Produced by Audrey Longhurst, LN Yaddanapudi, Leonard Johnson and
the PG Online Distributed Proofreading Team at https://www.pgdp.net
DOCTOR AND PATIENT.
BY
S. WEIR MITCHELL, M.D., LL.D. HARV.
MEMBER OF THE UNITED STATES NATIONAL ACADEMY OF SCIENCES, PRESIDENT
OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, PHYSICIAN
TO THE ORTHOPÆDIC HOSPITAL AND INFIRMARY
FOR NERVOUS DISEASES.
_Introductory_.
_The Physician_.
_Convalescence_.
_Pain and its Consequences_.
_The Moral Management of Sick or Invalid Children_.
_Nervousness and its Influence on Character_.
_Out-Door and Camp-Life for Women_.
_THIRD EDITION_.
PHILADELPHIA:
J.B. LIPPINCOTT COMPANY.
LONDON: 36 SOUTHAMPTON STREET, COVENT GARDEN.
1901.
CONTENTS.
INTRODUCTORY
THE PHYSICIAN
CONVALESCENCE
PAIN AND ITS CONSEQUENCES
THE MORAL MANAGEMENT OF SICK OR INVALID CHILDREN
NERVOUSNESS AND ITS INFLUENCE ON CHARACTER
OUT-DOOR AND CAMP-LIFE FOR WOMEN
INTRODUCTORY.
The essays which compose this volume deal chiefly with a variety of
subjects to which every physician must have given more or less thought.
Some of them touch on matters concerning the mutual relation of
physician and patient, but are meant to interest and instruct the laity
rather than the medical attendant. The larger number have from their
nature a closer relation to the needs of women than of men.
It has been my fate of late years to have in my medical care very many
women who, from one or another cause, were what is called nervous. Few
of them were so happily constituted as to need from me neither counsel
nor warnings. Very often such were desired, more commonly they were
given unsought, as but a part of that duty which the physician feels, a
duty which is but half fulfilled when we think of the body as our only
province.
Many times I have been asked if there were no book that helpfully dealt
with some of the questions which a weak or nervous woman, or a woman who
has been these, would wish to have answered. I knew of none, nor can I
flatter myself that the parts of this present little volume, in which I
have sought to aid this class of patients, are fully adequate to the
purpose.
I was tempted when I wrote these essays to call them lay sermons, so
serious did some of their subjects seem to me. They touch, indeed, on
matters involving certain of the most difficult problems in human life,
and involve so much that goes to mar or make character, that no man
could too gravely approach such a task. Not all, however, of these
chapters are of this nature, and I have, therefore, contented myself
with a title which does not so clearly suggest the preacher.
It would be scarcely correct to state that their substance or advice was
personally addressed to those still actually nervous. To them a word or
two of sustaining approval, a smiling remonstrance, or a few phrases of
definite explanation, are all that the wise and patient doctor should
then wish to use. Constant inquiries and a too great appearance of what
must be at times merely acted interest, are harmful.
When I was a small boy, my father watched me one day hoeing in my little
garden. In reply to a question, I said I was digging up my potatoes to
see if they were growing. He laughed, and returned, "When you are a man,
you will find it unwise to dig up your potatoes every day to see if they
are growing." Nor has the moral of his remark been lost on me. It is as
useless to be constantly digging up a person's symptoms to see if they
are better, and still greater folly to preach long sermons of advice to
such as are under the despotism of ungoverned emotion, or whirled on the
wayward currents of hysteria. To read the riot act to a mob of emotions
is valueless, and he who is wise will choose a more wholesome hour for
his exhortations. Before and after are the preacher's hopeful occasions,
not the moment when excitement is at its highest, and the self-control
we seek to get help from at its lowest ebb.
There are, as I have said, two periods when such an effort is wise,--the
days of health, or of the small beginnings of nervousness, and of the
uncontrol which is born of it, and the time when, after months or years
of sickness, you have given back to the patient physical vigor, and with
it a growing capacity to cultivate anew those lesser morals which
fatally wither before the weariness of pain and bodily weakness.
When you sit beside a woman you have saved from mournful years of
feebleness, and set afoot to taste anew the joy of wholesome life,
nothing seems easier than with hope at your side, and a chorus of
gratitude in the woman's soul, to show her how she has failed, and to
make clear to her how she is to regain and preserve domination over her
emotions; nor is it then less easy to point out how the moral failures,
which were the outcome of sickness, may be atoned for in the future, now
that she has been taught to see their meaning, their evils for herself,
and their sad influence on the lives of others.
To preach to a mass of unseen people is quite another and a less easy
matter. I approach it with a strong sense that it may have far less
certain utility than the advice and exhortation addressed to the
individual with such force as personal presence, backed by a knowledge
of their peculiar needs, may give. I am now, then, for the first time,
in the position of the higher class of teachers, who lay before a
multitude what will be usefully assimilated by the few.
If my power to say what is best fitted to help my readers were as large
as the experience that guides my speech, I should feel more assured of
its value. But sometimes the very excess of the material from which one
is to deduce formulas and to draw remembrances is an embarrassment, for
I think I may say without lack of modesty in statement, that perhaps
scarce any one can have seen more of women who have been made by
disease, disorder, outward circumstance, temperament, or some
combination of these, morbid in mind, or been tormented out of just
relation to the world about them.
The position of the physician who deals with this class of ailments,
with the nervous and feeble, the painworn, the hysterical, is one of the
utmost gravity. It demands the kindliest charity. It exacts the most
temperate judgments. It requires active, good temper. Patience,
firmness, and discretion are among its necessities. Above all, the man
who is to deal with such cases must carry with him that earnestness
which wins confidence. None other can learn all that should be learned
by a physician of the lives, habits, and symptoms of the different
people whose cases he has to treat. From the rack of sickness sad
confessions come to him, more, indeed, than he may care to hear. To
confess is, for mysterious reasons, most profoundly human, and in weak
and nervous women this tendency is sometimes exaggerated to the actual
distortion of facts. The priest hears the crime or folly of the hour,
but to the physician are oftener told the long, sad tales of a whole
life, its far-away mistakes, its failures, and its faults. None may be
quite foreign to his purpose or needs. The causes of breakdowns and
nervous disaster, and consequent emotional disturbances and their bitter
fruit, are often to be sought in the remote past. He may dislike the
quest, but he cannot avoid it. If he be a student of character, it will
have for him a personal interest as well as the relative value of its
applicative side. The moral world of the sick-bed explains in a measure
some of the things that are strange in daily life, and the man who does
not know sick women does not know women.
I have been often asked by ill women if my contact with the nervous
weaknesses, the petty moral deformities of nervous feminine natures, had
not lessened my esteem for woman. I say, surely, no! So much of these is
due to educational errors, so much to false relationships with husbands,
so much is born out of that which healthfully dealt with, or fortunately
surrounded, goes to make all that is sincerely charming in the best of
women. The largest knowledge finds the largest excuses, and therefore no
group of men so truly interprets, comprehends, and sympathizes with
woman as do physicians, who know how near to disorder and how close to
misfortune she is brought by the very peculiarities of her nature, which
evolve in health the flower and fruitage of her perfect life.
With all her weakness, her unstable emotionality, her tendency to
morally warp when long nervously ill, she is then far easier to deal
with, far more amenable to reason, far more sure to be comfortable as a
patient, than the man who is relatively in a like position. The reasons
for this are too obvious to delay me here, and physicians accustomed to
deal with both sexes as sick people will be apt to justify my position.
It would be easy, and in some sense valuable, could a man of large
experience and intelligent sympathies write a book for women, in which
he would treat plainly of the normal circle of their physiological
lives; but this would be a method of dealing with the whole matter which
would be open to criticism, and for me, at least, a task difficult to
the verge of the impossible. I propose a more superficial plan as on the
whole the most useful. The man who desires to write in a popular way of
nervous women and of her who is to be taught how not to become that
sorrowful thing, a nervous woman, must acknowledge, like the Anglo-Saxon
novelist, certain reputable limitations. The best readers are, however,
in a measure co-operative authors, and may be left to interpolate the
unsaid. A true book is the author, the book and the reader. And this is
so not only as to what is left for the reader to fill in, but also has
larger applications. All this may be commonplace enough, but naturally
comes back to one who is making personal appeals without the aid of
personal presence.
Because what I shall write is meant for popular use rather than for my
own profession, I have made my statements as simple as possible.
Scarcely a fact I state, or a piece of advice I give, might not be
explained or justified by physiological reasoning which would carry me
far beyond the depth of those for whom I wrote. All this I have
sedulously avoided.
What I shall have to say in these pages will trench but little on the
mooted ground of the differences between men and women. I take women as
they are to my experience. For me the grave significance of sexual
difference controls the whole question, and, if I say little of it in
words, I cannot exclude it from my thought of them and their
difficulties. The woman's desire to be on a level of competition with
man and to assume his duties is, I am sure, making mischief, for it is
my belief that no length of generations of change in her education and
modes of activity will ever really alter her characteristics. She is
physiologically other than the man. I am concerned with her now as she
is, only desiring to help her in my small way to be in wiser and more
healthful fashion what I believe her Maker meant her to be, and to teach
her how not to be that with which her physiological construction and the
strong ordeals of her sexual life threaten her as no contingencies of
man's career threaten in like measure or like number the feeblest of the
masculine sex.
THE PHYSICIAN.
I have long had in mind to write from a physician's point of view
something in regard to the way in which the well-trained man of my
profession does his work. My inclination to justify the labors and
sentiments of an often misunderstood body of men was lately reinforced
by remarks made to me by a very intelligent patient. I found him, when I
entered my room, standing before an admirable copy of the famous
portrait of the great William Harvey, the original of which is in the
Royal College of Physicians. After asking of whom it was a likeness, he
said, "I should be a little curious to know how he would have treated my
case."
I had to confess that of Harvey's modes of practice we know little, but
I took down from a shelf those odd and most interesting letters of
Howell's, clerk of council to James I., and turned to his account of
having consulted Harvey on returning home from Spain. Only too briefly
he tells what was done for him, but was naturally most concerned about
himself and thus missed a chance for us, because it so happens that we
know little of Harvey. At this page of Howelliana was a yellow
paper-marker. Once the book was Walpole's, and after him was
Thackeray's, and I like to fancy that Walpole left the marker, and that
Thackeray saw it and left it, too, as I did.
My patient, who liked books, was interested, and went on to say that he
had seen several physicians in Europe and America. That in France they
always advised spas and water-cure, and that at least three physicians
in America and one in London had told him there was nothing the matter
with him, and that finally a shrewd country doctor had remarked bluntly
that he would not give him any medicine, because he was overdosed
already with work and worries, which was true.
At last he came back to Harvey. "He looks ill," he said, which is true.
His honestly-painted knuckles make diagnosis easy. My friend thought
that this great man would probably have dosed him well, and, as he
added, would not have bothered him about too much sugar, nor forbidden
champágne. I had to reply that whatever ills were in the England of that
day,--and there was much dyspepsia and much gout,--sugar was the luxury
of the rich, and anything but as abundant as it is to-day, when we
consume annually fifty-six pounds per head or per stomach. I told him
that in all ages the best of us would have dwelt most on diet and habits
of living, and that Harvey was little likely to have been less wise than
his peers, and he has had but few. Then he said it would be curious to
put on paper a case, and to add just what a doctor in each century would
have ordered. The idea struck me as ingenious and fertile. I could wish
that some one would do this thing. It would, I think, be found that the
best men of every time were most apt to consider with care the general
habits of their patients as to exercise and diet, and to rely less than
others on mere use of drugs. As to this matter, one learns more from
men's lives than from their books, but nowadays care as to matters of
hygiene has become in a valuable degree the common wisdom of a large
part of my profession. Surveying our vast gains, we are a little apt to
undervalue the men of older days, and no lesson is wiser than sometimes
to go back and see how the best of them thought and acted amidst the
embarrassments of imperfect knowledge.
There is a charming life by Henry Morley, of Cardan, the great Italian
physician and algebraist, which gives us in accurate detail the daily
routine of a doctor's days in the sixteenth century. In it is an account
of Cardan's professional visit in 1551 to John Hamilton, archbishop of
St. Andrew's, Scotland, and practically the ruler of that turbulent
realm. Cardan's scientific opinion as to his patient is queer enough,
but, as Morley remarks, it is probably not more amusing to us than will
be our opinion in a like case to the smiling brother of our guild who
may chance to read it at some remote future day. The physician of whom I
now write was one who already dreaded bleeding, thought less of
medicines than his fellows, and was, in fact, exceptionally acute. He
did some droll things for the sick prelate, and had reasons yet more
droll for what he did, but his practice was, as may happen on the whole,
wiser than his reasons for its use. His patient was a man once bulky,
but now thin, overworked, worried, subject to asthma, troubled with a
bad stomach, prone to eat largely of coarse food, but indisposed to
physical exercise. Cardan advised that the full, heated head, of which
his patient much complained, should be washed night and morning with hot
water in a warm room, and then subjected to a cold shower-bath. Next was
to come a thorough dry rubbing, and rest for two hours. As to his
asthma, he forbade him to subject himself to night air or rainy weather.
He must sleep on silk, not feathers, and use a dry pillow of chopped
straw or sea-weed, but by no means of feathers. He forbade suppers if
too late, and asked the reverend lord to sleep ten hours, and even to
take time from study or business and give it to bed. He was to avoid
purgatives, to breakfast lightly, and to drink slowly at intervals four
pints a day of new asses' milk. As to other matters, he was to walk some
time in the shade at an early hour, and, discussing the time for the
fullest meal, Cardan remarks that established habits as to this point
are not to be lightly considered. His directions as to diet are many,
reasonable, and careful. His patient, once stout, had become perilously
thin. Turtle-soup and snail-broth would help him. Cardan insisted also
on the sternest rules as to hours of work, need for complete rest, daily
exercise, and was lucky enough to restore his patient to health and
vigor. The great churchman was grateful, and seems to have well
understood the unusual mental qualities of his physician. Nothing on the
whole could be better than the advice Cardan gave, and the story is well
worth reading as an illustration of the way in which a man of genius
rises above the level of the routine of his day.
I might go farther back in time, and show by examples that the great
fathers of medicine have usually possessed a like capacity, and learned
much from experience of that which, emphasized by larger use and
explained by scientific knowledge, has found its way into the text-books
of our own day and become common property.
It appears to me from a large mental survey of the gains of my
profession, that the English have above all other races contributed the
most towards enforcing the fact that on the whole dietetics, what a man
shall eat and drink, and also how he shall live as to rest, exercise,
and work, are more valuable than drugs, and do not exclude their use.[1]
[Footnote 1: By this I mean that the physician, if forced to choose
between absolute control of the air, diet, exercise, work, and general
habits of a patient, and use of drugs without these, would choose the
former, and yet there are cases where this decision would be a
death-warrant to the patient.]
The active physician has usually little time nowadays to give to the
older books, but it is still a valuable lesson in common sense to read,
not so much the generalizations as the cases of Whytt, Willis, Sydenham,
and others. Nearer our own day, Sir John Forbes, Bigelow, and Flint
taught us the great lesson that many diseases are self-limited, and need
only the great physician, Time, and reasonable dietetic care to get well
without other aid.
There is a popular belief that we have learned this from homoeopathy,
for the homoeopath, without knowing it, made for us on this matter ample
experiments, and was as confident he was giving powerful medicines as we
are that he was giving practically none. "He builded better than he
knew," and certainly his results aided our ablest thinkers to reach the
truth.
I have named one of the most illustrious of physicians, Sydenham, as
among the great Englishmen who brought to their work the clearest
perception of how nature was to be best aided. He will answer admirably
to exemplify my meaning.
Sydenham was born in 1624, and lived in and through the wild periods of
Charles I. and Cromwell, and was himself a stanch republican. He more
than any other in his century decisively taught caution as to mere
medication, and sedulously brought the clear light of common sense to
bear upon the practice of his time. It is interesting to note, as his
biographer remarks, that his theories were often as worthless as his
practice was good. Experience taught him to do that for which he felt
forced to find a reason, and the reason was often enough absurd. "The
contrast gives a fine light and shadow effect in his biography."[2]
[Footnote 2: R.G. Latham, p. xxxvi.]
His systematic beliefs were ofttimes worthless, but great acuteness in
observation was apt to lead him to do wisely in individual cases what
was at variance with his creed. Speaking of Hippocrates, he says, "His
system led him to assist nature, to support her when enfeebled and to
the coercion of her when she was outrageous."
As to mere drugs, Sydenham used them in what was for his day an
extremely moderate fashion, and sagaciously limited in the old and young
his practice as to bleeding, which was then immensely in vogue. The
courage required to treat smallpox, measles, and even other fevered
states by cooling methods, must have been of the highest, as it was
boldly in opposition to the public and private sentiment of his day. He
had, too, the intelligence to learn and teach that the Jesuit bark,
cinchona, was a tonic as well as the master of the agues, so common in
the England of his time.
He is at his best, however, in his statement of how he treated
individual cases, for then his written theories are given to the winds,
or the practice is far beyond the creed in its clear common-sense value.
Thus, horseback exercise he constantly speaks of. He tells you of a
friend who had been much dosed by many for dyspepsia, and how he bade
him ride, and abandon drugs, and how, after a thousand miles of such
riding, he regained health and vigor. See how this wise man touches the
matter of gout: "For years a man has feasted; has omitted his usual
exercises; has grown slow and sluggish; has been overstudious or
overanxious, etc." Then he reasons about "smothering the animal spirits,
which are the primary instruments of concoction," and so on, but at last
he says, "We must look beyond medicines. Wise men do this in gout and in
all other chronic diseases." And what does he advise? Here is the
substance of what he says. A gouty man must be moderate, not too
abstinent, so as to get weak. One meat is best; mixtures are bad. A milk
diet "has prevailed," only bread being added, but it must be rigid and
has its risks. He seems to have kept a nobleman on milk a year. Also
there must be total abstinence from wine and all fermented liquors.
Early bed hours and early rising are for the gouty. Then there come wise
words as to worry and overwork. But, above all, the gouty must ride on
horseback and exercise afoot. As to the wilder passions of men, he makes
this strangely interesting remark, "All such the old man should avoid,
for," he says, "by their indulgence he thus denies himself the privilege
of enjoying that jubilee which by the special and kind gift of nature is
conceded to old men: of whom it is the natural and happy lot to be
emancipated from the control of those lusts which during youth attacked
them."
This is a fair specimen of a master at his best. I would rather have
trusted Sydenham, with all his queer theories, than many a man with the
ampler resources of to-day; for his century may aid but does not make
the true physician, who is not the slave, but the master, of opinions.
To enforce again the fact that the greater men of my art, even in days
of the most extreme theories, were more sensible in their daily practice
than in their dogmatic statements, I would like to quote a letter of
Rush, which for several reasons is interesting and valuable. No man was
more positive in his beliefs and in the assertion of them than he. His
name is still associated with bleeding and purging, and if we considered
only some of his written assertions, made with the violence which
opposition always aroused in his positive nature, we should pause in
wonder at his great reputation. But what a man says or writes, and what
he does, are often far apart. We are apt to take his most decisive
statements as representative, and thus may seriously err. I have known a
number of men who were really trustworthy physicians, and who yet were
credited by us with a fondness for absurd ideas, which, in fact,
influenced their writings far more than their practice. Rush was to some
extent one of this class. His book on insanity is far in advance of his
time, and his descriptions of disease one of our best tests, most
admirable. Let us see how this physician who bled and dosed heavily
could think and act when face to face with a hopeless case. The letter
to which I have referred was given to the College of Physicians of
Philadelphia at my request by one of its associate fellows, Dr. Hunter
Maguire, of Richmond, Virginia. It is written to Rush's cousin, Dr.
Thornton, in 1789, and has an added interest from the fact that it is a
letter of advice in the case of the aged mother of Washington, who had a
cancer of the breast.
"PHILADELPHIA, July 6, 1789.
MY DEAR KINSMAN:
The respectable age and character of your venerable patient leads me to
regret that it is not in my power to suggest a remedy for the cure of
the disorder you have described in her breast. I know nothing of the
root that you mention as found in Carolina and Georgia, but, from a
variety of inquiries and experiments, I am disposed to believe that
there does not exist in the vegetable kingdom an antidote to cancers.
All the vegetable remedies I have heard of are composed of some mineral
caustics. The arsenic is the most powerful of any of them. It is the
basis of Dr. Martin's powder. I have used it in many cases with some
success, but have failed in some. From your account of Mrs. Washington's
breast, I am afraid no great good can be expected from the use of it.
Perhaps it may cleanse it, and thereby retard its spreading. You may try
it diluted in water. Continue the application of opium and camphor, and
wash it frequently with a decoction of red clover. Give anodynes when
necessary, and support the system with bark and wine. Under this
treatment she may live comfortably many years, and finally die of old
age."
He had here to deal with cancer, a disease which he knew to be
incurable. His experience taught him, however, that in the very old this
malady is slow and measured in its march, and that he could only aid and
not cure. What he says might with slight change have been penned to-day.
We have gone no further in helpfulness as regards this sad disease.
If what I write now is to have for the laity any value, it will be in
correcting certain of their judgments as to physicians, and in
suggesting to them some of the tests which will enable them to exercise
a reasonable judgment as to those in whose hands they place so often
without a thought the issues of life and death and the earthly fates of
their dearest.
I began, somewhat discursively, by showing how much care the masters of
my art gave even in past days to matters of diet and modes of life. This
is still to-day a test of larger applicability. There are those of my
profession who have a credulity about the action of drugs, a belief in
their supreme control and exactness of effect which amounts to
superstition, and fills many of us with amazement. This form of idolatry
is at times the dull-witted child of laziness, or it is a queer form of
self-esteem, which sets the idol of self-made opinion on too firm a base
to be easily shaken by the rudeness of facts. But, if you watched these
men, you would find them changing their idols. Such too profound belief
in mere drugs is apt, especially in the lazy thinker, to give rise to
neglect of more natural aids, and these tendencies are strengthened and
helped by the dislike of most patients to follow a schedule of life, and
by the comfort they seem to find in substituting three pills a day for a
troublesome obedience to strict rules of diet, of exercise, and of work.
The doctor who gives much medicine and many medicines, who is
continually changing them, and who does not insist with care on knowing
all about your habits as to diet, mealtimes, sleep, modes of work, and
hours of recreation, is, on the whole, one to avoid. The family doctor
is most of all apt to fail as to these details, especially if he be an
overworked victim of routine, and have not that habitual vigilance of
duty which should be an essential part of his value. He is supposed to
have some mysterious knowledge of your constitution, and yet may not
have asked you a medical question in months or years. Too much is taken
for granted, and inefficient opinions are the outcome of carelessness.
Every new case in a household should be dealt with as if it were a
stranger's, and outside familiarity should not be allowed to breed
contempt of caution in study or lead to half measures. Every consultant
will agree with me that this kind of social nearness of the doctor to
his patient is a common cause of inert advice, and nowhere more
distinctly so than when unwise physicians attempt to practise in their
own households on those they love.
There are very few instances of chronic ailments, however slight, which
should not be met by advice as to modes of living, in the full breadth
of this term; and only by a competent union of such, with reasonable use
of drugs, can all be done most speedily that should be done. I have said
"with use of drugs," for I am far from wishing to make any one believe
that medicines are valueless. Nor do I think that the most extreme
dosing employed nowadays by any one is as really hurtful as the neglect
to urge efficiently the value of definite hygienic means. There are,
indeed, diseases which can only be helped by heroic measures; but, in
this case, were I the patient, I should like to be pretty certain as to
the qualifications of my hero.
The popular view of the great hurtfulness of drugs is curiously
fallacious. I have spoken above more of their relative usefulness, as
compared to other means of relief, than with any desire to convince my
readers that they are such terrible things as some kinds of
practitioners would have us to believe. The dread of their employment is
a relic of the time of reaction against the senseless and excessive
dosing with calomel and strong purges, and nowadays, even as regards
bleeding, once wholly abandoned, it is clear that it still has at times
its uses, and valuable ones, too. As medicines are now employed, even by
the thoughtless, it must be rarely that they give rise to permanent
injury. Let any physician who reads these lines pause and reflect how
many times in his life he has seen lasting or serious evil results from
drugs.
Accidents happen, but they are the offspring of carelessness. Sometimes,
also, unexpected and temporary extreme results surprise us, as when an
opiate purges, or five grains of an iodide prove to be gravely
poisonous. These occurrences are due to individual peculiarities, which
we can as yet neither explain nor anticipate. One man can take opium
with almost the impunity which belongs naturally to birds. Another is
put to sleep by the dose you give a baby. All this teaches caution, but
it is not a matter for blame when it gives rise to alarming
consequences, and happily these cases of what we call idiosyncrasies are
exceptionally uncommon.
Physicians are often enough tempted to give a simple placebo to patients
who are impatient, and ask instant treatment when we know that time is
what we want, either for study of present symptoms or to enable the
growing disorder to spell itself out for us, as it were, letter by
letter, until its nature becomes clear. The practice is harmless, but
there is, of course, a better way, if we possess the entire confidence
of the patient or his friends. But sometimes it is undesirable to give
explanations until they can be securely correct, or haply the sick man
is too ill to receive them. Then we are apt, and wisely, to treat some
dominant symptom, and to wait until the disease assumes definite shape.
So it is that much of what we thus give is mild enough. The restless
mother is the cause with some doctors of much of this use of mere
harmless medicines. I once expressed surprise in a consultation that an
aged physician, who had called me in, should be so desirous of doing
something, when I as earnestly wished to wait. At last he said, "Doctor,
it is not the child I want to dose; it is the mother's mind." Perhaps
the anecdote may not be lost on some too solicitous woman, who naturally
desires that the doctor should be doing something just when he is most
anxious to be doing nothing.
Men yet live who can remember when all of our knowledge of disease was
acquired by the unaided use of the eye, the ear, and the touch. The
physician felt the pulse, and judged of fever by the sense of warmth. He
looked at the skin and tongue and the secretions, and formed
conclusions, more or less just in proportion to the educated acuteness
of his senses and the use he made of these accumulations of experience.
The shrewdness of the judgments thus formed shows us, to our wonder, how
sharply he must have trained his senses, and has led some to suspect
that our easier and more exact methods and means may have led us to
bestow less care in observation than did these less aided and less
fortunate students. The conclusion is, I am sure, erroneous, and I am
confident that the more refined the means the more do they train us to
exactness in all directions, so that even what we now do with the eye,
ear, or hand alone is better and more carefully done than when the
senses had none of the training due to the use of instruments of
precision. I may add that the results of their employment have also made
it easy in many cases to dispense with them, and to interpret readily
what has been won by the unassisted sense.
The history of precision in medicine is worth the telling, if only to
teach the lay reader something of that vast struggle to know the truths
of disease, which is little understood beyond the ranks of the most
scholarly of my profession. The first step was due to Galileo. In 1585
he used his pendulum to record the pulse, in a fashion at which we smile
to-day, and yet what he tried to do was the birth of precision in
medicine. Keeping a finger on the pulse, he set a pendulum in motion. If
it went faster than the pulse, he put the weight a little lower, or as I
may state it to make it clearer, he lengthened the pendulum. At last
when it moved so as to beat equal time with the pulse, he measured the
length of the swinging bar, and set down the pulse as, say ten inches;
next day it might be set at six, and so a record was made. He was soon
lost to medicine, but in 1625, Santorini, known to science as
Sanctorius, published a curious book, called "Commentaries on Avicenna,"
in which he figured a variety of similar instruments, called
"pulsilograms." We owe to him some of the first accurate studies of
diet, and also the discovery of the insensible perspiration, but his
pulsilogram was soon forgotten.
I think that Harvey but once or twice mentions the number of the pulse
even in his physiological books. In the case descriptions of his time
and of Sydenham's it is rare to find it noted, and this is true as a
rule all through the next century. The exceptions are interesting. In
Whytte's works, _circa_ 1745, he not rarely mentions the pulse number in
connection with his primary delineation of a case, but after that does
not often speak of its subsequent changes in number. The force and other
characters of the pulse receive, however, immense attention, and are on
the whole more valuable aids than mere numeration; but that cannot
nowadays be left out of our calculations, yet as early as the reign of
Anne, about 1710, an English physician, Sir John Floyer, wrote an able
and now half-forgotten book, quaintly called the "Pulse Watch." I am
pretty sure that he was the first to put a minute-hand on a watch to
enable him to time the pulse-beat, but nowhere in any English collection
have I been able to find one of his watches. Thus aided, he was the
first to count the minute's pulse, which is now a sort of recognized and
accepted matter as standard of comparison, so that we say merely, the
pulse was 60 or 90, as may chance, and do not even speak of the minute.
It is as true as strange that this convenient method was practically
lost to habitual use in medicine for quite a hundred years. It
reappeared in the writings of the time of the great teachers who arose
in France and Germany about 1825. To-day, in case of need, we have
instruments which write in instructive curves the form of the
pulse-wave, and enable us to settle questions which sometimes could not
be settled without this delicate means.
The study of the temperature of the body was, as I have said, a mere
matter of the touch until our same Galileo applied a thermometer to
learn more accurately its changes. Sanctorius again followed in his
steps, and has left us in his works curious drawings of forms of
thermometer applicable to medical uses. Our profession is, however,
inapt to hold on to useless things, and our knowledge of fever, its
risks and its remedies, was for many a day far behind any need for the
delicate appreciations of the thermometer.
Hence it is that very few physicians did more in the last three
centuries as regards the temperature of the body than speak of it as
high or low. Sanctorius was too far ahead of his time to teach us the
true value of medical thermometry. It was forgotten for many a day. In
the last century, in Dehaen and Hunter, it again receives some notice,
and again drops out of use. At last we are ripe for it, and Wunderlich,
in a classical book, about twenty-five years ago, puts it in a position
of permanent utility. The physician of to-day knows more both of fever
and of its consequences, and finds in his thermometer an indispensable
ally.
Within but a few years the instruments of precision have so multiplied
that a well-trained consultant may be called on to know and handle as
many tools as a mechanic. Their use, the exactness they teach and
demand, the increasing refinement in drugs, and our ability to give them
in condensed forms, all tend towards making the physician more accurate,
and by overtaxing him, owing to the time all such methodical studies
require, have made his work such that only the patient and the dutiful
can do it justice.
Primary examinations of chest, heart, and other viscera are long and
troublesome, and the first study of a case which is at all difficult,
demands such time as it is increasingly hard for the busy to find. A
good test for laymen in acute cases is the methodical manner in which a
physician of modern training goes over the case, nor is his preciseness
as to doses and medicines less worthy of note. I used to watch with
interest the late Professor P. at a sick-bed. The grave and tranquil
interest, the pauses for thought, the swift thoroughness of examination,
and then the delay, with, "Please, nurse, let me taste that last
medicine," were full of good lessons. Any consultant could tell you what
a rare quality is this union of precision and thoroughness.
Our profession has in its work enough of true difficulties, but we still
owe many of our worst errors to want of absolutely complete study of our
cases, and with the careless these slips are obvious enough to enable
any one who is watchful to sit in judgment on the failures. The more
delicate illustrations of the fine union of qualities which attain the
highest triumphs are, of course, only seen and comprehended by
physicians, whose general opinion on their fellows is in the end almost
always a just one. There is a potent combination of alertness in
observation, with a never-satisfied desire to know even the trifles of a
case, which, with sagacity, gives a medical mental character as rare as
it is valuable.
For such men there are no trifles, and, on entering a sick-room, they
seem to absorb at a glance matters which escape others, and yet to the
end are still so quietly observant and searching that they seem never to
be quite content with what they have learned. Not to know surely is to
them a form of unhappiness.
I remember well a consultation in a case of great obscurity, into which,
many years ago, the late Dr. G. was called, after three of his
colleagues had failed to reach a conclusion. It was suspected that
poisoning by lead was the cause of a singular and unusual train of
symptoms. Now, in such cases, a blue line around the junction of the
teeth and gums is a certain sign of the presence of that poisonous
metal. The patient, a man of seventy-five years, was known by his own
physician to wear full sets of artificial teeth, and he so said. This
having been stated no one looked at the gums. At the close of the second
meeting Dr. G. turned back unsatisfied. "Let me see your gums. Ah!" he
said. There was the stump of one incisor left, and around it the blue
line told a tale which ended all doubt.
On another occasion, a young physician well known to me, fell by a
chance into a consultation with Dr. P., the physician I have mentioned,
and the late Professor P. The case was one of a young man who several
times had been found at morning in a stupor. The attacks were rare, and
what caused them was unknown. The young physician, much embarrassed, was
civilly asked to examine the case, and did so with a thoroughness which
rather wearied the two older men. When they retired to an adjoining
room, he was asked, as our custom is, to give, as the youngest, the
first opinion. He said, "It is a case of epilepsy. He has bitten his
cheek in the fit." Dr. P. rose without a word and went out. Returning in
a few moments, he said, "You are right. I did not look far enough back.
You will reach, sir, a high rank in our profession." The case was
thenceforward plain enough. These are rare illustrations of my meaning,
and may suffice, with one which has a more humorous aspect. Meeting the
late Professor C. D. M. on the steps of a house where, the day before,
we had seen together a woman critically ill, he said to me, "Mrs. B. is
better, doctor, much better." "And how do you know that?" I returned.
"Her windows are open, my dear doctor. She wants more light. She must be
better, much better." And so she was, as it proved.
A final result of the multiplication of the means of research, and the
increasing difficulty in becoming expert in the use of the many and
delicate instruments they require, is the growth of what we call
specialties in medicine. The best of us learn to use the ophthalmoscope
to look into the eye, to use the laryngoscope for the larynx, and can at
need examine the urine and the blood, but the men must be rare who are
as competent to use each and all of these means as persons who devote
themselves to single branches of our work. Moreover, the element of time
comes in, as well as the element of such constant familiar practice as
makes for one man commonplace and easy what for another, who is more
generally occupied, is uncommon and unfamiliar. The specialist profits
by the fact that his experience becomes enormous and his work advantaged
by its definite limitations. On the other hand, and nowadays especially,
he is too apt to be one who, after brief hospital work of general
character, or without this, takes up, as we say, the eye, ear, throat,
or uterine organs. Unless he has had at some time a larger and more
varied experience, or unless he is a most unusual man, he is prone at
last to lose sight in his practice of the fact that eye, ear, and womb
are parts of a complicated mechanism, and suffer through its general or
local disorders. Hence the too common neglect of constitutional
conditions, to which are often due the apparent maladies of the organs
to which he devotes himself. Moreover, in certain of the organs of
sense, as the eye, are frequently seen the very first signals of spinal
or other maladies, and if, as too often happens, he sees in some such
sign or symptom only the evidence of a local trouble, and neglects to
look or reason beyond it, he may inflict on his patient the gravest
penalties, by depriving him of the chance of early treatment of some
serious disease, involving lifelong, or even fatal, consequences. This
is a criticism on the man and his training, not on the system of
specialties which has become invaluable.
A reasonable desire to seek aid from physicians of usefully limited
values is another test of the good family physician. I know of men who
are in the habit of saying that they dislike consultations and get
little good from them. As compared to those who too commonly subject
people to the expense of fresh advisers, they are the more dangerous
class. Apt enough in cases of acute disease to bring into the case some
one to share responsibilities which seem grave because near at hand,
they continue to treat chronic cases they do not understand, because
there is no crisis of pain, disability, or danger to bring them to
reason.
Hitherto I have dealt most with the intellectual outfit needed for the
best practice of medicine, but the criticism I have just made brings me
on more delicate ground. The man who feels himself so competent that his
self-esteem forbids him to seek advice when he knows and must know he
has come to the end of his reasonable resources, lacks the humility
which belongs to larger natures, and he, too, is a man to avoid.
Be sure that the physician cannot he a mere intellectual machine. None
know that better than we. Through all ages we have insisted that he
shall feel himself bound by a code of moral law, to which, on the whole,
he has held without question, while creeds of more serious nature were
shifting and changing. What the Greek fathers of medicine asked of him
we still ask of him to-day. He must guard the secrets wrung from you on
the rack of disease. He is more often than he likes a confessor, and
while the priest hears, as I have once said, the sins and foibles of
to-day, he is as like as not to have to hear the story of a life. He
must be what About calls him, "Le tombeau des secrets,"--the grave of
secrets. How can he be too prudent or too close-mouthed? Honor you must
ask of him, for you must feel free to speak. Charity you should expect
from him, for the heart is open to him as it is to no other, and
knowledge, large knowledge, is the food which nourishes charity in the
tender-hearted. In the tender-hearted? How can he be that? All his days
he has walked amidst misery, anguish, bodily and mental suffering. Be
careful when you come to test him by his ability to feel what you call
sympathy. In its loftiest meaning this is the capacity to enter into, to
realize, and hence to feel with and for you. There is a mystery about
this matter. I know men who have never suffered gravely in mind or body,
who yet have some dramatic power to enter into the griefs of others, and
to comprehend, as if by intuition, just what others feel, and hence how
best to say and do the things which heal or help. I know others,
seemingly as tender, who, with sad experience to aid them, appear to
lack the imaginative insight needed to make their education in sorrow of
use to their fellows. There are times when all that men can give of
sympathetic tenderness is of use. There are others when what you crave
is but the outcome of morbid desires for some form of interested
attention. You may ask too much, and every doctor knows how curiously
this persistent claim for what you call sympathy does, as the nurses
say, "take it out of a doctor." The selfishness of nervous women
sometimes exceeds belief in its capacity to claim pity and constancy of
expressed sympathy.
In times of more serious peril and suffering, be assured that the best
sympathy is that which calmly translates itself into the desire to be of
practical use, and that the extreme of capacity to feel your woes would
be in a measure enfeebling to energetic utility. This it is which makes
a man unfit to attend those who are dear to him, or, to emphasize the
illustration, to medically treat himself. He goes to extremes, loses
judgment, and does too much; fears to hurt, and does too little. I once
saw a very young physician burst into tears at sight of a burnt child, a
charming little girl. He was practically useless for the time. And I
have known men who had to abandon their profession on account of too
great sensibility to suffering.