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“Treatment is easy.” There is nothing much easier than to make the average sick person feel better, or, rather, to make him think he feels better. It is true that temporary relief is often a very important matter; it is sometimes all that the most skilled and thoughtful person can hope to accomplish under certain circumstances. But temporary relief is not satisfactory to either patient or physician for very long. The normal environment of the normal person does not include a doctor, be he never so skillful. The doctor who keeps his patients may be a very successful person, considered as a business man, but this is not quite the best proof of the successful physician. The successful physician’s patients seldom return except to bring their ailing friends. The exceptions to this rule are self-evident. In any system of practice it is easy to do things which help the average person to some extent, at least temporarily. The average person recovers, anyway, even with no help at all. Under the old system of drug giving, it was easy to prescribe some harmless thing which did not do much of anything, but made the patient feel better, partly because he knew somebody was trying to help him, partly because when the doctor was called he stopped worrying about having to call him. If he knew that a bill of size and dignity awaited his recovery, that fact might have some effect upon the speed with which the malfunction disappeared.
“Judgment is difficult,” becomes emphatically true when it is remembered that rational therapeutics must rest upon rational diagnosis. The term “diagnosis” has been often mis-used. Its literal significance is “to know through,” or “to know thoroughly,” and in that significance it must be used by the osteopath if he is to attain the full measure of his possible success. By too many physicians of all schools of practice, diagnosis is held to be satisfactory if the disease of the patient be named. It is supposed that a certain entity, a disease, affects people, and that these certain individual diseases can be driven from the body, or can be killed, etc. That is, by the ordinary practitioner as well as by the layman, diagnosis is considered satisfactory without any thought of etiology or pathology. This view is not at all satisfactory if diagnosis is to be used as a basis for the determination of therapeutics. Diagnosis must include not only the naming of the symptom complex, but also the determination of the exact condition of the patient. Even when the name is determined, the description of diseases given in the ordinary text books dealing with the nature and diagnosis of disease are almost worthless so far as giving any real knowledge of the condition of the patient is concerned.
The question, “What is the matter with him?” is very rarely answered in any satisfactory manner. It is true that our most careful study does not always permit a satisfactory answer to such a question as this, but it is also true that there is very little hope of our ever attaining any more satisfactory knowledge so long as we are satisfied with our present attainments. So long as our knowledge of the condition of the patient is unsatisfactory, so long will our therapeutic methods fail in doing the best thing for the patient. Diagnosis and etiology are described with much detail in the textbooks of the older systems of medical practice. The amount of work that has been done in disentangling the knots and uneven webs in disordered metabolism is simply marvelous. Lives upon lives have been freely given in these investigations, and they have been profitable, in a way. But in the descriptions of diseases, after all this tremendous amount of work, etiology bears almost no relation to diagnosis or pathology, and none of these, apparently, bear any further relation to therapeutics than the fact that the naming of a disease renders a convenient index possible. If the name of any symptom complex referred to any well defined condition the present system might be defended. But this is not true. The differential diagnosis is based upon the subjective symptoms, the history of the case, according to the statement of the patient and his friends, and the laws of averages. Possibly, the findings of some simple laboratory tests may be considered, or some methods of physical diagnosis may be suggested. The theories of averages and chances are very useful to the insurance man, no doubt, as well as to men in less respectable lines of business, but such considerations have absolutely no place whatever in professional life. If only one person in a thousand suffers from a certain group of symptoms, he suffers just as certainly as if the other nine hundred and ninety-nine were troubled in exactly the same manner. By the older schools of practice, it is still considered good diagnosis to name the disease, and good therapeutics to treat the disease.
If osteopathy differs in any respect from these irrational and unscientific methods it is in these respects that it is good osteopathic diagnosis to know the condition of the patient from top to toe, and it is good osteopathic therapeutics to treat the patient who is in that condition. The problems which each patient offers to the judgment of his physician are complicated by very many and very diverse factors. For this reason, the ultimate cause of any disease is often unrecognizable. In most cases the diseased condition of the patient who seeks a physician is not the manifestation of a single abnormal factor, but of a very complex series of coincident and successive factors. In many cases the symptoms of disease are the efforts at compensation or adaptation, and the efforts to combat these form one of the causes of further discomfort, if not of added embarrassment to the already injured body. Any abnormal condition of long standing, and many of those of apparently recent manifestation, must be considered as the resultant of many forces, some tending to a return to the normal function and structure, and some making for further injury or embarrassment. The judgment of the physician is at fault if he does not consider these predisposing factors as well as the exciting cause; the less noticeable elements of the complex of symptoms and laboratory findings, as well as the more evident manifestations of malfunction and suffering.
As an illustration of these conditions, almost any disease might be cited. The common case of indigestion is useful in illustration because it is familiar to most people. If anyone who is in good health becomes very weary, and at once eats a hearty meal, his digestion is very apt to be temporarily impaired. The indigestion is not due to the hearty meal alone, nor to the fatigue alone, but to the improper relation of these. A third factor often present in these cases is the existence of a mal-alignment of the ribs, or vertebrae, or both, which causes an abnormal flow of nerve impulses to and from the spinal and bulbar centers concerned in digestion. The slight malfunction so induced is temporary if not subjected to unwise tampering. If the patient repeats his error, or if he forces himself to eat again before his stomach is ready for food, or if he adds to the abnormal condition by the use of various methods of dosing, flushing, fasting, stuffing, purging and whatnot, the condition may become chronic. The judgment which is difficult must recognize the effects of the abnormal therapeutics, as well as the efforts of the original disorder.
Again, the person who is weary, or is hungry, or is poorly nourished because of the faulty quality of his food, or is over-fed, or whose habits of life have been abnormal, may be subjected to some bacterial invasion. His immunity is decreased by the abnormal conditions, and the bacteria are able to make themselves at home in his body, and to produce the symptoms characteristic of their presence. The specific disease that is produced is determined by the character of the organisms which gain entrance to his body, but the fact of invasion is determined by his bad habits, his deficient nourishment, his deficient elimination, or the structural mal-adjustments which interfere with the normal function of the tissues. The symptoms observed in such cases are not to be wisely interpreted without a consideration of the conditions which render the bacterial invasion possible. The presence of the bacteria or other parasite is merely an additional factor in the complex array of symptoms. There are many examples indicative of the complexity of diseases usually considered the most simple. It is evident to one who gives independent thought to the study of disease conditions that almost every patient must be to a certain extent unique. He alone has just such a body as his own. He alone has lived just such a life as his own, he alone suffers just such structural mal-adjustments, such mal-function, and such symptoms. "Judgment is difficult, thought hard; but treatment after thought is proper and profitable." Given
a thorough diagnosis, the best methods of treatment are fairly evident.
The determination of the treatment best adapted to the requirements of
the case is not difficult, and the prognosis is usually fairly evident.
Prognosis must always be somewhat uncertain, since it rests upon certain
possibilities of cell reactions which can not be determined by any methods
of investigation with which we are familiar. But there are very many factors
which modify the prognosis in any case which are subject to modem methods
of investigation, and these are part of a rational diagnosis.
Rational therapeutics must rest absolutely upon rational diagnosis. If judgment and thought have been given, if the physician knows the condition of his patient as thoroughly as is possible under the condition of the case, if he gives that “thought” which Hippocrates calls “hard,” then the thing which is done for the patient is that which will bring his body into normal relationship with a normal environment, if this is possible; or will assist him to a symptomatic cure by securing adaptation or compensation; or which, recognizing the utter impossibility of any cure, will make his last days as comfortable as possible. Because “judgment is difficult,” because “thought is hard,” “treatment after thought is proper and profitable.”
The thought of the physician must not be limited to the immediate good of his patient. So closely are all the individuals of civilized races bound together in mutual dependence, in a unity of thought and desire and endeavor, that the inheritance of future generations includes all of this generation’s endeavor that is worth perpetuating, whether the devisers of any certain good leave children or not. If a life be turned from weakness to strength, if brains be made normal and muscles be made strong, not only will that life be freer from pain and longer in years, but the world will have gained the fruits of the labor of those muscles and those brains, both in this generation and in all those which are coming. Even if the life of any patient seems of no particular value, the principle remains unchanged. The duty of the physician is to give to every person an opportunity to do his best possible work in the world. The normal brain has the wider outlook, the truer logic, the clearer conception of the relations of things with each other and with the individual; the more normal brain gives the more normal answer to environal changes; the more truthful viewpoint leads to the more generous attitude, the deeds characteristic of the altruistic spirit. These are the things that live, because these are the things that are characteristic of health in such brains as ours.
The responsibility of the physician is, then, first to his patient himself. To him he owes all that he can give which makes for thorough and permanent recovery. Next, he owes a duty to the world, that his patient shall be able to do his proper work therein. Then, he owes a duty to the future, that the descendants of his patient shall be worthy of life. Under certain conditions, it is the duty of the physician to conserve the best interests of the race by seeing that his patient is the last of his family. In other cases, reproduction should be encouraged. “Judgment is difficult” in no more superlative degree anywhere than in dealing with such considerations as these. These questions come to the doctor, and they are within his province. Any system of therapeutics which neglects the consideration of these factors is not fit to survive. If it sacrifice the good of the race to the good of the individual in any sufficient manner, it will perish, ultimately, by the extirpation of its devotees. But if it sacrifice the good of the race to the good of the individual in only slight degree, it may persist almost indefinitely, perpetuating a race of people who are fairly normal, who live fairly well, who are fairly progressive, but who never reach the possibilities of strength, longevity, mentality, and helpfulness which should be within their reach. Perhaps it is not altogether unwarranted to say that such a condition is that of a very large proportion of people in the world today. Very few people are living up to their potential best, either physically or mentally, and there are very few deaths which are not made the more sorrowful because they are known to be premature.
The task which awaits the rational physician is no easy one. His judgments are difficult. We who have lived in the world have been taught that the doctor is a person who takes our aches and pains away. We believe that he can “cure” us. We know that there are certain laws that govern the rest of the universe, but we think these laws cease their action at the limits of our bodies. We smile at childish faith in rabbits’ nests, new moons and four-leafed clovers, then we solemnly take a spoonful every hour as per direction. We know our lives are abnormal, but we refuse to yield one tidbit of the leeks and onions while we expect our doctor to guide us safely through to the promised land of ease and rest. We have been taught for ages that we were not expected to know anything about the care of our bodies. It is a pleasant doctrine, and takes kindly to our self-esteem that we are not to blame for our ignorance, that ill health is innocent, that amidst a universe of law, our own bodies are subject to caprice and unreason. The rational doctor must live up to the literal meaning of his degree, and become a teacher. He must see that the environment of every individual is such as is normal to one of his race and history. He must see that the environment of each organ of his patient’s body is such as is best adapted to its best functioning. He must teach his patients such laws of life as they are able to comprehend. Above all, he must teach that nothing but rest, nothing but work, nothing but play, nothing but air, and food, and drink, can supply the place of these things. Nothing but good blood, freely moving, can supply the needs of any tissue of the body. None but normal nerves can guide the body wisely, and none but clean and well-fed brains can serve as the organ of strong and rational and efficient thinking. Note A.—According to Marcus Aurelius, “What is good for the bee is good for the hive.” There is no field of human endeavor more productive of genuine good to the race than the effort to help people into clean, wholesome, rational, helpful lives. The person who wishes to give the most efficient aid to his fellow-man finds no finer opportunity than that afforded in the life of a physician.
The Value of Laboratory Diagnosis, C. A. Whiting in the Report of the Third Annual Meeting of the Osteopathic Association of the State of California. |