John Tyndall, Science and Man
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| And now I quote: "It is not popular . . . to do anything to thwart the efforts of the cancer society (i ' rotips that make a career of instilliiig in all of us the fear of a horrible cancer death . . . The fact is that none of the reported series of large-scale routine sigmoidoseopic surveys of apparently healthy people has turned tip very much information that could be used to help the patient."" Ftirthei- data: A series of 1000 consecutive patients at the Lahey Clini(, on whom sigmoidoscopy was done was evaluated.12 Of them, 637 had minor rectal conditions, most of which benefited from ad-,,ice ,11)oiit diet, local bygiede, Lnd medication. Only six c,iiic,ers \N-ei-e found, and in every one of these the patiezit~, li,i(I complaints of rectal bleeding. In a 1966 stirveN at the NfaN-o Clinic in ,t series of 1000 sigiiioi(10scopies on p.itieiits ,Nitbout symptoms, not one cancer was found-
I get the distinct impression that a patient would do better to turn his thoti(-,Iits aN~-ax, from his fundament tip to the spacious firmament oi, liigli. There is no need to co into (letail al)otit the other specialties. NVhat goes for oi-,e goes for all. The doctors trip their magic round, bcmtise their patients and tlieiiiselxres, and push aside the nagging ,iiats of doubt. The patients -NN~atcli the wondrous dance, applaud the priests and cry for more. Two i-i-take a team-doctor and patient. One skeptic on either side (lestron-s illusion. But perhaps illusion is more comfortable than reality. Oi)e thin(, is stii,e-it's not healthier. 13. FRAGNIENTATION A forty-year-old ,N-onian trying to recapture her youth began to -,N-eai- \-erN7 short skirts. She noticed that liei- ri(flit tliigli was qtiite a ])it sniallei- than her left. She went to an orthopedist, \N-lio measured both tliiglis and found she was correct. The circtimfereiice of the left tlii,,,Ii was three inches more than that of the right. The orthopedist put liei- tlii-otit,li a series of exercises. He found that there ,N-as no muscle or joint weakness. The woman could stand ~iiicl NN,alk \i,,itliotit trouble. He was puzzled by what lic~ considered an atropli,,, of the right tliigli. He sent the \),,oiiiaii into the hospital for a thorough clieck-tip. The iiiterii took- a complete historv and did a pli),~sical (,xadiiiiatioii on the \N-oniaii Ivin,, in bed. Because ati-ol)li,,7 of the tlii,,Ii iiia\, have resulted from a iietirologic, disorder iiid because he was going to be an ophthalmologist, the iiit(~i-ii paid particular attention to the enle grounds, a \,altiable iiidic~itor in multiple sclerosis, brain ttimors and related disorders. The e,,-e grotii-ids were normal. The residei)t went over the iiit(,i-ii's Iiistor-,- and physical. Because lie planned to be a ,\iiecolo,-~ist, the resident did a careful vaginal exaiiiiii,itioii ~iiid found nothing of moment. He made a note oi) the chart to that effect and ordered a laboratoi-\- \N-oi-k-tip. After $450 worth of lal)oratoi-,,- tests ( that cost the hospital less than $50 to do) came I)acl, negative, a neurologist examined the patient it) consultation. He found no iier\,e disorder that \N-otilct account for the right thigh being smaller than the left. After the tests were finished \N-itli and while the doctors were making tip their iiiiii(is NN'liat the diagnosis was, they ordered pliN-siotlierap~- to be given to the 11 Dr. Eddy D. Paliiier, "Diagnostic Endoseopy," Ciirrent Afedic(il Dige~t, .'\larch, 1968. t', Reported in Cti-A Cancer Joiiriial for Cli?iician~, Niarch, 1968. -13 Drs. C. Q. Ntoertel et al., iii Ifayo Clittic Proceeding,~, 41:368, 1966. 48
The attending doctor read the note and went over the left thigh. He found a flat fatty tumor, apparently under the posterior muscle of the left thigh. It was an ordinary lipoma, a benign growth that Deeded no treatment except for cosmetic reasons. The doctors all realized that the right thigh had nothing wrong with it. The difference in circumference from the left was due to the presence of the tumor on the left. 14. "Grammarian, orator, geometrician, painter, g,,.,innastics teacher, fortune teller, rope dancer, phn-siciaii, conjuror-he knows everything." itivenal, Satire, III And now we arrive at the great nonspecialist, at the family doctor, or the general practitioner, as -,,,on may call him. He's not happy with either name. (He's happy with his fees, though. Recently surveys show that the general practitioner is right up there at the top of the moneymakers. Probably because of Ns rarity, like chinchilla and uranium, he commands a high price. In a late issue of an advertising service for physicians, general practitioners are being sought at a starting minimum of $25,000 to $35,000 a year.) In a desperate attempt to build up his own ego the family doctor has begun to call himself a generalist vis-~-vis the specialist. He seems to think that the name gives him a cachet, that it implies that be knows everything about everything in medicine, that he is really the captain of the ship, with the specialists subordinate to him. Giving himself that name plus a little political pressure properly applied in some hospitals has led to the setting up of divisions of general practice in those hospitals. Theoretically, then, the family doctor is on a par with the surgeons, the internists, the pediatricians and all the o * ther specialists. Actually, he finds that for the most part he is not allowed to do operations more complicated than circumcisions or the removal of an ingrown toenail nor permitted to read electrocardiograms nor treat a child in convulsions. If a patient is sick enough to be hospitalized, the reasoning goes, he's sick enough to require the services of a specialist. When it comes to knowing everything about every The Medicine Me thing, alas, too often the general practitioner knows too little about not much. He's kept busy taking care of the everyday illnesses of the flesh, like tonsillitis, acute bronchitis, bellyaches and diarrhea, not to mention migraine, inflamed eyes, Dervous indigestion and infected scratches. He works very hard all day and many nights giving the medical care that specialists feel it is beneath their dignity to provide. He has little time to wade through the self-servidg puff articles in the medical journals so that he can separate the rare nugget of information from the dross. It follows then that he goes on doing what he was taught in medical school with the addition of what be gleans from an occasional lecture or the mountains of pharmaceutical company advertising matter that come in every, mail. He has a smattering, it is true, of every branch of medicine, but that smattering is spread thinner than a blood smear on a microscope slide. The situation is not entirely due to the general practitioner's stick-in-the-mud attitude. It is perpetuatedindeed, the process of deterioration is accelerated-byl the edtication doctors get, particularly in the clinical aspects and in the internship. How can you expect them to learn when residents (one notch higher on th totem pole) take care of all the minor and much majo surgery, do the deliveries and tend the very sic medical cases? About all the interii who's going to be general practitioner can do is look on, take orders an run errands. Some general practitioners complain tha they never get a chance to utilize the skills for whic they were trained; more likely, they were never traine for the skills tlie~, need. They are conscious of their incompetence. (That's harsh word. But wliei-i the doctor gets sick, does he g to a fellow general practitioner or to a specialist? Wh do you think?) They also resent their medicosociall inferior position. Family doctors, therefore, have song out various approaches for restoring their status i the hierarchy and for improving their image in the pti lic eye, to use Madison Avenue lingo. First they form an Academy of General Practice, membership in wlii required a definite number of hours spent in attendi lectures, conventions and classes. A good idea, fall amongst vacationers on cruise ships, at Las Vegas a on combined golf -and-learning trips. All one bad to was register to denote attendance, after which cr('~', could be claimed, and then the tired doctor colil(i fresh himself in more entertaining surroundings til.--. sleep-inducing darkened lecture hall. That metli(~,,; self-improvement and stattisseeking having sliox% - Members of One Body self to be innocuous and equally meaningless, other proposals were made. One group wanted family doctors to have freqi-iently repeated examinations to make sure that they're up to date in their diagnostic and therapei-itic techniques. Nlost of tl-ie gei-teral practitioi-iers were in violent opposition to that suggestion. They ol)jected, not without merit, to being singled out to take such examinations when specialists don't 1-iave to. Another group wanted to create a specialty board so that general practitioners would be able to call themselves specialists. Naturally, the specialists were against st-ich a board because it would dillite the N,alue of their own boards. Some fan-tiln, doctors, too, were i-iot wholeheartedly in favor of it because, in a rare burst of lioiiesty, they recognized that iianiiiig, like thinkii)g, would not change reality. A specialty board for faii-iil-,- physicians was fiiia]INIcreated, however. Are the general practitioners happ~, now'? Not so you could notice it. Some of them see further restrictions on them in the offiiig. Tlie,N- fear that the boiia fide specialists will say, "Yours is a iioiisurgical board. Good. No surgery for you," and then the G.P. will have en,eii fewer hospital privileges than lie has now. Othei-$ , xn,ai-n that the board will discourage medical students from troiii(r into ,eiiei-al practice because of the periodic recertification requirement, ,N,Iiicli is not required in the other specialties. A cn,nical feNNapplaud the board because iionv 11 specialist" ,eiiei-a] practitioners will be able to charge more for tbeii- sei-\~ices. Discontent is N,ocal: only 201-e' of California's (-reiieral practitioners said tliev would consider takiii,, the board examinations. Still another group, ,N,itli much support from medical schools, medical reforiiiei-s and iiiedical philosophers, igi-iores the board entirely. That group says that general I)i-actitioiiers should be transformed into I)i-iiiiai-,il ))Iitl Their function NN-ill be to DI~ike the first teiitati\-e to treat all trivial ailments, to direct ii-ioi-e to the proper specialists, to co-ordiiiate the ()f the specialists and to supervise treatilielit I', , 'i~(, tli~it they will be alerted to untoward effec.tn. III \%()I-CIs, the primary physiciai-i will act like a sortiiit_l ()i, Li I)attle aid station, separating the gra\-el\ hurt fr,),,ii ~\al~-iiig wounded. The faiiiil\- tli~it then they'll be merely the eqtii\-aleiit of hospital corpsmen or Europeaii-t~'pe Feltiiit,r\. (loii't \N,aiit to accept a permanently iiiferior \N-liat faiic,,, name it's given. Tlie~,l eii]int tilt- I)lil)ll(- oii their side. They object that such a s\-stt.~iii \%ill (It~I)ri\e patients of the 49 compassion and human sympathy doctors are noted for in soiig and story, and often in real life. That wziri-i-i interpersonal relationship is supposed to have a gi-eat therapeutic effect in the liealiiig process. Yoti'\,,e heard people say, "Nly doctor absolutely insists that I . . ." and "Nlv doctor strictly forbids me to . . ." and "i'\Iy doctor -,N,~is pleased that I . . ." You can just see the doctor I)eamiii,, and citick-eltickiiig. Tender I.o\,iii(, C~ti-e. Tlztit's the real specialty of the faii-iilv doctor. Ile is the coiisolei-, the adviser, the lay fatliei--coiifessoi-, the I)riii(,er of hope, the shoulderpatter. His art ti~iiisfoi-iiis cold science into wariii tinderstaiidiii(,,. He stztiicis, a fearless knight in rtimpled clothes, between the -kii(,cl of Death and the frightened family. A glowiii(r pic-tiit-(,. )'oti'\c, seen it in the iiio\,ies; ~,oti I \Te read about it in the iio\els. (1,-,\-eii the scurrilous aiitidoctoi- iio\-cls ()ii(~ iiatiii-e's nobleman arrayed ~t,gaiiist the licentiousness aii(I of ]]is coiifi-ei-es.) \-oti think N-oiir o\~lli (loctoi- is like that. I hope lie isn't. 1'eii(Icr Lox-iii(, Care is no stibstittite for coiiiiiioii s(~ii,,(,: can't take the place of aiitil)ioties~ ~-iii(Iii(~ss iii~tx~ he a cover foi- i(,iioraiice. NN'liat ),on need is ~t cloc~toi- \N-lio kiio\N,s \,%,hat lie is doiii(r ztiid wli-,,. If his I)c(l.sicle iii~iiiiier is sootliiii(y, if his pres(,iice spreads coiiifoi-t. so much the better. That's la(,,iiiappe, I)tit the pi-iiiie consideration is the applicatioii of a scientific attitude to\N-ai-cl the (li~i(,iiosis and treatment of (lise~ise. Otlici-\x,ise the cloc,toi- could dispeiise xn,itli his stethoscope and piesci-il)tioii pa(l: lie could (loi-i a biretta and s\viii(i a ceiisei,. Popular nia(,aziiie \N-riters bewail the 1)~L,,siii(, of the old-stn,le faiiiil\, (loctoi-. They advise tli(,ii- to ti-\, lwty to establish a iiieaiiiii(,ftil i-el~itioiisliip \N,itli a personal physician. Doctors iio(I ~ipl)i-()\,il of such fosteriiig of iiostal(,ia for the "good old (1~i\-s." NN'llat's looked for is rapidlv I)ecoiiiiii(, ~t Iii,,,toi-ic-~il curiosity, A (Tood thin(,, too, that it is. The I)tiiiil)liii(, but syii-ipatlietic doctor, so I)tisv I)a\-iii(, tli(, i-o~i(I to liell with his inteiitioiis, I)eloiigs in a iiitisetiiii, not Lit a patient's I)e(lside. Dr. LaSagiia sa\,s in Life. Death, (iii(I the Doctor, "The i-i-iaii whose life is tlii-e~tteiie(I ])\~ a coiiiplic~tteci it] fectioii . . . demands technical expertness, fi-odi a misaiitlirope, if need I)e." Then the doctor lied(les with, "But there still i-eiii~iii)s ~iii enormous range of human illiiess ... where 'iiia(,ic I)tillets' are lackiiig" and mantial skill or special ti-aiiiiii(ly is not needed, and for these ailments the doctor must dispense the milk of human kindness. I Ltsk \,ott-~.N-Iiy the doctor? NVhv not '\lama? 50
from hemorrhage from his ruptured spleen right at the door of the emergency room. They never forgot how he stayed all night with the Hammer woman in her labor, bustling around the kitchen, telling the three little children funny stories to keep their attention away from the shrieks from the bedroom, giving the suffering woman needle after needle to ease her pain, and thei-i having the miserable job of delivering a dead baby by high forceps. In the four terrible days of delirium before Mrs. Hammer died of sepsis, be was with her day and night, standing by her bedside, adjusting the tube that slowly dripped the serum into her veins. People iie,,-er tired of telling how Old Doe broke down and N,.,ept the iiight Mrs. Hammer was laid out and how Mr. Hammer had to drive him home. Old Doc had a social conscience too. He gave lecttii-es to the Boy Scouts on what they should know about health and hygiene, explaining to them the horril)le consequences of masturbation and evil living. He NN-as a generous contributor of cash to the Dorcas Home for Unwed Mothers, besides giving his services gratis and sboutiiig at those patients who cried out during labor so that the girls would learn a lesson they'd never forget. He was a vigorous advocate of compulsory immunizations and other preventive health measures such as tonsillectomy. He was not a stickin-the-mud. He gave birth control information to married women. He treated venereal diseases by the latest methods, making sure that his nurse immediately phoned in the name of the patient to the Board of Health as required by law, from hemorrhage from his ruptured spleen right at the door of the emergency room. They never forgot how he stayed all night with the Hammer woman in her labor, bustling around the kitchen, telling the three little children funny stories to keep their attention away from the shrieks from the bedroom, giving the suffering woman needle after needle to ease her pain, and then having the miserable job of delivering a dead baby by high forceps. In the four terrible days of delirium before Mrs. Hammer died of sepsis, he was with her day and night, standing by her bedside, adjusting the tube that slowly dripped the serum into her veins. People never tired of telling how Old Doe broke down and wept the night Mrs. Hammer was laid out and how Mr. Hammer had to drive him home. Old Doc had a social conscience too. He gave lectures to the Boy Scouts on what they should know about health and hygiene, explaining to them the horrible consequences of masturbation and evil living. He The Medicine Men was a generous contributor of cash to the Dorcas Home for Unwed Mothers, besides giving his services gratis and shouting at those patients who cried out during labor so that the girls would learn a lesson they'd never forget. He was a vigorous advocate of compulsory immunizations and other preventive health measures such as tonsillectomy. He was not a stick-in-the-mud. He gave birth control information to married women. He treated venereal diseases by the latest methods, making sure that his nurse immediately phoned in the name of the patient to the Board of Health as required by law, except when he knew the patient well. Then he used his judgment and ignored the law. Young and old alike adored the Doc. "When you come in the door, I'm halfway better already," was a common remark. His colleagues in the Lenape County Medical Society held him up to incoming physicians as a shining example of what a real doctor should be. The Old Doc began to have pains in his stomach and lost much weight. He went to the Medical Center fifty miles away. The doctors there marveled at the constant stream of flowers and getwell cards that poured into his room. "If we had more men like him," growled the professor of surgery, "there'd be none of this nonsensical talk about socialized medicine." Old Doc never came back from the ),Iedical Center. His cancer was too far gone. His funeral was magnificent. A young whippersnapper took over his practice, to the dissatisfaction of the townspeople. They missed Old Doc. Mrs. Smith, wbo'd been bedridden for a year with "kidney dropsy," grudgingly admitted when she began going back to church and eboir meetings that the new doctor's treatment was good, but he just didn't have the touch Old Doe had. Mr. Jones, whose "chronic rheumatism" disappeared on the diet and tablets the new man gave him for his gout, complained that he now had no chance for gabbing with the doctor about state politics. Miss Robinson, the schoolteacher, no longer looked forward to the badinage of the Saturday afternoons when she used to get her weekly liver shots for anemia; the new fellow removed her cervical polyp and the bleeding stopped. Old Doc's memory lingers on. Five years after his death, the Baby Health Station was named after him in gratitude for his long and arduous service to the people of the town. MORAL: The milk of human kindness may not be as effective as the proper medicine for an illness, but it tastes better. 51 The Powwow "Two great physicians first My loving husband tried To ease my paiii-iii N~aiii. At last he got a third And then I died." Epitaph in Cheltenham clitii-cliN-ai-(l The consultation, a convocation of medicine men, takes place when the patient's family has doubts. They worry that their own ai-igtir may have misinterpreted the omens. They worry that his brew lacks potency. They decide that their own death-wishes ("I wish Mama would get better or something") must be overcome by multiplication of magic. Two beads are better than one, they figure, even as shrunken ornaments. Doctors are well aware of how families feel. The patient is a secondary consideration. The families pay the bills. If the patient dies, the family must have no regrets that they have not done enough. If he lives, they must be able to congratulate themselves on their foresight in having a consultation. So virtue is made out of necessity. "In the interest of the patient" consultations are called. No families object. They are pleased that their doctor (in whom they say they have the greatest confidence) is asking anotl-ier doctor to give his opinion. They have two levels of thinking: on one they know that two doctors seldom disagree and that whatever changes in regimen will be made will be done solely to justify the consultation fee. On the other they klio%\- that a doctor one hundred pei- cent sure of him !f %%-oiild never think of asking another doctor to see T ~o -:iiiiiier in which consultations are conducted lm clia.-, --, (I on-er the years. It used to be that the doctor in %koiil(l tell the family that he wanted a coiistiltatio:-, If(- %%-oiild then call his consultant, meet him at the ()f the patient and send the familv outside the rOOTli Tli(~ c,)iistiltaiit would listen to the doctor's recotilltiT)Z of tlit, 1)atieiit's history and then would examine the patit,rit. -kfter\~-ards, both doctors would go into a huddle fir front family or patient, in another room if possible, or at least iii the I)athroom. Both doctors would then meet the fri,,Iiteiied family. The attending doctor would state the consultant's opin- ioii while the lattei- iio(l(iecl in al(ri-eciiieiit. The feNN, questions fi-oiii the f'ztiiiiln- \Noti](I I)e (leftl,,- ~iiisNN,ei-eci ii) double-talk, lea\-iii,-, tileiii c-()iifiis(,(]. The coiistilt~ijit would accept his fee ~iii(I (1(,I)zii-t. Tlieii the faiiiiIN, would ask the atteii(iii)(-r (loctoi-, "\N-liat (ii(i lie saN~'-)" aitcl listen to the iiitei-pi-t~t~ttioii of the oi-~ictilai- opii)ioii. That's cliaii(,cci iio\N-. The patient sick- ciioti(,I) to iiee(i a consultant is iistiill\- iii ~t liospit~il. The ~itteii(Iiii(, doctor, alert to the iiiixi(,ties of the kinfolk, tells them that he is liax~iii(, a coiisiilt~itioii. The coiistiltztiit c~oiiies iiiiannounced aii(I iiiiatteii(led, reads the hospital cliart, examines the I)ziti(,iit aii(i xn,i-ites his opiiiioii on the cliart. That ol)iiiioii is tiieii retailed to the faiiiiln- I)N ~the doctor iii c-li~ti-(,e, \\-Iici)eN-er lie ~,,,ets around to it, Preseiit-(Ia,,- pi-oc,ecitire is less foriii~il tliiii pi-c\-iotisl,,, but just as effecti\ c. The amenities are ol)sci-\ (,(I. NN'hen are coiistiltatioiis called? The .1()iiit ('()iiiiiiitt(~e on Hospital Acci-c,(Iitatioii reqtiii-es tli(,iii (',IC sareaii sectioii is to be doi)e for the fii~,,t tiiii(~, \\Iieii a therapeutic abortion is advised ~iii(I ()I)c,i-~itioiis designed to cause sterility (iiiltle ()i- Lti-c coii templated. In addition, coiistilt~itioii,, ti(, i-c(ltlii-ecl when the patient is not a ,oocl tlii~, plii-~ise is explained latei- on), wlieii the i-,, ol)sciii-e and when doubt exists as to the 1)(,st ti-(,~itiiieiit to be titilized. It is ratioiial to require a coiistiltitioii \N,-Iieii a woman is to be subjected to the (laii(~c,i-s of it (,~iesai-eaii sectioil, for the operation is daii,,ei-oiis, ~is the statistics slio\~,~. Butwlio's the coiistiltziiit iii such c~ises? Usti~tll,,~ the obstetrician who is (,oiii(, to do, oiassist at, the operation, or one \vlio \N-ill expect art equal favor when iie needs a consultation foi- tl)e siiiiie purpose. Is it not too much to expect of iiioi-t~il iii~iii that the\, will not stretch the indications foi- the operation, which pavs ii-tore than another tvpe of cleli\-er,,-" Especiallv if t~ie patient is wealtliy-else how account for the number of Cae 52
Consultation is necessary when the attending physician NN,aiits to do a therapeutic abortion. It is necessary for the doctor's protection against the powers of the state, against possible charges of malpractice and agaii)st his liecoming known as a too-willing complier with the NN,islies of the women wanting to get rid of their iiiixn,elcome passengers. Therapeutic abortion is a borderline euphemism. Therapeutic for whom? It can't be for the fetus in utero. It can be only for the pbysical or mental health of the mother, when the contii-iuatioii of the pregnancy is likely to harm her. In other ),%-oi-ds, her health in potentia, non in esse. Doctors in such cases do not hesitate to don the mantle of the prophet. For the record, I am not a Roman Catholic. Directory: 2013 2013 -> Annual InStructional unit plan 2013 -> The Ministry of Education and Science of Ukraine 2013 -> #1 a lifesafer of virginia inc 2013 -> Name(s): your name here team or Group #(if applicable): Professor’s name 2013 -> Alcott Local School Council (lcs) Meeting Minutes 2013 -> Table Of Contents introduction 2 2013 -> Supplemental demographic information 2013 -> 【Education&Working Experience】 Download 468.23 Kb. Share with your friends:
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