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cacy of this or that special line of treatment; and then I could not help suggesting that he himself would be astonished at the insufficiency and barrenness of those reasons when thus reviewed.
Now, it seems pretty clear, that the grounds upon which these reasons must be based are to be sought either in the result of a man's own experience, or in the information which he has obtained through the experience of others, and tested by his own opportunities of observation.
With regard to the results of a man's own experience, I would observe, that it can rarely, if ever, be taken as decisive of the advantages or disadvantages of any particular line of treatment, even though his experience be very great ; and there is no difficulty in understanding this, if we will reflect upon the endless complications which beset the subject of remedial agents and their effects, and the vast amount of disturbing causes which render satisfactory conclusions so hard to attain.
The conditions under which our remedies are necessarily administered are ever varying-so varying, that one may assume it to be a thing impossible to apply a like treatment to two exactly similar cases. We are early taught the modifications which age, sex, seasons, climates, diet, constitution, pre-existing disease, states of the mind, states of the different organs of the body, hereditary tendencies to disease, etc., etc., introduce into what are considered the ordinary and proper effects of remedies. What, again, is called the idiosyncrasy of an individual is that peculiarity of constitution which makes him to differ from another; and is there one individual living who does not differ from another in that sense which relates to the action of remedies upon the body? When we calmly take into our calculation the whole series of necessary or natural and accidental conditions of things which must in the human body inevitably act upon, and reciprocally be acted upon by, our remedial agents, before their influence can be brought to bear upon the disorder for which they were specially administered, we shall be forced to acknowledge that every living person has an idiosyncrasy as regards the administration of remedies; and that it is, in the present state of our knowledge, scarcely possible for any individual to decide as to the action of remedies by the light of his own experience alone; the action of remedies, I mean, upon those acute diseases, where the apparent effects are neither uniforın nor constant; where they have, in fact, so little uniformity and constancy in their results, as to induce certain trustworthy observers to doubt their efficacy altogether.
I trust I need scarcely observe here, that my remarks as to the treatinent of disease in no way whatever apply to those cases where the results of remedies are so constant and so little variable, as to leave no room for doubt in the mind of the candid inquirer as to their efficacy. I am confining my attention to those large classes of acute diseases, where treatment of the most opposite
character is declared by men, equally competent to judge concerning it, to be equally efficacious for their cure; and to other diseases, wherever difference of opinion as to the right mode of their treatment is so great, and so contradictory, as to justify an unprejudiced person in the belief, nay, as to force him to believe, that there must be some mistake in the conclusions drawn from the results of such treatment, and that the whole subject of the administration and effects of remedies is one demanding, reasonably, a reconsideration on the part of practitioners.
When we first apply ourselves to the treatment of disease, we are, in our inexperience, necessarily driven to place ourselves under the guidance of others, and the wisdom of our ancestors is there for our guidance and instruction; this experience of theirs, we are taught, is thus transmitted to us, to be tried and tested by our own daily experience, and modified or rejected accordingly as it bears that test; we are to hold firmly to that alone which stands this trial of experiment. And what, after all, is the value of the experience of individuals thus gained in this matter? what influence does it exercise over the majority of practitioners? We are, perhaps, ourselves, scarcely conscious (until we come to consider the matter a little closely), how little our own actual experience is a guide to us in directing our treatment of diseases, and how much more the experience of others influences our opinions and our actions.
We naturally enough receive, in the original instance, our ideas as to the efficacy of particular remedies from others; their teachings are our first guide; custom gives them favour in our eyes; and habit at length exerts such power over us, that the very name of a disease, when mentioned, becomes instantly associated in our minds with the name of some particular remedial agent. Every one must have felt, in his own person, the influence which the lessons of some favourite authority, learnt in early youth, have left upon his mind; in years, long after, the meaning of those lessons still lingers in his thoughts, and directs his hand in practice; and thus it happens that, more or less, and to the very last, our practice is biassed, guided, and directed, not so much by our own, as by the opinions which we have derived from others.
But it may be said in answer to this, that although men are thus governed by the opinions of others, still the results of their own practice, and their own personal experience, confirm those opinions, and so far prove their correctness; and what more forcible mode can there be of impressing belief in any conclusions on the mind, than by showing their constancy as results flowing from certain premises, as certain consequences following with regularity upon certain conditions of things. This objection seems very difficult to answer, and, undoubtedly, to the great majority of practitioners, it is unanswerable. Nevertheless, the following undoubted facts must, in a greater or less degree, demonstrate its speciousness in the present case, the facts, viz., that in the hands of different observers the same results flow similarly and equally from the most opposite methods of treatment; that the same treatment, in different hands, is followed by different results, longo intervallo, or toto cælo different; that a method of cure, lauded to the skies to-day, to-morrow deceives the hopes of him who sang its praises ; that there is a fashion attached to the use of the articles of the pharmacopeia, just as there is a fashion in other more indifferent matters ; that the treatment of one generation, and in the most striking particulars, is reversed by the judgment of the next generation.
As corroborative of the same position I am maintaining, I might also add this other fact, that in order to account for these diversities of opinions and these differences in results of treatment, the supposition has been made that diseases change their type, and that, therefore, a treatment which was well adapted to their cure at one epoch is useless at another; some observers, indeed, have very “firm convictions” that this typical change in diseases is true, and they almost take it for granted as an undeniable fact; but when we come to investigate the grounds upon which rest those convictions, then we find what “a baseless fabric of a dream” they form ; the convictions become mere vague ideas, resting on some floating notions in the mind. How, for example, can we prove the dissimilarity between pneumonia of to-day and pneumonia of ten years ago, except by comparison of the history of the disease now with its history then? Well, I fancy he must be a bold man who would undertake that effort. Differences in type at different epochs! why! how many differences in type does not the same disease present at the same epoch? What are all those different modifications in symptoms which disease presents to us except changes in its type; changes chargeable to the influence of age, sex, climate, and the thousand varying accidents which beset the life of man! We have acute pneumonia, “ franche.pneumonie,” the simple inflammation ; we have typhoid pneumonia; we have tubercular pneumonia, and so on ; and what different ideas as regards the prognosis and the treatment of pneumonia do not those qualifying terms excite in our minds ; surely these are types different enough of the same disease, and plenty more might be added to them ; how then, in the face of such facts as these, can we with any show of reason pretend to talk of pneumonia varying its type at different periods ? No, I am compelled to see in this idea also further evidence of the mistaken opinions we labour under regarding the influence of remedies over certain diseases. If the remedy which was found efficacious in the cure of disease by authorities of the past generations, prove a failure in our hands, we prefer rather to indulge in the visionary belief that the disease which they treated was not the disease which, under the same title, presents itself to our notice now-we prefer this, rather than question the treatment adopted, rather than admit a doubt as to the effects ascribed to the remedies administered.
Many years ago an indelible impression respecting the difficulty
attending the treatment of disease was made upon my mind. The incident which gave rise to it seemed to me then very startling, and as it is strongly illustrative of some of the remarks I have here ventured to make, I will shortly refer to it. The disease of whose treatment I am about to speak was typhus; the treatment was carried on in three separate wards of the same hospital, on the first, second, and third stories of the hospital; three physicians of high repute had charge of the wards, each of a separate ward. Now, it must be understood that into these wards were carried indiscriminately the fever cases of a large city, just as they occurred, and just as they presented themselves to the hospital, so that here at least there can be no room for the supposition of any peculiar types of the disease; any differences in the character of the fever attributable to different accidents of climate, modes of life, and so on; the class of people were the same, subjected equally to the same conditions of existence, to the same sources of contagion, and the same disgraceful sources of pollution, which then rendered their habitations notorious. These victims of fever when brought into the hospital were thus subjected to treatment.-In one ward, port wine and other stimuli were administered with an unsparing hand, and no period of the disease was too early for their prompt administration. In another ward the disease was treated pro re nata, there was no prescribed formula, but as symptoms indicated, or were supposed to indicate, so the remedies were directed. In the third ward the essence of the treatment consisted in the most energetic attempt to strangulate a certain inflammation which in this disease made the strongest efforts to fix its seat on that very vital organ the brain; the most copious effusions of blood, leechings, cuppings, and blisterings, formed the staple agents by which the physician of this ward attacked his foe; stimuli were forbidden with an unswerving rigour; the treatment was a combat à l'outrance between the lancet and the fever, at least in the physician's eyes.
I did not, of course, introduce this extreme case here for the sake of alluding to the treatment of fever, but solely to back me in the facts I am endeavouring to establish ; which treatment was right or which was wrong, or if they were all defective matters not here, but right or wrong this much is certain, that the students who year after year witnessed the treatment would in after life as practitioners, and to the end of their days, be more or less influenced in their treatment of fever by the accidental circumstance of their having studied under this or that physician; in one case they would see a disease which overwhelmed and oppressed the organs of the body, reducing their vital forces, enfeebling, and weakening, and annihilating; in the other case they would see just the reverse, an exaltation, acute inflammation of central organs and its destructive consequences.
I spoke before of how little we are really guided in the treatment of disease by the results of our own experience, and I cannot but NEW SERIES.—NO. III. MARCH 1855.
think that the results derived from experience had little to do with directing the treatment here. A predominant idea held possession of the physician's mind, and his treatment was guided thereby. The results were, of course, in his opinion, a justification of the treatment, but is it possible to believe that such totally opposite methods of dealing with the same disease could be followed by consequences which, in reason, equally justified these methods. I cannot but lay particular stress on this case, because I consider that if we will take the trouble to apply it to many of our own proceedings in practice, we shall find that the results of our practice do as little prove the merit of those proceedings as does the treatment here spoken of seem to do in the case of fever.
When a foregone conclusion has once taken full possession of the mind, the facility with which facts accidentally associated with such conclusion are made subservient to its illustration and proof is surprising. Unfortunately it happens that the occasion for the adoption of fallacies is very great in the conclusions which may be drawn regarding the action of remedies; between the administration of a remedy and what we presume to be its manifestations in the body, speaking generally, all is a complete mystery-all is hidden from us; and thus a large region is opened wherein imagination may delight herself. In this region it is that the empiric revels, delighting his facile clients with the special language of his class ; bracing up the nerves, purifying the humours, giving a tone to the system, fortifying it against outward attacks, settling on the nerves, poisoning the sources of life, and so forth ; such is the poetical language with which he charms his auditory, and effectually veils his own ignorance. Poetical figures of speech how often do they stand us also in good stead when hard pressed by our patients! We deceive them thereby into a belief that we possess a knowledge which we do not possess, and we end by deluding ourselves into a similar belief.
Perhaps I might mention one other remarkable fact connected with the treatment of fever as above spoken of, for it is not the least interesting or curious part of the story. A distinguished physiologist was pathologist of the hospital at the period in question, and during one year he collected carefully (and not a more careful, calm, cautious, and philosophic investigator of facts, adorned the university which had the honour to call him its scholar) the records of the mortality of the fever cases which took place in the hospital referred to; and he found after a careful comparison of the results that the mortality, other things being equal, under the several methods adopted in the treatment of the disease was very much the same.
Again, suppose a man of ordinary intelligence, not a practitioner of medicine, were to have laid before him the therapeutical history of mercury, its past and present history, the history of one of the most important items of the pharmacopoeia, what would he think of the condition of medicine as a science? I need not go back and make reference to its use, or I should say abuse, in past days; of the