From Chambers's Journal. USE AND ABUSE OF MEDICINE. BY A PHYSICIAN. THE English public attach too much importance to the mere administration of medicine. They appear to think that for every complaint medicine is to be taken; that the chief, if not the only duty of a medical man, is to prescribe and administer drugs; and that medicine is the sole cause of every change in a disease, whether for better or worse, which follows the use of it. In all this there is much error. An illustration will at once show what is meant, and prove its truth. Take a case of indigestion. The disease may have arisen from excess or impropriety in eating or drinking, or from some other bad habit continued through ignorance, necessity, or self-indulgence. In the majority of such cases, if the cause be removed, the suffering will cease. If the medical man, however, were to content himself with pointing out the cause, and directing the patient to avoid it, and were to prescribe no medicine, such is the inveterate expectation of physic, that most patients would go away dissatisfied. Medicine is therefore given, together with directions to avoid the injurious habit; the patient recovers, and the drugs get the credit. Too often the cause is repeated, and the same process of cure is again and again submitted to. It is not to be supposed that all cases of indigestion belong to the class from which the above example is taken. There are some in which the cause may not admit of being removed; those arising from mental anxiety, for instance; others in which, owing to great debility in the stomach, the suffering is very disproportionate to the offense. In both these medicine may be legitimately and usefully employed to palliate suffering, until time can be gained for effecting a more radical cure by other means. It is important to know that there is great power in the human body to throw off disease, and to restore health, without any help, when the cause is temporary, and has ceased to operate. This power alone is sufficient to cure many diseases, not merely the trifling, but even in many instances the more severe ones. Suppose a cold has been taken, and the subject of it is a little feverish. In the mass of cases the patient will get well without any medical assistance. The duty of the medical man, if called in, is to find out whether there be any serious disease: if there be, he will treat it; if not, little further may be needed. He may palliate suffering, and may shorten the illness-both good things; but nature would effect a cure without him. Again, suppose a case of measles, scarlet fever, or typhus fever. The disease has arisen from a contagious poison, and it will run a certain course. Some cases are very mild. In these the medical man has little to do but to keep the patient out of harm's way, and to be ready to act if the case becomes more severe. Each of these diseases is liable to become complicated with serious internal changes, or with a dangerous failing of the strength. A case that is mild to-day may be severe to-morrow. prompt attention of a professional man in these circumstances may save life. If it were known, however, beforehand that the case would be mild, it might be safely left to nature. In the case of typhus, it will be important to find out the cause of the attack, with a view to its removal, or to the removal of other members of the family from the sphere of its influence. Suppose, lastly, a case of erysipelas. It may be the most trifling or the most serious disease imaginable. Many cases are so mild, that they might very safely be left to themselves; others are so severe, as to baffle the highest professional skill. How often do we find the cure of the trifling cases ascribed wholly to the drugs taken, whether from the hand of a regular or an irregular practitioner; whether in the The ordinary doses of the allopath, or in the inconceivable dilutions of the homœopath. The habit of looking to physic for everything, and of taking it to excess, prevails much more in England than in Scotland; and the difference depends very much upon the difference in the circumstances of the medical profession in the two countries. Originally, the English apothecary was a dispenser of medicines only, and not a medical practitioner he compounded physicians' prescriptions. About the close of the seventeenth century, the apothecaries in London and its neighborhood began generally to prescribe, as well as to dispense medicines. The encroachment was resisted by the College of Physicians; and from a pamphlet published in 1724, defending the apothecaries, it seems that they only claimed permission to prescribe for the poor. Even so lately as 1812, the parties who were instrumental in obtaining the present Apothecaries' Act express the opinion, "that the management of the sick should be as much as possible under the superintendence of the physician." Since 1815, the course of instruction, and the examinations instituted by the Apothecaries' Company, have been gradually improved; so that the apothecary of the present day, instead of being ignorant of physic, as his prototype was, is a well-educated medical man; and, in point of attainment, may fairly rank with the surgeon. Whilst the education of the apothecary has been thus improving, and his position changing from that of a dispenser of medicines to a medical practitioner, the mode of remunerating him has not changed correspondingly. The old apothecary appears to have been paid for his medicines only, no account being taken of his visits or advice; for it has been only very recently decided by the judges that a licentiate of the Apothecaries' Company can legally claim compensation for his visits and his time. Many are still paid almost exclusively by their charges for medicine, and nearly all look to this as the chief source of their income. A very few charge cost-price only for their drugs, deriving their gains from charges for their visits. A still smaller number of general practitioners supply no medicines, but write prescriptions, and are paid solely for their visits and time. It is easy to see that the practitioner who is remunerated chiefly by payments for medicine, is not only subjected to the temptation, but is often really obliged to send more medicine than is needed, in order to be able to | live. It is not meant that medicine is sent which will do harm, but patients are often called upon to swallow innocent, though not always agreeable drugs, instead of being required to pay for the really useful articlenamely, the medical man's time and skill. A community so trained of course think all this medicine useful and necessary; an irrational faith in its powers is fostered; and they would feel dissatisfied with the man who should adopt the more straightforward and honest practice of sending them no more drugs than are good for them. The evil is not confined to the public: it has been equally felt by the medical man. He has been a petty trader rather than a professional man; his self-respect has been lessened by having to supply under really false pretenses, and to charge for an article not wanted; his position in public estimation has been lowered by the gradual discovery of the real state of things; and too often an unfounded degree of confidence in drugs has been fostered in his own mind. He gives physic for the sake of the pay, until he ends by believing in its necessity. A habit of meddlesome activity is apt to be engendered, by which not a few patients are made worse instead of better. His practice also suffers; for the public, finding themselves dosed with unnecessary drugs, often run into the opposite extreme; and losing all confidence in them, and in regular practitioners, fly to hydropathy, homoeopathy, and other forms of error or imposture. In Scotland a different state of things has prevailed. There they have druggists, surgeons, and physicians, but no apothecaries. The surgeons sometimes supply their own medicines, charging a low price for them, but more frequently they only prescribe. The duties of the general practitioner' are performed by surgeons, often by physicians, who in that case charge only a small fee; and very commonly by gentlemen possessing at the same time a surgeon's diploma and a physician's degree. Most of the leading physicians in Scotland are "family physicians' in a great number of families-that is to say, they are the only medical attendants. At the same time, being the most eminent men of their body, they are applied to as consulting practitioners" in cases of greater difficulty or danger. The physician in Scotland retains the place which he has always held, whereas in England he has been almost superseded as a "family physician" by the advancement of the apothecary, and he is too often regarded as a consulting practitioner only. It will be at once seen that the temptation to give unnecessary quantities of medicine has been much less in Scotland than in England, and that this fact will explain the corresponding difference in the habits of the profession and of the public in the two countries. The remedy for these evils is simple. Let the public be made to understand that the money which they pay to a medical man ought to be given chiefly for his time and skill, rather than for drugs. Except in remote country districts, it would probably be an advantage if medical men kept no drugs, but only wrote prescriptions. This would remove every temptation to the evils which have been described, and would also render the professional intercourse of the consulting and general practitioner more satisfactory. When two medical men agree upon a plan of treatment, it ought not to be in the power of one of the two to yield to the temptation, which may be presented in various ways, to adopt a different practice from that which has been settled between them. Whilst the evils adverted to admit of remedy, there is another class of evils far less remediable, not arising from the abuse of medicines, but still connected with the relationship between medical men and the public. It is very much to be regretted that even the most intelligent portion of the community have not, and perhaps never can be expected to have, the knowledge of physic required to enable them to compare justly the merits of one medical man with another, or of medical men with quacks. It is the right of each person to choose among a number of practitioners, regular and irregular, the one that he will employ, and to choose among rival systems that by which he will be treated. Yet nothing is more certain than that few persons are qualified to choose well. Their selection, even if it happen to be a wise one, is more likely to be determined by bad than by good reasons. There is much truth, as well as some exaggeration, in Dr. Johnson's remark, that "a physician in a great city seems to be the mere plaything of fortune; his degree of reputation is for the most part totally casual; they that employ him know not his excellence; they that reject him know not his deficience." This is a very discouraging circumstance in the life of a scientific physician, as compared with that of a member of either of the other learned professions. One or two illustrations, taken from actual observation, will show the kind of difficulties which the public encounter, and by which they are liable to be misled. The cure of a patient is accounted, and, with due precautions, ought to be accounted, a proof of skill. But the recovery of a patient is not always a proof of skill, nor even of the absence of ignorance on the part of the practitioner; for to keep a patient from immediate death is only one part of a medical man's duty. Take, as an example, rheumatic fever. The patient's suffering is excruciating, yet he seldom dies during the attack. Suppose two similar cases, treated by two different medical men, or one by a regular, and one by an irregular practitioner. Both patients will probably escape death, and both the practitioners will therefore probably be accounted skillful. But on further inquiry, it may be found that one case lasted four or five days only, the other twenty or thirty. Is it nothing to have saved a patient several weeks of agony? Both, however, at last resume their duties. It may then be found that the one can do anything that he was able to do before his illness, and with the same comfort; whilst the other begins to suffer, sooner or later, from symptoms which turn out to have their origin in disease of the heart, left by the rheumatism. Both these cases were reputed to be "cured," but surely the cure was a very different thing in the two cases. The one patient continues well; the other is an invalid from the first, and after a few years, dies of dropsy: yet the public know no difference. The disease to be treated may be an incurable one. Patients or their friends are too ready to think that it does not matter by whom an incurable disease is treated. There is the greatest difference, however, in the amount of suffering to be endured, and in the length of life in such cases, according as the treatment is judicious or otherwise. But the greatest difference between different medical men, and especially between medical men and quacks, in incurable diseases, as well as in others, is in their skill in finding out what the disease is; in other words, in what is technically termed the art of diagnosis. An ignorant medical man, conscious of his inferiority to abler ones in this branch of knowledge, often plumes himself upon being still able to treat disease as well as they can. But it is easy to show that, both in curable and incurable cases, the correct treatment must be based upon correct diagnosis; and therefore that the man who is inferior in the one art, must, in the great mass of cases, be inferior in the other also. A patient seeks ceed from an internal inflammation, bleeds largely, and so takes away that power which alone could resist the fatal poison of the disease. All these instances are taken from observation; and the same observation has shown that the patient and friends rarely see the difference between the two practitioners, and that they not unfrequently blame and discard the skillful one, and laud and patronize the ignorant or the dishonest one. advice, and, without perhaps suspecting it, | fever. One practitioner sees that it is the is in the early stage of consumption. How beginning of typhus, husbands the strength, much may depend upon the positive discov- and saves him. Another believes it to proery of the real disease! To say nothing of cure-which, if it is to be hoped for at all, can only be in the earliest period-nor of the prolongation of life by judicious change of climate, the discovery of the disease may affect the question of marriage, of entering into or leaving business, and of life insurance. Again, another patient seeks advice who suspects that he is consumptive. A man unskilled in diagnosis can only give an equivocal answer to the inquiries made, whilst another, better informed, may be able to state absolutely that the disease is not consumption, and that there is no reason to fear that disease, and so may dissipate at once the fearful anxiety of the sufferer and his family. Another patient suffers from dropsy. One man treats it by rule, and for the time gets rid of it, but does no more. Another discovers the cause of it, and gives the patient such further directions as may prolong his life for years. A patient is the subject of disease of the heart, but does not know it. A man who can detect it is able to apprise him of it, to warn him against injurious or dangerous habits, and so to prolong his life, and enable him to make arrangements in anticipation of a sudden death. Another patient fears that his heart is diseased, and seeks to have the question determined. A practitioner, skilled in diagnosis, may be able with certainty to assure him that the disease is only nervous palpitation, and is wholly free from danger. In curable diseases the importance of skill in diagnosis is even greater than in incurable ones. A patient is the subject of scurvy. One man does not know the disease, and cannot therefore treat it, and the patient dies. Another sees what it is, gives lemonjuice, restores health in a month, and then points out the causes from which it has arisen, and thereby enables the patient to avoid the disease in future. The ignorant medical man and the impudent quack, if asked the question, will no doubt answer that they can cure scurvy as well as the ablest man in the land. So they can, when they are told that the case to be treated is scurvy; but ere they discover this the patient dies. A female seeks advice with a pain in the side. One man sees in it a pleurisy, bleeds the patient, and throws her down for months. Another sees it is a nervous pain, strengthens the patient, and cures her in a month. A patient is seized with symptoms of high A medical man is often very unduly praised or blamed for changes which arise from the natural course of the disease, and with which he may have nothing to do. The same disease runs a very different course in different cases, from causes with which we are but imperfectly acquainted, and quite independently of any difference in treatment. The course of consumption will afford a good illustration of this truth. One case will get rapidly and progressively worse, and will end fatally in a few months, whatever treatment is adopted. Another case will begin and go on in the same way as the first up to a certain point; the patient will then improve, and perhaps appear to get well. After a time he relapses again; and these alternations of comparative health and severe suffering may occur many times, and the disease be protracted over a period of many years, ending fatally at last. The medical man commonly gets the credit of being the cause of each change, whether for good or ill, and is praised or blamed accordingly. Such cases are a fertile source of reputation to irregular practitioners, who claim credit for the improvement, and easily find something or some person, to blame for the aggravation of the disease. A surgeon is consulted in the early stage of a serious disease. The nature of it is yet doubtful; he may think the case trifling. The illness goes on; the patient becomes worse; consults another surgeon. The nature of the disease has then become plain, and is announced accordingly. The first surgeon is accounted a blunderer, the second skillful; yet the very reverse may be true. A surgeon makes a clear mistake; the patient finds out that he has done so, blames and discards his adviser forever. The surgeon may, notwithstanding, be a very able and a very skillful man. There is no man living who does not make mistakes sometimes. Two medical men are consulted in succession; each gives a different opinion. The patient almost invariably assumes that the second is right, and blames the first. If the two men previously occupied an equal professional station, the one opinion should still be regarded as equally good with the other, until further evidence has shown which was right. Another error consists in supposing that a medical man cannot have acquired much experience until he is considerably advanced in life. The frequent consequence of this is shown by the adage-"A physician cannot earn his bread until he has no teeth to eat it." The late eminent surgeon, Mr. Liston, has well exposed this error in the following words: "Years are not the measure of experience. It does not follow that the older the surgeon is, the more experienced and trustworthy he must be. The greatest number of well-assorted facts on a particular subject constitutes experience, whether these facts have been culled in five years or in fifty." One man advantageously placed may have seen more patients at the age of thirty than another has seen at seventy. But the number of patients seen is not the only guide to the amount of experience. One man, from natural ability, or industry, or the stimulus to think, furnished by the circumstances in which he is placed, sces more and reflects more, and therefore extracts more experience from one case than another does from a hundred. An excessive confidence in physic, if not the parent, is certainly the nurse of quackery or irregular practice, both without and within the pale of the profession. Whilst there is suffering to be relieved, there will be found ignorant and weak men, who deceive themselves, and dishonest men, who deceive others, in professing to have the power of relieving it. Examples of cure are adduced, circulated, and believed, and so the fame and practice of the empiric are extended. We do not propose to enter into a discussion of the subject of quakery: the question is too large for the end of an article like this, but one or two remarks upon it may not be without their use. Medical men and the public commonly take different views of this subject. Medical men are charged with professional prejudices, and with interested motives, which shut their eyes to the truth. They, on the other hand, think that the public are not qualified to discern, until schooled by a disastrous experience, the deceptions practised upon them. We believe that it is not the interest of medi cal men to oppose any improvement of their art, and that, as a body, they do not think it to be so; and as to professional prejudice, we ask for evidence of the existence of anything more than a due measure of scientific caution. History will show how many infallible remedies for various diseases have been vaunted and forgotten for how many improvements can history show us that we are indebted to quacks? But cures are adduced, and respectively attested. Facts are stubborn things-how are these to be set aside? Some of them are true, and some of them are false. The history of empiricism is full of interest to the mental philosopher. The phrenologists have an organ of wonder; and of the existence of the faculty ascribed to this organ, we think it is impossible to doubt. Whatever is new or marvellous has an irresistible attraction for some minds; to doubt the marvel is to rob them of their idol. What they love they cling to; and without a particle of conscious dishonesty, they will solemnly attest to be true that which is plainly and indubitably false. History will place beyond the power of any to doubt the assertion, that it is impossible to invent statements more absurd and more false than some which have been attested as facts by intelligent and respectable persons. One instance of this kind may be given from the life of an individual, of the value of whose pretensions most persons will probably by this time have formed the same opinion. St. John Long professed to have a liniment which would cure consumption; and he declared it to possess this remarkable property-that when rubbed upon the chest, it would produce a sore upon the skin over the diseased part of the lung, but would produce no effect upon the skin over the sound parts. Many persons of rank, intelligence, and undoubted integrity attested the truth of this statement in a court of justice. Yet the fact so attested was undoubtedly false, and few persons probably now believe it. The public caressed St. John Long, enriched him, and when, in spite of his own liniment, he fell a victim himself to consumption, they raised a splendid monument to his memory. The liniment still exists, and consumption finds as many victims as ever. Can it be a matter of surprise that medical men, whose pursuits necessarily familiarize them with a long succession of such frauds or follies, should be slow to believe the reports of improbable or impossible cures, which are propagated by silly, sanguine, or wicked men, even when they are attested by respectable and disinter |