Physician and patient

by Worthington Hooker

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.