“Let me not to the marriage of true minds
Admit impediments. Love is not love
Which alters when it alteration finds,
Or bends with the remover to remove”.
And so is resumed afresh the long line of clinical observers which has been lit by the genius of Hippocrates, of Sydenham, of Trousseau, of Osler, and of many others-masters in clinical research.
II. To-day we are witnessing the apothesis of the machine in human life and it is not surprising to find that medicine, like other spheres of action, is being mechanized. The public has come to believe that machinery is revolutionizing the healing art and is dispensing with the need for human judgment. It is true that the introduction of instruments of precision into medicine has been of great service, but the interpretation of the results obtained by them in the interpretation of the results obtained by them in the individual case still demands wisdom and experience on the part of the doctor.
Where the machine is greater than the man the patient perishes. A large section of the public does not understand this. It has such an incorrigible love for love for apparatus, and what it produces, that it hailed with acclamation a box of gadgets, constructed in defiance of all scientific principles, which claimed to hand out an exact diagnosis, and even the appropriate treatment, and thus make the application of so fallible a thing as the human mind unnecessary.
Failing the reduction of medicine to machinery, the public seeks salvation in the specialist and the expert; and the more apparatus, and the more complicated, employed by these, the greater its confidence. The number of really intelligent citizens, whose health is their best asset, and yet who have no physician or general practitioner, has greatly increased of late years. In consequence of this fact, situations arise which are no only ludicrous but dangerous.
Awaking in the night with a pain in the belly the immediate anxiety is not whether he will find the physician available, but whether the right specialist will be sent for. Is it the appendix, or the gallbladder-or the stomach- or the kidney-man he needs? What if he rings up the wrong one? Perhaps the trouble isnt in his belly at all, for he suddenly remembers that what his business friend thought was a severe attack of indigestion last week turned out to be coronary thrombosis. So perhaps it is a cardiologist he needs? God! how difficult life-and especially medicine-is!.
With the growth of specialism have appeared the diagnostic clinic and group medicine. I do not propose to discuss the pros and cons of this development. Undoubtedly the group system has its advantages, but I am quite sure that unless the team, whatever name it bears, has on its panel a general clinician of experience, it cannot effect the best service for the patient. For in the process involved there are two key points, both of them vital, at which his help is essential.
There is the point at which, after a complete history of the case is obtained, and a general and thorough overhaul is made, the decision is arrived at as to what special examinations shall be undertaken; and then there is the point at which the correlation and interpretation of the results of such special examinations are considered in relation to the particular case. If there is not assessor whose duty it is to undertake these two important functions, the whole system brake down.
In regard to the first point, a sensitive and apprehensive patient may easily be made still more so by elaborate investigations, which are not really indicated, or invalids may be constructed where previously they did not exist. In regard to the second point the danger is equally great. Patients dossiers are apt, in these days, to be so full and so heterogeneous that the courage to say of some of the reports, “noted, nothing doing”, is often the first step in the elucidation of the problem.
It falls to the clinician alone to become familiar with the range of health, to be sensitive to what lies with it it, and to what lies outside it. the exercise of this sensitiveness becomes more and more essential the more meticulously exact the reports of the experts may be.
And these reports tend to be more and more meticulously exact with the increasing tendency to specialism and the myopia which goes with it. the number of patient whose hearts are healthy is in inverse proportion to the number of cardiologists they consult, and the frequency with which they are “electrocardiographed”. An upper respiratory tract which is passed as “normal” by a careful “nose and throat man” will soon be so rare as to merit demonstration at the Academy of Medicine.
Someone must preserve his poise, and if the clinician does not, no one does. Think of the stunts-in diet, in exercise, in clothes, in habits-that the patient is besought to follow in order to be saved. Think of the panaceas by way of drugs, or of operations. Think of the many adventures in numerous therapeutic fields concerning which one can only say, when all is done, that one has been witnessing the triumph of technic over reason. Think again, of the fears that are bred in the minds even of those who are well, that if they do not follow this cult, or that, they will die the death.
There are in my country, and I believe you are not free from them in yours, pernicious folk who try to plant in the public mind the idea that to preserve health is a very ticklish thing. The citizen is led to believe that only by a series of close observances, and equally close restrictions, can he hope for physical salvation. The way of health is pictured as a tightrope along which we make a slow and trepidating progress. The least bias to right or left, not immediately corrected, or corrected inaccurately, and we plunge headlong into the abyss.
Here awaits us inflammations and ulcers and cancer-especially cancer. Of the people who disseminate these ideas the worst enemies are those of our own household, because they are thought to speak with authority. It is for the general clinician to prick this kind of bubble, and to point out that health is really a broad and well-paved road and, speaking generally, and given a modicum of good fortune, the wayfaring man must be a fool indeed if he errs therein.
Again, if the physician drops out there is no one left to make real contact with the patient on the psychological side. This becomes more and more a function of the doctors as men and women taken more and more control of their lives. To-day, the difficulty facing men and women is no longer that they are cramped by authority and by convention but that they get fatigued, or even run themselves to destruction, but their new found freedom.
Realizing that the causes of their unhappiness, as of their physical ills, lie in the biological sphere, they seek the physician rather than the priest. Bewildered by the prospect which their liberty opens out to them, and all unaccustomed to deal with the raw material of their natures as it is now revealed, they not seldom mistake their emotional confusion for physical illness and they come to us for guidance. To them the doctor is the realist, the link between the “fine abstraction” which still beckons them, and the “particular application” for which they long.
The doctor is in the privileged position of the Almighty: he, and only he, has-or can have if he will-all the evidence before him. “he that sinneth before his Maker, let him fall into the hands of the physician.” Why? Because to the physician the individual is not a metaphysical-constant but a physical variable and this outlook enables him lift up the weary head and to comfort the sorrowing heart. First the explanation, then the guidance, and hope, the best of tonics, is reborn.
To be a little more concrete may I remind you that patients go in and out of our consulting rooms, and pass through clinics and groups, with the salient points of their cases undiscovered because they are handled as bundle of organs and functions and not as human beings. One such case in illustration. A short time ago I was asked to examine a woman who had been put to bed on the advice of a cardiologist. Half of the estimated six weeks had passed and my permission was sought to waive the other half on the ground that she seemed so well.
I examined her and found no sings of disease. Puzzled, I asked if i might see her alone. When the doctor and the nurse had left the room the patient said, “You havent found anything the mater with me, have you, doctor?” “No,” I replied. “I didnt think you would,” said the patient. “But why are like this. I am very attached to my husband and I suddenly discovered he was keeping another establishment.
The shock was terrible, and I got no sleep for three nights. Then I looked so ill that my husband insisted upon sending for the doctor. He found my pulse was very quick so he sent me to a heart specialist. After his examination he advised me to go to bed for six weeks.” “But why didnt you tell him what had caused your palpitation?” I asked. ” tried to,” said the patient, “I tried to tell him twice, but each time he put his hand up and said Dont interrupt me, please, I am making my observations.
