MEDICAL NOTES AND REFLECTIONS. CHAPTER I. ON MEDICAL EVIDENCE. THERE can be few better tests of a sound understanding, than the right estimation of medical evidence; so various are the complexities it presents, so numerous the sources of error. The subjects of observation are those in which Matter and Mind are concurrently concerned; - Matter under the complex and subtle organization, whence vitality and all its functions are derived ;— Mind in its equally mysterious relations to the organs thus formed; - both subject to numerous agencies from without, — both undergoing great changes from disease within. Individualities of each have their influence in creating difficulties, and these amongst the most arduous which beset the path of the physician.* Few cases occur strictly alike, even when the source of disorder is manifestly the same. Primary causes of disease are often wholly obscured by those of secondary kind. Organs remote from each other by place and function are simultaneously disturbed. Idiosyncrasy, as arising in most cases from inappreciable causes, is the most absolute and inevitable difficulty in medical evidence; since no accumulation of instances, such as might suffice for the removal of all other doubts, can secure us wholly against this source of error. Translations of morbid action take place from one part to another. Nervous affections and sympathies often assume every character of real disease. While remedial agents are rendered uncertain in effect by the various forms of each disorder, by the idiosyncrasies of the patient, by the difficulty of securing their equal application or transmission into the system, and finally by the unequal quality of the remedies themselves. These difficulties, the solution of which gives medicine its highest character as a science, can be adequately conceived by the medical man alone. Neither those accustomed to legal evidence only, nor such as have pursued physical science in its more simple material forms, can rightly apprehend the vast difference made by the introduction of the principle of life, or, yet more, of the states and phenomena of mind, in connexion with bodily organization. We have here a new world of relations, occult and complex in their nature, to be reasoned upon and resolved; with a principle of change, moreover, ever operating among them, which makes all conclusions liable to a new source of error. It is the want of this right understanding of medical evidence, which makes the mass of mankind so prone to be deceived by imposture of every kind; whether it be the idle fashion as to particular remedies; or the worse, because wider, deception of some system, professing to have attained at once, what the most learned and acute observers have laboured after for ages in vain. It must be admitted, indeed, that this matter of medical testimony is too lightly weighed by physicians themselves. Else whence the so frequent description of effects and cures by agents put only once or twice upon trial; and the ready or eager belief given by those, who on other subjects, and even on the closely related questions of physiology, would in stantly feel the insufficient nature of the proof.* Conclusions requiring for their authority a long average of cases, carefully selected, and freed from the many chances of error or ambiguity, are often promulgated and received upon grounds barely sufficient to warrant a repetition of the trials which first suggested them. No science, unhappily, has abounded more in false statements and partial inferences; each usurping a place for the time in popular esteem; and each sanctioned by credulity, even where most dangerous in application to practice. During the last twenty years, omitting all lesser instances, I have known the rise and decline of five or six fashions in medical doctrine or treatment; some of them affecting the name of systems, and all deriving too much support from credulity or other causes, even among medical men themselves. Look at what is necessary, in strict reason, to attest the action and value of a new remedy or method of treatment. The identity or exact relation of the cases in which it is employed; a right estimate of the habits and temperament, moral as well as physical, of the subjects of experiment; allowance for the many modifications depending on dose, combination, quality of the medicine, and time of use; due observation of the indirect or secondary, as well as direct, effects; and such observation applied, not to one organ or function alone, but to the many which constitute the material of life. All these things, and yet more, are essential to the completeness of the testimony. All can rarely, if ever, be reached; and hence the inevitable imperfections of medicine as a science. But more, doubtless, of truth and beneficial * Id credunt esse experientiam, quando semel vel bis faustam, vel infelicem, in certo morbo a sumpto medicamento annotarunt efficaciam. — Hoffman. result might be attained, were these difficulties rightly appreciated, and the means of obviating them kept more constantly in view.* In no class of human events is the reasoning of “post hoc, propter hoc," so commonly applied by the world at large, as in what relates to the symptoms and treatment of disease. In none is this judgment so frequently both erroneous and prejudicial. It would seem as if the very complexity of the conditions necessary to sound evidence, tended to beget acquiescence in that which is lightest and most insufficient for truth. The difficulties occurring in practice from this source are great, and require a right temper as well as understanding to obviate them. Nor is there any subject upon which words and phrases, whether applied to diseases or remedies, exercise a larger influence. Terms have descended to us, which we can hardly put aside, maxims which fetter the understanding,- and methods of classification, which prevent the better suggestions of a sound experience. And these are among the evils most aggravated by public opinion, ever prone to be governed by names, and particularly in all that concerns the symptoms and treatment of disease. The deeper the interest belonging to the subject, the greater the liability to error. But in medical doctrine and theory also, there is scarcely less of difficulty from the nature of the evidence concerned. If example were needed to illustrate this, it might be drawn from what relates to the history of fever, whether idiopathic or symptomatic in kind. Here centuries of research, amidst facts of daily occurrence, have yet left some of the most im * Amongst the other difficulties of evidence in such cases must be noticed the ambiguity of all language as applied to denote and distinguish sensations; an evil familiar to every medical man, and only to be obviated by watchful experience. |
