he otherwise could not have. It not
only gives him a tact in influencing men generally; but in individual
cases, the revelations of thought and feeling which he has witnessed
at the fireside or in the sick room, made in the free and unguarded
moment, under the application of faithful tests, afford him such an
insight into the character, that he knows just what chord to strike,
to produce the effect which he desires. He needs not to feel his way
to the heart. He has already learned it. He knows just what motives
will act with the most certainty, and needs not to make any random
experiments.

What responsibility then rests upon the physician! How careful should
he be in the expression of his opinions! At what high ends should he
aim in his daily example! How important that he should be right upon
the great moral questions which agitate the community, and that his
morality should be strictly that of the Bible!

Too often is it the case, that the physician, who professes to
be governed by principle, exerts no such commanding influence,
as his relations to his fellow men enable him to do; but, as a
matter of policy, avoids committing himself decidedly and openly
upon those subjects which occasion any diversity of opinion in
the community. Those who thus for selfish ends fail to meet the
full responsibilities of their station, do not, indeed, like the
unprincipled, undertake to please everybody (a contemptible course,
and commonly a profitless one) but they at least make it a main
point to displease no one. In so doing, it is true, they make no
direct attack upon principle, and inflict no positive injury upon the
moral interests of society; but they are guilty of a sacrifice of
principle, and they neglect to do the good which it is in their power
to do. Suffice it to say, that while the physician should not court
opposition by any needless attacks upon the opinions and prejudices
of others, for this would impair his usefulness, a dignified and firm
expression of his sentiments, and a decided influence for good upon
every great moral question, we have a right to expect from one who
has so great a share, as the physician necessarily has, in moulding
the character of society.

Take, for example, the great moral question of Temperance, which has
for so many years agitated the community, and upon which there has
been so great a difference of opinion. It is difficult to conceive
that a physician, possessed of the ordinary feelings of humanity,
should fail to be decided on this subject, either in his opinions, or
his influence. No man has had so varied and extensive opportunities
of witnessing the ravages of intemperance. It is not an _occasional_
visit that he has made to the miserable home of the drunkard. It is
not _occasionally_ that he has heard from trembling lips the tale of
woe, and seen its painful and often hideous signs. It has been with
him an almost every day occurrence. Misery on every hand has made its
appeal to him. And if he has allowed his desire for popularity to
hinder him from heeding such touching and frequent appeals, it is not
too much to say to him, that he has been shamefully recreant to the
dictates of humanity, and that he will have to render a large account
of neglected opportunities of doing good.[44]

No one has more frequent opportunities than the physician for acting
as a peace-maker, an office which is very much needed, but which few
are inclined to take. There are always many, who are willing to act
as peace-makers in gross and palpable cases, when an actual quarrel
has burst out, and threatens a great and manifest damage to the
community, who yet may do nothing to repress the petty jealousies
and the slight contentions, which are generally the cause of the
greater commotions that heave up the very foundations of society.
But the true peace-maker is doing his work at the fountain head, at
the very beginnings of strife—not only when urgent occasions call
for it, but from day to day, in every circle, by every fireside
that he visits. Every day he sees the risings of ill-feeling, envy,
jealousy, and discontent; and he calms them down by an influence so
gentle and charm-like, that it is scarcely observed. A small thing, a
word, a look, may often put out the spark which is about to light the
destructive train. How few there are in this world of jealousy and
contention, who are ready to utter that word, or bestow that look,
and how many who will fan the spark of strife into a blaze, or will
at least let it alone, and take no pains to put it out.

The physician in his intercourse with his patients has so much of the
free familiarity of home, that he can see these sparks of contention,
as they kindle up here and there, more quickly than others can.
Thought and feeling are often revealed to him unconsciously, and the
very fountains from which they rise are almost open and naked to his
view, and, I may add, to his influence also. If he then be a man of
peace, he can do much from day to day in repressing those thoughts
and feelings, almost in their nascent state, which, if encouraged,
would distract and divide family circles, neighborhoods, and perhaps
communities. If, on the other hand, he is not a peace-maker, but
has an ear ever open to the tongue of scandal, and is himself a
tattler—if he is ready to secure his own aggrandizement by injuring
his competitors, and is therefore disposed to rejoice in the
misfortunes of others, he scatters the seeds of contention wherever
he goes, and the peculiar relation which he sustains to a large
portion of the community enables him so to scatter them, that they
will be sure to take root, and grow, and produce an abundance of
fruit.

This leads me to say that it is especially true of the physician,
that the most of his influence lies in the little hourly acts, and
in the familiarly, perhaps carelessly, dropped words, which make
up the chief part of his life, and not so much in the opinions
which are formally expressed, or in the acts which obviously follow
deliberate consideration. This is true to a great extent of every
man who mingles in society with the ordinary degree of freedom.
They indeed, who move about among their fellow-men with as little
familiarity or sympathy as a recluse, have but little influence, and
that only when they utter their formal opinions. But the occupation
of a physician necessarily puts him at the very antipodes with the
recluse. Even if he be disposed to shut up his heart against his
fellow men, and to make his intercourse with them of a strictly
scientific character, his bosom will very soon be unlocked, or he
must give up his profession. The fountains of sympathy and feeling
will be unsealed by the potent influence of daily intercourse with
human suffering and joy. He cannot from day to day administer to the
relief of distress without sympathy, and that sympathy cannot always
be suppressed. It will gush forth, and the frigid man of science will
become the kind and familiar friend. Mingling then, as the physician
necessarily does, so freely and intimately with the world around him,
it must be eminently true of him, that it is the spirit of the man,
as it breathes forth in his common every day words and acts, even in
his very manner, that really gives the character to his influence. So
that if he be not forward to speak out his sentiments, or to give his
advice, the sentiments which he has, and the advice which he would
give, are as well known, as if he uttered them. It is in truth this
aggregate influence (as it may be called) of his daily life in the
many homes to which his profession gives him admittance, that imparts
force to his advice, and opinions, and acts.

I have as yet said nothing especially of the influence of the
physician in the _sick room_. Here he treads upon sacred ground,
and has to do with the issues of life and death, both temporal and
eternal. Here he sees man in the weakness of his humanity, ‘crushed
before the moth,’ but often, too, in the strength of his immortality.
Here he is made a witness of the frailty of the tenement, which
the immortal spirit inhabits—he sees that its ‘foundation is in
the dust.’ He has communion with the spirit in its most momentous
hours—while it sees the walls of its habitation crumbling into dust,
and lingers about the ruins before its final flight into a world of
light or darkness, of joy or of woe—or perhaps, while with longing
desire, and occasional hope of its longer continuance here, it
trembles with the fear that it is about to be driven from its home
in this tabernacle, whose frailty is now staring it in the face—and
then too, there are times when he has converse with it as it is
becoming reinstated in the possession of its habitation by gracious
permission of its builder, who alone can repair it and redeem it
from destruction. Communion with the spirit of man in such momentous
seasons, how hallowed should it be! Trifling, selfishness, disregard
of principle, how out of place are they here!

It is not my design to enter fully into a discussion of the moral and
religious duties, which devolve upon the physician in the sick room.
I choose rather to refer the reader for instruction on these points
to the excellent letters of Dr. Burder, an English physician, which I
have introduced in the Appendix. I shall therefore only notice some
of the errors which are prevalent on this subject.

The great object of the physician should be to cure the patient.
This is his vocation, and nothing should be permitted to interfere
with it. And he must be on his guard, lest he give up this object
too readily. For often, very often, especially in acute diseases,
in cases which are apparently hopeless, recovery does occur. The
physician therefore should avoid, even in desperate cases, producing
the impression upon the mind of the patient, that he really believes
the case to be hopeless. Nothing but the most absolute certainty
would warrant his doing this. The cordial influence of hope,
as I have shown in the chapter on the Influence of Hope in the
Treatment of Disease, is often one of the means by which a recovery
is effected, and _the absence of this one means may prove fatal_.
Who then will dare to take the responsibility of withholding this
cordial, often so essential a remedy, with the vain expectation (for
experience shows that it is commonly vain,) that in the midst of all
the turmoil and agitation of the fearful struggle of life and death
for the mastery, the spirit may be led to make its peace with its
God? And yet it is often claimed, that the physician should under
such circumstances declare to the patient the certainty of his death;
and if he decline doing so, he is blamed for what is considered to be
a palpable neglect of duty.

Vain expectation, I say it is, which many indulge, of producing
repentance and reformation at such an hour. The mind is weakened by
the disease, thought and feeling and sensation are all confused,
the dim vision of the eye of flesh is the faithful index of the dim
vision of the mind, and the poor soul, while it sees everything thus
confusedly, is tossed about upon the billows of conflicting passions
and hopes and fears. It is true that there is a power, which can
pluck it from the billows, and plant its feet upon the rock of ages.
It is an almighty power that cannot be limited; but we have reason
to think, that seldom is this signal interposition put forth in this
extremity. A true philosophy declares, that this is no time for
the clearness of view, and definiteness of action, which religion
demands of man, and experience affirms the truth of the declaration.
Clergymen and physicians, who have had ample opportunities of
observation upon this point, have but little confidence in any
apparent change of character at the hour of death. It is their
universal testimony, that those who have made professions of
repentance and reformation, when they supposed themselves to be
near dying, and yet have recovered, have commonly given no evidence
afterward that those professions were well founded.

The above remarks have been made, it will be seen, in regard to acute
diseases only, and they apply to but a very limited extent to cases
of _chronic_ disease. During the lingering days, and weeks, and
sometimes months, of such cases, there are many opportunities for
exerting an influence upon the sick. And while it is true, that the
physician should adhere to the general rule, which I have stated in
regard to the effect of hope, it is his duty, and especially is it
the duty of the friends, to improve the opportunities which present
for the best good of the patient. And here let me say, that it is not
the formal and stately conversation, the professional sermonizing,
so often made use of, which is really the most effectual; but it is
the word dropped from day to day, with a spirit not roused up for
the occasion, but breathing forth naturally and easily—it is the
instruction suggested by events of daily occurrence, or by remarks
which are dropped in common conversation, and accompanied by the
affectionate appeal, when it is seen that the proper chord can be
struck—this is the kind of influence, which is brought to bear most
decidedly upon the moral and religious character of the sick man. It
is this that will enter his heart; while the arrows, which are duly
heralded by the note of preparation, will fall to the ground, warded
off by the shields which he raises against them.

Injudicious attempts are sometimes made to influence the sick, both
with regard to their temporal, and their eternal interests. I will
cite but a single case in illustration. It is a case which was
reported by the late Dr. Hale of Boston, in his work on Spotted
Fever. Although the patient was so sick, that Dr. H. considered it
of the utmost importance that he should be kept quiet, and gave the
most positive and authoritative injunctions to this effect, yet a
friend, to whom the proper adjustment of the sick man’s affairs,
if his sickness was to end in death, was a matter of considerable
interest, persisted in harrassing him on this subject. The result was
an alarming increase of the disease. The symptoms were afterward,
however, so much mitigated, as to give some ground for hope of a
recovery. As his mind was clear and rational when he came out of his
stupor, “his attendant with a very benevolent but mistaken zeal,
thought it more important to improve this opportunity in taking
care of his soul’s health, than in administering the remedies which
had been prescribed; and, instead of giving the medicines with care
and attention, and promoting his rest and quietness, as he ought
to have done, and had been strictly enjoined to do, he spent the
whole time in talking, and exciting him to talk, of his hopes and
prospects beyond the grave.” This conversation was continued for
about two hours, and then the patient sank back into a stupor, a
state of collapse which was caused by the previous excitement, and
he never awoke. If the quietness enjoined by the physician had been
maintained, this case would probably have resulted in recovery.

There are some cases, in which it is clear even to the careless
observer, that it is wrong to excite the mind of the patient on any
subject. Take, for example, a case of typhus fever. Even though it
may not be a severe case, the mental with the physical sensibilities
are so blunted and deranged, that no moral or religious influence
can do any good. If it rouse the patient’s torpid mind to action, it
will only do harm by the disturbance it creates; and if it produces
a mild, quiet effect, which may be gratifying to his friends, it
is worthy of no confidence, and when he recovers he may have no
recollection of the sayings which he uttered, and which would have
been garnered and kept, as a sacred treasure, by friendship and love,
if death had transported him to another world.

In such a case as this, when the mind is in so passive and torpid a
condition, the path of duty is clear. But there are some cases in
which it is difficult to know what our duty is. We must then decide
as well as we can in view of all the circumstances. And let me remark
here, that there should be no inconsiderate and irresponsible action
at such times; but what is done should be the result of a candid
conference between the physician and the friends of the patient. The
clergyman should not be disposed to act independently, and from his
own judgment alone; but, for obvious reasons, he should consult with
the physician in regard to each individual case.

Some are very anxious in regard to the spiritual welfare of the sick,
when they are thought to be nigh unto death; but if death does not
ensue, the moment that convalescence begins their anxiety ceases.
Religion with them is altogether a thing for great occasions, and the
season of death is of course one of them. Anything which is exciting
arouses them to action, and awakens their sympathies for their fellow
men. But they make little account of the every day influence which
is exerted in their common intercourse—an influence vast in amount
in a long life, though it may not be palpable in its results at any
one moment. While they would press upon the sick man the solemn and
faithful appeal, when they saw him to be near the borders of the
grave, and concentrate upon that dread hour all their energies, they
would perhaps, if he should recover, not even visit him at all during
his convalescence, and the first time they met him they would welcome
him back to that worldliness, in which they in common with him so
freely indulge.

And yet it is in convalescence generally that you can exert the
greatest influence upon the sick man. For look at the circumstances
of the case. He has just been released from suffering. The
recollection of those hours, when thought and feeling and sensation
were so confused, and all was dark and dim, is still vivid in his
mind. The world, from which he has been thoroughly secluded for a
little time, now opens fresh upon him again—a new sun shines upon
him, and he looks out upon a new earth. The pure air, as he remembers
the stifled breath and the languor of disease, has an invigorating
buoyancy that it never had before; and he now for the first time
knows the luxury of such common blessings as breathing, and again
and again he expands the chest to the full, to see how beautifully
it does its work. He feels the genial glow of returning health
pervading every part of his system, diffusing elasticity, energy,
I had almost said joy, everywhere. And then as he goes forth, he
meets on all sides the kind greetings of friends, some of whom had
been by his bedside during his sickness. All these circumstances
conspire to make both the sensations of his body and the feelings
of his heart agreeable, and thus open the avenues to moral and
religious influences. And then, too, the cares and selfishness of
the world have not yet resumed their control over him. When, I ask,
could there be a better time to awaken in that man’s heart proper
feelings towards his Maker, and toward all around him. As he comes
out afresh into life, with something of the simplicity of a child,
disencumbered by his sickness of the entanglements which had
gathered around his mind and heart in the midst of temptation and
sin, how easily can he be led to appreciate what is right, and good,
and enduring, in this evil and transitory world. His mind is not
now weakened, nor his sensibilities blunted or deranged by disease.
There is no dim vision now, but he sees things as they are, and his
sensibilities are lively and ready to respond to the touch of the
hand of friendship, like the chords of a newly-attuned instrument
that gives forth its clear and harmonious sounds to delight the ear.

I cannot dismiss the subject of the moral influence of physicians
without adverting to one topic, which I deem to be of no small
importance.

Every man, aside from the influence which he exerts as a citizen in
common with others, exerts also an influence through the business or
profession in which he is engaged, by the manner in which he performs
its duties and maintains its relations. There is a strong disposition
in the community to separate these influences, and to assign to them
for their governance two different sets of moral principles. This
disposition is very marked in regard to politics. But it exists
also in relation to other professions and employments. It has even
extended to medicine. Men often do as _physicians_ what they would be
ashamed to do as _men_. The strict morality of common intercourse is
relaxed in professional intercourse. But the man and the physician
cannot thus be separated. Obedience to principle, no matter in what
it appears, always has its good influence; and the same universality
attaches to the bad influence of disregard of principle. There is a
moral character belonging to every act. Strictly professional acts
and relations have a moral influence. If the physician has a proper
regard for the character and standing of his profession, promotes an
honorable intercourse among its members, upholds its organizations,
resists the encroachments of quackery, and helps to secure a good
standard of medical education, he in all these ways exerts an
indirect but important influence upon the general good order and
well-being of society. But if, on the other hand, he has no true
regard for the honor of his profession, sacrifices its interests to
his own aggrandizement, labors for success by intrigue and manœuvre,
and thus gives a license to quackery, though he may call himself a
strictly moral man, and be so esteemed by the public, he exerts by
his professional course a decidedly bad influence upon the general
tone of morality in the community, and therefore does not merit the
appellation of a good citizen.


FOOTNOTES:

[44] Our profession, to its honor be it spoken, has as a whole, done
much for the cause of temperance. “Dr. Rush,” says Dr. Stevens,
“paved the way to the great TEMPERANCE reform, and that cause, at
a later period, had no advocates more powerful than Dr. Sewall of
Washington, and Dr. Watts of New York, formerly President of the
College of Physicians and Surgeons. Among the living it now reckons
Dr. Warren of Boston, and Dr. Muzzy of Cincinnati, and a host of
other medical men.” It gives me much pleasure to state in this
connection, that at the great entertainment given by the physicians
of Massachusetts to the National Convention, at which there were more
than six hundred present, ‘the feast of reason and the flow of soul’
were ample and rich without the aid of the intoxicating cup.




CHAPTER XIX.

TRIALS AND PLEASURES OF A MEDICAL LIFE.


The physician has his peculiar trials, and also his peculiar
enjoyments. The principal of these it is my intention to notice very
briefly and cursorily in this closing chapter.

Let us first look at the _trials_ of a medical life.

The physician is subjected to great fatigue both of body and mind. He
has no time that he can call his own. That regularity of life, which
is so essential to comfort as well as to health, he must in a great
measure abandon, especially if he practice in a scattered population.
While most men have their stated seasons of repose, he is liable
to be called for at any hour, and often night after night sleep is
a stranger to his eyelids. His duties to his patients are often
of such immediate importance, that no stress of weather, however
violent, is considered as an excuse for delay. When prevailing
disease spreads terror through the community he must be at his post,
and expose himself to the pestilence under the influence of powerful
predisposing causes—anxiety and fatigue. And then there are at all
times anxieties and perplexities, producing a wear and tear of mind,
which is worse than all the bodily fatigue that he is called to
endure. It is not surprising then, that it has been satisfactorily
ascertained by statistics, that physicians constitute one of the
short-lived classes of the community.

And for all this generally the medical man gets comparatively a small
compensation. Though some physicians acquire wealth, especially
in our large cities, still as a body of men they are in moderate
circumstances, and the practice of medicine may be truly said to
be far from being a money-making business. A large proportion of
those whom they serve are too poor to give them any compensation,
and very many of those who are able to pay them do not without
reluctance and delay. This, it is true, is in part to be attributed
to the remissness of physicians in presenting their claims. But why
this remissness? If I mistake not, it arises from the unwillingness
to pay, which they so often meet with, even in quarters where they
have no reason to expect it. The consequent dislike to the business
of collecting begets a habit of neglecting it. A large proportion
of their patients feel a less urgent obligation to pay them, than
they do to pay others. I know not any other reason for this than the
_intangibility_ of the favor which is bestowed by the physician. If
a man buy a coat of the tailor, or a barrel of flour of the grocer,
he has a _tangible_ memento of his obligation; for the coat is seen,
and is felt upon his back, and the flour is eaten, and makes its
_sensible_ impression on the palate and stomach. But health restored
is a thing of air, and the visits of the physician, as they have
left no memorial behind them that addresses the _senses_, are easily
forgotten. For the same reason a man will not so easily forget his
obligations to his physician if he has amputated a limb for him, as
he would if he had attended him through a course of fever. His crutch
or his wooden leg, is ever present to remind him of them. And for the
same reason also, as the tailor and grocer can get their pay more
readily before the coat is worn out, and the flour is eaten up, than
they could a long time afterward, so the physician is more cheerfully
paid immediately after returning health, than he can be at any future
period.

While the physician is ordinarily but poorly compensated for all
his toil and anxiety, he is obliged often to see the quack and
hobby-rider amassing wealth by their gross impostures. Often does
the scientific and laborious practitioner, who is adding from his
daily observations rich treasures to the recorded experience of the
profession, suffer from the _res angusta domi_, while he sees some
proprietor of a patent medicine, the recipe for which he purchased of
some recreant physician, or filched from some medical book, acquiring
a fortune almost in a day, or some ignorant pretender, adopting
some system just then high in the popular favor, as Homœopathy for
example, making in a brief year or two all the display of a wealthy
citizen. And the offensiveness of such cases is enhanced by the
fact, that many of the well-informed and the learned unite with
the multitude in casting contempt upon the labors of science, by
upholding the pretensions and filling the coffers of sheer imposture.

The facility, with which the public are imposed upon in regard
to medicine, is a prolific source of vexation and trial to the
scientific and high-minded physician. He is subjected to a constant
encounter with false opinions, unfounded prejudices, unreasonable
caprices, and gross misapprehensions. He hears ignorance in high
places, as well as in low, putting forth its oracular opinions, as
it sits in judgment upon his practice, and that of his brethren.
The most reckless criticisms are made upon his mode of treatment in
individual cases, and the most inconsiderate and wanton aspersions
are cast upon his professional character.

If the practice of imposition were confined to those who are without
the pale of the profession, it would be a trial which could be borne
with comparative ease. But when the physician sees his own brethren
stooping to an occasional use of the arts of the charlatan, and
obtaining success thereby, even among the better portion of the
community, while they do it so covertly that they do not lose caste
with the profession, it is a sore trial to his spirit. He cannot but
regard such men as the chief enemies of the honor of his profession,
though they may talk loudly of their attachment to it, and as real
opposers of the advancement of medical science, though they may make
a great show of zeal in its pursuit. And yet so adroitly do they
manœuvre, that they generally escape exposure. This sly quackery,
which is practised by so many medical men, provoking an indignation,
to which it will do no good to give utterance, is one of the
prominent trials of the truly honorable physician.

It is a severe trial to the feelings of the humane physician
to see valuable lives sacrificed to a blind trust in ignorance
and unskilfulness. He is occasionally obliged to witness such
a sacrifice, and ordinarily under such circumstances that any
interference on his part would do no good, however strangely he
may be urged to it by the dictates of humanity. If he utter the
warning voice, however clear the case may be, it will be ascribed
to interested and unworthy motives. He may feel deeply for the poor
sufferer who is to be sacrificed, and for the family who are to be
thus bereaved by the ruthless hand of unskilful ignorance; but hard
as it is to hold his peace, he in most cases feels that he must do
it, because if he do otherwise, he will not only spend his breath in
vain, but will add to the evil by his ineffectual opposition.

The many sad scenes in which the physician is obliged to mingle
must often make him sorrowful, if he has not suffered his feelings
and sympathies to be destroyed by a total dereliction of principle.
As he watches with earnestness the struggle which occurs in severe
cases between life and death for the mastery, and does what he can to
give it a favorable issue, how deep is his anxiety, how painful the
sense of his responsibility, what balancings of hope and fear does he
experience; and then when the dread moment comes, when after all this
pressure and conflict of feeling, the physician becomes persuaded
that the issue is certain to be fatal, how is his spirit borne down
with the burden of his grief! And then, too, there are cases, in
which, though he has from the first had strong hopes of a favorable
termination, all at once a train of symptoms arises, threatening
immediate destruction. And to add to the painfulness of the case,
perhaps the friends of the patient have not perceived the change, so
secret has it been. As he goes to make his usual daily visit, cheered
with the expectation of finding his patient better, he is overwhelmed
with surprise when he sees, as he enters the sick chamber, that
death is rapidly and surely doing its work. Besides seeing his own
hope extinguished in a moment, he feels an unutterable pang in the
necessity, thus suddenly pressing upon him, of destroying the hopes
of the fond friends by whom the patient is surrounded.

In the Chapter on the Moral Influence of Physicians, I have spoken
of the intimate relation, in which the physician stands to so many
families, and of the strength and tenderness which his attachment
to them acquires, by the exercise of an active sympathy during a
long series of years. The accumulation of sympathy which thus occurs
deepens the sorrow which he feels, as he sees in the case of some
member of a family, upon which he has long attended, that his
efforts are unavailing, and that the resources of his art are all
exhausted. And as the friends gather round the bed of death, though
by a habit of self-control he has an air of composure which is
generally attributed to want of feeling he makes one of that circle,
entering into their griefs as the sympathizing friend, as well as
the faithful physician. And the very confidence which is reposed in
him, gratifying as it is, sometimes adds poignancy to his grief. ‘You
saved _my_ life, and why cant you save my husband?’—said a woman to
me in the extremity of her agony, when I told her that it was not
possible for her husband to recover.

Another circumstance which adds to the sorrow of the physician in
such seasons, especially when long acquaintance has created a strong
personal attachment, is the total want of preparation with which many
come to the hour of death. Even if the physician be not a religious
man, this consideration must press upon him at times with a painful
interest, if he has the common feelings of humanity. Especially
will this be the case, when he is obliged to witness some of those
horrible scenes, which sometimes occur in the last hours of a career
of vice.

The sorrowful scenes, which the physician witnesses occasionally in
the ordinary routine of his business, come with a painful frequency,
when some fatal epidemic is prevalent in the community. Then night
and day his mind is filled with anxiety. The sorrows of bereavement
continually call for his sympathy. And in the midst of all this, he
avoids solicitude for his own safety, only by forgetting himself in
the arduous duties which he performs for others’ welfare. While he
sees others fleeing from the pestilence, he must be ever at his post.
Though he may see some of his brethren falling around him, humanity
demands of him that he should go on in his services to the sick,
and to the honor of our profession I believe it may be said, that
this demand is very seldom disregarded. During the prevalence of the
yellow fever in Philadelphia in 1793, of the thirty-five physicians
who remained in the city, eight (nearly one fourth of the whole
number, died, and but three escaped an attack of the disease).

One of the greatest trials which the physician has to bear is the
ingratitude of those upon whom he has conferred favors. There are
services rendered by the medical man who is faithful to his high
trust, for which no money is an adequate compensation. His reward
for such services comes from two sources—the satisfaction always
attending the performance of duty, and the gratitude of those to whom
they are rendered. The wealthy by no means discharge in full their
obligations to the physician, who attends upon them in all their
sickness with unwearied fidelity, when they pay him in full for his
attendance. They owe to him the affection of a true friendship, and
the gratitude due to something more than a professional performance
of duty in their behalf. The relation of a physician to his
employers is not shut up within the narrow limits of mere pecuniary
considerations. There is a sacredness in it, which should forbid
its being subjected to the changes incident to the common relations
of trade and commerce among men. But many do not so regard it. They
dismiss a physician for as slight a reason as governs them in ceasing
to buy of one man, and giving their patronage to another, or, as
Dr. Rush says, “with as little feeling as they dismiss a servant,
or dispose of a family horse.” A mere whim, or caprice, is often
suffered to dissolve this relation, though it may have existed for
years. And generally the more frivolous and unfounded the reason for
the change, the greater will be the zeal with which they laud their
new favorite, and the harsher will be the aspersions, which they will
cast upon the professional character of the old and tried friend,
whom they have deserted.

Strange as it may seem, it is the experience of every physician, that
some of the strongest evidences of ingratitude come from some of
those upon whom he has conferred the highest favors, perhaps those
which are entirely gratuitous. One would suppose that they who have
had the services of a physician without making him any compensation,
would from motives of delicacy refrain from speaking ill of him,
if they chose to discharge him and employ another. But blame is
sometimes dealt out without stint under such circumstances. It would
be supposed also that the obligation, which a gratuitous attendance
imposes, would always be gratefully recognized by the patient.
But it is often otherwise. Many patients are disposed to forget
such obligations; and everything which may call them up to their
attention, and especially to the attention of others, is carefully
avoided. Dr. Rush speaks of some who had been attended gratuitously
in humble life, who deserted their family physician after their
elevation to rank and consequence in society, “lest they should be
reminded, by an intercourse with him, of their former obscure and
dependent situation.”

There is not as much gratitude in the world as is commonly supposed.
This is particularly true of the services of a physician. These are
received by many, as a matter of course, as being something to which
they have a sort of natural right. They seem to class them among the
common blessings, such as air and water, for which, because they are
so common, they have no idea of being grateful. Day after day, and
week after week, they may be the objects of the physician’s most
assiduous attentions, and his exertions may be blessed, and obviously
so, to the preservation of life; but when health comes they will
grudge him even the pittance of a half day’s labor from those hands
to which his skill has restored strength, though they spend days
and weeks every year in the most shiftless idleness. Quite a large
proportion of the poor treat the physician in this way.

An old physician of my acquaintance was used to say that there are
three kinds of poor—the Lord’s poor, the devil’s poor, and poor
devils; that is, the virtuous poor, the vicious poor, and those
who are poor from sheer shiftlessness. The _virtuous_ poor are
always grateful; and there are none among the wealthy upon whom the
physician attends more cheerfully, than he does upon some of this
class. Of his kind offices to them, and of their feelings in return
to him, it can be said in the beautiful language of Scripture, ‘When
the ear heard me, then it blessed me; and when the eye saw me it
gave witness to me: because I delivered the poor that cried and the
fatherless, and him that had none to help him. The blessing of him
that was ready to perish came upon me; and I caused the widow’s heart
to sing for joy.’ As the physician goes his daily rounds, there
is no one thing that so cheers him on in his course of toil and
benevolence, as the gratitude of the virtuous poor. And if there will
be tears shed at his death beyond the little circle of friends, in
the very bosom of which he lives, _they_ will shed them profusely and
long.

Not so, however, with the other two classes of the poor. The
shiftless poor, who were denominated by my aged friend ‘poor
devils,’ who go just as wind and tide will take them, and carry to
ultraism the principle of letting to-morrow take care of itself, are
actually too lazy to have so lively a feeling as gratitude. And
of the _vicious_ poor it may be said, that it requires something
more than the selfish principles of this world to attend upon them
with cheerful faithfulness. There is often, it is true, much show
of gratitude; but it is seldom, though it is sometimes, more than
mere show. The romance of doing good will not stand this trial.
Nothing short of the untiring benevolence of Christianity will do
it. Sometimes, indeed, so much effect is produced upon the views
and feelings of the poor by the bounty and kind attentions of the
benevolent, that an actual reform is effected, and an abode of vice
and misery is converted into one of virtue and happiness. Then, of
course, the most lively gratitude is manifested. But it is rarely so.
We must apparently _throw away_ much time and effort, and it is only
once in a great while that our hearts can be cheered by any obvious
good results, or any real gratitude. Benevolence does now and then
seem to have a magic wand, with which, almost in a twinkling, she
turns scenes of gloom and desolation into those of beauty, and makes
even the wilderness to blossom as the rose. But she is generally
employed in real drudgery with little immediate prospect of success.
She digs and digs patiently, and with the animation of hope. She
finds but few gems; but these, be it remembered, will survive all the
changes of time, and will shine in her coronet forever.

It is true that gratitude is sometimes awakened in the heart of
the vicious poor, even when our influence does not produce any
improvement in their moral condition. But it has only a momentary
existence, and, amid the giddy whirl of grovelling enjoyments, our
kindness is forgotten, and the recollection of it is excited only
by their returning necessities. And then too, the apathy, into
which the heart is apt to be schooled by the miserable monotony
of a vicious poverty, effaces every trace of feeling which may
occasionally be impressed upon it. This state of heart may be read
in the very countenance—the wooden features, which our kindness may
have roused to some degree of animation, soon resume their wonted
inexpressive fixedness after the exciting cause is gone. And often,
very often, the favors we dispense are received with a vacant stare,
the recipients being strangers themselves to any other motive than
selfishness, and therefore taking no cognizance of the existence of
anything like benevolence in the bosoms of others.

There is one class of the community that have been accustomed to be
attended gratuitously by physicians, who have so often wounded the
feelings of our profession by the course which they have pursued,
that I cannot pass them by without a particular notice. I refer to
clergymen. So scantily are they generally compensated for their
services, and so intimate is the relation which they hold to our
profession, that medical men have commonly very cheerfully made
their attendance upon them gratuitous. This being the case, they
have a right to expect of them, if not gratitude, at least a proper
regard for their rights as professional men. But I am constrained to
say that many of this class have failed to answer this reasonable
expectation. The physician often finds, that the clergyman, upon
whose family he has attended without charge, perhaps for a long
time, gives his certificate in recommendation of some nostrum, or
employs some quack, or becomes the noisy advocate of some new system
just now rising into popular favor, or perhaps, in his zeal for his
sect, becomes the active patron of some practitioner of his own
denomination, urging him even upon the families of the physician
whose services he has so long gratuitously enjoyed. Such acts as
these on the part of men who have received such favors, and who by
their station and character can exert so much influence, are among
the most vexatious trials of a medical life.

The feelings of the physician are tried not only by the treatment
of individuals, but by that general disposition against the medical
profession, which is to some extent manifest in every community. If
you look candidly upon the public benefits[45] which our profession
has conferred upon society, to say nothing of its toils and
self-denials, you will be impressed with the fact, that it does not
receive that respect and that regard for its interests to which it
is fairly entitled. The radicalism which aims to overthrow it is
in some measure countenanced by many, of whom we have a right to
expect better things. Many of the intelligent and well informed pay
an occasional tribute to empiricism, and manifest a distrust towards
medicine, which they do not manifest towards any other science.
Though they would be sure to employ none but lawyers of known
skill, and would sit under the teachings of none but well educated
clergymen; if sickness comes, they resort to some secret nostrum,
or employ some pretender, of whom perhaps they know little else,
than that he calls himself a German, and has an abundance of hair
about his visage; and if they have a dislocated or fractured bone,
they abjure scientific surgery as unworthy of confidence, and send
for a natural bone-setter. The reasons which secure their respect
for other sciences fail altogether when they come to medicine. They
even indulge in a playful contempt in speaking of its claims. They
banish it from the pale of reason; and submit themselves to vagaries
and fallacies and pretensions, the folly of which they would see
at once in relation to any other subject. They refuse to give to
either the science, or the profession, that steady esteem which is
clearly due to it from all stable and intelligent men. In seasons of
trial even, instead of extending to physicians their confidence and
support, they reward their toils with an ungenerous and inconsiderate
fault-finding. This ingratitude of the public is sometimes manifested
in the most offensive manner. After the yellow fever in Philadelphia
in 1798 had subsided, at a meeting of the citizens, in which the
committee who superintended the city during the prevalence of the
disease was honored with a vote of thanks, a similar vote was
proposed in relation to the physicians, _but was not even seconded_,
though, as I have stated in another place, nearly one fourth of their
number perished, in their efforts to save that ungrateful people from
the ravages of the pestilence.

Let us turn now to the consideration of the _pleasures_ of a medical
life. On this branch of the subject I shall be brief, not because the
physician has few joys, for he has many, but because they require no
extended notice to make the reader appreciate them.

If we look at medicine simply as a science it is full of interest,
and the study of it is therefore a rich source of gratification. Its
subjects have a wide range and an endless variety. No science has
such extensive and intimate connections with other sciences.[46] It
gathers to itself the resources of chemistry, botany, mechanics,
comparative anatomy and physiology, and mental philosophy; and fills
its storehouse of facts with a variety and abundance sufficient to
satisfy the wildest and most eager curiosity. The phenomena of life
even in the healthy condition are exceedingly diversified; but, as
modified by disease, and by the remedies which are administered,
their variations are never ending. And then the mysterious connection
of mind and body not only varies them still more, but opens to us
a mass of facts of a mingled mental and physical character, which
awaken an intense interest. The physician looks upon the human body,
not merely as a machine filled with contrivances so cunning and
elaborate, as to render all the mechanism of man in the comparison
rude and bungling; but as a machine instinct with life, having a
living nerve attached to every fibre of it, giving to it its power to
act; and, more than all, as a machine holding in strange connection
with its every fibre a reasoning soul, the image of the Deity,
destined, not to perish like the mind of the brute with the perishing
body, but to live through the ages of eternity.

The details of a science which treats of phenomena so interesting
in their character, and so wide in their range, are never dry and
uninteresting, as the details of other sciences sometimes are. There
are no tedious technicalities, no dull abstractions. There is no
tiresome monotony. There is therefore an absorbing enthusiasm in
the pursuit of medical science, which is not so common in other
studies. It is an enthusiasm which makes its votary disregard the
loathsomeness of putrefaction, and even forget danger, in his search
after truth.

An additional interest is given to his investigations by the
consideration, that if he discover a fact, or help to establish one,
he adds to the resources which our art can apply to the relief of
human misery. To experience this pleasure, so gratifying to the
humane and benevolent mind, he needs not to make any grand discovery.
The joy which Jenner realized in the contemplation of the benefits
of his discovery must have been almost overpowering; but the benefit
which results to our race from the humblest contribution to medical
knowledge is as real though not as great, and is a fitting subject
for joy to him who makes it, for it will assuage many a pang and save
many a life.

In the practice of medicine, though there is, as you have seen in my
first chapter, much uncertainty, there is a high satisfaction in the
very exercise of unravelling its perplexities, and in separating,
as it can be done by untiring and careful observation, the certain
from the uncertain, the true from the false. And though much is left
to nature by the judicious physician, still there is much pleasure
in watching her movements, in removing obstacles which oppose her
salutary processes, and in assisting her efforts so far as it may be
necessary to do so. This intelligent watch and guidance which medical
skill exercises over nature in removing disease is far from being
unsatisfactory to the rational practitioner. And then, too, though
the general use of _heroic_ remedies is injurious, there are times
when the careful observer sees opportunities for employing them to
great advantage in arresting morbid processes. And so accustomed
is he to make the requisite discriminations, that his efforts in
positive medication are well directed, and are almost sure to
accomplish their object. He has a satisfaction in such achievements,
of which the undiscriminating overdoser knows nothing.

The judicious physician experiences much gratification in the
_mental_ management of the sick. I refer not merely to the control
which by his tact and skill he exercises over the mind which is
manifestly deranged, but also to those multiplied and various mental
influences which he exerts so silently, but so effectually, even in
ordinary cases of sickness. Besides the pleasurable interest with
which he watches the operation of these influences, there is also a
high source of gratification in the consciousness of possessing such
a power over the minds of his fellow men. Especially is this the
case, when the power which he puts forth is exerted upon minds of
great refinement, and of a high order of talent.

The _results_ of the practice of the skilful and judicious physician
are as a whole very gratifying to him. His vocation is to relieve
pain and distress, and to deliver from disease; and when he fails
to do this, sad as it is, it is an occasional, we may say a _rare_
exception to the general result. In the great majority of even severe
cases, in which the pressure of responsibility is such a burden upon
his spirit, and the alternations between hope and fear are often so
painfully exciting, his heart is at length gladdened by a favorable
issue. The physician is therefore by habit a hopeful, a cheerful, a
happy man. As such he enters the sick room, the scene of the triumphs
of his art. As such he mingles in the family and social circles of
his fellow men, inspiring by his very air and manner cheerfulness in
the sad, and hope in the unfortunate and dispirited. The physician
then is apt to be not only the sympathising, but the _comforting_
friend.

But not only is the success with which he meets in combatting disease
a source of happiness to the physician, but so also especially is
the gratification of his humanity and benevolence, in relieving the
distresses of his fellow men, and in prolonging their lives. In some
cases in which the life which he has struggled to save is a valuable
one, the joy which fills his heart at the final successful issue of
that struggle no words can express.

It will be observed by the reader that in speaking of the
gratification which is derived from the successful treatment of
disease, I have had no reference at all to the _reputation_ for
success which is awarded to medical men by the community. This may
be based upon real merit, or it may not be. When it is not, but is
acquired by making false issues before the public, as is too often
the case, it is indeed a source of gratification—a gratification,
however, which is not only of a low order, but the hold which the
possessor has upon it is exceedingly uncertain. He feels it to be
so, and is in constant fear that some competitor, practising the
same arts, will overmatch him in skill, and filch from him his
ill-gotten joys. But on the other hand, the success of the honorable
practitioner in acquiring a medical reputation, based as it is upon
intelligent grounds, is a source of high gratification, and he has,
too, the satisfaction of feeling that it is a permanent possession.
True, there are some who employ and praise him from whim and caprice,
who from whim and caprice may desert and blame him; but his patients
are for the most part those who repose in him an intelligent and
firm confidence. And this affords him a gratification, of which
the caprices of the world and the intrigues of his brethren cannot
despoil him.

The attachments which the physician forms in so many families in
the different walks of life are rich sources of happiness. These
attachments are generally reciprocal. In some cases the interest
which he feels in the patient, beginning in infancy, and extending
through many scenes of sickness up to adult age, has accumulated all
this time more and more strength and tenderness. Sometimes in the
long life of a physician, this interest in some families of patients
reaches through three or even four generations. And these intimate
attachments bring the physician into very near relation with some
characters of rare excellence in the different walks of life. The
admiration and the love with which he looks upon such noble spirits,
of whom the world is not worthy, and the communion which he is
permitted to have with them up to the moment of their departure to a
world of bliss, are among the highest sources of the happiness of the
physician.

The opportunity which the physician has for observing human character
is a prolific source of enjoyment. It opens to him one of the most
interesting of all studies, and in his daily intercourse with
patients of every variety and degree, he finds no lack of material in
illustration of any supposable variation of character.

The nature of the physician’s employment, it must be obvious to
the reader, is calculated to fit him eminently to enjoy and to
adorn social life. He is commonly the pleasing companion as well as
the warm and faithful friend. The freedom of his intercourse with
all sorts and conditions of men imparts an ease and a zest to his
conversation, and he has an abundance of facts and anecdotes to
illustrate every remark which may be made. It is for this reason, as
Dr. Rush says, that “physicians in all countries have been the most
welcome guests at the tables of the great, and are frequently waited
for with the most impatience at clubs and in convivial companies.”

One of the chief sources of the happiness of the physician is the
gratitude of his patients. I have already said enough upon this
subject, and I would now simply remark, that, though there is much
ingratitude which is a sore trial to him, many of his patients
gladden him in the midst of his toils and anxieties with tokens of
gratitude of the most delightful character. And among these tokens,
the testimonials which he receives from the poor, humble as they are,
are often more highly prized than the costly and splendid presents of
the wealthy.

Finally, a great source of happiness is afforded to the truly
benevolent physician in the opportunity which he has for exerting
a good moral influence. When by his instrumentality the abode of
vice and misery has been converted into one of virtue and peace,
and especially when his counsel and influence have been the means
of saving a soul from death, he has a higher joy than all success
however brilliant, and honor however profusely awarded, and gratitude
however ardent, can impart to his soul.

In conclusion I remark, that, though the trials and disappointments
and mortifications of a medical life are numerous, very vexatious,
and sometimes almost insupportable, yet the pleasures which come
from the sources to which I have alluded vastly predominate over
them all, and make the practice of medicine, when pursued with right
motives, as a noble profession, and not as a trade, to be in the main
eminently satisfactory and delightful.


FOOTNOTES:

[45] To estimate the public benefits which the medical profession
has conferred upon the world, you need only to look at the zealous,
and I may say _leading_, agency, which it has always exercised in
instituting and maintaining Hospitals, Asylums for the Insane,
Institutions for the Instruction of the Deaf and Dumb, and the Blind,
and Associations for the advancement of the sciences.

[46] Hence comes the fact, that many of the most eminent men in the
various departments of science have been furnished from the ranks of
the medical profession.




APPENDIX

LETTERS[47]

FROM A SENIOR TO A JUNIOR PHYSICIAN.

ON THE IMPORTANCE OF PROMOTING THE RELIGIOUS WELFARE OF HIS PATIENTS.


LETTER I.

ON THE DIFFICULTIES OF THE UNDERTAKING.

  MY DEAR FRIEND,

You were pleased to desire me to send you the result of my
observation and experience on the deeply interesting subject of
endeavoring to promote the spiritual welfare of the sick committed to
your care. I cheerfully accede to your wish, although I can scarcely
hope to offer any suggestions which have not already occurred to your
own reflective mind.

If the soul of man be immortal, and if the state of the soul, at
the moment of its separation from the body, determine its happiness
or misery through endless ages, with what deep solicitude should
every Christian approach the bed of a fellow creature, who, to
all appearance, is about to undergo the momentous change, yet
unprepared “to meet his God!” If we saw a human being proceeding
blindfold towards a tremendous precipice, even already at its brink,
how eagerly should we try to snatch him from the threatening
destruction! And can we, my friend, remain insensible to the
spiritual danger of the dying man, who seems about to “take a leap
in the dark” into the gulf of inconceivable—irretrievable ruin?
How often, alas! are we called to witness the appalling scene,
unalleviated by the presence of a Christian minister, or any pious
relative, who might direct the helpless sufferer to Him, “who is able
to save to the uttermost!”

I am aware, indeed, that those alone who, like ourselves, have
felt the weight of medical responsibility, can fully estimate the
difficulties to be encountered in attempting to advance the _highest_
interest of a patient, while conscientiously discharging our primary
duty, in the exertion of our utmost efforts for the restoration or
relief of his bodily frame. Even to those, who, by habits of early
rising, punctuality, systematic arrangement, and calm despatch, have
been able to allot a sufficient portion of time to each appointment
of the day,—how often does it happen that some unexpected emergency,
some sudden complication of disease, the alarming sickness of
another member of the family, some anxious inquiries of the patient
or his friends, or other unforeseen circumstances, have more than
consumed the allotted time, and in justice to the indispensable
claims of other cases, rendered an immediate departure necessary:
thus affording no opportunity of even alluding to “things unseen and
eternal.”

Another difficulty is often found to arise, from the almost exclusive
occupation of the physician’s mind by the diseased condition of
the sufferer, the relief of which is, of course, our primary and
incumbent duty. In order to give to each symptom, as well as to the
whole assemblage of symptoms, a close and discriminating attention,
and to adapt, with equal care, a corresponding treatment in medicine,
diet and general management; to do this within a limited space of
time, requires a concentration of all the energies of the mind in a
degree scarcely compatible with attention to any other subject. Under
such circumstances, it is difficult in the extreme, to dispossess
the mind of the engrossing anxiety just described, so as to leave
it sufficiently free for availing itself of any suitable moment for
introducing, with needful delicacy and tenderness, the all-important
subject of eternity. How frequently, too, have we found that by the
time we have completed our medical inquiries and directions, the
patient has become too much exhausted to render any further exertion
safe or practicable!

In addition to the obstacles already specified, you have probably,
my dear friend, sometimes encountered opposition from the mistaken
kindness of the patient’s relatives, who have deemed it next to
madness to endanger the comfortable serenity of one “whose goodness
of heart,” they persuade themselves, “must secure him a happy
hereafter.” Generally, however, the confidence reposed in the
kindness and discretion of the medical attendant, will soon allay
such a feeling of alarm, and afford the assurance that nothing will
be attempted of a doubtful or hazardous character.

But the most formidable hindrance, I apprehend, exists _within
ourselves_. I refer to the prevailing impression among us, that the
religious welfare of a patient is foreign to our province; that to
aim, in any direct manner, at promoting it, is superfluous, if not
also obtrusive; and that the attempt might be regarded, moreover, as
an unbecoming interference with the sacred office. The _sedative_
influence of this opinion is often rendered still more paralysing by
a consciousness of not possessing the facility and tact supposed to
be essential to the success of the effort. Hence, opportunities for
speaking “a word in season,” are scarcely looked for or desired. The
mind, at length, rests satisfied with an abandonment of the matter,
as hopeless and impracticable, not duly considering _whose cause it
is_, nor recollecting the divine promise that “strength shall be made
perfect in weakness.”

Such, my valued friend, are among the difficulties in our way;
great, indeed, we must allow them to be, yet, happily, they are not
insurmountable.

Assuming, for the moment, that the duties and qualifications of
the medical practitioner do not impose upon him a higher degree of
responsibility, relative to the spiritual good of his patient, than
attaches to every other well-informed Christian, in reference to
his neighbor, I may safely assert that the profession of medicine
does in no wise release its member from a duty common to all
Christians—that of embracing every opportunity to testify their
gratitude to the adorable Saviour, and their anxious desire to
extend the blessings of redeeming mercy to those who “are ready to
perish.” But the assumption itself is incorrect; for it would not
be difficult to prove that the favorable opportunities and peculiar
facilities possessed by the physician do proportionably _augment_
his responsibility, and the consequent amount of obligation. Nor can
this fearful responsibility be evaded, by a general impression of our
unfitness for the task, unless we can conscientiously affirm that we
have tried to the utmost—that we have done all that we were able to
do.

As regards the alleged interference with the ministerial office,
I may truly say that, to the extent of my own observation, the
apprehension is entirely groundless. So far removed, indeed,
are the judicious, well-timed suggestions of the physician, in
relation to the immortal interests of his patient, from anything
like interference with the sacred function, that, in the instances
in which they are most needed, they may be strictly regarded as
_precursory_ and introductory to the more direct instructions of the
minister; as opening a way for him which would otherwise be closed,
as removing ill-founded objections to his assistance, and enkindling
a desire for his spiritual counsel. In many other instances, the
Christian physician proves a powerful _auxiliary_ to the faithful
minister of Christ, especially by facilitating his visits, pointing
out at what time, under what circumstances, and to what extent,
the patient may be likely to attend, with safety and advantage, to
“the things which make for his eternal peace.” I have good reason,
indeed, to believe that the enlightened ambassadors of the Saviour,
so far from entertaining a feeling of jealousy, do really hail with
cordial satisfaction such auxiliaries, in their trying visits to the
bed of sickness and death; persuaded that none can feel a deeper
interest than a Christian physician, in the well-being of _the whole
man_, bodily and spiritually, in reference to eternity as well as to
time. And how can jealousy be felt? Is not the glory of his Divine
Master in the salvation of immortal souls, the supreme object of
every pious minister’s pursuit? If so, even the feeblest attempt to
subserve the same cause must gain his hearty concurrence. Happily,
the un-scriptural, un-Protestant notion of religious instruction
devolving exclusively on the clergy has become obsolete. As well
might the Bible itself be read and studied by them alone. The very
constitution, indeed, of our most efficient religious institutions
speaks a contrary language; especially that of the visiting and
district societies, in which the principle of lay co-operation is
clearly recognized, and the obligation thence arising is fully
avowed. In truth, it requires but little sagacity to predict that,
in the noble enterprise now in progress for evangelizing the world,
the zealous exertions of Christians generally will be more and more
called forth. Such an active and pervading influence seems evidently
implied in the prophecy of Jeremiah, as cited by the apostle of the
Gentiles, alluding to the period when “they shall not teach _every
man_ his neighbor, and _every man_ his brother, saying, ‘know the
Lord;’ for all shall know me, from the least unto the greatest.” We
have yet, indeed, to realize the happy day when, even comparatively,
_every_ man shall seek the spiritual good of his neighbor; but we
are surely authorized to expect it, as well as bound to hasten it,
by earnest prayer and vigorous endeavor. We are even encouraged to
anticipate the more distant and glorious period, when the omnipotent
Saviour shall have given complete efficiency to the universal labor
of love, and when “He shall be all in all.”

Not to weary your patience further, I will here close my letter;
hoping, in a second communication, to present a few _encouragements_
which may serve to cheer you under the difficulties we have been
considering. I shall endeavor also to add some practical suggestions,
in reference to the most eligible _methods_ of introducing the
subject of religion to persons dangerously ill. Of the power of
executing the latter part of my task, especially, I cannot but
entertain much self-distrust.

                         I remain, my valued friend,
                             Your’s, with sincere regard,
                                             T. H. BURDER.

    _Tilford House, Jan. 1st, 1836._


LETTER II.

ON THE ENCOURAGEMENT TO BE EXPECTED IN THE ATTEMPT.

MY DEAR FRIEND,

In my former communication I placed before you the considerations
which had most impressed my own mind, in reference to the
_importance_ of aiming to promote the spiritual welfare of the sick.
You will have observed that, far from concealing, I fully admitted
the difficulties attendant on the effort, while I endeavored to show
that they were by no means insurmountable. I am now desirous of
presenting to your attention a few of the _encouragements_ which the
physician is warranted to expect in pursuing this “work of faith and
labor of love.” Such, I apprehend, will be found to arise from THE
PECULIAR FACILITIES WHICH THE PROFESSION AFFORDS; FROM THE DIVINE
BENEDICTION WHICH MAY BE HUMBLY, YET CONFIDENTLY, ANTICIPATED; AND
FROM THE SUCCESS WHICH HAS ALREADY CROWNED SIMILAR EFFORTS.

1.—No one who has witnessed the respect and confidence with which
the suggestions of a conscientious physician are received, can
doubt of his possessing an almost unlimited influence in the sick
chamber. He has become, in truth, the attached friend of the
family, to whom they freely unbosom their sorrows and their fears,
particularly such as appear to be inducing or aggravating any
existing or threatened disease. Hence the medical adviser, having
gained an important acquaintance with the mental constitution of his
patient, its individual peculiarities and tendencies, and with the
varying complexion of thought and feeling which bodily disturbance
has been wont to excite, is already prepared to introduce with
delicacy and address, such incidental remarks in reference to his
highest interests as the peculiar condition of the sufferer may
naturally call forth; and in the way best adapted to interest and
impress, while least likely to endanger that general quietude, on
the maintenance of which his recovery may materially depend. Being
aware, moreover, of the different aspect in which other topics of
practical importance have at various times appeared to his patient,
or to persons under similar circumstances, while viewed through
the distorting medium of disease, he will not be surprised if the
momentous subject of religion should also share (so far as natural
effects may be permitted) in the obliquity or indistinctness of the
mental vision. The same previous knowledge will often enable him
to calculate, with tolerable precision, the degree of influence,
whether exciting or depressing, which an allusion to the realities
of eternity may be likely to exert on the patient’s bodily frame;
and thus to attemper and apportion his suggestions to the particular
exigencies of the case.

2.—Among the _facilities_ to which we have adverted, I cannot but
regard as one of the most valuable, that arising from the numerous
opportunities possessed by the physician of connecting in the most
easy and natural manner, some serious remark with his medical
counsel. So intimately, indeed, is the mind united to the body,
and so generally does the one sympathize with the sufferings of
the other, as constantly to demand a considerable portion of the
physician’s vigilance and discrimination. He cannot but observe the
baneful influence of agitating and corroding emotions, in thwarting
every healing expedient; and being constrained, therefore, to
inculcate the importance of tranquillity, acquiescence, and cheering
hope, he is led by the most gentle transition to trace those virtues
to the true source of “every good and perfect gift,” and to the
surpassing value and efficacy of the Saviour’s peace, and of the
“hope that maketh not ashamed.”

You have often, my friend, observed in the moment of danger, with
what eager, anxious attention the patient listens to every word that
falls from his physician. He knows that his friend and counsellor is
deeply concerned for his well-being, and can have no interest apart
from his. He is aware of the value of professional time, and has
experienced the unwearied assiduities which have been exerted for the
preservation of his life. Should, therefore, the physician appear
to overstep the precise boundary of his province while touching
upon the concerns of immortality, the patient, I am persuaded, will
usually regard the solicitude thereby evinced, as an additional and
gratifying proof of genuine friendship. The sick man has also the
tranquillizing conviction, that nothing is likely to proceed from
his judicious adviser which would either aggravate the disease,
or interfere with the salutary operation of remedies. Hence, no
alarm, no perturbation is induced; while two or three well-adapted
hints are gaining a quiet admission into the mind, and affording
useful materials for private meditation and self-inquiry. Now, my
dear friend, if such be the advantageous position of a humane and
Christian physician in the chamber of sickness, and I am sure your
own observation will verify the statement, how deep must be the
regret that such ’vantage ground has ever been lost, yea, lost for
ever! That where the sick man’s anxious eye betokened confidence,
expectation, desire, we should have allowed so fair an opportunity
to pass away, without affectionately and urgently directing him to
“Behold the Lamb of God!” I will not again expatiate on the serious
responsibility which these facilities involve, but I respectfully
entreat my professional brethren to be on their guard, lest timidity,
apathy, or worldly policy should deprive them of the exalted
privilege of being instrumental in saving a soul from death, and
thus adding another jewel to the Redeemer’s crown. It may still be
said, that the afflicted patient will not be disposed to listen to
the _religious_ advice of his physician, considering it as altogether
foreign to his department. I believe, on the contrary, that such
advice, when tendered with kindness and discretion, will generally be
regarded the more highly because it is _not_ professional, because
it is _not_ a matter of course, but springing spontaneously from
the lively interest which the physician feels in the entire welfare
of his charge. This view of the subject seems to me quite compatible
with the sincerest respect for the labors of a Christian minister in
the time of sickness. His invaluable instructions have the weight and
sanction of official character; while, from the aptitude afforded by
kindred studies and pastoral duties, they may be expected to possess
an appropriateness not otherwise attainable. They are held, moreover,
in high estimation, because they are regular and ministerial; whereas
the religious hints of the physician, as I have before remarked,
acquire much of their interest and influence from the very opposite
consideration,—from the fact of their being occasional, unexpected,
and spontaneous.

3.—The powerful incentive arising from _an humble expectation
of the Divine blessing_, appears to me fully authorized. If I
have adequately shown the importance of the endeavor, and have
satisfactorily proved that the peculiar facilities afforded to
the physician, involve a proportionate amount of obligation (in
those cases, at least, which have not and perhaps cannot have,
the advantage of ministerial instruction,) it will follow, as a
necessary consequence, that in performing a Christian duty of such
moment, we are warranted to implore and to expect the special aid
of Omnipotence. The object at which we aim is nothing less than the
glory of the Divine Saviour, in the salvation of an immortal soul,
and how cheering are the assurances of infallible truth,—“I will
make my strength perfect in weakness.” “Him that honoreth me, I will
honor!” “He that converteth a sinner from the error of his ways,
shall save a soul from death, and hide a multitude of sins.”

And let not my valued friend be discouraged at the difficulty of the
undertaking. The cause is God’s. He hath all hearts in his hand,
all events at his disposal, and is often pleased to effectuate the
greatest designs by the most feeble instrumentality, in order to show
that “the excellency of the power is not in man, but in God” alone.
Far be it from me to depreciate the value of prudence and discretion
in an attempt of such importance; but I am bound to confess that
the danger has not generally arisen from the neglect of cautionary
maxims, but from permitting them to obtain an undue and paralysing
influence. Where eternity is at stake, let us not be exclusively
guided by the cold, calculating axioms of worldly policy. Selfishness
may whisper, “Am I my brother’s keeper?” and as the priest and the
Levite in the parable of the good Samaritan were probably willing to
persuade themselves that there spiritual functions imposed upon them
no obligation to afford _bodily_ succor to the “wounded, half-dead
man,”—so, my friend, may we be in danger of resting satisfied in
withholding our spiritual aid from our dying patients, on the hollow
and untenable ground that our responsibility extends only to the
body and to time. Oh! let us be rather like the good Samaritan, and
without hesitation or delay, endeavor to pour into the wounded spirit
the wine and oil of heavenly consolation,—thus adopting our blessed
Lord’s special application of the parable—“Go, and do thou likewise!”
Surely we may confidently hope that in rendering this obedience, we
shall experience super-human aid; and though our path may be dark and
rugged, and the obstacles many and powerful, yet may we cheerfully
and implicitly rely on that Almighty God, who is “a Sun and a Shield”
to those who put their trust in Him.

May I not add as a collateral encouragement, that while thus aiming
to promote the honor of the Divine Emanuel, we may humbly hope
that he may be “_with us_,” in granting efficiency to our strictly
professional exertions? When it is considered that the skilful or
unskilful decision of a moment may save or lose a valuable life, and
that even a well-selected remedy may prove salutary or detrimental as
the Divine benediction is vouchsafed or withheld, how inconceivably
important must we regard the guidance and the smile of Him, “in
whom we live and move, and have our being,” and in whom are all our
springs of intelligence and of usefulness! By “seeking the kingdom
of God and his righteousness” in the way we have described, we may
be rendered the happy instruments of giving occasion to our grateful
patients, to unite with the sweet singer of Israel, in ascribing
from their inmost souls, blessing and praise to Jehovah, for having
not only “forgiven all their iniquities,” but also “healed all their
diseases.”

One especial ground of encouragement yet remains—that which rests
upon _the actual success with which the God of all grace has been
pleased to crown similar efforts_. He, who hath all power in heaven
and on earth, _has_ given efficiency to such exertions: and while,
with “a single eye to His glory,” they are “begun, continued, and
ended in Him,” we cannot doubt that the ardent desire and persevering
endeavor to rescue immortal souls from endless perdition will be
accompanied by these gracious influences which can at once direct,
and animate and bless. Thus, “our labors shall not be in vain in the
Lord.”

It has already been remarked, that, in aiming to subserve the
spiritual as well as temporal interests of our patients, we shall
usually retain, if not increase, their confidence and regard.
Sometimes, however, it may prove otherwise; especially in reference
to the relatives and friends of the sick. This was strikingly evinced
in the experience of an aged and eminent, but now deceased physician,
then practising in Westminster, as communicated by him to the writer
of this letter. The veteran practitioner was called to the bedside of
a young lady, whom he found passing to her long home, yet destitute
of hope, unacquainted with the way to Christ, and peace, and heaven,
and surrounded by relatives equally ignorant with herself. He placed
in the hands of her attentive and (as it afterwards appeared) pious
nurse, a volume of the “Village Sermons,” requesting that a portion
might be occasionally read to the youthful patient. On getting out of
his carriage on his next visit, he was met by the mother, and thus
abruptly accosted—“I will not trouble you to go up stairs;” assigning
no motive for so unceremonious a dismission, except such as might be
read in a countenance of high displeasure. My sagacious friend at
once penetrated her mind, and retired. After some time had elapsed,
the nurse informed him that the young lady lived but a few days after
his visit, yet long enough to afford a delightful evidence of having
obtained pardon and peace through a crucified Redeemer. The very
volume, it appeared, that excluded the physician from the family, was
rendered instrumental in introducing the dying patient into spiritual
life. And never can I forget the pious elevation and the grateful
emphasis, with which my venerable friend closed his affecting
narrative: “cheerfully,” said he, “would I lose the best family in my
professional connection, if by my feeble instrumentality I could be
the means of saving another soul from death.”

Thus, my dear friend, I have endeavored to set before you the
principal encouragements for the endeavor. I have still to accomplish
the most difficult part of my task—that of submitting to you a few
suggestions on the _mode_ of communicating serious counsel to the
sick. This I must attempt in a future letter.

                    Believe me, with esteem,
                              Your very faithful friend,
                                                      T. H. B.

    _Tilford, Jan. 28th, 1836._


LETTER III.

ON THE MOST ELIGIBLE METHODS TO BE PURSUED.

MY DEAR FRIEND,

In accordance with your request, I now proceed to offer a few
suggestions derived from personal observation, on the methods which
appear to me best calculated to secure the important object of our
present correspondence. You will remember, that, even at a distance,
I doubted my ability for properly executing this part of the
undertaking; and I candidly own that my consciousness of inadequacy
has not diminished on a nearer view of the attending difficulties.
Should, however, the plain remarks you are about to receive, possess
little value in themselves, they may, I am willing to hope, prove
indirectly useful, by engaging your own attention more closely and
continuously to the subject.

You are too well aware, how deeply the feeling of medical
responsibility has pressed upon myself, to suppose for a single
moment, that I would inconsiderately superadd to a similar burthen
upon you any unnecessary weight of obligation as connected with the
spiritual condition of your patients. I cannot, indeed, relinquish
the opinion I have deliberately formed, and which has been before
avowed, namely, that the peculiar facilities afforded to the medical
practitioner entail upon him a proportionate responsibility; yet am
I very solicitous not to endanger the peace of a conscientious mind,
by incautious or exaggerated statements, or by urging the adoption
of any doubtful or impracticable measures. On a subject of such
manifest delicacy as well as difficulty, it is highly important that
our views should be well defined, and our opinions of the duties
and obligations involved, most carefully guarded and qualified,
otherwise we may not only inflict a needless wound on a pious mind,
but may actually defeat the very object we desire to promote, by
the disheartening influence of plans of operation unfeasible in
themselves, or inconsistent with our proper, indispensable, and
untransferable duties. Allow me, therefore, to request your attention
to two preliminary observations.

First,—I would remark that the desire of promoting the patient’s
religious welfare should never be allowed to interfere with the
thorough performance of medical duties. These cannot be superseded
by any other claims. Under this decided impression I would suggest,
as a general rule, the propriety of giving your sole, undivided
attention to the relief of the patient’s malady, as well as to every
circumstance and arrangement which his bodily condition may demand,
before you permit yourself to advert to his spiritual exigences.
You will kindly observe that I recommend this as a _general_ rule,
which may possibly admit of some exceptions. For example, I can
conceive that some highly-gifted individuals may have the power
of interspersing, in an unobjectionable manner, a few religious
hints among their medical enquiries and directions, and without
materially distracting their attention, or endangering the temporal
well-being of their charge. Yet, even with such facilities, there
would sometimes, I apprehend, be a risk of dispersing those energies
of mind which the physician ought assuredly, in the first place, to
concentrate on his patient, in the earnest, persevering endeavor to
remove his disease and preserve his life. Consequently the talent
referred to should be used with much judgment and caution. But I
foresee that your habits of discrimination will lead you to doubt
whether the example I have supposed really constitutes an exception
to the rule. It certainly is not foreign to the _spirit_ of the rule,
which I think may be thus expressed:—that no attempt should be made
by the physician to promote the religious welfare of the sick, which
is incompatible with the full, efficient, satisfactory discharge of
his medical duties and obligations.

The second preliminary relates to the distinction which it is
important to mark between that _general_ responsibility which, in my
humble opinion, requires the physician to be always on the alert to
profit by every incidental opportunity of employing his influence
for the spiritual good of his patient; and that _special_ obligation
which may sometimes devolve upon him, (in consequence of the total
absence of religious instruction,) to attempt, in a more particular
manner, to rescue the sinking soul from perdition, and direct it to
Him, who is able “to save to the uttermost.” This distinction leads
me to propose, as a second general rule, that, inasmuch as religious
instruction forms a part of ministerial and relative duty, it would
be highly inexpedient for the physician to add to his already onerous
engagements, that of undertaking the spiritual supervision of his
patient, except under circumstances of imperious necessity. Whenever,
therefore the aid of a Christian minister or a pious relation can be
obtained, the medical practitioner may, I conceive, regard himself as
free from any special obligation of that nature.

These limitations obviously imply that, in by far the greater number
of instances, the religious influence of the physician should be
exercised in an occasional, rather than in a stated and formal
manner. If alive to the spiritual welfare of his patient, such
opportunities of usefulness will not be wanting. Perhaps, nothing
would so essentially contribute to the furtherance of the object, as
the offering up of earnest supplications to the “Father of lights,”
for His especial guidance and help, before the physician enters
upon his daily engagements, that he may be enabled both to discern
and improve every suitable opportunity, which even in the ordinary
exercise of his profession may be presented, of doing good to the
souls of his patients.

In seeking, and humbly expecting, thus to employ your influence in
this sacred cause, I feel the most encouraging persuasion that “your
labors will not be in vain in the Lord.”

It may be convenient to arrange the few thoughts which have occurred
to me in reference to the _mode_ of offering “a word in season” in a
few leading particulars; premising that, next to the Divine blessing,
the secret of usefulness will be found, I humbly anticipate, in
the careful, discriminating adaptation of advice to the particular
circumstances of the case. Age, sex, degree of intellect and
cultivation, particular habits of body and of mind, the actual stage
of the disease, the hopes and fears of the patient in relation to
futurity, the religious knowledge already possessed, the presence or
absence of spiritual instruction, and many other circumstances, will,
I am persuaded, appear to you deserving of special consideration. I
can, therefore, only hope to suggest a few general principles which
may be indefinitely modified and applied, according to the varied and
ever-varying circumstances of each individual case.

My first suggestion has already been anticipated. I refer to the
importance of recommending and even urging the assistance of a
Christian minister or a pious friend, in cases of serious and
dangerous illness. I am aware that the very mention of the subject is
sometimes productive of considerable alarm, and certainly requires
much prudence and caution. With skilful management, however, the
exciting of any injurious degree of apprehension and foreboding may
generally, I would hope, be avoided. One may say, for example, in
the course of conversation, to a patient apparently unconcerned or
uninstructed in reference to Eternity, “You must find the change
from active life to the confinement of this room rather irksome.
Yet some time for calm reflection is really needful for us all.
When withdrawn from busy life, we can look upon the world at a
distance, as well as come into closer contact with ourselves. Indeed,
serious consideration can never be unsuitable. Human life itself
is confessedly uncertain, and of course, under disease, still more
so. Should you not find a little conversation with a pious minister
interesting under your present circumstances?” In this familiar way,
(pardon its homeliness,) one may sometimes introduce the subject
without abruptness. From having had much personal illness, I have
been able to press the matter further, by assuring the patient that
such assistance has repeatedly proved very consolatory to my own
mind; thus, presenting a living instance of the incorrectness of the
popular opinion that, to propose the visit of a minister to the sick,
is tantamount to a death-warrant.

Should the recommendation prove entirely fruitless; should the
unhappy patient, notwithstanding our utmost professional efforts,
be so rapidly hastening into eternity as to afford no opportunity
of procuring more efficient spiritual aid, the case will then
present one of those _special_ occasions before alluded to, which
call for our more immediate and devoted attention, in reference to
the immortal spirit. And who, that values his own soul, would not,
under such circumstances, endeavor with all possible earnestness and
affection, to exhibit to the dying man the compassionate and Almighty
Redeemer, as able to save even at the eleventh hour?

I may next suggest that the allusions of the physician to the subject
of religion should generally be _incidental_ and conversational;
arising spontaneously from a solicitous regard to the particular
situation of the sufferer. When such occasional advice appears
naturally to flow from the heart, partaking of the disposition
and character of the speaker, and having an evident bearing on
the special circumstances of the patient, there will be little
risk of its being regarded as superfluous or obtrusive. On the
contrary, I believe, it will usually be welcomed as a gratifying
proof of disinterested friendship. In this incidental way, one may
sometimes refer to the experience of great and good men under similar
sufferings, and to the signal support vouchsafed to them, and to
the happy results of their afflictions. On some occasions, it may
be useful to adduce the remarkable fact, that some of the brightest
ornaments of the Church and of the world have ascribed much of their
success in life to the discipline they were once called to endure in
the chamber of sickness and seclusion.

May I add, that the occasional hints of the physician should also be
_brief_? A single sentence well-timed, well-directed, appropriate,
and expressive, will possess the great advantage of not wearying the
attention of the sufferer, while it may, notwithstanding, supply
ample material for reflection during the succeeding hours of solitude
and silence. “_A word_ spoken in season, how good it is!”

Nor is it less important, I conceive, that such advice be expressed
with _clearness and simplicity_, in a few plain words and short
sentences, bearing a direct and obvious meaning, and free from
ambiguity and circumlocution.

Allow me also to suggest that the advice should be _considerate and
kind_; the evident effect of genuine sympathy and tender concern. No
word should be dropped that might seem to imply an unmindfulness of
the suffering, helpless, unresisting state of the patient, or oblige
him to attempt a lengthened and laborious reply. One kind sentence
delivered in a tone of kindness, and accompanied with a look of
kindness, may, and often will, _juvante Deo_, penetrate the heart.

In certain states of disease, in which high excitement, or extreme
debility prevails, it may sometimes be expedient to address a passing
hint to a relative or friend who may be present rather than to the
patient himself, thus leaving to the option of the latter, whether or
not to reply to the observation.

Yet should the hints be _faithful_. Any approach to temporizing
would be cruel in itself, and might prove fatally delusive in its
consequences. It would be, in effect, to administer a moral opiate,
from which the helpless victim might awake—only in Eternity.

Permit me also to remark that, whenever the circumstances of the
case will permit, our allusions to spiritual subjects should be
_attractive and encouraging_. Doubtless, the torpid insensibility of
the sinner may require to be roused by an alarming representation of
the direful consequences of transgression and unbelief; nor can we
reasonably expect that mercy will be sought until it be felt to be
needed. In general, however, I apprehend, that a cheering exhibition
of the Almighty Saviour, as “full of grace and truth,” as “ready to
forgive,” and “plenteous in mercy to all who call upon Him,” will be
found most effectual in softening the heart, and in exciting those
earnest desires for pardon and acceptance, which are emphatically
described, in our Lord’s own test of sincerity, in the case of
Saul,—“Behold, he prayeth.” Let us, my friend, never forget that “he
who _winneth_ souls is wise.” The promises of the gospel are, indeed,
peculiarly adapted to meet the exigencies of the afflicted and
distressed. The blessed Redeemer was pleased to described himself as
having come purposely “to seek and to save that which was lost.” Were
we even restricted to the use of a single sentence, as a scriptural
_vade-mecum_ in the sick chamber, we should still have a volume of
encouragement and consolation in our Lord’s assurance,—“Him that
cometh to me, I will in no wise cast out.”

Upon the whole, my dear friend, the best preparation for speaking
“a word in season” will be found in carefully studying the example,
and seeking to imbibe the spirit, of the incarnate Saviour, that
all-perfect Physician of the soul and of the body. What a lovely
union of simplicity and sincerity, of faithfulness and tenderness,
pervaded _His_ addresses to the sick and afflicted! How much is
comprised in that short sentence, “The gentleness of Christ!” He did
“not break the bruised reed nor quench the smoking flax; but came to
bind up the broken-hearted,” and heal their every wound. May we be
enabled by grace from on high, though necessarily in a very humble
measure, to tread in His steps!

In truth, _the Christian-like deportment_ of the physician comprises
within itself a sphere of very important usefulness, affording ample
scope for the development of those graces and affections which
characterise the sincere follower of the meek and forbearing, the
benevolent and sympathizing Saviour. And even should my friend find
it sometimes difficult or impracticable to offer a word of spiritual
counsel as he could wish, he may yet, in his habitual demeanor,
present to the patient and the surrounding relatives, a living
“epistle” which they can read and understand, and which, by directing
them to the source of every good gift, may issue in the attainment of
true and saving wisdom.

In concluding this letter, I must not altogether omit to refer to
_the season of convalescence_, as peculiarly favorable to religious
impression. If ever the mind and the heart be open to the feelings
of gratitude, love and praise, it is under the circumstances of
returning ease and health, and in the hope of being again permitted
to enter on the duties and enjoyments of life. It is then that the
physician, in my humble opinion, is more especially bound to avail
himself of the grateful attachment of his patient by referring
any skill or care he may have evinced to the God of all grace, and
thus endeavor to give a right direction to those kind and gladsome
emotions, which are bursting from a full heart. It is then, I
conceive, that the rescue from the grave should be held out as a
signal warning, and as a powerful incentive. Then, also, by adroitly
following out the convalescent’s own suggestions, a powerful appeal
may be made to his best feelings, and an affectionate plea presented
for an immediate and entire surrender of himself, “body, soul,
and spirit,” unto an Almighty and most merciful Father, who “hath
redeemed his life from destruction, and crowned him with loving
kindness and tender mercies.”

At such a period, too, we may often recommend, with great advantage,
some interesting volume adapted to our patient’s state. Biography and
easy letters, as being both interesting and not requiring much effort
of attention, will often be found peculiarly acceptable. Indeed,
the judicious recommendation of books and tracts may be regarded as
an important mode of employing our influence during every period of
illness, but particularly during the season of convalescence.

Such, my dear friend, are the few imperfect hints which have occurred
to me. I might, indeed, have availed myself of the assistance of
some valuable writers on the subject of affliction, particularly of
the highly interesting work of my pious and intellectual friend,
Mr. Sheppard, “_On Christian Encouragement and Consolation_;” and
the excellent “_Thoughts in Affliction_,” by another able friend,
the Rev. A. S. Thelwall. I might also have enriched these humble
letters by a reference to the “_Essays to do Good_,” of the eminent
Dr. Cotton Mather, which contain some admirable suggestions on the
same subject. From these several works I have formerly derived
much instruction and pleasure, but was unwilling to have recourse
to them on the present occasion, as well as from the wish of not
unnecessarily extending these letters, as in compliance with your
particular desire that I would send you the result of my own
observation and experience.

                         With every kind wish,
                                  Believe me, my dear Friend,
                                            Ever faithfully your’s,
                                                             T. H. B.

    _Tilford, March 1st, 1836._


FOOTNOTES:

[47] These letters were written by Dr. Burder, an English physician,
in answer to the inquiry made of him by Dr. Hope, “Can your
opportunities and experience furnish me with some hints how to
offer ‘a word in season’ to those who are seriously ill?” They
were published first in a periodical of extensive circulation, and
afterwards in the Appendix to the Memoir of Dr. Hope.




CODE OF MEDICAL ETHICS

ADOPTED BY THE

NATIONAL MEDICAL CONVENTION IN PHILADELPHIA, JUNE, 1847.


CHAPTER I.

OF THE DUTIES OF PHYSICIANS TO THEIR PATIENTS AND OF THE OBLIGATIONS
OF PATIENTS TO THEIR PHYSICIANS.


ART. I.—_Duties of physicians to their patients._

§ 1. A physician should not only be ever ready to obey the calls of
the sick, but his mind ought also to be imbued with the greatness
of his mission, and the responsibility he habitually incurs in its
discharge. Those obligations are the more deep and enduring, because
there is no tribunal other than his own conscience, to adjudge
penalties for carelessness or neglect. Physicians should, therefore,
minister to the sick with due impressions of the importance of their
office; reflecting that the ease, the health, and the lives of those
committed to their charge, depend on their skill, attention and
fidelity. They should study, also, in their deportment, so to unite
_tenderness_ with _firmness_, and _condescension_ with _authority_,
as to inspire the minds of their patients with gratitude, respect and
confidence.

§ 2. Every case committed to the charge of a physician should
be treated with attention, steadiness and humanity. Reasonable
indulgence should be granted to the mental imbecility and caprices
of the sick. Secrecy and delicacy, when required by peculiar
circumstances, should be strictly observed; and the familiar and
confidential intercourse to which physicians are admitted in their
professional visits, should be used with discretion, and with the
most scrupulous regard to fidelity and honor. The obligation of
secrecy extends beyond the period of professional services;—none
of the privacies of personal and domestic life, no infirmity of
disposition or flaw of character observed during professional
attendance, should ever be divulged by him except when he is
imperatively required to do so. The force and necessity of this
obligation are indeed so great, that professional men have, under
certain circumstances, been protected in their observance of secrecy,
by courts of justice.

§ 3. Frequent visits to the sick are in general requisite, since they
enable the physician to arrive at a more perfect knowledge of the
disease,—to meet promptly every change that may occur, and also tend
to preserve the confidence of the patient. But unnecessary visits are
to be avoided, as they give useless anxiety to the patient, tend to
diminish the authority of the physician, and render him liable to be
suspected of interested motives.

§ 4. A physician should not be forward to make gloomy
prognostications, because they savor of empiricism, by magnifying the
importance of his services in the treatment or cure of the disease.
But he should not fail, on proper occasions, to give to the friends
of the patient timely notice of danger, when it really occurs; and
even to the patient himself, if absolutely necessary. This office,
however, is so peculiarly alarming when executed by him, that it
ought to be declined whenever it can be assigned to any other person
of sufficient judgment and delicacy. For, the physician should be the
minister of hope and comfort to the sick; that, by such cordials to
the drooping spirit, he may smooth the bed of death, revive expiring
life, and counteract the depressing influence of those maladies which
often disturb the tranquillity of the most resigned, in their last
moments. The life of a sick person can be shortened not only by the
acts, but also by the words or the manner of a physician. It is,
therefore, a sacred duty to guard himself carefully in this respect,
and to avoid all things which have a tendency to discourage the
patient and to depress his spirits.

§ 5. A physician ought not to abandon a patient because the case is
deemed incurable; for his attendance may continue to be highly useful
to the patient, and comforting to the relatives around him, even in
the last period of a fatal malady, by alleviating pain and other
symptoms, and by soothing mental anguish. To decline attendance,
under such circumstances, would be sacrificing to fanciful delicacy
and mistaken liberality, that moral duty, which is independent of,
and far superior to all pecuniary consideration.

§ 6. Consultations should be promoted in difficult or protracted
cases, as they give rise to confidence, energy, and more enlarged
views in practice.

§ 7. The opportunity which a physician not unfrequently enjoys of
promoting and strengthening the good resolutions of his patients,
suffering under the consequences of vicious conduct, ought never
to be neglected. His counsels or even remonstrances, will give
satisfaction, not offence, if they be proffered with politeness and
evince a genuine love of virtue, accompanied by a sincere interest in
the welfare of the person to whom they are addressed.


ART. II.—_Obligations of patients to their physicians._

§ 1. The members of the medical profession, upon whom are enjoined
the performance of so many important and arduous duties towards
the community, and who are required to make so many sacrifices
to comfort, ease, and health, for the welfare of those who avail
themselves of their services, certainly have a right to expect and
require, that their patients should entertain a just sense of the
duties which they owe to their medical attendants.

§ 2. The first duty of a patient is, to select as his medical adviser
one who has received a regular professional education. In no trade
or occupation, do mankind rely on the skill of an untaught artist;
and in medicine, confessedly the most difficult and intricate of the
sciences, the world ought not to suppose that knowledge is intuitive.

§ 3. Patients should prefer a physician, whose habits of life are
regular, and who is not devoted to company, pleasure, or to any
pursuit incompatible with his professional obligations. A patient
should, also, confide the care of himself and family, as much
as possible to one physician, for a medical man who has become
acquainted with the peculiarities of constitution, habits, and
predispositions, of those he attends, is more likely to be successful
in his treatment, than one who does not possess that knowledge.

A patient who has thus selected his physician, should always apply
for advice in what may appear to him trivial cases, for the most
fatal results often supervene on the slightest accidents. It is of
still more importance that he should apply for assistance in the
forming stage of violent diseases; it is to a neglect of this precept
that medicine owes much of the uncertainty and imperfection with
which it has been reproached.

§ 4. Patients should faithfully and unreservedly communicate to
their physician the supposed cause of their disease. This is the
more important, as many diseases of a mental origin stimulate those
depending on external causes, and yet are only to be cured by
ministering to the mind diseased. A patient should never be afraid of
thus making his physician his friend and adviser; he should always
bear in mind that a medical man is under the strongest obligations of
secrecy. Even the female sex should never allow feelings of shame or
delicacy to prevent their disclosing the seat, symptoms and causes
of complaints peculiar to them. However commendable a modest reserve
may be in the common occurrences of life, its strict observance in
medicine is often attended with the most serious consequences, and a
patient may sink under a painful and loathsome disease, which might
have been readily prevented had timely intimation been given to the
physician.

§ 5. A patient should never weary his physician with a tedious detail
of events or matters not appertaining to his disease. Even as relates
to his actual symptoms, he will convey much more real information
by giving clear answers to interrogatories than by the most minute
account of his own framing. Neither should he obtrude the details of
his business nor the history of his family concerns.

§ 6. The obedience of a patient to the prescriptions of his physician
should be prompt and implicit. He should never permit his own crude
opinions as to their fitness, to influence his attention to them. A
failure in one particular may render an otherwise judicious treatment
dangerous, and even fatal. This remark is equally applicable to diet,
drink, and exercise. As patients become convalescent they are very
apt to suppose that the rules prescribed for them may be disregarded,
and the consequence, but too often, is a relapse. Patients should
never allow themselves to be persuaded to take any medicine whatever,
that may be recommended to them by the self-constituted doctors
and doctresses, who are so frequently met with, and who pretend to
possess infallible remedies for the cure of every disease. However
simple some of their prescriptions may appear to be, it often happens
that they are productive of much mischief, and in all cases they
are injurious, by contravening the plan of treatment adopted by the
physician.

§ 7. A patient should, if possible, avoid even the _friendly visits
of a physician_ who is not attending him,—and when he does receive
them, he should never converse on the subject of his disease, as an
observation may be made, without any intention of interference,
which may destroy his confidence in the course he is pursuing, and
induce him to neglect the directions prescribed to him. A patient
should never send for a consulting physician without the express
consent of his own medical attendant. It is of great importance
that physicians should act in concert; for, although their modes of
treatment may be attended with equal success, when employed singly,
yet conjointly they are very likely to be productive of disastrous
results.

§ 8. When a patient wishes to dismiss his physician, justice and
common courtesy require that he should declare his reasons for so
doing.

§ 9. Patients should always, when practicable, send for their
physician in the morning, before his usual hour of going out; for,
by being early aware of the visits he has to pay during the day,
the physician is able to apportion his time in such a manner as to
prevent an interference of engagements. Patients should also avoid
calling on their medical adviser unnecessarily during the hours
devoted to meals or sleep. They should always be in readiness to
receive the visits of their physician, as the detention of a few
minutes is often of serious inconvenience to him.

§ 10. A patient should, after his recovery, entertain a just and
enduring sense of the value of the services rendered him by his
physician; for these are of such a character, that no mere pecuniary
acknowledgment can repay or cancel them.


CHAPTER II.

OF THE DUTIES OF PHYSICIANS TO EACH OTHER, AND TO THE PROFESSION AT
LARGE.


ART. I.—_Duties for the support of professional character._

§ 1. Every individual, on entering the profession, as he becomes
thereby entitled to all its privileges and immunities, incurs an
obligation to exert his best abilities to maintain its dignity
and honor, to exalt its standing, and to extend the bounds of its
usefulness. He should therefore observe strictly, such laws as
are instituted for the government of its members;—should avoid
all contumelious and sarcastic remarks relative to the faculty,
as a body; and while, by unwearied diligence, he resorts to every
honorable means of enriching the science, he should entertain a due
respect for his seniors, who have, by their labors, brought it to the
elevated condition in which he finds it.

§ 2. There is no profession, from the members of which greater
purity of character, and a higher standard of moral excellence are
required, than the medical; and to attain such eminence is a duty
every physician owes alike to his profession and to his patients. It
is due to the latter, as without it he cannot command their respect
and confidence, and to both, because no scientific attainments can
compensate for the want of correct moral principles. It is also
incumbent upon the faculty to be temperate in all things, for the
practice of physic requires the unremitting exercise of a clear and
vigorous understanding; and, on emergencies for which no professional
man should be unprepared, a steady hand, an acute eye, and an
unclouded head may be essential to the well-being, and even to the
life, of a fellow creature.

§ 3. It is derogatory to the dignity of the profession, to resort to
public advertisements or private cards or handbills, inviting the
attention of individuals affected with particular diseases—publicly
offering advice and medicine to the poor gratis, or promising radical
cures; or to publish cases and operations in the daily prints or
suffer such publications to be made;—to invite laymen to be present
at operations,—to boast of cures and remedies,—to adduce certificates
of skill and success, or to perform any other similar acts. These are
the ordinary practices of empirics, and are highly reprehensible in a
regular physician.

§ 4. Equally derogatory to professional character is it, for a
physician to hold a patent for any surgical instrument, or medicine;
or to dispense a secret _nostrum_, whether it be the composition or
exclusive property of himself, or of others. For, if such nostrum
be of real efficacy, any concealment regarding it is inconsistent
with beneficence and professional liberality; and, if mystery alone
give it value and importance, such craft implies either disgraceful
ignorance, or fraudulent avarice. It is also reprehensible for
physicians to give certificates attesting the efficacy of patent or
secret medicines, or in any way to promote the use of them.


ART. II.—_Professional services of physicians to each other._

§ 1. All practitioners of medicine, their wives, and their children
while under the paternal care, are entitled to the gratuitous
services of any one or more of the faculty residing near them, whose
assistance may be desired. A physician afflicted with disease is
usually an incompetent judge of his own case; and the natural anxiety
and solicitude which he experiences at the sickness of a wife, a
child, or any one who by the ties of consanguinity is rendered
peculiarly dear to him, tend to obscure his judgment and produce
timidity and irresolution in his practice. Under such circumstances,
medical men are peculiarly dependent on each other, and kind offices
and professional aid should always be cheerfully and gratuitously
afforded. Visits ought not, however, to be obtruded officiously; as
such unasked civility may give rise to embarrassment, or interfere
with that choice, on which confidence depends. But, if a distant
member of the faculty, whose circumstances are affluent, request
attendance, and an honorarium be offered, it should not be declined;
for no pecuniary obligation ought to be imposed, which the party
receiving it would wish not to incur.


ART. III.—_Of the duties of physicians as respects vicarious offices._

§ 1. The affairs of life, the pursuit of health, and the various
accidents and contingencies to which a medical man is peculiarly
exposed, sometimes require him temporarily to withdraw from his
duties to his patients, and to request some of his professional
brethren to officiate for him. Compliance with this request is an
act of courtesy, which should always be performed with the utmost
consideration for the interest and character of the family physician,
and when exercised for a short period, all the pecuniary obligations
for such service should be awarded to him. But if a member of the
profession neglect his business in quest of pleasure and amusement,
he cannot be considered as entitled to the advantages of the frequent
and long-continued exercise of this fraternal courtesy, without
awarding to the physician who officiates the fees arising from the
discharge of his professional duties.

In obstetrical and important surgical cases, which give rise to
unusual fatigue, anxiety and responsibility, it is just that the fees
accruing therefrom should be awarded to the physician who officiates.


ART. IV.—_Of the duties of physicians in regard to consultations._

§ 1. A regular medical education furnishes the only presumptive
evidence of professional abilities and acquirements, and ought to
be the only acknowledged right of an individual to the exercise
and honors of his profession. Nevertheless, as in consultations
the good of the patient is the sole object in view, and this is
often dependent on personal confidence, no intelligent regular
practitioner, who has a license to practice from some medical
board of known and acknowledged respectability, recognized by this
association, and who is in good moral and professional standing
in the place in which he resides, should be fastidiously excluded
from fellowship, or his aid refused in consultation when it is
requested by the patient. But no one can be considered as a regular
practitioner, or a fit associate in consultation, whose practice is
based on an exclusive dogma, to the rejection of the accumulated
experience of the profession, and of the aids actually furnished by
anatomy, physiology, pathology, and organic chemistry.

§ 2. In consultations no rivalship or jealousy should be indulged;
candor, probity, and all due respect should be exercised towards the
physician having charge of the case.

§ 3. In consultations the attending physician should be the first
to propose the necessary questions to the sick; after which the
consulting physician should have the opportunity to make such farther
inquiries of the patient as may be necessary to satisfy him of the
true character of the case. Both physicians should then retire to
a private place for deliberation; and the one first in attendance
should communicate the directions agreed upon to the patient or his
friends, as well as any opinions which it may be thought proper to
express. But no statement or discussion of it should take place
before the patient or his friends, except in the presence of all the
faculty attending, and by their common consent; and _no opinions_ or
_prognostications_ should be delivered, which are not the result of
previous deliberation and concurrence.

§ 4. In consultations, the physician in attendance should deliver his
opinion first; and when there are several consulting, they should
deliver their opinions in the order in which they have been called
in. No decision, however, should restrain the attending physician
from making such variations in the mode of treatment, as any
subsequent unexpected change in the character of the case may demand.
But such variation and the reasons for it ought to be carefully
detailed at the next meeting in consultation. The same privilege
belongs also to the consulting physician if he is sent for in an
emergency, when the regular attendant is out of the way, and similar
explanations must be made by him, at the next consultation.

§ 5. The utmost punctuality should be observed in the visits of
physicians when they are to hold consultation together, and this is
generally practicable, for society has been considerate enough to
allow the plea of a professional engagement to take precedence of
all others, and to be an ample reason for the relinquishment of any
present occupation. But as professional engagements may sometimes
interfere, and delay one of the parties, the physician who first
arrives should wait for his associate a reasonable period, after
which the consultation should be considered as postponed to a new
appointment. If it be the attending physician who is present, he will
of course see the patient and prescribe; but if it be the consulting
one, he should retire, except in case of emergency, or when he has
been called from a considerable distance, in which latter case he may
examine the patient, and give his opinion in _writing_, and _under
seal_, to be delivered to his associate.

§ 6. In consultations, theoretical discussions should be avoided,
as occasioning perplexity and loss of time. For there may be much
diversity of opinion concerning speculative points, with perfect
agreement in those modes of practice which are founded, not on
hypothesis, but on experience and observation.

§ 7. All discussions in consultation should be held as secret and
confidential. Neither by words nor manner should any of the parties
to a consultation assert or insinuate, that any part of the treatment
pursued did not receive his assent. The responsibility must be
equally divided between the medical attendants,—they must equally
share the credit of success as well as the blame of failure.

§ 8. Should an irreconcilable diversity of opinion occur when several
physicians are called upon to consult together, the opinion of the
majority should be considered as decisive; but if the numbers be
equal on each side, then the decision should rest with the attending
physician. It may, moreover, sometimes happen, that two physicians
cannot agree in their views of the nature of a case, and the
treatment to be pursued. This is a circumstance much to be deplored,
and should always be avoided, if possible, by mutual concessions,
as far as they can be justified by a conscientious regard for the
dictates of judgment. But in the event of its occurrence, a third
physician should, if practicable, be called to act as umpire, and
if circumstances prevent the adoption of this course, it must be
left to the patient to select the physician in whom he is most
willing to confide. But as every physician relies upon the rectitude
of his judgment, he should, when left in the minority, politely
and consistently retire from any further deliberation in the
consultation, or participation in the management of the case.

§ 9. As circumstances sometimes occur to render a _special
consultation_ desirable, when the continued attendance of two
physicians might be objectionable to the patient, the member of
the faculty whose assistance is required in such cases, should
sedulously guard against all future unsolicited attendance. As such
consultations require an extraordinary portion both of time and
attention, at least a double honorarium may be reasonably expected.

§ 10. A physician who is called upon to consult, should observe the
most honorable and scrupulous regard for the character and standing
of the practitioner in attendance; the practice of the latter, if
necessary, should be justified as far as it can be, consistently with
a conscientious regard for truth, and no hint or insinuation should
be thrown out, which could impair the confidence reposed in him, or
affect his reputation. The consulting physician should also carefully
refrain from any of those extraordinary attentions or assiduities,
which are too often practiced by the dishonest for the base purpose
of gaining applause, or ingratiating themselves into the favor of
families and individuals.


ART. V.—_Duties of physicians in cases of interference._

§ 1. Medicine is a liberal profession, and those admitted into its
ranks should found their expectations of practice upon the extent of
their qualifications, not on intrigue or artifice.

§ 2. A physician, in his intercourse with a patient under the care
of another practitioner, should observe the strictest caution and
reserve. No meddling inquiries should be made; no disingenuous hints
given relative to the nature and treatment of his disorder; nor any
course of conduct pursued that may directly or indirectly tend to
diminish the trust reposed in the physician employed.

§ 3. The same circumspection and reserve should be observed, when,
from motives of business or friendship, a physician is prompted
to visit an individual who is under the direction of another
practitioner. Indeed, such visits should be avoided, except under
peculiar circumstances, and when they are made, no particular
inquiries should be instituted relative to the nature of the
disease, or the remedies employed, but the topics of conversation
should be as foreign to the case as circumstances will admit.

§ 4. A physician ought not to take charge of, or prescribe for a
patient who has recently been under the care of another member of the
faculty in the same illness, except in cases of sudden emergency,
or in consultation with the physician previously in attendance, or
when the latter has relinquished the case or been regularly notified
that his services are no longer desired. Under such circumstances no
unjust and illiberal insinuations should be thrown out in relation to
the conduct or practice previously pursued, which should be justified
as far as candor and regard for truth and probity will permit; for
it often happens, that patients become dissatisfied when they do not
experience immediate relief, and, as many diseases are naturally
protracted, the want of success, in the first stage of treatment,
affords no evidence of a lack of professional knowledge and skill.

§ 5. When a physician is called to an urgent case, because the
family attendant is not at hand, he ought, unless his assistance in
consultation be desired, to resign the care of the patient to the
latter immediately on his arrival.

§ 6. It oftens happens, in cases of sudden illness, or of recent
accidents and injuries, owing to the alarm and anxiety of friends,
that a number of physicians are simultaneously sent for. Under
these circumstances courtesy should assign the patient to the first
who arrives, who should select from those present any additional
assistance that he may deem necessary. In all such cases, however,
the practitioner who officiates, should request the family physician,
if there be one, to be called, and, unless his further attendance be
requested, should resign the case to the latter on his arrival.

§ 7. When a physician is called to the patient of another
practitioner, in consequence of the sickness or absence of the
latter, he ought, on the return or recovery of the regular attendant,
and with the consent of the patient, to surrender the case.

§ 8. A physician, when visiting a sick person in the country, may
be desired to see a neighboring patient who is under the regular
direction of another physician, in consequence of some sudden change
or aggravation of symptoms. The conduct to be pursued on such an
occasion is to give advice adapted to present circumstances; to
interfere no farther than is absolutely necessary with the general
plan of treatment; to assume no future direction, unless it be
expressly desired; and, in this last case, to request an immediate
consultation with the practitioner previously employed.

§ 9. A wealthy physician should not give advice _gratis_ to the
affluent; because his doing so is an injury to his professional
brethren. The office of a physician can never be supported as an
exclusively beneficent one; and it is defrauding, in some degree, the
common funds for its support, when fees are dispensed with, which
might, justly be claimed.

§ 10. When a physician who has been engaged to attend a case of
midwifery is absent, and another is sent for, if delivery is
accomplished during the attendance of the latter, he is entitled to
the fee, but should resign the patient to the practitioner first
engaged.


ART. VI.—_Of differences between physicians._

§ 1. Diversity of opinion, and opposition of interest, may, in the
medical, as in other professions, sometimes occasion controversy and
even contention. Whenever such cases unfortunately occur, and cannot
be immediately terminated, they should be referred to the arbitration
of a sufficient number of physicians, or a _court-medical_.

As peculiar reserve must be maintained by physicians towards the
public, in regard to professional matters, and as there exists
numerous points in medical ethics and etiquette through which
the feelings of medical men may be painfully assailed in their
intercourse with each other, and which cannot be understood or
appreciated by general society, neither the subject matter of such
differences nor the adjudication of the arbitrators should be made
public, as publicity in a case of this nature may be personally
injurious to the individuals concerned, and can hardly fail to bring
discredit on the faculty.


ART. VII.—_Of pecuniary acknowledgments._

§ 1. Some general rules should be adopted by the faculty, in every
town or district, relative to _pecuniary acknowledgments_ from their
patients; and it should be deemed a point of honor to adhere to these
rules with as much uniformity as varying circumstances will admit.


CHAPTER III.

OF THE DUTIES OF THE PROFESSION TO THE PUBLIC, AND OF THE OBLIGATIONS
OF THE PUBLIC TO THE PROFESSION.


ART. I.—_Duties of the profession to the public._

§ 1. As good citizens, it is the duty of physicians to be ever
vigilant for the welfare of the community, and to bear their part in
sustaining its institutions and burdens: they should also be ever
ready to give counsel to the public in relation to matters especially
appertaining to their profession, as on subjects of medical police,
public hygiène, and legal medicine. It is their province to enlighten
the public in regard to quarantine regulations,—the location,
arrangement, and dietaries of hospitals, asylums, schools, prisons,
and similar institutions,—in relation to the medical police of towns,
as drainage, ventilation, &c.,—and in regard to measures for the
prevention of epidemic and contagious diseases; and when pestilence
prevails, it is their duty to face the danger, and to continue their
labors for the alleviation of the suffering, even at the jeopardy of
their own lives.

§ 2. Medical men should also be always ready, when called on by the
legally constituted authorities, to enlighten coroners’ inquests and
courts of justice, on subjects strictly medical,—such as involve
questions relating to sanity, legitimacy, murder by poisons or other
violent means, and in regard to the various other subjects embraced
in the science of Medical Jurisprudence. But in these cases, and
especially where they are required to make a post-mortem examination,
it is just, in consequence of the time, labor and skill required, and
the responsibility and risk they incur, that the public should award
them a proper honorarium.

§ 3. There is no profession, by the members of which, eleemosynary
services are more liberally dispensed, than the medical, but justice
requires that some limits should be placed to the performance of
such good offices. Poverty, professional brotherhood, and certain
public duties referred to in section 1 of this chapter, should
always be recognized as presenting valid claims for gratuitous
services; but neither institutions endowed by the public or by rich
individuals, societies for mutual benefit, for the insurance of lives
or for analogous purposes, nor any profession or occupation, can be
admitted to possess such privilege. Nor can it be justly expected of
physicians to furnish certificates of inability to serve on juries,
to perform militia duty, or to testify to the state of health of
persons wishing to insure their lives, obtain pensions, or the like,
without a pecuniary acknowledgment. But to individuals in indigent
circumstances, such professional services should always be cheerfully
and freely accorded.

§ 4. It is the duty of physicians, who are frequent witnesses of
the enormities committed by quackery, and the injury to health and
even destruction of life caused by the use of quack medicines, to
enlighten the public on these subjects, to expose the injuries
sustained by the unwary from the devices and pretensions of artful
empirics and impostors. Physicians ought to use all the influence
which they may possess, as professors in Colleges of Pharmacy, and
by exercising their option in regard to the shops to which their
prescriptions shall be sent, to discourage druggists and apothecaries
from vending quack or secret medicines, or from being in any way
engaged in their manufacture and sale.


ART. II.—_Obligations of the public to physicians._

§ 1. The benefits accruing to the public directly and indirectly
from the active and unwearied beneficence of the profession, are
so numerous and important, that physicians are justly entitled
to the utmost consideration and respect from the community. The
public ought likewise to entertain a just appreciation of medical
qualifications; to make a proper discrimination between true
science and the assumptions of ignorance and empiricism,—to afford
every encouragement and facility for the acquisition of medical
education,—and no longer to allow the statute books to exhibit the
anomaly of exacting knowledge from physicians, under liability to
heavy penalties, and of making them obnoxious to punishment for
resorting to the only means of obtaining it.


THE END.




ERRATA.


  Page 38  and  39, for “abcess” read abscess.
   ”   40, line 19, for “inoperative” read in operation.
   ”   48,  ”    4, for “idiosyncrasies” read idiosyncrasy.
   ”  115,  ”   10, insert between “of” and “the,” certain substances,
                      for example.
   ”  253,  ”   20, for “organic relations” read organizations.
   ”  256,  ”    6, for “officially” read sufficiently.
   ”  262,  ”   15, for “voluntary” read voluntarily.
   ”  340,  ”   20, for “succeed” read succeeded.
   ”  387,  ”   20, insert “is” between “it” and “an.”
   ”  403,  ”   13, for “approbation” read appellation.




  Transcriber’s Notes

  pg 1 of advertisements Changed: Edwin Hall, Pastor of the Frst
                              to: Edwin Hall, Pastor of the First

  pg xviii Changed: Different theories of fever—Boerrhave
                to: Different theories of fever—Boerhaave

  pg xix Changed: its warfare with empricism
              to: its warfare with empiricism

  pg xxiii Changed: Though proper sometimes to withold
                to: Though proper sometimes to withhold

  pg 32 Changed: which act in entire secresy
             to: which act in entire secrecy

  pg 42 Changed: with the idea that it was controled
             to: with the idea that it was controlled

  pg 88 Changed: Was the introduction of innoculation
             to: Was the introduction of inoculation

  pg 96 Changed: Though this limiment had such wonderful power
             to: Though this liniment had such wonderful power

  pg 116 Changed: given to it from the similiarity
              to: given to it from the similarity

  pg 119 Changed: they have now amedical faculty
              to: they have now a medical faculty

  pg 141 Changed: they base their preference is so limiited
              to: they base their preference is so limited

  pg 181 Changed: vivid recollection of one which occured
              to: vivid recollection of one which occurred

  pg 230 Changed: and their exert their full influence
              to: and they exert their full influence

  pg 245 Changed: You will have to do something more, to convine
              to: You will have to do something more, to convince

  pg 252 Changed: the abounding and mnltiform
              to: the abounding and multiform

  pg 253 Changed: this leads to me say
              to: this leads me to say

  pg 297 Changed: This incident leads to me remark
              to: This incident leads me to remark

  pg 340 Changed: He succeed in obtaining a grant for a new trial
              to: He succeeded in obtaining a grant for a new trial

  pg 388 Changed: manifestly blunts the sensibibilities
              to: manifestly blunts the sensibilities

  pg 428 Changed: maintainence of which his recovery
              to: maintenance of which his recovery

  pg 451 Changed: The office of a physcian
              to: The office of a physician

  The Erratas on page 454 have be corrected in the text.