Doctor and Patient Part 1

Doctor and Patient.

by S. Weir Mitch.e.l.l.

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 const.i.tuted 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 cla.s.s 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 t.i.tle 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 grat.i.tude 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 ma.s.s 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 cla.s.s of teachers, who lay before a mult.i.tude what will be usefully a.s.similated 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 a.s.sured of its value. But sometimes the very excess of the material from which one is to deduce formulas and to draw remembrances is an embarra.s.sment, 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 circ.u.mstance, 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 cla.s.s 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 s.e.xes 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 s.e.xual 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 compet.i.tion with man and to a.s.sume 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 s.e.xual life threaten her as no contingencies of man's career threaten in like measure or like number the feeblest of the masculine s.e.x.

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 champagne. 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 embarra.s.sments 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, p.r.o.ne to eat largely of coa.r.s.e 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 a.s.ses' 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 ill.u.s.tration 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 h.o.m.oeopathy, for the h.o.m.oeopath, 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 ill.u.s.trious 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. x.x.xvi.]

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 a.s.sist 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 n.o.bleman 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 pa.s.sions 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 emanc.i.p.ated from the control of those l.u.s.ts 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 a.s.sertion of them than he. His name is still a.s.sociated with bleeding and purging, and if we considered only some of his written a.s.sertions, 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 cla.s.s. 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 a.s.sociate 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 a.r.s.enic 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 r.e.t.a.r.d 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.