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 in _appreciating
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 a _chronic_
inflammation. 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. The local 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
of _all_ the 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
the _application 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 in spite
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,
requiring an 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 the fight. 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 judicious general, 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 most watchful 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 commonly disregarded 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
tottering steps, 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 little strength, 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 such
perils. 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.