"hoc autem de quo nunc agimus id ipsum est quod utile appellatur."—cicero.
consultation. we are to have a consultation! what a sound is that! how many a heart has been set thumping by this one word. we doubt whether there be any in the english language that has more frequently disturbed the current it was intended to calm. but consultations must be. already the carriage of a physician has arrived, a tremendous rap has been given at the door, the interesting visitor is already in the library.
another rap, louder somewhat than the former, announces another physician, or a consulting surgeon. the general practitioner, taking advantage of his intimacy with the family, may have perhaps very sensibly walked in without knocking at all. they are now all assembled in the library, and, having remarked on a "storm scene" by gaspar poussin, which hangs over the fire-place, we leave them to the preliminaries of a consultation.
presently they are introduced to the patient, on whom the knocking has already had some effect. a short pause, and they are again assembled in the library. in a few minutes the bell rings, and the father of a fine young woman is summoned to hear their decision. as he proceeds, he stealthily removes a straggling tear that, with all care, would get out of bounds, enters the library, and hears the result of the consultation. neatly enveloped honoraria are presented to the consultants, the bell has rung, thomas has shown the gentlemen to their respective vehicles, and and so ends the consultation.
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the father, a widower, returns to the drawing-room, and his second daughter says: "well, papa, what do the doctors say of emily?" "well, my dear, they say that emily is very ill; that she requires great care; that they cannot say positively, but hope she may ultimately do well. they entirely coincide with our friend mr. smith jones as to the nature of the disease, and think his treatment of the case has been highly judicious. they say there are some points on which the case may turn, but of which they cannot speak positively to-day; but they hope to be able to do so when they meet again, which they are to do the day 'after to-morrow.' they all seem to consider the nervous system very much affected. they say we must keep emily very quiet. she is to have any light diet she desires, and to have some new medicine to-morrow. the cod-liver oil, they say, has done her all the good now that it is calculated to do, and she is this evening to take a composing draught." the family are silent, and so ends the consultation.
what! and are all consultations like that? no, reader, we hope not. many a valuable life has, we believe, been saved or prolonged by consultation; and perhaps many more would be, if people would only think a little more before they act in such important matters.
but how is this to be, when men and women who do think will dive into all other branches of knowledge, more or less, and neglect all inquiry into laws, a general knowledge of which may easily be acquired, and of which ignorance is so frequently visited by no less punishment than the premature separation of our dearest ties, and the loss or impairment of that which is acknowledged to be the first of temporal blessings. there are many things in consultations, which require putting right, which do not depend on any one man, or on any one class. what are we to say to a man who admits the ability, and approves of the investigative power and practice of another, but who cannot call him in because he orders so little medicine? or of the mode in which the public treat another, who, wishing to practise as a gentleman, and to be paid for his brains rather than his bottles, makes no charge for the latter; and yet who informed us that,249 having tried this for three years, he lost so many families by it, that if he had not relinquished the plan, he should have wanted bread for his own? or who shall we blame, when one man, calling in another to a patient, finds that the other feels no scruple in repaying the prestige which he thus owes to his confiding brother by taking the patient from him the first opportunity; albeit that he occupies what should be, and, we trust, as the rule is, a higher walk in the profession.
we have seen so much feeling arising from this practice, and we hold it as so serious an error, that we regard it as tending more than any one thing whatever to injure the position and character of the consulting branches of the profession.
again, how inconsiderate must be the adoption of that custom which first of all institutes an inquiry to ascertain whether there is any difference of opinion, and yet accompanies it with trammels, the tendency of which is to oblige men to appear to agree. when coincidence of opinion is alone safe, who can be expected to differ? the public have allowed lawyers to differ without that difference involving any reproach. they have also proverbially determined that "doctors do." yet that which they consider as an almost necessary rule in the one case, in the other they are very prone to visit, in regard to some one of the dissentients, as a proof of professional inferiority. a great deal of mischief results from this state of things; it indefinitely increases the difficulty of obtaining a really honest and unreserved opinion, and leads to other consequences which tend to impair that mutual confidence between man and man, which should be the very life-blood of a fine profession.
we recollect a case, on the nature of which two surgeons were consulted; and when the patient—a young lady—had been withdrawn, the father requested to know if there were any objection to his being present at the conference. the surgeon to whom he seemed to address himself said, "none on my part;" to which the other seemed also to assent. when the consultation was over, the surgeon who had thus seemed to consent addressed the other, saying: "if ever we meet again, sir, our consultation must not be in the presence of the friends of the patient." this was said250 in a tone to which the other had not been accustomed; but, as a lady had just then entered the room, no reply was made. the next morning, however, the gentleman was called on to re-consider the tone in which he had thus addressed his brother consultant, when a satisfactory explanation settled the matter.
such things, however, are extremely disagreeable, and illustrate how much more easy it is to go straightforward than by any zigzag route. what! could not a father hear the honest opinion of two men concerning his child, until results of the consultation had been shorn down, certain parts thrown out, and the rest dovetailed together so as to be made a symmetrical nondescript, adapted to the requisitions of a vulgar conventionalism?
in another case, in a consultation on a disease as plainly scrofulous as it was possible to be, the family attendant had pronounced that it was constitutional, but not scrofula. this was, it appeared, a miserable assentation to the prejudices of the family, for the result proved that he knew better. nevertheless, a consultation had taken place already with a very eminent surgeon, without the family being any the wiser in regard to the nature of the disease. the case not progressing, another surgeon was consulted, who, being asked what he considered the disease to be, replied that it was scrofula. upon this, considerable surprise and uneasiness were manifested on the part of the family; and the surgeon, wondering what, in so plain a case, could be the doubt, took occasion to see the former medical attendant, and to ask him what he thought of the case; when he said that it was clearly scrofula, and that he had never known the children of certain temperaments to which he considered the parents to belong, wholly without a tendency to that disease; so that he had all along been blinding the parents, so far as his opinion and that of another eminent man went, to the real nature of the malady.
an occurrence, singular, as we hope, took place one day in consultation, showing how comfortably the most questionable things may appear to sit on a man's conscience, if only supported by some supposed sanction from custom. two surgeons met to consider a case. they differed as to its nature and treatment; as251 thus—the one thought a certain remedy necessary, and that any prospective consequences on its employment merged into the necessity of the moment; the other thought that remedy wholly unnecessary, and therefore held even the possibility of any prospective mischief, an insuperable objection to its use; conceding, however, that it might possibly, if the treatment were conducted cautiously, be so managed as to secure the patient from the consequences in question; and that, if the patient preferred that course, after the matter had been fairly stated to him, he would superintend the plan.
having retired into another room to consult, they were now again introduced to the patient, when the junior was somewhat startled to hear his senior begin thus: "well, sir, we have considered your case, and we perfectly agree as to the nature of it." thinking that this unexpected exordium might possibly be preliminary to some explanation of the points on which they differed, the surgeon waited a minute to hear what followed; but finding that his brother was irremediably misrepresenting the matter, he said: "stop, let us understand each other!" and then stated what had really happened, and the exact nature of their respective opinions; on which the other, in the coolest manner possible, said: "yes—exactly, you are quite right!" and so ended the consultation.
there is, no doubt, some fault on all sides. the public are too uninformed on these important subjects, and therefore do much that is equally against their own interests and the preservation of that dignity and respect which should ever attach to a high-missioned profession. but is the profession itself free from blame? do they never themselves minister to this wretched system of double dealing? we fear there is but one answer to this question. we are not careful, for obvious reasons, to multiply examples of such things; but we are convinced that there must be a change; and since the profession cannot, as too many of the public may, plead ignorance—for this and a thousand other reasons, they should lead the way. we only claim for ourselves what we readily concede to others—the expression of our opinion—when we say that consultations should be bona fide examinations252 of the case, and should be followed by bona fide intelligible explanations of it to the patient or his friends, according to the obvious suggestions of prudence or humanity in the individual case. when the treatment is correct, the most honest proof should be afforded of it; namely, the continuance of the plan of the attendant in ordinary, unobscured by the farce or form of a prescription; or, if additional appliance only is adopted, in such a case its subordinate character should be honestly explained.
where there is difference of view, if it be material, that also should be candidly stated; and if this be done with real fairness, our experience has convinced us that it may be effected without damage to either party. in other differences of opinion, the public never think it necessary to impute ignorance or incapacity: let them, for their own sakes, repudiate this construction in regard to the medical profession. lastly, let them for ever abandon the practice of paying any man for his bottles, the number of which will often be an inverse ratio with his skill and judgment.
to return to abernethy. no doubt his manner varied in consultation; but of "manner" we shall speak in a separate chapter. we will here record our impressions as to "abernethy in consultation;" the conditions which seemed to secure a considerate opinion from him; the good sense and reasonableness of those conditions; the practical result of the observance of them, and the effect they were calculated to produce on the public, in giving to consultations that efficiency by which they should be characterized—an efficiency which every one begins to perceive to be necessary, and which must be equally to the advantage of the public and the elevation of the profession.