Chapter 2

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.