The Uncertain Art: Thoughts on a Life in Medicine

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9781400156238: The Uncertain Art: Thoughts on a Life in Medicine

Long-time physician Sherwin B. Nuland presents a provocative and stimulating collection of stories illustrating the vagaries of medical practice over the years. Among the fascinating and probing questions that Nuland investigates are: -What does the first Hippocratic Oath really mean? -What happens when knowledge comes before we're ready for it? -Why does major surgery using only acupuncture work? -Is there really sympathy between the organs of the body? -What happens when someone yells, "Is there a doctor in the house?" and you are the doctor? -What goes through the mind of a heart transplant candidate who doesn't make it?

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About the Author:

Sherwin B. Nuland, M.D., is the author of numerous books, including Doctors: The Biography of Medicine; The Wisdom of the Body; and How We Die: Reflections on Life's Final Chapter, which won the National Book Award.

Michael Prichard has recorded well over five hundred audiobooks and was named one of SmartMoney magazine's Top Ten Golden Voices. His numerous awards and accolades include an Audie Award and several AudioFile Earphones Awards.

Excerpt. Reprinted by permission. All rights reserved.:

THE WHOLE LAW OF MEDICINE

Life is short, and the Art is long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals, cooperate.

The First Aphorism

attributed to hippocrates, c. 400 b.c.e.

It has long been accepted that a considerable portion of the body of writings credited to Hippocrates was in fact authored by others, in the two centuries following his death. But until recent decades, scholars remained convinced that reliable criteria were recognizable by which at least a certain core of the material might still be identified as his own. They set this group of texts off from the rest by calling it “The Genuine Works of Hippocrates.”

English translations of these central teachings were inadequate and incomplete until the mid-nineteenth century, when the Sydenham Society of London commissioned the Scottish surgeon Francis Adams to provide a definitive edition. Published in 1849, the two-volume result of Adams’s efforts—naturally called The Genuine Works of Hippocrates—took its place as the authentic historic record.

During the last century, cracks began to appear in the supposed evidence by which some of even these “genuine” works had been certified into the canon, but the short book of pithy clinical maxims known as The Aphorisms held out longer than most. As recently as 1934, members of America’s first think tank of medical historians, based at Johns Hopkins University, could write in their Bulletin: “It is almost universally agreed that among the many Hippocratic writings, the Aphorisms are genuine.” The editors of the journal then went on to point out something that remains true to this day: “They are also undoubtedly by far the most popular books; printed, translated, and commented upon endless times, they were the physician’s bible for many centuries.” And in a little aside, they added the surprising—at least to me—statement that the introduction into English of the very word “aphorism” is owed to this “anthology of medical truths.”

Nowadays, finding a historian who agrees that The Aphorisms was actually written by the legendary Father of Medicine is as unlikely as finding a clinical physician who agrees that all of the 422 nuggets of advice contained in its pages are “medical truths.” Though enshrined in the tradition of almost two and a half millennia as the First Aphorism of Hippocrates, the words of this chapter’s epigraph, for example, were probably never uttered by their putative author. A few reasonably dependable bits of information are known about the great man’s life: he was born about 460 b.c.e. on the Greek island of Cos; he was probably an itinerant physician; he seems to have been a leader in the formation of a school for the training of young doctors. We know little more than that, and what we do know most assuredly does not include hard evidence that Hippocrates left any identifiable corpus of written work. As for the clinical pearls of wisdom: although some of them are nothing less than astonishing in the accuracy of their perceptiveness and the wisdom of their recommendations, others are so bewilderingly at odds with simple observation that they seem to have been inserted to keep the reader awake by making him laugh. What, for example, is a doctor to do with such pronouncements as “The bald are not subject to varicose veins” and “Stammerers are particularly liable to obstinate diarrhea”?

All this having been said, the First Aphorism continues to stand by itself as a model of, of—well, of precisely that: the perfect aphorism, well deserving of its priority, which, if that 1934 issue of the Bulletin of the Institute for the History of Medicine is to be believed, places it squarely as being indeed the first of all time. An aphorism should stand by itself, without reference to anything preceding or following it, and it must express a timeless truth in a brief burst of sagacity, requiring no editorializing, interpretation, or further comment.

But of course, the more memorable the aphorism, the more likely it is that editorializing, interpretation, and further comment will be its fate in perpetuity. Particularly when the epigrammatic saying incorporates principles that have guided a profession for two thousand years, as this one has, there is no end to the ways in which it is likely to be studied, discussed, and anatomized. Add to this its source in a classical language spoken by very few of those who would dissect its lesson, and the result is countless pages and perorations that have never added an iota of substance to the original.

In this it resembles the Hippocratic Oath, which has also been the object of much learned discourse and even a good deal of fretting, especially in today’s ferment of anxious debate over assisted suicide, abortion, and other ethical issues for which the profession and the public seek a precedent in time-honored codes of behavior, or at least a guide to immutable principles of morality. Ethicists and others have worried the Oath as a dog worries a bone, craving the meat and marrow of some eternal principia with which to strengthen the ancient bonds of professional obligation. Yet even as their elders cleave to the Oath, recent classes of graduating medical students have not hesitated to “bring the text up to date” or “make it relevant to our needs” in order to reflect whatever acceptable current values they are willing to espouse in this self-absorbed era of moral relativism. Like scripture, the Oath is quoted by both sinners and saints. For every traditionalist, there is a revisionist who claims it to be interpretable or amenable to alteration as needed, often in ways different from what its original words would seem to imply. There is even a body of historical opinion holding that in its day, large sections (or perhaps all) of it were ignored by most physicians. But here the case of the First Aphorism differs markedly from that of the Oath: though it has been the subject of plenty of discussion, there is little disagreement over the aphorism’s intent.

Clearly, the First Aphorism was written by one or more wise and vastly experienced physicians, but its purpose was not to provide a moral precept. It was meant simply as a statement of what it is like to try to care for the sick. Not only does the aphorism avoid preachiness, but, quite to the contrary, it is a testimony to the humility with which a doctor should approach his calling and a declaration of the profession’s delineated capabilities. Its subtext is the very basis upon which this book has been given its title: the uncertainty inherent in the art of medicine.

In my view, the First Aphorism should be read to every beginning class on its initial morning of medical school. A student is then still a “civilian,” one who has not yet absorbed so much as a particle of that fluctuating mix of science and art of which the profession has always consisted. From that hour forward, the values of the guild will soak ever more deeply into his or her mind and self-image, so that the end of the first academic year finds a young person vastly transformed. It would be good for that transformation to start with the First Aphorism—at the very least, a dawning of insight into what must be borne in mind if the task ahead is to be accomplished with scientific skill and humanity both, and with tolerance for the Art’s limitations as well as one’s own. It would be good, too, if the aphorism were to be reread yearly or even more often, that it might fix itself into the perceptions of the developing doctor so steadfastly as to remain ever in the forefront of thought. Like the Talmudic sage Hillel’s response when he was challenged to summarize his religion while standing on one foot—that one never do to others what is hateful to oneself—the First Aphorism is medicine’s whole law; the rest is commentary. Having learned that law, one should (as Hillel enjoined his challenger after both feet were back on the ground) go and study it.

The thing needs to be parsed. In doing so, I will deliberately avoid certain venerable scholarly differences of opinion about the proper translation of a few of the aphorism’s words, relying instead on the English as it appears in the original Adams publication, which, with slight variations, is the commonly accepted version. At first, I will restrict my comments to the statement’s first sentence. Life may be short, but I plan to make mine long enough to get back to that vastly important second section in a later chapter.
Life is short, and the Art is long. Although life expectancy is currently well more than twice what it was during the golden age of Greece, it will never be endowed with years enough for anyone to master the vast expanse of medical knowledge, or even that part of it sufficient for an individual doctor to care for all of his patients. In every era, some people live well beyond their expected span; Hippocrates himself seems to have been one hundred when he died in approximately 360 b.c.e. Yet even at the barest beginning of Western medicine’s history, it was recognized that no man’s lifetime was sufficient to learn all that was required.

In view of what comes next, it is pertinent to point out that some commentators have read these opening words in a different way, taking their meaning to be that medicine demands a certain amount of time to exert its healing powers, but the patient’s life may be short once disease strikes. Either way, there is a realization here of the inconsistency between the time required and the time available, a factor over which no physician has control.
The occasion fleeting. Here, too, the focus is the urgency that exists in mos...

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