The Physician : Part 5

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

(Page 6 of 14)

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.

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.