Are the obstacles to certainty and simplicity in practical medicine insurmountable?

Are the obstacles to certainty and simplicity in practical medicine insurmountable?

1 Dr. Herz’s essay “On the Medicinal uses of the Phellandrium aquaticum,” andc., in the first part of the second volume of the Journal der practischen Arzneykunde, plunged me into a sort of melancholy, which only by dint of long continued reflection has given place to a remote but lively hope.
Here one of the most thoughtful physicians of our time, after twenty years of active practice, finds himself obliged repeatedly to make the open, but most melancholy acknowledgment: (p. 40.) “That we can lay no claim to the attainment of the ideal of simplicity in medical treatment.” “That the hope of ever arriving at perfect simplicity in medical practice, cannot be otherwise than very feeble” (p. 47).
The obstacles to pure observation of the effects of medicines in the various diseases, he enumerates with most overwhelming fullness of detail, and there he leaves us alone in the old well-worn path of uncertainty, almost without a cheering glance at a better futurity, a simpler, surer method of cure; unless we are to reckon his very complaints as foreshadowing coming improvements, just as the impassioned warmth of the sceptical casuist has always appeared to me a proof of that immortality he would deny.
I myself felt the external hindrances to our art more than I could have wished; they continually beset my sphere of action; and I, too, long considered them insurmountable, and had almost made up my mind to despair, and to esteem my profession as but the sport of inevitable accident and insuperable obstacles, when the thought arose within me, “are not we physicians partly to blame for the complexity and the uncertainty of our art?”

Obedience of patients

I have seen medical men take under their care patients who had only half confidence, and from whose demeanour any one might perceive that they put themselves under the physician whom they had chosen, not from any enthusiastic regard for him, nor from a strong desire to be relieved from their sufferings. How could implicit obedience be expected from such persons? And even when they spoke of, and commended in commonplace terms, strict attention to the physician’s orders, could he trust them, and with confidence ascribe the issue to his prescriptions, his medicines? By no means!

Diet and regimen

It is a constant complaint of physicians that patients will not observe the prescribed diet.

“Who shall give them assurance of such compliance? and how impossible, then, is it to determine the issue of a disease, or the effect of the remedies employed, since on this point in no case can any certainty be attained?”

Pardon me! We may be perfectly sure of such as with implicit confidence entrust themselves to the care of their almost worshipped physician. Of course, others are less to be relied upon. Methinks, however, that medical men when thus complaining, do not draw a sufficient distinction between, 1st, the errors of diet which produced and kept up the patient’s disease; 2d. their ordinary indifferent diet; and, 3d, the new dietetic regulations laid down by the physician.
If, with respect to the first of these (the correction of the errors of diet), the physician thinks that he does not possess sufficient authority with his patient, who will not pay strict attention to rules, rather let him dismiss such fickle-minded persons; better no patients at all than such! Who, for example, would undertake to cure a drunkard of induration of the liver, who merely consulted the physician en passant, because, perhaps, he met him in the street; or had some business-matters to arrange with him; or, because the physician has come to reside in the neighbourhood; or has become a connexion of his; or for some other trifling reason, but not from having implicit confidence in his skill? What immense influence the medical man must have with such a confirmed debauchee, to feel assured that he will pay attention to his orders, and daily diminish his allowance of the poisonous liquor!
A patient with such bad habits, must show by some considerable sacrifice, that he intends to submit himself entirely to the will of the physician. The physician would do well to try to dissuade him from submitting to treatment; to represent to him, in strong terms, the difficulties which his ruinous vice throws in the way, and the magnitude of the disease. If he return repeatedly, and express his willingness to make any sacrifices, then, what should prevent the physician trusting him, so long as he sees indubitable proofs of his resolution? If he cannot withstand temptation, then let him go his way; he will, at any rate, not bring discredit on the art, nor disappoint the hopes of the much-deceived physician. Are there not enough of patients, who, when solicitously advised by a universally esteemed physician, will, for example, scrupulously abstain from eating pork during a quartan fever, and for months afterwards; who will carefully avoid potatoes, if they are asthmatic or leucophlegmatic; sedentary occupations, if they are gouty; and sour wine, if suffering from the wasting diseases of youth brought on by venereal excesses?

In the case of a woman affected with a nervous disorder, should not a good physician be able to effect a gradual diminution in the quantity of coffee taken; or, if otherwise, will he not be able to perceive that she will not follow his advice?

From my own experience I can say, that it is no uncommon circumstance to meet with both these cases; and in each the physician may reckon with certainty on his observation. If we go to work in this manner, we shall attain to a high degree of empirical certainty. Is this not certainty? Or does the statesman, the teacher, the lawyer, the merchant, the general, possess any other than empirical certainties? Or is there any other positive rule to guide us, in any imaginable profession in which the free-will of man is involved?

But is the ordinary diet of those classes of the community who are not altogether corrupted, of such an objectionable nature, that we are compelled, in every disease, to prescribe a new one? This is one of the rocks on which so many physicians split.

In every acute or chronic disease that comes under their notice, they earnestly insist on a very complicated artificial system of diet, withholding many things, and ordering a host of others. Do we physicians, however, know with such extreme precision, the effects of all kinds of food, as to be able with certainty to say, in this case such and such an article of diet is to be taken, and this and that other to be avoided! How does experience refute our fancied omniscience! For what a length of time did our forefathers insist in their so-called acute (putrid) fevers with diminished vital power, on watery drinks, tea, andc.; and exclaimed against beer and wine as little better than poison-which, however, the patients long for so much, and which is now the main support of our practice! How long did we forbid fresh meat in cases of haemorrhage from passive plethora, in wasting pulmonary complaints, in scurvy, and in most other chronic non-gastric diseases, where it is now reckoned, if not a perfect panacea, at any rate indispensable!

A universal diet, like a universal medicine, is an idle dream; but speaking generally, nothing is more wholesome than fruit in abundance, and green vegetables ad libitum; and yet they frequently oppress the stomach of those who have poverty of the blood, of exhausted persons, and those suffering from the effects of a sedentary life, and increase in them the disposition to acidity, flatulence and diarrhoea! Roast beef and raw ham are considered more difficult of digestion for a relaxed stomach than veal boiled to rags. Coffee has the reputation of strengthening and assisting digestion, and yet it only hastens the expulsion of half-digested food from the bowels. I have seen children deprived of the breast-milk, crammed to death with wafer-biscuits, and perishing in numbers of jaundice. My expostulations on the indigestible nature of this unleavened and hard-baked mass of dough, were of no avail against the plausible folly of my colleagues-“it is impossible to imagine any thing lighter (in weight), or more delicate (to the touch)!”

I once knew an ignorant over-officious practitioner prescribe such a severe diet to a healthy young woman after a favourable first-labour, that she was on the eve of starvation. She held up for some days under this water-gruel diet-all meat, beer, wine, coffee, bread, butter, nourishing vegetables, andc., were denied her; but at last she grew excessively weak, complained of agonising after-pains, was sleepless, costive, and, in short, dangerously ill. The medical attendant attributed all this to some infraction of his dietetic rules. She begged to be allowed some coffee, or broth, or something similar. The practitioner, strong in his principles, was inflexible: Not a drop! Driven to desperation by his severity and her hunger, she gave way to her innocent longings, drank coffee, and ate in moderation whatever she fancied. The practitioner found her, on his next visit, much to his surprise, not only out of danger, but lively and refreshed; so he complacently noted down in his memorandum-book the excellent effects of slop-diet in the treatment of lying-in-women. The convalescent took good care not to hint to him her natural transgression. This is the history of many, even published observations! Thus the disobedience of the patient not unfrequently saves the credit of the physician. Is the error calculi, in such a case, the fault of the art or the patient, or is it not rather the fault of the physician? The artificial diet prescribed by the physician, is frequently much more objectionable than the accustomed diet of his patient; or, at least, he frequently does wrong in rejecting the latter all at once. As the physician would do well, in order to observe more distinctly and simply the course of the disease and the effects of his medicines, not to give any orders at all about the diet, except with regard to articles of which he possesses a positive knowledge, and these will be but few; he would also be consulting the good of his patient by not depriving him of anything which long habit had rendered innocuous, or perhaps indispensable.

A country midwife fell sick of a gastric fever. I purged her. I ordered her for drink, water and weak beer, and extreme moderation in eating. At first, things went on very well; but, after a few days, a new continued fever, with thirst, wakefulness, weariness, confusion of ideas, came on to such an extent as to render her state dangerous. I left none of the ordinary remedies untried. All in vain. I now left off every thing, from the sulphuric acid to the soup (at the time I was not sufficiently acquainted with the properties of opium), and promised to prescribe something on my return. I informed the relations of the danger I apprehended. The following day I was told that the patient was recovering, and that I need not give myself any further trouble. To my astonishment, I saw her pass my window, a few days afterwards, perfectly recovered, I subsequently learned, that when I had discontinued the medicine, a quack had been called in, who had given her a large bottle of essence of wood, his universal medicine, and told her to take so many drops of it. No sooner had she tasted the brandy in it than she gained, as it were, new life. She took the drops by table-spoonfuls, and, after a good sleep, she rose completely cured. This happened when I first began practice, else I should have ascertained at the commencement that, when in health, she could not live without her daily dram, consequently could not recover without it.

It is far less frequently necessary than most physicians think, to make a material alteration in the diet of patients suffering from chronic complaints, at least in ordinary cases; in acute diseases, the awakened instinct of the patient is often considerably wiser than the physician who does not consult nature in his prescriptions. I do not now allude to cures effected by dietetic rules alone, which, if simple, are not to be despised, and which are very serviceable in many cases. What I particularly call attention to is, the frequently useless change of diet, when treating a case with medicine, whereby the simplest method of treatment is rendered complex, and a composite result is produced, of which I would defy OEdipus himself to guess what part was owing to the new diet, and what to the medicine. We must certainly prohibit what we know to be hurtful in this or that complaint; but this can at the most be but two or three articles of diet in chronic diseases; the gradual disuse of which (for sudden suppression is always dangerous in such affections), cannot produce any great revolution in the system; cannot, therefore, have much effect in deranging the pure action of the medicine we are using.

If it be necessary to make considerable changes in the diet and regimen, the ingenious physician will do well to mark what effect such changes will have on the disease, before he prescribes the mildest medicine. A deeply rooted scurvy can often be cured by the united action of warm clothing, dry country air, moderate exercise, change of the old salted meat for that freshly killed, along with sour-crout, cresses, and such like vegetables, and brisk beer for drink. What would be the use of medicine in such a case? To mask the good effects produced by the change of diet! Scurvy is produced by a system of diet opposite to this, therefore it may be cured by a dietetic course-the reverse of that which produced it; at any rate, we may wait to see the result of this method, before we begin with our medicines. Why should we render the syphilitic patient, for example, worse than he is by a change of diet, generally of a debilitating nature? We cannot cure him by any system of diet, for his disease is not produced by any errors of the sort. Why then, should we, in this case, make any change? Since this occurred to my mind, I have cured all venereal diseases (excepting gonorrhoea), without any dietetic restrictions, merely with mercury (and, when necessary, opium); the metal has not a debilitated constitution to act upon, and my patients recovered more rapidly than those of my colleagues. I also knew for certain, that every change that took place, either for the better or the worse, was owing to the medicine.

An old colonel, with “fair round belly,” and apparently fond of the pleasures of the table, had suffered for the last forty years from ulcers almost all over the legs, and issues on the thighs. His food consisted of the strongest and most nutritive materials-he drank a good deal of spirits, and, for several years past, he had been in the habit of taking a monthly purge. Otherwise, he was vigorous. I allowed the issues to heal up, made him keep his legs rolled up in a narrow flannel bandage, and immerse them daily a few minutes in cold water, and afterwards dress them with a weak solution of corrosive sublimate. I made not the slightest alteration in his diet; I even did not forbid the monthly purge, as he was so constantly in the habit of taking it. In the course of a year his legs gradually healed, and his vigour rather increased than diminished in this his seventy-third year. I watched him for two years, during which he remained perfectly well, and I have since had good accounts of his health. The legs have always continued completely healed. Can I suppose that he would have recovered more rapidly or permanently had I deprived him of his eight or ten dishes, and his daily allowance of liquors? Had I changed his diet, and had he grown worse, would I have known whether this unfavourable turn proceeded from the food so much lauded in works on dietetics, but so different to what he had been accustomed to, or from my external applications, for I gave nothing internally? It would have been easy for me to conform to the schools, and sacrifice my patient methodically to the ordinary dietetic regulations; but how could I at the same time abide by my conviction, my conscience, and that prime guiding principle of the physician, simplicity!

I have no intention of exalting myself at the expense of my brethren, when I acknowledge that I have cured the most difficult chronic diseases, without any particular change of diet. I consider that I do quite enough if I advise moderation in all things, or diminish or forbid altogether particular articles of diet, which would be prejudicial to the object I wish to accomplish; as, for example, acids, when I am employing stramonium, belladonna, foxglove, monkshood, or henbane (the effects of these medicines being entirely counteracted by vegetable acids); or salted meats, when I prescribe oxyde of mercury; or coffee, when I am giving opium. Thus, if my treatment fail, I know that I have done no harm by an artificial system of diet (how much that is dangerous and hypothetical is there not in our dietetic regulations!), I know it is owing to the medicine used that the case grew worse, or, at least, did not improve. If amendment ensue, then I know that the medicine produced it, as it certainly was not owing to any change in the diet. Hippocrates, himself, if I recollect right, hints at something similar in his aphorisms, when he says, that medicine and the vis naturae produce much more considerable and profound changes in diseases than any small irregularity in diet. How near was this great man to the philosopher’s stone of physicians-simplicity! and to think that after more than two thousand years, we should not have advanced one single step nearer the mark! on the contrary, have rather receded from it! PAGE 315 Did he only write books? or did he write much less than he actually cured? Did he do this so circuitously as we? It was owing to the simplicity of his treatment of diseases alone, that he saw all that he did see, and whereat we marvel.

Climate, weather, state of the barometer, etc.

Should we abandon ourselves to despair, because we do not know, to a nicety, what is the exact influence which a slight change in geographical position, a small variation of the hygrometer, the barometer, the anemometer, the thermometer, andc., exercises upon the action of our medicines or our patients? According to many observations of the first medical men, it is not so very difficult to arrive at a pretty accurate general knowledge of the differences produced by a warmer or colder climate on the nature and treatment of ordinary diseases. They are, for the most part, merely differences in degree. The most opposite climates never produce a completely opposite code of medical laws. Is not bark as efficacious for the cure of pure intermittent fever in Mexico as in Norway; in Batavia and Bengal (the only difference, being in quantity), as in Scotland? The venereal disease is cured in China by mercury, just as it is in the Antilles. In our country, we have, inflammations and suppurations of the liver of the same nature as in the tropics; although, in the latter regions, they are twenty times as numerous as here, that makes not the slightest difference in the treatment, as in both situations mercury and opium (or something better still) are serviceable. Typhus, and similar fevers, are here as there fatal, if treated by bloodletting and nitre (not, indeed, so rapidly here as there)! They must also be treated in our country with bark and opium (not, indeed, in such large doses as there), in order to increase the strength. These varieties of climate do not change the treatment in nature, but only in degree, and such differences are determinable. But that the powers given by nature to man and habit will triumph over all variations of climate, to the preservation of life and health, is proved by there being inhabitants in the island of Terra del Fuego, as well as on the banks of the Ganges, in Lapland, as well as Ethiopia, in the seventieth as well as the third degree of latitude. And are we so ignorant of the other influences which the nature of the soil and country have upon diseases; so very ignorant that we cannot reckon the influence they would have on our practice? Do we know nothing of the different effects produced by a residence in a hilly country and on the sea-coast, on haemoptysis and phthisis; nothing of the action of the effluvia from marshes and seething intramural grave-yards in the production of intermittent fever, and diseases of the liver and lymphatic system; nothing of the power of pure air on those affected with rickets and those debilitated by sedentary occupations; nothing of the advantages of a level country over confined Alpine valleys, the cradle of cretinism, goitre, and idiocy; nothing of the peculiar power of certain winds and seasons in the production of inflammatory, or asthenic diseases, or of the effect of a low state of the barometer on the apoplectic; nothing of the influence of the air of hospitals in the production of gangrene and typhus? PAGE 316 And it is only these, and similar great and important differences, which exercise a marked influence on health and life itself, which it is necessary for us to know in our treatment of diseases. We do know them, and can calculate their influence. The influence of the finer shades of these differences is too insignificant to prevent us treating successfully the ordinary diseases. The vital power and the proper medicine generally obtain the victory over any influence which such very fine shades of differences could exert. What might be said of the Creator, who, having afflicted the inhabitants of this earth with a vast host of diseases, should at the same time have placed an inconceivable number of obstacles in the way of their cure; to discover the influence of each of which would defy the greatest efforts of the physician-a knowledge of which in their full extent (if they were of such great importance) could not be attained by the greatest genius? We cure diseases in pestilential dungeons, although we cannot, at the same time, impart to the patient the vigour of the mountaineer. Who would desire us to transform the delicate city lady into the buxom peasant girl? We remove, however, most of the ailments of the former. The sedentary man of business seeks at our hands only tolerable health, for the nature of things denies us the power of giving him the strength of the blacksmith, or the ravenous appetite of the porter. “But,” objects some one, “look what a perceptible influence a slight variation of the temperature, moisture, or relative proportion of oxygen and nitrogen in the atmosphere, a slight change in the wind, a higher or lower state of the barometer, a greater or less quantity of atmospherical electricity, and a thousand other physical powers, small though they may be, which are perhaps, as yet unknown to us, sometimes have upon diseases, at least upon the nervous, hysterical, hypochondriacal, and asthmatic!”

Shall I speak out what I think? It appears to me much less profitable to endeavour to ascertain (which is moreover impossible) all the degrees and varieties of the influence of those physical impressions, when they approach the minute, than to do our endeavour to fortify the sufferers against all these innumerable impressions, by implanting in them a certain degree of strength, whereby their system will be enabled to resist these, and many other still unknown physical impressions; just as I consider it much more practicable to dispel the morose ideas of the melancholic by medicine, than to abolish for him the countless evils of the physical and moral world, or to argue him out of his fancies. Or could all the physical and moral adverse circumstances of the atmosphere, and of human life, be more effectually prevented exercising their pernicious influence on the gossamer nervous system of yon nervous, spasmodic, chlorotic girl, did we, with angels’ understanding, completely investigate and maturely weigh, in quality and quantity, all these impulses in their full extent, than if we should restore her monthly periods? I do not believe that it is the smallness of our knowledge, but only the faulty application of it, that hinders us from approaching, in medical science, nearer to certainty and simplicity.

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