Physician and patient

by Worthington Hooker

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.