CHAPTER II In the later eighties, I had about determined to make my (Part 3)

of these diseases, \lien food in the enteron has approached the peptone stage, its proteins are then poison if they become para-enteral and have to imdergo diges- tion by parenteral fluids and tissues before they have been dianged over into useful amino-acids. In the course of physical decline, when the ductless glands of people are losing their efficiency as protectors, it is my idea that parenteral protein poisons as well as enteral protein poisons are to exercise more and more influence in lessening the numbers of the physically weak, while population on the whole in- Some of the hospitals at the present time have a collection of experts in every department of medicine, so arranged that the whole machine can instantly be brought to bear for the benefit of any single case. This is an ideal condition which needs very large endowment by private funds or by the state. When more of our hospitals are organized upon that basis almost every patient may have a report from the internal secre- tions expert, before his case is taken in charge by the surgeon or internist. TO-MORROW'S TOPICS 73 Many young doctors consider it desirable after finishing their studies to take up work at a large dispensary where they see a great many cases, but I have often observed an injurious effect from their getting into the habit of making superficial diagnoses. They run over a mass of clinical material for the purpose of finding something interesting, before they have learned what really is interesting. Almost every case that came in could very profitably have been given at least an hour of study, and yet I have heard young doctors boast of dis- posing of twenty cases in that length of time. In "Thesetetus" the youth replies to Socrates: "According to my present notion, he who knows perceives what he knows, and there- fore I should say that knowledge is perception." When hastily disposing of a large number of clinical cases, the doctor perceives only what he already knows, without taking detailed steps for obtaining all of the knowledge which is extant in relation to a given case. The world needs every mind that can be developed, no matter to which sex it belongs. Women in the practice of medicine have not as a rule been quite as successful as they deserve to be, upon a basis of their accomplishments. There are a few exceptions, but it is rarely indeed that feminine nature, even that which remains in the presence of viraginity, can bear with equanimity the shocks which are incidental to taking an important position in the world's affairs. If a woman when devoting herself with all the conscientiousness of her nature to some scientific problem is said to be tmtruthful, or if her character is brought into question, feminine nature obliges her to stop and resent the imputation. Stopping to resent an imputation means diversion of energy, and should not be allowed to occur, because it leads to a dissipation of those forces which belong to professional work proper. The weaker ones among men are, to be sure, 74 TO-MORROW'S TOPICS diverted from their work when stopping to resent imputations. It is almost a virtue for a woman to be sensitive to personal attack, while for a man it is a bad vice. The reason why it is immoral for any man to be sensitive if he is engaged in serious work, is because response to irritation lessens his capacity for the work in which he is engaged. Another reason why women have not been as successful as they deserve to be in the practice of medicine is because other women do not seem to have a sufficient degree of confidence in them. It is said that the measure of a woman is her measure of other women. The majority of lay women do not seem to measure the capacity of women physicians accurately. The latter represent for the most part women of a high type of mind, who stand at the head of their classes in the humanities as well as in scientific work, and who show weakness only when they go out of their way to resent attack. One who does this is instinctively subjected to the familiar dictum "Qui s'excuse, s'accuse." The stronger men know it is better never to explain nor to complain, but women find it particularly difficult to avoid this rock. Among men it is generally conceded that the ones who have to be handled with gloves should really be handled with an axe in order to save time, but it is quite the exception to find a woman who does not need to be handled with gloves. According to the census reports the proportion of women who enter medical colleges has been diminishing steadily since 1905. There may be an increased proportion again under higher educational requirements because women stand so well in average scholarship. It probably means that difficulties are out of proportion to advantages gained in the practice of medicine by women. There are certain fields of practice in which it is very desirable to have women prac- I tjtioncrs, and a fairly large number of women who are peail- liarly well equipped for this work will continue to engage in TO-MORROW'S TOPICS 75 practice. In all probability the prejudice against women in medicine is primal in origin and means nothing more than the prejudice which is expressed against women or men in occu- pations which are felt to belong naturally to the other sex. Scholarship has been an obstacle to success among men in the medical profession when it has introduced doubt and speculative philosophy. In almost any town we may observe the object lesson of a doctor with mild degree of education succeeding better than one of highest academic attainments. We do not know as yet how this will work out among women physicians. The experiment is being made. We are not to assume that a dull fellow is to be more successful than the scholar as a logical sequence. There is another factor in the problem — our present system of education. Under our accepted educational methods a scholar may go far wrong merely through fidelity in adherence to what he is taught. The exemplar man on the other hand, using his common sense (robust uncultivated instinct) may become the better man in applied principles of practice. In some other cultural period the scholar may necessarily be the better doctor. Two degrees from the world's academy should go to women who have tried to do well. These degrees are A + L and A — L. A + L is admiration plus love, A — L admiration minus love. Not all women have the ability to win either one of the two degrees, but the rest may be classified very satisfactorily in this way. There is not less work for doctors to do at the present time, although preventive medicine has lessened the number of old fashioned cases. There is more work in fact, though ^ we do not fully realize it as yet. Preventive medicine results ^B in the saving of such a large proportion of defectives who ^B are marked by nature for elimination that we are immediately ^m confronted with a great new problem^that of managing the I TO-MORROW'S TOPICS double roses who are enormously valuable because tliey include the abnormally talented. Doctors have not as yet been able to adapt themselves quickly to the rapidly changing conditions. Many physicians during the past decade have become de- moralized by the dropping away of cases which formerly gave them good incomes for the support of their families. Instead of taking up the scientific study of toxic processes, which would have occupied them fully, but which required a high order of new education, they have too often turned toward lines of least resistance. There is no diminution or change in the amount of work for doctors to do. there is change only in the character of the work to be done. Let us say that in "visit-days," old- fashioned doctors had a great deal of occupation with typhoid fever, diphtheria, measles and other infections. To-morrow they are to arrive at "case days " instead of "visit-days" in practice. Members of the medical profession will begin to realize the necessity for giving as much attention to lumbago as they formerly gave to typhoid fever, and this will be profit- able to the paiient as well as to the doctor. He must give more attention to a case of neuritis than he ever gave to a case of diphtheria, with more profit to the patient and to himself. He must give more attention to eczema than he ever gave to measles, more attention to asthma than he ever gave to scarlet fever, and all with great profit to the patient and to himself. The day of the general practitioner is to return. One reason why so many men have given up general practice for special- ties is because the diminishing returns from general practice have not been sufficient to allow a good style of living. This is a more or less commercial view. The change back to the general practitioner will take place when a certain fundamental principle has been realized, the principle that a physician is TO-MORROW'S TOPICS yy to consider that his responsibility and charges belong to the case as a whole, rather than upon a basis of the number of visits. The responsibility of taking charge of a case of arte- riosclerosis, for instance, managed properly by the year, may be really worth let us say, two thousand dollars per year, and if the physician has a sufficient number of cases paying only a fraction of that sum, he will not need for income. The responsibility of caring for a case of dyspepsia, a case of pneumonia, of typhoid fever, should not longer be put upon the basis of visits but upon the basis of responsibility and degree of work involved in any given case. This to my mind is to bring about the change, and to bring back the physician who is the friend of the patient, the adviser of youth, the steersman with a hand on the wheel who guides a case through the best channels. This physician will employ experts, but he will remain a peer of all experts, and his emoluments will equal theirs. Many members of the profession may do as the Mayos have done. They must first have true merit for a basis. There are many towns with two men of true merit. Next in order organization of consultants is essential. Next, — organization of facilities. The whole organization can go as far as the basic character and skill upon which all else is built will allow. There are plenty of men with skill and character, but few with the added combination of executive ability. A young man just starting out in professional work has usually been trained both in his academic and scientific courses by men who teach subjects and principles, without relation to their concrete mixture with human nature. In practice he soon finds that he must work from a recognition of the purely human element. One of my early mistakes was the result of not realizing the difference between a patient and a case. At the time when [ 78 TO-MORROW'S TOPICS a famous public man was under treatment, and I believed tnat a certain method of procedure would be of value, a letter was written to one of the surgeons in the case stating my views and offering my services. At that early day I did not realize that a good deal of diplomacy is often exercised for "getting into a case," and that the matter came under social laws in preference to rules of scientific procedure. My only thought was of the case and not for a moment about the patient and his social relation. At the present time the writing of that letter seems to me quite as ridiculous as it did to the surgeons who were in charge. As a matter of fact, the responsibility for the writing of that letter can be shifted. No decent man shifts responsibility when it will impose a burden upon anyone else, but at this late date no one at all will be harmed by the statement that the idea of offering my services came from a much older physician, who had been impressed by my removal of the larynx for one of his patients. If memory serves correctly no one else had done the operation in this country at that time, and my older friend was sure that an operation which had saved the life of his humble patient would save the life of the famous public man. Details of the matter have all been forgotten long ago, and it is only when remembering past experiences which will sen,'e as a warning to younger men that I recall the genuine and simple-hearted interest of an older physician and of a young surgeon "in a case rather than in a patient." A doctor just out of the hospital interne part of his train- ing imagines that he will have no responsibility beyond the treating of cases, and in the latest and most scientific way. He gradually learns, however, that patients are no longer under his thumb, controlled through the very helpful weight of some one's else responsibility. He finds that it is the ^ TO-MORROW'S TOPICS 79 patient rather than the case which requires treatment. Not only that, but he must sometimes treat the psychology of the entire family of a patient. As he obtains a better and better clientele of patients, it will include a more and more highly sensitized group of people, and the complications will become so complex that he may fail as a physician, although possessing the most scientific sort of mind and the best of methods. He may make a complete failure unless he has a genuine human sympathy which allows him to understand a great range of psychology in other people. I have sometimes felt that the study of psychology ought to be a primary requisite for the medical student, but yet for him it might play only the per- functory part which arithmetic serves in the study of mathe- matics, by students who wish to pass up and then forget all about it. If one becomes interested in geometry before he is taught arithmetic he perceives the need for arithmetic and learns rapidly what is seen to be needed. If one were to be taught psychology as a primary study, preparatory to the prac- tice of medicine, it might not be of great advantage to him. When one gets to realize the real need for this study in con- trolling certain patients in his practice, he then begins to imderstand what advantages are given by a knowledge of psychology. In the eighties psychology had been made to assume a sem- blance of form but had been shaken down to little more than a massed jumble of speculative ideas. Since that time it has taken a place in line among the ambitious young sciences, but still bearing a heavy crop of metaphysics, which is the mistle- toe upon science. A little Phoradendron here and there is really decorative and adds an attractive bit of form and color, but when too much of it depends upon one host, it exerts destructive influence. There is so much of psychology which in its very nature cannot be comprehended, that a tendency 8o TO-MORROWrS TOPICS always remains for the psychologist to fill in vacant spaces with speculative philosophy. This, like the tail of a comet, becomes more and more tenuous as it recedes from the head, and then comet-like proceeds to travel more or less tail first through part of its elliptic. The atmosphere of this philo- sophic tail has a suffocating effect upon other sciences. The psychologist obscures vacant spaces in his science with a cloud of abstruseness. During the past thirty years psychology has passed from the classification of Psychologia Sp. (f) to that of Psychologia parascientia Var. Protagoreia, — ^and now, to Psychologia scientia. Characteristic varieties of the latter species are at present being industriously worked up. Now-a- days we may take the scientific kind of psychology quite seriously. We cannot as yet add psychology to the curriculum of the medical school, excepting in its most concrete and objective phases. ( Note the warning object lesson furnished by psych- analysts). Psychology remains partly in the dark ages, along with psychiatry and neurology, but some varieties are being classified upon a basis of science as a result of the active mutual recrimination between psychologist and physician. The psychologist, having given himself metaphysical .position, looks down with a sort of lofty disdain upon the comatosity of the physician in this field of practice. The physician calls up to the psychologist that most of his ideas are out of date so far as their practical value may be concerned, and he might better descend for awhile. Healthy activity evinced in the form of mutual recrimination follows the law of reactions in its working, and develops the mind very much as the screaming of a child leads to first-rate lung development as an end-result. Two negatives cannot make a positive in general ; there is an exception, however, in special application when warfare eliminates the unfit from both sides, leaving a I ■ pin I ■ the < ^B const TO-MORROW'S TOPICS positive family doctor — We do not wish the warfare between family doctor and psychologist to cease as yet. We hear a good deal about certain people having personal magnetism. Personal magnetism is nothing more than the reflection of a genuine interest in mankind in general. Almost everybody exerts attraction for at least one individual specific- ally, but one must have genuine interest in