The Physician : Part 4

Doctor and Patient
by S. Weir Mitchell, M.D.

(Page 5 of 14)

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.

About the Author

Silas Weir Mitchell was an American physician and writer. He studied at the University of Pennsylvania in that city, and received the degree of M.D. at Jefferson Medical College in 1850. During the Civil War he had charge of nervous injuries and maladies at Turners Lane Hospital, Philadelphia, and at the close of the war became a specialist in neurology.