CHAPTER II.SKILL IN MEDICINE.
The uncertainty of medicine is often most unjustly made to give a free license to blind experimenting. It should the rather stimulate to the most careful and searching observation of all the doubtful points of the case in hand, so that whatever of experimenting may be necessary, shall be as rational and intelligent as possible. This leads me to remark, that the views, which we have taken of the uncertainty of medicine, show us in what real skill in the practice of the medical art consists. It consists inappreciating the actual state of the patient in all respects, and then applying such remedies, and in such quantities and forms as will do the greatest probable amount of good. This is apparently a very simple proposition. But if we consider it in all its bearings, we shall find that more is included in it than at first sight appears. I will therefore dwell on some of these points in the order in which they are suggested to my mind.
Appreciating the true condition of the patient does not consist merely in finding out the seat, the nature, and the amount of the disease. This is exceedingly important, it is true. But it is by no means all of the case. Sometimes it is but a very partial view of it. For example,suppose that the patient has an inflammation of some organ, and to make the case stronger, let it be achronicinflammation. In chronic diseases, as you have seen, there are extensive results from sympathy and from the action of concurrent causes in different parts of the system. The physician, in investigating such a case, in order to proportion his curative measures with any accuracy to the ends to be accomplished, must look beyond the main disease, and take into view the whole case, the state of the different organs, and the state of the system as a congeries of organs.
A disregard of this important point is very common, and leads to many errors in practice. Let us look at a few of them.
Many physicians are disposed to consider the morbid state of the system in almost every case as arising from disease in some particular organ. They therefore, in examining the symptoms, search for this disease; and when they think that they have found it, they refer to this, either directly or indirectly, all the phenomena which the case presents. In their treatment of the case, therefore, they direct their remedial means principally to the local disease. They lose sight of the fact, that often there are several organs simultaneously affected, and that the organ which seems to be most diseased is sometimes found to be less so than some other organ, which exhibited no marked signs of its morbid state. They forget too another important fact—that the disease of an organ is often a mere result of a general bad condition of the system. If in such a case the physician considers the local disease the main thing to be attacked by remedies, and directs his efforts to that point, he commits a great error. And this is an error which occurs, I have no doubt, very often in regard to the most common of all chronic complaints—consumption. Thelocal disease is a result, and not a cause, much more often than is generally supposed, even by physicians.
Some physicians acquire exclusive and narrow notions of disease, by having their attention particularly directed to the diseases of certain organs. They get a sort of attachment to some localities in the system, and are disposed always to look to their favorite quarters in their search after the seats of disease. With such an inclination it is no wonder that they often suppose an organ to be the seat of fixed disease, which is merely sympathetically affected.
An undue attachment to certain modes of investigation, to the exclusion of others, is also frequently a source of error. I mention as an example a too implicit and exclusive reliance upon what are called the physical signs of disease. Percussion and auscultation are valuable sources of evidence, but when they are relied upon to the exclusion of other sources, as is often the case, they lead to error. Some who have attained to a high degree of skill in the use of the stethoscope, have on this account sometimes adopted very erroneous conclusions, which might have been avoided by a careful examination ofallthe sources of evidence in the case.
Having pointed out some of the errors produced by narrow and exclusive views in the investigation of the symptoms of disease, let us now attend to some of the errors which result from this cause, in theapplication of remedies.
A remedy may be applicable to a disease which the physician finds developed in a given case, but there may be some condition of some organ, which may render it wholly inapplicable to that case. For example, in a case of inflammation of the lungs, the state of the stomach may be such as utterly to forbid the use of some remedies, which would otherwise be proper. If they be administered inspite of this circumstance, they may perhaps produce a beneficial effect upon the inflammation, and yet may do a great injury to the patient, perhaps even a fatal one, by their direct effect upon the diseased stomach. Errors of this kind do often occur in the practice of those who observe inaccurately, or who have fallen into a sort of routine of practice from disinclination to mental effort.
The general condition of the patient sometimes fails to be appreciated by the practitioner. He may be pursuing a course which would be admirably adapted to cure the same disease in a more vigorous patient, and yet in the case in hand it may be ruinous. Though it may relieve and even cure the disease, it yet may destroy the patient. The judicious physician in some cases feels obliged to let morbid processes go on, because the violence which must necessarily be done to the debilitated system by the attempt to arrest them, would put the patient’s life in greater jeopardy, than it would to let them have their course. Questions frequently arise on this point, which tax the physician’s skill and judgment to the utmost. Even when it is proper to moderate the activity of a diseased process, it is often a very delicate point to determine just how far this can be done without doing harm to the patient. Fever is often moderated by means that irritate the system, or prostrate its powers to such an extent, that bad results, sometimes fatal ones, occur; when, if these means had been used less largely, or perhaps even if they had not been used at all, a recovery might have taken place.
Sometimes fearful issues depend upon the decision of the physician. For instance, here is a case which has been going on for some time without giving much occasion for anxiety; but all at once it assumes a new aspect. A new set of formidable symptoms have come on, requiringan entire change in the treatment. A variety of perplexing questions now arise in the mind of the physician,—such as these. If the attempt be made to remove the new symptoms, how much reason is there to fear that that attempt will so affect the debilitated patient as to destroy life? Severe as the symptoms are, is there a probability that, if a mild course be pursued, the patient may weather the storm? Will he certainly die if the symptoms are left to go on without any attempt to arrest them? And if so, what measures will probably arrest them with the least amount of risk to the patient’s life? Such are some of the momentous questions which press upon the physician’s mind; and, though he would like time to give them a patient examination, he cannot have it; for there is necessity for immediate decision and action. The reader can plainly see, that in order to decide such questions under such circumstances properly, great comprehensiveness and concentration of thought, and a cool and clear judgment, are requisite; and that a mind of narrow views, and loose habits of observation and reasoning, must often fail to come to a right decision of them.
Some, in such circumstances, amid all the uncertainty that beclouds this nice balancing of probabilities, will doubt and doubt, till the time in which anything effectual can be done is past by; and the patient dies without having a single intelligent effort put forth to save him. Others, in their confusion of ideas, pursue a vacillating course—at one moment inefficient, at another destructive; and no rational and steady plan is adopted. Others still, without waiting to consider the different questions which I have mentioned, see in the new group of symptoms nothing but a new enemy to be attacked, and plunge, at once, into thefight. A reckless course is entered upon, which must either kill or cure.
The truly judicious physician, in contrast with all these, is neither bewildered nor precipitate. He takes a rapid view of all the circumstances of the case, and looks carefully at the important and perplexing questions which start up one after another in his mind, and then decides intelligently, coolly, and definitely upon his plan of treatment. He may err, it is true; but if he does, it is not his fault, for he has made use of all possible precautions to prevent error. The plan which he fixes upon, he does not pursue obstinately, as being, without a doubt, the best. While it is that which he believes to be the best at the time, he watches its progress, and if he see reason afterward to alter it, he does so. Aware of the uncertainty of his knowledge, while he decides at every step what it is best to do, he is ready to reverse that decision, and change his course, whenever any new development in the case shall call for it.
Sometimes he decides that it is best to wait and watch the movements of the case. Many seem to demand that he shall pursue an active course of treatment all the time, to conquer the disease—that he shall be keeping up a constant cannonade upon it from beginning to end, not reflecting that if he do so, many of his shots must be worse than lost. And some physicians yield to this demand, and pursue this destructive course. The public call them bold practitioners; and they do gain some apparently splendid victories over disease; but if the results of their whole campaign (to carry out the illustration) could be fairly estimated, they would be found not to deserve the reputation for success, which is accorded to them. The prudent and judicious physician, like the prudent and judiciousgeneral, fires as few random shots as possible, taking good care, too, that he hit none but enemies—husbands carefully all his resources—rests from his battle with disease whenever it is best to do so, maintaining, for the time, a “masterly inactivity”—retreats when he finds his line of movement is likely to prove disastrous—calculates probabilities as accurately as he can at every step, and endeavors to make every measure tell upon the great result, avoiding, as far as possible, those which will not, and especially those which will hinder or defeat it.
Sometimes the physician finds that he must be satisfied for the present with but a partial view of the case before him. He sees that there are some agencies at work, which are hidden from his view. Under such circumstances, while the careless and adventurous practitioner makes up his theory of the case confidently, and acts upon it, supplying what is not known from his own imagination, and mingling all together in one confused mass; the judicious physician, on the other hand, cautiously distinguishes between what he actually knows and what may be supposed, acts upon this knowledge, and watches for farther developments to clear up what is doubtful. He treats the case according to the indications of the presenting symptoms, carefully scrutinizing the effects of his remedies. Perhaps he succeeds in cutting off at first some of the tributaries of the disease; and, by so doing, patiently and perseveringly, he at length comes at the main disease—the starting point of the whole case.
In pointing out the characteristics of medical skill, allusion was made to the quantities and forms in which remedies are administered. These must, of course, be varied to suit each individual case. Sometimes a very nice adaptation is necessary, especially in regard to quantity.A remedy, which is appropriate to a case, may be given in such a quantity as to be injurious. The use of a medicine may be continued too long. It may have accomplished all the good that it can; and the continuance of it will do harm, perhaps even beyond the undoing of all the good which it has effected. Sometimes a change occurs in the condition of the patient of such a character, that a remedy, which has been up to that time beneficial in its influence, will now produce bad results. Medicine is often continued under such circumstances. Such are some of the errors to which the physician is liable in regard to the quantity of medicine to be given, if he be at all loose in his habits of observation.
Perhaps there is no one thing in medical practice in which failure is so common, as in the accurate proportioning of remedies to the condition of each case. A physician may discover very clearly the nature of the malady, and decide with great correctness upon the appropriate medicines, and yet, may err after all in applying these medicines in the proper amounts, and at the proper intervals. The variations, in these respects, required by different cases, have a wide range—some demanding large doses to produce the needed effects, and others being strongly affected by small ones. In some cases of severe pain, for example, very large doses of opium in some of its forms are necessary to give relief; while, in other cases, in which, perhaps, the pain is by no means slight, quite small doses accomplish the purpose. Similar variations in the quantities of remedies, are required by other circumstances, which are less obvious in their indications on this point, than so palpable a symptom as pain is. The contingencies on which these variations depend, are often, indeed, so uncertain and so secret, that they elude the mostwatchful and patient investigation, much more that which is hasty and careless.
Experience gives to the shrewd and judicious physician a sort of tact in detecting these contingencies, and in so modifying his practice as to meet with some good degree of fitness the various indications which they present. This tact is to be acquired at the bedside of the sick, by patient watching of the workings of disease, and of the influence of remedies upon it; and though the experience of others is a valuable auxiliary in acquiring it, it is only an auxiliary, and cannot communicate it alone. There are a thousand little things that are observed in watching disease from day to day, which materially influence the physician in the details of his treatment, but which it is impossible to record in the history of the case. It is therefore peculiarly true of the wise and skillful physician, that when he dies much wisdom will die with him. And the student of medicine always finds, when he comes to actual practice, that disease, in the sick chamber, is a very different thing from what he supposed it to be when listening to descriptions of it in the lecture-room. One of the first lessons that he learns is, that the long troup of maladies, arranged in the syllabus of the professor, gives but a faint idea of the various and Protean shapes of disease, as they appear before him, in all their complications, with mingled and confused lineaments, instead of the distinct ones with which they are necessarily described in books and lectures. He sees that the general principles which he has learned, are to be applied with almost endless variations; and that a searching and ever-vigilant observation is needed to apply them aright.
The points which I have endeavored to elucidate, in regard to skill in the management of disease, are very commonlydisregarded by the community, and too often even by physicians. To impress them more vividly upon the mind of the reader, I will resort to an illustration, in which some of the same principles are applied to quite a different matter.
Two travellers are wending their way through a mountain-pass to their home. Their path is a perilous one; now lying along on the very brink of a precipice, and now across a succession of points of rock, with an abyss yawning below. Often the foothold of the traveller is but a slight one, and would scarcely suffice were there not some shrub near by that could be caught hold of, or some projecting point of rock on which he could hook his fingers. One of the travellers is weary and sick, and the other is helping him along. The shades of evening have come on, and the flying clouds occasionally obscure the light of the moon that shines upon their path.
It needs a watchful eye, a strong arm, and a firm foot, to go through this pass with safety, even by broad daylight. How fearful, then, are the dangers that threaten the sick traveller? If he were alone, he could not possibly get to the journey’s end. He would fail to reach some foothold, or would let go his grasp upon some shrub, or totter from some giddy height, and be dashed to pieces. His companion sees the difficulties of the task before him, and bidding the poor sick man to be of good cheer, nerves himself for labors that will tax all his strength and all his skill.
See how varied is the assistance which he renders! Now he is before, with outstretched hand raising him up; and now behind, doing the same office, while the feeble man clings to some branch, or to some projecting point of rock. Now you see him gently supporting his totteringsteps, as he leads him slowly along a narrow path on the edge of a precipice, where, if he but stumble, he is lost. The effort is now but a slight one; but it requires caution, firmness, and skill. And now there is needed a strong, almost an Herculean effort. He must raise him to the top of a rock just large enough to stand upon, and there let him rest a moment, so that he may step carefully to another rock which offers a secure resting-place. He pauses before making the effort, to calculate with precision the amount of force needed. He sees that if he come short of raising him to the right spot even an inch, his feet may slip, and he is gone. And on the other hand, if he use too much force, he may throw him too far, and then he will plunge over beyond. His courage almost fails him, as he sees the fearful issues—the issues of life and death, that hang on that one effort. But it must be made. Uttering the cheerful words of hope in his companion’s ear, with his whole frame roused to its utmost tension, he makes the attempt. The poor man’s feet just reach a jutting edge of the rock, while he catches with his fingers upon another projection, and there he hangs. His strength is almost exhausted; but he knows that if he lets go he is lost. His friend presses his feet fast to the rock, and tells him to hold on. Then finding some foothold by which he can raise himself a little higher, he lifts his sick companion gently to the summit. There he remains a few moments, trembling, and almost poised upon a point, fearing to move, or even to look down from that giddy height, lest he should slip off. But soon, with the little rest that he gets in this perilous situation, and encouraged by the firm and cheerful voice of his friend, he steps to the next rock, where a broad and sure foothold enables him to pause and recover his littlestrength, which was well-nigh exhausted by his anxiety and his exertions.
The path is now an easy one for some distance, but soon they are confronted by a high crag, up which they must clamber. It looks gloomy and formidable in the dim and fitful light of the partially-obscured moon. The sick man’s heart almost dies within him, as his companion eyes narrowly the small footholds which are notched up its steep side. Some of them he sees but faintly; but soon the full light of the moon, through the breaking clouds, shows him every notch with distinctness. He calculates their distances in a moment, and as his eye runs upward to the top, he plans out the whole of his ascent. In an instant he seizes his friend; and, again bidding him be of good cheer, tells him to place his foot in the first notch, then raises him gently, but firmly, to the second, and so on to the summit.
It is thus that the sick man, aided and cheered by his friend, after going through with many narrow escapes, at length reaches his home.
The points of resemblance between this journey and the journey of sickness, are sufficiently obvious to suggest themselves at once to the minds of my readers. The journey of sickness has sometimes the same variety of peril, and demands of the physician the same variety of assistance, to suit its various stages and conditions. His efforts, in rendering this assistance, must sometimes be strong and sometimes gentle; sometimes bold and sometimes cautious; always careful and never precipitate. The uncertain and varying light, shining upon the path of the traveller, has its counterpart in the journey of sickness; and sometimes the darkness is so great, that the physician must stop short, and not move at a venture amid suchperils. There are times, too, when the light breaks through the clouds of uncertainty that hang over his path, and his eye must be open and ready, as was the traveller’s, to discern all that the light may reveal of that which lies before him.
Often, in most of the journey of sickness, a gentle, but firm support and guidance are needed, on the part of the physician, just as it was in the case of the traveller, when the path lay along the edge of a precipice; and here, in the one journey as well as in the other, an officious and hurrying assistance might prove ruinous. Then there are times (and fearful times they are) when the physician sees, as did the sick man’s companion, that while mighty efforts are required of him, even a slight error in regard to the right proportion in those efforts, may prove fatal. And, as the traveller found occasionally some broad and sure resting-place, where his friend could recruit his wasted energies after a severe effort; so in the journey of sickness there are such resting-places, and the physician must take care to give his patient the benefit of them, and not run the risk of an entire exhaustion of his powers, from too much anxiety to hasten to the journey’s end.
One more point of resemblance, and one which I deem of no small importance, I will barely notice. As the sick man, in all the way through the mountain-pass, was encouraged by his friend, so should the physician cheer his patient with his hopeful voice and manner, amid all the gloom and peril of the journey of sickness; and should hold out to him, in all seasons of despondency, so far as truth will allow him to do so, the hope that he will at length reach the end of that journey in safety.