THE average meeting of local, or even of national, medical societies is given up, as a rule, and justly and wisely enough, to the discussion of themes of immediately practical interest, and to the relation of personal experience in medical fields. “In a short hour, a short journey,” says the proverb. The hours which the busy practitioner can give to friendly meetings for mutual counsel are short indeed, and it is quite natural that the object of the short journeys these short hours make possible should be the reaping of practical hints as to how to meet every- day perplexities. But the present occasion is an exceptional one.
“World’s Congress” is a phrase of wide promise, and from it the essayist of the hour may take privilege to journey a little afield from the familiar highway of experience toward the virgin forests of theory. This is my excuse for bringing here, where others are unfolding from their rich stores things new and old in the way of clinical experience and of clinical fact, a few crude guesses as to what like should be the clinician himself-the scientific clinician-which, as matters now stand in the medical world, I fear is but another name for the ideal clinician. To pursue the ideal is not, after all, so unpractical an occupation as it at first seems. We may not overtake it, but we may glimpse it, and it is only by glimpses of the ideal that we can be helped to shape the actual to better uses.
What is a clinician? Foster, prince of makers of medical dictionaries, defines the clinician as “one whose observations, inferences, and methods of treatment are based on clinical work, i,e., on experience in the care of living subjects as distinguished form the study of morbid specimens or of the writings of others.” A fine, succinct definition this, and one that, but for one fact, might well stand not only for the clinician, generally speaking, but for the scientific clinician, to define whom is the object of this paper.
That disqualifying fact is that Foster’s definition says nothing about the quality of the clinical work on which the physician founds his “observations, inferences, and methods of treatment.” Here is exactly our point of departure. In proportion as that work is done in the true scientific spirit, which is that of broad-minded receptivity guarded by the unsleeping demand for all attainable accuracy; in proportion as that work is done according to scientific methods, which are those of patient, exact, intelligent experimentation, will the work be scientific work, and the clinician a scientific clinician.
No scientific clinician is an empiricist. Every clinician is, to the end of his working days, inevitably and in some sense an empiricist, but he is a scientific clinician exactly in proportion as he recognizes his empiricism and is in the effort to emancipate himself from it. One often finds, among homoeopathists, the idea almost drolly prevalent that an empiricist in medicine means a physician who gives Old-School medicines according to the needs of Old-School experience. In point of fact there are very nearly if not quite as many empiricists among Homoeopathists as anywhere else.
For an empiricist is not such by virtue of practicing under this or that therapeutic rule or lack of therapeutic rule, but by virtue of accepting and acting on a thing because he has seen for himself that it is true and why it is true. It is an unsavoury dose for professional vanity to swallow, but it is well for our growth in science for us to remember that the girl who buys cuticura soap because the advertising testimonials in the newspapers tell her it is good for her complexion, is no more in empiricist than the Allopathic physician who gives Morphia for every kind of pain because he has been told it is the proper thing to do, of than the Homoeopathist who cheerfully administers inert substances whose potency he has never once tested on himself or for himself because he has read in one of his journals that certain symptoms have been created and are controlled by them.
The prevalence of empiricism in the Homoeopathic school would make a subject-and a very melancholy subject-for the essayist taken by itself, and where the empiricist reigns the scientific clinician will rarely be. Empiricism, let me again remind you, just means the unreasoning acceptance of hearsay and the acting upon second-hand knowledge. We are, therefore, empiricists, and nothing else, when we take our materia medica, as it stands, on hearsay, and make no effort to satisfy ourselves, as with a little tie and trouble we can quite easily satisfy ourselves, which drugs hold the if place there by right of reliable and satisfactory provings, and which are there-and a very great many are there-merely by acceptance e of empirical hearsay, and therefore have no right there whatever.
The scientific clinician never employs a drug whose pathogenetic power he does not know all about that can be known by personal experimentation if possible; at all events, from evidence so direct, manifold, and solidly convincing that hearsay has no place in it. The acceptance of this rule is the first step taken by the Homoeopathist toward becoming a scientific clinician. The administration for the relief, in the sick, of certain symptoms which the drug administered can be proved to cause in the healthy organism-this, and nothing else, is Homoeopathy.
To administer, to the sick, drugs whose power over the healthy organism is neither known nor demonstrable, is to be neither Homoeopathist nor scientific clinician, but an empiricist, pure and simple. A convincing instance of what hold empiricism has upon Homoeopathy is the prevalence, in so-called Homoeopathic practice, of what is known as Schusslerism.
The Schussler remedies beyond, in a few instances bearing the names of drugs known to our materia medica, and being recommended for administration in small doses, have no more in common with Homoeopathic treatment than have “safe” kidney cures and “infallible” spring tonics. One would suppose this fact would be recognizable at a glance; yet so widespread and insidious is the influence of empiricism that there are Homoeopathists the country over who employ the Schussler remedies in absolute ignorance of their pathogenetic power or if they possess any such. Such possibilities must cease to exist before we can hope to become a school of scientific clinicians.
To accept nothing on hearsay, to investigate personally when personal investigation is possible, and in any case to demand evidence of a thoroughly reliable sort before acting in any given direction, that is the first qualification, that is the very hall-mark of the scientific clinicism. For the rest, he must be a trained observer, a logical reasoner, an unbiased thinker, a truth-seeker of such high calibre that no theory, however cherished, will be respected by him when he finds it opposed by demonstrable fact.
He must be a trained observer. In our craft, as elsewhere, there are certain inborn aptitudes the possession of which is invaluable to the craftsmen, as helping him toward the ideals of his work. Keenness of the natural senses is a fortunate possession for the clinician. Smell, touch, sight, hearing, taste-these in the clinician, who must be an acute diagnostician, should be as carefully trained, as instantly, involuntarily serviceable, as they are in the woodsman and the plainsman. Listen to Milner Fothergill, whose inspired common-sense every student of medicine would do well to profit by. “When a patient comes, the first thing to do is to look at him.
Some varieties of information may be safely left in the library, and it is quite enough for the busy practitioner to know where to find it when the wants it; but there is other information which is required several times every day. The more the eye learns to see, the more it can see and will see. There is nothing worth knowing that is got without trouble. So is it with the education of the eye. The education of the eye is most important to a medical man; it cannot be forgotten or mislaid like an instrument; it is of incalculable value when the patient is unconscious or deaf, or a foreigner whose language the doctor does not know.
A scar at the corner of the mouth will reveal the secret of malnutrition in a child who has hitherto resisted all remedial measures; a little puffiness under the lower eyelid may indicate the chronic Bright’s disease underlying the bronchitis for which the doctor is consulted; the hue of the skin will very often furnish the clue to the malarial neuralgia which is very troublesome; a tortuous, visibly pulsating temporal artery will tell in all but articulate language of the gouty heart and its associated conditions. These are a few instances of what the eye can do in the way of diagnosis.”
What the trained ear can do, especially in cases of pulmonary and cardiac disease, to aid accurate diagnosis needs no dwelling upon. Touch has acquired infinite significance, since we have learned what accurate diagnoses, even in complicated cases, can be made by the exquisitely trained and sensitive touch of the totally blind. “When the sense of smell is sufficiently developed”-to again quote Fothergill-“it is of definite aid to the diagnostician. In the exanthemata a certain animal odor, often amounting to positive stench, is emitted. Certain lunatics and, markedly, general paralytics, possess a very disagreeable odor. In pyaemia the breath caries with it a characteristic smell, described as that of hay or earth”.
