Nurses for our neighbors

Front matter

2 Park Srreet, Boston

NOT TO BE TAKEN FROM THE SHELVES EXCEPT BY PERMISSION OF THE LIBRARIAN et Sy) RW ere remy te eS Ai? P ade a ae ioe a x wou 10.4 MEF Lipp co i c ay U .

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Contents

Our ComMMon PROBLEM

IpeaL Nursinc: My Searcy ror It .

Tue Art or NursING IN THE OLD WorLD

Chapter II Medical Methods Old And New

A THIRD of a century ago it was commonly remarked that medical science had not kept pace with the advance of other sciences. Then it might have been hard to disprove :the allegation, but no such charge would now be made. For within recent years there has been a rapid succession of brilliant discoveries regarding the causation of diseases. And already much has been learned regarding the destruction of disease-producing germs.

Many of the most dreaded diseases are accordingly in rapid progress of extermination. It is practically certain that the time of great epidemics in civilized countries is past. And just as surely many of our endemic diseases, such as typhoid fever, diphtheria, and tuberculosis, might also be exterminated. Only the application of knowledge already ours is needed to rid civilization of these pests.

These facts regarding the wonderful progress of medical science are well known. But not much has yet been said about the great change that the medical profession itself has meanwhile undergone. The subject needs attention.

Let us first bring into view the typical practitioner of forty or fifty years ago. Insome of the villages, and in old-fashioned corners of our cities, physicians can still be found who are practising in much the same way that they began, and, indeed, in much the same way that their predecessors began to practise. For in their youth they learned the healing art as apprentices, which, in spite of present methods, is really the only way any art ever can be learned. These old-fashioned doctors do not begin to know as much about diseases as second-year medical students now know; but even when they left the employ of their preceptors they knew more about patients than many medical graduates of to-day ever will know, for in the formative period of their lives they had greater opportunities for acquiring this knowledge than the modern medical school affords.

If you have not known this passing type of family doctor, and if you are incredulous of his existence, follow one whom I will select for you on his daily rounds. Do not laugh at his old buggy, nor at his rough-haired horse. Like the doctor himself, and like his well-worn clothes, they have seen better days.. For his practice is not so lucrative as it formerly was. The younger doctors in their shiny automobiles have taken away many of his paying patients. The specialists have taken most of the rest. Nor do those unable to pay even his small fees in money pay him in kind as they used to do. And, after he has paid for fuel and food and provender and his excessive taxes, he has little enough for personal embellishment.

Do not judge by appearances. Study rather the man himself. Come in with him into this cottage where the anxious mother is worn out by long bedside watching. Her daughter, till lately her sole support, is plainly nearing the end. ‘Too well they both know it. They have no need of a scientific diagnosis or prognosis. Little is there in that sick room to interest the student of disease. It is only a case of common consumption. But just watch the old doctor. See how slowly and quietly he seats himself by the bedside, how carefully he feels the pulse, which still means more to him than does the temperature, and how carefully he inquires how she has slept, and if she has managed to swallow the extra eggs he has been urging. Then see him gravely nod his head in regretful.assent to her complaints, and listen to his skillful emphasis upon all the little favorable details in the story of the past night. Has he all day to spend there? He shows not the slightest impatience of the passing time. He knows far too much of human cravings to take out his watch or tell of his hurry to reach another patient. For the time being this one has all of his devotion. She feels it. His visit cheers and comforts her. Nor is his mission fulfilled the moment he leaves the sick room. His thoughtfulness for the poor mother prompts him to tarry in the garden as he bids her rejoice in the clear air which ‘surely will make her daughter’s coughing easier.”” He leaves no drugs, he writes no prescriptions. Quite useless are his visits from the scientific standpoint, useless, indeed, in his own estimation, and yet he goes there day after day without so much as ever entering his visits in the ledger. Profitless practice this, according to modern estimation, but it is what he was taught to do. Never yet has he deserted a dying patient on the miserable excuse that he could do nothing more.

But now we must hurry if we would follow him. His plan was to make all the visits needed along this road, but an imperative call has come for service in an opposite direction. And his life-long habit obliges him to inconvenience himself even upon the chance of being needed. Often it is a false alarm. So it is this time. A boy had fallen from the cherry tree. The neighbors thought him killed, but it was only a stun and as soon as he caught his breath it was evident enough he was living. But his crying is hushed as the old doctor drives hurriedly into the yard. ‘You were quite right,” he answers the mother’s apologies, “to send for me; you were, of course, terribly frightened, and it is far better to have the child thoroughly examined.” The boy is immensely relieved to see the doctor come in, — the old doctor who always gives him a smile - as he passes. Not that the doctor remembers his name, any more than he can remember the names of the thousands of other children he has helped into the world, but there is nevertheless some bond of sympathy between them, and the boy feels it. His faith in his doctor is absolute. Without a murmur he lets him pull off the little jacket and trousers, when only a moment ago he was screaming if they tried to move him. And after the doctor has gone the little fellow will fiercely resent any omissions or changes in the treatment ordered. Everything the old doctor did and every word he said the boy will remember. And later when sick or suffering, if he cannot himself go to the doctor, he will demand a visit from him. Many a call comes to the old man both by night and by day “because the child would have the doctor sent for.”

The morning’s rounds have been interrupted by this episode, and now we can follow him in some of the visits he started out to make. But notice that before he leaves this neighborhood he asks after several of his former patients. “Has your husband found work yet, or is his rheumatism still preventing him?” he asks of a sad-faced woman standing in her doorway. “Is your mother comfortable these days?” he asks of another. And reining up as he meets the fishman he inquires if ““Mary is doing well.”

As we drive with him into the factory village one well might hesitate to enter the dirty tenements. For the day is hot, and even outside there is little comfort in breathing. The kitchens are fearfully close. In one there is a desperately sick baby. The ignorant mother is doing her best; but between washing and cooking for her large family she has little time to brush away the flies or even to scald the nursing bottles as she has again and again been told she must do. More discouraging conditions could not be imagined. What earthly use is there in giving directions that will not be followed? Why, then, does not the old doctor give it up? That is not his way. Just listen to him as he tells the mother she does not realize how sick the baby is, and that funerals cost more than proper nursing. Is this the same man who an hour ago was cheering the consumptive girl’s mother? Yes, and his purpose is the same. He knows how to get the most help for his patient. In this case, only by blunt exposure of the danger can he rouse the stolid, discouraged mother into action. After her crying is over she begs for help and promises to obey the orders. The baby’s chances of recovery are bettered because it will be better cared for during the next twentyfour hours. Out of loyalty to his profession, in obedience to his conception of the physician’s duty, the old doctor forced himself into that stifling kitchen, triumphed over his discouragement, and, in his intense desire to help the helpless baby, he deliberately stirred up the mother’s anxiety, and then, seizing the psychological moment, he impressed upon her his directions. He is himself pale and wearied as he comes out. Nor is it wholly because of the heat and closeness of the kitchen. That is his own diagnosis as he mops his wet brow. But really he is half faint from intense exertion. He has given himself, his whole strength of mind and heart, and the exhaustion of it is tremendous.

Can it be that the old man’s strength has been transferred to the mother and that she in turn can transfer it to the wee life that hangs in the balance? Could any idea be more unscientific?

But we must not stop to analyze, for already the horse of his own accord has stopped at a shabby house. Not a moment is lost. The pale-faced widow herself opens the door. Everything is ready, so as to save the doctor’s time. For years, ten or more, he has made this semi-weekly visit to dilate an intestinal stricture. Except for his faithfulness, she long ago would have died. True, she would have been saved much agony, but her two children would not have had the modest home her incessant needlework has maintained for them. No one would have known about all this had not the old doctor in his pneumonia the winter before begged the young physician, who took care of him and his practice, to go on with this service to the widow in case he should not recover. “And please makeno charge,” he added, ““she has more than she can bear.”’ No words are wasted. The dilatation is done. The widow in spite of her tears smiles her gratitude, and the old man hurries away.

The forenoon has more than gone. He does not mind that his dinner must be only a warmed-over affair; he is well used to that. But he is worrying to have kept his office patients waiting. Who are they? The first to shuffle from the old parlor waiting-room into the little box-like office, which years ago was hitched on to the house, is a seedy, brokendown young man. Dissipation and poverty have made sad havoc. Now that his health has gone he appeals for help, and not in vain.

NURSES FOR OUR NEIGHBORS.

For the doctor listens to the dismal story, gives him some medicine and only casually adds the warning that while taking this medicine not a drop of liquor must be drunk. “If you at any time feel that you must have a drink, come here to me for it.” This he always says to drunkards. Sometimes it works, as no unsympathetic scientific treatment ever will. And, however hopeless to others the drunkard’s disease may be, the old doctor never despairs. Why should he? Didi you not on this morning’s drive see the fishman greet him? Well, he was once a drunkard. He first came to the doctor to have his scalp sewn up after a drunken brawl. By the time that was well he had consented to work for a farmer for his board. For many days he was too weak to be of much use, but the farmer owed the doctor a heavy debt of gratitude and so for the doctor’s sake kept encouraging the drunkard. The priest also helped. And when the year of pledge was nearly ended, the doctor, keeping the man in mind, with a small loan helped him to a hand-cart fish route. That 30 was years ago, but never a drop of liquor has the man since drunk.

The next patient in the office hastens to say she has not come for professional advice. She wants to find work. Her husband brings back only a pittance of his wages, yes, and beats her when she can give him no meat for dinner. Does she tongue-lash him? the doctor asks. “Yes, who would n’t?” Then he tells her the old story of the wife who tamed her brutal husband by holding holy water in her own mouth. Does she ever herself drink? he asks. And then, taking full advantage of her discomfiture, he encourages her to try once more, and still again, to make her little home more lovely and attractive by doing the work in it that she would do for hire in other homes. He has seen wives win by this method, he tells her.

Now comes the richly dressed lady who has not concealed her impatience at having to waitherturn. Volubly she rehearses her symptoms. One would think she was the greatest sufferer on earth. Not only are all of her vital organs out of order; her maid has given notice, and that, too, when all of the next week must be devoted to the dressmaker. No one gives her help or even sympathy. As for the last medicine the doctor gave, she positively could not swallow it, and when she did, “It made her worse.” In vain the old man tries to divert her. No, she does not want to hear of others’ woes; “that always makes her more wretched.” Her neighbors’ poverty is their own fault; why do they not save up against rainy days as she herself does?

What can be done for her? Her case would discourage the saints. And yet she is diseased, —and with the most intractable of all diseases. She is self-centered. But that does not relieve the doctor from trying to save her. Indeed, in spite of the annoyance she is to him, he pities her. And as visions flit before him of the vast amount of good she might do, of the comfort she might be to her hopeless, ex- _hausted husband, to her poorer relatives, to the sick and suffering in her own immediate neighborhood, if only she could be persuaded to look outwards and upwards, he braces himself to one more supreme effort. He tells her squarely that her woes are all imaginary. Her anger encourages him. He takes up the long list of symptoms she has related and shows her how they contradict each other. His attention to her dismal story gives him the upper hand, for his memory of what she said is better than hers. Then he softens. Imaginary woes are always worse than real woes, he tells her. And when solid bottom has been reached, in answer to her appeal for help he tells her how to get up and out of herself. He does not confuse her with his own long vista of the road she must travel, of, the high ladder she must climb, but he gives plain directions for the first steps. He purposely proposes what she especially dislikes. He insists that she shall call on the Italian family whose cabin she: has hated to see built in the edge of the woods she blames her husband for not having preémpted. He does not tell her of the lame girl there who he hopes will remind her of the’ little daughter she never mentions. Reiterating his explicit directions, he follows her out to her carriage, partly out of politeness, partly for his own relief to see her go. Well has he earned his fee, the first one that will be charged on his books for this day.

The last to come in is the saddest case of all. At first brazenly lying, she soon surrenders under his mercilessly plain questioning. Yes, he is right. He has uncovered her secret woe. She still tries to evade all blame. Again and again she protests that it was only just once she fell, and that was when no help was near. But he has been waiting for just this chance. When her father appealed to him to talk to her, “‘to scare her within an inch of her life,” he knew too much to join in the useless coercion. But now when she is crying so bitterly, he can do something. Nor in his heart or from his lips is there one word of condemnation for the erring child: His very silence comforts her. In pouring out her confession she finds peace, not because of any priestly absolution he can give, but because of her human nature and his. For the time being he is her father, she is his daughter. In answer to her piteous pleading to be relieved of the burden she carries, and of the inevitable shame, he tells her of the great dangers and of the serious criminality involved. He tells her that it is not only his own unwillingness to go to State’s prison, but his unwillingness to murder the defenseless, that compels his refusal. And then he gives her the chance to go into retirement, he promises to stand by her and her child so long as they all shall live. Lovingly he pleads with her. Yes, he will be the one to break the awful news to her parents, and he will plead with them that she shall not be cast out into utter darkness. After such a day the old doctor surely deserves to have rest. You who are only following him may well be weary. But no, Mrs. Jones’s labor has begun. He too well remembers what hard labors she always has. It will be a long night’s job for him. Of what use is it to go out there now? Nevertheless, he goes. She will have more courage if she knows he is near at hand. And, besides, there is the old paralyzed farmer hard by who has lately been sinking peacefully away. True, he is absolutely unconscious, and his devoted daughter knows his release isnear. But then she has never seen a body die, and, though long expected, the end will be a great shock to her. Moreover, is it not his business to help at the going out as it is at the coming in? He remembers his old preceptor’s teaching; and never if he can help it will he miss standing by his dying patients. ‘Too many times he has been repaid by the last handclasp, and by the last look of unspeakable gratitude, to doubt such opportunities for fellow-service. And besides, he knows how those just bereft need, as at no other times in their lives, a strong friend to lean upon. He remembers how tottering he himself was when his own dear ones left him.

We need not follow him further, either in his loving welcome of the newborn child or in his steadying influence at the deathbed. Nor need we watch him as he returns, completely tired out, thankful that the world is asleep and that he at last is alone with the stars which from his childhood up have calmed him.

So much for the passing type of medical practitioner, the old family doctor, the beloved physician. Who is taking his place? How are the medical students of to-day being taught the art of medical practice? Was there nothing lost when in the evolution of medical schools the old apprenticeship system was given up?

In the old days a young man who wanted to be a physician entered into the service of the most successful practitioner within reach. He studied anatomy and recited his daily lessons. Occasionally he had furtive opportunity for dissecting. He did the chores. He rode and he lived with his preceptor, who handed down to him the lessons he himself had learned from great physicians gone before. Of course only the common, everyday ailments were thus studied. There was little learned about the nature of diseases, but there was a lot thus learned about human helplessness. Afterwards, in similar emergencies, the man so trained would instinctively imitate his teacher’s methods. And in this way was handed on from one generation to another the art of curing or of caring for the helpless. We need not give more than passing notice to the usefulness of the courses of lectures and surgical operations that the young medical student had to attend in order to get his diploma. But it is not out of place to insist that, however valueless in comparison with laboratory research didactic lectures are, nevertheless there is positive value to the medical student in the opportunity to hear and see great phy- Sicians and surgeons giving forth their best. |

The modern medical school offers most admirable opportunity for the study of disease. In the laboratories, and in the hospital wards and morgues, diseases can be studied in culture tubes, in human patients, and in guinea pigs. But, what opportunity amid such research is there for the study of human nature? Ability to diagnosticate disease is all very well. It is one of the necessary foundations for medical practice, but it is not the only foundation. A knowledge of materia medica is also a necessary foundation, but of what use is it to a physician ignorant of therapeutics? In the hospital and dispensary classes it is true that modern medical students can see all manner of diseases. They can see what treatment is ordered. ‘They may see the same patients a second or even a third time. But what can they there learn of the healing art? What inkling can be taught them there of the truly serviceable relationship between physician and patient?

« Itis generally believed that physicians nowadays rush into specialist practice because of their desire to excel in some one direction. Such may be the reason with some, but with many the compelling reason is their sense of unfitness for general practice. In the specialties it is not necessary to know one’s patient, it is enough to know his disease; whereas in general practice poor diagnosticians are often very successful, because of their knowledge of human nature and of the art of caring for human helplessness.

There is, in short, a radical difference between the science of medicine and the art of medical practice. In the former education of physicians little attention was paid to the science of medicine, and, indeed, there was then not much medical science; but the art of medical practice was taught. In the modern medical schools science is enthroned. Carried away by the brilliance of etiological discoveries, the whole strength of the schools is devoted to the study of diseases. The art of medical practice is not taught; even its existence is hardly recognized. And in consequence the graduates of the medical schools of to-day are not properly fitted for the practice of their profession.

This is a sweeping charge. Let us see if it can be substantiated by a study of the new kind of doctor. To make the contrast as plain as possible, let us see how he would meet the problems that we have just seen confront the old physician. We must of course make allowance for the difference in age and experience, but some of the new kind of doctors are by no means young, and not all of the old-fashioned doctors are even yet so very old.

. Moreover, they both continue to practice in the ways they were taught. One was taught to think first of the patient, to get into direct close relationship with him, to feel his pain and misery, and to strive in every way to relieve him. As a means to this end some thought was of course to be given to the disease. The new kind of physician, on the other hand, has been taught to give his entire attention to the disease, and even the idiosyncrasies of patients are noteworthy to him only in so far as they serve to modify their diseases.

, So when we go with the younger doctor into the consumptive’s cottage, it will be on his weekly instead of his daily visit. What if the girl is dying, is it not of that most uninteresting (because so common) disease? Moreover, are they not poor, and so is it not better to avoid a large account against them? But never mind his reasoning; come in with him. Brusque and hearty, he wastes no time. See him uncover the poor girl’s chest to percuss it, and to listen through his stethoscope to the choking respiration and to the fluttering heart beats. Oh no, he never omits that process. Not that

‘NURSES FOR OUR NEIGHBORS!

he supposes it will do any good; he does it simply because he does not know what else to do. It is the way he was taught to treat consumptives. His answer to her complaints is another prescription, or another kind of tablets. ‘To the anxious mother he is honest. He tells her, what she very well knows, that her daughter is failing rapidly. He tells her of the danger to herself of infection, and that no one can do anything for the poor girl; and, utterly oblivious of the preciousness to the mother of every day and hour of her child’s life, he almost voices his own wish that the end shall come soon. Little wonder is it that families so treated turn in their desperation to the Christian Scientists and to the charlatans who, either in their absurd denials of the existence of disease or for mercenary reasons, at least leave some hope in the sick-room.

The small boy who fell from the cherry tree will fare better than the consumptive has fared at the scientific doctor’s hands, for although he will yell while being examined, he will nevertheless be told that no bones are broken. And his mother will have some comfort in hearing that, unless some internal damage has been done, the boy will be all right again.

How will the sick baby’s mother fare? As _ far as frightening her, he can do that well enough. And he can scold her for not following his directions. Instead of the broth advised by the old doctor, orders will be left for some complicated milk modification, far beyond the mother’s ability to prepare. Very likely the baby will be studied more carefully; its dejections at any rate will be. And if only his orders are carried out, the baby will have better chances of living. For it will hardly feel, and at any rate will not remember, the doctor’s lack of sympathy; and the mother deserved her scolding. Will he go there again? Possibly, but not unless sent for, and it is not at all unlikely the summons will be for another physician.

The contrast between the old and the new methods of medical practice is most glaring in the department of midwifery. It used to be recognized that child-bearing after all is something of a natural process, and that most women if let alone get on very well with having their babies. Indeed, it is not so very long since doctors were first allowed to be present on such occasions. It is of course quite true that obstetric science has saved the lives of many mothers and babies who otherwise would have been lost. And it is also true that many mothers and babies have been sacrificed by meddlesome midwifery and by infections carried into the lying-in chamber by physicians. Just at the time when this fact dawned upon. the medical profession, and when it would have been very becoming of doctors to hide their heads in shame for their past blunders, the new school of obstetricians, instead of returning to a more proper trust in nature, began to treat this most natural process of child-bearing as if it were an unnatural surgical operation. It was necessary only that the doctors should disinfect themselves. But, lo and behold, they insisted upon such elaborate disinfections of the poor mothers and upon such expensive provision for the expected event, that no wonder the problem of race suicide has engaged presidential attention. No prudent family could afford to be caught twice. The outrageously unnecessary expense, however, isa small part of the damage. The chief harm of modern obstetric practice has come from requiring such abnormal preparations, and such needless subsequent invalidism, that common folks have come to consider child-bearing as a burden to be avoided.

We need not try with the scientific doctor to follow the old physician’s practice too closely. Some of the latter’s patients would never come to him, or stay with him long. The widow with the stricture would have been operated on long before. Perhaps she would have been made well; and perhaps she would have been otherwise relieved of her burdens.

Neither the drunkard nor the wayward girl would be so likely to appeal to the modern doctor. And if they did, they would not detain him long.

The self-centered lady would be given a name for at least some of her imaginary diseases. For a time she would be highly gratified by his attention to her symptoms, by his minute examination of her body and of its excretions. And he will surely find some organ out of order. It is his business to do so. He does not yet know that persistent search for the abnormal in human bodies will reveal some trifling trouble nine times out of ten. Nor does he yet know enough to keep to himself such discoveries, at least until he has carefully estimated their insignificance. He has yet to learn how rapidly physical defects become worse under the concentrated attention of the patient and of the patient’s family and friends. His ignorance of human nature allows him, and his scientific prowess inclines him, always to reveal the defects and infirmities that Nature herself is so kindly concealing. His devotion to what he conceives to be the truth is admirable. On the other hand, his implicit trust in his own observations and in his own opinions is appalling. While concerned with examinations of the excretions, or of the dead body, his methods are unimpeachable, and his 46 conclusions are scientifically sound; or, more strictly speaking, are in accordance with present scientific theories and hypotheses. It is when dealing with the mysteries of life that his science fails him. He has not been taught the therapeutic value of sympathy and of encouragement. In his search for diseases and for their causes he is far ahead of the old-fashioned physician. In the prevention of diseases he can be of immense use to the community. That is his real calling. That is what he has been trained for. In short, wherever knowledge of disease is needed, there the modern doctor excels. But his training has not fitted him to be a physician.